Early repolarization is independently associated with African-American race, younger age, higher BMI and lower heart rate.

Background: Early repolarization (ER) is commonly seen in young adults. The goal of this study was to evaluate predictors of ER. Method: The authors used ECGs, available from 636 subjects, performed on healthy students for screening purposes. Results: The prevalence of ER was 13.5%. The prevalence of ER was higher in African-American subjects (48.0% vs 10.8%; odds ratio: 5.9; CI: 3.5-9.7; p < 0.0001), those with a BMI >25 (18.6% vs 11.7%; p = 0.02), those age <30 (16.4% vs 2.0%; p < 0.0001), male subjects (17.1% vs 8.3%; p = 0.001) and those with heart rate <70 (18.2% vs 9.2%; p = 0.001). With multivariate analysis, except gender, all other parameters remained significantly correlating with ER. Conclusion: The authors found younger age, African-American race, higher BMI and lower heart rate to be predictors of ER.

A finding in an ECG called early repolarization is very common and usually is a benign condition except in some genetic disorders. The authors studied the rate of this occurrence in a young population and found that it is very common in African­Americans. Furthermore, it is more common in individuals with obesity, those with a slow heart rate and higher BMI.

Left ventricular hypertrophy is independently associated with all-cause mortality.

BACKGROUND: Left Ventricular Hypertrophy (LVH) is associated with adverse outcomes. The goal of this study was to evaluate any association between LVH and all-cause mortality using a large echocardiographic database. METHODS: We retrospectively evaluated 2,352 echocardiograms between the ages 16-99 years that were performed from 1983 to 1998 for clinical reasons in Southern California. Mortality data were extracted from the national mortality database at the end of the year 2007. Using uni- and multi-variant analysis, we evaluated any association between total mortality and echocardiographic presence of LVH defined as any wall thickness >11 mm. RESULTS: LVH was significantly associated with all-cause mortality [207/583 (35.5%) of patients died with LVH vs. 416/1769 (23.5%) of patients with normal wall thickness, P<0.001, HR 1.79, CI: 1.46-2.19]. Using multivariate analysis adjusting for age, gender, abnormal left ventricular systolic function, and significant valvular abnormalities, LVH remained independently associated with all-cause mortality (OR 1.39, CI 1.10-1.74, P=0.005). CONCLUSION: Using a large echocardiographic database, we found that LVH is independently associated with all-cause mortality. Our finding confirms the negative effect of LVH on the long-term outcome.

Transcatheter Aortic Valve Replacement: Comprehensive Review and Present Status.

Aortic stenosis is the most common valvular heart disease in the developed world. About 7% of the population over age 65 years suffers from degenerative aortic stenosis. The prognosis of patients with symptomatic severe aortic stenosis is dismal without valve replacement. Even though the American College of Cardiology recommends aortic valve replacement to treat this condition as a class I recommendation, approximately one third of these patients over the age of 75 years are not referred for surgery. Typically, this is from concern about prohibitive surgical risk associated with patient frailty, comorbidities, age, and severe left ventricular dysfunction. The advent in France of transcatheter aortic valve replacement has raised the hope in the United States for an alternative, less invasive treatment for aortic stenosis. Two recent trials-the Placement of AoRTic TraNscathetER Valve Trial Edwards SAPIEN Transcatheter Heart Valve (Partner) and the CoreValve US Pivotal-have established transcatheter aortic valve replacement as the preferred approach in patients who are at high or prohibitive surgical risk. The more recently published Partner 2 trial has shown the feasibility of transcatheter aortic valve replacement in intermediate-surgical-risk patients as well. With a profile that promises easier use and better valve performance and delivery, newer-generation valves have shown their potential for further improvement in safety profile and overall outcomes. We review the history and status of this topic.

Clinical and angiographic outcomes with everolimus eluting stents for the treatment of cardiac allograft vasculopathy.

