Beta Blockers in Contemporary Cardiology: Is It Better to Cast Them Out?

Beta blockers are one of the commonest prescription drugs in medicine and they have been thought to revolutionize the treatment of heart failure (HF) with reduced ejection fraction (HFrEF) in the last century. In addition to HFrEF, they are prescribed for a variety of diseases in cardiology from hypertension to HF, angina, and stable coronary artery disease (CAD). The increased prescription of beta blockers in conditions like HF with preserved ejection fraction (HFpEF), and stable CAD may be doing more harm than good as per the data we have so far. The available data shows that beta blockers are associated with increased stroke risk and atrial fibrillation (AF) in hypertension and in patients with HFpEF, they have been associated with decreased exercise capacity. In patients with stable CAD and patients with myocardial infarction with normal systolic functions, beta blockers don't offer any mortality benefit. In this article, we critically review the common indications and the uses of beta blockers in patients with HFpEF, CAD, hypertension and AF and we propose that beta blockers are over-prescribed under the shadow of their beneficial effects in patients with HFrEF.

Patient Characteristics Associated With Phone and Video Visits at a Tele-Urgent Care Center During the Initial COVID-19 Response: Cross-Sectional Study.

BACKGROUND: Health systems rapidly adopted telemedicine as an alternative health care delivery modality in response to the COVID-19 pandemic. Demographic factors, such as age and gender, may play a role in patients' choice of a phone or video visit. However, it is unknown whether there are differences in utilization between phone and video visits. OBJECTIVE: This study aimed to investigate patients' characteristics, patient utilization, and service characteristics of a tele-urgent care clinic during the initial response to the pandemic. METHODS: We conducted a cross-sectional study of urgent care patients using a statewide, on-demand telemedicine clinic with board-certified physicians during the initial phases of the pandemic. The study data were collected from March 3, 2020, through May 3, 2020. RESULTS: Of 1803 telemedicine visits, 1278 (70.9%) patients were women, 730 (40.5%) were aged 18 to 34 years, and 1423 (78.9%) were uninsured. There were significant differences between telemedicine modalities and gender (P<.001), age (P<.001), insurance status (P<.001), prescriptions given (P<.001), and wait times (P<.001). Phone visits provided significantly more access to rural areas than video visits (P<.001). CONCLUSIONS: Our findings suggest that offering patients a combination of phone and video options provided additional flexibility for various patient subgroups, particularly patients living in rural regions with limited internet bandwidth. Differences in utilization were significant based on patient gender, age, and insurance status. We also found differences in prescription administration between phone and video visits that require additional investigation.

Electrocardiographic lead reversals.

Misplacement of cables during the recording of a 12-lead electrocardiogram [ECG] poses a non-negligible risk of creating panic and confusion at the bedside in daily clinical practice. Clinical awareness about the manifestations of commonly encountered electrode misplacements is imperative for avoiding misdiagnosis. A basic understanding of the electrophysiology behind these anomalous ECG tracings is likely to aid in prompt suspicion, accurate detection, and appropriate rectification in most cases. We discuss the abnormalities produced on 12-lead ECG tracings by the misplacement of electrode cables, with a focus on the clinical implications of the same. We suggest a mnemonic - 'SPIRAL' - as a quick screening criterion to detect commonly encountered lead reversals.

Does Cardiac Arrhythmia Predict Worse Outcome in Mild or Moderate Covid-19 Infection?

