[Cardiac Lipoma - Case presentation].

Cardiac lipomas are very rare benign tumors of the heart. They are usually asymptomatic and are often an incidental finding on cardiac imaging. This case report involves an 82-year-old female with a history of diabetes admitted because of poor glycemic control. An echocardiogram requested because of arrhythmias and heart failure revealed a tumor in the right atrium. Computed tomographic and ultrasound appearances were consistent with a lipoma and demonstrated a large mass in the right atrium, causing a significant stenosis of the superior vena cava but no clinical symptoms or signs of superior vena cava syndrome.

Ignoring instead of chasing after coagulation factor VII during warfarin management: an interrupted time series study.

During warfarin management, variability in prothrombin time-based international normalized ratio (PT-INR) is caused, in part, by clinically inconsequential fluctuations in factor VII (FVII). The new factor II and X (Fiix)-prothrombin time (Fiix-PT) and Fiix-normalized ratio (Fiix-NR), unlike PT-INR, are only affected by reduced FII and FX. We assessed the incidence of thromboembolism (TE) and major bleeding (MB) in all 2667 patients on maintenance-phase warfarin managed at our anticoagulation management service during 30 months; 12 months prior to and 18 months after replacing PT-INR monitoring with Fiix-NR monitoring. Months 13 to 18 were predefined as transitional months. Using 2-segmented regression, a breakpoint in the monthly incidence of TE became evident 6 months after test replacement, that was followed by a 56% reduction in incidence (from 2.82% to 1.23% per patient-year; P = .019). Three-segmented regression did not find any significant trend in TE incidence (slope, +0.03) prior to test replacement; however, during months 13 to 18 and 19 to 30, the incidence of TE decreased gradually (slope, -0.12; R2 = 0.20; P = .007). The incidence of MB (2.79% per patient-year) did not differ. Incidence comparison during the 12-month Fiix and PT periods confirmed a statistically significant reduction (55-62%) in TE. Fiix monitoring reduced testing, dose adjustments, and normalized ratio variability and prolonged testing intervals and time in range. We conclude that ignoring FVII during Fiix-NR monitoring in real-world practice stabilizes the anticoagulant effect of warfarin and associates with a major reduction in TEs without increasing bleeding.

Oral anticoagulant monitoring: Are we on the right track?

Vitamin K antagonists (VKAs) cannot be administered without regular monitoring in order to assure their efficacy and safety. Indeed, if well managed, the VKAs appear to be no less efficacious or safe than the newer direct oral anticoagulants (DOACs). Although it is claimed that no regular monitoring of the DOACs is needed, their levels are increasingly being measured under a variety of circumstances, for example, prior to surgery, in suspected overdose, to confirm effective reversal, in patients with malabsorption and to assess patient compliance. Although no therapeutic range has been identified for the DOACs, it has been demonstrated for dabigatran and edoxaban that their antithrombotic effect increases gradually with increasing concentrations and that the risk of major bleeding also gradually increases. Furthermore, it has been determined that almost all dabigatran-related thrombotic events occur in patients with the lowest quartile concentration of the drug. This suggests that to assure an ideal effect of DOACs in all patients taking them, some form of regular monitoring and dose tailoring should be performed. For the vitamin K antagonists, the best outcome is obtained using formal algorithms and centralized management. Furthermore, data suggest that replacing the standard prothrombin time as a monitoring test may increase the stability of VKA anticoagulation with consequent reduction in thromboembolism without an increase in bleeding. Thus, it is likely that the outcome of all current oral anticoagulants can be improved in the coming years by improving monitoring and tailoring their effect.

"No culprit" ST-elevation myocardial infarction: role of cardiac magnetic resonance imaging.

Patients with presumed ST-elevation myocardial infarction (STEMI) have no clear culprit artery in approximately 10-15% of cases. We examined the value of cardiac magnetic resonance (CMR) for diagnosis in patients with "no culprit" STEMI. Data from a comprehensive prospective registry of STEMI patients were reviewed from March 2003 to December 2009. "No culprit" patients were followed for diagnosis and clinical outcome. CMR was performed at the discretion of the attending cardiologist. Of 2728 consecutive presumed STEMI patients, 412 (15%) had no clear culprit artery. Of these, 202 (49%) had abnormal cardiac biomarkers with a definitive diagnosis in 157 (78%). Diagnoses in this group included myocardial infarction without a culprit lesion (24%), myopericarditis (22%), and stress cardiomyopathy (21%). In 210 (51%) patients with normal biomarkers, only 84 (40%) received a definitive diagnosis. Diagnoses in this group included myopericarditis (27%), noncardiac causes (21%), and cardiomyopathy (14%). CMR was performed in 123 (30%) "no culprit" patients. Patients who had CMR were more likely to have a definitive diagnosis than those who did not (95/123 [77%] vs. 144/289 [50%]; P=0.01). In particular, "no culprit" patients with abnormal biomarkers were more likely to have a definitive diagnosis with CMR. CMR led to a diagnosis different from the presumptive clinical diagnosis in 53% of all cases. CMR is a valuable diagnostic tool to improve diagnostic accuracy in patients with "no culprit" STEMI.

