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Dawadi S, Oli PR, Shrestha DB, Shtembari J, Pant K, Shrestha B, Mattumpuram J, Katz DH. Transcarotid versus trans-axillary/subclavian transcatheter aortic valve replacement (TAVR): A systematic review and meta-analysis. Curr Probl Cardiol 2024; 49:102488. [PMID: 38417474 DOI: 10.1016/j.cpcardiol.2024.102488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 02/24/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Transcatheter Aortic Valve Replacement (TAVR) is the treatment of choice in patients with severe aortic stenosis. Transcarotid (TCa) or Trans-axillary/subclavian (TAx/Sc) are safer and less invasive non-femoral approaches, where transfemoral access is difficult or impossible to obtain. METHODS This meta-analysis was performed based on PRISMA guidelines after registering in PROSPERO (CRD42023482842). This meta-analysis was performed to compare the safety of the transcarotid and trans-axillary/subclavian approach for TAVR including studies from inception to October 2023. RESULTS Seven studies with a total of 6227 patients were included in the analysis (TCa: 2566; TAx/Sc: 3661). Transcarotid TAVR approach had a favorable trend for composite of stroke and all-cause mortality (OR 0.79, CI 0.60-1.04), all-cause mortality, stroke, major vascular complication, and new requirement of permanent pacemaker though those were statistically insignificant. On sub-analysis of the results of the studies based on the territory (USA vs French), composite outcome of all cause mortality, stroke and major bleeding (OR 0.54, CI 0.54-0.81), composite of stroke and all cause mortality (OR 0.64, CI 0.50-0.81), and stroke/TIA (OR 0.53, CI 0.39-0.73) showed lower odds of occurrence among patient managed with TCa approach in the American cohort. CONCLUSION Overall, transcarotid approach had favorable though statistically insignificant odds for composite (stroke and all-cause mortality) and individual outcomes (stroke, all-cause mortality, etc.). There are significant variations in observed outcomes based on study's geographic location. Large prospective randomized clinical trials comparing the two approaches with representative samples are necessary to guide the clinicians in choosing among these approaches.
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Affiliation(s)
- Sagun Dawadi
- Department of Internal Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, 44600, Nepal
| | - Prakash Raj Oli
- Department of Internal Medicine, Province Hospital, Birendranagar, Surkhet, Karnali Province 21700, Nepal
| | | | - Jurgen Shtembari
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, IL 60608, USA
| | - Kailash Pant
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Illinois College of Medicine, OSF Healthcare, Peoria, IL 61614, USA
| | - Bishesh Shrestha
- Division of Cardiology, Department of Internal Medicine, Bassett Medical Center, 1 Atwell Rd, Cooperstown, NY 13326, USA
| | - Jishanth Mattumpuram
- Division of Cardiology, Department of Internal Medicine, University of Louisville School of Medicine, 550 S Jackson St, Louisville, KY 40202, USA.
| | - Daniel H Katz
- Division of Cardiology, Department of Internal Medicine, Bassett Medical Center, 1 Atwell Rd, Cooperstown, NY 13326, USA
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Adelkhanova A, Oli PR, Shrestha DB, Shtembari J, Jha V, Shantha G, Bodziock GM, Biswas M, Zaman MO, Patel NK. Safety and efficacy of direct oral anticoagulants in comparison to warfarin in obese patients with atrial fibrillation: A systematic review and meta-analysis. Health Sci Rep 2024; 7:e2044. [PMID: 38650729 PMCID: PMC11033493 DOI: 10.1002/hsr2.2044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 09/13/2023] [Revised: 03/15/2024] [Accepted: 03/21/2024] [Indexed: 04/25/2024] Open
Abstract
Background and Aim Obesity affects nearly 650 million adults worldwide, and the prevalence is steadily rising. This condition has significant adverse effects on cardiovascular health, increasing the risk of hypertension, coronary artery disease, heart failure, and atrial fibrillation (AF). While anticoagulation for obese patients with AF is a well-established therapy for the prevention of thromboembolism, the safety and efficacy of different anticoagulants in this specific population are not well explored. This meta-analysis aimed to compare direct oral anticoagulants (DOAC) to vitamin K antagonists in obese populations with AF. Methods The PRISMA guidelines were followed for this meta-analysis, registered in PROSPERO (CRD42023392711). PubMed, PubMed Central, Embase, Cochrane Library, and Scopus databases were searched for relevant articles from inception through January 2023. Two independent authors screened titles and abstracts, followed by a full-text review in Covidence. Data were extracted in Microsoft Excel and analyzed using RevMan v5.4 using odds ratio as an effect measure. Results Two thousand two hundred fifty-nine studies were identified from the database search, and 18 were included in the analysis. There were statistically significant reductions in the odds of ischemic and hemorrhagic stroke in the DOAC group compared with the VKA group (OR 0.70, CI 0.66-0.75) and (OR 0.47, CI 0.35-0.62), respectively. In addition, the DOAC group exhibited lower odds of systemic embolism (OR 0.67, CI 0.54-0.83), major bleeding (OR 0.62, CI 0.54-0.72), and composite outcome (OR 0.72, CI 0.63-0.81). Conclusion Based on the findings from this meta-analysis, DOACs demonstrate superior safety and efficacy in obese patients with AF compared with VKAs. These results may have significant implications for guiding anticoagulation strategies in this patient population.
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Affiliation(s)
- Alla Adelkhanova
- Department of Internal MedicineMount Sinai HospitalChicagoIllinoisUSA
| | - Prakash Raj Oli
- Department of Internal MedicineProvince HospitalBirendranagarNepal
| | | | - Jurgen Shtembari
- Department of Internal MedicineMount Sinai HospitalChicagoIllinoisUSA
| | - Vivek Jha
- Department of Internal MedicineJohn H. Stroger, Jr. Hospital of Cook CountyChicagoIllinoisUSA
| | - Ghanshyam Shantha
- Department of Internal Medicine, Division of Cardiac ElectrophysiologyWake Forest University School of MedicineWinston SalemNorth CarolinaUSA
| | - George Michael Bodziock
- Department of Internal Medicine, Division of Cardiac ElectrophysiologyWake Forest University School of MedicineWinston SalemNorth CarolinaUSA
| | - Monodeep Biswas
- Department of Internal Medicine, Division of Cardiac ElectrophysiologyUniversity of Maryland Medical CenterBaltimoreMarylandUSA
| | - Muhammad Omer Zaman
- Department of Internal Medicine, Division of CardiologyRudd Heart HospitalLouisvilleKentuckyUSA
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Oli PR, Shrestha DB, Dawadi S, Shtembari J, Regmi L, Pant K, Shrestha B, Mattumpuram J, Katz DH. Immediate vs. multistage revascularization of non-infarct coronary artery(-ies) in patients with hemodynamically stable multivessel disease acute myocardial infarction: a systematic review and meta-analysis. Coron Artery Dis 2024:00019501-990000000-00208. [PMID: 38451559 DOI: 10.1097/mca.0000000000001353] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
BACKGROUND Untreated multivessel disease (MVD) in acute myocardial infarction (AMI) has been linked to a higher risk of recurrent ischemia and death within one year . Current guidelines recommend percutaneous coronary intervention (PCI) for significant non-infarct artery (-ies) (non-IRA) stenosis in hemodynamically stable AMI patients with MVD, either during or after successful primary PCI, within 45-days. However, deciding the timing of revascularization for non-IRA in cases of MVD is uncertain. METHODS This meta-analysis was performed based on PRISMA guidelines after registering in PROSPERO (CRD42023472652). Databases were searched for relevant articles published before 10 November 2023. Pertinent data from the included studies were extracted and analyzed using RevMan v5.4. RESULTS Out of 640 studies evaluated, there were 13 RCTs with 5144 patients with AMI with MVD. The immediate non-IRA PCI is associated with a significantly lower occurrence of unplanned ischemia-driven PCI (OR 0.60; confidence interval [CI] 0.44-0.83) and target-vessel revascularization (OR 0.72; CI 0.53-0.97) . Although there is a favorable trend for major adverse cardiovascular and cerebrovascular events (MACCE), nonfatal AMI, cerebrovascular events, and major bleeding in the immediate non-culprit artery (-ies) PCI, those were statistically non-significant. Similarly, all-cause mortality, cardiovascular mortality, stent thrombosis, and acute renal insufficiency did not show significant differences between two groups. CONCLUSION Among hemodynamically stable patients with multivessel AMI, the immediate PCI strategy was superior to the multistage PCI strategy for the unplanned ischemia-driven PCI and target-vessel revascularization while odds are favorable in terms of MACCE, nonfatal AMI, cerebrovascular events, and major bleeding at longest follow-up.
