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BACKGROUND: Surveys of patients with cardiovascular disease have suggested that “home-time”—being alive and out of any healthcare institution—is a prioritized outcome. This novel measure has not been studied among patients with heart failure (HF). OBJECTIVES: This study sought to characterize home-time following hospitalization for HF and to assess its relationship with patient characteristics and traditionally reported clinical outcomes. METHODS: Using Get With The Guidelines-Heart Failure registry data, patients with a HF hospitalization and discharged alive between 2011 to 2014 and age ≥65 years were identified. Using Medicare claims, post-discharge home-time over 30-day and 1-year follow-up was calculated for each patient as the number of days alive and spent outside of a hospital, skilled nursing facility (SNF), or rehabilitation facility. RESULTS: Among 59,736 patients, 57,992 (97.1%) and 42,153 (70.6%) had complete follow-up for home-time calculation through 30 days and 1 year, respectively. Mean (standard deviation) home-time was 21.6 (11.7) days at 30 days and 243.9 (137.6) days at 1 year. Contributions to reduced home-time varied by follow-up period, with days spent in SNF being the largest contributor though 30 days and death being the largest contributor through 1 year. Over 1 year, 2,044 (4.8%) patients had no home-time following index hospitalization discharge, while 8,194 (19.4%) had 365 days of home-time. In regression models, several conditions were associated with substantially reduced home-time, including pulmonary disease, renal insufficiency, and dementia. Through 1-year, home-time was highly correlated with time-to-event endpoints of death (r=0.94) and the composite of death or HF readmission (r=0.73). CONCLUSIONS: Home-time, which can be readily calculated from administrative claims data, is substantially reduced for many patients following hospitalization for HF and is highly correlated with traditional time-to-event mortality and hospitalization outcomes. Home-time represents a novel, easily measured, patient-centered endpoint that may reflect effectiveness of interventions in future HF studies.

[Figure][1] The Heart Research Follow-up Program at the University of Rochester Medical Center has an ongoing record of successfully carrying out large-scale clinical cardiovascular studies and randomized clinical trials for >35 years, and nearly all of the original executive committee

Introduction: Cannabis is a commonly utilized recreational substance which contains numerous bioactive agents. As more states legalize the use of marijuana, it’s effect on various disease conditions is expected to become more pronounced. Cannabis’ anti-inflammatory effects could suppress pro-inflammatory conditions. For example, chronic inflammation with extracellular matrix degradation resulting in weakness and abnormal dilatation of the aortic wall is a hallmark of Aortic Aneurysm. We, therefore, hypothesized that cannabis users would have less prevalence of aortic aneurysms. Objective: To identify the relationship between chronic cannabis use (CU) and diagnosis of aortic aneurysms (AA) among hospitalized patients. Methods: After selecting patients who were 55 years and above from 2012 to 2014 National Inpatient Sample database, we identified those who had a diagnosis of Aortic Aneurysm and those who utilize Cannabis. We then stratified the CU into two groups: nondependent (NDU) and dependent users (DU). Using logistic regression, we estimated the Odds Ratio (AOR) after controlling for numerous factors. Results: In our total 10,461,694 sample, 99.6% (10,419,972) are non-users, 0.37% (38,514) are nondependent users and 0.03% (3,208) are dependent users. About 3.21% (336,202) of the patients had a diagnosis of AA versus 96.79% (10,125,492) without a diagnosis of AA. Compared to non-users of cannabis, the odds of AA is about 35% less among CU (AOR 0.66[0.62-0.71]), 40% less among DU (aOR 0.58[0.44-0.76]), and 33% less among NDU (AOR 0.67[0.62-0.72]). The odds of AA was lower in females (AOR 0.61[0.60-0.610]), but higher in many conditions such as: among >=65 years (AOR 1.16[1.15-1.17]), tobacco users (AOR 1.18[1.17-1.19]), predisposing hereditary conditions (AOR 5.31[4.60-6.13]), and atherosclerosis (AOR 3.04[3.00-3.08]). Conclusions: Our result shows that Cannabis use is associated with less occurrence of AA. Cannabidiol, an anti-inflammatory alkaloid in Cannabis could potentially suppress the release of proteolytic inflammatory mediators which might be responsible for the gradual weakening of the vascular walls. We recommend more basic research to evaluate this effect of Cannabidiol.

Background: Although, in-hospital mortality from acute myocardial infarction (AMI) have declined in the United States recently, there is a gap in knowledge regarding racial differences in this trend. We sought to evaluate the effect of race on the trends in outcomes after Acute Myocardial Infarction among Medicaid patients in a nationwide cohort from 2007-2011 Methods: We extracted data from the Nationwide Inpatient Sample (NIS) for all hospitalizations between 2007 and 2011 for Medicaid patients aged 45 years or older with principal diagnosis of AMI using ICD-9-CM codes. Primary outcome of this study was all cause in-hospital mortality. We then stratified hospitalizations by racial groups; Whites, African Americans and Hispanics, and assessed the time trends of in-hospital mortality before and after multivariate analysis. Results: The overall mortality from AMI among Medicaid patients declined during the study period (8.80% in 2007 to 7.46% in 2011). In the adjusted models, compared to 2007, in-hospital mortality from AMI for Medicaid patients decreased across the 3 racial groups; Whites (aOR= 0.88, CI=0.70-0.99), African Americans (aOR=0.76, CI=0.57-1.01), Hispanics (aOR=0.87, CI=0.66-1.25). While the length of hospital stay declined significantly among African American and Hispanic with 2 days and 1.76 days decline respectively, the length of stay remained unchanged for Whites. There was non-significant increase in the incidence of stroke across the various racial groups; Whites (aOR= 1.23, CI=0.90 -1.69), African Americans (aOR=1.10, CI=0.73 -1.64), Hispanics (aOR=1.03, CI=0.68-1.55) when compared to 2007. Conclusion: In this study, we found that in-hospital mortality from AMI among Medicaid patients have declined across the racial groups. However, while the length of stay following AMI declined for African Americans and Hispanics with Medicaid insurance, it has remained unchanged for Whites. Future studies are necessary to identify determinants of these significant racial disparities in outcomes for AMI.

Background: With increasing legalization of cannabis, there is a growing number of cannabis users in the US. Cannabidiol - a component of cannabis with no psychoactive or cognitive effect has been proven in animal models to have vasodilatory and anti-inflammatory effect on the blood vessels. However, in clinical literature, the association between cerebrovascular accident (CVA) and cannabis remains inconclusive. Objective: To examine if there is a difference in the prevalence of CVA among patients who use cannabis and non-users. Methods: We identified patients > 18 years (N=12,114,360) from the 2012 -2014 National Inpatient Sample database. Using the ICD-9 code, we categorized patients using cannabis (non-dependent and dependent users) and non-users. Our outcome of interest was prevalence of CVA in this population. Logistic regression analysis was performed to assess the association between cannabis use and CVA. Using multivariate regression model, we adjusted for known confounders of CVA; age, gender, race, insurance type, socioeconomic status, tobacco use, cocaine use, alcohol abuse, amphetamine use, hyperlipidemia, diabetes, hypertension, renal failure, prior history of CVA and family history of CVA. Results: From our study sample (12,114,360 hospitalized patients), 2.1% (253,752) had a diagnosis of CVA, 1.48% (179,576) were non-dependent cannabis users and 0.21% (25,968) dependent users. Among hospitalized patient, non-dependent cannabis use was associated with an 8% increased odds of CVA (AOR 1.08 [1.03-1.13]) compared to non-users. However, dependent cannabis use was associated with a 60% decreased odds of CVA (AOR 0.40 [0.31-0.49]) compared to non-users. Also, In-group comparison shows a 60% decreased odds of CVA among dependent cannabis users (AOR 0.36[0.29-0.46]) compared to non-dependent cannabis users. Conclusions: Non-dependent cannabis use was associated with a slightly increased odd of CVA while dependent cannabis use was independently protective against CVA. Our study used the largest repository of clinical information to explore this association, however we recommend more clinical study to explore this correlation in other to maximize the pharmacological benefit of cannabidiol in cannabis for the prevention of CVA.