Identification of unexpected nonatherosclerotic cardiovascular disease with coronary CT angiography.

OBJECTIVES: The aim of this study was to assess, in a general cardiology cohort screened for obstructive coronary artery disease (CAD), the effectiveness and frequency with which multidetector computed tomography (MDCT) angiography unexpectedly imaged and identified other nonatherosclerotic cardiovascular diseases. BACKGROUND: MDCT angiography is a novel imaging strategy employed primarily to diagnose CAD that, in the course of these studies, can also potentially identify other important but previously unrecognized cardiovascular abnormalities. METHODS: Consecutive 64-slice MDCT angiography studies were obtained in 4,543 patients with suspected atherosclerotic CAD at the Minneapolis Heart Institute, over a 29-month period (2005 to 2007). RESULTS: Nonatherosclerotic-related cardiovascular abnormalities judged to be of potential clinical relevance were identified in 201 patients (4.4%). In 50 of these patients (1.1% of 4,543) the abnormality was previously unrecognized despite other imaging studies performed in 40%. Most common among the 50 patients were: congenital coronary artery anomalies (38%; largely right coronary artery from the left aortic sinus); ascending aortic aneurysms > or = 45 mm (22%); hypertrophic cardiomyopathy with apical left ventricular (LV) wall thickening (14%); valvular heart diseases (8%), congenital heart diseases, including ventricular septal defect (6%); pulmonary embolus (6%); as well as LV noncompaction, left atrial myxoma, and LV apical aneurysm (2% each). As a consequence of MDCT angiography findings, new management strategies were instituted in 15 of 50 patients (30%), including surgical correction of coronary artery anomalies of wrong sinus origin, ascending aneurysm graft repair, thrombolytic therapy for pulmonary embolism, and myxoma resection. CONCLUSIONS: Approximately 1% of patients undergoing MDCT angiography for suspicion of CAD proved to have otherwise unsuspected, but clinically relevant, cardiovascular abnormalities unrelated to coronary atherosclerosis. Almost one-third of these patients had cardiovascular diseases with major clinical implications for subsequent therapy. These findings underscore the value of MDCT angiography and the importance of careful assessment of scans for the recognition of a variety of cardiovascular abnormalities.

Practical approaches to overcoming artifacts in coronary CT angiography.

Coronary CT angiography is a novel noninvasive imaging technology that provides a unique view of cardiac and coronary artery pathologies. Despite proper preparation, artifacts and noisy scans can occur and are usually caused by cardiac or respiratory motion or both and obesity. This article formulates a practical approach for salvaging difficult or potentially uninterpretable studies by diagnosing the causes of artifacts and providing an approach for scan improvement with the reconstruction of new data sets. Multiple pictorial examples of scan editing are provided. In addition, tables link the likelihood that a specific cause of an artifact will allow a scan to be salvaged. An approach for interpreting scans with excess noise is also discussed.

Multidetector CT coronary angiography for patient triage to invasive coronary angiography: Performance and cost in ambulatory patients with equivocal or suspected inaccurate noninvasive stress tests.

BACKGROUND: Multidetector-CT angiography (MDCTA) differs from noninvasive stress tests by directly imaging coronary anatomy. The utility of MDCTA for invasive triage is undefined however. We evaluated MDCTA triage to invasive coronary angiography in outpatients with indeterminate or suspected inaccurate stress tests, and estimated cost savings by MDCTA in this role. METHODS: Consecutive MDCTA patients were retrospectively compared with noninvasive stress tests if performed within 6 months of MDCTA. Twelve-month clinical follow up was obtained for patients not undergoing invasive angiography, and cost using MDCTA for triage to invasive coronary angiography was calculated. RESULTS: MDCTA was performed in 385 patients who had noninvasive stress testing. Stress tests include included treadmill (n = 37), stress echo (n = 178), and nuclear perfusion imaging (n = 170). Invasive angiography was performed in 57 (14.8%). MDCTA compared to CA showed positive and negative predictive values of 94%/100% respectively for lesions found by invasive QCA. Stress testing compared to MDCTA showed positive/negative predictive values of 100%/67% for treadmill exercise, 60%/54% for stress echo, and 59%/55% of nuclear perfusion examinations respectively. One year clinical follow up in 314 patients showed no coronary events in 98% (309) of patients. Triage to invasive angiography by MDCTA showed a 4-fold cost reduction. CONCLUSIONS: MDCTA shows excellent performance as a triage for invasive angiography in patients with stress tests that are equivocal or thought inaccurate. A negative CTA confers good 12-month prognosis. Substantial cost savings may accrue using MDCTA in this triage role.

Clinical utility of coronary CT angiography: coronary stenosis detection and prognosis in ambulatory patients.

