Pre-existing Coronary Disease Research Articles

Abstract 13925: Initial Triglyceride Glucose Index as a Predictor of No-Reflow After Primary Percutaneous Coronary Intervention

Introduction: The triglyceride glucose (TyG) index is a screening method for insulin resistance that can be used on a daily clinical basis and only requires two laboratory determinations: serum triglycerides and serum glucose. Prospective studies of predictive values of the TyG index for cardiovascular diseases (CVD) have primarily focused on pre-existing coronary arterial disease or diabetes mortality, and the TyG index has been shown to be associated with subclinical atherosclerosis symptoms, such as arterial stiffness and preclinical coronary arterial calcification. The study aimed to investigate the possible correlation between the TyG index and the no-reflow phenomenon in patients presented with acute STEMI undergoing primary percutaneous coronary intervention (PPCI). Methods: A total number of 702 patients who presented with acute STEMI in the period from 1/9/2015 to 1/9/2019 who underwent PPCI according to the standard techniques were included. Patients with a previous history of diabetes, dyslipidemia, or on statin therapy were excluded from the study. Initial triglyceride levels as well as fasting blood glucose were tested in all patients at the time of admission. TyG index was calculated for all patients. No-reflow was defined as distal Thrombolysis in Myocardial Infarction (TIMI) flow less than III. Results: 618 patients (88 %) had normal flow while 84 patients (12%) had no-reflow. The mean TyG index was 4.3±0.4 in the no-reflow group versus 4.2±0.4 in the normal reflow group (P = 0.03). After propensity matching, the mean TyG index was 4.2 ± 0.3 in both groups. (P = 0.99) Conclusion: In a retrospective observational study, there was no statistically significant difference between no-reflow and normal flow groups after propensity matching. Further research is required to detect whether the TyG index can be used as a readily available independent predictor of cardiovascular morbidity and mortality.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Incidence, predictors, and outcomes associated with acute kidney injury in patients undergoing transcatheter aortic valve replacement: from the BRAVO-3 randomized trial.

Acute kidney injury (AKI) is not uncommon in patients undergoing transcatheter aortic valve replacement (TAVR). We examined the incidence, predictors, and outcomes of AKI from the BRAVO 3 randomized trial. The BRAVO-3 trial included 802 patients undergoing transfemoral TAVR randomized to bivalirudin vs. unfractionated heparin (UFH). The primary endpoint of the trial was Bleeding Academic Research Consortium (BARC) type ≥ 3b bleeding at 48h. Total follow-up was to 30days. AKI was adjudicated using the modified RIFLE (Valve Academic Research Consortium, VARC 1) criteria through 30-day follow-up, and in a sensitivity analysis AKIwas assessed at 7days (modified VARC-2 criteria). We examined the incidence, predictors, and 30-day outcomes associated with diagnosis of AKI. We also examined the effect of procedural anticoagulant (bivalirudin or unfractionated heparin, UFH) on AKI within 48hafter TAVR. The trial population had a mean age of 82.3 ± 6.5years including 48.8% women with mean EuroScore I 17.05 ± 10.3%. AKI occurred in 17.0% during 30-day follow-up and was associated with greater adjusted risk of 30-day death (13.0% vs. 3.5%, OR 5.84, 95% CI 2.62-12.99) and a trend for more BARC ≥ 3b bleeding (15.1% vs. 8.6%, OR 1.80, 95% CI 0.99-3.25). Predictors of 30-day AKI were baseline hemoglobin, body weight, and pre-existing coronary disease. AKI occurred in 10.7% at 7days and was associated with significantly greater risk of 30-day death (OR 6.99, 95% CI 2.85-17.15). Independent predictors of AKI within 7days included pre-existing coronary or cerebrovascular disease, chronic kidney disease (CKD), and transfusion which increased risk, whereas post-dilation was protective. The incidence of 48-h AKI was higher with bivalirudin compared to UFH in the intention to treat cohort (10.9% vs. 6.5%, p = 0.03), but not in the per-protocol assessment (10.7% vs. 7.1%, p = 0.08). In the BRAVO 3 trial, AKI occurred in 17% at 30days and in 10.7% at 7days. AKI was associated with a significantly greater adjusted risk for 30-day death. Multivariate predictors of AKI at 30days included baseline hemoglobin, body weight, and prior coronary artery disease, and predictors at 7days included pre-existing vascular disease, CKD, transfusion, and valve post-dilation. Bivalirudin was associated with greater AKI within 48h in the intention to treat but not in the per-protocol analysis.