Background: Despite being illegal in most countries, cannabis is highly utilised by a growing number of individuals for recreational purposes worldwide. With its increasing legalisation in many states across the United States, the effects of cannabis on different body systems are expected to rise. Its association with peripheral vascular disease (PVD) remains ambiguous. Objective: To examine if there is a difference in prevalence of PVD amongst patients who use cannabis when compared to non-users. Methods: Using the 2014 National Inpatient Sample database (N=7,071,762), we identified patients with and without a diagnosis of PVD. We also identified patients using cannabis (nondependent and dependent users) and non-users. We performed the univariate and bivariate analysis. After we had composed the crude models, we adjusted for every known risk factor for PVD. These factors included age, gender, tobacco, hypercholesterolemia, coronary artery disease (CAD), cerebrovascular vessel disease (CVD), hypertension, diabetes, renal failure, alcohol, obesity, race, insurance type, average income at the location of residence, and family history of PVD/CVD/CAD. Results: In our total 7,071,762 sample, 98.27% (6,949,339) are non-users, 1.54% (108,910) are nondependent users and 0.19% (13,513) are dependent users. About 3.75% (264,920) of the patients had a diagnosis of PVD versus 96.25% (6,806,842) without a diagnosis of PVD. The odds of PVD is 20% less among nondependent users when compared to nonusers (AOR 0.80[0.76-0.85]). Furthermore, dependent users have a 55% reduced odds of developing PVD when compared to nonusers (AOR 0.45[0.35-0.57]) showing a dose-response relationship. The in-group comparison showed that dependent users were 44% less likely to have PVD when compared to non-dependent users (AOR: 0.56[0.44-0.72]). Overall, the odds of PVD remain significantly high among patients who uses tobacco (AOR 1.97 [1.95-1.99]), diabetes (AOR 1.54 [1.53-1.55]), hypercholesterolemia (AOR 1.46 [1.45-1.47]), family history of PVD/CVD/CAD (AOR 1.03 [1.01-1.05]), personal history of CAD (AOR 2.55 [2.53-2.57]). Conclusions: Cannabis is an independent protective factor against PVD. Molecular biology evidence shows that cannabis contains various bioactive agents. Beta-caryophyllene (out of many) preferentially binds to CB-2 receptors on immune cells causing an anti-inflammatory response. We believe that more molecular studies targeting such receptors or isolating such anti-inflammatory compounds in cannabis might be useful in the treatment of vascular disease.

Background: Diabetes has been associated with complications and poor perioperative outcomes. In Radiofrequency catheter ablation - therapy of choice for drug refractory atrial fibrillation and flutter, association between diabetes and procedural complications are less documented. Objectives: To examine if there is a difference in perioperative complications in patients with chronic diabetes who underwent RFA for atrial fibrillation/flutter when compared with non-diabetics. Methods: We selected patients > 45 years from the National Inpatient Survey data 2014. We identified 8356 patients (69.6 ± 9.1yrs) who underwent catheter ablation. Logistic regression analyses were performed to investigate the difference in perioperative complications (hemorrhage, cardiac perforation, cardiac complications, respiratory complications, peripheral vascular complications, stroke and in-hospital mortality) between diabetics and non-diabetics. All models were adjusted for age, gender, race, residential income, insurance, co-morbidities, hospital bed size, hospital location/teaching status, hospital region, length of stay and median household income. Results: Among our selected 8356 patients, 5777(69.1%) were non-diabetics, 2203(26.4%) had uncomplicated diabetes and 376 (4.5%) complicated diabetes. Overall there were 634 events (240 hemorrhages, 56 perforations, 163 cardiac complications, 43 respiratory complications, 12 strokes, 40 peripheral vascular complications and 80 in-hospital death. Rates of complications were the same among diabetes and non-diabetics. In the multivariate models, the odds of complications remain statistically non-significant across all the groups. However, among all the patients who underwent RFA, there is an increased odds of hemorrhage among patients with Medicare insurance versus private insurance (OR 1.73 95%CI 1.11-2.70), peripheral vascular complications among hospitals in the south (OR 3.35 95%CI 1.30-9.62), respiratory complications among patients with CHF (4.60 95%CI 1.68-12.60), death among patients with renal failure (OR 2.22 95%CI 1.32-3.73) and hospitals in the south (2.55 95% CI 1.08-6.0) and west (OR 3.23 95%CI 1.25-8.3) compared to the northeast. Odds of stroke were less among both urban non-teaching (OR 0.02 95%CI 0.01 - 0.34) and teaching hospital (OR 0.05 95%CI 0.01-0.36) when compared to rural hospital. Conclusions: RFA has a similar procedural safety in diabetics when compared to non-diabetic patients. It remains a safe procedure in diabetics with drug-refractory atrial fibrillation and flutter. Renal failure, CHF, type of Insurance, hospital location and teaching status are predictors of complications after RFA.

We compare the diagnostic accuracy of multidetector row computed tomography (MDCT) to cardiac magnetic resonance imaging (CMR) for evaluating global left ventricular function. We systematically searched PubMed, CINAHL, Cochrane CENTRAL, Scopus, and the Web of Science databases for studies published between 1966 to January 2013 that compared left ventricle (LV) volumes, ejection fraction (EF) and LV mass measured by MDCT and CMR. We performed meta-analyses and used random-effects model with inverse variance weighting test to determine the overall bias and limits of agreement of LV end-diastolic volume, end-systolic volume, stroke volume, and EF measured by MDCT and CMR. Furthermore, subgroup analyses were performed to compare 16-slice and 64-slice MDCT with CMR. Two study authors independently reviewed the 90 articles originally identified and selected 27 studies (n = 831) for analysis. Excellent correlation and a linear relation were seen between MDCT and CMR for LV end-diastolic volume (r = 0.93; p0.001), LV end-systolic volume (r = 0.95; p0.001), LV stroke volume (r = 0.85; p0.001), LV ejection fraction (r = 0.93; p0.001), and LV mass (r = 0.86; p0.001). Subgroup analyses showed strong positive correlations for both 16- and 64-slice MDCT. In conclusion, although not the first-line test for LV function assessment in most patients, when appropriate, retrospectively gated MDCT provides an accurate and valid assessment of LV function compared with CMR.

