Bridging Care Transition After Hospitalization for Atrial Fibrillation and Coronary Interventions.

ABSTRACT: Treatment fragmentation between hospitals and the community can result in catastrophic outcomes; uninterrupted treatment with anticoagulant and platelet aggregation inhibitors is particularly important. We assessed the proportion and characteristics of patients who did not visit their primary community-based physician within 1 week of discharge from our department of cardiovascular medicine and the proportion that failed to procure essential drugs at the community pharmacy. We prospectively studied 423 patients who were discharged from our department. They were provided detailed explanations, tablets for 7 days, prescriptions, and a printed drug plan. We traced the time from discharge until a visit with a primary community-based physician, and the time until the procurement of medications, using our computerized community-hospital-integrated system. Complete data were available for 313 patients, of whom 220 were treated with anticoagulants or platelet aggregation inhibitors. For 175 patients, these drugs were initiated during index hospitalizations. Only 1 patient did not receive platelet aggregation inhibitors despite recommendations. Seventy-nine patients (25%) first visited their primary care physicians more than 1 week after discharge. Predictors for delayed visits were living alone (hazard ratio 1.91) and having an in-house caregiver (hazard ratio 2.01). In conclusion, all but 1 patient continued drug therapy after discharge from the hospital. The simple predischarge steps included patient education and provision of a 1-week supply of tablets and prescriptions. Treatment continuation was independent of visits to the community-based primary physician. Patients living alone or with an in-house caregiver more often delayed visits to primary physicians yet continued relevant drug therapy.

Global longitudinal strain and long-term outcome in patients presenting to the emergency department with suspected acute coronary syndrome.

AIMS: We have previously shown that 2-dimentional strain is not a useful tool for ruling out acute coronary syndrome (ACS) in the emergency department (ED). The aim of the present study was to determine whether in patients with suspected ACS, global longitudinal strain (GLS), measured in the ED using 2-dimensional strain imaging, can predict long-term outcome. METHODS: Long-term (median 7.7 years [IQR 6.7-8.2]) major adverse cardiac events (MACE; cardiac death, ACS, revascularization, hospitalization for heart failure, or atrial fibrillation) and all-cause mortality data were available in 525/605 patients (87%) enrolled in the Two-Dimensional Strain for Diagnosing Chest Pain in the Emergency Room (2DSPER) study. The study prospectively enrolled patients presenting to the ED with chest pain and suspected ACS but without a diagnostic ECG or elevated troponin. GLS was computed using echocardiograms performed within 24 hours of chest pain. MACE of patients with worse GLS (>median GLS) were compared to patients with better GLS (≤ median GLS). RESULTS: Median GLS was -18.7%. MACE occurred in 47/261 (18%) of patients with worse GLS as compared with 45/264 (17%) with better GLS, adjusted HR 0.87 (95% CI 0.57-1.33, P = .57). There was no significant difference in all-cause mortality or individual endpoints between groups. GLS did not predict MACE even in patients with optimal 2-dimensional image quality (n = 164, adjusted HR=1.51, 95% CI 0.76-3.0). CONCLUSIONS: Global longitudinal strain did not predict long-term outcome in patients presenting to the ED with chest pain and suspected ACS, supporting our findings in the 2DSPER study.

Impact of diabetes and early revascularization on the need for late and repeat procedures.

