The Inverse Correlation Between the Duration of Lifetime Occupational Radiation Exposure and the Prevalence of Atrial Arrhythmia.

Objective: Advancements in fluoroscopy-assisted procedures have increased radiation exposure among cardiologists. Radiation has been linked to cardiovascular complications but its effect on cardiac rhythm, specifically, is underexplored. Methods: Demographic, social, occupational, and medical history information was collected from board-certified cardiologists via an electronic survey. Bivariate and multivariable logistic regression analyses were performed to assess the risk of atrial arrhythmias (AA). Results: We received 1,478 responses (8.8% response rate) from cardiologists, of whom 85.4% were male, and 66.1% were ≤65 years of age. Approximately 36% were interventional cardiologists and 16% were electrophysiologists. Cardiologists > 50 years of age, with > 10,000 hours (h) of radiation exposure, had a significantly lower prevalence of AA vs. those with ≤10,000 h (11.1% vs. 16.7%, p = 0.019). A multivariable logistic regression was performed and among cardiologists > 50 years of age, exposure to > 10,000 radiation hours was significantly associated with a lower likelihood of AA, after adjusting for age, sex, diabetes mellitus, hypertension, and obstructive sleep apnea (adjusted OR 0.57; 95% CI 0.38-0.85, p = 0.007). The traditional risk factors for AA (age, sex, hypertension, diabetes mellitus, and obstructive sleep apnea) correlated positively with AA in our data set. Cataracts, a well-established complication of radiation exposure, were more prevalent in those exposed to > 10,000 h of radiation vs. those exposed to ≤10,000 h of radiation, validating the dependent (AA) and independent variables (radiation exposure), respectively. Conclusion: AA prevalence may be inversely associated with radiation exposure in Cardiologists based on self-reported data on diagnosis and radiation hours. Large-scale prospective studies are needed to validate these findings.

Renal Denervation in the Management of Hypertension: A Meta-Analysis of Sham-Controlled Trials.

INTRODUCTION: Sympathetic renal denervation (RD) can potentially reduce blood pressure (BP) in people with resistant hypertension (RH) and uncontrolled hypertension (UH). While a large sham-controlled trial (SCT) showed similar outcomes of RD vs. sham control, in the recent trials, RD was effective in reducing BP in hypertensive people. We performed a meta-analysis of SCTs of RD vs. sham in hypertensive patients. METHODS: Multiple electronic databases were searched since inception through September 2018 for SCTs that compared RD vs. sham. Change in 24-hour, daytime and nighttime ambulatory and office BP were efficacy outcomes. Various adverse events were safety outcomes. RESULTS: A total of 7 SCTs were included in the analysis. RD vs. sham significantly reduced 24-hour ambulatory SBP by 3.45 mmHg [95% CI (-5.01, -1.88); P < 0.0001] and DBP by 1.87 mmHg [(-3.59, -0.15); P = 0.01], office DBP by 2.97 mmHg [(-4.76, -1.18); P = 0.001] and daytime ambulatory SBP by 4.03 mmHg [(-6.37, -1.68); P = 0.0008] and DBP by 1.53 mmHg [(-2.69, -0.37); P = 0.01]. RD vs. sham caused non-significant reduction in office SBP by 3.99 mmHg [(-8.10, 0.11); P = 0.06] and nighttime ambulatory SBP by 3.05 mmHg [(-6.86, 0.75), P = 0.12] and DBP by 1.03 mmHg [(-3.01, 0.96); P = 0.31]. There was no difference in the risk of hypertensive crisis/emergency [0.62; 0.24-1.60; P = 0.33] between the two strategies. CONCLUSIONS: Current meta-analysis shows that RD reduces ambulatory BP and office DBP in patients with hypertension. Future trials with longer follow-up should confirm these findings.

Ischemic and bleeding outcomes of triple therapy in patients on chronic anticoagulation undergoing percutaneous coronary intervention: A meta-analysis of randomized trials.

