Clinical and echocardiographic predictors of new-onset atrial fibrillation in patients admitted with blunt trauma.

BACKGROUND: Atrial fibrillation (AF) is a common arrhythmia after trauma or burn injury; however, its predisposing factors are not well known. Moreover, little is known about its effect on mortality and other short-term clinical outcomes. OBJECTIVES: This study is aimed at identifying risk factors for new-onset AF in patients admitted with blunt trauma or burn injuries at a Level 1 academic trauma center, and to determine its effects on the short-term clinical outcomes. METHODS: This case-control study compared patients with new-onset AF with a cohort of patients without AF during the hospital stay after trauma or burn injury. Patients with prior AF or lack of transthoracic echocardiogram were excluded. Demographic, clinical factors including injury severity score and echocardiographic parameters were compared in both cohorts. Risks of short-term clinical outcomes, namely persistent AF, new stroke, myocardial infarction, or death, were compared. RESULTS: Older age, sepsis, CHADS2-VASC score >1, larger left atrium (LA) size, left ventricular hypertrophy (LVH), and left ventricular diastolic dysfunction imposed a significant risk for new-onset AF on univariate analysis. On multivariate, independent predictors of new-onset AF were LA dilation and LVH. LA enlargement increased odds of new-onset AF by 23-fold (OR 23; CI: 5.7-92, P < 0.0001) and the presence of LVH increased the odds of new-onset AF more than 20-fold (OR 20.8; CI: 5-87, P < 0.0001). CONCLUSIONS: Dilated LA and LVH are independent predictors of new-onset AF in the patients with blunt trauma or burn. New-onset AF did not confer increased risk for in-hospital mortality.

Paradoxical Hemodynamic Instability After Pericardial Window.

Paradoxical hemodynamic instability (PHI), also called postoperative low cardiac output syndrome (LCOS), is a rare but fatal complication after drainage of a pericardial effusion (PEf). This condition usually develops within hours postprocedure and appears unrelated to the method of drainage. The exact mechanism of this condition is not well understood. We present a case of an 84-year-old patient with no previous cardiac or cancer history who presented with acute shortness of breath (SOB). Computed tomography (CT) ruled out pulmonary embolism and echocardiography confirmed early tamponade. Following emergent subxiphoid pericardiectomy, the patient developed hemodynamic instability and shock and subsequent multiorgan failure. Repeat echocardiography revealed left ventricular (LV) hypercontractility and new right ventricular (RV) dilatation with akinesis. The patient's condition continued to deteriorate in spite of maximal doses of pressors. The patient died after the family's request to discontinue further extraordinary measures.

Effects of Renin-Angiotensin-Aldosterone System Blockade in Patients with End-Stage Renal Disease.

Blockers of the renin-angiotensin-aldosterone system (RAAS), such as angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are routinely used in patients with chronic kidney disease because of their cardiovascular (CV) and renoprotective effects. However, there are no uniform recommendations about RAAS blockers for CV protection in the end-stage renal disease (ESRD) population other than the preferred drug class for blood pressure control. This uncertainty stems from the fact that patients with ESRD were generally excluded from randomized controlled trials evaluating the cardioprotective benefits of RAAS blockers. It is important to weigh the potential harms associated with the use of RAAS blockers, such as electrolyte disturbances and worsening anemia, with their role in protection of residual kidney function, alleviation of thirst and potential CV benefits. The objective of this review is to summarize the current knowledge about the use of RAAS blockers in patients with ESRD.

Right Ventricular Function Is Associated with Left Ventricular Stroke Volume in Patients with Severe Aortic Stenosis and Preserved Ejection Fraction.

BACKGROUND: A subset of patients with severe aortic stenosis (AS) have lower stroke volumes and valve gradients despite a normal left ventricular ejection fraction (LVEF), referred to as paradoxical low-flow AS (PLF AS). However, the role of right ventricular (RV) function in patients with severe AS and preserved LVEF is not known. We hypothesized that right ventricular function is associated with left ventricular stroke volume in patients with severe AS and preserved LVEF. METHODS: From an echocardiographic database, we retrospectively identified 102 patients with an indexed aortic valve area ≤0.6 cm(2) /m(2) and LVEF ≥ 50%. We used univariate and multivariate linear regression analysis to assess the association between aortic valve stroke volume index (SVi) and right ventricular systolic function as measured by tricuspid annular plane systolic excursion (TAPSE) and by right ventricular fractional area change (FAC). RESULTS: Our population was 98% male with mean age 77.4 ± 9.3 years and mean SVi of 36.1 ± 7.9 mL/m(2) . Forty-four patients (43%) met criteria for PLF AS. TAPSE and FAC were positively associated with SVi in both univariate and multivariate regression analysis after correcting for left ventricular variables (ß coefficient - TAPSE (cm): 4.59 ± 1.3, P = 0.001; FAC (%): 0.19 ± 0.08, P = 0.014). Additionally, PLF AS patients had significantly lower mean TAPSE and lower mean FAC when compared dichotomously to normal flow AS patients (P < 0.05). CONCLUSIONS: Right ventricular systolic function assessed by TAPSE and FAC is significantly related to aortic valve flow in patients with severe AS and preserved LVEF.

State of the Art Review: Colorectal Cancer Screening.

Although colorectal cancer is the third leading cause of cancer-related deaths in the U.S., the burden of this disease could be dramatically reduced by increased utilization of screening. Evidence-based recommendations and guidelines from national societies recommend screening all average risk adults starting at age fifty. However, the myriad of screening options and slight differences in screening recommendations between guidelines may lead to confusion among patients and their primary care providers. This goal of this review is to briefly summarize the colorectal cancer screening guidelines issued by three major organizations, compare their recommendations, and address emerging issues in colorectal cancer screening.