BACKGROUND: Coronary artery disease often progresses more rapidly in diabetics, but the integrated impact of diabetes and early revascularization status on late or repeat revascularization in the contemporary era is less clear. METHODS: Coronary angiography was performed in 12,420 patients between the years 2000-2015 and early revascularization status [none, percutaneous coronary intervention (PCI) or bypass surgery (CABG)] was determined. Subsequent revascularization procedures were recorded over a median follow-up of 67 months and its relation to diabetic and baseline revascularization status was studied. RESULTS: Early revascularization status was none in 5391, PCI in 5682 and CABG in 1347 patients. Late revascularization rates were 10, 26 and 11.1% respectively. Diabetes was present in 37%; a stepwise relationship of diabetic status with late revascularization was observed: no diabetes (reference) 14.4%, non-insulin treated diabetes 21% (adjusted HR 1.35, 95% CI 1.23-1.49, p < 0.001) and insulin-treated diabetes 32.8% (adjusted HR 2.20, 95% CI 1.91-2.54, p < 0.001), which was similar in magnitude for each early revascularization state (none, PCI or CABG). Further revascularizations (≥ 2) were also significantly more common in diabetics, in particular if insulin-treated. Glycosylated hemoglobin level was moderately associated with late revascularization in diabetics after early PCI but not following diagnostic catheterization or CABG. CONCLUSIONS: Diabetic status graded by treatment, and in particular insulin therapy, is a strong predictor for late or repeat revascularization irrespective of early revascularization status. The high rate of repeat revascularization in diabetics following PCI remains a challenging issue.

Characterization of Coronary Artery Disease in Young Adults and Assessment of Long-term Outcomes.

BACKGROUND: Contemporary data on clinical profiles and long-term outcomes of young adults with coronary artery disease (CAD) are limited. OBJECTIVES: To determine the risk profile, presentation, and outcomes of young adults undergoing coronary angiography. METHODS: A retrospective analysis (2000-2017) of patients aged ≤ 35 years undergoing angiography for evaluation and/or treatment of CAD was conducted. RESULTS: Coronary angiography was performed in 108 patients (88% males): 67 acute coronary syndrome (ACS) and 41 non-ACS chest pain syndromes. Risk factors were similar: dyslipidemia (69%), positive family history (64%), smoking (61%), obesity (39%), hypertension (32%), and diabetes (22%). Eight of the ACS patients (12%) and 29 of the non-ACS (71%) had normal coronary arteries without subsequent cardiac events. Of the 71 with angiographic evidence of CAD, long-term outcomes (114 ± 60 months) were similar in ACS compared to non-ACS presentations: revascularization 41% vs. 58%, myocardial infarction 32% vs. 33%, and all-cause death 8.5% vs. 8.3%. Familial hypercholesterolemia (FH) was diagnosed in 25% of those with CAD, with higher rates of myocardial infarction (adjusted hazard ratio [HR] 2.62, 95% confidence interval [95%CI] 1.15-5.99) and revascularization (HR 4.30, 95%CI 2.01-9.18) during follow-up. Only 17% of patients with CAD attained a low-density lipoprotein cholesterol treatment goal < 70 mg/dl. CONCLUSIONS: CAD in young adults is associated with marked burden of traditional risk factors and high rates of future adverse cardiac events, regardless of acuity of presentation, especially in patients with FH, emphasizing the importance of detecting cardiovascular risk factors and addressing atherosclerosis at young age.

An Intervention to Reduce the Time Interval Between Hospital Entry and Emergency Coronary Angiography in Patients with ST-Elevation Myocardial Infarction.

BACKGROUND: Outcomes of patients with acute ST-elevation myocardial infarction (STEMI) are strongly correlated to the time interval from hospital entry to primary percutaneous coronary intervention (PPCI). Current guidelines recommend a door to balloon time of < 90 minutes. OBJECTIVES: To reduce the time from hospital admission to PPCI and to increase the proportion of patients treated within 90 minutes. METHODS: In March 2013 the authors launched a seven-component intervention program:  Direct patient evacuation by out-of-hospital emergency medical services to the coronary intensive care unit or catheterization laboratory Education program for the emergency department staff Dissemination of information regarding the urgency of the PPCI decision Activation of the catheterization team by a single phone call Reimbursement for transportation costs to on-call staff who use their own cars Improvement in the quality of medical records Investigation of failed cases and feedback. RESULTS: During the 14 months prior to the intervention, initiation of catheterization occurred within 90 minutes of hospital arrival in 88/133 patients(65%); during the 18 months following the start of the intervention, the rate was 181/200 (90%) (P < 0.01). The respective mean/median times to treatment were 126/67 minutes and 52/47 minutes (P < 0.01). Intervention also resulted in shortening of the time interval from hospital entry to PPCI on nights and weekends. CONCLUSIONS: Following implementation of a comprehensive intervention, the time from hospital admission to PPCI of STEMI patients shortened significantly, as did the proportion of patients treated within 90 minutes of hospital arrival.

