[Show abstract][Hide abstract] ABSTRACT: The American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines has recently released the new cholesterol treatment guideline. This update was based on a systematic review of the evidence and replaces the previous guidelines from 2002 that were widely accepted and implemented in clinical practice. The new cholesterol treatment guideline emphasizes matching the intensity of statin treatment to the level of atherosclerotic cardiovascular disease (ASCVD) risk and replaces the old paradigm of pursuing low-density lipoprotein cholesterol targets. The new guideline also emphasizes the primacy of the evidence base for statin therapy for ASCVD risk reduction and lists several patient groups that will not benefit from statin treatment despite their high cardiovascular risk, such as those with heart failure (New York Heart Association class II-IV) and patients undergoing hemodialysis. The guideline has been received with mixed reviews and significant controversy. Because of the evidence-based nature of the guideline, there is room for several questions and uncertainties on when and how to use lipid-lowering therapy in clinical practice. The goal of the Mayo Clinic Task Force in the assessment, interpretation, and expansion of the ACC/AHA cholesterol treatment guideline is to address gaps in information and some of the controversial aspects of the newly released cholesterol management guideline using additional sources of evidence and expert opinion as needed to guide clinicians on key aspects of ASCVD risk reduction.
[Show abstract][Hide abstract] ABSTRACT: Stent thrombosis (ST) is a rare but life-threatening complication of coronary artery stenting. Although dual-antiplatelet therapy is an effective management strategy in reducing the risk for ST, some patients may need to interrupt their regimens because of unforeseen circumstances, such as the requirement for surgery. In conclusion, this case presentation highlights some pertinent issues related to ST, including its risk factors, the perioperative management of antiplatelet agents, and treatment for ST.
The American journal of cardiology 07/2013; · 3.58 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: To identify the risk of sudden cardiac death (SCD) associated with obstructive sleep apnea (OSA). BACKGROUND: Risk stratification for SCD, a major cause of mortality, is difficult. OSA is linked to cardiovascular disease and arrhythmias, and has been shown to increase the risk of nocturnal SCD. It is unknown if OSA independently increases the risk of SCD. METHODS: We included 10,701 consecutive adults undergoing their first diagnostic polysomnogram between 7/1987 and 7/2003. During follow-up up to 15 years, we assessed incident resuscitated or fatal SCD in relationship to the presence of OSA, physiological data including the apnea-hypopnea index (AHI) and nocturnal oxygen saturation (O2sat) parameters, and relevant comorbidities. RESULTS: During an average follow-up of 5.3 years, 142 patients had resuscitated or fatal SCD (annual rate 0.27%). In multivariate analysis, independent risk factors for SCD were age, hypertension, coronary artery disease, cardiomyopathy or heart failure, ventricular ectopy or nonsustained ventricular tachycardia, and lowest nocturnal O2sat (per -10%, HR 1.14, P=0.029). SCD was best predicted by age >60 years (HR 5.53), AHI >20 (HR 1.60), mean nocturnal O2sat <93% (HR 2.93), and lowest nocturnal O2sat <78% (HR 2.60, all P<0.0001). CONCLUSIONS: In a population of 10,701 adults referred for polysomnography, OSA predicted incident SCD, and the magnitude of risk was predicted by multiple parameters characterizing OSA severity. Nocturnal hypoxemia, an important pathophysiological feature of OSA, strongly predicted SCD independently of well-established risk factors. These findings implicate OSA, a prevalent condition, as a novel risk factor for SCD.
Journal of the American College of Cardiology 06/2013; · 14.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Evidence suggests that metabolic syndrome (MbS) is associated with early senescence of bioprosthetic aortic valve prostheses. The purpose of this study was to determine whether MbS is also associated with accelerated failure of bioprosthetic valves prostheses in the mitral position.
Records of all patients undergoing bioprosthetic mitral valve replacement (MVR) from 1993 to 2000 were reviewed.
