Comparing stress testing and fractional flow reserve to evaluate presence,location and extent of ischemia in coronary artery disease

Background

FFR provides an accurate and reproducible assessment of the functional severity of coronary stenosis. Whereas stress testing remains the preferred initial modality for assessment of ischemia, there is limited data comparing it with FFR. We sought to determine the correlation between cardiac stress testing and coronary fractional flow reserve (FFR) measurement for assessing the presence, location, and burden of myocardial ischemia in patients referred for evaluation of coronary artery disease (CAD).

Methods

Over 5-year study period, of the 5420 consecutive coronary angiograms that were screened, 326 patients had FFR measurements. Of these, 96 patients with FFR measurements who had a preceding stress test (stress echocardiography [SE] or myocardial perfusion imaging [MPI]) within a year were included.

Results

Of the 96 patients, there were 46 (48%) men and 50 (52%) women with a mean age of 61 ± 10 years. SE was performed in 57 (59.3%) and MPI in 32 (40.7%) of patients. FFR was ≤0.79 in 54 (56%) patients. Stress testing had low sensitivity (55%) and specificity (47%) compared to FFR. The concordance between FFR and stress testing was low for both presence (k = 0.03) and location (k = 0.05) of the ischemic territory. The number of ischemic vascular territories was correctly estimated in only 39% of the stress tests. SE was more likely to overestimate and MPI more likely to underestimate extent of ischemia.

Conclusions

In patients referred for evaluation of CAD, there was poor correlation between stress testing and FFR. A prospective study comparing these two modalities with FFR is needed.     

B-Type natriuretic peptide levels predict extent and severity of coronary artery disease in non-ST elevation acute coronary syndrome and normal left ventricular function

Background

B-type natriuretic peptide has been used as a biological marker for prognosis in patients with acute coronary syndrome (ACS). However, a relation between the quantity of BNP levels and the severity of coronary artery disease has not been systematically evaluated.

Methods

197 patients with ACS without ST elevation with normal LV systolic function were enrolled. BNP was measured in all recruited patients within 12 h of hospitalization. All patients underwent coronary angiography. We correlated BNP levels in patients with unstable angina (USAP) and non ST-elevation myocardial infarction (NSTEMI) with angiographic disease severity including Gensini Score.

Results

BNP levels were significantly higher in the NSTEMI group in comparison to the USAP Group (161 ± 149.3 vs 79.6 ± 94.2 pg/mL; p < 0.001). BNP levels rose significantly with increasing number of vessels involved (1-vessel = 51.4 ± 31.6; 2-vessels = 114.0 ± 67.8; 3 vessels = 265.4 ± 188.8 pg/mL, p < 0.001). Most importantly, BNP> 80 pg/ml was found to strongly predict the presence of Triple vessel disease (odds ratio 18.87; 95% confidence intervals 5.36–66.36), and Double vessel disease (odds ratio 3.62; 95% confidence intervals 1.75–7.47). In single vessel group, BNP was significantly higher when LAD was involved vessel (64.78 vs 49.76 pg/mL, p < 0.05).Gensini Score showed a strong correlation with BNP levels (r = 0.675, p < 0.01), and Gensini Score was significantly higher in those with BNP> 80 pg/ml (40.9 ± 29.7 vs 13.4 ± 16.5 p < 0.001).

Conclusion

Circulating BNP levels appear elevated in Non ST Elevation ACS, even in the absence of LV systolic dysfunction. High BNP levels are associated with multi-vessel disease and diffuse coronary atherosclerosis.     

Do circulating blood cell types correlate with modifiable risk factors and outcomes in patients with acute coronary syndrome (ACS)?

Aims

Atherosclerosis is an inflammatory process with different cardiovascular risk factors (CVRFs) contributing to its pathogenesis. We aimed to evaluate the specific relationship between circulating blood leukocytes, troponin I and CVRFs.

Methods

We prospectively enrolled 959 patients with evidence of acute coronary syndrome either in form of unstable angina or STEMI or NSTEMI. Details demographic characteristics, CVRF and biochemical parameters such as total white blood cells (WBC), neutrophil, lymphocytes, platelet, neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), and troponin I were collected.

