In Hospital Outcomes of Patients With Right Bundle Branch Block and Anterior Wall ST-Segment Elevation Myocardial Infarction (From a Nationwide Study Using the National Inpatient Sample).

Previous studies have reported worse outcomes for patients with right bundle branch block (RBBB) complicating acute ST-segment elevation myocardial infarction (STEMI). There is a paucity of data examining outcomes with RBBB and STEMI in contemporary large-scale studies. This study aims to explore the outcomes of patients with anterior wall STEMI (AW-STEMI) and RBBB. Using ICD-9 codes, we queried the National Inpatient Sample of 1999 to 2014 to identify AW-STEMI admissions and stratified them for the presence of RBBB. Primary outcome was in-hospital mortality within 30 days. Secondary outcomes included acute heart failure, complete heart block, and permanent pacemaker implantation. Cox-proportional logistic regression models were used to determine the hazard ratios of the primary outcome and secondary outcomes and interventions. Among 1,075,875 weighted anterior wall STEMI (AW-STEMI) admissions, 19,153 (1.8%) had RBBB. Compared with patients without RBBB, mortality was significantly higher for patients with RBBB (9.2% vs 15.3%; p <0.0001). RBBB in the setting of AW-STEMI was associated with a 66% increased risk of 30-day in-hospital mortality (hazard ratios [HR], 1.66; 95% confidence interval [CI], 1.52 to1.81; p <0.0001) and a higher likelihood of acute heart failure (HR, 1.37; 95% CI, 1.29 to 1.45; p <0.0001), complete heart block (HR, 2.90; 95% CI, 2.64 to 3.18; p <0.0001) and utilization of a permanent pacemaker (HR, 2.51; 95% CI, 1.89 to 3.35; p <0.0001). In conclusion, the presence of RBBB in the setting of an AW-STEMI is a significant independent predictor of a poor prognosis, including a higher rate of acute heart failure, complete heart block, need for a permanent pacemaker, and a higher 30-day in-hospital mortality.

Lessons for Treating Structural Heart Patients during the COVID-19 Pandemic and Beyond.

Background: We sought to compare characteristics and outcomes of structural heart disease (SHD) patients treated during the regional peak of the Coronavirus Disease 2019 (COVID-19) pandemic ("COVID era") compared with historical controls. During the COVID era, elective SHD procedures at Beth Israel Deaconess Medical Center were canceled but urgent cases were still performed. We enacted several practice changes in an effort to minimize complications, prevent COVID transmission, and decrease hospital stay during the pandemic. Methods: Baseline characteristics and outcomes were collected on all patients who underwent SHD procedures during the COVID era and compared with patients treated during the same time period in 2019. Results: Compared with SHD patients treated during 2019 (N = 259), those treated during the COVID era (N = 26) had higher left ventricular end diastolic pressure (LVEDP; 28 vs. 21 mmHg, p = 0.001), and were more likely New York Heart Association class IV (26.9% vs. 10.0%, p = 0.019), but had a lower rate of bleeding/vascular complications (0% vs. 16.2%, p = 0.013), a lower rate of permanent pacemaker implantation (0% vs. 17.4%, p = 0.019), and a greater proportion of patients were discharged on post-operative day 1 (POD#1; 68.2% vs. 22.2%, p < 0.001). Conclusion: Practice changes employed for patients treated during the COVID era were associated with fewer vascular complications, a greater proportion of patients discharged on POD#1, and a lower rate of pacemaker implantation despite more severe illness. As a result, we plan to continue these practices in the post-COVID era.

Treatment of an external iliac artery chronic total occlusion using alternate access sites.

BACKGROUND: With the advent of endovascular techniques, alternate sites such as the pedal and radial arteries can now be accessed when treating peripheral arterial disease to reduce procedural complications, shorten recovery time, and improve patient comfort. However, a paucity of literature exists on the availability of support devices that can be utilized during challenging cases. CASE PRESENTATION: A 70 year-old female patient presented for evaluation of severe lifestyle-limiting left-sided claudication refractory to maximal medical therapy. Angiography revealed a chronic total occlusion of the left external iliac artery, which was treated successfully by percutaneous intervention via a primary transpedal approach and with the assistance of the Outback® Elite re-entry device. The patient was discharged 2 h after the procedure and reported significant symptom improvement at follow-up. CONCLUSION: This case highlights a newly adopted endovascular approach through an alternate access site and illustrates how the Outback® Elite device can be used as an adjunctive tool in the treatment of complex lower-extremity vascular lesions.

Impact of gender on in-hospital outcomes in patients with Takotsubo syndrome: A nationwide analysis from 2006 to 2014.

