Comorbidities Of Coronary Artery Disease Research Articles

Retrospective Study to Evaluate Probability of MR4 Maintenance Following Frontline Nilotinib Dose De-Escalation after MR4 Achievement in the Patients with Chronic Myeloid Leukemia in Chronic Phase

Introduction: Nilotinib (NIL) is a potent second-generation tyrosine kinase inhibitor (TKI) approved for the treatment of newly diagnosed chronic myeloid leukemia (CML) patients (pts) in chronic phase, but reported to increase long-term toxicity such as cardiovascular (CV) risks. The ENESTfreedom study (Leukemia 2021) has reported 55% of treatment-free remission (TFR) rate after front line NIL discontinuation with a median 43.5 months of NIL treatment duration. Question still remains how to improve TFR rate after NIL frontline therapy. A potential solution is dose de-escalation (DESC) after MR4 achievement which could reduce the CV risk while extending MR4 duration prior to TFR attempt, thus increasing the chance of successful TFR attempt. DESTINY trial (Lancet Haematology 2019) had attempted TKI dose DESC to half of the standard dose for 12 months before stopping TKI therapy, reporting only 3 pts (2.4%) lost molecular response after TKI dose DESC in 125 pts who achieved molecular response with 4 log or deeper (MR4). However, 85% of this cohort is mainly treated with imatinib, limiting applying this experience in NIL treated pts. Accordingly, the present study attempted to evaluate the efficacy of NIL dose DESC following MR4 achievement based on real-world experience. Patients & Method: We have retrospectively analyzed the outcome of adult pts with CML in chronic phase treated with NIL frontline therapy and achieved sustained MR4 ( BCR::ABL1 transcript ≤0.01%IS). From the pts treated with NIL frontline therapy, we identified the cases attempted NIL de-scalation after achievement of MR4. The molecular response after NIL de-escalation was closely monitored every 3 months using BCR::ABL1 qPCR. Molecular recurrence was defined as an increase in BCR::ABL1 transcript levels above MR4 on at least two consecutive occasions or a single increase in BCR::ABL1 transcript level above MR3 ( BCR::ABL1 transcript ≤0.1%IS). At any time, pts who lost MR3 had returned Nilotinib dose to 300 mg BID. Primary endpoint of the study was event-free survival (EFS) following NIL de-escalation, which was defined from NIL DESC starts to molecular recurrence or death from any cause. Results: We have identified 52 pts who started NIL as first line therapy for CML-CP under clinical practice. With median follow-up duration of 9 years (range:2-12 years), 33 patient (64%) remains on NIL at the last follow-up visit. In 33 pts on NIL treatment, with a median follow up duration of 8 years (range;2-12), 25 (76%) had attempted NIL DESC at median of 6 years (range; 1-10 years) after frontline NIL therapy start, of whom the median time from NIL start to MR4 achievement was 12 months (range: 5-50 months). The median time from first achievement of MR4 to NIL DESC starts was 50 months (range: 3-105 months), while the median time from NIL start to NIL DESC was 77 months (range: 13-121 months). At the latest follow up, only one patient experienced molecular recurrence at 3 months after DESC but regained MR3 in 9 months after re-escalation of NIL to 300mg BID. One patient died of cardiac arrest at 80 months after NIL DESC with other comorbidities of coronary artery disease, hypertension and diabetes. One patient discontinued NIL at 51 months post DESC and has sustained MR4 till last follow up. In the DESC group, the EFS at 3 years, 95% (69.5-99.3%). There is another case developed myocardial infarction while on DESC dose of NIL, who switched the treatment to Asciminib. Conclusion: Achieving early and sustained MR4 with frontline NIL treatment facilitates DESC approach without compromising molecular response and might promote the TFR rate by extending MR4 duration. This DESC strategy can bridge CML pts on NIL frontline therapy prior to NIL discontinuation for TFR attempt.

Pathophysiological role of epicardial adipose tissue and its phenotypes in patients with diabetes and cardiovascular comorbidities

