Peripartum Cardiomyopathy: Predictors of Recovery

Introduction: Peripartum Cardiomyopathy (PPCM) is a rare, but poorly understood disease process with significant clinical implications in pregnant women during and after delivery. Improvement in left ventricular (LV) ejection fraction (EF) varies widely and few studies exist that define predictors of improvement in LV function in this sub population. The use of implantable cardioverter defibrillator (ICD) has also not been clearly understood in this population. Methods: A retrospective study was conducted at 2 academic centers between January 1st 1999 and December 31st 2010. Clinical and demographic variables and delivery records of patients with a discharge or outpatient diagnosis of PPCM (ICD9 -674.5) were reviewed. Patients were followed over time until December 31st 2012 to assess improvement in LV function. Results: The total sample comprised 100 patients of whom 55% were African Americans, 39% were Caucasians and 6% were Hispanic with mean age of 30±6 years. The mean time to diagnosis after delivery was 1.1±4 weeks. Mean EF at diagnosis was 28±9%. Forty two percent of patients showed some improvement in LVEF over a mean duration of 33±21 months. Postpartum diagnosis (HR 3, p=0.01) and Caucasian/Hispanic race (HR 2.2, p=0.01) were predictors of LVEF improvement. Only 7 of the 58 patients (12%) who did not improve their EF, had ICD implanted. There were 11 deaths with a trend towards higher mortality in those that did not display improved LV function (15% vs. 5%, p=0.1). Conclusions: More than one-third of the women with PPCM improve LV function with delayed recovery noted in the majority of these women. Caucasians and those diagnosed postpartum seem to be most likely to recover. ICDs were underutilized for primary prevention of sudden cardiac death in this population

AV Nodal Reentrant Tachycardia Causing Inappropriate ICD Shocks In A Patient With Arrhythmogenic RV Dysplasia

We report a patient with an implantable cardioverter defibrillator (ICD) for arrhythmogenic right ventricular dysplasia (ARVD) who received inappropriate shocks for atrioventricular node reentry tachycardia (AVRNT). Patient had multiple shocks for tachycardia with EGM characteristics of very short VA interval and CL of 300 msec. An electrophysiologic (EP) study reproducibly induced typical AVNRT with similar features. The slow AV nodal pathway ablation resolved the ICD shocks. Despite increasingly sophisticated discrimination algorithms available in modern ICDs, the ability to differentiate SVT from VT can be challenging. Our patient received inappropriate shocks for AVNRT. When device interrogation alone is not conclusive, an EP study may be necessary to determine the appropriate therapeutic course

Ezetimibe in combination with a statin does not reduce all-cause mortality

BACKGROUND: Although the ezetimibe-statin combination has been shown to reduce LDL cholesterol by 12% compared to a statin alone, its effect on hard clinical endpoints such as mortality is less certain. Prior trials evaluated this combination in highly select population groups, but impact on all- cause mortality in the general population has not been reported. METHODS: A total of 3,827 subjects who were prescribed either a statin (group 1) or the combination of statin with ezetimibe (group 2) between January 1st, 2005 and January 1st, 2008 were studied. Socio-demographic and clinical variables and mortality records were analyzed. Univariate and stepwise multivariate logistic regression analysis was performed to identify the impact of ezetimibe on all-cause mortality, controlling for patient characteristics, selected cardiovascular diseases and risk factors, and medications. RESULTS: Group 1 (n = 2,909), and group 2 (n = 918) were similar in regards to most demographic variables, 152 patients died from any cause during the study period. There was no difference in all cause mortality between the groups. Hypertension, higher HDL-C and omega-3 fatty acid use were associated with ezetimibe use in this cohort of patients and were considered as covariates in the analysis. Patients on the drug combination did not experience lower mortality after controlling for covariates and other significant risk factors. CONCLUSIONS: No significant mortality benefit was found with the use of ezetimibe in combination with a statin over use of a statin alone. Omega-3 fatty acid use and higher HDL-C demonstrated a substantial survival benefit