Of 114 patients undergoing bioprosthetic MVR, 48 (42%) had MbS. Mean age was 73 years (vs. 74 years for no MbS). Patients underwent MVR for regurgitation (n = 97; 85%), stenosis (n = 12; 11%), or mixed lesions (n = 4; 4%). Etiology was degenerative (n = 35; 32%), rheumatic (n = 26; 24%), ischemic (n = 30; 28%), calcific (n = 9; 8%), and endocarditis (n = 8; 8%). Mean follow-up was 4.5 years. Overall survival at 5 and 10 years was 56% and 26%, respectively. Survival was similar between groups (p = 0.15). Five patients (2 MbS; 4% vs. 3 no MbS; 5%) required mitral reoperation at a mean of 3.8 years after initial MVR. The risk of prosthetic valve failure was not different between groups (p = 0.66). Despite no initial difference in transmitral gradients, gradients beyond five-year follow-up were greater for those with MbS (6.8 mmHg MbS vs. 4.7 mmHg no MbS, p = 0.007). Independent predictors of gradient progression beyond two years were MbS (p = 0.027) and female gender (p = 0.012). There were no significant differences in valve area, regurgitation, or ejection fraction.
Although overall survival following bioprosthetic MVR is challenging, MbS did not predict diminished survival or excess reoperative risk compared to non-MbS patients. The trend toward more rapid progression of transprosthetic gradients in MbS patients warrants further investigation.
Journal of Cardiac Surgery 03/2012; 27(2):146-51. · 1.35 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Impaired brachial flow-mediated dilation (FMD) is associated with risk for subsequent cardiovascular events in patients after myocardial infarction (MI). These patients often have obstructive sleep apnea (OSA). We tested the hypothesis that patients with OSA post MI will exhibit more severe impairment in FMD.
We studied 64 patients with MI admitted to our hospital. OSA was determined using polysomnography. FMD was measured using high-resolution ultrasonography, with researchers blind to the OSA diagnosis.
The mean age was 60 ± 11 years, and the mean BMI was 29 (26, 32 kg/m(2)), 84% of patients were men, 39% had moderate to severe OSA (apnea-hypopnea index [AHI] > 15), and 31% of the patients had mild OSA (5 ≤ AHI < 15). FMD was severely impaired in patients with moderate to severe OSA (0.8% ± 0.7%) as compared with patients without OSA (4.7% ± 0.8%, P = .001) and with mild OSA (3.9% ± 0.8%, P = .015). Linear regression showed that FMD was associated with log nocturnal nadir oxygen saturation (minSaO(2)) (β = 31.17, P = .0001), age (β = -0.11, P = .006). MinSaO(2) was an independent predictor of FMD after adjustment for possible confounders (β = 26.15, P = .001).
FMD is severely impaired in patients with moderate to severe OSA post MI, which may be partially related to nocturnal hypoxemia. Patients with OSA may, therefore, be at higher risk for subsequent cardiovascular events after an MI. Identifying and treating OSA may have important implications in the long-term prognosis of patients post MI. Further studies are necessary to determine if the presence of OSA would affect the long-term occurrence of cardiovascular events after an MI.
[Show abstract][Hide abstract] ABSTRACT: Infectious complications secondary to lumbar facet injections are exceedingly rare, follow an indolent course, and local sequelae include abscess spread or infections of the central nervous system. We present the case of the development of a facet abscess and infective endocarditis, which developed shortly after a lumbar facet injection. With the increase in interventional pain procedures, physicians must be aware of potential infectious complications.
European journal of pain (London, England) 05/2008; 12(3):261-5. · 3.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study sought to assess the long-term prognosis of patients with apical ballooning syndrome (ABS).
Apical ballooning syndrome is a recently described acute cardiac syndrome of uncertain etiology and prognosis.
We retrospectively identified 100 unselected patients with a confirmed diagnosis of ABS by angiography. Recurrences of ABS and mortality were recorded.
Over a mean follow-up of 4.4 +/- 4.6 years, 31 patients continued to have episodes of chest pain and 10 patients had recurrence of ABS, for a recurrence rate of 11.4% over the first 4 years. Seventeen patients died in 4.7 +/- 4.8 years of follow-up. There was no difference in survival or in cardiovascular survival to an age- and gender-matched population.
The recurrence rate for ABS was 11.4% over 4 years after initial presentation. Recurrence of chest pain is common. Four-year survival was not different from that in an age-matched and gender-matched population.
