Ventricular late gadolinium enhancement by cardiac MRI as a predictor of atrial fibrillation in hypertrophic cardiomyopathy.

BACKGROUND: Atrial fibrillation (AF) increases stroke and mortality in patients with hypertrophic cardiomyopathy (HCM). Cardiac MRI (CMR) is increasingly used to detect late gadolinium enhancement (LGE) as a reliable indicator of left ventricular fibrosis, a potential predisposing factor of AF. Our research explored the correlation between left ventricular LGE and AF prevalence in HCM. METHODS: This retrospective study involved 351 HCM patients who underwent CMR. LGE percentages (0%, 1-5%, 6-14%, ≥15%) on CMR were compared with AF prevalence in HCM patients. Demographic, comorbidity, and imaging data were analyzed using appropriate univariate and multivariate analyses assessing for significant differences in AF prevalence. The predetermined significance level was p < 0.05. RESULTS: CMR demonstrated increased LGE in those with AF (p = 0.004). Increased LGE correlated with increased AF rates: 27.6% (0% LGE), 38.5% (1-5% LGE), 44.4% (6-14% LGE), and 54.7% (≥15% LGE) (p = 0.101, p = 0.043, p = 0.002, respectively, vs. 0% LGE). Adjusted for age, differences persisted and were most evident for LGE >15% (p = 0.001). Multivariate analysis, factoring age, gender, BMI, RVSP, and LVEF, supported LGE (odds ratio of 1.20, p = 0.036) and LAVI (odds ratio 1.05, 1.02-1.07, p < 0.001) as predictive markers for AF prevalence. CONCLUSIONS: Our study suggests a correlation between ventricular LGE and AF in patients with HCM. LGE exceeding 15% was associated with a significant increase in AF prevalence. These patients may require more frequent AF monitoring.

The life of a laboratory requisition form: Patient compliance with clinical laboratory testing in a Canadian primary care health region.

OBJECTIVE: To examine patient laboratory testing compliance by tracking time to submission of laboratory requisitions in Southern Alberta, Canada as part of a quality improvement initiative. METHODS: Data was collected retrospectively from patients from the Chinook Primary Care Network in Alberta, Canada, who received a laboratory requisition consisting of a complete blood count (CBC) test order between September 1, 2016 and August 31, 2017. To allow for all laboratory requisitions created to be submitted within one year, the study collection period was from September 1, 2016 to August 31, 2018. Patient age, sex, and dates of laboratory requisition creation and submission were collected. The days-to-test-submission served as a marker of compliance. Association of age, sex, and clinic location with time to laboratory requisition completion was determined using Cox regression analysis. RESULTS: During the study period, 70.4% (n = 1607) of laboratory requisitions created were completed within one year, and over half (50.5%) of the laboratory requisitions ordered were completed within two weeks. There were no significant associations between time to laboratory requisition submission and sex or clinic locations (P > 0.05), but there were significant associations between patients who were 20-49 or 70-79 and increased laboratory requisition compliance (P < 0.05). However, 26.0% of the laboratory requisitions created were not submitted at all. CONCLUSIONS: This was the first study that quantified the proportion and timing of laboratory requisitions that were submitted by patients in a primary care setting. Community patients should be engaged and educated regarding the importance of complying with their physician-ordered laboratory requests in a timely manner.

Comparison of Radiation Exposure Among Interventional Echocardiographers, Interventional Cardiologists, and Sonographers During Percutaneous Structural Heart Interventions.