Impact of preexisting coronary arterial disease in patients undergoing percutaneous mitral valve repair (MitraClip).

Percutaneous mitral valve repair with Mitraclip device has been approved for the treatment of symptomatic mitral valve regurgitation in patients deemed high surgical risk. It's unclear whether the presence of preexisting coronary arterial disease (CAD) affects the postprocedural outcomes of Mitraclip. The study population was extracted from the 2016 Nationwide Readmissions Data (NRD) using the International Classification of Diseases, Tenth Revision, Clinical Modifications/Procedure Coding System (ICD-10-CM/PCS) for Mitraclip, preexisting CAD, and postprocedural complications. Study primary endpoints included in-hospital all-cause mortality, cardiogenic shock, acute myocardial infarction (AMI), acute kidney injury (AKI), stroke, acute respiratory failure, length of hospital stay (LOS), and 30-day readmission rate. A total of 2,539 discharges that had Mitraclip during the index hospitalization, 62.3% had history of preexisting CAD. Mean age was 78.5 years and 46.6% were female. Overall, the presence of preexisting CAD was associated with higher AMI (1.6 vs. 0.4%, p < .01), however, there was no significant differences in terms of in-hospital all-cause mortality (2.2 vs. 2.6%, p = .52), cardiogenic shock (3.4 vs. 4.1%, p = .39), AKI (14.7 vs. 13.6%, p = .43), stroke (0.9 vs. 0.5%, p = .31), acute respiratory failure (9.7 vs. 8.8%, p = .43), LOS (5.3 vs. 5.3 days, p = .85) or 30-day readmission rate (14.6 vs. 14.4%, p = .92). These results persisted after adjustment for baseline characteristics. The subgroup of CAD patients who received percutaneous coronary intervention (PCI) was associated with higher in-hospital mortality (22.5 vs. 2.0%, p < .01), cardiogenic shock (25.0 vs. 3.3%, p < .01), AMI (22.5 vs. 0.8%, p < .01), AKI (55.0 vs. 13.7%, p < .01), stroke (10.0 vs. 0.6%, p < .01), acute respiratory failure (45.0 vs. 8.8%, p < .01), and longer LOS (21.5 vs. 5.1 days, p < .01), however there was no significant difference in 30-day readmission rate (15.0 vs. 14.5%, p = .95). Preexisting CAD was associated with higher in-hospital AMI post-Mitraclip but with comparable mortality and other morbidities. Patients who received PCI during the same index hospitalization had higher in-hospital mortality and morbidity.

The Weight of Evidence From Electrophysiology, Observational, and Cardiovascular End Point Studies Demonstrates the Safety of Azithromycin.

Increased use of azithromycin (AZ) in treating infections associated with coronavirus disease 2019 (COVID‐19) and reports of increased incidence of prolonged corrected QT (QTc) interval associated with AZ used with hydroxychloroquine prompted us to review the latest evidence in the literature, present additional analyses of human cardiovascular (CV) electrophysiology studies, and to describe sequential steps in research and development that were undertaken to characterize the benefit‐risk profile of AZ. Combined QTc findings from electrocardiograms taken during oral and i.v. pharmacokinetic‐pharmacodynamic studies of AZ suggest that clinically meaningful QTc prolongation is unlikely. Findings from several observational studies were heterogeneous and not as consistent as results from at least two large randomized controlled trials (RCTs). The QTc findings presented and observational data from studies with large numbers of events are not consistent with either a proarrhythmic action of AZ or an increase in frequency of CV deaths. Well‐powered RCTs do not suggest a presence of increased risk of CV or sudden cardiac death after short‐term or protracted periods of AZ usage, even in patients at higher risk from pre‐existing coronary disease.

Coronary Events in Patients Presenting for Repair of Acute Type A Aortic Dissection.

Background: Preoperative coronary angiography is often not performed in acute Type A dissection. We examined differences in the incidence of pre-existing coronary disease and subsequent coronary events between patients undergoing acute Type A dissection repair and patients undergoing elective proximal aortic aneurysm repair. Methods: From 2000 to 2015, there were 154 acute Type A dissection repairs and 457 elective proximal aortic aneurysm repairs. We performed a retrospective review to evaluate preoperative coronary disease and postoperative coronary interventions such as percutaneous coronary intervention (PCI) and coronary bypass grafting (CABG). Results: A total of 31 (20%) dissection patients and 123 (27%) elective surgery patients had preoperative evidence of coronary artery disease (p = 0.094). All elective surgery patients but only six (4%) dissection patients had preoperative coronary catheterization. More CABGs were performed in the elective surgery group (19%) than in the dissection group (3%, p < 0.001). There were no differences in the incidence of prior PCI, CABG, or myocardial infarction between groups. Following dissection repair, four patients required coronary interventions. Of these, two (1.3%) experienced chest pain and underwent PCI at 4.7 and 4.3 months postoperatively, respectively, and another two experienced symptoms and required PCI at 5 and 7 years, respectively. The 30-day and 14-year mortality rates after dissection repair were 13% and 24%, respectively. Although the dissection group had poorer survival than the elective surgery group (p < 0.001), there was no difference in conditional survival after aortic-related deaths over the first year were censored (p = 0.104). Conclusions: Given the low incidence of missed significant coronary disease (1.3%), it is reasonable to perform Type A dissection repair without coronary angiography.

