Peter A. McCullough M.D.

Rosol, Z. P., K. F. Kopecky, B. R. Minehart, K. M. Tecson, A. Vasudevan, P. A. McCullough, P. A. Grayburn and J. M. Schussler (2020). “Limitations of transoesophageal echocardiogram in acute ischaemic stroke.” Open Heart 7(1): e001176.

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Objective: The role of transoesophageal echocardiography (TOE) in identifying ischaemic stroke aetiology is debated. In 2018, the American Heart Association/American Stroke Association (AHA/ASA) issued class IIa recommendation for echocardiography, with the qualifying statement of use in cases where it will alter management. Hence, we sought to determine the rate at which TOE findings altered management in cases of confirmed ischaemic stroke. Methods: We retrospectively analysed TOE cases with confirmed ischaemic stroke at our centre between April 2015 and February 2017. We defined a change in management as the initiation of anticoagulation therapy, antibiotic therapy or patent foramen ovale closure as a direct result of TOE findings. Results: There were 185 patients included in this analysis; 19 (10%) experienced a change in management. However, only 7 of the 19 (4% of all subjects) experienced a change in management due to TOE findings. The remaining 12 were initiated on oral antigoagulation as a result of discoveries during routine workup, mainly atrial fibrillation on telemetry monitoring. Conclusions: This work suggests an overuse of TOE and provides support for the 2018 AHA/ASA stroke guidelines, which recommend against the routine use of echocardiography in the work up of cerebrovascular accident due to a cardioembolic source.

Weir, M. R., P. A. McCullough, J. B. Buse and J. Anderson (2020). “Renal and Cardiovascular Effects of Sodium Glucose Co-Transporter 2 Inhibitors in Patients with Type 2 Diabetes and Chronic Kidney Disease: Perspectives on the Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation Trial Results.” Am J Nephrol Mar 13:1-13. [Epub ahead of print].

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BACKGROUND: Chronic kidney disease (CKD) risk is elevated in patients with type 2 diabetes mellitus (T2DM). Disease management in these patients has been generally focused on glycemic control and controlling other renal and cardiac risk factors as, historically, few protective therapies have been available. The Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation -(CREDENCE) trial of canagliflozin was the first study to demonstrate renal protection with a sodium glucose co-transporter 2 inhibitor in patients with T2DM and CKD, and these results could have important implications for clinical practice. SUMMARY: In CREDENCE, participants with T2DM and estimated glomerular filtration rate 30-<90 mL/min/1.73 m2 and urinary albumin-creatinine ratio >300-5,000 mg/g who were treated with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for >/=4 weeks prior to randomization at either the maximum labeled or tolerated dose were randomized to receive either canagliflozin 100 mg or placebo. Canagliflozin significantly reduced the risk of the primary composite outcome of doubling of serum creatinine, end-stage kidney disease, or renal or cardiovascular (CV) death compared with placebo (hazard ratio 0.70, 95% CI 0.59-0.82; p = 0.00001). Canagliflozin also reduced the risk of secondary renal and CV outcomes. The safety profile of canagliflozin in CREDENCE was generally similar to previous studies of canagliflozin. No imbalances were observed between canagliflozin and placebo in the risk of amputation or fracture in the CREDENCE population. Key Messages: The positive renal and CV effects of canagliflozin observed in the -CREDENCE trial could have a substantial impact on improving outcomes for patients with T2DM and CKD.

Ronco, F., G. Tarantini and P. A. McCullough (2020). “Contrast induced acute kidney injury in interventional cardiology: an update and key guidance for clinicians.” Rev Cardiovasc Med 21(1): 9-23.

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Contrast-induced acute kidney injury (CI-AKI) is a serious complication that can affect outcome and prognosis of patients undergoing percutaneous diagnostic and interventional procedures in catheterization laboratories. There have been advancements in case definition and epidemiology. Additionally strategies have emerged that are positioned to have impact in the catheterization laboratory for patients undergoing cardiovascular procedures. The aim of this review is to provide the state-of-the-art of diagnosis, prevention and management of CI-AKI in interventional cardiology.

McCullough, P. A., J. Eidt, J. Rangaswami, E. Lerma, J. Tumlin, K. Wheelan, N. Katz, N. E. Lepor, K. Vijay, S. Soman, B. Singh, S. P. McCullough, H. B. McCullough, A. Palazzuoli, G. M. Ruocco and C. Ronco (2020). “Urgent need for individual mobile phone and institutional reporting of at home, hospitalized, and intensive care unit cases of SARS-CoV-2 (COVID-19) infection.” Rev Cardiovasc Med 21(1): 1-7.

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Approximately 90 days of the SARS-CoV-2 (COVID-19) spreading originally from Wuhan, China, and across the globe has led to a widespread chain of events with imminent threats to the fragile relationship between community health and economic health. Despite near hourly reporting on this crisis, there has been no regular, updated, or accurate reporting of hospitalizations for COVID-19. It is known that many test-positive individuals may not develop symptoms or have a mild self-limited viral syndrome consisting of fever, malaise, dry cough, and constitutional symptoms. However some individuals develop a more fulminant syndrome including viral pneumonia, respiratory failure requiring oxygen, acute respiratory distress syndrome requiring mechanical ventilation, and in substantial fractions leading to death attributable to COVID-19. The pandemic is evolving in a clustered, non-inform fashion resulting in many hospitals with preparedness but few or no cases, and others that are completely overwhelmed. Thus, a considerable risk of spread when personal protection equipment becomes exhausted and a large fraction of mortality in those not offered mechanical ventilation are both attributable to a crisis due to maldistribution of resources. The pandemic is amenable to self-reporting through a mobile phone application that could obtain critical information on suspected cases and report on the results of self testing and actions taken. The only method to understand the clustering and the immediate hospital resource needs is mandatory, uniform, daily reporting of hospital censuses of COVID-19 cases admitted to hospital wards and intensive care units. Current reports of hospitalizations are delayed, uncertain, and wholly inadequate. This paper urges all the relevant stakeholders to take up self-reporting and reporting of hospitalizations of COVID-19 as an urgent task in combating this devastating pandemic.

Lo, K. B., P. A. McCullough and J. Rangaswami (2020). “Antihypertensive drugs and risk of COVID-19?” Lancet Respir Med(Mar 26. pii: S2213-2600(20)30156-9. [Epub ahead of print]).

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We caution against indiscriminate discontinuation of ACEIs and ARBs in patients who rely on these drugs for treatment of heart failure and who, additionally, might benefit from the postulated positive effects during overwhelming infection with SARS-CoV-2. Discontinuation of ACEIs or ARBs is associated with readmission to hospital and mortality among patients with heart failure.8 A surge of admissions to hospital for heart failure because of indiscriminate cessation of these important agents could overload already burdened health-care systems with vulnerable patients and cause diagnostic problems in view of the range of symptoms shared between acute heart failure and COVID-19, such as cough and shortness of breath. (Excerpt from text, no abstract available.)