ECG dilemma

"A 55-year-old female with a history of type 2 diabetes was admitted for chest pain and was diagnosed with Non-ST segment elevation myocardial infarction (NSTEMI). An electrocardiogram (ECG) performed at the time of admission is shown below (Image 1). She subsequently underwent a percutaneous coronary intervention (PCI) to the proximal left anterior descending artery (LAD). Two hours later on the inpatient floor, her chest pain recurred, and a 12 lead ECG was repeated (image 2). What is the most likely cause of her recurrent chest pain?"Sudarshan Ball (Division of Cardiology, West Virginia University School of Medicine)Includes bibliographical reference

ECG dilemma

"A 48-year-old white male presented to the emergency room (ER) with 5-day history of fever and chills. He also reported chest pain, which he described as heaviness and radiating to the left arm. He reports generalized weakness. He has no significant past medical history. He was told to have a murmur since childhood. He does not have orthopnea nor paroxysmal nocturnal dyspnea. Vitals on examination were: Heart rate 30 bpm, blood pressure 100/60 mm Hg. Physical examination: Ejection systolic murmur grade 3/6 heard at the right upper sternal border and radiating to both carotids, lungs were clear to auscultation, skin and extremity examination was normal. Laboratory studies obtained in the ER: WBC 26, 900 /[mu]l, hemoglobin 12.2 g/dl, BUN 23 mg/dl creatinine 0.97 mg/dl, troponin I 0.3 ng/ml, hemoglobin A1c 9.2[percent]. Blood culture results obtained the next day showed 4 of 4 cultures positive for Gram positive cocci in chains. Electrocardiogram obtained is shown below. Transthoracic echocardiogram was performed – valves were not adequately visualized due to poor imaging windows but showed mild mitral and tricuspid regurgitation, aortic valve was calcified with moderate stenosis."Sudarshan Balla (1), Archana Vasudevan (2) ; 1. Division of Cardiology, West Virginia University School of Medicine. 2. Department of Medicine – Division of Infectious Diseases, University of MissouriIncludes bibliographical reference

ECG dilemma

A 45-year-old male was seen as a response to an EMS call. Patient's neighbor saw the patient collapsed in the backyard. Patient had a history of substance abuse and depression. Patient was intubated on field for airway protection. On arrival to the ER, a 12 lead ECG was obtained as shown below. Medication history was not available. Vitals on exam were: HR 60 bpm, BP 90/60 mm Hg. GCS was 8. Pupils were dilated but reactive. Head CT was obtained and was negative for any intracranial concerns. Urine drug screen was positive for cannabis, tricyclics and opiates

Trial Sequential Analysis Comparing Bleeding and Major Adverse Cardiovascular Events in Patients with Atrial Fibrillation and Acute Coronary Syndrome on Dual versus Triple Therapy

Objective To assess efficacy and safety of dual therapy (DT) and triple therapy (TT) in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) with or without percutaneous coronary intervention (PCI) and evaluate the quality of evidence with respect to said outcomes based on contemporary randomized trials (RCTs). The efficacy outcome taken was major adverse cardiovascular events (MACE) while safety outcome was major bleeding events. Introduction Appropriate anti-thrombotic therapy is still controversial in patients with AF and concomitant ACS or PCI. We conducted a conventional meta-analysis pooling data from major RCTs to assess the efficacy and safety of DT and TT. Additionally, we utilized advanced analytic properties of trial sequential analysis (TSA) to assess for quality of evidence in this realm. Methods and results A total of 8,732 patients from five major RCTs were enrolled in this study. There was a statistically significant reduction in major bleeding on the DT group compared to the TT group (RR 0.65, 95% CI 0.48, 0.86). The incidence of major adverse cardiovascular events (MACE) was similar in both groups (RR 0.97, 95% CI 0.8,1.17). The trial sequential analysis showed strong evidence supporting reduction in bleeding from current major RCTs while being inconclusive based on MACE outcome. Conclusion Sufficient quality evidence could be ascertained from contemporary RCTs on reduced incidence of bleeding in DT patients compared to TT patients. Further adequately powered RCTs are needed to ensure non-inferiority of DT over TT with respect to MACE outcome

Safety and Long-term Efficacy of Thoracoscopic Epicardial Ablation in Patients with Paroxysmal Atrial Fibrillation: A Retrospective Study

Background: The aim of this study is to report the long-term efficacy and safety of thoracoscopic epicardial left atrial ablation (TELA) in patients with paroxysmal atrial fibrillation (AF). Methods: This was a retrospective review of medical records. We included all patients diagnosed with paroxysmal AF who underwent TELA at our institution between 04/2011 and 06/2017. TELA included pulmonary vein isolation, LA dome lesions and LA appendage exclusion. All (n = 55) patients received an implantable loop recorder (ILR), 30 days post-operatively. Antiarrhythmic and anticoagulation therapy were discontinued at 90 and 180 days postoperatively, respectively, if patients were free of AF recurrence. Failure was defined as ≥two minutes of continuous AF, or atrial tachycardia. Results: Fifty-five patients (78% males, mean age = 61.6 years) qualified for the study. The average duration in AF was 3.64 +/− 3.4 years, mean CHA2DS2-VASc Score was 2.0 +/− 1.6. The procedure was attempted in 57 patients and completed successfully in 55 (96.5%). Two patients experienced a minor pulmonary vein bleed that was managed conservatively. Post procedure, one patient experienced pulmonary edema, another experienced a pneumothorax requiring a chest tube and another experienced acute respiratory distress syndrome resulting in longer hospitalization. Otherwise, there were no major procedural complications. Success rates were 89.1% (n = 49/ 55), 85.5% (n = 47/55) and 76.9% (n = 40/52) at 6, 12 and 24 months, respectively. In the multivariate coxproportional hazard model, survival at the mean of covariates was 86 and 74% at 12 and 24 months, respectively. Conclusion: In this single center experience, TELA was a safe and efficacious procedure for patients with paroxysmal AF

