Statin use prior to angiography for the prevention of contrast-induced acute kidney injury: a meta-analysis of 19 randomised trials.

AIMS: A systematic review and a meta-analysis were performed to define better the role of statin use prior to angiography in preventing contrast-induced acute kidney injury (CI-AKI). METHODS AND RESULTS: MEDLINE, Embase, Cochrane Library, references from review articles, and conference proceedings were searched, with no language restriction, for randomised controlled trials (RCT) evaluating the use of statin therapy prior to angiography for the prevention of CI-AKI. Nineteen RCTs including 7,161 patients were identified. The pooled analysis demonstrated a significant reduction in the incidence of CI-AKI in patients treated with statin prior to invasive angiography when compared with control (RR 0.52; 95% CI: 0.40-0.67). Patients with chronic kidney disease stage 3 or worse were largely underrepresented in these trials, and statin therapy did not significantly reduce the risk of CI-AKI in the three studies which enrolled a patient population with a mean eGFR of <60 ml/min (RR 0.54; 95% CI: 0.2-1.42). CONCLUSIONS: This meta-analysis suggests a potential benefit for statin use prior to angiography to reduce the incidence of CI-AKI. Additional research is needed to define better the benefits of statin therapy prior to angiography to prevent CI-AKI, especially in high-risk patients with chronic kidney disease who were largely underrepresented in the available trials.

Racial disparities in outcomes following PEA and asystole in-hospital cardiac arrests.

AIM: To define the racial differences present after PEA and asystolic IHCA and explore factors that could contribute to this disparity. METHODS: We analyzed PEA and asystolic IHCA in the Get-With-The-Guidelines-Resuscitation database. Multilevel conditional fixed effects logistic regression models were used to estimate the relationship between race and survival to discharge and return of spontaneous circulation (ROSC), sequentially controlling for hospital, patient demographics, comorbidities, arrest characteristic, process measures, and interventions in place at time of arrest. RESULTS: Among the 561 hospitals, there were 76,835 patients who experienced IHCA with an initial rhythm of PEA or asystole (74.8% white, 25.2% black). Unadjusted ROSC rate was 55.1% for white patients and 54.1% for black patients (unadjusted OR: 0.94 [95% CI, 0.90-0.98], p=0.016). Survival to discharge was 12.8% for white patients and 10.4% for black patients (unadjusted OR: 0.83 [95% CI, 0.78-0.87], p<0.001). After adjusting for temporal trends, patient characteristics, hospital, and arrest characteristics, there remained a difference in survival to discharge (OR: 0.85 [95% CI, 0.79-0.92]) and rate of ROSC (OR: 0.88 [95% CI, 0.84-0.92]). Black patients had a worse mental status at discharge after survival. Rates of DNAR placed after survival from were lower in black patients with a rate of 38.3% compared to 44.5% in white patients (p<0.001). CONCLUSION: Black patients are less likely to experience ROSC and survival to discharge after PEA or asystole IHCA. Individual patient characteristics, event characteristics, and hospital characteristics don't fully explain this disparity. It is possible that disease burden and end-of-life preferences contribute to the racial disparity.

Report from a consensus conference on primary graft dysfunction after cardiac transplantation.

Although primary graft dysfunction (PGD) is fairly common early after cardiac transplant, standardized schemes for diagnosis and treatment remain contentious. Most major cardiac transplant centers use different definitions and parameters of cardiac function. Thus, there is difficulty comparing published reports and no agreed protocol for management. A consensus conference was organized to better define, diagnose, and manage PGD. There were 71 participants (transplant cardiologists, surgeons, immunologists and pathologists), with vast clinical and published experience in PGD, representing 42 heart transplant centers worldwide. State-of-the-art PGD presentations occurred with subsequent breakout sessions planned in an attempt to reach consensus on various issues. Graft dysfunction will be classified into primary graft dysfunction (PGD) or secondary graft dysfunction where there is a discernible cause such as hyperacute rejection, pulmonary hypertension, or surgical complications. PGD must be diagnosed within 24 hours of completion of surgery. PGD is divided into PGD-left ventricle and PGD-right ventricle. PGD-left ventricle is categorized into mild, moderate, or severe grades depending on the level of cardiac function and the extent of inotrope and mechanical support required. Agreed risk factors for PGD include donor, recipient, and surgical procedural factors. Recommended management involves minimization of risk factors, gradual increase of inotropes, and use of mechanical circulatory support as needed. Retransplantation may be indicated if risk factors are minimal. With a standardized definition of PGD, there will be more consistent recognition of this phenomenon and treatment modalities will be more comparable. This should lead to better understanding of PGD and prevention/minimization of its adverse outcomes.

Correlation between myocardial fibrosis and restrictive cardiac physiology in patients undergoing retransplantation.