Abstract 164: Impact of Sex and Race on the Likelihood of Mortality, Cardiology Consultation, and Coronary Angiography Among Hospitalized Patients Evaluated With Cardiac Troponin

Introduction: Serum troponin (Tn) is a highly sensitive test useful in diagnosing acute myocardial infarction. Elevated Tn is associated with higher mortality and greater use of cardiovascular services. The effect of sex and race on these observations has not been well characterized. We hypothesize that sex and race will be independent predictors of cardiology consultation and cardiac catheterization. Methods: We analyzed adult patients hospitalized between 2012 and 2015 who had Tn testing. Patients were compared in 2 cohorts: those with and those without elevation in Tn. We extracted data on demographics, self-reported race, medical history, new inpatient diagnoses, Charlson comorbidity index (CCI), and mortality (up to 3 years). We developed a Cox proportional hazard model for mortality and used logistic regression to determine associations with cardiology consultation and cardiac catheterization. Results: Of the 26,663 included, 22.0% were black, 50.1% were women, 9.8% had diabetes, and 6.4% had pre-existing coronary disease. Cardiac catheterization was performed on 1,800 (6.8%), 3,672 (13.8%) had a cardiology consult, and 4,962 (18.6%) had elevated Tn. Among the variables associated with cardiology consultation were elevated Tn (odds ratio [OR] =3.44, 95% confidence interval [CI] 3.19-3.72, p&lt;0.0001), male sex (OR=1.29, 95% CI 1.20-1.39, p&lt;0.0001) and black race (OR=0.85, 95% CI 0.77-0.93, p=0.0006). Cardiac catheterization was associated with elevated Tn (OR=8.16, 95% CI 7.34-9.06, p&lt;0.0001), male sex (OR=1.45, 95% CI 1.31-1.61, p&lt;0.0001), CCI &gt;4 (OR=0.44, 95% CI 0.35-0.54, p&lt;0.0001), and black race (OR=0.72, 95% CI 0.63-0.82, p&lt;0.0001). A total of 4,697 patients died during follow-up. Elevated Tn (hazard ratio [HR] =2.05, p&lt;0.0001), male sex (HR=1.14, p&lt;0.0001), and CCI &gt;4 (HR=3.33, p&lt;0.0001) were associated with a higher risk of death, while risk among black patients was lower (HR=0.86, p&lt;0.0001). Conclusion: As observed in other investigations, elevated Tn is associated with a higher risk of mortality, cardiac catheterization, and cardiology consultation. We observed that men were more likely to undergo catheterization and consultation, while black patients were less likely to have either. Further investigation into reasons for the observed disparities is warranted.

Differential impact of smoking on mortality and kidney transplantation among adult Men and Women undergoing dialysis.

BackgroundThe extent to which smoking contributes to adverse outcomes among men and women of all ages undergoing dialysis is uncertain. The objective of this study was to determine the differential impact of smoking on risks of mortality and kidney transplantation by age and by sex at dialysis initiation.MethodsWe conducted a population-based cohort of incident U.S dialysis patients (n = 1, 220, 000) from 1995–2010. Age- and sex-specific mortality and kidney transplantation rates were determined for patients with and without a history of cardiovascular disease. Multivariable Cox regression evaluated relative hazard ratios (HR) for death and kidney transplantation at 2 years stratified by atherosclerotic condition, smoking status and age. Analyses were adjusted for demographic characteristics, non-cardiovascular conditions, laboratory variables, socioeconomic and lifestyle factors.ResultsThe average age was 62.8 (±15) years old, 54 % were male, and the majority was white. During 2-year follow-up, 40.5 % died and 5.7 % were transplanted. Age- and sex-specific mortality rates were significantly higher while transplantation rates were significantly lower for smokers with atherosclerotic conditions than non-smokers (P < 0.01). The adjusted mortality hazards were significantly higher for smokers with pre-existing coronary disease (HR 1.15, 95 % CI (1.11–1.18), stroke (HR 1.21, 1.16–1.27) and peripheral vascular disease (HR = 1.21, 1.17–1.25) compared to non-smokers without these conditions (HR 1.00, referent group). The magnitude of effect was greatest for younger patients than older patients. Contrastingly, the adjusted risks of kidney transplantation were significantly lower for smokers with coronary disease: (HR 0.60, 0.52–0.69), stroke; (HR 0.47, 0.37–0.60), and peripheral arterial disease (HR 0.55, 0.46–0.66) respectively compared to non-smokers without these conditions.ConclusionsWe provide compelling evidence that smoking is associated with adverse clinical outcomes and reduced lifespans among dialysis patients of all ages and sexes. The adverse impact is greatest for younger men and women.Electronic supplementary materialThe online version of this article (doi:10.1186/s12882-016-0311-x) contains supplementary material, which is available to authorized users.