BACKGROUND: Takotsubo syndrome (TTS) is characterized by acute, transient systolic dysfunction of the left ventricle not attributed to coronary artery disease (CAD). HYPOTHESIS: There are differences in hospital outcomes in patients admitted with TTS based on their gender. METHODS: The National Inpatient Sample database was searched for patients admitted with a principal diagnosis of TTS from 2006 to 2014 using the ICD9-CM code 429.83. Using Pearson's χ2 and Student's t test analyses, the P-value was calculated for differences among baseline characteristics of patients. Multivariate regression models were then created to adjust for potential confounders. RESULTS: A total of 39 662 admissions with TTS were identified, 91.7% female and 8.3% male with mean age of 66.5 and 61.6 years, respectively. The incidence of TTS increased progressively from 2006 to 2014. Female patients were more likely to have hypertension, hypothyroidism, or depression. Males were more likely to use tobacco, or have known CAD. Males had almost 4-fold higher probability of in-hospital mortality compared to females (3.7% vs 1.1%; P<0.001). Certain complications including cardiogenic shock, ventricular fibrillation/tachycardia, and acute kidney injury were more common in males. CONCLUSIONS: There are distinct gender differences in clinical characteristics of patients admitted with TTS. Although TTS is more common in females, it is associated with higher morbidity and mortality in males.

Meta-Analysis of Randomized Clinical Trials Comparing Biodegradable Polymer Drug-Eluting Stent to Second-Generation Durable Polymer Drug-Eluting Stents.

OBJECTIVES: The authors sought to perform a meta-analysis of randomized clinical trials (RCTs) comparing the safety and efficacy of biodegradable polymer drug-eluting stents (BP-DES) to second-generation durable polymer drug-eluting stents (DP-DES). BACKGROUND: Prior meta-analyses have established the superiority of BP-DES over bare-metal stents and first-generation DP-DES; however, their advantage compared with second-generation DP-DES remains controversial. METHODS: The authors searched PubMed and Scopus databases for RCTs comparing BP-DES to the second-generation DP-DES. Outcomes included target vessel revascularization (TVR) as efficacy outcome and cardiac death, myocardial infarction (MI), and definite or probable stent thrombosis (ST) as safety outcomes. In addition, we performed landmark analysis for endpoints beyond 1 year of follow-up and a subgroup analysis based on the stent characteristics. RESULTS: The authors included 16 RCTs comprising 19,886 patients in the meta-analysis. At the longest available follow-up (mean duration 26 months), we observed no significant differences in TVR (p = 0.62), cardiac death (p = 0.46), MI (p = 0.98), or ST (risk ratio: 0.83, 95% confidence interval: 0.64 to 1.09; p = 0.19). Our landmark analysis showed that BP-DES were not associated with a reduction in the risk of very late ST (risk ratio: 0.87, 95% confidence interval: 0.49 to 1.53; p = 0.62). Similar outcomes were seen regardless of the eluting drug (biolimus vs. sirolimus), the stent platform (stainless steel vs. alloy), the kinetics of polymer degradation or drug release (<6 months vs. >6 months), the strut thickness of the BP-DES (thin <100 µm vs. thick >100 µm), or the DAPT duration (≥6 months vs. ≥12 months). CONCLUSIONS: BP-DES have similar safety and efficacy profiles to second-generation DP-DES.

Evolving Electrocardiographic Changes in Lamotrigine Overdose: A Case Report and Literature Review.

Lamotrigine overdose usually follows a benign pattern, and the majority of cases reported involve a co-ingestant. Prior reports have suggested the possible use of intravenous lipid emulsion in cases of severe sodium channel blockade. We describe the electrocardiographic changes in a massive lamotrigine overdose treated with intravenous lipid emulsion. A 36-year-old male with bipolar disorder ingested 13.5 g of lamotrigine in a suicidal attempt. The lamotrigine level was 78.0 µg/mL. Comprehensive drug screen was negative for all screened compounds. The electrocardiogram demonstrated a prolonged QRS complex and signs suggestive of sodium channel blockade. Refractory to treatment with sodium bicarbonate was treated with intravenous lipid emulsion, with immediate resolution of the electrocardiographic changes. Lamotrigine inhibits the voltage-gated sodium channel opening, attenuating the release of excitatory neurotransmitters. Cardiac intraventricular conduction could be delayed in cases of lamotrigine overdose resulting in QRS and QTc prolongation and R waves >3 mm in leads I and aVR. A potential role for intravenous lipid emulsion therapy has been described in patients with toxic levels of lamotrigine and electrocardiographic changes refractory to the treatment with sodium bicarbonate. Intravenous lipid emulsion has been successfully used in the treatment of lamotrigine cardiac toxicity.

