Risk of arrhythmic events after alcohol septal ablation for hypertrophic cardiomyopathy using continuous implantable cardiac monitoring.

BACKGROUND: Alcohol septal ablation (ASA) in patients with hypertrophic cardiomyopathy (HCM) can lead to heart rhythm disturbances including complete heart block (CHB) and atrial and ventricular arrhythmias. OBJECTIVE: We aimed to evaluate the utility of long-term arrhythmia monitoring with an implantable cardiac monitor (ICM) after ASA. METHODS: Between February 2014 and March 2019, 56 patients with HCM undergoing ASA were enrolled in a prospective study and underwent ICM implantation. Kaplan-Meier survival analysis was used to assess the rate of ICM-detected arrhythmic events. RESULTS: The mean age was 59 ± 11 years, and 20 (36%) were women. The median (25th, 75th percentile) resting left ventricular outflow tract gradient obtained by echocardiography was 43 (22, 81) mm Hg. Greater than 1 septal perforating artery was injected in 48 patients (86%). The Kaplan-Meier cumulative rate of ICM-detected arrhythmic events at 18 months of follow-up was 71%, with an event rate of 43% occurring within 3 months of ASA. The cumulative rate of the ICM-detected first atrial fibrillation event at 18 months was 37%, and the corresponding rate of CHB was 19%. All atrial fibrillation and CHB events were actionable, leading to the initiation of anticoagulation and pacemaker implantation, respectively. No baseline demographic or procedural variables were identified as independent predictors of an increased risk of developing ICM-detected arrhythmic events. CONCLUSION: After ASA, ICM is effective in capturing clinically actionable arrhythmic events in patients with HCM regardless of patient's baseline risk factors.

Implantable Cardioverter Defibrillators and Survival in Continuous-Flow Left Ventricular Assist Device Patients.

The association of an implantable cardioverter defibrillator (ICD) with survival in patients with left ventricular assist devices (LVADs) is not well understood. We evaluated all-cause mortality by the presence of an ICD at the time of LVAD implantation, or by ICD implantation after LVAD placement in 191 patients, using Kaplan-Meier survival analyses and Cox models with multivariate adjustment. During the median follow-up of 23 months, 33 of 129 patients (26%) with an ICD and 17 of 62 patients (27%) without an ICD died. Patients had similar all-cause mortality with or without an ICD before LVAD, after censoring for post-LVAD ICD implantation (log-rank p = 0.889). Multivariate models after adjustments revealed no statistically significant survival benefit from an ICD before LVAD (hazard ratio [HR]: 0.65, 95% CI: 0.27-1.57, p = 0.340). Thirty-one of 62 (50%) patients without an ICD before LVAD implantation subsequently received an ICD after LVAD, although these patients did not have significantly better survival when compared with those with no ICD in a time-dependent analysis (HR: 0.70, 95% CI: 0.25-1.95, p = 0.497). Among LVAD patients, neither a previously implanted ICD nor a new ICD implantation after LVAD yielded statistically significant survival benefit. Further studies are warranted to investigate the role of ICD implantation in LVAD patients.

CIED malfunction in patients receiving radiation is a rare event that could be detected by remote monitoring.

INTRODUCTION: An increasing number of patients with cardiac devices require radiation therapy for treatment of a variety of cancers. This study aimed to identify the incidence and predictors of cardiac implantable electronic devices (CIED) malfunction in a real-world population that has received radiation therapy. METHODS: This retrospective cohort study included 109 adult patients who received radiation therapy at the University of Rochester Medical Center, Radiation Oncology Department, between 2000 and 2015. Sixty patients had pacemakers and 49 had automatic implantable cardioverter defibrillators. Subjects received either high energy (16 MV) and/or low energy (6 MV) photon beams with or without electron beams (6-16 MeV). We included interrogations done from first day of radiation and up to 3 months' postradiation therapy. Outcomes analyzed were device-related malfunctions and device-related clinical events. Fisher's exact, Wilcoxon, and Kruskall-Wallis tests were used for bivariate analysis. Logistic regression with robust adjustment was used for multivariate analysis. RESULTS: We identified six device-related malfunctions. All events were minor and included partial settings reset leading to loss of historical data, pacing thresholds changes, lead impedance changes, and LV output increase. Two patients had device-related clinical events, including dyspnea and diaphragmatic-stimulation. In bivariate analysis, CIED malfunction was associated with CIED duration in situ. In multivariate analysis, there was no significant statistical association between adverse events and beam energy type, CIED location, or dose of radiation delivered to the target. CONCLUSIONS: CIED malfunctions are uncommon in real-world patients and associated with minor clinical events. In our cohort, remote CIED monitoring would have identified all events.

