Cardiology Commons^™

J-Wave Syndromes: Brugada And Early Repolarization Syndromes., Charles Antzelevitch, Gan-Xin Yan

Department of Medicine Faculty Papers

A prominent J wave is encountered in a number of life-threatening cardiac arrhythmia syndromes, including the Brugada syndrome and early repolarization syndromes. Brugada syndrome and early repolarization syndromes differ with respect to the magnitude and lead location of abnormal J waves and are thought to represent a continuous spectrum of phenotypic expression termed J-wave syndromes. Despite two decades of intensive research, risk stratification and the approach to therapy of these 2 inherited cardiac arrhythmia syndromes are still undergoing rapid evolution. Our objective in this review is to provide an integrated synopsis of the clinical characteristics, risk stratifiers, and molecular, ionic, …

Current Management Of Heart Failure: When To Refer To Heart Failure Specialist And When Hospice Is The Best Option., Behnam Bozorgnia, Paul J. Mather

Division of Cardiology Faculty Papers

Heart failure is a common syndrome caused by different abnormalities of the cardiovascular system that result in impairment of the ventricles in filling or ejecting blood. It is one of the most common causes of hospitalization in the United States, with a very high cost to the health care system. This article focuses on the causes of left ventricle dysfunction and the presentation and management of heart failure, both acute and chronic.

Significance Of Qrs Duration In Non-St Elevation Myocardial Infarction., Chinualumogu Nwakile, Bhaskar Purushottam, Vikas Bhalla, Daniel Ukpong, Mahek Shah, Jeong Yun, D Lynn Morris, Vincent M. Figueredo, M.D.

Division of Cardiology Faculty Papers

No abstract provided.

Practical Management Of Anticoagulation In Patients With Atrial Fibrillation., Richard J Kovacs, Greg C Flaker, Sherry J Saxonhouse, John U. Doherty, Kim K Birtcher, Adam Cuker, Bruce L Davidson, Robert P Giugliano, Christopher B Granger, Amir K Jaffer, Bella H Mehta, Edith Nutescu, Kim A Williams

Department of Medicine Faculty Papers

Anticoagulation for atrial fibrillation has become more complex due to the introduction of new anticoagulant agents, the number and kinds of patients requiring therapy, and the interactions of those patients in the matrix of care. The management of anticoagulation has become a "team sport" involving multiple specialties in multiple sites of care. The American College of Cardiology, through the College's Anticoagulation Initiative, convened a roundtable of experts from multiple specialties to discuss topics important to the management of patients requiring anticoagulation and to make expert recommendations on issues such as the initiation and interruption of anticoagulation, quality of anticoagulation care, …

Utility Of The Qt Interval In Predicting Outcomes In Patients Presenting To The Emergency Department With Chest Pain., Toni A De Venecia, Marvin Y Lu, Chinualumogu C Nwakile, Vincent M. Figueredo, M.D.

Division of Cardiology Faculty Papers

OBJECTIVES: The aim of this study was to investigate whether prolongation of the heart rate-corrected QT interval (QTc) is an independent risk factor for predicting future acute coronary syndrome (ACS) occurrence or mortality in patients with at least one cardiac risk factor presenting with chest pain to the emergency department (ED).

METHODS: This is a single-center, retrospective study of patients presenting with chest pain to the ED of Einstein Medical Center, Philadelphia, between 2011 and 2012. Proportional hazards models were used to calculate hazard ratios (HRs) for occurrence of ACS or death within 1 year. Kaplan-Meier curves were used to …

Low-Density Lipoprotein Cholesterol Lowering Therapies: What Is On The Horizon?, Ramprasad Gadi, Vincent M. Figueredo, M.D.

Division of Cardiology Faculty Papers

Elevated low-density lipoprotein cholesterol (LDL-C) levels are associated with an increased risk for cardiovascular disease (CVD). Statins have been the cornerstone of lipid therapy to lower LDL-C for the past two decades, but despite significant clinical efficacy in a majority of patients, a large residual risk remains for the development of initial or recurrent atherosclerotic CVD. In addition, owing to the side-effects, a significant percentage of patients cannot tolerate any statin dose or a high enough statin dose. Thus, novel therapeutic agents are currently being developed to lower LDL-C levels further. This review will highlight these novel therapeutic agents including …

Senile Cardiac Amyloidosis: An Undervalued Cause Of Heart Failure., Toni Anne Alvarez De Venecia, Scott Blumhof, Daniel Ukpong, Marvin Lu, Claudia Nieves, Vincent M. Figueredo, M.D.