Results

The results indicated that patients having either hypertension, diabetes or smoking habit had significantly higher levels of total WBC (p = 0.013), neutrophil (p = 0.029), NLR (p = 0.029) and PLR (p = 0.009). The level of troponin I was unaffected by these risk factors. Significant association of hypertension was found with total WBC (p = 0.0392), lymphocytes (p = 0.0384) and PLR (p = 0.0027), whereas in diabetes and females all other leukocyte subtypes were significantly altered except for platelet and troponin I. Smokers had higher level of total WBC count (p = 0.0033) and PLR (p = 0.0464). No relationship between CVRFs and leukocytes was observed in males. The age independent effect was observed with PLR, whereas association with total WBC, lymphocytes, NLR, platelet was specific in older population. In younger patients NLR (p = 0.0453) is more likely to be elevated. Mortality was significantly associated with changes in the leukocytes but not with the CVRF presence.

Conclusion

We demonstrate that the neutrophils, lymphocytes and total WBC along with its ratios predict mortality and are more likely to be elevated in presence of CVRFs.     

Epidemiological and evolutionary characteristics of heart failure in patients with left bundle branch block – A Moroccan center-based study

Background

In patients with heart failure, left bundle branch block (LBBB) seems to be associated with an increased risk of cardiovascular mortality.

Purpose

The purpose of this study is to determine the in-hospital outcome of congestive heart failure patients with LBBB versus those without.

Methods

We conducted a prospective observational study at the Department of Intensive Care and Rhythmology at the Mohammed V Military Hospital of Rabat, where 330 patients were admitted for heart failure between January 2008 and September 2012. Screening out patients with missing data yielded a cohort of 274 patients. Among the 274 patients, only 110 had LBBB and a left ventricular ejection fraction lower than 50%. We randomly selected a subset of 110 patients diagnosed as non-LBBB to ensure a significant statistical comparison between LBBB and non-LBBB patients. We therefore considered two groups in our analysis: 110 heart failure (HF) patients with LBBB and 110 HF patients without LBBB. Patients with incomplete records were excluded.

Results

Male gender was dominant in both groups (82.7% vs. 66.7%, p = 0.005). Patients with LBBB had a higher prevalence of idiopathic dilated cardiomyopathy (39.1% vs. 4.8%, p < 0.001); and a higher prevalence of previous hospitalization for heart failure (64.5% vs. 23.3%, p < 0.001). The left ventricular ejection fraction was significantly lower in the group with LBBB (25.49% vs. 39.53%, p < 0.001). Age, cardiovascular risk factors, rhythmic and thromboembolic complications did not significantly differ. In patients with LBBB, 61.8% received cardiac resynchronization therapy performed both during the index hospital stay (50.9%) and previously (10.9%). Hospital outcome was marked by 20 in-hospital deaths in the group with LBBB and eight deaths in the group without LBBB (p = 0.008).

Conclusion

Our analysis emphasizes increased in-hospital mortality and higher disease severity, over a short period of stay, in heart failure patients with left bundle branch block.     

Predictors of acute myocardial infarct size in STEMI patients receiving thrombolytic therapy: A delayed contrast enhanced cardiac MRI study

Introduction

Delayed contrast enhanced Cardiac MRI has been accepted as a standard tool worldwide for determination of infarcted myocardium and viability. Infarct size as determined by cardiac MRI has important therapeutic and prognostic information.

Methods

Twenty six STEMI patients who had received thrombolytic therapy were subjected to cardiac MRI assessment at 5–7 day of admission. Base line variables of the study population were compared with the acute infarct size as determined by the Cardiac MRI.

Results

The mean acute infarct size in our study population was 27.2 ± 17.4% of LV. We found through univariate analysis that final infarct size was dependent on time to thrombolysis (p = 0.04), Status of Thrombolysis (p = 0.01), smoking status (p = 0.02), location of infarct (p < 0.00001), presence of microvascular obstruction (p = 0.01) and viability status (p = 0.0004). Thus, larger acute infarct size was seen in delayed time to thrombolysis, failed status of thrombolysis, smokers, anterior location of the infarct, presence of microvascular obstruction and non viable myocardial status.