BACKGROUND: Triple therapy (TT) that includes oral anticoagulation and dual antiplatelet therapy is recommended in patients who are on chronic anticoagulation and undergo percutaneous coronary intervention (PCI). The randomized clinical trials (RCTs) comparing the effectiveness and safety of TT compared to double therapy (DT), which consists of an oral anticoagulation and one of the P2Y12 inhibitors, have shown increased risk of bleeding; however, none of the individual studies were powered to show a difference in ischemic outcomes. To compare the clinical outcomes of TT and DT, we performed this meta-analysis of RCTs. METHODS: Electronic search of PubMed, EMBASE and Cochrane CENTRAL databases was performed for RCTs comparing TT and DT in patients who were on oral anticoagulation (Vitamin K antagonist or non-vitamin K antagonist oral anticoagulant) who underwent PCI. All-cause and cardiovascular mortality, myocardial infarction (MI), stroke, stent thrombosis (ST) and TIMI major and minor bleeding were the major outcomes. RESULTS: An analysis of 5 trials including 10,592 total patients showed that TT, compared to DT, resulted in non-significant difference in risk of all-cause [odds ratio (OR); 1.14;95% confidence interval (CI):(0.80-1.63); P = 0.46) and cardiovascular mortality [1.43(0.58-3.36); P = 0.44], MI [0.88 (0.64-1.21); P = 0.42], stroke [1.10(0.75-1.62); P = 0.63] and ST [0.82(0.46-1.45); P = 0.49]. TT, compared to DT resulted in higher risk of TIMI major bleeding [1.61(1.09-2.37); P = 0.02], TIMI minor bleeding [1.85(1.23-2.79); P = 0.003] and TIMI major and minor bleeding [1.81 (1.38-2.38); P < 0.0001; I2 = 52%]. CONCLUSION: Compared to DT, the patients receiving TT are at a higher risk of major and minor bleeding with no survival benefit or impact on thrombotic outcomes.

Who benefits from percutaneous closure of patent foramen ovale vs medical therapy for stroke prevention? In-depth and updated meta-analysis of randomized trials.

BACKGROUND: A few randomized clinical trials (RCT) and their meta-analyses have found patent foramen ovale closure (PFOC) to be beneficial in prevention of stroke compared to medical therapy. Whether the benefit is extended across all groups of patients remains unclear. AIM: To evaluate the efficacy and safety of PFOC vs medical therapy in different groups of patients presenting with stroke, we performed this meta-analysis of RCTs. METHODS: Electronic search of PubMed, EMBASE, Cochrane Central, CINAHL and ProQuest Central and manual search were performed from inception through September 2018 for RCTs. Ischemic stroke (IS), transient ischemic attack (TIA), a composite of IS, TIA and systemic embolism (SE), mortality, major bleeding, atrial fibrillation (AF) and procedural complications were the major outcomes. Random-effects model was used to perform analyses. RESULTS: Meta-analysis of 6 RCTs including 3560 patients showed that the PFOC, compared to medical therapy reduced the risk of IS [odds ratio: 0.34; 95% confidence interval: 0.15-0.78; P = 0.01] and the composite of IS, TIA and SE [0.55 (0.32-0.93); P = 0.02] and increased the AF risk [4.79 (2.35-9.77); P < 0.0001]. No statistical difference was observed in the risk of TIA [0.86 (0.54-1.38); P = 0.54], mortality [0.74 (0.28-1.93); P = 0.53] and major bleeding [0.81 (0.42-1.56); P = 0.53] between two strategies. Subgroup analyses showed that compared to medical therapy, PFOC reduced the risk of stroke in persons who were males, ≤ 45 years of age and had large shunt or atrial septal aneurysm. CONCLUSION: In certain groups of patients presenting with stroke, PFOC is beneficial in preventing future stroke compared to medical therapy.

Utility of routine pretreatment evaluation of left ventricular ejection fraction in breast cancer patients receiving anthracyclines.

Anthracycline-based chemotherapy is widely used in the management of breast cancer. Despite the lack of clinical evidence, obtaining prechemotherapy left ventricular ejection fraction (LVEF) by echocardiogram or multigated acquisition scan is a widely adopted practice throughout the world. We present here the results of a retrospective analysis of breast cancer patients who had LVEF measurements in anticipation of an anthracycline chemotherapy to determine whether predefined cardiac risk factors predicted for poor cardiac function. Retrospective data were analyzed from 482 female breast cancer patients in whom LVEF was measured before starting anthracycline-based chemotherapy. Baseline demographics and multiple risk factors associated with congestive heart failure were collected. Twenty-six possible risk factors for CHF were defined, and the frequency of finding an abnormal LVEF as a function of total risk factors was assessed. Statistical tests include chi-squared and logistic regression analysis. The median age of the study population was 52 years. The original chemotherapy plan was changed in 7 patients (1.45%) based on LVEF findings, all of which had asymptomatic LV dysfunction (LVEF ranging 40%-50%). In 32 patients, despite normal LVEF results, anthracyclines were omitted secondary to prior cardiac issues. In 17 patients where LVEF was reported normal, anthracyclines were skipped based on patient's preference, tumor characteristics, or upstaging of the cancer based on imaging studies. No patient with ≤2 risk factors had an abnormal LVEF (N = 350). The probability of finding an abnormal LVEF in patients without any cardiac risk factors is extremely rare. Skipping baseline LVEF assessment may be an option in some patients with no cardiac risk factors undergoing anthracycline-based chemotherapy.

