18th World Congress on Heart Disease

VANCOUVER, B.C. – Ready to get started doing transradial percutaneous interventions? Begin under the guidance of an experienced practitioner, perform simple cases in lower-risk patients, and progress to more difficult cases as expertise builds, advised Dr. Asim Cheema, an interventional cardiologist at St. Michael’s Hospital in Toronto.

It’s best to start with a solid foundation in transfemoral PCI, and begin using the radial approach in stable patients who have single vessel disease and are presenting for angiography or some other elective procedure, he said.

"After about 40 patients, you can gradually start to become more comfortable doing multivessel PCI. Then, you can move on to an [acute coronary syndrome] setting, but still not STEMI [ST segment elevation myocardial infarction], and still predominately in larger males" because they have larger radial arteries. In the transition from transfemoral to transradial PCI, don’t hesitate to "switch to femoral [access] for unusual anatomy, technical difficulties," or other problems, Dr. Cheema said at the18th World Congress on Heart Disease.

At first, it’s best to avoid smaller and older patients. Transradial failure rates are greatest for those over age 75 years, in part because of subclavian tortuosity. Also, "if you are dealing with a small woman, she might have very small radial arteries that increase the chances of failure." Prior bypass grafting is a red flag for newer operators, too; among other problems, the grafts may be occluded. "Young patients and big patients and elective cases are where you want to start," he said.

Primary and complex PCI involving saphenous vein grafts or left main disease should not be attempted before doing more than 150 transradial procedures," recommended Dr. Cheema, who is a transradial PCI practitioner and researcher.

Familiarity with the technology is another important consideration, he said.

Hydrophilic sheaths, tapered and with a slippery coating, are important "because the radial artery is a small caliber vessel, [so] it’s more prone to spasm than the femoral artery. If you use a regular sheath, it causes spasm and you cannot maintain access," Dr. Cheema said.

"You want to use a 260-cm" exchange-length guide wire, as well, instead of the 180-cm wires used in femoral cases. "When you are doing radial [PCI], you have to be very careful about maintaining the wire position. You need a longer wire so it stays in place and your catheter can be exchanged," he said.

Dr. Cheema said he has no disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – Ready to get started doing transradial percutaneous interventions? Begin under the guidance of an experienced practitioner, perform simple cases in lower-risk patients, and progress to more difficult cases as expertise builds, advised Dr. Asim Cheema, an interventional cardiologist at St. Michael’s Hospital in Toronto.

It’s best to start with a solid foundation in transfemoral PCI, and begin using the radial approach in stable patients who have single vessel disease and are presenting for angiography or some other elective procedure, he said.

"After about 40 patients, you can gradually start to become more comfortable doing multivessel PCI. Then, you can move on to an [acute coronary syndrome] setting, but still not STEMI [ST segment elevation myocardial infarction], and still predominately in larger males" because they have larger radial arteries. In the transition from transfemoral to transradial PCI, don’t hesitate to "switch to femoral [access] for unusual anatomy, technical difficulties," or other problems, Dr. Cheema said at the18th World Congress on Heart Disease.

At first, it’s best to avoid smaller and older patients. Transradial failure rates are greatest for those over age 75 years, in part because of subclavian tortuosity. Also, "if you are dealing with a small woman, she might have very small radial arteries that increase the chances of failure." Prior bypass grafting is a red flag for newer operators, too; among other problems, the grafts may be occluded. "Young patients and big patients and elective cases are where you want to start," he said.

Primary and complex PCI involving saphenous vein grafts or left main disease should not be attempted before doing more than 150 transradial procedures," recommended Dr. Cheema, who is a transradial PCI practitioner and researcher.

Familiarity with the technology is another important consideration, he said.

Hydrophilic sheaths, tapered and with a slippery coating, are important "because the radial artery is a small caliber vessel, [so] it’s more prone to spasm than the femoral artery. If you use a regular sheath, it causes spasm and you cannot maintain access," Dr. Cheema said.

"You want to use a 260-cm" exchange-length guide wire, as well, instead of the 180-cm wires used in femoral cases. "When you are doing radial [PCI], you have to be very careful about maintaining the wire position. You need a longer wire so it stays in place and your catheter can be exchanged," he said.

Dr. Cheema said he has no disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – Ready to get started doing transradial percutaneous interventions? Begin under the guidance of an experienced practitioner, perform simple cases in lower-risk patients, and progress to more difficult cases as expertise builds, advised Dr. Asim Cheema, an interventional cardiologist at St. Michael’s Hospital in Toronto.

It’s best to start with a solid foundation in transfemoral PCI, and begin using the radial approach in stable patients who have single vessel disease and are presenting for angiography or some other elective procedure, he said.

"After about 40 patients, you can gradually start to become more comfortable doing multivessel PCI. Then, you can move on to an [acute coronary syndrome] setting, but still not STEMI [ST segment elevation myocardial infarction], and still predominately in larger males" because they have larger radial arteries. In the transition from transfemoral to transradial PCI, don’t hesitate to "switch to femoral [access] for unusual anatomy, technical difficulties," or other problems, Dr. Cheema said at the18th World Congress on Heart Disease.

At first, it’s best to avoid smaller and older patients. Transradial failure rates are greatest for those over age 75 years, in part because of subclavian tortuosity. Also, "if you are dealing with a small woman, she might have very small radial arteries that increase the chances of failure." Prior bypass grafting is a red flag for newer operators, too; among other problems, the grafts may be occluded. "Young patients and big patients and elective cases are where you want to start," he said.

Primary and complex PCI involving saphenous vein grafts or left main disease should not be attempted before doing more than 150 transradial procedures," recommended Dr. Cheema, who is a transradial PCI practitioner and researcher.

Familiarity with the technology is another important consideration, he said.

Hydrophilic sheaths, tapered and with a slippery coating, are important "because the radial artery is a small caliber vessel, [so] it’s more prone to spasm than the femoral artery. If you use a regular sheath, it causes spasm and you cannot maintain access," Dr. Cheema said.

"You want to use a 260-cm" exchange-length guide wire, as well, instead of the 180-cm wires used in femoral cases. "When you are doing radial [PCI], you have to be very careful about maintaining the wire position. You need a longer wire so it stays in place and your catheter can be exchanged," he said.

Dr. Cheema said he has no disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – B-type natriuretic peptide elevations above 1,000 pg/mL may herald worse prognosis in patients with diastolic heart failure but normal renal function, according to a retrospective database analysis from the University of California, Davis.

Among 421 hospitalized patients with diastolic heart failure – heart failure (HF) with ejection fractions above 45% – investigators found that 117 (28%) patients had B-type natriuretic peptide (BNP) levels above 1,000 pg/mL.

Fifty of those patients (43%) had stage IV or V chronic kidney disease, compared with 7 (13%) of the 54 diastolic HF patients with BNPs below 100 pg/mL. The team also found a significant relationship between estimated glomerular filtration rate (eGFR) and BNP (R = 0.39). In most cases, BNP levels above 1,000 pg/mL "were likely due to reduced [renal] clearance and associated factors. The degree of renal dysfunction is related to the degree of BNP elevation," said senior investigator Dr. Saul Schaefer, professor at the university and also chief of cardiology at the Veterans Affairs Medical Center in Sacramento.

But 25 patients (21%) with BNPs above 1,000 pg/mL "actually had normal renal function; that is, an [eGFR] greater than 60 mL/min per 1.73 m². It’s unclear why these patients would have such an elevated BNP. They were older [mean age 70.2 years vs. 67.7 years] and had slightly reduced ejection fractions in comparison to the overall group," he said at the 18th World Congress on Heart Disease.

"My guess is that these patients with high BNPs and normal renal function have more severe abnormalities and diastolic failure. It’s a potential marker of higher risk. We could potentially follow these patients more closely and treat them more aggressively," he said.

Before that happens, however, "we need to prospectively look at these patients and see if they can be distinguished from the lower-BNP patients, and track them to see whether their prognosis is adversely affected," Dr. Schaefer said.

Compared with diastolic HF patients in the study with BNPs below 100 pg/mL, the 117 with levels above 1,000 pg/mL tended to be older (68 vs. 61.4 years), have higher troponin levels (0.2 vs. 0 ng/mL), and have greater use of antihypertensive medications, suggesting that they had more chronic hypertension. There were no associations between markedly elevated BNP and gender, diabetes, or ischemic heart disease. Echo parameters did not predict BNP.

Dr. Schaefer said that he had no relevant disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – B-type natriuretic peptide elevations above 1,000 pg/mL may herald worse prognosis in patients with diastolic heart failure but normal renal function, according to a retrospective database analysis from the University of California, Davis.

Among 421 hospitalized patients with diastolic heart failure – heart failure (HF) with ejection fractions above 45% – investigators found that 117 (28%) patients had B-type natriuretic peptide (BNP) levels above 1,000 pg/mL.

