1
|
Zhong WW, Blue M, Michaels AD. Acute Isolated Right Ventricular Infarction: Unusual Presentation of Anterior ST-Segment-Elevation Myocardial Infarction. Tex Heart Inst J 2019; 46:151-154. [PMID: 31236085 DOI: 10.14503/thij-17-6581] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
. Emergency coronary angiograms revealed that acute thrombotic occlusion of the right ventricular marginal branch of the dominant right coronary artery caused the clinical manifestations in the first patient, whereas occlusion of the proximal nondominant right coronary artery was the culprit lesion in the second patient. Both lesions caused right ventricular myocardial infarction. The patients underwent successful primary percutaneous coronary intervention. These cases illustrate the importance of carefully reviewing angiographic findings to accurately diagnose an acute isolated right ventricular myocardial infarction, which may mimic the electrocardiographic features of an anterior-wall myocardial infarction.
Collapse
|
2
|
Senthilkumaran S, Meenakshisundaram R, Michaels AD, Thirumalaikolundusubramanian P. Isolated thigh pain in myocardial infarction. Am J Emerg Med 2013; 31:998.e1-2. [PMID: 23481159 DOI: 10.1016/j.ajem.2013.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 02/02/2013] [Indexed: 11/30/2022] Open
Abstract
The referred pain of angina to upper half of the body is well known. However, isolated pain in the thigh as a presenting symptom in myocardial infarction is neither considered nor discussed at all. Here, we report a middle-aged man without demonstrable risk factors who presented to the emergency department for isolated bilateral anteromedial thigh pain. He was diagnosed with acute inferior wall myocardial infarction. After thrombolysis, the thigh pain improved. The probable mechanism for this is attributable to radiation of pain via sensory cardiac fibers that is present in the lumbar sympathetic ganglia, which resulted in pain.
Collapse
Affiliation(s)
- Subramanian Senthilkumaran
- Department of Emergency & Critical Care Medicine, Sri Gokulam Hospitals and Research Institute, Salem-636004, Tamil Nadu, India.
| | | | | | | |
Collapse
|
3
|
Chan W, Woldeyohannes M, Colman R, Arand P, Michaels AD, Parker JD, Granton JT, Mak S. Haemodynamic and structural correlates of the first and second heart sounds in pulmonary arterial hypertension: an acoustic cardiography cohort study. BMJ Open 2013; 3:bmjopen-2013-002660. [PMID: 23572199 PMCID: PMC3641463 DOI: 10.1136/bmjopen-2013-002660] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE To examine the relationship between acoustic characteristics of the first and second heart sounds (S1 and S2) and underlying cardiac structure and haemodynamics in patients with isolated pulmonary arterial hypertension (PAH) and controls. DESIGN Prospective multicentre cohort study. SETTING Tertiary referral and community hospitals. PARTICIPANTS We prospectively evaluated 40 PAH patients undergoing right-heart catheterisation with contemporaneous digital acoustic cardiography (intensity and complexity) and two-dimensional transthoracic echocardiography. To normalise for differences in body habitus, acoustic variables were also expressed as a ratio (S2/S1). 130 participants (55 also had haemodynamic and/or echocardiographic assessment) without clinical or haemodynamic evidence of PAH or congestive heart failure acted as controls. RESULTS Patients with PAH had higher mean pulmonary artery pressure (mPA; 40±13 vs 16±4 mm Hg, p<0.0001) and pulmonary vascular resistance (9±6 vs 1±1 Wood Units, p<0.0001) compared with controls, but cardiac index and mean pulmonary capillary wedge pressure were similar. More PAH patients had evidence of right ventricular (RV) dilation (50% vs 19%) and RV systolic dysfunction (41% vs 9%) in the moderate-severe range (all p<0.05). Compared with controls, the acoustic profiles of PAH patients were characterised by increased S2 complexity, S2/S1 complexity and S2/S1 intensity (all p<0.05). In the PAH cohort, S2 complexity was inversely related to S1 complexity. mPA was the only independent multivariate predictor of S2 complexity. The severity of RV enlargement and systolic impairment had reciprocal effects on the complexity of S2 (increased) and S1 (decreased). Decreased S1 complexity was also related to evidence of a small left ventricular cavity. CONCLUSIONS Acoustic characteristics of both S1 and S2 are related to the severity of PAH and are associated with RV enlargement and systolic dysfunction. The reciprocal relationship between S2 and S1 complexity may also reflect the underlying ventricular interaction associated with PAH.
Collapse
Affiliation(s)
- William Chan
- Division of Cardiology, Mount Sinai Hospital, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Maryam Woldeyohannes
- Division of Cardiology, Mount Sinai Hospital, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Rebecca Colman
- University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Patti Arand
- Inovise Medical, Inc., Beaverton, Oregon, USA
| | - Andrew D Michaels
- Division of Cardiology, St. Joseph Hospital, Eureka, California, USA
| | - John D Parker
- Division of Cardiology, Mount Sinai Hospital, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - John T Granton
- University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Susanna Mak
- Division of Cardiology, Mount Sinai Hospital, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
4
|
Senthilkumaran S, Meenakshisundaram R, Michaels AD, Suresh P, Thirumalaikolundusubramanian P. Cardiovascular Complications in Ciguatera Fish Poisoning: A Wake-up Call. Heart Views 2012; 12:166-8. [PMID: 22574244 PMCID: PMC3345153 DOI: 10.4103/1995-705x.90905] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Ciguatera fish poisoning occurs with ingestion of fish containing ciguatoxin. It causes a clinical syndrome that comprises classic gastrointestinal, neurological and cardiovascular symptoms. Ciguatoxin is a sodium channel agonist with cholinergic and adrenergic activity. Although cardiovascular symptoms are rare with ciguatoxin, we report two cases with bradycardia and hypotension. Fatality and long-term sequelae are not uncommon with ciguatoxin poisoning and educating the general population is essential.
Collapse
Affiliation(s)
- Subramanian Senthilkumaran
- Department of Accident, Emergency and Critical Care Medicine, Sri Gokulam Hospitals and Research Institute, Salem, Tamil Nadu, India
| | | | | | | | | |
Collapse
|
5
|
Senthilkumaran S, Meenakshisundaram R, Michaels AD, Suresh P, Thirumalaikolundusubramanian P. Acute ST-segment elevation myocardial infarction from a centipede bite. J Cardiovasc Dis Res 2012; 2:244-6. [PMID: 22135485 PMCID: PMC3224447 DOI: 10.4103/0975-3583.89811] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Acute myocardial infarction (AMI) following a centipede bite has been very rarely reported. Here, we describe a 22 year-old man who had ST-segment elevation AMI after a centipede bite. He presented with typical chest pain, electro and echocardiographic abnormalities, and elevated cardiac enzymes with normal coronary angiography. The probable mechanisms were described. Practitioners treating centipede bites shall not consider it lightly, as centipede envenomation may produce a variety of systemic and local manifestations in susceptible individuals.
