High output cardiac state: evaluating the incidence, plausible etiologies and outcomes.

INTRODUCTION: The high output cardiac state (HOCS) [cardiac index (CI) >4 L/min/m2 ], primarily driven by abnormally low systemic vascular resistance (SVR), is a relatively under-recognized condition. Although, majority of these patients meet criteria for heart failure (HF), their treatment should be aimed at the primary pathology, as the majority of guideline directed HF therapies can reduce SVR further. OBJECTIVES: To characterize patients with HOCS and provide valuable insight into the condition. METHODS: Patients investigated by right heart catheterization (RHC) at the St. Boniface Hospital, Winnipeg, Canada between January 2009 and November 2021 were reviewed. Two groups of patients were included: 1) HOCS [CI >4 L/min/m2], and 2) pre-HOCS [CI between 3.8-4.0 L/min/m2]. Their medical records were reviewed to identify plausible etiologies, relevant investigations, and outcomes. RESULTS: 177/2950 (6 %) patients met criteria for inclusion: 144/177 (81 %) with HOCS [mean age 51 years (range 19 - 82); 67/144 (47 %) female] and 33/177 (19 %) with pre-HOCS [mean age 55 years (range 30 - 83); 6/33 (18 %) female]. The most common plausible etiologies for the HOCS included anemia (36 %), obesity (34 %), cirrhosis (17 %), and lung disease (32 %). Trans-thoracic echocardiography and magnetic resonance imaging findings were non-specific and predominantly described preserved left ventricular ejection fraction, and pulmonary hypertension. The population experienced high rates of hospitalization, and significantly high mortality [36/144 (25 %) of HOCS at a median follow-up of 31.5 months, and 13/33 (39 %) of pre-HOCS at a median follow-up of 17 months]. CONCLUSIONS: HOCS is not an uncommon condition and is associated with high mortality. Current HF guideline should incorporate such evaluation into the diagnostic criteria.

Alternatives to Hospitalization: Adding the Patient Voice to Advanced Heart Failure Management.

Advanced heart failure (HF) is associated with the extensive use of acute care services, especially at the end of life, often in stark contrast to the wishes of most HF patients to remain at home for as long as possible. The current Canadian model of hospital-centric care is not only inconsistent with patient goals, but also unsustainable in the setting of the current hospital-bed availability crisis across the country. Given this context, we present a narrative to discuss factors necessary for the avoidance of hospitalization in advanced HF patients. First, patients eligible for alternatives to hospitalization should be identified through comprehensive, values-based, goals-of-care discussions, including involvement of both patients and caregivers, and assessment of caregiver burnout. Second, we present pharmaceutical interventions that have shown promise in reducing HF hospitalizations. Such interventions include strategies to combat diuretic resistance, as well as nondiuretic treatments of dyspnea, and the continuation of guideline-directed medical therapies. Finally, to successfully care for advanced HF patients at home, care models, such as transitional care, telehealth, collaborative home-based palliative care programs, and home hospitals, must be robust. Care must be individualized and coordinated through an integrated care model, such as the spoke-hub-and-node model. Although barriers exist to the implementation of these models and strategies, they should not prevent clinicians from striving to provide individualized person-centred care. Doing so will not only alleviate strain on the healthcare system, but also prioritize patient goals, which is of the utmost importance.

