Post-Myocardial Infarction Ventricular Septal Defect: A Comprehensive Review.

Post-myocardial infarction (MI) ventricular septal defect (VSD) is a rare but potentially catastrophic mechanical complication that occurs in <1% of patients following a myocardial infarction and it is associated with a high morbidity and mortality despite improvements in medical and surgical therapies. Post-MI VSD is a medical emergency and outcome is very poor in medically treated patients. Treatment of choice remains surgical closure of defect and transcatheter defect closure less so. We performed a comprehensive review of the clinical presentation and management options of post-MI VSD.

Risk, Outcomes, and Predictors of Clostridium difficile Infection in Lymphoma: A Nationwide Study.

OBJECTIVE: The risk of Clostridium difficile infection (CDI) has not been well studied in patients with lymphoma. We thus sought to determine the risk of CDI in hospitalizations with lymphoma along with its trend, outcomes, and predictors using a large database. METHODS: Hospital discharge data from the Nationwide Inpatient Sample (NIS) from 2007 to 2011 were used for the study. Using the International Classification of Diseases, Ninth Revision, Clinical Modification codes, all adult patients aged 18 years or older having a primary diagnosis of lymphoma were queried for the presence of CDI as any of the secondary diagnoses. The risk of CDI in lymphoma and its yearly trend were assessed. We performed multivariate logistic regression to determine the independent risk factors of CDI in lymphoma. Furthermore, we studied mortality and other adverse outcomes of CDI in patients with lymphoma. RESULTS: There were 236,312 discharges (weighted) with the primary diagnosis of lymphoma. CDI was present in 2.13% of patients with lymphoma versus 0.8% in the nonlymphoma group (P < 0.001). On multivariate analysis, the significant predictors of CDI in lymphoma were presence of infection (odds ratio [OR] 3.1, 95% confidence interval [CI] 2.7-3.6), stem cell transplant (OR 2.7, 95% CI 2.3-3.4), graft-versus-host disease (OR 1.9, 95% CI 1.4-2.8), race (Asian vs white, OR 1.6, 95% CI 1.1-2.4), chemotherapy (OR 1.6, 95% CI 1.4-1.8), gastrointestinal surgery (OR 1.4, 95% CI 1.2-1.7), and Charlson Comorbidity Index (CCI) (CCI of 2 vs 0-1: OR 1.2, 95% CI 1.1-1.4; CCI of 3 vs 0-1: OR 1.3, 95% CI 1.03-1.6). CDI in lymphoma was associated with worse hospital outcomes such as increased mortality (17% vs 8%), increased length of stay (23.6 vs 9.9 days), mean total hospital charges ($197,015 vs $79,392), rate of intubation (13% vs 4% vs 13%), and rate of total parenteral nutrition (11% vs 3%). CONCLUSIONS: Hospitalization with lymphoma was associated with an increased risk of CDI. The significant predictors for CDI in lymphoma were infection, stem cell transplant, graft-versus-host disease, race, chemotherapy, gastrointestinal surgery, and Charlson Comorbidity Index. CDI in lymphoma was associated with increased mortality and other adverse outcomes warranting a need of more vigilance for CDI in patients with lymphoma.

Modifiable Predictors of In-Hospital Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has become an acceptable therapy for patients with severe aortic valve stenosis at high or prohibitive surgical risk. Attempts are ongoing to validate risk prediction models for in-hospital mortality after TAVR. Our aim was to define modifiable risk factors predictive of in-hospital mortality after TAVR. METHODS: We identified patients who underwent TAVR from the 2012 database of the National Inpatient Sample. Patients who died during the index hospitalization were compared to those that were successfully discharged. The predictors of in-hospital mortality were analyzed using multivariate logistic regression. RESULTS: A total of 1,360 patients (mean age 81 ± 8.8 years, whites 80.1%, blacks 3.5%) had TAVR and 68 (5%) died during hospitalization (χ2 [1, n = 1,360] = 1,101.6, P < 0.001). The average length of hospital stay was 8.33 ± 6.7 days. The positive predictors of in-hospital mortality in the unadjusted model were comorbidities such as congestive heart failure, coagulopathy, fluid and electrolyte disorder, weight loss and history of drug abuse. Hypertension was a negative predictor of in-hospital mortality. Following multivariate analysis and adjustment for possible confounders, fluid and electrolyte disorder was the only significant positive predictor of in-hospital mortality (odds ratio = 1.89, CI: 1.11-3.22, P = 0.019). The odds of in-hospital mortality were reduced in patients with hypertension (odds ratio = 0.45, CI: 0.26-0.78, P = 0.004). CONCLUSIONS: Fluid and electrolyte disturbance could be a modifiable predictor of in-hospital mortality following TAVR. Efforts should be geared towards reducing its occurrence in this patient population.