Reduction of vascular complication rates from femoral artery access in contemporary women undergoing cardiac catheterization.

BACKGROUND: Femoral arterial access (FAA) during diagnostic coronary angiography (CAG) and percutaneous coronary interventions (PCI) are associated with several vascular complications (VC). VC rate in our experience a decade ago was 3.02% and higher in women (4.7% in women, and 1.67% in men, p < 0.0006), with an OR of 2.81 (95% CI: 1.51-5.22). METHODS: Patients who underwent CAG and PCI utilizing FAA (n = 2617) were separated into Period 1 (2005 to 2008; 1970 patients; Male 1045; Female 925) and Period 2 (2016-2017; 647 patients; Male 357; Female 290). FA access was preceded by anatomic FA localization during Period 1 vs. additional fluoroscopic marking of femoral head during Period 2. Ultrasound guidance was not utilized during either period. VCs were defined as hematoma>3 cm, major bleeding requiring blood transfusion or hemoglobin drop >2 g, retroperitoneal bleed, pseudoaneurysm, AV fistula, arterial thrombosis, distal embolism, dissection, and transient limb ischemia. RESULTS: Rate of VCs did not differ from Periods 1 to 2 (2.44% vs. 2.32%, p = 1.0). An elevated rate of VCs experienced by women in Period 1 (Female 3.68% vs. Male 1.34%, p < 0.05) is no longer noted in Period 2(Female 2.07% vs. Male 2.52%, p = 0.79). Vascular closure device (VCD) use was protective in both Periods 1 and 2. CONCLUSIONS: The use of fluoroscopic marking of femoral head prior to access, smaller sheath size, and being a high femoral volume center may have contributed to the reduced incidence of VCs in women. VCD utilization is continuing to reduce VC rates in both men and women.

Does micropuncture technique really help reduce vascular complications?

BACKGROUND: Micropuncture technique (MPT) is being adapted nationally to reduce vascular complications (VC). We initiated a quality improvement project in our cath lab to reduce VCs utilizing MPT. METHODS: We utilized MPT on all of our non-STEMI femoral artery (FA) access cases starting September 2016. As a comparator group, we collected data from April to August 2016. Anatomic localization of FA and fluoroscopic marking of femoral head was utilized in all cases. VCs were defined by BARC definitions for bleeding/hematomas, retroperitoneal bleed, pseudoaneurysm, AV fistula, arterial thrombosis, distal embolism, dissection, and transient limb ischemia. RESULTS: A total of 647 patients (Male 357, Female 290; MPT 333) were included in the analysis. MPT as compared to regular 18-gauge needle access did not demonstrate a reduction in VCs (2.4% vs. 2.2%; p = 1.0). MPT utilization did not affect the risk of VCs on univariate (OR 1.08; 95% CI 0.38-3.01; p = 0.88) or multivariate analysis (OR 0.91, 95% CI 0.28-2.93; p + 0.87). Vascular closure device (VCD) utilization as compared to manual/fem-stop hemostasis was the only factor that demonstrated a statistically significant and lower VC rate on both univariate (OR 0.28; 95% CI: 0.08-0.89; p = 0.03), and multivariate (OR 0.24; 95% CI 0.06-0.93; p = 0.039) analysis. CONCLUSION: Utilization of MPT in conjunction with fluoroscopic marking of the femoral head and without ultrasound guidance did not contribute to statistically significant reduction in the VC rate. The only factor found to be beneficial is utilization of VCDs. Further large randomized studies are required to demonstrate benefit of routinely utilizing MPT.

Total sulfane sulfur bioavailability reflects ethnic and gender disparities in cardiovascular disease.

