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• Authors' reply.

  Authors: Matthias Greutmann, Christine H Attenhofer Josb, Rolf Jenni, Erwin N Oechslin

  The American journal of cardiology. 109(11):1686.

• Thromboembolic risk in atrial flutter resembles non-valvular atrial fibrillation (insights from transesophageal echocardiography).

  Authors: Rui Providência

  The American journal of cardiology. 109(11):1686-7.

• Needed-electrocardiographic findings in left ventricular noncompaction.

  Authors: John E Madias

  The American journal of cardiology. 109(11):1686.

• Cardiovascular death and cancer death-competing risk?

  Authors: Franz H Messerli, Sripal Bangalore

  The American journal of cardiology. 109(11):1687.

• Support for routine use of metabolic stress testing in hypertrophic cardiomyopathy.

  Authors: Daniel Jacoby, William J McKenna

  The American journal of cardiology. 109(10):1534-5.

• Is there a role of implantable cardioverter defibrillator in sudden unexpected death in epilepsy?

  Authors: Mohit K Turagam, Poonam Velagapudi

  The American journal of cardiology. 109(10):1536.

• Proceedings of the Editorial Board Meeting of The American Journal of Cardiology on March 25, 2012.

  Authors: William Clifford Roberts

  The American journal of cardiology.

• Patterns and Loss of Sexual Activity in the Year Following Hospitalization for Acute Myocardial Infarction (a United States National Multisite Observational Study).

  Authors: Stacy Tessler Lindau, Emily Abramsohn, Kensey Gosch, Kristen Wroblewski, Erica S Spatz, Paul S Chan, John Spertus, Harlan M Krumholz

  The American journal of cardiology. 109(10):1439-44.

  A multisite observational study of sexual activity-related outcomes in patients enrolled in the TRIUMPH registry during hospitalization for an acute myocardial infarction (AMI) was conducted toA multisite observational study of sexual activity-related outcomes in patients enrolled in the TRIUMPH registry during hospitalization for an acute myocardial infarction (AMI) was conducted to identify patterns and loss of sexual activity 1 year after hospitalization for AMI. Gender-specific multivariable hierarchical models were used to identify correlates of loss of sexual activity including physician counseling. Main outcome measurements included "loss of sexual activity" (less frequent or no sexual activity 1 year after an AMI in those who were sexually active in the year before the AMI) and 1-year mortality. Mean ages were 61.1 years for women (n = 605) and 58.6 years for men (n = 1,274). Many were sexually active in the year before and 1 year after hospitalization (44% and 40% of women, 74% and 68% of men, respectively). One third of women and 47% of men reported receiving hospital discharge instructions about resuming sex. Those who did not receive instructions were more likely to report loss of sexual activity (women, adjusted relative risk 1.44, 95% confidence interval 1.16 to 1.79; men, adjusted relative risk 1.27, 95% confidence interval 1.11 to 1.46). One year mortality after AMI was similar in those who reported sexual activity in the first month after AMI (2.1%) and those who were sexually inactive (4.1%, p = 0.08). In conclusion, although many patients were sexually active before AMI, only a minority received discharge counseling about resuming sexual activity. Lack of counseling was associated with loss of sexual activity 1 year later. Mortality was not significantly increased in patients who were sexually active soon after their AMI.

• Balloon angioplasty for congenital aortic valve stenosis.

  Authors: George G S Sandor, Derek G Human, James E Potts

  The American journal of cardiology. 109(10):1536-7.

• Statins in patients with renal dysfunction.

  Authors: Vasilios G Athyros, Asterios Karagiannis, Niki Katsiki, Dimitri P Mikhailidis

  The American journal of cardiology. 109(10):1537.

• Utility of Cardiac Magnetic Resonance Imaging to Differentiate Cardiac Sarcoidosis from Arrhythmogenic Right Ventricular Cardiomyopathy.

  Authors: David A Steckman, Preston M Schneider, Joseph L Schuller, Ryan G Aleong, Duy T Nguyen, Gianfranco Sinagra, Giancarlo Vitrella, Francesca Brun, Maria A Cova, Lorenzo Pagnan, Luisa Mestroni, Paul D Varosy, William H Sauer

  The American journal of cardiology.

