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Circulation, Volume 146, Issue 20, Page e282-e283, November 15, 2022.
Circulation, Volume 146, Issue 20, Page e284-e285, November 15, 2022.
New England Journal of Medicine, Ahead of Print.
This case report describes the electrocardiogram findings of a patient in their 60s who was hospitalized with upper right quadrant discomfort for more than 10 days.
This Viewpoint describes the miscommunication and potential adverse effects of the phrase “we got it all” after cancer surgery and advises using with caution.
Circulation, Volume 146, Issue Suppl_1, Page A14760-A14760, November 8, 2022. Introduction:Although several studies have demonstrated that elevated troponin predicts mortality in septic patients, data concerning the independent risk factors predisposing to higher chance of troponin leak are conflicting.Hypothesis:In this study we aim to identify predictors of troponinemia and lactatemia in the setting of sepsis and more specifically to clarify how hemodynamics affect these biomarkers.Methods:This is a retrospective cohort study on patients admitted to the intensive care units with severe sepsis. A total of 354 patients were included. Elevated admission troponin-T and lactate were defined as ≥0.01ng/mL and 2.5mmol/L respectively. Modified shock index defined as heart rate/mean arterial blood pressure (MSI) was used as a surrogate of hemodynamic instability. Linear regression models where generated to examine multi variate associations and Cox regression models were used for mortality outcomes. Analysis was done using STATA I/C 16.1.Results:The only independent predictor of elevated troponin in the setting of septic shock was pre-existing coronary artery disease (Coef.= 6 [1.9 – 10] p = 0.001). Troponin was not associated with mean arterial pressure (MAP) nor Modified Shock Index (Heart rate/MAP). On the other hand, elevation of lactate was significantly associated with Modified Shock index (Coef.=1.7 [CI 0.4 – 3] p= 0.001) and history of Diabetes (Coef.=1.2[0.04-2.3] p= 0.04). In a Cox regression modeling assessing for predictors of mortality in septic shock, lactate levels were strongly associated with death (OR= 1.17 [1.12-1.2] p= 0.0001) followed by male sex (OR= 1.8 [1.02-3] p=0.04) and Modified Shock Index (OR=1.5 [1.23-3.2] p=0.03) but troponin leak failed to show any correlation with mortality.Conclusions:Troponin leak is associated only with pre-existing CAD, not associated with hemodynamics and does not predict mortality.
Circulation, Volume 146, Issue Suppl_1, Page A15817-A15817, November 8, 2022. Introduction:In the current United States Organ Sharing heart transplant allocation system, hemodynamic criteria, systolic blood pressure (SBP), cardiac index (CI), and pulmonary capillary wedge pressure (PCWP), are utilized to justify certain listing statuses.Hypothesis:We sought to identify how currently utilized, and advanced, hemodynamics discriminated patients by listing status.Methods:Retrospective analysis of the Scientific Registry of Transplant Candidates including all adults listed for heart transplant since the updated listing criteria went live in October 2018 was completed. In addition to SBP, CI, and PCWP, the mean advanced hemodynamic metrics of aortic pulsatility index (API), cardiac power output (CPO), left ventricular stroke work index (LVSWI), right ventricular stroke work index (RVSWI), and pulmonary artery pulsatility index (PAPI), were calculated for each status.Results:Since October 2018, 9,418 patients were listed for heart transplant, and 8,636 had complete hemodynamic data at time of listing. Currently utilized hemodynamic metrics failed to discriminate lower acuity statuses (3 through 6 for PCWP and CI; 4 through 6 for SBP). For advanced hemodynamic metrics, mean API was lowest for Status 1 patients, and rose consistently with increasing status with a clear stepwise and statistically significant difference for sequential statuses (p < 0.001). CPO and LVSWI were unable to discriminate statuses 3-6. For right-sided hemodynamics, PAPI was unable to discriminate statuses 2 through 6, and there were no significant differences across any status for RVSWI.Conclusions:API is the only hemodynamic metric that is able to differentiate patients on the heart transplant waiting list across all active statuses by increasing in a stepwise fashion. Incorporation of API into future iterations of the UNOS heart allocation system may help better risk stratify patients and minimize waitlist mortality.