Conclusion

Infarct size as determined by Cardiac MRI has been shown to carry important therapeutic and prognostic information. We have tried to evaluate predictors of acute infarct on cardiac MRI in STEMI patients during their initial hospital stay. Knowing the predictors of acute infarct size can help in early intervention and provide prognostic information for future cardiac events.     

The Effectiveness of a Physician-Only and Physician–Patient Intervention on Colorectal Cancer Screening Discussions Between Providers and African American and Latino Patients

BACKGROUND

Physician recommendation of colorectal cancer (CRC) screening is a critical facilitator of screening completion. Providing patients a choice of screening options may increase CRC screening completion, particularly among racial and ethnic minorities.

OBJECTIVE

Our purpose was to assess the effectiveness of physician-only and physician–patient interventions on increasing rates of CRC screening discussions as compared to usual care.

DESIGN

This study was quasi-experimental. Clinics were allocated to intervention or usual care; patients in intervention clinics were randomized to receipt of patient intervention.

PARTICIPANTS

Patients aged 50 to 75 years, due for CRC screening, receiving care at either a federally qualified health care center or an academic health center participated in the study.

INTERVENTION

Intervention physicians received continuous quality improvement and communication skills training. Intervention patients watched an educational video immediately before their appointment.

MAIN MEASURES

Rates of patient-reported 1) CRC screening discussions, and 2) discussions of more than one screening test.

KEY RESULTS

The physician–patient intervention (n = 167) resulted in higher rates of CRC screening discussions compared to both physician-only intervention (n = 183; 61.1 % vs.50.3 %, p = 0.008) and usual care (n = 153; 61.1 % vs. 34.0 % p = 0.03). More discussions of specific CRC screening tests and discussions of more than one test occurred in the intervention arms than in usual care (44.6 % vs. 22.9 %,p = 0.03) and (5.1 % vs. 2.0 %, p = 0.036), respectively, but discussion of more than one test was uncommon. Across all arms, 143 patients (28.4 %) reported discussion of colonoscopy only; 21 (4.2 %) reported discussion of both colonoscopy and stool tests.

CONCLUSIONS

Compared to usual care and a physician-only intervention, a physician–patient intervention increased rates of CRC screening discussions, yet discussions overwhelmingly focused solely on colonoscopy. In underserved patient populations where access to colonoscopy may be limited, interventions encouraging discussions of both stool tests and colonoscopy may be needed.KEY WORDS: colorectal cancer screening, health literacy, randomized trial, physician communication of preventive care     

Nurse-Led Behavioral Management of Diabetes and Hypertension in Community Practices: A Randomized Trial

Background

Several trials have demonstrated the efficacy of nurse telephone case management for diabetes (DM) and hypertension (HTN) in academic or vertically integrated systems. Little is known about the real-world potency of these interventions.

Objective

To assess the effectiveness of nurse behavioral management of DM and HTN in community practices among patients with both diseases.

Design

The study was designed as a patient-level randomized controlled trial.

Participants

Participants included adult patients with both type 2 DM and HTN who were receiving care at one of nine community fee-for-service practices. Subjects were required to have inadequately controlled DM (hemoglobin A1c [A1c] ≥ 7.5 %) but could have well-controlled HTN.

Interventions

All patients received a call from a nurse experienced in DM and HTN management once every two months over a period of two years, for a total of 12 calls. Intervention patients received tailored DM- and HTN- focused behavioral content; control patients received non-tailored, non-interactive information regarding health issues unrelated to DM and HTN (e.g., skin cancer prevention).

Main Outcomes and Measures

Systolic blood pressure (SBP) and A1c were co-primary outcomes, measured at 6, 12, and 24 months; 24 months was the primary time point.

Results

Three hundred seventy-seven subjects were enrolled; 193 were randomized to intervention, 184 to control. Subjects were 55 % female and 50 % white; the mean baseline A1c was 9.1 % (SD = 1 %) and mean SBP was 142 mmHg (SD = 20). Eighty-two percent of scheduled interviews were conducted; 69 % of intervention patients and 70 % of control patients reached the 24-month time point. Expressing model estimated differences as (intervention – control), at 24 months, intervention patients had similar A1c [diff = 0.1 %, 95 % CI (−0.3, 0.5), p = 0.51] and SBP [diff = −0.9 mmH g, 95% CI (−5.4, 3.5), p = 0.68] values compared to control patients. Likewise, DBP (diff = 0.4 mmHg, p = 0.76), weight (diff = 0.3 kg, p = 0.80), and physical activity levels (diff = 153 MET-min/week, p = 0.41) were similar between control and intervention patients. Results were also similar at the 6- and 12-month time points.

