Cardiovascular Diseases Commons^™

H2s, Sg-1002, Protects Against Myocardial Oxidative Damage And Hypertrophy In Vitro Via Induction Of Cystathionine Β-Synthase And Antioxidant Proteins, Rahib K. Islam, Erinn Donnelly, Erminia Donnarumma, Fokhrul Hossain, Jason D. Gardner, Kazi N. Islam

School of Medicine Faculty Publications

Endogenously produced hydrogen sulfide (H2S) is critical for cardiovascular homeostasis. Therapeutic strategies aimed at increasing H2S levels have proven cardioprotective in models of acute myocardial infarction (MI) and heart failure (HF). The present study was undertaken to investigate the effects of a novel H2S prodrug, SG-1002, on stress induced hypertrophic signaling in murine HL-1 cardiac muscle cells. Treatment of HL-1 cells with SG-1002 under serum starvation without or with H2O2 increased the levels of H2S, H2S producing enzyme, and cystathionine β-synthase (CBS), as well as antioxidant protein levels, such as super oxide dismutase1 (SOD1) and catalase, and additionally decreased oxidative …

Magnetic Resonance Imaging-Derived Microvascular Perfusion Modeling To Assess Peripheral Artery Disease, Olga A. Gimnich, Tatiana Belousova, Christina M. Short, Addison A. Taylor, Vijay Nambi, Joel D. Morrisett, Christie M. Ballantyne, Jean Bismuth, Dipan J. Shah, Gerd Brunner

School of Medicine Faculty Publications

BACKGROUND: Computational fluid dynamics has shown good agreement with contrast-enhanced magnetic resonance imaging measurements in cardiovascular disease applications. We have developed a biomechanical model of microvascular perfusion using contrast-enhanced magnetic resonance imaging signal intensities derived from skeletal calf muscles to study peripheral artery disease (PAD). METHODS AND RESULTS: The computational microvascular model was used to study skeletal calf muscle perfusion in 56 in-dividuals (36 patients with PAD, 20 matched controls). The recruited participants underwent contrast-enhanced magnetic resonance imaging and ankle-brachial index testing at rest and after 6-minute treadmill walking. We have determined associations of microvascular model parameters including the transfer …

Exploring The Efficacy Of Mir-33 Antagonism In Promoting Regression Of Intracranial Atherosclerosis In A Nonhuman Primate Model, Peter Hecker

Theses and Dissertations--Pharmacology and Nutritional Sciences

Atherosclerosis, characterized by lipid accumulation and arterial inflammation, is a major contributor to global morbidity and mortality. Despite significant progress in understanding atherosclerosis in extracranial arteries, the study of intracranial atherosclerosis (ICAS) has been relatively neglected, despite its crucial role in stroke and vascular cognitive impairment. Challenges related to ICAS, including its location within the cranium and limited availability of suitable animal models, have hindered research progress in this area. Although nonhuman primates (NHPs) are commonly used for studying extracranial atherosclerosis, a comprehensive understanding of ICAS pathophysiology in these animals is lacking. By subjecting NHPs to a high-fat/cholesterol diet, we …

Multi-Ancestry Genome-Wide Association Analyses Improve Resolution Of Genes And Pathways Influencing Lung Function And Chronic Obstructive Pulmonary Disease Risk, Nick Shrine, Abril G. Izquierdo, Jing Chen, Richard Packer, Robert J. Hall, Anna L. Guyatt, Chiara Batini, Rebecca J. Thompson, Chandan Puvuluri, Vidhi Malik, Brian D. Hobbs, Matthew Moll, Wonji Kim, Ruth Tal-Singer, Per Bakke, Katherine A. Fawcett, Catherine John, Kayesha Coley, Noemi Nicole Piga, Sinjini Sikdar, Martin D. Tobin, Et Al.