Abstract Introduction Epicardial adipose tissue (EAT) is an active endocrine organ that regulates multiple aspects of cardiac biology including myocardial redox state, intracellular Ca2+ cycling, the electrophysiological and contractile properties of cardiomyocytes, cardiac fibrosis, and coronary atherosclerosis progression. Purpose We evaluated associations of CMR-measured EAT area (EATa) with myocardial structure, function and 31P-MRS assessed energetics (phosphocreatine to ATP ratio) in patients with type 2 diabetes (T2D) with and without comorbidities of coronary artery disease (CAD) requiring coronary artery bypass grafting (CABG) and aortic stenosis requiring aortic valve replacement (AVR). We also examined the EAT phenotypes in patients with T2D with and without CAD, CAD patients without T2D and compared them to controls with severe AS without T2D. Methods 145 participants were recruited including CAD patients undergoing CABG with (30) and without T2D (25); severe AS patients with (20) and without T2D (20) undergoing AVR; T2D patients without cardiovascular disease (30) and healthy controls (20). A month prior to surgery cardiac PCr/ATP; EATa; LV volumes, mass, ejection fraction, mitral inflow E/A ratio, global longitudinal strain (GLS) and myocardial tissue characteristics were assessed. EAT samples were obtained from patients undergoing cardiac surgery for histological assessments. Results Participants were matched in age, sex distribution, and body mass index. Across all groups, patients with T2D showed higher EATa compared to those without T2D (138±50 vs 101±51cm2; p<0.0001). EATa was significantly higher in AS patients with T2D versus AS patients without T2D, while there was no significant difference in EATa between the CAD patients with and without T2D. Among the structural parameters, there were significant correlations between the EATa and myocardial pre-contrast T1 (p=0.02; r=0.20). Among the functional parameters there were inverse correlations of EATa with mitral inflow E/A (r=-0.34, p=0.002) and with GLS (r=-0.23, p=0.009). Among the metabolic biomarkers, there were no correlations between the EATa and PCr/ATP ratio. Histologically, compared to the control group of AS patients without T2D, patients with CAD with and without T2D showed larger adipocyte size and higher tissue fibrosis. There were no significant differences in EAT phenotype in adipocyte size, tissue fibrosis or inflammation between CAD patients with and without T2D. Conclusions This comprehensive EAT phenotyping study combined invasive and non-invasive methodologies and showed similar magnitudes of changes in EATa, adipocyte size and EAT fibrosis in CAD patients with and without T2D. While we have detected significant relationship of the EATa with the myocardial fibrosis, diastolic function and GLS, there were no correlations of myocardial PCr/ATP with the EATa suggesting other key mechanisms involved in the energetic deficit in patients with T2D.

Identification of the susceptible genes and mechanism underlying the comorbid presence of coronary artery disease and rheumatoid arthritis: a network modularization analysis

ObjectiveThe comorbidities of coronary artery disease (CAD) and rheumatoid arthritis (RA) are mutual risk factors, which lead to higher mortality, but the biological mechanisms connecting the two remain unclear. Here, we aimed to identify the risk genes for the comorbid presence of these two complex diseases using a network modularization approach, to offer insights into clinical therapy and drug development for these diseases.MethodThe expression profile data of patients CAD with and without RA were obtained from the GEO database (GSE110008). Based on the differentially expressed genes (DEGs), weighted gene co-expression network analysis (WGCNA) was used to construct a gene network, detect co-expression modules, and explore their relation to clinical traits. The Zsummary index, gene significance (GS), and module membership (MM) were utilized to screen the important differentiated modules and hub genes. The GO and KEGG pathway enrichment analysis were applied to analyze potential mechanisms.ResultBased on the 278 DEGs obtained, 41 modules were identified, of which 17 and 24 modules were positively and negatively correlated with the comorbid occurrence of CAD and RA (CAD&RA), respectively. Thirteen modules with Zsummary < 2 were found to be the underlying modules, which may be related to CAD&RA. With GS ≥ 0.5 and MM ≥ 0.8, 49 hub genes were identified, such as ADO, ABCA11P, POT1, ZNF141, GPATCH8, ATF6 and MIA3, etc. The area under the curve values of the representative seven hub genes under the three models (LR, KNN, SVM) were greater than 0.88. Enrichment analysis revealed that the biological functions of the targeted modules were mainly involved in cAMP-dependent protein kinase activity, demethylase activity, regulation of calcium ion import, positive regulation of tyrosine, phosphorylation of STAT protein, and tissue migration, etc.ConclusionThirteen characteristic modules and 49 susceptibility hub genes were identified, and their corresponding molecular functions may reflect the underlying mechanism of CAD&RA, hence providing insights into the development of clinical therapies against these diseases.