Despite an early invasive strategy and the use of dual antiplatelet therapy, patients with acute coronary syndrome (ACS) continue to be at substantial risk for recurrent ischemic events. It is believed that this risk is, at least in part, due to an intrinsic coagulation pathway that remains activated for a prolonged period after ACS. Earlier studies using warfarin showed a reduction in ischemic events, but the overall benefits were offset by increased bleeding complications. Recently, there has been increased interest in the potential role of new oral anticoagulants, some of which target factor Xa, after ACS. Factor Xa is important for the coagulation pathway and also plays a role in cellular proliferation and inflammation. It may thus be an attractive target for therapeutic intervention in ACS. Recently, various oral factor Xa inhibitors have been studied as potential treatment options for ACS. This review will focus on currently available data to evaluate the possible role of factor Xa inhibitors in the management of patients with ACS.

Background Clinical studies have suggested an association between bisphosphonate use and the onset of atrial fibrillation (AF). However, data on the risk of developing AF, stroke, and cardiovascular mortality with the use of bisphosphonate are conflicting. The objective of this study was to evaluate the risk of serious AF (events that required hospital admission), stroke, and cardiovascular mortality with the use of bisphosphonates through a systematic review of the literature. Methods We searched the PubMed, CENTRAL, and EMBASE databases for observational studies and randomized controlled trials (RCTs) on the use of bisphosphonates from 1966 to April 2012 that reported the number of patients who developed serious AF, stroke, and cardiovascular mortality at follow-up. The random-effects Mantel-Haenszel test was used to evaluate relative risk-adverse cardiovascular outcomes with the use of bisphosphonates. Results Six observational studies (n = 149,856) and six RCTs (n = 41,375) were included for analysis. On pooling observational studies, there was an increased risk of AF (OR, 1.27; 95% CI, 1.16-1.39) among bisphosphonate users. Further, analysis of RCTs revealed a statistically significant increase in the risk of serious AF (OR, 1.40; 95% CI, 1.02-1.93) and no increase in the risk of stroke (OR, 1.07; 95% CI, 0.85-1.34) or cardiovascular mortality (OR, 0.92; 95% CI, 0.68-1.26) with the use of bisphosphonates. Conclusions Evidence from RCTs and observational studies suggests a significantly increased risk of AF requiring hospitalization, but no increase in risk of stroke or cardiovascular mortality, with the use of bisphosphonate.

Background We attempted to evaluate if an oral-only regimen was as effective in preventing postoperative atrial fibrillation (POAF) after cardiac surgery, in comparison to a regimen that included intravenous (IV) administration using a network meta-analysis of available data, and also attempted to assess if preoperative administration at least 1 day before surgery was superior to postoperative prophylaxis (at least 1 day after surgery). Methods We searched PubMed, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials’ databases for randomized controlled trials conducted between 1990 and 2011 that assessed rates of POAF with amiodarone. Finally an interaction odds ratio was computed to assess the efficacy of an oral-only regimen of amiodarone compared to one including IV administration and to evaluate if preoperative amiodarone was superior to postoperative prophylaxis. Results Twenty-three studies (total N = 3,950) were included. Both regimens of amiodarone improved risk of POAF; oral-only risk ratio (RR) was 0.59 (95% confidence interval [CI] 0.49–0.70; P < 0.01) and regimen including IV RR was 0.57 (95% CI 0.43–0.75, P < 0.01). The interaction odds ratio was 1.17 (95% CI 0.72–1.89, P = 0.533). Both preoperative amiodarone (P < 0.01) and postoperative prophylaxis were effective (P = 0.0009), irrespective of duration. Conclusions This systematic review suggests a regimen of both oral-only and one including IV administration, as well pre- and postoperative administration of amiodarone is effective in prevention of POAF after cardiac surgery.

Objectives: Some early trials comparing intensive glucose control in type 2 diabetics with an acute myocardial infarction (MI) reported a decrease in mortality over a short period of follow up leading to a presumption of improved survival with intensive glucose control. Later data refuted this hypothesis. The 2009 ACC/AHA focused update on ST elevation MI gave a weak recommendation for the use of an insulin based regimen to achieve and maintain blood glucose less than 180 mg/dL. We decided to assess the validity of this recommendation. Methods: The authors searched the Pub- Med, Cochrane CENTRAL and EMBASE databases for randomized controlled trials from 1965 through 2011.Trials included were direct head-to-head comparisons of an intensive blood glucose control strategy using pharmacological means (insulin in most cases) with a less intensive regimen. The primary outcome assessed was the risk of all -cause mortality in the two groups at the end of follow up. Also assessed was the rate of hypoglycemia. The methodological quality of the studies was assessed. Event rates were compared using a forest plot of relative risk (RR; 95% confidence interval [CI]) using a random effects model (Mantel-Haenszel) assuming inter-study heterogeneity. Statistical analysis was done with Review Manager V5.1 and SYSTAT. Meta-regression was done with duration of therapy as covariate. Results: Three studies (total N = 2113) met the inclusion ⁄ exclusion criteria. Mortality was not different between the groups (RR 0.94, 95% CI of 0.66-1.34; p=0.73.). Rate of hypoglycemia was significantly higher in the intensive glucose control group (RR 13.40, 95% CI 3.69-48.61; p

a Division of Cardiovascular Medicine, State University of New York Downstate Medical Center, NY, United States b Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands c Division of Cardiology, University of Kansas Medical Center, Kansas City, KS, United States d Department of Medicine, Maimonides Medical Center, NY, United States e Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-the University of Queensland School of Medicine, New Orleans, LA, United States f Department of Medicine, Saint Peter's University Hospital, NJ, United States g Division of Cardiology, Texas Tech University, TX, United States

Article history: Received 28 January 2016 Accepted 20 February 2016 Available online 24 February 2016 tests were used to compare baseline characteristics. All analyses were performed using IBM SPSS Statistics 22.0. A 2-tailed p-value b0.05 was considered significant. The study included 217 subjects; 53 patients were male and 137 were Caucasian. Sixty-eight percent of the patients had normal sinus rhythm but only 17 patients (8%) had a normal ECG. Themost common

Background: In patients with atrial fibrillation (AF), ventricular rate control with medications has been found to be noninferior in preventing clinical events, compared to a strategy converting patients to sinus rhythm and maintaining it with medications. Guidelines have accepted rate control as an acceptable therapeutic option. Most of the prior studies excluded patients without significant left ventricular dysfunction, or permanent AF. Methods: The authors searched the PubMed, CENTRAL, and EMBASE databases for randomized controlled trials from 1966 to 2011. Trials included were direct head-to-head comparisons of rate- and rhythm-control strategy using pharmacological means. The primary outcome assessed was risk of all-cause mortality. We also assessed other pooled clinical endpoints using a random effects model (Mantel-Haenszel) between rate and rhythm-control strategies. Results: Ten studies (total N = 7,867) met inclusion/exclusion criteria. In-hospital mortality was not different between groups (P = 0.31). The rates of stroke, systemic embolism, worsening heart failure, myocardial infarction, and bleeding were also similar. However, rates of rehospitalization were much lower with a rate-control strategy (P = 0.007). An exploratory analysis in patients younger than 65 years revealed a rhythm-control strategy was superior to rate control in the prevention of all-cause mortality (P = 0.0007). Conclusions: This systematic review suggests no difference in clinical outcomes with a rate or rhythm-control strategy with AF. However, rehospitalization rates appear to be lower with pharmacological rate control for all ages, while finding support for rhythm control in younger patients. (PACE 2013; 36:122–133)

