Left atrial appendage closure: the journey today and tomorrow.

PURPOSE OF REVIEW: This review aims to discuss the rationale behind the development of percutaneous LAAC devices as a treatment option for atrial fibrillation patients ineligible for long-term anticoagulation. The evolution of LAAC, from early experiences and challenges to risk mitigation and improved devices and techniques, will be examined. Furthermore, the review will explore our current understanding of the potential and limitations of LAAC in stroke prevention. RECENT FINDINGS: Multiple trials confirm LAAC device safety and efficacy for stroke prevention, but peri-device leak and thrombus remain concerns postimplantation. Even small leaks pose increased stroke risk. While guidelines suggest short-term anticoagulation postimplant; real-world data show equivalent efficacy with dual antiplatelet regimen. SUMMARY: LAAC device design has evolved and now serve as a viable option for stroke prevention in high-risk atrial fibrillation patients, offering protection in the absence of anticoagulation.

Impact of Median Sternotomy on Safety and Efficacy of the Subcutaneous Implantable Cardioverter Defibrillator.

BACKGROUND: Subcutaneous implantable cardioverter defibrillators (S-ICDs) are an attractive alternative to transvenous ICDs among those not requiring pacing. However, the risks of damage to the S-ICD electrode during sternotomy and adverse interactions with sternal wires remain unclear. We sought to determine the rates of damage to the S-ICD lead during sternotomy, inappropriate shocks from electrical noise due to interaction with sternal wires, and failure to terminate spontaneous or induced ventricular arrhythmias. METHODS: Retrospective, multicenter study of patients undergoing sternotomy before or after S-ICD implantation. Clinical, procedural, and device-related data were collected by each center and analyzed by the coordinating center. These data were compared with a historical control cohort of nonsternotomy patients. RESULTS: Of 196 identified patients (52±16 years, 47 women), 166 underwent S-ICD implantation after sternotomy and 30 sternotomy after S-ICD. There was no damage to any lead among those who underwent sternotomy after S-ICD. Defibrillation threshold testing was performed in 63% at implant, with 91% first shock success. During a median follow-up of 29 months (range, 1-188), S-ICD first shocks successfully terminated spontaneous ventricular arrhythmias in 31 of 32 patients (97%). Inappropriate shocks occurred in 22 patients, most commonly related to T wave oversensing (n=14). Compared with the nonsternotomy controls, there were no differences in rates of first shock success for induced or spontaneous arrhythmias or rate of inappropriate shocks. CONCLUSIONS: Sternotomy before or after S-ICD does not confer additional risk relative to a historical control group without sternotomy.

A Case of Unicentric Castleman Disease with Concomitant Myasthenia Gravis and Persistent Left Superior Vena Cava.

BACKGROUND Castleman disease was first described in 1956 as mediastinal masses composed of benign lymphoid hyperplasia with germinal center formation and capillary proliferation closely resembling thymomas. It has been linked with many multi-system disorders, including myasthenia gravis. Cases of Castleman disease with corresponding myasthenia gravis have higher rates of postoperative myasthenic crisis, which are reported as high as 37.5%. We encountered a case of Castleman disease with myasthenia gravis that was discovered early and managed successfully with complete surgical resection and no postoperative myasthenic crisis. CASE REPORT A 25-year-old woman with an uncomplicated history presented with shortness of breath, numbness in hands, tiring with chewing, and fatigue. Myasthenia gravis was diagnosed with serology test results, and a 7.5×7.0-cm mediastinal mass was discovered in addition to the incidental finding of a persistent left superior vena cava, closely abutting the mass. Biopsy showed lymphoid proliferation, regressed germinal centers surrounded by small lymphocytes, and vascular proliferation, consistent with unicentric Castleman disease, hyaline-vascular type. The patient was successfully treated for Castleman disease with myasthenia gravis, and no postoperative myasthenic crisis occurred. CONCLUSIONS Castleman disease associated with myasthenia gravis can dramatically increase the risk of postoperative myasthenic crisis. Our literature review of all 16 cases of Castleman disease with myasthenia gravis since 1973 revealed that 18.75% of cases were associated with a postoperative myasthenic crisis. This association elicits the importance of prompt diagnosis of myasthenia gravis when evaluating mediastinal masses and the value of having neurology and anesthesiology staff aware of the increased risk of crisis.

