Left atrial echocardiographic parameters predict the onset of atrial fibrillation: the SMASH2 scoring system.

BACKGROUND: As AF-associated morbidity and mortality are increasing, there is an acute need for improved surveillance and prevention strategies to reduce the impact of AF and related strokes. Specific echocardiographic parameters that can best predict future onset of AF within 3 months are lacking. METHODS: Twenty patients with AF, as identified by presence of ICD-9 diagnosis code, were compared with a control group of twenty age- and sex-matched patients selected from the same clinic population but without a diagnosis of AF. Transthoracic echocardiograms (TTE) obtained within 90 days prior to first documented AF episode (study group) or obtained closest to first clinic visit (control) were selected for review. RESULTS: Baseline characteristics, including age, BMI, presence of hypertension, hyperlipidemia, diabetes, and heart failure were comparable. Increased left atrial (LA) size (end systolic major axis in 2-chamber view: AF 4.62±0.03 vs control 3.79±0.21, P =0.03), increased mitral inflow (E/A ratio: AF 1.35±0.15 vs control 1.06±0.07, P =0.04), and reduced LA global longitudinal strain (AF -2.69±0.26 vs control - 3.59±0.31, P =0.04) were most closely associated with AF compared with the control group. Multivariate logistic regression was used to develop predictive models for AF onset. A combination of imaging and traditional clinical risk factors was the best AF prediction model with AUC of 0.94, which greatly exceeds the current best predictors published. From these parameters, we developed the SMASH2 scoring system for 90- day AF risk estimation. CONCLUSIONS: Risk factors for AF and early features of atrial cardiomyopathy including male sex, hypertension, LA enlargement, reduced mitral inflow, and reduced LA strain are powerful predictors of AF onset within 90 days, and may be used to prognosticate future AF risk.

Nonbacterial thrombotic endocarditis in a patient with primary antiphospholipid syndrome.

Nonbacterial thrombotic endocarditis (NBTE) is described in patients with mucin-producing cancers and connective tissue disorders (usually SLE). We report NBTE in the setting of primary antiphospholipid antibody syndrome (APS). A 65-year-old female with APS was incidentally found to have thickened mitral leaflets on transthoracic echocardiogram with no signs of infection. Transesophageal echocardiogram (TEE) showed a mobile mitral mass (1.4 × 0.7 cm) and moderate mitral regurgitation. Differential diagnoses included bacterial endocarditis, NBTE, thrombus or tumor. Given the history of primary APS, the absence of fever and negative blood cultures, NBTE was considered. Low-molecular-weight heparin, hydroxychloroquine and corticosteroid were initiated. Repeat TEE in a week revealed shrinkage of the mass (0.6 × 0.7 cm), indicating an inflammatory nature. Lifelong anticoagulation is indicated regardless of embolism occurrence. Hydroxychloroquine and corticosteroids may have roles in the treatment. Determining and treating the underlying etiology is important.

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.

Transient Ischemic Dilation Ratio in Regadenoson, Single Isotope Gated Single-photon Emission Computed Tomography Myocardial Perfusion Imaging.

Single isotope 99mTc single-photon emission computed tomography-myocardial perfusion imaging (SPECT-MPI) is the most commonly used protocol for nuclear stress testing. Transient ischemic dilation of the left ventricle (TID) has been considered a specific marker of severe coronary artery disease (CAD). Recent publications have questioned the clinical utility of TID, specifically with regadenoson as a stressor and 4DM-SPECT software for TID analysis. These findings have not been demonstrated using other imaging packages. The goal of our study was to establish the TID threshold in the identification of Multi-vessel CAD using Quantitative Perfusion SPECT (QPS) software. Included in this study are 190 patients that had undergone regadenoson-stress, same day, single-isotope 99mTc MPI and had a coronary angiography within a designated 3-month period. QPS (Cedars-Sinai, LA, CA) automated image analysis software was used to calculate TID ratios which were compared across different CAD categories. Coronary angiograms were reviewed to identify both obstructive and nonobstructive CAD. The mean TID for patients with nonobstructive CAD (n = 91) was 1.02 ± 0.11, and the threshold for TID was 1.24. A receiver operating characteristic curve showed that TID had a poor discriminatory capacity to identify MVD (area under the curve 0.58) with a sensitivity of 3% and a specificity of 97%. In our study with regadenoson MPI in a predominantly African-American population, TID was found to be a poor predictor of MVD using QPS software. The reason is unclear but possibly related to the significant decline in the prevalence of severe CAD in the area where our study took place.