  Some patients diagnosed with arrhythmogenic right ventricular cardiomyopathy (ARVC) are eventually found to have cardiac sarcoidosis (CS). Accurate differentiation between these 2 conditions hasSome patients diagnosed with arrhythmogenic right ventricular cardiomyopathy (ARVC) are eventually found to have cardiac sarcoidosis (CS). Accurate differentiation between these 2 conditions has implications for immunosuppressive therapy and familial screening. We sought to determine whether cardiac magnetic resonance imaging (MRI) could be used to identify the characteristic findings to accurately differentiate between CS and ARVC. Consecutive patients with a diagnostic MRI scan indicating CS and/or ARVC constituted the cohort. All patients diagnosed with CS had histologic confirmation of sarcoidosis, and all patients with ARVC met the diagnostic task force criteria. The cardiac MRI data were retrospectively analyzed to identify possible differentiating characteristics. Of the patients, 40 had CS and 21 had ARVC. Those with CS were older and had more left ventricular scar. The presence of mediastinal lymphadenopathy or left ventricular septal involvement was seen exclusively in the patients with CS (p <0.001). A family history of sudden cardiac death was seen only in the ARVC group (p = 0.012). The right ventricular ejection fraction and ventricular volumes were also significantly different between the 2 groups. In conclusion, patients with CS have significantly different cardiac MRI characteristics than patients with ARVC. The cardiac volume, in addition to the degree and location of cardiac involvement, can be used to distinguish between these 2 disease entities. The presence of mediastinal lymphadenopathy and left ventricular septal scar favors a diagnosis of CS and not ARVC. Consideration of CS should be given if these MRI findings are observed during the evaluation for possible ARVC.

• Meta-Analysis of Cytochrome P450 2C19 Polymorphism and Risk of Adverse Clinical Outcomes Among Coronary Artery Disease Patients of Different Ethnic Groups Treated With Clopidogrel.

  Authors: Jae-Sik Jang, Kyoung-Im Cho, Han-Young Jin, Jeong-Sook Seo, Tae-Hyun Yang, Dae-Kyeong Kim, Dong-Soo Kim, Sang-Hoon Seol, Doo-Il Kim, Bo-Hyun Kim, Yong Hyun Park, Hyung-Gon Je, Young-Hoon Jeong, Seung-Whan Lee

  The American journal of cardiology.

  Loss-of-function (LOF) variants of cytochrome P450 2C19 (CYP2C19) have been hypothesized to be associated with lesser degrees of platelet inhibition and increased risk for recurrent ischemic eventsLoss-of-function (LOF) variants of cytochrome P450 2C19 (CYP2C19) have been hypothesized to be associated with lesser degrees of platelet inhibition and increased risk for recurrent ischemic events in patients with coronary artery disease on clopidogrel therapy; however, studies from Western countries have yielded mixed results. We aimed to assess the impact of CYP2C19 LOF variants on clinical outcomes from different ethnic groups. Sixteen prospective cohort studies including 7,035 patients carrying ≥1 CYP2C19 LOF allele and 13,750 patients with the wild-type genotype were included in this meta-analysis. Carriers of ≥1 CYP2C19 LOF allele were at significantly higher risk for adverse clinical events compared to noncarriers during clopidogrel therapy (odds ratio [OR] 1.42, 95% confidence interval [CI] 1.13 to 1.78). The summary OR showed a significant association between CYP2C19 LOF variants and an increased risk of cardiac death (OR 2.18, 95% CI 1.37 to 3.47), myocardial infarction (OR 1.42, 95% CI 1.12 to 1.81), and stent thrombosis (OR 2.41, 95% CI 1.76 to 3.30). Stratified analysis by ethnicity of study population suggested higher odds of adverse clinical events in the Asian population with LOF variants of CYP2C19 (OR 1.89, 95% CI 1.32 to 2.72) compared to Western populations (OR 1.28, 95% CI 1.00 to 1.64). In conclusion, carrier status for LOF CYP2C19 is associated with an increased risk of adverse clinical events in patients with coronary artery disease on clopidogrel therapy despite differences in clinical significance according to ethnicity.

• Predictors of Atrial Fibrillation Termination and Clinical Success of Catheter Ablation of Persistent Atrial Fibrillation.

  Authors: E Kevin Heist, Fadi Chalhoub, Conor Barrett, Stephan Danik, Jeremy N Ruskin, Moussa Mansour

  The American journal of cardiology.