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Affiliation(s)
- Prakash Raj Oli
- Department of Internal Medicine, Province Hospital, Birendranagar, Surkhet, Karnali province, Nepal
| | | | - Sagun Dawadi
- Department of Internal Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Jurgen Shtembari
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, Illinois, USA
| | - Laxmi Regmi
- Department of Internal Medicine, Province Hospital, Birendranagar, Surkhet, Karnali province, Nepal
| | - Kailash Pant
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Illinois College of Medicine, OSF Healthcare, Peoria, Illinois
| | - Bishesh Shrestha
- Division of Cardiology, Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY
| | - Jishanth Mattumpuram
- Division of Cardiology, Department of Internal Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Daniel H Katz
- Division of Cardiology, Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY
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Shtembari J, Shrestha DB, Tung R, Upadhyay GA. Inadvertent septal perforation during conduction system pacing device implant: a case report. Eur Heart J Case Rep 2024; 8:ytae106. [PMID: 38500489 PMCID: PMC10946411 DOI: 10.1093/ehjcr/ytae106] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 06/24/2023] [Revised: 02/10/2024] [Accepted: 02/21/2024] [Indexed: 03/20/2024]
Abstract
Background There has been recent growing interest in the use of conduction system pacing (CSP) for both bradycardia and heart failure indications. There remains a paucity of data, however, regarding complications related to the intraventricular septum associated with CSP implant and the management of these events. Case summary We present a case of a patient with non-ischemic dilated cardiomyopathy presenting for cardiac resynchronization therapy in whom left bundle branch area pacing was complicated with interventricular septal perforation and managed intra-procedurally with repositioning of the lead to provide His bundle pacing (HBP) for QRS correction of underlying left bundle branch block. Post-procedure echocardiography did not show persistent ventricular septal defect. Left ventricular ejection fraction improved from 13% four months before implant to 30% at 32 months post-implant. Corrective HBP pacing thresholds showed a rise at 3-year follow-up. Discussion Interventricular septal perforation during CSP is a possible complication during lead fixation. Pre-operative septal assessment with imaging can be helpful to provide important septal anatomical features. Septal perforation can be managed appropriately with lead repositioning intra-procedurally and close follow-up.
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Affiliation(s)
- Jurgen Shtembari
- The University of Chicago Medicine, Center for Arrhythmia Care, Section of Cardiology, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, IL, USA
| | - Dhan Bahadur Shrestha
- The University of Chicago Medicine, Center for Arrhythmia Care, Section of Cardiology, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, IL, USA
| | - Roderick Tung
- The University of Chicago Medicine, Center for Arrhythmia Care, Section of Cardiology, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Gaurav A Upadhyay
- The University of Chicago Medicine, Center for Arrhythmia Care, Section of Cardiology, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
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Proskuriakova E, Shrestha DB, Jasaraj R, Reddy VK, Shtembari J, Raut A, Gaire S, Khosla P, Kadariya D. Cardiovascular Adverse Events Associated With Second-generation Bruton Tyrosine Kinase Inhibitor Therapy: A Systematic Review and Meta-analysis. Clin Ther 2024; 46:134-145. [PMID: 38102000 DOI: 10.1016/j.clinthera.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/17/2023] [Accepted: 11/16/2023] [Indexed: 12/17/2023]
Abstract
PURPOSE Cardiovascular adverse events (CVAEs) are common adverse effects of first-generation Bruton tyrosine kinase inhibitors (BTKis) and limit their use considerably. This led to the development of second-generation BTKis-acalabrutinib and zanubrutinib-which are more selective, potent, and presumed to have better safety profiles than the previous group of medications. However, there have been sporadic reports of CVAEs associated with second-generation BTKis in clinical practice. To address this issue, a comprehensive meta-analysis to pool the documented CVAEs was performed, including major hemorrhage, any bleeding, atrioventricular block, atrial fibrillation/flutter, pericardial effusion, pericarditis, heart failure, cardiac arrest, myocardial infarction, hypertension, hypotension, and stroke. This meta-analysis incorporated 8 studies. Among these, 6 were Phase III trials and 2 were Phase II trials. These studies collectively enrolled a total of 2938 patients. METHODS Multiple databases, including PubMed, MEDLINE, Cochrane Library, Scopus, and EMBASE, were systematically searched for relevant clinical trials from inception through January 14, 2023. The effect measure used was odds ratio (OR) and 95% CI. FINDINGS Of a total of 1774 studies identified during the initial database search, 8 were included in the meta-analysis. The incidence of overall and cardiovascular mortality was comparable between the 2 groups. There were no significant differences observed for cardiovascular mortality (OR = 0.36; 95% CI, 0.08-1.65; n = 2588; I2 = 45%; P = 0.19). Similar results were found for all-cause mortality (OR = 0.85; 95% CI, 0.67-1.07), any bleeding (OR = 1.90; 95% CI, 0.88-4.09), major bleeding (OR = 1.07; 95% CI, 0.65-1.76), atrioventricular block (OR = 0.74; 95% CI, 0.15-3.68), atrial fibrillation/flutter (OR = 0.74; 95% CI, 0.37-1.50), and other CVAEs associated with second-generation BTKis. IMPLICATIONS Based on the available evidence, there is no indication of worse cardiovascular outcomes or superiority of second-generation BTKis compared with standard treatments in terms of safety profile. However, additional large-scale controlled trials are needed to provide robust support for the superior tolerability of new-generation BTKis.