OBJECTIVES: This study aimed to examine clinical efficacy, safety, and intermediate clinical outcomes with everolimus-eluting stents (EESs) in patients with transplant coronary artery disease (TCAD). BACKGROUND: TCAD is a major cause of mortality in patients following orthotopic heart transplantation (OHT). Systemic everolimus in OHT patients has been shown to reduce TCAD. The safety and efficacy of an EES, the Xience V, have not been evaluated in this population. METHODS: Patients post-OHT with hemodynamically significant CAD who underwent percutaneous coronary intervention (PCI) with EES were included. Participants were maintained on dual antiplatelet therapy for 1-year post-PCI. We examined procedural success, in-hospital and 1-year mortality, stent thrombosis, angiographic restenosis, and myocardial infarction rates. All patients had follow-up angiography 1-year after PCI. Target vessel revascularization (TVR), target lesion revascularization (TLR), in-segment restenosis, target vessel failure (TVF), and lumen late loss were noted. RESULTS: PCI was performed in 34 de novo lesions in 21 patients, and 40 EES were placed. Procedural success rate was 100%. Average stent was 16.5 ± 5.1 mm long and 3.0 ± 0.6 mm in diameter. All patients had angiographic follow-up (409 ± 201 days). There was no stent thrombosis, deaths, or myocardial infarctions during follow-up. Two patients had focal in-stent restenosis. TLR rate was 5.9% (2/34), and TVR rate was 11.1% (3/27). Quantitative coronary angiography (QCA) showed stenosis diameter to be 19.98 ± 17.57%. CONCLUSIONS: Use of an EES is associated with a low incidence of TVR and TLR in patients with TCAD. Further studies are needed to determine whether PCI with EES changes long-term outcomes.

Mitral annulus calcification is independently associated with all-cause mortality.

BACKGROUND: Mitral annulus calcification (MAC) is an important echocardiographic finding that is significantly associated with valvular abnormalities. However, the effect of documented MAC on all-cause mortality is not known. Using a large database, associations between MAC and long-term all-cause mortality were evaluated. METHODS: A retrospective analysis of 3169 echocardiograms, which were performed for clinical reasons in southern California between 1983 and 1998 in patients between 16 and 99 years of age, was performed. Mortality data were extracted from the national mortality database at the end of 2007. Using uni- and multivariate analysis, associations between total mortality and the echocardiographic presence of MAC documented in the final report by the interpreting cardiologist were evaluated. RESULTS: MAC was significantly associated with all-cause mortality (174 of 334 [52.1%] patients with MAC died versus 709 of 2835 [25.0%] patients without MAC; OR 3.26 [95% CI 2.58 to 4.10]; P<0.001). Using multivariate analysis adjusting for age, left ventricular hypertrophy, sex, abnormal left ventricular systolic function and significant valvular abnormalities, MAC remained independently associated with all-cause mortality (OR 2.50 [95% CI 1.81 to 3.45]; P<0.001). CONCLUSION: Using a large echocardiographic database, MAC was found to be independently associated with all-cause mortality. This finding confirms the importance of an abnormal mitral annulus as an important prognostic marker.

Declining in-hospital mortality in patients undergoing coronary bypass surgery in the United States irrespective of presence of type 2 diabetes or congestive heart failure.