L'insuffisance cardiaque avancée est associée à une utilisation considérable des services de soins de courte durée, surtout en fin de vie et souvent en contradiction totale avec les désirs de la plupart des patients, qui sont de rester à la maison le plus longtemps possible. Le modèle canadien actuel, centré sur les soins hospitaliers, n'est pas seulement incompatible avec les objectifs des patients, mais il est n'est pas viable vu le manque criant de lits constaté dans des hôpitaux de partout au pays. En tenant compte de ce contexte, nous présentons une perspective permettant de discuter des facteurs nécessaires pour éviter l'hospitalisation des patients atteints d'insuffisance cardiaque avancée. Il faut d'abord identifier les patients admissibles à des soins non hospitaliers en menant des discussions exhaustives sur les objectifs de soins qui se fondent sur les valeurs et qui portent notamment sur la participation du patient et de ses aidants et sur l'évaluation de l'épuisement des aidants. Nous présentons ici les interventions pharmaceutiques qui se sont révélées prometteuses dans la réduction des hospitalisations pour cause d'insuffisance cardiaque. Il s'agit de stratégies visant à lutter contre la résistance aux diurétiques et de traitements non diurétiques de la dyspnée, ainsi que de la poursuite des traitements médicaux indiqués par les lignes directrices. Enfin, pour bien soigner les patients atteints d'insuffisance cardiaque avancée à domicile, les modèles de soins, comme les soins de transition, la télémédecine, les programmes collaboratifs de soins palliatifs à domicile et les programmes d'hospitalisation à domicile, doivent être robustes. Les soins doivent être personnalisés et coordonnés par un modèle de soins intégré, comme le modèle en étoile (spoke-hub-and-node). Bien qu'il existe des obstacles à l'instauration de ces modèles et stratégies, ceux-ci ne devraient pas empêcher les médecins de s'employer à offrir des soins adaptés axés sur la personne. Cette pratique libérera le système de santé d'un poids et permettra de mettre de l'avant les objectifs des patients, qui sont de la plus grande importance.

Impact of C-reactive protein levels on lipoprotein(a)-associated aortic stenosis incidence and progression.

Aims: Elevated lipoprotein(a) [Lp(a)] levels are associated with the risk of coronary artery disease (CAD) and calcific aortic valve stenosis (CAVS). Observational studies revealed that Lp(a) and C-reactive protein (CRP) levels, a biomarker of systemic inflammation, may jointly predict CAD risk. Whether Lp(a) and CRP levels also jointly predict CAVS incidence and progression is unknown. Methods and results: We investigated the association of Lp(a) with CAVS according to CRP levels in the European Prospective Investigation into Cancer and Nutrition (EPIC)-Norfolk study (n = 18 226, 406 incident cases) and the UK Biobank (n = 438 260, 4582 incident cases), as well as in the ASTRONOMER study (n = 220), which assessed the haemodynamic progression rate of pre-existing mild-to-moderate aortic stenosis. In EPIC-Norfolk, in comparison to individuals with low Lp(a) levels (<50 mg/dL) and low CRP levels (<2.0 mg/L), those with elevated Lp(a) (>50 mg/dL) and low CRP levels (<2.0 mg/L) and those with elevated Lp(a) (>50 mg/dL) and elevated CRP levels (>2.0 mg/L) had a higher CAVS risk [hazard ratio (HR) = 1.86 (95% confidence intervals, 1.30-2.67) and 2.08 (1.44-2.99), respectively]. A comparable predictive value of Lp(a) in patients with vs. without elevated CRP levels was also noted in the UK Biobank. In ASTRONOMER, CAVS progression was comparable in patients with elevated Lp(a) levels with or without elevated CRP levels. Conclusion: Lp(a) predicts the incidence and possibly progression of CAVS regardless of plasma CRP levels. Lowering Lp(a) levels may warrant further investigation in the prevention and treatment of CAVS, regardless of systemic inflammation.

COVID-19 Vaccination-Induced Myopericarditis: An Imager's Perspective.

COVID-19 vaccine-induced myocarditis is a rare adverse event in the current pandemic. The following is a case series of 10 individuals with COVID-19 vaccine-related myocarditis confirmed by cardiac magnetic resonance imaging. In this cohort of predominantly male patients, with a mean age of 23 years, chest discomfort and positive cardiac biomarkers occurred at a median of 3 days after the second COVID-19 vaccine dose. Although systolic function was relatively preserved on noninvasive cardiac imaging, evidence was seen of delayed enhancement on cardiac magnetic resonance imaging, confirming myocarditis. As COVID-19 vaccine-induced myocarditis has a relatively benign clinical course, the benefits of vaccination still, by far, outweigh this small risk.