Dronedarone is a benzofuran derivative approved by the Food and Drug Administration to decrease the risk of cardiovascular hospitalization in patients with paroxysmal or persistent atrial fibrillation (AF) and associated cardiovascular risk factors who are in sinus rhythm or will undergo cardioversion. There has been recent evidence to suggest that dronedarone may not have a favorable safety profile. We decided to evaluate all available evidence on the cardiovascular safety of this drug. A systematic search was made of the PubMed, CENTRAL, and EMBASE databases for randomized controlled trials from 1966 through 2011 comparing dronedarone to comparators in AF/heart failure. Intervention was dronedarone for AF for some studies and heart failure for others. Comparators included standard medical therapy and/or placebo and amiodarone for 1 study. Outcomes assessed were all-cause mortality, cardiovascular mortality, ventricular arrhythmias, embolic events, acute coronary syndrome, heart failure exacerbations, and hospitalization rates in the intervention versus comparator group at the end of ≥ 3 months of follow up with abstraction of data by 1 author. Seven randomized controlled trials were included in our analysis. Dronedarone use was associated with a trend toward worse all-cause and cardiovascular mortalities and increased heart failure exacerbations. It also showed numerically higher event rates for all other outcome events except acute coronary syndrome. Our pooled analysis showed increased all-cause and cardiovascular mortalities and increased heart failure exacerbations with use of dronedarone across a wide spectrum of populations. In conclusion, we recommend exercising caution using dronedarone, especially in patients with cardiovascular risk factors.

Takotsubo cardiomyopathy (TC) is a unique transient nonischemic cardiomyopathy that mimics acute myocardial infarction (MI). The aim of our study was to evaluate electrocardiographic changes in patients with TC, including the frequency of ST elevation and other abnormalities.

Background— This study aimed to determine whether QRS morphology identifies patients who benefit from cardiac resynchronization therapy with a defibrillator (CRT-D) and whether it influences the risk of primary and secondary end points in patients enrolled in the Multicenter Automatic Defibrillator Implantation Trial–Cardiac Resynchronization Therapy (MADIT-CRT) trial. Methods and Results— Baseline 12-lead ECGs were evaluated with regard to QRS morphology. Heart failure event or death was the primary end point of the trial. Death, heart failure event, ventricular tachycardia, and ventricular fibrillation were secondary end points. Among 1817 patients with available sinus rhythm ECGs at baseline, there were 1281 (70%) with left bundle-branch block (LBBB), 228 (13%) with right bundle-branch block, and 308 (17%) with nonspecific intraventricular conduction disturbances. The latter 2 groups were defined as non-LBBB groups. Hazard ratios for the primary end point for comparisons of CRT-D patients versus patients who only received an implantable cardioverter defibrillator (ICD) were significantly ( P P P =0.257). The risk of ventricular tachycardia, ventricular fibrillation, or death was decreased significantly in CRT-D patients with LBBB but not in non-LBBB patients. Echocardiographic parameters showed significantly ( P Conclusions— Heart failure patients with New York Heart Association class I or II and ejection fraction ≤30% and LBBB derive substantial clinical benefit from CRT-D: a reduction in heart failure progression and a reduction in the risk of ventricular tachyarrhythmias. No clinical benefit was observed in patients with a non-LBBB QRS pattern (right bundle-branch block or intraventricular conduction disturbances). Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00180271.

Objective: To investigate the relationship of body mass index (BMI) with total mortality, cardiac mortality and risk of hospitalization in patients with chronic heart failure (HF). Methods: A systematic search of studies published between 1966 to January 31, 2014 was conducted using Pub Med, CINAHL, Cochrane CENTRAL and the Web of Science databases. Studies reporting rate of total mortality, cardiac mortality and risk of hospitalization in patients with HF in various BMI categories [=35 kg/m2 (severely obese)] were identified. Event rates were compared using a forest plot of relative risk using a random effects model assuming inter-study heterogeneity. Results: Two study authors independently reviewed the 124 articles and identified 6 for final analyses (N=22807). After mean follow up of 2.85 years, the risk of total mortality, cardiovascular (CV) mortality and of hospitalization was highest among patients with low BMI (RR 1.27 [95% CI 1.17 - 1.37]; 1.20 [95% CI 1.01 -1.43]; 1.19 [95% CI 1.09 - 1.30] respectively). Risk of cardiac mortality and hospitalization was lowest in overweight patients (RR0.79 [95% CI 0.70-0.90] and 0.92 [95% CI 0.86-0.97] respectively). Increasing degree of obesity failed to achieve a statistically significant effect on CV mortality (0.82 [0.64-1.05] and 0.71 [0.50-1.01] for obese and severely obese, respectively) and on hospitalization (0.99 [0.92-1.07] and 1.28 [0.88-1.87] for obese and severely obese, respectively) Conclusion: Risk of total mortality, cardiac mortality and hospitalization was highest among chronic HF patients who were underweight as defined by low BMI, whereas risk of cardiac mortality and hospitalization was lowest in the overweight. Further prospective studies are needed to investigate this association and apparent “overweight paradox” and explore potential underlying mechanisms for this association.

Cardiac-related clinical practice guidelines have become an integral part of the practice of cardiology. Unfortunately, these guidelines are often long, complex, and difficult for practicing cardiologists to use. Guidelines should be condensed and their format upgraded, so that the key messages are easier to comprehend and can be applied more readily by those involved in patient care. After presenting the historical background and describing the guideline structure, we make several recommendations to make clinical practice guidelines more user-friendly for clinical cardiologists. Our most important recommendations are that the clinical cardiology guidelines should focus exclusively on (1) class I recommendations with established benefits that are supported by randomized clinical trials and (2) class III recommendations for diagnostic or therapeutic approaches in which quality studies show no benefit or possible harm. Class II recommendations are not evidence based but reflect expert opinions related to published clinical studies, with potential for personal bias by members of the guideline committee. Class II recommendations should be published separately as "Expert Consensus Statements" or "Task Force Committee Opinions," so that both majority and minority expert opinions can be presented in a less dogmatic form than the way these recommendations currently appear in clinical practice guidelines.

Background: Acute coronary syndrome (ACS) resulting from culprit lesion in left main coronary artery (LMCA) can cause rapid hemodynamic deterioration. It is important to identify these patients early to facilitate timely revascularization. ST segment elevation in aVR greater than or equal to V 1 (aVR-V 1 ≥ 0) has been suggested as a sensitive predictor of LMCA disease. As a result of balanced forces, we hypothesized that ST deviation in V 6 greater than or equal to ST deviation in V 1 (V 6 -V 1 ≥ 0) might be a good determinant of LMCA disease. Methods: We compared admission 12-lead ECGs of ACS resulting from culprit LMCA lesion (n = 75, group I) with ACS resulting from culprit left anterior descending lesion (n = 81, group II). Group I was selected over a period of 10 years. We compared V 6 -V 1 ≥ 0 to aVR-V 1 ≥ 0 in both groups. We also looked at ratios of ST deviations in V 6 ,V 1 (V 6 /V 1 ≥ 1) and aVR,V 1 (aVR/V 1 ≥ 1) in patients where ST segment in V 1 was not isoelectric (group I = 54 and group II = 55). Results: ST deviation in V 6 was significantly greater in group I as compared to group II (P < 0.001). The reliabilities of V 6 -V 1 ≥ 0, V 6 /V 1 ≥ 1, aVR-V 1 ≥ 0, and aVR/V 1 ≥ 1 in predicting LMCA disease were determined. Conclusion: This is the largest series of ECG analysis on ACS resulting from culprit LMCA lesion. V 6 -V 1 ≥ 0 and V 6 /V 1 ≥ 1 were more sensitive in predicting LMCA as culprit vessel in comparison to previously reported greater ST segment elevation in aVR than V 1 .