Collapse
|
6
|
Meenakshisundaram R, Devidutta S, Michaels AD, Senthilkumaran S, Rajendiran C, Thirumalaikolundusubramanian P. Significance of the intima-media thickness of carotid and thoracic aorta in coronary artery disease in the South Indian population. Heart Views 2012; 12:150-6. [PMID: 22574240 PMCID: PMC3345149 DOI: 10.4103/1995-705x.90901] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: Ultrasound detected intima-media thickness (IMT) of the carotid artery and thoracic aorta are possible screening tests to assess the risk of coronary artery disease (CAD) in asymptomatic individuals. Objective: Aim of the study was to assess the utility of carotid and aortic IMT as a predictor of CAD and to assess the extent of IMT with severity of CAD in a South Indian population. Patients and Methods: A cross-sectional and analytical study was carried out among 40 cases, who had angiographic evidence of CAD against 30 healthy control subjects with a normal treadmill test. At plaque-free regions, the carotid IMT was evaluated by B-mode ultrasonography and thoracic aorta IMT was evaluated by trans-esophageal echocardiography (TEE). The significance of difference in means between two groups was analyzed using one-way ANOVA F-test and the significance of difference in proportions by Chi-square test. Multiple comparisons were done by Bonferroni t test. The correlation between IMT and severity of CAD was assessed by Spearman's method. Results: There were 38 males and 2 females among cases with age 51.7 ± 8.3 years, and 28 males and 2 females among control subjects with age 52.2 ± 7.1 years. Increased carotid IMT was noted among 24 cases and 2 control subjects, and the association was significant for CAD [P < 0.001, Chi-square = 20.89, odds ratio (OR) = 21.00, and 95% confidence interval (CI) = 4.78-89.59]. Similarly, 19 cases and one control subject had abnormal IMT with positive correlation for CAD (P < 0.001, Chi-square = 16.39, OR = 28.24, and 95% CI = 4.06-163.21). There was no association between IMT and diabetes, hypertension, or smoking; however, IMT was significantly associated with age and dyslipidemia. Also, there was no correlation between extent of IMT and severity of CAD. Conclusions: IMT of the carotid and thoracic aorta is strongly associated with risk of CAD in a South Indian population, and may be used as a non-invasive screening tool for coronary atherosclerosis in resource-limited settings. The presence of dyslipidemia influenced IMT and may be used as a tool to follow patients on hypolipidemic drugs.
Collapse
|
7
|
Owan TE, Roe MT, Messenger JC, Dai D, Michaels AD. Contemporary use of adjunctive thrombectomy during primary percutaneous coronary intervention for ST-elevation myocardial infarction in the united states. Catheter Cardiovasc Interv 2012; 80:1173-80. [DOI: 10.1002/ccd.24306] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Revised: 10/25/2011] [Accepted: 12/18/2011] [Indexed: 11/06/2022]
|
8
|
Wang MX, Wu GF, Gu JL, Li L, Lu K, Yang D, Chen L, Zhang X, Luo FT, Michaels AD, Ma H. Defective T wave combined with incomplete right bundle branch block: a new electrocardiographic index for diagnosing atrial septal defect. Chin Med J (Engl) 2012; 125:1057-1062. [PMID: 22613531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Incomplete right bundle branch block (ICRBBB) is commonly associated with atrial septal defect (ASD), but lacks sufficient diagnostic test characteristics. An abnormal T wave is also often observed in ASD, with horizontal or inverted displacement of the proximal T wave limb in the right precordial leads, termed "defective T wave" (DTW). METHODS We examined the diagnostic test characteristics of combining ICRBBB with DTW as a new index to diagnose ASD. A total of 132 consecutive patients with ASD and 132 cases of age/gender-matched controls without ASD were enrolled. RESULTS Sensitivities of DTW, ICRBBB, and both were 87.1% - 87.9%. Specificities were 97.0%, 96.2%, and 100%, respectively. Positive predictive values were 1.3%, 1.1%, and 100.0% respectively, while negative predictive values were 99.9% for each. CONCLUSION Combining ICRBBB with DTW in electrocardiogram (ECG) as a new index significantly increased the specificity and positive predictive values while maintaining a high sensitivity in diagnosing ASD.
Collapse
Affiliation(s)
- Mu-xuan Wang
- Department of Cardiovascular Disease, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Senthilkumaran S, Meenakshisundaram R, Michaels AD, Balamurgan N, Thirumalaikolundusubramanian P. Ventricular fibrillation after exposure to air freshener—death just a breath away. J Electrocardiol 2012; 45:164-6. [DOI: 10.1016/j.jelectrocard.2011.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2011] [Indexed: 11/28/2022]
|
10
|
Senthilkumaran S, Meenakshisundaram R, Michaels AD, Thirumalaikolundusubramanian P. Electrocardiographic changes in spontaneous pneumothorax. Int J Cardiol 2011; 153:78-80. [PMID: 21911271 DOI: 10.1016/j.ijcard.2011.08.057] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Revised: 08/14/2011] [Accepted: 08/17/2011] [Indexed: 10/17/2022]
|
11
|
Abstract
BACKGROUND Clinical assessment of diastolic heart sounds is challenging. HYPOTHESIS We sought to examine whether visual inspection of acoustic cardiographic tracings augments the accuracy of medical students' and physicians' detection of third and fourth heart sounds (S(3), S(4)) compared to auscultation alone. METHODS A total of 90 adults referred for left heart catheterization underwent digital precordial heart sound recordings by computerized acoustic cardiography. Two blinded, experienced readers using a consensus method determined the presence of the S(3)/S(4) on each file. There were 35 subjects from the following 5 groups participating in this study from 1 teaching institution: first-year medical students (n = 5), fourth-year medical students (n = 5), interns (n = 5), medicine residents (n = 5), cardiology fellows (n = 5), and attendings (n = 10). Using a computer module, each subject listened to the heart sounds alone and documented whether an S(3)/S(4) was present. Next, subjects listened to each recording in random order while viewing phonocardiographic tracings, and recorded S(3)/S(4) presence. RESULTS An S(3) was present in 21 patients (23%) and an S(4) in 31 patients (34%) by consensus overread in 90 recordings. Baseline accuracy for auscultation of S(3)/S(4) did not change with level of experience. While viewing the acoustic cardiogram, first-year medical students had minimal improvement in S(3) (2%) and S(4) (11%) accuracy. More experienced subjects improved S(3) accuracy by 8% to 18% and S(4) by 15% to 32% (P < .05). Accuracy was superior for S(3) compared to S(4) in all ausculatory groups. CONCLUSIONS While listening to heart sound recordings, viewing acoustic cardiography increased subjects' accuracy in detecting diastolic heart sounds, particularly among more experienced subjects. There was greater improvement for S(4) compared to S(3) detection.
