Factors associated with the change in prevalence of cardiomyopathy at delivery in the period 2000-2009: a population-based prevalence study.

OBJECTIVE: Cardiomyopathy (CM) at delivery is increasing in prevalance. The objective of this study was to determine which medical conditions are attributable to this increasing prevalance. DESIGN: Population prevalence study from 2000 to 2009. SETTING: The Nationwide Inpatient Sample (NIS). SAMPLE: Pregnant women admitted for delivery were identified in the NIS for the years 2000-2009. METHODS: Temporal trends in pre-existing medical conditions and in medical and obstetric complications at delivery admissions were determined by linear regression. The change in the prevalence of CM among all pregnant women was compared with the change in the prevalance of CM among pregnant women without pre-existing conditions or complications. MAIN OUTCOME MEASURE: Prevalence of CM. RESULTS: The prevalence of CM increased from 0.25 per 1000 deliveries in 2000 to 0.43 per 1000 deliveries in 2009 (P < 0.0001). Women with chronic hypertension had increased odds of developing CM compared with women without chronic hypertension (odds ratio, OR, 13.2; 95% confidence interval, 95% CI, 12.5-13.7). The linear increase in chronic hypertension over the 10-year period was the single identified pre-existing medical condition that explained the increasing prevalence of CM at delivery (P = 0.005 for the differences in slopes for linear trends). CONCLUSIONS: Pregnant women with chronic hypertenion are at an increased risk for CM at delivery, and the increasing prevalence of chronic hypertension is an important factor associated with the increasing prevalence of CM at the time of delivery. Among women without chronic hypertension, the prevalence of CM at delivery did not change during the time period.

Maternal obesity and risk of cesarean delivery: a meta-analysis.

Despite numerous studies reporting an increased risk of cesarean delivery among overweight or obese compared with normal weight women, the magnitude of the association remains uncertain. Therefore, we conducted a meta-analysis of the current literature to provide a quantitative estimate of this association. We identified studies from three sources: (i) a PubMed search of relevant articles published between January 1980 and September 2005; (ii) reference lists of publications selected from the search; and (iii) reference lists of review articles published between 2000 and 2005. We included cohort designed studies that reported obesity measures reflecting pregnancy body mass, had a normal weight comparison group, and presented data allowing a quantitative measurement of risk. We used a Bayesian random effects model to perform the meta-analysis and meta-regression. Thirty-three studies were included. The unadjusted odd ratios of a cesarean delivery were 1.46 [95% confidence interval (CI): 1.34-1.60], 2.05 (95% CI: 1.86-2.27) and 2.89 (95% CI: 2.28-3.79) among overweight, obese and severely obese women, respectively, compared with normal weight pregnant women. The meta-regression found no evidence that these estimates were affected by selected study characteristics. Our findings provide a quantitative estimate of the risk of cesarean delivery associated with high maternal body mass.

Urinary tract infections during pregnancy in South Carolina.

This study presents evidence that over 20 percent of pregnant women with a UTI in South Carolina did not have an antibiotic pharmacy claim within 14 days of diagnosis. Untreated maternal UTI in pregnancy was associated with a 22 percent increased risk for MR/DD in the infant compared to the risk for women who had a UTI and a pharmacy claim for an antibiotic and 31 percent increased risk compared to women who did not have a UTI. The importance of medications compliance should be emphasized in the care of pregnant women.

Perinatal risk for mortality and mental retardation associated with maternal urinary-tract infections.

OBJECTIVE: The researchers analyzed the relationship between fetal exposure to maternal urinary tract infections (UTIs) and mental retardation or developmental delay and fetal death. STUDY DESIGN: A retrospective cohort design was used to explore the risk for fetal death and mental retardation or developmental delay associated with exposure to maternal UTI during pregnancy. POPULATION: Matched maternal-child pairs from the National Collaborative Perinatal Project (NCPP) from the decades of 1960 and 1970 were compared with a previous analysis of the South Carolina Medicaid Reimbursement System (Medicaid) for 1995-1996. Both data sets are representative of poor women and their children. OUTCOMES MEASURED: The outcomes measured were fetal death and mental retardation or developmental delay in the live-born children. RESULTS: There was an increased relative risk (RR) for mental retardation or developmental delay in the third trimester of pregnancy (RR=1.40; 95% confidence interval [CI], 1.01-1.95) in the NCPP, and there was a similar risk in the Medicaid data. The third trimester relative hazard for fetal death associated with maternal UTI was 2.23 (95% CI, 1.40-3.55). CONCLUSIONS: The findings support an association between maternal UTI and fetal death and mental retardation or developmental delay. These results confirm the importance of diligent diagnosis and treatment of maternal UTI by prenatal care providers.