49. The Differences of Clinical Characteristics between Coronary Artery Disease Patients with and without Hypertension

Background: Hypertension may appear concomitantly and share the same pathophysiology with other comorbidities of coronary artery disease (CAD), which may indicate a relation between the two. This study aims to compare the differences between CAD patients with and without hypertension. Methods: This retrospective study includes subjects from the CAD registry in Dr. Hasan Sadikin General Hospital Bandung, from March-September 2022. Hypertension was defined as blood pressure $140/90 mmHg, known history of hypertension, or routinely consumed hypertension medication. Salt intake, history of smoking, low physical activity, body mass index (BMI), heart failure (HF), stroke, type-2 diabetes mellitus (T2DM), chronic kidney disease (CKD), obstructive sleep apnea (OSA), dyslipidemia, and chronic obstructive pulmonary disease (COPD) were compared between CAD patients with and without hypertension. Results: From 173 subjects included in this study, 124 (71.7%) subjects had hypertension, consist of 66.7% of male population and 93.8% of female population. The mean age in CAD patients with hypertension were higher than without hypertension (59.8 ± 8.3 vs 56.4 ± 8.8 years). There was no significant difference (p-value &gt;0.05) regarding salt intake, history of smoking, low physical activity, BMI, diabetes, CKD, OSA, dyslipidemia, and COPD. Significant difference was found with age, female, HF, and stroke (p-value &lt; 0.05). Multivariate analysis showed that hypertension was only independently associated with age [OR 1.04 (1–1.08, p-value 0.045)], female [OR 6.97 (1.57–30.86 p-value 0.01)], and HF [OR 3.5 (1.01–12.82, p-value 0.048)]. Conclusion: CAD patients with hypertension was higher in female, older population, and those who have heart failure compared to CAD patients without hypertension.

The Prognostic Value of Thyroid-Stimulating Hormone in Patients with Coronary Artery Disease and Depression

PurposePatients with the comorbidity of coronary artery disease (CAD) and depression are very common and always have poor prognosis. The relationship between thyroid-stimulating hormone (TSH) levels and major cardiovascular event (MACE) in these patients is still unknown. We aimed to explore this association.Patients and MethodsWe enrolled 203 CAD patients proven by coronary angiography (CAG). In the meanwhile, they were all assessed to have depression symptom by professional psycho-cardiologists. After an average follow-up of 23.7 months, patients were divided into two groups (high TSH group with TSH ≥ 1.395μIU/mL and low TSH group with TSH < 1.395μIU/mL) according to the cut-off value of baseline TSH. The impact of two different TSH groups for adverse events in CAD patients with depression was evaluated.ResultsThe average age of these patients was 64.9 years old. The two TSH groups had no significant difference in the comparison of other baseline data. Area under the receiver operating characteristic (ROC) curves (AUC) analysis indicated the well-discriminatory power of TSH levels for the occurrence of MACE (AUC = 0.61, 95% CI: 0.52–0.70, P = 0.03). In the KM survival analysis, high TSH group had a higher risk of MACE (P = 0.029). After multi-factor adjustment, there still existed a higher risk of MACE in high TSH group (HR = 2.05, 95% CI: 1.08–3.88, P = 0.028).ConclusionIn patients with the comorbidity of CAD and depression, higher TSH levels are associated with the occurrence of MACE. More researches need to be conducted to prove this association and explore whether the drug-related TSH reduction can decrease the occurrence of adverse events in the future.

Сomorbidity of coronary artery disease and its significance in predicting the results of coronary artery bypass grafting

The review presents an analysis of the scientific literature on comorbidity of coronary artery disease (CAD) and assessment of its impact on the results of coronary artery bypass grafting (CABG). Arterial hypertension (AH), chronic obstructive pulmonary disease (COPD), metabolic syndrome (MS), and diabetes mellitus (DM) have been shown to be the most common comorbidities in CAD patients. Clinical manifestations of cardiovascular comorbidities also include atrial fibrillation, acute cerebral ischemia, atherosclerosis of carotid and lower limb arteries, and chronic heart failure.Concomitant COPD doubles the risk of postoperative complications after CABG and reduces the 10-year survival rate in patients to 30%. In CAD patients with MS, the risk of postoperative mortality increases by 1.4 times, and the 5-year survival rate decreases by 3 times. Diabetes significantly worsens the long-term survival of patients after CABG and is an independent predictor of acute cardiovascular events after revascularization in the long term. The presence of various comorbidities in CAD patients requires a personalized approach to managing the risks of adverse outcomes after CABG and introduction of modern artificial intelligence (AI) technologies into clinical practice, which significantly increase the accuracy of prognosis.

Malnutrition and the risk for contrast-induced acute kidney injury in patients with coronary artery disease.