Importance: Transesophageal echocardiography during percutaneous left atrial appendage closure (LAAO) and transcatheter edge-to-edge mitral valve repair (TEER) require an interventional echocardiographer to stand near the radiation source and patient, the primary source of scatter radiation. Despite previous work demonstrating high radiation exposure for interventional cardiologists performing percutaneous coronary and structural heart interventions, similar data for interventional echocardiographers are lacking. Objective: To assess whether interventional echocardiographers are exposed to greater radiation doses than interventional cardiologists and sonographers during structural heart procedures. Design, Setting, and Participants: In this single-center cross-sectional study, radiation doses were collected from interventional echocardiographers, interventional cardiologists, and sonographers at a quaternary care center during 30 sequential LAAO and 30 sequential TEER procedures from July 1, 2016, to January 31, 2018. Participants and study personnel were blinded to radiation doses through data analysis (January 1, 2020, to October 12, 2021). Exposures: Occupation defined as interventional echocardiographers, interventional cardiologists, and sonographers. Main Outcomes and Measures: Measured personal dose equivalents per case were recorded using real-time radiation dosimeters. Results: A total of 60 (30 TEER and 30 LAAO) procedures were performed in 60 patients (mean [SD] age, 79 [8] years; 32 [53.3%] male) with a high cardiovascular risk factor burden. The median radiation dose per case was higher for interventional echocardiographers (10.6 µSv; IQR, 4.2-22.4 µSv) than for interventional cardiologists (2.1 µSv; IQR, 0.2-8.3 µSv; P < .001). During TEER, interventional echocardiographers received a median radiation dose of 10.5 µSv (IQR, 3.1-20.5 µSv), which was higher than the median radiation dose received by interventional cardiologists (0.9 µSv; IQR, 0.1-12.2 µSv; P < .001). During LAAO procedures, the median radiation dose was 10.6 µSv (IQR, 5.8-24.1 µSv) among interventional echocardiographers and 3.5 (IQR, 1.3-6.3 µSv) among interventional cardiologists (P < .001). Compared with interventional echocardiographers, sonographers exhibited low median radiation doses during both LAAO (0.2 µSv; IQR, 0.0-1.6 µSv; P < .001) and TEER (0.0 µSv; IQR, 0.0-0.1 µSv; P < .001). Conclusions and Relevance: In this cross-sectional study, interventional echocardiographers were exposed to higher radiation doses than interventional cardiologists during LAAO and TEER procedures, whereas sonographers demonstrated comparatively lower radiation doses. Higher radiation doses indicate a previously underappreciated occupational risk faced by interventional echocardiographers, which has implications for the rapidly expanding structural heart team.

A novel mortality risk score for female patients undergoing endovascular interventions.

BACKGROUND: Peripheral arterial disease (PAD) has been described as a rising epidemic in recent years. The majority of subjects studied in PAD literature have been male, leaving female patients an underrepresented population with regard to revascularization outcomes. The goal of our study was to determine the death rate and predictors of mortality in female patients undergoing endovascular intervention (EI) for symptomatic PAD. METHODS AND RESULTS: This study was conducted as a single-center retrospective chart review of 292 female patients who underwent EI for symptomatic PAD. Patient variables including demographics and procedural data were analyzed for statistical significance with regard to mortality. Age, history of congestive heart failure (CHF), and chronic kidney disease (CKD) were found to be significant predictors of mortality on multivariable analysis. A death risk score was formulated based on the above variables, risk stratifying patients into low, medium, or high risk groups for mortality after EI. Overall, 76 patients (26%) fell into the low risk category with a mortality of 5.3%, 102 patients (35%) fell into the moderate risk with a mortality of 15.7%, and 112 patients (39%) fell into the high-risk group with a mortality of 45.5% (P < 0.0001). CONCLUSIONS: Our study is the first of its kind to specify predictors of mortality in female patients with symptomatic PAD. This study also provides a tool to identify female PAD patients at high risk for death after EI. Finally, it highlights the effect of CKD, age, and CHF on mortality of patients with PAD.

Laboratory reporting of framingham risk score increases statin prescriptions in at-risk patients.

BACKGROUND: The under-utilization of cardiovascular preventative therapy with statins warrants novel interventions to optimize prescriptions in at-risk patients. We investigated the role of a laboratory generated Framingham Risk Score (FRS) provided to primary care clinicians in changing statin use in a primary care setting. METHODS: Data was acquired from the electronic medical records of 1573 anonymized patients undergoing routine lipid testing. Follow-up statin use and low-density lipoprotein cholesterol levels were obtained for 2 years post intervention. FRS parameters were entered into a laboratory information system, and provided to ordering physicians along with the cholesterol profile and the appropriate current Canadian Dyslipidemia treatment recommendation in a single report. Statin prescription rates following the intervention were compared with historical use 6 months prior to the study. RESULTS: A total of 1283 participants (mean age of 60 ± 11 years) had an FRS report and were considered for analysis. Two hundred individuals filled a statin prescription in the 6 months prior to their index lipid test, and an additional 84 filled a statin prescription following the intervention (42% increase). The relative and absolute increase in statin prescription was 47.3% and 13.6% in the high-risk group p < 0.001, 53.3% and 8.1% in the intermediate-risk group p < 0.001, and 17.0% and 1.42% in the low-risk group p = 0.008, respectively. CONCLUSION: The use of the laboratory reported FRS was associated with a significant increase in the rate of statin prescription across all risk groups. The expansion of FRS reporting across other health regions would improve cardiovascular risk prevention.