Association of Vitamin B12 Deficiency with Homozygosity of the TT MTHFR C677T Genotype, Hyperhomocysteinemia, and Endothelial Cell Dysfunction.

BACKGROUND: Hyperhomocysteinemia is associated with increased cardiovascular risk, but treatment with folic acid has no effect on outcome in unselected patient populations. OBJECTIVES: To confirm previous observations on the association of homozygosity for the TT MTHFR genotype with B12 deficiency and endothelial dysfunction, and to investigate whether patients with B12 deficiency should be tested for 677MTHFR genotype. METHODS: We enrolled 100 individuals with B12 deficiency, tested them for the MTHFR C677T polymorphism and measured their homocysteine levels. Forearm endothelial function was checked in 23 B12-deficient individuals (13 with TT MTHFR genotype and 10 with CT or CC genotypes). Flow-mediated dilatation (FMD) was tested after short-term treatment with B12 and folic acid in 12 TT MTHFR homozygotes. RESULTS: Frequency of the TT MTHFR genotype was 28/100 (28%), compared with 47/313 (15%) in a previously published cohort of individuals with normal B12 levels (P = 0.005). Mean homocysteine level was 21.2 ± 16 µM among TT homozygotes as compared to 12.3 ± 5.6 µM in individuals with the CC or CT genotype (P = 0.008). FMD was abnormal ( 6%) in 9/13 TT individuals with B12 deficiency (69%), and was still abnormal in 7/12 of those tested 6 weeks after B12 and folic treatment (58%). CONCLUSIONS: Among individuals with B12 deficiency, the frequency of the TT MTHFR genotype was particularly high. The TT polymorphism was associated with endothelial dysfunction even after 6 weeks of treatment with B12 and folic acid. Based on our findings we suggest that B12 deficiency be tested for MTHFR polymorphism in order to identify potential vascular abnormalities and increased cardiovascular risk.

Characteristics, management and outcome of patients with late-arrival STEMI in the Acute Coronary Syndrome Israeli Surveys (ACSIS).

Introduction: Patients with ST-elevation myocardial infarction (STEMI) and late arrival (>12 h) after symptom onset, are at high risk for mortality and heart failure and represent a challenge for management. We aimed to define patient characteristics, management, and outcome of late-arrival STEMI in Israel over the last 20 years. Methods: We analyzed data of late-arrival STEMI (12-48 h and > 48 h) from the biennial acute coronary syndrome Israeli Surveys (ACSIS), as well as time-dependent changes [early (2000-2010) Vs. late (2013-2021) period]. Results: Data regarding time from symptom onset to hospital arrival was available in 6,466 STEMI patients. Of these, 9.6 % arrived 12-48 h and 3 % >48 h from symptom onset. Late-arrival patients were more likely to be older women with diabetes and high GRACE score and less likely to have prior myocardial infarction.In recent years, 95 % of patients arriving 12-48 h and 96 % of those arriving > 48 h had coronary angiography, as opposed to 75 % and 77 % in the early years (p = 0.007). Percutaneous coronary intervention (PCI) increased from 60 % and 55 % respectively to 85 % (p ≤ 0.001).TIMI-3 flow after primary PCI was 89-92 %, irrespective of arrival time. Late arrival patients (12-48 h but not > 48 h) who had PCI had better adjusted 1-year survival, HR 0.49 (95 %CI 0.29-0.82), p = 0.01. Conclusions: Late-arrival STEMI patients have higher risk characteristics. Most late-arrival patients undergo coronary angiography and PCI and have TIMI-3 flow after primary PCI. In patients arriving 12-48 h after symptom onset PCI is associated with better survival.

Multimodality imaging in subclavian steal syndrome.

