Serum Biomarkers are Associated With Atherosclerotic Cardiovascular Disease Among Patients With Nonalcoholic Fatty Liver Disease Undergoing Elective Angiography.

BACKGROUND & AIMS: Cardiovascular disease is the most common cause of death among patients with nonalcoholic fatty liver disease (NAFLD). We assessed select cardiac biomarker associations for existing or future coronary artery disease (CAD) risk in patients with NAFLD. METHODS: Patients with/without NAFLD undergoing elective cardiac angiography were prospectively enrolled. Severe CAD was defined as presence of at least 1 proximal artery >70% stenosis; risk of severe CAD as either existing severe CAD or atherosclerotic cardiovascular disease score ≥20; NAFLD was defined as hepatic fat in the absence of other liver diseases. Cardiac biomarkers (high-sensitivity C-reactive protein, N-terminal pro-brain natriuretic peptide, and high-sensitivity cardiac troponin I [hs-cTnI]) were measured using Atellica Solution assays (Siemens Healthineers). RESULTS: A total of 619 patients were enrolled (mean age, 63 ± 10 years; 80% male; 31% type 2 diabetes; 65% NAFLD); 42% had severe CAD, and 57% had risk of severe CAD. NAFLD prevalence was similar between patients with and without severe CAD (68% vs 62%; P > .05). Patients with NAFLD with severe CAD (44%) or with risk of severe CAD (58%) had higher levels of hs-cTnI than NAFLD controls (both P < .001). Presence of severe CAD or risk of severe CAD in all patients was associated with older age, male, aspects of metabolic syndrome, and elevated hs-cTnI: odds ratio 2.0 (95% confidence interval [CI],1.4-2.9) and 1.8 (95% CI, 1.1-3.0), respectively; 2.3 (95% CI, 1.4-3.8) and 2.2 (95% CI, 1.2-4.2), respectively, in patients with NAFLD (all P < .02). CONCLUSION: CAD is common in patients with NAFLD. High hs-cTnI was associated with an increased risk of CAD. Pending validation, hs-cTnI may be a useful marker for CAD risk prediction in patients with NAFLD.

Standardized Team-Based Care for Cardiogenic Shock.

BACKGROUND: Cardiogenic shock (CS) is a multifactorial, hemodynamically complex syndrome associated with high mortality. Despite advances in reperfusion and mechanical circulatory support, management remains highly variable and outcomes poor. OBJECTIVES: This study investigated whether a standardized team-based approach can improve outcomes in CS and whether a risk score can guide clinical decision making. METHODS: A total of 204 consecutive patients with CS were identified. CS etiology, patient demographic characteristics, right heart catheterization, mechanical circulatory support use, and survival were determined. Cardiac power output (CPO) and pulmonary arterial pulsatility index (PAPi) were measured at baseline and 24 h after the CS diagnosis. Thresholds at 24 h for lactate (<3.0 mg/dl), CPO (>0.6 W), and PAPi (>1.0) were determined. Using logistic regression analysis, a validated risk stratification score was developed. RESULTS: Compared with 30-day survival of 47% in 2016, 30-day survival in 2017 and 2018 increased to 57.9% and 76.6%, respectively (p < 0.01). Independent predictors of 30-day mortality were age ≥71 years, diabetes mellitus, dialysis, ≥36 h of vasopressor use at time of diagnosis, lactate levels ≥3.0 mg/dl, CPO <0.6 W, and PAPi <1.0 at 24 h after diagnosis and implementation of therapies. Either 1 or 2 points were assigned to each variable, and a 3-category risk score was determined: 0 to 1 (low), 2 to 4 (moderate), and ≥5 (high). CONCLUSIONS: This observational study suggests that a standardized team-based approach may improve CS outcomes. A score incorporating demographic, laboratory, and hemodynamic data may be used to quantify risk and guide clinical decision-making for all phenotypes of CS.

3D transesophageal echocardiography and radiography of mitral valve prostheses and repairs.

