Is Race a Risk Factor for the Development of Renal Artery Stenosis?

Atherosclerotic renal artery disease is a common cause of hypertension and chronic kidney disease that may progress into end stage renal failure if not diagnosed and treated early. Renal artery stenosis (RAS) has been shown to be an independent risk factor for mortality in patients with coronary artery disease. We sought to determine whether race is an independent risk factor for developing RAS. A retrospective study was conducted including 324 patients with resistant hypertension who underwent renal angiography with or without coronary angiography. In univariate analysis, Caucasian race was associated with significant risk of RAS (OR = 2.3, P = .01). However, this association was no longer significant after correcting for additional clinical variables in a multivariate model (OR = 1.5, P = .07). There was a strong association between smoking and RAS (OR 2.0, P = .02). We conclude that traditional risk factors, especially smoking, rather than race, are the most important predictors of RAS development

Urban vs Suburban: Is the Door-to-Balloon Time Affected by Geographic, Socioeconomic, or Racial Differences? A Tale of Two Campuses

Background. In 2004, the ACC/AHA released guidelines in the treatment of ST-segment elevation myocardial infarction (STEMI) within a time window from the time a patient physically enters the hospital to the time of percutaneous coronary intervention (PCI). This time window is defined as the door-to-balloon time (DTB) and is recommended to be under 90 minutes to improve patient mortality. To add another layer of complexity, patients with varying socioeconomic status and racial differences experience large disparities in health. Our institution provides care for patients in two locations separated by approximately 30 miles within the Detroit metropolitan area. We aimed this study to investigate any differences between DTB times of our two campuses (urban versus suburban population) as well as any differences in the components that comprise DTB times. Methods. We retrospectively collected data on all patients who presented to either Campus 1 or Campus 2 with a STEMI from 2016 to 17. DTB times, demographical, temporal, and anatomical data were collected and analyzed. Our search included 169 patients who met the full inclusion criteria. Results. The combined average of the overall DTB time for both campuses was 81 minutes, 15 seconds (95% CI: 78:05, 84:25). The average DTB time in Campus 1 was 78 minutes and 41 seconds (95% CI: 73:05, 84:18) versus 82 minutes and 46 seconds (95% CI: 78:55, 86:38) for Campus 2 (p=0.24). There were no statistically significant differences between either campuses within the separate metrics that comprise DTB times. Conclusions. Our study demonstrated that we have been able to provide high-quality care to all of our patients presenting with STEMI at either campus, regardless of socioeconomic differences in the populations they serve. Additionally, each campus has demonstrated DTB well below the nationally recommended guidelines

Timeout for Contrast: Using Physician Behavior Modification to Reduce Contrast in the Catheterization Laboratory

Background. As the number of procedures using contrast media continues to rise, the ensuing complications place an ever increasing burden on the healthcare system. Contrast-induced nephropathy (CIN) is a common postprocedural complication after cardiac catheterization. Objectives. The purpose of our study was to evaluate the impact of physician behavioral modification on reducing the amount of contrast used during the procedure. Methods. All patients who underwent procedures in the cardiac catheterization laboratory from January 2013 to August 2016 were identified in addition to the total contrast used during the procedure, the type of procedure performed, and the operator performing the procedure. A new addition was made to the preprocedure checklist in September-October 2013 in the form of maximum allowed contrast for the patient. Results. A total of 12,118 cases were identified. Across all procedures, the mean contrast used during the 8 months prior to the intervention was 118 ml per procedure. Mean contrast used per procedure for the first year after the revised timeout was 105 ml, for the second year was 106 ml, and for the third year was 99 ml. Conclusion. A significant reduction in radiocontrast use across all operators and procedures after the introduction of a revised timeout procedure that was seen, which is a change that was sustained over a period of three years. With this straightforward intervention involving physician behavioral modification, patients were exposed to less of the nephrotoxic contrast and were consequently at a lower risk of developing dose-depended CIN and other associated complications

At the “threshold” of certainty: Risk stratification and clinical assessment incongruity in the diagnosis of aortic dissection

The use of D-dimer assay to screen for aortic dissection has become routine in clinical practice. Although an uncommon disease entity, aortic dissection is rapidly fatal without prompt diagnosis, and biochemical detection in the proper clinical context is crucial. We performed a retrospective chart review of all aortic dissections presenting to a community tertiary care center between 2000 and 2016 and identified three patients in whom laboratory D-dimer testing was positive and a diagnosis of Stanford Type A aortic dissection was confirmed with computed tomography angiography based on clinical assessment and a newly validated risk stratification tool

Odynophagia after Cardiac Catheterization: A Rare Complication in the Presence of Aberrant Subclavian Artery

Background. Vascular complications from transradial cardiac catheterization are uncommon. Mediastinal hematoma is a rare complication with life-threatening potential. We present a case of a patient who underwent cardiac catheterization and subsequently experienced odynophagia from injury to an aberrant subclavian artery that led to a mediastinal hematoma. Case Report. A 59-year-old female with past medical history of coronary artery disease presented with complaints of angina and underwent a transradial cardiac catheterization. Immediately after the procedure, the patient complained of chest pain and odynophagia. EKG and echocardiogram were unremarkable, and a CT scan of the chest demonstrated an ill-defined fluid collection present in the superior mediastinum and an aberrant right subclavian artery. The patient was closely monitored in the Intensive Care Unit, and the patient remained hemodynamically stable throughout the admission. The patient was subsequently discharged home in good condition and did well on outpatient follow-up. Conclusion. Vascular injuries associated with delivery of standard radial catheters in the subclavian artery are rare, with very few cases reported in the literature. We presented the case of a patient who had a previously unidentified right aberrant subclavian artery with a retroesophageal course which precipitated the hematoma and subsequently resulted in odynophagia despite an uncomplicated catheterization. This rare complication of a commonplace procedure necessitates prompt recognition, appropriate hemodynamic management, and possible repair of the injured vessel to appropriately manage a potentially life-threatening condition

