Thursday, December 10, 2015

Every 10% increase in hypertension treatment would lead to an additional 14,000 deaths annually prevented

Every 10% increase in treatment of elevated low-density lipoprotein cholesterol or aspirin prophylaxis would lead to 8000 deaths prevented in those aged <80 years, per year. Overall, the models suggest that optimal use of all of these interventions could prevent 50,000-100,000 deaths per year in those aged <80 years and 25,000-40,000 deaths per year in those aged <65 years.

2013 and 2014 review of evidence for possible beneficial effects of diuretics and dopamine in patients with decompensated heart failure(HF) and acute kidney injury ( AKI)

2013: Dictum;
Loop diuretics (furosemide, bumetanide, torsemide, ethacrynic acid) have long been used to “convert” oliguric to nonoliguric AKI. However, it is most likely that oliguric patients who respond to diuretics have a lesser renal injury than those who do not, with an intrinsically more favorable outcome. Moreover there is evidence that “forced” diuresis may exacerbate hypovolemia and renal injury. Once dialysis is required, high dose furosemide does not alter the natural history of AKI.

2- Dopamine:
Dopaminergic agents (dopamine, fenoldopam) potentially confer renal protection by increasing renal blood flow (RBF), diuresis and saliuresis. By activating cyclic AMP they “turn off” the energy-dependent tubular sodium pump and thereby decrease tubular oxygen consumption; increased intratubular urine flow protects against tubular obstruction.In part this may be because there is very wide variability in dopamine pharmacokinetics, i.e. some patients given low dose dopamine may achieve high plasma levels, i.e. in the beta- or alpha-adrenergic range.
Unfortunately, in 2013, there is no compelling evidence that any pharmacologic intervention can definitively prevent or attenuate AKI and alter patient outcome. The current recommendation is that diuretic therapy, low dose dopamine, fenoldopam or atrial natriuretic peptide should NOT be used to prevent or treat AKI. The question is, where do we go from here?
2014 Dictums :
The Heart Failure clinical Research Network , funded by the National Heart,Lung and blood Institute in the USA , addressed the possibility that low dose dopamine or low- dose nesiritide could safely augment the diuresis induced by loop diuretics in patients with decompensated HF. The trial , in 360 patients , showed no evidence that diuresis or decongestion was enhanced by such combined therapy or that renal function was better preserved .
The is that we should continue what we are doing maintain aggressive approach to diuretic therapy , and perhaps concern ourselves less when renal function transiently worsen .
Final Message :
Despite more than thirty years of use as a renal vasodilator , low dose dopamine (2Mic/kg/m) has shown no evidence of benefit in patients with acute oliguric renal failure on the basis of its action on dopaminergic renal receptors . In fact , low -dose dopamine can have deleterious effects on hemodynamics ( decreased splanchnic blood flow ) immune function ( inhibition of T-cell lymphocyte function ) and endocrine function ( inhibition of thyroid _stimulating hormone release from the pituitary ) .
For more information read here ;>>>
Greet van den Berghe’s work shows neuroendocrine dysfunction as well as immunological modulation secondary to prolactin
-Reasons Dopamine is Bad
-Does not benefit the renal system
-Induces Natriuresis and Diuresis
-Shunts blood away from outer medulla, which is the region most prone to ischemic damage
-Possible induction of decreased splanchnic perfusion
-Decreases GI Motility
-Impairs ventilatory response to hypoxemia and hypercapnia
-Effects on anterior pituitary–decreases prolactin secretion.

Sunday, October 25, 2015

SYNCOPE/Pre-syncope its Causes and mechanisms

How the heart's cells contract and relax

Types of chest pain ! Which one is cardiac ?

A-Typical angina – pain or discomfort that is ;
1) substernal,
2) provoked by exercise and/or emotion, and
3) relieved by rest and/or nitroglycerin.

B-Atypical angina – pain or discomfort that has two of the three features listed for typical angina.

C-Non-anginal chest pain – pain or discomfort that has one or none of the three features listed for typical angina .
It should be emphasized that patients with non-anginal chest pain may still be at risk for acute myocardial infarction or acute coronary syndrome.

