Saturday, October 21, 2017

Cardiac manifestations of neuromuscular diseases


An AHA scientific statement. Free full text.

Friday, October 20, 2017

Discontinuation of low dose aspirin leads to increased cardiovascular events



Results: During a median of 3.0 years of follow-up, 62 690 cardiovascular events occurred. Patients who discontinued aspirin had a higher rate of cardiovascular events than those who continued (multivariable-adjusted hazard ratio, 1.37; 95% confidence interval, 1.34–1.41), corresponding to an additional cardiovascular event observed per year in 1 of every 74 patients who discontinue aspirin. The risk increased shortly after discontinuation and did not appear to diminish over time.

Conclusions: In long-term users, discontinuation of low-dose aspirin in the absence of major surgery or bleeding was associated with a greater than 30% increased risk of cardiovascular events. Adherence to low-dose aspirin treatment in the absence of major surgery or bleeding is likely an important treatment goal.

These were people who were on it for either primary or secondary prevention.

Thursday, October 19, 2017

Atrioesophageal fistula after atrial fibrillation ablation


This is frightening. Fortunately, quite rare.

From the paper:

Esophageal perforation is a dreaded complication of atrial fibrillation ablation that occurs in 0.1% to 0.25% of atrial fibrillation ablation procedures. Delayed diagnosis is associated with the development of atrial-esophageal fistula (AEF) and increased mortality. The relationship between the esophagus and the left atrial posterior wall is variable, and the esophagus is most susceptible to injury where it is closest to areas of endocardial ablation. Esophageal ulcer seems to precede AEF development, and postablation endoscopy documenting esophageal ulcer may identify patients at higher risk for AEF. AEF has been reported with all modalities of atrial fibrillation ablation despite esophageal temperature monitoring. Despite the name AEF, fistulas functionally act 1 way, esophageal to atrial, which accounts for the observed symptoms and imaging findings. Because of the rarity of AEF, evaluation and validation of strategies to reduce AEF remain challenging. A high index of suspicion is recommended in patients who develop constitutional symptoms or sudden onset chest pain that start days or weeks after atrial fibrillation ablation. Early detection by computed tomography scan with oral and intravenous contrast is safe and feasible, whereas performance of esophageal endoscopy in the presence of AEF may result in significant neurological injury resulting from air embolism. Outcomes for esophageal stenting are poor in AEF. Aggressive intervention with skilled cardiac and thoracic surgeons may improve chances of stroke-free survival for all types of esophageal perforation.

Wednesday, October 18, 2017

Neurotoxicity of cefepime in relation to plasma concentration



Methods

In this single-centre retrospective cohort study, we enrolled all adult hospitalized patients receiving cefepime and undergoing TDM from January 2013 through July 2016. The primary outcome was the incidence of clinical toxicity; a secondary outcome was clinical failure. Plasma samples were analysed via high-performance liquid chromatography with ultraviolet detection.

Results

A total of 161 cefepime concentrations were drawn from 93 patients. Roughly half (82/161, 51%) and one-third (49/161, 30%) were trough and steady-state levels from patients receiving intermittent and continuous infusions, respectively; median concentrations were 17.6 mg/L (IQR 9.7-35.2) and 29.2 mg/L (IQR 18.9-45.9). Ten patients (11%) experienced a neurologic event considered at least possibly related to cefepime; neurotoxicity was associated with poorer renal function (median creatinine clearance 54 (IQR 39-97) vs. 75 mL/min/1.732 (IQR 44-104)) and longer cefepime durations (mean 8.3 (SD±6.7) vs. 13.3 days (± 14.2), p = 0.071). Patients with trough levels greater than 20 mg/L had a fivefold higher risk for neurologic events (OR 5.05, 95% CI 1.3-19.8).

Conclusions

Neurotoxicity potentially related to cefepime occurred at plasma concentrations greater than 35 mg/L. For those receiving intermittent infusions, trough concentrations greater than 20 mg/L should be avoided until further information is available from prospective studies.

Tuesday, October 17, 2017

Which of the two popular regimens for community acquired pneumonia is best?