Ruptured Abdominal Aortic Aneurysm - Results and Prognostic Factors at a Certified Centre of Vascular Surgery

Introduction: Although the perioperative management has been optimised over the past few decades, there has not been a remarkable improvement in the mortality rates of patients with a ruptured abdominal aortic aneurysm (rAAA). The aim of this retrospective trial was to define pre-, intra- and postoperative parameters which influence the perioperative and long-term outcome of patients and which can be modified by the operating team. Methods: A retrospective database analysis was performed in 49 patients who had undergone an operation of rAAA in our certified centre of vascular surgery between the beginning of 2006 and the end of 2012. The minimal follow-up period was 30 months. The statistical analysis was done univariately using the Kaplan-Meier method and a log-rank-test, and multivariately with the Cox model. Results: Intrahospital mortality was 40.8 %, perioperative mortality (30 postoperative days) was 28.9 %. The survival rate for 1 year was 52.4 %; the survival rate for 5 years was 45.3 %. In the univariate analysis, significant differences in the early postoperative survival rates were found depending on preoperative systolic blood pressure, preoperative haemoglobin (< 10 vs. ≥ 10 g/dl), the intraoperative need of blood and frozen plasma transfusions, type of perforation, type of AAA, the need for further surgical interventions, postoperative MOF, acute kidney failure and postoperative septicaemia. The late survival rates were significantly influenced by the type of perforation and AAA, pre-existing coronary disease and diabetes mellitus in fully identified patients discharged from hospital (n = 27). In the multivariate analysis pursuant to the Cox model, patients with pre-existing coronary disease had a 3.9-fold higher relative risk to die after the operation of rAAA, while patients with a free perforation of the rAA had a 10-fold higher relative risk. Conclusion: The high mortality of rAAA is caused by haemorrhagic shock and its complications, which are mostly non-surgical. Therapeutic efforts should focus on those perioperative parameters which can be modified by the treating teams. Alongside the centralisation of rAAA in high-volume-departments of vascular surgery, the systematic sonographic screening for asymptomatic AAA in the population older than 65 years should be enforced. A possible advantage of EVAR in rAAA has yet to be shown by trials in progress such as IMPROVE, AJAX and RCAR.

Abstract 17309: Validation of a Novel Prediction Tool for Circulatory Etiology Death After Cardiac Arrest

Introduction: Post-resuscitation cardiac arrest (CA) triage to urgent angiography, percutaneous intervention, and mechanical circulatory support is hampered by inconclusive risk stratification, especially among patients without ST elevation myocardial infarction (STEMI). We analyzed registry data to develop a prediction tool to determine the risk of circulatory-etiology (CV) death in patients without STEMI, and validated it in a separate cohort. Methods: Using the International Cardiac Arrest Registry (INTCAR)-Cardiology data set and stepwise linear regression with an inclusion rule of P≤0.1, we determined demographic and clinical factors independently associated with CV death, and created a weighted prediction model for patients presenting after CA without STEMI. The model was then validated in a separate, larger cohort from INTCAR. This project was approved by the Maine Medical Center IRB. Results: Of 468 patients in the derivation cohort, 90 met criteria for the endpoint. In the multivariable model, age greater than 65 (OR=2.4, p=0.0001), preexisting coronary disease (OR=1.9, P=0.0065), diabetes (OR=1.8, P=0.01), in-hospital arrest (OR=1.5, P=0.1), time from collapse to return of circulation (TTROSC) greater than 25 minutes (OR=1.7, p=0.02), shock at presentation (OR=3.9, P&lt;0.0001), and EF&lt;30% on first echo (OR=1.6, P=0.05) were independently associated with CV death. Using weighted predictors (age&gt;65 =1, prior CAD =1, diabetes =1, in-hospital arrest =1, TTROSC&gt;25 =1, admission LVEF&lt;30% =1, shock =2,), an additive score of 0-2 predicted CV death in 8.5% and ≥3 in 34% in the derivation cohort. In the validation cohort, which comprised 1197 patients, of whom 263 met criteria for CV death, a score of 0-2 was associated with 13.1% and ≥3 with 35.1% CV death, respectively. Conclusions: A simple bedside prediction tool can predict high (34-35.1%) vs. low (8.5-13.1%) risk of circulatory-etiology death in cardiac arrest survivors without STEMI. This model could be used to risk-stratify cardiac arrest survivors, and aid in the triage of patients to appropriate and cost-effective post-resuscitation treatments.

