Cardiac conduction disturbances in rheumatologic disease: a cross-sectional study.

BACKGROUND: Cardiovascular abnormalities are common in patients with rheumatologic disorders. Tachy-arrhythmias occur more frequently in these patients than the general population; however, the prevalence of bradyarrhythmias in this group is less clear. This investigation aimed to analyze the incidence and predictors of bradyarrhythmias and conduction disturbances, as well as the presence and influence of cardiologist management, in patients with rheumatologic disorders. METHODS: We performed a retrospective chart review of 57 consecutive patients with rheumatologic conditions evaluated at a tertiary-care safety-net hospital. Conduction disturbances were defined by any electrocardiogram (ECG) finding indicating: bradycardia, sinoatrial block of any degree, atrioventricular nodal block of any degree, left anterior or posterior fascicular block, non-specific intraventricular conduction delay, complete or incomplete right bundle branch block, left bundle branch block, or paced rhythm. Univariate and multivariate analyses were used to assess the association of relative predictors of conduction disturbance, the primary outcome of this investigation, as well as the secondary outcome of cardiologist involvement in patient care. Statistical significance was defined as P<0.05. Variables found to be statistically significant in a univariate analysis were included in a multivariable logistic regression analysis. RESULTS: The most common rheumatologic condition in our patient population was systemic lupus erythematous (21 patients, 36.8%) followed by gout (15 patients, 26.3%), rheumatoid arthritis (13 patients, 22.8%), sarcoidosis (6 patients, 10.5%), and two patients (3.5%) with other autoimmune diseases. A total of 31.6% of patients in this study were found to have conduction disturbances, higher than the prevalence of conduction disturbances in the general population. Multivariate logistic regression analysis showed significantly increased odds for conduction disturbances with increased age (odds ratio (OR): 1.05, 95% confidence interval (CI): 1.01-1.10, P<0.05). Similar analysis for the involvement of a cardiologist in the care of a patient with a rheumatologic disorder found increased odds for cardiologist involvement with advanced age (OR: 1.05, 95% CI: 1.002-1.09, P<0.05) and cardiovascular disease (OR: 5.0, 95% CI 1.24-21.90, P<0.05). CONCLUSION: Prevalence of conduction abnormalities is greater in rheumatologic patients than the general population. Odds for conduction abnormalities increased with age; and the odds of cardiologist involvement increased with age and cardiovascular disease.

Dilated Cardiomyopathy Associated with Paraquat Herbicide Poisoning.

Dilated cardiomyopathy is a subset of cardiomyopathies defined by reduced ejection fraction of less than 45% and a dilated left ventricle. While dilated cardiomyopathy is common, its etiology is not always readily evident. Paraquat is used as an herbicide worldwide and is one of the main causes of fatal poisoning in underdeveloped countries in Asia, Central America, and the Pacific Islands. The most commonly affected organs are the lungs and kidneys. However, experimental research has shown that Paraquat can affect the heart indirectly through increased vascular permeability. In vivo animal studies have shown that paraquat poisoning causes myocardial contractile dysfunction by decreased fractional shortening and cardiac remodeling. We report the first case in published literature of a 52-year-old Hispanic man with dilated cardiomyopathy strongly associated with Paraquat exposure. It is important to obtain detailed medical history and proper diagnostic work-up including work, social, and family history, and echocardiography, baseline EKG, lab work, and ischemia cardiac testing as it can lead to improved diagnostic evaluation of possible etiologies of the commonly seen dilated cardiomyopathies and help identify less well-known etiologies as seen in our patient.

Determining the clinical significance of computer interpreted electrocardiography conclusions.

BACKGROUND: Computerized electrocardiogram (EKG) interpretation technology was developed in the mid-20th century, but its use continues to be controversial. This study aims to determine clinical factors which indicate greater odds of clinical significance of an abnormal computerized EKG interpretation. METHODS: The inclusion criteria for this retrospective study were patients who underwent outpatient echocardiography for the indication of an abnormal EKG and had an EKG abnormality diagnosed by the computerized EKG system. Qualifying patients had the results of their computerized EKG, echocardiogram, and charted patient characteristics collected. Computerized diagnoses and patient characteristics were assessed to determine if they were associated with increasing or decreasing the odds of an echocardiographic abnormality via logistic regression. Chi-square and t-test analyses were used for categorical and continuous variables, respectively. Odds ratios are presented as odds ratio [95% confidence interval]. A P-value of ≤ 0.05 was considered statistically significant. RESULTS: A total of 515 patients were included in this study. The population was 59% women with an average age of 57 ± 16 years, and a mean BMI of 30.1 ± 7.3 kg/m2. Patients with echocardiographic abnormalities tended to have more cardiac risk factors than patients without abnormalities. In our final odds ratio model consisting of both patient characteristics and EKG diagnoses, age, coronary disease (CAD), and diabetes mellitus (DM) increased the odds of an echocardiographic abnormality (1.04 [1.02-1.06], 2.68 [1.41-5.09], and 1.75 [1.01-3.04], respectively). That model noted low QRS voltage decreased the odds of an abnormal echocardiogram (0.31 [0.10-0.91]). CONCLUSION: Our findings suggest that in patients with an abnormal computerized EKG reading, the specific factors of older age, CAD, and DM are associated with higher odds of abnormalities on follow-up echocardiography. These results, plus practitioner overreading, can be used to determine more appropriate management when faced with an abnormal computerized EKG diagnosis.