Fifty of those patients (43%) had stage IV or V chronic kidney disease, compared with 7 (13%) of the 54 diastolic HF patients with BNPs below 100 pg/mL. The team also found a significant relationship between estimated glomerular filtration rate (eGFR) and BNP (R = 0.39). In most cases, BNP levels above 1,000 pg/mL "were likely due to reduced [renal] clearance and associated factors. The degree of renal dysfunction is related to the degree of BNP elevation," said senior investigator Dr. Saul Schaefer, professor at the university and also chief of cardiology at the Veterans Affairs Medical Center in Sacramento.

But 25 patients (21%) with BNPs above 1,000 pg/mL "actually had normal renal function; that is, an [eGFR] greater than 60 mL/min per 1.73 m². It’s unclear why these patients would have such an elevated BNP. They were older [mean age 70.2 years vs. 67.7 years] and had slightly reduced ejection fractions in comparison to the overall group," he said at the 18th World Congress on Heart Disease.

"My guess is that these patients with high BNPs and normal renal function have more severe abnormalities and diastolic failure. It’s a potential marker of higher risk. We could potentially follow these patients more closely and treat them more aggressively," he said.

Before that happens, however, "we need to prospectively look at these patients and see if they can be distinguished from the lower-BNP patients, and track them to see whether their prognosis is adversely affected," Dr. Schaefer said.

Compared with diastolic HF patients in the study with BNPs below 100 pg/mL, the 117 with levels above 1,000 pg/mL tended to be older (68 vs. 61.4 years), have higher troponin levels (0.2 vs. 0 ng/mL), and have greater use of antihypertensive medications, suggesting that they had more chronic hypertension. There were no associations between markedly elevated BNP and gender, diabetes, or ischemic heart disease. Echo parameters did not predict BNP.

Dr. Schaefer said that he had no relevant disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – B-type natriuretic peptide elevations above 1,000 pg/mL may herald worse prognosis in patients with diastolic heart failure but normal renal function, according to a retrospective database analysis from the University of California, Davis.

Among 421 hospitalized patients with diastolic heart failure – heart failure (HF) with ejection fractions above 45% – investigators found that 117 (28%) patients had B-type natriuretic peptide (BNP) levels above 1,000 pg/mL.

Fifty of those patients (43%) had stage IV or V chronic kidney disease, compared with 7 (13%) of the 54 diastolic HF patients with BNPs below 100 pg/mL. The team also found a significant relationship between estimated glomerular filtration rate (eGFR) and BNP (R = 0.39). In most cases, BNP levels above 1,000 pg/mL "were likely due to reduced [renal] clearance and associated factors. The degree of renal dysfunction is related to the degree of BNP elevation," said senior investigator Dr. Saul Schaefer, professor at the university and also chief of cardiology at the Veterans Affairs Medical Center in Sacramento.

But 25 patients (21%) with BNPs above 1,000 pg/mL "actually had normal renal function; that is, an [eGFR] greater than 60 mL/min per 1.73 m². It’s unclear why these patients would have such an elevated BNP. They were older [mean age 70.2 years vs. 67.7 years] and had slightly reduced ejection fractions in comparison to the overall group," he said at the 18th World Congress on Heart Disease.

"My guess is that these patients with high BNPs and normal renal function have more severe abnormalities and diastolic failure. It’s a potential marker of higher risk. We could potentially follow these patients more closely and treat them more aggressively," he said.

Before that happens, however, "we need to prospectively look at these patients and see if they can be distinguished from the lower-BNP patients, and track them to see whether their prognosis is adversely affected," Dr. Schaefer said.

Compared with diastolic HF patients in the study with BNPs below 100 pg/mL, the 117 with levels above 1,000 pg/mL tended to be older (68 vs. 61.4 years), have higher troponin levels (0.2 vs. 0 ng/mL), and have greater use of antihypertensive medications, suggesting that they had more chronic hypertension. There were no associations between markedly elevated BNP and gender, diabetes, or ischemic heart disease. Echo parameters did not predict BNP.

Dr. Schaefer said that he had no relevant disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – ECG leads were misplaced in 3% of 1,470 pediatric ECGs, based on a review study performed at the Ochsner Medical Center in New Orleans.

Crisscrossed leads were seen in 45 studies; 19 were left arm/left leg reversals, 15 were left arm/right arm reversals, 8 were precordial misplacements, and 3 were right arm/right leg reversals. The majority, 31 of the 45 errors, happened in the pediatric outpatient clinic. Six occurred in the emergency department, and eight in the hospital. While the placements were done by nurses and technicians, pediatric electrophysiologists and other physicians signed off on the reports without catching the mistakes.

Part of the problem "is the high number of ECGs that you have to read, the low reimbursement rate, and people talking" over your shoulder expecting a quick signature because most pediatric ECGs turn up nothing, said senior investigator Dr. Christopher Snyder, a pediatric cardiologist and electrophysiologist formerly at Ochsner, but now with Case Western Reserve University in Cleveland. "Small chests can also make lead placement tricky; the kids were 10.4 years old on average."

That being said, Dr. Snyder said he reviewed all of these cases "in an hour and 20 minutes. You can pick these out pretty easily" from polarity reversals and other signs.

"I think we need to take maybe 3 seconds to interpret ECGs, as opposed to 1," he remarked.

Dr. Snyder undertook the review after an ECG error resulted in a child being sent to the cath lab at Ochsner with a presumed MI.

"I came in on a Saturday morning and found out that this kid was in the cath lab, and he’d already had his coronaries shot. I ran down there and said ‘this is lead reversal,’ but they didn’t buy into it," even after his coronaries turned out to be normal, Dr. Snyder said. The leads were misplaced; the nurse didn’t understand that "left and right are reversed when you’re looking at someone."

In general, lead misplacement doesn’t result in that much harm, but it does lead to echoes, Holters, and follow-up visits that wouldn’t have happened if ECGs had been done right in the first place, he said.

Dr. Snyder said he had no relevant disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – ECG leads were misplaced in 3% of 1,470 pediatric ECGs, based on a review study performed at the Ochsner Medical Center in New Orleans.

Crisscrossed leads were seen in 45 studies; 19 were left arm/left leg reversals, 15 were left arm/right arm reversals, 8 were precordial misplacements, and 3 were right arm/right leg reversals. The majority, 31 of the 45 errors, happened in the pediatric outpatient clinic. Six occurred in the emergency department, and eight in the hospital. While the placements were done by nurses and technicians, pediatric electrophysiologists and other physicians signed off on the reports without catching the mistakes.

Part of the problem "is the high number of ECGs that you have to read, the low reimbursement rate, and people talking" over your shoulder expecting a quick signature because most pediatric ECGs turn up nothing, said senior investigator Dr. Christopher Snyder, a pediatric cardiologist and electrophysiologist formerly at Ochsner, but now with Case Western Reserve University in Cleveland. "Small chests can also make lead placement tricky; the kids were 10.4 years old on average."

That being said, Dr. Snyder said he reviewed all of these cases "in an hour and 20 minutes. You can pick these out pretty easily" from polarity reversals and other signs.

"I think we need to take maybe 3 seconds to interpret ECGs, as opposed to 1," he remarked.

Dr. Snyder undertook the review after an ECG error resulted in a child being sent to the cath lab at Ochsner with a presumed MI.

"I came in on a Saturday morning and found out that this kid was in the cath lab, and he’d already had his coronaries shot. I ran down there and said ‘this is lead reversal,’ but they didn’t buy into it," even after his coronaries turned out to be normal, Dr. Snyder said. The leads were misplaced; the nurse didn’t understand that "left and right are reversed when you’re looking at someone."

In general, lead misplacement doesn’t result in that much harm, but it does lead to echoes, Holters, and follow-up visits that wouldn’t have happened if ECGs had been done right in the first place, he said.

Dr. Snyder said he had no relevant disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – ECG leads were misplaced in 3% of 1,470 pediatric ECGs, based on a review study performed at the Ochsner Medical Center in New Orleans.

Crisscrossed leads were seen in 45 studies; 19 were left arm/left leg reversals, 15 were left arm/right arm reversals, 8 were precordial misplacements, and 3 were right arm/right leg reversals. The majority, 31 of the 45 errors, happened in the pediatric outpatient clinic. Six occurred in the emergency department, and eight in the hospital. While the placements were done by nurses and technicians, pediatric electrophysiologists and other physicians signed off on the reports without catching the mistakes.

Part of the problem "is the high number of ECGs that you have to read, the low reimbursement rate, and people talking" over your shoulder expecting a quick signature because most pediatric ECGs turn up nothing, said senior investigator Dr. Christopher Snyder, a pediatric cardiologist and electrophysiologist formerly at Ochsner, but now with Case Western Reserve University in Cleveland. "Small chests can also make lead placement tricky; the kids were 10.4 years old on average."

