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Objectives Vascular access site complications after percutaneous transfemoral cardiovascular procedures remain a common cause of morbidity and mortality. We evaluated the SiteSeal® VCD for achieving hemostasis following diagnostic cardiac catheterization. Methods We conducted a prospective case control single center study to assess the safety and efficacy of SiteSeal® VCD compared to standard manual compression following diagnostic cardiac catheterization. Forty patients were enrolled in study to receive either SiteSeal® device or manual compression (20 in each group). Results Patients in the SiteSeal® group achieved hemostasis in a significantly shorter time (4 ± 2.4 vs. 19 ± 2.4 min, P 24 h after discharge from the hospital and was managed conservatively. In the remaining device patients, there was no clinical or Doppler ultrasound evidence of major or minor vascular complication with good overall patient comfort at discharge, 7 days and 30 days follow-up. Conclusions In this first clinical experience, the SiteSeal® VCD achieved safe and efficient hemostasis, allowed for earlier ambulation and faster discharge compared to manual compression.

Objective To investigate the risk factors for postoperative delirium and the impact of delirium on mortality and morbidity following transcatheter aortic valve implantation (TAVI). Design Patients who underwent TAVI were identified using the International Classification of Diseases, 9th revision clinical modification codes from the National Inpatient Sample database. Statistical analysis of preoperative and perioperative risk factors was done to identify the independent risk factors for delirium after TAVI. Setting Multi-institutional. Participants Patients who underwent TAVI from 2012 to 2013. Interventions TAVI. Measurements and Main Results Over the period of 2 years (2012-2013), 7,566 patients underwent TAVI. The incidence of delirium post-TAVI was 4.57% (345). Age >85 (odds ratio [OR] 1.03; 95% confidence interval [CI] 1.01-1.05; p = 0.003), electrolyte abnormalities (OR 1.83; 95% CI 1.17-2.87; p = 0.008), prior neurologic illness (OR 1.67; 95% CI 1.10-3.15; p = 0.01), and weight loss in the hospital (OR 1.77; 95% CI 1.05-2.99; p = 0.03) were independent risk factors for postoperative delirium (POD). Unilateral or bilateral carotid stenosis did not predispose to the development of delirium. POD was an independent risk factor for procedural morbidity (OR 3.29; 95% CI 2.05-5.28; p Conclusion Age of >85, electrolyte disturbance, pre-existing neurologic disease and weight loss were found to be independent risk factors for delirium. POD was associated significantly with morbidity. Owing to a significant increase in the morbidity, a thorough screening protocol and effective strategies to predict, prevent, and treat postoperative delirium would reduce the cost associated with TAVI.

Perioperative stroke rate after surgical aortic valve replacement (SAVR) varies between 1.3% and 6.2%, whereas the operative mortality ranges between 1% and 16.4%. The aim of this study was to determine whether perioperative stroke is a risk factor for operative mortality after SAVR by performing a meta-analysis of relevant studies.PubMed, EMBASE, and Web of Science databases were searched to retrieve relevant literature. Screening of the articles was done independently on the basis of predetermined criteria. Data from the relevant studies were extracted and a random effects model was used to calculate the odds of mortality among patients with perioperative strokes after aortic valve replacement compared with those without such strokes. Subgroup analyses of patients (1) aged above and below 70 years and (2) undergoing isolated valve replacement procedure were performed. Metaregression to check for association of effect estimate and (1) sex, (2) mechanical valve replacement, (3) New York Heart Association class III/IV, (4) left ventricle ejection fraction30%, and (5) preoperative atrial fibrillation was performed.Statistical analyses using a random effects model showed that patients with perioperative strokes had 4.74 times greater odds for operative mortality after SAVR, independent of the following covariates: (1) sex, (2) mechanical valve replacement, (3) New York Heart Association class III/IV, (4) left ventricle ejection fraction30%, and (5) preoperative atrial fibrillation.Patients with perioperative strokes after SAVR have nearly 5 times greater odds of experiencing operative mortality compared with those without. Thus, perioperative strokes are associated with increased risk of early mortality and require further examination of preventive strategies.

BACKGROUND AND PURPOSE Perioperative stroke is a significant complication of transcatheter aortic valve implantation (TAVI). This study aimed to quantify perioperative stroke as an independent risk factor for in-hospital mortality and postoperative morbidity in patients receiving TAVI. METHODS A retrospective cohort study was conducted using the National Inpatient Sample. Patients undergoing TAVI during 2012 and 2013 were identified using diagnostic codes of International Classification of Diseases, ninth revision. Univariate and multivariate analyses were performed using patient demographics and comorbidities to identify predictors of mortality and morbidity, defined by a length of stay of >14 days and/or discharge to a place other than home. RESULTS Data were obtained from 7,556 patients undergoing TAVI during 2012 and 2013. The incidence rates of mortality and morbidity were 4.57 and 71.12%, respectively. Perioperative stroke was an independent risk factor for mortality [odds ratio (OR)=3.182, 95% confidence interval (CI)=1.530-6.618, p=0.002], as were infection (OR=17.899, 95% CI=9.876-32.440, p