Conclusions

In nine community fee-for-service practices, telephonic nurse case management did not lead to improvement in A1c or SBP. Gains seen in telephonic behavioral self-management interventions in optimal settings may not translate to the wider range of primary care settings.KEY WORDS: Diabetes, Hypertension, Implementation     

CYP 450 2C19 polymorphisms in Indian patients with coronary artery disease

Background

Dual antiplatelet therapy is the cornerstone in the management of acute coronary syndromes (ACS) and prevention of stent thrombosis (ST). Genetic polymorphisms in CYP2C19 gene involved in hepatic activation of clopidogrel leads to clopidogrel non-responsiveness and may influence clinical outcomes. These polymorphisms in CYP2C19 gene and their impact on clinical outcome in coronary artery disease (CAD) have not been studied in Indian population.

Methods

We studied 110 consecutive patients (mean age 55.7 ± 10.7 years; 90% male) taking clopidogrel with angiographically proven CAD for various genetic polymorphisms in CYP2C19 gene. Relationship between loss of function mutation and clinical presentation with recurrent ACS including ST was analyzed.

Results

Out of 110 patients, 26 (23.64%) had normal genotype, 52 (47.23%) had loss of function mutation *2 and 39 (35.45%) had a gain of function mutation *17, 7 (6.36%) patients were undefined metabolizers (*2/*17) which were excluded from analyses. Final analyses included 103 patients, with 45 (40.90%) having loss of function. Overall 51 patients had ACS, with 27 developing recurrence while on clopidogrel. The prevalence of loss of function mutation was no different between the group with recurrences and those without recurrences (55.6% vs. 50%, p = 0.7). Two patients developed ST while on clopidogrel; both had loss of function mutation.

Conclusion

CYP2C19 gene polymorphisms are common in Indian population. Loss of function mutation status did not affect the clinical outcomes. A larger study also considering P2Y12 receptor polymorphisms together with platelet activity testing, may be required to establish the role of CYP2C19 gene polymorphisms in clinical practice.     

Impact of lipid disorders on mortality among Saudi patients with heart failure

Background

Dyslipidemia, a known cardiovascular risk factor, is extremely common among Saudis, both adults and children. The impact, however, of dyslipidemia and several other lipid disorders in patients with congestive heart failure in this particular population has not been documented. This study aims to fill the gap.

Methods

This retrospective, single center study was conducted at King Abdulaziz Medical City, Riyadh, Saudi Arabia. Of the 500 cases seen during the period between 2002 and 2008, 392 were included in the study. Charts were reviewed and information on medical history, medications, and lipid status were documented.

Results

Low HDL-cholesterol level was the most common lipid disorder with 82.9%, followed by hypertriglyceridemia (35.2%), atherogenic dyslipidemia (27.8%), and hypercholesterolemia (9.2%). Diabetes mellitus was the single most significant predictor of mortality (p = 0.001). Among the lipid disorders, only low levels of HDL-cholesterol contributed to significant mortality risk [OR 1.29 (Confidence Interval 1.04–1.59) (p-value < 0.01)] adjusted for age, gender and statin use.

Conclusion

The results of this study suggest that emphasis should be on the elevation of HDL-cholesterol levels among subjects with congestive heart failure, without compromising any ongoing management of LDL-lowering drugs. Management should not be limited to conventional statin use and should promote other treatments to elevate HDL-cholesterol levels.     

Gender-related differences in the presentation,management, and outcomes among patients with acute coronary syndrome from Oman

Objective

To assess gender-related differences in the presentation, management, and in-hospital outcomes among acute coronary syndrome (ACS) patients from Oman.

Methods

Data were analyzed from 1579 consecutive ACS patients from Oman during May 8, 2006 to June 6, 2006 and January 29, 2007 to June 29, 2007, as part of Gulf RACE (Registry of Acute Coronary Events). Analyses were conducted using univariate and multivariate statistical techniques.