Journal of the American College of Cardiology 08/2007; 50(5):448-52. · 14.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Statin therapy has recently been shown to decrease adverse perioperative events in patients undergoing vascular surgery. The potential beneficial effect of lipid-lowering therapy in patients undergoing coronary artery bypass grafting (CABG) is not well known. This was an observational analysis of 4,739 patients who underwent first-time isolated CABG at a single institution from 1995 to 2001. Patients were categorized into 2 groups based on treatment with a lipid-lowering agent within 30 days before surgery. Univariate and multivariate analyses were used to determine the association between lipid-lowering therapy and survival to hospital discharge. Patients in the lipid-lowering group (n = 2,334) tended to be younger (mean age 66 +/- 10 vs 68 +/- 10 years), were more likely to be diabetic (31% vs 28%), and on beta blockers (77% vs 70%) than patients in the nonlipid-lowering group (n = 2,405). In-hospital mortality was significantly lower in the lipid-lowering group than in the nonlipid-lowering therapy group (1.4% vs 2.2%, odds ratio 0.62, 95% confidence interval 0.40 to 0.96, p = 0.03). A multivariable model demonstrated a loss of statistical significance for the effect of lipid-lowering therapy on in-hospital mortality (adjusted odds ratio 0.83, 95% confidence interval 0.5 to 1.37, p = 0.46). In conclusion, preoperative use of lipid-lowering therapy in patients undergoing CABG appears safe and is associated with improved survival to hospital discharge compared with patients not receiving lipid-lowering therapy. However, patient risk factors and other cardioprotective medication use associated with the use of preoperative lipid-lowering therapy appear to explain the association with improved survival.
The American Journal of Cardiology 04/2007; 99(6):785-9. · 3.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The presentation and electrocardiographic (ECG) characteristics of transient left ventricular apical ballooning syndrome (TLVABS) can be similar to that of anterior ST-segment elevation myocardial infarction (STEMI). We tested the hypothesis that the ECG on presentation could reliably differentiate these syndromes.
Between January 1, 2002 and July 31, 2004, we identified 18 consecutive patients with TLVABS who were matched with 36 subjects presenting with acute anterior STEMI due to atherothrombotic left anterior descending coronary artery occlusion.
All patients with TLVABS were women (mean age, 72.0 +/- 13.1 years). The heart rate, PR interval, QRS duration, and corrected QT interval were similar between groups. Distribution of ST elevation was similar, but patients with anterior STEMI exhibited greater ST elevation. Regressive partitioning analysis indicated that the combination of ST elevation in lead V2 of less than 1.75 mm and ST-segment elevation in lead V3 of less than 2.5 mm was a suggestive predictor of TLVABS (sensitivity, 67%; specificity, 94%). Conditional logistic regression indicated that the formula: (3 x ST-elevation lead V2) + (ST-elevation V3) + (2 x ST-elevation V5) allowed possible discrimination between TLVABS and anterior STEMI with an optimal cutoff level of less than 11.5 mm for TLVABS (sensitivity, 94%; specificity, 72%). Patients with TLVABS were less likely to have concurrent ST-segment depression (6% vs 44%; P = .003).
Women presenting with TLVABS have similar ECG findings to patients with anterior infarct but with less-prominent ST-segment elevation in the anterior precordial ECG leads. These ECG findings are relatively subtle and do not have sufficient predictive value to allow reliable emergency differentiation of these syndromes.