The association of a group of prespecified atherosclerotic risk genotypes with recurrent coronary events (coronary-related death, nonfatal myocardial infarction, or unstable angina) was investigated in a cohort of 1,008 patients after infarction during an average follow-up of 28 months. We used a carrier-ship approach with time-dependent survivorship analysis to evaluate the average risk of each carried genotype. Contrary to expectation, the hazard ratio for recurrent coronary events per carried versus noncarried genotype was 0.89 (95% confidence interval 0.80 to 0.99, p = 0.03) after adjustment for relevant genetic, clinical, and environmental covariates. This hazard ratio, derived from the 7 prespecified genotypes, indicated an average 11% reduction in the risk of recurrent coronary events per carried versus noncarried genotype. At 1 year after hospital discharge, the cumulative probability of recurrent coronary events was 26% in those who carriedor =1, 20% for those with 2 to 4, and 13% for those withor =5 of these genotypes (p = 0.02). This unexpected risk reversal is a likely consequence of changes in the mix of risk factors in pre- and postinfarction populations. In conclusion, this under appreciated, population-based, risk-reversal phenomenon may explain the inconsistent associations of genetic risk factors with outcome events in previous reports involving coronary populations with different risk attributes.

OBJECTIVES/SPECIFIC AIMS: To assess the effect of cannabis on impaired judgment and health outcomes among heart failure patients in the emergency room. METHODS/STUDY POPULATION: Patients with heart failure presenting to the emergency room. Cannabis with confounders such as income level, insurance type, tobacco use, and age. Discharged against medical advice to assess impaired judgment. Hospitalization rates, length of stay, and death rate to assess health outcomes. Multivariate logistic regression to access the odds of each of these outcomes from cannabis RESULTS/ANTICIPATED RESULTS: Cannabis is associated with impaired outcome (increase in discharge against medical advice). Cannabis have poorer health outcome in terms of more hospitalizations from the emergency department. Cannabis also have better health outcome in terms of shorter length of stay and death rate among cannabis users Versus nonusers. DISCUSSION/SIGNIFICANCE OF IMPACT: This is crucial to inform health care providers to ensure better counseling of cannabis users. This result should also be considered to interpret other publications that shows better outcomes in patients taking cannabis. Cannabis users might only seem to have a better outcome because they tend to discharge against medical advice and thereby die outside the hospital, etc.

Background: Right ventricular (RV) dysfunction has been associated with adverse clinical outcomes in patients with heart failure (HF). Cardiac resynchronization therapy (CRT) improves left ventricular size and function in patients with markedly abnormal ECG QRS duration. However, the effect of CRT on RV function has not been well described. Objective: To evaluate change in RV function after CRT. Methods: A systematic search of studies published between 1966 to May 2014 was conducted using Pub Med, CINAHL, Cochrane CENTRAL and the Web of Science databases. Studies reporting tricuspid annular plane systolic excursion (TAPSE) or RV basal strain or RV long axis diameter or RV short axis diameter or RV fractional area change (FAC) before and after CRT were identified. A meta-analysis was performed using random effects with inverse variance method to determine the change in various parameters of RV function after CRT therapy. Results: Twelve studies (N=1478) were selected for final analysis. CRT therapy led to statistically significant increase in TAPSE [1.32(95% CI 0.67 -1.96; p Conclusion: CRT resulted in improved RV size and function as measured by TAPSE, RV FAC, RV basal strain, RV long axis and short axis diameters. Future studies should assess the impact of these changes on symptoms, quality of life and major HF morbidity and mortality.

Smoking continues to be the leading cause of preventable deaths in the USA, accounting for one in every five deaths every year, and cardiovascular (CV) disease remains the leading cause of those deaths. Hence, there is increasing awareness to quit smoking among the public and counseling plays an important role in smoking cessation. There are different pharmacological methods to help quit smoking that includes nicotine replacement products available over the counter, including patch, gum, and lozenges, to prescription medications, such as bupropion and varenicline. There have been reports of both nonserious and serious adverse CV events associated with the use of these different pharmacological methods, especially varenicline, which has been gaining media attention recently. Therefore, we systematically reviewed the various pharmacotherapies used in smoking cessation and analyzed the evidence behind these CV events reported with these therapeutic agents.

Clinical studies suggest an association between bisphosphonate use and new-onset atrial fibrillation (AF). Intravenous bisphosphonates more potently increase the release of inflammatory cytokines than do oral bisphosphonates; thus, the risk of developing AF may be greater with intravenous preparations. We have evaluated incidence of new-onset AF with use of oral and intravenous bisphosphonates through a systematic review and meta-analysis of the literature. We searched PubMed, CINAHL, Cochrane Central Register of Controlled Trials, Scopus, and EMBASE databases for observational studies and randomized controlled trials (RCTs) published from 1966 to April 2013 that reported the number of patients developing AF with use of oral or intravenous bisphosphonates. The random-effects Mantel-Haenszel test was used to evaluate the relative risk of AF with use of oral and intravenous bisphosphonates. Nine studies (5 RCTs and 4 observational studies) were included in the final analysis. Pooled data from RCTs and observational studies (n = 135,347) showed a statistically significantly increased risk of new-onset AF with both intravenous (relative risk 1.40, 95% confidence interval 1.32 to 1.49) and oral (relative risk 1.22, 95% confidence interval 1.14 to 1.31) bisphosphonates. The z statistic, which assesses the difference between the 2 risk ratios, indicated higher risk of AF with intravenous bisphosphonates versus oral bisphosphonates (p = 0.03). In conclusion, pooled data from RCTs and observational studies suggest that risk of AF is increased by use of oral or intravenous bisphosphonates but further suggest that risk is relatively greater with intravenous preparations.

This study sought to investigate the interplay between antibody and T cell responses triggered by an acute myocardial infarction (MI) and their possible role in the progress of this disease. Serum samples were collected from two groups of patients, group A (n = 26) within the first week of MI, and group B (n = 28) at 2 weeks and 2 months after MI. Patients in group A were older and had higher prevalence of hypertension and previous attack of MI than patients in group B. The levels of anti-myosin immunoglobulin M and immunoglobulin G antibodies in the serum samples from group A were significantly higher than those in normal control subjects. In group B, the levels of both antibodies were lower than those in group A but remained significantly higher than those in normal control subjects at both 2 weeks and 2 months. The levels of intercellular adhesion molecule-1 (sICAM-1) and vascular cell adhesion molecule-1 (sVCAM-1) in the serum samples from group A patients were significantly higher than those in normal control subjects. At 2 weeks after MI (group B), only the level of sVCAM-1, but not that of sICAM-1, was significantly higher than that in normal control subjects, and there were no significant changes in the levels of these two molecules from 2 weeks to 2 months after MI. We conclude that the higher levels of anti-myosin antibodies and adhesion molecules in group A patients as compared with group B patients may be due to higher or more frequent exposures of their immune systems to heart antigens. Furthermore, the immunoglobulin M antibody response during the first week of MI had an inverse relationship with the level of interleukin-2R (sIL-2R), which suggested a possible suppressive or regulatory role of this antibody on the cellular immune response during this time.

