Diagnostic and treatment utility of echocardiography in the management of the cardiac patient

© The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved. BACKGROUND Echocardiograms are an incredibly useful diagnostic tool due to their lack of harmful radiation, the relative ease and speed with which they can be performed, and their almost ubiquitous availability. Unfortunately, the advantages that support the use of echocardiography can also lead to the overuse of this technology. We sought to evaluate the physician perceived impact echocardiography has on patient management. AIM To evaluate the physician perceived impact echocardiography has on patient management. METHODS Surveys were distributed to the ordering physician for echocardiograms performed at our institution over a 10-wk period. Only transthoracic echocardiograms performed on the inpatient service were included. Surveys were distributed to either the attending physician or the resident physician listed on the echocardiogram order. The information requested in the survey focused on the indication for the study and the perceived importance and effect of the study. Observational statistical analysis was performed on all of the answers from the collected surveys. RESULTS A total of 103 surveys were obtained and analyzed. The internal medicine (57%) and cardiology (37%) specialties ordered the most echocardiograms. The most common reason for ordering an echocardiogram was to rule out a diagnosis (38.2%). Only 27.5% of physicians reported that the echocardiogram significantly affected patient care, with 18.6% reporting a moderate effect, and 30.4% reporting a mild effect. A total of 19.6% of physicians stated that there was no effect on patient management. Additionally, 43.1% of physicians reported that they made changes in patient management due to no change having occurred in the disease, 11.8% reported that changes in management were based on the recommendation of a specialist, and only 9.8% reported that further imaging was ordered due to the results of the echocardiogram. The majority of physicians (67.6%) considered an echocardiogram to be “somewhat essential” in the management of adult inpatients, with only 15.7% considering it “essential”. CONCLUSION The majority of physicians surveyed report the echocardiogram had only a mild effect on management with only 27.5% reporting a significant effect. However, the majority of physicians (83.3%) perceived an echocardiogram to be somewhat or entirely essential for management. Only 9.8% reported the echo led to further imaging. These insights into ordering physician reasoning should help guide better definition of the optimal and ideal use of echocardiography

Metformin and Myocardial Injury in Patients With Diabetes and ST-Segment Elevation Myocardial Infarction: A Propensity Score Matched Analysis

BACKGROUND: Although animal studies have documented metformin's cardioprotective effects, the impact in humans remains elusive. The study objective was to explore the association between metformin and myocardial infarct size in patients with diabetes presenting with ST‐segment elevation myocardial infarction. METHODS AND RESULTS: Data extraction used the National Cardiovascular Data CathPCI Registry in all patients with diabetes aged >18 years presenting with ST‐segment elevation myocardial infarction at 2 academic medical centers from January 2010 to December 2013. The exposure of interest was ongoing metformin use before the event. Propensity score matching was used for the metformin and nonmetformin groups on key prognostic variables. All matched pairs had acceptable D scores of <10%, confirming an efficient matching procedure. The primary outcome was myocardial infarct size, reflected by peak serum creatine kinase–myocardial band, troponin T, and hospital discharge left ventricular ejection fraction. Of all 1726 ST‐segment elevation myocardial infarction cases reviewed, 493 patients had diabetes (28.5%), with 208 metformin users (42.1%) and 285 nonusers. Matched pairs analysis yielded 137 cases per group. The difference between metformin and nonmetformin groups was −18.1 ng/mL (95% CI −55.0 to 18.8; P=0.56) for total peak serum creatine kinase–myocardial band and −1.1 ng/mL (95% CI −2.8 to 0.5; P=0.41) for troponin T. Median discharge left ventricular ejection fraction in both groups was 45, and the difference between metformin and nonmetformin users was 0.7% (95% CI −2.2 to 3.6; P=0.99). CONCLUSIONS: No statistically significant association of cardioprotection was found between metformin and myocardial infarct size in patients with diabetes and acute ST‐segment elevation myocardial infarction

Impact of cardiologist intervention on guideline-directed use of statin therapy

© The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved. BACKGROUND Statins have an important and well-established role in the prevention of atherosclerotic cardiovascular disease (ASCVD). However, several studies have reported widespread underuse of statins in various practice settings and populations. Review of relevant literature reveals opportunities for improvement in the implementation of guideline-directed statin therapy (GDST). AIM To examine the impact of cardiologist intervention on the use of GDST in the ambulatory setting. METHODS Patients with at least one encounter at the adult Internal Medicine Clinic (IMC) and/or Cardiology Clinic (CC), who had an available serum cholesterol test performed, were evaluated. The 2 comparison groups were defined as: (1) Patients only seen by IMC; and (2) Patients seen by both IMC and CC. Patients were excluded if variables needed for calculation of ASCVD risk scores were lacking, and if demographic information lacked guideline-directed treatment recommendations. Data were analyzed using student t-tests or χ2, as appropriate. Analysis of Variance was used to compare rates of adherence to GDST. RESULTS A total of 268 patients met the inclusion criteria for this study; 211 in the IMC group and 57 in the IMC-CC group. Overall, 56% of patients were female, mean age 56 years (± 10.65, SD), 22% Black or African American, 56% Hispanic/Latino, 14% had clinical ASCVD, 13% current smokers, 66% diabetic and 63% hypertensive. Statin use was observed in 55% (n = 147/268) of the entire patient cohort. In the IMC-CC group, 73.6% (n = 42/57) of patients were prescribed statin therapy compared to 50.7% (n = 107/211) of patients in the IMC group (P = 0.002). In terms of appropriate statin use based on guidelines, there was no statistical difference between groups [IMC-CC group 61.4% (n = 35/57) vs IMC group, 55.5% (n = 117/211), P = 0.421]. Patients in the IMC-CC group were older, had more cardiac risk factors and had higher proportions of non-white patients compared to the IMC group (P \u3c 0.02, all). CONCLUSION Although overall use of GDST was suboptimal, there was no statistical difference in appropriate statin use based on guidelines between groups managed by general internists alone or co-managed with a cardiologist. These findings highlight the need to design and implement strategies to improve adherence rates to GDST across all specialties