Malnutrition is a common comorbidity of coronary artery disease (CAD) and is often associated with adverse events. The malnutrition often means lower cholesterol, albumin and high lymphocyte, as risk factors of Contrast-Induced Acute Kidney Injury (CI-AKI). We aim to evaluate the association between malnutrition and CI-AKI following coronary angiography (CAG) in CAD patients. We analyzed 3170 CAD patients with variables of nutritional status (Controlling Nutritional Status score (CONUT)) from the prospective multicenter study, REICIN (NCT01402232) including 4,271 consecutive patients undergoing CAG from January 2013 to February 2016. Patients were divided into the normal group (CONUT score 0-1) and malnutrition group (CONUT score > 1). The association of malnutrition and the risk of CI-AKI was examined in all CAD patients using multivariable logistics regression analysis. Among the 3170 patients (mean age: 63.1 ± 10.7years), 1865 (58.8%) suffered from malnutrition, 111 (3.5%) developed CI-AKI, including 23 (1.76%) in normal group and 88 (4.72%) in malnutrition group (p < 0.01). The malnourished patients were older, and likely had anemia and worse cardiorenal function. After adjustment for confounders, the risk of CI-AKI was 1.04 times higher in the malnutrition group than in the normal group (adjusted OR: 2.04, 95% CI 1.28-3.38, p < 0.01). Among CAD patients undergoing CAG, malnutrition is extremely common and associated with a double risk of CI-AKI. Further studies are needed to investigate the potential renal protection of intervening malnutrition in CAD patients.

Does continuous positive airway pressure therapy benefit patients with coronary artery disease and obstructive sleep apnea? A systematic review and meta-analysis.

The prevalent co‐morbidity of coronary artery disease (CAD) and obstructive sleep apnea (OSA) has attracted great interest. However, effects of continuous positive airway pressure (CPAP) in patients with OSA and CAD for cardiovascular outcomes and deaths are still controversial. Usage of CPAP among patients with CAD and OSA could decrease the risk of cardiovascular events and death in adults. PubMed, EMBASE, Web of science, and Cochrane Library were systematically searched. Studies that described association of CPAP treatment with cardiovascular events in CAD and OSA patients were included. The main outcome was the major adverse cardiovascular events (MACE), including all‐cause death, cardiovascular death, myocardial infarction (MI), stroke, and repeat revascularization. Summary relative risks (risk ratios [RRs]) and 95% confidence intervals (CIs) of outcomes were pooled and heterogeneity was assessed with the I2 statistic. Nine studies enrolling 2590 participants with OSA and CAD were included and extracted data. There was significant association of CPAP with reduced risk of MACE (RR, 0.73, 95% CI [0.55, 0.96]), particularly among those with AHI less than 30 events/h (RR, 0.43, 95% CI [0.22, 0.84]). Similarly, the same result was found in all‐cause death (RR, 0.66, 95% CI, [0.46, 0.94]) and cardiovascular death (RR, 0.495, 95% CI [0.292, 0.838]). Our data suggested that CPAP usage, compared to usual care, was associated with reduced risks of cardiovascular outcomes or death in patients with OSA and CAD, particularly in the subgroup with AHI less than 30 events/h, which still needs further studies to confirm.

Opioid use following a total shoulder arthroplasty: who requires refills and for how long?

IntroductionPain control following a total shoulder arthroplasty (TSA) is multifactorial. The current standard of care includes the utilization of a multimodal analgesic approach including breakthrough prescription opioid medication in an effort to provide postoperative analgesia. While this original opioid prescription is sufficient for the majority of patients, some go on to require prolonged opioid use. Our study investigated patient risk factors associated with opioid refill postsurgery.MethodsThe Truven Marketscan® database was queried for all patients who underwent either a primary anatomic TSA or primary reverse TSA from 2010 to 2017. Opioid data were collected using National Drug Codes (NDC) from outpatient pharmacy claims. Only opioid-naïve patients were included. Patients were then grouped into 1 of 3 cohorts based on postoperative opioid use: 1) Patients with no additional refills, 2) patients with a minimum of one additional refill up through 6 months postoperatively, and 3) patients with additional refills and continued opioid use past 6 months.ResultsOf the total of 17,706 opioid-naïve patients that underwent a TSA, 10,882 (61.5%) did not have any additional refills, 4473 (25.3%) required an additional prescription within 6 months after surgery, and 2351 (13.3%) had prolonged opioid use beyond 6 months postoperatively. A dose-dependent relationship was identified between initial opioid prescription quantity and risk for refill and prolonged use. The prolonged use group was prescribed an equivalent of 20.0 more 5 mg oxycodone pills than the no refill group and 12.7 more than the refill group (P < .001). On multivariate analysis, younger age, female gender, and tobacco use, along with the comorbidities of coronary artery disease, clinical depression, diabetes, and rheumatic disease were all found to be predictive factors of prolonged opioid use.DiscussionThe dose-dependent relationship observed between original opioid prescription data and number of additional refills needed, suggests that initially overprescribing opioids may lead to prolonged dependency. This study also identified several independent risk factors for prolonged opioid use, including younger age, depression, and tobacco use. This study will hopefully help recognize high-risk patient populations and serve as the foundation for future studies into opioid prescription standardization and preoperative opioid education.