A comprehensive meta-analysis of stem cell therapy for chronic angina.

BACKGROUND: A substantial proportion of patients with coronary artery disease do not achieve complete revascularization and continue to experience refractory angina despite optimal medical therapy. Recently, stem cell therapy has emerged as a potential therapeutic option for these patients. However, findings of individual trials have been scrutinized because of their small sample sizes and lack of statistical power. Therefore, we conducted an updated comprehensive meta-analysis of available randomized controlled trials (RCTs) with the largest sample size ever reported on this subject. HYPOTHESIS: In patients with chronic angina stem cell therapy improves clinical outcomes. METHODS: Scientific databases and websites were searched for RCTs. Data were independently collected by 2 investigators, and disagreements were resolved by consensus. Data from 10 trials including 658 patients were analyzed. RESULTS: Stem cell therapy improved Canadian Cardiovascular Society angina class (risk ratio: 1.53, 95% CI: 1.09 to 2.15, P = 0.013), exercise capacity (standardized mean difference [SMD]: 0.56, 95% CI: 0.23 to 0.88, P = 0.001), and left ventricular ejection fraction (SMD: 0.63, 95% CI: 0.27 to 1.00, P = 0.001) compared with placebo. It also decreased anginal episodes (SMD: -1.21, 95% CI: -2.40 to -0.02, P = 0.045) and myocardial perfusion defects (SMD: -0.70, 95% CI: -1.11 to -0.29, P = 0.001). However, no improvements in all-cause mortality were observed after a relatively short follow-up. CONCLUSIONS: In patients with chronic angina on optimal medical therapy, stem cell therapy improves symptoms, exercise capacity, and left ventricular ejection fraction. These findings warrant confirmation using larger trials.

Positive Predictive Value of Noninvasive Stress Testing Is Poor in the Real World.

Abnormal noninvasive stress test (NIST) findings do not always correlate with angiographically significant (luminal obstruction ≥50%) coronary artery disease. Positive predictive value (PPV) of NIST in the real clinical practice is not well known. The goal of this retrospective study was to determine the PPV of NIST and assess the factors affecting PPV in a US community hospital. This study included all consecutive patients (n = 355) who underwent invasive coronary angiography after a positive NIST within ~1-year duration at our institution. Three hundred twenty-four patients were included in the analysis after exclusion of 31 patients. Sixty percent of patients were female and mean age was 63.2 (SD 12.4). Myocardial perfusion imaging, echocardiogram (treadmill or dobutamine), and treadmill electrocardiogram were the tests of choice in 95% (n = 307), 4% (n = 14), and 1% (n = 3) of patients, respectively. Overall PPV of NIST was 36.4% (118/324). When patients were stratified by age (<50 years, 50-65 years, ≥65 years), older age groups had significantly higher PPV (<0.001). When patients were grouped by body mass index (<25, 25-30, ≥30), those in lower body mass index groups had higher PPV (P = 0.01). Stress echocardiogram had significantly higher PPV compared with myocardial perfusion imaging stress test (71% vs. 35%; P < 0.005). Stress test site (in-hospital vs. outpatient office) or specialty of interpreting physician did not significantly impact PPV. Multivariable logistic regression analysis revealed that older age, male sex, and total number of cardiac risk factors were significant determinants of higher PPV. Our single-center study revealed that overall PPV of NIST is poor (36.4%), more notably in young, female, or obese patients.

Severe sepsis and cardiac arrhythmias.