La myocardite induite par le vaccin contre la COVID-19 est un événement indésirable rare de la pandémie actuelle. Voici une série de cas de 10 individus atteints d'une myocardite liée au vaccin de la COVID-19 confirmée par l'imagerie par résonance magnétique cardiaque (RMC). Dans cette cohorte principalement composée d'hommes, dont l'âge moyen était de 23 ans, qui ont manifesté un inconfort à la poitrine et montré des biomarqueurs cardiaques positifs à une médiane de trois jours après la deuxième dose du vaccin contre la COVID-19. Bien que l'imagerie cardiaque non invasive a montré une fonction systolique relativement préservée, la RMC mettait en évidence un rehaussement tardif qui confirmait la myocardite. Puisque la myocardite induite par le vaccin contre la COVID-19 a une évolution clinique relativement bénigne, les avantages de la vaccination restent de loin supérieurs à ce risque minime.

The Critical Transfer From Paediatrics to Adult Care in Patients With Congenital Heart Disease: Predictors of Transfer and Retention of Care.

Background: Congenital heart disease is the most common congenital birth defect and presents with differing degrees of complexity. Patients require lifelong specialized care. The transfer from paediatric to adult care is a time of risk that may result in lapses or loss of care. A successful transfer from paediatric to adult care is integral for improved patient outcomes. Methods: In this retrospective study, we used the paediatric cardiology database and the electronic records at the adult congenital heart disease (ACHD) clinic to identify referrals and successful transfer between 2008 and 2017. Successful transfer was defined as a patient referred to the ACHD clinic who was seen in the clinic and has ongoing follow-up. We also sought to identify predictors of a successful transfer. Results: A total of 555 patients were referred to the ACHD clinic (2008-2017). Of all patients referred, 62% had a successful transfer and an ongoing specialist care. The remaining 38% either did not show for first appointments or missed 3 consecutive visits. Independent predictors of a successful transfer were the presence of moderate or complex ACHD, residing within the city limits, older age at the time of referral, and a more recent year of referral. Conclusions: Over one-third of patients did not achieve successful transfer, namely attendance at first clinic visit plus early retention in care. We were able to identify several variables that predict successful transfer. Further research is required to identify interventions that can be implemented to reduce lapses in patient care.

Contexte: La cardiopathie congénitale, qui est la malformation congénitale la plus courante, présente divers degrés de complexité. Les patients qui en sont atteints nécessitent des soins spécialisés tout au long de leur vie. La transition entre les soins pédiatriques et les soins pour adultes est un moment risqué qui peut occasionner un relâchement ou une interruption des soins. Le succès de ce transfert des soins pédiatriques aux soins pour adultes est essentiel à l'amélioration des résultats pour les patients. Méthodologie: Pour cette étude rétrospective, nous avons utilisé la base de données de cardiologie pédiatrique et les dossiers électroniques de la clinique de cardiopathie congénitale de l'adulte (CCA) pour relever les cas de réorientation et de transfert réussi survenus entre 2008 et 2017. On entendait par « transfert réussi ¼ le fait qu'un patient orienté vers la clinique de CCA ait été vu en consultation à la clinique et qu'il fasse l'objet d'un suivi. Nous avons aussi cherché à identifier les facteurs prédictifs d'un transfert réussi. Résultats: Au total, 555 patients ont été orientés à la clinique de CCA entre 2008 et 2017. Chez 62 % de tous ces patients orientés, le transfert a été réussi et les soins spécialisés ont été poursuivis. Les patients représentant les 38 % restants ne se sont pas présentés soit à leur premier rendez-vous, soit à trois visites subséquentes consécutives. Les facteurs prédictifs indépendants du transfert réussi étaient la présence d'une CCA modérée ou complexe, le fait de résider à l'intérieur des limites de la ville, un âge plus avancé au moment de la réorientation et le caractère plus récent de la réorientation. Conclusions: Chez plus du tiers des patients, le transfert n'a pas été réussi, c'est-à-dire que ces patients ne se sont pas présentés à leur première visite à la clinique et que leurs soins n'ont pas été poursuivis rapidement après le transfert. Nous avons pu cerner plusieurs variables qui prédisent les transferts réussis. D'autres recherches seront nécessaires pour trouver les interventions à mettre en œuvre pour réduire les interruptions dans les soins aux patients.