Metabolic Profiling of Dividing Cells in Live Rodent Brain by Proton Magnetic Resonance Spectroscopy (1HMRS) and LCModel Analysis

RATIONALE: Dividing cells can be detected in the live brain by positron emission tomography or optical imaging. Here we apply proton magnetic resonance spectroscopy (1HMRS) and a widely used spectral fitting algorithm to characterize the effect of increased neurogenesis after electroconvulsive shock in the live rodent brain via spectral signatures representing mobile lipids resonating at approximately 1.30 ppm. In addition, we also apply the same 1HMRS methodology to metabolically profile glioblastomas with actively dividing cells growing in RCAS-PDGF mice. METHODS: 1HMRS metabolic profiles were acquired on a 9.4T MRI instrument in combination with LCModel spectral analysis of: 1) rat brains before and after ECS or sham treatments and 2) RCAS-PDGF mice with glioblastomas and wild-type controls. Quantified 1HMRS data were compared to post-mortem histology. RESULTS: Dividing cells in the rat hippocampus increased approximately 3-fold after ECS compared to sham treatment. Quantification of hippocampal metabolites revealed significant decreases in N-acetyl-aspartate but no evidence of an elevated signal at approximately 1.3 ppm (Lip13a+Lip13b) in the ECS compared to the sham group. In RCAS-PDGF mice a high density (22%) of dividing cells characterized glioblastomas. Nile Red staining revealed a small fraction (3%) of dying cells with intracellular lipid droplets in the tumors of RCAS-PDGF mice. Concentrations of NAA were lower, whereas lactate and Lip13a+Lip13b were found to be significantly higher in glioblastomas of RCAS-PDGF mice, when compared to normal brain tissue in the control mice. CONCLUSIONS: Metabolic profiling using 1HMRS in combination with LCModel analysis did not reveal correlation between Lip13a+Lip13b spectral signatures and an increase in neurogenesis in adult rat hippocampus after ECS. However, increases in Lip13a+Lip13b were evident in glioblastomas suggesting that a higher density of actively dividing cells and/or the presence of lipid droplets is necessary for LCModel to reveal mobile lipids

Transesophageal echocardiography, more than a diagnostic tool: use during surgical ligation of coronary artery fistulae - a case report

Coronary artery fistulae (CAF) are an infrequent coronary abnormality. Herein, we describe the use of intraoperative transesophageal echocardiography (TEE) in the treatment of CAF. A 61 year-old woman presented with chest pain and symptoms consistent with unstable angina. Subsequent coronary angiography revealed the presence of 2 CAF, one extending from the left anterior descending artery to the pulmonary artery (PA) and the other extending from the proximal right coronary artery to the PA. Surgical ligation of the CAF without coronary bypass was arranged. Intraoperative TEE was successfully employed to localize the CAF, monitor fistula blood flow and heart wall motion, and confirm successful ligation. The patient recovered without complications. This case highlights the utility of intraoperative TEE during ligation of CAF

Depression diagnoses following the identification of bipolar disorder: costly incongruent diagnoses

<p>Abstract</p> <p>Background</p> <p>Previous research has documented that the symptoms of bipolar disorder are often mistaken for unipolar depression prior to a patient's first bipolar diagnosis. The assumption has been that once a patient receives a bipolar diagnosis they will no longer be given a misdiagnosis of depression. The objectives of this study were 1) to assess the rate of subsequent unipolar depression diagnosis in individuals with a history of bipolar disorder and 2) to assess the increased cost associated with this potential misdiagnosis.</p> <p>Methods</p> <p>This study utilized a retrospective cohort design using administrative claims data from 2002 and 2003. Patient inclusion criteria for the study were 1) at least 2 bipolar diagnoses in 2002, 2) continuous enrollment during 2002 and 2003, 3) a pharmacy benefit, and 4) age 18 to 64. Patients with at least 2 unipolar depression diagnoses in 2003 were categorized as having an incongruent diagnosis of unipolar depression. We used propensity scoring to control for selection bias. Utilization was evaluated using negative binomial models. We evaluated cost differences between patient cohorts using generalized linear models.</p> <p>Results</p> <p>Of the 7981 patients who met all inclusion criteria for the analysis, 17.5% (1400) had an incongruent depression diagnosis (IDD). After controlling for background differences, individuals who received an IDD had higher rates of inpatient and outpatient psychiatric utilization and cost, on average, an additional $1641 per year compared to individuals without an IDD.</p> <p>Conclusions</p> <p>A strikingly high proportion of bipolar patients are given the differential diagnosis of unipolar depression <it>after </it>being identified as having bipolar disorder. Individuals with an IDD had increased acute psychiatric care services, suggesting higher levels of relapses, and were at risk for inappropriate treatment, as antidepressant therapy without a concomitant mood-stabilizing medication is contraindicated in bipolar disorder. Further prospective research is needed to validate the findings from this retrospective administrative claims-based analysis.</p