This paper provides a comprehensive overview of 3D transesophageal echocardiography still images and movies of mechanical mitral valves, mitral bioprostheses, and mitral valve repairs. Alongside these visual descriptions, the historical overview of surgical and percutaneous mitral valve intervention is described with the special emphasis on the incremental value of 3D transesophageal echocardiography (3DTEE). For each mitral valve intervention, 2D echocardiography, chest x-ray, and fluoroscopy images corresponding to 3DTEE are given. In addition, key references on echocardiographic imaging of individual valves and procedures are enumerated in accompanying figures and tables.

Practice changes in blood glucose management following open heart surgery: from a prospective randomized study to everyday practice.

OBJECTIVES: Targeted blood glucose (BG) levels following cardiac surgery continues to be debated. According to the Society of Thoracic Surgeons (STS) guidelines, BG should be kept <180 mg/dl following cardiac surgery. However, our practice and others shifted to a stricter BG control (90-110 mg/dl) based on data suggesting an association with improved outcome. Recently, we conducted a randomized control study that demonstrated no added value to stricter control over liberal control (120-180 mg/dl). As a result, we shifted our management accordingly. The purpose of this study was to evaluate the impact that this change to a more liberal BG management (BGM) had on patient outcomes at our centre. METHODS: BGM was changed in June 2011 from strict (90-110 mg/dl) to liberal (120-180 mg/dl). Insulin drips, managed through a computerized algorithm, controlled BG for the first 72 h post surgery. Consecutive cardiac surgery patients operated on throughout 1 year prior to BGM change (n = 934) were propensity score matched to patients operated on throughout 1 year after the change (n = 927). RESULTS: After matching, there were 846 patient pairs. There was no difference between cohorts for length of stay and perioperative complications, and both cohorts achieved acceptable outcomes. Incidence of perioperative renal failure (P = 0.02) and renal failure requiring dialysis (P = 0.004) were better for the cohort with liberal BGM. One-year cumulative survival did not differ between cohorts (log-rank = 0.70, P = 0.40). CONCLUSIONS: Implementation of glycaemic control of 120-180 mg/dl into clinical practice was not associated with increased morbidity. The present results confirm our prior findings that a more liberal glycaemic control strategy to maintain BG is equal to a stricter target range. These findings are important for patient care and demonstrate the safety and efficacy of practice change for all patients following a successful randomized controlled trial.

In-stent thrombosis following DDAVP administration: case report and review of the literature.

A 67-year-old man with a drug-eluting stent in his proximal left anterior descending artery was admitted to the hospital after sustaining a traumatic injury to the skull. Due to persistent bleeding from a subgaleal hematoma, intravenous 1-desamino-8-D-arginine vasopressin (DDAVP) was administered. Five hours later, the patient complained of crushing chest pain. A 12-lead electrocardiogram demonstrated 2 mm ST-segment elevations in the precordial leads with reciprocal depressions in the inferior leads. Emergency cardiac catheterization demonstrated total occlusion of the proximal left anterior descending stent with TIMI 0 flow. Another drug-eluting stent was placed inside the original stent with restoration of TIMI 3 flow. During the catheterization, the patient became progressively hypoxic and hypotensive requiring intubation, dopamine drip, and placement of an intra-aortic balloon pump. The patient's hospitalization was complicated by prolonged shock requiring inotropes and vasopressors. This is the first reported case of an ST-elevation myocardial infarction due to in-stent thrombosis occurring after DDAVP administration. Though DDAVP is well tolerated and efficacious in treating several types of coagulopathies, this case illustrates its potential pro-thrombotic effects. Therefore, DDAVP should be used with caution in patients with known coronary artery disease and coronary stents.

Role of RAAS Inhibition in the Prevention of Cardiovascular Disease.