Cardiovascular risk estimation in older persons: SCORE O.P.

Estimation of cardiovascular disease risk, using SCORE (Systematic COronary Risk Evaluation) is recommended by European guidelines on cardiovascular disease prevention. Risk estimation is inaccurate in older people. We hypothesized that this may be due to the assumption, inherent in current risk estimation systems, that risk factors function similarly in all age groups. We aimed to derive and validate a risk estimation function, SCORE O.P., solely from data from individuals aged 65 years and older. 20,704 men and 20,121 women, aged 65 and over and without pre-existing coronary disease, from four representative, prospective studies of the general population were included. These were Italian, Belgian and Danish studies (from original SCORE dataset) and the CONOR (Cohort of Norway) study. The variables which remained statistically significant in Cox proportional hazards model and were included in the SCORE O.P. model were: age, total cholesterol, high-density lipoprotein cholesterol, systolic blood pressure, smoking status and diabetes. SCORE O.P. showed good discrimination; area under receiver operator characteristic curve (AUROC) 0.74 (95% confidence interval: 0.73 to 0.75). Calibration was also reasonable, Hosmer-Lemeshow goodness of fit test: 17.16 (men), 22.70 (women). Compared with the original SCORE function extrapolated to the ≥65 years age group discrimination improved, p = 0.05 (men), p < 0.001 (women). Simple risk charts were constructed. On simulated external validation, performed using 10-fold cross validation, AUROC was 0.74 and predicted/observed ratio was 1.02. SCORE O.P. provides improved accuracy in risk estimation in older people and may reduce excessive use of medication in this vulnerable population.

Galectin-3 and incident heart failure among patients with pre-existing coronary artery disease: The ADVANCE study

BackgroundGalectin-3 (Gal-3) is a novel fibrosis biomarker. We ascertained: 1) the correlates of Gal-3, and 2) its association with incident heart failure among 1312 participants in The ADVANCE study (871 subjects with acute myocardial infarction [AMI] and 441 subjects with stable angina). MethodsCohort design, with Gal-3 measured in stored baseline serum samples (2002–04). After a median (SD) follow-up of 8.1 (3.2) years, 74 incident heart failure events were documented. ResultsThe significant independent correlates of Gal-3 were age, gender, diabetes, C-reactive protein and estimated glomerular filtration rate. In Cox regression with adjustment for these variables plus race, CAD presentation, smoking status, body mass index, hypertension and cholesterol lowering drugs, there was a 1.51-fold (95% CI, 1.24 to 1.85; p<0.0001) increased hazard of heart failure for each SD linear increment in Gal-3. In the fully-adjusted model, quartile four of Gal-3 (relative to quartile one) was associated with 2.1-fold increased hazard of heart failure (95% CI, 1.05 to 4.2). The C-statistic increased to 0.78 from 0.75 (p=0.12) and the net reclassification index was 0.13 (SE=0.06; p=0.03) after adding Gal-3 quartiles to the model containing all risk factors. ConclusionsGal-3 is a useful marker of heart failure risk among patients with pre-existing coronary disease and may play an etiological role in the development of heart failure.