Awareness and Knowledge Among Internal Medicine House-Staff for Dose Adjustment of Cardiovascular Drugs in Chronic Kidney Disease.

INTRODUCTION: Patients with chronic kidney disease (CKD) are vulnerable to adverse-drug events from cardiovascular drugs. AIM: To evaluate awareness and knowledge for appropriate dose adjustment of cardiovascular drugs in CKD patients among Internal Medicine house-staff (IMHS). METHODS: Cross-sectional convenience sample survey in Fall 2015 among 341 IMHS from multiple academic institutions in the suburban New York City metropolitan area. Awareness was whether drug dose adjustment was needed. Knowledge was correct GFR level for drug dose adjustment. Multivariate logistic regression was conducted. RESULTS: We found overall high percentages and high odds for all cardiovascular drugs for incorrect awareness and knowledge. Postgraduate year (PGY)-1 had greater odds than PGY-3 for Carvedilol (OR: 5.56, 95% CI: 2.19-14.12, p < 0.001) and Digoxin (OR: 3.87, 95% CI: 1.37-10.95, p < 0.05), and lesser odds than PGY3 for Atenolol (OR: 0.31, 95% CI: 0.10-0.91, p < 0.05). Nephrology exposure during medical school rotation, renal clinic, or family history had lesser odds for Carvedilol (OR: 0.45, 95% CI: 0.21-0.97, p < 0.05), Simvastatin (OR: 0.40, 95% CI: 0.16-0.97, p < 0.05), and Hydralazine (OR: 0.31, 95% CI: 0.12-0.81, p < 0.05). Nephrology exposure during residency (OR: 1.96, 95% CI: 1.10-3.50, p < 0.05) and US osteopathic graduates (OR: 2.40, 95% CI: 1.04-5.50, p < 0.05) each had greater odds for Enalapril (OR: 2.40, 95% CI: 1.04-5.50, p < 0.05). International medical graduates had lesser odds than US graduates for Amlodipine (OR: 0.30, 95% CI: 0.11-0.82, p < 0.05). CONCLUSIONS: IMHS had overall poor awareness and knowledge for dose adjustment for common cardiovascular drugs in patients with CKD. As the majority of CKD patients are managed by their primary care providers, training programs should ensure that IMHS have adequate education in Nephrology during their residency training.

Impact of cardiologist intervention on guideline-directed use of statin therapy.

BACKGROUND: Statins have an important and well-established role in the prevention of atherosclerotic cardiovascular disease (ASCVD). However, several studies have reported widespread underuse of statins in various practice settings and populations. Review of relevant literature reveals opportunities for improvement in the implementation of guideline-directed statin therapy (GDST). AIM: To examine the impact of cardiologist intervention on the use of GDST in the ambulatory setting. METHODS: Patients with at least one encounter at the adult Internal Medicine Clinic (IMC) and/or Cardiology Clinic (CC), who had an available serum cholesterol test performed, were evaluated. The 2 comparison groups were defined as: (1) Patients only seen by IMC; and (2) Patients seen by both IMC and CC. Patients were excluded if variables needed for calculation of ASCVD risk scores were lacking, and if demographic information lacked guideline-directed treatment recommendations. Data were analyzed using student t-tests or χ 2, as appropriate. Analysis of Variance was used to compare rates of adherence to GDST. RESULTS: A total of 268 patients met the inclusion criteria for this study; 211 in the IMC group and 57 in the IMC-CC group. Overall, 56% of patients were female, mean age 56 years (± 10.65, SD), 22% Black or African American, 56% Hispanic/Latino, 14% had clinical ASCVD, 13% current smokers, 66% diabetic and 63% hypertensive. Statin use was observed in 55% (n = 147/268) of the entire patient cohort. In the IMC-CC group, 73.6% (n = 42/57) of patients were prescribed statin therapy compared to 50.7% (n = 107/211) of patients in the IMC group (P = 0.002). In terms of appropriate statin use based on guidelines, there was no statistical difference between groups [IMC-CC group 61.4% (n = 35/57) vs IMC group, 55.5% (n = 117/211), P = 0.421]. Patients in the IMC-CC group were older, had more cardiac risk factors and had higher proportions of non-white patients compared to the IMC group (P < 0.02, all). CONCLUSION: Although overall use of GDST was suboptimal, there was no statistical difference in appropriate statin use based on guidelines between groups managed by general internists alone or co-managed with a cardiologist. These findings highlight the need to design and implement strategies to improve adherence rates to GDST across all specialties.