Division of Cardiology Faculty Papers

Despite recurrent hospitalizations for heart failure exacerbations, the underlying cause can be missed. Senile amyloidosis is a disease prevalent in the elderly African American population. Senile amyloidosis is underdiagnosed as a cause of heart failure because of its occurrence with more common comorbidities, such as long-standing systemic hypertension. It is important to maintain a high index of suspicion for senile amyloidosis in patients such as this case, who presented with multiple exacerbations of heart failure combined with characteristic electrocardiographic and echocardiographic findings.

Dipstick Proteinuria Is An Independent Predictor Of High On Treatment Platelet Reactivity In Patients On Clopidogrel, But Not Aspirin, Admitted For Major Adverse Cardiovascular Events., Carlos D. Davila, Fernando Vargas, Kuan-Hsiang Gary Huang, Thomas Monaco, Anastasios Dimou, Janani Rangaswami, Vincent M. Figueredo, M.D.

Division of Cardiology Faculty Papers

Abstract The effectiveness of aspirin and clopidogrel in patients with chronic kidney disease (CKD) suffering from acute cardiovascular events is unclear. High on treatment platelet reactivity (HTPR) has been associated with worse outcomes. Here, we assessed the association of dipstick proteinuria (DP) and renal function on HTPR and clinical outcomes. Retrospective cohort analysis of 261 consecutive, non-dialysis patients admitted for Major Adverse Cardiovascular Events (MACE) that had VerifyNow P2Y12 and VerifyNow Aspirin assays performed. HTPR was defined as P2Y12 reactivity unit (PRU) > 208 for clopidogrel and aspirin reaction units (ARU) > 550 for aspirin. Renal function was classified based on the …

Clinical Vignette: A Case Of Successful Surgical Decortication For Empyema With Trapped Lung, In A Patient With Decompensated Cirrhosis, Tripti R. Chopade, Md, She-Yan Wong, Md, David A. Sass, Md, Scott W. Cowan, Md, Jesse M. Civan, Md

Division of Gastroenterology and Hepatology Faculty Papers

Introduction

Hepatic hydrothorax (HH) is a difficult-to-control complication of cirrhosis. Chest tube (CT) drainage is an option for management of HH, but is associated with a high rate of secondary infection and other complications.

Regular Dipyridamole Therapy Produces Sustained Protection Against Cardiac Ischemia-Reperfusion Injury: Is It Time To Revisit Paris?, Vincent M. Figueredo, M.D., Chika Okusa, Kazuhiro Kaneda, Yoshitaka Inamura, Masami Miyamae

Division of Cardiology Faculty Papers

BACKGROUND: Increased activated Akt and eNOS expression coincide with this persistent cardioprotection. Emergent coronary reperfusion therapies are rarely carried out before considerable myocardial injury has occurred. Moreover, reperfusion after prolonged ischemia produces paradoxical ischemia-reperfusion injury, attenuating the efficacy of reperfusion therapies. This has provided impetus for identifying chronic therapies to protect against ischemia-reperfusion injury in those at risk. We previously found that regular dipyridamole therapy produces a chronic preconditioning-like effect mediated through adenosine A1 receptors.

METHODS: To determine how long this chronic preconditioning effect of dipyridamole remains present after discontinuing therapy, guinea pigs received 4 mg/kg/day in their water for …

Rationale And Design Of The Guide-It Study: Guiding Evidence Based Therapy Using Biomarker Intensified Treatment In Heart Failure., G. Michael Felker, Tariq Ahmad, Kevin J. Anstrom, Kirkwood F. Adams, Lawton S. Cooper, Justin A. Ezekowitz, Mona Fiuzat, Nancy Houston-Miller, James L. Januzzi, Eric S. Leifer, Daniel B. Mark, Patrice Desvigne-Nickens, Gayle Paynter, Ileana L. Piña, David J. Whellan, Christopher M. O'Connor

