Background Quantification of left atrial late gadolinium enhancement is a powerful clinical and research tool. Fibrosis burden has been shown to predict the success of pulmonary vein isolation, post-ablation reoccurrence, and major adverse cardiovascular events such as stroke. Overview The standardized cardiovascular magnetic resonance imaging protocols 2020 update describes the key components of the examination. This review is a more in-depth guide, geared toward building left atrial late gadolinium enhancement imaging from the ground up. The standard protocol consists of the following: localization, pulmonary vein magnetic resonance angiography, cardiac cines, left ventricular, and atrial late gadolinium enhancement. We also review typical segmentation and post-processing techniques, as well as discuss pitfalls, limitations, and potential future innovations in this area. Conclusions With sufficient experience and optimized protocols, left atrial late gadolinium enhancement imaging is a strong addition to the cardiac magnetic resonance imaging repertoire.

Aims and Objectives: Takotsubo cardiomyopathy (TCMP) is an acquired cardiomyopathy associated with physical, emotional, and surgical stress. Current literature on TCMP in liver transplant recipients (LTRs) is limited to case reports and case series. Methods: The Nationwide Readmission Database was utilized to identify all adults with an index admission for LT between 2010 and 2014 who developed TCMP. The prevalence of TCMP at the LT admission or readmission within the calendar year was examined. Predictors of development and health-care utilization of patients with and without TCMP in LTR were compared. Multivariable regression analysis was performed. Results: The prevalence of TCMP in LTRs was found to be 0.5% (141/28,067). Most of these patients developed early TCMP on the index admission for LT (n = 115; 82%). Older (57.5 ± 1.3 vs. 55.1 ± 0.3 years, P < 0.001) females (adjusted odds ratio [aOR]: 2.27; confidence interval [CI]: 1.20–4.27; P = 0.01) with ≥4 Elixhauser comorbidity (aOR: 2.36; CI: 1.15–4.83; P = 0.02) were predisposed to develop TCMP in LTRs. LT at a medium-sized center (aOR: 0.17; CI: 0.03–0.88) has a protective effect on the development of TCMP. Increased health-care utilization in the form of mechanical ventilation, hemodialysis, vasopressors, and intra-aortic balloon pumps is observed in patients with TCMP. This resulted in increased length of stay and cost in patients with TCMP. Moreover, increased mortality was seen in patients who developed TCMP within the same calendar year. Conclusion: This is the first report showing the prevalence of TCMP in LTRs to be 0.5%. Older females with increased comorbidity are predisposed to TCMP. Patients who developed TCMP necessitate a higher acuity of medical care and cause an increased health-care burden and ultimately experience an increase in mortality.

Background: Stress cardiomyopathy is characterized by transient myocardial dysfunction that mimics a myocardial infarction in the absence of obstructive coronary artery disease. The onset is frequently triggered by an acute illness or intense physical or emotional stress. Case Report: We describe the case of a 47-year-old woman who was brought to the emergency department with acute onset shortness of breath while scuba diving. She was found to have acute pulmonary edema radiographically. Her troponins were noted to be positive. Initial echocardiogram showed basal hypokinesis with hyperkinesis of apex. She was treated with noninvasive ventilation and intravenous diuretic therapy and her symptoms significantly improved. She subsequently underwent cardiac catheterization which revealed nonobstructive coronary artery disease. An exercise stress echocardiogram was performed 2 days later that revealed resolution of the wall motion abnormality and no ischemia at high levels of exercise. A diagnosis of reverse stress (Takotsubo) cardiomyopathy was made based on Mayo Clinic Diagnostic criteria. Why Should an Emergency Physician Be Aware of This?: This case brings to light the risk of stress cardiomyopathy in divers. The diagnosis should be considered in patients presenting with acute pulmonary edema during diving. (C) 2016 Elsevier Inc.

Habitual light to moderate alcohol intake (up to 1 drink per day for women and 1 or 2 drinks per day for men) is associated with decreased risks for total mortality, coronary artery disease, diabetes mellitus, congestive heart failure, and stroke. However, higher levels of alcohol consumption are associated with increased cardiovascular risk. Indeed, behind only smoking and obesity, excessive alcohol consumption is the third leading cause of premature death in the United States. Heavy alcohol use (1) is one of the most common causes of reversible hypertension, (2) accounts for about one-third of all cases of nonischemic dilated cardiomyopathy, (3) is a frequent cause of atrial fibrillation, and (4) markedly increases risks of stroke-both ischemic and hemorrhagic. The risk-to-benefit ratio of drinking appears higher in younger individuals, who also have higher rates of excessive or binge drinking and more frequently have adverse consequences of acute intoxication (for example, accidents, violence, and social strife). In fact, among males aged 15 to 59 years, alcohol abuse is the leading risk factor for premature death. Of the various drinking patterns, daily low- to moderate-dose alcohol intake, ideally red wine before or during the evening meal, is associated with the strongest reduction in adverse cardiovascular outcomes. Health care professionals should not recommend alcohol to nondrinkers because of the paucity of randomized outcome data and the potential for problem drinking even among individuals at apparently low risk. The findings in this review were based on a literature search of PubMed for the 15-year period 1997 through 2012 using the search terms alcohol, ethanol, cardiovascular disease, coronary artery disease, heart failure, hypertension, stroke, and mortality. Studies were considered if they were deemed to be of high quality, objective, and methodologically sound.