Background —Thrombosis is a pivotal event in the pathogenesis of coronary disease. We hypothesized that the presence of blood factors that reflect enhanced thrombogenic activity would be associated with an increased risk of recurrent coronary events during long-term follow-up of patients who have recovered from myocardial infarction. Methods and Results —We prospectively enrolled 1045 patients 2 months after an index myocardial infarction. Baseline thrombogenic blood tests included 6 hemostatic variables ( d -dimer, fibrinogen, factor VII, factor VIIa, von Willebrand factor, and plasminogen activator inhibitor-1), 7 lipid factors [cholesterol, triglycerides, HDL cholesterol, LDL cholesterol, lipoprotein(a), apolipoprotein (apo)A-I, and apoB], and insulin. Patients were followed up for an average of 26 months, with the primary end point being coronary death or nonfatal myocardial infarction, whichever occurred first. The hemostatic, lipid, and insulin parameters were dichotomized into their top and the lower 3 risk quartiles and evaluated for entry into a Cox survivorship model. High levels of d -dimer (hazard ratio, 2.43; 95% CI, 1.49, 3.97) and apoB (hazard ratio, 1.82; 95% CI, 1.10, 3.00) and low levels of apoA-I (hazard ratio, 1.84; 95% CI, 1.10, 3.08) were independently associated with recurrent coronary events in the Cox model after adjustment for 6 relevant clinical covariates. Conclusions —Our findings indicate that a procoagulant state, as reflected in elevated levels of d -dimer, and disordered lipid transport, as indicated by low apoA-1 and high apoB levels, contribute independently to recurrent coronary events in postinfarction patients.

Hospitalization for worsening heart failure (HF) is known to increase mortality and morbidity risk and has been frequently used as an endpoint in randomized clinical trials. Whether outpatient management of HF exacerbation carries similar prognostic and therapeutic information is less well known, but could be important for the design of trials that use HF hospitalization as an endpoint.MADIT-CRT randomized patients with mild HF symptoms to resynchronization therapy vs. control with an average follow-up of 3.3 years and a total of 191 deaths. HF events were centrally adjudicated for receiving i.v. decongestive therapy in an outpatient setting, or an augmented HF regimen during a hospital stay. Patients were compared according to whether their first HF was an out- or inpatient event. The first primary event was non-fatal outpatient HF, non-fatal inpatient HF, and death in 52, 331, and 78 patients, respectively. Patients with inpatient HF tended to be older and more likely to have HF of ischaemic aetiology than subjects who developed outpatient HF events. The risk of death following either type of non-fatal HF events was extremely high [hazard ratio (HR) 12.4, 95% confidence interval (CI) 9.1-16.9 for inpatient HF; HR 10.7, 95% CI 6.1-18.7 for outpatient HF] compared with subjects without non-fatal HF events. Allocation to CRT-D was associated with significant reduction in both types of HF.Outpatient management of worsening HF portends a high risk of death, similar to inpatient HF events, and may be equally sensitive to the effects of therapy. These findings suggest that outpatient HF events should be considered in publicly reported outcomes measures and future HF clinical trials.NCT01294449.

PurposePatients with Atrial Fibrillation (AF) and prior stroke are classified as high risk in all risk stratification schemes. A systematic review and meta-analysis was performed to compare the efficacy and safety of New Oral Anticoagulants (NOACs) to warfarin in patients with AF and previous stroke or transient ischemic attack (TIA). MethodsThree randomized controlled trials (RCTs), including total 14527 patients, comparing NOACs (apixaban, dabigatran and rivaroxaban) with warfarin were included in the analysis. Primary efficacy endpoint was ischemic stroke, and primary safety endpoint was intracranial bleeding. Random-effects models were used to pool efficacy and safety data across RCTs. RevMan and Stata software were used for direct and indirect comparisons, respectively. ResultsIn patients with AF and previous stroke or TIA, effects of NOACs were not statistically different from that of warfarin, in reduction of stroke (Odds Ratio [OR] 0.86, 95% confidence interval [CI] 0.73- 1.01), disabling and fatal stroke (OR 0.85, 95% CI 0.71-1.04), and all-cause mortality (OR 0.90, 95% CI 0.79 -1.02). Randomization to NOACs was associated with a significantly lower risk of intracranial bleeding (OR 0.42, 95% CI 0.25-0.70). There were no major differences in efficacy between apixaban, dabigatran (110 mg BID and 150 mg BID) and rivaroxaban. Major bleeding was significantly lower with apixaban and dabigatran (110 mg BID) compared with dabigatran (150 mg BID) and rivaroxaban. ConclusionNOACs may not be more effective than warfarin in the secondary prevention of ischemic stroke in patients with a prior history of cerebrovascular ischemia, but have a lower risk of intracranial bleeding.

Clinical studies have suggested an association between bisphosphonate use and the onset of atrial fibrillation (AF). However, data on the risk of developing AF, stroke, and cardiovascular mortality with the use of bisphosphonate are conflicting. The objective of this study was to evaluate the risk of serious AF (events that required hospital admission), stroke, and cardiovascular mortality with the use of bisphosphonates through a systematic review of the literature.We searched the PubMed, CENTRAL, and EMBASE databases for observational studies and randomized controlled trials (RCTs) on the use of bisphosphonates from 1966 to April 2012 that reported the number of patients who developed serious AF, stroke, and cardiovascular mortality at follow-up. The random-effects Mantel-Haenszel test was used to evaluate relative risk-adverse cardiovascular outcomes with the use of bisphosphonates.Six observational studies (n = 149,856) and six RCTs (n = 41,375) were included for analysis. On pooling observational studies, there was an increased risk of AF (OR, 1.27; 95% CI, 1.16-1.39) among bisphosphonate users. Further, analysis of RCTs revealed a statistically significant increase in the risk of serious AF (OR, 1.40; 95% CI, 1.02-1.93) and no increase in the risk of stroke (OR, 1.07; 95% CI, 0.85-1.34) or cardiovascular mortality (OR, 0.92; 95% CI, 0.68-1.26) with the use of bisphosphonates.Evidence from RCTs and observational studies suggests a significantly increased risk of AF requiring hospitalization, but no increase in risk of stroke or cardiovascular mortality, with the use of bisphosphonate.

An increasing number of academic senior physicians are approaching their potential retirement in good health with accumulated clinical and research experience that can be a valuable asset to an academic institution. Considering the need to let the next generation ascend to leadership roles, when and how should a medical career be brought to a close? We explore the roles for academic medical faculty as they move into their senior years and approach various retirement options. The individual and institutional considerations require a frank dialogue among the interested parties to optimize the benefits while minimizing the risks for both. In the United States there is no fixed age for retirement as there is in Europe, but European physicians are initiating changes. What is certain is that careful planning, innovative thinking, and the incorporation of new patterns of medical practice are all part of this complex transition and timing of senior academic physicians into retirement.

Patients with Atrial Fibrillation (AF) and prior stroke are classified as high risk. A systematic review and meta-analysis was performed to compare the efficacy and safety of New Oral Anticoagulants (NOACs) to warfarin in patients with AF and previous stroke or transient ischemic attack (TIA).