  The termination of persistent atrial fibrillation (AF) during catheter ablation has been associated in some, but not all, studies with reduced arrhythmia during clinical follow-up. We sought toThe termination of persistent atrial fibrillation (AF) during catheter ablation has been associated in some, but not all, studies with reduced arrhythmia during clinical follow-up. We sought to determine the rate of persistent AF termination achievable with a stepwise ablation strategy, the predictors of AF termination, and the clinical outcomes associated with termination and nontermination. A total of 143 consecutive patients (age 62 ± 9 years, AF duration 5.7 ± 5.2 years) with persistent and longstanding persistent AF resistant to antiarrhythmic medication who presented in AF for catheter ablation were studied. Ablation was done with a stepwise approach, including pulmonary vein isolation, followed by complex fractionated atrial electrogram ablation and ablation of resultant atrial tachycardias. Clinical follow-up was then performed after a 2-month blanking period to assess arrhythmia recurrence, defined as AF or atrial tachycardia lasting ≥30 seconds. AF termination by ablation was achieved in 95 (66%) of the 143 patients. Multivariate predictors of AF termination included longer baseline AF cycle length (p <0.001) and smaller left atrial size (p = 0.002). AF termination by ablation was associated with both a lower incidence of arrhythmia recurrence after a single procedure without antiarrhythmic drugs (p = 0.01) and overall clinical success (single or multiple procedures, with or without antiarrhythmic drugs; p = 0.005). On multivariate analysis, the predictors of overall clinical success included AF termination by ablation (p = 0.001), a shorter ablation duration (p = 0.002), younger age (p = 0.02), male gender (p = 0.03), and the presence of hypertension (p = 0.03). In conclusion, among patients with persistent AF, termination of AF by ablation can be achieved in most patients and is associated with reduced recurrence of arrhythmia.

• Safety of "Bridging" With Eptifibatide for Patients With Coronary Stents Before Cardiac and Non-Cardiac Surgery.

  Authors: Andrew N Rassi, Eugene Blackstone, Michael A Militello, Gus Theodos, Matthew A Cavender, Zhiyuan Sun, Stephen G Ellis, Leslie Cho

  The American journal of cardiology.

  Patients with previously implanted coronary stents are at risk for stent thrombosis if dual-antiplatelet therapy is prematurely discontinued. Bridging with a glycoprotein IIb/IIIa inhibitor has beenPatients with previously implanted coronary stents are at risk for stent thrombosis if dual-antiplatelet therapy is prematurely discontinued. Bridging with a glycoprotein IIb/IIIa inhibitor has been advocated as an alternative, with few supporting data. The aim of this study was to determine the safety of such a strategy by retrospectively analyzing bleeding in 100 consecutive patients with previously implanted coronary stents who were bridged to surgery with eptifibatide after discontinuing thienopyridine therapy. A propensity-matched control comparison was performed for a subgroup of 71 patients who underwent cardiovascular surgery. Blood transfusions were required in 65% in the bridged group versus 66% in the control group (p = 0.86). The mean numbers of units transfused were 4.84 ± 6.93 and 3.65 ± 7.46, respectively (p >0.25). Rates of return to the operating room for bleeding or tamponade were 10% and 2.9%, respectively (p = 0.085). Increased rates of transfusion were noted for patients who received concomitant aspirin and/or intravenous heparin infusion. In conclusion, there does not appear to be any increase in the need for blood transfusions or rate of return to the operating room for patients being bridged with eptifibatide when thienopyridines are discontinued in the perioperative period, but concomitant use of additional antiplatelet or anticoagulant agents may increase transfusions and delays to surgery. Clinicians who are considering this strategy must weigh the risks of stent thrombosis versus bleeding.

• Meta-Analysis Comparing Bivalirudin Versus Heparin Monotherapy on Ischemic and Bleeding Outcomes After Percutaneous Coronary Intervention.

  Authors: Olivier F Bertrand, Sanjit S Jolly, Sunil V Rao, Tejas Patel, Loic Belle, Ivo Bernat, Guido Parodi, Olivier Costerousse, Tift Mann

  The American journal of cardiology.