Atrioesophageal fistula following ablation procedures for atrial fibrillation: systematic review of case reports.

BACKGROUND: Atrioesophageal fistula (AEF) is a rare but serious adverse event of atrial fibrillation (AF) ablation. OBJECTIVE: To identify the clinical characteristics of AEF following ablation procedures for AF and determine the associated mortality. METHODS: A systematic review of observational cases of AEF following ablation procedures for AF was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement protocol. RESULTS: 53 cases were identified. Mean age was 54±13 years; 73% (39/53) of cases occurred in males. Mean interval between procedure and presentation was 20±12 days, ranging from 2 to 60 days. AEF was observed in 12 patients who underwent surgical radiofrequency ablation (RFA) and in 41 patients with percutaneous RFA. Fever was the most common presenting symptom (n=44) followed by neurological deficits (n=27) and haematemesis (n=19). CT of the chest (n=27) was the preferred diagnostic test. Patients who did not receive a primary esophageal repair were more likely to have a deadly outcome (34% vs 83%; p<0.05). No difference in mortality rate was found between patients who underwent surgical RFA when compared with percutaneous RFA (58% vs 56%; p=0.579). No association was found between onset of symptoms and mortality (19±10 vs 23±14 days; p=0.355). CONCLUSIONS: AEF following ablation procedures for AF is a serious complication with high mortality rates. Presenting symptoms most often include a triad of fever, neurological deficit and/or haematemesis within 60 days of procedure. The preferred diagnostic test is CT of the chest. The treatments of choice is surgical repair.

Meta-Analysis of Randomized Controlled Trials Comparing Multivessel Versus Culprit-Only Revascularization for Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Disease Undergoing Primary Percutaneous Coronary Intervention.

Current guidelines recommend against revascularization of the noninfarct artery during the index percutaneous coronary intervention (PCI) in hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI). This was based largely on observational studies with few data coming from randomized controlled trials (RCTs). Recently, several small-to-moderate sized RCTs have provided data, suggesting that a multivessel revascularization approach may be appropriate. We performed a meta-analysis of RCTs comparing multivessel percutaneous coronary intervention (MV PCI) versus culprit vessel-only revascularization (COR) during primary PCI in patients with STEMI and multivessel coronary disease (MVCD). We searched Medline, PubMed, and Scopus databases for RCTs comparing MV PCI versus COR in patients with STEMI and MVCD. The incidence of all-cause death, cardiac death, recurrent myocardial infarction, and revascularization during follow-up were extracted. Four RCTs fit our primary selection criteria. Among these, 566 patients underwent MV PCI (either at the time of the primary PCI or as a staged procedure) and 478 patients underwent COR. During long-term follow-up (range 1 to 2.5 years), combined data indicated a significant reduction in all-cause mortality (relative risk [RR] 0.57, 95% confidence interval [CI] 0.36 to 0.92, p = 0.02) and in cardiac death (RR 0.38, 95% CI 0.20 to 0.73, p = 0.004) with MV PCI. In addition, there was a significantly lower risk of recurrent myocardial infarction (RR 0.41, 95% CI 0.23 to 0.75; p = 0.004) and future revascularization (RR 0.37, 95% CI 0.27 to 0.52; p <0.00001). In conclusion, from the RCT data, MV PCI appears to improve outcomes in patients with STEMI and MVCD.

Intermittent brugada syndrome presenting with syncope in an adult female.

Background. Brugada syndrome accounts for 4-12% of all sudden deaths worldwide and at least 20% of sudden deaths in patients with structurally normal hearts. Case Report. A 48-year-old female presented to the emergency department after two witnessed syncopal episodes. While awaiting discharge had a third collapse followed by cardiac arrest with shockable rhythm. Initial electrocardiogram showed wide QRS complex with left axis deviation, ST-segment elevation of <1 mm in V1 and V2, and flattening of T waves in V1. The angiogram did not demonstrate obstructive coronary disease. The electrocardiogram obtained two days after these events showed a right bundle branch block with ST-segment elevation of >2 mm followed by a negative T wave with no isoelectric separation, suggestive of spontaneous intermittent Brugada type 1 pattern. Cardiac magnetic resonance imaging demonstrated neither structural heart disease nor abnormal myocardium. After placement of an implantable cardioverter defibrillator the patient was discharged. Why should an emergency physician be aware of this? Brugada syndrome is an infrequently encountered clinical entity which may have a fatal outcome. This syndrome primarily presents with syncope. It should be considered as a component of differential diagnosis in patients with family history of syncope and sudden cardiac death.