New Opioid Persistence in Veterans Following Major and Minor Surgery.

INTRODUCTION: Opioids are often a mainstay of managing postsurgical pain. Persistent use of opioids for more than 90 days after surgery is problematic, and the incidence of this adverse outcome has been reported in the civilian population ranging from 0.4% to 7%. Veterans compose a special population exposed to trauma and stressful situations and consequently face increased risk for habit-forming behavior and drug overdose. This evaluation determined the prevalence of opioid persistence after surgery and its relationship to patient characteristics in a military veteran population. METHODS: A retrospective chart review was completed on 1,257 veterans who were opioid naive and had undergone a surgical procedure between January 2017 and May 2018. Patient characteristics, health conditions, and discharge opioid medications were recorded, and the incidence of persistent opioid use beyond 90 days was determined. RESULTS: The incidence of opioid persistence following major (3.3%) and minor (3.4%) procedures was similar. The incidence in patients younger than 45 years (3.3%), between 45 and 64 years (4.3%), and 65 years and older (2.2%) was also determined to be similar. Univariate patient factors associated with an increased risk for persistent opioid use include cancer (odds ratio [OR], 2.13; 95% CI, 1.11-4.09), mental health disorders (OR, 2.32; 95% CI, 1.17-4.60), and substance use disorders (OR, 2.09; 95% CI, 1.09-4.00). CONCLUSIONS: Among a cohort of over 1,200 opioid-naïve veterans undergoing surgery at a VA Medical Center, just over 3% went on to develop persistent opioid use beyond 3 months following their procedure. Persistent use was not found to be related to the type of procedure (major or minor) or patient age. Significant patient-level risk factors for opioid persistence were cancer and a history of mental health and substance use disorders.

Outcomes Of Manifest Right Free Wall Accessory Pathway Ablation: Data From A Single Center.

BACKGROUND: Right free wall (RFW) accessory pathways (AP) typically present anatomical challenges to ablation leading to high rates of procedural failure and recovery of AP conduction. METHODS: Patients with a diagnosis of Wolff-Parkinson-White Syndrome (WPW) and a manifest RFW AP undergoing an electrophysiology study (EPS) or an ablation at our center between 01/01/2008 and 08/01/2019 were identified from our databases using diagnosis codes and manual chart review. RESULTS: Twenty-one patients with manifest RFW AP underwent EPS, all of which were targeted for ablation. Single procedure success rate was 19 / 21 (90.5%). Of the 19 successful cases, 4 (17.4%) patients were found to have recurrent right free wall pathway conduction at follow-up and each underwent a successful 2nd procedure (9.5%). Fluoroscopic and 3D electroanatomic mapping software was used in all cases to guide ablation. A 4 mm or 8 mm non-irrigated radiofrequency (RF) ablation catheter was used in 76% of cases while an 8 mm cryo-catheter was used in one case. More than one type of ablation catheter was used in four cases (16%). A steerable sheath was used in 68% of cases. CONCLUSIONS: In a tertiary center, RFW AP ablation has high acute success (>90%) but approximately 21% of patients with initially successful ablation required a 2nd procedure for recurrence of pathway conduction. A combination of a large tip ablation catheter and a steerable sheath were used in most cases.

Ablation of manifest septal accessory pathways: a single-center experience.

BACKGROUND: Ablation of septal accessory pathways (SAPs) is associated with an increased risk of heart block. Data on outcomes of SAP ablation in adults are limited. OBJECTIVES: To describe outcomes of SAP ablation in our center. METHODS: Patients with Wolff-Parkinson-White syndrome (WPW) undergoing an EP study at our center between January 2008 and August 2019 were identified from our institutional database. Location of the pathway was noted as anteroseptal (AS), midseptal (MS), or posteroseptal (PS). Outcomes of the ablation including success, complication rates, and recurrences were also recorded. RESULTS: Thirty-three patients with SAP underwent 35 EP studies: AS (n = 13), MS (n = 5), and PS (n = 15). Thirty pathways were targeted for ablation, two of which required a 2nd procedure resulting in 32 attempts at ablation in 30 patients. In the remaining 3 patients, SAP did not have malignant features and were not targeted for ablation. Single-procedure success rate was 28/30 (93.33%): 9/10 AS, 5/5 MS, and 14/15 PS ablations. One AS pathway was successfully ablated during a 2nd procedure. Two complications were observed: 1 pericardial effusion in a patient who underwent epicardial mapping and ablation of both PS and right free wall APs. Additionally, transient 2:1 AV block occurred during an MS pathway ablation that recovered during follow-up and did not require permanent pacing procedure. CONCLUSION: In this single-center experience, ablation of manifest SAP was associated with high success rates and low complication rates. No instances of permanent heart block requiring pacing occurred.