Collapse
Affiliation(s)
- Andrew D Michaels
- Division of Cardiology, Department of Medicine, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132-2401, USA.
| | | | | |
Collapse
|
12
|
Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, Jenkins JS, Kline JA, Michaels AD, Thistlethwaite P, Vedantham S, White RJ, Zierler BK. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 2011; 123:1788-830. [PMID: 21422387 DOI: 10.1161/cir.0b013e318214914f] [Citation(s) in RCA: 1447] [Impact Index Per Article: 111.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Venous thromboembolism (VTE) is responsible for the hospitalization of >250 000 Americans annually and represents a significant risk for morbidity and mortality. Despite the publication of evidence-based clinical practice guidelines to aid in the management of VTE in its acute and chronic forms, the clinician is frequently confronted with manifestations of VTE for which data are sparse and optimal management is unclear. In particular, the optimal use of advanced therapies for acute VTE, including thrombolysis and catheter-based therapies, remains uncertain. This report addresses the management of massive and submassive pulmonary embolism (PE), iliofemoral deep vein thrombosis (IFDVT),and chronic thromboembolic pulmonary hypertension (CTEPH). The goal is to provide practical advice to enable the busy clinician to optimize the management of patients with these severe manifestations of VTE. Although this document makes recommendations for management, optimal medical decisions must incorporate other factors, including patient wishes, quality of life, and life expectancy based on age and comorbidities. The appropriateness of these recommendations for a specific patient may vary depending on these factors and will be best judged by the bedside clinician.
Collapse
|
13
|
Michaels AD, Mester D. Ex vivo hemodynamic assessment of mechanical aortic valve gradients using a high-fidelity pressure wire. Catheter Cardiovasc Interv 2011; 77:726-32. [DOI: 10.1002/ccd.22883] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Revised: 10/15/2010] [Accepted: 10/19/2010] [Indexed: 11/06/2022]
|
14
|
Affiliation(s)
- Shadi Karebsheh
- Division of Cardiology, University of Utah, Salt Lake City, USA
| | | |
Collapse
|
15
|
Kuppahally SS, Michaels AD, Tandar A, Gilbert EM, Litwin SE, Bader FM. Can echocardiographic evaluation of cardiopulmonary hemodynamics decrease right heart catheterizations in end-stage heart failure patients awaiting transplantation? Am J Cardiol 2010; 106:1657-62. [PMID: 21094370 DOI: 10.1016/j.amjcard.2010.07.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Revised: 07/14/2010] [Accepted: 07/14/2010] [Indexed: 11/28/2022]
Abstract
Candidacy for heart transplantation is influenced by the severity of pulmonary hypertension. In this study, invasive hemodynamics from right-sided cardiac catheterization were compared with values obtained by validated equations from Doppler 2-dimensional transthoracic echocardiography. This prospective study was conducted in 40 patients with end-stage heart failure evaluated for heart transplantation or ventricular assist device implantation. Transthoracic echocardiography and right-sided cardiac catheterization were performed within 4 hours. From continuous-wave Doppler of the tricuspid regurgitation jet, pulmonary artery systolic pressure was calculated as the peak gradient across the tricuspid valve plus right atrial pressure estimated from inferior vena cava filling. Mean pulmonary artery pressure was calculated as (0.61 × pulmonary artery systolic pressure) + 2. Pulmonary vascular resistance (PVR) was calculated as (tricuspid regurgitation velocity/right ventricular outflow tract time-velocity integral × 10) + 0.16. Pulmonary capillary wedge pressure was calculated as 1.91 + (1.24 × E/E'). Pearson's correlation and Bland-Altman analysis of mean differences between echocardiographic and right-sided cardiac catheterization measurements were statistically significant for all hemodynamic parameters (pulmonary artery systolic pressure: r = 0.82, p < 0.05, mean difference 3.1 mm Hg, 95% confidence interval [CI] -0.2 to 6.3; mean pulmonary artery pressure: r = 0.80, p < 0.05, mean difference 2.5 mm Hg, 95% CI 0.3 to 4.6; PVR: r = 0.52, p < 0.05, mean difference 0.8 Wood units, 95% CI 0.3 to 1.4; pulmonary capillary wedge pressure: r = 0.65, p < 0.05, mean difference 2.2 mm Hg, 95% CI 0.1 to 4.3). Compared with right-sided cardiac catheterization, PVR by Doppler echocardiography identified all patients with PVR > 4 Wood units (n = 4), 73% of patients with PVR <2 Wood units (n = 8), and 52% of patients with PVR from 2 to 4 Wood units (n = 10). In conclusion, echocardiographic estimation of cardiopulmonary hemodynamics is reliable in patients with end-stage cardiomyopathy. The noninvasive assessment of hemodynamics by echocardiography may be able to decrease the number of serial right-sided cardiac catheterizations in selected patients awaiting heart transplantation. However, in patients with borderline PVR, right-sided cardiac catheterization is indicated to assess eligibility for transplantation.
Collapse
|
16
|
Gupta S, Gupta N, Arand P, Michaels AD. Computerized acoustic cardiography correlates with echocardiography and invasive haemodynamics after percutaneous transvenous mitral commissurotomy. J Med Eng Technol 2010; 35:59-64. [PMID: 21039322 DOI: 10.3109/03091902.2010.525687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Rheumatic mitral stenosis severity has been assessed by the systolic time interval between the QRS onset and the first heart sound (QS1) by phonocardiography. We hypothesized that non-invasive computerized acoustic cardiography could evaluate mitral stenosis severity compared with echocardiography and invasive haemodynamics in patients undergoing percutaneous transvenous mitral commissurotomy (PTMC). METHODS 27 patients underwent computerized acoustic cardiography, echocardiography, and invasive haemodynamic measurements prior to and after PTMC. RESULTS The mean age was 31 ± 10 years, and 21 (78%) were female. By echocardiography, mitral valve area increased from 0.82 ± 0.14 to 1.50 ± 0.24 cm(2) (p < 0.0001). The QS1 interval decreased from 101.7 ± 12.9 to 93.2 ± 9.2 ms (p < 0.0001). The change in the QS1 interval correlated with the change in mitral valve area by echocardiography (p = 0.037), right ventricular systolic pressure (p < 0.0001), and the invasive mitral valve gradient (p = 0.076). CONCLUSIONS Acoustic cardiography may be used as an adjunctive non-invasive diagnostic tool to assess mitral stenosis severity.