That being said, Dr. Snyder said he reviewed all of these cases "in an hour and 20 minutes. You can pick these out pretty easily" from polarity reversals and other signs.

"I think we need to take maybe 3 seconds to interpret ECGs, as opposed to 1," he remarked.

Dr. Snyder undertook the review after an ECG error resulted in a child being sent to the cath lab at Ochsner with a presumed MI.

"I came in on a Saturday morning and found out that this kid was in the cath lab, and he’d already had his coronaries shot. I ran down there and said ‘this is lead reversal,’ but they didn’t buy into it," even after his coronaries turned out to be normal, Dr. Snyder said. The leads were misplaced; the nurse didn’t understand that "left and right are reversed when you’re looking at someone."

In general, lead misplacement doesn’t result in that much harm, but it does lead to echoes, Holters, and follow-up visits that wouldn’t have happened if ECGs had been done right in the first place, he said.

Dr. Snyder said he had no relevant disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – When done safely, MRI imaging has an important role to play in patients with pacemakers and implanted cardioverter defibrillators, according to a study of 32 patients who underwent the procedure without complications at Allegheny General Hospital in Pittsburgh.

"It looks like this is safe in the right situation," based on the results and ongoing research elsewhere. "There are occasions – more often than you might think – when" MRI imaging of such patients has "potentially life-saving consequences. I would suggest it is probably no longer taboo," said lead investigator Dr. Robert Biederman, director of cardiovascular MRI at Allegheny and an associate professor of medicine at Drexel University in Philadelphia.

Among the 32 patients in the study, 23 underwent neurologic MRI imaging, and 9 underwent cardiac MRI imaging.

The neurologic MRI imaging picked up a case of Creutzfeldt–Jakob disease in one with unexplained altered mental status, and a syrinx in another who had unexplained arm weakness, a finding that made a "huge difference neurosurgically." Overall, neurologic imaging made or altered diagnoses in 15 patients, and confirmed them in eight, Dr. Biederman said at the 18th World Congress on Heart Disease.

Cardiac MRI imaging picked up cardiac sarcoidosis in one, and constrictive pericarditis in another. In six cases, it simply confirmed provisional diagnoses. Even so, "there is value in confirming for surgeons, patients, and family members that they are doing the right thing," he said.

Often, in the absence of a solid diagnosis, the "patients were going to die." Imaging was only done, however, after conversations that sometimes ran more than an hour with patients and family members about the risks of MRIs with pacemakers (PM) and automated implantable cardioverter-defibrillators (AICD), including tissue cauterization, fibrosis, lethal tachycardia, and device misfire. "This was absolutely done with the patient’s full knowledge of risk," he said.

Although MRIs have caused at least 12 deaths in patients with PMs and AICDs over the last 3 decades, ongoing research with newer devices is beginning to suggest it’s safe if proper device and MRI adjustments are made; well over 1,000 patients have undergone MRIs in recent years with no complications. Even so, "assuming it is safe, no one’s asked if it makes a difference. This is the first time to my knowledge that anyone has stepped beyond the question of safety to see if results from MRIs" in these patients "warrant the risk," Dr. Biederman said (e.g., Am. Heart J. 2013;165:266-72).

Four of the patients had combination PM/AICDs, 18 had dual-chamber PMs, three dependent PMs, five AICDs, and two just single pacer leads. Only one patient had a Revo MRI SureScan Pacing System, the only pacer FDA- approved for MRI use. Scans ran an average of a half hour, plus or minus 15 minutes; a few patients were scanned twice.

The MRIs were performed in a dedicated cardiovascular MRI suite with continuous ECG, blood pressure, heart rate, and oxygen saturation monitoring. "We turned all the defibrillator technology off, and tried to turn the pacemaker off. If we couldn’t, we turned it to an asynchronous mode." Sequences were done at a specific absorption rate (SAR) of less than 2 W/kg, because "there is less radiofrequency energy being sent at a slower rate, so [it’s] less likely" to heat the device. "We try to keep the specific absorption rate as low as possible," Dr. Biederman said.

Devices were reset and tested after the procedure to ensure that impedance, thresholds, amplitudes, and shock impedances were the same as before the scans.

Dr. Biederman said he has no disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – When done safely, MRI imaging has an important role to play in patients with pacemakers and implanted cardioverter defibrillators, according to a study of 32 patients who underwent the procedure without complications at Allegheny General Hospital in Pittsburgh.

"It looks like this is safe in the right situation," based on the results and ongoing research elsewhere. "There are occasions – more often than you might think – when" MRI imaging of such patients has "potentially life-saving consequences. I would suggest it is probably no longer taboo," said lead investigator Dr. Robert Biederman, director of cardiovascular MRI at Allegheny and an associate professor of medicine at Drexel University in Philadelphia.

Among the 32 patients in the study, 23 underwent neurologic MRI imaging, and 9 underwent cardiac MRI imaging.

The neurologic MRI imaging picked up a case of Creutzfeldt–Jakob disease in one with unexplained altered mental status, and a syrinx in another who had unexplained arm weakness, a finding that made a "huge difference neurosurgically." Overall, neurologic imaging made or altered diagnoses in 15 patients, and confirmed them in eight, Dr. Biederman said at the 18th World Congress on Heart Disease.

Cardiac MRI imaging picked up cardiac sarcoidosis in one, and constrictive pericarditis in another. In six cases, it simply confirmed provisional diagnoses. Even so, "there is value in confirming for surgeons, patients, and family members that they are doing the right thing," he said.

Often, in the absence of a solid diagnosis, the "patients were going to die." Imaging was only done, however, after conversations that sometimes ran more than an hour with patients and family members about the risks of MRIs with pacemakers (PM) and automated implantable cardioverter-defibrillators (AICD), including tissue cauterization, fibrosis, lethal tachycardia, and device misfire. "This was absolutely done with the patient’s full knowledge of risk," he said.

Although MRIs have caused at least 12 deaths in patients with PMs and AICDs over the last 3 decades, ongoing research with newer devices is beginning to suggest it’s safe if proper device and MRI adjustments are made; well over 1,000 patients have undergone MRIs in recent years with no complications. Even so, "assuming it is safe, no one’s asked if it makes a difference. This is the first time to my knowledge that anyone has stepped beyond the question of safety to see if results from MRIs" in these patients "warrant the risk," Dr. Biederman said (e.g., Am. Heart J. 2013;165:266-72).

Four of the patients had combination PM/AICDs, 18 had dual-chamber PMs, three dependent PMs, five AICDs, and two just single pacer leads. Only one patient had a Revo MRI SureScan Pacing System, the only pacer FDA- approved for MRI use. Scans ran an average of a half hour, plus or minus 15 minutes; a few patients were scanned twice.

The MRIs were performed in a dedicated cardiovascular MRI suite with continuous ECG, blood pressure, heart rate, and oxygen saturation monitoring. "We turned all the defibrillator technology off, and tried to turn the pacemaker off. If we couldn’t, we turned it to an asynchronous mode." Sequences were done at a specific absorption rate (SAR) of less than 2 W/kg, because "there is less radiofrequency energy being sent at a slower rate, so [it’s] less likely" to heat the device. "We try to keep the specific absorption rate as low as possible," Dr. Biederman said.

Devices were reset and tested after the procedure to ensure that impedance, thresholds, amplitudes, and shock impedances were the same as before the scans.

Dr. Biederman said he has no disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – When done safely, MRI imaging has an important role to play in patients with pacemakers and implanted cardioverter defibrillators, according to a study of 32 patients who underwent the procedure without complications at Allegheny General Hospital in Pittsburgh.

"It looks like this is safe in the right situation," based on the results and ongoing research elsewhere. "There are occasions – more often than you might think – when" MRI imaging of such patients has "potentially life-saving consequences. I would suggest it is probably no longer taboo," said lead investigator Dr. Robert Biederman, director of cardiovascular MRI at Allegheny and an associate professor of medicine at Drexel University in Philadelphia.

Among the 32 patients in the study, 23 underwent neurologic MRI imaging, and 9 underwent cardiac MRI imaging.

The neurologic MRI imaging picked up a case of Creutzfeldt–Jakob disease in one with unexplained altered mental status, and a syrinx in another who had unexplained arm weakness, a finding that made a "huge difference neurosurgically." Overall, neurologic imaging made or altered diagnoses in 15 patients, and confirmed them in eight, Dr. Biederman said at the 18th World Congress on Heart Disease.

Cardiac MRI imaging picked up cardiac sarcoidosis in one, and constrictive pericarditis in another. In six cases, it simply confirmed provisional diagnoses. Even so, "there is value in confirming for surgeons, patients, and family members that they are doing the right thing," he said.

Often, in the absence of a solid diagnosis, the "patients were going to die." Imaging was only done, however, after conversations that sometimes ran more than an hour with patients and family members about the risks of MRIs with pacemakers (PM) and automated implantable cardioverter-defibrillators (AICD), including tissue cauterization, fibrosis, lethal tachycardia, and device misfire. "This was absolutely done with the patient’s full knowledge of risk," he said.