BACKGROUND: Significant advances in surgical techniques and postsurgical care have been made in the last 10 years. The goal of this study was to evaluate any decline in the age-adjusted in-hospital mortality rate of patients undergoing coronary artery bypass grafting (CABG) using a national database from 1989 to 2004 in the United States. HYPOTHESIS: Reduction in CABG related mortality in recent years. METHODS: Using the Nationwide Inpatient Sample (NIS) database, we obtained specific ICD-9-CM codes forCABG to compile the data. To exclude nonatherosclerotic cause of coronary disease, we studied only patients older than 40 years. We calculated total and age-adjusted mortality rate per 100,000 for this period. RESULTS: The NIS database contained 1 145 285 patients who had CABG performed from 1988 to 2004. The mean age for these patients was 71.05 ± 9.20 years. From 1989, the age-adjusted rate for all CABG-related mortality has been decreasing steadily and reached the lowest level in 2004: 300.3 per 100 000 in 1989, (95%confidence interval [CI], 20.4-575.9) and 104.69 per 100 000 (95% CI, 22.6-186.7) in 2004. Total death also declined from 5.5% to 3.06%. This decline occurred irrespective of comorbidities such as congestive heart failure, diabetes, or acute myocardial infarction, albeit increasing the number of CABG procedures performed in high-risk patients. CONCLUSIONS: The age-adjusted in-hospital mortality rate from CABG has been declining steadily and reached its lowest level in 2004, irrespective of comorbidities. This decline most likely reflects advances in surgical techniques and the use of evidence-based medicine in patients undergoing CABG.

Novel antiplatelet agent ticagrelor in the management of acute coronary syndrome.

Current clinical guidelines recommend dual antiplatelet agents namely aspirin and clopidogrel for the treatment of patients suffering from acute coronary syndrome (ACS). But the efficacy of clopidogrel is variable as it is a pro-drug, which has to be metabolized to become an active drug thus exhibiting variable platelet inhibition, increases risk of bleeding, stent thrombosis, and ischemia. To overcome this limitation, prasugrel was developed with increased antiplatelet activity thereby reducing the risk of myocardial ischemia and stent thrombosis. This action of prasugrel was associated with an increased risk of major bleeding. Finally, a novel reversible and direct-acting oral adenosine diphosphate (ADP) receptor antagonist, ticagrelor was developed that showed consistent and increased P2Y12 inhibition with similar incidence of bleeding but greater reduction in cardiac events compared to clopidogrel. The focus of this article is to review ticagrelor as a new class of P2Y12 inhibitor.

Reverse or inverted takotsubo cardiomyopathy (reverse left ventricular apical ballooning syndrome) presents at a younger age compared with the mid or apical variant and is always associated with triggering stress.

Takotsubo cardiomyopathy is usually caused by triggering stress. It has 4 different subtypes. There has been no consensus to differentiate various types with regard to characteristics of the patient population. The goal of this study was to evaluate any clinical differences between the reverse type in comparison to common apical and mid-cavitary types using case series of reported cases. The authors searched published articles in PubMed and Medline on takotsubo or stress-induced cardiomyopathy. They included only cases that reported different types of takotsubo cardiomyopathy with baseline clinical characteristics. They identified 60 patients for the final analysis. The types of takotsubo cardiomyopathy seen in this study are classified as classic (66.7%), mid-cavitary (10%), or reverse (inverted) (23.3%). Patients with reverse-type takotsubo cardiomyopathy were significantly younger compared with those with other types (mean age, 36 for reverse vs 62 for other types; P<.001). Furthermore, all patients with the reverse type had physical or mental stress, whereas those with other types had no triggering stress in 02% of the reported cases (P<.0001). Among patients presenting with takotsubo cardiomyopathy, the reverse or inverted variant presents at a younger age and is always associated with a triggering of emotional or physical stress.

Nationwide trends in the age adjusted prevalence of non-ST elevation myocardial infarction (NSTEMI) across various races and gender in the USA.

BACKGROUND: Advances in the prevention and treatment of atherosclerosis have been dramatic. The goal of this study was to evaluate any decline in the age adjusted incidence of acute non ST elevation myocardial infarction (NSTEMI) using a large database. METHOD: The Nationwide Inpatient Sample (NIS) database was utilized to calculate the age-adjusted rate for NSTEMI from 1988 to 2004 retrospectively. Specific ICD-9-CM codes for NSTEMI were used to compile the data. Patient demographic data was also analyzed from the database and adjusted for age. RESULTS: The NIS database contained a total of 1 423 156 patients who had a diagnosis of NSTEMI from 1988 to 2004. The age-adjusted rate for all acute NSTEMI gradually increased from 1988 until 2000-26.21 per 100 000 (95% CI: 23.9-28.4) in 1988 and 92.6 per 100 000 (95% CI: 86.0-99.3, P <0.01 in 2000,). It remained unchanged from 2000 until 2004 (91.7 per 100 000 (95% CI: 85.3-98.0). This trend was similar across different race and gender. CONCLUSION: The increasing incidence of NSTEMI from 1988 until year 2000 has suddenly stabilized by the year 2000. The cause of this finding is unknown. It could be related to the recent adaptation of troponin testing or recent advancement in the prevention and treatment of atherosclerosis.