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Affiliation(s)
| | | | - Ranjit Jasaraj
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, Illinois
| | - Vijay Ketan Reddy
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, Illinois
| | - Jurgen Shtembari
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, Illinois
| | - Anuradha Raut
- Department of Internal Medicine, Nepal Medical College, Kathmandu, Nepal
| | - Suman Gaire
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, Illinois
| | - Paramjeet Khosla
- Department of Hematology and Oncology, Mount Sinai Hospital, Chicago, Illinois
| | - Dinesh Kadariya
- Department of Internal Medicine, Division of Cardiology, University of Florida-Jacksonville, Jacksonville, Florida
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Shrestha DB, Sedhai YR, Oli PR, Proskuriakova E, Adelkhanova A, Shtembari J, Khan TMA, Singh K, Ahmed MA, Waheed I, Kazimuddin N, Steff R, Acharya R, Patel NK. Prior Use of Angiotensin-converting Enzyme Inhibitors or Angiotensin II Receptor Blockers and Clinical Outcomes of Sepsis and Septic Shock: A Systematic Review and Meta-analysis. J Cardiovasc Pharmacol 2024; 83:16-22. [PMID: 37815234 DOI: 10.1097/fjc.0000000000001491] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 09/15/2023] [Indexed: 10/11/2023]
Abstract
ABSTRACT Sepsis and septic shock are life-threatening conditions that are associated with high mortality and considerable health care costs. The association between prior angiotensin-converting enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARBs) use and outcomes after sepsis is elusive. The aim of this study was to evaluate the role of the prior use of ACEi or ARBs and outcomes after sepsis and septic shock. A relevant literature review was performed in 4 databases from inception until July 2022. Independent reviewers first screened the title, abstract, and full text, and then, data extraction and analysis were performed. One post hoc analysis of a trial and 6 retrospective cohort studies were included in this review. There were 22% lower odds of in-hospital/30-day mortality among patients who have used ACEi/ARBs in the past [23.83% vs. 37.20%; odds ratio (OR), 0.78, 95% confidence interval (CI), 0.64-0.96], and reduced 90-day mortality (OR, 0.80, 95% CI, 0.69-0.92). ACEi/ARBs users were found to have 31% lesser odds of developing acute kidney injury as compared with nonusers (OR, 0.69, 95% CI, 0.63-0.76). There was no significant difference in the length of hospital stay (MD 1.26, 95% CI, ‒7.89 to 10.42), need for renal replacement therapy (OR, 0.71, 95% CI, 0.13-3.92), mechanical ventilation (OR, 1.10, 95% CI, 0.88-1.37) or use of vasopressors (OR, 1.21, 95% CI, 0.91-1.61). Based on this analysis, prior use of ACEi/ARBs lowers the risk of mortality and adverse renal events in patients with sepsis and septic shock.
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Affiliation(s)
| | - Yub Raj Sedhai
- Division of Pulmonary Disease and Critical Care Medicine, University of Kentucky College of Medicine, Bowling Green, KY
| | - Prakash Raj Oli
- Department of Internal Medicine, Province Hospital, Birendranagar, Nepal
| | | | - Alla Adelkhanova
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, IL
| | - Jurgen Shtembari
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, IL
| | - Tahir Muhammad Abdullah Khan
- Division of Pulmonary Disease and Critical Care Medicine, University of Kentucky College of Medicine, Bowling Green, KY
| | - Karan Singh
- Division of Pulmonary Disease and Critical Care Medicine, University of Kentucky College of Medicine, Bowling Green, KY
| | - Muhammad Altaf Ahmed
- Division of Pulmonary Disease and Critical Care Medicine, University of Kentucky College of Medicine, Bowling Green, KY
| | - Irfan Waheed
- Division of Pulmonary Disease and Critical Care Medicine, University of Kentucky College of Medicine, Bowling Green, KY
| | - Nisarfathima Kazimuddin
- Division of Pulmonary Disease and Critical Care Medicine, University of Kentucky College of Medicine, Bowling Green, KY
| | - Rodney Steff
- Division of Pulmonary Disease and Critical Care Medicine, University of Kentucky College of Medicine, Bowling Green, KY
| | - Roshan Acharya
- Department of Internal Medicine, Division of Pulmonary Disease and Critical Care Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA; and
| | - Nimesh K Patel
- Department of Internal Medicine, Division of Cardiology, Virginia Commonwealth University, School of Medicine, Richmond, VA
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Shtembari J, Shrestha DB, Awal S, Raut A, Gyawali P, Abe T, Patel NK, Deshmukh A, Voruganti D, Bhave PD, Whalen P, Pothineni NVK, Shantha G. Comparative assessment of safety with leadless pacemakers compared to transvenous pacemakers: a systemic review and meta-analysis. J Interv Card Electrophysiol 2023; 66:2165-2175. [PMID: 37106267 DOI: 10.1007/s10840-023-01550-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 03/09/2023] [Accepted: 04/10/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Leadless pacemakers (LP) and transvenous pacemakers (TVP) are two stable pacing platforms currently available in clinical practice. Observational data show mixed results with regards to their comparative safety. This meta-analysis was aimed to evaluate the comparative safety of LP over TVP. METHODS The study protocol was registered in PROSPERO registry (CRD42022325376). Six databases were searched for published literature from inception to April 12, 2022. RevMan 5.4.1 was used for statistical analysis. Odds ratio (OR) and mean difference were used to estimate the outcome with a 95% confidence interval (CI). RESULTS A total of 879 studies were imported from the databases. Among these, 41 papers were screened for full text and 17 meet the inclusion criteria. Among them, pooled results showed 42% lower odds of occurrence of complications in the LP group (OR 0.58, CI 0.42-0.80) compared to TVP group. Notably, 70% lower odds of device dislodgment (OR 0.30, CI 0.21-0.43), 46% lower odds of re-intervention (OR 0.54, CI 0.45-0.64), 87% lower odds of pneumothorax (OR 0.13, CI 0.03-0.57), albeit, 2.65 times higher odds of pericardial effusion (OR 2.65, CI 1.49-4.70) were observed in the LP group. CONCLUSIONS This meta-analysis showed LP to be a significantly safer modality compared to TVP, in terms of re-intervention, device dislodgment, pneumothoraxes, and overall complications. However, there were higher rates of pericardial effusion in the LP group. There was a diverse number of patients included, and all studies were observational. Randomized trials are needed to validate our findings.
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Affiliation(s)
- Jurgen Shtembari
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, IL, USA
| | | | - Shila Awal
- Department of Internal Medicine, Suryabinayak Municipal Hospital, Suryabinayak, Nepal
| | - Anuradha Raut
- Department of Internal Medicine, Nepal Medical College, Kathmandu, Nepal
| | - Pratik Gyawali
- Department of Internal Medicine, Om Saibaba Memorial Hospital, Kathmandu, Nepal
| | - Temidayo Abe
- Department of Internal Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nimesh K Patel
- Department of Internal Medicine, Division of Cardiology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Abhishek Deshmukh
- Department of Cardiology, Division of Electrophysiology, Mayo Clinic, Rochester, MN, USA
| | - Dinesh Voruganti
- Department of Internal Medicine, Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Prashant Dattatraya Bhave
- Department of Cardiology, Division of Electrophysiology, Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - Patrick Whalen
- Department of Cardiology, Division of Electrophysiology, Wake Forest University School of Medicine, Winston Salem, NC, USA
| | | | - Ghanshyam Shantha
- Department of Cardiology, Division of Electrophysiology, Wake Forest University School of Medicine, Winston Salem, NC, USA.
