An assessment of transesophageal echocardiography studies rated as rarely appropriate tests for infective endocarditis at an academic medical center.

PURPOSE: Endocardial involvement documented by echocardiography is a major criterion of the modified Duke criteria (MDC) for infective endocarditis (IE). Though transesophageal echocardiography (TEE) is sensitive in the diagnosis of IE, it can be inappropriately used. METHODS: This retrospective study included all patients who underwent TEE due to bacteremia, fever, and/or endocarditis in a single, tertiary academic medical center in 2013. Data collected from electronic medical charts were as follows: demographics, history, physical examination, blood cultures, and transthoracic (TTE) and TEE findings. Cases were categorized based on appropriate use criteria (AUC) and MDC. An infectious disease (ID) specialist reviewed cases with rarely appropriate TEE use. RESULTS: In the 194 patients included, 147 (75.8%) were rated as appropriate, 36 (18.6%) rarely appropriate, and 11 (5.6%) uncertain. Of the 36 with rarely appropriate TEEs, using MDC 31 (86%) were rejected and 5 (14%) were possible for IE. Retrospective chart review by an ID specialist determined that 10 of these patients warranted TEE due to compelling issues, including immunosuppression or complicated infection. CONCLUSIONS: In this retrospective cohort, almost one fifth of cases were rated as rarely appropriate. However, a review of these cases showed that TEE was often pursued when the clinical situation involved immunosuppression or complex infectious process. There remains room for improvement to our screening process for TEE and a need to implement a nuanced educational plan to better precisely identify appropriate cases for TEE usage.

The relationship between glycosylated hemoglobin and myocardial perfusion imaging.

BACKGROUND: The relationship between long-term glucose control (measured by glycosylated hemoglobin [HgbA1C]) and myocardial perfusion imaging (MPI) abnormalities in symptomatic diabetic patients has not been studied. HYPOTHESIS: We hypothesized that diabetic patients with poorly controlled HgbA1C would have more abnormal MPI compared to both patients without diabetes and diabetic patients with tighter glycemic control. METHODS: This was a retrospective evaluation of 1037 consecutive patients referred for MPI. All patients completed a 1-day MPI protocol. The electronic medical records were accessed for demographics and relevant medical history. RESULTS: Diabetic patients had a higher risk of abnormal MPI (including ischemia, infarction, and mixed ischemia/infarction) compared to nondiabetic patients (relative risk [RR] = 1.77). The populations with suboptimal (HgbA1C ≥ 7%) and poor (HgbA1C ≥ 8%) glycemic control had significantly higher risk of abnormal MPI (RR = 1.78 and 2.17, respectively) compared to nondiabetic patients. Coronary angiography supported the MPI results; 66% of diabetic patients had coronary artery disease (CAD), which was higher than the 53% of patients without diabetes found to have CAD. CONCLUSIONS: The importance of strict glycemic control to reduce cardiovascular complications in diabetic patients is well known. Our study shows a significantly higher risk of abnormal MPI and CAD in diabetic patients with suboptimal and poor long-term glycemic control, further emphasizing the need for aggressive risk factor modification to minimize vascular complications from DM.

Low-density lipoprotein cholesterol target achievement in patients at high risk for coronary heart disease.

OBJECTIVES: Although improvement in target lipid achievement has been observed in recent studies, a significant proportion of patients still do not reach their recommended low-density lipoprotein (LDL-C) targets. We conducted a study in high-risk patients to evaluate the success rate in attaining LDL-C goals. METHODS: Medical records of patients referred for cardiac stress testing were reviewed. Demographic data, coronary heart disease (CHD) risk factors, and the most recent lipid profile were recorded. The patients who did not achieve LDL-C target on initial evaluation were reassessed in 12 months. RESULTS: A total of 765 patients were classified as high-risk CHD. The average age was 66 ± 12 years; 62% were men, and 29% had a previous history of CHD. The mean LDL-C was 96 ± 35 mg/dL and the LDL-C goal of less than 100 mg/dL was achieved in 62%. In 217 patients with very high CHD risk, 83% had LDL-C less than 100 mg/dL and 37% had LDL-C less than 70 mg/dL. At month 12, data from 267 patients were reviewed, and 161 patients (60%) reached LDL-C less than 100 mg/dL. The mean LDL-C was 131 ± 27 mg/dL and 100 ± 29 mg/dL (P < .001) at month 0 and 12, respectively. Antihyperlipidemics were initially prescribed in 49% of these patients and 71% at month 12 (P < .001). CONCLUSION: Our study confirms an improving trend in lipid goal attainment in high and very high CHD-risk patients, but despite this, certain high- and very high-risk patients may require more aggressive intervention.