Although MRIs have caused at least 12 deaths in patients with PMs and AICDs over the last 3 decades, ongoing research with newer devices is beginning to suggest it’s safe if proper device and MRI adjustments are made; well over 1,000 patients have undergone MRIs in recent years with no complications. Even so, "assuming it is safe, no one’s asked if it makes a difference. This is the first time to my knowledge that anyone has stepped beyond the question of safety to see if results from MRIs" in these patients "warrant the risk," Dr. Biederman said (e.g., Am. Heart J. 2013;165:266-72).

Four of the patients had combination PM/AICDs, 18 had dual-chamber PMs, three dependent PMs, five AICDs, and two just single pacer leads. Only one patient had a Revo MRI SureScan Pacing System, the only pacer FDA- approved for MRI use. Scans ran an average of a half hour, plus or minus 15 minutes; a few patients were scanned twice.

The MRIs were performed in a dedicated cardiovascular MRI suite with continuous ECG, blood pressure, heart rate, and oxygen saturation monitoring. "We turned all the defibrillator technology off, and tried to turn the pacemaker off. If we couldn’t, we turned it to an asynchronous mode." Sequences were done at a specific absorption rate (SAR) of less than 2 W/kg, because "there is less radiofrequency energy being sent at a slower rate, so [it’s] less likely" to heat the device. "We try to keep the specific absorption rate as low as possible," Dr. Biederman said.

Devices were reset and tested after the procedure to ensure that impedance, thresholds, amplitudes, and shock impedances were the same as before the scans.

Dr. Biederman said he has no disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – It makes little difference if percutaneous coronary interventions are done in a facility with on-site bypass rescue or not; safety outcomes are statistically the same, according to a prospective observational study of more than 100,000 PCI cases in California.

Adjusted for lesion, patient, and other risk factors, the composite rate of in-hospital death or emergent coronary artery bypass grafting (CABG) was 2.11% for 99,332 PCIs – about 18% of them ST-elevation myocardial infarctions – at 116 facilities offering on-site cardiac surgery and 1.58% for 2,601 procedures – about a third of them STEMIs – at six facilities where patients had to be transferred elsewhere, if needed, for emergency bypass.

The on-site hospitals had 1.16% of their non–ST-elevation MI (NSTEMI) cases end in death or emergent CABG; 1.15% of NSTEMI cases ended that way in the six sites that did not offer cardiac surgery, a nonsignificant difference.

"Off-site hospitals can do just as well as on-site hospitals for the overall composite of mortality and emergent CABG. The overall success rates are the same," said lead investigator Dr. William Bommer, president of California’s American College of Cardiology chapter.

The goal of the ongoing project is to see if it would be safe to end California’s requirement that PCIs, for the most part, be done only in hospitals that offer on-site cardiovascular surgery, a question other states are struggling with as well. The California provision dates to the 1980s, when the procedure was more risky than it is now. Prompted by Dr. Bommer and his chapter’s suggestion, the state legislature allowed the six pilot sites to offer PCI.

Part of the problem with the restriction is that it limits PCI access for rural STEMI patients in Northern California. Many people there and elsewhere are more than an hour away from STEMI centers, even by airlift. As indicated by the higher proportion of STEMI patients in the six demonstration sites, "the population we are bringing in by opening [this] up tends to be sicker," said Dr. Bommer, also professor of cardiovascular medicine at the University of California, Davis.

There’s also the issue of hospitals keeping expensive CABG programs going mostly so that they can qualify to offer PCI. A handful of hospitals in the state do less than one CABG per week; almost half do less than two. "That’s not good medicine," Dr. Bommer said at the 18th World Congress on Heart Disease.

"Once this [change] goes through and you no longer, in selected cases, need heart surgery to do PCI, the biggest change will not be a flurry of new PCI labs; the biggest change will be an attenuation of [low-volume] cardiac surgery" programs, he said in an interview.

Dr. Bommer said he has no financial interests in nonsurgical PCI centers.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – It makes little difference if percutaneous coronary interventions are done in a facility with on-site bypass rescue or not; safety outcomes are statistically the same, according to a prospective observational study of more than 100,000 PCI cases in California.

Adjusted for lesion, patient, and other risk factors, the composite rate of in-hospital death or emergent coronary artery bypass grafting (CABG) was 2.11% for 99,332 PCIs – about 18% of them ST-elevation myocardial infarctions – at 116 facilities offering on-site cardiac surgery and 1.58% for 2,601 procedures – about a third of them STEMIs – at six facilities where patients had to be transferred elsewhere, if needed, for emergency bypass.

The on-site hospitals had 1.16% of their non–ST-elevation MI (NSTEMI) cases end in death or emergent CABG; 1.15% of NSTEMI cases ended that way in the six sites that did not offer cardiac surgery, a nonsignificant difference.

"Off-site hospitals can do just as well as on-site hospitals for the overall composite of mortality and emergent CABG. The overall success rates are the same," said lead investigator Dr. William Bommer, president of California’s American College of Cardiology chapter.

The goal of the ongoing project is to see if it would be safe to end California’s requirement that PCIs, for the most part, be done only in hospitals that offer on-site cardiovascular surgery, a question other states are struggling with as well. The California provision dates to the 1980s, when the procedure was more risky than it is now. Prompted by Dr. Bommer and his chapter’s suggestion, the state legislature allowed the six pilot sites to offer PCI.

Part of the problem with the restriction is that it limits PCI access for rural STEMI patients in Northern California. Many people there and elsewhere are more than an hour away from STEMI centers, even by airlift. As indicated by the higher proportion of STEMI patients in the six demonstration sites, "the population we are bringing in by opening [this] up tends to be sicker," said Dr. Bommer, also professor of cardiovascular medicine at the University of California, Davis.

There’s also the issue of hospitals keeping expensive CABG programs going mostly so that they can qualify to offer PCI. A handful of hospitals in the state do less than one CABG per week; almost half do less than two. "That’s not good medicine," Dr. Bommer said at the 18th World Congress on Heart Disease.

"Once this [change] goes through and you no longer, in selected cases, need heart surgery to do PCI, the biggest change will not be a flurry of new PCI labs; the biggest change will be an attenuation of [low-volume] cardiac surgery" programs, he said in an interview.

Dr. Bommer said he has no financial interests in nonsurgical PCI centers.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – It makes little difference if percutaneous coronary interventions are done in a facility with on-site bypass rescue or not; safety outcomes are statistically the same, according to a prospective observational study of more than 100,000 PCI cases in California.

Adjusted for lesion, patient, and other risk factors, the composite rate of in-hospital death or emergent coronary artery bypass grafting (CABG) was 2.11% for 99,332 PCIs – about 18% of them ST-elevation myocardial infarctions – at 116 facilities offering on-site cardiac surgery and 1.58% for 2,601 procedures – about a third of them STEMIs – at six facilities where patients had to be transferred elsewhere, if needed, for emergency bypass.

The on-site hospitals had 1.16% of their non–ST-elevation MI (NSTEMI) cases end in death or emergent CABG; 1.15% of NSTEMI cases ended that way in the six sites that did not offer cardiac surgery, a nonsignificant difference.

"Off-site hospitals can do just as well as on-site hospitals for the overall composite of mortality and emergent CABG. The overall success rates are the same," said lead investigator Dr. William Bommer, president of California’s American College of Cardiology chapter.

The goal of the ongoing project is to see if it would be safe to end California’s requirement that PCIs, for the most part, be done only in hospitals that offer on-site cardiovascular surgery, a question other states are struggling with as well. The California provision dates to the 1980s, when the procedure was more risky than it is now. Prompted by Dr. Bommer and his chapter’s suggestion, the state legislature allowed the six pilot sites to offer PCI.

Part of the problem with the restriction is that it limits PCI access for rural STEMI patients in Northern California. Many people there and elsewhere are more than an hour away from STEMI centers, even by airlift. As indicated by the higher proportion of STEMI patients in the six demonstration sites, "the population we are bringing in by opening [this] up tends to be sicker," said Dr. Bommer, also professor of cardiovascular medicine at the University of California, Davis.

There’s also the issue of hospitals keeping expensive CABG programs going mostly so that they can qualify to offer PCI. A handful of hospitals in the state do less than one CABG per week; almost half do less than two. "That’s not good medicine," Dr. Bommer said at the 18th World Congress on Heart Disease.

"Once this [change] goes through and you no longer, in selected cases, need heart surgery to do PCI, the biggest change will not be a flurry of new PCI labs; the biggest change will be an attenuation of [low-volume] cardiac surgery" programs, he said in an interview.

Dr. Bommer said he has no financial interests in nonsurgical PCI centers.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – Count arthritis among the possible side effects of clopidogrel, according to investigators from the Westchester Medical Center in Valhalla, N.Y.