Subclavian steal syndrome is a rare vascular cause of recurrent effort-related syncope events, affecting ~2% of the general population. Here, we report a case of a 64-year-old male who was hospitalized because of recurrent effort-related syncope events. Physical examination revealed several characteristic clinical clues for subclavian steal syndrome. Indeed, through the use of multimodality imaging, the diagnosis was established. We demonstrate that the combination of history taking, thorough physical exam and subsequent imaging studies can establish a relatively rare diagnosis of recurrent syncope.

Pericardial constriction with calcified cystic mass compressing the right ventricle and right coronary artery.

Constrictive pericarditis is characterized by fibrosis and calcification of the pericardium that progressively impair the diastolic filling of the heart, causing heart failure. Uncommonly, pericardial constriction may be localized leading to a focal cystic mass formation that may compress nearby cardiac structures. We describe a unique case of a patient presenting with right heart failure due to idiopathic calcific constrictive pericarditis that was associated with a large pericardial cystic mass compressing the right ventricular free wall. This led to reduced cardiac output and possibly severe focal stenosis of the proximal right coronary artery that was resolved after pericardiectomy, the only definitive treatment for chronic progressive constrictive pericarditis. .

Door-to-balloon time and mortality in patients with ST-elevation myocardial infarction undergoing primary angioplasty.

AIMS: The evidence are not conclusive that a small incremental increase in door-to-balloon (D2B) time leads to a significant increase in death of ST-elevation myocardial infarction (STEMI) patients. In a previous study, we described a quality improvement intervention that reduced D2B time in 333 patients with STEMI. The aim of the current study was to compare mortality rates of the patients, before and after the intervention. METHODS AND RESULTS: We examined the survival of 133 consecutive patients with STEMI treated prior to an intervention to decrease D2B time and 200 treated after the intervention. The mortality rate was the same before and after the quality intervention. The median D2B time for the entire cohort was 55 min. The number of patients with D2B time >55 min prior to the intervention was 82/133 (61%) and after the intervention 74/200 (37%) P < 0.00001. Thirty-day mortality among the patients with D2B time ≤55 min was 5/178 (2.8%) and among those with D2B time >55 min was 15/155 (9.7%), P < 0.008. The hazard ratio for 30-day mortality when the D2B time was >55 min was 3.7 (1.3-10.4). CONCLUSION: Mortality and non-fatal complications did not differ significantly between STEMI patients before and after a quality improvement intervention. However, the number of patients treated within 55 min from arrival was significantly higher after the intervention; and coronary intervention within this time was associated with a lower death rate.

Causes of mortality in a department of cardiology over a 15-year period.

AIMS: Over the last four decades, in-hospital mortality from acute coronary syndromes (ACS) has declined. We characterized the patients who died in our cardiovascular intensive care unit (CICU) over a 15-year period. Based on these data, we described the changing patient population in the CICU. METHODS: This retrospective study compared characteristics of patients who died in our CICU in 2005-6, 2013-4 and 2019. During these 5 years, 13,931 patients were hospitalized; 251 (1.8%) died. The mean age of the patients who died was 76 years, 144 (57%) were men. ACS was the leading cause of admission (93 patients, 37%), and 145 (58%) patients had a history of heart failure prior to hospitalization. The leading cause of death was cardiogenic shock in 104 (41%) patients, septic shock in 48 (19%) patients, and combined cardiogenic and septic shock in 31 (12%). Patients hospitalized in the later years of the study were significantly older (67.7, 69.0 and 70.5 years, 2005-6, 2013-4 and 2019, respectively, p < 0.02) but their medical characteristics did not differ significantly between the years examined. CONCLUSIONS: The profile of the patients who died did not change significantly over the 15-year study period. Age of admitted patients was higher in later years of the study. The leading cause of admission was ACS and the leading causes of death were cardiogenic and septic shock. Based on our observations, additional skills should be added to the curriculum of cardiology, including the management of patients with multiorgan failure.