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.

Mitral Annular Calcification as a Possible Nidus for Endocarditis: A Descriptive Series with Bacteriological Differences Noted.

BACKGROUND: Mitral annular calcification (MAC) is a chronic inflammatory process with similarities to atherosclerosis. It is common in elderly patients and those with renal dysfunction. Although MAC is associated with cardiovascular morbidity, its relationship to infective endocarditis is unclear. The aim of this study was to test the hypothesis that MAC would be prevalent in patients with mitral valve vegetations and that vegetations would frequently occur on calcific nodules. A secondary aim was to look for possible bacteriological differences between vegetations attached to the calcified annulus versus leaflet vegetations. METHODS: We retrospectively reviewed all echocardiographic studies of patients with native mitral valve vegetations from January 2007 to August 2015 (N = 56). We searched for (1) presence of MAC, (2) location of MAC, and (3) vegetation location (on calcium deposits or distant). MAC was defined as focal echo brightness in a nodular or band-like pattern. The modified Duke criteria were used to confirm the diagnosis of infective endocarditis. Transthoracic, transesophageal, and three-dimensional echocardiograms (when available) at the time of infection were evaluated by a single reader. RESULTS: Twenty-eight subjects were infected with Staphylococcus aureus, 17 with a streptococcal species, and five with other organisms; blood cultures were sterile in 6. Thirty-four (61%) subjects had some degree of MAC, while 22 (39%) had none. Among those with MAC, the vegetation was located on the calcium deposits in 22 (65%), versus in 12 (35%) where it was not. Among all 56 subjects, when S. aureus was the infecting organism it was present on MAC in 16/28 (57%) versus 6/28 (21%; P = .01) for other bacterial species. By contrast, streptococcal infections more frequently involved the leaflets (16/17 [94%]) versus nonstreptococcal infections (18/39 [46%]; P = .0008). CONCLUSIONS: MAC may act as a nidus for infection especially with S. aureus. Differences in mechanism of attachment between S. aureus and streptococci may account for the observed difference in frequency of attachment of vegetations to MAC.

Natural history of severe aortic stenosis: Diastolic wall strain as a novel prognostic marker.

BACKGROUND AND AIM: Diastolic wall strain (DWS) has been proposed as a simple noninvasive measure of left ventricular (LV) stiffness. This study investigated DWS as a possible predictor of mortality in severe aortic stenosis (AS). METHODS: 138 patients with severe AS (indexed aortic valve area [AVA]<0.6 cm2 /m2 ) and normal ejection fraction (>55%) were included. 52 patients (38%) had aortic valve interventions or poor image quality (n=5) and were excluded leaving 86 in the study group (84±8 years, 70% female, 69% African American). DWS was defined as (LVPWs-LVPWd)/LVPWs where LVPWs=left ventricular posterior wall thickness in systole and LVPWd=left ventricular wall thickness in diastole. RESULTS: Follow-up extended 2.0±1.9 years (median 1.6 years). Mean DWS for the group was 0.21±0.11 (normal=0.4±0.07). In patients who died, DWS was significantly lower than in survivors (0.18±0.09 vs 0.24±0.11, P=.02). By contrast, traditional measures of diastolic dysfunction did not predict death. Regression analysis showed DWS predicted death even after adjusting for age, sex, race, indexed AVA, symptoms (angina, shortness of breath, dizziness, syncope), and clinical factors (creatinine, smoking, diabetes, hypertension, hyperlipidemia) (HR 2.5 [95% CI 1.02-5.90], P<.05). The best cutoff value for DWS of 0.25 had a sensitivity of 42% and specificity of 83% for predicting death. CONCLUSIONS: DWS is an independent predictor of all-cause mortality in patients with severe AS, even after accounting for traditional clinical and echocardiographic parameters.