Prevalence of Metabolic Syndrome in Patients with HIV in the Era of Highly Active Antiretroviral Therapy.

OBJECTIVES: Since the introduction of combination antiretroviral therapy (cART) as the standard of care for HIV disease, there has been a precipitous decline in the death rate due to HIV/ AIDS. The purpose of this study was to report the prevalence of metabolic syndrome in HIV infected patients. METHODS: Retrospective, cross-sectional, observational study of 259 patients with HIV infection treated with cART from an urban community hospital. Metabolic syndrome prevalence was defined using the International Diabetes Federation (IDF) and the U.S. National Cholesterol Education Program Adult Treatment Panel III (ATP III) criteria. Study patients were included regardless of the duration of cART. RESULTS: The prevalence of metabolic syndrome was 27% using IDF criteria and 26% using ATP III criteria. Logistic regression analysis found an association between treatment with the protease inhibitor darunavir and metabolic syndrome. (OR 3.32 with 95% confidence interval between 1.54 and 7.15). CONCLUSION: There is a high prevalence of metabolic syndrome and obesity in HIV patients treated with cART, especially those taking the protease inhibitor darunavir.

Psychosocial and cardiac outcomes of yoga for ICD patients: a randomized clinical control trial.

BACKGROUND: Because as many as 46% of implantable cardioverter defibrillator (ICD) patients experience clinical symptoms of shock anxiety, this randomized controlled study evaluated the efficacy of adapted yoga (vs usual care) in reducing clinical psychosocial risks shown to impact morbidity and mortality in ICD recipients. METHODS: Forty-six participants were randomized to a control group or an 8-week adapted yoga group that followed a standardized protocol with weekly classes and home practice. Medical and psychosocial data were collected at baseline and follow-up, then compared and analyzed. RESULTS: Total shock anxiety decreased for the yoga group and increased for the control group, t(4.43, 36), P < 0.0001, with significant differences between these changes. Similarly, consequential anxiety decreased for the yoga group but increased for the control group t(2.86,36) P = 0.007. Compared to the control, the yoga group had greater overall self-compassion, t(-2.84,37), P = 0.007, and greater mindfulness, t(-2.10,37) P = 0.04, at the end of the study. Exploratory analyses utilizing a linear model (R(2) = 0.98) of observed device-treated ventricular (DTV) events revealed that the expected number of DTV events in the yoga group was significantly lower than in the control group (P < 0.0001). Compared to the control, the yoga group had a 32% lower risk of experiencing device-related firings at end of follow-up. CONCLUSIONS: Our study demonstrated psychosocial benefits from a program of adapted yoga (vs usual care) for ICD recipients. These data support continued research to better understand the role of complementary medicine to address ICD-specific stress in cardiac outcomes.

Disulfiram--alcohol reaction mimicking an acute coronary syndrome.

Disulfiram treatment for alcohol dependence is used with acceptable outcomes. By inhibiting the aldehyde dehydrogenase enzyme, this treatment increases acetaldehyde concentration after the ingestion of alcohol causing an unpleasant disulfiram-alcohol reaction. Typical symptoms include flushing, headache, nausea, vomiting, sweating, vertigo, and lightheadedness. However, there have also been descriptions of more serious reactions including severe hypotension, arrhythmias, myocardial infarction, and cardiovascular collapse. We report a patient with a severe disulfiram-alcohol reaction marked by flushing, confusion, generalized malaise, epigastric pain, and hypotension. Cardiac biomarker and electrocardiographic changes were suggestive of non-ST-elevation myocardial infarction (NSTEMI). Left heart catheterization showed no angiographic evidence of coronary artery disease. Because of the frequency of alcohol dependence and its treatment with disulfiram, it is critical for physicians to be aware of these types of life-threatening complications.

Prospective chest pain evaluation in the emergency department with use of high-sensitivity C-reactive protein (PROCEED-CRP study).