BACKGROUND: Although sepsis is a known risk factor for cardiac arrhythmias, data on incidence and outcomes of atrial and ventricular arrhythmias in severe sepsis is limited. The purpose of this study is to examine the association of severe sepsis with cardiac arrhythmias and their impact on outcome in this patient population. METHODS: We used hospital discharge data from the Nationwide Inpatient Sample (NIS) during the year 2012. All patients 18 years or older were included in the study. The International Classification of Diseases-Clinical Modification, 9th revision (ICD-9-CM) code was used to identify patients with discharge diagnosis of severe sepsis, atrial fibrillation (A Fib), atrial flutter (AFL), ventricular fibrillation (VF) arrest and non-ventricular fibrillation (non-VF) arrest. In order to study the association of arrhythmias with severe sepsis, two groups were defined: group a-with severe sepsis was compared to group b-without severe sepsis. Univariate and multivariate logistic regression methods were used to adjust for potential confounding factors and variables associated with cardiac arrhythmias were determined. RESULTS: A total of 30,712,524 NIS hospital discharges (weighted for national estimate) were included in our study, of which 1,756,965 (5.7%) had severe sepsis. On multivariate analysis, after adjusting for potential confounders, severe sepsis was associated with higher risk of A Fib (OR, 1.23; 95% CI, 1.21-1.24), AFL (OR, 1.34; 95% CI, 1.30-1.40), VF arrest (OR, 2.58; 95% CI, 2.38-2.79) (OR, 3.31; 95% CI, 3.07-3.57) and non-VF arrest (OR, 4.91; 95% CI, 4.74-5.07). In the severe sepsis group, cardiac arrhythmia was associated with higher in-hospital mortality (OR, 1.41; 95% CI, 1.37-1.45), length of stay (LOS) >75% quartile (OR, 1.50; 95% CI, 1.46-1.53) and total hospital charges >75% quartile (OR, 1.37; 95% CI, 1.34-1.41). Advanced age, male sex, ischemic heart disease, diabetes mellitus (DM), congestive heart failure (CHF), valvular heart disease, respiratory failure, mechanical ventilation and use of vasopressors were independently associated with cardiac arrhythmias. CONCLUSIONS: Patients with severe sepsis are at high risk of atrial and life threatening ventricular arrhythmias. Despite adjustment for potential confounding factors, patients hospitalized with severe sepsis carry a significantly higher risk for cardiac arrest and increased mortality.

Trends, predictors and outcomes of ischemic stroke and intracranial hemorrhage in patients with a left ventricular assist device.

BACKGROUND: Patients with a left ventricular assist device (LVAD) are at a higher risk of ischemic stroke (IS) and intracranial hemorrhage (ICH). There is limited data available on risk factors and outcomes associated with IS and ICH in LVAD patients. METHODS: All patients >18 years of age with an LVAD were identified based on the U.S. Nationwide Inpatient Sample (NIS) database from the year 2007 to 2011. Patients with a discharge diagnosis of IS were compared to those without IS. In a separate analysis, patients with a discharge diagnosis of ICH were compared to patients without ICH. Trends, predictors and outcomes of IS and ICH were analyzed using a multivariate regression model. RESULTS: Out of 17,323 discharges with a primary diagnosis of heart failure with LVAD, 624 (3.6%) patients had a co-diagnosis of IS and 387 (2.2%) had a co-diagnosis of ICH. From 2007 to 2011, the discharge diagnosis of heart failure with LVAD increased from 946 to 5,540, but the proportion of patients with IS remained about 3.4%, while the incidence of ICH decreased from 3.8% in 2007 to a plateau of around 2.2% in the following years. After adjusting for potential confounders, increasing Charlson Comorbidity Index (CCI) score was an independent predictor of IS and ICH. In-hospital mortality was four-fold higher in the IS group (odds ratio: 4.2; 95% CI: 2.3-7.6; P<0.0001) and 18-fold higher in the ICH group (OR: 18; 95% CI: 9-34, P<0.0001). Renal disease (OR: 5.3; CI: 1.3-22.1; P=0.02), liver disease (OR: 4.9; CI: 1.1-21.2; P=0.03) and abnormal coagulation profile (OR: 4.8; CI: 1.6-14.4; P=0.01) were independent predictors of mortality in LVAD patients with IS. Presence of diabetes mellitus (OR 4.3, P=0.1) and liver disease (or 2.8, P=0.2) showed trends towards predicting mortality in LVAD patients with ICH but did not reach statistical significance. CONCLUSIONS: Increasing comorbidity burden significantly increases the risk of both IS and ICH with LVAD. In our cohort, the incidence of IS and ICH increases the mortality 4- and 18-fold, respectively. Renal disease, liver disease and abnormal coagulation profile were independent predictors of mortality in LVAD patients with IS.