Invasive Hemodynamic Monitoring in Cardiogenic Shock Is Associated With Lower In-Hospital Mortality

Background: There is increasing utilization of cardiogenic shock treatment algorithms. The cornerstone of these algorithms is the use of invasive hemodynamic monitoring (IHM). We sought to compare the in-hospital outcomes in patients who received IHM versus no IHM in a real-world contemporary database. Methods and Results Patients with cardiogenic shock admitted during October 1, 2015 to December 31, 2018, were identified from the National Inpatient Sample. Among this group, we compared the outcomes among patients who received IHM versus no IHM. The primary end point was in-hospital mortality. Secondary end points included vascular complications, major bleeding, need for renal replacement therapy, length of stay, cost of hospitalization, and rate of utilization of left ventricular assist devices and heart transplantation. Propensity score matching was used for covariate adjustment. A total of 394 635 (IHM=62 565; no IHM=332 070) patients were included. After propensity score matching, 2 well-matched groups were compared (IHM=62 220; no IHM=62 220). The IHM group had lower in-hospital mortality (24.1% versus 30.6%, P\u3c0.01), higher percentages of left ventricular assist devices (4.4% versus 1.3%, P\u3c0.01) and heart transplantation (1.3% versus 0.7%, P\u3c0.01) utilization, longer length of hospitalization and higher costs. There was no difference between the 2 groups in terms of vascular complications, major bleeding, and the need for renal replacement therapy. Conclusions: Among patients with cardiogenic shock, the use of IHM is associated with a reduction in in-hospital mortality and increased utilization of advanced heart failure therapies. Due to the observational nature of the current study, the results should be considered hypothesis-generating, and future prospective studies confirming these findings are needed

Utilization of palliative care in patients hospitalized with heart failure: A contemporary national perspective

Background Despite advances in therapy, heart failure (HF) patients have significant symptom burden and poor quality of life. However, data on palliative care (PC) utilization in this population are scarce. We sought to assess national trends in PC utilization in patients admitted with acute HF. Methods Adults hospitalized with HF without acute coronary syndrome were identified in the National inpatient sample. PC was identified using ICD‐9‐CM‐Code V66.7. Trends in PC utilization, its predictors and its association with length‐of‐stay and cost were assessed. Results A total of 939 680 HF patients were hospitalized with HF between 2003 and 2014. Of those,1.2% received PC during the hospitalization, with an upward trend in the use of PC over time (0.12% in 2003 to 3.6% in 2014, P \u3c 0.001). Compared with patients who did not receive PC, those who had PC were older (79 ± 12 vs 69 ± 16 years), and had higher prevalence of Caucasian race (73.4% vs 51.8%), coronary disease (45.6% vs 39.3%), chronic renal disease (79.3% vs 42.8%), and pulmonary hypertension (28.3% vs 15.1%) (P \u3c 0.001). In‐hospital mortality (35.2% vs 2.2%), length‐of‐stay (9 ± 13 days vs 6 ± 6, P \u3c 0.001), cost ($19 984 ± 42 922 vs$11 921 ± 18 175), and non‐home discharges (46% vs 19.2%) (P \u3c 0.001) were higher in the PC group. In‐hospital mortality in PC group trended downward over time (69% in 2003 vs 29% in 2014, P \u3c 0.001). Conclusion PC is being utilized in an increasing but overall small number of patients hospitalized with HF. Further research is needed to identify the optimal role and timing of PC in HF patients

Trial Sequential Analysis Comparing Bleeding and Major Adverse Cardiovascular Events in Patients with Atrial Fibrillation and Acute Coronary Syndrome on Dual versus Triple Therapy

Objective To assess efficacy and safety of dual therapy (DT) and triple therapy (TT) in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) with or without percutaneous coronary intervention (PCI) and evaluate the quality of evidence with respect to said outcomes based on contemporary randomized trials (RCTs). The efficacy outcome taken was major adverse cardiovascular events (MACE) while safety outcome was major bleeding events. Introduction Appropriate anti-thrombotic therapy is still controversial in patients with AF and concomitant ACS or PCI. We conducted a conventional meta-analysis pooling data from major RCTs to assess the efficacy and safety of DT and TT. Additionally, we utilized advanced analytic properties of trial sequential analysis (TSA) to assess for quality of evidence in this realm. Methods and results A total of 8,732 patients from five major RCTs were enrolled in this study. There was a statistically significant reduction in major bleeding on the DT group compared to the TT group (RR 0.65, 95% CI 0.48, 0.86). The incidence of major adverse cardiovascular events (MACE) was similar in both groups (RR 0.97, 95% CI 0.8,1.17). The trial sequential analysis showed strong evidence supporting reduction in bleeding from current major RCTs while being inconclusive based on MACE outcome. Conclusion Sufficient quality evidence could be ascertained from contemporary RCTs on reduced incidence of bleeding in DT patients compared to TT patients. Further adequately powered RCTs are needed to ensure non-inferiority of DT over TT with respect to MACE outcome