  With femoral access, bivalirudin decreases risks of major bleeding after percutaneous coronary intervention (PCI) and provides better net clinical benefit compared to unfractionated heparin (UFH)With femoral access, bivalirudin decreases risks of major bleeding after percutaneous coronary intervention (PCI) and provides better net clinical benefit compared to unfractionated heparin (UFH) plus planned glycoprotein IIb/IIIa inhibitors. Whether this benefit exists compared to UFH monotherapy is less clear. We performed a systematic review and meta-analysis to compare outcomes in patients undergoing transfemoral PCI with UFH or bivalirudin. Randomized trials (n = 3) and observational studies (n = 13) comparing bivalirudin to UFH monotherapy were reviewed. Primary outcomes were 30-day rates of major adverse cardiovascular events (MACEs) including death, myocardial infarction (MI), urgent revascularization, as well as all-cause mortality, MI, major bleeding, and blood transfusion. We collected data from 16 studies involving 32,492 patients undergoing PCI. Most observational studies were performed in the United States, whereas all randomized trials were done in Europe. Compared to UFH monotherapy, bivalirudin was associated with similar risk of MACEs (odds ratios [OR] 0.92, 95% confidence interval [CI] 0.75 to 1.12), a substantial 45% relative decrease in major bleeding (OR 0.55, 95% CI 0.43 to 0.72), and a trend in the decrease of transfusion (OR 0.87, 95% CI 0.70 to 1.08). A decrease in mortality was seen in observational studies (OR 0.62, 95% CI 0.45 to 0.85) but remained inconclusive in randomized trials (OR 0.63, 95% CI 0.20 to 2.01). MI rate was similar with the 2 anticoagulants. In conclusion, in patients undergoing transfemoral PCI, the benefit of bivalirudin over UFH monotherapy is driven by a significant decrease in major bleeding with similar rates of MACE. As PCI practice moves toward other bleeding-avoidance strategies such as the radial approach, future studies should focus on the interaction between anticoagulant strategy and access-site choice.

• Cardiac Transplantation in Patients With Hypertrophic Cardiomyopathy.

  Authors: Tomoko S Kato, Hiroo Takayama, Saeko Yoshizawa, Charles Marboe, P Christian Schulze, Maryjane Farr, Yoshifumi Naka, Donna Mancini, Mathew S Maurer

  The American journal of cardiology.

  Cardiac transplantation is a treatment option for patients with hypertrophic cardiomyopathy (HC) who developed refractory heart failure and/or intractable arrhythmia. However, the pretransplantCardiac transplantation is a treatment option for patients with hypertrophic cardiomyopathy (HC) who developed refractory heart failure and/or intractable arrhythmia. However, the pretransplant characteristics and post-transplant prognosis for patients with nondilated idiopathic HC has not yet fully elucidated. Therefore, we retrospectively reviewed 813 consecutive transplant recipients undergoing cardiac transplantation at Columbia University Medical Center from 1999 to 2010 and compared the clinical course of 41 patients with idiopathic HC with that of 373 patients with ischemic heart disease and 398 patients with other heart disease. The patients with HC were younger than those with ischemic heart disease (47.8 ± 14.0 vs 57.1 ± 9.4 years; p <0.0001). The proportion of patients undergoing ventricular assist devise surgery for bridge-to-transplant was lower in patients with HC than in those with ischemic heart disease or other heart disease (14.6% vs 31.1% vs 35.7%, all p <0.01). The post-transplant survival of those with HC was better than that for those with ischemic heart disease (90.1% vs 85.8% and 83.9% vs 67.1% at 1 and 5 years, respectively; p = 0.0359), although it was not significantly different from those with other heart disease. Proportional hazards analysis revealed that the subjects with HC had reduced post-transplant mortality (hazard ratio 0.4760, 95% confidential interval 0.1889 to 0.9762; p = 0.042) on univariate, but not multivariate, analysis. Most patients with HC had nondilated left ventricles (left ventricular end-diastolic dimension ≤55 mm; n = 27), and post-transplant survival did not differ from that for those with dilated left ventricles (left ventricular end-diastolic dimension >55 mm; n = 14). In conclusion, the post-transplant survival of those with HC did not differ from those of the subjects who underwent transplant for other non-HC indications.

• Outcome of Noncardiac and Nonvascular Surgery in Patients With Mechanical Heart Valves.

  Authors: Murat Biteker, Ahmet İlker Tekkeşin, Mehmet Mustafa Can, Akın Dayan, Erkan Ilhan, Funda Müşerref Türkmen

  The American journal of cardiology.