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Oli PR, Shrestha DB, Shtembari J, Gyawali P, Regmi L, Bhandari A, Dhungel S, Mattumpuram J, Pant K, Mungee S. Bivalirudin versus heparin in STEMI after BRIGHT-4 trial: an updated meta-analysis. Coron Artery Dis 2023; 34:562-579. [PMID: 37865864 DOI: 10.1097/mca.0000000000001289] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
BACKGROUND The use of bivalirudin-based anticoagulation over heparin-based anticoagulation for coronary percutaneous intervention has been debated for a long time. Multiple trials have shown promising benefits of bivalirudin over heparin therapy with the most recent addition being the BRIGHT-4 trial. We performed a meta-analysis to assess evidence from these trials, focusing on the coronary intervention of the STEMI population. METHODS This meta-analysis was performed based on PRISMA guidelines after registering in PROSPERO (CRD42023394701). Databases were searched for relevant articles published before January 2023. Pertinent data from the included studies were extracted and analyzed using RevMan v5.4. RESULTS Out of 2375 studies evaluated, 13 randomized control trials with 24 360 acute ST-elevation myocardial infarction patients were included for analysis. The bivalirudin-based anticoagulation reduced the net clinical events (OR 0.75, CI 0.61-0.92), major adverse cardiac or cerebral events (OR 0.85, CI 0.74-0.98), any bleeding (OR 0.61, CI 0.45-0.83), major bleeding (OR 0.54, CI 0.39-0.75), all-cause mortality (OR 0.79, CI 0.67-0.92) and cardiac mortality (OR 0.78, CI 0.65-0.93) significantly without increasing the risk of any stent thrombosis (OR 0.92, 95% CI 0.52-1.61), definite stent thrombosis (OR 1.17, 95% CI 0.62-2.22) and acute stent thrombosis (OR 2.06, 95% CI 0.69-6.09) significantly at 30 days. CONCLUSION Based on this meta-analysis, bivalirudin plus a post-PCI high-dose infusion-based anticoagulation during STEMI PCI has significant benefits over heparin therapy for cardiovascular outcomes without a significant increase in the risk of thrombotic outcomes.
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Affiliation(s)
- Prakash Raj Oli
- Department of Internal Medicine, Karnali Province Hospital, Birendranagar, Nepal
| | | | - Jurgen Shtembari
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, Illinois, USA
| | - Pratik Gyawali
- Department of Internal Medicine, Om Saibaba Memorial Hospital, Kathmandu
| | - Laxmi Regmi
- Department of Internal Medicine, Karnali Province Hospital, Birendranagar
| | - Amit Bhandari
- Department of Internal Medicine, Sait Johns Hospital, HSHS Medical Group, Springfield
| | - Swati Dhungel
- Department of Internal Medicine, Division of Cardiovascular Medicine, John H Stroger Jr. Hospital of Cook County, Chicago, Illinois
| | - Jishanth Mattumpuram
- Division of Cardiology, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky
| | - Kailash Pant
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Illinois College of Medicine, OSF Healthcare, Peoria, Illinois, USA
| | - Sudhir Mungee
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Illinois College of Medicine, OSF Healthcare, Peoria, Illinois, USA
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Shrestha DB, Dawadi S, Dhakal B, Shtembari J, Patel T, Shaikh R, Bodziock GM, Shantha G, Trankle CR, Patel NK. Direct oral anticoagulants (DOAC) versus vitamin K antagonist in left ventricular thrombus: An updated meta-analysis. Health Sci Rep 2023; 6:e1736. [PMID: 38028683 PMCID: PMC10667961 DOI: 10.1002/hsr2.1736] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 07/15/2023] [Revised: 10/29/2023] [Accepted: 11/06/2023] [Indexed: 12/01/2023] Open
Abstract
Background and Aims Current clinical guidelines for treating left ventricular thrombus (LVT) are limited by inadequate evidence to inform the comparative efficacy of oral anticoagulants. In this meta-analysis, we aimed to compare the efficacy and safety of direct oral anticoagulants (DOAC) to vitamin K antagonists (VKA) in patients with LVT. Methods Four standard databases were searched for relevant literature comparing the efficacy and safety between DOAC and VKA for LVT treatment, published before August 19, 2023. Both the randomized controlled trials and observational studies were included in the analysis. The outcomes of interest were the resolution of LVT, all-cause mortality, stroke, systemic embolism, and bleeding. Data from the selected studies were extracted and analyzed using RevMan 5.4 using odds ratio. Results Among 3959 studies from the database search and bibliography review, 33 were included in the analysis. LVT resolution was observed in 72.59% in the DOAC group versus 67.49% in the VKA group (odds ratio [OR]: 1.28, confidence interval [CI]: 1.07-1.53). Mortality was lower in the DOAC group (11.71% vs. 18.56%) (OR: 0.60, CI: 0.36-1.00; borderline statistical significance). Likewise, bleeding events (9.60% vs. 13.19%) (OR: 0.65, CI: 0.52-0.81) and stroke (7.54% vs. 11.04%) (OR: 0.71, CI: 0.53-0.96) were also significantly lower in the DOAC group. Conclusion DOAC use for LVT showed better thrombus resolution and reduced risk of bleeding and stroke compared to VKA. Likewise, DOAC use was associated with lower mortality with borderline statistical significance.
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Affiliation(s)
- Dhan B. Shrestha
- Department of Internal MedicineMount Sinai HospitalChicagoIllinoisUSA
| | - Sagun Dawadi
- Department of Internal MedicineNepalese Army Institute of Health SciencesSanobharyangKathmanduNepal
| | - Bishal Dhakal
- Department of Internal MedicineNepalese Army Institute of Health SciencesSanobharyangKathmanduNepal
| | - Jurgen Shtembari
- Department of Internal MedicineMount Sinai HospitalChicagoIllinoisUSA
| | - Toralben Patel
- Department of Internal Medicine, Division of CardiologyAdventHealth ‐ AdventHealth Medical Group at East OrlandoOrlandoFloridaUSA
| | - Rafae Shaikh
- Department of CardiologyBon SecoursRichmondVirginiaUSA
| | - George M. Bodziock
- Department of Internal Medicine, Division of ElectrophysiologyAtrium Health Wake Forest Baptist Medical Center, Medical Center BoulevardWinston‐SalemNorth CarolinaUSA
| | - Ghanshyam Shantha
- Department of Internal Medicine, Division of ElectrophysiologyAtrium Health Wake Forest Baptist Medical Center, Medical Center BoulevardWinston‐SalemNorth CarolinaUSA
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10
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Shrestha DB, Pathak BD, Thapa N, Shrestha O, Karki S, Shtembari J, Patel NK, Kapoor K, Kalahasty G, Bodziock G, Whalen P, Pothineni NVK, Narasimhan B, Koneru J, Shantha G. Catheter ablation using pulmonary vein isolation with versus without left atrial posterior wall isolation for persistent atrial fibrillation: an updated systematic review and meta-analysis. J Interv Card Electrophysiol 2023:10.1007/s10840-023-01656-z. [PMID: 37773559 DOI: 10.1007/s10840-023-01656-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 09/20/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation of atrial fibrillation (AF); however, the results are suboptimal for persistent AF. The left atrial posterior wall (LAPW) is thought to be a major additional area in initiation and perpetuation of persistent AF. Therefore, adjunctive ablation of the posterior wall may reduce AF recurrence in patients with persistent AF. OBJECTIVE The objective of this study was to compare outcomes of catheter ablation in patients with persistent AF using PVI alone versus a combination of PVI and LAPW isolation. METHODS Literature search was conducted in PubMed, PubMed Central, Scopus, and Embase since inception to February 2023. Screening of studies was done via Covidence software. Risk of bias assessment was done using appropriate tools. Data extraction and a narrative synthesis were carried out accordingly. RESULTS Ten studies were included, of which five were randomized controlled trials. PVI with LAPW ablation group had significantly lower recurrence of overall atrial tachyarrhythmia (OR 0.47, CI 0.32-0.70) and AF (OR 0.39, CI 0.23-0.69). In sensitivity analysis, freedom from atrial arrhythmias was noted to be significantly higher in the PVI with LAPW ablation group (OR 2.22, CI 1.36-3.64). However, there was no significant difference in occurrence of atrial flutter (OR 1.36, CI 0.86-2.14) or with periprocedural adverse events (OR 1.10, CI 0.60-1.99). CONCLUSION LAPW ablation, in addition to PVI, significantly improves the rates of arrhythmia freedom and reduces the recurrence of overall atrial tachyarrhythmia. There was no significant difference in atrial flutter or periprocedural adverse events.
