Association between the Charlson comorbidity index and outcomes after implantable cardioverter defibrillator generator replacement.

BACKGROUND: Recipients of implantable cardioverter defibrillator (ICD) generator replacement with multiple medical comorbidities may be at higher risk of adverse outcomes that attenuate the benefit of ICD replacement. The aim of this investigation was to study the association between the Charlson comorbidity index (CCI) and outcomes after ICD generator replacement. METHODS: All patients undergoing first ICD generator replacement at Mayo Clinic, Rochester and Beth Israel Deaconess Medical Center, Boston between 2001 and 2011 were identified. Outcomes included: (a) all-cause mortality, (b) appropriate ICD therapy, and (c) death prior to appropriate therapy. Multivariable Cox regression analysis was performed to assess association between CCI and outcomes. RESULTS: We identified 1421 patients with mean age of 69.6 ± 12.1 years, 81% male and median (range) CCI of 3 (0-18). During a mean follow-up of 3.9 ± 3 years, 52% of patients died, 30.6% experienced an appropriate therapy, and 23.6% died without experiencing an appropriate therapy. In multivariable analysis, higher CCI score was associated with increased all-cause mortality (Hazard ratio, HR 1.10 [1.06-1.13] per 1 point increase in CCI, P < .001), death without prior appropriate therapy (HR 1.11 [1.07-1.15], P < .0001), but not associated with appropriate therapy (HR 1.01 [0.97-1.05], P = .53). Patients with CCI ≥5 had an annual risk of death of 12.2% compared to 8.7% annual rate of appropriate therapy. CONCLUSIONS: CCI is predictive of mortality following ICD generator replacement. The benefit of ICD replacement in patients with CCI score ≥5 should be investigated in prospective studies.

Paclitaxel-induced Chest Pain and Left Bundle Branch Block in the Absence of Cardiac Ischemia.

How to cite this article: Brenes-Salazar JA. Paclitaxel-induced Chest Pain and Left Bundle Branch Block in the Absence of Cardiac Ischemia. IJCCM 2019;23(11):526-528.

Characteristics and long term outcomes of patients with acute coronary syndromes due to culprit left main coronary artery disease treated with percutaneous coronary intervention.

BACKGROUND: Patients with acute coronary syndrome (ACS) due to unprotected culprit left main coronary artery disease (LMCAD) treated with percutaneous coronary intervention (PCI) are rare, high-risk, and not represented in trials. Data regarding long term outcome after PCI are limited. METHODS: Between January 2000 and December 2014, there were 8,794 patients hospitalized with unstable angina/non-ST elevation myocardial infarction (UA/NSTEMI) or ST-elevation myocardial infarction (STEMI) treated with PCI at our institution; of these, 83 (0.94%) patients were identified as having culprit LMCAD ACS. RESULTS: Of the 83 patients with unprotected LMCAD ACS, 40 patients presented with STEMI and 43 patients presented with UA/NSTEMI. As compared to LM UA/NSTEMI, LM STEMI patients were younger and had less hypertension, with a trend towards greater frequency of cardiogenic shock. Distal LM involvement was common in both groups and did not differ by ACS type. In-hospital mortality was 33% in LM STEMI and 9% in LM UA/NSTEMI (P = .009). Over median follow up of 6.3 years, long term survival rates in both groups were similar (46% for STEMI vs 51% for UA/NSTEMI; P = .50 by log-rank). CONCLUSIONS: Unprotected culprit LMCAD ACS necessitating PCI is uncommon, occurring in <1% of cases, but is associated with reduced survival, with long term follow-up noting continued and similar risk of death regardless of index ACS type.

Electrocardiogram algorithms used to differentiate wide complex tachycardias demonstrate diagnostic limitations when applied by non-cardiologists.