Population and Resource Utilization Among Patients With Adult Congenital Heart Disease: A Snapshot View of a Moderate-Size Canadian Regional Centre.

BACKGROUND: Health care resource utilization for patients with adult congenital heart disease (ACHD) has not been well characterized outside of large Canadian specialized regional centres. We sought to describe the ACHD population and resource utilization patterns seen in a medium regional Canadian centre providing specialized ACHD care. METHODS: A cross-sectional retrospective study was done from a sample of patients seen in 2018 at the ACHD clinic in Manitoba, Canada. Demographic data were collected along with cardiac anatomy and repair type. Health care resource utilization, clinic visits, hospital admissions, unexpected hospital presentations, and cardiac interventions were measured over a 5-year period. RESULTS: A random sample of 262 patients was selected from our specialized ACHD clinic. Mean age was 33.5 (±13.7) years; 48% of the population was female, and >50% resided within the major city limits. A total of 21% of the population had simple anatomy, 44% had moderate anatomy, and 35% had complex anatomy. The most commonly used imaging modality was echocardiography, followed by cardiac magnetic resonance imaging, with more frequent imaging done in patients with complex anatomy. Unexpected hospital encounters occurred at a rate of 16 per 100 person-years. Total inpatient hospital days occurred at a rate of 33 per 100 person-years, and visits to the congenital clinic occurred at a rate of 90 per 100 person-years. CONCLUSIONS: Health care resource utilization appears to be highest in older adults and those with more complex ACHD anatomy. As the overall cohort of adults with ACHD continues to age, resource needs are likely to increase.

CONTEXTE: L'utilisation des ressources de santé à l'extérieur des grands centres spécialisés régionaux au Canada n'a pas été bien caractérisée pour les patients atteints de cardiopathie congénitale de l'adulte (CCA). Nous avons cherché à décrire la population atteinte de CCA et les schémas d'utilisation des ressources observés dans un centre régional canadien de taille moyenne fournissant des soins spécialisés en CCA. MÉTHODOLOGIE: Une étude transversale rétrospective a été réalisée à partir d'un échantillon de patients rencontrés en 2018 dans une clinique spécialisée en CCA du Manitoba, au Canada. Des données démographiques ont été recueillies de même que des données sur l'anatomie cardiaque et le type de réparation. L'utilisation des ressources de soins de santé, les visites à la clinique, les admissions à l'hôpital, les consultions hospitalières imprévues et les interventions cardiaques ont été mesurées sur une période de cinq ans. RÉSULTATS: Un échantillon aléatoire de 262 patients a été sélectionné dans notre clinique spécialisée en CCA. L'âge moyen des patients était de 33,5 (±13,7) ans; 48 % de la population était de sexe féminin et plus de 50 % résidait dans les limites d'une grande ville. Au total, 21 % de la population présentait une anatomie cardiaque simple, 44 % une anatomie modérément complexe et 35 % une anatomie complexe. La technique d'imagerie la plus utilisée était l'échocardiographie, suivie de l'imagerie par résonance magnétique cardiaque, l'imagerie étant plus fréquente chez les patients présentant une anatomie cardiaque complexe. Le taux de consultations hospitalières imprévues était de 16 pour 100 années-patient. Le nombre total de jours d'hospitalisation était de 33 pour 100 années-patient, et le nombre de visites à la clinique spécialisée en CCA était de 90 pour 100 années-patient. CONCLUSIONS: L'utilisation des ressources de soins de santé semble être plus élevée chez les adultes plus âgés et chez ceux qui présentent une anatomie plus complexe liée à la CCA. Puisque l'ensemble de la cohorte d'adultes atteints de CCA continue de vieillir, les besoins en ressources sont susceptibles d'augmenter.

Cardiac failure and pulmonary hypertension secondary to renal arteriovenous malformation: a case report.