The platelet phenotype in patients with ST-segment elevation myocardial infarction is different from non-ST-segment elevation myocardial infarction.

It is assumed that platelets in diseased conditions share similar properties to platelets in healthy conditions, although this has never been examined in detail for myocardial infarction (MI). We examined platelets from patients with ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) compared with platelets from healthy volunteers to evaluate for differences in platelet phenotype and function. Platelet activation was examined and postreceptor signal transduction pathways were assessed. Platelet-derived plasma biomarkers were evaluated by receiver operator characteristic curve analysis. Maximum platelet activation through the thromboxane receptor was greater in STEMI than in NSTEMI but less through protease-activated receptor 1. Extracellular-signal related-kinase 5 activation, which can activate platelets, was increased in platelets from subjects with STEMI and especially in platelets from patients with NSTEMI. Matrix metalloproteinase 9 (MMP9) protein content and enzymatic activity were several-fold greater in platelets with MI than in control. Mean plasma MMP9 concentration in patients with MI distinguished between STEMI and NSTEMI (area under curve [AUC] 75% [confidence interval (CI) 60-91], P = 0.006) which was superior to troponin T (AUC 66% [CI 48-85, P = 0.08), predicting STEMI with 80% sensitivity (95% CI 56-94), 90% specificity (CI 68-99), 70% AUC (CI 54-86, P < 0.0001), and NSTEMI with 50% sensitivity (CI 27-70), 90% specificity (CI 68-99), 70% AUC (CI 54-86, P = 0.03). Platelets from patients with STEMI and NSTEMI show differences in platelet surface receptor activation and postreceptor signal transduction, suggesting the healthy platelet phenotype in which antiplatelet agents are often evaluated in preclinical studies is different from platelets in patients with MI.

Patient and Physician Perspectives on Public Reporting of Mortality Ratings for Percutaneous Coronary Intervention in New York State.

BACKGROUND: Public reporting of physician-specific outcome data for procedures, such as percutaneous coronary intervention (PCI), can influence physicians to avoid high-risk patients who may benefit from treatment. Prior physician attitudes toward public scorecards in New York State (NYS) have been studied, but the exclusion criteria have evolved. Additionally, patient perceptions toward such reports remain poorly understood. This study evaluates (1) whether exclusion of certain high-risk patients from public reporting of PCI outcomes in NYS has influenced physician attitudes, (2) current patient awareness and use of publicly reported outcome data, and (3) differences in physician and patient attitudes toward public reporting. METHODS AND RESULTS: A questionnaire was administered to interventional cardiologists in NYS with specific emphasis on how modifications in publicly reported outcome data have influenced their practice. The results were compared with a 2003 survey administered by our group. A separate questionnaire regarding the publicly available NYS PCI Report was administered to patients referred to our center for possible PCI. The majority of interventional cardiologists indicated that the exclusion of patients with anoxic brain injury and refractory cardiogenic shock from public reporting has made them more likely to perform PCI for these subgroups. While patient awareness of the NYS PCI Report was low, patients were significantly more likely than physicians to think that publication of physician-specific mortality data can provide an accurate measure of physician quality, serve to improve patient care, and provide useful information in terms of physician selection. CONCLUSIONS: The study provides further evidence that public reporting of physician-specific outcome data influences physician behavior and indicates that significant discrepancies exist in how scorecards are perceived by physicians versus patients.

Prevalence of Non-Left Anterior Descending Septal Perforator Culprit in Patients With Hypertrophic Cardiomyopathy Undergoing Alcohol Septal Ablation.