Results

In this study, 608 (39%) patients were women with mean age 62 ± 12 vs. 57 ± 13 years (p < 0.001). More women were seen in the older age groups (age <55 years: 25% vs. 43%, 55–74 years: 60% vs. 49% and >75 years: 15% vs. 8%; p < 0.001). Women had higher frequencies of diabetes, hypertension, hyperlipidemia, obesity, angina, and aspirin use, but less history of smoking. Women were significantly less likely to have ischemic chest pain, ST-elevation myocardial infarction (STEMI), non-STEMI and were more likely to have dyspnea, unstable angina, ST depression and left bundle branch block. Both groups received ACS medications and cardiac catheterization equally; however, women received anticoagulants (88% vs. 79%; p < 0.001), angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) (70% vs. 65%; p = 0.050) more and clopidogrel less (20% vs. 29%; p < 0.001). Women experienced more recurrent ischemia and heart failure but with similar in-hospital mortality (4.6% vs. 4.3%) even after adjusting for age (p = 0.500).

Conclusions

Women admitted with ACS were older than men, had more risk factors, presented differently with no difference in hospital mortality. This is similar to Gulf RACE study except for mortality. Women received anticoagulants/ACEIs /ARBs more but were under-treated with clopidogrel.     

Association of ST elevation with apical aneurysm in hypertrophic cardiomyopathy

Objectives

Apical aneurysms in patients with hypertrophic cardiomyopathy (HCM) represent an underrecognized but clinically important subset of HCM patients. However it may be frequently missed by echocardiography because of poor image quality of left ventricular apex. We aimed to compare electrocardiographic STE in HCM patients with and without apical aneurysm.

Methods

We developed this clinical review using an extensive MEDLINE review of the literature and data from our laboratories; and some electrocardiographic parameters including STE were analysed in HCM patients with and without apical aneurysm.

Results

There were 29 HCM patients without apical aneurysm (Group 1; 52.6 ± 17.7years, 69% male) and 28 HCM patients with apical aneurysm (Group 2; 59.6 ± 13.2years, 57% male). The STE in V4-6 derivations were statistically more frequent in patients with apical aneurysm compared to those without aneurysm (93% vs 7%, p < 0.001). There was a positive correlation between the presence of the STE in V4-6 derivations and the presence of the apical aneurysm (Spearman''s ρ = 0.895, p < 0.001).

Conclusions

Clinicians and specifically echocardiographers must pay special attention on the electrocardiography to correctly detect the frequently overlooked apical aneurysm in HCM patients, and should be careful for apical aneurysm particularly in the presence of STE in V4-6 derivations.     

Outcome of low body weight (<2.2 kg) infants undergoing cardiac surgery

Introduction

Infants with low body weight (LBW) following cardiac surgery are a major challenge for the post cardiac surgery care unit. It has been observed that post surgery outcome for LBW infants is worse compared to the outcome of normal body weight infants. A study was conducted to compare post operative course and outcome of infants with body weight of 2.2 kg or less against infants with normal body weight who underwent similar cardiac surgeries.

Methods

A retrospective review was performed for all infants below 2.2 kg who underwent cardiac operations at King Abdulaziz Cardiac Center from January 2001 to October 2011. Cases with LBW (Group A) were compared with matching group (Group B) of normal body weight infants who had similar cardiac surgeries and matching surgical risk category. The demographic, ICU parameters, complications, and short-term outcome of both groups were analyzed.

Results

Two groups were formed, with 37 patients in Group A, and 39 patients in Group B. Except for weight (2.13 ± 0.08 kg in Group A vs 3.17 ± 0.2 kg in Group B), there was no statistical difference in demographic data between both groups. Cardiac procedures included coarctation repair, arterial switch, ventricular septal defect (VSD) repair, tetralogy of Fallot repair, systemic to pulmonary shunt and Norwood procedures. Patients in Group A had statistically significant difference from Group B in terms of bypass time (p = 0.01), duration of inotropes (p = 0.01), duration of mechanical ventilation (p = 0.004), number of re-intubations (p = 0.015), PCICU length of stay (p = 0.007), and hospital mortality: 13.5% in Group A vs 0% in Group B (p value 0.02).