Multimodality Intracoronary Imaging With Near-Infrared Spectroscopy and Intravascular Ultrasound in Asymptomatic Individuals With High Calcium Scores.

BACKGROUND: This study sought to determine the frequency of large lipid-rich plaques (LRP) in the coronary arteries of individuals with high coronary artery calcium scores (CACS) and to determine whether the CACS correlates with coronary lipid burden. METHODS AND RESULTS: Combined near-infrared spectroscopy and intravascular ultrasound was performed in 57 vessels in 20 asymptomatic individuals (90% on statins) with no prior history of coronary artery disease who had a screening CACS ≥300 Agatston units. Among 268 10-mm coronary segments, near-infrared spectroscopy images were analyzed for LRP, defined as a bright yellow block on the near-infrared spectroscopy block chemogram. Lipid burden was assessed as the lipid core burden index (LCBI), and large LRP were defined as a maximum LCBI in 4 mm ≥400. Vessel plaque volume was measured by quantitative intravascular ultrasound. Vessel-level CACS significantly correlated with plaque volume by intravascular ultrasound (r=0.69; P<0.0001) but not with LCBI by near-infrared spectroscopy (r=0.24; P=0.07). Despite a high CACS, no LRP was detected in 8 (40.0%) subjects. Large LRP having a maximum LCBI in 4 mm ≥400 were infrequent, found in only 5 (25.0%) of 20 subjects and in only 5 (1.9%) of 268 10-mm coronary segments analyzed. CONCLUSIONS: Among individuals with a CACS ≥300 Agatston units mostly on statins, CACS correlated with total plaque volume but not LCBI. This observation may have implications on coronary risk among individuals with a high CACS considering that it is coronary LRP, rather than calcification, that underlies the majority of acute coronary events.

Large lipid-rich coronary plaques detected by near-infrared spectroscopy at non-stented sites in the target artery identify patients likely to experience future major adverse cardiovascular events.

AIMS: A recent study demonstrated that intracoronary near-infrared spectroscopy (NIRS) findings in non-target vessels are associated with major adverse cardiovascular and cerebrovascular events (MACCE). It is unknown whether NIRS findings at non-stented sites in target vessels are similarly associated with future MACCE. This study evaluated the association between large lipid-rich plaques (LRP) detected by NIRS at non-stented sites in a target artery and subsequent MACCE. METHODS AND RESULTS: This study evaluated 121 consecutive registry patients undergoing NIRS imaging in a target artery. After excluding stented segments, target arteries were evaluated for a large LRP, defined as a maximum lipid core burden index in 4 mm (maxLCBI4 mm) ≥400. Excluding events in stented segments, Cox regression analysis was performed to evaluate for an association between a maxLCBI4 mm ≥400 and future MACCE, defined as all-cause mortality, non-fatal acute coronary syndrome, and cerebrovascular events. NIRS detected a maxLCBI4 mm ≥400 in a non-stented segment of the target artery in 17.4% of patients. The only baseline clinical variable marginally associated with MACCE was ejection fraction (HR 0.96, 95% CI 0.93-1.00, P = 0.054). A maxLCBI4 mm ≥400 in a non-stented segment at baseline was significantly associated with MACCE during follow-up (HR 10.2, 95% CI 3.4-30.6, P < 0.001). CONCLUSION: Detection of large LRP by NIRS at non-stented sites in a target artery was associated with an increased risk of future MACCE. These findings support ongoing prospective studies to further evaluate the ability of NIRS to identify vulnerable patients.