The number of reported cases – 11 – is vanishingly small compared with the number of people who have used the drug. In 2012 alone, 11.3 million prescriptions were written for the branded product Plavix in the United States, according to IMS Health, a health care information company.

Still, it’s something to keep in mind if a patient suddenly develops stiff, swollen joints shortly after starting the drug, exactly what happened to a 64-year-old man at the medical center following a 300-mg loading dose and a few days of 75-mg maintenance therapy after stent placement.

"He had been on the maintenance dose for 3 days when he first started to have a fever, and then he started to have joint symptoms" about 2 weeks after the procedure, said Dr. Sahil Agrawal, an internal medicine resident and lead investigator. The fever persisted, and did not respond to antibiotics.

The man presented with a stiff neck, painful right shoulder, and markedly limited range of motion in both joints; the next day he developed painful swelling, redness, and a restricted range of motion in both hands and wrists. His erythrocyte sedimentation rate and C-reactive protein levels were both elevated, but findings from uric acid concentration and other tests were normal. Radiographs of the affected joints showed only degenerative changes; a few white cells were aspirated from his shoulder joint. He was negative for Lyme disease, brucellosis, and familial Mediterranean fever.

"We did an extensive differential diagnosis and ruled out everything under the sun. At the same time, we learned that he had [similar] symptoms with" a single loading dose of Plavix a year earlier, "so we went back into the literature. Once we had an idea that this was possible, we stopped his clopidogrel and switched him to prasugrel. Within the next few days, his symptoms went away and have not come back," Dr. Agrawal said at the 18th World Congress on Heart Disease.

The timing of the man’s symptoms and their quick resolution when the drug was stopped "strongly suggest clopidogrel-associated arthritis. [Previous authors have] advised careful use of clopidogrel in patients with a history of arthritis. We recommend considering clopidogrel as a cause of acute arthritis," and avoiding using it again "in patients with a prior unexplained episode of arthritis temporally related to clopidogrel therapy," Dr. Agrawal and his colleagues concluded in their recently published case report and literature review (J. Investig. Med. 2013 Aug. 5 [doi:10.1177/2324709613500239]).

All but 1 of the previous 10 reported cases were in men. Joint symptoms started after 2-3 weeks of maintenance therapy, except in one case when they started after 3 days. Both small and large joints were affected, usually more than one. Synovitis was the hallmark exam finding.

Erythrocyte sedimentation rate and C-reactive protein levels were elevated in all cases; fever, itching, and maculopapular rashes were also common. The pattern "suggests a possible immunologic basis for these symptoms," the investigators noted.

In every case, the symptoms went away shortly after clopidogrel was stopped.

Dr. Agrawal and his colleagues reported having no relevant financial disclosures.

motto@frontlinemedcom.com

VANCOUVER, B.C. – Count arthritis among the possible side effects of clopidogrel, according to investigators from the Westchester Medical Center in Valhalla, N.Y.

The number of reported cases – 11 – is vanishingly small compared with the number of people who have used the drug. In 2012 alone, 11.3 million prescriptions were written for the branded product Plavix in the United States, according to IMS Health, a health care information company.

Still, it’s something to keep in mind if a patient suddenly develops stiff, swollen joints shortly after starting the drug, exactly what happened to a 64-year-old man at the medical center following a 300-mg loading dose and a few days of 75-mg maintenance therapy after stent placement.

"He had been on the maintenance dose for 3 days when he first started to have a fever, and then he started to have joint symptoms" about 2 weeks after the procedure, said Dr. Sahil Agrawal, an internal medicine resident and lead investigator. The fever persisted, and did not respond to antibiotics.

The man presented with a stiff neck, painful right shoulder, and markedly limited range of motion in both joints; the next day he developed painful swelling, redness, and a restricted range of motion in both hands and wrists. His erythrocyte sedimentation rate and C-reactive protein levels were both elevated, but findings from uric acid concentration and other tests were normal. Radiographs of the affected joints showed only degenerative changes; a few white cells were aspirated from his shoulder joint. He was negative for Lyme disease, brucellosis, and familial Mediterranean fever.

"We did an extensive differential diagnosis and ruled out everything under the sun. At the same time, we learned that he had [similar] symptoms with" a single loading dose of Plavix a year earlier, "so we went back into the literature. Once we had an idea that this was possible, we stopped his clopidogrel and switched him to prasugrel. Within the next few days, his symptoms went away and have not come back," Dr. Agrawal said at the 18th World Congress on Heart Disease.

The timing of the man’s symptoms and their quick resolution when the drug was stopped "strongly suggest clopidogrel-associated arthritis. [Previous authors have] advised careful use of clopidogrel in patients with a history of arthritis. We recommend considering clopidogrel as a cause of acute arthritis," and avoiding using it again "in patients with a prior unexplained episode of arthritis temporally related to clopidogrel therapy," Dr. Agrawal and his colleagues concluded in their recently published case report and literature review (J. Investig. Med. 2013 Aug. 5 [doi:10.1177/2324709613500239]).

All but 1 of the previous 10 reported cases were in men. Joint symptoms started after 2-3 weeks of maintenance therapy, except in one case when they started after 3 days. Both small and large joints were affected, usually more than one. Synovitis was the hallmark exam finding.

Erythrocyte sedimentation rate and C-reactive protein levels were elevated in all cases; fever, itching, and maculopapular rashes were also common. The pattern "suggests a possible immunologic basis for these symptoms," the investigators noted.

In every case, the symptoms went away shortly after clopidogrel was stopped.

Dr. Agrawal and his colleagues reported having no relevant financial disclosures.

motto@frontlinemedcom.com

VANCOUVER, B.C. – Count arthritis among the possible side effects of clopidogrel, according to investigators from the Westchester Medical Center in Valhalla, N.Y.

The number of reported cases – 11 – is vanishingly small compared with the number of people who have used the drug. In 2012 alone, 11.3 million prescriptions were written for the branded product Plavix in the United States, according to IMS Health, a health care information company.

Still, it’s something to keep in mind if a patient suddenly develops stiff, swollen joints shortly after starting the drug, exactly what happened to a 64-year-old man at the medical center following a 300-mg loading dose and a few days of 75-mg maintenance therapy after stent placement.

"He had been on the maintenance dose for 3 days when he first started to have a fever, and then he started to have joint symptoms" about 2 weeks after the procedure, said Dr. Sahil Agrawal, an internal medicine resident and lead investigator. The fever persisted, and did not respond to antibiotics.

The man presented with a stiff neck, painful right shoulder, and markedly limited range of motion in both joints; the next day he developed painful swelling, redness, and a restricted range of motion in both hands and wrists. His erythrocyte sedimentation rate and C-reactive protein levels were both elevated, but findings from uric acid concentration and other tests were normal. Radiographs of the affected joints showed only degenerative changes; a few white cells were aspirated from his shoulder joint. He was negative for Lyme disease, brucellosis, and familial Mediterranean fever.

"We did an extensive differential diagnosis and ruled out everything under the sun. At the same time, we learned that he had [similar] symptoms with" a single loading dose of Plavix a year earlier, "so we went back into the literature. Once we had an idea that this was possible, we stopped his clopidogrel and switched him to prasugrel. Within the next few days, his symptoms went away and have not come back," Dr. Agrawal said at the 18th World Congress on Heart Disease.

The timing of the man’s symptoms and their quick resolution when the drug was stopped "strongly suggest clopidogrel-associated arthritis. [Previous authors have] advised careful use of clopidogrel in patients with a history of arthritis. We recommend considering clopidogrel as a cause of acute arthritis," and avoiding using it again "in patients with a prior unexplained episode of arthritis temporally related to clopidogrel therapy," Dr. Agrawal and his colleagues concluded in their recently published case report and literature review (J. Investig. Med. 2013 Aug. 5 [doi:10.1177/2324709613500239]).

All but 1 of the previous 10 reported cases were in men. Joint symptoms started after 2-3 weeks of maintenance therapy, except in one case when they started after 3 days. Both small and large joints were affected, usually more than one. Synovitis was the hallmark exam finding.

Erythrocyte sedimentation rate and C-reactive protein levels were elevated in all cases; fever, itching, and maculopapular rashes were also common. The pattern "suggests a possible immunologic basis for these symptoms," the investigators noted.

In every case, the symptoms went away shortly after clopidogrel was stopped.

Dr. Agrawal and his colleagues reported having no relevant financial disclosures.

motto@frontlinemedcom.com

VANCOUVER, B.C. – Among patients undergoing percutaneous coronary interventions, bivalirudin was associated with significantly fewer bleeding complications than eptifibatide, but bleeding complications were more severe with bivalirudin, according to a retrospective case-cohort study from Mt. Auburn Hospital in Cambridge, Mass.

Investigators compared bleeding complications among 660 angioplasty patients who received bivalirudin (Angiomax) with 345 who received eptifibatide (Integrilin) instead. MIs were the most common indication for intervention.

