Procedural Volume and Outcomes with Atrial Fibrillation Ablation: A Report from the NCDR AFib Ablation Registry.

BACKGROUND: The association between hospital and physician procedure volume outcome has not been well evaluated for atrial fibrillation (AF) ablation in contemporary practice. OBJECTIVE: To determine the association between hospital and physician AF ablation volume and procedural success (isolation of all pulmonary veins) and major adverse events (MAE). METHODS: Procedures reported to the NCDR AFib Ablation Registry between July 2019 and June 2022 were included. Hospital and physician procedural volumes were annualized and stratified into quartiles (Q) to compare outcomes. Three level hierarchical (patient, hospital and physician) models were used to assess the procedural volume outcome relationship. RESULTS: A total of 70,296 first-time AF ablations at 186 U.S. hospitals were included. Overall, procedural success and MAE rate were 98.5 % and 1.0% respectively. With hospital volume (Q4) as a reference, the likelihood of procedural success was lower for Q1 (OR 0.44, 95%CI 0.29-0.68), Q2 (OR 0.50, 95%CI 0.33-0.75) and Q3 (OR 0.60, 95%CI 0.40-0.89); the results were similarly signifant for physician volume. With MAE for hospitals, there was an inverse procedural volume relationship for Q1 (OR 1.78, 95%CI 1.26-2.51) but not for Q2 (OR 1.06, 95%CI 0.77-1.46) or Q3 (OR 1.19, 95%CI 0.89-1.58) and similarly for physicians in Q1 and Q2, not in Q3. An adjusted MAE ≤ 1% was predicted by an annual volume of approximately 190 for hospitals and 60 for physicians. CONCLUSION: In this national cohort, hospital and physician AF ablation procedural volumes were directly related to acute procedural success and inversely related to rates of MAE.

QT prolongation predicts all-cause mortality above and beyond a validated risk score.

INTRODUCTION: QT prolongation is a risk factor for life-threatening arrhythmias and sudden cardiac death. In large cohorts, QT interval was associated with all-cause mortality, but these analyses may contain residual confounding. Whether the QT interval provides prognostic information above and beyond a validated mortality risk score is unknown. We hypothesized that QT interval on ECG will independently predict mortality after adjustment for the Care Assessment Needs (CAN) score, which was validated to predict mortality nationwide at the Veterans Administration (VA) (c-index 0.86). METHODS: Outpatients with an ECG at the Minneapolis VA from 2012 to 2016 were included in this retrospective cohort study. ECGs with ventricular rate < 50 or > 100 beats/min and those with QRS > 120 ms were excluded. QT intervals were corrected (QTc) using the Bazett's formula. CAN score, calculated within 1-week of the ECG, was obtained from the VA Corporate Data Warehouse. RESULTS: Of the 31,201 patients, 427 (1.4%) had QTc ≥ 500 ms, 1799 (5.8%) had QTc 470-500 ms and 28,975 (92.9%) had QTc < 470 ms. Compared to those with QTc < 470 ms, CAN-adjusted odds ratios (OR) for 1-year mortality (1.76 for QTc 470-500 and 2.70 for QTc > 500 ms; p < 0.0001 for both) and for 5-year mortality (1.75 for QTc 470-500 and 2.48 for QTc > 500 ms; p < 0.0001 for both) were significantly higher in those with longer QTc. C-index for CAN score and QTc predicting 1-year mortality was 0.837. CONCLUSIONS: QT prolongation predicts all-cause mortality independently of a validated mortality risk prediction score.

Left atrial appendage volume as a prognostic Indicator of long-term mortality in Cancer survivors treated with thoracic radiation.