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Affiliation(s)
| | - Bishnu Deep Pathak
- Department of Internal Medicine, Jibjibe Primary Health Care Center, Rasuwa, Nepal
| | - Niranjan Thapa
- Department of Internal Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Oshan Shrestha
- Department of Internal Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Sagun Karki
- Department of Internal Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Jurgen Shtembari
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, IL, USA
| | - Nimesh K Patel
- Department of Internal Medicine, Division of Cardiology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Kunal Kapoor
- Department of Internal Medicine, Division of Cardiology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Gautham Kalahasty
- Department of Internal Medicine, Division of Electrophysiology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - George Bodziock
- Department of Cardiology, Division of Electrophysiology, Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - Patrick Whalen
- Department of Cardiology, Division of Electrophysiology, Wake Forest University School of Medicine, Winston Salem, NC, USA
| | | | - Bharat Narasimhan
- Department of Cardiology, Debakey Cardiovascular Institute, Houston Methodist, Houston, TX, USA
| | - Jayanthi Koneru
- Department of Internal Medicine, Division of Electrophysiology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Ghanshyam Shantha
- Department of Cardiology, Division of Electrophysiology, Wake Forest University School of Medicine, Winston Salem, NC, USA
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11
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Shehata K, Shrestha DB, Shtembari J, Khatiwada R, Khosla S. Left circumflex STEMI presenting as de Winter sign, an ECG Zebra that gives you the chills! A case report. J Electrocardiol 2023; 80:96-98. [PMID: 37295166 DOI: 10.1016/j.jelectrocard.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/10/2023] [Accepted: 05/12/2023] [Indexed: 06/12/2023]
Abstract
de Winter ECG sign is an anterior ST-segment elevation myocardial infarction equivalent, which refers to an occlusion of the proximal left anterior descending (LAD) coronary artery with tall T waves and the absence of ST elevations in the precordial leads on the electrocardiogram (ECG). This sign is often under-recognized and not treated as an ST-segment elevation myocardial infarction which can increase the morbidity and mortality of such a life-threatening condition. Here we report a characteristic de Winter ECG sign involving left circumflex artery as culprit vessel, which was managed with PCI.
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Affiliation(s)
- Kerolus Shehata
- Department of Internal Medicine, Division of Cardiology, Mount Sinai Hospital, Chicago, IL 60608, USA
| | | | - Jurgen Shtembari
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, IL 60608, USA
| | - Roshan Khatiwada
- Department of Internal Medicine, Himal Hospital, Kathmandu 44600, Nepal
| | - Sandeep Khosla
- Department of Internal Medicine, Division of Cardiology, Mount Sinai Hospital, Chicago, IL 60608, USA
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12
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Shrestha DB, Shtembari J, Lamichhane S, Baniya A, Shahi M, Dhungel S, Pant K, Sutton NR, Villablanca P, Mungee S. Safety and efficacy of cerebral embolic protection devices for patients undergoing transcatheter aortic valve replacement: An updated meta-analysis. Health Sci Rep 2023; 6:e1391. [PMID: 37404451 PMCID: PMC10314975 DOI: 10.1002/hsr2.1391] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 03/30/2023] [Revised: 06/18/2023] [Accepted: 06/20/2023] [Indexed: 07/06/2023] Open
Abstract
Background and Aims Cerebral embolic protection (CEP) devices are employed to capture embolic debris and reduce the risk of stroke during transcatheter aortic valve replacement (TAVR). Evidence is mixed regarding the safety and efficacy of CEP. We aimed to summarize the safety and effectiveness of CEP use during TAVR. Methods Electronic databases, including PubMed, PubMed Central, Scopus, Cochrane Library, and Embase, were searched using relevant search terms for articles relating to CEP. All relevant data from 20 studies were extracted into a standardized form. Statistical analyses were performed using Revman 5.4. Odds ratio (OR) or mean differences (MDs) were used to estimate the desired outcome with a 95% confidence interval (CI). Results Twenty studies (eight randomized controlled trials [RCTs]) involving 210,871 patients (19,261 in the CEP group and 191,610 in TAVR without the CEP group) were included. The use of CEP was associated with a lower odds of 30-day mortality by 39% (OR: 0.61, 95% CI: 0.53-0.70) and stroke by 31% (OR: 0.69, 95% CI: 0.52-0.92). Comparing devices, benefit in terms of mortality and stroke was observed with the use of the Sentinel device (Boston Scientific), but not among other devices. No differences were observed in the outcomes of acute kidney injury, major or life-threatening bleeding events, or major vascular complications between groups. When only RCTs were included, there were no observed differences in the primary or secondary outcomes for CEP versus no CEP use during TAVR. Conclusions The totality of evidence suggests a net benefit for the use of CEP, weighted by studies in which the Sentinal device was used. However, given the RCT subanalysis, additional evidence is needed to identify patients at the highest risk of stroke for optimal decision-making.
