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Background: A retrospective analysis of severe bicuspid aortic stenosis was performed to evaluate hemodynamic profiles and incidence of adverse conduction effects in Sievers Type 0 compared to Siev...

Dual-antiplatelet therapy with aspirin and a P2Y12 inhibitor is the cornerstone therapy for patients with acute coronary syndrome (ACS) and those undergoing percutaneous coronary intervention (PCI). Despite its widespread use, clopidogrel is hindered by inadequate response in up to 30% of white

BACKGROUND Among patients with heart failure and left ventricular (LV) dysfunction despite guideline directed medical therapy, cardiac resynchronization (CRT) is an effective technology to reverse LV remodeling. Given that a large portion of patients are non-responders, alternatives to traditional LV-lead placement have been explored. A promising alternative is image targeted placement of an LV-lead to latest mechanically activated segment without scar. METHODS Electronic database search for randomized controlled trials (RCTs) that evaluated the imaging-guided LV-lead placement on clinical, echocardiographic, and functional outcomes. The primary outcome was a composite of mortality and heart failure hospitalization. The secondary outcomes included CRT responders, New York Heart Association (NYHA), 6-minute walk test, Minnesota Living with Heart Failure Questionnaire (MLHFQ), and ejection fraction (EF) changes. RESULTS Analysis included 4 RCTs of 691 patients with an average follow-up of 2 years (age 69.5 ± 10.3 years, 76% males, 54% ischemic cardiomyopathy, 81% with NYHA classes III/IV, and EF of 24.4% ± 8). The most common site for LV-lead paced segment was the anterolateral segment (45%) and at mid-LV (49%). Compared with the control, imaging-guided LV-lead placement was associated with a significant reduction of the primary outcome (hazard ratio [HR] = 0.60; 95% CI = 0.40-0.88; p = .01), higher CRT responders (odd ratio [OR] = 2.10; p

Introduction: Individuals with Familial Hypercholesterolemia (FH) are at high risk for ASCVD events. However, little is known about the incidence, predictors, and outcomes of admissions for acute coronary syndromes (ACS) in this population. Objectives: To describe the in-hospital outcomes, readmission rates, and predictors of recurrent ACS in the FH population. Methods: Utilizing the National Readmission Databases from 10/2016 to 12/2017, we identified individuals with FH (ICD-10 E78.01) admitted with ACS. The primary outcome was in-hospital complications, which was compared using propensity-score matching (PSM 1:3). Multivariate logistic regression was performed to identify the predictors of 30-day readmissions. Results: There were a total of 1,697,513 ACS admissions during the study period (non-FH=1,969,979 and FH=534). Individuals admitted for ACS with FH were younger (median age 57 vs 69), had fewer comorbidities (hypertension, diabetes mellitus, and heart failure), were more likely to present with STEMI (32.8% vs 22.6%; p Conclusions: Individuals with FH admitted with ACS are younger, have fewer comorbidities, and more frequently present with STEMIs compared to those without FH. FH patients were more likely to suffer in-hospital cardiac complications. These results highlight the high-risk status of ACS and post-ACS care in FH patients.

A 63-year-old male with recent diagnosis of idiopathic pericarditis presented to the hospital with atrial fibrillation and rapid ventricular rates. He reported one week of palpitations and subacute lower extremity weakness. On exam he was hemodynamically stable with evidence of intra- and extravascular fluid overload. Lab analysis showed elevated creatinine, inflammatory markers, and serum protein gap. Chest radiograph showed bilateral pleural effusions and a focal sclerotic thoracic vertebra. TTE revealed mildly reduced biventricular function, elevated RVSP, and moderate pericardial effusion. The presence of pericardial and pleural effusions with elevated inflammatory markers suggest serositis, and a differential of malignant, autoimmune, and infectious etiologies were considered. Hepatosplenomegaly was noted on CT imaging. Blood, pleural, and pericardial cultures revealed no growth and autoimmune serologies were negative. Given these findings- the differential was narrowed to lymphoma, myeloma with or without amyloidosis, and paraneoplastic syndromes. Electrophoresis revealed presence of an M protein, fat pad biopsy was negative for amyloid fibrils. Bone marrow biopsy revealed an abnormal plasma cell population and biopsy of sclerotic vertebra showed no malignancy. Whole body FDG PET showed no focal uptake in the heart nor elsewhere. VEGF levels were significantly elevated. On the basis of the plasma cell dyscrasia, polyneuropathy, sclerotic bone lesion, elevated VEGF level, hepatosplenomegaly, and pericardial effusion the patient was diagnosed with POEMS syndrome- an extremely rare paraneoplastic syndrome with multisystemic end-organ effects. Cardiac manifestations are infrequent, but include pericardial effusion, myocardial edema and dysfunction, pulmonary hypertension, and volume overload. No specific cardiac therapy exists, but involvement may regress with chemotherapy for treatment of the underlying malignancy. This case demonstrates the importance of recognizing cardiac manifestations as the initial or cardinal presentation of underlying systemic disease, where accurate diagnosis may rely on identification of subtle non-cardiac symptoms, laboratory, and imaging findings as demonstrated here.

