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Data on the prognostic value of regadenoson SPECT myocardial perfusion imaging (MPI) is limited and based on small cohorts. We conducted a single-center, retrospective cohort study of 10,275 consecutive patients who underwent regadenoson SPECT-MPI. Among the study subjects, 28.7% had abnormal MPI and 25.5% had myocardial ischemia. Patients were followed for a mean of 2.4 ± 2.2 years for major adverse cardiac events (MACE), defined as cardiac death or myocardial infarction. There was a significant stepwise increase in MACE with an increasing burden of perfusion abnormality (P

Background: Direct oral anticoagulants (DOACs) have been found to be similar or superior to warfarin in reducing ischemic stroke and intracranial hemorrhage (ICH) in patients with atrial fibrillation (AF). We sought to examine the anticoagulation prescription patterns in community since the advent of DOACs and also evaluate the outcomes in terms of gastrointestinal (GI) bleeding, ischemic stroke, and ICH in real-world patients with AF receiving anticoagulation. Methods: This is a retrospective study comprising patients who were newly diagnosed with nonvalvular AF and were prescribed anticoagulants for stroke prevention. Prescription pattern of the anticoagulants based on CHA2DS2Vasc score was studied. Clinical outcomes of GI bleeding, ischemic stroke, and ICH were analyzed using a multivariate logistic regression model. Results: Of the 2362 patients with AF on anticoagulation, 44.7% were prescribed DOACs. Patients with CHA2DS2VASc score of ≥3 received a prescription for warfarin more often than DOACs ( P < .001). Multivariate logistic regression analysis revealed that the incidence of GI bleed (odds ratio [OR]: 0.91, 95% confidence interval [CI]: 0.62-1.35, P = .66) and stroke (OR: 0.77, 95% CI: 0.57-1.05, P = .10) was similar between warfarin and DOAC users. However, there was a trend toward lower ICH in the DOAC group (OR: 0.60, 95% CI: 0.36-1.01, P = .06). Conclusions: Prescription rate of DOACs for nonvalvular AF has increased significantly, with apixaban being the most commonly used agent. Patients with higher CHA2DS2-VASc score (≥3) are prescribed DOACs less often than warfarin. The reason for this discrepancy is unclear. Given the favorable risk–benefit profile of DOACs, further studies are needed to identify factors that determine anticoagulant selection in patients with AF with high thromboembolic risk.

Introduction: Infective pericarditis is a relatively uncommon condition in the modern antibiotic era, has a high mortality rate (20-30%) and is associated with immunosuppression, alcohol use, illicit drug use, thoracic surgery. Outcomes data in the current era is unknown. We aim to analyze the baseline characteristics and outcomes of patients admitted in the hospital with infective pericarditis. Methods: We conducted a retrospective study using National Inpatient Sample (NIS) database from 2016 to 2017. Hospital visits with a primary diagnosis of infective pericarditis (ICD10, I30.1) during which a pericardial procedure was performed were identified using ICD-10-CM and ICD-10-PCS Codes. Our primary outcome was basic characteristics and in-hospital all-cause mortality. Multivariate regression model was used to adjust for the pericardial procedure approach, age, and cardiac tamponade. R (Version 3.6.1) was utilized for the analysis. Results: A total of 1010 weighted hospitalizations in adult patients with infective pericarditis were identified. The mean age was 56.7±1.1 years (woman - 41.4%). The baseline characteristics and comorbidities are described in table 1 and table 2. 60.5% of the patients underwent percutaneous pericardial drainage, 36.4% had open surgery, and 3.2% had VATs. The mean time from admission to a pericardial procedure is 1.7±0.2 days. In-hospital all-cause mortality was 2.27%. The mean length of stay was 7.59±0.43 days. The mean total cost was 22530±1193 US dollars. Among all hospitalizations, 61.8% of them were complicated by hemodynamic instability and 56.8% had cardiac tamponade. Compared to pericardiocentesis, patients who underwent pericardiotomy had a higher mortality (5% vs 0.8%, adjusted OR 8.03, P = 0.043). Conclusions: Our study demonstrates relatively low inpatient mortality with infective pericarditis compared to older studies. Around half of the patients had cardiac tamponade.

To examine the utility and methods of coronary artery disease (CAD) assessment in patients with new-onset heart failure with reduced ejection fraction (HFrEF) of unclear etiology. Moreover, we sought to review the role and techniques of assessing myocardial viability to guide coronary revascularization in patients with established ischemic cardiomyopathy. Data indicates that surgical coronary revascularization in patients with HFrEF due to ischemic cardiomyopathy leads to lower long-term all-cause mortality and cardiovascular hospitalizations. Thus, identifying ischemic heart disease in patients with new-onset HFrEF is essential. In addition to invasive coronary angiography (ICA), radionuclide myocardial perfusion imaging, coronary CT angiography (CCTA), and cardiac magnetic resonance (CMR) imaging have emerged as effective non-invasive tools in the assessment of CAD in this population. Viability testing remains an area of particular interest and debate and its full potential has not been fully addressed. We propose stepwise algorithms for CAD and viability assessment in this patient population. Non-invasive testing with radionuclide myocardial perfusion imaging, CCTA, and CMR is an alternative to ICA for CAD assessment in patients with new-onset HFrEF of unclear etiology. Several non-invasive imaging modalities have proved to be effective in detecting viable myocardium in patients with ischemic cardiomyopathy. The use of viability imaging to guide coronary revascularization should be individualized.