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Affiliation(s)
| | - Jurgen Shtembari
- Department of Internal MedicineMount Sinai HospitalChicagoIllinoisUSA
| | - Sandesh Lamichhane
- Department of Internal MedicineChitwan Medical College Teaching HospitalBharatpurNepal
| | - Abinash Baniya
- Department of Internal MedicineChitwan Medical College Teaching HospitalBharatpurNepal
| | - Manoj Shahi
- Department of Internal MedicineChitwan Medical College Teaching HospitalBharatpurNepal
| | - Swati Dhungel
- Division of Cardiovascular Medicine, Department of Internal Medicine, John H. StrogerJr. Hospital of Cook CountyChicagoIllinoisUSA
| | - Kailash Pant
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of Illinois College of Medicine, OSF HealthcarePeoriaIllinoisUSA
| | - Nadia R. Sutton
- Division of Cardiovascular Medicine, Department of Internal MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
- Department of Biomedical EngineeringVanderbilt UniversityNashvilleTennesseeUSA
| | - Pedro Villablanca
- Division of Interventional Cardiology and Structural Heart Disease, Department of Internal MedicineThe Center for Structural Heart Disease Henry Ford HospitalDetroitMichiganUSA
| | - Sudhir Mungee
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of Illinois College of Medicine, OSF HealthcarePeoriaIllinoisUSA
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13
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Shrestha B, Shrestha DB, Sedhai YR, Shtembari J, Oli PR, Shikhrakar S, Paudel B, Roberts M, Patel NK, Singh A, Singh K, Waheed I, Basnyat S, Khan MS, Kazimuddin M, Elgendy IY. Differences in treatment and outcomes among patients with ST-segment elevation myocardial infarction with and without standard modifiable risk factors: a systematic review and meta-analysis. Ann Med Surg (Lond) 2023; 85:2916-2923. [PMID: 37363488 PMCID: PMC10289527 DOI: 10.1097/ms9.0000000000000738] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 01/09/2023] [Accepted: 04/19/2023] [Indexed: 06/28/2023] Open
Abstract
There are limited data available on outcomes and pathophysiology behind ST-segment elevation myocardial infarction (STEMI) in populations without standard modifiable risk factors (SMuRFs). The authors carried out this meta-analysis to understand the differences in treatment and outcomes of STEMI patients with and without SMuRFs. Methods A systematic database search was performed for relevant studies. Studies reporting desired outcomes among STEMI patients with and without SMuRFs were selected based on predefined criteria in the study protocol (PROSPERO: CRD42022341389). Two reviewers independently screened titles and abstracts using Covidence. Full texts of the selected studies were independently reviewed to confirm eligibility. Data were extracted from all eligible studies via a full-text review of the primary article for qualitative and quantitative analysis. In-hospital mortality following the first episode of STEMI was the primary outcome, with major adverse cardiovascular events (MACE), repeat myocardial infarction (MI), cardiogenic shock, heart failure, and stroke as secondary outcomes of interest. Odds ratio (OR) with a 95% CI was used to estimate the effect. Results A total of 2135 studies were identified from database search, six studies with 521 150 patients with the first STEMI episode were included in the analysis. The authors found higher in-hospital mortality (OR: 1.43; CI: 1.40-1.47) and cardiogenic shock (OR: 1.59; 95% CI: 1.55-1.63) in the SMuRF-less group with no differences in MACE, recurrent MI, major bleeding, heart failure, and stroke. There were lower prescriptions of statin (OR: 0.62; CI: 0.42-0.91) and Angiotensin converting enzyme inhibitor /Angiotensin II receptor blocker (OR: 0.49; CI: 0.28-0.87) at discharge in SMuRF-less patients. There was no difference in procedures like coronary artery bypass graft, percutaneous coronary intervention, and thrombolysis. Conclusion In the SMuRF-less STEMI patients, higher in-hospital mortality and treatment discrepancies were noted at discharge.
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Affiliation(s)
| | | | - Yub R. Sedhai
- Department of Internal Medicine, Division of Pulmonary Disease and Critical Care, University of Kentucky College of Medicine-Bowling Green Campus, Bowling Green, Kentucky
| | | | - Prakash R. Oli
- Department of Internal Medicine, Province Hospital, Birendranagar, Surkhet
| | - Shreeja Shikhrakar
- Department of Internal Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, Kavrepalanchok, Nepal
| | - Bidhya Paudel
- Department of Internal Medicine, AMITA Health, Ascension Saint Francis, Evanston, Illinois
| | - Madhur Roberts
- Department of Internal Medicine, Division of Cardiology, Tulane University, New Orleans, Louisiana
| | - Nimesh K. Patel
- Department of Internal Medicine, Division of Cardiology, VCU Pauley Heart Center, Virginia Commonwealth University, School of Medicine, Richmond, Virginia, USA
| | - Aniruddha Singh
- Department of Internal Medicine, Division of Cardiology, Tower Health Program, West Reading, Pennsylvania
| | - Karan Singh
- Department of Internal Medicine, Division of Pulmonary Disease and Critical Care, University of Kentucky College of Medicine-Bowling Green Campus, Bowling Green, Kentucky
| | - Irfan Waheed
- Department of Internal Medicine, Division of Pulmonary Disease and Critical Care, University of Kentucky College of Medicine-Bowling Green Campus, Bowling Green, Kentucky
| | - Soney Basnyat
- Department of Internal Medicine, University of Kentucky College of Medicine-Bowling Green Campus
| | - Mohammad S. Khan
- Department of Internal Medicine, Division of Cardiology, University of Kentucky College of Medicine-Bowling Green Campus, Bowling Green
| | - Mohammed Kazimuddin
- Department of Internal Medicine, Division of Cardiology, University of Kentucky College of Medicine-Bowling Green Campus, Bowling Green
| | - Islam Y. Elgendy
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington
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14
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Shrestha DB, Shtembari J, Shehata K, Gondi H, Munagala A, Villegas Santamaria E, Oli PR, Kovacs D, Khosla S. Spontaneous Coronary Artery Dissection in Young Patients: A Case Series and Review of Current Management Algorithm. Cureus 2023; 15:e39393. [PMID: 37378181 PMCID: PMC10292098 DOI: 10.7759/cureus.39393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 02/26/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023] Open
Abstract
Spontaneous coronary artery dissection (SCAD) is a rare but increasingly recognized non-atherosclerotic cause of acute coronary syndrome. Common risk factors for SCAD are coronary atherosclerosis, female gender, peripartum period, systemic inflammatory conditions, and connective tissue disorders. It manifests as myocardial ischemia and infarction, arrhythmia, and sudden cardiac death. We present a case series of two young men and one young female with SCAD who had chest pain and were diagnosed with SCAD-associated ST-elevation myocardial infarction. Its diagnosis requires a high degree of clinical suspicion and its management is guided by the patient's clinical condition and the characteristics of the lesions.
