Background: We sought to investigate the rate of radial artery occlusion (RAO) after same-day dual radial artery puncture. The trans-radial arterial approach (TRA) for diagnostic and interventional procedures has risen significantly in the United States. Although becoming more commonly performed, TRA is not without risk, and a potential complication is RAO. The rate of RAO after same-day dual artery puncture is unknown. Methods: A retrospective analysis of 27 patients who underwent same-day dual radial artery puncture for percutaneous coronary intervention (PCI) at our institution (Providence Heart Institute in Southfield, MI, USA) from November 2011 to December 2013 were included after initially presenting for cardiac catheterization at a non-PCI-capable facility. The study patients were asked to follow up for evaluation of the radial artery, including obtaining a duplex ultrasound evaluation. Results: The mean age of the patients was 65 years old with 66% of the patients being male. Of the 27 study participants, there were no symptoms reported that were related to RAO. Overall, one (3.7%) patient had an absent radial pulse. The modified Allen’s test was normal in all of the patients with a mean return of palmar flush time of 4 seconds. Duplex ultrasound revealed subtotal RAO in four (14.8%) patients and no patients experienced total occlusion following the intervention. Conclusion: Dual radial artery puncture appears to be a well-tolerated and viable strategy in patients that are transferred to a PCI-capable hospital for coronary interventions.

Objective: Neutrophil gelatinase-associated lipocalin (NGAL) is produced in response to tubular injury. Contrast-induced acute kidney injury (CI-AKI) is associated with adverse outcomes in chronic kidney disease (CKD) patients. We sought to characterize blood NGAL level and the degree of kidney injury in CKD patients who underwent coronary angiography. Methods: This study was a prospective, blinded assessment of blood samples obtained from patients with estimated glomerular filtration rates (eGFRs) between 15 and 90 mL/min/1.73 m(2) undergoing elective coronary angiography with iodinated contrast. Blood NGAL and serum creatinine were measured at baseline, 1, 2, 4, 6, 12, 24 and 48 h after contrast administration. Results: A total of 63 subjects with a mean eGFR of 48.17 +/- 16.45 mL/min/1.73 m(2) were enrolled. There was a graded increase in baseline NGAL levels across worsening stages of CKD (p = 0.0001). Post-procedure NGAL increased from baseline in each stage of CKD. Eight (12.7%) patients were diagnosed with CI-AKI by diagnostic criteria of 2012 KDIGO definition of CI-AKI, and seven (11.1%) patients developed subclinical CI-AKI defined by a twofold or greater rise in NGAL. There was no relationship between baseline eGFR and diabetes on the composite outcome of subclinical and clinical CI-AKI. Conclusions: Baseline and post-procedure NGAL are progressively elevated according to the baseline stage of CKD. Using a twofold rise in NGAL, 46.7% of composite CI-AKI is detected and complements the 53.3% of cases identified using KDIGO criteria. Traditional risk predictors were not independently associated with this composite outcome.

The prevalence of congestive heart failure (CHF) is increasing. A rare cause of CHF is hyperthyroidism. It can affect the cardiovascular system manifesting from decreased systemic vascular resistance, increased left ventricular contractility, and sinus tachycardia to atrial fibrillation. Less than 0.5% is due to tachycardia- mediated mechanism. Heart failure in the absence of underlying cardiac disease or arrhythmia is thought to reflect a rate related cardiomyopathy that most likely resolves with treatment. Our patient is a 56 year-old African American female with past medical history of subacute thyroiditis and medication noncompliance presented to ER with a two-week history of increasing exertional dyspnea and bilateral leg edema. She was hypertensive, tachycardic and tachypnic. Examination revealed bibasilar rales and 2+ pitting edema. Laboratory data revealed a TSH of 0.01 and free T4 of 3.3, consistent with hyperthyroidism. Two-dimensional echocardiogram revealed biventricular enlargement and ejection fraction of 25%. Thyroid uptake scan demonstrated significant homogenous uptake in both lobes consistent with Grave’s disease. Six months ago her thyroid scan showed 5% uptake with hyperthyroid state, consistent with subacute thyroiditis. She was treated with beta-blockers and diuretics with profound symptomatic improvement. Definitive therapy consisted of maintaining euthyroid state. This case illustrates an unusual presentation of Grave’s disease with CHF without atrial fibrillation. Typically, thyrotoxicosis presents as high output failure. However, as time progresses it can cause low output failure. Dilated cardiomyopathy is an unusual manifestation of hyperthyroidism with unclear etiology. Early diagnosis is of utmost importance as some patients with hyperthyroidism may have a reversible form of dilated cardiomyopathy.