Other causes of ST-Elevation on ECG

The Criteria for diagnosing MI with LBBB And other ECG changes to be taken into account

Variant forms of dyspnea & Cardiovascular causes of dyspnea

Saturday, September 19, 2015

CABG Skyrockets Among Diabetics; Lessons for Heart Surgeons Diabetics: Worse Outcomes After CABG

The proportion of diabetics who underwent coronary artery bypass grafting (CABG) jumped almost fivefold over the past 40 years, according to a recent single-center study covering over 57,000 patients at the Cleveland Clinic.
And although surgical outcomes have improved substantially, this combination of diabetes and heart bypass has become an excessively costly healthcare burden, as the results also show that diabetics have more postoperative complications and worse survival than nondiabetics, contributing to ballooning healthcare costs.
Diabetes is both a marker for high-risk, resource-intensive, and expensive care after CABG, and an independent risk factor for reduced long-term surviva.Moreover, heart disease represents the major cause of death in diabetes.

While endocrinologists may be the physicians bearing the greatest responsibility for managing patients with diabetes, the disease is also having a tremendous impact on surgery, this new analysis shows, which included 10,362 patients with diabetes and 45,139 patients without the disease who underwent first-time CABG between January 1972 and January 2011.
Results showed that the proportion of diabetics who underwent CABG jumped from 7% in the 1970s to 37% in the 2000s.
Diabetics also had worse outcomes after coronary bypass compared with nondiabetics: more in-hospital deaths (2.0% vs 1.3%), more deep sternal wound infections (2.3% vs 1.2%), more strokes (2.2% vs 1.4%), more renal failure (4.0% vs 1.3%), and longer hospital stays (9.6% vs 6.0%), (P<.05 for all). Diabetics also spent more hours in the intensive care unit than nondiabetics.Eleven percent of nondiabetic patients and 7.5% of diabetic patients received bilateral internal thoracic artery (ITA) grafts.

After propensity matching, 5-year survival was 80% in diabetics vs 84% in nondiabetics. But at 10 years, survival was 56% in diabetics vs 66% in nondiabetics. And at 20 years, it was 20% in diabetics vs 32% in nondiabetics.
After matching, diabetics still had longer hospital stays, as well as higher incidences of sternal wound infection and stroke, although cost differences between diabetics and nondiabetics were no longer significant.
"The use of skeletonized bilateral internal thoracic arteries in young, nonobese diabetic patients with a greater-than-10-year life expectancy is a reasonable risk to take," they assert.
"Perhaps in an elderly, morbidly obese female diabetic patient at high risk for sternal infection and shorter life expectancy, a single left internal thoracic artery would be best."
Other options to improve long-term survival after CABG in diabetic patients include using radial artery grafts and delaying elective procedures until glycemic control improves, they add.
Another expert, Paul Kurlansky, MD, assistant professor of surgery at Columbia University College of Physicians and Surgeons in New York, says arterial conduits may be the "optimal form of coronary revascularization [in diabetic patients]," in a third linked editorial, published in the August issue.
"Arterial conduits have greater long-term patency. The internal mammary artery [IMA], in particular, may be beneficial to the downstream vascular endothelium through the active secretion of nitric oxide," he commented.
"Although many surgeons have been reluctant to use the internal mammary artery in diabetic patients…several studies have documented that using a skeletonized approach to bilateral IMA grafting can be performed in diabetics without an increase in sternal wound infection, but with an improved long-term survival," he observes (Circulation. 2012;126:2935-2942).
Some evidence also supports using one IMA and one radial artery in diabetic patients, Dr Kurlansky continues.
"Given the incredibly low rate of bilateral IMA grafting in the United States — less than 5% in general, even less for diabetics — the surgical community is obligated to meet the rising challenge of the diabetic patient with the optimal therapeutic approach, which clearly supports arterial grafting," he emphasizes.
In the meantime, cardiac surgeons can play an important role in extending the lives of patients with diabetes by optimizing coronary revascularization, performing bilateral internal thoracic artery grafting with complete revascularization whenever feasible.

Reference :
J Thorac Cardiovasc Surg. 2015;150:304-312, 313–314, 284–285, and published online July 16, 2015.

Tuesday, September 1, 2015

Cardiologists fail to identify basic and advanced murmurs 90-minute training improves ability to recognize indications of heart conditions

LONDON (Aug. 31, 2015) -- Cardiologists failed to identify more than half of basic and about 35 percent of advanced pre-recorded murmurs, but skills improved after a 90 minute training session, according to research presented today at the European Society of Cardiology Congress 2015.
Recent breakthroughs in the transcatheter treatment of aortic and mitral valve disorders provide new therapies for patients, but physicians must be able to detect valve problems in a timely manner for patients to see the full benefit of these advances, said Michael Barrett, MD, the lead investigator in the study.
Barrett recruited a total of 1,098 cardiologists to undergo assessment of their auscultation skills at the American College of Cardiology Annual Scientific Sessions over four years, from 2011 to 2014. Participants chose to be tested on a set of basic murmurs, on a set of advanced murmurs, or both.