BACKGROUND: Cancer survivors with prior chest radiation therapy (CXRT) frequently present with atrial fibrillation, heart failure, and have higher overall long-term mortality. There are no data examining the utility of left atrial (LA) and LA appendage (LAA) volume-indices to predict clinical outcomes in these patients. OBJECTIVES: We examined the prognostic value of cardiac phase-dependent 3-D volume-rendered cardiac computerized tomography (CT)-derived LA and LAA volume-indices to predict mortality and major adverse cardiac events (MACE) in cancer survivors treated with thoracic irradiation. METHOD: We screened 625 consecutive patients with severe aortic stenosis who had undergone transcatheter aortic valve replacement from 2012 to 2017. Based on the gated cardiac CT image quality, we included 184 patients (CXRT:43, non-CXRT:141) for further analysis. We utilized multiplane-3D-reconstructed cardiac CT images to calculate LA and LAA volume-indices, and examined the prognostic role of CCT-derived LA and LAA volume-indices in predicting the all-cause mortality, cardiovascular (CV) mortality, and MACE. We used multivariate cox-proportional hazard analysis to identify the clinical predictors of survival. RESULTS: Overall, the CXRT group had significantly elevated LAA volume-index compared to non-CXRT group (CXRT:11.2 ± 8.9 ml/m2; non-CXRT:8.6 ± 4.5 ml/m2, p = 0.03). On multivariate cox-proportional hazard analysis, the elevated LAA volume and LAA volume-index were the strongest predictors of reduced survival in CXRT group compared to non-CXRT group (LAA volume: RR = 1.03,95% CI 1.0-1.01, p = 0.01; and LAA volume index: RR = 1.05, 95% CI 1.0-1.01, p = 0.03). LAA volume > 21.9 ml was associated with increased mortality. In contrast, LA volume was not a significant predictor of mortality. CONCLUSION: We describe a novel technique to assess LA and LAA volume using 3-D volume-rendered cardiac CT. This study shows enlarged LAA volume rather than LA volume carries a poor prognosis in cancer-survivors treated with prior CXRT. Compared to conventionally reported markers, LAA volume of > 21.9 ml was incremental to that of other risk factors.

Contemporary approach to catheter ablation of ventricular tachycardia in nonischemic cardiomyopathy.

Nonischemic cardiomyopathy (NICM) comprises a heterogenous group of disorders with myocardial dysfunction unrelated to significant coronary disease. As the use of implantable defibrillators has increased in this patient population, catheter ablation is being utilized more frequently to treat NICM patients with ventricular tachycardia (VT). Progress has been made in identifying multiple subtypes of NICM with variable scar patterns. The distribution of scar is often mid-myocardial and subepicardial, and identifying and ablating this substrate can be challenging. Here, we will review the current understanding of NICM subtypes and the outcomes of VT ablation in this population. We will discuss the use of cardiac imaging, electrocardiography, and electroanatomic mapping to define the VT substrate and the ablation techniques required to successfully prevent VT recurrence.

Echocardiographic and Cardiac MRI Comparison of Longitudinal Strain and Strain Rate in Cancer Patients Treated with Immune Checkpoint Inhibitors.

Background: Immune checkpoint inhibitor (ICI)-induced cardiac side effects in cancer patients are increasingly being recognized and can be fatal. There is no standardized cardiac imaging test to examine the effects of ICIs in myocardial morphology and function. Objective: To study the utility of echocardiography and cardiac MRI in examining regional and global changes arising from ICI-induced myocarditis and cardiomyopathy in high-risk subjects suspected to have developed ICI cardiomyopathy. Methods: We studied eight consecutive patients referred for cardiac MRI (CMR) from a comprehensive cancer center for suspected ICI-induced myocarditis and compared the data with sixteen age-matched controls. Using newly developed strain analysis algorithms, we measured myocardial strain and strain rates using echocardiography and CMR. Then, we compared the mean longitudinal strain and strain rates derived from echocardiography and CMR in the same ICI-treated cohort of patients (n = 8). They underwent both of these imaging studies with images taken 24−48 h apart and followed up prospectively within the same hospital course. Results: All our cases had preserved ejection fraction (EF) > 50%. Echocardiogram showed reduced mean systolic longitudinal strain (LS, %) (ICI: −12.381 ± 4.161; control: −19.761 ± 1.925; p < 0.001), peak systolic strain rate (SRS, s−1) (ICI: −0.597 ± 0.218; control: −0.947 ± 0.135; p = 0.002) and early diastolic strain rate (SRE, s−1) (ICI: 0.562 ± 0.295; control: 1.073 ± 0.228; p = 0.002) in ICI-treated cases. Direct comparison between the echocardiogram vs. CMR obtained within the same hospital course demonstrated strong a correlation of LS scores (r = 0.83, p = 0.012) and SRS scores (r = 0.71, p = 0.048). The Bland−Altman plots showed that 95% of the data points fitted within the ±1.96 SD of the mean difference, suggesting an agreement among these two imaging modalities. Conclusion: In this feasibility cohort study, both echocardiography- and CMR-based strain indices illustrate changes in myocardial contractility and relaxation suggestive of ICI-induced cardiomyopathy. Our data, after validation in a larger cohort, can form the basis of myocardial imaging in cancer patients treated with ICIs.