Transcatheter aortic valve implantation (TAVI) is a rapidly evolving safe method with decreasing incidence of perioperative stroke. There is a void in literature concerning the impact of stroke after TAVI in predicting 30-day stroke-related mortality. The primary aim of this meta-analysis was to determine whether perioperative stroke increases risk of stroke-related mortality after TAVI. Online databases, using relevant keywords, and additional related records were searched to retrieve articles involving TAVI and stroke after TAVI. Data were extracted from the finalized studies and analyzed to generate a summary odds ratio (OR) of stroke-related mortality after TAVI. The stroke rate and stroke-related mortality rate in the total patient population were 3.07% (893 of 29,043) and 12.27% (252 of 2,053), respectively. The all-cause mortality rate was 7.07% (2,053 of 29,043). Summary OR of stroke-related mortality after TAVI was estimated to be 6.45 (95% confidence interval 3.90 to 10.66, p0.0001). Subgroup analyses were performed among age, approach, and valve type. Only 1 subgroup, transapical TAVI, was not significantly associated with stroke-related mortality (OR 1.97, 95% confidence interval, 0.43 to 7.43, p = 0.42). A metaregression was conducted among females, New York Heart Association class III/IV status, previous stroke, valve type, and implantation route. All failed to exhibit any significant associations with the OR. In conclusion, perioperative strokes after TAVI are associated with6 times greater risk of 30-day stroke-related mortality. Transapical TAVI is not associated with increased stroke-related mortality in patients who suffer from perioperative stroke. Preventative measures need to be taken to alleviate the elevated rates of stroke after TAVI and subsequent direct mortality.

Background The goal of this study is to assess the effect of cardiac resynchronization therapy (CRT) over time on renal function and its impact on mortality. The effect of CRT on renal function in patients with heart failure is not well understood. Methods All patients who underwent CRT implantation at University of Kansas between year 2000 and 2009 were reviewed and patients who had pre and post CRT renal function studied were included in our study. Stages of chronic kidney disease (CKD) were defined based on Kidney Disease Outcome Quality Initiative (KDOQI) guidelines. The effect of CRT on renal and cardiac function were studied at short term (≤6 months post implantation) and long term (>6 months). Results A total of 588 patients with mean age of 67 ± 12 yrs were included in the study. CRT responders (defined by increase in LVEF ≥ 5%) were 54% during short term follow-up and 65% on long term follow-up. When compared to baseline, there was no significant deterioration in mean Glomerular Filtration Rate (GFR) during follow up. When analyzed based on the stages of CKD, there was significant improvement of renal function in patients with advanced kidney disease. Multivariate logistic regression analysis showed that stable GFR or an improvement in GFR independently predicted mortality after adjusting for co-morbidities. Conclusions CRT was associated with stabilization of renal function in patients with severe LV dysfunction and improvement in stage 4 and 5 CKD. Improved renal function was associated with a lower mortality.

Background: Cholesterol management guidelines from the American College of Cardiology/American Heart Association (ACC/AHA-2013) recommend fixed statin dosing (dose depends on age ≤ or >75 years) compared to the earlier adult treatment panel III (ATPIII) guidelines which recommended specific low-density lipoprotein-cholesterol (LDL-C) targets. Clinical implications of this recommendation are not known. Methods: We retrospectively compared cholesterol levels and statin utilization across cohorts with coronary artery disease (CAD) (n = 9563), peripheral arterial disease (PAD) (n = 596) and CAD + PAD (n = 975) by applying both guidelines. The percentage of patients who achieved guideline-specific targets using 2013 ACC/AHA (use of moderate/high intensity statins) or ATPIII guidelines (LDL-C 100 mg/dl. Conclusions: Application of the ACC/AHA guidelines results in a higher percentage of patients considered to be ‘at goal’ when compared to the ATP III guidelines without changes in clinical practice. This is due to patients ≤75 years old on adequate statin doses but still have LDL-C levels >100 mg/dl, thereby raising concerns that physicians may not pursue alternate LDL reduction strategies since they are now considered at goal despite LDL-C >100 mg/dl. Lipid management of PAD patients remains sub-optimal as compared to CAD and CAD + PAD.

Ankle-brachial index (ABI) is conventionally derived as the ratio of higher of the 2 systolic ankle blood pressures to the higher brachial pressure (HABI method). Alternatively, ABI may be derived using the lower of the 2 systolic ankle pressures (LABI method). The objective of this study was to assess the utility and difference between 2 techniques in predicting peripheral artery disease (PAD). Participants who underwent both ABI measurement and arteriography from July 2005 to June 2010 were reviewed. Angiographic disease burden was scored semiquantitatively (0=50%, 1=50% to 75%, and 2=75% stenosis of any lower extremity arterial segment), and PAD by angiography was defined as50% stenosis of any 1 lower extremity arterial segment. A combined PAD disease score was calculated for each leg. A total of 130 patients were enrolled (260 limbs). The ABI was0.9 (abnormal) in 68% of patients by HABI method and in 84% by LABI. LABI method had higher sensitivity and overall accuracy to detect PAD compared with the HABI method. Regression analysis showed that an abnormal ABI detected by LABI method is more likely to predict angiographic PAD and total PAD burden compared with HABI. Moreover, abnormal ABI by LABI method had higher sensitivity and accuracy to detect PAD in patients with diabetes and below knee PAD compared with the HABI method. In conclusion, ABI determined by the LABI method has higher sensitivity and is a better predictor of PAD compared with the conventional (HABI) method.