Collapse
Affiliation(s)
- S Gupta
- Department of Medicine, Division of Cardiology, Oregon Health & Science University, UHN-62, 3181 SW Sam Jackson Park Road, Portland, Oregon, USA
| | | | | | | |
Collapse
|
17
|
Kosmicki DL, Collins SP, Kontos MC, Zuber M, Kipfer P, Attenhofer Jost C, Michaels AD. Noninvasive Prediction of Left Ventricular Systolic Dysfunction in Patients With Clinically Suspected Heart Failure Using Acoustic Cardiography. ACTA ACUST UNITED AC 2010; 16:249-53. [DOI: 10.1111/j.1751-7133.2010.00191.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
18
|
Dennis A, Michaels AD, Arand P, Ventura D. Noninvasive diagnosis of pulmonary hypertension using heart sound analysis. Comput Biol Med 2010; 40:758-64. [PMID: 20691967 DOI: 10.1016/j.compbiomed.2010.07.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Accepted: 07/19/2010] [Indexed: 11/18/2022]
Abstract
Right-heart catheterization is the most accurate method for measuring pulmonary artery pressure (PAP). It is an expensive, invasive procedure, exposes patients to the risk of infection, and is not suited for long-term monitoring situations. Medical researchers have shown that PAP influences the characteristics of heart sounds. This suggests that heart sound analysis is a potential method for the noninvasive diagnosis of pulmonary hypertension. We describe the development of a prototype system, called PHD (pulmonary hypertension diagnoser), that implements this method. PHD uses patient data with machine learning algorithms to build models of how pulmonary hypertension affects heart sounds. Data from 20 patients were used to build the models and data from another 31 patients were used as a validation set. PHD diagnosed pulmonary hypertension in the validation set with 77% accuracy and 0.78 area under the receiver-operating-characteristic curve.
Collapse
Affiliation(s)
- Aaron Dennis
- Department of Computer Science, Brigham Young University, Provo, UT 84602, USA.
| | | | | | | |
Collapse
|
19
|
Shah SJ, Michaels AD. Acute effects of intravenous nesiritide on cardiac contractility in heart failure. J Card Fail 2010; 16:720-7. [PMID: 20797595 DOI: 10.1016/j.cardfail.2010.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2009] [Revised: 03/31/2010] [Accepted: 04/12/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Although nesiritide is a potent vasodilator, studies using myocytes and isolated muscle strips have shown that recombinant B-type natriuretic peptide (BNP; nesiritide) decreases contractility. We sought to determine whether nesiritide decreases contractility in heart failure patients. METHODS AND RESULTS Twenty-five heart failure patients underwent left heart catheterization (using a pressure-volume conductance catheter) and echocardiography at baseline and after a 2 mcg/kg bolus and 30-minute nesiritide infusion (0.01 mcg.kg.min). From invasive and noninvasive measurements, left ventricular (LV) systolic function indices were calculated, including ejection fraction, end-systolic elastance (E(es); single-beat invasive and noninvasive methods) and preload-recruitable stroke work (PRSW; noninvasive, single-beat method). The mean age was 60 +/- 11 years, 48% were male, 56% had coronary disease, and 64% had hypertension. Although nesiritide did not change LV ejection fraction, it did decrease contractility on pressure-volume analysis. Noninvasive E(es) decreased from 2.6 +/- 1.6 to 2.0 +/- 1.4 mm Hg/mL (P = .02). For those with reduced ejection fraction, E(es) decreased by invasive (P = .006) and noninvasive (P = .02) methods. PRSW decreased from 76 +/- 37 to 62 +/- 28 g/cm(2) (P = .003). On tissue Doppler imaging, nesiritide reduced the systolic annular tissue velocity of the mitral annulus from 8.0 +/- 1.9 to 6.9 +/- 1.3 cm/s (P = .04). CONCLUSIONS Nesiritide infusion acutely decreases derived measures of contractility and systolic function in patients with chronic heart failure.
Collapse
Affiliation(s)
- Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | |
Collapse
|
20
|
Kuppahally SS, Litwin SE, Michaels AD. Endomyocardial biopsy of right atrial angiosarcoma guided by intracardiac echocardiography. Cardiol Res Pract 2010; 2010:681726. [PMID: 20585357 PMCID: PMC2878669 DOI: 10.4061/2010/681726] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Accepted: 03/09/2010] [Indexed: 11/23/2022] Open
Abstract
We report a case of a 22-year-old female who presented with pericardial effusion and cardiac tamponade. She was diagnosed with a right atrial mass by computed tomography and was referred to our institution for biopsy of this mass. Transcatheter biopsy was performed with intracardiac echocardiography (ICE) guidance, avoiding the need for transesophageal echocardiography or surgery to obtain the biopsy. ICE for transcatheter biopsy of an intracardiac mass is an attractive modality which provides precise localization of the cardiac structures.
Collapse
Affiliation(s)
- Suman S Kuppahally
- Department of Medicine, Division of Cardiology, The University of Utah, Salt Lake City, UT 84132, USA
| | | | | |
Collapse
|
21
|
Kuppahally SS, Litwin SE, Green LS, Ishihara SM, Freedman RA, Michaels AD. Utility of Intracardiac Echocardiography for Atrial Baffle Leak Closure in Repaired Transposition of the Great Arteries. Echocardiography 2010; 27:E90-3. [DOI: 10.1111/j.1540-8175.2010.01171.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
22
|
Rogers RK, Stehlik J, Stoddard GJ, Greene T, Collins SP, Peacock WF, Maisel AD, Clopton P, Michaels AD. Corrigendum to ‘Adjusting for clinical covariates improves the ability of B-type natriuretic peptide to distinguish cardiac from non-cardiac dyspnoea: a sub-study of HEARD-IT’ [ Eur J Heart Fail2009;11:1043-1049]. Eur J Heart Fail 2010. [DOI: 10.1093/eurjhf/hfq041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
23
|
Michaels AD, Powell DL, Whitehead KJ. Reply to a Letter to Editor “Nickel Allergy, Amplatzer Atrial Septal Occluder Device, and the Risk of Kounis Syndrome”. Clin Cardiol 2010; 33:E61. [DOI: 10.1002/clc.20743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
|
24
|
Michaels AD, Spinler SA, Leeper B, Ohman EM, Alexander KP, Newby LK, Ay H, Gibler WB. Medication errors in acute cardiovascular and stroke patients: a scientific statement from the American Heart Association. Circulation 2010; 121:1664-82. [PMID: 20308619 DOI: 10.1161/cir.0b013e3181d4b43e] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
|
25
|
Owan TE, Reddy BT, Michaels AD. Retrograde left-ventricular hemodynamic assessment of mechanical aortic and mitral valve gradients using a high-fidelity pressure wire: A case series. Catheter Cardiovasc Interv 2010; 76:621-5. [DOI: 10.1002/ccd.22548] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
26
|
Kuppahally S, Gilbert EM, Litwin SE, Ishihara SM, Neuharth R, Michaels AD, Tandar A, Bader F. CAN ECHOCARDIOGRAPHIC EVALUATION OF CARDIOPULMONARY HEMODYNAMICS REPLACE RIGHT HEART CATHETERIZATION IN END-STAGE HEART FAILURE PATIENTS AWAITING TRANSPLANTATION? J Am Coll Cardiol 2010. [DOI: 10.1016/s0735-1097(10)60252-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
27
|
Kuppahally SS, Green LS, Michaels AD, Ishihara SM, Freedman RA, Litwin SE. Inadvertent placement of pacemaker lead into the systemic ventricle in repaired D-transposition of the great arteries. Circulation 2010; 121:e32. [PMID: 20159837 DOI: 10.1161/cir.0b013e3181d23036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Suman S Kuppahally
- Department of Cardiology, University of Utah, 50 North Medical Drive, Salt Lake City, UT 84132, USA.