Biventricular Strain Imaging with Cardiac MRI in Genotyped and Histology Validated Amyloid Cardiomyopathy.

Cardiac amyloidosis (CA) is a common and potentially fatal infiltrative cardiomyopathy. Contrast-enhanced cardiac MRI (CMR) is used as a diagnostic tool. However, utility of CMR for the comprehensive analysis of biventricular strains and strain rates is not reported as extensively as echocardiography. In addition, RV strain analysis using CMR has not been described previously. OBJECTIVES: We sought to study the global and regional indices of biventricular strain and strain rates in endomyocardial biopsy (EMB)-proven, genotyped cases of CA. METHODS: A database of 80 EMBs was curated from 2012 to 2019 based on histology. A total of 19 EMBs positive for CA were subjected to further tissue-characterization with histology, and compared with four normal biopsy specimens. Samples were genotyped for ATTR- or AL-subtypes. Five patients, with both echocardiography and contrast-enhanced CMR performed 72-h apart, were subjected to comprehensive analysis of biventricular strain and strain-rates. RESULTS: Histology confirmed that the selected samples were indeed positive for cardiac amyloid. Echocardiography showed reduced global and regional left-ventricular (LV) longitudinal strain indices. CMR with tissue-characterization of LV showed global reductions in circumferential, radial and longitudinal strains and strain-rates, following a general trend with the echocardiographic findings. The basal right-ventricular (RV) segments had reduced circumferential strains with no changes in longitudinal strain. CONCLUSIONS: In addition to providing a clinical diagnosis of CA based on contrast clearance-dynamics, CMR can be a potent tool for accurate functional assessment of global and regional changes in strain and strain-rates involving both LV and RV. Further studies are warranted to validate and curate the strain imaging capacity of CMR in CA.

Elevated myocardial wall stress after percutaneous coronary intervention in acute ST elevation myocardial infraction is associated with increased mortality.

BACKGROUND: Despite early attempts to salvage myocardium-at-risk with percutaneous coronary intervention (PCI), changes in myocardial wall stress (MWS) leads to ventricular dilatation and dysfunction after acute ST-elevation myocardial infraction (STEMI). Whether this is transient or leads to long-term adverse outcomes major adverse cardiovascular events (MACE) is not known. We studied the association between MWS and MACE in patients after a successful PCI for acute STEMI. OBJECTIVES: To study the MWS in percutaneously revascularized STEMI patients in relation to all-cause mortality and MACE. METHODS: We prospectively enrolled 142 patients who presented to our tertiary care hospital with acute STEMI requiring emergent PCI. In addition to the standard clinical biomarkers, both end-systolic and end-diastolic MWS was calculated using our recently validated Echocardiographic indices. Patients were then prospectively followed up to an average of 16.5 (± 12.0) months to assess all-cause mortality and MACE. RESULTS: During the follow-up period, 9% of the patients died and 17% developed MACE. Patients who died had significantly elevated end-systolic WS compared to those who survived (mean ESWS, 80.01 ± 36.86 vs 59.28 ± 27.68). There was no significant difference in end-diastolic WS, left ventricular systolic function and peak troponin levels among survivors versus non-survivors. Elevated ESWS (>62.5 Kpa) and age remained the significant predictors of mortality on multivariate logistic analysis (OR 7.75, CI 1.33-73.86, P = .03; OR 1.16, CI 1.06-1.31, P = .002). CONCLUSION: Elevated ESWS measured by echocardiogram is associated with increased odds of long-term mortality in STEMI patients who have undergone emergent PCI. This finding can help clinicians to risk stratify high-risk patients.

Change in hospitalization rates following transcatheter left atrial appendage occlusion.