Journal of electrocardiology 02/2007; 40(1):38.e1-6. · 1.08 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Right ventricular myocardial infarction (RVMI) is associated with substantial in-hospital and first-year mortality, but few published studies have documented late survival to 5 to 10 years after infarction. We retrospectively identified 69 consecutive patients from Olmsted County, Minnesota, with new RVMI diagnosed between January 1, 1988 and January 1, 1998, in whom coronary angiography was performed soon after admission. Long-term follow-up status was determined for all patients. RVMI secondary to isolated right coronary artery (RCA) disease had a 10-year actuarial survival of 62%, versus 52% for those with combined RCA and left coronary artery (LCA) disease (p = 0.21). Mortality within the first year after infarction was substantial for all patients with RVMI; however, there was a nonsignificant trend for patients with RCA disease (18%) versus those with RCA and LCA disease (27%; p = 0.21). Annual actuarial risks of death beyond the first year to 10 years after infarction were 2% per year for RCA disease and 3% for combined RCA and LCA disease. Patients with combined LCA and RCA disease were older (p = 0.01) but otherwise similar in baseline characteristics to patients with RCA disease. Occurrence of congestive heart failure, atrial fibrillation, and mechanical complications was similar in the 2 groups. In conclusion, RVMI is associated with substantial first-year mortality, which decreases to a much lower attrition rate between years 1 and 10, with no greater long-term mortality in those patients with concomitant LCA disease.
The American Journal of Cardiology 01/2007; 98(12):1571-3. · 3.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To evaluate the influence of elevated body mass index (BMI) on short- and long-term survival following acute myocardial infarction (AMI).
Recent studies suggest an obesity survival paradox in individuals undergoing percutaneous coronary intervention with better 30-day and 1-year outcomes in obese relative to normal weight patients. We tested a similar obesity paradox hypothesis following acute myocardial infarction.
Short- and long-term all-cause mortality, and risk of recurrent AMI were evaluated according to BMI status in 894 consecutive survivors of AMI <80 years of age admitted to the Mayo Clinic Coronary Care Unit between January 1, 1988 and April 16, 2001. Normal weight, overweight and obesity were defined as BMI <25, 25-29.9, and >30 kg/m(2), respectively.
Overall mortality following hospital discharge was significantly lower in overweight and obese patients and was mostly attributable to lower 6-month mortality (adjusted HR = 0.47, P = 0.01 for BMI >25 kg/m(2)) relative to normal weight patients, while long-term mortality among 6-month survivors was similar in all 3 groups. The risk of recurrent AMI was higher in patients with BMI >25 kg/m(2) (adjusted HR = 2.30, P = 0.01). Overweight and obese patients were significantly more likely to die from cardiac rather than non-cardiac causes (P < 0.01).
Following AMI, overweight and obese individuals although paradoxically protected from short-term death have a long-term mortality risk that is similar to normal weight individuals. Younger age at the time of initial infarction and fewer non-cardiovascular comorbidities presumably explain the short-lived obesity survival paradox following myocardial infarction.
International Journal of Cardiology 06/2006; 110(2):153-9. · 6.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Reports have demonstrated an association between statin therapy during the first day of hospitalization for acute myocardial infarction (AMI) and reduced mortality. There are little data about whether early statin therapy reduces risk of CHF and alters timing of death.
We identified 3226 consecutive patients with AMI from 1993 through 2000 and divided them into early statin therapy (statins were administered within the initial 24 h of hospitalization, n=220) and non-statin therapy groups (n=3006). We compared mortality risks, rates of CHF development and measures of peak CK and CK-MB values between the groups.
In-hospital mortality was lower in the early statin therapy group (2.7%) compared to the non-statin therapy group (9.2%), p=0.001. We observed no differences in the median time to death (statin group 132 h vs. non-statin group 72 h), p=0.3. Patients with very early statin treatment had lower peak CK (624 ng/ml) and CK-MB (46 ng/ml) values compared to non-statin patients (848 ng/ml and 84 ng/ml), p<0.01. Patients in the early statin group had lower risks of developing CHF during hospitalization (10.2 %) compared to the non-statin group (25.7%), p<0.001.
Very early administration of statin therapy during the first day of hospitalization for AMI was associated with lower in-hospital mortality, lower rates of developing CHF and reduced peak biomarker release. These data support a benefit from early statin therapy in AMI and support the need for prospective studies which test whether very early statin therapy might also reduce infarct size.
International Journal of Cardiology 04/2006; 108(3):314-9. · 6.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The last decade has seen extraordinary advances in the cardiovascular arena, particularly in the evaluation and management of the patient who has acute coronary syndromes. From bedside markers of myocardial damage to drug-eluting stents, technical advances are proliferating. Efforts in developing an international registry for acute aortic dissection have helped elucidate the acute presentation, management, and prognosis of this uncommon but lethal disease. Finally, the multiple research efforts in coordinating clinical decision-making with serologic markers and advanced imaging for the diagnosis of pulmonary embolism is changing the approach to the patient at risk for thromboembolic disease.