Mathematics & Statistics Faculty Publications

Lung-function impairment underlies chronic obstructive pulmonary disease (COPD) and predicts mortality. In the largest multi-ancestry genome-wide association meta-analysis of lung function to date, comprising 580,869 participants, we identified 1,020 independent association signals implicating 559 genes supported by ≥2 criteria from a systematic variant-to-gene mapping framework. These genes were enriched in 29 pathways. Individual variants showed heterogeneity across ancestries, age and smoking groups, and collectively as a genetic risk score showed strong association with COPD across ancestry groups. We undertook phenome-wide association studies for selected associated variants as well as trait and pathway-specific genetic risk scores to infer possible consequences of …

Topographical Distribution And Morphology Of Sympathetic Postganglionic Innervation And Chronic Intermittent Hypoxia (Cih) Induced Remodeling Of The Whole Heart At Single Cell/Axon/Varicosity Scale, Ariege Bizanti

Electronic Theses and Dissertations, 2020-2023

The sympathetic nervous system is crucial for controlling multiple cardiac functions and its overactivity is associated with many cardiovascular diseases (CVD). Chronic intermittent hypoxia (CIH) is a current model for sleep apnea, which constitutes a major risk factor for CVD through sympathetic overactivity. However, a comprehensive neuroanatomical map of the sympathetic innervation of the heart is unavailable which impedes our understanding of the remodeling of this map in pathological conditions. First, we used a combination of state-of-the-art techniques, including flat-mount tissue processing, immunohistochemistry for tyrosine hydroxylase (TH, a sympathetic marker), confocal microscopy and Neurolucida 360 software to trace, digitize, and …

Pengaruh Diaphragmatic Breathing Dan Endurance Exercise Terhdap Peningkatan Kapasitas Kardiorespirasi Pada Pasien Hospital-Acquired Pneumonia, Alifia Azzahra, Annisya Puspitarani, Zahra Sativani, Riza Pahlawi

Jurnal Fisioterapi Terapan Indonesia

The purpose of this case study is to determine the effect of diaphragmatic breathing and endurance exercise in hospital-acquired pneumonia (HAP) cases. HAP is a nosocomial pneumonia that occurs 48 hours or more after the patient is admitted to the hospital, without any signs of pulmonary infection at the time of initial treatment. The existence of clinical manifestations that appear, patients with HAP tend to avoid physical activity which can decrease the functional capacity of the respiratory system and have an impact on decreasing endurance. Diaphragmatic breathing exercise is thought to be able to help reduce shortness of breath, reduce …

Glucocentric Drugs In Cardiovascular Disease Protection And Heart Failure, Khawaja M. Talha, Gregg C. Fonarow, Salim S. Virani, Javed Butler

Office of the Provost

Evidence for cardiovascular outcomes with older-generation antihyperglycemic drugs in the management of type 2 diabetes is based on aggregated data from prior randomized controlled trials and observational studies that were not focused on prespecified cardiovascular end points. Newer antihyperglycemic medications have undergone a rigorous evaluation of cardiovascular outcomes through randomized controlled trials since the US Food and Drug Administration imposed a mandatory requirement for all glucose-lowering drugs in 2008. The three classes of drugs that have been most extensively studied are dipeptidyl peptidase 4 inhibitors, glucagon-like peptide 1 receptor agonists, and sodium-glucose cotransporter-2 (SGLT2) inhibitors, the latter two reporting significant …

Trends, Predictors, And Outcomes Of Transcatheter Aortic Valve Implantation In Patients With Bicuspid Aortic Valve Related Disease: Insights From The Nationwide Inpatient Sample And Nationwide Readmission Database, Waqas Ullah, Salman Zahid, Hamza Muhammadzai, Fouad Khalil, Arnav Kumar, Abdul Mannan Khan Minhas, Muhammad Zia Khan, Salim S. Virani, David L. Fischman, Pinak Shah

Office of the Provost

Background: Transcatheter aortic valve implantation (TAVI) has increasingly been utilized in patients with bicuspid aortic valve (BAV) related aortic stenosis (AS) with insufficient large-scale data on its safety.
Methods: The Nationwide Inpatient Sample and Nationwide Readmission Database (2011-2018) were queried to identify patients undergoing TAVI for BAV versus trileaflet aortic valve (TAV) associated AS. The in-hospital, 30- and 180-day odds of outcomes were assessed using a propensity-matched analysis (PSM) to calculate adjusted odds ratios (aOR) with its 95% confidence interval (CI).
Results: A total of 216,723 TAVI (TAV: 214,050 and BAV: 2,673) crude and 5,347 matched population (TAV: 2,674 and …

Statins: Masked Anti-Epileptic Warriors, Govinda Khatri, Priya Kotak, Ayush Kumar, Mohammad Mehedi Hasan

Medical College Documents

No abstract provided.

