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International journal of cardiology 04/2013; · 7.08 Impact Factor
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The American journal of cardiology 04/2012; 109(8):1238. · 3.58 Impact Factor
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Journal of the American College of Cardiology 01/2012; 59(5):542-3. · 14.16 Impact Factor
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ABSTRACT: Implantable cardioverter defibrillators (ICD), despite an unequivocal clinical benefit, are known to have a complex psychosocial impact on the patients. ICD shocks and the resultant psychobiological changes are known to contribute to increased levels of anxiety, depression, and post-shock stress symptoms in these patients. Phantom shock is a patient-reported perception of an ICD shock in the absence of any actual shock; however, its pathophysiological understanding is poor.
A retrospective chart review of the University hospital ICD patients' database from June 2006 to April 2010 was conducted. A total of 38 patients with documented phantom shocks as cases and 76 age- and sex-matched patients with no phantom shocks as controls were selected from the database. Patient characteristics were analyzed for their potential association with the occurrence of phantom shocks.
Phantom shock patients had higher prevalence of documented depression (31.6%), anxiety (23.7%), and cocaine use (42.1%). Additionally, patients who had previous ICD shock storms were more likely to have phantom shocks (39.5%; p = 0.001). More importantly, no phantom shocks were reported in patients who did not receive defibrillation threshold testing or past ICD shock storms.
Phantom shocks are primarily observed in ICD patients who had prior exposure to traumatic device shocks and are more common in patients with a history of depression, anxiety, or substance abuse. A pathophysiological mechanism is proposed as a guide to potential prevention.
Journal of Interventional Cardiac Electrophysiology 12/2011; 34(2):205-13. · 1.17 Impact Factor
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ABSTRACT: Microalbuminuria (MA), a renal marker of vascular injury, is an independent predictor of cardiovascular (CV) events. Red cell distribution width (RDW), an emerging CV risk predictor, has not been evaluated for its association with MA.
We evaluated 8,499 participants of the National Health and Nutrition Examination Survey (NHANES) 1999-2006, where RDW was evaluated as a continuous variable and in quartiles (Q(1) ≤ 12.1, Q(2) 12.2-12.5, Q(3) 12.6-13 and Q(4) >13). Multivariate adjusted logistic regression analysis was performed to estimate the odds of having MA (n = 1,736; adjusted for traditional CV risk factors, race, BMI, estimated glomerular filtration rate, hemoglobin, mean corpuscular volume, high-sensitivity C-reactive protein and nutritional factors deficiencies of iron, folate and vitamin B(12)).
The prevalence of MA increased with increasing RDW (13.52% in Q(1) vs. 30.02% in Q(4), p < 0.001). The odds of having MA for those in Q(4) was 2.49 (95% CI: 1.95-3.18, p < 0.001) compared to those in Q(1) after the adjustments. No effect modification was observed by covariates on the association between RDW and MA.
Elevated RDW is independently associated with a higher risk of MA. An interaction between chronic inflammation, oxidative stress, neurohumoral overactivity and endothelial dysfunction may explain this association and the attendant elevated CV/renal risk.
Nephron Clinical Practice 09/2011; 119(4):c277-82. · 2.04 Impact Factor
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ABSTRACT: Supraventricular tachyarrhythmias including atrial fibrillation are common and troubling complications after cardiac surgery, and thus considerable interest in pharmacologic prophylaxis has developed. The aim of this study was to evaluate the efficacy of sotalol in the prevention of postoperative supraventricular tachyarrhythmias.
Standard methods of meta-analysis were used. Randomized clinical trials published in English language were eligible for the meta-analysis.