Objective

The best treatment option for hospitalized patients with community-acquired pneumonia (CAP) has not been defined. The effectiveness of β-lactam/fluoroquinolone (BLFQ) versus β-lactam/macrolide (BLM) combinations for the treatment of patients with CAP was evaluated.

Methods

PubMed, Scopus and the Cochrane Library were searched for observational cohort studies, non-randomized and randomized controlled trials providing data for patients with CAP receiving BLM or BLFQ. Mortality was the primary outcome. A meta-analysis was performed. MINORS and GRADE were used for data quality assessment.

Results

Seventeen studies (16 684 patients) were included. Randomized trials were not identified. A variety of β-lactams, fluoroquinolones and macrolides were used within and between the studies. Mortality was reported at different time points. The available body of evidence had very low quality. In the analysis of unadjusted data, mortality with BLFQ was higher than with BLM (risk ratio 1.33, 95% CI 1.15–1.54, I2 28%). BLFQ was associated with higher mortality regardless of the study design, mortality recording time, study period and study BLM group mortality. BLFQ was associated with higher mortality in American but not European studies. No difference was observed in patients with bacteraemia and septic shock. In the meta-analysis of adjusted mortality data, a non-significant difference between the two regimens was observed (eight studies, adjusted risk ratio 1.26, 95% CI 0.95–1.67, I2 43%).

Conclusion

In the absence of data from randomized controlled trials recommendations cannot be made for or against either of the studied regimens in this group of hospitalized patients with CAP. Well designed randomized controlled trials comparing the two regimens are warranted.

Of interest, they didn’t compare fluoroquinolone monotherapy which is also popular and endorsed by CAP guidelines.


Monday, October 16, 2017

Sunday, October 15, 2017

The coming microbial apocalypse: Staph aureus in retreat?


Twenty years ago the post antibiotic era was predicted for gram positive infections. Five years or so later CA-MRSA began to overtake HA-MRSA. The takeover is complete, with the result that today’s MRSA, though resistant to most beta lactam antibiotics, is sensitive to several older antimicrobial agents besides vancomycin, in contrast to the older traditional MRSA (HA-MRSA). In a new development, a goodly number of MSSA  infections show susceptibility to plain penicillin.

Friday, October 13, 2017

Inappropriate IVC filter use continues apace


This is despite mounting evidence supporting restricted use as recommended in guidelines. This was the topic of several articles of interest in the May issue of Thrombosis Research.


Methods and results

We analyzed hospital discharge records of all patients with active cancer who were admitted to a California hospital specifically for acute DVT or PE between 2005 through 2009. Propensity and competing risk methodology were used to determine if IVCF-use lowered either 30-day mortality or the risk of recurrent PE, DVT, and major bleeding within 180 days. Among 14,000 patients, an IVCF was placed in 2747 (19.6%), but only 577 (21%) of these IVCF patients had an apparent indication for filter use because of acute bleeding or undergoing major surgery. Data on anticoagulation use was not available. Filter-use provided no reduction in either 30-day mortality (HR = 1.12, 95% CI: 0.99–1.26, p = 0.08) or the adjusted 180-day risk of subsequent PE (±DVT) (HR = 0.81, 95% CI: 0.52–1.27, p = 0.36). Filter use was, however, associated with an increase in the adjusted180-day risk of recurrent DVT (HR = 2.10, 95% CI: 1.53–2.89, p less than 0.0001).

Conclusions

We conclude that in this population-based study, approximately 20% of cancer patients with acute VTE received an IVCF, but only 21% of these had an indication for IVCF use. Overall, IVCF use provided neither a short-term survival benefit nor a reduction in risk of recurrent PE, but IVCF use was associated with a higher risk of recurrent DVT.



Introduction

Inferior vena cava filters are used to prevent embolization of a lower extremity deep vein thrombosis when the risk of pulmonary embolism is thought to be high. However, evidence is lacking for their benefit and guidelines differ on the recommended indications for filter insertion. The study aim was to determine the reasons for inferior vena cava filter placement and subsequent complication rate.

Materials and methods

A retrospective cohort of patients receiving inferior vena cava filters in Edmonton, Alberta, Canada from 2007 to 2011. Main outcome was the indication of inferior vena cava filter insertion. Other measures include baseline demographic and medical history of patients, clinical outcomes and filter retrieval rates.

