The American Journal of Cardiology (AM J CARDIOL )

Publisher: American College of Cardiology, Elsevier


Full Text Online Access, and More, to Paid Subscribers at Published 24 times a year, The American Journal of Cardiology® is an independent journal designed for cardiovascular disease specialists and internists with a subspecialty in cardiology throughout the world. AJC is an independent, scientific, peer-reviewed journal of original articles that focus on the practical, clinical approach to the diagnosis and treatment of cardiovascular disease. AJC has the shortest lag time of all scientific journals (less than 5 months) from receipt of manuscript to publication. Features report on systemic hypertension, methodology, drugs, pacing, arrhythmia, preventive cardiology, congestive heart failure, valvular heart disease, congenital heart disease, and cardiomyopathy. Also included are case reports, brief reports, editorials, readers' comments, and symposia.

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    The American journal of cardiology
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Publications in this journal

  • [Show abstract] [Hide abstract]
    ABSTRACT: Physician practice patterns in the management of hospitalized acute decompensated heart failure (ADHF) patients may vary by specialty; comparative practice patterns in ADHF management, as well as clinical outcomes as a function of provider type have not been well reported. We studied a total of 496 patients discharged with the principal diagnosis of ADHF to analyze practice patterns among 3 provider types (cardiologists, hospitalists, and non-hospitalists). We examined outcomes of death and re-hospitalization for HF, as well as adherence to the Joint Commission HF performance core measures. Cardiologists had the highest adherence among all 4 HF core measures compared to hospitalists and non-hospitalists. At 6 months, 6.0 % of the patients cared by cardiologists died compared to 10.9% and 11.4% cared by hospitalist and non-hospitalists (p =0.12). Patients cared for by cardiologists had a significantly lower 6-month ADHF readmission rate (16.2%) compared to hospitalists (40.1%) and non-hospitalists (34.9%; P <.001). In multivariate analysis, both hospitalist and non-hospitalist provider types were an independent predictor for 6-month ADHF related readmission (hospitalists vs cardiologists, Hazard ratio [HR]adjusted 3.01; 95% confidence interval (CI) 1.84 to 4.89, P <.001; and non-hospitalists vs cardiologists, HR adjusted 2.07; 95% CI 1.24 to 3.46, P = .005). In conclusion, cardiologist-delivered ADHF care is associated with greater adherence to HF core measures and with significantly lower rates of adverse outcome compared to non-cardiologists.
    The American Journal of Cardiology 11/2014;
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    ABSTRACT: There is increasing emphasis on optimizing evidence-based medication (EBM) persistence as a means to improve longitudinal patient outcomes after acute myocardial infarction (MI); yet it is unknown whether differences in medication persistence exist between patients discharged from academic versus nonacademic hospitals. We linked Medicare pharmacy claims data with 3,184 patients with non–ST-segment elevation MI >65 years of age who were treated in 2006 at 253 hospitals participating in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology and American Heart Association guidelines registry. Using multivariate regression, we compared persistent filling of β blockers, angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers, clopidogrel, and statins at 90 days and 1 year postdischarge between patients discharged from academic and nonacademic hospitals. Patients treated at academic hospitals were more frequently nonwhite (19% vs 8%, p <0.001) and had a greater co-morbidity burden (Charlson score ≥4 in 36% vs 30%, p = 0.001) than patients treated at nonacademic hospitals. Composite persistence to all EBMs prescribed at discharge was low and not significantly different between academic and nonacademic hospitals at 90 days (46% vs 45%, adjusted incidence rate ratio = 0.99, 95% confidence interval 0.95 to 1.04) and at 1 year (39% vs 39%, adjusted incidence rate ratio = 1.02, 95% confidence interval 0.98 to 1.07). Rates of persistence to EBMs were similar between patients with MI >65 years old treated at academic versus nonacademic hospitals; however, persistence rates are low both early and late postdischarge, highlighting a continued need for quality improvement efforts to optimize post-MI management.
    The American Journal of Cardiology 11/2014; 114.