Introduction: About 5.8 million patients suffer from Heart failure in the United States and this number is expected to be on the rise. These patients have been shown to be at increased risk of developing Deep Vein Thrombosis (DVT). We analyzed 10 years of data from a nationwide database of inpatients to compare the outcomes of heart failure in patients with and without DVT. Methods: A retrospective analysis was conducted using data from the Nationwide Inpatient Sample (NIS) from 1998 to 2007(10 years). All Adult patients (above 18 years old) with Heart failure during this period were identified using ICD 9 codes. Baseline characteristics and outcomes of heart failure patients with documented DVT vs. without DVT were compared during the incident admission. Multivariate regression for mortality was conducted, controlling for age, gender, and the presence of co-morbidities. Another multivariate analysis was conducted to determine predictors of developing DVT in this population of heart failure patients. Results: Among 7,880,500 patients managed for Heart failure in this database during the study period, patients with DVT were more likely to have been older than those without DVT (p

Objective To evaluate the risk of myocardial infarction (MI) associated with the use of rivaroxaban. Methods We searched PubMed, CINAHL, Cochrane CENTRAL, Scopus, and the Web of Science for randomized controlled trials of rivaroxaban that reported on MI as clinical outcomes. We express the associations as odds ratios and their 95% confidence intervals. A trial sequential analysis was carried out to ensure validity of our findings. Results Nine trials were selected (N=53 827), including one study on stroke prophylaxis in atrial fibrillation, two in acute coronary syndrome, four of short-term prophylaxis of deep venous thrombosis, and two for treatment of deep venous thrombosis/pulmonary embolism. Control arms included warfarin, enoxaparin, or placebo administration. Rivaroxaban was associated with a significantly lower risk of MI compared with the agents used in the control group (odds ratio, 0.82; 95% confidence interval, 0.72-0.94; P=0.004). No heterogeneity was noted in the risk (I=0%; P=0.55); trial sequential analysis reinforced the validity of our findings. Conclusion Rivaroxaban is associated with a significantly lower risk of MI in a broad spectrum of patients when tested against different controls.

We evaluated the association of moderate hyperhomocyst(e)inemia and vitamin B-12 status with coronary artery disease (CAD) and left ventricular ejection fraction in 367 elderly patients undergoing coronary angiography. The extent of CAD was scored, left ventricular ejection fraction was assessed and vitamins B-12 and folate and the metabolites homocyst(e)ine, methylmalonic acid and 2-methylcitric acid were measured. There was no significant trend in change in homocyst(e)ine as the extent of CAD increased. There was an association between vitamin B-12 deficiency, i.e., vitamin B-12221 pmol/l and homocyst(e)ine16 nmol/ml and low left ventricular ejection fraction (P = 0.014). Of 105 samples, selected for vitamin B-12221 pmol/l or high normal vitamin B-12 and folate levels, metabolites including methylmalonic acid revealed a specific diagnosis of vitamin B-12 deficiency in 18 patients. The trend among these vitamin B-12-deficient patients and low left ventricular ejection fraction was significant (P = 0.028). In vitro studies on rat heart revealed that nitrous oxide in the presence of 200 microM/l methionine reduced contractility of the heart. In conclusion, vitamin B-12-deficient patients had significantly lower left ventricular ejection fractions than nonvitamin B-12-deficient patients. Whether low left ventricular ejection fraction results in malabsorption of vitamin B-12 and vitamin B-12 deficiency, or conversely, whether vitamin B-12 and its marker, elevated homocyst(e)ine, depress left ventricular function warrants further evaluation.

Background: The aim of this study was to analyze the characteristics of stable patients with resting ST segment depression on the resting electrocardiogram (ECG) following an acute ischemic event (i.e., infarction or unstable angina) to better understand its association with subsequent cardiac death and nonfatal infarction. The recent Multicenter Study of Myocardial Ischemia (MSMI) demonstrated that the resting ST segment depression had an independent prognostic value. Methods: We studied clinical features, noninvasive test results and coronary arteriography findings in 99 patients with ST depression on the resting ECG and 837 patients without ST segment depression with respect to endpoints of cardiac death and hospitalization for acute myocardial infarction or unstable angina. Results: Our results showed that patients with resting ECG ST depression were significantly older with a higher incidence of hypertension, angina, claudication, and tobacco use. ST depression on the resting ECG correlated closely with ST segment depression on the 24-hour ambulatory ECG and the exercise ECG but not with redistribution on the thallium perfusion scan. Left ventricular diastolic pressure was higher and exercise duration less in patients with ST depression. Although not achieving statistical significance, patients with ST depression did show more extensive coronary disease and a lower ejection fraction. Conclusions: ECG ST depression was associated with cardiac death and nonfatal reinfarction over the follow-up period only in patients originally admitted with an acute infarction but not in patients hospitalized for unstable angina. The reason for this appears to be an association of ST depression with increased age, the presence of hypertension, the presence of more severe coronary disease, and more extensive myocardial damage.

The authors present a 20-year follow-up of a patient with well-documented coronary artery spasm, who initially presented with syncope. The patient had excellent response to calcium channel antagonists and long-acting nitrates.

To evaluate the relationship of CRT on various echocardiographic parameters of right ventricular (RV) function. A systematic search of studies reporting tricuspid annular plane systolic excursion (TAPSE) or RV basal strain or RV long or short axis diameter or RV fractional area change (FAC), before

We attempted to evaluate if an oral-only regimen was as effective in preventing postoperative atrial fibrillation (POAF) after cardiac surgery, in comparison to a regimen that included intravenous (IV) administration using a network meta-analysis of available data, and also attempted to assess if preoperative administration at least 1 day before surgery was superior to postoperative prophylaxis (at least 1 day after surgery).We searched PubMed, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials' databases for randomized controlled trials conducted between 1990 and 2011 that assessed rates of POAF with amiodarone. Finally an interaction odds ratio was computed to assess the efficacy of an oral-only regimen of amiodarone compared to one including IV administration and to evaluate if preoperative amiodarone was superior to postoperative prophylaxis.Twenty-three studies (total N = 3,950) were included. Both regimens of amiodarone improved risk of POAF; oral-only risk ratio (RR) was 0.59 (95% confidence interval [CI] 0.49-0.70; P0.01) and regimen including IV RR was 0.57 (95% CI 0.43-0.75, P0.01). The interaction odds ratio was 1.17 (95% CI 0.72-1.89, P = 0.533). Both preoperative amiodarone (P0.01) and postoperative prophylaxis were effective (P = 0.0009), irrespective of duration.This systematic review suggests a regimen of both oral-only and one including IV administration, as well pre- and postoperative administration of amiodarone is effective in prevention of POAF after cardiac surgery.