Clinical correlates of hand-held ultrasound-guided assessments of the inferior vena cava in patients with acute decompensated heart failure.

BACKGROUND: Accurately assessing volume status in acutely decompensated heart failure (ADHF) can be challenging. Inferior vena cava (IVC) dynamics by echocardiography allow indirect assessment of volume status in these patients. Recently introduced hand-held ultrasound devices are promising. We aimed to describe the clinical correlates of volume status assessment using a hand-held ultrasound device in ADHF. METHODS: In this prospective study, we evaluated 106 patients admitted with ADHF. First scan was performed within 24 hours of admission and timed in reference to first dose of intravenous diuretic. Daily resting and inspiratory (sniff) IVC diameters were measured according to standard echocardiography methods during hospitalization including the day of discharge. IVC collapsibility index (IVC-CI = Maximum IVC diameter-Inspiratory IVC diameter/maximum diameter; <0.5 representing hypervolemia) was calculated. Primary study endpoint was 30-day readmission. Research activities were independent of clinical decision-making. RESULTS: Data for 106 patients was analyzed. Mean age was 66.7 ± 13.8 years, of which 53.8% were females, and a mean ejection fraction was 39 ± 18%. Initial scan of the IVC was obtained at an average time of 5.2 ± 8.04 hours from first diuretic dose. 81.2% of patients at admission had an IVC-CI <0.5. 63.2% patients had an IVC-CI <0.5 at discharge. There were no significant differences in age, length of stay, diuretic dose, or 30-day readmissions between patients with a discharge IVC-CI <0.5 vs ≥ 0.5. CONCLUSION: Hand-held ultrasound assessment of IVC-CI in ADHF patients, although a feasible concept, is unable to predict 30-day readmissions in our study. Further prospective studies are necessary.

The Safety and Feasibility of Same-Day Discharge After Implantation of MICRA Transcatheter Leadless Pacemaker System.

BACKGROUND: Data suggests that same day discharge after implantation of trans-venous pacemakers is safe and feasible. We sought to determine whether same day discharge was feasible and safe following implantation of Medtronic MICRA leadless pacemakers. METHODS: We retrospectively identified all patients undergoing MICRA placement at our institution between April 2014 to August 2018 (n=167). Patients were stratified into two groups: those discharged on the same day as their procedure (SD, n=25), and those observed for at least one night in the hospital (HD, n=142). The primary endpoint included a composite of major complications including: access site complications, new pericardial effusion, device dislodgement, and need for device revision up to approximately 45 days of follow up. RESULTS: SD and HD had similar age (75±13 vs. 75±13 years, p=0.923), prevalence of male sex (49 vs. 44%, p=0.669), and frequency of high-grade heart block as an indication for pacing (38 vs. 32%, p=0.596). There were more Caucasians in the SD group (72 vs. 66%, p=0.038). The rate of the composite endpoint was statistically non-significantly higher in the HD group (3.5% vs. 0.0%, p=1.00). The rates of each individual components comprising the composite endpoint were similar between groups. CONCLUSIONS: Our data suggest that in appropriately selected patients, same day discharge can occur safely following Micra leadless pacemaker implantation.

Development of a Risk Score to Predict New Pacemaker Implantation After Transcatheter Aortic Valve Replacement.