Purpose of reviewTea and coffee, after water, are the most commonly consumed beverages in the world and are the top sources of caffeine and antioxidant polyphenols in the American diet. The purpose of this review is to assess the health effects of chronic tea and/or coffee consumption. Recent findingsTea consumption, especially green tea, is associated with significantly reduced risks for stroke, diabetes and depression, and improved levels of glucose, cholesterol, abdominal obesity and blood pressure. Habitual coffee consumption in large epidemiological studies is associated with reduced mortality, both for all-cause and cardiovascular deaths. In addition, coffee intake is associated with risks of heart failure, stroke, diabetes mellitus and some cancers in an inverse dose-dependent fashion. Surprisingly, coffee is associated with neutral to reduced risks for both atrial and ventricular arrhythmias. However, caffeine at high doses can increase anxiety, insomnia, calcium loss and possibly the risk of fractures. SummaryCoffee and tea can generally be recommended as health-promoting additions to an adult diet. Adequate dietary calcium intake may be particularly important for tea and coffee drinkers.

Purpose of review Tea and coffee, after water, are the most commonly consumed beverages in the world and are the top sources of caffeine and antioxidant polyphenols in the American diet. The purpose of this review is to assess the health effects of chronic tea and/or coffee consumption. Recent findings Tea consumption, especially green tea, is associated with significantly reduced risks for stroke, diabetes and depression, and improved levels of glucose, cholesterol, abdominal obesity and blood pressure. Habitual coffee consumption in large epidemiological studies is associated with reduced mortality, both for all-cause and cardiovascular deaths. In addition, coffee intake is associated with risks of heart failure, stroke, diabetes mellitus and some cancers in an inverse dose-dependent fashion. Surprisingly, coffee is associated with neutral to reduced risks for both atrial and ventricular arrhythmias. However, caffeine at high doses can increase anxiety, insomnia, calcium loss and possibly the risk of fractures. Summary Coffee and tea can generally be recommended as health-promoting additions to an adult diet. Adequate dietary calcium intake may be particularly important for tea and coffee drinkers.

Objectives: To report and compare the outcomes and survival of patients with abnormal computed tomography-derived coronary artery calcium (CT-CAC) scores undergoing aggressive medical treatment at a cardiac prevention clinic.Patients and Methods: We conducted a retrospective analysis of 849 patients with intermediate risk based on the Framingham risk score and an abnormal CT-CAC score who were aggressively treated in a preventive cardiology risk factor modification program from June 23, 2000, to September 1, 2012. The primary outcome was a composite end point of myocardial infarction, resuscitated cardiac arrest, revascularization, and cardiovascular death. The effect of the CT-CAC subgroup on major adverse coronary heart disease events (MACEs) was evaluated by calculating hazard ratios with Cox proportional hazards regression modeling. The Centers for Disease Control and Prevention Wonder database was used to identify age- and sex-matched controls from the general population of Kansas and Missouri.Results: The mean age of the study patients was 65.4 years (58.4% men [496]). The median follow-up was 58 months, and the mean CT-CAC score was 336 Agatston units. Thirty-four patients (4.0%) reached the primary end point, including 4 deaths. The adjusted 10-year mortality rates were similar in the study group and control group (9.3 vs 10.6; P=.80). After adjustment, a CT-CAC score greater than 400 Agatston units correlated with a higher risk of MACEs (hazard ratio, 3.55; P=.01).Conclusion: These results suggest that intermediate-risk patients with abnormal CT-CAC scores when treated with intensive risk factor reduction have lower rates of MACEs than predicted by the Framingham risk score and the presence of coronary artery calcium. (c) 2013 Mayo Foundation for Medical Education and Research