Results

464 patients received inferior vena cava filters. An acute deep vein thrombosis with a contraindication to anticoagulation was the indication for 206 (44.4%) filter insertions. No contraindication to anticoagulation could be identified in 20.7% of filter placements. 30.6% were placed in those with active cancer, in which mortality was significantly higher. Only 38.9% of retrievable filters were successfully retrieved.

Conclusions

Inferior vena cava filters were placed frequently in patients with weak or no guideline-supported indications for filter placement and in up to 20% of patients with no contraindication to anticoagulation. The high rates of cancer and the high mortality rate of the cohort raise the possibility that some filters are placed inappropriately in end of life settings.

Here are a couple of related editorials: [1] [2]



Thursday, October 12, 2017

Inappropriate anaerobic coverage for patients with pneumonia in the ICU


This practice was common in this study. Anaerobic coverage is often provided as a knee jerk response to “suspected aspiration” without careful assessment of the risk factors for anaerobic infection.

Wednesday, October 11, 2017

An association between gout and aortic stenosis risk



Conclusions

Aortic stenosis patients had a markedly higher prevalence of precedent gout than age-matched controls. Whether gout is a marker of, or a risk factor for, the development of aortic stenosis remains uncertain. Studies investigating the potential role of gout in the pathophysiology of aortic stenosis are warranted and could have therapeutic implications.

Tuesday, October 10, 2017

Glioma and VTE


Glioma is associated with hypercoagulability to a greater extent than many other neoplasms. However, as noted in this paper, the CNS bleed rate of anticoagulated glioma patients is significant.

Sunday, October 08, 2017

Better cardiovascular outcomes with gastric bypass surgery


Friday, October 06, 2017

Fecal occult blood testing in patients with suspected GI bleeds



I tend to agree although given its low harm, cost and frequency of use, is it even worth talking about?

Thursday, October 05, 2017

Do foreign trained docs save more lives?



Conclusions Data on older Medicare patients admitted to hospital in the US showed that patients treated by international graduates had lower mortality than patients cared for by US graduates.

And slightly lower cost per case.


I will take an IMG to work by my side any day of the week. You need to be twice as smart, motivated, and industrious to make your way to American shores.

Tuesday, October 03, 2017

Monday, October 02, 2017

Even brief use of any NSAID is associated with increased risk of MI


BMJ report here.

Despite the evidence of cardiovascular risk piling up NSAID use will only increase as people look for ways to reduce opiate usage.

The FDA wants opiate makers to offer docs training in quackery



Now the FDA is proposing an expansion of that educational mandate for opioid makers — to teach physicians how to manage pain with yoga, cognitive therapy, acupuncture, chiropractic, and other nonpharmacologic methods.

"Nobody has overdosed from too much mindfulness," said Corey Waller, MD..

Sunday, October 01, 2017

Saturday, September 30, 2017

Systemic anticoagulation for stroke prevention: should the indications be expanded?


A recent review suggests considering systemic anticoagulation in elderly patients in sinus rhythm but with frequent atrial ectopy, interatrial block and high CHADSVASC score. (What about these same patients who have cryptogenic stroke?).

Friday, September 29, 2017

Exercise improves cognitive function



Conclusions Physical exercise improved cognitive function in the over 50s, regardless of the cognitive status of participants. To improve cognitive function, this meta-analysis provides clinicians with evidence to recommend that patients obtain both aerobic and resistance exercise of at least moderate intensity on as many days of the week as feasible, in line with current exercise guidelines.

Thursday, September 28, 2017

Hospitalist mission creep: feeling dumped on


Alcohol and stroke risk




Background

Whether light-to-moderate alcohol consumption is protective against stroke, and whether any association differs by stroke type, is controversial. We conducted a meta-analysis to summarize the evidence from prospective studies on alcohol drinking and stroke types.

Methods

Studies were identified by searching PubMed to September 1, 2016, and reference lists of retrieved articles. Additional data from 73,587 Swedish adults in two prospective studies were included. Study-specific results were combined in a random-effects model.