Isolated left ventricular apical hypoplasia.

Isolated left ventricular (LV) apical hypoplasia is a recently described congenital abnormality characterized by: (1) a truncated and spherical LV configuration with rightward bulging of the interventricular septum, (2) deficiency of the myocardium within the LV apex with adipose tissue infiltrating the apex, (3) origin of the papillary muscle in the flattened anterior apex, and (4) elongation of the right ventricle wrapping around the deficient LV apex. In this report, we demonstrate these characteristic features with cardiac magnetic resonance imaging and summarize the existing information on isolated LV apical hypoplasia.

CHADS(2) score is predictive of left atrial thrombus on precardioversion transesophageal echocardiography in atrial fibrillation.

OBJECTIVE: The goals of this study were to determine: 1) if the CHADS(2) score correlates with left atrial (LA) or left atrial appendage (LAA) thrombus on pre-cardioversion transesophageal echocardiography (TEE) in nonvalvular atrial fibrillation (NVAF); and 2) what, if any, components of the CHADS(2) score are most important in predicting LA/LAA thrombus. BACKGROUND: It is unknown if CHADS(2) score, a marker of thromboembolic risk in NVAF, accurately predicts LA/LAA thrombus on pre-cardioversion TEE. METHODS: We retrospectively studied patients undergoing precardioversion TEE for NVAF at a tertiary hospital. TEE reports were reviewed for presence of LA/LAA thrombus. Using medical records and an ICD-9 coding database, a CHADS(2) score was derived, and the association between CHADS(2) and thrombus was evaluated with Mantel-Haenszel Chi-Square. The relation between the singular components of CHADS(2) and thrombus were analyzed using Pearson's Chi-Square. RESULTS: In 643 consecutive patients undergoing pre-cardioversion TEE, LA/LAA thrombus was identified in 46 (7.2 %). A strong association was present between CHADS(2)score and LA/LAA thrombus (p = 0.0005). No thrombi were identified in patients with CHADS(2) = 0. Among 46 patients with thrombus, all (100%) had CHF. Of the singular components, CHF was the only factor independently associated with thrombus (p < 0.0001). CONCLUSIONS: In non-valvular atrial fibrillation, CHADS(2) is strongly associated with LA thrombus on TEE. Our findings suggest pre-cardioversion TEE may be unnecessary if the CHADS(2) score = 0. Of the components of the CHADS(2) score, CHF was the only independently associated risk factor which correlated with LA/LAA thrombus.

Safety of AngioJet thrombectomy in acute ST-segment elevation myocardial infarction: a large, single-center experience.

OBJECTIVES: To determine the clinical outcomes associated with use of AngioJet thrombectomy (AT) during percutaneous coronary intervention (PCI) for acute ST-segment elevation myocardial infarction (STEMI). BACKGROUND: Embolization of thrombus and atherosclerotic plaque is thought to contribute to sub-optimal myocardial reperfusion and worse clinical outcomes in STEMI. However, in a recent randomized trial, a higher mortality and infarct size was observed in patients treated with AT. METHODS: We performed a retrospective analysis of all patients who underwent primary or rescue PCI for STEMI between January 2000 and December 2005. Angiographic, procedural and in-hospital outcomes were compared between patients treated with or without AT. RESULTS: 1,260 STEMI patients underwent primary or rescue PCI at our hospital during the study period. Of these, 239 (19%) underwent adjunctive treatment with AT. Patients treated with AT were more likely to be female, smokers and have a right coronary artery culprit. A slightly lower incidence of thrombolysis in myocardial infarction (TIMI) 3 grade flow was observed in the AT group after PCI (86% vs. 90%, p = 0.04). There was no significant difference in the incidence of in-lab ventricular tachycardia/ventricular fibrillation, vascular complications or transfusion between the study groups. The peak creatine kinase was higher in patients treated with AT. The incidence of in-hospital major adverse cardiac events was 7.5% in the AT group and 9.0% in the control group (p = NS). CONCLUSIONS: In this large, single-center experience, use of AT during mechanical reperfusion for STEMI was not associated with an increased risk of adverse outcomes. Our data suggest that AT may be performed safely in selected patients with STEMI.