Conclusion

Patients with LBW (<2.2 kg) underwent cardiac surgery with overall satisfactory results, but with increased risk of ICU morbidity and mortality.     

Role of angiotensin II type I (AT1 A1166C) receptor polymorphism in susceptibility of left ventricular dysfunction

Background

Left ventricular dysfunction (LVD) with subsequent congestive heart failure (CHF) constitutes the final common pathway for a host of cardiac disorders. The impaired LV function develops in response to an ischemic insult followed by a fall in cardiac output that leads to activation of renin-angiotensin-system (RAS). Angiotensin II type I receptor (AT1), which mediate the vasoconstrictive and salt-conserving actions of the RAS, represent interesting candidate genes for cardiovascular diseases. Therefore, we conducted an association study between single nucleotide polymorphism (SNP) in AT1 gene and LVD in CAD patients.

Methods and results

The present study recruited a total of 950 subjects including 720 angiography confirmed CAD patients and 230 healthy controls. Among 720 CAD patients, 229 with reduced left ventricle ejection fraction (LVEF ≤ 45%) were categorized as LVD. The AT1 (A1166C, rs5186) polymorphism was determined by ARMS-PCR. Our results showed that the frequency of AT1 1166AC and CC genotypes were significantly higher in LVD patients in comparison to non-LVD (LVEF >45%) patients (p value = 0.003; OR = 1.81 and p value <0.001; OR = 4.33). Further analysis showed that AT1 A1166C polymorphism was significantly associated with LV end diastole (p-value = 0.031), end systole (p-value = 0.038) dimensions, and mean LVEF (p-value = 0.035). Moreover, on comparing the AT1 A1166C polymorphism in CAD patients with healthy controls, we did not find any association both at genotypic and allelic level (p value = 0.927; OR = 1.04 and p value = 0.219; OR = 0.83) respectively.

Conclusions

Our study suggests that AT1 A1166C polymorphism may play significant role in conferring genetic susceptibility of LVD.     

Effects of loco regional treatments before living donor liver transplantation on overall survival and recurrence-free survival in South Korean patients with hepatocellular carcinoma

Background

We evaluated the effects of pre-transplant locoregional treatment on survival in living donor liver transplantation (LDLT), and the most accurate method for predicting survival after LDLT in patients who received pre-transplant locoregional treatment.

Methods

From December 2003 to December 2012, 234 patients underwent LDLT for hepatocellular carcinoma (HCC) at our transplant center. We retrospectively reviewed 86 patients newly diagnosed with HCC and who received pre-transplant locoregional treatments at our hospital.

Results

Of the 33 patients with HCC initially beyond the Milan criteria, 12 experienced successful down-staging after locoregional treatments, and the 5-year recurrence-free survival was 81.8%, which was comparable to those in patients with HCC initially within the Milan criteria. A bad responder according to the modified Response Evaluation Criteria in Solid Tumors (mRECIST) [HR, 4.874 (1.059–22.442), p = 0.042], and increased AFP levels [HR 4.002 (1.540–10.397), p = 0.004] during pre-transplant locoregional treatments were independent risk factors for HCC recurrence after LDLT in multivariate analysis.

Conclusions

Liver transplantation may be considered after successful down-staging in patients with HCC initially beyond the Milan criteria. The mRECIST and serum AFP level changes are better selection criteria for LDLT in patients who have received locoregional treatments.     

Patient profile and results of percutaneous transvenous mitral commissurotomy in mitral restenosis following prior percutaneous transvenous mitral commissurotomy vs surgical commissurotomy

Background

Patients with mitral restenosis who have undergone prior PTMC or surgical commissurotomy have increased. Predictors of outcome of repeat PTMC in either subgroup of patients may be different.

Aims and objectives

Aim was to assess and compare the immediate results of PTMC in patients who had undergone a prior PTMC or surgical commissurotomy.