BACKGROUND: Heart failure is usually associated with a low-cardiac-output state; however, a minority of these patients are characterized by a high-output cardiac state, described as a cardiac index of > 4 L/minute/m2. Usually such circulation is associated with low systemic vascular resistance or arteriovenous malformation (AVM), resulting in depressurized circulation and a high-output cardiac state. Treating physicians should be cognizant of such pathology when investigating patients with heart failure. As an example, renal arteriovenous malformations are a rare vascular phenomena that are typically the result of iatrogenic, traumatic or congenital etiology. Generally, non-salient, most are detected as an incidental finding. CASE PRESENTATION: A 75-year-old Afro-Caribbean man with multiple comorbidities presented to the emergency department with a 6-month history of heart failure symptoms. Cardiac catheterization demonstrated a giant right renal AVM leading to a significant left-to-right, post-tricuspid shunt that was treated with transcatheter coiling. CONCLUSIONS: We present this case to emphasize the significance of a detailed workup in a patient with heart failure symptoms.

The Use of Intranasal Fentanyl for the Palliation of Incident Dyspnea in Advanced Congestive Heart Failure: A Pilot Study.

BACKGROUND:: Dyspnea is distressing in palliative patients with end-stage heart failure and many are hospitalized to optimize this symptom. We hoped to conduct a pilot study to determine whether the administration of intranasal fentanyl would decrease activity-induced dyspnea in this patient population. METHODS:: Patients performed two 6-minute walk tests with and without the administration of 50 µg of intranasal fentanyl. Vital signs were recorded before and after each walk, as were participant reported dyspnea and adverse events scores. RESULTS:: Twenty-four patients were screened, 13 were deemed eligible, and 6 completed the study. Dyspnea scores changed from a mean of 6.00 immediately after the walk without fentanyl to a mean of 3.83 after the walk with fentanyl ( P = .048). Mean respiratory rate decreased from 21.0 to 18.7 ( P = .034) breaths per minute and was considered a favorable outcome by the participants. Distance walked did not significantly increase with the fentanyl pretreatment (136.0-144.2 m; P = .283), although the participants reported feeling better while walking a similar distance. CONCLUSIONS:: In this pilot study, the preadministration of intranasal fentanyl prior to activity in palliative, end-stage hospitalized heart failure patients, safely reduced tachypnea, and the feeling of shortness of breath. This approach may help palliate advanced heart failure patients by alleviating symptoms brought on by exertional activities.

An Atypical Case of Takotsubo Cardiomyopathy and Transient Global Amnesia.

Takotsubo cardiomyopathy (TTC) may clinically mimic an acute coronary syndrome and is most often associated with an acute stressor. In this case report, we describe an atypical case of TTC triggered by multiple subacute stressors rather than 1 acute stressor. We also report TTC and transient global amnesia occurring concurrently. This case highlights that TTC can present without a typical stressor and should nonetheless by considered in the appropriate clinical context. Concomitant presentation with transient global amnesia is uncommon, but may result from the 2 conditions potentially sharing an underlying etiology.

La cardiomyopathie de Takotsubo (CTT) peut ressembler sur le plan clinique à un syndrome coronarien aigu et est plus souvent associée à un facteur de stress aigu. Dans ce rapport de cas, nous décrivons un cas atypique de CTT provoquée par de nombreux facteurs de stress subaigu plutôt que 1 facteur de stress aigu. Nous faisons également état de la survenue simultanée de la CTT et de l'amnésie globale transitoire. Ce cas illustre que la CTT peut survenir sans facteur de stress typique et qu'elle devrait néanmoins être considérée dans le contexte clinique approprié. La survenue concomitante de la CTT et de l'amnésie globale transitoire n'est pas fréquente, mais peut résulter de 2 affections ayant possiblement en commun une étiologie sous-jacente.

Cor Triatriatum Sinister: An Unusual Cause of Atrial Fibrillation in Adults.