Severe biventricular thrombosis in eosinophilic granulomatosis with polyangiitis: a case report.

BACKGROUND: Eosinophilic granulomatosis with polyangiitis (EGPA), formerly known as Churg-Strauss syndrome, is a rare multisystem disease characterized by asthma, rhinosinusitis, and eosinophilia. Cardiac involvement, present in half the patients, may be life threatening. CASE SUMMARY: A young woman with long-standing asthma and nasal polyposis was admitted with new-onset dyspnoea, sinus tachycardia, and eosinophilia. She had severe biventricular thrombosis and severe tricuspid regurgitation (TR) on echocardiography, with preserved ejection fraction of both ventricles. Cardiac magnetic resonance (CMR) imaging showed diffuse subendocardial late gadolinium enhancement (LGE). She had a positive test for perinuclear antineutrophil cytoplasmic antibodies (p-ANCA) confirming the diagnosis of ANCA positive EGPA. She was treated with anticoagulation, high-dose corticosteroids, cyclophosphamide, and rituximab with gradual resolution of her symptoms. Follow-up echocardiography showed significant improvement in ventricular thrombi and TR but could not reliably exclude residual ventricular thrombus. Repeat CMR at 11 months confirmed complete resolution of both ventricular thrombi and near complete resolution of LGE. DISCUSSION: Cardiac involvement in EGPA, a rare cause of heart failure, can manifest as severe biventricular thrombosis and severe TR, resulting in heart failure with preserved ejection fraction. Combined immunosuppression and anticoagulation can lead to complete remission within a year. CMR is instrumental for both diagnosis and follow-up of EGPA, allowing for safe discontinuation of oral anticoagulation.

Avoidance of Coronary Angiography in High-Risk Patients With Acute Coronary Syndromes: The ACSIS Registry Findings.

BACKGROUND/PURPOSE: Patients with acute coronary syndrome (ACS) are at high-risk for recurrent coronary syndromes, heart failure and death. Early coronary intervention combined with medications reduces these risks. The ACS Israeli Survey (ACSIS) is conducted over a 2-month period, every 2-3 years. ACSIS includes all patients discharged with a diagnosis of ACS from the 24 coronary care units and cardiology departments in Israel. We compared clinical profiles and 1-year survival between ACS patients who did and did not undergo coronary angiography. METHODS/MATERIALS: We reviewed ACSIS for the period 2002-2013. RESULTS: The prognosis of patients who did not undergo coronary angiography during hospitalization (N = 2078) was significantly worse than for patients who underwent angiography (N = 9550). Avoidance of angiography was less common in ST-elevation myocardial infarction (STEMI) patients than in non-STEMI/unstable angina (NSTEMI/UAP) patients (13% vs. 22%, p < 0.001). Among NSTEMI/UAP patients, those who did not undergo angiography were older (mean: 71 vs. 64 years, p < 0.001), had higher incidences of diabetes (47% vs. 38%, p < 0.001), and renal (55% vs. 27%, p < 0.001) and heart failure (35% vs. 13%, p < 0.01) on admission, compared to those who underwent angiography. Even patients that underwent only diagnostic angiography had had a better prognosis than patients who did not undergo angiography. After propensity score matching for the major differences mentioned above, survival was still significantly better for patients who underwent angiography. CONCLUSION: ACS patients who did not undergo coronary angiography had higher-risk clinical profiles and worse 1-year survival than ACS patients who underwent angiography. After propensity score matching, the absence of angiography was independently associated with higher mortality. SUMMARY: Data over 10 years were reviewed from a national registry of acute coronary syndrome. Patients who did not undergo coronary angiography during hospitalization were older and with more comorbidities than patients who underwent angiography. After propensity score matching, the absence of angiography remained independently associated with 1-year mortality.

Ethnic Differences Among Acute Coronary Syndrome Patients in Israel.