Objective: Poor oral health is common in the United States. The incidence of periodontal disease in young adults in USA is around 7-10%.The current review finds that periodontal disease is associated with a 24% increase in the risk for CHD. Background: Evidence for a link between periodontal disease and several systemic diseases is growing rapidly. Current evidence suggests that periodontitis is associated with an increased likelihood of coronary heart disease, diabetes and metabolic syndrome. In recent times there has been increasing awareness that immune responses are central to atherogenesis and a mechanism by which infection may initiate and facilitate the progression of atherosclerosis. The passage of periodontal pathogens, and their products, through ulcerated epithelium into the circulation, leading to bacteraemia and/or provocation of systemic immune and inflammatory responses is of concern. In a meta-analysis, periodontal disease increased the risk for incident CHD by a risk ratio of 1.24. Almost 1/3 of diabetes has severe periodontal disease. Methods: A retrospective analysis was performed from January 2007 to December 2009 in all acute coronary syndromes admitted in Providence Hospital’s Heart Institute, who are less than 50 years old. Patient charts were reviewed. Patient’s demographics and traditional risk factors were charted. Patients were called and specific questions regarding periodontal disease were asked. Results: A total of 130 patients were included in the analysis. 97 patients (70%) responded. The Patients were matched to the baseline demographics and traditional risk factors. Periodontal disease is found almost among 37% of patients in this study, which is approximately four and a half times the expected prevalence for this age group according to the findings of The National Health and Nutrition Examination Survey, 1999-2004. There is no increase in MACE events because of small sample size. Conclusion: The mouth is, thus, a significant contributor to both the total burden of infection and inflammation and, hence, to overall health and well-being. The examination of the oralcavity is often neglected. Our findings support considering periodontal disease as a nontraditional risk factor for coronary artery disease and thus the implementation of screening for both primary and secondary prevention. We also recommend patient compliance with the American Dental Association recommendations regarding basic oral health.

Background: Neutrophil gelatinase-associated lipocalin (NGAL, siderocalin) is a protein secreted by the kidney in the setting of acute kidney injury in an attempt to regulate and bind the release of catalytic iron from injured cells. We sought to evaluate the relationships between baseline NGAL, renal filtration function, and the degree of injury reflected by further increases in NGAL. Methods: This study was a prospective, blinded assessment of blood samples taken from patients with estimated glomerular filtration rate (eGFR) <75 ml/min/1.73 m2 undergoing non-urgent coronary angiography and intervention using iodinated contrast. Renal transplant recipients, dialysis patients, and administration of iodinated contrast in the prior 30 days were exclusion criteria. Plasma NGAL was measured using the Alere™ assay. Serum creatinine (Cr) was measured using calibrated methods at a core laboratory. Samples were obtained at baseline, 1, 2, 4, 6, 12, 24, and 48 h after contrast administration. Results: A total of 63 subjects were enrolled with a mean age of 69.4 ± 9.1 years, 73% male, 35% with diabetes, and a mean eGFR of 47.82 ± 15.46 ml/min/1.73 m2. The correlation between eGFR and NGAL was r = –0.61, 95% CI –0.74 to –0.44, p < 0.001. When stratified by baseline NGAL tertile, the peak NGAL observed for each group occurred at 29.0 ± 22.2 h and there was a twofold increase in the mean and peak change in NGAL across the tertiles. NGAL began to rise 6 h after contrast exposure and followed a similar course to serum Cr and at 48 h the overall mean NGAL was still rising. Only 2 patients sustained a rise in Cr of >25% or ≥0.5 mg/dl. Multivariate regression revealed that baseline NGAL (p < 0.001) and not eGFR (p = 0.95) was independently associated with the NGAL value at 48 h. Conclusions: Baseline NGAL is strongly correlated with eGFR in patients with reduced renal filtration function undergoing coronary angiography. The magnitude of rise in NGAL is positively associated with the baseline value and is analogous to the time course of Cr in blood after contrast exposure. NGAL and not eGFR is an independent predictor of changes in the post-procedure NGAL. A baseline NGAL level is necessary for the interpretation of NGAL levels in the evaluation of acute kidney injury.

Objective. We examined the cause of transfer delay in patients with an acute ST-segment myocardial infarction (STEMI) from non percutaneous coronary intervention (PCI) capable to PCI capable hospitals. We then implemented a novel, simple, and reliable initiative to improve the transfer process. Background. Guidelines established by the ACC/AHA call for door-to-balloon times of ≤90 minutes for patients with STEMI. When hospital transfer is necessary, this is only met in 8.6% of cases. Methods. All patients presenting with STEMI to a non-PCI capable hospital from April 2006 to February 2009 were analyzed retrospectively. After identifying causes of transfer delay the “Register and Roll” initiative was developed. An analysis of effect was conducted from March 2009 to July 2011. Results. 144 patients were included, 74 pre-initiative and 70 post- initiative. Time to EMS activation was a major delay in patient transfer. After implementation, the EMS activation time has significantly decreased and time to reperfusion approaches recommended goal (Median 114 min versus 90 min, P < 0.001), with 55% in <90 minutes. Conclusion. “Register and Roll” streamlines the triage process and improves hospital transfer times. This initiative is easily instituted and reliable in a community hospital setting where resources are limited.