AIMS: Non-cardiologists (NCs) are often responsible for the preliminary diagnosis and early management of patients presenting with ventricular tachycardia (VT) or supraventricular wide complex tachycardia (SWCT). At present, the Vereckei aVR and Brugada algorithms are the most widely recognized and frequently relied upon wide complex tachycardia (WCT) differentiation criteria by NCs. This study aimed to determine the diagnostic efficacy of the Vereckei aVR and Brugada algorithms when applied by NCs. METHODS: In a blinded fashion, three internal medicine residents prospectively interpreted WCTs using the Vereckei aVR and Brugada algorithms. The diagnostic performance of each method was evaluated according to their agreement with the correct rhythm diagnosis. RESULTS: Two-hundred sixty-nine WCTs (160 VT, 109 SWCT) from 186 patients were independently interpreted by each participant (807 separate interpretations per algorithm). The aVR and Brugada algorithms accurately classified 546 out of 807 (67.7%) and 622 out of 807 (77.1%) interpreted WCTs, respectively. Overall sensitivity and specificity of the aVR algorithm for VT was 92.1% and 31.8%, respectively. Overall sensitivity and specificity of the Brugada algorithm for VT was 89.4% and 59.0%, respectively. Both algorithms yielded modestly favorable overall positive predictive values (aVR 66.5%; Brugada 76.2%) and negative predictive values (73.3%; Brugada 79.1%). CONCLUSION: Non-cardiologist algorithm users correctly identified most "actual" VTs, but did not sufficiently revise VT probability to conclusively distinguish VT and SWCT. Newer WCT differentiation methods are needed to improve NC's ability to accurately differentiate WCTs.

Minocycline: a bacteriostatic antibiotic with pleiotropic cardioprotective effects.

Minocycline belongs to the family of tetracyclines, which are drugs traditionally approved as antibiotics. Based on preclinical animal cardiac models and clinical neurology trials, this drug has gained special attention as a promising cardiovascular therapeutic agent given its anti-inflammatory, antiapoptotic, antioxidant, and antienzymatic properties. This review focuses on the available evidence for minocycline as a cardioprotective drug, with special attention to mechanisms of action. Ongoing cardiovascular clinical trials are briefly discussed.

Troponin elevations following vascular surgery in patients without preoperative myocardial ischemia.

OBJECTIVES: A normal preoperative myocardial perfusion-imaging (MPI) test in advance of vascular surgery predicts a low risk of postoperative clinical events at 30 days. Among patients undergoing vascular surgery with a normal preoperative MPI, cardiac troponin I (cTnI) elevations are common and predictive of a poor long-term outcome. METHODS: The study cohort comprised 182 patients. Between January 2005 and December 2009, we studied these patients, who had no evidence of myocardial ischemia on preoperative MPI and were undergoing vascular surgery. Blood was obtained in all of the patients in the first 2 days following vascular surgery, and cTnI levels were measured. The values that exceeded the upper reference limit (URL) were categorized as either low (+) (greater than or equal to the URL but less than three times the URL) or high (+) (greater than or equal to three times the URL). Long-term survival was determined from the time of the vascular operation. RESULTS: The mean age of the population was 69 ± 8 years, and the mean revised cardiac risk index was 1.80 ± 0.77. The most common indication for vascular intervention was an expanding abdominal aortic aneurysm (n = 96, 52.5%). Within 48 hours of surgery, 58 patients (32%) had a typical rise and fall in TnI, with at least one value exceeding the URL. Of these patients, 17 (9%) were classified as high (+) and 41 (22.5%) as low (+). At 1 year post-vascular surgery, mortality was 8% for the overall cohort. A high (+) Tn elevation was an identifier of decreased 1-year survival (29%) relative to normal (3%) and low (+) (14%; P < 0.001). Stratified cTn was an independent predictor of the long-term risk of death. CONCLUSIONS: Among patients undergoing vascular procedures without evidence of myocardial ischemia on MPI, an elevation in TnI is common and predictive of long-term mortality risk.

Cardiovascular Manifestations of COVID-19.