Cor triatriatum is a rare congenital heart defect that is associated with an increased risk for developing atrial fibrillation. We report a case of a healthy 38-year-old man who presented in decompensated heart failure and atrial fibrillation with a rapid ventricular response. A transthoracic echocardiogram (TTE) demonstrated severe biventricular dysfunction and dilatation in addition to cor triatriatum sinister. He was diuresed with resolution of his symptoms and spontaneously converted back to sinus rhythm. There is limited evidence in the literature surrounding anticoagulation and associated left ventricular dysfunction in the setting of cor triatriatum which posed difficult therapeutic decisions.

Relationship of Extreme Cold Weather and Implantable Cardioverter Defibrillator Shocks.

Cold weather to 0°C has been implicated as a risk factor for ventricular arrhythmias and implantable cardioverter defibrillator (ICD) shocks. The effect of more extreme cold weather on the risk of ventricular arrhythmias and ICD shocks is unknown. We sought to describe the relationship between extreme cold weather and the risk of ICD shocks. We retrospectively identified patients seen at the Pacemaker and Defibrillator Clinic at St. Boniface Hospital in Winnipeg, Manitoba, Canada between 2010 and 2015 with an ICD shock. We excluded multiple shocks occurring on the same day in a single patient. We collected weather data, and evaluated the relationship between ICD shocks and weather on the same day as the shock using Negative Binomial regression. Three hundred and sixty patients experienced a total of 1,355 shocks. When excluding multiple shocks occurring in a single patient on the same day, there were 756 unique shocks. The daily high (DH) was the strongest predictor of receiving an ICD shock. Compared with the warmest days (DH above 10°C), shocks were 25% more common on the coldest days (DH below -10°C), and 8% more common on cold days (DH between -10°C and 10°C). This linear trend was statistically significant, with a p-value of 0.04. In conclusion, we found an association between extreme cold weather and ICD shocks.

Venous Diversion Surgery Revisited: A Baffling Situation.

With the increasing number of survivors with congenital heart disease (CHD) reaching adulthood, it is important for the clinician to be familiar with the various surgical options performed in this growing patient population. We describe the case of a 65-year-old female who presented with hypoxia and right-to-left shunting following a surgical repair of an atrial septal defect (ASD) secundum and anomalous pulmonary veins with a partial atrial diversion procedure in childhood. The use of multimodality cardiovascular imaging using echocardiography, computed tomography, magnetic resonance imaging, and invasive cardiac catheterization was complementary in the preoperative diagnosis and management of this unique baffling situation.

Autoantibodies and immune complexes to oxidation-specific epitopes and progression of aortic stenosis: Results from the ASTRONOMER trial.

BACKGROUND AND AIMS: Elevated levels of lipoprotein(a) [Lp(a)] and oxidized phospholipids on apolipoprotein B-100 (OxPL-apoB) predict the progression of pre-existing mild-to-moderate calcific aortic valve stenosis (CAVS). Whether indirect markers of oxidation-specific epitopes (OSE) are also predictive is not known. The association between IgG and IgM autoantibodies and malondialdehyde-modified low density lipoprotein (MDA-LDL) and IgG and IgM apolipoprotein B immune complexes (apoB-IC), and the hemodynamic progression rate of CAVS was determined in the ASTRONOMER (Aortic Stenosis Progression Observation: Measuring Effects of Rosuvastatin, NCT00800800) trial. METHODS: Plasma levels of IgG and IgM MDA-LDL and apoB-IC were measured in 220 patients with mild-to-moderate CAVS from the ASTRONOMER trial. The endpoint of this study was the progression rate of CAVS, measured by the annualized increase in peak aortic jet velocity (Vpeak) over a median follow-up of 3.5 [2.9-4.5] years. RESULTS: There was no difference in the progression rate of CAVS across tertiles of IgG and IgM MDA-LDL and apoB-IC levels (all p > 0.05). After multivariable analysis, no marker reached significance level to predict faster CAVS progression or need for aortic valve replacement (all p > 0.05). There was no interaction between the OSE antibody titers and plasma levels of Lp(a) or OxPL-apoB, as well as age, with regards to the progression rate of CAVS. CONCLUSIONS: Autoantibody titers to MDA-LDL and apoB-IC, which are an indirect measurement of OSE, unlike direct measurements of OxPL-apoB or their major lipoprotein carrier Lp(a), do not predict the progression of CAVS or need for AVR.