Background Data from pharmacokinetic and pharmacodynamic studies indicate that the adverse clopidogrel – proton pump inhibitor (PPI) interaction may vary between PPIs, with pantoprazole considered relatively less problematic. We aimed to evaluate systematically whether individual PPIs differ in their risk for cardiovascular events when concomitantly administered with clopidogrel. Methods We searched MEDLINE, EMBASE and Cochrane Trials Register up to December 2011 for randomized and non-randomized studies that reported adverse cardiovascular events with exposure to specific PPIs in patients receiving clopidogrel. We performed random effects meta-analysis, and assessed heterogeneity using the I 2 statistic. Results A total of 23 studies with 222,311 participants were included. Meta-analysis of major adverse cardiovascular events was mostly limited by moderate-substantial heterogeneity. Pooled estimates of cardiovascular risk were significantly elevated for individual PPIs such as omeprazole, esomeprazole, lansoprazole, and pantoprazole when used with clopidogrel. However, meta-analysis of adverse cardiovascular risk in seven observational studies reporting on PPI therapy alone (without concomitant clopidogrel) also found an elevated odds ratio of 1.28 (95% CI 1.14–1.44) compared with no clopidogrel/no PPI exposure. Meta-analysis of two randomized controlled trials did not show significant adverse cardiovascular effect from omeprazole or esomeprazole. Conclusions The absence of consistent evidence on differential cardiovascular risk amongst PPIs (particularly regarding safety of pantoprazole) is in direct opposition to the platelet function and pharmacokinetic data. Our findings of increased cardiovascular risk with PPIs in the absence of clopidogrel suggest that confounding and bias are strong possibilities. The clinical validity or relevance of the hypothesized PPI-clopidogrel interaction remains questionable.

Loss of biventricular (BiV) pacing occurs during ventricular sensed events such as frequent ventricular ectopy, nonsustained ventricular tachycardia, and intrinsic atrioventricular nodal conduction, such as in atrial fibrillation. Ventricular sense response (VSR) pacing, a novel cardiac resynchronization therapy pacing strategy, maintains BiV pacing during these sensed ventricular events. Patients who underwent echocardiographic optimization after BiV pacemaker implantation were enrolled, and aortic velocity-time integrals (VTIs) were recorded and compared during intrinsic conduction without pacing, optimized BiV pacing, and intrinsic conduction with VSR pacing alone. Thirty-two patients were enrolled (mean age 68 +/- 11 years, 78% men), with a mean baseline QRS duration of 164 +/- 24 ms and a mean left ventricular ejection fraction of 23 +/- 10%. The mean aortic VTI during intrinsic conduction with VSR pacing was 16.5 +/- 3.6 cm, compared with 15.3 +/- 3.4 cm during intrinsic conduction without pacing (p0.001). The mean aortic VTI with optimized BiV pacing was 17.3 +/- 3.6 cm, significantly better (p0.001) compared with intrinsic conduction without pacing. Improvements in aortic VTI were higher with optimized BiV pacing compared with VSR pacing alone (p = 0.02). In the subgroup of patients with left bundle branch block-type activation, the hemodynamic improvements realized with VSR pacing were similar to optimized BiV pacing. Mean aortic VTI improvements with VSR were similar in patients with ischemic and nonischemic cardiomyopathy. In conclusion, a cardiac resynchronization therapy algorithm that maintains BiV pacing during a ventricular sensed event appears to have an aortic VTI response that is significantly better compared with intrinsic conduction without pacing.

Objectives: Type 2 diabetics are at higher risk for cardiovascular disease. To reduce this risk, the American Diabetes Association recommends traditional cardiovascular disease risk factor modification, reducing hemoglobin Alc (HbAlc), and the use of aspirin for patients over 30 years of age. The goal of this study was to analyze how well these goals were achieved in type 2 diabetics. Methods: Patients with type 2 diabetes from July 2004 to June 2005 were included. Data were collected on demographics, preexisting coronary artery disease (CAD), blood pressure control, HbAlc, low-density lipoprotein cholesterol level, and microalbuminuria. Results: One hundred thirty-nine patients were included (18% had CAD). Blood pressure was controlled in 46.04% of patients; 41.72% reached target HbAlc; 47.48% reached target low-density lipoprotein cholesterol; and 43.88% had microalbuminuria. No significant difference was noted between diabetics with or without CAD. Aspirin was used in 64% of patients with CAD and in 28.15% patients without CAD. Conclusions: Optimal cardiovascular risk modification was achieved in less than 50% of type 2 diabetics. Aspirin remains underused for primary prevention. These results highlight the continued difficulties in achieving control of diabetes to the extent recommended by American Diabetes Association guidelines.

Background: Late referral to nephrologists is common and associated with increased morbidity and mortality. We aimed to analyze the prevalence rates, predictors and consequences of late referral to nephrologists by primary care physicians for chronic kidney disease (CKD) care. Methods: A retrospective analysis of 204 patients started on dialysis for CKD in two community hospitals between March 2003 and March 2005 was conducted. Relevant clinical and laboratory data were obtained from the patient records of the nephrology clinics and dialysis units. Patients referred in CKD stage 5 (estimated glomerular filtration rate 15 ml/min) as early referral. Results: Forty-five (22%) of the 204 patients were referred late. In the multivariate analysis, non-diabetic kidney disease (odds ratio = 2.46, p = 0.02) and Charlson comorbidity index (odds ratio = 1.17, p = 0.009) were significantly associated with late referral. The late referral group had lower hematocrit and serum calcium levels, and higher serum phosphorus and parathyroid hormone levels than the early referral group (p ≤0.05) at the time of referral. Late referral resulted in less permanent vascular access for initiation of dialysis (p = 0.03). Even though there was twice the number of deaths in the late referral group in 1 year (18 vs. 9%), this was not statistically significant (p = 0.07). Conclusion: Referring physicians should pay special attention to patients with non-diabetic kidney disease and patients with multiple comorbidities since delayed referral to nephrologists may result in poorer patient-related outcomes. Larger and long-term prospective studies analyzing the long-term consequences of late referral to nephrologists are needed.