We evaluated the clinical value of a single measurement of high-sensitivity C-reactive protein (hs- CRP) in patients presenting to the emergency department with chest pain. We screened 408 consecutive patients of whom 292 comprised the final cohort for this study. Hs-CRP measured in the emergency department (ED) in patients presenting with chest pain and admitted for evaluation of acute myocardial infarction was neither sensitive nor specific in predicting acute myocardial infarction, myocardial ischemia on SPECT imaging, need for coronary revascularization, or cardiovascular or all-cause rehospitalization at 30 days. In addition, use of a specific CRP cut off >1 was not associated with an increase in all-cause rehospitalization at 30 days.

Isolated left ventricular noncompaction: a review of three different presentations for a rare disease.

Isolated left ventricular noncompaction (ILVNC) is a rare cardiomyopathy with a genetic background characterized by numerous prominent trabeculations and deep intertrabecular recesses. It occurs in the absence of any coexisting congenital lesion or hemodynamic abnormality and is rare in the adult population. Heart failure, ventricular arrhythmias, and embolic events are the three major clinical manifestations of ILVNC. Medical and surgical treatment is similar to other systolic dysfunction cardiomyopathies and depends on the presenting clinical manifestations. In this review, we present three patients with different clinical presentations of ILVNC leading to different treatment modalities ranging from medications alone to device implantation and transplantation. Pathologic findings from one of our patients are also presented.

A Multigroup Analysis of Bidirectional Work-Family Enrichment on Family Satisfaction of Hospitality Employees during the Pandemic: Where Religiosity and Marital Status Matter.

The COVID-19 pandemic has changed our lives. As many industries face a complete stand-still, it also highlights the need to maintain family satisfaction (FS) during this challenging time, empirical research on achieving this remains scant. This study elucidates how marital status influences employees' religiosity, work-family enrichment (WFE) and FS. Data from 295 employees was examined using the analyzed using the partial least squares method structural equation modeling (PLS-SEM) multigroup analysis. Results suggest that religiosity has a positive significant relationship on the bidirectionality of WFE. The multigroup analysis indicates a significant difference in how single and married employees interpret work-family experience. We extend family-work interfaces by incorporating both the construct of marital status and religiosity. It advances the body of knowledge in understanding work-family interfaces, especially in times of the pandemic.

Stratifying Deterioration Risk by Acuity at Admission Offers Triage Insights for Coronavirus Disease 2019 Patients.

OBJECTIVES: Triaging patients at admission to determine subsequent deterioration risk can be difficult. This is especially true of coronavirus disease 2019 patients, some of whom experience significant physiologic deterioration due to dysregulated immune response following admission. A well-established acuity measure, the Rothman Index, is evaluated for stratification of patients at admission into high or low risk of subsequent deterioration. DESIGN: Multicenter retrospective study. SETTING: One academic medical center in Connecticut, and three community hospitals in Connecticut and Maryland. PATIENTS: Three thousand four hundred ninety-nine coronavirus disease 2019 and 14,658 noncoronavirus disease 2019 adult patients admitted to a medical service between January 1, 2020, and September 15, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Performance of the Rothman Index at admission to predict in-hospital mortality or ICU utilization for both general medical and coronavirus disease 2019 populations was evaluated using the area under the curve. Precision and recall for mortality prediction were calculated, high- and low-risk thresholds were determined, and patients meeting threshold criteria were characterized. The Rothman Index at admission has good to excellent discriminatory performance for in-hospital mortality in the coronavirus disease 2019 (area under the curve, 0.81-0.84) and noncoronavirus disease 2019 (area under the curve, 0.90-0.92) populations. We show that for a given admission acuity, the risk of deterioration for coronavirus disease 2019 patients is significantly higher than for noncoronavirus disease 2019 patients. At admission, Rothman Index-based thresholds segregate the majority of patients into either high- or low-risk groups; high-risk groups have mortality rates of 34-45% (coronavirus disease 2019) and 17-25% (noncoronavirus disease 2019), whereas low-risk groups have mortality rates of 2-5% (coronavirus disease 2019) and 0.2-0.4% (noncoronavirus disease 2019). Similarly large differences in ICU utilization are also found. CONCLUSIONS: Acuity level at admission may support rapid and effective risk triage. Notably, in-hospital mortality risk associated with a given acuity at admission is significantly higher for coronavirus disease 2019 patients than for noncoronavirus disease 2019 patients. This insight may help physicians more effectively triage coronavirus disease 2019 patients, guiding level of care decisions and resource allocation.