Associations and limited shared genetic aetiology between bipolar disorder and cardiometabolic traits in the UK Biobank.

People with bipolar disorder (BPD) are more likely to die prematurely, which is partly attributed to comorbid cardiometabolic traits. Previous studies report cardiometabolic abnormalities in BPD, but their shared aetiology remains poorly understood. This study examined the phenotypic associations and shared genetic aetiology between BPD and various cardiometabolic traits. In a subset of the UK Biobank sample (N = 61 508) we investigated phenotypic associations between BPD (ncases = 4186) and cardiometabolic traits, represented by biomarkers, anthropometric traits and cardiometabolic diseases. To determine shared genetic aetiology in European ancestry, polygenic risk scores (PRS) and genetic correlations were calculated between BPD and cardiometabolic traits. Several traits were significantly associated with increased risk for BPD, namely low total cholesterol, low high-density lipoprotein cholesterol, high triglycerides, high glycated haemoglobin, low systolic blood pressure, high body mass index, high waist-to-hip ratio; and stroke, coronary artery disease and type 2 diabetes diagnosis. BPD was associated with higher polygenic risk for triglycerides, waist-to-hip ratio, coronary artery disease and type 2 diabetes. Shared genetic aetiology persisted for coronary artery disease, when correcting PRS associations for cardiometabolic base phenotypes. Associations were not replicated using genetic correlations. This large study identified increased phenotypic cardiometabolic abnormalities in BPD participants. It is found that the comorbidity of coronary artery disease may be based on shared genetic aetiology. These results motivate hypothesis-driven research to consider individual cardiometabolic traits rather than a composite metabolic syndrome when attempting to disentangle driving mechanisms of cardiometabolic abnormalities in BPD.

P1865Incidence and predictors of invasively-treated pericardial effusion during catheter ablation of atrial fibrillation in Japan

Abstract Purpose and method Japanese Heart Rhythm Society requested electrophysiology centers to register the data of patients who underwent catheter ablation for atrial fibrillation (AF) in designated eight months from 2011 to 2017. We assessed the incidence and predictors of pericardial effusion (PE) as an early complication of AF ablation. Results More than two hundred EP centers reported the data of 13,233 AF ablation cases (age; 64.2±10.7 years, male; 72.6%, paroxysmal AF; 63.4%). Clinically significant complications occurred in 601 subjects (4.5%). Critical PE occurred in 116 patients (0.8%), while six of them required open-chest surgery. Overall complication rate did not show significant changes. In contrast, incidence of PE declined over time (2012:1.2%, 2017:0.5%, p=0.003). Multiple logistic regression analysis showed that seven factors were related with higher incidence of PE. Among these factors, primary extra-PV ablation and hypertrophic cardiomyopathy (HCM) were more remarkably associated with higher rate of PE (PVI[−] vs. PVI[+]= 9.0% vs. 0.8%, OR 12.3, p&lt;0.001; HCM: [+] vs. [−] = 2.6% vs. 0.8%, OR 3.26, p=0.001). Comorbidity of coronary artery disease (CAD) and use of CARTO system were related with lower PE rate (CAD: [+] vs [−] = 0.2% vs. 0.9%, OR 0.22 [p=0.034], CARTO: [+] vs [−] = 0.7% vs. 1.2%, OR 0.52 [p=0.001]). None of cryobaloon ablation, gender, type of AF, center volume, periprocedural oral anticoagulant, or left atrial diameter was significantly related with the occurrence of PE. Conclusions Incidence of critical PE decreased recently. HCM and primary extra-PV ablation were outstanding predictors of critical PE.

Results of 1-year follow-up of patients with comorbidity of coronary artery disease and respiratory disease underwent scheduled myocardial revascularization

The first goal of this study was to analyze a relationship between 1-year outcomes and respiratory comorbidity in patients with coronary artery disease (CAD) underwent scheduled coronary artery bypass grafting (CABG); the second goal of the study was to determine the most significant predictors of fatal outcome in these patients. Methods. The study involved 251 patients underwent CABG. They were stratified according to having comorbid chronic obstructive (n = 62; 24.7%) or non-obstructive lung disease (n = 65; 25.9%) or not having chronic respiratory disease (n = 124; 49.4%). Cardiovascular events during 1 year were registered. Results. An expected decrease in functional classes of CAD and chronic heart failure (CHF) was noted over 1 year. Number of non-fatal significant cardiovascular events didn’t differ in patients with or without chronic obstructive pulmonary disease (COPD). Seven patients (2.78%) died during the year; the cause of death was cardiovascular disease in all cases. Factors predicting poor outcomes included age, occupational exposure to chemicals &gt; 3 years, incomplete myocardial revascularization, FEV1/FVC ratio, and left ventricular ejection fraction &lt; 40%. Conclusion. COPD is a predictor of poor outcome of myocardial revascularization in patients with CAD.