Results

The meta-analysis included 27 prospective studies with data on ischemic stroke (25 studies), intracerebral hemorrhage (11 studies), and/or subarachnoid hemorrhage (11 studies). Light and moderate alcohol consumption was associated with a lower risk of ischemic stroke, whereas high and heavy drinking was associated with an increased risk; the overall RRs were 0.90 (95 % CI, 0.85–0.95) for less than 1 drink/day, 0.92 (95 % CI, 0.87–0.97) for 1–2 drinks/day, 1.08 (95 % CI, 1.01–1.15) for more than 2–4 drinks/day, and 1.14 (95 % CI, 1.02–1.28) for more than 4 drinks/day. Light and moderate alcohol drinking was not associated with any hemorrhagic stroke subtype. High alcohol consumption (greater than 2–4 drinks/day) was associated with a non-significant increased risk of both hemorrhagic stroke subtypes, and the relative risk for heavy drinking (greater than 4 drinks/day) were 1.67 (95 % CI, 1.25–2.23) for intracerebral hemorrhage and 1.82 (95 % CI, 1.18–2.82) for subarachnoid hemorrhage.

Conclusion

Light and moderate alcohol consumption was inversely associated only with ischemic stroke, whereas heavy drinking was associated with increased risk of all stroke types with a stronger association for hemorrhagic strokes.

Saturday, September 23, 2017

Risk of thrombosis in patients with essential thrombocythemia



Abstract

To assess the role of platelet (PLT) count for thrombotic complications in Essential Thrombocythemia (ET), 1201 patients followed in 11 Hematological centers in the Latium region were retrospectively evaluated. At multivariate analysis, the following factors at diagnosis were predictive for a worse Thrombosis-free Survival (TFS): the occurrence of previous thrombotic events (p = 0.0004), age greater than  60 years (p = 0.0044), spleen enlargement (p = 0.042) and a lower PLT count (p = 0.03). Receiver Operating Characteristic (ROC) analyses based on thrombotic events during follow-up identified a baseline platelet count of 944 × 109/l as the best predictive threshold: thrombotic events were 40/384 (10.4%) in patients with PLT count greater than 944 × 109/l and 109/817 (13.3%) in patients with PLT count less than 944 × 109/l, respectively (p = 0.04). Patients with PLT count less than 944 × 109/l were older (median age 60.4 years. vs 57.1 years., p = 0.016), had a lower median WBC count (8.8 × 109/l vs 10.6 × 109/l, p less than 0.0001), a higher median Hb level (14.1 g/dl vs 13.6 g/dl, p less than 0.0001) and a higher rate of JAK-2-V617F positivity (67.2% vs 41.6%, p less than 0.0001); no difference was observed as to thrombotic events before diagnosis, spleen enlargement and concomitant Cardiovascular Risk Factors. In conclusion, our results confirm the protective role for thrombosis of an high PLT count at diagnosis. The older age and the higher rate of JAK-2 V617F positivity in the group of patients with a baseline lower PLT count could in part be responsible of this counterintuitive finding.

The last sentence helps explain the paradox.

Friday, September 22, 2017

Adult onset Still’s disease


Thursday, September 21, 2017

Epinephrine in cardiac arrest: how strongly is it supported by the evidence?



Background

Sudden cardiac arrest accounts for approximately 15% of deaths in developed nations, with poor survival rate. The American Heart Association states that epinephrine is reasonable for patients with cardiac arrest, though the literature behind its use is not strong.

Objective

To review the evidence behind epinephrine for cardiac arrest.

Discussion

Sudden cardiac arrest causes over 450,000 deaths annually in the United States. The American Heart Association recommends epinephrine may be reasonable in patients with cardiac arrest, as part of Advanced Cardiac Life Support. This recommendation is partly based on studies conducted on dogs in the 1960s. High-dose epinephrine is harmful and is not recommended. Epinephrine may improve return of spontaneous circulation, but does not improve survival to discharge or neurologic outcome. Literature suggests that three phases of resuscitation are present: electrical, circulatory, and metabolic. Epinephrine may improve outcomes in the circulatory phase prior to 10 min post arrest, though further study is needed. Basic Life Support measures including adequate chest compressions and early defibrillation provide the greatest benefit.