Long-term outcome of Tako-tsubo cardiomyopathy.

BACKGROUND: Current data suggest an excellent outcome for patients with Tako-tsubo cardiomyopathy (TC). The objectives of this study were to evaluate the long-term outcome and the prognostic implication of thrombolysis in myocardial infarction myocardial perfusion grade (TMPG) in patients with TC. METHODS: Retrospective analysis of all patients diagnosed with TC at our hospital between 2003 and 2008. RESULTS: During the five-year period, we identified 27 patients with TC out of 1374 cases of emergent left heart catheterisation (2%). Mean follow-up was 27 ± 16 months. The majority were Caucasian (81%) female (96%), postmenopausal (96%), with a mean age of 68 ± 14 years. A precipitating stressor event was found in 74% of the patients, 30% being gastrointestinal triggers. Fourteen patients (52%) reached a combined end point of all cause death, cardiogenic shock, sudden cardiac death and rehospitalisation for cardiac reasons. TMPG was abnormal in 37% cases with no correlation with the outcome. CONCLUSIONS: The long-term outcome of patients with TC is worse than previously reported. TMPG does not correlate with the outcome in TC.

ECG findings in acute left main coronary artery thrombosis: a case report and review of the literature.

Acute coronary syndrome due to left main coronary artery (LMCA) thrombosis is a catastrophic event associated with poor prognosis and high in-hospital mortality. Early recognition and emergent revascularization is vital for survival. Unfortunately, the electrocardiographic manifestations of LMCA thrombosis are nonspecific. This report describes the electrocardiogram (ECG) findings in a patient with LMCA thrombosis. A new right bundle branch block (RBBB) pattern, especially when associated with ST elevation in aVR and V1, should raise suspicion of this diagnosis.

Papillary fibroelastoma arising from the pulmonary valve associated with pulmonary embolization.

Cardiac papillary fibroelastomas are rare, usuallybenign tumors that can be detected at autopsy, during open-heart surgery, or with echocardiography. They usually arise from the cardiac valves and more commonly are found on the left side of the heart. Embolization of left-sided and tricuspid valve tumors has been well documented. This is the 1st reported case of pulmonary embolization of a papillary fibroelastoma arising from the pulmonary valve.

Nesiritide in the initial management of acute decompensated congestive heart failure.

BACKGROUND: In the era of evolving therapy for heart failure (HF), optimal medical therapy has become challenging. Nesiritide is being used for HF therapy but its impact is still controversial. METHODS: Prospective and randomized controlled study of 34 patients who presented to the emergency department (ED) with HF and remained symptomatic despite maximal standard therapy delivered for at least one hour. All patients had B-type natriuretic peptide BNP >100 pg/dl. Patients were randomized into Group A which received maximal standard therapy and group B which received nesiritide bolus followed by an infusion (0.01 mcg/kg/min) in addition to maximal therapy. Primary endpoints included HF hospital readmission, and hospital length of stay (LOS). Secondary endpoints included HF, cardiovascular, all-cause mortality, and adverse events. Composite risk score was designed. Results were analyzed using a logistic regression model and bootstrapping simulating approach. RESULTS: Decrease in rehospitalizations for HF was observed during the 30 days and six-month follow-up in Group B. Earlier initiation of nesiritide therapy consistently shortened hospital LOS. Group B had a decrease in 30-day mortality but not after one year. CONCLUSIONS: Acute HF patients who do not respond to maximal standard therapy appear to benefit from the early addition of nesiritide.