Pathophysiology Of Aortic Stenosis, Melissa Lee

Nursing Student Class Projects (Formerly MSN)

Pathophysiology of Aortic Stenosis

Melissa J. Lee

Department of Nursing, Otterbein University

NURS 6810: Advanced Pathophysiology for the Advanced Practice Nurse

Dr. Deana Batross & Dr. Shivani Bhatnagar

July 29, 2022

Pathophysiology of Aortic Stenosis

Proper evaluation of co-morbidities is imperative for patient safety and successful outcomes for patients undergoing anesthesia. Aortic stenosis (AS) is one of the most complex diseases encountered in anesthesia, affecting five percent of older adults and ten percent of the 80-89-year-old-cohort (Joseph et al., 2017). The pathophysiological development of AS is the end result of an inflammatory process caused by endothelial damage from mechanical stress, …

Perioperative Risks Of The Patient With Heart Failure, Gabrielle Metoyer

Nursing Student Class Projects (Formerly MSN)

Perioperative Risks of the Patient with Heart Failure

Gabrielle Metoyer

Department of Nursing, Otterbein University

NURS 6810 – Advanced Pathophysiology

Dr. Deanna Batross and Dr. Shivani Bhatnagar

August 5, 2022

Abstract

According to the CDC (2020), heart failure occurs when the heart cannot pump enough blood and oxygen to support other organs in your body. Heart failure is an epidemic disease affecting 1-2% of the population worldwide (Schwinger, 2020). It is one of the leading causes of morbidity and mortality worldwide with an estimated 6.5 million adults with heart failure in the United States (Lo et al., 2021). Medical advances …

The Influence Of Demographic, Social, And Economic Factors On Referral For Heart Failure Services, Catherine Elaine Kelty

Dissertations

Patients with end-stage advanced heart failure must go through an extensive evaluation process before being selected for either heart transplantation or left ventricular assist device (LVAD). This evaluation not only assesses a patient’s medical need for advanced heart failure treatments but also includes an assessment of psychosocial and economic factors that may affect a patient’s success post-treatment. While it is important to allocate scarce resources, such as donated organs, to the patients who will benefit the most, there is also a need for equity in the allocation of and access to healthcare services. This raises the question of whether patients …

Diaphragmatic Adjacencies: Pulmonary Embolism Presenting As Abdominal Pain, Joseph Piraneo, Christopher Schwartz, Russell Mordecai

Rowan-Virtua Research Day

Pulmonary embolism is a common yet potentially life-threatening diagnosis that should not be missed in the Emergency Department. Common presenting symptoms include dyspnea, pleuritic chest pain, cough, hemoptysis, syncope or pre-syncope. Less often, however, presenting symptoms can include abdominal pain. A clinician should recognize that pain adjacent to the diaphragm (including the lower chest and upper abdomen), can be secondary to underlying pathology either above or below the diaphragm. Here we describe an unusual case of pleuritic, post-prandial, right upper quadrant abdominal pain that was a result of pulmonary embolism.

The Cloak Of Invisibility: Subclinical Infective Endocarditis Resulting In Chordae Tendineae Rupture In Mitral Valve Prolapse, Jason Naftulin, Trinava Roy, Anjeli Patel, Steven Silver

Rowan-Virtua Research Day

While Chordae tendineae rupture(CTR) is often caused due to mitral valve prolapse, rheumatic heart disease or infective endocarditis, CTR secondary to a combination of the factors is not often seen. We present a unique case of CTR due to subclinical infective endocarditis(IE) with underlying mitral valve prolapse(MVP).

Arterial Thromboembolism As A Sequela Of Mild Covid-19 Pneumonia With Resultant Gangrene Of The Right Lower Extremity, Sean Coulson, Brian Thomas, Christopher Chhoun

Rowan-Virtua Research Day

Hypercoagulable states leading to stroke, pulmonary embolism, and acute limb ischemia are well documented phenomena secondary to moderate-to-severe COVID-19 infections that produce significant respiratory morbidity.

Incidence is largely unknown with additional emerging clinical manifestations including, but not limited to: Viral and secondary bacterial pneumonia, respiratory failure, sepsis, stroke, acute kidney injury, pulmonary embolism, disseminated intravascular coagulation (DIC), as well as arterial and venous thromboembolism.