Coronavirus disease 2019 (COVID-19) first emerged in a group of patients who presented with severe pneumonia in Wuhan, China, in December 2019. A novel virus, now called SARSCoV- 2 (Severe Acute Respiratory Syndrome Coronavirus-2), was isolated from lower respiratory tract samples. The current outbreak of infection has spread to over 100 countries and killed more than 340,000 people as of 25th May, 2020. The predominant clinical manifestation of COVID-19 is a respiratory disease- ranging from mild flu-like symptoms to fulminant pneumonia and Acute Respiratory Distress Syndrome (ARDS). Patients with pre-existing cardiovascular risk factors are considered more susceptible to the virus, and these conditions are often worsened by the infection. Furthermore, COVID-19 infection has led to de novo cardiac complications, like acute myocardial injury and arrhythmias. In this review, we have focused on the cardiovascular manifestations of COVID-19 infection that have been reported in the literature so far. We have also outlined the effect of pre-existing cardiovascular disease as well as risk factors on the clinical course and outcomes of COVID-19 infection.

Sex and Gender Disparities in the Management and Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in Older Adults.

OBJECTIVE: To evaluate outcomes by sex in older adults with cardiogenic shock complicating acute myocardial infarction (AMI-CS). MATERIALS AND METHODS: A retrospective cohort of older (≥75 years) AMI-CS admissions during January 1, 2000, to December 31, 2014, was identified using the National Inpatient Sample. Interhospital transfers were excluded. Use of angiography, percutaneous coronary intervention (PCI), mechanical circulatory support (MCS), and noncardiac interventions was identified. The primary outcome was in-hospital mortality stratified by sex, and secondary outcomes included temporal trends of prevalence, in-hospital mortality, use of cardiac and noncardiac interventions, hospitalization costs, and length of stay. RESULTS: In this 15-year period, there were 134,501 AMI-CS admissions 75 years or older, of whom 51.5% (n=69,220) were women. Women were on average older, were more often Hispanic or nonwhite race, and had lower comorbidity, acute organ failure, and concomitant cardiac arrest. Compared with older men (n=65,281), older women (n=69,220) had lower use of coronary angiography (55.4% [n=35,905] vs 49.2% [n=33,918]), PCI (36.3% [n=23,501] vs 34.4% [n=23,535]), MCS (34.3% [n=22,391] vs 27.2% [n=18,689]), mechanical ventilation, and hemodialysis (all P<.001). Female sex was an independent predictor of higher in-hospital mortality (adjusted odds ratio, 1.05; 95% CI, 1.02-1.08; P<.001) and more frequent discharges to a skilled nursing facility. In subgroup analyses of ethnicity, presence of cardiac arrest, and those receiving PCI and MCS, female sex remained an independent predictor of increased mortality. CONCLUSION: Female sex is an independent predictor of worse in-hospital outcomes in older adults with AMI-CS in the United States.

Admission Braden Skin Score Independently Predicts Mortality in Cardiac Intensive Care Patients.

OBJECTIVE: To determine whether a low Braden skin score (BSS), reflecting increased risk for skin pressure injury, would predict lower survival in cardiac intensive care unit (CICU) patients after adjustment for illness severity and comorbidities. PATIENTS AND METHODS: This retrospective cohort study included consecutive unique adult patients admitted to a single tertiary care referral hospital CICU from January 1, 2007, through December 31, 2015, who had a BSS documented on CICU admission. The primary outcome was all-cause hospital mortality, using elastic net penalized logistic regression to determine predictors of hospital mortality. The secondary outcome was all-cause post-discharge mortality, using Cox proportional hazards models to determine predictors of post-discharge mortality. RESULTS: The study included 9552 patients with a mean age of 67.4±15.2 years (3589 [37.6%] were females) and a hospital mortality rate of 8.3%. Admission BSS was inversely associated with hospital mortality (unadjusted odds ratio, 0.70; 95% CI, 0.68-0.72; P<.001; area under the receiver operator curve, 0.80; 95% CI, 0.78-0.82), with increased short-term mortality as a function of decreasing admission BSS. After adjustment for illness severity and comorbidities using multivariable analysis, admission BSS remained inversely associated with hospital mortality (adjusted odds ratio, 0.88; 95% CI, 0.85-0.92; P<.001). Among hospital survivors, admission BSS was inversely associated with post-discharge mortality after adjustment for illness severity and comorbidities (adjusted hazard ratio, 0.89; 95% CI, 0.88-0. 90; P<.001). CONCLUSION: The admission BSS, a simple inexpensive bedside nursing assessment potentially reflecting frailty and overall illness acuity, was independently associated with hospital and post-discharge mortality when added to established multiparametric illness severity scores among contemporary CICU patients.