Objective: The Centers for Disease Control (CDC) recommends trivalent influenza (TIV) and pneumococcal (PPV) vaccination for eligible hospitalized patients. We conducted a retrospective study comparing two different methods of assessment and its impact on TIV and PPV vaccination in hospitalized patients. Design: Two sequential models were compared in a community hospital for assessing patients' vaccination status and eligibility for TIV and PPV in an inpatient setting. In the first model (Model I), physicians were responsible for assessing eligibility and ordering TIV and/or PPV. In the second model (Model II), nurses were responsible for assessment and vaccination of eligible patients. Charts of hospitalized patients were randomly analyzed for completion rates of the assessment form, rate of vaccination, and documentation of the reason for not vaccinating eligible patients. Results: A total of 138 charts were analyzed for Model I and 168 charts were analyzed for Model II. A significantly higher completion rate for assessment was noted for Model II compared with Model I (79.16% versus 34.78%, P < 0.001 for TIV; 72.02% versus 33.33%, P < 0.001 for PPV). Hospital vaccination rates were not significantly different between the two models for TIV (P = 0.625) and PPV (P = 0.689). A significant percentage of patients refused PPV in Model II [8.03% versus Model I at 3.2% (P = 0.04)]. Conclusion: A standing order protocol for assessing hospitalized patients' vaccination status by nursing staff and allowing them to vaccinate eligible patients without depending upon a physician order significantly improved the assessment compliance rate, but not the vaccination rates. Our findings suggest that a system-based method with nursing assessing the need for vaccination and a physician ordering the vaccination would probably have a higher potential for success.

The number of catheter ablations performed for atrial fibrillation (AF) has increased dramatically over the past several years. Regional variation in left atrial (LA) wall thickness is known to exist but have not been described in detail. AF ablation success and complication rates may be related to regional differences in LA wall thickness. To evaluate differences in transmural wall thickness in five pre-defined anatomic areas within the LA which are commonly targeted for AF ablation. We measured LA wall transmural thickness in 34 human heart specimens using calipers in five anatomic areas frequently targeted during AF ablation (anterior wall, septum, mitral isthmus, posterior wall and roof). The autopsied individuals were 53% female, 67.7% had CAD, 14.7% had atrial fibrillation, 61.8% had hypertension, and 21.6% had congestive heart failure. The roof was the thinnest region with mean thickness measuring significantly less than each other area (p 0.005 for the posterior wall and

Introduction: Results from randomized controlled trials (RCTs) of bone marrow cell (BMC) therapy for cardiac repair have been discordant. The true impact of BMC therapy in patients with chronic ischemic heart disease (CIHD) and ischemic heart failure remain unclear. Hypothesis: We hypothesized that BMC injection would improve clinical outcomes and left ventricular (LV) parameters in patients with CIHD. Methods: We performed a systematic review and meta-analysis of data from RCTs of BMC therapy on LV ejection fraction (LVEF), LV end-systolic volume (LVESV), LV end-diastolic volume (LVEDV), infarct scar size, and clinical outcomes in patients with CIHD. Database searches based on specified criteria identified 15 eligible RCTs (enrolling 648 CIHD patients). Changes in predefined parameters were analyzed with random-effects meta-analysis. Peto odds ratio (OR) was calculated for clinical outcomes. Results: Compared with standard therapy, BMC transplantation improved LVEF (3.84%; 95% confidence interval [CI], 2.30 to 5.38; P Conclusions: BMC therapy improves LVEF, LVESV, and infarct scar size in patients with CIHD. The improvement in LVEF was also confirmed in meta-analysis of RCTs using MRI. Importantly, these numerically small benefits translated into improved clinical outcomes in BMC-treated CIHD patients.

Introduction: The results from clinical trials of bone marrow cell (BMC) therapy in ischemic heart disease (IHD) have been discordant with regard to left ventricular (LV) functional improvement. This discrepancy has been attributed, in part, to the use of dissimilar cardiac imaging modalities. MRI is the gold standard for assessment of cardiac structure/function. Hypothesis: We hypothesized that BMC therapy will improve LV parameters in patients with IHD when assessed by cardiac MRI. Methods: We performed a systematic review and meta-analysis of data from randomized controlled trials (RCTs) of BMC therapy in patients with IHD that used cardiac MRI. Database searches through May 30, 2015 identified 27 eligible RCTs (enrolling 1826 patients). The MRI data on LV ejection fraction (EF), infarct size, LV end-systolic volume (LVESV), and LV end-diastolic volume (LVEDV) were analyzed with random-effects meta-analysis. Clinical outcomes were analyzed using Peto odds ratio (OR). Results: Compared with standard therapy, BMC therapy improved LVEF (1.62%; 95% confidence interval [CI]: 0.49 to 2.75; P=0.005) and reduced LVESV (-2.00 ml; 95% CI: -3.19 to -0.82; P=0.0009). The improvement in LVEF was similar in patients with acute myocardial infarction (MI) and chronic IHD. Perhaps more importantly, BMC therapy was associated with reduced incidence of recurrent MI (OR: 0.39; 95% CI: 0.20 to 0.78; P=0.007) along with substantial improvement in other outcome parameters, including mortality (Table). However, these changes did not reach statistical significance perhaps due to smaller patient numbers. Conclusions: These results from meta-analysis of RCTs using cardiac MRI indicate that BMC therapy improves LV function and outcomes in patients with IHD. These data may help resolve the controversy regarding whether the reported benefits of BMC therapy are dependent on the selection of imaging modalities.