Fortuitous Diagnosis Of Total Anomalous Pulmonary Venous Return In A Newborn With Hypoglycemia, Joseph Maes, Terence Zach

Child Health Research Institute Pediatric Research Forum

No abstract provided.

The Impact Of Long Term Ovariectomy On Diastolic Function And Fibrosis Following Chronic Sympathetic Stimulation In Mice, Erin Moore

Undergraduate Honors Theses

Cardiovascular Disease (CVD) accounts for the leading number of deaths worldwide. Prior to menopause, women exhibit lower rates of CVD compared to age-matched men, however, risks for women increase with menopause. Studies show estrogen loss and age exacerbating cardiac β-adrenergic receptor (β-AR) signaling and contractile function. We therefore hypothesized that prolonged estrogen deficiency and chronic β-adrenergic stimulation cause decreases in cardiac function and increases in fibrosis in aged female hearts. Female mice underwent either an ovariectomy (OVX) or a control SHAM surgery at 10 weeks old and were infused with Isoproterenol for three days via mini osmotic pumps in …

Alternative Fixation Of Venous Valves For Bioprosthetic Applications, Makenzie Kapales

Biomedical Engineering Undergraduate Honors Theses

Venous valve failure allows for the retrograde, or backward, flow of blood into the lower extremities, which leads to Chronic Venous Insufficiency (CVI). CVI infringes upon quality of life through ulceration and can result in death due to Deep Vein Thrombosis (DVT), or blood clots, causing pulmonary embolism. A successful treatment of CVI restores valve function and prevents retrograde blood flow; however, current bioprosthetic venous valves exhibit low patency and high calcification. To improve upon bioprosthetic venous valves and CVI treatment, the University of Arkansas’s Cardiovascular Biomechanics Lab conducts studies with the purpose of comparing the properties and performance of …

Electrocardiogram-Based Machine Learning Emulator Model For Predicting Novel Echocardiography-Derived Phenogroups For Cardiac Risk-Stratification: A Prospective Multicenter Cohort Study, Heenaben B. Patel, Naveena Yanamala, Brijesh Patel, Sameer Raina, Peter D. Farjo, Srinidhi Sunkara, Márton Tokodi, Nobuyuki Kagiyama, Grace Casaclang-Verzosa, Partho P. Sengupta

Journal of Patient-Centered Research and Reviews

Purpose: Electrocardiography (ECG)-derived machine learning models can predict echocardiography (echo)-derived indices of systolic or diastolic function. However, systolic and diastolic dysfunction frequently coexists, which necessitates an integrated assessment for optimal risk-stratification. We explored an ECG-derived model that emulates an echo-derived model that combines multiple parameters for identifying patient phenogroups at risk for major adverse cardiac events (MACE).

Methods: In this substudy of a prospective, multicenter study, patients from 3 institutions (n = 727) formed an internal cohort, and the fourth institution was reserved as an external test set (n = 518). A previously validated patient similarity analysis model was used …

Efficacy And Safety Of Direct Oral Anticoagulants With And Without Aspirin: A Systematic Review And Meta-Analysis, Talal Almas, Adeena Musheer, Arooba Ejaz, Fahd Niaz Shaikh, Anousheh Awais Paracha, Fizza Raza, Maryam Sarwar Khan, Fahad Masood, Faiza Siddiqui, Muhammad Hasnain Mankani

Medical College Documents

Background: Various anticoagulant therapies are prescribed to patients under physicians' discretion and recently Direct Oral Anticoagulants(DOAC) have been under trials to evaluate their safety and efficacy. In addition to this, the regimen of DOACs and Aspirin is of keen interest as researchers continue to find an optimal regimen to treat blood clots in patients. This study is a systematic review and meta-analysis of randomized controlled trials and observational studies that asses the safety and efficacy of DOAC with and without Aspirin.
Methods: We queried MEDLINE and Cochrane CENTRAL from their inception to April 2021, for published and randomized controlled …

Epidemiology, Clinical Ramifications, And Cellular Pathogenesis Of Covid-19 Mrna-Vaccination-Induced Adverse Cardiovascular Outcomes: A State-Of-The-Heart Review, Talal Almas, Sarah Rehman, Eyad Mansour, Tarek Khedro, Ali Alansari, Jahanzeb Malik, Norah Alshareef, Vikneswaran Raj Nagarajan, Abdulla Hussain Al-Awaid, Reema Alsufyani