IMPORTANCE: QT-prolonging medications (QTPMs) are a reported risk factor for sudden cardiac death (SCD) when defined by consensus criteria that presume an arrhythmic cause. The effect of QTPM on autopsy-defined sudden arrhythmic death (SAD) is unknown. OBJECTIVE: To evaluate the association between QTPM and autopsy-defined SAD vs nonarrhythmic cause of sudden death. DESIGN, SETTING, AND PARTICIPANTS: This prospective countywide case-control study included World Health Organization–defined (presumed) SCD cases who underwent autopsy as part of the San Francisco Postmortem Systematic Investigation of Sudden Cardiac Death Study (POST SCD) to determine arrhythmic or nonarrhythmic cause, and control deaths due to trauma (hereinafter referred to as trauma controls) in San Francisco County, California, from February 1, 2011, to March 1, 2014. Multivariate regression was used to evaluate the association of QTPM with the risk of presumed SCD, autopsy-defined SAD, and non-SAD compared with trauma controls. Medication exposure, determined by prescription lists and postmortem toxicologic findings, was used to calculate a summative QTPM exposure score (range, 0-20). Data were analyzed from September 1, 2018, to June 15, 2019. EXPOSURE: QT-prolonging medication exposure, as measured by QTPM score (1 indicated low; 2-4, moderate; and >4, high). MAIN OUTCOMES AND MEASURES: Death due to trauma, presumed SCD, and autopsy-defined non-SAD and SAD with no postmortem findings of extracardiac cause. RESULTS: A total of 629 patients (mean [SD] age, 61.4 [15.7] years; 439 men [69.8%]) were included, 525 with presumed SCDs and 104 traumatic death controls. Individuals with presumed SCDs had higher exposure and were more likely to be taking any QTPM (291 [55.4%] vs 28 [26.9%]; P

Patients with end-stage renal disease who are undergoing dialysis are reported to be at high risk of sudden cardiac death (SCD), and to date, no therapy has been shown to be effective in reducing this risk. The feasibility and value of prophylactic implantable cardioverter-defibrillator (ICD) implantation to prevent SCD is uncertain.We conducted the ICD2 trial (Implantable Cardioverter-Defibrillator in Dialysis Patients), a prospective, randomized, controlled study investigating the value and safety of ICD implantation to prevent SCD in 200 patients on dialysis with a left ventricular ejection fraction ≥35%, after adequate screening and optimization of other treatments. The primary end point was SCD. Secondary end points were all-cause mortality and ICD-related complications.The trial was stopped as per the recommendation of the data and safety monitoring board for futility reasons after inclusion of 188 patients, 97 in the ICD group and 91 in the control group. The median duration of follow-up was 6.8 years (interquartile range, 3.8-8.8 years). SCD occurred in 19 of 188 cases (10.1%), 11 of 97 in the ICD group and 8 of 91 in the control group. The cumulative SCD incidence at 5 years was 9.7% (95% CI, 3.3%-16.2%) in the ICD group and 7.9% (95% CI, 1.7-14.0%) in the control group, resulting in a hazard ratio of 1.32 (95% CI, 0.53-3.29; P=0.55). Overall, 99 of 188 patients died (52.7%), 52 in the ICD group and 47 in the control group. Five-year survival probability was 50.6% (95% CI, 39.8%-61.5%) in the ICD group and 54.5% (95% CI, 43.0-66.0%) in the control group, resulting in a hazard ratio of 1.02 (95% CI, 0.69-1.52; P=0.92). Among 80 patients who received an ICD, 25 adverse events related to ICD implantation occurred.In a well-screened and well-treated population undergoing dialysis, prophylactic ICD therapy did not reduce the rate of SCD or all-cause mortality, which remained high.URL: http://www.controlled-trials.com . Unique identifier: ISRCTN20479861.

Drug coated balloons (DCB) are an established therapy for the treatment of in-stent restenosis. However, their efficacy and safety in de-novo CAD compared with bare metal (BMS) and drug eluting stents (DES) remains unclear. We performed a meta-analysis of RCTs that evaluated the role of DCB in de

BACKGROUND: Little research has been done on primary care–based models to improve health care use after an emergency department (ED) visit. OBJECTIVE: To examine the effectiveness of a primary care–based, nurse telephone support intervention for Veterans treated and released from the ED. DESIGN: Randomized controlled trial with 1:1 assignment to telephone support intervention or usual care arms (ClinicalTrials.gov: NCT01717976). SETTING: Department of Veterans Affairs Health Care System (VAHCS) in Durham, NC. PARTICIPANTS: Five hundred thirteen Veterans who were at high risk for repeat ED visits. INTERVENTION: The telephone support intervention consisted of two core calls in the week following an ED visit. Call content focused on improving the ED to primary care transition, enhancing chronic disease management, and educating Veterans and family members about VHA and community services. MAIN MEASURES: The primary outcome was repeat ED use within 30 days. KEY RESULTS: Observed rates of repeat ED use at 30 days in usual care and intervention groups were 23.1% and 24.9%, respectively (OR = 1.1; 95% CI = 0.7, 1.7; P = 0.6). The intervention group had a higher rate of having at least 1 primary care visit at 30 days (OR = 1.6, 95% CI = 1.1–2.3). At 180 days, the intervention group had a higher rate of usage of a weight management program (OR = 3.5, 95% CI = 1.6–7.5), diabetes/nutrition (OR = 1.8, 95% CI = 1.0–3.0), and home telehealth services (OR = 1.7, 95% CI = 1.0–2.9) compared with usual care. CONCLUSIONS: A brief primary care–based nurse telephone support program after an ED visit did not reduce repeat ED visits within 30 days, despite intervention participants’ increased engagement with primary care and some chronic disease management services. TRIALS REGISTRATION: ClinicalTrials.gov NCT01717976.