Cardiology

Roden-Foreman, J. W., N. R. Rapier, L. Yelverton and M. L. Foreman (2018). “Avoiding Cribari gridlock: the Standardized Triage Assessment Tool improves the accuracy of the Cribari Matrix Method in identifying potential over- and undertriage.” J Trauma Acute Care Surg. Jan 24. [Epub ahead of print].

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BACKGROUND: The Cribari matrix method (CMM) is the standard to identify potential over- and undertriage but requires case reviews to correct for the fact that Injury Severity Score does not account for physiology or comorbidities, nor is it well correlated with resource consumption. Further, the secondary reviews introduce undesirable subjectivity. This study assessed if the Standardized Triage Assessment Tool (STAT)-a combination of the CMM and the Need For Trauma Intervention-could more accurately determine over- and undertriage than the CMM alone. METHODS: The registry of an ACS verified Level I adult trauma center in Texas was queried for all new ED traumas 2013-2016 (n = 11,110). Binary logistic regressions were used to test the associations between the triage determinations of each metric against indicators of injury severity (risk factors, complications, and mortality) and resource consumption (number of procedures in three days and total length of stay). RESULTS: Both metrics were associated with the indicators of injury severity and resource consumption in the expected directions, but STAT had stronger or equivalent associations with all variables tested. Using the CMM, there was 50.4% overtriage and 9.1% undertriage. Using STAT, overtriage was reduced to 30.8% (relative reduction = 38.9%) and undertriage was reduced to 3.3% (relative reduction = 63.7%). CONCLUSIONS: Using the CMM with secondary case reviews makes valid multi-institutional triage rate comparisons impossible because of the subjective and unstandardized nature of these reviews. STAT’s out-of-box triage determinations (i.e., without manual case review) outperformed CMM in almost every tested variable for both over- and undertriage. STAT, an automatic, standardized method offers significant improvements compared to the current subjective system. Further, by accounting for both anatomic injury severity and resource consumption, STAT may allow trauma centers to better allocate resources and predict patient needs with fewer cases requiring manual review. LEVEL OF EVIDENCE: diagnostic criteria, level II.

Packer, M. (2018). “Do Sodium-Glucose Cotransporter-2 Inhibitors Prevent Heart Failure With a Preserved Ejection Fraction by Counterbalancing the Effects of Leptin? A Novel Hypothesis.” Diabetes Obes Metab. Jan 23. [Epub ahead of print].

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Sodium-glucose transporter-2 (SGLT2) inhibitors reduce the risk of serious heart failure events in patients with type 2 diabetes, but little is known about mechanisms that might mediate this benefit. The most common heart failure phenotype in type 2 diabetes is obesity-related heart failure with a preserved ejection fraction (HFpEF). It has been hypothesized that the synthesis of leptin in this disorder leads to sodium retention and plasma volume expansion as well as to cardiac and renal inflammation and fibrosis. Interestingly, leptin-mediated neurohormonal activation appears to enhance the expression of SGLT2 in the renal tubules, and SGLT2 inhibitors exert natriuretic actions at multiple renal tubular sites in a manner that can oppose the sodium retention produced by leptin. In addition, SGLT2 inhibitors reduce the accumulation and inflammation of perivisceral adipose tissue, thus minimizing the secretion of leptin and its paracrine actions on the heart and kidneys to promote fibrosis. Such fibrosis likely contributes to the impairment of cardiac distensibility and glomerular function that characterizes obesity-related HFpEF. Ongoing clinical trials with SGLT2 inhibitors in heart failure are positioned to confirm or refute the hypothesis that these drugs may favorably influence the course of obesity-related HFpEF by their ability to attenuate the secretion and actions of leptin.

Ko, J. M., K. M. Tecson, V. A. Rashida, S. Sodhi, J. Saef, M. Mufti, K. S. White, P. A. Ludbrook and A. M. Cedars (2018). “Clinical and Psychological Drivers of Perceived Health Status in Adults With Congenital Heart Disease.” Am J Cardiol 121(3): 377-381.