Late thrombosis of drug-eluting stents after discontinuation of clopidogrel: report of two cases and review of the literature.

Thrombosis of intracoronary stents is a major complication associated with significant morbidity and mortality. Of concern are case reports of late (more than six months from deployment) drug-eluting stent thrombosis temporally associated with discontinuation of antiplatelet therapy and when stent endothelialization was presumed to be complete. In certain patients it appears that vascular healing at the stented segments is incomplete with increased susceptibility to late thrombosis. We report two cases of late stent thrombosis occuring more than one year after stent deployment and within weeks of discontinuation of clopidogrel. A review of the literature is presented to identify clinical and angiographic predictors of increased risk.

Apical aneurysm in a patient with apical hypertrophic cardiomyopathy.

Apical hypertrophic cardiomyopathy (AHC) is a variant of hypertrophic cardiomyopathy (HCM) in which the hypertrophy predominantly involves the left ventricular apex. The typical features of AHC include giant negative T waves in the precordial ECG leads, a spade-like configuration of the left ventricle at end-systole, the absence of an outflow tract pressure gradient, and mild symptoms. We present a patient with AHC, evidence of prior myocardial infarction with aneurysm of the apical region, and myocardial ischemia on radionuclide scanning despite angiographically normal coronary arteries. The characteristic electrocardiographic, echocardiographic, hemodynamic and angiographic findings as well as prognosis and treatment options are discussed.

Coronary stenting is safe and effective in a high-risk octogenarian patient cohort.

BACKGROUND: Octogenarians represent an increasing percentage of patients with coronary heart disease and are an inherently high-risk population. We sought to define the immediate and long-term results of coronary stenting in the "real-world" environment of a community teaching hospital. METHODS: One hundred ninety-seven consecutive patients older then 80 years who underwent 214 coronary stent procedures were studied. Each patient had postprocedural serial cardiac enzymes and ECG's collected, and was followed for a minimum of 12 months after the procedure. Procedural success was defined as less than 20% residual stenosis, TIMI 3 flow, and absence of major complications (death, nonfatal myocardial infarction, emergent coronary artery bypass graft surgery and stroke). Sixty-five percent of patients presented with an acute coronary syndrome and 93% were functionally New York Heart Association (NYHA) Class III or IV. RESULTS: Procedural success was 95%. Death during the index hospitalization occurred in 3% of patients. An additional 4.1% of patients died during follow-up. The target vessel revascularization rate (TVR) during follow up was 8.6%. Multivariate analysis of selected angiographic and clinical variables did not reveal any predictors of major cardiac events. CONCLUSIONS: Despite a high-risk clinical and angiographic profile, coronary stenting can be safely performed in octogenarians with a high procedural success rate, low complication rate, and excellent 12-month outcome.

Circadian variation and outcome of in-hospital cardiopulmonary resuscitation.