Outpatient and inpatient readmission rates of 3- and 4-level anterior cervical discectomy and fusion surgeries.

With the costs related to the United States medical system constantly rising, efforts are being made to turn traditional inpatient procedures into outpatient same-day surgeries. In this study the authors looked at the various comorbidities and perioperative complications and their impact on readmission rates of patients undergoing outpatient versus inpatient 3- and 4-level anterior cervical discectomy and fusion (ACDF). This was a retrospective study of 337 3- and 4- level ACDF procedures in 332 patients (5 patients had both primary and revision surgeries that were included in this total of 337 procedures) between May 2012 and June 2017. In total, 331 procedures were analyzed, as 6 patients were lost to follow-up. Outpatient surgery was performed for 299 procedures (102 4-level procedures and 197 3-level procedures), and inpatient surgery was performed for 32 procedures (11 4-level procedures and 21 3-level procedures). Age, sex, comorbidities, number of fusion levels, pain level, and perioperative complications were compared between both cohorts. Analysis was performed for 331 3- and 4-level ACDF procedures done at 6 different hospitals. The overall 30-day readmission rate was 1.2% (outpatient 3 [1.0%] vs inpatient 1 [3.1%], p = 0.847). Outpatients had increased readmission risk, with comorbidities of coronary artery disease (OR 1.058, p = 0.039), autoimmune disease (OR 1.142, p = 0.006), diabetes (OR 1.056, p = 0.001), and chronic kidney disease (OR 0.933, p = 0.035). Perioperative complications of delirium (OR 2.709, p < 0.001) and surgical site infection (OR 2.709, p < 0.001) were associated with increased risk of 30-day hospital readmission in outpatients compared to inpatients. This study demonstrates the safety and effectiveness of 3- and 4-level ACDF surgery, although various comorbidities and perioperative complications may lead to higher readmission rates. Patient selection for outpatient 3- and 4-level ACDF cases might play a role in the safety of performing these procedures in the ambulatory setting, but further studies are needed to accurately identify which factors are most pertinent for appropriate selection.

Clinical Features and Outcomes of Peripheral Vascular Disease Patients Receiving Red Blood Cell Transfusions.

BackgroundPeripheral vascular disease (PVD) patients are commonly transfused with red blood cells (RBC) due to their inability to compensate for anemia and blood loss. Anemias, as well as allogeneic transfusions, have been demonstrated as independent risk factors for increased mortality and morbidity following cardiovascular procedures. The relationships between anemia, transfusion, and adverse outcomes in PVD patients remain unascertained and understudied.MethodsA retrospective cohort study was conducted to determine mortality at 30-day, one-year, and three-year markers among 330 randomly selected PVD patients. The clinical features of patients receiving transfusions were examined, and the mortality rates were compared between patients who received an RBC transfusion and those who did not. Cox regression analysis was employed to identify independent variables predicting mortality.ResultsTransfusions were found to have increased mortality rates over non-transfused patients at 30 days (6.1% vs. 1.8%, p = 0.05), one year (21.8% vs 12.1%, p = 0.02), and three years (41.2% vs. 23.0%, p = 0.001). Using a multivariate regression model, it was determined that the transfusion itself was not a significant cause of this decrease in survival, while the propensity to transfuse was a predictor for both short (30 days, 36.73 [1.85-728.06], p = 0.04) and long-term mortality (one year (8.83 [2.62-29.77], p < 0.001; three years (7.07 [1.46-8.07], p <0.01). Anti-coagulation therapy using intravenous (IV) heparin and the chronic comorbidities of coronary artery disease and diabetes mellitus were also robust independent predictors of decreased survival.ConclusionThis study was able to find an association between RBC transfusion and reduction in short-term (three months) and long-term (three years) survival. Those requiring IV heparin during the hospital stay were at an increased risk of requiring blood transfusion, and patients receiving IV heparin were also found to have a significant increase in mortality rates.

Asymptomatic hyperuricemia and coronary artery disease in elderly patients without comorbidities.