Division of Cardiology Faculty Papers

OBJECTIVES: The GUIDE-IT (Guiding Evidence Based Therapy Using Biomarker Intensified Treatment in Heart Failure) study is designed to determine the safety, efficacy, and cost-effectiveness of a strategy of adjusting therapy with the goal of achieving and maintaining a target N-terminal pro-B-type natriuretic peptide (NT-proBNP) level of

BACKGROUND: Elevations in natriuretic peptide (NP) levels provide key prognostic information in patients with HF. Therapies proven to improve outcomes in patients with HF are generally associated with decreasing levels of NPs, and observational data show that decreases in NP levels over time are associated with favorable outcomes. Results from smaller prospective, randomized studies …

Seeing Is Believing: Optical Computed Tomography (Oct) And Histologic Analysis To Define Pathophysiology Of “Very”, Very Late Stent Thrombosis Occurring More Than 7 Years After Drug Eluting Stent Implantation, Antony G. Kaliyadan, Md, Alec Vishnevsky, Md, Henry Siu, Md, David Fishman, Md, John Farber, Md, Nicholas Ruggiero Ii, Md, Michael P. Savage, Md

Department of Pathology, Anatomy, and Cell Biology Faculty Papers

Case Presentation

• 58-year-old male with prior non-ST elevation MI with PCI performed using a sirolimus eluting stent placed in a large OM1 branch 86 months prior presented with five hours chest pain similar to prior MI >7 years earlier.
• Additional history of hypertension, hyperlipidemia, non-compliance with antiplatelet therapy and active tobacco abuse at time of presentation.
• Patient reported self-discontinuation of medications (aspirin (time unknown), statin, beta blocker) and resumed smoking.
• Clopidogrel was discontinued by his primary physician 97 days prior to presentation
• Initial electrocardiogram revealed a lateral ST elevation MI and the patient was taken to the cardiac catheterization lab …

Return To Work After Stroke: A Nursing State Of The Science., Catherine Harris, Phd, Mba, Crnp

College of Nursing Faculty Papers & Presentations

There is a lack of research related to return to work (RTW) after acute ischemic stroke. Historically considered a disease of the elderly, acute ischemic stroke studies have not routinely used return to work as an outcome. Major stroke trials have not routinely collected this data as an endpoint. However, the mean age for acute ischemic stroke (AIS) has declined to 69 years of age, while the incidence in patients under the age of 55 has increased to 19%^1-3. Changes in retirement age have also affected RTW as a consideration in stroke patients. Failure to RTW after recovery …

Evaluation Of Echogenic Material On Transvenous Leads By Transesophageal Echocardiography In Patients With And Without Lead-Associated Endocarditis, Toshimasa Okabe, Md, Praveen Mehrotra, Md, Henry Siu, Md, Arnold J. Greenspon, Md

Division of Cardiology Faculty Papers

Echogenic material (EM) on non-infected leads in patients with cardiac implantable device is common on transesophageal echocardiography (TEE). Although several morphologic characteristics of EM are more commonly seen in transvenous lead-associated endocarditis, these characteristics alone are not diagnostic for lead-associated endocardiatis. Lead-associated EM on TEE should be interpreted within the overall clinical context.

Ventricular Septal Rupture In The Cardiac Catheterization Laboratory, Loheetha Ragupathi, Md, Xin Zhang, Md, Gregary D. Marhefka, Md, Facp, Facc

Division of Cardiology Faculty Papers

Introduction

• Ventricular septal rupture is a rare but deadly complication of acute myocardial infarction (AMI)

• We describe a case that was recognized at time of occurrence in the cardiac catheterization lab

Underutilization Of Statins And Aspirin Following Coronary Artery Bypass Graft Surgery, Kevin M. Curl, Md, Bryan Lebude, Md, Nicholas Ruggiero, Md, D L Fischman, Md, Andrew Rose, Md, Sulay Patel, Md, J. David Ogilby, Md, Paul Walinsky, Md, Babu Jasti, Md, Michael P. Savage, Md

Division of Cardiology Faculty Papers

Introduction

Coronary artery bypass graft (CABG) surgery continues to be an important procedure for the treatment of coronary artery disease. However, clinically significant stenoses and complete bypass graft occlusion rates remain high, especially among saphenous vein grafts1. This is associated with significant morbidity and mortality. Both statin medications and aspirin have been shown in numerous clinical trials to play an important role in the medical management of coronary artery disease following CABG surgery. As per the ACC/AHA guidelines, both statin medications and aspirin have class I indications to support their use indefinitely following CABG, unless contraindication exists2. Long term studies …

Wandering Acute Myocardial Infarction., Kamal R. Joshi, D Lynn Morris, Vincent M. Figueredo, M.D.