Methods and results

This is a single center, prospective, open label study. Of 70 patients in study, 44 (62.85%) patients had prior history of PTMC and 26 (37.15%) had prior surgical commissurotomy (closed/open). Average time from the initial procedure was 8.88 ± 5.36 years overall, 6.75 ± 3.38 for patients with prior PTMC and 16.73 ± 3.67 for patients with prior surgical commissurotomy. Prior PTMC group had 75% female, patients with prior surgical commissurotomy were older (44 ± 7 vs 33.57 ± 9.1 years, p = 0.001), had higher NYHA class (III/IV in100% vs 86.36%, p = 0.006.), higher atrial fibrillation (73.1% vs 25% p < 0.0001) and higher Wilkins'' score (>8 in 88.46% vs 68.18%, p = 0.05). Successful PTMC was lower (65.4% vs 84.1%) in patients with prior surgical commissurotomy, though statistically not significant (p = 0.07). After PTMC, mitral valve area, PA systolic pressure, LA mean pressure and trans-mitral gradient were similar. Post procedure complications were not different in both the groups.

Conclusion

PTMC for mitral restenosis in patients with prior surgical valvotomy is as effective as in patients with prior PTMC despite older age, higher NYHA class, higher Wilkins score and atrial fibrillation and can be considered in all patients with restenosis irrespective of the type of past procedures done.     

Study of clinical,radiological and echocardiographic features and correlation of Qanadli CT index with RV dysfunction and outcomes in pulmonary embolism

Background

There are no Indian studies correlating the CT pulmonary embolism index (Qanadli) with right ventricular function and outcome. In the present study we aimed to study the clinical manifestations of patients presenting with acute pulmonary thromboembolism and correlate the radiographic features with echocardiographic features and outcome.

Methods

Thirty five patients presenting with symptomatic acute pulmonary thromboembolism in between 2011 and 2013 were studied for clinical, radiological and echocardiographic features and outcome (in-hospital & 1 month follow up).

Results

The mean duration of presentation after onset of symptoms was 5.7 ± 3.7 days. Right ventricular dysfunction was observed in 11 (31.4%) patients. Out of 35 patients in whom CT pulmonary angiogram performed, 14 patients had Qanadli PE index >60% of whom 11 (78.6%) patients had right ventricular dysfunction. None had right ventricular dysfunction when PE index was <60% (p < 0.001). There was significant correlation between pulmonary vascular obstruction index and right ventricular dysfunction (p < 0.0001). Nine (25.7%) patients were thrombolysed with Streptokinase. Total mortality including in-hospital and 1 month follow up was 11.4% (4 patients). The mortality in patients with PE index >60% was 21.4% and was nil with <60% (p = 0.02). The mortality in patients with right ventricular dysfunction was 27.2% and was nil without right ventricular dysfunction (p = 0.0075).

Conclusion

A PE index which was shown to be a strong independent predictor of right ventricular dysfunction in PE, correlating linearly with different variables associated with higher morbidity and mortality, enabling accurate risk stratification and selection of patients for more aggressive treatment.     

A Randomized Controlled Trial of a CPR and Intubation Video Decision Support Tool for Hospitalized Patients

BACKGROUND

Decisions about cardiopulmonary resuscitation (CPR) and intubation are a core part of advance care planning, particularly for seriously ill hospitalized patients. However, these discussions are often avoided.

OBJECTIVES

We aimed to examine the impact of a video decision tool for CPR and intubation on patients’ choices, knowledge, medical orders, and discussions with providers.

DESIGN

This was a prospective randomized trial conducted between 9 March 2011 and 1 June 2013 on the internal medicine services at two hospitals in Boston.

PARTICIPANTS

One hundred and fifty seriously ill hospitalized patients over the age of 60 with an advanced illness and a prognosis of 1 year or less were included. Mean age was 76 and 51 % were women.

INTERVENTION

Three-minute video describing CPR and intubation plus verbal communication of participants’ preferences to their physicians (intervention) (N = 75) or control arm (usual care) (N = 75).

MAIN MEASURES

The primary outcome was participants’ preferences for CPR and intubation (immediately after viewing the video in the intervention arm). Secondary outcomes included: orders to withhold CPR/intubation, documented discussions with providers during hospitalization, and participants’ knowledge of CPR/ intubation (five-item test, range 0–5, higher scores indicate greater knowledge).