OPINION STATEMENT: The pathogenesis of cardiovascular disease is a complex and dynamic process. The renin-angiotensin-aldosterone system (RAAS) is a potent and powerful mediator in the homeostasis of the cardiovascular and renal systems. RAAS blockade via angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) has been consistently proven to be an effective and safe strategy for the primary and secondary prevention of cardiovascular disease in patients across a wide spectrum of risk. Although the beneficial effects of RAAS blockade may be due to its effects on central and peripheral blood pressure, there are many additional mechanisms to consider that may contribute additional protection. While a combination of ACE inhibitors and ARBs has not yielded significantly positive results, the newer class of direct renin inhibitors (DRIs) may offer a novel and effective strategy for monotherapy as well as in combination.

Performance of four risk algorithms in predicting intermediate survival in patients undergoing aortic valve replacement.

OBJECTIVE: : Several risk models exist to predict operative outcomes after cardiac surgery and are used in selecting patients for alternative procedures such as transcatheter valve implantation. We sought to evaluate the performance of the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) model in accurately identifying patients at high risk for aortic valve replacement (AVR). METHODS: : Three hundred and ninety four consecutive patients who underwent isolated AVR from January 1, 2001, to July 1, 2007, at a tertiary care center were analyzed using the STS database. Patients were stratified into tertiles according to operative surgical risk calculated by the four models [STS-PROM, European system for cardiac operative risk evaluation (EuroSCORE), Ambler, and Providence]. Vital status at 1 year was determined using the National Death Index and Social Security Death Index. RESULTS: : There were 310 low-risk patients, 56 intermediate-risk patients, and 28 high-risk patients with respect to the STS-PROM. The predicted risk of death for the low-risk, intermediate-risk, and high-risk groups were 2.4% ± 1.1%, 6.9% ± 1.4%, 15.8% ± 7.6% (P < 0.001) with respect to the STS-PROM model. Actual operative mortality for each respective group was 1.94%, 5.36%, 14.29% (P < 0.001) and 1-year mortality was 3.23%, 12.50%, 21.43% (P < 0.001), respectively. CONCLUSIONS: : High-risk patients have significantly high mortality after AVR. The STS-PROM accurately predicts operative mortality and can be used to predict 1-year survival as well. This risk model may be preferentially used instead of the EuroSCORE.

The effect of previous coronary artery stenting on short- and intermediate-term outcome after surgical revascularization in patients with diabetes mellitus.

OBJECTIVES: Percutaneous intervention for coronary revascularization is associated with an increased risk of repeat revascularization, especially in patients with diabetes mellitus. In this study we sought to examine the effect of previous percutaneous intervention on the rate of adverse perioperative outcome and intermediate-term survival in patients undergoing coronary artery bypass surgery. METHODS: Between January 1, 2001, and December 31, 2006, 1758 consecutive patients with diabetes mellitus who underwent first-time isolated coronary artery bypass surgery were identified. Survival and major perioperative complications for 1537 patients who did not have prior percutaneous intervention (group 1) were compared with those in 221 patients with prior percutaneous intervention (group 2) after adjusting for baseline risk factors. Vital status was determined by using the National Death Index and Social Security Death Index. Age-adjusted survival at 2 years' follow-up was calculated with the Cox singular proportional hazards model. RESULTS: At baseline, group 2 patients had higher incidences of hypercholesterolemia and myocardial infarction. Compared with group 1 patient, group 2 patients had significantly higher operative mortality (adjusted odds ratio, 4.05; 95% confidence interval, 1.41-11.63), perioperative major adverse cardiac events (adjusted odds ratio, 2.72; 95% confidence interval, 1.08-6.85), and atrial fibrillation (adjusted odds ratio, 1.97; 95% confidence interval, 1.29-3.01). Group 2 patients had worse age-adjusted survival at 2 years' follow-up (93.4% vs 87.4%, P < .017). CONCLUSIONS: Patients with diabetes mellitus and a history of percutaneous coronary stenting before coronary artery bypass surgery were found to have an increased risk of operative death, increased perioperative complications, and decreased age-adjusted survival at 2 years' follow-up.