  There is a tendency to avoid noncardiac surgery in patients with mechanical heart valves (MHVs) owing to the increased risk of perioperative thromboembolism, infective endocarditis, and bleeding. WeThere is a tendency to avoid noncardiac surgery in patients with mechanical heart valves (MHVs) owing to the increased risk of perioperative thromboembolism, infective endocarditis, and bleeding. We aimed to determine the risk of cardiac and noncardiac complications in patients with MHVs who underwent noncardiothoracic, nonvascular surgery. A total of 140 patients with MHVs (77 aortic, 46 mitral, and 17 double valve) and 1,200 patients with native valves (control group) were prospectively followed up for a minimum of 3 months after noncardiothoracic and nonvascular surgery. Patients with bioprostheses were excluded. Those patients aged >18 years who underwent an elective, non-outpatient, open surgical procedure were enrolled. Subcutaneous enoxaparin 1 mg/kg, twice daily, was used as bridging anticoagulation. The demographics, co-morbidities, and preoperative (medications, echocardiographic findings, laboratory results) and postoperative data were evaluated for their association with the occurrence of perioperative adverse events. The incidence of perioperative adverse cardiovascular (10.8% vs 10.7%, p = 0.985) and noncardiovascular (11.9% vs 11.4%, p = 0.989) events was similar in those patients with and without MHVs. Bleeding (18.6% vs 14.2%, p = 0.989), thromboembolism (3.6% vs 2%, p = 0.989), and mortality at 3 months (1.4% vs 1.3%, p = 0.825) were also similar for the 2 groups. In conclusion, with close follow-up and strict adherence to the guidelines, patients with MHVs and patients with native heart valves undergoing noncardiac and nonvascular surgery have a similar risk of mortality and morbidity.

• Comparison of Frequency of Complications With On-Label Versus Off-Label Use of Rotational Atherectomy.

  Authors: Kenichi Sakakura, Junya Ako, Hiroshi Wada, Ryo Naito, Hiroshi Funayama, Kenshiro Arao, Norifumi Kubo, Shin-Ichi Momomura

  The American journal of cardiology.

  Although rotational atherectomy (RA) is used for complex lesions in percutaneous coronary intervention, there are several contraindications and precautions. The purpose of our study was to compareAlthough rotational atherectomy (RA) is used for complex lesions in percutaneous coronary intervention, there are several contraindications and precautions. The purpose of our study was to compare complications between off-label and on-label use of RA. We identified 250 consecutive patients who underwent RA. Off-label characteristics included saphenous vein graft lesions, presence of thrombus, unprotected left main stenosis, coronary artery dissection, acute myocardial infarction (MI), left ventricular dysfunction, 3-vessel disease, long lesion (≥25 mm), or angulated lesion (≥45°). Patients who had ≥1 off-label characteristic were assigned to the off-label group (156 patients), and patients who had no off-label characteristics were assigned to the on-label group (94 patients). Occurrence of slow flow or periprocedural MI in the off-label group was higher than that in the on-label group (slow flow 30% vs 18%, p = 0.06; MI 8.8% vs 2.1%, p = 0.04), whereas severe complications such as burr entrapment, transection of the guidewire, or perforation were rare in the 2 groups. In conclusion, compared to the on-label group, the off-label group had a higher incidence of slow flow and periprocedural MI. Severe complications such as burr entrapment, transection of the guidewire, or perforation were rare in the 2 groups.

• Influence of Resting Heart Rate on Mortality in Patients Undergoing Coronary Angiography (from the Ludwigshafen Risk and Cardiovascular Health [LURIC] Study).

  Authors: Bríain O Hartaigh, Jos A Bosch, Stefan Pilz, Adrian Loerbroks, Marcus E Kleber, Tanja B Grammer, Joachim E Fischer, Bernhard O Boehm, G Neil Thomas, Winfried März

  The American journal of cardiology.

  Several epidemiologic studies have reported an association between elevated heart rate (HR) at rest and reduced survival. The usefulness of HR at rest in predicting end points in high-risk patientsSeveral epidemiologic studies have reported an association between elevated heart rate (HR) at rest and reduced survival. The usefulness of HR at rest in predicting end points in high-risk patients is yet to be definitively established. The purpose of this study was to clarify the relation between HR at rest with total and cardiovascular mortality in patients who underwent coronary angiography. A total of 3,316 Caucasian patients with available coronary angiograms were prospectively followed from 2001 to 2011 (median 9.9 years). The effect of HR at rest on total and cardiovascular mortality was explored, while correcting for a number of confounders. Patients in the highest quartile (HR at rest ≥84 beats/min) had survival times reduced by 1.2 and 1.4 years for overall and cardiovascular mortality, respectively. Likewise, these patients had significantly elevated adjusted risk for total (hazard ratio 1.39, 95% confidence interval 1.17 to 1.67, p for trend <0.001) and cardiovascular mortality (hazard ratio 1.38, 95% confidence interval 1.08 to 1.78, p for trend = 0.004). In conclusion, HR at rest is an inexpensive, easily measured, and modifiable predictor of mortality.