AIMS: Life expectancy has increased in Israel during recent decades. However, compared to the majority, mostly Jewish population, life expectancy remains low among Israeli Arabs minority, and cardiovascular diseases are the leading cause of death. We compared baseline characteristics and outcomes between Israeli Arab and non-Arab patients hospitalized with acute coronary syndrome (ACS). METHODS AND RESULTS: A national survey accessed data of 7055 patients (1251, 18% Arabs) hospitalized with ACS. Compared to non-Arab, Arab patients were younger at ACS presentation (59 ± 11 vs. 65 ± 12 years, p < 0.01), more likely male (81% vs. 77%, p = 0.01), and with higher prevalence of diabetes mellitus (47% vs. 34%, p < 0.01) and smoking history (57% vs. 34%, p < 0.001). Among patients with ST-elevation myocardial infarction (STEMI) ACS, the mean time from first medical contact to the hospital was similar for Arab and non-Arab patients (133 and 137 min, respectively). After adjustment for age, gender, time from first medical contact to hospital arrival, diabetes, hypertension and renal failure, 1-year survival was lower among Arab patients (93.4% vs. 95.1%, p = 0.027), and 5-year survival was not statistically different (84.0% vs. 86.8%, p = 0.059). The survival differences were mostly derived from reduced survival at 1 and 5 years of STEMI Arab patients. CONCLUSIONS: Israeli Arabs present with ACS at a younger age than non-Arabs and have higher prevalence of smoking and diabetes at presentation. Adjusted 1-year survival was lower among Arab patients. Access to medical care and in-hospital practices during ACS were similar for Arabs and non-Arabs. The findings highlight the impact of risk factors on the early presentation of ACS and the need for a robust risk reduction program for Israeli Arabs.

Clinical features and outcomes of revascularization in very old patients with left main coronary artery disease.

BACKGROUND: Coronary artery disease (CAD) is often more extensive in older adults and may involve multivessel and left main coronary artery (LMCA) disease. Elderly patients are commonly excluded from clinical trials, and limited real-world data exist on the management of LMCA disease in the very old. We aimed to investigate clinical features and outcomes of very old patients undergoing revascularization due to LMCA disease. PATIENTS AND METHODS: A retrospective single-center analysis of patients at least 80 years (n = 139) who underwent revascularization owing to CAD involving unprotected LMCA stenosis more than 50% was conducted. Subsequent major adverse cardiovascular events (MACE: myocardial infarction, stroke, and all-cause death) and repeat revascularizations were recorded, and their relation to revascularization procedure was studied. RESULTS: Percutaneous coronary intervention (PCI) was performed in 74 patients and coronary artery bypass surgery (CABG) in 65. Most patients (80%) had multivessel disease involving at least 2 additional coronary arteries. PCI was associated with older age, higher rates of baseline disability, previous revascularization, reduced ventricular function, significant aortic stenosis, and presentation with acute coronary syndrome, compared with CABG. Cumulative 3-year MACE rates were higher in patients undergoing PCI versus CABG (P = 0.009). After multivariable adjustment, predictors of MACE included presentation with ST-segment elevation myocardial infarction (STEMI) [hazard ratio (HR) = 2.39; 95% confidence interval: 1.24-4.63; P = 0.010], revascularization by PCI compared with CABG [HR = 2.21 (1.18-4.15); P = 0.013], baseline disability [HR = 2.17 (1.20-3.91); P = 0.010], and distal LMCA disease [HR = 1.87 (1.04-3.38); P = 0.038]. The difference in 3-year MACE between PCI and CABG was not observed in a propensity-score analysis of 90 patients matched 1: 1 for baseline disability, STEMI, and aortic stenosis (P = 0.797). CONCLUSION: In very old patients undergoing coronary revascularization owing to LMCA disease, PCI was associated with worse cardiovascular outcomes compared with CABG, influenced by a more severe and comorbid population selected for PCI. Baseline disability, presentation with STEMI, and distal LMCA bifurcation disease were additional independent outcome predictors.

Usefulness of 64-slice cardiac computed tomographic angiography for diagnosing acute coronary syndromes and predicting clinical outcome in emergency department patients with chest pain of uncertain origin.