Introduction: Left atrial appendage occlusion (LAAO) is recommended in patients with non-valvular atrial fibrillation (AF) who have contraindications to or are intolerant of long-term oral anticoagulants (OAC), but its impact on hospitalization rates has not been well described. The objective of our study is to describe the incidence of all-cause, bleeding-related, and thrombosis-related hospitalizations before and after LAAO. Material and methods: We used the Nationwide Readmission Database to include patients aged ≥ 18 years with a diagnosis of AF who underwent transcatheter LAAO during the months of February-November in each year between 2016 and 2018. Patients who died during the index procedure or had missing length of hospital stay or mortality information were excluded. Results: A total of 27,633 patients were included (median age: 77 years, 41% female) with an average pre- and post-LAAO monitoring period of 6.5 and 5.5 months respectively. Of these, 10,808 (39.1%) patients had one or more admissions prior to the procedure compared to 7,196 (26.0%) after the procedure. There was a 26% reduction in incidence of all-cause admissions (rate ratio (RR) = 0.74, 95% confidence interval (CI): 0.71-0.76; p < 0.001), 49% reduction in bleeding-related admissions (RR = 0.51, 95% CI: 0.48-0.55; p < 0.001), and 71% reduction in thrombosis-related readmissions (RR = 0.29, 95% CI: 0.26-0.33; p < 0.001) after LAAO. Conclusions: In a contemporary, nationally representative dataset, we found that LAAO is associated with a significant decrease in all-cause, bleeding-related, and thrombosis-related admissions. These findings lend support to the current use of transcatheter LAAO in clinical practice for patients with contraindications to OAC and/or at high risk of bleeding.

The Ideal Hospital Discharge Summary: A Survey of U.S. Physicians.

BACKGROUND: Hospital discharge summaries enable communication between inpatient and outpatient physicians. Despite existing guidelines for discharge summaries, they are frequently suboptimal. OBJECTIVE: The aim of this study was to assess physicians' perspectives about discharge summaries and the differences between summaries' authors (hospitalists) and readers (primary care physicians [PCPs]). METHODS: A national survey of 1600 U.S. physicians was undertaken. Primary measures included physicians' preferences in discharge summary standardization, content, format, and audience. RESULTS: A total of 815 physicians responded (response rate = 51%). Eighty-nine percent agreed that discharge summaries "should have a standardized format." Most agreed that summaries should "document everything that was done, found, and recommended in the hospital" (64%) yet "only include details that are highly pertinent to the hospitalization" (66%). Although 74% perceived patients as an important audience of discharge summaries, only 43% agreed that summaries "should be written in language that patients…can easily understand," and 68% agreed that it "should be written solely for provider-to-provider communication." Compared with hospitalists, PCPs preferred comprehensive summaries (68% versus 59%, P = 0.002). More PCPs agreed that separate summaries should be created for patients and for provider-to-provider communication than hospitalists (60% versus 47%, P < 0.001). Compared with PCPs, more hospitalists believe that "hospitalists are too busy to prepare a high-quality discharge summary" (44% versus 23%, P < 0.001) and "PCPs have insufficient time to read an entire discharge summary" (60% versus 38%, P < 0.001). CONCLUSIONS: Physicians believe that discharge summaries should have a standardized format but do not agree on how comprehensive or in what format they should be. Efforts are necessary to build consensus toward the ideal discharge summary.

Macrophage-specific protein perforin-2 is associated with poor neurological recovery and reduced survival after sudden cardiac arrest.

BACKGROUND: Biomarkers involved in inflammation and stress response were implicated in patients who were successfully resuscitated from out of hospital cardiac arrest (sR-OHCA). Here we report that macrophage-expressed gene, perforin-2, an evolutionarily conserved protein with membrane attack domain, is associated with poor neurological outcomes and mortality after sR-OHCA. OBJECTIVES: To examine the association between circulating perforin-2 protein measured within 6-h of sR-OHCA, mortality and neurological outcomes. METHODS: We prospectively enrolled 144 sR-OHCA patients from 4 different tertiary care centers. We measured perforin-2 and other conventional clinical biomarkers and compared between survivors vs. non-survivors. The neurological outcomes were dichotomized as poor or good according to the cereberal performance score. RESULTS: At the end of the hospital stay, 45% of the patients had died and 46% had poor neurological outcomes. Serum perforin-2 levels were significantly higher in patients with poor neurological recovery, compared to the ones with good neurological recovery (ng/mL, 13.7 ±â€¯45.9 vs. 1.2 ±â€¯7.0, p = 0.01). There were no differences in other routinely measured biomarkers and left ventricular ejection fraction. On multivariate logistic regression, elevated perforin-2 (OR: 12.78, 95% CI: 1.0-17.8, p = 0.02), comatose on presentation (OR: 27.82, 95% CI: 0.2-19.5, p = 0.02) and non-shockable rhythm (OR: 17.04, 95% CI: 0.7-15.7, p = 0.01) were the significant predictors of poor neurological outcome. CONCLUSIONS: This study reports a novel macrophage-expressed circulating biomarker perforin-2 to be strongly associated with reduced survival and poor neurological outcomes in sR-OHCA. These data can guide clinicians to prognosticate survival and neurological outcomes in sR-OHCA, and also form the basis for future therapeutic approaches.