Basic murmurs included aortic stenosis, aortic, regurgitation, mitral stenosis, mitral regurgitation. Advanced murmurs included bicuspid aortic valve, mitral valve prolapse, combined aortic stenosis and regurgitation, and combined mitral stenosis and regurgitation.
After the pretest, all of the participants listened to 400 repetitions of each murmur while viewing cardiac images including phonocardiograms relevant to each lesion.

Training time averaged 90 minutes for each set of murmurs. Immediately after the training, there was a post-test of the murmurs in a randomized order and from different patients than the training samples.

On the basic murmurs, 980 cardiologists scored on average 48 percent correct on the pretest, with a margin of error of 12 percent. Post-test scores increased to 88 percent, with a 15 percent margin of error.

On the advanced murmurs, 932 cardiologists scored on average 66 percent correct (margin of error +/- 13 percent), improving to 93 percent (+/- 16 percent) on the post-test.

"These findings confirm the widely held view that auscultation skills among cardiologists have eroded over time," said Patrick T. O'Gara, past-president of the American College of Cardiology and a co-investigator on the study. "As shown in this and other studies, however, these skills can improve with repetition and training. Accurate auscultation is the first step in the cost-effective evaluation of patients with suspected valvular heart disease."

The study used training tools from Heart Songs 3, an online/downloadable training program developed by Barrett and offered by the American College of Cardiology to help health professionals improve their auscultation skills. The program is based on psychoacoustic research that shows it takes the human brain intensive repetition to master a new sound.

Saturday, August 29, 2015

This is the time that doctors' bag content should be changed! Doctors debate need for stethoscope as health care goes high-tech and that turns 200 years old .

Dr. Andrea Leeds, a Bellmore pediatrician, said she never leaves home without hers.
The doctor runs an old-fashioned practice out of her house, just as her father did in Brooklyn a generation earlier.
"I can tell you with 100 percent certainty that not only do I go everywhere with my stethoscope, I use it for every exam.
"I have picked up pneumonia using my stethoscope when the child has come in with a stomachache," Leeds said.
Using a stethoscope, she said, is one of the most important skills doctors acquire.
Chief Medical Officer Dr. Ronald Gulotta of St. Francis Hospital in Flower Hill thinks younger doctors do not know how to use them the way physicians of his father's generation learned to diagnose with them. And Dr. Stephen Gulotta, now retired after more than 50 years in medicine, is certain his son is right.

All of these doctors have an interest in the use and future of the stethoscope, perhaps the best-recognized symbol of the medical profession and a tool that turns 200 years old next year. The instrument's bicentennial arrives at a crossroads, some experts say.
Hank Campbell, president of the American Council on Science and Health in Manhattan, said that while the stethoscope is the instrument that personalized medicine -- bringing the doctor within 8 inches of the patient -- it's on its way out.
He predicts handheld ultrasound devices will replace them in the not-too-distant future.
And Dr. Jagat Narula, chief of cardiology at St. Luke's and Roosevelt Hospitals, divisions of Mount Sinai in Manhattan, is even more succinct: "The stethoscope is dead," Narula said.
That is not welcome news for Leeds, who says she will never give up her stethoscope.
"It's definitely a learned art. You have to know what you're listening to and it takes a lot of practice. I hope it's a skill that we don't lose. Being a doctor is a calling, not a job, and the stethoscope is one of the most important tools of our trade."

"There's a lot of useful information to be gained from using a stethoscope to examine the heart, lungs and abdomen," said Dr. Bruce Polsky, a specialist in infectious diseases at Winthrop-University Hospital in Mineola.
Information gathered through "auscultation," Polsky said of listening to and discerning the meaning of sounds the body makes, provides the basis for further evaluation.

Gulotta, a cardiologist and medical director of St. Francis, thinks technology has lessened the need for the stethoscope compared with its use in 1958, when his father graduated from medical school.
"I graduated from medical school in 1986 and it's still important," Gulotta said. "As a cardiologist there is still an emphasis on the utility of it. But we have the CT scan and echocardiography. Those technologies really gave us the real structure and anatomy, so when there's a murmur you can actually visualize it."
Gulotta, however, has seen decreasing reliance on stethoscopes among new medical school graduates. And he's saddened, he said, because it means the physical diagnosis of patients is an art in decline.
For his dad, he added, the stethoscope was viewed as gold and central to the physical exam.
"The physical examination of the patient was extremely important and the stethoscope had tremendous utility," Gulotta said. "They spent a lot of time with patients and they were true masters of auscultation."
Abnormal heartbeats; rales in the lungs, which are abnormal rattling or clicking sounds; obstructions in the bowel and in the carotid arteries that run along each side of the neck are some of the sounds the trained ear can hear through a stethoscope, which was invented by René Laennec.
"They would put patients through different maneuvers -- to lie on this side or on that side, stand up, squat, inhale, exhale -- to give them clues about the diagnosis" while listening with a stethoscope, Gulotta said.
"We are starting to lose its importance," he said.