Cellular therapies for chronic ischemic heart failure.

The development of stem cell therapies for chronic ischemic heart failure is highly sought after to attempt to improve morbidity and mortality of this prevalent disease. This article reviews clinical trials that investigate stem cell therapy for chronic ischemic heart failure. To generate this review article, PubMed was searched using keywords "stem cell therapy heart failure" with the article type "Clinical Trial" selected on 10/04/2016. The raw search yielded 156 articles; 53 articles were selected for inclusion in the review between the original literature search and manual research/cross-referencing. Additional reviews and original articles were also manually researched and cross-referenced. Cellular-based therapies utilizing peripheral blood progenitor cells, bone marrow cells, mesenchymal stem cells, cells of cardiac origin, and embryonic stem cells have yielded mixed results, but some studies have shown modest efficacy. Skeletal myoblasts raised concerns about safety due to arrhythmias. Optimizing cell type and delivery method will be of critical importance in enhancing efficacy of therapy within various subsets of chronic ischemic heart failure patients. Although much more work needs to be done to optimize treatment strategies, developing stem cell therapies for chronic ischemic heart failure could be of critical importance to lessen the impactful health burden that heart failure has on patients and society.

Echocardiography in centenarians: characteristics, utility and follow-up.

BACKGROUND: Echocardiography has been shown to be a valuable resource in the diagnosis of many cardiac conditions, and can be used in all age groups, from the fetus to the oldest old. In the context of an increasingly aging population, the impact and utility of echocardiography in centenarians is largely unknown. This study is to determine whether echocardiography in centenarians aids in making clinical patient management decisions. METHODS: A retrospective review of echocardiograms from 1986 to 2014, at two affiliated tertiary centers, in individuals who were 100 years or older at the time of the examination. Patient and echocardiogram characteristics, management decisions based on echocardiography, and mortality were documented. RESULTS: 114 centenarians had echocardiograms, with ages ranging from 100 to 107 years (101 ± 1.4 years). In 82 of the centenarians evaluated (72%), no changes in management occurred as a consequence of the echocardiogram. From all management changes directly related to the echocardiogram, 81% (n = 26) of these corresponded to medication adjustments; interventional or surgical procedures followed the echocardiogram only in 4% (n = 5) of the total number of centenarians. Echocardiogram-based changes in management were only significant in patients that were referred for congestive heart failure (P = 0.02). After the echocardiogram was performed, 1-month and 1-year mortality were 15% and 47%, respectively. The median survival after the echocardiogram was obtained was 13 months (range 0.03 to 145 months), with no difference if there was a change or no change in management (P = 0.21). CONCLUSIONS: Among centenarians undergoing echocardiography, despite additional diagnostic information, echocardiograms in centenarians influence management in a minority of cases, most commonly in the form of medication changes for treatment of heart failure. A significant proportion of centenarians are deceased within a year of undergoing echocardiographic assessment. These findings may question the overall utility of echocardiography in these late survivors.

Outcomes of Nonagenarians Admitted to the Cardiac Intensive Care Unit by the Elders Risk Assessment Score for Long-Term Mortality Risk Stratification.