OBJECTIVES: The aim of this study was to define risk factors and develop a predictive risk score for new pacemaker implantation (PMI) after transcatheter aortic valve replacement (TAVR). BACKGROUND: TAVR has become an accepted treatment alternative for patients with severe aortic stenosis at elevated surgical risk. New PMI is a common occurrence after TAVR and is associated with poorer outcomes. METHODS: All patients without prior valve procedures undergoing elective TAVR with the Edwards SAPIEN 3 at a single institution (n = 1,266) were evaluated. Multivariate analysis was performed to evaluate for predictors of PMI in this population in a derivation cohort of patients with complete data (n = 778), and this model was used to develop the Emory risk score (ERS), which was tested in a validation cohort (n = 367). RESULTS: Fifty-seven patients (7.3%) in the derivation cohort required PMI. In a regression model, history of syncope (odds ratio [OR]: 2.5; p = 0.026), baseline right bundle branch block (OR: 4.3; p < 0.001), QRS duration ≥138 ms (OR: 2.5; p = 0.017), and valve oversizing >15.6% (OR: 1.9; p = 0.041) remained independent predictors of PMI and were included in the ERS. The ERS was strongly associated with PMI (per point increase OR: 2.2; p < 0.001) with an area under the receiver-operating characteristic curve of 0.778 (p < 0.001), which was similar to its performance in the derivation cohort. CONCLUSIONS: A history of syncope, right bundle branch block, longer QRS duration, and higher degree of oversizing are predictive of the need for PMI after TAVR. Additionally, the ERS for PMI was developed and validated, representing a simple bedside tool to aid in risk stratification for patients for undergoing TAVR.

ECG clues for false ST-segment elevation myocardial infarction activations.

BACKGROUND: Rapid diagnosis of ST-segment elevation myocardial infarction (STEMI) is crucial for appropriate management. Catheterization for a false STEMI activation has risks including exposure to contrast agent and radiation, increased healthcare costs and delay in treatment of the primary medical condition. PATIENTS AND METHODS: This was a single center retrospective study including all 'cath alerts' between January 2012 and December 2015. 'Cath alert' is a term used to activate the interventional cardiology team when STEMI is suspected by the emergency department physicians based on review of the initial ECG. We reviewed all STEMI alerts to understand ECG differences between true and false STEMI. RESULTS: Our study population (N = 361) included 221 (61%) men and 140 (39%) women, with average age 60 ± 4.2 years. Among the 361 STEMI alerts, 82 (22.7%) did not have acute coronary syndrome. Common ECG causes of misdiagnosis included left ventricular hypertrophy (LVH, found in 40/82, 49%), early repolarization changes (20/82, 24%), right bundle branch block (RBBB) (13/82, 16%), and Brugada pattern (3/82, 4%). Multivariate regression analysis showed that LVH and RBBB were independent predictors of nonacute coronary syndrome false STEMI (odds ratio: 0.54; 95% confidence interval: 0.32-0.93; P = 0.03 for LVH, and odds ratio: 0.26, 95% confidence interval: 0.1-0.62, P = 0.004 for RBBB). CONCLUSION: The incidence of false STEMI alerts was almost 23% at our center. This number might be reduced with additional training of emergency department physicians in ECG interpretation, and recognition of common causes of misdiagnosis such as LVH, early repolarization changes, RBBB, and Brugada pattern.

Usefulness of the Echocardiographic Calcium Score to Refine Risk of Major Adverse Cardiovascular Events Beyond the Traditional Framingham Risk Score.

Echocardiographic calcifications are associated with major adverse cardiovascular events (MACE). A recently described semiquantitative Global Cardiac Calcium Score (GCCS) has been associated with mortality and stroke, with increasing scores associated with increasing risk. This score assigns points for calcium in the aortic root and valve, mitral valve and annulus, and submitral apparatus, with additional points for restricted leaflet mobility. We tested the hypothesis that the GCCS could improve prediction of MACE beyond traditional risk scores. This was a retrospective study of 216 subjects from a general echocardiography database (mean age 59 ± 15; 51% male). Follow-up was 3.8 ± 1.7 years. The Framingham Risk Score (FRS) and Pooled Cohort Equations (PCE) were applied to each patient. Mean GCCS was 3.2 ± 2. In the total cohort, GCCS predicted MACE (myocardial infarction, stroke, all-cause mortality), even after adjusting for FRS (odd ratio 1.19, p = 0.03). There were 106 subjects (49%) in the low-risk FRS group, 71 (33%) in the intermediate-risk group, and 39 (18%) in the high-risk group. GCCS ≥3 was associated with increased MACE (vs <3) in the low-risk group (p = 0.03), while GCCS <3 was associated with decreased MACE (vs ≥3) in the high-risk group (p = 0.04). When applied to the PCE risk estimate (dichotomized at <7.5% vs ≥7.5%) the GCCS similarly refined risk prediction. In conclusion, the semiquantitative GCCS appears to be a marker of additional unaccounted risk factors; it is easily applied and can further stratify risk of MACE beyond traditional FRS or PCE estimates.