After cardiac transplant, there is often development of restrictive cardiac physiology. Little is known about the factors that contribute to this physiology and its correlation with pathology. Heart retransplantation provides a valuable opportunity to further understand this relationship. In this study, we investigated the correlation of myocardial fibrosis and restrictive physiology, and possible risk factors utilizing data from all retransplants at our center. A retrospective review of the 30 patients who underwent retransplantation at our institution between 1994 and 2004 was performed. Hemodynamic and imaging data were reviewed for the presence of restrictive physiology. Pathology reports were reviewed for the presence of myocardial fibrosis in the explanted hearts. The cohort with restrictive physiology preceding redo heart transplant had significantly more patients exhibiting myocardial fibrosis compared with the non-restrictive physiology group (94.1% vs. 15.4%, p < 0.001). We found no difference in the immunosuppressive regimen, history of rejection, and reason for transplant. In our study, we observed that myocardial fibrosis is an important contributor to the development of restrictive physiology. Further work needs to be done for risk stratification and the mechanism of fibrosis development.

A text messaging intervention to improve heart failure self-management after hospital discharge in a largely African-American population: before-after study.

BACKGROUND: There is increasing interest in finding novel approaches to reduce health disparities in readmissions for acute decompensated heart failure (ADHF). Text messaging is a promising platform for improving chronic disease self-management in low-income populations, yet is largely unexplored in ADHF. OBJECTIVE: The purpose of this pre-post study was to assess the feasibility and acceptability of a text message-based (SMS: short message service) intervention in a largely African American population with ADHF and explore its effects on self-management. METHODS: Hospitalized patients with ADHF were enrolled in an automated text message-based heart failure program for 30 days following discharge. Messages provided self-care reminders and patient education on diet, symptom recognition, and health care navigation. Demographic and cell phone usage data were collected on enrollment, and an exit survey was administered on completion. The Self-Care of Heart Failure Index (SCHFI) was administered preintervention and postintervention and compared using sample t tests (composite) and Wilcoxon rank sum tests (individual). Clinical data were collected through chart abstraction. RESULTS: Of 51 patients approached for recruitment, 27 agreed to participate and 15 were enrolled (14 African-American, 1 White). Barriers to enrollment included not owning a personal cell phone (n=12), failing the Mini-Mental exam (n=3), needing a proxy (n=2), hard of hearing (n=1), and refusal (n=3). Another 3 participants left the study for health reasons and 3 others had technology issues. A total of 6 patients (5 African-American, 1 White) completed the postintervention surveys. The mean age was 50 years (range 23-69) and over half had Medicaid or were uninsured (60%, 9/15). The mean ejection fraction for those with systolic dysfunction was 22%, and at least two-thirds had a prior hospitalization in the past year. Participants strongly agreed that the program was easy to use (83%), reduced pills missed (66%), and decreased salt intake (66%). Maintenance (mean composite score 49 to 78, P=.003) and management (57 to 86, P=.002) improved at 4 weeks, whereas confidence did not change (57 to 75, P=.11). Of the 6 SCHFI items that showed a statistically significant improvement, 5 were specifically targeted by the texting intervention. CONCLUSIONS: Over half of ADHF patients in an urban, largely African American community were eligible and interested in participating in a text messaging program following discharge. Access to mobile phones was a significant barrier that should be addressed in future interventions. Among the participants who completed the study, we observed a high rate of satisfaction and preliminary evidence of improvements in heart failure self-management.

Resident education in free clinics: an internal medicine continuity clinic experience.

BACKGROUND: Most internal medicine (IM) residency programs provide ambulatory training in academic medical centers. Community-based ambulatory training has been suggested to improve ambulatory and primary care education. Free clinics offer another potential training setting, but there have been few reports about the experience of IM residents in free clinics. OBJECTIVE: We assessed the feasibility and acceptability of inclusion of an ambulatory rotation in a free clinic and IM residency curriculum and the advantages of the free clinic setting over the traditional ambulatory clinic model. METHODS: In 2010, the University of Chicago Internal Medicine Residency Program partnered with a free clinic in order to establish a community-based continuity clinic experience. To assess the feasibility of this innovation, 16 residents were surveyed 9 months after implementation of the clinic to determine satisfaction, perceived preparation to address common medical conditions, and attitudes toward the underserved care population. A subset of these responses was compared to responses from residents in the traditional clinic model. RESULTS: Residents in the free clinic rotation were more satisfied and perceived they were more prepared to work in low-resource settings and reported similar levels of preparation regarding common outpatient conditions than residents in a traditional continuity clinic format. They reported increased future likelihood of working in an underserved clinic. CONCLUSIONS: Our exploratory study suggests free clinics may be an effective platform for community-based continuity clinic training.

Comparison of the updated 2011 appropriate use criteria for echocardiography to the original criteria for transthoracic, transesophageal, and stress echocardiography.