• Comparison of Safety and Efficacy of Bivalirudin Versus Unfractionated Heparin in High-Risk Patients Undergoing Percutaneous Coronary Intervention (from the Anti-Thrombotic Strategy for Reduction of Myocardial Damage During Angioplasty-Bivalirudin vs Heparin Study).

  Authors: Giuseppe Patti, Vincenzo Pasceri, Luca D'Antonio, Andrea D'Ambrosio, Michele Macrì, Giordano Dicuonzo, Giuseppe Colonna, Antonio Montinaro, Germano Di Sciascio

  The American journal of cardiology.

  Bivalirudin, a direct thrombin inhibitor, is as effective as unfractionated heparin (UFH), with decreased bleeding in patients with acute coronary syndromes who undergo percutaneous coronaryBivalirudin, a direct thrombin inhibitor, is as effective as unfractionated heparin (UFH), with decreased bleeding in patients with acute coronary syndromes who undergo percutaneous coronary intervention (PCI). The aim of this study was to evaluate the effectiveness of bivalirudin versus UFH in selected PCI patients at high bleeding risk. Four hundred one consecutive patients who underwent PCI fulfilling ≥1 enrollment criterion (age >75 years, chronic renal failure, and diabetes mellitus) were randomized to bivalirudin (bolus 0.75 mg/kg followed by infusion during the procedure; n = 198) or UFH (75 IU/kg; n = 203). In the overall population, 39% were aged >75 years, 22% had renal failure, 63% had diabetes, and 29% had acute coronary syndromes. The primary efficacy end point was the 30-day incidence of major adverse cardiac events (cardiac death, myocardial infarction, stent thrombosis, or target vessel revascularization). The primary safety end point was the occurrence of any bleeding or entry-site complications after PCI. All patients were preloaded with clopidogrel 600 mg. Glycoprotein IIb/IIIa inhibitors were used at the operators' discretion. Thirty-day major adverse cardiac event rates were 11.1% in the bivalirudin group and 8.9% in the UFH group (p = 0.56); the primary efficacy end point was reached mainly because of periprocedural myocardial infarction; 1 patient in the bivalirudin group had stent thrombosis. Occurrence of the primary safety end point was 1.5% in the bivalirudin group and 9.9% in the UFH group (p = 0.0001); this benefit was essentially driven by the prevention of entry-site hematomas >10 cm (0.5% vs 6.9%, p = 0.002). In conclusion, Anti-Thrombotic Strategy for Reduction of Myocardial Damage During Angioplasty-Bivalirudin vs Heparin (ARMYDA-7 BIVALVE) indicates that bivalirudin, compared with UFH, causes significantly lower bleeding and has a similar incidence of major adverse cardiac events in patients with older age, diabetes mellitus, or chronic renal failure who undergo PCI.

• Red Blood Cell Membrane Concentration of cis-Palmitoleic and cis-Vaccenic Acids and Risk of Coronary Heart Disease.

  Authors: Luc Djoussé, Nirupa R Matthan, Alice H Lichtenstein, John M Gaziano

  The American journal of cardiology.

  Although previous studies have suggested associations between plasma palmitoleic acid and coronary heart disease (CHD) risk factors, including blood pressure, inflammation, and insulin resistance,Although previous studies have suggested associations between plasma palmitoleic acid and coronary heart disease (CHD) risk factors, including blood pressure, inflammation, and insulin resistance, little is known about the relation of palmitoleic acid and CHD. This ancillary study of the Physicians' Health Study was designed to examine whether red blood cell (RBC) membrane cis-palmitoleic acid and cis-vaccenic acid-2 fatty acids that can be synthesized endogenously-are associated with CHD risk. We used a risk set sampling method to prospectively select 1,000 incident CHD events and 1,000 matched controls. RBC membrane fatty acids were measured using gas chromatography. The CHD cases were ascertained using an annual follow-up questionnaire and validated by an End Point Committee through a review of the medical records. In a conditional logistic regression analysis adjusting for demographics, anthropometric, lifestyle factors, and co-morbidity, the odds ratios and 95% confidence intervals (CIs) for CHD were 1.0 (referent), 1.29 (95% CI 0.95 to 1.75), 1.08 (95% CI 0.78 to 1.51), 1.25 (95% CI 0.90 to 1.75), and 1.48 (95% CI 1.03 to 2.14) across consecutive quintiles of RBC membrane cis-palmitoleic acid (p for trend = 0.041). The odds ratio associated with each SD higher RBC membrane cis-palmitoleic acid level was 1.19 (95% CI 1.06 to 1.35) in a multivariate-adjusted model. Finally, RBC membrane cis-vaccenic acid was inversely associated with CHD risk (odds ratio 0.79, 95% CI 0.69 to 0.91, per SD increase). In conclusion, our data showed a positive association between RBC membrane cis-palmitoleic acid and CHD risk in male physicians. Furthermore, RBC membrane cis-vaccenic acid was inversely related to CHD.