Comparing outcomes after transcatheter aortic valve replacement in patients with stenotic bicuspid and tricuspid aortic valve: A systematic review and meta-analysis.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has become an alternative treatment to surgery in patients with severe aortic stenosis. However, patients with bicuspid aortic stenosis (BAV) are usually excluded from major TAVR studies. The aim of this study is to reexamine current evidence of TAVR in patients with severe aortic stenosis and BAV compared with tricuspid aortic valve (TAV). HYPOTHESIS: There might be differences in outcomes post TAVR between patients with BAV comparing to TAV. METHOD: Databases were systematically searched for relevant articles featuring cohort studies that included patients with BAV and TAV who underwent TAVR studies, of which reported outcomes of interest included mortality and complications in both groups. Pooled effect size was calculated with a random-effect model and weighted for the inverse of variance, to compare outcomes post-TAVR between BAV and TAV. RESULTS: Nine studies were included in the meta-analysis. There was no difference in 30-day mortality rate in patients with BAV compared with TAV (OR: 1.27, 95% CI: 0.84-1.93, I2 = 0). Patients with BAV were more likely to have a moderate to severe paravalvular leak (9 studies; OR: 1.42, 95% CI: 1.08-1.87, I2 = 0) and conversion to surgery (5 studies; OR: 5.48, 95% CI: 1.74-17.27, I2 = 0), and less likely to have device success compared with patients with TAV (5 studies; OR: 0.57, 95% CI: 0.40-0.81, I2 = 0%). CONCLUSIONS: There was no difference in mortality post-TAVR in patients with BAV compared with TAV. Further randomized studies should be done in newer-generation prostheses to assess this association.

Etiologies, Predictors, and Economic Impact of 30-Day Readmissions Among Patients With Peripartum Cardiomyopathy.

Peripartum cardiomyopathy (PPCM) is a pregnancy-associated cause of heart failure. Given the significant impact of heart failure on healthcare, we sought to identify etiologies and predictive factors for readmission in PPCM. We queried the 2013 to 2014 National Readmissions Database to identify patients admitted with a diagnosis of PPCM. Patients who were readmitted within 30 days were evaluated to identify etiologies and predictors of readmission. We identified 6,977 index admissions with PPCM. Of the 6,880 (98.6%) patients who survived the index hospitalization, 30-day readmission rate was 13%. Seventy-six percent of readmitted patients were admitted once, and the other 24% were readmitted at least twice within 30 days of discharge. Length of stay was ≥8 days (adjusted odds ratio [aOR] 2.80, 95% confidence interval [CI] 2.08 to 3.77), multiparity (aOR 2.07, 95% CI 1.09 to 3.92), coronary artery disease (aOR 2.28, 95% CI 1.42 to 3.67), and long-term anticoagulation use (aOR 2.51, 95% CI 1.73 to 3.64) were independently associated with increased risk of 30-day readmission. Among the readmissions, 48% were due to cardiac causes, where PPCM and related complications (24%) were the most common cardiac cause followed by heart failure (16%). The annual cost of stay for index admissions was $64.2 million (average cost for index admission was $16,892). The annual charges attributed to readmission within 30 days were ≈$9 million. Cardiac etiologies were the most common cause for 30-day readmissions in PPCM patients, with a readmission rate of 13%. Long-term anticoagulation use, multiparity, coronary disease and length of stay predicted higher 30-day readmission.

Ventricular tachyarrhythmia in a 78-year-old woman with essential thrombocythaemia.

Anagrelide is a phosphodiesterase-3 inhibitor used in the treatment of essential thrombocythaemia. Cardiovascular side effects such as ventricular tachycardia and cardiomyopathy are rare but potentially fatal and should be made known to patients before starting the medication. It usually arises within the first 6 months after initiation of therapy and may be dose related. The elderly population are particularly susceptible. These cardiotoxicities result from an increase in cyclic AMP that induces positive inotropic and chronotropic effects and are often reversible with cessation of use. We report a case of a 78-year-old woman with essential thrombocythaemia and recently started on anagrelide who presented with syncope and multiple bruises and facial trauma and found to have developed ventricular tachyarrhythmia.

Clinical Characteristics, Management, and Outcomes of Suspected Poststroke Acute Coronary Syndrome.