Decreasing in-hospital mortality of patients undergoing percutaneous coronary intervention with persistent higher mortality rates in women and minorities in the United States.

BACKGROUND: Advances in interventional techniques have been dramatic in the last 10 years. The goal of this study was to evaluate the age-adjusted in-hospital mortality rate in patients undergoing percutaneous coronary intervention (PCI) using a large database. METHODS: The Nationwide Inpatient Sample (NIS) database was utilized to calculate the age-adjusted mortality rate for PCI from 1988 to 2004 in patients over the age of 40 retrospectively. Specific ICD-9- CM codes for PCI were used for this study. Demographic data were also analyzed and adjusted for age. RESULTS: The mean age for these patients was 71.56 +/- 10.59 years (53.55% male). From 1988 to 1995, the age-adjusted mortality rate was stable. However, after 1995 the age-adjusted mortality rate showed persistent decline to the lowest level in 2004. (In 1988, age-adjusted mortality rate was 75.43 per 100,000 [95% CI = -7.88-158.76], in 1995, 66.83 per 100,000 [95% CI = 24.62-109.050] and in 2004, 38.38 per 100,000 [95% CI 19.53- 57.22]; p < 0.01). Total death also declined from 1.8% to 1.2%. This trend was similar across gender and ethnicities except for Asians. Furthermore, minorities and women had persistently higher mortality in comparison to males and Caucasians. CONCLUSION: The age-adjusted in-hospital mortality rate from PCI was steady until 1995 and declined to its lowest level in 2004. Despite this decline, racial and gender disparity in regard to mortality persisted over the study years.

Sex- and ethnic group-specific nationwide trends in the use of coronary artery bypass grafting in the United States.

OBJECTIVE: This study examined nationwide trends in use of coronary artery bypass grafting between 1988 and 2004. METHODS: The Nationwide Inpatient Sample database was used to calculate age-adjusted rate of coronary artery bypass grafting from 1988 to 2004. Specific International Classification of Diseases, Ninth Revision, Clinical Modification codes for coronary artery bypass grafting were used to compile data. Patient demographic data were also analyzed. RESULTS: The database recorded 1,145,285 patients older than 40 years who underwent coronary artery bypass grafting from 1988 to 2004. Mean age was 60.21 +/- 10.55 years. Male patients underwent coronary artery bypass grafting more than twice as frequently as female patients (70.6% vs 29.4%). From 1988, total age-adjusted rate gradually increased for 10 years until 1997 (79.29 per 100,000 with 95% confidence interval 70.88-87.71 per 100,000 in 1988, 131.31 per 100,000 with 95% confidence interval 119.02-143.59 per 100,000 in 1997, P < .01), with ensuing rapid decline to nearly the lowest level at end of study in 2004 (83.01 per 100,000 with 95% confidence interval 75.68-90.33 per 100,000, P < .01). Although trends were similar across ethnicity and sex, female and ethnic minority patients had lower rates of bypass surgery than did male and white patients. CONCLUSIONS: Use of coronary artery bypass grafting has decreased dramatically in recent years, with even lower use among female and ethnic minority patients. This decline may be related to significant advances in percutaneous coronary interventions and improved medical treatment of atherosclerosis in the past 10 years.

Nationwide trends in the utilisation of percutaneous coronary intervention (PCI) in the United States of America based on gender and ethnicities.