Coffee, after water, is the most widely consumed beverage in the United States, and is the principal source of caffeine intake among adults. The biological effects of coffee may be substantial and are not limited to the actions of caffeine. Coffee is a complex beverage containing hundreds of biologically active compounds, and the health effects of chronic coffee intake are wide ranging. From a cardiovascular (CV) standpoint, coffee consumption may reduce the risk of type 2 diabetes mellitus and hypertension, as well as other conditions associated with CV risk such as obesity and depression; but it may adversely affect lipid profiles depending on how the beverage is prepared. Regardless, a growing body of data suggests that habitual coffee consumption is neutral to beneficial regarding the risks of a variety of adverse CV outcomes including coronary heart disease, congestive heart failure, arrhythmias, and stroke. Moreover, large epidemiological studies suggest that regular coffee drinkers have reduced risks of mortality, both CV and all-cause. The potential benefits also include protection against neurodegenerative diseases, improved asthma control, and lower risk of select gastrointestinal diseases. A daily intake of ∼2 to 3 cups of coffee appears to be safe and is associated with neutral to beneficial effects for most of the studied health outcomes. However, most of the data on coffee's health effects are based on observational data, with very few randomized, controlled studies, and association does not prove causation. Additionally, the possible advantages of regular coffee consumption have to be weighed against potential risks (which are mostly related to its high caffeine content) including anxiety, insomnia, tremulousness, and palpitations, as well as bone loss and possibly increased risk of fractures.

A 60-year-old woman presented with chest pressure and emesis. Her electrocardiogram was abnormal but non-diagnostic for an acute myocardial infarction. Echocardiography revealed mid- and basal-left ventricular akinesis, with sparing of the apical segments, consistent with apical sparing variant of stress cardiomyopathy (see Supplementary data online, Multimedia files 1 and 2 and Figure 1 A ). Coronary angiography revealed no significant disease. Figure 1 ( A ) End-systolic short-axis images of the …

Patients with type 2 diabetes mellitus (DM) have a very high risk for major adverse cardiovascular (CV) events. Previous studies have shown that traditional oral diabetic medications, despite lowering blood glucose levels, generally do not improve CV outcomes. The safety of some oral hypoglycemic medications has been questioned. We aimed to evaluate the CV safety of dipeptidyl peptidase-4 (DPP4) inhibitors, a novel class of oral diabetic medications, by performing a meta-analysis of DPP4 inhibitors for type 2 DM. A search of electronic databases of published and unpublished literature (until September 30, 2011) was performed to identify randomized controlled trials of >= 24 weeks that compared DPP4 inhibitors to other oral diabetic medications. A meta-analysis was performed using fixed and random effects to determine risk ratio (RR) for adverse CV events with DPP4 inhibitor monotherapy compared to other oral diabetic medications or to placebo. Eighteen randomized met our inclusion criteria, comprising 4,998 patients who were randomized to DPP4 inhibitors and 3,546 to a comparator, with a median duration of therapy of 46.4 weeks. In pooled analysis, the RR of any adverse CV event with a DPP4 inhibitor was 0.48 (0.31 to 0.75, p = 0.001), and the RR for nonfatal myocardial infarction or acute coronary syndrome was 0.40 (0.18 to 0.88, p = 0.02). In conclusion, this meta-analysis provides evidence that DPP4 inhibitors are safe from a CV standpoint and may possibly decrease risk of adverse CV events. (C) 2012 Elsevier Inc. All rights reserved. (Am J Cardiol 2012;110:826-833)

Drug and device therapy for heart failure is increasingly determined based on left ventricular ejection fraction. Significant disparity frequently exists between echocardiographic and nuclear scintigraphic techniques, even when testing is performed nearly simultaneously in clinically stable patients. In 119 patients with left ventricular dysfunction who underwent both echocardiography and stress testing with nuclear imaging within seven days (but with significant disparity in reported left ventricular ejection fraction), we identified four clinical variables which were associated with left ventricular ejection fraction difference. These clinical variables included atrial fibrillation, left ventricular hypertrophy, severe mitral regurgitation and paced rhythm.

Address for Correspondence/Yaz›şma Adresi: Adnan K. Chhatriwalla, MD, Saint Luke's Mid America Heart Institute, 4300 Wornall Rd, Suite 2000 Kansas City, MO 64111-USA Phone: 816-931-1883 Fax: 816-554-4849 E-mail: achhatriwalla@cc-pc.com Accepted Date/Kabul Tarihi: 02.02.2012 Available Online Date/Çevrimiçi Yayın Tarihi: 24.02.2012 ©Telif Hakk› 2011 AVES Yay›nc›l›k Ltd. Şti. Makale metnine www.anakarder.com web sayfas›ndan ulaş›labilir. ©Copyright 2011 by AVES Yay›nc›l›k Ltd. Available on-line at www.anakarder.com doi:10.5152/akd.2012.066 231