Covid-19 is a multisystem disease with the lungs being predominantly affected. Cardiac involvement is mostly seen as a rise in troponins, arrhythmias, and ventricular dysfunction. This study aimed to estimate the incidence of arrhythmias seen in Covid-19 infection and assess if arrhythmias predict worsening or mortality. Prospective observational study involving patients with mild to moderate Covid illness admitted in a tertiary care centre. Among the 85 patients (Mean age 45.8 + 14.1 years; 75.31% men), worsening of Covid-19 illness was seen in 29 (34.1%) patients. New onset arrhythmias were detected on Holter in 9 (10.5%) patients. Supraventricular tachycardia was seen in 7 (8.2%) patients of whom 6 showed worsening which was statistically significant (p-value-0.006). Risk factors associated with worsening on univariate analysis were male gender (OR [95%CI] = 6.93(1.49-32.31), p-value - 0.014), new onset supraventricular tachycardia (OR [95% CI] = 14.35 [1.64-125.94], p-value - 0.016) and D-dimer elevation (OR [95% CI] = 1.00(1.00-1.01), p-value - 0.02). On multivariate analysis D-dimer (OR [95% CI] = 1.00(1.00-1.01; p-value 0.046) and supraventricular arrhythmias (OR [95% CI] = 11.12 (1.22-101.14); p-value - 0.033) were independently associated with worsening. Covid-19 infection can lead to cardiac arrhythmias. The development of supraventricular tachycardia in patients with Covid-19 infection predicts higher morbidity and worsening.

A Pilot Study of Electrocardiographic Features in Patients with Obesity from a Tertiary Care Centre in Southern India (Electron).

Background: Obesity is associated with increased all-cause mortality and cardiovascular disease (CVD). An electrocardiogram (ECG) may be used to screen for subtle signs of CVD or altered cardiac morphology in the obese. Methodology: This observational cross-sectional analysed ECG changes in patients with obesity at a tertiary care centre in southern India. Results: One hundred and fifty adult patients with a mean (SD) BMI of 39.9 (6.7) kg/m2 were recruited in the study after excluding those with comorbidities (diabetes mellitus, systemic hypertension) or on chronic medications (ACE inhibitors). The cohort showed a female predominance (69.3%), with a mean (SD) age of 45.4 (11.2) years. Most patients exhibited a sinus rhythm (78%), with one patient showing features of first-degree conduction block. Sinus tachycardia was seen in 32 (21.3%) patients. We observed left and right ventricular hypertrophy in five (3.3%) and three (2%) patients, respectively. Observed ECG patterns included a prolonged QTc in 16 (10.7%) patients, inverted T-waves (mostly in the inferior leads) in 39 (26%) patients and ST-segment depression (predominantly in the lateral leads) in 14 (9.3%) patients. A greater prevalence was noted for morbid obesity. No deaths were reported in our cohort. Conclusions: The predominant ECG variations in this cohort included tachycardia, atrial enlargement, ventricular hypertrophy, conduction defects, LAD, features of ischemia or old infarction and repolarization abnormalities, with a greater prevalence in morbid obesity. Further studies are needed to assess the impact of weight reducing measures on reversibility of these changes and determine the association with outcomes in obese patients.

Atrial depolarization abnormalities in pulmonary sarcoidosis.

BACKGROUND: Cardiac sarcoidosis, often manifested as sudden death, can be the first manifestation of sarcoidosis. Since 12-lead electrocardiogram (ECG) is recommended as an initial screening tool for cardiac sarcoidosis, the recognition of subtle abnormalities assumes utmost significance. The objective of this study was to identify the electrocardiographic abnormalities in patients with pulmonary sarcoidosis. RESULTS: A detailed analysis of 12-lead ECGs obtained from sixty patients with histopathologically proven pulmonary sarcoidosis and no overt cardiac involvement was done. The findings were compared with those of an age-matched control group. Varying degrees of intraventricular conduction defects were common in the study group [67%], as well as the control group [57%] [P = 0.23]. There was a higher prevalence of biphasic P wave [P = 0.003] and bifid P wave [P = 0.029] in lead III and rsr' in lead aVF [P = 0.03] in the study group as compared to the control group. CONCLUSIONS: Our study demonstrates a greater prevalence of subtle ECG abnormalities in patients with pulmonary sarcoidosis as compared to patients with other forms of pulmonary disease. Atrial depolarization abnormalities were commoner in patients with pulmonary sarcoidosis.