Rationale: Notwithstanding the uncertainties about the outcomes of bone marrow cell (BMC) therapy for heart repair, further insights are critically needed to improve this promising approach. Objective: To delineate the true effect of BMC therapy for cardiac repair and gain insights for future trials through systematic review and meta-analysis of data from eligible randomized controlled trials. Methods and Results: Database searches through August 2014 identified 48 eligible randomized controlled trials (enrolling 2602 patients). Weighted mean differences for changes in left ventricular (LV) ejection fraction, infarct size, LV end-systolic volume, and LV end-diastolic volume were analyzed with random-effects meta-analysis. Compared with standard therapy, BMC transplantation improved LV ejection fraction (2.92%; 95% confidence interval, 1.91–3.92; P P =0.0007) and LV end-systolic volume (−6.37 mL; 95% confidence interval, −8.95 to −3.80; P P =0.06). Similar effects were noted when data were analyzed after excluding studies with discrepancies in reporting of outcomes. The benefits also persisted when cardiac catheterization was performed in control patients as well. Although imaging modalities partly influenced the outcomes, LV ejection fraction improved in BMC-treated patients when assessed by magnetic resonance imaging. Early ( Conclusions: Transplantation of adult BMCs improves LV ejection fraction, reduces infarct size, and ameliorates remodeling in patients with ischemic heart disease. These effects are upheld in the analyses of studies using magnetic resonance imaging and also after excluding studies with discrepant reporting of outcomes. BMC transplantation may also reduce the incidence of death, recurrent myocardial Infarction, ventricular arrhythmia, and cerebrovascular accident during follow-up.

Diabetes mellitus (DM), coronary artery disease (CAD), and noncoronary atherosclerotic vascular diseases (NCVDs) have similar risks of cardiovascular events and similar recommendations for lipid control. There are limited data regarding lipid control in diabetic patients with NCVD in current clinical practice.To assess current day practice of lipid control in patients with DM with NCVD vs those with CAD.We retrospectively identified 3336 patients with DM and known atherosclerotic vascular disease between January 2009 and March 2012. We compared demographic variables, lipid levels, and statin use in diabetics with CAD alone vs diabetics without CAD but with one or more NCVD.There were 234 patients in DM with NCVD group and 3102 patients in DM with CAD group. The DM with NCVD group had a higher mean total cholesterol (152 ± 40 vs 146 ± 42 mg/dL; P = .019) and mean low-density lipoprotein (LDL; 86 ± 35 vs 80 ± 34 mg/dL; P = .04) with only 70% of patients achieving LDL of100 mg/dL (compared with 80% in the DM with CAD group; P .001). Statin use was 100% in CAD vs 75% in NCVD group (P .001). In addition to limited use of more potent statins in the NCVD group, there was also a significantly lower dose of statins used overall.Our study demonstrates lower use and less aggressive application of statins among diabetics with NCVD compared with diabetics with CAD, resulting in higher mean LDL and total cholesterol in the NCVD group.

We report a rare case of inadvertent reversal of the defibrillator shock coils during generator change which then resulted in both intermittent, recurrent "noise" on both the rate sensing and the shock electrogram leads and multiple inappropriate shocks.

Peripheral arterial disease (PAD), similar to coronary artery disease (CAD), is a significant predictor of cardiovascular morbidity and mortality. Guidelines recommend a low-density lipoprotein (LDL) goal of100 mg/dl for both groups. We assessed whether lipid control and statin use were as aggressively applied to PAD as to patients with CAD. This retrospective study of patients with the diagnosis of CAD, PAD, or both CAD and PAD compared lipid levels and statin use. For comparison of statins, we used a statin potency unit (1 potency unit=10 mg of simvastatin). Among 11,134 subjects (CAD 9,563, PAD 596, and both CAD and PAD 975), mean LDL in the PAD group was higher than the CAD (92 vs 83 mg/dl, respectively, p0.001) and the combined CAD and PAD groups (92 vs 80 mg/dl, respectively, p0.001). Fewer patients with PAD achieved a target LDL of100 mg/dl compared with CAD (62% vs 78%, respectively, p0.001) and the combined group (62% vs 79%, respectively, p0.001). Similar differences were noted for a target LDL of70 mg/dl. Compared with the CAD group, a lesser number of patients with PAD received statin therapy (76% vs 100%, respectively, p0.001) with lower mean potency unit (5.3 vs 8.1, respectively, p0.001). In conclusion, our study demonstrated lower use and less aggressive application of statins in patients with PAD compared with patients with CAD, ensuing lower mean LDL in the CAD and combined PAD and CAD groups. Our study suggests that physicians are more aggressive with lipid control in patients with CAD compared with patients with PAD alone.

We thank Dr Delewi and colleagues for a careful review of our report1 and thoughtful comments. The authors point out that our meta-analysis of 50 trials did not include 3 large trials (REGENT [Myocardial Regeneration by Intracoronary Infusion of Selected Population of Stem Cells in Acute Myocardial Infarction], BONAMI [Bone Marrow in Acute Myocardial Infarction], and HEBE).2–4 As mentioned under “Study Selection,” our meta-analysis included trials that reported data as mean and standard deviation. The REGENT trial2 reported data with median values and therefore could not be included. As a preliminary screening step, we reviewed the titles of all …

Background. The impact of advances in therapy and patient management on the trends in hospitalization, outcomes, costs and readmissions in patients with ST-elevation (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) remains unclear. Using a large database, we analyzed these trends over the course of 10 years. Methods. The 2000-2009 Nationwide In-patient Sample Database (the largest all-payer, in-patient database in the US) was used to identify patients with STEMI and NSTEMI, based on the ICD-9 discharge diagnosis codes. The trends for each diagnosis, the patient characteristics, hospital charges, and outcomes were analyzed. Results. During 2000-2009, 2.9 million patients were diagnosed with STEMI and 3.9 million with NSTEMI. The analyses of yearly data revealed a progressive and significant decline in the number of patients with STEMI over the decade ( P P =0.046) (Figure, Panel A) During the same time, the in-hospital mortality for STEMI decreased from 11.3% in 2000 to 8.6% in 2009, and for NSTEMI from 5.5% in 2000 to 4.0% in 2009 ( P P =0.003) and from 5.8 days in 2000 to 5.1 days in 2009 in patients with NSTEMI ( P P P P =0.05) (Figure, Panel D). Although the incidence of STEMI decreased across all age groups, the proportions of each age group accounting for either STEMI or NSTEMI did not change significantly over the years. The age-group 64-84 years accounted for the highest number of MI-related hospitalizations accounting for 46% and 53% of STEMIs and NSTEMIs, respectively. Gender-stratified analysis revealed that on average 58% STEMIs and 52% NSTEMIs occur in males and this distribution did not change significantly over the decade. Conclusions. During the 2000-2009 period, the incidence of STEMI has decreased progressively and significantly in the US, while the incidence of NSTEMI has increased. Although the decrease in mortality rates for patients with STEMI and NSTEMI is encouraging, the worrisome increase in costs associated with the index hospitalization, and the increase in rates of rehospitalization deserve further attention.