Anomalous Right Superior Vena Cava in an Asymptomatic Patient.

Congenital superior vena cava (SVC) anomalies are not uncommon. However, an absence of a left SVC and an anomalous right SVC without additional congenital heart defects is very rare. We present a 38-year-old male with an 'anomalous SVC' that was found to be descending anterior to the pleural space and draining into the inferior vena cava (IVC) at the level of the right atrium. This was associated with an anomalous right upper and lower pulmonary vein draining into this anomalous SVC. To our knowledge, this combination of congenital anomalies has not been previously described in the medical literature.

Information Transfer at Hospital Discharge: A Systematic Review.

BACKGROUND: Prompt, complete, and accurate information transfer at the time of discharge between hospital-based and primary care providers (PCPs) is needed for the provision of safe and effective care. PURPOSE OF THE STUDY: To evaluate timeliness, quality, and interventions to improve timeliness and quality of hospital discharge summaries. DATA SOURCES: PubMed, MEDLINE, EMBASE, CINAHL, Web of Science, and Scopus database published in English between January 2007 and February 2014 were searched. We also hand-searched bibliographies of relevant articles. STUDY SELECTION: Observational studies investigating transfer of information at hospital discharge (n = 7) and controlled studies evaluating interventions to improve timeliness and quality of discharge information (n = 12) were included. DATA EXTRACTION: We extracted data on availability, timeliness, and content of hospital discharge summaries and on the effectiveness of interventions targeting discharge summaries. Results of studies are presented narratively and using descriptive statistics. DATA SYNTHESIS: Across the studies, discharge summaries were completed within 48 hours in a median of 67% and were available to PCPs within 48 hours only 55% of the time. Most of the time, discharge summaries included demographics, primary diagnosis, hospital course, and discharge instructions. However, information was limited to pending test results (25%), diagnostic tests performed (60%), and postdischarge medications (78%). In 6 interventional studies, implementation of electronic discharge summaries was associated with improvement in timeliness but not quality. CONCLUSIONS: Delayed or insufficient transfer of discharge information between hospital-based providers and PCPs remains common. Creation of electronic discharge summaries seems to improve timeliness and availability but does not consistently improve quality.

Clinical Outcomes after Transcatheter Aortic Valve Replacement in Cancer Survivors Treated with Ionizing Radiation.

BACKGROUND: Improved cancer survival in patients treated with thoracic ionizing radiation (XRT) has resulted in unanticipated surge of aortic stenosis. Transcatheter aortic valve replacement (TAVR) has revolutionized the management of severe aortic stenosis. However, long-term clinical outcomes in radiation-exposed cohorts undergoing TAVR are unknown. We compared the all-cause mortality and major adverse cardiac events (MACE) in patients with prior chest XRT (C-XRT) undergoing TAVR. METHODS: This is an observational cohort study in subjects who underwent TAVR for symptomatic severe aortic stenosis from 2012 to 2017 in a tertiary care referral center. We examined the all-cause mortality and MACE using cox proportional hazard analysis to identify the clinical predictors of survival in the cohort of patients who had a history of prior C-XRT for malignancy. RESULTS: Of the 610 patients who underwent TAVR for symptomatic severe aortic stenosis, 75 had prior C-XRT. The majority of C-XRT patients had prior breast cancer (44%) followed by Hodgkin's lymphoma (31%), with the median time from XRT to TAVR of 19.0 years. During a mean follow up of 17.1 months after TAVR, all-cause mortality was 17%. Those with prior C-XRT had higher all-cause mortality (XRT: 29%; non-XRT:15%, p<0.01) and MACE (XRT: 57%; non-XRT: 27%, p<0.001) after TAVR. Patients with prior XRT had a higher incidence of atrial fibrillation (XRT: 48 %; non-XRT: 2.4%, p<0.01) and high-grade heart block (XRT: 20%; non-XRT: 9.1%, p=0.007) requiring pacemaker implant after TAVR. On multivariate cox proportional hazard analysis, prior XRT (HR: 2.07, p=0.003), poor renal function (HR: 1.29, p<0.001) and post-operative anemia requiring transfusion (HR: 1.16, p:0.001) were the strongest predictors of reduced survival. CONCLUSIONS: Cancer survivors with prior C- XRT have higher incidence of all-cause mortality and MACE after TAVR. Careful patient selection and follow-up strategies are needed to improve outcomes.