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The factors having the greatest impact on self-reported health status in adults with congenital heart disease (ACHD) remain incompletely studied. We conducted a single-site, cross-sectional study of ACHD patients followed at the Center for ACHD at Washington University School of Medicine, including retrospectively gathered clinical data and psychometric and health status assessments completed at the time of enrollment. To identify primary drivers of perceived health status, we investigated the impact of the demographic, clinical, and psychological variables on self-reported health status as assessed using the Rand 36-Item Short Form Health Survey. Variables with significant associations within each domain were considered jointly in multivariable models constructed via stepwise selection. There was domain-specific heterogeneity in the variables having the greatest effect on self-reported health status. Depression was responsible for the greatest amount of variability in health status in all domains except physical functioning. In the physical functioning domain, depression remained responsible for 5% of total variability, the third most significant variable in the model. In every domain, depression more strongly influenced health status than did any cardiac-specific variable. In conclusion, depression was responsible for a significant amount of heterogeneity in all domains of self-perceived health status. Psychological variables were better predictors of health status than clinical variables.

Gupta, N., V. Konda and U. D. Siddiqui (2018). “Gastric cardia lesion with abnormal volumetric laser endomicroscopy imaging result.” Gastrointest Endosc Feb; 87(2): 610-612.

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A 71-year-old man with a history of epigastric pain and dyspepsia had previously been found to have Barrett’s esophagus (BE) with low-grade dysplasia. He presented to our institution for repeated EGD to thoroughly assess the Barrett’s segment. EGD showed short-segment BE with a 2-cm area of nodular, polypoid-appearing mucosa on the gastric cardia side of the gastroesophageal junction (A). The area was examined by high-definition white-light endoscopy (WLE) and narrow-band imaging (NBI) with near focus (A). Volumetric laser endomicroscopy (VLE) was also used (NVisionVLE, NinePoint Medical, Cambridge, Mass) and showed suggestive features including irregular surface (blue arrow) and atypical glands (red circle) in the area corresponding to the nodular mucosa (B). Further assessment with EUS did not reveal any obvious lesions. The lesion seen on WLE and NBI was nonspecific; however, the suggestive VLE features raised concern about malignancy, so EMR was performed of the polypoid mucosa and associated abnormal VLE area. Four hemostatic clips were placed at the site of resection because of bleeding (C). Dysplasia suspected on the basis of VLE was confirmed by a final pathologic examination, which showed cellular atypia consistent with high-grade dysplasia/intramucosal carcinoma arising from BE (D) and clear resection margins. A 3-month surveillance EGD found a small nodular area of gastric foveolar hyperplasia but no dysplasia. [Excerpt from text of this image study.]

Filardo, G., R. J. Damiano, Jr., G. Ailawadi, V. H. Thourani, B. D. Pollock, D. M. Sass, T. K. Phan, H. Nguyen and B. da Graca (2018). “Epidemiology of new-onset atrial fibrillation following coronary artery bypass graft surgery.” Heart. Jan 11. [Epub ahead of print].

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OBJECTIVES: Postoperative atrial fibrillation (AF) following coronary artery bypass graft surgery (CABG) is significantly associated with reduced survival, but poor characterisation and inconsistent definitions present barriers to developing effective prophylaxis and management. We sought to address this knowledge gap. METHODS: From 2002 to 2010, 11 239 consecutive patients without AF underwent isolated CABG at five sites. Clinical data collected for the Society of Thoracic Surgeons (STS) Database were augmented with details on AF detected via continuous in-hospital ECG/telemetry monitoring to assess new-onset post-CABG AF (adjusted for STS risk of mortality); time to first AF; durations of first and longest AF episodes; total in-hospital time in AF; number of in-hospital AF episodes; operative mortality; stroke; discharge in AF; and length of stay (LOS). RESULTS: Unadjusted incidence of new-onset post-CABG AF was 29.5%. Risk-adjusted incidence was 33.1% and varied little over time (P=0.139). Among 3312 patients with post-CABG AF, adjusted median time to first AF was 52 (IQR: 48-55) hours; mean (SD) duration of first and longest events were 7.2 (5.3,9.1) and 13.1 (10.4,15.9) hours, respectively, and adjusted median total time in AF was 22 (IQR: 18-26) hours. Adjusted rates of operative mortality, stroke and discharge in AF did not vary significantly over time (P=0.156, P=0.965 and P=0.347, respectively). LOS varied (P=0.035), but in no discernible pattern. CONCLUSIONS: Each year, ~800 000 people undergo CABG worldwide; >264 000 will develop post-CABG AF. Onset is typically 2-3 days post-CABG and episodes last, on average, several hours. Effective prophylaxis and management is urgently needed to reduce associated risks of adverse outcomes.