Conclusions

Epinephrine may improve return of spontaneous circulation, but it does not improve survival to discharge or neurologic outcome. Timing of epinephrine may affect patient outcome, but Basic Life Support measures are the most important aspect of resuscitation and patient survival.


Wednesday, September 20, 2017

EMRs slow physicians down and distract from real clinical care


Tuesday, September 19, 2017

An automated warning system for deteriorating ward patients modestly improved outcomes




Background

Delayed response to clinical deterioration of ward patients is common.

Methods

We performed a prospective before-and-after study in all patients admitted to two clinical ward areas in a district general hospital in the UK. We examined the effect on clinical outcomes of deploying an electronic automated advisory vital signs monitoring and notification system, which relayed abnormal vital signs to a rapid response team (RRT).

Results

We studied 2139 patients before (control) and 2263 after the intervention. During the intervention the number of RRT notifications increased from 405 to 524 (p = 0.001) with more notifications triggering fluid therapy, bronchodilators and antibiotics. Moreover, despite an increase in the number of patients with “do not attempt resuscitation” orders (from 99 to 135; p = 0.047), mortality decreased from 173 to 147 (p = 0.042) patients and cardiac arrests decreased from 14 to 2 events (p = 0.002). Finally, the severity of illness in patients admitted to the ICU was reduced (mean Acute Physiology and Chronic Health Evaluation II score: 26 (SD 9) vs. 18 (SD 8)), as was their mortality (from 45% to 24%; p = 0.04).

Conclusions

Deployment of an electronic automated advisory vital signs monitoring and notification system to signal clinical deterioration in ward patients was associated with significant improvements in key patient-centered clinical outcomes.

This sort of thing has great potential if usage is optimized. Unfortunately, RRT usage has gone far beyond the original intent and unintended consequences abound.


Monday, September 18, 2017

Risk factors for atrial fibrillation in the elderly


Comprehensive free full text review.

Sunday, September 17, 2017

A pleural effusion may have more than one etiology


---especially given recent trends toward increasingly frequent complex comorbidities. From a recent review:

Abstract:

Purpose of review: Historically, pleural effusions have been attributed to a single cause. There is growing recognition that a substantial proportion of pleural effusions may have more than one underlying cause. The purpose of this review is to summarise recent findings regarding the diagnosis and treatment of effusions secondary to more than one aetiology.

Recent findings: A recent prospective study identified that 30% of pleural effusions had more than one underlying aetiology. With a rising prevalence of cardiovascular and malignant disease, the incidence of the complex pleural patient is increasing. The use of biomarkers, including pro-B-type natriuretic peptide, have been suggested as a way of identifying contributing disease process.

Summary: Understanding that there are potentially concurrent causes to a pleural effusion is vital in establishing the diagnoses of multiple underlying aetiologies. New diagnostic pathways, with increasing use of biomarkers, will be required to identify the complex pleural effusion. Further studies on whether the targeting of separate aetiologies improves outcomes will help develop future management strategies.

Saturday, September 16, 2017

DOAC dosing errors



Three points to be made here:

DOAC dosing is much more “indication based” than warfarin.

DOAC may be less forgiving of dosing errors than warfarin.

Unlike warfarin, DOACs have no monitoring safety net.

Friday, September 15, 2017

Thursday, September 14, 2017

Are blood ammonia levels helpful?



Here are their recommendations:

HE is a diagnosis of exclusion and is made on clinical grounds.

Do not check serum ammonia levels in patients with CLD to diagnose HE, to assess the severity of HE, or to determine whether HE is resolving.

Use your clinical evaluation to determine the severity and course of HE.

Treatment should be tailored according to clinical findings, not ammonia levels.

I get a little nervous about absolute recommendations to stop a widely accepted, physiologically rational, low tech, low harm practice just because there’s a lack of “high level” supporting evidence. An unfounded assumption here is that a lack of high level evidence equates to evidence against.