  • The American Journal of Cardiology 11/2014;
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    ABSTRACT: Early repolarization associated with sudden cardiac death is based on the presence of >1-mm J-point elevations in inferior and/or lateral leads with horizontal and/or downsloping ST segments. Automated electrocardiographic readings of early repolarization (AER) obtained in clinical practice, in contrast, are defined by ST-segment elevation in addition to J-point elevation. Nonetheless, such automated readings may cause alarm. We therefore assessed the prevalence and prognostic significance of AER in 211,920 patients aged 18 to 75 years. The study was performed at a tertiary medical center serving a racially diverse urban population with a large proportion of Hispanics (43%). The first recorded electrocardiogram of each individual from 2000 to 2012 was included. Patients with ventricular paced rhythm or acute coronary syndrome at the time of acquisition were excluded from the analysis. All automated electrocardiographic interpretations were reviewed for accuracy by a board-certified cardiologist. The primary end point was death during a median follow-up of 8.0 ± 2.6 years. AER was present in 3,450 subjects (1.6%). The prevalence varied significantly with race (African-Americans 2.2%, Hispanics 1.5%, and non-Hispanic whites 0.9%, p <0.01) and gender (male 2.4% vs female 0.6%, p <0.001). In a Cox proportional hazards model controlling for age, smoking status, heart rate, QTc, systolic blood pressure, low-density lipoprotein cholesterol, body mass index, and coronary artery disease, there was no significant difference in mortality regardless of race or gender (relative risk 0.98, 95% confidence interval 0.89 to 1.07). This was true even if J waves were present. In conclusion, AER was not associated with an increased risk of death, regardless of race or gender, and should not trigger additional diagnostic testing.
    The American Journal of Cardiology 11/2014; 114(9):1431-1436.
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    ABSTRACT: Increased combined free light chains (cFLC) are strongly prognostic of death in general populations and in patients with chronic kidney disease, but scarce data are available on cFLC in heart failure (HF). We aimed to assess the dynamics and prognostic significance of cFLC levels in patients following admission with acute heart failure (AHF). cFLC measurements were compared in 49 patients with AHF, 37 patients with stable HF, 43 patients with stable coronary artery disease and without HF (‘disease controls’), and 37 healthy controls. The association of cFLC with death and/or rehospitalisation was assessed. Patients with AHF had significantly elevated cFLC levels, compared to other groups (p<0.001). Patients with stable HF showed higher levels of cFLC than healthy controls. In AHF, cFLC levels correlated with cystatin C (Spearman r=0.63, p<0.001), and creatinine (Spearman r=0.47, p=0.002). During 3 months follow up brain natriuretic peptide (BNP) reduced significantly (p=0.017), but cFLC did not change significantly. In a multivariate Cox regression analysis, the higher quartiles of cFLC were significantly associated with death/readmission (hazard ratio (HR) 8.34 [95% CI 2.38-29.22] p=0.0009) after adjustment for age, gender, BNP and cystatin C levels. Higher quartiles of cFLC were prognostic for death alone (HR 14.0 [95% CI 1.72-113.8], p=0.014). In conclusion, raised serum cFLC concentrations in patients with AHF were independently associated with prognosis. In AHF, elevated cFLC levels persist long after clinical stabilisation, which may reflect immune disturbances and/or the reduced capacity of (perhaps functionally impaired) kidneys and the endothelium to eliminate them.
    The American Journal of Cardiology 10/2014;
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    ABSTRACT: Several studies have highlighted the prognostic role of preprocedural Thrombolysis In Myocardial Infarction (TIMI) flow in the infarct-related artery (IRA) in patients with ST-segment elevation myocardial infarction (STEMI). However, the impact of preprocedural IRA occlusion in patients with diabetes with STEMI has been insufficiently studied. The aim of this study was to evaluate the effects of baseline IRA occlusion and diabetic status in patients with STEMI who underwent primary percutaneous coronary intervention by using data from a pooled analysis of randomized trials comparing intracoronary with intravenous abciximab bolus administration. A total of 3,046 patients with STEMI who underwent primary percutaneous coronary intervention were included. Diabetes was present in 578 patients (19%). The primary outcome was mortality after a median follow-up period of 375 days. Secondary end points were reinfarction and stent thrombosis. In patients without diabetes, IRA occlusion versus no occlusion was not associated with increased rates of mortality (4.3% vs 2.7%, p = 0.051) and reinfarction (3.3% vs 2.5%, p = 0.33). Patients with diabetes with IRA occlusion compared with those without occlusion showed higher rates of mortality (10.6% vs 4.6%, p = 0.01) and reinfarction (5.6% vs 2.1%, p = 0.03). Baseline IRA occlusion increased the rate of stent thrombosis in the nondiabetic (2.1% vs 1.0%, p = 0.04) and diabetic (3.2% vs 0.8%, p = 0.05) cohorts. Interaction analysis demonstrated that the risk for death and reinfarction was significantly increased when diabetes and IRA occlusion occurred concomitantly. In conclusion, patients with STEMI with diabetes and baseline IRA occlusion had disproportionately higher rates of death and reinfarction. Preprocedural IRA occlusion increased the risk for stent thrombosis, irrespective of diabetic status.