Gulotta's dad, Stephen, who lives in Greenwich, Connecticut, said he spent hours in classes as an intern and resident at Montefiore Hospital in the Bronx mastering the sounds the body makes.
"Most people younger than 50 don't know how to examine the heart," said Gulotta, also a cardiologist who, in 1967, founded the cardiopulmonary department at North Shore University Hospital in Manhasset. He later moved to St. Francis.
During his internship and residency, Gulotta said he used what was called a phonocardiographic machine, which had high-fidelity recordings of various heart sounds, including very subtle ones.
He became so astute at diagnosing heart problems with a stethoscope that even now he can diagnose mild, moderate or severe valvular disease with that instrument alone. He officially retired in December.
"I've seen young cardiologists examining patients in the emergency room and it's a disgrace," Gulotta said. "These are ostensibly good cardiologists. But they'll listen to one spot with a stethoscope for two seconds, then another spot for two seconds and they're finished. I am shocked by it; a lot of old guys are shocked by it."
Campbell, meanwhile, predicts that handheld ultrasound devices are the wave of the future. "Nostalgia and symbolism will give way to increased accuracy," he said. "With anything that's 200 years old there's always a lot of art and a lot less science."

Narula agrees and thinks the $8,000 price tag on handheld ultrasound devices will decline if more doctors adopt the new technology. "The physical examination is becoming less and less popular," he said.
all prefer a device that visualizes patient complaints because it avoids guesswork and ultimately saves money spent on additional tests.
"I believe seeing is believing," Narula said. "Why should I imagine what is there? If I have the ultrasound in my hand, I can look at it."

Fondaparinux the Best Option to Tackle NSTEMI?

APRIL 20, 2015
DEATH and in-hospital bleeding in patients with non-ST-segment elevation myocardial infarction (NSTEMI) appears less likely through the use of fondaparinux, a factor Xa inhibitor, compared with low-molecular-weight heparin (LMWH).

These conclusions were drawn from the results of a Swedish registry, which consisted of 14,791 patients with NSTEMI treated with fondaparinux and 25,825 treated with LMWH. Of those who received fondaparinux, 1.1% had a bleeding event and 2.7% died in-hospital, whereas of those who received LMWH 1.8% had a bleeding event and 4.0% died in-hospital.

Patients in the fondaparinux group also showed a significantly reduced risk of severe bleeding and mortality at 30 and 180 days when compared with those in the LMWH group. 4.2% and 8.3% of patients treated with fondaparinux died at 30 and 180 days, respectively, compared with 5.8% and 11.8% of patients treated with LMWH. The results confirm the conclusions of the earlier OASIS-5 study that treatment with fondaparinux is associated with a significant reduction in mortality at 30 and 180 days. Patients in the Swedish registry had lower rates of hypertension and a more frequent history of myocardial infarction and stroke compared with OASIS-5.
The rate of severe bleeding was 5-fold greater in patients with impaired renal function, although fondaparinux lowered bleeding rates in-hospital and at 30 days compared with LMWH. However, these results were not statistically significant in those with the most severe renal dysfunction. The authors note that the successful prevention of bleeding may result in reduced mortality.
However, even though the odds of bleeding were consistently lower across all renal-function categories, the lower mortality with fondaparinux compared with LMWH was not significant in those with worst renal function.This may indicate that the elevated risk of death in those with the lowest renal-function category is explained by other mechanisms unrelated to bleeding.”
While the European Society of Cardiology recommends fondaparinux as a first-choice anticoagulant for acute coronary syndrome patients treated noninvasively or with percutaneous coronary intervention (PCI), in the USA the American College of Cardiology/American Heart Association recommends an anticoagulant for patients with NSTEMI, either fondaparinux or enoxaparin, but only for those not undergoing PCI.