Urinary tract infections during pregnancy and mental retardation and developmental delay.

OBJECTIVE: To investigate the association between urinary tract infections during pregnancy and mental retardation or developmental delay in infants. METHODS: An inception cohort design was used to analyze Medicaid maternal and infant-linked records and vital records for 41,090 pregnancies from 1995-1998. RESULTS: The relative risk (RR) for mental retardation or developmental delay among infants of mothers with diagnosed urinary tract infections but no antibiotic claims was 1.31 with a 95% confidence interval (CI) of 1. 12, 1.54 compared with the group without urinary tract infections. The RR for infants of mothers with urinary tract infections without antibiotic claims was 1.22 (95% CI 1.02, 1.46) compared with infants of mothers with urinary tract infections and antibiotic claims. The RR was significant in the first trimester (1.46, 95% CI 1.07, 1.99) and third trimester (1.41, 95% CI 1.11, 1.79) after controlling for race and gestational age at birth. CONCLUSION: There was a statistically significant association between maternal urinary tract infections without evidence of antibiotics and mental retardation or developmental delay in infants. The relationship persisted when we assumed that over 30% of women who had antibiotic claims filled but did not take the medicine, and 40% of the women who did not have antibiotic claims did take the medication.

Utility of introducing ventricular premature complexes during reciprocating tachycardia in specifying the location of left free wall accessory pathways.

The usefulness of the response to single and double ventricular premature complexes (VPCs) introduced during reciprocating tachycardia (RT) in predicting the location of a left free wall accessory pathway was studied in 55 patients with the Wolff-Parkinson-White syndrome. One VPC introduced from the right ventricle into narrow QRS RT when the His bundle was refractory resulted in retrograde atrial preexcitation in 25 of 55 (45%) patients, while 30 (55%) showed no preexcitation. Double VPCs produced retrograde atrial preexcitation in 9 of 26 patients not responding to a single VPC. No difference in RT cycle length, AH, HV or ventriculoatrial intervals was found between those patients who did or did not show retrograde atrial preexcitation. The response to single and double VPCs during RT was related to the location of the AP. The average distance of the AP from the crux determined by intraoperative epicardial mapping in the 41 patients who underwent surgery was 2.7 +/- 0.7 mapping units (left posterolateral region) in patients showing retrograde atrial preexcitation with a single VPC, 3.6 +/- 0.7 units (at the lateral left ventricular margin) in those responding to double VPCs and 4.3 +/- 0.8 units (beyond the LV margin) in those showing no response. Left bundle--branch block (LBBB) aberrancy during RT resulted in an average 60 +/- 14 ms prolongation of the ventriculoatrial interval in 40 patients, including 5 in whom LBBB was seen only after procainamide infusion. VPCs introduced into LBBB RT resulted in significant retrograde atrial preexcitation in 6 additional patients in whom no response during normal QRS RT was observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Late restenosis after emergent coronary angioplasty for acute myocardial infarction: comparison with elective coronary angioplasty.

The late restenosis rate after emergent percutaneous transluminal coronary angioplasty for acute myocardial infarction was assessed by performing outpatient follow-up cardiac catheterization in 79 (87%) of 91 consecutive patients who had been discharged from the hospital with a successful coronary angioplasty. The majority of patients (90%) received high dose intravenous thrombolytic therapy with streptokinase in addition to angioplasty. Similar follow-up data were obtained in 206 (90%) of 228 consecutive patients who had successful elective angioplasty during the same period. The interval from angioplasty to follow-up was 28 +/- 9 weeks for the myocardial infarction group and 30 +/- 11 weeks for the elective group. Baseline clinical variables were similar for both the myocardial infarction and elective groups except for a higher percentage of men in the infarction group (81 versus 63%, p = 0.001). The number of coronary lesions undergoing angioplasty and the incidence of intimal dissection were similar, but multivessel angioplasty was more common in the elective group (13 versus 4%, p = 0.02). The rate of in-hospital reocclusion was higher in the patients receiving angioplasty for myocardial infarction (13 versus 2%, p = 0.0001). At the time of late follow-up after hospital discharge, the patients with myocardial infarction were more often asymptomatic (79 versus 55%, p = 0.0001), and the rate of angiographic coronary restenosis was lower for the infarction group both overall (19 versus 35%, p = 0.006) and when multivessel angioplasty patients were excluded (19 versus 33%, p = 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary perfusion during acute myocardial infarction with a combined therapy of coronary angioplasty and high-dose intravenous streptokinase.