A systematic review revealed 15 eligible publications that provided 20 comparisons of sotalol with a control group. The incidence and relative risk (RR) with 95% confidence interval (CI) of developing postoperative supraventricular tachyarrhythmias while taking sotalol were sotalol (n=489) versus placebo (n=499): 22.5% versus 41.5%, RR=0.55 (CI, 0.454-0.667, P<.001); sotalol (n=304) versus no treatment (n=311): 12% versus 39%, RR=0.329 (CI, 0.236-0.459, P<.001); sotalol (n=488) versus beta-blocker (n=555): 14% versus 23%, RR=0.644 (CI, 0.495-0.838, P<.001); sotalol (n=139) versus amiodarone (n=146): no significant differences in supraventricular tachyarrhythmia prevention; and sotalol (n=51) versus magnesium (n=54): no significant differences in supraventricular tachyarrhythmia prevention. Initiating sotalol orally or intravenously had no significant effect on efficacy. Initiating sotalol after surgery showed a trend toward less adverse events (before: RR=1.700 [CI, 0.903-3.200] and after: RR=0.767 [CI, 0.391-1.505]).
Sotalol is more effective in the prevention of supraventricular tachyarrhythmia than placebo or beta-blockers. Initiating sotalol before cardiac surgery has no advantage compared with initiating sotalol shortly after surgery. Starting sotalol intravenously after surgery may be a more reliable method than administering via a nasogastric tube or delaying treatment until the patient can take oral medication.
The American journal of medicine 09/2011; 124(9):875.e1-9. · 4.47 Impact Factor
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ABSTRACT: The purpose of this study was to examine whether adding homocysteine (Hcy) to a model based on traditional cardiovascular disease (CVD) risk factors improves risk classification.
Data on using Hcy to reclassify individuals in various risk categories beyond traditional approaches have not been adequately scrutinized.
We performed a post hoc analysis of the MESA (Multi-Ethnic Study of Atherosclerosis) and NHANES III (National Health and Nutrition Examination Survey III) datasets. Hcy was used to predict composite CVD and hard coronary heart disease (CHD) events in the MESA study and CVD and CHD mortality in the NHANES III survey using adjusted Cox-proportional hazard analysis. Reclassification of CHD events was performed using a net reclassification improvement (NRI) index with a Framingham risk score (FRS) model with and without Hcy.
Hcy level (>15 μmol/l) significantly predicted CVD (adjusted hazard ratio [aHR]: 1.79, 95% confidence intervals [CI]: 1.19 to 1.95; p = 0.006) and CHD events (aHR: 2.22, 95% CI: 1.20 to 4.09; p = 0.01) in the MESA trial and CVD (aHR: 2.72, 95% CI: 2.01 to 3.68; p < 0.001) and CHD mortality (aHR: 2.61, 95% CI: 1.83 to 3.73; p < 0.001) in the NHANES III, after adjustments for traditional risk factors and C-reactive protein. The level of Hcy, when added to FRS, significantly reclassified 12.9% and 18.3% of the overall and 21.2% and 19.2% of the intermediate-risk population from the MESA and NHANES cohorts, respectively. The categoryless NRI also showed significant reclassification in both MESA (NRI: 0.35, 95% CI: 0.17 to 0.53; p < 0.001) and NHANES III (NRI: 0.57, 95% CI: 0.43 to 0.71; p < 0.001) datasets.
From these 2 disparate population cohorts, we found that addition of Hcy level to FRS significantly improved risk prediction, especially in individuals at intermediate risk for CHD events.
Journal of the American College of Cardiology 08/2011; 58(10):1025-33. · 14.16 Impact Factor
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ABSTRACT: Almost 50% of patients with congestive heart failure (HF) have preserved ejection fraction (PEF). Data on the effect of HF-PEF on atrial fibrillation outcomes are lacking. We assessed the prognostic significance of HF-PEF in an atrial fibrillation population compared to a systolic heart failure (SHF) population. A post hoc analysis of the National Heart, Lung, and Blood Institute-limited access data set of the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial was carried out. The patients with a history of congestive HF and a preserved ejection fraction (EF >50%) were classified as having HF-PEF (n = 320). The patients with congestive HF and a qualitatively depressed EF (EF <50%) were classified as having SHF (n = 402). Cox proportional hazards analysis was performed. The mean follow-up duration was 1,181 ± 534 days/patient. The patients with HF-PEF had lower all-cause mortality (hazard ratio [HR] 0.62, 95% confidence interval [CI] 0.46 to 0.85, p = 0.003) and cardiovascular mortality (HR 0.56, 95% CI 0.38 to 0.84, p = 0.006), with a possible decreased arrhythmic end point (HR 0.39, 95% CI 0.16 to 1.006, p = 0.052) than did the patients with SHF. No differences were observed for ischemic stroke (HR 1.08, 95% CI 0.48 to 2.39, p = 0.86), rehospitalization (HR 0.89, 95% CI 0.75 to 1.07, p = 0.24), or progression to New York Heart Association class III-IV (odds ratio 0.80, 95% CI 0.42 to 1.54, p = 0.522). In conclusion, although patients with HF-PEF have better mortality outcomes than those with SHF, the morbidity appears to be similar.