The implementation and outcome of a 2-year prospective audit and feedback based antimicrobial stewardship program at a private tertiary care hospital.

PURPOSE: Antimicrobial resistance has emerged as a major public health problem in India. Hence effective antimicrobial stewardship programs (AMSP) are needed. We report the design, implementation and results of a prospective audit and feedback based AMSP at a private tertiary care hospital. METHODS: During the study period - January 2018 to December 2019 - the prescription of restricted antimicrobials required the filling of a justification form which was reviewed by the antimicrobial stewardship committee (AMSC) at 48-72 â€‹h. Patients in whom the restricted antimicrobial was stopped earlier than 48 â€‹h were not applicable for review. The eligible prescriptions were judged as justified/unjustified by AMSC based on the patient's clinical and previous antimicrobial history, course, results of investigations/cultures, guidelines and communicated to the treating team. Compliance to the recommendations of the AMSC was measured. Days of therapy for each restricted antimicrobial/1000 patient days was calculated. Colistin resistance rates in pathogens causing central line associated blood stream infections (CLABSI) were compared with previous years. RESULTS: A total of 2397 restricted antimicrobials in 1366 patients were prescribed in the study period of which 1801 prescriptions were applicable for review (75%). Overall, 1.4% of admitted patients were prescribed restricted antimicrobials. The total days of therapy with restricted antimicrobials was 41/1000 patient days. The AMSC committee adjudged 12.5% of prescriptions as unjustified and recommendations for de-escalation were accepted in 89%. There was no significant difference in the study outcomes between 2018 and 2019. CONCLUSION: The prospective audit and feedback component of AMSP provided insight into the use of restricted antimicrobials at our hospital. This component should be considered by hospitals for inclusion in their AMSP program on an ongoing basis even if limited to a few drugs and in few areas of the hospital.

Effects of heat stroke on surface ECG: a study on clinical outcomes.

AIMS: Classic heat stroke is associated with high in-hospital mortality and morbidity. The relation between the ECG findings in heat stroke and the clinical outcomes of these patients has not been studied. The aim of this study was to describe the electrocardiographic features in patients with classic heat stroke and to determine if there is any correlation of ECG findings with in-hospital outcomes. METHODS: We performed a retrospective study on 50 patients with classic heat stroke during summer months of 2016-2018. All 12-lead electrocardiographic recordings obtained from these patients were subjected to in-depth analysis. Statistical analysis was done to determine the correlation of electrocardiographic findings with in-hospital outcomes. RESULTS: 37 patients were in sinus rhythm, while supraventricular arrhythmias including atrial fibrillation (n=6), ectopic atrial tachycardia (n=4) and atrial flutter (n=2) were observed in the rest. There was a high prevalence of QTc prolongation, low voltage P waves, conduction defects like incomplete right bundle branch block and repolarisation abnormalities. The ratio of QRS voltage in the limb leads to that in precordial leads was ≤0.5 in nearly three-fourths of the patients. Among the observed electrocardiographic features, low P-wave voltage (<0.01 mV) in lead II was found to have statistically significant correlation with adverse in-hospital outcome (OR 8.93, p=0.04), after adjustment for clinical covariates. CONCLUSION: There was high incidence of atrial arrhythmias in patients with classic heat stroke. A low P-wave voltage (<0.01 mV) in lead II was predictive of adverse in-hospital outcome in this cohort of patients.

Devil is in the detail.

A 15-year-old girl of Asian origin, hailing from a rural agrarian background, presented with history of multiple episodes of dizziness for 3 years. The episodes were precipitated mostly by emotional and/or physical stress and relieved on lying down, with a few episodes culminating in transient loss of consciousness. As preliminary cardiac and neurological evaluation were normal, she was being treated by the primary physician as a case of probable psychogenic syncope, supported by the consistent association of the episodes with emotional stress. A detailed review of family history revealed that the premature demise of the patient's siblings which were attributed to snakebite and head trauma by the family could have been in reality sudden cardiac deaths. Treadmill test revealed exercise-induced polymorphic ventricular tachycardia confirmatory for the diagnosis of catecholaminergic polymorphic ventricular tachycardia. She was initiated on beta-blocker therapy to which she showed remarkable response.