Identifying the coronary branch that supplies the basal septum is the cornerstone for successful alcohol septal ablation (ASA). The basal septum is often supplied by septal perforator artery/arteries (SPA/SPAs) not originating from the left anterior descending (LAD) coronary artery. We aim to investigate the prevalence and significance of non-LAD septal "culprit" in patients undergoing ASA. A retrospective review of patients who underwent ASA from 2006 to 2014 was conducted. Procedural and midterm outcomes of patients who had ASA of LAD and non-LAD culprit SPA were reported. A total 89 patients were included in the analysis; 13 patients (15%) had ASA of non-LAD SPA. These patients were more likely to have a history of failed ASA, more than one SPA treated, more ethanol dose injected, longer procedures, and higher contrast use compared with those who had ASA of LAD-SPA. In-hospital outcomes, residual gradient, symptom improvement, and midterm mortality were similar in the 2 groups. In conclusion, in a cohort of patients undergoing ASA, 15% had ablation of SPA culprit that did not originate from the LAD. Half of these patients had previous unsuccessful ASA. Systematic screening for the ideal culprit SPA with nonselective coronary injection of echo contrast should be used to avoid incomplete or failed ASA.

The Baroreflex in Hypertension.

Hypertension is a complex syndrome that increases the risk of developing other medical comorbidities and interacts with other medical conditions to increase the risk of target end-organ damage such as cardiovascular disease, stroke, and renal disease. Hypertension remains under-recognized and poorly controlled in the USA and worldwide. In some patients, hypertension is resistant to optimal medical therapy. Over the last few decades, there has been an increasing understanding of the role of the sympathetic nervous system in the development and maintenance of hypertension. This update reviews the physiology and role of the sympathetic nervous system in hypertension and pharmacological and interventional treatments directed at nervous system involvement in secondary hypertension.

Exploring The Obesity Paradox In Atrial Fibrillation. AFBAR (Atrial Fibrillation Barbanza Area) Registry Results.

INTRODUCTION AND OBJECTIVES: Previous studies have described an inverse relationship between obesity and adverse events in a variety of conditions. Our aim was to investigate the relationship between obesity and prognosis in patients with atrial fibrillation. METHODS: We studied 746 patients who were prospectively included, between January and April 2008, in the AFBAR (Atrial Fibrillation in BARbanza area) registry. Patients were categorized into 3 body mass index groups using baseline measurements: normal (< 25 kg/m2), overweight (25-30 kg/m2), and obese (≥30 kg/m2). Survival free from the composite endpoint hospitalization for cardiovascular causes or all-cause mortality was compared across the 3 body mass index groups. A multivariable Cox proportional hazard regression was also performed to determine the independent effect of obesity as well as overweight, with respect to normal body mass index as a reference category, regarding the study endpoint. Median follow-up time was 36 (28-36) months. RESULTS: 49.3% were obese and 38.2% had overweight. The composite endpoint rate was 70.9%, 67.5%, and 57.6% for obese, overweight, and normal weight patients, respectively (log rank test; p=0.02). An inverse association of obesity with a favorable prognosis persisted even after multivariable adjustment: hazard ratio 0.668; 95% confidence interval 0.449-0.995; p=0.047. Hazard ratio of overweight, however, was 0.741; 95% confidence interval: 0.500-1.098; p=0.096. CONCLUSIONS: Obesity, defined as a body mass index ≥ 30 kg/m2, is associated with better prognosis in a community-based cohort of patients with atrial fibrillation.

Association of atrial fibrosis quantified using LGE-MRI with atrial appendage thrombus and spontaneous contrast on transesophageal echocardiography in patients with atrial fibrillation.