Just 31 (3%) of those patients had a bleeding episode; 1 patient was excluded for receiving both medications. Of the remaining bleeding cases, 10 were in the bivalirudin group, and 20 were in the eptifibatide group, a significant difference.

However, 7 of those 10 bivalirudin bleeding cases were severe according to GUSTO (Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries) criteria, meaning patients had either intracranial hemorrhages or bleeding that caused hemodynamic compromise and required intervention. One patient had a retroperitoneal bleed that required 10 transfusions and surgical hematoma decompression. Among eptifibatide patients, 7 cases (35%) were severe.

There were three moderate bleeding cases – bleeding that required blood transfusions but did not result in hemodynamic compromise – among bivalirudin patients, and nine in the eptifibatide group, which also had four mild bleeds. For bivalirudin bleeding cases, the average length of hospital stay was 9.6 days; for eptifibatide cases, 8.7 days. Urgent PCI cases were associated with more bleeding complications.

All of the patients were on aspirin, with most also given thienopyridines. About 20% in each group were on warfarin. About 90% of patients on eptifibatide, an antiplatelet drug, were on concomitant heparin, compared with 20% on bivalirudin, itself an anticoagulant.

Bivalirudin is generally thought to cause less bleeding, but "we never looked at the severity of those [bleeds]. Although bivalirudin caused less bleeding, those episodes tended to be much more serious," something that was "unexpected," said lead investigator Dr. Smita Kohli, a cardiology research fellow now at Henry Ford Hospital in Detroit.

Age may have played a role. Eptifibatide bleeders were aged 66 years on average, but bivalirudin bleeders were aged 76 years. Because they were older, maybe they had a greater risk of severe bleeding, Dr. Kohli suggested. Another potential factor – kidney function – did not seem to play a role. Patients in both groups "had similar baseline kidney function," with a mean creatinine level of 1.0 mg/dL, Dr. Kohli said at the 18th World Congress on Heart Disease.

The numbers in the study are small, and "we haven’t really identified what caused those cases to be severe," she said. For now, the findings are more hypothesis generating, not a guide to practice, she added.

Dr. Kohli said she has no disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – Among patients undergoing percutaneous coronary interventions, bivalirudin was associated with significantly fewer bleeding complications than eptifibatide, but bleeding complications were more severe with bivalirudin, according to a retrospective case-cohort study from Mt. Auburn Hospital in Cambridge, Mass.

Investigators compared bleeding complications among 660 angioplasty patients who received bivalirudin (Angiomax) with 345 who received eptifibatide (Integrilin) instead. MIs were the most common indication for intervention.

Just 31 (3%) of those patients had a bleeding episode; 1 patient was excluded for receiving both medications. Of the remaining bleeding cases, 10 were in the bivalirudin group, and 20 were in the eptifibatide group, a significant difference.

However, 7 of those 10 bivalirudin bleeding cases were severe according to GUSTO (Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries) criteria, meaning patients had either intracranial hemorrhages or bleeding that caused hemodynamic compromise and required intervention. One patient had a retroperitoneal bleed that required 10 transfusions and surgical hematoma decompression. Among eptifibatide patients, 7 cases (35%) were severe.

There were three moderate bleeding cases – bleeding that required blood transfusions but did not result in hemodynamic compromise – among bivalirudin patients, and nine in the eptifibatide group, which also had four mild bleeds. For bivalirudin bleeding cases, the average length of hospital stay was 9.6 days; for eptifibatide cases, 8.7 days. Urgent PCI cases were associated with more bleeding complications.

All of the patients were on aspirin, with most also given thienopyridines. About 20% in each group were on warfarin. About 90% of patients on eptifibatide, an antiplatelet drug, were on concomitant heparin, compared with 20% on bivalirudin, itself an anticoagulant.

Bivalirudin is generally thought to cause less bleeding, but "we never looked at the severity of those [bleeds]. Although bivalirudin caused less bleeding, those episodes tended to be much more serious," something that was "unexpected," said lead investigator Dr. Smita Kohli, a cardiology research fellow now at Henry Ford Hospital in Detroit.

Age may have played a role. Eptifibatide bleeders were aged 66 years on average, but bivalirudin bleeders were aged 76 years. Because they were older, maybe they had a greater risk of severe bleeding, Dr. Kohli suggested. Another potential factor – kidney function – did not seem to play a role. Patients in both groups "had similar baseline kidney function," with a mean creatinine level of 1.0 mg/dL, Dr. Kohli said at the 18th World Congress on Heart Disease.

The numbers in the study are small, and "we haven’t really identified what caused those cases to be severe," she said. For now, the findings are more hypothesis generating, not a guide to practice, she added.

Dr. Kohli said she has no disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – Among patients undergoing percutaneous coronary interventions, bivalirudin was associated with significantly fewer bleeding complications than eptifibatide, but bleeding complications were more severe with bivalirudin, according to a retrospective case-cohort study from Mt. Auburn Hospital in Cambridge, Mass.

Investigators compared bleeding complications among 660 angioplasty patients who received bivalirudin (Angiomax) with 345 who received eptifibatide (Integrilin) instead. MIs were the most common indication for intervention.

Just 31 (3%) of those patients had a bleeding episode; 1 patient was excluded for receiving both medications. Of the remaining bleeding cases, 10 were in the bivalirudin group, and 20 were in the eptifibatide group, a significant difference.

However, 7 of those 10 bivalirudin bleeding cases were severe according to GUSTO (Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries) criteria, meaning patients had either intracranial hemorrhages or bleeding that caused hemodynamic compromise and required intervention. One patient had a retroperitoneal bleed that required 10 transfusions and surgical hematoma decompression. Among eptifibatide patients, 7 cases (35%) were severe.

There were three moderate bleeding cases – bleeding that required blood transfusions but did not result in hemodynamic compromise – among bivalirudin patients, and nine in the eptifibatide group, which also had four mild bleeds. For bivalirudin bleeding cases, the average length of hospital stay was 9.6 days; for eptifibatide cases, 8.7 days. Urgent PCI cases were associated with more bleeding complications.

All of the patients were on aspirin, with most also given thienopyridines. About 20% in each group were on warfarin. About 90% of patients on eptifibatide, an antiplatelet drug, were on concomitant heparin, compared with 20% on bivalirudin, itself an anticoagulant.

Bivalirudin is generally thought to cause less bleeding, but "we never looked at the severity of those [bleeds]. Although bivalirudin caused less bleeding, those episodes tended to be much more serious," something that was "unexpected," said lead investigator Dr. Smita Kohli, a cardiology research fellow now at Henry Ford Hospital in Detroit.

Age may have played a role. Eptifibatide bleeders were aged 66 years on average, but bivalirudin bleeders were aged 76 years. Because they were older, maybe they had a greater risk of severe bleeding, Dr. Kohli suggested. Another potential factor – kidney function – did not seem to play a role. Patients in both groups "had similar baseline kidney function," with a mean creatinine level of 1.0 mg/dL, Dr. Kohli said at the 18th World Congress on Heart Disease.

The numbers in the study are small, and "we haven’t really identified what caused those cases to be severe," she said. For now, the findings are more hypothesis generating, not a guide to practice, she added.

Dr. Kohli said she has no disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – The volume of denervated myocardium after a heart attack predicts the likelihood of sudden cardiac death and the need for an implantable defibrillator, according to results from a prospective, 4-year observational study.

"In this study, we found that in patients with ischemic cardiomyopathy who are eligible for an ICD [implantable cardioverter defibrillator], the volume of denervated myocardium predicts sudden death. It’s independent of more traditional endpoints that have been used," such as B-type natriuretic peptide, left ventricular ejection fraction, and New York Heart Association (NYHA) class. "Thus, molecular imaging may improve risk stratification for current ICD candidates," said investigator and cardiologist Dr. Michael E. Cain, dean of the School of Medicine and Biomedical Sciences, University at Buffalo (N.Y.).

The goal of the study is to better predict who will benefit from a defibrillator, he said at the 18th World Congress on Heart Disease.

He and his fellow investigators at the university found that about 30% of post-MI patients with more than 33% of their left ventricle denervated experienced arrhythmic death or – in those who had them – a defibrillator discharge for ventricular tachycardia or fibrillation greater than 240 beats per minute within 4 years of their heart attack; on average, about 6.7% met those endpoints each year.

In contrast, only about 5% of patients with less than 22% left ventricular sympathetic denervation met those endpoints, as did about 10% of those with 22%-33% left ventricular denervation, as assessed by myocardial response to a norepinephrine analogue on positron emission tomography. Denervated myocardium had a hazard ratio of 3.5 for sudden cardiac arrest or equivalent in the trial (P = .001).