BACKGROUND: The aim of this study was to compare appropriateness designations as determined by the updated 2011 appropriate use criteria (AUC) for echocardiography with prior versions of the AUC for transthoracic echocardiographic (TTE) imaging, transesophageal echocardiographic (TEE) imaging, and stress echocardiographic (SE) imaging. An additional goal was to define relationships between appropriateness determinations and echocardiographic findings for each modality. METHODS: Previously published data sets of TTE, TEE, and SE studies were reclassified according to the 2011 AUC, and indication representation, appropriateness designations, and echocardiographic findings were compared with prior classifications according to the 2007 AUC for TTE and TEE imaging and the 2008 AUC for SE imaging. RESULTS: Overall, 2,247 echocardiographic studies were analyzed. The 2011 AUC addressed the vast majority of studies (98%), a marked increase compared with prior versions of the AUC (89%) (P < .001). An increase in addressed studies was present in each echocardiographic modality (TTE imaging: n = 1,525, 98% vs 89%, P < .001; TEE imaging: n = 405, 99.7% vs 91%, P < .01; SE imaging: n = 289, 97% vs 88%, P < .01). Among all echocardiographic procedures, the 2011 AUC found a lower frequency of appropriate studies compared with prior AUC (82% vs 88%, P < .01), primarily because of new uncertain indications for TTE imaging. The frequency of inappropriate echocardiographic studies was unchanged (11%). Among all echocardiographic procedures, the 2011 AUC found appropriate studies to have more new abnormal echocardiographic findings compared with inappropriate studies (45% vs 13%, P < .001). Interestingly, 2011 AUC inappropriate TTE studies had fewer major new echocardiographic abnormalities than 2007 AUC inappropriate TTE studies (9% vs 17%, P = .04). CONCLUSIONS: The updated 2011 AUC for echocardiography encompass the vast majority of echocardiographic procedures in a university hospital practice, filling virtually all of the gaps identified in prior versions of the AUC for TTE, TEE, and SE imaging. The 2011 AUC also reasonably stratify the likelihood of finding an echocardiographic abnormality, demonstrating improvement compared with the prior AUC.

Bedside hand-carried ultrasound by internal medicine residents versus traditional clinical assessment for the identification of systolic dysfunction in patients admitted with decompensated heart failure.

BACKGROUND: The rapid detection of left ventricular systolic dysfunction (LVSD) is an important step in the clinical management of patients admitted with acute decompensated heart failure, because it allows the initiation of treatment specific to LVSD and avoidance of contraindicated therapies. The aim of this study was to determine whether internal medicine residents with limited ultrasound training could use hand-carried ultrasound (HCU) to identify LVSD. METHODS: Fifty patients admitted with acute decompensated heart failure were imaged from the parasternal window at the bedside with an HCU device by residents blinded to all clinical data, who had undergone limited cardiac ultrasound training (20 practice studies). Ejection fraction (EF) on HCU was graded as >40% or <40%. HCU EF and a number of physical exam findings and electrocardiographic and laboratory variables were compared for their ability to predict to formal echocardiographic left ventricular EF. RESULTS: The average formal EF was 32 ± 16% (range, 7%-70%), with 66% of patients having EFs < 40%. The residents' ability to detect an EF < 40% with HCU was excellent (sensitivity, 94%; specificity, 94%; negative predictive value, 88%; positive predictive value, 97%). Binary logistic regression demonstrated that HCU EF was the most powerful predictor of EF < 40%, with minimal additional value from clinical, exam, lab, and electrocardiographic variables. The time interval between clinical assessment and availability of formal echocardiographic results was 22 ± 17 hours. CONCLUSIONS: Residents with limited training in cardiac ultrasound were able to identify LVSD in patients with acute decompensated heart failure with superior accuracy compared with clinical, physical exam, lab, and electrocardiographic findings and an average of 22 hours before the results of formal echocardiography were available.

Use of a web-based application of the American College of Cardiology Foundation/American Society of Echocardiography Appropriateness Use Criteria for Transthoracic Echocardiography: a pilot study.

BACKGROUND: Clinical application of the American College of Cardiology Foundation Appropriate Use Criteria (AUC) represents a potentially feasible alternative to third-party pre-certification for imaging procedures and will soon be required as part of the accreditation process for imaging laboratories. Electronic tools that rapidly apply the AUC are needed in clinical practice. We developed and tested a web-based application of the AUC to track appropriateness of transthoracic echocardiography (TTE). METHODS: Indications for outpatient TTE studies performed in a university hospital echocardiography laboratory were assessed prospectively at the point of service using a prototype web-based AUC application (Echo AUC App). The Echo AUC App was developed on the basis of our own prior published data regarding indication frequency to minimize time and screens required for completion. Echo AUC App-determined indications were compared with blinded investigator-determined indications based on review of relevant medical records. Echo AUC App characteristics, including Echo AUC App entry time, were recorded. RESULTS: Of the 258 studies enrolled, Echo AUC App-determined TTE indications were Appropriate (A) in 77% (n = 198), Inappropriate (I) in 9% (n = 23), and Not Classified (NC) by the AUC in 14% (n = 37). Agreement between Echo AUC App- and investigator-determined classifications was excellent (94%, kappa statistic 0.83). Mean Echo AUC App study entry time was 55 seconds (range 25-280 seconds). CONCLUSION: The use of an electronic application allows rapid and accurate implementation of the AUC for TTE at the point of service. Such an application could be installed in echocardiography laboratories to track appropriateness in accordance with soon-to-be-implemented accreditation requirements. Further study of this Echo AUC App at the point of order may provide an alternative to third-party pre-certification procedures.