Division of Cardiology Faculty Papers

Incorrect electrode placement or cable connection during electrocardiographic (ECG) recording can significantly alter the ECG morphology. We report a case of ST-segment elevation myocardial infarction causing a diagnostic dilemma due to cable interchange.

Patient Characteristics And Predictors Of Mortality Associated With Pericardial Decompression Syndrome, Rajesh Pradhan, Md, Toshimasa Okabe, Md, Kazuki Yoshida, Md, Dimitrios Angouras, Md, Matthew Decaro, Md, Gregary D. Marhefka, Md

Division of Cardiology Faculty Papers

Pericardial decompression syndrome is a rare complication of pericardiocentesis and surgical drainage of pericardial effusion with a high morality rate. The minimum amount of drained effusion in our serious was 450 ml. Surgical drainage was associated with a higher mortality rate.

Tachycardia Mediated Cardiomyopathy: Pathophysiology, Mechanisms, Clinical Features And Management., Shuchita Gupta, Vincent M. Figueredo, M.D.

Division of Cardiology Faculty Papers

Tachycardia mediated cardiomyopathy (TMC) is a reversible form of dilated cardiomyopathy that can occur with most supraventricular and ventricular arrhythmias. Despite the plethora of literature describing this entity in animal models, as well as humans, it remains poorly understood. Over the last decade, new etiologies of TMC, such as frequent premature ventricular complexes in normal hearts, have been identified. Recent advances in catheter-based ablation therapies, particularly for atrial fibrillation and ventricular arrhythmias, have added a new dimension to the treatment of this condition. This review describes the pathophysiology, proposed mechanisms, clinical features and management in various arrhythmic conditions.

Integrated Guidance On The Care Of Familial Hypercholesterolaemia From The International Fh Foundation., Gerald F Watts, Samuel Gidding, Anthony S Wierzbicki, Peter P Toth, Rodrigo Alonso, W Virgil Brown, Eric Bruckert, Joep Defesche, Khoo Kah Lin, Michael Livingston, Pedro Mata, Klaus G Parhofer, Frederick J Raal, Raul D Santos, Eric J G Sijbrands, William G Simpson, David R Sullivan, Andrey V Susekov, Brian Tomlinson, Albert Wiegman, Shizuya Yamashita, John J P Kastelein

Division of Cardiology Faculty Papers

Familial hypercholesterolaemia (FH) is a dominantly inherited disorder present from birth that markedly elevates plasma low-density lipoprotein (LDL) cholesterol and causes premature coronary heart disease. There are at least 20million people with FH worldwide, but the majority remain undetected and current treatment is often suboptimal. To address this major gap in coronary prevention we present, from an international perspective, consensus-based guidance on the care of FH. The guidance was generated from seminars and workshops held at an international symposium. The recommendations focus on the detection, diagnosis, assessment and management of FH in adults and children, and set guidelines for clinical …

Induction Of Autophagy Restores The Loss Of Sevoflurane Cardiac Preconditioning Seen With Prolonged Ischemic Insult., Mayumi Shiomi, Masami Miyamae, Genzou Takemura, Kazuhiro Kaneda, Yoshitaka Inamura, Anna Onishi, Shizuka Koshinuma, Yoshihiro Momota, Toshiaki Minami, Vincent M. Figueredo, M.D.

Division of Cardiology Faculty Papers

Sevoflurane preconditioning against myocardial ischemia-reperfusion injury is lost if the ischemic insult is too long. Emerging evidence suggests that induction of autophagy may also confer cardioprotection against ischemia-reperfusion injury. We examined whether induction of autophagy prolongs sevoflurane preconditioning protection during a longer ischemic insult. Isolated guinea pigs hearts were subjected to 30 or 45 min ischemia, followed by 120 min reperfusion (control). Anesthetic preconditioning was elicited with 2% sevoflurane for 10 min prior to ischemia (SEVO-30, SEVO-45). Chloramphenicol (autophagy upregulator, 300 µM) was administered starting 20 min before ischemia and throughout reperfusion in SEVO-45 (SEVO-45+CAP). To inhibit autophagy, 3-methyladenine (10 …

Update On Ranolazine In The Management Of Angina., J Nicolás Codolosa, Subroto Acharjee, Vincent M. Figueredo, M.D.