Left ventricular structure and diastolic function by cardiac magnetic resonance imaging in hypertrophic cardiomyopathy.

OBJECTIVE: Diastolic dysfunction is common in hypertrophic cardiomyopathy (HCM) and hypertensive heart disease (HHD), but its relationships with left ventricular (LV) parameters have not been well studied. Our objective was to assess the relationship of various measures of diastolic function, and maximum left ventricular wall thickness (MLVWT) and left ventricular mass index (LVMI) in HCM, HHD and normal controls using cardiac magnetic resonance imaging (CMR). We also assessed LV parameters and diastolic function in relation to late gadolinium enhancement (LGE) and right ventricular (RV) hypertrophy in HCM. METHODS: 41 patients with HCM, 21 patients with HHD and 20 controls were studied. Peak filling rate (PFR), time to peak filling (TPF), MLVWT and LVMI were measured using CMR. LGE and RV morphology were assessed in HCM patients. RESULTS: MLVWT correlated with TPF in HCM (r=0.38; p=0.02), HHD (r=0.58; p=0.01) and controls (r=0.54; p=0.01); correlation between MLVWT and TPF was weaker in HCM than HHD. LVMI did not correlate with diastolic function. In HCM, LGE extent correlated with MLVWT (τ=0.41; p=0.002) and with TPF (τ=0.29; p=0.02). The HCM patients with RV hypertrophy had higher MLVWT (p<0.001) and TPF (p=0.03) than patients without RV hypertrophy. CONCLUSION: MLVWT correlates with diastolic function (TPF) in HCM, HHD and controls. LVMI did not show significant correlation with TPF. The diastolic dysfunction in HCM is not entirely explained by wall thickening. LGE and RV involvement are associated with worse LV diastolic function, suggesting that these may be markers of more severe underlying myocardial disarray and fibrosis that contribute to diastolic dysfunction.

Analgesic Efficacy of Transverse Abdominal Plane Block after Elective Cesarean Delivery - Bupivacaine with Fentanyl versus Bupivacaine Alone: A Randomized, Double-blind Controlled Clinical Trial.

BACKGROUND: The analgesic benefit of transversus abdominis plane (TAP) blocks for cesarean delivery remains controversial. In our study, we compared the analgesic efficacy of TAP block using local anesthetic bupivacaine and adjunct fentanyl with bupivacaine alone in patients undergoing elective cesarean section. METHODS: Our study was a randomized, double-blind, controlled clinical trial where sixty patients undergoing elective cesarean delivery under subarachanoid block (2 ml of 0.5% bupivacaine) were randomized into two groups, A and B. At the end of the surgical procedure, bilateral TAP block was performed guided by the ultrasound. Group A received 38 ml of 0.25% bupivacaine and 2 ml of 50 µg of fentanyl, whereas Group B received 38 ml of 0.25% bupivacaine + 2 ml of normal saline. The total volume was divided equally and administered bilaterally. Each patient was assessed for 24 h after TAP block, for time to rescue analgesia, pain using visual analog scale (VAS) score at rest and on movement, hemodynamic parameters (heart rate and blood pressure), nausea, vomiting, and sedation. Diclofenac 75 mg was given as rescue analgesia when the patient complained of pain or when VAS score >4. RESULTS: Prolonged postoperative analgesia was noticed with both the groups, with a mean time to rescue analgesia of approximately 6.5 h. There was no significant difference in time to rescue analgesia (6.49 ± 0.477 vs. 6.5 ± 0.480) when both the groups were compared among themselves. The pain scores among the two groups when compared did not show any added benefit. Incidence of nausea, vomiting, and sedation when compared between both the groups showed no difference. CONCLUSION: The TAP block as a part of a multimodal analgesic regimen definitely has a role in providing superior analgesia in the postoperative period. However, adjunct fentanyl to local anesthetic bupivacaine was found to have no added advantage when quality and duration of analgesia was compared.