| | | | | | | | | | | |
Collapse
|
28
|
Steenblik MH, Mineau GP, Pimentel R, Michaels AD. Population-based assessment of familial inheritance and neurologic comorbidities among patients with an isolated atrial septal defect. CONGENIT HEART DIS 2010; 4:459-63. [PMID: 19925540 DOI: 10.1111/j.1747-0803.2009.00340.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Interatrial shunts, caused by either atrial septal defect (ASD) or patent foramen ovale, have been reported to have a familial association. We sought to examine the familial risk of isolated interatrial shunt and explore associated comorbidities of stroke, transient ischemic attack (TIA), and migraine using a population database. METHODS The Utah Population Database is linked to inpatient and outpatient records from the University of Utah Health Science Center. Patients with an interatrial shunt were identified, and those with any other form of congenital heart disease or an inheritable syndrome associated with ASD were excluded. Of the 9452 individuals diagnosed with isolated interatrial shunt, 6179 (65%) had sufficient familial and follow-up data for analysis. Five age/gender matched controls were randomly selected per case. Cases and their relatives were compared with controls to assess the relative risk for each comorbid condition. RESULTS Relatives of interatrial shunt cases had an increased risk for interatrial shunt: siblings relative risk (RR) 6.98 (95% confidence interval [CI] 5.75-8.48; P < 1.0 x 10(-16)), first-degree RR 5.64 (95% CI 4.76-6.68; P < 1.0 x 10(-16)), and second-degree RR 1.75 (95% CI 1.32-2.32; P= 0.0001). Patients with interatrial shunt were more likely to have a comorbid condition compared with controls (RR 21.3, 95% CI 17.1-26.5; P < 1.0 x 10(-16)). First-degree relatives of cases had an increased risk of TIA (RR 1.70, 95% CI 1.18-2.45; P= 0.0045), but no increase risk of stroke or migraine compared with controls. CONCLUSIONS There is a strong familial inheritance pattern for isolated interatrial shunt, with significantly higher risk of interatrial shunt among affected patients' siblings, first-, and second-degree relatives. Relatives of affected individuals also had a higher risk of TIA, a trend toward an increased risk for stroke, but no increased risk of migraine headache.
Collapse
|
29
|
Lee E, Drew BJ, Selvester RH, Michaels AD. Diastolic heart sounds as an adjunctive diagnostic tool with ST criteria for acute myocardial ischemia. ACTA ACUST UNITED AC 2009; 11:229-35. [DOI: 10.1080/17482940903203071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
30
|
Michaels AD, Karabsheh S, Neuharth RM, Masood S, Arand P. Noninvasive computerized acoustic cardiographic prediction of pulmonary hypertension. J Electrocardiol 2009. [DOI: 10.1016/j.jelectrocard.2009.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
31
|
Lee E, Michaels AD, Selvester RH, Drew BJ. P-terminal force changes with ischemia induced by percutaneous coronary intervention. J Electrocardiol 2009. [DOI: 10.1016/j.jelectrocard.2009.08.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
32
|
Wei Y, Xie P, Pang W, Hu D, Michaels AD, Sun Y. The relationship between the coronary sinus and coronary artery using multislice spiral computed tomography and conventional invasive angiography. Int J Cardiol 2009; 137:276-81. [DOI: 10.1016/j.ijcard.2008.12.217] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2008] [Revised: 12/03/2008] [Accepted: 12/29/2008] [Indexed: 10/21/2022]
|
33
|
Michaels AD, Burlew BS. Pacemaker lead thrombus causing cryptogenic stroke in a patient referred for percutaneous patent foramen ovale closure. J Invasive Cardiol 2009; 21:E224-E225. [PMID: 19901425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Andrew D Michaels
- Division of Cardiology, Department of Medicine, University of Utah, 30 North 1900 East, Room 4A100, Salt Lake City, UT 84132-2401, USA.
| | | |
Collapse
|
34
|
Michaels AD, Neuharth RM, Hendrix MA, McDonnall D, Hiatt S. Intravenous electrocardiographic guidance for placement of peripherally inserted central catheters. J Electrocardiol 2009. [DOI: 10.1016/j.jelectrocard.2009.08.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
35
|
Rabkin DG, Whitehead KJ, Michaels AD, Powell DL, Karwande SV. Unusual presentation of nickel allergy requiring explantation of an Amplatzer atrial septal occluder device. Clin Cardiol 2009; 32:E55-7. [PMID: 19455702 DOI: 10.1002/clc.20427] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Systemic allergic reaction to a percutaneous patent foramen ovale (PFO) occlusion device is a rare event with only scattered reports in the literature. Serious allergic reactions to these devices have a poorly defined incidence, presentation, and natural history. We present a woman with a previously unknown nickel allergy who developed severe chest pain beginning the morning after percutaneous device closure of the PFO. Despite multiple visits to her cardiologists and primary care physicians, the cause of her chest pain remained unclear. After seeking a second opinion at our medical center, skin testing showed a severe reaction to nickel. These symptoms were refractory to treatment until device explantation 18 mo later. This case highlights the importance of recognizing nickel allergy as a cause of chest pain following implantation of certain types of devices used for closure of PFOs and other heart defects.