Ankle-brachial index (ABI) is conventionally derived as the ratio of higher of the two systolic ankle blood pressures to the higher brachial pressure (HABI method). Alternatively, ABI may be derived using the lower of the two systolic ankle pressures (LABI method). The utility and difference between

Background— Despite rapid clinical translation and widespread enthusiasm, the therapeutic benefits of adult bone marrow cell (BMC) transplantation in patients with ischemic heart disease continue to remain controversial. A synthesis of the available data is critical to appreciate and underscore the true impact of this promising approach. Methods and Results— A total of 50 studies (enrolling 2625 patients) identified by database searches through January 2012 were included. Weighted mean differences for changes in left ventricular (LV) ejection fraction, infarct size, LV end-systolic volume, and LV end-diastolic volume were estimated with random-effects meta-analysis. Compared with control subjects, BMC-treated patients exhibited greater LV ejection fraction (3.96%; 95% confidence interval, 2.90–5.02; P P P P Conclusions— Transplantation of adult BMCs improves LV function, infarct size, and remodeling in patients with ischemic heart disease compared with standard therapy, and these benefits persist during long-term follow-up. BMC transplantation also reduces the incidence of death, recurrent myocardial infarction, and stent thrombosis in patients with ischemic heart disease.

Late referral of patients with chronic kidney disease (CKD) by primary care physicians (PCPs) is associated with poor outcomes. We sought to assess factors influencing PCPs referral patterns in the general population and in geriatric patients, and compared their perceptions to the referral patterns.We retrospectively reviewed 268 patients with Stage 3 CKD (early referral) and 280 with Stage 4 CKD (appropriate referral) seen in renal clinic and compared them to 268 randomly selected non-referred Stage 4 CKD patients from primary care physicians office records. We also surveyed 400 regional PCPs on factors influencing their referral for CKD.Non-referred patients were significantly (p0.05) more likely to be over 65 years (OR: 3.5; 95% CI: 2.3 - 5.2), females (OR: 1.4; 95% CI: 1.0 - 2.0) and of non-white race (OR: 2.6; 95% CI: 1.5 - 4.5) after adjusting for relevant confounding variables. Charlson comorbidity index greater than 4 was associated with non-referral when the non-referral group was compared to the early referral group. Among geriatric patients, women and a higher comorbidity index were associated with non-referral. 25% of PCPs completed the survey and 62% PCPs were unfamiliar with K/DOQI referral guidelines. Age75 years, limited life expectancy, patient noncompliance or refusal to consider dialysis influenced PCPs decision to refer.Our study shows that elderly women, minorities and patients with multiple comorbidities are at risk for non-referral for CKD care. Educating PCPs on the appropriate referral of CKD patients, especially those at risk for late or non-referral to a nephrologist is warranted, as are trials assessing different educational strategies.

The effects of radiofrequency catheter ablation (RFCA) on left atrial (LA) size, volumes, and function in patients with atrial fibrillation (AF) are not well understood. The aim of this study was to systematically review the effects of RFCA on LA size, volumes, and function in patients with AF. Medline, the Web of Science, the Cochrane Central Register of Controlled Trials, and the reference lists of retrieved reports were searched for relevant studies through April 2009. Studies conducted in patients with AF were included if their primary outcomes were changes in LA size or volumes and/or function before and after RFCA. Weighted mean differences for changes in LA diameter, LA maximum volume, LA minimum volume, LA ejection fraction, and LA active emptying fraction were estimated using fixed- and random-effects meta-analyses. Seventeen relevant studies (enrolling 869 patients) among 192 identified studies were included in the final analysis. Compared to preablation values, there were significant decreases in LA diameter and LA volumes at postablation follow-up. However, compared to preablation values, there were no significant differences in LA ejection fraction and LA active emptying fraction at postablation follow-up. Decreases in LA diameter and LA volumes remained significant in those without AF recurrence but not in those with AF recurrence. LA ejection fraction and LA active emptying fraction did not decrease in patients without AF recurrence, whereas they decreased in patients with AF recurrence. In conclusion, successful RFCA in patients with AF significantly decreases LA size and volumes and does not seem to adversely affect LA function.

