Prognostic significance of ischaemic electrocardiographic changes during stress testing in patients with normal nuclear myocardial perfusion imaging

Objective: To evaluate cardiovascular outcomes in patients with normal nuclear myocardial perfusion imaging, but ischaemic electrocardiogram changes during pharmacological or exercise stress tests.Methods: The retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised data of patients who underwent either pharmacological or exercise stress myocardial perfusion scan and had a normal scan with ischaemic electrocardiogram changes between January 2013 and December 2014. All cardiac events, including angina, myocardial infarction, heart failure, coronary revascularisation and cardiac death, as well as non-cardiac deaths were noted. Data was analysed using STATA 14.2.Results: Of the 2770 patients whose data was initially checked, 296(10.6%) developed ischaemic electrocardiogram changes during the stress test but had normal myocardial perfusion scan. Of them, 181(61%) patients were male, and the overall mean age was 62±15 years. Follow-up data was available for 280(94.5%) of these patients, with a mean follow-up of 48±7 months. Of these patients, 8(2.8%) died, and 1(0.3%) of them died due to inferior wall myocardial infarction. Myocardial infarction was found in 2(0.7%) patients, and 1(0.3%) patient was hospitalised with heart failure. Also, 12(4.3%) patients underwent revascularization for stable angina, 9(3.2%) underwent percutaneous transluminal coronary angioplasty, and 3(1.07%) needed coronary artery bypass grafting.Conclusions: Ischaemic electrocardiographic changes during stress testing in patients with normal myocardial perfusion scan were not associated with adverse outcomes, and the risk of cardiovascular events was relatively low for an intermediate follow-up period

Recurrent bacterial endocarditis after Prosthethetic valve replacement for native valve endocarditis complicated by perivalvular abscess: A case report

Introduction:Infective endocarditis involving left side of heart remains a major medical problem with numerous complications and considerable morbidity and mortality despite advancements in surgical and medical management ; Presence of prosthetic valve is one of the major factors associated with shortened overall survival in patients with IE and increases the risk of recurrence of endocarditis after valve replacement for native valve endocarditis( NVE); with recurrence rates varying from 10-15%. This is a unique case report that highlights recurrent infective endocarditis after prosthetic valve replacement for NVE ; with initial native valve disease complicated by perivalvular abscess and heart failure and later on prosthetic valve endocarditis(PVE) complicated by stroke and perivalvular leakage and regurgitant murmur leading to redo MVR. Case Report: 56 year old gentleman presented to the medicine department of AKUH with a 15-20 days history of high grade fever, GI discomfort and dysuria. Examination revealed a PSM radiating to axilla and Blood culture showed MRSA. Transthorasic and Trans esophageal echo revealed vegetations on both leaflets of mitral valve with a perivalvular abscess. Antibiotics were started, but since the course was complicated by CHF, early MVR was done with bio prosthetic valve. 2 years later, the patient landed with PVE complicated by Right MCA infarct, coagulase negative Staphylococcus (not aureus) on blood culture and vegetation with increased gradients on TEE. Patient was treated medically with antibiotics and anticoagulants and discharged only with follow up echocardiograms; only to be readmitted 3 months later for redo MVR as the patient developed perivalvular leakage and severe MR. Conclusion: Recurrent infective endocarditis after prosthetic valve replacement for NVE adds to increased morbidity and mortality already associated with left sided endocarditis. The cause is multifactorial; duration of antibiotic therapy, complications and timing of surgery and surgical procedure performed, all play an important etiological role. Perivalvular abscess is a feared complication of left sided endocarditis and should be treated with antibiotics and surgically. Keywords: infective endocarditis, PVE: prosthetic valve endocarditis, NVE: native valve endocarditis, perivalvular absces

Prognostic significance of ischemic electrocardiographic changes during stress testing in patients with normal nuclear myocardial perfusion imaging

Objectives: The main objective of this study was to evaluate cardiovascular outcome in patients with normal nuclear myocardial perfusion imaging but ischemic ECG changes during pharmacological or exercise stress test. Methods: In this retrospective study, we included a cohort of patients who underwent either pharmacological or exercise stress MPS and have a normal scan with ischemic EKG changes at Aga Khan University Hospital, from January 2013 to December 2014. All cardiac events including angina, myocardial infarction, heart failure, coronary revascularization and cardiac death as well as non-cardiac death were determined for the whole follow up period. Results: Among 2770 eligible patients, 296 patients (10.6%) developed ischemic EKG changes during stress test but myocardial perfusion scan was normal. Out of 296 patients 181(61%) were male and mean age was 61.98 + 15 years. We were able to follow 280 patients (94.5%). During a mean follow-up of 4 years + 7 months, 8 patients (2.8 %) died, of which only one patient (0.3%) died due to cardiac cause. Angina occurred in 25patients (8.9%), myocardial infarction in 2 patients (0.7%) and one patient hospitalized with heart failure (0.3%). We performed coronary angiography of 16 patients (5.7%), of which nine underwent percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) was done in three patients. Conclusion: The ischemic electrocardiographic changes during stress testing in patients with normal MPI are not associated with poor out come and the risk of cardiovascular events is relatively low for an intermediate follow up period.  Continuous...

Cost-effective analysis of proton pump inhibitors in long-term management of gastroesophageal reflux disease: A narrative review

Background: Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder that results from regurgitation of acid from the stomach into the esophagus. Treatment available for GERD includes lifestyle changes, antacids, histamine-2 receptor antagonists (H2RAs), proton pump inhibitors (PPIs), and anti-reflux surgery. Aim: The aim of this review is to assess the cost-effectiveness of the use of PPIs in the long-term management of patients with GERD. Method: We searched in PubMed to identify related original articles with close consideration based on inclusion and exclusion criteria to choose the best studies for this narrative review. The first section compares the cost-effectiveness of PPIs with H2RAs in long-term heartburn management. The other sections shall only discuss the cost-effectiveness of PPIs in 5 different strategies, namely, continuous (step-up, step-down, and maintenance), on-demand, and intermittent therapies.Results: Of 55 articles published, 10 studies published from 2000 to 2015 were included. Overall, PPIs are more effective in relieving heartburn in comparison with ranitidine. The use of PPIs in managing heartburn in long-term consumption of nonsteroidal anti-inflammatory drug (NSAID) has higher cost compared with H2RA. However, if the decision-maker is willing to pay more than US$174 788.60 per extra quality-adjusted life year (QALY), then the optimal strategy is traditional NSAID (tNSAID) and PPIs. The probability of being cost-effective was also highest for NSAID and PPI co-therapy users. On-demand PPI treatment strategy showed dominant with an incremental cost-effectiveness ratio of US$2197 per QALY gained and was most effective and cost saving compared with all the other treatments. The average cost-effectiveness ratio was lower for rabeprazole therapy than for ranitidine therapy. Conclusion: Our review revealed that long-term treatment with PPIs is effective but costly. To achieve long-term cost-effective approach, we recommend on-demand approach to treat heartburn symptoms, but if the symptoms persist, treatment with continuous step-down therapy should be applied