BACKGROUND: Acute coronary syndrome (ACS) can complicate acute ischemic stroke, causing significant morbidity and mortality. To date, literatures that describe poststroke acute coronary syndrome and its morbidity and mortality burden are lacking. METHODS: This is a single center, retrospective study where clinical characteristics, cardiac evaluation, and management of patients with suspected poststroke ACS were compared and analyzed for their association with inpatient mortality and 1-year all-cause mortality. RESULTS: Of the 82 patients, 32% had chest pain and 88% had ischemic ECG changes; mean peak troponin level was 18, and mean ejection fraction was 40%. The medical management group had older individuals (73 versus 67 years, p < 0.05), lower mean peak troponin levels (12 versus 49, p < 0.05), and lower mean length of stay (12 versus 25 days, p < 0.05) compared to those who underwent stent or CABG. Troponin levels were significantly associated with 1-year all-cause mortality. CONCLUSION: Age and troponin level appear to play a role in the current clinical decision making for patient with suspected poststroke ACS. Troponin level appears to significantly correlate with 1-year all-cause mortality. In the management of poststroke acute coronary syndrome, optimal medical therapy had similar inpatient and all-cause mortality compared to PCI and/or CABG.

Psychiatric conditions as predictors of rehospitalization among African American patients hospitalized with heart failure.

INTRODUCTION: African Americans (AAs) have the highest risk of developing heart failure (HF) among all ethnicities in the United States and are associated with higher rates of readmissions and mortality. This study aims to determine the prevalence and relationship of common psychiatric conditions to outcomes of patients hospitalized with HF. HYPOTHESIS: Psychiatric conditions lead to worse outcomes in HF patients. METHODS: This single-center retrospective study enrolled 611 AA patients admitted to an urban teaching community hospital for HF from 2010 to 2013. Patient demographics, clinical variables, and history of psychiatric disorders were obtained. Cox proportional hazards regression was used to assess impact of psychiatric disorders on readmission rates and mortality. RESULTS: The mean age was 66 ± 15 years; 53% were men. Median follow-up time from index admission for HF was 3.2 years. Ninety-seven patients had a psychiatric condition: 46 had depression, 11 had bipolar mood disorder (BMD), and 40 had schizophrenia. After adjustment of known risk factors and clinical metrics, our study showed that AA HF patients with a psychiatric illness were 3.84× more likely to be admitted within 30 days for HF, compared with those without (P < 0.001). Individually, adjusted Cox multivariable logistic regression analysis also showed that, for 30-day readmission, schizophrenia had a hazard ratio (HR) of 4.92 (P < 0.001); BMD, an HR of 3.44 (P = 0.02); and depression, an HR 3.15 (P = 0.001). No associations were found with mortality. CONCLUSIONS: Psychiatric conditions of schizophrenia, BMD, and depression were significantly associated with a higher 30-day and overall readmission rate for HF among AA patients.

Clinical utility of the HEART score in patients admitted with chest pain to an inner-city hospital in the USA.

BACKGROUND: Chest pain is one of the most common presentations to a hospital, and appropriate triaging of these patients can be challenging. The HEART score has been used for such purposes in some countries and only a few validation studies from the USA are available. We aim to determine the utility of the HEART score in patients presenting with chest pain to an inner-city hospital in the USA. PATIENTS AND METHODS: We retrospectively screened 417 consecutive patients admitted with chest pain to the observation/telemetry units at Einstein Medical Center Philadelphia. After applying inclusion and exclusion criteria, 299 patients were included in the analysis. Patients were divided into low-risk (0-3) and intermediate-high (≥4)-risk HEART score groups. Baseline characteristics, thrombolysis in myocardial infarction score, need for revascularization during index hospitalization, and major adverse cardiovascular events (MACE) at 6 weeks and 12 months were recorded. RESULTS: There were 98 and 201 patients in the low-score group and intermediate-high-score group, respectively. Compared with the low-score group, patients in the intermediate-high-risk group had a higher incidence of revascularization during the index hospital stay (16.4 vs. 0%; P=0.001), longer hospital stay, higher MACE at 6 weeks (9.5 vs. 0%) and 12 months (20.4 vs. 3.1%), and higher cardiac readmissions. HEART score of at least 4 independently predicted MACE at 12 months (odds ratio 7.456, 95% confidence interval: 2.175-25.56; P=0.001) after adjusting for other risk factors in regression analysis. CONCLUSION: HEART score of at least 4 was predictive of worse outcomes in patients with chest pain in an inner-city USA hospital. If validated in multicenter prospective studies, the HEART score could potentially be useful in risk-stratifying patients presenting with chest pain in the USA and could impact clinical decision-making.