Wedged Sensor in Distress? Lessons Learned from Troubleshooting Dampened Transmitted PA Waveforms of CardioMEMS Device

Introduction. Cardiovascular disease is a leading cause of morbidity and mortality with heart failure constituting a large portion of this spectrum. Heart failure patients have 90-day readmission rates of nearly 41% associated with a high expense. Numerous strategies to reduce readmissions have been attempted with the CardioMEMS pulmonary artery pressure monitoring system as one of the more successful ones. As this device becomes used more frequently, it is important to recognize procedural complications. We present of a rare complication where a patient underwent successful device placement and was subsequently found to have dampened waveforms which were due to device migration. Case Report. A 79-year-old male underwent successful CardioMEMS placement due to recurrent heart failure hospitalizations. 6 months later, the transmitted waveforms appeared dampened, and repeat angiography revealed a device that had migrated. Rather than abandoning the device, it was recalibrated and continued to transmit data and helped manage the patient’s heart failure. Conclusion. CardioMEMS is a cost-effective tool to help reduce heart failure hospitalizations. Device migration is a rare complication and can lead to inaccurate data. However, as seen in this case, the device can be successfully recalibrated and can continue to be utilized to help reduce heart failure admissions

Leriche syndrome: The inferior mesenteric artery saves the lower extremity

Leriche syndrome presents as a triad of claudication, erectile dysfunction, and decreased distal pulses. This syndrome is a well-recognized entity in the current literature; however, our case report illustrates that even with a severe ostial lesion of the inferior mesenteric artery, the vessel was able to provide perfusion to bilateral lower extremities. The patient presented with symptoms of progressive pain in his right leg that limited his physical activity and he also complained of paresthesia, pallor, and cold skin with black discoloration of his toes bilaterally. Diagnostic testing confirmed Leriche syndrome and he successfully underwent surgical revascularization

False activation of the cardiac catheterization laboratory: The price to pay for shorter treatment delay

Introduction In patients with acute ST elevation myocardial ischemia (STEMI), national efforts have focused on reducing door-to-balloon (D2B) times for primary percutaneous coronary intervention (PCI). This emphasis on time-to-treatment may increase the rate of inappropriate cardiac catheterization laboratory (CCL) activations and unnecessary healthcare utilization. To achieve lower D2B times, community hospitals and EMS systems have enabled emergency medical technicians (EMTs) and emergency department (ED) physicians to activate the CCLs without immediately consulting a cardiologist. Objective The purpose of this study is to determine the rate and main causes of inappropriate activation of the CCL which will aid in finding solutions to reduce this occurrence. Method This is a retrospective study, based on an electronic medical system review of all inappropriate CCL activation who presented to Providence Hospital and Medical Centers (PHMC) in Michigan, from January 2015 to July 2016. Results The CCL was activated 375 times for suspected STEMI. The false STEMI activation was identified in 47 patients which represents 12.5% of total CCL activation. The vast majority of this false activation was due to non-diagnostic electrocardiogram (ECG) that did not meet the STEMI criteria. Conclusion The subjective interpretation of the ECG by EMTs and ED physicians tend to show a wide variability, which may lead to higher-than-anticipated false activation rates of up to 36% in one study. Some studies had reported that up to 72% of inappropriate activations were caused by ECG misinterpretations. These false activations have ramifications that lead to both clinical and financial costs

Validating Left Ventricular Filling Pressure Measurements in Patients with Congestive Heart Failure: CardioMEMS™ Pulmonary Arterial Diastolic Pressure versus Left Atrial Pressure Measurement by Transthoracic Echocardiography

Background. Routine ambulatory echocardiographic estimates of left ventricular (LV) filling pressures are not cost-effective and are occasionally fraught with anatomic, physiologic as well as logistical limitations. The use of implantable hemodynamic devices such as CardioMEMS Heart Failure (HF) System has been shown to reduce HF-related readmission rates by remote monitoring of LV filling pressures. Little is known about the correlation between CardioMEMS and echocardiography-derived estimates of central hemodynamics. Methods. We performed a prospective, single-center study enrolling seventeen participants with New York Heart Association functional class II-III HF and preimplanted CardioMEMS sensor. Simultaneous CardioMEMS readings and a limited echocardiogram were performed at individual clinic visits. Estimated left atrial pressure (LAP) by echocardiogram was calculated by the Nagueh formula. Linear regression was used as a measure of agreement. Variability between methods was evaluated by Bland–Altman analysis. Results. Mean age was 74 ± 9 years; 59% (10/17) were males. LV systolic dysfunction was present in 76% (13/17) of subjects. Mean PAdP was 18 ± 4 mmHg and 19 ± 5 mmHg for CardioMEMS and echocardiographic-derived estimates, respectively, with a significant correlation between both methods (r2=0.798,  p≤0.001). Conclusions. Our study illustrates a direct linear correlation between PAdP measured by CardioMEMS and simultaneous measurement of LV filling pressures derived by echocardiography