INTRODUCTION: Transesophageal echocardiography (TEE) is used to evaluate for left atrial appendage (LAA) thrombi prior to restoration of sinus rhythm in atrial fibrillation (AF). We examined the relationship of atrial fibrosis quantified using late gadolinium enhancement MRI (LGE-MRI) with TEE findings. METHODS AND RESULTS: We included 178 patients with AF, undergoing TEE and LGE-MRI prior to ablation or cardioversion. LGE-MRI and subsequent image processing was used to quantify atrial fibrosis based on signal intensity analysis. The mean CHADS2 score was 1.24 ± 1.08 and CHA2 DS2 -VASc was 2.08 ± 1.33. The LAA was classified as normal, spontaneous echocardiographic contrast (SEC) present or thrombus present. LAA thrombus was found in 12 patients (6.7%) while SEC was identified in 19 patients (10.7%). Patients with thrombus had higher atrial fibrosis compared to patients without thrombus (26.9 ± 17.4% vs 16.7 ± 10.5%; P < 0.01). Atrial fibrosis was also higher in patients with SEC (23.3 ± 13.7%) compared to those without SEC (16.7 ± 10.8%; P = 0.01). Patients with high atrial fibrosis (>20%) were more likely to have a LAA thrombus (odds ratio 4.6; P = 0.02) and SEC (odds ratio 2.6; P = 0.06). Multivariate logistic regression showed high fibrosis (odds ratio 3.6; P < 0.01) and CHADS2 ≥2 (odds ratio 3.5; P < 0.01) were significant predictors of TEE abnormalities (LAA thrombus or SEC). The area under the curve for the model including high fibrosis, AF type and CHADS2 ≥2 or CHA2 DS2 -VASc ≥2 was 0.73 compared to 0.63 and 0.65 for CHADS2 and CHA2 DS2 -VASc alone. CONCLUSIONS: Atrial fibrosis is independently associated with appendage thrombus and spontaneous contrast. It provides additional risk stratification not captured by clinical parameters.

Statin myopathy: a common dilemma not reflected in clinical trials.

Although statins are remarkably effective, they are still underprescribed because of concerns about muscle toxicity. We review the aspects of statin myopathy that are important to the primary care physician and provide a guide for evaluating patients on statins who present with muscle complaints. We outline the differential diagnosis, the risks and benefits of statin therapy in patients with possible toxicity, and the subsequent treatment options.

Cardiopulmonary hemodynamic clues for pulmonary vein stenosis diagnosis.

Pulmonary vein stenosis (PVS) post radiofrequency ablation for chronic atrial fibrillation poses a diagnostic challenge for the clinician. PVS presents with nonspecific symptoms, signs and radiographic features, and may be associated with significant pulmonary vascular involvement. Interestingly, others have described variation of the pulmonary artery wedge pressure between sites of the lung as a clue to pulmonary veno-occlusive disorders. We report, to the best of our knowledge, the first case that describes the regional loss of V waves while recording the mean pulmonary artery wedge pressure (mPawp) as well as the difference in pulmonary artery wedge pressure gradients as the main diagnostic clues for PVS.

Usefulness of adjusting for clinical covariates to improve the ability of B-type natriuretic peptide to distinguish cardiac from noncardiac dyspnea.

Certain clinical characteristics affect brain natriuretic peptide (BNP) levels independently of clinical heart failure (HF). However, it is unclear how to adjust the diagnostic cutoffs of BNP for these variables. We hypothesized that adjusting for important covariates would improve the diagnostic accuracy of BNP for HF in the emergency room setting. We included patients presenting with dyspnea at the Salt Lake City Veterans Affairs Medical Center. Physicians unaware of the BNP values adjudicated the outcome as dyspnea due to HF or noncardiac dyspnea. Subgroup analyses and logistic regression analysis were used to adjust the BNP cutoffs. The mean age of the study population (n = 335) was 72 +/- 11 years. A BNP of 100 pg/ml had a sensitivity of 91%, and a BNP of 400 pg/ml had a specificity of 92%. The covariates age, history of atrial fibrillation, creatinine, and body mass index affected BNP levels independently of HF. The subgroup-specific BNP cutoff that maintained 91% sensitivity was 184 pg/ml for patients > or =75 years, 150 pg/ml for those with atrial fibrillation, and 449 pg/ml for patients with a creatinine > or =2 mg/dl. These subgroup-specific cutoffs improved specificity compared to a cutoff of 100 pg/ml. The regression model that adjusted BNP improved the reclassification of patients as having cardiac or noncardiac dyspnea compared to the conventional BNP cutoffs. Of the patients without HF, 11% were correctly reclassified as having noncardiac dyspnea (p = 0.003). In conclusion, adjusting BNP levels for clinical covariates improves its diagnostic performance.