Division of Cardiology Faculty Papers

Mortality rates attributable to coronary heart disease have declined in recent years, possibly related to changes in clinical presentation patterns and use of proven secondary prevention strategies. Chronic stable angina (CSA) remains prevalent, and the goal of treatment is control of symptoms and reduction in cardiovascular events. Ranolazine is a selective inhibitor of the late sodium current in myocytes with anti-ischemic and metabolic properties. It was approved by the US Food and Drug Administration in 2006 for use in patients with CSA. Multiple, randomized, placebo-controlled trials have shown that ranolazine improves functional capacity and decreases anginal episodes in CSA patients, …

Novel Partial Anomalous Pulmonary Venous Connection Associated With Brain Abscess., Anish Koka, Md, Amit Sachdev, Md, Moussa F Yazbeck, Md, Rodney Bell, Md, Christopher Farrellc, Md

Department of Neurology Faculty Papers

BACKGROUND: Right-to-left vascular shunts are associated with brain abscess.

CASE REPORT: We present a 47-year-old female with a cryptogenic left thalamic abscess on which Streptococcus mitis grew upon aspiration. Computed tomography of the chest with contrast agent revealed an anomalous connection between the left superior pulmonary and brachiocephalic veins. A right-to-left shunt was confirmed in a transthoracic echocardiogram study in which bubbles were injected into the left arm; this shunt had not previously been noted upon right-arm injection.

CONCLUSIONS: We recommend aggressive evaluation for right-to-left shunts in patients who present with cryptogenic brain abscesses. In addition to imaging, this should …

Primary Stroke In A Woman With Sickle Cell Anemia Responsive To Hydroxyurea Therapy., Samir K. Ballas, Ubaldo E. Martinez-Outshoorn, Michael P. Savage

Cardeza Foundation for Hematologic Research

The most common cause of stroke in children with sickle cell anemia is infarction due to ischemia. In adults, however, stroke is most commonly hemorrhagic in nature. Other causes of stroke in patients with sickle cell disease are very rare. In this short communication, we describe a woman with sickle cell anemia responsive to hydroxyurea (HU) therapy who had primary stroke due to paradoxical embolization caused by a large atrial septal defect. Successful management of the stroke included surgical closure of the defect with trans-esophageal echocardiographic guidance. To the best of our knowledge, this is the first patient with sickle …

Achieving High-Value Cardiac Imaging: Challenges And Opportunities., David H Wiener

Division of Cardiology Faculty Papers

Cardiac imaging is under intense scrutiny as a contributor to health care costs, with multiple initiatives under way to reduce and eliminate inappropriate testing. Appropriate use criteria are valuable guides to selecting imaging studies but until recently have focused on the test rather than the patient. Patient-centered means are needed to define the true value of imaging for patients in specific clinical situations. This article provides a definition of high-value cardiac imaging. A paradigm to judge the efficacy of echocardiography in the absence of randomized controlled trials is presented. Candidate clinical scenarios are proposed in which echocardiography constitutes high-value imaging, …

Sevoflurane Induces Cardioprotection Through Reactive Oxygen Species-Mediated Upregulation Of Autophagy In Isolated Guinea Pig Hearts., Mayumi Shiomi, Masami Miyamae, Genzou Takemura, Kazuhiro Kaneda, Yoshitaka Inamura, Anna Onishi, Shizuka Koshinuma, Yoshihiro Momota, Toshiaki Minami, Vincent M. Figueredo

Division of Cardiology Faculty Papers

PURPOSE: Sevoflurane increases reactive oxygen species (ROS), which mediate cardioprotection against myocardial ischemia-reperfusion injury. Emerging evidence suggests that autophagy is involved in cardioprotection. We examined whether reactive oxygen species mediate sevoflurane preconditioning through autophagy.