Inter- and Intraoperator Variability in Measurement of On-Site CT-derived Fractional Flow Reserve Based on Structural and Fluid Analysis: A Comprehensive Analysis.

PURPOSE: To measure the inter- and intraobserver variability among operators of varying expertise in conducting CT-derived fractional flow reserve (CT FFR) measurements on-site by using structural and fluid analysis and to evaluate differences in reproducibility between two different training methods for end users. MATERIALS AND METHODS: This retrospective analysis of the prospectively enrolled cohort included 22 symptomatic patients who underwent both 320-detector row coronary CT angiography and catheter-derived fractional flow reserve (FFR) within 90 days. Thirteen operators of varying expertise were assigned to one of two training arms: arm 1, on-site training by a specialist in CT FFR technology; arm 2, self-training through use of written materials. After the training, all 13 operators reviewed the CT data and measured CT FFR in 24 vessels in 22 patients. Inter- and intraoperator variability and agreements between CT FFR and catheter-derived FFR measurements were evaluated. RESULTS: The overall intraclass correlation coefficient (ICC) among operators was 0.71 (95% confidence interval: 0.58, 0.83) with a mean absolute difference (± standard deviation) of 0.027 ± 0.022. The operators in arm 2 showed greater interoperator differences than those in arm 1 (0.031 ± 0.024 vs 0.023 ± 0.018; P = .024). Among operators who recalculated CT FFR, the mean CT FFR value did not significantly differ between the first and second calculations (ICC, 0.66; 95% confidence interval: 0.46, 0.87), with the medical specialists producing the lowest intraoperator variability (0.053 ± 0.060). The overall correlation coefficient between CT FFR and catheter FFR was r = 0.61, with a mean absolute difference of 0.096 ± 0.089. CONCLUSION: Good reproducibility of CT FFR values calculated on-site on the basis of structural and fluid analysis was observed among operators of varying expertise. Face-to-face training sessions may cause less variability.© RSNA, 2019Supplemental material is available for this article.

Elevated end-diastolic wall stress after acute myocardial infarction predicts adverse cardiovascular outcomes and longer hospital length of stay.

BACKGROUND: Acute myocardial infarction (MI) leads to ventricular remodeling in response to oxygen demand. Such changes include left ventricular (LV) dilatation and increased myocardial wall stress. Prior studies showed that wall stress is a vital parameter of cardiac remodeling. However, outcome data are lacking. We aim to investigate wall stress post-MI in relation to biomarkers of cardiac remodeling and cardiovascular outcomes. METHODS: Patients presenting with ST-elevation MI (STEMI) requiring primary percutaneous intervention (PCI) were enrolled prospectively. LVEF and volume-based end-diastolic (EDWS) and end-systolic (ESWS) wall stress were measured from predischarge echocardiograms. Serum samples were collected for measurement of serum biomarkers. We identified 81 patients meeting inclusion criteria (64% men, 36% women) with a mean age of 61. The primary outcome was major adverse cardiovascular events (MACE) defined as 1-year composite endpoint of cardiac mortality, recurrent MI, revascularization, or stroke. Length of hospitalization (LOH) was recorded. RESULTS: Major adverse cardiovascular events-positive patients (n = 12) had significantly higher EDWS levels (15.87 vs 12.33, P = 0.045), and galectin-3 levels (19.07 vs 11.75, P = 0.015), and lower LVEF (40.0% vs 48.4%, P = 0.023) compared to MACE-negative patients. Patients with LOH > 72 hours (n = 33) had significantly higher EDWS, galectin-3, and peak troponin, and lower LVEF compared to patients with LOH < 72 hours. EDWS positively correlated with LOH and galectin-3. EDWS was an independent predictor of MACE by binomial regression analysis. CONCLUSION: End-diastolic walls tress is a potential prognostic tool for risk stratifying STEMI patients, providing an assessment of the functional consequences of myocardial remodeling. It is predictive of MACE independent of LVEF, associated with longer hospitalizations, and correlates with galectin-3, a biomarker of cardiac remodeling.

Motivation, Perception, and Treatment Beliefs in the Myocardial Infarction Genes (MI-GENES) Randomized Clinical Trial.