[Effect of the location of previous atherosclerotic disease on prognosis in diabetic patients. The Barbanza Diabetes Study]. / Impacto pronóstico de la localización de la enfermedad aterosclerosa previa en pacientes diabéticos. Estudio Barbanza-diabetes.

INTRODUCTION AND OBJECTIVES: To assess the effect of different forms of atherosclerotic disease on prognosis in diabetic patients. METHODS: This multicenter prospective cohort study involved 1423 consecutive patients with diabetes mellitus who were recruited by 31 primary care physicians. The patients' characteristics were recorded and they were followed up for 45 +/- 10 months. RESULTS: The mean age of the patients (50% male) was 66 years, 64% had hypertension, 70% had dyslipidemia, and 26% had had a previous cardiovascular event. By the end of follow-up, 81 (6.2%) had died, 40 (3%) of whom due to cardiovascular causes, and 393 (30%) had been hospitalized, 179 (14%) of whom for cardiovascular disease. Multivariate analysis identified the following factors as independent predictors of mortality: age (hazard ratio [HR]=1.08; 95% confidence interval [CI],1.05-1.11), previous cardiovascular disease (HR=2.15; 95% CI, 1.12-4.14) and diuretic treatment (HR=3.40; 95% CI, 1.76-6.56), while the prescription of an angiotensin-converting enzyme inhibitor or an angiotensin-receptor antagonist had a protective effect (HR=0.48; 95% CI, 0.25-0.93). Compared with diabetics without a previous cardiovascular event, the risk of a cardiovascular event during follow-up was greater in those with a history of either ischemic heart disease (HR=2.48; 95% CI, 1.51-4.07), cerebrovascular disease (HR=2.51; 95% CI, 1.28-4.92), or peripheral vascular disease (HR=1.46; 95% CI, 0.81-2.60). CONCLUSIONS: The increase in the risk of a cardiovascular event was similar in diabetics with ischemic heart disease and those with cerebrovascular disease. In both cases, the risk was more than double that in patients without a history of cardiovascular disease.

Impacto pronóstico de la localización de la enfermedad aterosclerosa previa en pacientes diabéticos. Estudio Barbanza-diabetes / Effect of the location of previous atherosclerotic disease on prognosis in diabetic patients. The Barbanza Diabetes Study

Introducción y objetivos. Evaluar las diferencias pronósticas de las distintas formas de presentación de la enfermedad aterosclerosa en pacientes diabéticos. Métodos. Estudio multicéntrico de cohortes prospectivas, en el que participaron 31 médicos de atención primaria que registraron las características de 1.423 pacientes diabéticos que acudieron de forma consecutiva a sus consultas y fueron seguidos durante 45 ± 10 meses. Resultados. Pacientes (el 50%, varones) con media de edad de 66 años, el 64% hipertensos, el 70% dislipémicos y el 26% con eventos cardiovasculares previos. Tras el período de seguimiento, fallecieron 81 (6,2%) pacientes, 40 (3%) por causa cardiaca, y reingresaron 393 (30%), 179 (14%) por causa cardiovascular. En el análisis multivariable, resultaron determinantes independientes de mortalidad: la edad (hazard ratio [HR] = 1,08; inter-valo de confianza [IC] del 95%, 1,05-1,11), tener enfermedad cardiovascular (HR = 2,15; IC del 95%, 1,12-4,14) y seguir tratamiento con diuréticos (HR = 3,40; IC del 95%, 1,76-6,56), mientras que la prescripción de inhibidores de la enzima de conversión de angiotensina y/o antagonistas de los receptores de angiotensina II resultó factor protector (HR = 0,48; IC del 95%, 0,25-0,93). En comparación con diabéticos sin evento cardiovascular previo, el riesgo de tener una complicación cardiovascular fue superior en los pacientes con antecedentes de cardiopatía isquémica (HR = 2,48; IC del 95%, 1,51-4,07), enfermedad cerebrovascular (HR = 2,51; IC del 95%, 1,28-4,92) y enfermedad vascular periférica (HR = 1,46; IC del 95%, 0,81-2,60). Conclusiones. El incremento del riesgo de complicaciones cardiovasculares es semejante entre los diabéticos con cardiopatía isquémica y con enfermedad cerebrovascular y más del doble respecto a diabéticos sin afección cardiovascular evidente (AU)