    The American Journal of Cardiology 10/2014; 114(8):1145–1150.
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    ABSTRACT: We aimed to describe the impact of the vascular access used when patients are treated with primary percutaneous coronary intervention (PPCI) and to assess whether this translates into differences in angiographic outcomes. ST-elevation myocardial infarction (STEMI) patients undergoing PPCI were divided into three groups: successful radial access (RA), successful femoral access (FA) and Crossover (failed RA with need for bailout FA) groups. Vascular access-related time (VART) was defined as the delay in PPCI that can be attributed to vascular access-related issues. Study endpoint was the final corrected TIMI frame count (CTFC). Multivariable analysis was used to identify predictors of RA failure (RAF: FA+Crossover). We included 241 patients (RA n=172, FA n=49, Crossover n=20). Mean VART was longer in Crossover (10.3 (8.8-12.4) min), relative to RA (4.1 (3.2-5.5) min) and FA (4.6 (3.4-8.4) min, p<0.001). A similar situation was found for time-to-first-device (Crossover: 22.5 (20.3-32.0); RA: 15.0 (12.0-19.8); FA: 17.9 (13.5-22.3) min; p<0.001) and total procedure time (Crossover: 60.3 (51.6-71.5); RA: 46.8 (38.1-59.7); FA: 52.3 (41.9-74.7) min; p<0.001). No differences in CTFC were observed (Crossover: 26 (18-32) frames; RA: 24 (18-32) frames; FA: 25 (16-34) frames; p=0.625). Killip class IV (OR 3.628, 95% CI: 1.098-11.981, p=0.035), cardiopulmonary resuscitation prior to arrival (OR 3.572, 95% CI: 1.028-12.407, p=0.045) and glomerular filtration rate (OR 0.861, 95% CI: 0.758-0.978, p=0.021) were independent predictors of RAF. In conclusion, in the setting of PPCI, radial-to-femoral access crossover can lead to VART delays that do not impact angiographic outcomes, in comparison with successful RA.
    The American Journal of Cardiology 10/2014;
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    ABSTRACT: Age, Creatinine, and Ejection Fraction (ACEF) score predict clinical outcomes in pts undergoing elective PCI of non-occlusive coronary stenoses. We aimed at assessing the prognostic value of the ACEF score in patients undergoing successful PCI of CTO. ACEF score was calculated in 587 pts treated with PCI of CTO: successful in 433 (74%)(success group) and failed in 154 pts (26%)(failure group). Pts were divided in ACEF tertiles: 1st <0.950, 2nd from 0.950 to 1.207, 3rd ACEF tertile >1.207. Major adverse cardiac events (MACE=overall death + non-fatal myocardial infarction + clinically driven target vessel revascularization [TVR]) were assessed in 558 pts (95%) up to 24 months (8-24 months). In success group, higher MACE rate was significantly associated with increasing ACEF tertile (1st=7%, 2nd=13%, 3rd ACEF=18%, p=0.02). MACE-free survival was significantly decreased with increasing ACEF tertile (Log-Rank: 5.58, p=0.018). In the failure group, lower MACE rate was significantly associated with increasing ACEF tertile (p=0.041). This was mainly driven by significant decreasing rate of TVR along the tertiles (1st =34%, 2nd =19%, 3rd ACEF=10%, p=0.007). Compared to success group, in failure group MACE rate was significantly higher in the 1st tertile (p<0.001), and similar in the 3rd tertile (p=0.59). In conclusion, ACEF score represents a simple tool in the prognostication of patients successfully treated with PCI of CTO, and identifies those patients who would not derive any significant clinical harm despite failed percutaneous revascularization of the CTO.