The American journal of cardiology 08/2011; 108(9):1283-8. · 3.58 Impact Factor
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The American journal of cardiology 08/2011; 108(3):474. · 3.58 Impact Factor
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ABSTRACT: We used the National Heart, Lung, and Blood Institute Limited Access Dataset of Prevention of Events with Angiotensin-Converting Enzyme Inhibition (PEACE) Trial (n = 8290) which included patients with stable coronary artery disease (CAD) and preserved ejection fraction (>40%). We identified risk factors for the development of critical peripheral arterial disease (PAD; those needing angioplasty, bypass grafting, or aneurysm repair) and formulated a risk score by multivariate analyses. A total of 220 patients (2.8%) developed critical PAD over a mean follow-up of 4.7 years. Significant predictors of critical PAD were history of intermittent claudication, smoking, hypertension (HTN), coronary-artery bypass grafting (CABG), diabetes, age, serum cholesterol, and body mass index (BMI). Incident critical PAD was associated with increased composite outcome of cardiovascular death, myocardial infarction, percutaneous transluminal coronary angioplasty, or CABG (hazard ratio 1.82, 95% CI 1.50-2.22, P < .001). Risk assessment using our score may identify CAD patients at risk for critical PAD events.
Angiology 08/2011; 62(6):473-9. · 1.51 Impact Factor
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Mohamed A El-Haddad,
Sandip K Zalawadiya,
Hany Awdallah,
Sameh Sabet,
Haitham A El-Haddad,
Ashraf Mostafa,
Ahmed Rashed,
Wael El-Naggar,
Nabil Farag,
Mohamed A Saleb, Sony Jacob
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ABSTRACT: Atrial fibrillation (AF) is a common complication of cardiothoracic surgery (CTS). Existing evidence about the potential protective role of angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]) for post-CTS AF has been limited and conflicting. In this single-blind, open-label, randomized prospective pilot study, we evaluated the potential protective role of irbesartan (an ARB) in post-coronary artery bypass graft (CABG) AF.
A total of 100 consecutive patients undergoing CABG were randomly assigned to irbesartan (n = 50) versus no irbesartan (n = 50) for 5 days prior to the scheduled surgery. Data were collected for imaging studies, laboratory values, and peri-operative details. Patients were monitored post-operatively for in-hospital AF episodes. Unadjusted and adjusted logistic regression analysis was performed to assess the effect of irbesartan on the incidence of post-CABG AF.
A total of 14 patients developed AF during their post-operative hospital stay. The incidence of AF in patients who received irbesartan was 6% (n = 3) compared with 22% (n = 11) in patients who did not receive irbesartan (p = 0.021). Univariate logistic regression analysis identified irbesartan and age as statistically significant variables. An adjusted multivariate logistic model identified irbesartan as an important protective factor against development of post-CABG AF (adjusted odds ratio [OR] 0.20; 95% confidence interval [CI] 0.04, 0.94; p = 0.04). Increasing age (adjusted OR 1.09, 95% CI 1.01, 1.17; p = 0.03) was also identified as an independent risk factor for development of post-CABG AF.