RESULTS

Intervention participants (vs. controls) were more likely not to want CPR (64 % vs. 32 %, p <0.0001) and intubation (72 % vs. 43 %, p < 0.0001). Intervention participants (vs. controls) were also more likely to have orders to withhold CPR (57 % vs. 19 %, p < 0.0001) and intubation (64 % vs.19 %, p < 0.0001) by hospital discharge, documented discussions about their preferences (81 % vs. 43 %, p < 0.0001), and higher mean knowledge scores (4.11 vs. 2.45; p < 0.0001).

CONCLUSIONS

Seriously ill patients who viewed a video about CPR and intubation were more likely not to want these treatments, be better informed about their options, have orders to forgo CPR/ intubation, and discuss preferences with providers.Trial registration: Clinicaltrials.gov {"type":"clinical-trial","attrs":{"text":"NCT01325519","term_id":"NCT01325519"}}NCT01325519Registry Name: A prospective randomized trial using video images in advance care planning in seriously ill hospitalized patients.     

Comparison of cardiac magnetic resonance with gated SPECT for evaluation of left ventricular function and volumes in patients with severe and multiple myocardial perfusion defects

Objectives

Gated SPECT is an accurate technique for assessment of myocardial perfusion (MP), left ventricular ejection fraction (LVEF), end-diastolic volume (EDV) and end-systolic volume (ESV). However recent studies have concluded that there are large discrepancies in assessment of LVEF and volumes by gated SPECT in patients with multiple severe myocardial perfusion defects. We sought to investigate the correlation between LVEF and volumes calculated by gated SPECT and cardiac magnetic resonance (CMR) in patients with severe multiple perfusion defects who are referred for CMR.

Methods

Twenty-nine patients (20 male and 9 female, mean age: 63 years ± 11) with multiple severe fixed perfusion defects (mean 5 ± 3 segments) were referred to undergo CMR. The average time between CMR and SPECT was 4 weeks. LVEF, EDV, and ESV were derived automatically from gated SPECT. In the CMR studies, the endocardial and epicardial borders were delineated manually in the short axis planes to calculate the LVEF and volumes.

Results

The different parameters were compared using linear regression, and correlation coefficients were calculated. Substantial correlation was found between CMR and gated SPECT for EDV: r = 0.7, p < 0.001. Moderate correlation between CMR and gated SPECT for LVEF: r = 0.5, p < 0.007 and ESV r =0 .53, p < 0.003.

Conclusion

Our data showed that the gated SPECT correlates substantially with MRI for measurement of EDV and moderately for ESV and LVEF in patients with multiple and severe perfusion defects. Thus, when accurate measurement is required, cardiac MRI is recommended.     

The platelet-to-lymphocyte ratio as a predictor of all-cause mortality in patients with coronary artery disease undergoing elective percutaneous coronary intervention and stent implantation

Background

There is no data regarding the association between the platelet-to-lymphocyte ratio (PLR) and long-term mortality in patients with stable coronary artery disease (SCAD). The aim of this study is to evaluate the utility of the pre-procedural PLR for predicting long-term, all-cause mortality in patients with SCAD undergoing percutaneous coronary intervention (PCI) and stent implantation.

Methods

We analyzed a total of 2959 consecutive patients with SCAD who underwent PCI (balloon angioplasty followed by stent implantation or direct stenting) between July 2006 and December 2011 at our institution. The patients were stratified into tertiles according to their admission PLR. The association between the PLR value and the outcomes was assessed using Cox proportional regression analysis after adjusting for clinical angiographic and laboratory data.

Results

During median follow-up of 1124 days, mortality was highest in patients with PLR within the 3rd tertile as compared to the 2nd and the 1st tertile (11.0% vs 8.7% vs. 9.6%, respectively, p = 0.03). PLR remained associated with mortality in multivariable analysis including clinical variables, ejection fraction and angiographic parameters HR (per 10 units increase) = 1.02 [95%CI,1.01 ÷ 1.04, p = 0.006]. After adjustment for the eGFR and hemoglobin levels, PLR was however no longer significantly associated with mortality.

Conclusion

PLR has potential predictive value in patients with SCAD, which has not been reported previously, but statistical significance disappears after adjusting for estimated glomerular filtration rate (eGFR) and hemoglobin levels as a potential confounding variable.