Decrement Evoked Potential Mapping: Basis of a Mechanistic Strategy for Ventricular Tachycardia Ablation.

BACKGROUND: Substrate-based mapping for ventricular tachycardia (VT) ablation is hampered by its inability to determine critical sites of the VT circuit. We hypothesized that those potentials, which delay with a decremental extrastimulus (decrement evoked potentials or DEEPs), are more likely to colocalize with the diastolic pathways of VT circuits. METHODS AND RESULTS: DEEPs were identified in intraoperative left ventricular maps from 6 patients with ischemic cardiomyopathy (total 9 VTs) and were compared with late potential (LP) and activation maps of the diastolic pathway for each VT. Mathematical modeling was also used to further validate and elucidate the mechanisms of DEEP mapping. All patients demonstrated regions of DEEPs and LPs. The mean endocardial surface area of these potentials was 18±4% and 21±6%, respectively (P=0.13). The mean sensitivity for identifying the diastolic pathway in VT was 50±23% for DEEPs and 36±32% for LPs (P=0.31). The mean specificity was 43±23% versus 20±8% for DEEP and LP mapping, respectively (P=0.031). The electrograms that displayed the greatest decrement in each case had a sensitivity and specificity for the VT isthmus of 29±10% and 95±1%, respectively. Mathematical modeling studies recapitulated DEEPs at the VT isthmus and demonstrated their role in VT initiation with a critical degree of decrement. CONCLUSIONS: In this preliminary study, DEEP mapping was more specific than LP mapping for identifying the critical targets of VT ablation. The mechanism of DEEPs relates to conduction velocity restitution magnified by zigzag conduction within scar channels.

Limb-girdle muscular dystrophy with obesity for elective cesarean section: Anesthetic management and brief review of the literature.

Limb-girdle muscular dystrophy (LGMD) is an autosomal recessive disorder in which the pelvic or shoulder girdle musculature is predominantly or primarily involved. We report the management of a 27-year-old primigravida with LGMD associated with obesity posted for elective cesarean section. She was successfully managed with epidural anesthesia assisted with noninvasive positive pressure ventilation. She had an uncomplicated intra- and post-operative course.

Nintendo wii sports and wii fit game analysis, validation, and application to stroke rehabilitation.

BACKGROUND: Interactive video gaming has become ubiquitous in the practice of rehabilitation. The Nintendo Wii is one such system. Interactive gaming can promote intensive task-based therapy in a manner that is motivating for the user. Widespread enthusiasm for consoles and their games prompted us to analyze the games for their rehabilitation elements related to improving balance and mobility for individuals poststroke. PURPOSE: The purpose of this article is to provide a game analysis for clinical application and evaluation of the game elements for research on interactive video gaming. METHODS: Using a team of game players and raters, 5 tables (1 for the Wii Sports and 4 for the Wii Fit) were developed and validated. The tables consist of 3 categories: game description, impairments targeted (strength, endurance, balance, and coordination), and feedback provided (knowledge of performance [KP] and knowledge of results [KR]). Two domain content experts established face validity. Construct validity was performed by 2 therapist-raters who had more than 15 years' clinical experience and postgraduate training in motor learning. Observations about the games including the fidelity of the interfaces, the nature of the feedback, and some of the challenges to adapting the games for rehabilitation are presented. RESULTS: An 80% agreement between raters set as the criterion for establishing the construct validity was met for feedback evaluation. There was 100% agreement on impairment ratings. Games provide a greater amount of KR compared with KP. CONCLUSION: Given the preponderance of KR, therapists will need to monitor motor performance. Adaptation of interactive video consoles for rehabilitation requires careful evaluation of the games' attributes using relevant rehabilitation construits.