• Comparison of Outcomes of Illicit Drug Users and Nonusers Hospitalized With Heart Failure.

  Authors: Ahmad M Slim, Hillary Thomas, Roy Parish, Ishak Mansi

  The American journal of cardiology.

  The long-term effects of illicit drug use (IDU) on the clinical outcome of patients with heart failure (HF) are not well described. The objective of the present study was to describe theThe long-term effects of illicit drug use (IDU) on the clinical outcome of patients with heart failure (HF) are not well described. The objective of the present study was to describe the characteristics of patients with HF who used illicit drugs and to determine the effects of IDU on the clinical outcomes such as in-hospital mortality and hospital readmission for HF. A retrospective cohort study was conducted that included all patients admitted with HF from June 2003 to September 2004 and followed up until 2008 at a university hospital serving an at-risk population. The patients were divided into 2 groups: IDU and non-IDU according to self-reported use or positive laboratory results. The outcome measures were in-hospital mortality, HF readmission rate, interval to readmission for HF, and average brain natriuretic peptide and troponin levels throughout the follow-up period. Of 646 reviewed records, 542, representing 357 patients, were included in the present analysis. Of the 357 patients, 53 patients were in the IDU group and 304 were in the non-IDU group. Kaplan-Meier log-rank analysis and Cox proportional hazard analysis showed that IDU was associated with a shorter interval to readmission for HF (hazard ratio 3.8, 95% confidence interval 2.3 to 10.7, p <0.0001) but not with in-hospital mortality (hazard ratio 0.7, 95% confidence interval 0.3 to 1.7, p = 0.4). Multiple linear regression analysis identified IDU as an independent variable for the HF readmission rate (p = 0.0001) but not for average brain natriuretic peptide or average troponin levels. In conclusion, the results of the present study have demonstrated that IDU was associated with a decreased interval to readmission for HF and greater HF readmission rates.

• Relation Between Angiographic Lesion Severity, Vulnerable Plaque Morphology and Future Adverse Cardiac Events (from the Providing Regional Observations to Study Predictors of Events in the Coronary Tree Study).

  Authors: Kyeong Ho Yun, Gary S Mintz, Naim Farhat, Steven P Marso, Nevio Taglieri, Stefan Verheye, Michael C Foster, M Pauliina Margolis, Barry Templin, Ke Xu, Ovidiu Dressler, Roxana Mehran, Gregg W Stone, Akiko Maehara

  The American journal of cardiology.

  Previous angiographic studies have suggested that the future risk for major adverse cardiovascular events (MACEs) is related to coronary stenosis severity. The aim of this study was to use thePrevious angiographic studies have suggested that the future risk for major adverse cardiovascular events (MACEs) is related to coronary stenosis severity. The aim of this study was to use the grayscale and virtual histology (VH)-intravascular ultrasound (IVUS) data from the Providing Regional Observations to Study Predictors of Events in the Coronary Tree (PROSPECT) study to identify underlying lesion morphologic characteristics that might explain these findings. In PROSPECT, patients presenting with acute coronary syndromes in whom percutaneous coronary intervention was successful underwent 3-vessel grayscale and VH-IVUS and were followed for a median of 3.4 years for the incidence of MACEs. Overall, 3,115 nonculprit lesions detected by IVUS were divided into quartiles according to baseline angiographic diameter stenosis. From the first to fourth quartiles, there were increases in the prevalence of lesions with IVUS minimum luminal areas ≤4 mm(2), IVUS plaque burden ≥70%, and VH-IVUS thin-cap fibroatheroma (13.4%, 22.0%, 24.2%, and 30.3%, respectively, p <0.001), along with an increased frequency of plaque ruptures and greater necrotic core volumes. The incidence of lesions with plaque burden ≥70%, minimum luminal area ≤4 mm(2), and VH thin-cap fibroatheroma was highest in the fourth quartile (0%, 0.4%, 0.4%, and 2.8% in the first through fourth quartiles, respectively, p <0.001). Three-year MACE rates were also highest in the fourth quartile (0.3%, 0.7%, 1.3%, and 5.1%, respectively, p <0.001). In conclusion, increasing angiographic diameter stenosis was associated with an increased frequency of grayscale and VH-IVUS lesion morphologic features that have been associated with adverse events and that may, in part, explain why future MACEs were related to baseline lesion severity.