Diabetes mellitus (DM), a modern-day epidemic, is a significant risk factor for cardiovascular disease. It is believed that statins elevate the risk of incident DM. Multiple trials were suggestive of the hyperglycemic effect of long-term statin use. This has prompted the Food and Drug Administration to include the risk of DM in the product label of statins. New-onset DM with statin use is biologically plausible and can be explained based on the multiple pathways in glucose metabolism affected by statins. Most pivotal clinical trials on statins were not powered to adequately assess the risk of incident DM with statin use, and the results from multiple meta-analyses are mixed. Currently, the US Preventive Services Task Force recommend the use of statins for primary prevention in patients with at least 1 cardiovascular risk factor and a 10-year risk of >7.5%. With the new American College of Cardiology/American Heart Association guidelines, the number of patients eligible for statin therapy has increased exponentially, which also calls for caution and increased vigilance in prescribing physicians regarding the controversies surrounding statin use. This article aims to highlight the existing data on statin use for primary prevention in diabetics and nondiabetics and the association of statins use with new-onset DM and its postulated mechanisms.

OBJECTIVES Auscultation is an important clue to the presence of aortic stenosis (AS). We sought to assess the effect of symptom status, prior knowledge of diagnosis, and other patient factors on murmur detection. METHODS Patients with moderate-to-severe AS by echocardiography at a single center between June 2015 and June 2016 were included. Five consecutive patient encounters (inpatient and outpatient) within 12 months before the echocardiogram were analyzed. RESULTS Ninety-five patients (418 different clinician encounters) were studied. The murmur of AS was identified by only 39% of clinicians. In multivariate analysis, significant determinants of murmur detection were examination in outpatient setting (odds ratio [OR] 3.40, 95% confidence interval [CI] 1.75-6.61), known history of AS (OR 2.77, 95% CI 1.53-5.01), female sex (OR 1.97, 95% CI 1.07-3.60), and presence of symptoms (OR 1.91 95% CI 1.12-3.26). Compared with the murmur detection findings by clinicians in medicine, the findings of surgical specialty clinicians were significantly lower (OR 0.12, 95% CI 0.06-0.26, P < 0.001). CONCLUSIONS In this real-world assessment, clinical context played an important role in the auscultation of AS murmur. The findings have important implications for the clinical diagnosis of asymptomatic advanced AS.

Background: Electrocardiogram (ECG) differentiation of wide complex tachycardia (WCT) into ventricular tachycardia (VT) and supraventricular tachycardia with aberration (SVT-A) is often challenging. Objective: To determine if the presence of Q-waveforms (QS, Qr, QRs) in the inferior leads (II, III, aVF) can differentiate VT from SVT-A in a WCT compared to Brugada algorithm. We studied 2 inferior lead criteria namely QWC-A where all the inferior leads had a similar Q wave pattern and QWC-B where only lead aVF had a Q-waveform. Methods: A total of 181 consecutive cases of WCT were identified, digitally separated into precordial leads and inferior leads and independently reviewed by 2 electrophysiologists. An electrocardiographic diagnosis of VT or SVT-A was assigned based on Brugada and inferior lead algorithms. Results were compared to the final clinical diagnosis. Results: VT was the final clinical diagnosis in 24.9% of ECG cohort (45/181); 75.1% (136/181) were SVT-A. QWC-A and QWC-B had a high specificity (93.3% and 82.8%) and accuracy (78.2% and 71.0%), but low sensitivity (33.3% and 35.6%) in differentiating VT from SVT-A. The Brugada algorithm yielded a sensitivity of 82.2% and specificity of 68.4%. Area under the curve in ROC analysis was highest with Brugada algorithm (0.75, 95% CI 0.69-0.81) followed by QWC-A (0.63, 95% CI 0.56-0.70) and QWC-B (0.59, 95% CI 0.52-0.67). Conclusion: QWC-A and QWC-B criteria had poor sensitivity but high specificity in diagnosing VT in patients presenting with WCT. Further research combining this simple criterion with other newer diagnostic algorithms can potentially improve the accuracy of the overall diagnostic algorithm.

This editorial refers to ‘Supplemental thiamine for the treatment of acute heart failure syndrome: a randomized controlled trial’, by Smithline et al ., BMC Complementary and Alternative Medicine 2019;19:96.

ECG differentiation of wide complex tachycardia (WCT) into Ventricular Tachycardia (VT) and Supraventricular Tachycardia with Aberrancy (SVT-A) poses challenges. Many criteria have been published of which the Q waves in inferior leads are relatively less studied. 181 consecutive cases of wide

Oesophageal ultrasound with bronchoscope (EUS-B) is designed to evaluate mediastinal structures. We describe a case of a 78-year-old woman who presented with altered mental status for 2 weeks. CT head revealed a subacute infarct in the right middle cerebral artery distribution. She was also found to have a lung mass on chest imaging. EUS-B-guided fine needle aspiration demonstrated the presence of adenocarcinoma in station 7 lymph node and in the mass. Immunohistochemistry confirmed it to be a lung primary as the Thyroid Transcription Factor-1 (TTF-1) was strongly positive. During the procedure, the cardiac valves were evaluated, and a mitral valve vegetation was noted. Formal echocardiography confirmed the presence of the vegetation. During hospital stay, the patient developed fever. Her blood cultures grew oxacillin-resistant Staphylococcus aureus. She was subsequently treated for infective endocarditis. We suggest that the use of EUS-B to routinely scan adjacent structures during a procedure may help obtain additional clinical information that may be critical to patient management.