Because many subjects with hyperuricemia have comorbidities, it can be difficult to differentiate the role of hyperuricemia from that of other comorbidities of coronary artery disease (CAD). Subjects aged ≥ 65 years were enrolled in the study and were available at enrollment and at 5-year follow-up. Subjects were excluded if they were overweight or obese, hypertensive, diabetic, hyperlipidemic, had a pre-existing cardiovascular disease, a history of gout or hyperuricemia on medications, or chronic kidney disease as estimated by a glomerular filtration rate (eGFR) < 60 mL/min per 1.73 m2. We used Poisson regression to estimate the hazard ratio (HR) for incident CAD events between hyperuricemic (> 7 mg/dL in men and ≥ 6 mg/dL in women) and normouricemic subjects. A total of 2,142 subjects without comorbidities (mean age of 70.7 ± 5.9 years, 1,194 men) were followed for 57.4 ± 8.9 months. Hyperuricemia was associated with an increased cumulative incidence of incident CAD events (15.0% versus 8.8%, P < 0.001). After adjusting for confounding factors, hyperuricemia independently predicted the risk of incident CAD events (HR=1.71, 95% CI 1.26–2.34). In conclusion, asymptomatic hyperuricemia is a valuable biomarker for predicting the development of incident CAD events.

Granular Cell Tumor of Rectum: A Very Rare Entity

Granular cell tumor (GCT), also called as Abrikossoff tumor is a rare neoplastic process which is mostly benign. Granular cell tumors can develop in any part of the body, though oral cavity and subcutaneous tissue are the most common sites. Only about 10% of the tumors develop in the gastrointestinal tract with esophagus being the most common site and rectum being the rarest. We here present one such rare case of rectal granular cell tumor. A 61-year-old man with medical comorbidities of coronary artery disease, congestive heart failure, hypertension, dyslipidemia presented to the GI clinic for screening colonoscopy. The patient denied any gastrointestinal related complaints. Screening colonoscopy revealed good bowel preparation with a score of 8 on Boston Bowel Preparation Scale, a 1cm serrated adenomatous polyp in the transverse colon that was removed with hot snare polypectomy and a firm 4mm nodule in the rectum that was removed with biopsy forceps (Figure - 1). Biopsy of the rectal nodule revealed a granular cell tumor with positive periodic acid-Schiff (PAS) staining (Figure - 2). Immunohistochemical staining for S100 protein was positive as well (Figure - 3). A subsequent rectal endoscopic ultrasound (EUS) confirmed complete removal of the tumor. Granular cell tumors (GCTs) are mostly benign and very rarely malignant with tumors >4cm in size having metastatic potential. Patients with GCTs are mostly asymptomatic and GCTs are usually incidental findings. However, large tumors are known to present with hematochezia and/or pain. GCTs are more common in women than in men. Patients with GCTs are usually between the 4th and the 6th decades of life. The tumor can present as a painless, non-ulcerated nodule or a yellowish-gray sessile polyp with firm consistency. Endoscopic ultrasound can be used to evaluate the tumor invasion into the wall of the gastrointestinal tract. Diagnosis is made with histology. Fanburg-Smith et al. proposed six histological criteria to differentiate benign tumors from malignant ones. The six criteria include- cellular necrosis, pleomorphism, increased nuclear-cytoplasmic ratio, enlarged nucleoli, increased mitotic activity and cell elongation. A tumor is considered malignant if 3 or more criteria are fulfilled. Benign tumor can be removed with endoscopic resection as was the case with our patient. Surgical resection should be reserved for large and multifocal tumors.Figure 1Figure 2Figure 3

Heydeʼs Syndrome: An Integrative Disease

Heyde's syndrome is an integrative disease process that involves gastrointestinal bleeding, von-Willebrand's factor, and aortic stenosis. First described in 1958 through simple observations from an internist, its etiological description has since evolved, with clinical and bench research now indicating quite elegant pathophysiological underpinnings. We here present a case of Heyde's syndrome resulting in recurrent gastrointestinal bleeding. A 68-year-old Caucasian woman with medical comorbidities of coronary artery disease, severe aortic stenosis, hypertension, hyperlipidemia, and diabetes mellitus type 2 presented with 2 day onset of worsening chest pain and exertional dyspnea. On further inquiry, the patient also reported multiple dark bowel movements over the preceding three days. Initial laboratory values were significant for severe anemia (Hemoglobin of 7.1gm/dL). The patient was admitted for severe symptomatic anemia. A transthoracic echocardiogram revealed severe aortic stenosis (Figure 1). The patient underwent bidirectional endoscopy which demonstrated multiple arteriovenous malformations (AVMs) requiring the use of argon plasma coagulation and injection of epinephrine to achieve hemostasis. The patient was subsequently referred for expedited aortic valve replacement. It is quite infrequent that the disciplines of gastroenterology, hematology and cardiology intersect with each other in regards to forming pathophysiological basis of a disease. Heyde's syndrome represents one such example. Loss of Von-Willebrand factor (a high molecular weight protein multimer that is involved in primary hemostasis) in patients with severe aortic stenosis, is implicated in the pathogenesis. It is now believed that high-velocity flow through a stenotic aortic valve causes conformational change in the configuration of large molecular weight von-Willebrand factor, making it vulnerable to cleavage by the plasma protein ADATS13 and subsequently rendering it hemostatically inferior to the normal high molecular weight multimers. Von-Willebrand factor may have also an essential role in maintaining vascular integrity which could explain the development of angiodysplasias in patients with deficiency of this factor. Aortic valve replacement was shown to improve the levels of Von-Willebrand factor significantly and is considered the definitive treatment for Heyde's syndrome.Figure 1