BACKGROUND: Multidetector computed tomography (MDCT) has high diagnostic value for detecting or excluding coronary artery stenosis. We examined performance characteristics of MDCT for diagnosing or excluding an acute coronary syndrome in patients presenting to the emergency department (ED) with possible ischemic chest pain and examined relation to clinical outcome during a 15-month follow-up period. METHODS AND RESULTS: We prospectively studied 58 patients (56+/-10 years of age, 36% female) with chest pain possibly ischemic in origin and no new ECG changes or elevated biomarkers. The patients underwent 64-slice contrast-enhanced MDCT, which showed normal coronary vessels (no or trivial atheroma) in 15 patients, nonobstructive plaque in 20 (MDCT-negative patients), and obstructive coronary disease (> or = 50% luminal narrowing) in 23 (MDCT-positive group). By further investigation (new elevation of cardiac biomarkers, abnormal myocardial perfusion scintigraphy and/or invasive angiography), acute coronary syndrome was diagnosed in 20 of the 23 MDCT-positive patients (ED MDCT sensitivity 100% [20/20], specificity 92% [35/38], positive predictive value 87% [20/23], negative predictive value 100% [35/35]). During a 15-month follow-up period, no deaths or myocardial infarctions occurred in the 35 patients discharged from the ED after initial triage and MDCT findings. One patient underwent late percutaneous coronary intervention (late major adverse cardiovascular events rate, 2.8%). Overall, ED MDCT sensitivity for predicting major adverse cardiovascular events (death, myocardial infarction, or revascularization) during hospitalization and follow-up was 92% (12/13), specificity was 76% (34/45), positive predictive value was 52% (12/23), and negative predictive value was 97% (34/35). CONCLUSIONS: We found that 64-slice cardiac MDCT is a potentially valuable diagnostic tool in ED patients with chest pain of uncertain origin, providing early direct noninvasive visualization of coronary anatomy. ED MDCT had high positive predictive value for diagnosing acute coronary syndrome, whereas a negative MDCT study predicted a low rate of major adverse cardiovascular events and favorable outcome during follow-up.

Influence of Body Mass Index on Long-Term Survival After Cardiac Catheterization.

We examined 18,654 patients who underwent cardiac catheterization in a single center to clarify the association between catheterization indication, body mass index (BMI), and long-term survival over a mean follow-up of 81 months. Patients were grouped by indication for catheterization: (a) acute coronary syndromes (ACS), 7,426 patients; (b) coronary artery disease (CAD) evaluation in stable clinical presentation, 6,911 patients; and (c) primarily non-CAD cardiac evaluations, 4,317 patients. Compared with normal weight, overweight and obesity (but not morbid obesity) was associated with lower risk of long-term mortality. Underweight patients had the greatest risk of mortality. After multivariate adjustment, survival benefit of the overweight and obese was retained in the ACS group [hazard ratio 0.86, 95% confidence interval (0.77-0.96), p = 0.006 and 0.79, (0.68-0.91), p = 0.001, respectively] and in overweight patients in the stable presentation CAD group [0.83, (0.72-0.94), p = 0.005], whereas there was no survival benefit in any of the BMI categories in those catheterized primarily for non-CAD indications. Further analysis of matched cohorts showed similar patterns of survival benefit of the overweight/obese. In conclusion, among patients who underwent cardiac catheterization, an inverse association between BMI and long-term mortality was observed, with the lowest risk noted in the overweight and obese population; the obesity paradox was principally demonstrated in patients with ACS, and was eliminated after covariate adjustment in those catheterized primarily for non-CAD indications.

Impact of 64-slice cardiac computed tomographic angiography on clinical decision-making in emergency department patients with chest pain of possible myocardial ischemic origin.