Pretreatment with irbesartan tends to have a significant protective effect against the occurrence of AF during the post-operative period in patients undergoing CABG.
American Journal of Cardiovascular Drugs 05/2011; 11(4):277-84. · 1.77 Impact Factor
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ABSTRACT: The growing indications for permanent pacemaker and implantable cardioverter defibrillator (ICD) implantation have increased the number of patients with these cardiac rhythm management devices (CRMDs). Cardiac rhythm management devices occasionally perform inappropriately in response to electromagnetic interference (e.g. surgical electrocautery) or lead noise over-sensing (e.g. lead fracture). Temporary reprogramming of the CRMDs using device programmers can prevent these untoward device responses. However, these programmers are device manufacturer specific and require technically qualified personnel to operate. This could cause delayed patient care and increased use of resources in certain clinical situations. Alternatively, clinical magnets, when appropriately positioned over the device site, can change the pacing to an asynchronous mode in pacemakers and suspend tachycardia therapies in ICDs. Although readily available, clinical magnets have not been widely used for this purpose, perhaps due to the unfamiliarity with the variable responses of CRMDs to magnet application. This article provides a comprehensive overview of the current literature on the mechanism of action and the specific responses of various CRMDs to clinical magnets.
Europace 05/2011; 13(9):1222-30. · 1.98 Impact Factor
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ABSTRACT: Metabolic syndrome poses a significant risk for cardiovascular disease. Recently, glycosylated hemoglobin (HbA1c) has been included in the diagnostic criteria for diabetes mellitus and prediabetes. We sought to determine if HbA1c is associated with prevalent metabolic syndrome in nondiabetic U.S. adults.
A total of 9,022 nondiabetic participants of National Health and Nutrition Examination Surveys 1999-2008 (age, 47.5 ± 18.3 years, 51% females) were divided into quintiles (Q) of HbA1c: Q1 (reference), ≤5%; Q2, 5.1%-5.3%; Q3, 5.4%-5.5%; Q4, 5.6%-5.7%; and Q5, ≥5.8%. Modified National Cholesterol Education Program Adult Treatment Panel III criteria were used to identify metabolic syndrome (n=2,821; 31.3%). Unadjusted and adjusted multivariate logistic regression analysis was performed to assess the risk of metabolic syndrome.
A graded increase in odds of having prevalent metabolic syndrome with increase from each quintile of HbA1c compared to Q1 was observed after adjusting for age, sex, race, body mass index (BMI), total cholesterol, lipid-lowering therapy, current smoking, family history of diabetes, C-reactive protein, and fasting insulin. Stratified analysis based on gender, ethnicity, and BMI showed similar results. The HbA1c value of ≥5.4% remained appropriate cutoff for predicting metabolic syndrome in Caucasians and Hispanics, whereas ≥5.6% provided the best accuracy for African Americans based on receiver operating characteristics analysis.
HbA1c much below the level for prediabetes was associated with prevalence of the metabolic syndrome in a cohort of nondiabetic U.S. adults. HbA1c can be considered as a surrogate marker for metabolic syndrome in nondiabetics.
Metabolic syndrome and related disorders 05/2011; 9(5):361-7.
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ABSTRACT: Atrial fibrillation (AF) is one of the most common arrhythmia encountered in clinical practice. Although AF is due to the structural and electrophysiological alterations in the atria, its sustainability is multifactorial, and the actual mechanisms are still not clear. Despite the recent advances in catheter ablation technology and techniques, pharmacotherapy still remains the first-line therapy for the management of AF. Current pharmacotherapy targets ion channel alterations that in fact represent only one aspect of the management of this complex arrhythmia. Successful pharmacological treatment of AF and restoration of sinus rhythm is limited and is in part due to its potential deleterious side effects. Newer agents having diverse mechanisms acting on the recently uncovered pathophysiological processes are on the horizon. These include atrial repolarization delaying agents, newer class III agents, Na(+)-Ca(2+) channel blockers, stretch receptor blockers, I(KACH) blockers, gap junction modifiers, upstream therapies, and agents targeting ischemia-induced AF. Gene- and cell-specific therapies including 'tailored nanopharmacy,' newer rate control medications with minimal side effects and the emergence of novel drugs targeting multiple areas of AF arrhythmogenesis in tandem with electrical therapy may be the future direction in the management of AF.