Two hundred and sixteen patients with acute myocardial infarction were treated with immediate infusion of high-dose (1.5 million units) intravenous streptokinase followed by emergency coronary angioplasty. The infarct lesion was crossed and dilated in 99% and persistent coronary perfusion after the procedure was achieved in 90% (including 3% with significant residual stenosis). Total in-hospital mortality was 12%. Multivariable analysis showed a higher hospital mortality with cardiogenic shock (41% vs 5% without shock), older age, lower left ventricular ejection fraction, and female sex. Final patency of the infarct-related vessel was determined by follow-up in-hospital cardiac catheterization. Coronary reocclusion occurred in 11% (symptomatic in 7%, treated with emergency angioplasty or bypass surgery; silent in 4%, treated medically). Of the surviving patients with successful initial establishment of infarct vessel patency, 94% were discharged from the hospital with an open infarct artery or a bypass graft to the infarct vessel. There was significant improvement in both ejection fraction (44% to 49%; p less than .0001) and regional wall motion in the infarct zone (-3.0 SD to -2.4 SD; p less than .0001) among patients with persistent coronary perfusion and insignificant residual stenosis at the time of the follow-up cardiac catheterization. Thus, a treatment strategy for acute myocardial infarction that includes immediate administration of streptokinase followed by emergency coronary angioplasty, and coronary bypass surgery when necessary, results in a high rate of early and sustained patency of the infarct-related vessel.

Disappearance of high-grade left anterior descending stenosis after revascularization.

Complete resolution of a high-grade left anterior descending (LAD) stenosis 6 months after revascularization with a left internal mammary artery (IMA) graft and the first reported case of spontaneous IMA graft spasm during repeat cardiac catheterization for continued atypical chest pain in the same patient are reported. Mechanisms involving regression of atherosclerosis and atypical spasm are briefly discussed.

Medical approaches to prevention of restenosis after coronary angioplasty.

Although initial success rates for coronary angioplasty have improved, the rate of restenosis within 6 months of the procedure has persisted at 30 to 40%. The relation of restenosis to initial success, recurrence of symptoms and risk factors suggests that high grade or total lesions, long lesions, lesions in the proximal left anterior descending artery or in saphenous grafts, and the absence of intimal dissection after angioplasty are associated with an increased risk of restenosis. Unstable angina, male sex and diabetes are clinical factors associated with a greater risk of restenosis. Pathologic specimens suggest that plaque splitting and disruption are found acutely after angioplasty, but that restenosis occurs as an excessive reparative, proliferative response of smooth muscle cells leading to recurrent luminal narrowing. A prospective analysis of therapeutic interventions to prevent restenosis, such as administering antiplatelet and lipid-lowering agents, intensive diabetic therapy and administration of calcium antagonists, is proposed. Problems with timing of studies, design and sample size are considered. Current recommendations for anti-restenosis therapy include antiplatelet therapy before and after angioplasty, administration of heparin in some patients and intensive risk factor intervention for the 6 months after the procedure.

Frequency, diagnosis and clinical characteristics of patients with multiple accessory atrioventricular pathways.

Multiple accessory atrioventricular (AV) pathways were documented in 52 of 388 patients (13%) who underwent detailed electrophysiologic evaluation. Multiple AV pathways were identified during intraoperative mapping or electrophysiologic study by different patterns of ventricular preexcitation during atrial fibrillation, flutter or atrial pacing with different delta-wave morphologic and ventricular activation patterns; different sites of atrial activation during right ventricular pacing or orthodromic reciprocating tachycardia; or preexcited reciprocating tachycardia using a second pathway as the retrograde limb of the tachycardia. A logistic model was used to determine which clinical, electrocardiographic and electrophysiologic variables were associated with multiple AV pathways. Right free-wall and posteroseptal accessory AV pathways were more common in patients with multiple AV pathways and were frequently associated. Multivariate logistic regression identified Ebstein's anomaly, and a history of preexcited reciprocating tachycardia as significant variables (p less than 0.0001). Pathway location was not subjected to statistical analysis because of confounding variables.

Characterization of retrograde conduction by direct endocardial recording from an accessory atrioventricular pathway.

Accessory pathway electrograms are rarely recorded in patients with Wolff-Parkinson-White syndrome. In one patient, during electrophysiologic study, simultaneous local ventricular (V) accessory pathway (AP) and atrial (A) deflections were recorded during bipolar catheter endocardial mapping over the pathway. Analysis of changes in electrographic intervals during performance of the ventricular extrastimulus technique allowed characterization of the retrograde conduction properties of the pathway. As coupling intervals were decreased, an initial increase was seen in the AP2A2 interval with subsequent ventriculoatrial block between the accessory pathway and atrium. When coupling intervals were further decreased, the V2AP2 interval lengthened with ultimate block between the ventricle and accessory pathway. These findings support the concept of impedance mismatch as the cause of conduction block in accessory pathways with the distal junction of the accessory pathway being the most vulnerable.