Due to difficulties in diagnosing coronary ischemia in patients with left bundle branch block (LBBB), identifying clinical characteristics that might help to predict coronary artery disease (CAD) is important. Our study aimed to identify clinical predictors of CAD among patients with and without LBBB who undergo myocardial perfusion imaging (MPI).All patients with LBBB who underwent MPI (LBBB group) from June 2005 to February 2007 were compared with patients with normal baseline electrocardiography who underwent treadmill MPI (non-LBBB group) during the same period.LBBB patients with CAD were younger and had lower ejection fraction (EF) compared to LBBB patients without CAD. Similarly non-LBBB patients with CAD had lower EF, but did not differ significantly in age compared to non-LBBB patients without CAD. Regression analysis among patients with LBBB showed that EF55% was the most significant predictor of CAD, after controlling for other factors. A regression analysis in non-LBBB patients showed that male gender and EF pound 55% were significant predictors of CAD. A regression analysis conducted in the combined data of both LBBB and non-LBBB groups showed male gender, EF pound 55% and LBBB to be the most significant predictors of CAD.Patients with LBBB have a high probability of CAD based on MPI findings. Patients with LBBB and reduced EF have a much higher likelihood of CAD compared to patients without LBBB and normal EF. Further studies on early invasive approach in patients with LBBB and reduced EF seem warranted.

Heart failure continues to be a major public health problem with high morbidity and mortality rates, despite the advances in medical treatment. Advanced heart failure patients have severe persistent symptoms and a poor quality of life. Cardiac resynchronization therapy (CRT), an invasive therapy which involves synchronized pacing of both right and left ventricles, improves ventricular conduction delay and left ventricular performance. Several clinical trials of CRT in medically refractory heart failure patients with wide QRS (120 ms), left ventricular ejection fractionor=35% and New York Heart Association (NYHA) class III and IV have shown improved quality of life, NYHA class, left ventricular ejection fraction and reduced mortality. About 30% of heart failure patients who receive CRT do not respond to treatment. Mechanical dyssynchrony may play a role in identifying patients who may respond better to CRT treatment. However, recent large scale clinical trials PROSPECT and RethinQ have challenged this concept. The role of CRT in heart failure patients with narrow QRS (120 ms), NYHA class I and II, atrioventricular nodal ablation in patients with atrial fibrillation and triple site pacing are evolving. Our review discusses the current evidence, indications, upcoming trials and future directions.

Bisphosphonates are widely used in osteoporosis, but there have been concerns about a potential link between bisphosphonate therapy and atrial fibrillation.We aimed to systematically evaluate the risk of atrial fibrillation associated with bisphosphonate use.We searched MEDLINE, regulatory authority websites, pharmaceutical company trial registers and product information sheets for randomized controlled trials (RCTs) and controlled observational studies published in English through to May 2008. We selected RCTs of bisphosphonates versus placebo for osteoporosis or fractures, with at least 3 months of follow-up, and data on atrial fibrillation. For the observational studies, we included case-control or cohort studies that evaluated the risk of atrial fibrillation in patients exposed to bisphosphonates compared with non-exposure. Data on atrial fibrillation as the primary outcome, and stroke and cardiovascular mortality as secondary outcomes, were extracted. DATA SYNTHESIS/RESULTS: We calculated pooled odds ratio (OR) using random effects meta-analysis, and estimated statistical heterogeneity with the I2 statistic. Bisphosphonate exposure was significantly associated with risk of atrial fibrillation serious adverse events in a meta-analysis of four trial datasets (OR 1.47; 95% CI 1.01, 2.14; p = 0.04; I2 = 46%). However, meta-analysis of all atrial fibrillation events (serious and non-serious) from the same datasets yielded a pooled OR of 1.14 (95% CI 0.96, 1.36; p = 0.15; I2 = 0%). We identified two case-control studies, one of which found an association between bisphosphonate exposure (ever users) and atrial fibrillation (adjusted OR 1.86; 95% CI 1.09, 3.15) while the other showed no association (adjusted OR 0.99; 95% CI 0.90, 1.10). Both studies failed to demonstrate a significant association in 'current' users. We did not find a significant increase in the risk of stroke (three trial datasets; OR 1.00; 95% CI 0.82, 1.22; p = 0.99; I2 = 0%) or cardiovascular mortality (three trial datasets; OR 0.86; 95% CI 0.66, 1.13; p = 0.28; I2 = 31%).While there are some data linking bisphosphonates to serious atrial fibrillation, heterogeneity of the existing evidence, as well as paucity of information on some of the agents, precludes any definitive conclusions on the exact nature of the risk.

Left ventricular performance is routinely measured during dobutamine cardiovascular magnetic resonance (DCMR) and the stress induced left ventricular changes have been well described. Left atrial (LA) size and volume are associated with increased risk of developing atrial fibrillation, stroke and congestive heart failure; however changes in LA volume and LA ejection fraction (LAEF) during DCMR have not been described.

While the effect of age, gender, body mass index and renal failure on B-type natriuretic peptide (BNP) has been studied individually in different trials, the influence of all these co-morbidities in patients with dyspnea needs to be evaluated. The objective of our study was to examine the effect of age, gender, obesity and co-morbid conditions on the evaluation of higher BNP levels in patients presenting with dyspnea.A total of 382 patients admitted with shortness of breath and suspected to have congestive heart failure were included in the study. The co-morbid conditions studied were pulmonary hypertension, pleural effusion, obesity, renal failure and chronic obstructive pulmonary disease.The mean BNP levels significantly increased with age. Women tended to have slightly higher mean BNP levels than men, but the differences were not statistically significant. The body mass index had an inverse correlation with the BNP level. Regression analysis demonstrated that the most significant predictors of a higher BNP were the lower left ventricular ejection fraction (OR 6.2: 95% CI 2.74-14.02), renal failure (OR 3.88: 95% CI 1.9-7.91) and pulmonary hypertension (OR 2.28: 95% CI 1.14-4.54).A lower left ventricular ejection fraction, renal failure and pulmonary hypertension were the most significant predictors of an increased BNP level. Age, gender, obesity and pleural effusion minimally influenced the BNP level and were not significantly predictive of congestive heart failure.