Collapse
Affiliation(s)
- David G Rabkin
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Medical Center, Salt Lake City, Utah, USA
| | | | | | | | | |
Collapse
|
36
|
Abstract
BACKGROUND Poor performance by physicians-in-training and interobserver variability between physicians has diminished clinicians' confidence in the value of the fourth heart sound (S4). HYPOTHESIS We sought to determine if accurate auscultation of an S4 improves with advancing levels of experience. METHODS We performed a prospective study of 100 patients undergoing left heart catheterization. Patients underwent blinded auscultation by 4 physicians (each from 1 of 4 different levels of experience), computerized acoustic cardiography, measurement of B-type natriuretic peptide (BNP) levels, echocardiography for measurement of left ventricular ejection fraction (LVEF), and cardiac catheterization for measurement of left ventricular end-diastolic pressure (LVEDP). RESULTS While cardiology fellows', residents', and interns' auscultatory findings demonstrated no significant agreement with acoustic cardiography, an S4 auscultated by cardiology attendings had moderate diagnostic accuracy with acoustic cardiography (odds ratio [OR]: 2.31; receiver-operating-characteristic [ROC] area: 0.60). The sensitivities of the S4 were low (39%-46%) for identifying patients with abnormal measures of left ventricular filling pressure (BNP and LVEDP, respectively), and the specificities were fair (76%-80%) with acoustic cardiography. The S4 was not associated with abnormal LVEF. None of the ausculatory groups performed as well as acoustic cardiography in separating patients based on objective measures of left ventricular filling pressure. Acoustic cardiography had the lowest (superior) negative likelihood ratios compared to any ausculatory group. CONCLUSIONS The S4 auscultated by cardiology attendings demonstrated superior diagnostic test characteristics compared with internal medicine housestaff and cardiology fellows. Correlations between the S4 and measures of ventricular filling pressure were superior for acoustic cardiography compared to the auscultator groups.
Collapse
Affiliation(s)
- Saurabh Gupta
- Division of Cardiology, Department of Medicine, University of Utah, Salt Lake City, Utah 84132-2401, USA
| | | |
Collapse
|
37
|
Kevin Rogers R, Stehlik J, Stoddard GJ, Greene T, Collins SP, Peacock WF, Maisel AD, Clopton P, Michaels AD. Adjusting for clinical covariates improves the ability of B-type natriuretic peptide to distinguish cardiac from non-cardiac dyspnoea: a sub-study of HEARD-IT. Eur J Heart Fail 2009; 11:1043-9. [PMID: 19812054 DOI: 10.1093/eurjhf/hfp127] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS We sought to create a model that adjusts B-type natriuretic peptide (BNP) for specific covariates to better distinguish cardiac from non-cardiac dyspnoea. METHODS AND RESULTS HEARD-IT was a multicentre, prospective study of the diagnostic utility of acoustic cardiography in the emergency department. Dyspnoeic patients more than 40 years were eligible. Two cardiologists independently adjudicated the HF outcome. Using logistic regression, a model adjusting BNP for pertinent covariates was developed (n = 740). The mean age was 66 +/- 13 years. Age, gender, ethnicity, body mass index, blood urea nitrogen, and creatinine affected BNP levels independently of HF. The model adjusting BNP for these covariates improved the area under receiver operator characteristic curve for HF compared with BNP alone (0.948, 95% CI 0.934-0.963 vs. 0.937, 95% CI 0.920-0.954; P = 0.004). Net reclassification improvement, a novel metric of model performance, was 3.5% for those without HF (P = 0.05) compared with conventional, unadjusted BNP cut-offs. Thirteen of 116 (11%) patients without HF, but with unadjusted BNP values > or =100 pg/mL, were correctly reclassified as not having HF with the adjusted BNP model. CONCLUSION Adjusting BNP for important covariates may improve its ability to distinguish cardiac from non-cardiac dyspnoea.
Collapse
Affiliation(s)
- R Kevin Rogers
- Division of Cardiology, University of Utah Health Sciences Centre, Salt Lake City, UT 84132-2401, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
38
|
|
39
|
Rogers RK, Stoddard GJ, Greene T, Michaels AD, Fernandez G, Freeman A, Nord J, Stehlik J. Usefulness of adjusting for clinical covariates to improve the ability of B-type natriuretic peptide to distinguish cardiac from noncardiac dyspnea. Am J Cardiol 2009; 104:689-94. [PMID: 19699346 DOI: 10.1016/j.amjcard.2009.04.043] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2009] [Revised: 04/26/2009] [Accepted: 04/26/2009] [Indexed: 11/25/2022]
Abstract
Certain clinical characteristics affect brain natriuretic peptide (BNP) levels independently of clinical heart failure (HF). However, it is unclear how to adjust the diagnostic cutoffs of BNP for these variables. We hypothesized that adjusting for important covariates would improve the diagnostic accuracy of BNP for HF in the emergency room setting. We included patients presenting with dyspnea at the Salt Lake City Veterans Affairs Medical Center. Physicians unaware of the BNP values adjudicated the outcome as dyspnea due to HF or noncardiac dyspnea. Subgroup analyses and logistic regression analysis were used to adjust the BNP cutoffs. The mean age of the study population (n = 335) was 72 +/- 11 years. A BNP of 100 pg/ml had a sensitivity of 91%, and a BNP of 400 pg/ml had a specificity of 92%. The covariates age, history of atrial fibrillation, creatinine, and body mass index affected BNP levels independently of HF. The subgroup-specific BNP cutoff that maintained 91% sensitivity was 184 pg/ml for patients > or =75 years, 150 pg/ml for those with atrial fibrillation, and 449 pg/ml for patients with a creatinine > or =2 mg/dl. These subgroup-specific cutoffs improved specificity compared to a cutoff of 100 pg/ml. The regression model that adjusted BNP improved the reclassification of patients as having cardiac or noncardiac dyspnea compared to the conventional BNP cutoffs. Of the patients without HF, 11% were correctly reclassified as having noncardiac dyspnea (p = 0.003). In conclusion, adjusting BNP levels for clinical covariates improves its diagnostic performance.