    The American Journal of Cardiology 10/2014;
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    ABSTRACT: Myocardial deformation analysis by speckle-tracking echocardiography (STE) has been used for analysis of myocardial viability and myocardial fibrosis. Patients with severe aortic stenosis are known to develop myocardial fibrosis. This study evaluated the association between myocardial fibrosis determined by late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) and 2-dimensional (2D) STE in patients with severe aortic stenosis. In 30 patients (58±7 years) with severe aortic stenosis (mean gradient 53±21 mmHg), peak systolic circumferential strain based on 2D echocardiography parasternal short axis views and peak systolic longitudinal strain based on apical views was determined for analysis of regional function. LGE CMR was performed to define the amount of fibrosis in each segment within 24 hours of echocardiography. Relative amount of fibrosis was determined based on LGE CMR as gray-scale threshold 6 standard deviations above the mean signal intensity of the normal remote myocardium. There was a decrease in LGE from base to apex (14.4±8.7% for basal segments, 3.4±3.0% for midventricular segments and 2.1±3.0% for apical segments; p<0.001). Simultaneously, there was an increase in myocardial deformation expressed as peak systolic longitudinal strain from base to apex (-11.6±7.0% for basal segments, -16.9±6.5% for midventricular segments and -17.4±7.7% for apical segments; p=0.001). There was a negative correlation between the amount of myocardial fibrosis determined by LGE CMR and peak systolic longitudinal strain for the total LV (r=-0.538; p=0.007). Myocardial fibrosis defined as LGE>10% could be identified by peak systolic longitudinal strain less than -11.6% with a sensitivity of 65% and a specificity of 75% (ROC area under the curve 0.69). In conclusion, myocardial fibrosis increases from apical to basal LV segments in patients with severe aortic stenosis. There is an association between severity of myocardial fibrosis defined by LGE CMR and myocardial deformation by STE.
    The American Journal of Cardiology 10/2014;
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    ABSTRACT: Low-flow low-gradient aortic stenosis with normal ejection fraction (LFLGNEF AS) is a newly characterized poorly understood entity within the AS spectrum. Whether LFLGNEF AS has a worse prognosis than typical AS remains controversial. We retrospectively identified 4,546 individual patients with any type of AS on echocardiogram from 2003 through 2013 and categorized them into 5 cohorts: (1) mild AS, (2) moderate AS, (3) severe AS, (4) LFLGNEF AS (ejection fraction ≥55%), and (5) low-flow low-gradient low ejection fraction AS (LFLGLEF AS; ejection fraction <55%). Survival analysis was used to compare outcomes of LFLGNEF AS with those of the other cohorts. AS was classified as mild in 591 patients, moderate in 2,358, severe in 500, LFLGNEF in 776, and LFLGLEF in 318. The study group had a mean age of 80.5 years, 61% were women, and the patients were followed for 2.26 ± 1.16 years. Among subjects managed without valve replacement, total mortality for the LFLGNEF AS group was lower compared with that in both the severe AS and the LFLGLEF AS groups (p = 0.007 and p <0.001, respectively). The prognosis for LFLGNEF AS was worse, however, compared with those with mild and moderate AS (p <0.001, both). In conclusion, no survival differences were found among AS types among those who received valve replacement. The survival rate in LFLGNEF is better than that in severe AS or LFLGLEF but is worse than that in mild or moderate AS. Valve replacement seems reasonable to pursue in select patients.
    The American Journal of Cardiology 10/2014; 114(7):1069–1074.
  • The American Journal of Cardiology 10/2014; 114(7):1126.
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    ABSTRACT: We describe a 45-year old man who experienced a potentially fatal arrhythmia after consumption of multiple energy drinks. At 5 years old, he underwent "repair" of tetralogy of Fallot using a patch in the right ventricular outflow tract, and at age 40 had an automatic implantable cardiac defibrillator (AICD) placed. His first AICD shock occurred within 30 minutes after he finished the third energy drink and was preceded by feelings of lightheadedness and severe dizziness. Without the AICD, he likely would have died. The risk of consuming energy drinks in those with underlying structural heart disease and the general population should be determined. Warning labels should be required to inform consumers of the risks posed by these drinks and of appropriate limits for consumption.