Stress CMR Reduces Revascularization, Hospital Readmission, and Recurrent Cardiac Testing in Intermediate-Risk Patients With Acute Chest Pain

The aim of this study was to determine the effect of stress cardiac magnetic resonance (CMR) imaging in an observation unit (OU) on revascularization, hospital readmission, and recurrent cardiac testing in intermediate-risk patients with possible acute coronary syndromes (ACS). Intermediate-risk patients commonly undergo hospital admission with high rates of coronary revascularization. It is unknown whether OU-based care with CMR is a more efficient alternative. A total of 105 intermediate-risk participants with symptoms of ACS but without definite ACS on the basis of the first electrocardiogram and troponin were randomized to usual care provided by cardiologists and internists (n = 53) or to OU care with stress CMR (n = 52). The primary composite endpoint of coronary artery revascularization, hospital readmission, and recurrent cardiac testing at 90 days was determined. The secondary endpoint was length of stay from randomization to index visit discharge; safety was measured as ACS after discharge. The median age of participants was 56 years (range 35 to 91 years), 54% were men, and 20% had pre-existing coronary disease. Index hospital admission was avoided in 85% of the OU CMR participants. The primary outcome occurred in 20 usual care participants (38%) versus 7 OU CMR participants (13%) (hazard ratio: 3.4; 95% confidence interval: 1.4 to 8.0, p = 0.006). The OU CMR group experienced significant reductions in all components: revascularizations (15% vs. 2%, p = 0.03), hospital readmissions (23% vs. 8%, p = 0.03), and recurrent cardiac testing (17% vs. 4%, p = 0.03). Median length of stay was 26 h (interquartile range: 23 to 45 h) in the usual care group and 21 h (interquartile range: 15 to 25 h) in the OU CMR group (p < 0.001). ACS after discharge occurred in 3 usual care participants (6%) and no OU CMR participants. In this single-center trial, management of intermediate-risk patients with possible ACS in an OU with stress CMR reduced coronary artery revascularization, hospital readmissions, and recurrent cardiac testing, without an increase in post-discharge ACS at 90 days. (Randomized Investigation of Chest Pain Diagnostic Strategies; NCT01035047).

Impact of Aortic Stenosis on Postoperative Outcomes After Noncardiac Surgeries

Preoperative management of patients with aortic stenosis (AS) who need noncardiac surgery (NCS) remains controversial. We sought to determine the impact of AS on the postoperative outcomes after NCS. Patients undergoing NCS with moderate AS (valve area: 1.0-1.5 cm(2)) or severe AS (valve area: <1.0 cm(2)) were identified using the surgical and the echocardiographic databases. Using propensity score analysis, we obtained 4 matched control patients without AS for each patient with AS undergoing NCS. The propensity score matching used the 6 revised cardiac risk index criteria, in addition to age and sex. Primary outcome was a composite of 30-day mortality and postoperative myocardial infarction. We matched 634 patients with AS undergoing NCS to 2536 controls. There were 244 patients with severe AS and 390 patients with moderate AS. Thirty-day mortality was 2.1% for AS patients compared with 1.0% in non-AS controls (P=0.036). Postoperative myocardial infarction was more frequent in patients with AS compared with controls (3.0% versus 1.1%; P=0.001). Combined primary outcome was significantly worse for both moderate and severe AS patients compared with respective controls (4.4% versus 1.7%; P=0.002; and 5.7% versus 2.7%; P=0.02, respectively). High-risk surgery, symptomatic severe AS, coexisting mitral regurgitation, and preexisting coronary disease were significant predictors of primary outcome in patients with AS. Presence of AS adversely affects postoperative outcomes among patients undergoing NCS, evidenced by a higher 30-day mortality and postoperative myocardial infarction after NCS.

Reduction in Observation Unit Length of Stay With Coronary Computed Tomography Angiography Depends on Time of Emergency Department Presentation

Prior studies demonstrating shorter length of stay (LOS) from coronary computed tomography angiography (CCTA) relative to stress testing in emergency department (ED) patients have not considered time of patient presentation. The objectives of this study were to determine whether low-risk chest pain patients receiving stress testing or CCTA have differences in ED plus observation unit (OU) LOS and if there are disparities in testing modality use, based on the time of patient presentation to the ED. The authors examined a cohort of low-risk chest pain patients evaluated in an ED-based OU using prospective and retrospective OU registry data. During the study period, stress testing and CCTA were both available from 08:00 to 17:00 hours. CCTA was not available on weekends, and therefore only subjects presenting on weekdays were included. Cox regression analysis was used to model the effect of testing modality (stress testing vs. CCTA) on OU LOS. Separate models were fit based on time of patient presentation to the ED using 4-hour blocks beginning at midnight. The primary independent variable was testing modality: stress testing or CCTA. Age, sex, and race were included as covariates. Logistic regression was used to model testing modality choice by time period adjusted for age, sex, and race. Over the study period, 841 subjects presented Monday through Friday. Median LOS was 18.0 hours (interquartile range [IQR] = 11.7 to 22.9 hours). Objective cardiac testing was completed in 788 of 841 (94%) patients, with 496 (63%) receiving stress testing and 292 (37%) receiving CCTA. After age, race, and sex were adjusted for, patients presenting between 08:00 and 11:59 hours not only had a shorter LOS associated with CCTA (p < 0.0001), but also had a greater likelihood of being tested by CCTA (p = 0.001). None of the other time periods had significant differences in LOS or testing modality choice for CCTA relative to stress testing. In an OU setting with weekday and standard business hours CCTA availability, CCTA testing was associated with shorter LOS among low-risk chest pain patients only in patients presenting to the ED between 08:00 and 11:59 hours. That time period was also associated with a greater likelihood of being tested by CCTA, suggesting that ED providers may have intuited the inability of CCTA to shorten LOS during other times.