Introduction and objectives. To assess the effect of different forms of atherosclerotic disease on prognosis in diabetic patients. Methods. This multicenter prospective cohort study involved 1423 consecutive patients with diabetes mellitus who were recruited by 31 primary care physicians. The patients' characteristics were recorded and they were followed up for 45 (10) months. Results. The mean age of the patients (50% male) was 66 years, 64% had hypertension, 70% had dyslipidemia, and 26% had had a previous cardiovascular event. By the end of follow-up, 81 (6.2%) had died, 40 (3%) of whom due to cardiovascular causes, and 393 (30%) had been hospitalized, 179 (14%) of whom for cardiovascular disease. Multivariate analysis identified the following factors as independent predictors of mortality: age (hazard ratio [HR]=1.08; 95% confidence interval [CI], 1.05-1.11), previous cardiovascular disease (HR=2.15; 95% CI, 1.12-4.14) and diuretic treatment (HR=3.40; 95% CI, 1.76-6.56), while the prescription of an angiotensin-converting enzyme inhibitor or an angiotensin-receptor antagonist had a protective effect (HR=0.48; 95% CI, 0.25-0.93). Compared with diabetics without a previous cardiovascular event, the risk of a cardiovascular event during follow-up was greater in those with a history of either ischemic heart disease (HR=2.48; 95% CI, 1.51-4.07), cerebrovascular disease (HR=2.51; 95% CI, 1.28-4.92), or peripheral vascular disease (HR=1.46; 95% CI, 0.81-2.60). Conclusions. The increase in the risk of a cardiovascular event was similar in diabetics with ischemic heart disease and those with cerebrovascular disease. In both cases, the risk was more than double that in patients without a history of cardiovascular disease (AU)

Medical school faculty discontent: prevalence and predictors of intent to leave academic careers.

BACKGROUND: Medical school faculty are less enthusiastic about their academic careers than ever before. In this study, we measured the prevalence and determinants of intent to leave academic medicine. METHODS: A 75-question survey was administered to faculty at a School of Medicine. Questions addressed quality of life, faculty responsibilities, support for teaching, clinical work and scholarship, mentoring and participation in governance. RESULTS: Of 1,408 eligible faculty members, 532 (38%) participated. Among respondents, 224 (40%; CI95: 0.35, 0.44) reported that their careers were not progressing satisfactorily; 236 (42%; CI95: 0.38, 0.46) were "seriously considering leaving academic medicine in the next five years." Members of clinical departments (OR = 1.71; CI95: 1.01, 2.91) were more likely to consider leaving; members of inter-disciplinary centers were less likely (OR = 0.68; CI95: 0.47, 0.98). The predictors of "serious intent to leave" included: Difficulties balancing work and family (OR = 3.52; CI95: 2.34, 5.30); inability to comment on performance of institutional leaders (OR = 3.08; CI95: 2.07, 4.72); absence of faculty development programs (OR = 3.03; CI95: 2.00, 4.60); lack of recognition of clinical work (OR = 2.73; CI95: 1.60, 4.68) and teaching (OR = 2.47; CI95: 1.59, 3.83) in promotion evaluations; absence of "academic community" (OR = 2.67; CI95: 1.86, 3.83); and failure of chairs to evaluate academic progress regularly (OR = 2.60; CI95: 1.80, 3.74). CONCLUSION: Faculty are a medical school's key resource, but 42 percent are seriously considering leaving. Medical schools should refocus faculty retention efforts on professional development programs, regular performance feedback, balancing career and family, tangible recognition of teaching and clinical service and meaningful faculty participation in institutional governance.