Renal Insufficiency and Early Bystander CPR Predict In-Hospital Outcomes in Cardiac Arrest Patients Undergoing Mild Therapeutic Hypothermia and Cardiac Catheterization: Return of Spontaneous Circulation, Cooling, and Catheterization Registry (ROSCCC Registry).

Objective. Out of hospital cardiac arrest (OHCA) patients are a critically ill patient population with high mortality. Combining mild therapeutic hypothermia (MTH) with early coronary intervention may improve outcomes in this population. The aim of this study was to evaluate predictors of mortality in OHCA patients undergoing MTH with and without cardiac catheterization. Design. A retrospective cohort of OHCA patients who underwent MTH with catheterization (MTH + C) and without catheterization (MTH + NC) between 2006 and 2011 was analyzed at a single tertiary care centre. Predictors of in-hospital mortality and neurologic outcome were determined. Results. The study population included 176 patients who underwent MTH for OHCA. A total of 66 patients underwent cardiac catheterization (MTH + C) and 110 patients did not undergo cardiac catheterization (MTH + NC). Immediate bystander CPR occurred in approximately half of the total population. In the MTH + C and MTH + NC groups, the in-hospital mortality was 48% and 78%, respectively. The only independent predictor of in-hospital mortality for patients with MTH + C, after multivariate analysis, was baseline renal insufficiency (OR = 8.2, 95% CI 1.8-47.1, and p = 0.009). Conclusion. Despite early cardiac catheterization, renal insufficiency and the absence of immediate CPR are potent predictors of death and poor neurologic outcome in patients with OHCA.

Oxidized Phospholipids, Lipoprotein(a), and Progression of Calcific Aortic Valve Stenosis.

BACKGROUND: Elevated lipoprotein(a) (Lp[a]) is associated with aortic stenosis (AS). Oxidized phospholipids (OxPL) are key mediators of calcification in valvular cells and are carried by Lp(a). OBJECTIVES: This study sought to determine whether Lp(a) and OxPL are associated with hemodynamic progression of AS and AS-related events. METHODS: OxPL on apolipoprotein B-100 (OxPL-apoB), which reflects the biological activity of Lp(a), and Lp(a) levels were measured in 220 patients with mild-to-moderate AS. The primary endpoint was the progression rate of AS, measured by the annualized increase in peak aortic jet velocity in m/s/year by Doppler echocardiography; the secondary endpoint was need for aortic valve replacement and cardiac death during 3.5 ± 1.2 years of follow-up. RESULTS: AS progression was faster in patients in the top tertiles of Lp(a) (peak aortic jet velocity: +0.26 ± 0.26 vs. +0.17 ± 0.21 m/s/year; p = 0.005) and OxPL-apoB (+0.26 ± 0.26 m/s/year vs. +0.17 ± 0.21 m/s/year; p = 0.01). After multivariable adjustment, elevated Lp(a) or OxPL-apoB levels remained independent predictors of faster AS progression. After adjustment for age, sex, and baseline AS severity, patients in the top tertile of Lp(a) or OxPL-apoB had increased risk of aortic valve replacement and cardiac death. CONCLUSIONS: Elevated Lp(a) and OxPL-apoB levels are associated with faster AS progression and need for aortic valve replacement. These findings support the hypothesis that Lp(a) mediates AS progression through its associated OxPL and provide a rationale for randomized trials of Lp(a)-lowering and OxPL-apoB-lowering therapies in AS. (Aortic Stenosis Progression Observation: Measuring Effects of Rosuvastatin [ASTRONOMER]; NCT00800800).

Novel high-sensitivity troponin assay requires higher cut-off value to separate acute myocardial infarction from non-acute myocardial infarction in a high-risk population.