Another questionable assumption is that the test inherently is bad. Certainly at the cutoff of 55, as cited in the article, the test characteristics are poor. At extreme values, however, it may be more helpful. In a comatose patient presenting to ER whose baseline level is known to be 40, for example, a triple digit ammonia may add greatly to the diagnostic confidence and obviate an MRI and LP pending a therapeutic trial directed at HE. In such a case it might even save resources. This article strikes me as a case of black and white thinking. How about a more nuanced approach in which the ordering threshold is proportional to the cost and potential harm of the test?

Wednesday, September 13, 2017

Benzos and opiates given to ward patients increase the risk of deterioration (ICU transfer or arrest)




BACKGROUND

Opioids and benzodiazepines are frequently used in hospitals, but little is known about outcomes among ward patients receiving these medications.

OBJECTIVE

To determine the association between opioid and benzodiazepine administration and clinical deterioration.

DESIGN

Observational cohort study.

SETTING

500-bed academic urban tertiary-care hospital.

PATIENTS

All adults hospitalized on the wards from November 2008 to January 2016 were included. Patients who were “comfort care” status, had tracheostomies, sickle-cell disease, and patients at risk for alcohol withdrawal or seizures were excluded.

MEASUREMENTS

The primary outcome was the composite of intensive care unit transfer or ward cardiac arrest. Discrete-time survival analysis was used to calculate the odds of this outcome during exposed time periods compared to unexposed time periods with respect to the medications of interest, with adjustment for patient demographics, comorbidities, severity of illness, and pain score.

RESULTS

In total, 120,518 admissions from 67,097 patients were included, with 67% of admissions involving opioids, and 21% involving benzodiazepines. After adjustment, each equivalent of 15 mg oral morphine was associated with a 1.9% increase in the odds of the primary outcome within 6 hours (odds ratio [OR], 1.019; 95% confidence interval [CI], 1.013-1.026; P less than 0.001), and each 1 mg oral lorazepam equivalent was associated with a 29% increase in the odds of the composite outcome within 6 hours (OR, 1.29; CI, 1.16-1.45; P less than 0.001).

CONCLUSION

Among ward patients, opioids were associated with increased risk for clinical deterioration in the 6 hours after administration. Benzodiazepines were associated with even higher risk. These results have implications for ward-monitoring strategies. Journal of Hospital Medicine 2017;12:428-434. © 2017 Society of Hospital Medicine


Tuesday, September 12, 2017

Review of the ECG findings in WPW


Monday, September 11, 2017

The ER ECG in drug overdose


Sunday, September 10, 2017

Biomarker guided heart failure treatment versus usual (guideline based) care: take your pick!



Question Does a strategy of titrating therapy to a specific amino-terminal pro–B-type natriuretic peptide (NT-proBNP) target improve clinical outcomes in high-risk patients with heart failure and reduced ejection fraction?

Findings In this randomized clinical trial including 894 adults, a strategy of NT-proBNP–guided therapy compared with usual care did not significantly improve time to first hospitalization or cardiovascular mortality (hazard ratio, 0.98).

Meaning These findings do not support NT-proBNP–guided therapy for management of heart failure with reduced ejection fraction.

From table 2 in the paper we learn that both groups got the same treatment. That is, whether you tended to ignore proBNP levels and just do your best to adhere to guidelines or individualized therapy based on proBNP levels, you ended up with the same regimen. These, or course, were trial participants. What would happen in the real world where guideline goal achievement is horrible?

An accompanying editorial summarized what we knew before:

Assays for natriuretic peptide biomarkers, B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP), have become well established for assisting with the diagnosis and assessment of the severity of heart failure and for providing prognostic information in both the setting of acute care of decompensated heart failure and outpatient care of chronic heart failure...

..several randomized clinical trials have evaluated whether the application of serial measurement of natriuretic peptide to guide the titration of medical therapy in chronic heart failure could improve outcomes.4,6 Those trials have yielded mixed results.


Saturday, September 09, 2017

The ECG and future heart failure risk



Background Several markers detected on the routine 12‐lead ECG are associated with future heart failure events. We examined whether these markers are able to separate the risk of heart failure with reduced ejection fraction (HFrEF) from heart failure with preserved ejection fraction (HFpEF).