Infected ascites: Distinguishing secondary peritonitis from spontaneous bacterial peritonitis in a cirrhotic patient with classic symptoms.

INTRODUCTION: Spontaneous bacterial peritonitis can be differentiated from secondary bacterial peritonitis by the absence of a surgically treatable intra-abdominal source of infection. However, oftentimes this is unapparent and other clinical clues need to be sought after to make the right diagnosis. CASE: A 64-year-old woman was admitted because of three days of worsening diffuse abdominal pain and distention. She was morbidly obese and had a history of non-alcoholic steatohepatitis (NASH) cirrhosis. She was febrile at 38.2 °C. Her abdomen was soft, diffusely tender and distended with a reducible umbilical hernia. Laboratory exam showed a white blood cell count 6700/mcl. Ascitic fluid analysis showed a yellow cloudy fluid with an absolute neutrophil count (ANC) of 720 cells/m3, a total protein of 1.1 g/dl and a lactate dehydrogenase of 242 IU\l. She was given ceftriaxone and albumin. The ascitic fluid culture grew pansensitive Viridans streptococcus. The following days she continued to have fever and abdominal pain and a repeat paracentesis was done which showed improvement in her ANC. Abdominal computed tomography scan was done which showed hernia inflammation with a rim-enhancing fluid collection. Surgery was consulted who did a primary repair of the umbilical hernia and over the next few days the patient improved and was discharged stable. CONCLUSION: Persistence of signs and symptoms of peritonitis despite improvement in ascitic fluid analysis in cirrhotic patients treated for or early relapse of peritonitis with the same organism should prompt the physician to evaluate for secondary peritonitis and surgical management should be considered for potentially correctable sources.

IVC filters-Trends in placement and indications, a study of 2 populations.

Inferior vena cava filter (IVCF) placement appears to be expanding over time despite absence of clear directing evidence.Two populations were studied. The first population included patients who received an IVCF between January 2005 and August 2013 at our community hospital center. Demographic information, indications for placement, and retrieval rate was recorded among other variables. The second population comprised of patients receiving an IVCF from 2005 to 2012 according to the Nationwide Inpatient Sample (NIS) using ICD-9CM coding. Patients were divided into 2 groups based on the year of admission for comparison, that is, first group from 2005 to 2008 and the second from 2009 to 2012. In addition, we analyzed annual trends in filter placement, acute venothromboembolic events (VTE) and several underlying comorbidities within this population.At our center, 802 IVCFs were placed (55.2% retrievable); 34% for absolute, 61% for relative, and 5% for prophylactic indications. Major bleeding (27.5%), minor self-limited bleeding (13.7%), and fall history (11.2%) were the commonest indications. Periprocedural complication rate was 0.7%, and filter retrieval rate was 7%. The NIS population (811,487 filters) saw a decline in IVCF placement after year 2009, following an initial uptrend (Ptrend < 0.01). IVCF use among patients with neither acute VTE nor bleeding among prior VTE saw a 3-fold absolute reduction from 2005 to 2012 (33,075-11,655; Ptrend < 0.01). Patients from 2009 to 2012 were more likely to be male and had higher rates of acute VTE, thrombolytic use, cancer, bleeding, hypotension, acute cardiorespiratory failure, shock, prior falls, blood product transfusion, hospital mortality including higher Charlson comorbidity scores. The patients were younger, had shorter length of stay, and were less likely to be associated with strokes including hemorrhagic or require ventilator support. Prior falls (adjusted odds ratio-aOR 2.8), thrombolytic use (aOR 1.76), and shock (aOR 1.45) were most predictive of IVCF placement between 2009 and 2012 on regression analysis.Recent trends suggest that a higher proportion of patients receive temporary IVCF, for predominantly relative indications. Nationally, the number of filters being placed is decreasing, especially among those who did not experience acute VTE or bleeding events. Prior falls, thrombolytic therapy, and shock were most predictive of IVCF placement in latter half of the study period.