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Affiliation(s)
- Dhan B Shrestha
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, USA
| | - Jurgen Shtembari
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, USA
| | - Kerolus Shehata
- Department of Cardiology, Mount Sinai Hospital, Chicago, USA
| | - Harsha Gondi
- Department of Cardiology, Mount Sinai Hospital, Chicago, USA
| | - Anish Munagala
- Department of Cardiology, Mount Sinai Hospital, Chicago, USA
| | | | - Prakash Raj Oli
- Department of Internal Medicine, Province Hospital, Surkhet, NPL
| | - Daniela Kovacs
- Department of Cardiology, Mount Sinai Hospital, Chicago, USA
| | - Sandeep Khosla
- Department of Cardiology, Mount Sinai Hospital, Chicago, USA
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15
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Shrestha DB, Sedhai YR, Dawadi S, Dhakal B, Shtembari J, Singh K, Acharya R, Basnyat S, Waheed I, Khan MS, Kazimuddin M, Patel NK, Kalahasty G, Bhave PD, Whalen P, Shantha G. Outcome of In-Hospital Cardiac Arrest among Patients with COVID-19: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12082796. [PMID: 37109134 PMCID: PMC10144838 DOI: 10.3390/jcm12082796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/10/2023] [Accepted: 04/06/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Outcomes following in-hospital cardiac arrest (IHCA) in patients with COVID-19 have been reported by several small single-institutional studies; however, there are no large studies contrasting COVID-19 IHCA with non-COVID-19 IHCA. The objective of this study was to compare the outcomes following IHCA between COVID-19 and non-COVID-19 patients. METHODS We searched databases using predefined search terms and appropriate Boolean operators. All the relevant articles published till August 2022 were included in the analyses. The systematic review and meta-analysis were conducted as per Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. An odds ratio with a 95% confidence interval (CI) was used to measure effects. RESULTS Among 855 studies screened, 6 studies with 27,453 IHCA patients (63.84% male) with COVID-19 and 20,766 (59.7% male) without COVID-19 were included in the analysis. IHCA among patients with COVID-19 has lower odds of achieving return of spontaneous circulation (ROSC) (OR: 0.66, 95% CI: 0.62-0.70). Similarly, patients with COVID-19 have higher odds of 30-day mortality following IHCA (OR: 2.26, 95% CI: 2.08-2.45) and have 45% lower odds of cardiac arrest because of a shockable rhythm (OR: 0.55, 95% CI: 0.50-0.60) (9.59% vs. 16.39%). COVID-19 patients less commonly underwent targeted temperature management (TTM) or coronary angiography; however, they were more commonly intubated and on vasopressor therapy as compared to patients who did not have a COVID-19 infection. CONCLUSIONS This meta-analysis showed that IHCA with COVID-19 has a higher mortality and lower rates of ROSC compared with non-COVID-19 IHCA. COVID-19 is an independent risk factor for poor outcomes in IHCA patients.
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Affiliation(s)
| | - Yub Raj Sedhai
- Division of Pulmonary Disease and Critical Care, University of Kentucky College of Medicine-Bowling Green Campus, E 1st Ave, Bowling Green, KY 42101, USA
| | - Sagun Dawadi
- Department of Internal Medicine, Nepalese Army Institute of Health Sciences, Kathmandu 44600, Nepal
| | - Bishal Dhakal
- Department of Internal Medicine, Nepalese Army Institute of Health Sciences, Kathmandu 44600, Nepal
| | - Jurgen Shtembari
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, IL 60608, USA
| | - Karan Singh
- Division of Pulmonary Disease and Critical Care, University of Kentucky College of Medicine-Bowling Green Campus, E 1st Ave, Bowling Green, KY 42101, USA
| | - Roshan Acharya
- Division of Pulmonary Disease and Critical Care Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA 24014, USA
| | - Soney Basnyat
- Department of Internal Medicine, University of Kentucky College of Medicine-Bowling Green Campus, E 1st Ave, Bowling Green, KY 42101, USA
| | - Irfan Waheed
- Division of Pulmonary Disease and Critical Care, University of Kentucky College of Medicine-Bowling Green Campus, E 1st Ave, Bowling Green, KY 42101, USA
| | - Mohammad Saud Khan
- Division of Cardiology, University of Kentucky College of Medicine-Bowling Green Campus, E 1st Ave, Bowling Green, KY 42101, USA
| | - Mohammed Kazimuddin
- Division of Cardiology, University of Kentucky College of Medicine-Bowling Green Campus, E 1st Ave, Bowling Green, KY 42101, USA
| | - Nimesh K Patel
- Department of Internal Medicine, Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, VA 23219, USA
| | - Gautham Kalahasty
- Department of Internal Medicine, Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, VA 23219, USA
| | - Prashant Dattatraya Bhave
- Department of Internal Medicine, Division of Electrophysiology, Atrium Health Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Patrick Whalen
- Department of Internal Medicine, Division of Electrophysiology, Atrium Health Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Ghanshyam Shantha
- Department of Internal Medicine, Division of Electrophysiology, Atrium Health Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157, USA
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16
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Shtembari J, Shrestha DB, Zhang K, Mir WAY. A Rare Case of Right-Sided Aortic Arch With Mirror-Image Branching and Congenital Absence of the Left Pulmonary Artery. Cureus 2023; 15:e38242. [PMID: 37261155 PMCID: PMC10226825 DOI: 10.7759/cureus.38242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 03/05/2023] [Accepted: 04/27/2023] [Indexed: 06/02/2023] Open
Abstract
Both the right-sided aortic arch with mirror-image branching (RAMI) and the congenital absence of the left pulmonary artery are sporadic congenital defects. Both diseases are typically diagnosed in childhood, but occasionally asymptomatic cases may be incidentally detected through imaging in adulthood. We reported a 43-year-old female patient with a RAMI and congenital absence of the left pulmonary artery who was relatively asymptomatic until adulthood.
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Affiliation(s)
- Jurgen Shtembari
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, USA
| | - Dhan B Shrestha
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, USA
| | - Kaiyuan Zhang
- Department of Internal Medicine, Ross University School of Medicine, Bridgetown, BRB
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17
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Shtembari J, Shrestha DB, Zhang K, Rengarajan D, Joshi T. Heroin-Induced Leukoencephalopathy Leading to Locked-In Syndrome: A Case Report. Cureus 2023; 15:e38020. [PMID: 37228564 PMCID: PMC10207984 DOI: 10.7759/cureus.38020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 01/15/2023] [Accepted: 04/23/2023] [Indexed: 05/27/2023] Open
Abstract
Heroin-induced leukoencephalopathy (HLE) is a rare neurological sequela of heroin use. Heroin can be consumed through different routes such as inhalation, intravenous injection, and snorting. HLE cases have been reported via each route. However, heroin vapor inhalation has a higher rate of HLE and is also known as "chasing the dragon syndrome." We present a 65-year-old male who came unresponsive after heroin intoxication. During the hospital stay, he developed locked-in syndrome secondary to brain damage by HLE sequelae.
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Affiliation(s)
- Jurgen Shtembari
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, USA
| | | | - Kaiyuan Zhang
- Department of Internal Medicine, Ross University School of Medicine, Barbados, BRB
| | | | - Tilak Joshi
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, USA
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18
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Shrestha DB, Shtembari J, Sowunmi L, Adhikari A, Joshi T. Streptococcus agalactiae as a Primary Cause of Infective Endocarditis With Septic Emboli in an Undiagnosed Rheumatic Mitral Stenosis Patient: An Encounter in a US-Based Safety-Net Hospital. Cureus 2023; 15:e37802. [PMID: 37213989 PMCID: PMC10198664 DOI: 10.7759/cureus.37802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 09/01/2022] [Accepted: 04/18/2023] [Indexed: 05/23/2023] Open
Abstract
Splenic infarct is a rare sequel of Streptococcus agalactiae infective endocarditis (IE). We report a case of a 43-year-old woman with multiple comorbidities diagnosed with a splenic infarct secondary to group B Streptococcus IE. The development of a splenic hematoma complicated the hospital course. This case highlights the less common etiology of IE and the potential complications.