Visipaque Reduces Risk of Renal and Cardiac Events During Angioplasty

CARDIAC and renal events are significantly less frequent during angioplasty procedures using isosmolar contrast medium (IOCM) agent VisipaqueTM (iodixanol) compared with procedures using low-osmolar contrast media (LOCM), according to research presented at EuroPCR 2015.
The results of this study are highly encouraging and support the use of isosmolar contrast media in high-risk percutaneous coronary intervention.

The study, funded by GE Healthcare, retrospectively analysed data from the Premier hospital database in the USA, which describes 334,001 angioplasty procedures that took place between January 2008 and September 2013. The researchers found that 10.5% fewer major adverse renal and cardiac events (MARCE) occurred when Visipaque was used compared with LOCM (p<0.01). The difference was even greater between those hospitals that solely used either IOCM or LOCM, with 26.7% fewer MARCE taking place in the IOCM group compared with the LOCM group. In addition, 2.7% and 0.6% fewer renal failure and kidney injury events, respectively, were observed with the use of IOCM compared with LOCM.
The results of this study are highly encouraging and support the use of isosmolar contrast media in high-risk percutaneous coronary intervention. These data suggest that prior studies with signal of reduced risk of contrast-induced acute kidney injury with Visipaque do indeed translate into a reduction in clinically meaningful MARCE.
These findings are likely to be of great benefit to patients undergoing angioplasty procedures, especially those who are more vulnerable. Indeed, the data showed that angioplasty procedures that used Visipaque tended to be performed in older (66.8 versus 63.8 years; p<0.01) and sicker patients based on the Charlson Comorbidity Index (4.0 versus 3.4; p<0.01). Compared with LOCM, IOCM was also used in more emergency procedures and in more patients who were classified as ‘major’ or ‘extreme’ according to the 3MTM APR-DRG indices of mortality and severity of illness.

IVUS vs. Angiography

Intravascular ultrasound (IVUS) is a valuable adjunct to angiography, providing new insights in the diagnosis of and therapy for coronary disease. Angiography depicts only a 2D silhouette of the lumen, whereas IVUS allows tomographic assessment of lumen area, plaque size, distribution, and composition. The safety of IVUS is well documented, and the assessment of luminal dimensions represents an important application of this modality.

In general IVUS is recommended for complex lesions: bifurcation lesions, long lesions, diabetics, left main and particularly restenosis lesions. But, there are very few cases where IVUS is not useful. The lesions one should  avoid doing IVUS in are situations where we have calcified tortuous anatomy, maybe hemodynamically unstable patients where it’s an emergency and you just need to get in there and get it fixed. Maybe a situation where we’re dealing with a small, very small artery, and there isn’t much doubt that the only size stent we are  going to be able to use is a 2.5mm drug-eluting stent and going in there and IVUS-ing a baseline is probably not going to change the mind.

Sometimes, we can see a somewhat sharp turn artery as a diseased vessel on angiogram which can be rule out by IVUS-ing. Once should not stenting the anxiety related reactions of chest pain with normal coronaries which only confirmed by a doubtful angiography.
IVUS  really helps us figure out where to land our stent. We’ve known for a long time that we want to land the distal end of our stent in as normal an artery segment as we can. Of course, the problem with angiography is we underestimate mild disease. So sometimes the vessel looks pretty good just beyond the lesion, but when we are  looking at that same region on ultrasound, many times we can see pretty severe disease in there.
In the future there will probably be this type of integrated IVUS-angiographic system called AIM, which stands for Angiographic IVUS Mapping, It is  believed by doctors , so you could look at the angiogram and see where your lesion is, put a cursor on there and the IVUS image would automatically link right to that spot.

In IVUS-guided versus non–IVUS-guided procedures, the incidence of stent thrombosis was reduced by 53% (0.55% vs 1.16%; P = .004), the incidence of MI was reduced by 38% (3.47% vs 5.59%; P < .0001), and the incidence of major adverse cardiovascular events (MACE, a composite of stent thrombosis, cardiac death, and MI) was reduced by 34% (4.9% vs 7.4%; P < .001).
IVUS guidance changed the procedure 74% of the time. IVUS use was associated with longer stent length and larger stent size without increasing periprocedural MI or the number of stents utilized. The majority of stents used in the study were of the latest generation and marketed globally. No additional safety issues were identified in the procedures in the study in which IVUS was used to place stents, noted the company.

References :
1-Michael C.Foster ,MD.FACC

2- Relationship Between Intravascular Ultrasound Guidance and ClinicalOutcomes After Drug-Eluting Stents: The ADAPT-DES StudyRunning title:Witzenbichler et al.; IVUS and DES Outcomes-Circulation , 2013