Medical College Documents

The coronavirus disease 2019 (COVID-19) has overwhelming healthcare systems globally. To date, a myriad of therapeutic regimens has been employed in an attempt to curb the ramifications of a severe COVID-19 infection. Amidst the ongoing pandemic, the advent and efficacious uptake of COVID-19 vaccination has significantly reduced disease-related hospitalizations and mortality. Nevertheless, many side-effects are being reported after COVID-19 vaccinations and myocarditis is the most commonly reported sequelae post vaccination. Majority of these diseases are associated with COVID-19 mRNA vaccines. Various studies have established a temporal relationship between these complications, yet the causality and the underlying pathogenesis remain hypothetical. In …

Tirofiban And Rivaroxaban Use In The Management Of Right Coronary Artery Thrombus As A Primary Manifestation Of Essential Thrombocythemia, Muhummad Nasir Rahman, Maleeha Javed

Section of Cardiology

A 45 year old male with hypertension was presented to our centre with a recent inferior wall myocardial infarction (IWMI) and post infarction angina. Invasive coronary angiography revealed an occluded proximal right coronary artery (RCA) with high thrombus burden, in the absence of obstructive disease in the remaining coronary vasculature. Based on raised platelet counts of 923,000/microliter and positive Janus kinase (JAK 2- V617) mutations tested by polymerase chain reaction (PCR), a diagnosis of essential thrombocythemia (ET) was made. A therapeutic strategy of aspiration thrombectomy along with I/V Tirofiban was used for three days, followed by reassessed angiogram and percutaneous …

Determinant Of Repeat Revascularization Within 5 Years Of Percutaneous Coronary Lntervention At A Tertiary Care Hospital, Karachi: A Matched Case-Control Study, Komal Valliani, Azmina Artani, Iqbal Azam, Javed Tai, M. Masood Kadir

Community Health Sciences

Objective: To determine factors associated with repeat revascularization among adults aged 25 years and above within 5 years of first Percutaneous Coronary Intervention (PCI) at a tertiary care hospital.
Methods: A matched case-control study was conducted through a hospital records review. A total of 90 cases with repeat revascularization and 180 controls without repeat revascularization were included. Data was analyzed using Multiple Conditional Logistic Regression.
Results: The mean age was similar in cases and controls (60.05 ± 10.01 vs 62.20 ± 10.43 years) and sex (male: 77.8% vs. 76.1%). History of being an ever-smoker (40% vs. 25%), overweight (36.3% vs. …

Early Postoperative Arrhythmias After Pediatric Congenital Heart Disease Surgery: A 5-Year Audit From A Lower- To Middle-Income Country, Sidra Ishaque, Saleem Akhtar, Asma Akbar Ladak, Russell Seth Martins, Muhammad Kamran Younis Memon, Alisha Raza Kazmi, Fatima Mahmood, Anwar Ul Haque

Department of Paediatrics and Child Health

Background: Postoperative arrhythmias are a known complication after surgical repair for congenital heart disease (CHD). This study aimed to identify and discuss the prevalence, diagnosis, and management of common rhythm disturbances seen in the immediate postoperative period after surgery for CHD in the pediatric population at a tertiary care hospital in Pakistan.
Methods: A retrospective study was conducted at a tertiary care hospital in Pakistan between January 2014 and December 2018. All pediatric (old) patients admitted to the intensive care unit and undergoing continuous electrocardiographic monitoring after surgery for CHD were included in this study. Data pertaining to the incidence, …

Conceptual Framework For A Cardiac Surgery Simulation Laboratory And Competency-Based Curriculum In Pakistan - A Short Innovation Report, Ali Aahil Noorali, Asma A H. Merchant, Sardar Shahmir Babar Chauhan, Mustafa Ali Khan, Anam Noor Ehsan, Mohammad Bin Pervez, Muhammad Tariq, Saulat Fatimi

Medical College Documents

Simulation is a commonly utilized technique in healthcare education as it provides trainees a realistic, but safe, environment to learn a variety of skills. Trainees belonging to fields known for high stakes with low margins for error, such as cardiac surgery, can greatly benefit from simulation-based education. We propose the establishment of the first multi-tier high fidelity cardiac surgery simulation lab with a structured curriculum that will eventually provide multidisciplinary training to promising cardiac surgeons across Pakistan. The simulation lab may also be used for research, grant acquisition and patent development. Our setup will include the following levels of simulation: …