Cardiology Clinics 03/2006; 24(1):1-17, v. · 1.32 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Apical ballooning syndrome (ABS) is a poorly understood clinical entity characterized by acute, transient systolic dysfunction of the left ventricular (LV) apex in the absence of epicardial coronary artery disease and commonly associated with acute emotional stress. We report abnormal regional myocardial perfusion and glucose uptake in 4 consecutive ABS patients studied using positron emission tomography with 13N-ammonia and 18F-fluorodeoxyglucose within 72 hours of presentation with ABS.
All patients were postmenopausal females, 3 of whom had a major recent life stress event. Coronary angiography revealed no or minimal obstructive epicardial coronary artery disease. All patients exhibited reduced glucose uptake in the mid-LV and apical myocardial segments, which was out of proportion to perfusion abnormalities in half of the cases.
In all 4 patients, affected regions subsequently recovered regional LV systolic function within 6 weeks.
Journal of Nuclear Cardiology 01/2006; 13(2):244-50. · 2.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine the incidence, risk factors, associated pathogens, and outcome of ventilator-associated pneumonia (VAP) in patients admitted to a coronary care unit (CCU).
This retrospective cohort study was performed in the CCU of a single tertiary medical center. Patients who were admitted to the CCU between March 23, 2002, and May 25, 2003, and who required invasive mechanical ventilation for more than 48 hours were included.
Of the 92 patients who met the study criteria, 17 (18.5%; 95% confidence interval, 11.9%-27.6%) developed VAP. The incidence of VAP was 36.3 (95% confidence interval, 21.1-58.1) per 1000 days of mechanical ventilation. There were no statistically significant differences in demographics, presence of chronic obstructive pulmonary disease, or use of continuous intravenous sedatives or neuromuscular blockers between patients with and without VAP. The most commonly isolated organisms were methicillin-sensitive Staphylococcus aureus, Sphingomonas paucimobilis, and Stenotrophomonas maltophilia. The median length of stay in the CCU for patients with VAP was 10 days compared to 6 days for patients without VAP (P < .01). Eight (47%) of the 17 patients with VAP died compared to 29 (39%) of 75 patients without VAP (P = .52).
The incidence of VAP in the CCU is similar to or higher than that reported in other intensive care units. The development of VAP in CCU patients is associated with a prolonged CCU stay but not with an increased hospital mortality.
Mayo Clinic Proceedings 01/2006; 81(1):32-5. · 5.79 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We determined the effects of early statin treatment in acute myocardial infarction (AMI) on in-hospital morbidity and mortality. Experimental models of ischemia and reperfusion have shown that statins have early cardioprotective effects. However, the effect of statin use within the first 24 hours of admission on early morbidity and mortality in AMI has not been well studied. Data were collected on 300,823 patients who had AMI in the National Registry of Myocardial Infarction 4. In-hospital events were compared between patients who continued statin therapy received before the index AMI hospitalization (n = 17,118) or newly started statin therapy within the first 24 hours of hospitalization (n = 21,978) and patients who did not receive early statin treatment (n = 126,128) or whose statin therapy was discontinued (n = 9,411). New or continued treatment with a statin in the first 24 hours was associated with a decreased risk of mortality compared with no statin use (4.0% and 5.3% compared with 15.4% no statin). Discontinuation of statin treatment was associated with a slightly increased risk of mortality (16.5%). Early statin use was also associated with a lower incidence of cardiogenic shock, arrhythmias, cardiac arrest, rupture, but not recurrent myocardial infarction. Propensity analysis yielded mortality odds ratios of 0.46 for continued therapy, 0.42 for newly started therapy, and 1.25 for discontinued therapy for matched pairs versus no statin therapy (all p values <0.0001). In conclusion, the use of statin therapy within the first 24 hours of hospitalization for AMI is associated with a significantly lower rate of early complications and in-hospital mortality.
The American Journal of Cardiology 09/2005; 96(5):611-6. · 3.21 Impact Factor