Objective: We sought to determine whether the survival benefits of beta-blockade in the ACS population are associated with the magnitude of heart rate reduction. Background: Atherosclerotic coronary artery disease is the leading cause of morbidity and mortality in the United States with nearly 1.6 million hospitalizations for acute coronary syndrome (ACS) alone in 2004. Beta-blocker therapy along with anti-platelet medications, nitrates, and statins has been the corner stone of medical therapy. ACC guidelines recommend a resting heart rate (HR) goal of 50 to 60 beats per minute (bpm) in patients with ACS. However, these recommendations are not based on randomized clinical trials rather expert opinion. To date, there fails to be evidence-based clinical trials demonstrating the ideal target heart rate after initiation of beta-blockers in ACS patients. Methods: A retrospective analysis was performed from January 2007 to December 2008 in all ACS patients who underwent coronary angiography with or without PCI at Providence Hospital's Heart Institute. Patient charts, medication list and diagnostic reports were reviewed. Patients presenting with cardiogenic shock or contraindications to beta-blocker therapy were excluded. Results: A total of 430 patients were included in the analysis. (210 STEMI and 220 NSTEMI patients) HR was classified as upper (above 80 bpm), middle (67 to 80 bpm), and lower (below 67 bpm) quartiles. Each quartile was classified according to percent change in HR, the absolute change in HR between admission and discharge, and admission HR and discharge HR. Each quartile was correlated to major adverse cardiac events (MACE) and cardiac death at 30 days. There was a statistically significant difference in the composite endpoints between the upper and lower quartile on discharge HR (9% vs. 4%. p value < 0.05) in both STEMI and NSTEMI patients. Conclusion: In those with ACS, primarily STEMI and NSTEMI, lower discharge HR conferred a decrease in composite endpoints at 30 days. It's unclear whether the reduction in MACE will persist beyond the initial follow-up or if there is a long-term mortality benefit with this degree of HR reduction at discharge. Further studies are needed to investigate the clinical benefits of HR reduction in the ACS population.

There are several factors that may be responsible for the observed increase in mortality in patients with CKD. First, decreased kidney function along with the background use of antithrombotic therapy and anti- platelet therapy (aspirin, thienopyridines, glycopro- tein IIb/IIIa inhibitors) place patients with CKD under- going PCI at a high risk for procedure-related bleeding and need for blood transfusion post PCI. 8 Second, the incidenceofstentthrombosis,particularlyafterimplan- tation of DES, mandates uninterrupted treatment with dual antiplatelet therapy for at least 1 year in all patients receiving DES or those receiving BMS im- plantation in the setting of acute coronary syn- drome. 13 The full course of dual antiplatelet therapy along with the complex medical regimen often encoun- tered in patients with CKD make nonadherence to or abrupt discontinuation of antiplatelet therapy more likely. Interestingly, irrespective of dual antiplatelet therapy, the presence of kidney failure has been shown to be an independent predictor of thrombotic events following successful implantation of DES. 14

Objective: We sought to identify the cause of delay in the first door-to-balloon times (1stD2B) in patients presenting with an acute ST-segment myocardial infarction (STEMI) requiring transfer to a PCI capable hospital with post hoc implementation of novel yet simple and reliable initiative “Register and Roll” to improve the overall D2B. Background: National guidelines established by the ACC/AHA call for door-to-balloon (D2B) times of ≤ 90 minutes for patients presenting with STEMI undergoing PCI to facilitate timely reperfusion and salvage of the ischemic myocardium. In patients presenting to non-PCI capable hospitals the timely reperfusion (D2B ≤ 90 min) is met in only 8.6% of patients. Methods: A retrospective analysis was performed from April 2006 to May 2009 in all STEMI patients transferred for primary PCI (PPCI) to Providence Hospital's Heart Institute from non-PCI capable hospitals. Patient charts and available electronic records were reviewed. Patients under 18 years of age and those with indeterminate initial electrocardiogram were excluded. The” Register and Roll Initiative” designed to facilitate transfer to our PCI center was implemented in all transfer patients starting in June 2009 to December 2010. Results: A total of 148 patients were transferred for PPCI with 47 patients included post “Register and Roll”. Three local hospitals were involved in transferring of patients. The time to ECG, time to EMS activation, door-in-door-out, EMS transport time, and the first-door-to-balloon time were compared pre and post implementation. The door in-door out time played a major role in prolonging the time to reperfusion and after implantation; the patients were transferred sooner for PPCI resulting in improved 1stD2B. (140 min vs. 100 min, P < 0.05) Conclusion: Our novel initiative, “Register and Roll”, to facilitate prompt transfer of STEMI patients for primary PCI involves simple guideline, a CATH KIT and EMS notification, which improved delays in door-in-door-out time. This initiative is simple and reliable to follow in a community hospital setting, where resources are limited. AHA's “Lifeline Mission” recommends every health system to implement their own methods to facilitate the transfer and achieve the goal.