Little is known about individuals' motivation, perception, and treatment beliefs towards the use of genetic information in risk estimates for coronary heart disease (CHD). In this study, participants at intermediate 10-year risk of CHD were randomized to receive either their estimated conventional risk score (CRS) alone, or a CRS and a genetic risk score (GRS), by a genetic counselor. Surveys on motivation to participate in and perception of genetic testing for CHD were administered at 3 months and treatment beliefs at 6 months following risk disclosure. Survey responses used Likert scales. Linear and logistic regression were used for analysis. Overall, motivation to participate in genomic clinical trials was favorable and did not differ between the CRS and GRS groups (16.95 ± 0.82 vs. 17.58 ± 0.83, p = 0.091), but participants who initially received their GRS indicated a greater desire to find ways to improve health as a reason for participation (OR: 0.53 (95%CI: 0.29, 0.94), p = 0.028). Perception of genetic testing was also favorable in both groups (15.29 ± 0.39 vs. 15.12 ± 0.40, p = 0.835). Participants who initially received their GRS were more inclined to recommend genetic testing to family and friends (9.95 ± 1.88 vs. 10.52 ± 2.17, p = 0.023). In the MI-GENES study, motivation to participate in and perception of genetic testing among study participants were overall favorable. Genetic risk disclosure was associated with increased motivation to recommend genetic testing to family and friends.

Association between elevated blood glucose level on admission and long-term mortality in patients with acute decompensated heart failure.

BACKGROUND: The effect of elevated blood glucose (BG) levels on the long-term prognosis of acute decompensated heart failure (ADHF) patients has not been well defined. The purpose of this study is to evaluate the long-term prognosis of ADHF with elevated BG. METHODS: A cohort of patients consecutively admitted to the cardiac intensive care unit from 2007 to 2011 was studied. Among these, 495 patients who met the criteria were divided into 4 groups based on their BG level and diabetes mellitus (DM) status. The risks for all-cause mortality in each group were assessed using the multivariate Cox proportional hazards model. RESULTS: At a median follow-up of 1.8 years, 148 patients had died. There were 168 patients without either BG elevation or DM, 67 without BG elevation but with DM, 105 with BG elevation but not DM, and 155 with both BG elevation and DM. In a multivariate model, those with BG elevation, regardless of DM status, showed a greater risk of increased mortality when compared with patients without either BG elevation or DM [hazard ratio (HR), 1.79; p=0.042 for BG elevation without DM and HR, 1.73; p=0.048 for BG elevation with DM]. CONCLUSION: Elevated BG levels, irrespective of the DM status, at the time of admission in patients with ADHF, appear to be a prognostic marker for ADHF.

An effect of left ventricular hypertrophy on mild-to-moderate left ventricular diastolic dysfunction.

OBJECTIVES: Left ventricular diastolic dysfunction (LVDD) is associated with a variety of medical conditions. Left ventricular hypertrophy (LVH) is one of the most common abnormalities that induce LVDD. However, it is unclear whether LVH is a predictor of future LVDD deterioration that leads to diastolic heart failure in patients who already have mild-to-moderate LVDD. In this study, we investigated the effect of LVH on LV diastolic function in mild-to-moderate LVDD patients. METHODS: Of the patients with mild-to-moderate LVDD (Grade I and II) with preserved left ventricular ejection fraction (EF), 225 with LVH (LVH group) and 225 without LVH (non-LVH group) were consecutively selected. LVDD was defined by the abnormal patterns of Doppler mitral inflow and tissue Doppler. Left ventricular filling pressure (FP) was estimated by the following formula: 1.9 +1.24× [early mitral inflow velocity (E)/early mitral annular velocity (e')]. The Tei index was implemented to assess global (both systolic and diastolic) left ventricular function. Echocardiographic parameters for LVDD, such as isovolumic relaxation time (IVRT), were compared between the two groups. RESULTS: FP and Tei index were significantly higher in the LVH group compared to the non-LVH group [15.68 mmHg vs. 14.07 mmHg, P < 0.0001, and 0.58 vs. 0.53, P < 0.003, respectively]. IVRT was significantly longer in the LVH group than in the non-LVH group [103.93 ± 23.93 vs. 95.94 ± 20.16, P < 0.0001]. CONCLUSIONS: In mild-to-moderate LVDD patients, both FP and the Tei index were significantly higher when LVH was present. This may suggest LVH as a possible predictor for the future development of severe LVDD and diastolic heart failure.