    The American Journal of Cardiology 10/2014;
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    ABSTRACT: Increased myocardial trabeculations define non-compaction cardiomyopathy (NCC). Imaging advancements have led to increasingly common identification of prominent trabeculations with unknown implications. We quantified and determined the impact of trabeculations’ burden on cardiac function and stretch in a population of healthy young adults. One hundred adults aged 18-35 (28±4 years, 55% women) without known cardiovascular disease were prospectively studied by cardiovascular magnetic resonance (CMR). Left ventricular (LV) volumes, segmental function, and ejection fraction (EF), and left atrial (LA) volumes were determined. Thickness and area of trabeculated (T) and dense (D) myocardium were measured for each standardized LV segment. N-terminal pro-brain natriuretic peptide (Nt-pro-BNP) was measured. Eighteen % of individuals had ≥1 positive traditional criteria for NCC and 11% meet new proposed NCC CMR criteria. T/D ratios were uniformly greater at end-diastole vs. end-systole (0.90±0.25 vs. 0.42 ±0.13, p<0.0001), in women vs. men (0.85±0.24 vs. 0.72±0.19, p=0.006), at anterior vs. non-anterior segments (1.41±0.59 vs. 0.88±0.35, p<0.0001), and at apical vs. non-apical segments (1.31±0.56 vs. 0.87±0.38, p<0.0001). The largest T/D ratios were associated with lower LVEF (57.0±5.3 vs. 62±5.5, p=0.0001) and greater Nt-pro-BNP (203±98 vs. 155±103, p=0.04). Multivariable regression identified greater end-systolic T/D ratios as the strongest independent predictor of lower LVEF, beyond age and gender, LA or LV volumes, and Nt-pro-BNP (β=-9.9, 95% CI -15-4.9, p<0.001). In conclusion, healthy adults possess variable amounts of trabeculations that regularly meet criteria for NCC. Greater trabeculations are associated with decreased LV function. Apparently healthy young adults with increased trabecular burden possess evidence of mildly impaired cardiac function.
    The American Journal of Cardiology 10/2014;
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    ABSTRACT: Obtaining the right chest electrocardiogram (ECG) is essential for diagnosing concomitant right ventricular infarction in patients with inferior wall acute myocardial infarction (AMI). A software program to synthesize right chest ECG waveforms from 12-lead ECG waveforms is available in Japan. However, its reliability has not been fully investigated. Accordingly, we examined the reliability of ST-segment shifts in the synthesized V3R–V5R leads. ST-segment shifts in actual and synthesized V3R–V5R leads were compared during the last 10 seconds of 131 balloon inflations while performing elective percutaneous coronary intervention in 56 patients with coronary artery disease. The ST-segment shifts in the actual and synthesized V3R–V5R leads were correlated (r = 0.96, p <0.001; r = 0.94, p <0.001; r = 0.91, p <0.001, respectively). A Bland-Altman analysis showed that the bias between the ST-segment shifts in the actual and synthesized V3R–V5R leads was -3.1 μV, -5.4 μV and -4.2 μV, respectively, while the limit of agreement between the ST-segment shifts in the actual and synthesized V3R–V5R leads was -59.2 – 52.9 μV, -61.9 – 51.1 μV and -59.7 – 51.3 μV, respectively. The kappa coefficients for ST-segment elevation of ≥50 μV and ≥100 μV in the actual and synthesized V3R–V5R leads were 0.83 and 0.81, 0.66 and 0.83 and 0.57 and 0.80, respectively. In conclusion, this study indicates that ST-segment shifts in the synthesized V3R–V5R leads have acceptable reliability, suggesting that the synthesized right chest ECG can be used to diagnose concomitant right ventricular infarction in patients with inferior wall AMI.
    The American Journal of Cardiology 10/2014;
  • The American Journal of Cardiology 10/2014;
  • The American Journal of Cardiology 10/2014;
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    ABSTRACT: There are limited data integrating findings at right heart catheterization (RHC) and cardiopulmonary exercise testing (CPX) in ambulatory patients with heart failure (HF). We retrospectively evaluated 187 outpatients with HF referred to Duke Medical Center for consideration of advanced HF therapies. All patients had undergone both RHC and CPX; the median cardiac index (CI) was 2.0 L/min/m2 (interquartile range [IQR] 1.7 – 2.3) and the median peak oxygen consumption (VO2) was 11.3 ml/kg/min (IQR 9.2 – 13.8). Despite aggressive medical therapy, 97 patients (52%) failed medical management at 18 months, defined as undergoing left ventricular assist device (LVAD) implantation, cardiac transplantation, or death. After multivariable adjustment, factors associated with failure of optimal medical management included percent achieved of predicted peak VO2, low CI (i.e., <2 L/min/m2), left ventricular size, and exercise time. Patients with discordant findings at RHC and CPX were common, occurring in 88 patients (47%). The most common profile was preserved CI but reduced functional capacity, and these patients remained at high risk for requiring advanced therapies, while patients with reduced CI but preserved exercise capacity were uncommon. In conclusion, low CI was independently associated with higher rates of death, transplant or LVAD in our study. We also found that patients with preserved resting CI but poor functional capacity, so called “cardiac insufficiency,” were commonly encountered and had poor outcomes with medical management.
    The American Journal of Cardiology 10/2014;