To examine the impact of contrast enhanced multidetector computed tomography (MDCT) on clinical decision-making in patients who present to the emergency department (ED) with chest pain of possible ischemic origin, we studied 58 consecutive patients (age 56 +/- 10 years, 36% female) with chest pain, intermediate risk, and no ischemic electrocardiographic changes or increased biomarker measurements. After standard ED patient assessment including cardiology consultation, a diagnosis of acute coronary syndrome was made in 41 patients (71%), hospitalization was recommended in 47 (81%), and 32 (55%) were scheduled for an early invasive strategy. Patients underwent 64-slice contrast agent-enhanced MDCT with image reconstruction in multiple formats using retrospective electrocardiographic gating, which revealed normal (no or trivial atheroma) coronary vasculature in 15 patients, nonobstructive atheroma in 20 patients, and obstructive coronary disease (> or =1 luminal narrowing of > or =50%) in 23 patients. After MDCT, the diagnosis of acute coronary syndrome was revised in 18 of 41 patients (44%; 16 normal MDCT/widely patent stents, 2 alternative diagnoses), planned hospitalization canceled in 21 of 47 patients (45%; 13 normal MDCT/patent stent, 8 minor branch vessel disease), and planned early invasive strategy altered in 25 of 58 patients (43%; unnecessary in 20 of 32, advisable in 5 of 26 others). Effect of MDCT on clinical decisions was greater in the 36 patients without known preceding coronary disease. In 32 patients discharged from the ED (11 after initial triage, 21 patients after MDCT), there were no major adverse cardiac events (e.g., death, myocardial infarction, unplanned revascularization) during a 12-month follow-up period. In conclusion, contrast agent-enhanced 64-slice cardiac MDCT was a valuable diagnostic tool in the ED triage of patients with chest pain of possible ischemic origin and decreased the need for hospitalization by almost half in this patient cohort.

Thrombolysis followed by early revascularization: an effective reperfusion strategy in real world patients with ST-elevation myocardial infarction.

BACKGROUND: Several trials suggested superiority of primary percutaneous coronary intervention (PPCI) angioplasty over thrombolysis in patients with ST-elevation myocardial infarction (STEMI), but many trials were characterized by low rates of early revascularization in patients treated with initial thrombolysis. We tested the hypothesis that in patients with hemodynamically stable STEMI, initial thrombolysis followed by an active early rescue/definitive revascularization strategy could achieve salutary short- and long-term outcomes. METHODS: A prospective registry documented all 212 STEMI patients who received initial thrombolytic therapy over a 2-year period in a single medical center. Median patient age was 58 (range: 29-92) years, 47 (22%) patients were aged >70 years and 18 (8%) >80 years. Fifty-two (25%) patients underwent rescue angioplasty <6 h after thrombolysis for inadequate clinical reperfusion. In 194/212 (92%) patients, coronary angiography was performed during initial hospitalization, PCI in 168 (79%), and coronary bypass surgery in 18 (8%). RESULTS: Thirty-day mortality was 4.7% and 1-year mortality 6.7%. Mortality was not related to diabetes mellitus, hypertension, anterior infarction location, fibrin-specific thrombolytic drug or rescue PCI. By multivariate analysis, in-hospital definitive angiography/revascularization (p < 0.0001) and TIMI risk score >3 on admission (p < 0.01) were significant independent predictors of both 30 day and 12 month outcome. CONCLUSIONS: Initial thrombolysis was useful and effective in real-world STEMI patients when coupled with an aggressive policy of rescue angioplasty and early in-hospital revascularization. Outcomes compared favorably with those reported for PPCI trials. The adverse prognosis in older patients with higher TIMI risk score suggests that in those patients alternative initial treatment strategies such as PPCI should be considered.

Desensitization therapy in a patient with furosemide allergy.

Allergy to furosemide is a rare phenomenon. Desensitization to this sulfa-containing drug has not been frequently performed. We describe a patient with severe congestive heart failure and type I allergy to furosemide. Because of the severity of her condition, we decided to use a rapid intravenous desensitization protocol. Following the desensitization, the patient was treated with intravenous and oral furosemide with a dramatic improvement in her clinical state. We suggest that rapid desensitization may be a safe and effective way of introducing furosemide to allergic patients for whom loop diuretics are urgently indicated.