Coronary artery disease with normal lipids and low coronary artery calcium in two women with high lipoprotein(a).

We present 2 patients with elevated levels of lipoprotein (a) and significant coronary artery disease despite having little coronary artery calcification. Clinicians should be aware that patients with elevated lipoprotein (a) may have important coronary artery disease with low coronary artery calcification scores.

Clinical effectiveness of an outpatient pathway for low-risk chest pain emergency department visits.

BACKGROUND: Studies suggest that patients who present with atypical chest pain and are low or low-intermediate risk can safely undergo a rapid rule-out for cardiac ischemia with serial ECGs and cardiac biomarkers followed by additional testing as needed. We sought to evaluate a novel Emergency Department (ED) protocol for patients to undergo their additional functional testing as an outpatient. METHODS: Patients presenting to the ED with atypical chest pain, normal ECG, and negative cardiac troponin felt to be low risk were referred for outpatient stress testing within 72 hours of presentation as part of a pilot program. We analyzed test characteristics, length of stay, and 30-day return visits to ED in the pilot group and compared results to a similar cohort assessed in the ED by a traditional chest pain observation protocol. RESULTS: A total of 156 patients were included over a 5-month period with 29.5% not returning for testing. There was a 70% reduction in length of stay for outpatient stress test protocol patients. All-cause and cardiac return visits to the ED were not significantly different between the outpatient cohort and the traditional chest pain unit group and were reduced by 47 and 75%, respectively, in patients who completed their outpatient testing. The provisional injection protocol resulted in a 81% reduction in radiation exposure when compared to traditional MPI stress protocols due to a greater utilization of exercise treadmill tests without imaging. CONCLUSION: Outpatient stress testing is a reliable alternative to traditional chest pain observation with a significantly shorter length of stay, reduced healthcare costs, and improved radiation safety profile for patients when compared to traditional inpatient observation.

A Case of Imatinib-Induced Hepatitis.

A 71-year-old female with a past medical history of Philadelphia chromosome-positive chronic myelogenous leukemia on imatinib therapy, Sjogren's syndrome, and hypothyroidism presents with acute hepatitis. After a comprehensive workup ruling out viral, infectious and metabolic etiologies imatinib is stopped which results in immediate improvement. The biopsy is consistent with drug-induced liver damage; the patient is started on oral prednisone and discharged. Unfortunately, our patient's liver function does not improve over the course of the next week and she is readmitted for hepatic and renal failure. During this second admission patient's condition continues to deteriorate with concomitant gastric bleeding, renal injury, and cellulitis. She ultimately chooses a palliative approach.

Influence of Left Ventricular Hypertrophy on In-Hospital Outcomes in Acute Exacerbation of Chronic Obstructive Pulmonary Disease.

Left ventricular hypertrophy (LVH) is associated with worse outcomes in chronic obstructive pulmonary disease (COPD); however, its role in an acute exacerbation of COPD (AECOPD) has not been reported. This was a retrospective cohort study during 2008-2012 at an academic medical center. AECOPD patients >18 years with available echocardiographic data were included. LVH was defined as LV mass index (LVMI) >95 g/m2 (women) and >115g/m2 (men). Relative wall thickness was used to classify LVH as concentric (>0.42) or eccentric (<0.42). Outcomes included need for and duration of non-invasive ventilation (NIV) and mechanical ventilation (MV), NIV failure, intensive care unit (ICU) and total length of stay (LOS), and in-hospital mortality. Two-tailed p < 0.05 was considered statistically significant. Of 802 patients with AECOPD, 615 patients with 264 (42.9%) having LVH were included. The LVH cohort had higher LVMI (141.1 ± 39.4 g/m2 vs. 79.7 ± 19.1 g/m2; p < 0.001) and lower LV ejection fraction (44.5±21.9% vs. 50.0±21.6%; p ≤ 0.001). The LVH cohort had statistically non-significant longer ICU LOS, and higher NIV and MV use and duration. Of the 264 LVH patients, concentric LVH (198; 75.0%) was predictive of greater NIV use [82 (41.4%) vs. 16 (24.2%), p = 0.01] and duration (1.0 ± 1.9 vs. 0.6 ± 1.4 days, p = 0.01) compared to eccentric LVH. Concentric LVH remained independently associated with NIV use and duration. In-hospital outcomes in patients with AECOPD were comparable in patients with and without LVH. Patients with concentric LVH had higher NIV need and duration in comparison to eccentric LVH.

Stent and Non-Stent Based Outcomes of Infrainguinal Peripheral Artery Interventions From the Multicenter XLPAD Registry.

BACKGROUND: There are limited data regarding contemporary use of stent and non-stent based treatment strategies of infrainguinal peripheral artery disease (PAD). METHODS: We analyzed data from the ongoing multicenter XLPAD registry between July 2005 and October 2013 to report on the use of non-stent (atherectomy ± balloon angioplasty) and stent-based treatment of superficial femoral artery (SFA), popliteal, and below-the-knee (BTK) vessels in contemporary clinical practice. RESULTS: A total of 584 interventions (SFA, 82.5%; popliteal, 7.2%; BTK, 9.9%) were performed in 372 patients (mean age, 63.2 years; diabetes mellitus, 57.7%; Rutherford category 1-3, 73.5%; Rutherford category 4-6, 20.1%). Stents were deployed in 389 lesions (66.6%; SFA, 90.5%; popliteal, 5.1%; BTK, 4.1%) and non-stent strategy (atherectomy, 49%) in 195 lesions (33.4%; SFA, 66.7%; popliteal, 11.3%; BTK, 21.5%). In the stent and non-stent groups, mean lesion lengths were 133.9 mm and 86.0 mm (P<.001), chronic total occlusions (CTOs) constituted 63.0% and 49.7% (P<.01), and restenotic lesions were 12.6% and 32.3% (P<.001), respectively. At a mean follow-up of 260 ± 130 days, in the stent and non-stent treated patients, all-cause mortality was 4.3% and 3.5% (P=.65), clinically indicated repeat revascularization was 17.5% and 14.9% (P=.42), and amputation was 4.6% and 9.2% (P<.01), respectively. SFA lesion location, long lesion length, and CTO were associated with the use of stents. Advanced Rutherford class was associated with a non-stent treatment strategy. CONCLUSION: The majority of endovascular peripheral arterial interventions are performed in the SFA; most include a CTO and in patients with diabetes mellitus. Operators use stents to primarily treat complex SFA lesions with overall similar outcomes, except for fewer amputations compared to a non-stent strategy.