Abstract 289: Continuum of Care of Prehospital to Hospital Hypothermia Therapy, Outcomes in a Large Prehospital System in Conjunction With a Major Metropolitan Hospital.

Introduction: Hypothermia in patients after Return of Spontaneous Circulation (R.O.S.C.) was recommended in the 2005 American College of Cardiology/American Heart Association Guidelines. Prehospital use of cold saline (32-34°c) and ice packs to the proximal extremities, has been used for patients with R.O.S.C.. In hospital use of intravascular cooling and heart catheterization yield the best neurological and cardiac outcomes as recommended by the A.C.C./A.H.A. 2008 guidelines. METHODS: A retrospective chart review was conducted spanning 3/2009 to 9/2010. Including prehospital run sheets and hospital records. Prehospital provider protocols for 968 paramedics (11 municipalities) were modified to allow the providers to place ice packs at the proximal extremities and to start iced saline I.V. (temp 32-34°c) for victims of cardiorespiratory arrest with R.O.S.C. On arrival to the hospital the cardiologist and the emergency physicians started internal cooling of these patients. The cardiologist and the catheterization team diagnosed and treated preexisting coronary disease in the catheterization laboratory. Cooling was continued for twenty four hours. The patients were then evaluated to determine their level of neurological function prior to discharge. Results: 31 patients were brought in by paramedics after starting the prehospital hypothermia protocol, after R.O.S.C. 26 men and 5 women. All patients were admitted through the emergency department to the heart catheterization laboratory where central cooling was started and coronary angiography was performed, with angioplasty and stenting was done when indicated. Cooling was at 32°c and was maintained for 24 hours. 13/31 patients expired prior to discharge (42%) from the hospital. 5/31 patients were transferred for hospice care or to long term-care facilities (16%). 12/31 patients left the hospital neurologically intact (39%). Conclusion: The sequential use of prehospital cooling and inhospital intravascular cooling for victims of cardiorespiratory arrest with R.O.S.C. is feasible, safe and effective. Our results for neurologically intact hospital discharges of 39%, is higher than that reported by prior investigators.

Intravenous tissue plasminogen activator, ischemic stroke, and the risk of Kounis Syndrome

Sir, We have read with great interest the report by Sweda et al that was published in this Journal. It described two patients who developed acute myocardial infarction (MI) following intravenous tissue plasminogen activator (tPA) for acute ischemic stroke.[1] The authors of this report speculated that fragmentation and lysis of any intracardiac thrombus may have resulted in embolization of coronary arteries and development MI after use of tPA. They did not exclude any remote possibility of coincidental occurrence of two atherosclerotic events MI and ischemic stroke. However, both patients died from fatal cardiac arrhythmia. Postmortem examination was not carried out. The first patient had a history of hypertension and the second patient had a history of hypertension, ischemic heart disease, kidney disease, and diabetes. Both patients developed hypotension, with breathlessness the first, and cardiovascular collapse the second, following the intravenous administration of tPA. Although the classical symptoms and signs of an allergic, anaphylactic, or anaphylactoid reaction were not described, and therefore such a work up was not performed, these two patients could have suffered type II variant of Kounis syndrome.[2] This syndrome is defined today as the concurrence of acute coronary syndromes with conditions associated with mast cell activation, involving interrelated and interacting inflammatory cells. These inflammatory cells namely mast cells, T-cells, and macrophages activate each other via multidirectional stimuli and behave as a ball of thread. These cells can release inflammatory mediators capable to induce coronary events. Platelets with high and low affinity IgE receptors are involving also in this process.[3] Three variants of this syndrome have been described.[4] Type I variant, which includes patients with normal coronaries in whom the allergic insult can induce either coronary artery spasm or coronary artery spasm progressing to acute myocardial infarction. Type II variant, which includes patients with culprit but quiescent pre-existing coronary disease in whom the allergic insult can induce either coronary artery spasm or plaque erosion or rupture manifesting as acute myocardial infarction. Type III variant, which includes patients with coronary artery stent thrombosis in whom aspirated thrombus specimens demonstrate the presence of eosinophils and mast cells. Allergic reactions with the use of fibrinolytics have been described in the literature, more often with streptokinase but also with the use of tPA.[5] True and obvious anaphylactic reactions to tPA are rare but anaphylactoid reactions occur in up to 0.002% of patients treated for acute MI and from 1.5% to 1.9% those treated for acute ischemic stroke.[6] Therefore, Kounis syndrome should be always being considered in such occasions, because this syndrome is not a rare disease but is a rarely diagnosed condition.[4]