Simultaneous acute cardio-cerebral infarction: is there a consensus for management?

Acute ischemic stroke (AIS) and acute myocardial infarction (AMI) are both life-threatening medical conditions with narrow therapeutic time-window that carry grave prognosis if not addressed promptly. The acute management of both condition is well documented in the literature, however the management of a simultaneous presentation of both AIS and AMI is unclear. A delayed intervention of one infarcted territory for the other may result in permanent irreversible morbidity or disability, and even death. In addition, the use of antiplatelet and anticoagulants that are inherently part of an AMI management may increase the risk for hemorrhagic conversion associated with intravenous thrombolysis used in AIS, and the use of a thrombolytic in AIS increases the risk of cardiac wall rupture in the setting of an AMI. Despite this ambiguity, there is no clear evidence-based guideline or clinical studies that have addressed the optimal management of this rare co-occurrence. This review paper examines the existing literature on the management of simultaneous acute cardio-cerebral infarction (CCI) and highlights the existing challenge to management.

Outcomes of In-Hospital Cardiopulmonary Resuscitation in Morbidly Obese Patients.

OBJECTIVES: This study sought to assess the impact of morbid obesity on outcomes in patients with in-hospital cardiac arrest (IHCA). BACKGROUND: Obesity is associated with increased risk of out-of-hospital cardiac arrest; however, little is known about survival of morbidly obese patients with IHCA. METHODS: Using the Nationwide Inpatient Sample database from 2001 to 2008, we identified adult patients undergoing resuscitation for IHCA, including those with morbid obesity (body mass index ≥40 kg/m2) by using International Classification of Diseases 9th edition codes and clinical outcomes. Outcomes including in-hospital mortality, length of stay, and discharge dispositions were identified. Logistic regression model was used to examine the independent association of morbid obesity with mortality. RESULTS: Of 1,293,071 IHCA cases, 27,469 cases (2.1%) were morbidly obese. The overall mortality was significantly higher for the morbidly obese group than for the nonobese group experiencing in-hospital non-ventricular fibrillation (non-VF) (77% vs. 73%, respectively; p = 0.006) or VF (65% vs. 58%, respectively; p = 0.01) arrest particularly if cardiac arrest happened late (>7 days) after hospitalization. Discharge to home was significantly lower in the morbidly obese group (21% vs. 31%, respectively; p = 0.04). After we adjusted for baseline variables, morbid obesity remained an independent predictor of increased mortality. Other independent predictors of mortality were age and severe sepsis for non-VF and VF group and venous thromboembolism, cirrhosis, stroke, malignancy, and rheumatologic conditions for non-VF group. CONCLUSIONS: The overall mortality of morbidly obese patients after IHCA is worse than that for nonobese patients, especially if IHCA occurs after 7 days of hospitalization and survivors are more likely to be transferred to a skilled nursing facility.

Implantable cardioverter defibrillators in diabetics: efficacy and safety in patients at risk of sudden cardiac death.

Diabetes mellitus is a major risk factor for arrhythmogenesis and is associated with a two-fold increase in all-cause mortality and a four-fold increase in cardiovascular mortality including sudden cardiac death when compared with nondiabetics. Implantable cardioverter defibrillators (ICD) have been shown to effectively reduce arrhythmic death and all-cause mortality in patients with severe myocardial dysfunction. With a high competing risk of nonarrhythmic cardiac and noncardiac death, survival benefit of ICD in patients with diabetes mellitus could be reduced, but the subanalysis of diabetic patients in randomized clinical trials provides reassurance regarding a similar beneficial survival effect of ICD and cardiac resynchronization therapy in diabetics, as observed in the overall population with advanced heart disease. In this article, the authors highlight some of the clinical issues related to diabetes, summarize the data on the efficacy of ICD in diabetics when compared with nondiabetics and discuss concerns related to ICD implantation in patients with diabetes.