AIMS: With advancement in technology, the number of percutaneous coronary interventions performed are rising. The goal of this study was to evaluate nationwide trend over a long period of time in the utilisation of percutaneous coronary intervention (PCI) using a large database. METHODS AND RESULTS: The Nationwide Inpatient Sample (NIS) database was utilised to calculate the age-adjusted rate for PCI from 1988 to 2004. Specific ICD-9-CM codes for all PCIs were used to compile the data. The NIS database contained 1,747,736 patients who had PCI performed from 1988 to 2004. The mean age for these patients was 63.75+/-11.07 years old. From 1988, the age-adjusted rate for all PCI gradually increased to more than three times until 2001 (80.3 per 100,000 [95%CI=71.86-88.92] in 1988 and 244 per 100,000 [95%CI=221.31-266.39, p<0.01] in 2001), but remained relatively unchanged (slight decline in the last few years of the study) until the end of the study (232.17 per 100,000 95%CI=211.69-252.66) in 2004. These trends were similar across ethnicity, gender and comorbid conditions. CONCLUSIONS: The utilisation of PCI has dramatically increased from 1988 to 2001, but remained steady thereafter. The availability of drug eluting stents in the USA after 2001 may have contributed to this trend.

Decline in the nationwide trends in in-hospital mortality of patients undergoing multivessel percutaneous coronary intervention.

BACKGROUND: Advances in the safety of percutaneous coronary interventions have been significant in recent years. The goal of this study was to evaluate any decline in the age-adjusted in-hospital mortality rate in patients undergoing multivessel percutaneous coronary intervention (MVPCI) using a very large database from 1988 to 2004 in the United States. METHOD: The Nationwide Inpatient Sample (NIS) database was utilized to calculate the age-adjusted mortality rate for MVPCI from 1988 to 2004 in patients over the age of 40 years retrospectively. Specific ICD-9-CM codes for MVPCI were used for this study. Patient demographic data were also analyzed and adjusted for age from the database. RESULTS: The mean age was 71.56 +/- 10.59 years (53.55% male). From 1988 the age-adjusted mortality rate was stable until 1999, with a steady decline to the lowest level in 2004. In 1988, the rate was 67.42 (95% CI = 181-316.14), in 1999 51.02 (95% CI = 27-129.32), and in 2004, 40.06 (95% CI 5.6-85.83) per 100,000. Total death also declined from 1.77% to 1.25%. This trend was similar across gender and ethnicities. CONCLUSION: The age-adjusted mortality from MVPCI was steady until 1999, but declined to the lowest level in 2004. This trend most likely reflects advancements in the care of patients undergoing high-risk coronary interventions.

Rate of acute ST-elevation myocardial infarction in the United States from 1988 to 2004 (from the Nationwide Inpatient Sample).

Advances in the management of atherosclerosis risk factors have been dramatic in the previous 10 years. The goal of this study was to evaluate any decrease in age-adjusted incidence of acute ST-elevation myocardial infarction (STEMI) in a very large database of inpatient admissions from 1988 to 2004. The Nationwide Inpatient Sample database was used to calculate the age-adjusted rate for STEMI from 1988 to 2004 retrospectively. Specific International Classification of Diseases, Ninth Revision, codes for MIs consistent with STEMI were used. Patient demographic data were also analyzed and adjusted for age. The Nationwide Inpatient Sample database contained 1,352,574 patients >40 years of age who had a diagnosis of STEMI from 1988 to 2004. Mean age for these patients was 66.06 +/- 13.69 years. Men had almost 2 times the age-adjusted STEMI rate as women (men 62.4%, women 37.6%). From 1988 the age-adjusted rate for all acute STEMIs remained steady for 8 years (108.3 per 100,000, 95% confidence interval [CI] 99.0 to 117.5, in 1988 and 102.5 per 100,000, 95% CI 94.7 to 110.4, in 1996). However, from 1996 onward, the age-adjusted incidence of STEMI steadily decreased to 1/2 the incidence of the previous 8 years (50.0 per 100.000, 95% CI 46.5 to 53.5, by 2004, p <0.01). This decrease was similar across various races and genders. In conclusion, the incidence of STEMI was stable from 1988 to 1996, with a steady linear decrease to 1/2 by 2004. The cause of the steady decrease in STEMI rate most likely reflects the advancement in management of patients with atherosclerosis.