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Affiliation(s)
- Dhan B Shrestha
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, USA
| | - Jurgen Shtembari
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, USA
| | - Leanne Sowunmi
- Department of Internal Medicine, Ross University School of Medicine, Bridgetown, BRB
| | - Aarya Adhikari
- Department of Internal Medicine, Chitwan Medical College, Bharatpur, NPL
| | - Tilak Joshi
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, USA
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Shtembari J, Shrestha DB, Oli PR, Munagala A, Mullaj E, Shehata K, Kovacs D, Khosla S. Anomalous Origin of the Left Coronary Artery From the Right Coronary Cusp: A Case Report. Cureus 2023; 15:e35711. [PMID: 37025716 PMCID: PMC10072173 DOI: 10.7759/cureus.35711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/02/2023] [Indexed: 03/06/2023] Open
Abstract
Anomalous origin of the left main coronary trunk from the right coronary sinus is a rare condition and is associated with a significantly increased risk of cardiac events, including sudden cardiac death, and it may pose difficulties in their management using revascularization strategies. We present a case of a 68-year-old man with worsening chest pain. Initial evaluation revealed ST elevation of the inferior wall leads and elevated troponins. He was diagnosed with ST-elevation myocardial infarction (STEMI) and sent for emergency cardiac catheterization. Coronary angiography showed 50% stenosis of the mid-right coronary artery (RCA) that extended as a total occlusion to the distal RCA and an unexpected anomalous origin of the left main coronary artery (LMCA). Our patient's LMCA originated from the right cusp sharing a single ostium with the RCA. Multiple attempts of revascularization with percutaneous coronary intervention (PCI), using multiple wires, catheters, and different-sized balloons, were unsuccessful due to complex anatomy. Our patient was managed with medical therapy and discharged home with close cardiology follow-up.
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Shtembari J, Shrestha D, Salazar P, Roy D, Upadhyay GA. INADVERTENT VENTRICULAR SEPTAL DEFECT DURING CONDUCTION SYSTEM PACING DEVICE IMPLANT:A CASE REPORT. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)04320-6] [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: 03/06/2023]
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Khiella M, Shrestha D, Shtembari J, Tran S, Gondi H, Kovacs DF. SEVERE CORONARY VASOSPASM PRESENTING AS A FATAL VENTRICULAR FIBRILLATION: A RARE PRESENTATION. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)04297-3] [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: 03/07/2023]
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Prasai P, Shrestha D, Saad E, Trongtorsak A, Adhikari A, Gaire S, Adhikari P, Devkota A, Oli PR, Shtembari J, Sedhai YR, Akbar MS. ELECTRIC CARDIOVERSION VS PHARMACOLOGICAL THEN ELECTRIC CARDIOVERSION FOR NEW ONSET ATRIAL FIBRILLATION: A META-ANALYSIS. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)00619-8] [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: 03/06/2023]
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Prasai P, Shrestha DB, Saad E, Trongtorsak A, Adhikari A, Gaire S, Oli PR, Shtembari J, Adhikari P, Sedhai YR, Akbar MS, Elgendy IY, Shantha G. Electric Cardioversion vs. Pharmacological with or without Electric Cardioversion for Stable New-Onset Atrial Fibrillation: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12031165. [PMID: 36769812 PMCID: PMC9918032 DOI: 10.3390/jcm12031165] [Citation(s) in RCA: 1] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/16/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND There is no clear consensus on the preference for pharmacological cardioversion (PC) in comparison to electric cardioversion (EC) for hemodynamically stable new-onset atrial fibrillation (NOAF) patients presenting to the emergency department (ED). METHODS A systematic review and meta-analysis was conducted to assess PC (whether being followed by EC or not) vs. EC in achieving cardioversion for hemodynamically stable NOAF patients. PubMed, PubMed Central, Embase, Scopus, and Cochrane databases were searched to include relevant studies until 7 March 2022. The primary outcome was the successful restoration of sinus rhythm, and secondary outcomes included emergency department (ED) revisits with atrial fibrillation (AF), hospital readmission rate, length of hospital stay, and cardioversion-associated adverse events. RESULTS A total of three randomized controlled trials (RCTs) and one observational study were included. There was no difference in the rates of successful restoration to sinus rhythm (88.66% vs. 85.25%; OR 1.14, 95% CI 0.35-3.71; n = 868). There was no statistical difference across the two groups for ED revisits with AF, readmission rates, length of hospital stay, and cardioversion-associated adverse effects, with the exception of hypotension, whose incidence was lower in the EC group (OR 0.11, 95% CI 0.04-0.27: n = 727). CONCLUSION This meta-analysis suggests that there is no difference in successful restoration of sinus rhythm with either modality among patients with hemodynamically stable NOAF.
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Affiliation(s)
- Paritosh Prasai
- Department of Internal Medicine, Ascension Health St. Francis Hospital, Evanston, IL 60202, USA
- Correspondence: (P.P.); (D.B.S.)
| | - Dhan Bahadur Shrestha
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, IL 60608, USA
- Correspondence: (P.P.); (D.B.S.)
| | - Eltaib Saad
- Department of Internal Medicine, Ascension Health St. Francis Hospital, Evanston, IL 60202, USA
| | - Angkawipa Trongtorsak
- Department of Internal Medicine, Ascension Health St. Francis Hospital, Evanston, IL 60202, USA
| | - Aarya Adhikari
- Department of Internal Medicine, Chitwan Medical College, Chitwan 44200, Nepal
| | - Suman Gaire
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, IL 60608, USA
| | - Prakash Raj Oli
- Department of Internal Medicine, Province Hospital, Birendranagar 21700, Nepal
| | - Jurgen Shtembari
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, IL 60608, USA
| | - Pabitra Adhikari
- Department of Internal Medicine, Ascension Health St. Francis Hospital, Evanston, IL 60202, USA
| | - Yub Raj Sedhai
- Division of Pulmonary Disease and Critical Care Medicine, University of Kentucky College of Medicine, Bowling Green, KY 42101, USA
| | - Muhammad Sikander Akbar
- Department of Internal Medicine, Division of Cardiology, Ascension Health St. Francis Hospital, Evanston, IL 60202, USA
| | - Islam Y. Elgendy
- Division of Cardiology, University of Kentucky, Lexington, KY 40506, USA
| | - Ghanshyam Shantha
- Department of Internal Medicine, Division of Electrophysiology, Atrium Health, Wake Forest Baptist Health, Medical Center Boulevard, Winston-Salem, NC 27157, USA
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Shrestha DB, Shtembari J, Achhami E, Adhikari L, Rengarajan D. Posterior Reversible Encephalopathy Syndrome in a Male With Polysubstance Abuse: A Case Report. Cureus 2023; 15:e34477. [PMID: 36874686 PMCID: PMC9981862 DOI: 10.7759/cureus.34477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 09/17/2022] [Accepted: 01/31/2023] [Indexed: 02/04/2023] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a neurologic disorder with multiple etiologies. The signs and symptoms of PRES are non-specific, making the differential diagnosis broad. Although PRES is suspected clinically, a diagnosis requires characteristic findings on imaging. In patients with undiagnosed PRES, the coexistence of substance abuse can divert the care provider from pursuing imaging studies, leading to a missed diagnosis. We describe the case of a 51-year-old male who presented with altered mental status and was diagnosed with PRES despite having a positive urine drug screen.
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Affiliation(s)
| | - Jurgen Shtembari
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, USA
| | - Eliz Achhami
- Department of Internal Medicine, Sukraraj Tropical & Infectious Disease Hospital, Kathmandu, NPL
| | - Lukash Adhikari
- Department of Internal Medicine, Patan Academy of Health Sciences, Lalitpur, NPL
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