Circulation, Volume 146, Issue Suppl_1, Page A15102-A15102, November 8, 2022. Background:Non-ischemic cardiomyopathies (NICM) occur in the absence of contributory coronary artery disease or significant valvular heart disease. This study examined if VT recurrence post-scar-homogenization in NICM patients was due to progression of the disease after successful ablation or incomplete ablation during the index procedure.Methods:Consecutive NICM patients receiving redo procedure after their 1st VT ablation were included. All patients underwent bipolar substrate mapping with standard scar settings of normal tissue >1.5 mV and severe scar
Circulation, Volume 146, Issue Suppl_1, Page A14458-A14458, November 8, 2022. Introduction:We present a case of a 65 year-old man with severe aortic regurgitation requiring a stented 23mm Edwards bioprosthetic aortic valve (BioAVR), who presented with 3-months of fevers and fatigue found to haveStreptococcus gordonii(S. gordonii) infectious endocarditis (IE). He underwent dental cleaning 3-months prior sans prophylactic antibiotics. An echocardiogram on admission revealed increased peak/mean systolic gradients across the BioAVR to 46/26mmHg compared to gradients one year prior (32/19mmHg). Initially, a vegetation was not visualized by transthoracic echocardiogram (TTE) despite radiographic evidence of multi-organ emboli. Serial TTEs and transesophageal echocardiograms (TEEs) were performed due to persistent symptoms. Eventually, a new vegetation was visualized by TEE. A team effort involving cardiology, infectious disease, neurology, and cardiac surgery was required for management. Revision of the BioAVR was not pursued due to resolution of the vegetation. The patient was discharged after a prolonged hospitalization with recommendations to take amoxicillin 2g prior to future dental work.Results:Figure 1. A new 0.5cm vegetation visualized by TEE (A) with enlargement to 0.8cm (B), followed by a healed vegetation (C), and resolution 7-months later.Conclusions:S. gordoniihas historically been a rare cause of IE therefore requiring a high clinical suspicion for diagnosis. Approximately 8% of IE cases are caused by streptococci. However, a recent study in Denmark on streptococci IE implicatedS. gordoniiin 44.2% of IE cases. S. gordoniiis a gram-positive cocci found in oral flora known to cause subacute bacterial endocarditis. Our case highlights the importance of detailed history-taking to identify sources of infection, serial multi-modal imaging evaluation despite initial negative findings particularly with persistent clinical symptoms, and a multidisciplinary approach to IE cases due to multi-organ involvement.
Circulation, Volume 146, Issue Suppl_1, Page A15382-A15382, November 8, 2022. Introduction:Transthyretin amyloid cardiomyopathy (ATTR) is thought to be a rare cause of HF, but recent studies showed this is the cause of 30% of HFpEF patients older than 75. With new treatments for amyloidosis, timely diagnosis has become critical.Case:A 78-female with HFpEF, HTN, and diabetes followed for progressive functional decline and hospitalizations for HFpEF exacerbations. EKG at baseline showed LBBB with normal QRS voltages. Serial echocardiogram (echo) showed an ejection fraction (EF) of 60-70%, mild LVH, and moderate TR with RVSP >50 mmHg. Latest echo showed progressive LA enlargement, MR, a new small pericardial effusion, and EF 50%. Regadenoson nuclear scan showed normal perfusion with preserved LVEF. Despite adequate control of her HTN, dyspnea continued to worsen. Because of this, the diagnosis of Cardiac amyloidosiswas considered. Further review revealed a history of Carpal Tunnel Syndrome (CTS) and speckled pattern within the ventricular wall on echo. A technetium pyrophosphate scintigraphy (99mTc-PYP) confirmed ATTR with grade three uptake, AL amyloid was ruled out with normal SPEP/UPEP, and she was started on Tafamidis.Discussion:Cardiac amyloidosis should be considered in HFpEF patients with functional decline despite medical optimization. It can mimic LVH caused by HTN on echo and easily dismissed in patients with traditional risk factors, but presence of CTS or lumbar spinal stenosis can be supportive. Traditionally ATTR is associated with low-voltage EKG, however this patient presented with normal QRS voltages for years, making the diagnosis more elusive.Conclusion:Advances in noninvasive imaging and treatments allow for early diagnosis of cardiac amyloidosis, reducing morbidity and mortality. Diagnosis is often delayed or missed, as features could be subtle and mimic other more common cardiac disease. Screening 99mTc-PYP for elderly patients with HFpEF could translate to improved outcomes