• Early Readmissions After Percutaneous Coronary Intervention in a Rural Tertiary Care Center (from the Guthrie Health Off-Label Stent [GHOST] Registry).

  Authors: Kishore J Harjai, Maninder Singh, Judy Boura

  The American journal of cardiology.

  Early readmissions (ERs) impose a huge cost to the health care system, lower patients' quality of life, and may be an indicator of quality of initial care. We performed this single-center study toEarly readmissions (ERs) impose a huge cost to the health care system, lower patients' quality of life, and may be an indicator of quality of initial care. We performed this single-center study to assess the incidence, predictors, and implications of 30-day readmission after percutaneous coronary intervention (PCI) in a tertiary care rural setting. In 4,262 consecutive patients who underwent PCI, we evaluated 30-day readmission rates and assessed demographic, clinical, and angiographic correlates of ER. Using Cox regression analyses, we estimated the multivariable impact of an ER on 1-year all-cause mortality and major adverse events (MACEs; death, myocardial infarction, target vessel revascularization, stent thrombosis). ER occurred in 486 patients (11.4%) including 366 (8.6%) for cardiac reasons and 120 (2.8%) for noncardiac reasons. Multivariable models predicting any readmission, cardiac readmission, and noncardiac readmission had c-statistic values of 0.63, 0.63, and 0.68, respectively. One-year mortality and MACEs were higher in the readmitted versus not readmitted patients (7.9% vs 3.2%, 18 vs 9.7%, p <0.0001 for the 2 comparisons). ER had a significant and independent impact on 1-year mortality (adjusted hazards ratio 2.2, 95% confidence interval 1.4 to 3.4) and MACEs (hazards ratio 2.2, 95% confidence interval 1.8 to 2.8). In conclusion, readmission within 30 days after PCI is common and frequently related to cardiac causes. Patients who require an ER after PCI have higher 1-year mortality and MACEs.

• Prediction of Outcome by Highly Sensitive Troponin T in Outpatients With Chronic Systolic Left Ventricular Heart Failure.

  Authors: Michael Egstrup, Morten Schou, Christian D Tuxen, Caroline N Kistorp, Per R Hildebrandt, Finn Gustafsson, Jens Faber, Jens-Peter Goetze, Ida Gustafsson

  The American journal of cardiology.

  Our aim was to assess the prognostic impact of a high-sensitivity cardiac troponin T (hs-cTnT) assay in an outpatient population with chronic systolic left ventricular heart failure (HF). FourOur aim was to assess the prognostic impact of a high-sensitivity cardiac troponin T (hs-cTnT) assay in an outpatient population with chronic systolic left ventricular heart failure (HF). Four hundred sixteen patients with chronic HF and left ventricular ejection fraction ≤45% were enrolled in a prospective cohort study. In addition to hs-cTnT, plasma amino-terminal pro-B-type natriuretic peptide was measured at baseline. Mean age was 71 years, 29% were women, 62% had coronary artery disease (CAD), mean left ventricular ejection fraction was 31%, and 57% had abnormal level of hs-cTnT. During 4.4 years of follow-up, 211 (51%) patients died. In multivariate Cox regression models, hs-cTnT was categorized as quartiles or dichotomized by the 99th percentile of a healthy population. Adjusted hazard ratios for all-cause mortality for quartiles 2 to 4, with quartile 1 as reference, were 1.4 (95% confidence interval 0.9 to 2.4, p = 0.16) for quartile 2, 1.7 (0.9 to 2.5, p = 0.12) for quartile 3, and 2.6 (1.6 to 4.4, p <0.001) for quartile 4 and 1.7 (1.2 to 2.5, p = 0.003) for abnormal versus normal level of hs-cTnT. In patients without CAD, quartile 4 of hs-cTnT was associated with an adjusted hazard ratio of 6.8. In conclusion, hs-cTnT is increased in most outpatients with chronic systolic HF and carries prognostic information beyond clinical parameters and amino-terminal pro-B-type natriuretic peptide. Increased hs-cTnT indicated a particularly deleterious prognosis in patients without CAD.

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