Hydrogen sulfide (H2S) has emerged as an important physiological and pathophysiological signaling molecule in the cardiovascular system influencing vascular tone, cytoprotective responses, redox reactions, vascular adaptation, and mitochondrial respiration. However, bioavailable levels of H2S in its various biochemical metabolite forms during clinical cardiovascular disease remain poorly understood. We performed a case-controlled study to quantify and compare the bioavailability of various biochemical forms of H2S in patients with and without cardiovascular disease (CVD). In our study, we used the reverse-phase high performance liquid chromatography monobromobimane assay to analytically measure bioavailable pools of H2S. Single nucleotide polymorphisms (SNPs) were also identified using DNA Pyrosequencing. We found that plasma acid labile sulfide levels were significantly reduced in Caucasian females with CVD compared with those without the disease. Conversely, plasma bound sulfane sulfur levels were significantly reduced in Caucasian males with CVD compared with those without the disease. Surprisingly, gender differences of H2S bioavailability were not observed in African Americans, although H2S bioavailability was significantly lower overall in this ethnic group compared to Caucasians. We also performed SNP analysis of H2S synthesizing enzymes and found a significant increase in cystathionine gamma-lyase (CTH) 1364 G-T allele frequency in patients with CVD compared to controls. Lastly, plasma H2S bioavailability was found to be predictive for cardiovascular disease in Caucasian subjects as determined by receiver operator characteristic analysis. These findings reveal that plasma H2S bioavailability could be considered a biomarker for CVD in an ethnic and gender manner. Cystathionine gamma-lyase 1346 G-T SNP might also contribute to the risk of cardiovascular disease development.

Comparison of manual compression and vascular hemostasis devices after coronary angiography or percutaneous coronary intervention through femoral artery access: A meta-analysis of randomized controlled trials.

OBJECTIVES: To compare the efficacy and safety of manual compression (MC) with vascular hemostasis devices (VHD) in patients undergoing coronary angiography (CA) or percutaneous coronary intervention (PCI) through femoral artery access. INTRODUCTION: The use of femoral artery access for coronary procedures may result in access-related complications, prolonged immobility and discomfort for the patients. MC results in longer time-to-hemostasis (TTH) and time-to-ambulation (TTA) compared to VHDs but its role in access-related complications remains unclear in patients undergoing coronary procedures. METHODS: We searched MEDLINE, EMBASE, Cochrane CENTRAL and relevant references for English language randomized controlled trials (RCT) from inception through September 30, 2016. We performed the meta-analysis using random effects model. The outcomes were time-to-hemostasis, time-to-ambulation, major bleeding, large hematoma >5cm, pseudoaneurysm and other adverse events. RESULTS: The electronic database search resulted in a total of 44 RCTs with a total of 18,802 patients for analysis. MC, compared to VHD resulted in longer TTH [mean difference (MD): 11.21min; 95% confidence interval (CI) 8.13-14.29; P<0.00001] and TTA [standardized mean difference: 1.2 (0.79-1.62); P<0.00001] along with excess risk of hematoma >5cm formation [risk ratio (RR): 1.38 (1.15-1.67); P=0.0008]. MC resulted in similar risk of major bleeding [1.01 (0.64-1.60); P=0.95] pseudoaneurysm [0.99 (0.75-1.29); P=0.92], infections [0.52 (0.25-1.10); P=0.09], need of surgery [0.60 (0.29-1.22); P=0.16), AV fistula [0.93 (0.68-1.27); P=0.63] and ipsilateral leg ischemia [0.95 (0.57-1.60); P=0.86] compared to VHD. CONCLUSION: Manual compression increase time-to-hemostasis, time-to-ambulation and risk of hematoma formation compared vascular hemostasis devices.

Comparison of prasugrel and ticagrelor in patients with acute coronary syndrome undergoing percutaneous coronary intervention: A meta-analysis of randomized and non-randomized studies.