OBJECTIVE: Assessment of contemporary in-hospital cardiopulmonary resuscitation outcomes. METHODS: The study was designed as a retrospective, single-institution, registry investigation of all adult patients for whom a cardiopulmonary resuscitation (CPR) was attempted between October 1, 2002 and September 30, 2004. Hospital, patient's, arrest and outcome variables were included based on the "Utstein Style" of reviewing, reporting, and conducting research on in-hospital resuscitation. RESULTS: 202 patients (94 women, age 70 +/- 15 years) received in-hospital CPR during the study period. One hundred-two events were primary respiratory arrests. Overall, 67% (95% CI 59%-72%) of patients were successfully resuscitated and 38% (95% CI 31%-45%) survived to hospital discharge. Of the patients with initial respiratory depression followed by circulatory collapse, 57% (95% CI 47%-66%) were alive at the end of hospitalization, while 20% (95% CI 13.3%-28.8%) of patients with cardiac arrest survived to hospital discharge (OR=5.2, 95% CI=2.8-9.5, P<0.0001). A circadian variation in the occurrence of primary cardiac arrests was noted with a nadir between midnight and 0600 hours. Though there were fewer events during overnight hours, CPR for patients with a primary cardiac arrest occurring at this time was less likely to be successful (OR = 2.5, 95% CI=1.01-6.1, p=0.04). This did not result in a difference in survival to discharge (OR=2.6, 95% CI=0.7-9.4, p=0.14). CONCLUSION: Primary cardiac arrest has a significantly worse in-hospital outcome when compared to an initial respiratory event. The finding of a circadian variation in both the incidence and outcome of in-hospital primary cardiac arrest is intriguing and warrants further study.

Long-term patency of the right internal mammary artery used as a coronary bypass conduit and the effect of the recipient vessel.

This study reviewed our experience with the long-term patency of the right internal mammary coronary artery (RIMA) bypass graft in 58 patients over 1 year. Thirty-one percent (n = 18) of patients had obstructive lesions in the RIMA. In vessels with any lesion, the percent stenosis was 85.5% (range 30% to 100%). Eleven of 38 patients (28%) with right-sided recipient vessels had significant stenosis, whereas 21% of left-sided recipient vessels had significant stenosis of the RIMA. When compared with left internal mammary artery grafting, the long-term patency of the RIMA was lower than expected and warrants larger prospective studies.

Patterns of anticoagulation in patients hospitalized with atrial fibrillation: warfarin is underused in paroxysmal atrial fibrillation.

Paroxysmal atrial fibrillation (PAF) has a similar stroke risk when compared with chronic atrial fibrillation (CAF). Our study sought to define the incidence of warfarin use at time of admission and discharge in patients hospitalized with PAF and CAF. Anticoagulation rates upon hospital admission were 89% in the patients with CAF and 38% in patients with PAF, and increased to 100% for patients with CAF and 81% for patients with PAF at the time of hospital discharge. Despite a similar risk of stroke, patients with paroxysmal atrial fibrillation were less likely to receive long-term oral anticoagulation (AC) compared to patients with chronic atrial fibrillation.

Natural history of the Sprint Fidelis lead: survival analysis from a large single-center study.

PURPOSE: The purposes of our study were to: (1) determine lead failure rate in a large single-center cohort of Sprint Fidelis 6949 (Fidelis) leads, (2) define the risk of lead failure over time, (3) assess the impact of the Lead Integrity Alert (LIA) on lead failure presentation, and (4) identify independent predictors of Fidelis lead failure. METHODS: All patients who underwent implantation of a Fidelis lead between September 2004 and July 2007 were included. Demographic, clinical, and device characteristics at the time of implant and prior to failure were collected and analyzed. RESULTS: A total of 971 Fidelis leads (706 men, 265 women,mean age 68.4±12.8 years) were implanted. Over a mean follow-up of 46.3 months, there were 69 lead failures(7.1%). The 5-year lead survival rate was 90.3%. The risk of lead failure demonstrated a double-peaked pattern at 34 and 61 months. In multivariate analysis, there were no independent predictors of lead failure. Inappropriate shocks(IS) were the first sign of lead failure in 29 patients (42%).The incidence (32.6% vs. 65.2%, p=0.01) and number ofIS (2.8±7.2 vs. 11.3±18.7, p=0.01) were significantly lower in patients with LIA. CONCLUSIONS: This study presents a single-center experience on the natural history of the Fidelis lead. In our experience, lead survival declines at a lower rate when compared to prior reports. The risk of lead failure demonstrated a double peaked pattern at approximately 3 and 5 years. No identified variable was predictive of lead failure. LIA was effective in reducing the incidence and number of IS.