Temporary Epicardial Pacing Wires In Isolated Coronary Artery Bypass Graft: Necessity Or Force Of Habit?, Mian Mustafa Kamal, Abdul Ahad Sohail, Majid Osman, Shiraz Hashmi, Muhammad Mehdi, Asma Altaf Hussain Merchant, Hasanat Sharif

Section of Cardiothoracic Surgery

Objective: To determine the frequency of Temporary epicardial pacing wires usage and its predictors in the immediate postoperative period in isolated coronary artery bypass graft surgery.
Methods: The longitudinal study was conducted at the Aga Khan University Hospital, Karachi, from September 2019 to August 2020, and comprised adult patients of either gender who underwent isolated coronary artery bypass graft in the Department of Cardiothoracic Surgery. Demographic, peri-operative and post-operative Temporary Epicardial Pacing Wires use data was extracted from patient's files and the institutional electronic database. Logistic regression models were built to explore predictors of Temporary epicardial pacing wires usage. Data …

Endothelial Nitric Oxide Synthase (Enos) And The Cardiovascular System: In Physiology And In Disease States, N Tran, T Garcia, M Aniqa, S Ali, A Ally, Surya M. Nauli

Pharmacy Faculty Articles and Research

Endothelial nitric oxide synthase (eNOS) plays a critical role in regulating and maintaining a healthy cardiovascular system. The importance of eNOS can be emphasized from the genetic polymorphisms of the eNOS gene, uncoupling of eNOS dimerization, and its numerous signaling regulations. The activity of eNOS on the cardiac myocytes, vasculature, and the central nervous system are discussed. The effects of eNOS on the sympathetic autonomic nervous system (SANS) and the parasympathetic autonomic nervous system (PANS), both of which profoundly influence the cardiovascular system, will be elaborated. The relationship between the eNOS protein with cardiovascular autonomic reflexes such as the baroreflex …

Severe Mixed Mitral Valve Disease Due To Massive Mitral Annular Calcification: A Case Report And Literature Review, Fateh Ali Tipoo Sultan, Sheema Saadia

Section of Cardiology

We present an unusual case of massive mitral annular calcification (MAC) leading to severe mixed mitral valve disease, viz severe mitral regurgitation and severe mitral stenosis. To our knowledge, severe mixed mitral valve disease secondary to MAC is extremely rare. The patient (a 65-year-old lady) presented with worsening shortness of breath and signs of congestive heart failure. Echocardiographic examination revealed massive mitral annular calcification. Despite the massive annular calcification, she had experienced neither embolism nor endocarditis in the past. Because of severe symptomatic mitral regurgitation and mitral stenosis, surgery was advised; however, the patient declined it.

Self-Measured Blood Pressure Monitoring: A Patient Empowerment Project, Alison Cusmano

Doctor of Nursing Practice Final Manuscripts

Hypertension is a public health issue estimated to affect 112 million adults by 2030. Primary care patients in an outpatient clinic in Southern California with elevated blood pressure readings in the office did not have an organized system for close follow-up. The purpose of this evidence-based project (EBP) was to educate patients on self-measured blood pressure monitoring (SMBP), Dietary Approaches to Stop Hypertension (DASH), diet interventions, and healthy weight loss to improve hypertension rates. Through these interventions, patients developed an understanding of their systolic and diastolic blood pressure goals. Nurse practitioners, medical assistants, and licensed vocational nurses screened for high …

The Role Of Pre-Participation Exams In Identifying Student Athletes At Risk For Sudden Cardiac Arrest, Elizabeth Frey

Honors Projects

Sudden cardiac arrest (SCA) is the leading cause of death in young student athletes (Drezner et al., 2007). With athletes being recognized as some of the healthiest members of society, a catastrophic event like this can stimulate debate over pre-participation screening and appropriate emergency actions. With 55-80% cases of sudden cardiac death (SCD) being asymptomatic before the event (Drezner et al., 2007), looking into how well pre-participation screenings identify at risk individuals becomes much more important. This project investigates to what extent pre-participation physicals (PPE) can be improved to better identify student athletes at risk for sudden cardiac death and …