Methods and Results We analyzed data of 6664 participants (53% female; mean age 62±10 years) from MESA (Multi‐Ethnic Study of Atherosclerosis) who were free of cardiovascular disease at baseline (2000–2002). A competing risks analysis was used to compare the association of several baseline ECG predictors with HFrEF and HFpEF detected during a median follow‐up of 12.1 years. A total of 127 HFrEF and 117 HFpEF events were detected during follow‐up. In a multivariable adjusted model, prolonged QRS duration, delayed intrinsicoid deflection, left‐axis deviation, right‐axis deviation, prolonged QT interval, abnormal QRS‐T axis, left ventricular hypertrophy, ST/T‐wave abnormalities, and left bundle‐branch block were associated with HFrEF. In contrast, higher resting heart rate, abnormal P‐wave axis, and abnormal QRS‐T axis were associated with HFpEF. The risk of HFrEF versus HFpEF was significantly differently for delayed intrinsicoid deflection (hazard ratio: 4.90 [95% confidence interval (CI), 2.77–8.68] versus 0.94 [95% CI, 0.29–2.97]; comparison P=0.013), prolonged QT interval (hazard ratio: 2.39 [95% CI, 1.55–3.68] versus 0.52 [95% CI, 0.23–1.19]; comparison P less than 0.001), and ST/T‐wave abnormalities (hazard ratio: 2.47 [95% CI, 1.69–3.62] versus 1.13 [95% CI, 0.72–1.77]; comparison P=0.0093).

Conclusions Markers of ventricular repolarization and delayed ventricular activation are able to distinguish between the future risk of HFrEF and HFpEF. These findings suggest a role for ECG markers in the personalized risk assessment of heart failure subtypes.

Friday, September 08, 2017

Glossary of critical appraisal


This piece has some helpful information. However it’s a bit imprecise, offering descriptions that “talk around” the various terms rather than actual definitions.

Wednesday, September 06, 2017

Ace inhibitor use in patients with Duchenne and Becker muscular dystrophy slows progression of myocardial fibrosis



Importance In Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD), interventions reducing the progression of myocardial disease could affect survival.

Objective To assess the effect of early angiotensin-converting enzyme (ACE) inhibitor therapy in patients with normal left ventricular function on the progression of myocardial fibrosis (MF) identified on cardiovascular magnetic resonance (CMR).

Design, Setting, and Participants A randomized clinical trial conducted in 2 centers included 76 male patients with DMD or BMD undergoing 2 CMR studies with a 2-year interval for ventricular function and MF assessment. In a non–intent-to-treat trial, 42 patients with MF and normal left ventricular ejection fraction (LVEF) were randomized (1:1) to receive or not receive ACE inhibitor therapy. The study was conducted from June 26, 2009, to June 30, 2012. Data analysis was performed from June 30, 2013, to October 3, 2016.

Interventions Randomization (1:1) to receive or not receive ACE inhibitor therapy.

Main Outcomes and Measures Primary outcome was MF progression from baseline to the 2-year CMR study.

Results Of the 76 male patients included in the study, 70 had DMD (92%) and 6 had BMD (8%); mean (SD) age at baseline was 13.1 (4.4) years. Myocardial fibrosis was present in 55 patients (72%) and LV systolic dysfunction was identified in 13 patients (24%). Myocardial fibrosis at baseline was an independent indicator of lower LVEF at follow-up (coefficient [SE], −0.16 [0.07]; P = .03). Among patients with MF and preserved LVEF (42 [55%]), those randomized (21 patients in each arm) to receive ACE inhibitors demonstrated slower MF progression compared with the untreated group (mean [SD] increase of 3.1% [7.4%] vs 10.0% [6.2%] as a percentage of LV mass; P = .001). In multivariate analysis, ACE inhibitor therapy was an independent indicator of decreased MF progression (coefficient [SE], −4.51 [2.11]; P = .04). Patients with MF noted on CMR had a higher probability of cardiovascular events (event rate, 10 of 55 [18.2%] vs 0 of 21 [0%]; log-rank P = .04).

Conclusions and Relevance In this 2-year, follow-up, randomized clinical trial of patients with Duchenne or Becker muscular dystrophy whose LVEF was preserved and MF was present as determined on CMR, ACE inhibitor therapy was associated with significantly slower progression of MF. The presence of MF was associated with worse patient prognosis.