BACKGROUND: The newer oral P2Y12 receptor antagonists (i.e. prasugrel and ticagrelor) are recommended over clopidogrel for patients with acute coronary syndrome (ACS) going for percutaneous coronary intervention (PCI). As the superiority of one agent over the other remains unclear, we designed a systematic review and meta-analysis of these agents in patients with ACS undergoing PCI. METHODS: PUBMED, EMBASE, Cochrane CENTRAL, CINAHL and manual search were performed through 11/02/2016. Mortality, myocardial infarction (MI), stroke, repeat revascularization, stent thrombosis (ST) and BARC bleeding ≥2 were the major outcomes. RESULTS: A total of 9 studies with 21,360 total patients were included in the meta-analysis. Compared to ticagrelor, prasugrel was associated with lower rate of MI [0.8% vs. 1.9%; 0.54 (0.29-0.99); P=0.05] but no difference was noted in mortality [2.1% vs. 2.4%; 0.84 (0.64-1.09); P=0.19], repeat revascularization [1.6% vs. 2.1%; 0.82 (0.61-1.10); P=0.19] and stroke [0.2% vs. 0.3%; 0.68 (0.25-1.83); P=0.44] between two agents. In addition, prasugrel was associated with lower risk of BARC ≥2 bleeding [2.5% vs. 3.8%; 0.75 (0.59-0.95); P=0.02] and showed a trend toward a lower risk of ST [0.3% vs. 0.6%; 0.55 (0.28-1.07); P=0.08] in comparison with ticagrelor. CONCLUSIONS: Based on this meta-analysis of observational and randomized studies, prasugrel appears to be equivalent or superior to ticagrelor in patients with ACS undergoing PCI on the 30-day follow up. Larger randomized trials with longer follow-ups are needed to establish superiority of one agent over the other.

Acute ST elevation myocardial infarction in fulminant systemic p-ANCA vasculitis: a rare catastrophic complication.

A 45-year-old Caucasian man presented to the hospital with a 3-month history of fatigue, bilateral upper and lower limb paresthesias and gradually worsening ascending paralysis. A few weeks later, he developed acute renal failure requiring haemodialysis. Investigations revealed presence of myeloperoxidase (MPO) perinuclear antineutrophil cytoplasmic antibodies (ANCA). Renal biopsy was conclusive for rapidly progressive glomerulonephritis with crescents. Treatment for ANCA positive vasculitis was initiated with pulsed steroids, cyclophosphamide and plasmapheresis. The hospital course took an unexpected turn when the patient developed acute chest pain with an EKG consistent with inferior ST elevation myocardial infarction (STEMI). Urgent left heart catheterisation revealed distal occlusions in multivessel coronary distribution. Coronary involvement is rare in ANCA vasculitis and STEMI has not been reported in MPO-ANCA positive vasculitis, to the best of our knowledge.

Cocaine-induced postpartum coronary artery dissection: a case report and 80-year review of literature.

The incidence of cocaine-induced myocardial infarction (MI) in pregnancy is unknown. During the peripartum period, cocaine-abusing women are highly susceptible to MI caused by the effect of cocaine on a heart that is already stressed by hemodynamic changes of pregnancy. MI is an infrequent event during pregnancy and the peripartum period, with an estimated rate of 1 in 16,000 patients. Spontaneous coronary artery dissection (SCAD) can account for up to 27% of pregnancy-related MIs. We describe a case of MI diagnosed by increased troponin I levels in a postpartum patient with recent crack cocaine use in the setting of SCAD that required percutaneous coronary intervention of the left anterior descending and diagonal arteries. We also provide a comprehensive review of published literature related to this clinical entity.

Differential targeting of nuclear pore complex proteins in poliovirus-infected cells.

Poliovirus disrupts nucleocytoplasmic trafficking and results in the cleavage of two nuclear pore complex (NPC) proteins, Nup153 and Nup62. The NPC is a 125-MDa complex composed of multiple copies of 30 different proteins. Here we have extended the analysis of the NPC in infected cells by examining the status of Nup98, an interferon-induced NPC protein with a major role in mRNA export. Our results indicate that Nup98 is targeted for cleavage after infection but that this occurs much more rapidly than it does for Nup153 and Nup62. In addition, we find that cleavage of these NPC proteins displays differential sensitivity to the viral RNA synthesis inhibitor guanidine hydrochloride. Inhibition of nuclear import and relocalization of host nuclear proteins to the cytoplasm were only apparent at later times after infection when all three nucleoporins (Nups) were cleaved. Surprisingly, analysis of the distribution of mRNA in infected cells revealed that proteolysis of Nup98 did not result in an inhibition of mRNA export. Cleavage of Nup98 could be reconstituted by the addition of purified rhinovirus type 2 2A(pro) to whole-cell lysates prepared from uninfected cells, suggesting that the 2A protease has a role in this process in vivo. These results indicate that poliovirus differentially targets subsets of NPC proteins at early and late times postinfection. In addition, targeting of interferon-inducible NPC proteins, such as Nup98, may be an additional weapon in the arsenal of poliovirus and perhaps other picornaviruses to overcome host defense mechanisms.