Collapse
|
40
|
Efstratiadis S, Michaels AD. Acute hemodynamic effects of intravenous nesiritide on left ventricular diastolic function in heart failure patients. J Card Fail 2009; 15:673-80. [PMID: 19786256 DOI: 10.1016/j.cardfail.2009.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Revised: 03/15/2009] [Accepted: 03/19/2009] [Indexed: 01/15/2023]
Abstract
BACKGROUND Nesiritide is recombinant human B-type natriuretic peptide with vasodilatory effects used in patients with decompensated congestive heart failure. We sought to evaluate the effects of nesiritide on left ventricular diastolic function in heart failure patients. METHODS AND RESULTS Twenty-five heart failure patients underwent left heart catheterization (using a pressure-volume conductance catheter) and echocardiography at baseline and 30 minutes after an intravenous bolus and infusion of nesiritide. Invasive and noninvasive measurements of load-dependent (deceleration time, echocardiographic diastolic function classification, negative dP/dt, left ventricular diastolic pressure, tau) parameters of diastolic function were assessed. The nonlinear slope of the end-diastolic pressure volume relationship (EDPVR) using 2 single-beat methods for measuring left ventricular end-diastolic elastance was calculated to assess load-independent parameters of diastolic function. Nesiritide reduced biventricular diastolic pressure and systemic vascular resistance. Tau and negative dP/dt showed modest improvement. Deceleration time, isovolumetric relaxation time, diastolic stiffness indices (E/E'/stroke volume (SV) and E/E'/left ventricular end-diastolic volume index (LVEDVI)), and the echocardiographic diastolic filling pattern classification did not change. Furthermore, there was no change in the EDPVR. CONCLUSIONS Although nesiritide is an effective vasodilator resulting in decreased left ventricular preload and afterload in heart failure patients, intrinsic left ventricular diastolic function did not change acutely, suggesting that nesiritide has no significant acute lusitropic effect.
Collapse
Affiliation(s)
- Stilianos Efstratiadis
- Division of Cardiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah 84132-2401, USA
| | | |
Collapse
|
41
|
Lee E, Drew BJ, Selvester RH, Michaels AD. Sequence of electrocardiographic and acoustic cardiographic changes and angina during coronary occlusion and reperfusion in patients undergoing percutaneous coronary intervention. Ann Noninvasive Electrocardiol 2009; 14:137-46. [PMID: 19419398 DOI: 10.1111/j.1542-474x.2009.00288.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Previous studies have suggested that ventricular function may be impaired without or prior to electrocardiographic changes or angina during ischemia. Understanding of temporal sequence of electrical and functional ischemic events may improve the detection of myocardial ischemia. METHODS A prospective study was performed in 21 subjects undergoing percutaneous coronary intervention (PCI) who had both ST amplitude changes >2 standard deviations above baseline on 12-lead electrocardiography (ECG), and new or increased third or fourth heart sound (S3 or S4) intensity measured by computerized acoustic cardiography. The sequence of the onset and resolution of these signs of ischemia were examined following coronary balloon inflation and deflation. RESULTS Electrocardiographic ST amplitude and diastolic heart sound changes occurred contemporaneously, shortly after coronary occlusion (mean onset from balloon inflation; ST changes, 21 +/- 17 seconds; S4, 25 +/- 26 seconds; S3, 45 +/- 43 seconds). In 40% of patients, a new or increased S3 or S4 developed earlier than ST changes. Anginal symptoms occurred in only 2 of the 21 subjects during ischemia with a mean onset time of 68 seconds. ST-segment changes resolved earliest (33 seconds after balloon deflation) while diastolic heart sounds (89 +/- 146 seconds) and angina (586 +/- 653 seconds) resolved later. CONCLUSION A new or intensified S3 and/or S4 occurred contemporaneously with electrocardiographic changes during ischemia. These diastolic heart sounds persisted longer than ST changes following coronary reperfusion. Acoustic cardiographic assessment of diastolic heart sounds may aid in the early detection of myocardial ischemia, particularly in those patients with an uninterpretable ECG.
Collapse
Affiliation(s)
- Eunyoung Lee
- Department of Physiological Nursing, University of California-San Francisco, 2 Koret Way, San Francisco, CA 94143-0610, USA.
| | | | | | | |
Collapse
|
42
|
Collins SP, Lindsell CJ, Kontos MC, Zuber M, Kipfer P, Jost CA, Kosmicki D, Michaels AD. Bedside prediction of increased filling pressure using acoustic electrocardiography. Am J Emerg Med 2009; 27:397-408. [DOI: 10.1016/j.ajem.2008.03.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2008] [Revised: 03/06/2008] [Accepted: 03/06/2008] [Indexed: 02/06/2023] Open
|
43
|
Garcia JA, Agostoni P, Green NE, Maddux JT, Chen SYJ, Messenger JC, Casserly IP, Hansgen A, Wink O, Movassaghi B, Groves BM, Van Den Heuvel P, Verheye S, Van Langenhove G, Vermeersch P, Van den Branden F, Yeghiazarians Y, Michaels AD, Carroll JD. Rotational vs. standard coronary angiography: An image content analysis. Catheter Cardiovasc Interv 2009; 73:753-61. [DOI: 10.1002/ccd.21918] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
|
44
|
Abstract
Bedside diagnostic tools remain important in the care of patients with heart failure. Over the past two centuries, cardiac auscultation and phonocardiography have been essential in understanding cardiac pathophysiology and caring for patients with heart disease. Diastolic heart sounds (S3 and S4) and systolic time intervals have been particularly useful in this regard. Unfortunately, auscultation skills have declined considerably, and systolic time intervals have traditionally required carotid pulse tracings. Newer technology allows the automated detection of heart sounds and measurement of systolic time intervals in a simple, inexpensive, noninvasive system. Using the newer system, the authors present data on the hemodynamic correlates of the S3 and abnormal systolic time intervals. These data serve as the foundation for using the system to better understand the test characteristics and pathophysiology of the S3 and systolic time intervals, and help to define their use in improving the bedside diagnosis and management of patients with heart failure.