Thirty-three of 204 post-MI patients experienced arrhythmic death or defibrillator discharge during the project. Most of the patients had undergone initial revascularization, and all were eligible for defibrillators at baseline. Overall, they were in their mid-60s, with left ventricular ejection fractions of about 26% and greater than NYHA class II heart failure. There were no significant demographic differences between patients who did and did not meet the study’s endpoints.

Prediction of sudden cardiac death events was even better when denervation was used in conjunction with three other factors: increase in the left ventricular end-diastolic volume index, creatinine greater than 1.5 mg/dL, and lack of angiotensin-converting enzyme inhibitor or angiotensin II receptor antagonist therapy.

Four-year event-free survival was about 98% in patients with none of those risk factors, about 85% in patients with one, and 50% in patients with two or more. The volume of infarcted or hibernating myocardium did not predict sudden cardiac arrest.

"The proven metric is left ventricle ejection fraction," but it and the many other methods that have been tried "have good negative predictive accuracy but not that good positive predictive accuracy, and so you are putting in defibrillators for people who don’t need them," he said.

For now, however, it would be "a leap of faith from a study that was prospective and observational" to actually use denervation "to determine therapies," he said.

Dr. Cain reported having no disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – The volume of denervated myocardium after a heart attack predicts the likelihood of sudden cardiac death and the need for an implantable defibrillator, according to results from a prospective, 4-year observational study.

"In this study, we found that in patients with ischemic cardiomyopathy who are eligible for an ICD [implantable cardioverter defibrillator], the volume of denervated myocardium predicts sudden death. It’s independent of more traditional endpoints that have been used," such as B-type natriuretic peptide, left ventricular ejection fraction, and New York Heart Association (NYHA) class. "Thus, molecular imaging may improve risk stratification for current ICD candidates," said investigator and cardiologist Dr. Michael E. Cain, dean of the School of Medicine and Biomedical Sciences, University at Buffalo (N.Y.).

The goal of the study is to better predict who will benefit from a defibrillator, he said at the 18th World Congress on Heart Disease.

He and his fellow investigators at the university found that about 30% of post-MI patients with more than 33% of their left ventricle denervated experienced arrhythmic death or – in those who had them – a defibrillator discharge for ventricular tachycardia or fibrillation greater than 240 beats per minute within 4 years of their heart attack; on average, about 6.7% met those endpoints each year.

In contrast, only about 5% of patients with less than 22% left ventricular sympathetic denervation met those endpoints, as did about 10% of those with 22%-33% left ventricular denervation, as assessed by myocardial response to a norepinephrine analogue on positron emission tomography. Denervated myocardium had a hazard ratio of 3.5 for sudden cardiac arrest or equivalent in the trial (P = .001).

Thirty-three of 204 post-MI patients experienced arrhythmic death or defibrillator discharge during the project. Most of the patients had undergone initial revascularization, and all were eligible for defibrillators at baseline. Overall, they were in their mid-60s, with left ventricular ejection fractions of about 26% and greater than NYHA class II heart failure. There were no significant demographic differences between patients who did and did not meet the study’s endpoints.

Prediction of sudden cardiac death events was even better when denervation was used in conjunction with three other factors: increase in the left ventricular end-diastolic volume index, creatinine greater than 1.5 mg/dL, and lack of angiotensin-converting enzyme inhibitor or angiotensin II receptor antagonist therapy.

Four-year event-free survival was about 98% in patients with none of those risk factors, about 85% in patients with one, and 50% in patients with two or more. The volume of infarcted or hibernating myocardium did not predict sudden cardiac arrest.

"The proven metric is left ventricle ejection fraction," but it and the many other methods that have been tried "have good negative predictive accuracy but not that good positive predictive accuracy, and so you are putting in defibrillators for people who don’t need them," he said.

For now, however, it would be "a leap of faith from a study that was prospective and observational" to actually use denervation "to determine therapies," he said.

Dr. Cain reported having no disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – The volume of denervated myocardium after a heart attack predicts the likelihood of sudden cardiac death and the need for an implantable defibrillator, according to results from a prospective, 4-year observational study.

"In this study, we found that in patients with ischemic cardiomyopathy who are eligible for an ICD [implantable cardioverter defibrillator], the volume of denervated myocardium predicts sudden death. It’s independent of more traditional endpoints that have been used," such as B-type natriuretic peptide, left ventricular ejection fraction, and New York Heart Association (NYHA) class. "Thus, molecular imaging may improve risk stratification for current ICD candidates," said investigator and cardiologist Dr. Michael E. Cain, dean of the School of Medicine and Biomedical Sciences, University at Buffalo (N.Y.).

The goal of the study is to better predict who will benefit from a defibrillator, he said at the 18th World Congress on Heart Disease.

He and his fellow investigators at the university found that about 30% of post-MI patients with more than 33% of their left ventricle denervated experienced arrhythmic death or – in those who had them – a defibrillator discharge for ventricular tachycardia or fibrillation greater than 240 beats per minute within 4 years of their heart attack; on average, about 6.7% met those endpoints each year.

In contrast, only about 5% of patients with less than 22% left ventricular sympathetic denervation met those endpoints, as did about 10% of those with 22%-33% left ventricular denervation, as assessed by myocardial response to a norepinephrine analogue on positron emission tomography. Denervated myocardium had a hazard ratio of 3.5 for sudden cardiac arrest or equivalent in the trial (P = .001).

Thirty-three of 204 post-MI patients experienced arrhythmic death or defibrillator discharge during the project. Most of the patients had undergone initial revascularization, and all were eligible for defibrillators at baseline. Overall, they were in their mid-60s, with left ventricular ejection fractions of about 26% and greater than NYHA class II heart failure. There were no significant demographic differences between patients who did and did not meet the study’s endpoints.

Prediction of sudden cardiac death events was even better when denervation was used in conjunction with three other factors: increase in the left ventricular end-diastolic volume index, creatinine greater than 1.5 mg/dL, and lack of angiotensin-converting enzyme inhibitor or angiotensin II receptor antagonist therapy.

Four-year event-free survival was about 98% in patients with none of those risk factors, about 85% in patients with one, and 50% in patients with two or more. The volume of infarcted or hibernating myocardium did not predict sudden cardiac arrest.

"The proven metric is left ventricle ejection fraction," but it and the many other methods that have been tried "have good negative predictive accuracy but not that good positive predictive accuracy, and so you are putting in defibrillators for people who don’t need them," he said.

For now, however, it would be "a leap of faith from a study that was prospective and observational" to actually use denervation "to determine therapies," he said.

Dr. Cain reported having no disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – Patients with baseline PR intervals less than 200 ms have a better response to biventricular cardiac resynchronization therapy than do those with longer baseline intervals, a finding that may help predict who will respond to pacing, judging from recent data.

Investigators compared biventricular CRT [cardiac resynchronization therapy] outcomes in 66 patients with baseline PR intervals less than 200 ms to outcomes in 37 patients with intervals of 200 ms or greater.

Overall, left ventricular ejection fractions improved from 23.7% to 32.2%, but patients with baseline intervals below 200 ms had greater improvement (+11.8% vs. +4.9%) and had greater reductions in left ventricular end-systolic diameters (–0.37 mm vs. –0.06 mm) and mitral regurgitation grade (–0.16 vs. –0.03). Left ventricular end-diastolic diameters deteriorated in both groups, but less so among patients with shorter baseline PR intervals (+0.05 mm vs. +0.1 mm), according to the lead investigator Preya Simlote, a medical student at Thomas Jefferson University Hospital in Philadelphia.

Men accounted for two-thirds of the patients, and the average age in the study was 68 years. Patients had either coronary artery disease or nonischemic cardiomyopathy and were followed for a mean of about 282 days.

At baseline, patients in the longer–PR interval group had slower heart rates (68.7 bpm vs. 75.3 bpm), shorter QRS intervals (144.4 ms vs. 154.8 ms), worse mitral regurgitation (grade 2.29 vs. 1.95), and larger left atriums.

The findings suggest that the severity of "preexisting conduction system disease ... may be a more powerful marker of poor outcomes [than] the effects of short [atrioventricular] delay and truncated transmitral flow," the investigators concluded.

"We were kind of expecting that maybe people who had the longer PR interval would show more improvement. What we actually found was the opposite," Ms. Simlote said.

"Patients are given CRT based on their QRS interval and their symptoms, and their left ventricular ejection fraction. This suggests perhaps we should also be checking patients’ PR interval to predict how they will respond to CRT," she said at the 18th World Congress on Heart Disease.

Ms. Simlote had no disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – Patients with baseline PR intervals less than 200 ms have a better response to biventricular cardiac resynchronization therapy than do those with longer baseline intervals, a finding that may help predict who will respond to pacing, judging from recent data.

Investigators compared biventricular CRT [cardiac resynchronization therapy] outcomes in 66 patients with baseline PR intervals less than 200 ms to outcomes in 37 patients with intervals of 200 ms or greater.