INTRODUCTION: Multislice CT coronary angiography (MSCTA) accurately detects stenosis in patients undergoing coronary arteriography, but its accuracy in clinical outpatients is less certain. This study retrospectively analyzed MSCTA performance in a large outpatient cohort and examined 6-month clinical follow-up in those without invasive CA. METHODS: Patients underwent MSCTA for clinical indications including symptoms or noninvasive results being either equivocal or suspected as incorrect by referring clinicians. Standard 16-slice CT scanner techniques were used, and results were analyzed on the basis of both patient and vessel. Patients were treated medically or sent to invasive angiography on the basis of MSCTA results and judgment of referring clinicians. All invasive angiograms were analyzed using quantitative coronary angiography. Six-month clinical follow-up was determined in patients without CA. RESULTS: One thousand fifty-three consecutive patients were referred for MSCTA, resulting in 994 interpretable scans. Mean age was 58+/-13 years, 55% were male, 50% had prior noninvasive testing, and 90% had symptoms. Invasive angiography was performed in 160 patients, with significant stenoses present in 69%. MSCTA demonstrated 87% and 89% accuracy by patient- and vessel-based analysis, respectively, and was most accurate in the left main and right coronary arteries. Only two patients not referred for angiography had significant stenosis in those undergoing 6-month follow-up. CONCLUSIONS: MSCTA accurately detects obstructive coronary stenosis in clinical patients with possible cardiac symptoms, and effectively triages them for invasive angiography. Negative results are highly accurate in ruling out obstructive disease. Six-month prognosis is excellent in patients without significant disease determined by MSCT.

Design of a standardized system for transfer of patients with ST-elevation myocardial infarction for percutaneous coronary intervention.

BACKGROUND: Direct percutaneous coronary intervention (PCI) is the preferred method of reperfusion for ST-elevation myocardial infarction (STEMI). Transfer from community hospitals to PCI centers increases availability for direct PCI, which improves outcomes compared to fibrinolysis in Europe. It has been difficult to achieve similar door-to-balloon times for transfer patients in the United States. METHODS: We designed a standardized protocol and integrated system of transfer for patients with STEMI. We report the door-to-balloon times for the pre- and postpilot patients in the index hospital and describe the details of the current Level 1 MI Program. RESULTS: In the 15 months before the pilot project, the door-to-balloon time for patients receiving ad hoc transfer for direct PCI was 192 minutes, similar to the national average. The door-to-balloon time for the patients receiving rescue PCI after failed thrombolysis was 221 minutes. The standardized protocol decreased door-to-balloon time to 98 minutes in the pilot trial (P < .01) and has now been applied successfully in 29 community hospitals. CONCLUSIONS: Rapid transfer of patients with STEMI is feasible in the United States using a standardized protocol and integrated transfer system. This requires a team approach with cooperation between cardiologists, emergency physicians, nurses, and the emergency medical system as well as various health care organizations.

Physician-led: good idea or not?

Whether physicians or not, leaders must possess certain skills and qualities to achieve success. Take a look at what's required to be an effective leader.

Clinical profile of stroke in 900 patients with hypertrophic cardiomyopathy.

OBJECTIVES: We sought to assess the occurrence and clinical significance of stroke and peripheral arterial embolizations at non-central nervous system sites in a large, community-based cohort with hypertrophic cardiomyopathy (HCM). BACKGROUND: Such vascular events are insufficiently appreciated complications of HCM for which there is limited information on occurrence, clinical profile and determinants. METHODS: We assessed the clinical features of patients with stroke and other peripheral vascular events in a consecutive group of patients with HCM from four regional cohorts not subject to significant tertiary referral bias. RESULTS: Of the 900 patients, 51 (6%) patients experienced stroke or other vascular events over 7 +/- 7 years, including 44 patients with stroke; 21 (41%) of these 51 patients died or were permanently disabled. The overall incidence was 0.8%/year and 1.9% for patients >60 years old. Age at first event ranged from 29 to 86 years (mean 61 +/- 14 years). Most (n = 37; 72%) events occurred in those >50 years, although 14 (28%) younger patients (< or = 50 years) also had events. Multivariate analysis showed stroke and other peripheral vascular events to be independently associated with congestive symptoms and advanced age, as well as with atrial fibrillation (in 45 [88%] of 51 patients), at the initial evaluation. The cumulative incidence of these events among patients with atrial fibrillation was significantly higher in non-anticoagulated patients as compared with patients receiving warfarin (31% vs. 18%; p < 0.05). CONCLUSIONS: Stroke and peripheral embolizations showed a 6% prevalence rate and an incidence of 0.8%/year in a large, unselected HCM group. These profound complications of HCM, which may lead to disability and death, were substantially more common in the elderly, occurred almost exclusively in patients with paroxysmal or chronic atrial fibrillation and appeared to be reduced in frequency by anticoagulation.