Clinical guidance is deficient regarding deactivation of implantable cardioverter-defibrillators (ICDs) in patients with terminal illnesses. We hypothesized that many physicians are apprehensive about discussing ICD deactivation with their dying patients. Thus, we conducted an anonymous survey of all the physicians in the Department of Medicine at Unity Health System in Rochester, NY. The survey collected information about the knowledge and preferences of these physicians regarding the medical, ethical, and legal issues involved in caring for patients with an ICD and terminal illness. Of the 204 surveys distributed, 87 (43%) were returned. Among the physicians who responded, 64 (74%) reported experience caring for a patient with an ICD and terminal illness. Forty physicians (46%) either thought it was illegal or were not sure if it was legal to deactivate an ICD in these circumstances. However, if reassured about the legality of discontinuing ICD therapy, 79 (91%) of these same respondents said that they would be willing to discuss voluntary ICD deactivation with their dying patients. With increased knowledge about managing the withdrawal of this potentially life-prolonging therapy, physicians are likely to become more skilled at caring for dying patients with an ICD.

Inability to perform defibrillation threshold (DFT) testing during implantable cardioverter defibrillator (ICD) implantation due to co-morbidities may influence long-term survival.Retrospective review at The University of Michigan (1999-2004) identified 55 patients undergoing ICD implantation without DFT testing ("No-DFT group"). A randomly selected sample of patients (n = 57) undergoing standard DFT testing ("DFT group") was compared in terms of appropriate shocks, clinical shock efficacy and all-cause mortality.DFT testing was withheld due to hypotension, atrial fibrillation with inability to exclude left atrial thrombus, left ventricular thrombus, CHF and/or ischemia. The No-DFT group had a similar appropriate shock rate, but lower total survival (69.1% vs. 91.2%, p = 0.004) than the DFT group. The No-DFT group had a higher incidence of ventricular fibrillation (VF) episodes (9.1% vs. 3.1%, p = 0.037), and deaths attributable to VF (3 of 17 deaths vs. 0 of 5 deaths) compared to the DFT group. Multivariate analysis found a trend toward increased risk of death in the No-DFT group (HR 3.18, 95% CI 0.82-12.41, p = 0.095) after adjusting for baseline differences in gender distribution, NYHA class and prior CABG.In summary, overall mortality was higher in the No-DFT group. More deaths attributable to VF occurred in the No-DFT group. Thus, DFT testing should therefore remain the standard of care. Nevertheless, ICD therapy should not be withheld in patients who meet appropriate implant criteria simply on the basis of clinical scenarios that preclude routine DFT testing. (Cardiol J 2007; 14: 463-469).

To systematically review the benefits of cardiac resynchronization therapy (CRT) in heart failure patients with narrow QRS (120 ms) who have baseline mechanical asynchrony.We searched the MEDLINE, Cochrane Central Register of Controlled Trials, and reference lists of retrieved articles for relevant trials through October 2007. Studies were included if they were clinical trials in heart failure patients with narrow QRS complex, had at least 3 months of duration and measured baseline mechanical dyssynchrony. Weighted mean difference (WMD) for changes in left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) class and 6 minute walk distance (6MWD) at the end of follow up period were estimated using fixed effects meta-analysis.Three relevant clinical trials (enrolling 98 patients) out of 80 identified studies were included in the final analysis. When compared to baseline, CRT in heart failure patients with narrow QRS complex significantly improved mean LVEF (WMD 7.98%, 95% CI 5.94, 10.03) and 6MWD (WMD 67 m, 95% CI 39.12, 94.98) at the end of follow up period with no significant heterogeneity between the included studies (I(2)50%). Similarly, there was a significant reduction in NYHA at the end of follow-up (WMD -0.87, 95% CI -1.01, -0.74) but there was significant heterogeneity between the included studies.In patients with narrow QRS complex and baseline mechanical asynchrony, who underwent CRT after optimal medical management, there was a significant reduction in NYHA class, improvement in LVEF and increase in 6MWD during follow up. Further data from large randomized trials are warranted to explore the role of CRT in heart failure patients with narrow QRS complex.

OBJECTIVE To determine whether a difference exists in the levels of high sensitivity C-reactive protein (Hs-CRP) in patients with and without calcific aortic valve disease (CAVD). PATIENTS AND METHODS This cross-sectional study consisted of 110 patients who had undergone echocardiographic examination from January 2005 to February 2006 at our institution. Information on demographic variables, coronary risk factors, and medications was obtained. More than 200 patients were excluded on the basis of any evidence of infection, active connective tissue disorder, rheumatoid arthritis, recent episodes of bleeding, acute fractures, bowel obstruction, or acute coronary syndrome or use of corticosteroids, nonsteroidal anti-inflammatory drugs, or antibiotic treatment. The values of Hs-CRP, total cholesterol, and erythrocyte sedimentation rate were included. RESULTS Of the 110 study subjects, 38 patients had aortic sclerosis, 36 patients had aortic stenosis, and 36 were controls. The mean Hs-CRP level in the control group was significantly lower (4.84±6.9 mg/L) compared with the levels in the groups with aortic sclerosis (14.9±19.6 mg/L) and aortic stenosis (13.6±17.3 mg/L) ( P =.01). No statistically significant difference was found between the patients in the aortic sclerosis and aortic stenosis groups. Among the patients with aortic stenosis, no significant correlation existed between Hs-CRP levels and aortic stenosis severity. CONCLUSIONS The Hs-CRP seems to have a significant association with CAVD during its early stage. The study findings did not have sufficient evidence to suggest the use of Hs-CRP as a marker of progression of calcific aortic stenosis. The Hs-CRP may have a role in identifying patients in the early stages of CAVD and in whom medical treatment may be beneficial to halt the progression to irreversible aortic valvular calcification and stenosis.