Circulation, Volume 146, Issue Suppl_1, Page A11018-A11018, November 8, 2022. Introduction:Wearable devices such as smartwatches and fitness trackers are widely used. While marketed to consumers for general wellness, many devices measure physiologic parameters with implications for cardiovascular health. The prevalence of wearable device use in contemporary patient populations is unknown. We sought to 1) determine characteristics of current and prospective device users within a large healthcare system and 2) assess user interest in incorporating device data into the electronic health record for clinical research purposes.Methods:Participants were selected from a database of adults aged ≥ 18 years who received longitudinal primary or cardiac care at one of 11 hospitals within the Mass General Brigham network between 1/2010 and 7/2021. We identified living patients with an active electronic portal account for direct communication. Portal users were invited to complete a survey about use and medical applications of wearable devices. Multivariable logistic regression was used to identify factors associated with device use.Results:Between 11/2021 and 4/2022, 214,935 patients were contacted with 10,947 (5%) unique survey respondents. Rates of device use were similar among primary care (56%, n=4,739) and cardiology (53%, n=2,190) patients. Almost all non-users (97%, n=4,540) reported that they would use a device if not for cost. In a multivariable model, factors associated with device use included: age (odds ratio [OR] per 5-year increase 0.89, 95% CI [0.87,0.90]), female sex (1.19 [1.09, 1.29]), cardiac vs primary care (1.27 [1.16, 1.39]), median household income by zip code (OR per 1-standard deviation increase 1.10 [1.06, 1.15]), and better self-reported health (OR for “excellent” vs “poor” health 3.35 [2.27, 4.99]). Almost all users and potential users (96%, n=9,811) would share device data with researchers studying health outcomes.Conclusion:Among survey respondents, younger age, female sex, cardiac care, higher income, and better self-reported health were associated with wearable device use. Current and prospective device users are interested in sharing longitudinal data, which will enable further study of wearable devices and their role in care delivery, clinical outcomes, and health disparities.
Circulation, Volume 146, Issue Suppl_1, Page A14826-A14826, November 8, 2022. Introduction:Due to pro-arrhythmic effects associated with Sotalol, inpatient initiation with QTc monitoring for five doses is recommended. An IV loading dose followed by two oral doses has been shown to achieve steady-state concentrations.Hypothesis:To evaluate the safety of single day loading of IV sotalol in patients with atrial fibrillation and atrial flutter (AF/AFL).Methods:We prospectively evaluated 40 patients at our institution who received IV sotalol as single day loading dose for initiation of oral sotalol therapy for AF/AFL. IV sotalol dose was calculated based on target oral dose as indicated by baseline QTc interval and renal function. Patients’ QTc (in sinus) was measured via ECG on 15 minutes intervals and after IV loading completion. Loading was considered complete after second oral dose. All patients were monitored via a mobile cardiac outpatient monitor for 3 days followed by a final 12 ECG.Results:A total of 40 patients were included in the study. The mean age was 69+8.2 years, 78.9% of patients were men. QTc significantly increased from 435.9+26.4 to 462.9+31.6 with following IV loading (p
New England Journal of Medicine, Ahead of Print.
Circulation, Volume 146, Issue 17, Page 1266-1267, October 25, 2022.
New England Journal of Medicine, Volume 387, Issue 16, October 2022.
This Medical News feature discusses the challenges of predicting how severe flu season might be.