PURPOSE: The novel high-sensitivity troponin T assay (hs-cTnT) has been validated for diagnosing AMI in the emergency room. However its utility in high-risk in-patient populations is unknown. METHODS: We retrospectively reviewed admissions to a general cardiology unit that had 2 hs-cTnT measurements in the first 12 h of presentation. We assessed 8 diagnostic algorithms that used hs-cTnT concentration and changes in concentration (including the 99th percentile cut-off of 14 ng/L) for their diagnostic utility in separating AMI patients from cardiac/nonACS and non-cardiac chest-pain patients. UA was excluded. RESULTS: There were 233 patients (mean age 67 years, 153 were males (66%)) admitted over a 2 month period, with AMI diagnosed in 118 of these patients (51%). The recommended 99th percentile cut-off had modest accuracy (65%), good sensitivity (88%), and poor specificity (25%); a higher cut-off of 75 ng/L had a better diagnostic accuracy of 73%, p < 0.05. While some hs-cTnT algorithms were either highly sensitive or specific, none were both. CONCLUSION: In high-risk cardiology in-patients, no hs-cTnT concentration cut-off or change more accurately diagnosed and excluded AMI, although higher cut-offs had better diagnostic utility.

Early diagnosis and management of myocardial rupture.

Left ventricular free wall rupture is a catastrophic mechanical complication of myocardial infarction. We present an 82-year-old woman with an anterolateral ST segment elevation myocardial infarction treated with thrombolysis. Because of unexplained hypotension, echocardiography was performed and contrast (Definity; Lantheus Medical Imaging) was used to improve visualization. Findings included a small- to moderate-sized circumferential pericardial effusion without frank tamponade, however, there was significant intramyocardial tracking of the contrast into the epicardial space, localized to the mid to apical portion of the anterior septum, consistent with rupture or disruption of the wall segment. The patient was promptly taken to the operating room where fresh blood and clots were evacuated from the pericardial space with immediate hemodynamic improvement. The patient underwent successful surgical repair.

Embolus from probable Takotsubo cardiomyopathy: a bedside diagnosis.

A 59-year-old woman with stroke and thromboembolic aortoiliac disease in the setting of profound stress was found to have severe left ventricular (LV) systolic dysfunction and large mobile clot on focused cardiac ultrasonography (FCU). Marked recovery of LV function and thrombus resolution within 4 days suggested resolving Takotsubo cardiomyopathy. The role of FCU in early diagnosis and treatment is outlined here.

Circulating levels of matrix gla protein and progression of aortic stenosis: a substudy of the Aortic Stenosis Progression Observation: Measuring Effects of rosuvastatin (ASTRONOMER) trial.

BACKGROUND: Matrix γ-carboxyglutamate protein is an inhibitor of cardiovascular calcification. The objective of this substudy of the Aortic Stenosis Progression Observation: Measuring Effects of Rosuvastatin (ASTRONOMER) trial was to examine the relationship between total (ie, carboxylated [active] form + uncarboxylated [inactive] form) circulating desphosphorylated matrix γ-carboxyglutamate protein (dpMGP) level and the progression rate of aortic stenosis (AS). METHODS: Among the patients included in the ASTRONOMER trial, 215 patients had measures of baseline circulating total dpMGP level and an echocardiographic follow-up (mean follow-up: 3.5 ± 1.3 years). Progression of AS was assessed according to the measurement of the annualized increase in peak aortic jet velocity. RESULTS: In the whole cohort, baseline dpMGP level was associated with faster progression rate of peak aortic jet velocity (r = 0.16; P = 0.02) in individual analysis but not in multivariable analysis (P = 0.40). However, there was a significant interaction (P = 0.03) between dpMGP level and age, with respect to the effect on AS progression. After dichotomization according to median value of age (ie, 57 years old), total dpMGP level was associated with faster AS progression rate (r = 0.24; P = 0.008) in the younger patients, and this association remained significant in multivariable analysis (P = 0.04), but not in the older ones. The independent correlates of dpMGP level were fasting glucose (P = 0.009) and oxidized low-density lipoprotein (P = 0.01). CONCLUSIONS: This is the first prospective study to demonstrate a relationship between increased circulating levels of total dpMGP and faster progression rate of AS in younger individuals. Future studies are needed to determine if dpMGP is simply a marker or a contributing factor to ectopic mineralization of aortic valve.