Collapse
Affiliation(s)
- Sanjiv J Shah
- Department of Medicine, Division of Cardiology, University of California, San Francisco, San Francisco, CA, USA
| | | |
Collapse
|
45
|
Michaels AD, Kennard ED, Kelsey SE, Holubkov R, Soran O, Spence S, Chou TM. Does higher diastolic augmentation predict clinical benefit from enhanced external counterpulsation?: Data from the International EECP Patient Registry (IEPR). Clin Cardiol 2009; 24:453-8. [PMID: 11403506 PMCID: PMC6655252 DOI: 10.1002/clc.4960240607] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Enhanced external counterpulsation (EECP) has been demonstrated to be an effective treatment for stable angina in patients with coronary disease. The hemodynamic effects of EECP are maximized when the ratio of diastolic to systolic pressure area is in the range of 1.5 to 2.0. HYPOTHESIS It is hypothesized that patients undergoing EECP who are able to achieve higher diastolic augmentation (DA) ratios may derive greater clinical benefit. This study examines the relationship between the DA ratio and clinical outcomes in patients undergoing EECP. METHODS We analyzed demographic, noninvasive hemodynamic, and clinical outcome data on 1,004 patients enrolled in the International EECP Patient Registry (IEPR) for treatment of chronic angina between January 1998 and August 1999. Blood pressure waveforms were recorded from finger plethysmography. Six-month clinical outcomes were obtained by telephone interview. RESULTS At the end of EECP treatment, 370 (37%) patients had a higher DA ratio (defined as > or = 1.5) and 634 (63%) had a lower DA ratio (defined as < 1.5). Factors associated with a lower DA ratio included age > or =65 years (p <0.001), female gender (p < 0.001), left ventricular ejection fraction < 35% (p < 0.05), hypertension (p < 0.01), prior coronary bypass surgery (p < 0.01), noncardiac vascular disease (p < 0.001), multivessel disease (p < 0.01), congestive heart failure (p < 0.01), current smoking (p < 0.01), unsuitability for further revascularization (p < 0.001), and higher baseline angina class (p < 0.001). There were no significant differences regarding diabetes mellitus, prior coronary angioplasty, prior myocardial infarction, or antianginal medication use between patients with higher or lower DA ratios. Based on a multiple logistic regression model, independent predictors of a DA ratio < 1.5 at the end of EECP included current smoking (odds ratio 3.3; 95% confidence intervals 2.0-5.4); multivessel disease (1.7; 1.3-2.3); female gender (2.2; 1.7-3.0); no prior EECP (1.9; 1.1-3.3); noncardiac vascular disease (2.3; 1.7-2.9); age > or = 65 years (1.7; 1.4-2.2), and patients not suitable for revascularization (1.6; 1.2-2.0). By the end of therapy, there were no significant differences in myocardial infarction, revascularization rates, or nitroglycerin use with respect to higher DA ratios. At 6-month follow-up, patients with higher DA had a trend toward a greater reduction in angina class compared with those with lower DA (p = 0.069). There was a significantly higher rate of unstable angina and congestive heart failure in the group not achieving higher augmentation (p < 0.05). CONCLUSIONS Patients who are younger, male, nonsmoking, and without multivessel coronary or noncardiac vascular disease are most likely to have higher DA with EECP. Patients with higher DA tended to have a greater reduction in angina class at 6-month follow-up compared with those with lower DA ratios. There is evidence that higher DA ratios are associated with improved short- or long-term clinical outcomes, suggesting that clinical benefit from EECP is associated with the magnitude of DA.
Collapse
Affiliation(s)
- A D Michaels
- Department of Medicine, University of California at San Francisco Medical Center, 94143-0124, USA
| | | | | | | | | | | | | |
Collapse
|
46
|
Abstract
A 50-year-old man was admitted with acute inferior and anterior myocardial infarction. The patient was diagnosed with essential thrombocythemia (ET) based on the findings of marked thrombocytosis of 1,113 x 10(3)/mm3, splenomegaly, and numerous clumping megakaryocytes on bone marrow biopsy. Emergent coronary angiography revealed extensive multivessel thrombosis involving the left main coronary artery and completely occluding the proximal right coronary artery. In addition to standard therapy with aspirin, heparin, and primary angioplasty of the right coronary artery, the patient received additional antiplatelet therapy with ticlopidine, hydroxyurea, and the platelet glycoprotein IIb/IIIa receptor-inhibiting monoclonal antibody drug abciximab (ReoPro). Serial coronary angiograms 1 and 5 days following the infarction showed progressive thrombus resolution. The pathophysiologic mechanisms and therapeutic challenges of ET-associated coronary thrombosis are discussed in this report.
Collapse
Affiliation(s)
- A D Michaels
- Department of Medicine, University of California-San Francisco Medical Center, 94110, USA
| | | | | |
Collapse
|
47
|
Jiji RS, Michaels AD. Heparin-induced thrombocytopenia (HIT) causing pulmonary emboli during coronary intervention. Catheter Cardiovasc Interv 2008; 72:819-22. [DOI: 10.1002/ccd.21732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
48
|
Karabsheh S, Arand P, Michaels AD. Acoustic electrocardiographic indices of transmyocardial ischemia. J Electrocardiol 2008. [DOI: 10.1016/j.jelectrocard.2008.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
49
|
Efstratiadis S, Kennard ED, Kelsey SF, Michaels AD. Passive tobacco exposure may impair symptomatic improvement in patients with chronic angina undergoing enhanced external counterpulsation. BMC Cardiovasc Disord 2008; 8:23. [PMID: 18798998 PMCID: PMC2553398 DOI: 10.1186/1471-2261-8-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2007] [Accepted: 09/17/2008] [Indexed: 11/23/2022] Open
Abstract
Background The adverse effects of tobacco abuse on cardiovascular outcomes are well-known. However, the impact of passive smoke exposure on angina status and therapeutic response is less well-established. We examined the impact of second-hand smoke (SHS) exposure on symptomatic improvement in patients with chronic ischemic coronary disease undergoing enhanced external counterpulsation (EECP). Methods This observational study included 1,026 non-smokers (108 exposed and 918 not-exposed to SHS) from the Second International EECP Patient Registry. We also assessed angina response in 363 current smokers. Patient demographics, symptomatic improvement and quality of life assessment were determined by self-report prior and after EECP treatment. Results Non-smoking SHS subjects had a lower prevalence of prior revascularization (85% vs 90%), and had an increased prevalence of stroke (13% vs 7%) and prior smoking (72% vs 61%; all p < 0.05) compared to non-smokers without SHS exposure. Despite comparable degrees of coronary disease, baseline angina class, medical regimens and side effects during EECP, fewer SHS non-smokers completed a full 35-hour treatment course (77% vs 85%, p = 0.020) compared to non-smokers without SHS. Compared to non-smokers without SHS, non-smoking SHS subjects had less angina relief after EECP (angina class decreased ≥ 1 class: 68% vs 79%; p = 0.0082), both higher than that achieved in current smokers (66%). By multivariable logistic regression, SHS exposure was an independent predictor of failure to symptomatic improvement after EECP among non-smokers (OR 1.81, 95% confidence intervals 1.16–2.83). Conclusion Non-smokers with SHS exposure had an attenuated improvement in anginal symptoms compared to those without SHS following EECP.
Collapse
Affiliation(s)
- Stilianos Efstratiadis
- Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City, Utah, USA.
| | | | | | | | | |
Collapse
|
50
|
Weeks SG, Shapiro M, Foster E, Michaels AD. Echocardiographic Predictors of Change in Left Ventricular Diastolic Pressure in Heart Failure Patients Receiving Nesiritide. Echocardiography 2008; 25:849-55. [DOI: 10.1111/j.1540-8175.2008.00705.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|