Association between intracardiac hemodynamics and respiratory function in patients with coronary artery disease and respiratory comorbidity

The aim of this study was to investigate a relationship between the myocardial structure and function and respiratory parameters in patients with coronary artery disease (CAD) and respiratory disease.Methods. We performed spirometry, body plethysmography, lung diffusing capacity test and measured the left ventricle (LV) systolic and diastolic function in patients with CAD with or without respiratory diseases and ventilation disorders.Results. Patients with CAD (n = 662) participated in the study. The LV systolic dysfunction was found only in 60 patients (9.1%), while diastolic dysfunction was found in 387 patients with CAD (58.4%). Most patients with obstructive ventilation disorders had the systolic or diastolic LV dysfunction (40 patients (66.7%) and 197 patients (79.4%), respectively). Flow and volume lung function parameters and the lung diffusing capacity were associated with some echocardiographic and pulsed wave Doppler parameters.Conclusion. Comorbidity of CAD and lung obstructive disease was associated with more frequent systolic and diastolic LV dysfunction. The relationship between respiratory and cardiac parameters could indicate the cross impact that could deteriorate the course of both the diseases.

Prevalence of anxiety and depression symptoms and their relationship with other coronary artery disease risk factors: A population-based study on 5900 residents in Southeast Iran.

Anxiety and depression are reported as the most prevalent psychiatric disorders worldwide. Here, we studied the prevalence of such disorders with co-morbidities of coronary artery disease (CAD) risk factors in an urban population in Iran. 5900 people were selected from 15 to 75-years-olds through single-stage cluster sampling. In addition to examining them for CAD risk factors, Beck anxiety and depression inventories were used to measure anxiety and depression symptoms. The standardized population prevalence of such disorders is reported and the predictors of having anxiety or depression were assessed using Poisson regression model. Overall 25.4% had moderate and 22.7% had severe anxiety. Severe anxiety significantly and constantly increased by age groups (p=0.01). The risk for anxiety was higher among females (Adjusted Risk Ratio, ARR 1.2), and those who were student/soldier (ARR 1.07). Those with high level of physical activity were at lower risk for anxiety (ARR 0.92). The risk of depression (any level) was higher among females (ARR 1.3), those holding high-school level of education (ARR 1.41), and those who used opium either occasionally (ARR 1.17) or frequently (ARR 1.3). Both anxiety and depression were significantly associated with two main CAD risk factors, low physical activity and opium use. We found that the majority of residents in Kerman, particularly women, are suffering from mild to server depression and anxiety symptoms. Public health interventions to increase public awareness on such symptoms, screening and delivery of prevention and treatment services are required to prevent from the growing burden of such disorders and cardiovascular diseases.

Gout is associated with organic and psychogenic erectile dysfunction

BackgroundGout is a deposition disease with an inflammatory response that can increase the risk of cardiovascular disease. Gout is stressful for affected individuals, and can cause erectile dysfunction (ED). The objective of this study was to identify the association between gout and psychogenic ED (PED) and organic ED (OED). MethodWe analyzed 35,265 patients from the National Health Insurance Research Database who had been diagnosed with gout between 2000 and 2011. A total of 70,529 matched controls were included in the study as a comparison. Patients with a history of PED and OED occurring before the index date, aged less than 20years, or with incomplete demographic information were excluded. Control patients were selected from the population of people without a history of gout, PED, or OED. The following risk factors for PED and OED were included as covariates in the multivariable models: age, comorbidities of coronary artery disease (CAD), peripheral arterial disease, chronic kidney disease (CKD), hypertension, diabetes, hyperlipidemia, depression and anxiety. ResultMen with gout were more likely to have an increased risk (1.21 times) of ED than were those without gout. Patients with gout were 1.52 times more likely to develop OED and 1.18 times more likely to develop PED than patients in the control group. The risk of developing ED was greater for patients with comorbidities of CKD, diabetes, hyperlipidemia, depression and anxiety. ConclusionGout is associated with organic and psychogenic ED. Clinical physicians should consider this association when treating patients with gout.