Cardiology

Howard, C. E. and P. A. McCullough (2017). “Decoding acute myocardial infarction among patients on dialysis.” J Am Soc Nephrol 28(5): 1337-1339.

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In this issue of the Journal of the American Society of Nephrology, Shroff et al. utilized hospital billing records from patients on HD in the United States.3 In brief, professional coding specialists determine the principal diagnosis as that condition, established after study, which resulted in the patient’s admission to the hospital. Secondary diagnoses include comorbidities, complications, and other diagnoses that are documented by the attending physician on the inpatient face sheet, discharge summary, history and physical, consultation reports, operative reports, and other ancillary reports. Age, sex, discharge destination, principal diagnosis, up to 24 secondary diagnoses, and up to 25 procedure codes are entered into a computerized algorithm to generate the Medicare diagnosis-related group that determines payment to the hospital.4 The authors demonstrated that although the overall AMI claims in patients on dialysis have increased, the proportion of those in the principal position decreased, whereas those in the secondary position increased.3 In particular, the overall and proportional increase of NSTEMI claims increased dramatically in both the principal and secondary coding positions. These data are consistent with the general population, where several studies have shown a sharp decline in ST-segment elevation myocardial infarction (STEMI) and a lesser decline or increase in NSTEMI.5,6 Interestingly, other data sources suggest that unstable angina is ever less frequent because more sensitive troponin assays clinch a diagnosis of NSTEMI over unstable angina in about 98% of cases.7

Mack, M. (2017). “The transatlantic relationship: Hands across the ocean from borst to mohr.” Thorac Cardiovasc Surg 65(S 03): S164-s166.

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The metaphor of “hands across the ocean” was first embraced by Hans Borst in 1985 to define the close, collaborative relationship between German and American thoracic surgeons ([Fig. 1]).[1] In the postwar era, numerous American surgeons helped put German thoracic surgery back on its feet. This led to a bidirectional transatlantic alliance in which patients in both countries benefited from the cross-fertilization and coeducation among surgeons. Prof. Friedrich Mohr crossed the ocean in the late 1980s to build a lifelong collaboration with, among others, Jack Matloff and Frank Litvak at the Cedars-Sinai Medical Center in Los Angeles, United States.

Rosenthal, R. L. (2017). “Electronic stethoscope for coronary stenosis detection.” Am J Med 130(5): e225.

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I read with interest the report by Azimpour et al1 on the ability of an electronic stethoscope to detect turbulent diastolic flow in coronary arteries associated with coronary stenosis by the use of a signal processing algorithm. Instead of the “gold standard” of percentage coronary stenosis they adopt as the reference standard, it would be more physiologically pertinent to explore the relationship to fractional flow reserve or some other similar measure of trans-stenotic flow gradient, such as the instantaneous wave-free ratio.

Sorokin, I., S. L. Stevens and J. A. Cadeddu (2017). “Periarterial papaverine to treat renal artery vasospasm during robot-assisted laparoscopic partial nephrectomy.” J Robot Surg: Apr [Epub ahead of print].

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Renal artery vasospasm can be a troublesome complication during robot-assisted laparoscopic partial nephrectomy. Urologists performing this procedure, especially if utilizing selective arterial vascular microdissection, should be aware of using papaverine for both prevention and treatment of renal artery vasospasm. We present a 33-year-old male who developed severe renal artery vasospasm just with hilar dissection causing the kidney to become ischemic. Papaverine was topically applied on the renal arteries resulting in vasodilation and reperfusion of the kidney. Our objective of this report is to raise awareness of this complication as well as to review the literature on periarterial papaverine use and the dosing for topical applications.

Packer, M. (2017). “Response by packer to letter regarding article, “development and evolution of a hierarchical clinical composite end point for the evaluation of drugs and devices for acute and chronic heart failure: A 20-year perspective”.” Circulation 135(15): e892-e893.

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The hierarchical clinical composite end point (HCCE) was developed to address 2 important goals in the analysis of clinical trial data: (1) to minimize the bias inherent in the censoring of important adverse events when the primary end point was focused entirely on a patient benefit, and (2) to expand the range of responses when the primary end point was focused entirely on the risk of an adverse event. Over the past 20 years, the hierarchical clinical composite has succeeded with respect to both goals, and yet, as I described in my article,1 the HCCE still has important limitations and remains a work in progress.