American journal of therapeutics 05/2011; 18(3):241-60.
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ABSTRACT: BACKGROUND Left ventricular ejection fraction (EF) in post-myocardial infarction (MI) patients is a strong predictor of adverse cardiovascular events. Although resting EF as measured by transthoracic echocardiography (TTE), contrast ventriculography (CNV), and radionuclide angiography (RNA) exhibit high correlation, there is only modest agreement between these modalities. This study sought to explore whether modality of EF assessment influences prognostication of post-MI patients with normal or slightly reduced EF. METHODS AND RESULTS The National Heart, Lung, and Blood Institute (NHLBI) limited access dataset of the Prevention of Events with Angiotensin Converting Enzyme Inhibition (PEACE) Trial (1996-2003, n=8290) comparing trandolapril versus placebo was used. The cohort was partitioned into TTE (n=2582), RNA (n=816), and CNV (n=1155) groups based on modality of EF assessment. EF was a significant predictor of cardiovascular mortality (HR 0.97, 95% CI 0.95 to 0.98; p<0.005) and all cause mortality (HR 0.98, 95% CI 0.97 to 0.99; p=0.0002) on multivariate analysis in this population with preserved or mildly depressed EF. Although CNV, TTE, and RNA groups differed significantly in terms of baseline variables, no appreciable differences were noted between RNA (HR 1.13, 95% CI 0.85 to 1.50; ns) and CNV (HR 1.13, 95% CI 0.99 to 1.27; ns) groups, compared with TTE for all cause mortality. Similarly, no significant differences were observed for cardiovascular mortality between RNA (HR 1.23, 95% CI 0.82 to 1.84; p=0.31) and CNV (HR 1.14, 95% CI 0.78 to 1.67, p=0.49) versus TTE. CONCLUSION EF is a significant predictor of all-cause mortality and cardiovascular mortality in patients with preserved or mildly depressed EF. Modalities of EF measurement are interchangeable and do not play a significant role in prognostication in a post-MI population.
Postgraduate medical journal 03/2011; 87(1028):400-4. · 1.38 Impact Factor
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International journal of cardiology 02/2011; 155(1):87-9. · 7.08 Impact Factor
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Heart rhythm: the official journal of the Heart Rhythm Society 01/2011; 8(6):915-22. · 4.56 Impact Factor
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ABSTRACT: Cardiac arrhythmogenesis and cryptogenic epilepsy can be due to ion channel dysfunction and may coexist in the same patient. Sudden unexplained death in epilepsy (SUDEP) is a known entity with unknown cause, with the possibility of ventricular tachyarrhythmias being one of the causes. However, no prior study has investigated epileptic survivors of sudden cardiac death (SCD), recurrent life-threatening ventricular tachyarrhythmia (LTVA) and other outcomes in this patient population.
The Antiarrhythmics Versus Implantable Cardioverter Defibrillators (AVID) Trial (n = 1016) was a multicenter trial comparing a cardioverter-defibrillator device (ICD) (n = 507) and anti-arrhythmic drugs (AADs) (n = 499) for secondary prevention of LTVAs. Mean follow-up duration was 916 ± 471 days per patient. Patients with a history of epilepsy (n = 6) in the ICD arm were included in this analysis. End points were recurrence of LTVA, cardiac death and all-cause mortality.
History of epilepsy (n = 6) was a significant predictor of recurrent LTVA [hazard ratio 3.53, 95% confidence interval (CI) 1.30-9.56], cardiac death (hazard ratio 4.14, 95% CI 1.30-13.14) and all-cause mortality (hazard ratio 3.82, 95% CI 1.40-10.48) in the ICD arm (n = 498). This relationship remained unchanged on multivariate analysis after controlling for baseline clinical differences.