Background: Centenarian population in the United States is increasing, and cardiovascular disease is the most common cause of death in this group of patients. We report electrocardiographic changes in a group of 124 centenarians. METHODS: We included ECGs of 124 patients aged 100 to 112 years (mean age 102 years), who were seen either on office visits or on recent admission to the hospital. ECGs were analyzed by 2 different investigators. Results: Women were at least 2 times men in number (31% vs 69%, 39 vs 85 of 124); thus women outlived men in the centenarian group. 58% (72 of 124) patients had normal sinus rhythm and only 7 of 124 patients (6%, all women) had normal ECGs. The most common electrocardiographic abnormalities were: left-axis deviation (29%, 36 of 124), atrial fibrillation (AF) (27%, 34 of 124), right bundle branch block (15%, 18 of 124), left anterior fascicular block (14%, 17 of 124), left ventricular hypertrophy (14%, 17 of 124), first-degree atrioventricular (AV) block (13%, 16 of 124), nonspecific ST-T changes (13%, 16 of 124), premature atrial complexes (13%, 16 of 124), premature ventricular complexes (10%, 13 of 124) and pacemaker rhythm (10%, 13 of 124). Almost all Q waves were suggestive of old inferior wall infarcts and were present in 8% (10 of 124) of patients. Only 3 centenarians had QTc prolongation. Conclusion: Fewer men live long enough to reach 100 years of age, consistent with higher incidence of ischemic heart disease in men. Centenarians had higher incidence of AF indicative of increased incidence of AF with age. Increased incidence of left-axis deviation, left anterior fascicular block and left ventricular hypertrophy in centenarians can be attributed to age related cardiac hypertrophy and prevalence of hypertension. Also higher prevalence of conduction disturbances including AV block and bundle branch block indicates that a degenerative conduction system disorder may progress with advancing age. The finding of pacemaker rhythm in a few subjects confirms that pacemaker implantation may allow some patients to reach extreme longevity. Overall centenarians represent a model of successful aging and have satisfactory electrocardiographic framework that reflects a good cardiac function, contributing to attainment of extreme longevity.

Summary. Background: Duration of thromboprophylaxis beyond hospital discharge for medically ill patients has been controversial. Therefore an evaluation was made of the evidence currently available. Methods: A search was made of the Pub Med, CENTRAL and EMBASE databases for randomized controlled trials from 1966 through to 2011. Interventions included thromboprophylaxis administered over an extended period in patients hospitalized for acute medical illness with decreased level of mobility. No differentiation was made for the medication used for individual studies. The comparator included standard medical therapy and/or placebo. The efficacy outcomes assessed were a composite of asymptomatic and symptomatic deep vein thromboses (DVT), pulmonary emboli (PE) and venous thromboembolism (VTE)-related deaths in the intervention group vs. the comparator group, as well as the safety outcomes evaluated with rates of bleeding events at the end of at least 30 days of follow-up. The methodological quality of the studies was assessed, as was publication bias. Event rates were compared using a forest plot of relative risk (RR; 95% confidence interval (CI)) using a random effects model (Mantel-Haenszel) between the active thromboprophylaxis and controls. Statistical analysis was carried out with Review Manager V5.1. Results: Three recent studies were included. Extended duration thromboprophylaxis reduced the combined composite event rate, RR 0.75 (0.64, 0.88). However, individual clinical endpoints were not significantly improved with extended prophylaxis: asymptomatic proximal DVT, RR 0.85 (0.68, 1.05); symptomatic DVT, RR 0.44 (0.19, 1.00); symptomatic non-fatal PE, RR 0.80 (0.43, 1.48); VTE-related death, RR 0.64 (0.38, 1.10). However, bleeding events were far more prevalent with extended thromboprophylaxis with major bleeds, RR 2.68 (1.78, 4.05), with a number needed to harm of 194. Conclusion: Currently available evidence does not indicate that routine administration of post-discharge prophylaxis will be beneficial to the patients admitted for medical illness.

In patients with atrial fibrillation (AF), ventricular rate control with medications has been found to be noninferior in preventing clinical events, compared to a strategy converting patients to sinus rhythm and maintaining it with medications. Guidelines have accepted rate control as an acceptable therapeutic option. Most of the prior studies excluded patients without significant left ventricular dysfunction, or permanent AF.The authors searched the PubMed, CENTRAL, and EMBASE databases for randomized controlled trials from 1966 to 2011. Trials included were direct head-to-head comparisons of rate- and rhythm-control strategy using pharmacological means. The primary outcome assessed was risk of all-cause mortality. We also assessed other pooled clinical endpoints using a random effects model (Mantel-Haenszel) between rate and rhythm-control strategies.Ten studies (total N = 7,867) met inclusion/exclusion criteria. In-hospital mortality was not different between groups (P = 0.31). The rates of stroke, systemic embolism, worsening heart failure, myocardial infarction, and bleeding were also similar. However, rates of rehospitalization were much lower with a rate-control strategy (P = 0.007). An exploratory analysis in patients younger than 65 years revealed a rhythm-control strategy was superior to rate control in the prevention of all-cause mortality (P = 0.0007).This systematic review suggests no difference in clinical outcomes with a rate or rhythm-control strategy with AF. However, rehospitalization rates appear to be lower with pharmacological rate control for all ages, while finding support for rhythm control in younger patients.

Eplerenone is publicized to be extremely effective in reducing mortality from heart failure, with a reasonable side-effect profile. However, it is much more expensive compared with older aldosterone antagonists. We reviewed available evidence to assess whether increased expense was justified with outcomes data.The authors searched the PubMed, CENTRAL, CINAHL, and EMBASE databases for randomized controlled trials from 1966 through July 2011. Interventions included aldosterone antagonists (Aldactone [Pfizer, NY, NY], canrenone, eplerenone) in systolic heart failure. The comparator included standard medical therapy or placebo, or both. Outcomes assessed were mortality in the intervention versus the comparator groups, and rates of adverse events at the end of at least 8 weeks of follow-up. Event rates were compared using a forest plot of relative risk (RR) (95% confidence interval [CI]) using a random-effects model (Mantel-Haenszel) between the aldosterone antagonists and controls. We included 13 studies for aldosterone antagonists other than eplerenone, and 3 studies for eplerenone. There was significant reduction of mortality with all aldosterone antagonists, but eplerenone (15% mortality relative reduction; RR 0.85; 95% CI, 0.77-0.93; P=.0007) was outperformed by other aldosterone antagonists, namely, spironolactone and canrenone (26% mortality relative reduction; RR 0.74; 95% CI, 0.66-0.83; P.0001). Reduction in cardiovascular mortality with eplerenone was 17% (RR 0.83; 95% CI, 0.75-0.92; P=.0005), while that with other aldosterone antagonists was 25% (RR 0.75; 95% CI, 0.67-0.84, P.0001), without contributing significantly to an improved side-effect profile.Eplerenone does not appear to be more effective in reducing clinical events compared with older, less expensive aldosterone antagonists.

Infective endocarditis is significantly more common and causes greater morbidity and mortality in patients receiving hemodialysis than in the general population. Episodes of bacteremia during hemodialysis are primarily the result of frequent vascular access through an arteriovenous fistula, a vascular graft, or an indwelling vascular catheter. This leads to dialysis access infection and secondary bacteremia. We describe 4 cases of patients receiving hemodialysis, with an indwelling intravascular dialysis catheter, who developed right-sided endocarditis with vegetations located exclusively on the superior vena cava and right atrium wall. All patients had persistent bacteremia with Staphylococcus, secondary to an indwelling intravascular hemodialysis catheter, which led to seeding of the right-sided cardiac wall, causing infective endocarditis. The rates of acceptance for hemodialysis are increasing, along with improved survival in this group of patients. This will probably lead to an increase in the incidence of infective endocarditis, with atypical presentations such as superior vena cava and right-sided cardiac wall endocarditis.