Intravascular device infections: epidemiology, diagnosis, and management.

Intravascular devices such as pacemakers, implantable cardioverter-defibrillators (ICDs), left ventricular assist devices (LVADs), and prosthetic vascular grafts are life-saving therapies for patients with malignant arrhythmias, heart failure, and various vascular diseases. As indications for their use have increased, so has the prevalence of infectious complications associated with these devices. We present a review of the clinical literature on the epidemiology, diagnosis, and management of infectious complications of these intravascular devices. Most intravascular device infections are thought to result from skin flora contamination during implantation. Infection of the subcutaneous portion of the device can subsequently track to deeper intravascular tissues. Infection that involves the intravascular or intracardiac portion of these devices carries a high morbidity and mortality. Despite appropriate antibiotic therapy, cure of infection is frequently possible only with device removal. Well-designed placebo-controlled, randomized studies evaluating antimicrobial therapy for treatment of intravascular device infections are lacking. In the absence of better information, authorities recommend antibiotics targeted toward cultured organisms for approximately 4 to 6 weeks and device removal.

Resolving hyperlipidemia after liver transplantation in a patient with primary sclerosing cholangitis.

A 64-year-old man with primary sclerosing cholangitis (PSC) and resultant liver failure presented to our hospital with severe dyslipidemia (total cholesterol, 525 mg/dL; low-density lipoprotein (LDL) cholesterol, 489 mg/dL; high-density lipoprotein (HDL) cholesterol, 13 mg/dL; triglycerides, 114 mg/d) and coronary artery disease. The abnormal lipid profile of patients with cholestatic liver disease, such as PSC, includes an abnormal atherogenic LDL called lipoproteinX. The patient's dyslipidemia persisted despite treatment with a statin. Lipids normalized only after liver transplantation (total cholesterol, 135 mg/dL; LDL cholesterol, 60 mg/dL; high-density lipoprotein cholesterol, 48 mg/dL; triglycerides, 130 mg/dL). To the best of our knowledge, the dramatic improvement in the lipid profile after liver transplantation represents the first such published report for PSC. The recognition of dyslipidemia and atherosclerosis in those with cholestatic liver disease and the normalization of lipid profile after liver transplantation warrant further study. We present a review of dyslipidemia in cholestatic liver disease, its relationship to atherosclerosis, and its treatment.

Anomalous origin of the left main coronary artery from the right sinus of Valsalva with an intramural course identified by transesophageal echocardiography in a 14 year old with acute myocardial infarction.

Coronary artery anomalies have an incidence of 0.6% to 1.3% in angiographic studies and 0.3% in an autopsy series. Anomalous origin of the left main coronary artery (LMCA) from the right sinus of Valsalva (RSOV) represents a small fraction (1.3%) of these anomalies, with an overall prevalence of 0.017% to 0.03% in angiographic studies. The high incidence of sudden cardiac death associated with this specific anomaly during or immediately after vigorous physical exercise makes identification and appropriate surgical intervention critical. We present a case report of a 14-year-old patient with an LMCA arising from the RSOV with an initial intramural course, presenting with acute myocardial infarction (AMI) as the first indication of the anomaly. Transthoracic echocardiogram suggested this anomaly, which was confirmed by cardiac catheterization and transesophageal echocardiogram.

Prevalence of adequate control of increased serum low-density lipoprotein cholesterol in self-pay or Medicare patients versus Medicaid or private insurance patients followed in a University General Medicine Clinic.

In a study of 514 patients with increased serum low-density lipoprotein (LDL) cholesterol followed in a general medicine clinic at a university hospital, the serum LDL cholesterol in patients with coronary heart disease (CHD), other atherosclerotic vascular disease, or diabetes mellitus was <100 mg/dl in 219 of 276 patients (79%) with Medicaid or private insurance and in 28 of 67 self-pay or Medicare patients (42%) without pharmaceutical coverage (p <0.001). The serum LDL cholesterol was <130 mg/dl in patients with 2+ risk factor and a 10-year risk for CHD of < or =20% or <160 mg/dl in patients with a 0 to 1 risk factor, and a 10-year risk for CHD of <10% in 54 of 141 patients (38%) with Medicaid or private insurance and in 5 of 30 self-pay or Medicare patients (17%) (p <0.025).

Prevalence of adequate blood pressure control in self-pay or Medicare patients versus Medicaid or private insurance patients with systemic hypertension followed in a university cardiology or general medicine clinic.

The prevalence of adequate blood pressure control was investigated in 614 patients (mean age 60 +/- 16 years) with systemic hypertension followed in a university cardiology or general medicine clinic. Systemic hypertension was adequately controlled in 46 of 122 patients (38%) who had to pay for their medications (self-pay or Medicare patients) versus 342 of 492 patients (70%) who received their medications at minimal or no cost because they were on Medicaid or had private insurance (p <0.001).

Screening coronary arteriography in the primary prevention of coronary artery disease.

Recent studies indicate an expansion of the population eligible for primary prevention of coronary artery disease with lipid-lowering therapy. This change has led to the unnecessary treatment of many individuals and an overall decreased effectiveness of medication with potentially significant side effects. If instead, the asymptomatic population is screened for the presence of early coronary artery disease (CAD), lipid lowering can be targeted to those who can truly benefit. The prevalence of asymptomatic CAD in men older than 50 years of age approaches 20% and arteriography is currently the best available test to identify these men. The approximate complication rate of arteriography in such a population (1 or 2 per 10,000) approaches that of other screening tests. Although insufficient data exists for formal cost analysis, approximations indicate significant savings for arteriographically targeted treatment of at-risk asymptomatic individuals. The authors show that coronary arteriography is a potentially safe and cost-effective method of screening an asymptomatic adult population for presence of early CAD, allowing for the targeting of lipid lowering to those who can benefit most from this therapy.