Chelation therapy to prevent diabetes-associated cardiovascular events

Purpose of review For over 60 years, chelation therapy with disodium ethylene diamine tetraacetic acid (EDTA, edetate) had been used for the treatment of cardiovascular disease (CVD) despite lack of scientific evidence for efficacy and safety. The Trial to Assess Chelation Therapy (TACT) was developed and received funding from the National Institutes of Health (NIH) to ascertain the safety and efficacy of chelation therapy in patients with CVD. Recent findings This pivotal trial demonstrated an improvement in outcomes in postmyocardial infarction (MI) patients. Interestingly, it also showed a particularly large reduction in CVD events and all-cause mortality in the prespecified subgroup of patients with diabetes. The TACT results may support the concept of metal chelation to reduce metal-catalyzed oxidation reactions that promote the formation of advanced glycation end products, a precursor of diabetic atherosclerosis. Summary In this review, we summarize the epidemiological and basic evidence linking toxic metal accumulation and diabetes-related CVD, supported by the salutary effects of chelation in TACT. If the ongoing NIH-funded TACT2, in diabetic post-MI patients, proves positive, this unique therapy will enter the armamentarium of endocrinologists and cardiologists seeking to reduce the atherosclerotic risk of their diabetic patients

Appropriateness of Inpatient Transthoracic Echocardiography in a Community Hospital with a New Cardiology Fellowship Program

Background: The 2011 Appropriate Use Criteria (AUC) for echocardiography was developed to guide in the rational use of high quality cardiovascular imaging. Transthoracic echocardiography (TTE) orders with seemingly inappropriate indications were repeatedly identified at our hospital. Our goals were to identify the percentage of inappropriate TTEs, find a correlation between ordering physicians and appropriateness of TTEs, and reduce the inappropriate use of TTEs in the inpatient setting. Methods: After implementing a required free-text indication for TTE orders, the indications of 100 random TTEs were retrospectively categorized as appropriate, inappropriate, and uncertain based on the AUC. TTEs for cardiac evaluation prior to cardiac surgery, structural heart procedures, or electrophysiology procedures were excluded. Ordering physicians were categorized as resident, ER physician, intensivist, hospitalist, or cardiologist. Linear regression statistical analysis was used to identify correlations between a category of ordering physicians and appropriateness of TTE orders. Results: Most TTE orders were placed by residents (37%) and hospitalists (36%). TTE indications were mostly appropriate (88%). Only 6 TTE orders were inappropriately indicated (4 were placed by residents). There was no significant correlation between a category of ordering physicians and appropriateness of TTE orders (p-value = 0.44). Hemodynamic instability, heart failure, atrial fibrillation with rapid ventricular rate, and stroke were the most common appropriate indications. Conclusion: In our hospital, most TTEs are appropriately indicated and without a significant correlation between ordering physicians and TTE appropriateness. Based on our findings, we plan to improve our TTE order sets by creating a short drop-down menu with the most common appropriate indications