Myocardial infarction following convulsive and nonconvulsive seizures

Myocardial infarction (MI) has been rarely reported in association with seizures, and only of convulsive type. Methods We describe a series of five patients observed over a 4-year period, who presented MI immediately following seizures, either convulsive or nonconvulsive. Results Patient 1 had pre-existent coronary disease (CD) and presented multiple focal nonconvulsive seizures. Patient 2 had no CD, normal coronary angiography and presented secondary generalized convulsive seizures. Patient 3 had no history of CD, normal angiography and had a first single convulsive seizure. Patient 4 had severe CD and suffered from a single convulsive event. Patient 5 had a partial and a generalized seizure and had no known CD. Conclusions MI following seizures is not an exceptional event and can occur in a spectrum of conditions including single or repeated, convulsive or nonconvulsive seizures, in patients with or without pre-existing coronary disease. We suggest that the occurrence of MI should be considered in epileptic patients during and shortly after seizures.

Gender-Dependent Impact of Risk Factors for Cardiovascular and Non-Cardiovascular Mortality in End-Stage Renal Disease Patients on Haemodialysis

We investigated whether mortality risk factors are gender dependent in haemodialysis patients. Patients (n = 230; 118 women, 112 men) on haemodialysis were followed for 52 months to assess the incidence of death due to cardiovascular or non-cardiovascular causes. Survival was compared by Cox regression analysis using age, diabetes, pre-existing coronary disease, troponin T and C-reactive protein as covariates. In total, 120 participants (52.2%) died within the 52 months of follow-up: 57 patients died of cardiovascular disease, 35 patients died of infectious diseases. Cox regression revealed that age, pre-existing coronary heart disease and troponin T were independent all-cause mortality risk factors for both sexes. Analyzing men and women separately revealed that diabetes and C-reactive protein seemed to be a stronger risk factors for all-cause mortality in women. Cardiovascular mortality was predicted by troponin T in women (relative risk = 5.16, 95% CI: 1.67–15.88; p = 0.004), but not in men (relative risk = 1.69; 95% CI: 0.72–3.96; p = 0.23). Our study showed for the first time that the impact of risk factors in predicting death due to cardiovascular disease is clearly gender dependent.

The Framingham Predictive Instrument in Chronic Kidney Disease

We sought to determine the utility of the Framingham equations in individuals with chronic kidney disease (CKD). The Framingham equations predict incident coronary disease. The utility of these equations is unknown in CKD. We pooled individuals without pre-existing coronary disease age 45 to 74 years from the ARIC (Atherosclerosis Risk In Communities) and CHS (Cardiovascular Health Study) trials with CKD, defined by an estimated glomerular filtration rate of 15 to 60 ml/min/1.73 m(2). Using gender-specific models, we determined 5- and 10-year risk of incident myocardial infarction and fatal coronary disease, and evaluated discriminative and calibration ability of the Framingham equations for predicting coronary events. There were 577 women and 357 men with CKD. Thirty-five men (9.8%) and 30 women (5.2%) and 74 men (20.7%) and 56 women (9.7%) had cardiac events within 5 and 10 years, respectively; 5-year events were predicted in 6.0% and 1.9% and 10-year events in 13.9% and 4.8% of men and women, respectively. For 5-year events, C-statistics assessing discrimination were 0.62 and 0.77, while 10-year C-statistics were 0.60 and 0.73 for men and women, respectively. Calibration was also poor, with Framingham scores generally underpredicting events in individuals with CKD at 5 and 10 years. Discrimination was significantly improved by refitting models with population-specific coefficients, while recalibration improved prediction in women. The Framingham instrument demonstrates poor overall accuracy in predicting cardiac events in individuals with CKD, although refit models can substantially improve discrimination. Calibration in women can be moderately improved with adjustment for higher event rates. Development of CKD-specific equations is needed.