There are limited data on outcomes of older adults admitted to cardiac intensive care units (CICU), and there are no data on outcomes after admission to the CICU in nonagenarians. Our purpose was to identify whether the Elders Risk Assessment (ERA) index could risk stratify older adults after CICU admission. We retrospectively identified 453 nonagenarians admitted to the CICU between 2004 and 2013. End points included mortality, length of stay, incidence of delirium, and discharge disposition. Average age of the cohort was 92 ± 2 years, and the average ERA score was 13 ± 6. A total of 258 patients were female (57%). Most common admission indication was acute decompensated heart failure (57%) followed by acute myocardial infarction (49%). Loss of independence was observed after CICU admission, with 66% of patients living independently before admission, decreasing to 47% at discharge. Overall length of stay was 6 ± 5 days and CICU stay was 2 ± 2 days. Fifteen percent of patients died before hospital discharge. Median survival was 452 (interquartile range 40 to 1,371) days. ERA score effectively predicted survival (log-rank test, p = 0.002). ERA score of 16 or greater and ERA score of 9 to 15 were both associated with increased risk of mortality compared with the reference (score 4 to 8): hazard ratio 2.00, 95% confidence interval 1.37 to 2.90, p = 0.003, and hazard ratio 1.48, 95% confidence interval 1.06 to 2.08, p = 0.02, respectively. In conclusion, nonagenarians admitted to CICU experience reasonable outcomes. The ERA score effectively risk stratifies nonagenarians admitted to the CICU and may help with identification of vulnerable patients at risk of adverse outcomes.

Takotsubo Cardiomyopathy Associated with Severe Hypothyroidism in an Elderly Female.

Takotsubo cardiomyopathy, also known as stress cardiomyopathy, is a syndrome that affects predominantly postmenopausal women. Despite multiple described mechanisms, intense, neuroadrenergic myocardial stimulation appears to be the main trigger. Hyperthyroidism, but rarely hypothyroidism, has been described in association with Takotsubo cardiomyopathy. Herein, we present a case of stress cardiomyopathy in the setting of symptomatic hypothyroidism.

Advances in percutaneous coronary interventions for elderly patients.

Coronary heart disease (CHD) is one of the leading causes of morbidity and the most common cause of death in older adults. Paradoxically, elderly patients tend to be systematically excluded from randomized-controlled cardiovascular trials, which complicates decision-making in this population. Management of CHD in the elderly is frequently more difficult in virtue of chronic comorbid conditions and aging-intrinsic dynamics. Despite these challenges, the number of elderly and very elderly patients undergoing percutaneous coronary interventions (PCI) is increasing. Elderly patients in many registries and large clinical series exhibit even a greater benefit from interventional procedures than younger patients, but they have a higher rate of overall complications. We present an overview of the current available evidence of PCI in older adults with stable and unstable CHD, including comparisons between drug-eluting and bare-metal stents, transfemoral and transradial access, and methods of revascularization. Adjuvant antiplatelet and antithrombotic therapies are also discussed.

Paradoxical respiratory sinus arrhythmia due to a large thoracic empyema in an ambulatory patient.

We report a case of paradoxical respiratory sinus arrhythmia (PRSA) caused by a retro-cardiac empyema in an ambulatory patient. The case describes the dynamics and deleterious impact of PRSA on cardio-respiratory cycle, its electrocardiographic, radiologic and echocardiographic findings. Furthermore, it discusses a probable mechanism of paradoxical respiratory sinus arrhythmia in the setting of a retrocardiac mass and suggests a need for physicians to check for the changes in ventilation perfusion mismatch and rise in physiological dead space in such patients. In conclusion, to the best of our knowledge, this is the first documented report of paradoxical respiratory sinus arrhythmia in an ambulatory, non-anesthetized spontaneously breathing patient.

Recurrent transient apical cardiomyopathy (tako-tsubo-like left ventricular dysfunction) in a postmenopausal female with diffuse esophageal spasms.

Transient apical cardiomyopathy, also known as Takot-tsubo-like left ventricular dysfunction, is a clinical syndrome characterized by reversible left ventricular dysfunction at the apex with preserved basal contractility, in the setting of new ST and T wave changes suggestive of ischemia but no evidence of obstructive coronary artery disease on angiography. The main mechanism appears to be intense neuroadrenergic myocardial stimulation with endothelial dysfunction of the coronary vasculature. It has been noted that patients with esophageal spasms also have a tendency for coronary spasms. We present the case of a postmenopausal female with documented severe esophageal spasms who presented with atypical angina and recurrent Tako-tsubo cardiomyopathy.