This is the first study to investigate the effect of epilepsy on secondary prevention of LTVA. Epileptic survivors of SCD are at significantly greater risk of recurrent arrhythmias and death as compared to other survivors of recurrent LTVA. Role of coexisting channelopathies in both epilepsy and arrhythmogenesis may explain SUDEP and requires further investigation.
Journal of Cardiovascular Medicine 11/2010; 11(11):810-4. · 1.51 Impact Factor
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ABSTRACT: The use of recreational drugs has been observed to have deleterious effects on the heart. The aim of our study was to evaluate the effect of substance abuse on the defibrillation threshold (DFT) in patients with implantable cardioverter-defibrillators (ICDs).
A retrospective analysis was conducted on patients who had undergone ICD placement at a tertiary university medical center in Detroit, Michigan. Subjects were identified based on self-reported drug use and placed into one of the three groups: controls, cocaine, and other illicit drugs. Due to a disparity in race among groups, the main analysis on DFT value was conducted on African-American patients only. Furthermore, exploratory analyses were conducted to investigate the effects of marijuana use and race on DFT values.
A history of cocaine use (n = 17) significantly increases DFT among African Americans (17.3 ± 8 Joule [J] vs 12.5 ± 5 J in cases vs controls, P < 0.05), while previous use of marijuana does not significantly influence DFT. African-American patients with a history of illicit drug use had indications for ICD implantation at an earlier age and that within the control (nondrug using) group; African Americans (n = 73) had higher DFT compared to Caucasians (n = 32), (14.5 ± 0.5 J vs 9.7 ± 0.6 J, P < 0.05).
A history of cocaine use in African Americans with ICD is a risk factor for high DFT and race itself (being African American) may be a risk for high DFT. Use of high-energy ICDs and other DFT lowering techniques may be considered for patients who have used or continue to use cocaine or in whom DFT testing cannot be performed at the time of implantation.
Pacing and Clinical Electrophysiology 10/2010; 34(2):193-9. · 1.35 Impact Factor
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Luis Afonso,
Anupama Kottam,
Ashutosh Niraj,
Joya Ganguly,
Pawan Hari,
Mengistu Simegn,
Rajeev Sudhakar, Sony Jacob,
Seemant Chaturvedi,
Greg J Ensing,
Theodore P Abraham
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ABSTRACT: Patent foramen ovale (PFO) is associated with cryptogenic stroke, migraine headache, decompression sickness, and platypnea-orthodeoxia syndrome. Patients undergoing transesophageal echocardiography are often hypovolemic from preprocedural fasting and might not demonstrate right to left shunting owing to insufficient right atrial pressure generation, despite provocative maneuvers. We hypothesized that volume replenishment with saline loading could potentially unmask a PFO by favorably modulating the interatrial pressure gradient. Our study sought to examine the role of pre- or intraprocedural intravenous fluid replenishment on PFO detection during transesophageal echocardiography. A total of 103 patients were enrolled. An initial series of bubble injections was performed unprovoked and then with provocative maneuvers such as the Valsalva maneuver and coughing. The patients were then given a rapid 500 ml saline bolus, and the same sequence of bubble injections was repeated. The presence, type, and magnitude of the right to left shunts were noted before and after the saline bolus. The detection rate of PFO increased from 10.6% to 26.2% after saline loading without any provocative maneuvers. When combined with provocative maneuvers (Valsalva or cough), saline loading improved the detection rate from 17.4% to 32.0%. Overall, from amongst the 103 enrolled patients, saline bolusing resulted in a de novo diagnosis of PFO in 15 patients, atrial septal aneurysm in 15, PFO coexisting with an atrial septal aneurysm in 10, and pulmonary arteriovenous fistula in 5 patients. In conclusion, saline infusion in appropriately selected patients during transesophageal echocardiography significantly enhances the detection of PFOs and pulmonary arteriovenous fistulas.
The American journal of cardiology 10/2010; 106(7):1054-8. · 3.58 Impact Factor