METHODS: Isolated guinea pigs hearts were subjected to 30 min ischemia followed by 120 min reperfusion (control). Anesthetic preconditioning was elicited with 2 % sevoflurane for 10 min before ischemia (SEVO). The ROS-scavenger, N-(2-mercaptopropionyl) glycine (MPG, 1 mmol/l), was administered starting 30 min before ischemia to sevoflurane-treated (SEVO + MPG) or non-sevoflurane-treated (MPG) hearts. Infarct size was determined by triphenyltetrazolium chloride stain. Tissue samples were obtained …

Combination Of Necroptosis And Apoptosis Inhibition Enhances Cardioprotection Against Myocardial Ischemia-Reperfusion Injury., Shizuka Koshinuma, Masami Miyamae, Kazuhiro Kaneda, Junichiro Kotani, Vincent M. Figueredo

Division of Cardiology Faculty Papers

PURPOSE: Necroptosis has been proposed as a mode of cell death that is a caspase-independent programmed necrosis. We investigated whether necroptosis is involved in myocardial ischemia-reperfusion injury in isolated guinea pig hearts and, if so, whether simultaneous inhibition of necroptosis and apoptosis confers enhanced cardioprotection.

METHODS: Isolated perfused guinea pig hearts were subjected to 30 min ischemia and 4 h reperfusion (control = CTL, n = 8). Necrostatin-1 (necroptosis inhibitor, 10 μM), Z-VAD (apoptosis inhibitor, 0.1 μM) and both inhibitors were administered starting 5 min before ischemia and during the initial 30 min of reperfusion (Nec, Z-VAD, Nec + Z-VAD; …

Meditation: Should A Cardiologist Care?, Stephen Olex, Andrew B. Newberg, Md, Vincent M. Figueredo, M.D.

Division of Cardiology Faculty Papers

Meditation refers to a family of practices that may share many similarities, but can have differences in underlying methods and goals. Religious and spiritual associations are common but are not requisite for meditation practice and it should be recognized that the basis of many if not all practices is the training of the brain and body, a process that appears to have profound effects on both structure and function. In recent decades there has been interest regarding the effects of these ancient practices on the cardiovascular system, as meditation has intuitive appeal for benefit in this area. Though there is …

Sevoflurane Confers Additive Cardioprotection To Ethanol Preconditioning Associated With Enhanced Phosphorylation Of Glycogen Synthase Kinase-3Β And Inhibition Of Mitochondrial Permeability Transition Pore Opening., Anna Onishi, Masami Miyamae, Hiroshi Inoue, Kazuhiro Kaneda, Chika Okusa, Yoshitaka Inamura, Mayumi Shiomi, Shizuka Koshinuma, Yoshihiro Momota, Vincent M. Figueredo

Division of Cardiology Faculty Papers

OBJECTIVE: The purposes of this study were to investigate whether sevoflurane (SEVO) enhances moderate-dose ethanol (EtOH) preconditioning and whether this additional cardioprotection is associated with glycogen synthase kinase-3β (GSK-3β), protein kinase B (Akt), mammalian target of rapamycin (mTOR), 70-kDa ribosomal s6 kinase-1 (p70s6K), and/or mitochondrial permeability transition pore (MPTP) opening.

DESIGN: In vitro study using an isolated heart Langendorff preparation.

SETTING: University research laboratory.

PARTICIPANTS: Male guinea pigs (n = 170).

INTERVENTIONS: Isolated perfused guinea pig hearts underwent 30-minute ischemia and 120-minute reperfusion (control). The EtOH group received 5% EtOH in the drinking water for 8 weeks. Anesthetic preconditioning was …

Hdl-C: Does It Matter? An Update On Novel Hdl-Directed Pharmaco-Therapeutic Strategies., Ramprasad Gadi, Aman Amanullah, Vincent M. Figueredo

Division of Cardiology Faculty Papers

It has long been recognized that elevated levels of low-density lipoprotein cholesterol (LDL-C) increase the risk of cardiovascular disease (CHD) and that pharmacologic therapy to decrease LDL-C significantly reduces cardiovascular events. Despite the effectiveness of statins for CHD risk reduction, even optimal LDL-lowering therapy alone fails to avert 60% to 70% of CHD cases. A low plasma concentration of high-density lipoprotein cholesterol (HDL-C) is also associated with increased risk of CHD. However, the convincing epidemiologic data linking HDL cholesterol (HDL-C) to CHD risk in an inverse correlation has not yet translated into clinical trial evidence supporting linearity between HDL-C increases …