Levels of troponin release can aid in the early exclusion of stress-induced (takotsubo) cardiomyopathy.

BACKGROUND: Stress-induced cardiomyopathy is usually associated with an increased level of cardiac enzymes, leading to difficulties in differentiating this condition from acute coronary syndrome. The final diagnosis is usually made based on angiographic findings revealing normal coronary arteries. It was hypothesized that maximal cardiac enzyme elevation in these patients should have an upper limit. In the present study, reported cases of stress cardiomyopathy were compared with documented cardiac enzyme levels to evaluate the upper cut-off point of troponin in this population. METHOD: All of the articles published in PubMed and MEDLINE from November 2007 to July 2008, on takotsubo or stress-induced cardiomyopathy, were identified. Only the cases that reported the absolute or mean level of cardiac enzymes were included. The level of various enzymes were correlated with cardiac function, and the upper limit of enzyme elevation was calculated in these patients. RESULTS: A total of 114 patients (mean [+/- SD] age 63.5+/-14.5 years) were included in the study. Seventy-one per cent of the patients were older than 50 years of age and 86% were female. Mean values for troponin I, troponin T, creatine kinase (CK) and CK-MB were 6.5 ng/mL, 3.6 ng/mL, 556 U/L and 32.9 U/L, respectively. All of the patients with takotsubo cardiomyopathy had a troponin T level of 6 ng/mL or less and troponin I level of 15 ng/mL or less. Troponin T showed a significant inverse correlation with initial ejection fraction (R(2)=0.6), which was not seen with the levels of troponin I, CK and CK-MB. Takotsubo cardiomyopathy was classified as classic (66.7%), mid-cavitary (10%), reverse (23.3%) or local (0%). CONCLUSION: Among patients with takotsubo cardiomyopathy, troponin T level correlated with initial ejection fraction. Furthermore, the diagnosis of takotsubo cardiomyopathy appears to be unlikely in patients with troponin T greater than 6 ng/mL or troponin I greater than 15 ng/mL.

Nationwide trends in the utilization of multivessel percutaneous coronary intervention (MVPCI) in the United States across different gender and ethnicities.

BACKGROUND: To evaluate nationwide trends in the utilization of Multivessel Percutaneous Coronary Intervention (MVPCI) in the past compared to recent years using a large database from 1988 to 2004. METHOD: The Nationwide Inpatient Sample (NIS) database was utilized to calculate the age-adjusted rate for multivessel percutaneous coronary intervention (MVPCI) from 1988 to 2004. Specific ICD-9-CM codes for MVPCI were used to compile the data. Patient demographic data were also analyzed from the database. RESULTS: According to the NIS database, MVPCI was performed in 241,319 patients from 1988 to 2004. Males underwent MVPCI twice as many as compared to females (male: 67.87%, female 32.13%). The mean age for these patients was 64.89 +/- 11.84 years old. From 1988, the age-adjusted rate for MVPCI gradually increased to more than three times in 1998 [(6.62 per 100,000 (95%CI = 5.92-7.33) in 1988 to 23.92 per 100,000 (95%CI = 21.62-26.22, P < 0.01) in 1998] and accelerated to more than 6 times that of 1988 at the end of the study in 2004 (41.50 per 100,000 (95%CI = 37.84-45.16). In recent years, this trend was similar for both genders and ethnicities. CONCLUSION: The utilization of MVPCI has increased six times from 1988 to 2004, with acceleration in recent years. The cause of this acceleration is most likely related to the advancement in the percutaneous coronary interventional techniques.