Background: Drug and device therapy of heart failure is increasingly determined based on left ventricular ejection fraction (LVEF) partition values. Many patients undergo both single photon emission computed tomography (SPECT) and echocardiographic assessment of LVEF. Significant disparity frequently exists between these 2 techniques, even when testing is performed near simultaneously in clinically stable patients. Objective: We aimed to determine clinical predictors of LVEF disparity in patients undergoing multimodality testing. Methods: Between January 2006 and July 2007, 2937 patients underwent both echo and SPECT testing within a 7 day period. Of these, 119 patients had an LVEF <50% by 1 or both techniques, and an absolute LVEF difference between the 2 techniques of at least 10%. A control group comprising of 118 patients had an LVEF <50% by 1 or both techniques, and an absolute LVEF difference between the 2 techniques of less than 10%. In a logistic model with a stepwise selection method 30 candidate clinical variables were available to be selected in the model. Results: The predictive model resulted in five variables: Atrial Fibrillation, Severe mitral regurgitation, Left ventricular hypertrophy, high basal heart rate during echocardiogram and Paced rhythm. The model obtained good predictability(c=0.82) and fit (Hosmer-Lemeshow p=0.51). The point estimates and odds ratios are shown in the figure below. Conclusions: In patients with LVEF < 50%, atrial fibrillation, severe mitral regurgitation, left ventricular hypertrophy, high basal heart rate during echocardiogram and paced rhythm are associated with a >10% LVEF disparity between the two imaging techniques.

Background: Concern regarding the growth of RNI led to the creation of Appropriate Use Criteria (AUC) as a foundation for evaluating potential overuse. No data exist surrounding the proportion of patients who would be considered appropriate for RNI, but who are not referred for the procedure. Methods: We reviewed charts of 997 randomly selected patients, regardless of their medical history, seen in the outpatient setting of a single-specialty cardiology group from January to July 2008. Records were reviewed by physicians who were trained to abstract all relevant information to assign an AUC Class; including prior revascularization, recent MI, risk factors, functional capacity, chest pain, anginal control, symptoms and Framingham Risk score. The 2009 Update to the SPECT AUC were used to systematically assign each patient an indication for SPECT of Inappropriate (I), Uncertain (U) or Appropriate (A). Descriptive statistics were calculated to describe the prevalence of AUC ratings. Results: Of the 997 subjects included, 268 were referred for cardiac RNI and 729 (73%) patients were not. Baseline characteristics of those who were not referred for RNI are reviewed in the table . Among those not referred, 28% (206/729) would have been A, 13% (93/729) U, 42% (308/729) I and 17% (124/729) had insufficient information to classify. Conclusions: While there are important concerns of RNI overuse, more than 1 in 4 patients not referred for RNI would have meet the AUC criteria for being an appropriate indication. Whether avoiding testing in this group represents judicious use of expensive resources, or these patients outcomes are worse than comparable patients referred for RNI requires follow up and additional research. Baseline demographics of subjects not undergoing RNI (n= 729) Age; years (mean±SD) 64 ±16 Male 419(57%) Prior Revascularization 253 (35%) CABG>5 yrs 59 (8%) CABG<5 yrs 28 (4%) PCI>2 yrs 112 (15%) PCI<2 yrs 54 (7%) DM 104 (14%) Framingham Risk Score (FRS) Moderate risk 97 (13%) Low risk 229 (31%) Data not available 386 (39%) CHD High Risk (DM or high FRS) 119 (16%) Chest Pain 23 (3%) Anginal equivalent Present 160 (22%) Absent 409 (56%) Data not available 160 (22%) Symptoms Absent 371 (51%) Present 196 (27%) Data not available 162 (22%) Functional capacity Good 457 (63%) Poor 113 (15%) Data not available 161 (22%)

RATIONALE: IL-33 is a newly described member of the IL-1 cytokine family that is constitutively expressed in endothelium and epithelium and is important in TH2 inflammation, as well as anaphylaxis. Our objective was to investigate the relationship between IL-33 and inflammatory cells in respiratory secretions from asthmatics. METHODS: Sputa from 100 Severe Asthma Research Program (SARP) subjects were collected along with demographic and clinical information. Sputum supernatants were analyzed for IL-33 (ELISA) and total protein (BCA microassay). Total and differential cell counts were also obtained. Data not meeting normal distribution tests were log transformed before standard statistical analyses including linear regressions. RESULTS: We observed a significant negative association between IL-33 pg/mg total protein and the percentage of neutrophils (R=-0.27, p=0.013), and conversely, a significant positive association for the percentage of macrophages (R=0.26, p=0.02). However, a significant negative association was observed between IL-33 pg/mg total protein and actual macrophage numbers (R=-0.35, p=0.002) and a trend towards a significant negative association between IL-33 and actual neutrophil count (R=-0.20, p=0.07). Corresponding to the negative association of IL-33 with percent and actual number of neutrophils, there was also a significant negative association with IL-8, a neutrophil-relevant cytokine (R=-0.42, p=0.008). CONCLUSION: Increased numbers of macrophages and neutrophils appear to be associated with decreased release of IL-33 into asthmatic sputum. We hypothesize that this may be due to increased metabolism of IL-33 or release of other mediators by these cells, for example IL-8, which suppress IL-33 release.