Overall, left ventricular ejection fractions improved from 23.7% to 32.2%, but patients with baseline intervals below 200 ms had greater improvement (+11.8% vs. +4.9%) and had greater reductions in left ventricular end-systolic diameters (–0.37 mm vs. –0.06 mm) and mitral regurgitation grade (–0.16 vs. –0.03). Left ventricular end-diastolic diameters deteriorated in both groups, but less so among patients with shorter baseline PR intervals (+0.05 mm vs. +0.1 mm), according to the lead investigator Preya Simlote, a medical student at Thomas Jefferson University Hospital in Philadelphia.

Men accounted for two-thirds of the patients, and the average age in the study was 68 years. Patients had either coronary artery disease or nonischemic cardiomyopathy and were followed for a mean of about 282 days.

At baseline, patients in the longer–PR interval group had slower heart rates (68.7 bpm vs. 75.3 bpm), shorter QRS intervals (144.4 ms vs. 154.8 ms), worse mitral regurgitation (grade 2.29 vs. 1.95), and larger left atriums.

The findings suggest that the severity of "preexisting conduction system disease ... may be a more powerful marker of poor outcomes [than] the effects of short [atrioventricular] delay and truncated transmitral flow," the investigators concluded.

"We were kind of expecting that maybe people who had the longer PR interval would show more improvement. What we actually found was the opposite," Ms. Simlote said.

"Patients are given CRT based on their QRS interval and their symptoms, and their left ventricular ejection fraction. This suggests perhaps we should also be checking patients’ PR interval to predict how they will respond to CRT," she said at the 18th World Congress on Heart Disease.

Ms. Simlote had no disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – Patients with baseline PR intervals less than 200 ms have a better response to biventricular cardiac resynchronization therapy than do those with longer baseline intervals, a finding that may help predict who will respond to pacing, judging from recent data.

Investigators compared biventricular CRT [cardiac resynchronization therapy] outcomes in 66 patients with baseline PR intervals less than 200 ms to outcomes in 37 patients with intervals of 200 ms or greater.

Overall, left ventricular ejection fractions improved from 23.7% to 32.2%, but patients with baseline intervals below 200 ms had greater improvement (+11.8% vs. +4.9%) and had greater reductions in left ventricular end-systolic diameters (–0.37 mm vs. –0.06 mm) and mitral regurgitation grade (–0.16 vs. –0.03). Left ventricular end-diastolic diameters deteriorated in both groups, but less so among patients with shorter baseline PR intervals (+0.05 mm vs. +0.1 mm), according to the lead investigator Preya Simlote, a medical student at Thomas Jefferson University Hospital in Philadelphia.

Men accounted for two-thirds of the patients, and the average age in the study was 68 years. Patients had either coronary artery disease or nonischemic cardiomyopathy and were followed for a mean of about 282 days.

At baseline, patients in the longer–PR interval group had slower heart rates (68.7 bpm vs. 75.3 bpm), shorter QRS intervals (144.4 ms vs. 154.8 ms), worse mitral regurgitation (grade 2.29 vs. 1.95), and larger left atriums.

The findings suggest that the severity of "preexisting conduction system disease ... may be a more powerful marker of poor outcomes [than] the effects of short [atrioventricular] delay and truncated transmitral flow," the investigators concluded.

"We were kind of expecting that maybe people who had the longer PR interval would show more improvement. What we actually found was the opposite," Ms. Simlote said.

"Patients are given CRT based on their QRS interval and their symptoms, and their left ventricular ejection fraction. This suggests perhaps we should also be checking patients’ PR interval to predict how they will respond to CRT," she said at the 18th World Congress on Heart Disease.

Ms. Simlote had no disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – Laser lead extraction can damage nearby adjacent leads, and the damage isn’t always apparent at the time of removal, according to findings from a recent small study presented by Dr. Jeffrey Snow.

Sixteen patients underwent laser lead extraction at Winthrop University Hospital on Long Island (N.Y.) during defibrillator upgrades or replacement of recalled leads; 24 adjacent leads were left in place and reused. After a mean follow-up of 24 months, a reused lead failed in 4 of the 16 patients. Two patients had a loss of capture, one a fractured lead, and another a sensing noise artifact; the leads appeared to be working fine at the time of extraction.

Meanwhile, 40 control patients had new leads placed without laser extraction; 60 adjacent leads were left in place and reused. Not one failed during a mean follow-up of 25 months (P = .0099).

"In this study," leads remaining after laser extraction "were shown to have a decreased lifespan. If the finding is proved in a larger population, it would have a significant impact on our treatment strategy for recalled defibrillator leads," the authors concluded.

"This comes up most often in patients with a recalled lead. We have to figure out what to do about those leads; there isn’t a good answer out there in the literature," said lead investigator Dr. Snow, an electrophysiologist at Winthrop.

"You have the choice of trying to slip a new lead in alongside it, but that doesn’t always work. There may not be venous access. You could try to remove the lead that you worry may become defective and put a new lead in, which is what we were doing. It took us by surprise that by doing that, we were having a higher than expected failure rate in adjacent leads," he said at the 18th World Congress on Heart Disease.

"We act more quickly now to take out adjacent leads and just start fresh," especially if "it was a difficult extraction that took a lot of time and a lot of force or traction. We don’t want to find out in 6 months that [an adjacent] lead went bad and we have to operate for a third time," Dr. Snow said.

Dr. Snow said he has no relevant disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – Laser lead extraction can damage nearby adjacent leads, and the damage isn’t always apparent at the time of removal, according to findings from a recent small study presented by Dr. Jeffrey Snow.

Sixteen patients underwent laser lead extraction at Winthrop University Hospital on Long Island (N.Y.) during defibrillator upgrades or replacement of recalled leads; 24 adjacent leads were left in place and reused. After a mean follow-up of 24 months, a reused lead failed in 4 of the 16 patients. Two patients had a loss of capture, one a fractured lead, and another a sensing noise artifact; the leads appeared to be working fine at the time of extraction.

Meanwhile, 40 control patients had new leads placed without laser extraction; 60 adjacent leads were left in place and reused. Not one failed during a mean follow-up of 25 months (P = .0099).

"In this study," leads remaining after laser extraction "were shown to have a decreased lifespan. If the finding is proved in a larger population, it would have a significant impact on our treatment strategy for recalled defibrillator leads," the authors concluded.

"This comes up most often in patients with a recalled lead. We have to figure out what to do about those leads; there isn’t a good answer out there in the literature," said lead investigator Dr. Snow, an electrophysiologist at Winthrop.

"You have the choice of trying to slip a new lead in alongside it, but that doesn’t always work. There may not be venous access. You could try to remove the lead that you worry may become defective and put a new lead in, which is what we were doing. It took us by surprise that by doing that, we were having a higher than expected failure rate in adjacent leads," he said at the 18th World Congress on Heart Disease.

"We act more quickly now to take out adjacent leads and just start fresh," especially if "it was a difficult extraction that took a lot of time and a lot of force or traction. We don’t want to find out in 6 months that [an adjacent] lead went bad and we have to operate for a third time," Dr. Snow said.

Dr. Snow said he has no relevant disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – Laser lead extraction can damage nearby adjacent leads, and the damage isn’t always apparent at the time of removal, according to findings from a recent small study presented by Dr. Jeffrey Snow.

Sixteen patients underwent laser lead extraction at Winthrop University Hospital on Long Island (N.Y.) during defibrillator upgrades or replacement of recalled leads; 24 adjacent leads were left in place and reused. After a mean follow-up of 24 months, a reused lead failed in 4 of the 16 patients. Two patients had a loss of capture, one a fractured lead, and another a sensing noise artifact; the leads appeared to be working fine at the time of extraction.

Meanwhile, 40 control patients had new leads placed without laser extraction; 60 adjacent leads were left in place and reused. Not one failed during a mean follow-up of 25 months (P = .0099).

"In this study," leads remaining after laser extraction "were shown to have a decreased lifespan. If the finding is proved in a larger population, it would have a significant impact on our treatment strategy for recalled defibrillator leads," the authors concluded.

"This comes up most often in patients with a recalled lead. We have to figure out what to do about those leads; there isn’t a good answer out there in the literature," said lead investigator Dr. Snow, an electrophysiologist at Winthrop.

"You have the choice of trying to slip a new lead in alongside it, but that doesn’t always work. There may not be venous access. You could try to remove the lead that you worry may become defective and put a new lead in, which is what we were doing. It took us by surprise that by doing that, we were having a higher than expected failure rate in adjacent leads," he said at the 18th World Congress on Heart Disease.

"We act more quickly now to take out adjacent leads and just start fresh," especially if "it was a difficult extraction that took a lot of time and a lot of force or traction. We don’t want to find out in 6 months that [an adjacent] lead went bad and we have to operate for a third time," Dr. Snow said.

Dr. Snow said he has no relevant disclosures.

aotto@frontlinemedcom.com