ObjectiveTo investigate the relative predictive value of circulating immune cell markers for cardiovascular mortality in ambulatory adults without cardiovascular disease.MethodsWe analyzed data of participants enrolled in the National Health and Nutrition Examination Survey from January 1, 1999, to December 31, 2010, with the total leukocyte count within a normal range (4000-11,000 cells/μL [to convert to cells ×109/L, multiply by 0.001]) and without cardiovascular disease. The relative predictive value of circulating immune cell markers measured at enrollment—including total leukocyte count, absolute neutrophil count, absolute lymphocyte count, absolute monocyte count, monocyte-lymphocyte ratio (MLR), neutrophil-lymphocyte ratio, and C-reactive protein—for cardiovascular mortality was evaluated. The marker with the best predictive value was added to the 10-year atherosclerotic cardiovascular disease (ASCVD) risk score to estimate net risk reclassification indices for 10-year cardiovascular mortality.ResultsAmong 21,599 participants eligible for this analysis, the median age was 47 years (interquartile range, 34-63 years); 10,651 (49.2%) participants were women, and 10,713 (49.5%) were self-reported non-Hispanic white. During a median follow-up of 9.6 years (interquartile range, 6.8-13.1 years), there were 627 cardiovascular deaths. MLR had the best predictive value for cardiovascular mortality. The addition of elevated MLR (≥0.3) to the 10-year ASCVD risk score improved the classification by 2.7%±1.4% (P=.04). Elevated MLR had better predictive value than C-reactive protein and several components of the 10-year ASCVD risk score.ConclusionAmong ambulatory US adults without preexisting cardiovascular disease, we found that MLR had the best predictive value for cardiovascular mortality among circulating immune markers. The addition of MLR to the 10-year risk score significantly improved the risk classification of participants.

BACKGROUND:Teleconsultation services in India, especially in neurosurgery, are relatively new. Despite its large-scale adoption during the COVID-19 pandemic, comprehensive analyses of patients' perspectives and hurdles are lacking.MATERIALS AND METHODS:We conducted an anonymized telephonic survey of consecutive neurosurgical patients who availed telemedicine services at our institute, using a validated, structured questionnaire. To prevent bias, interviewers were not involved in the study design/analyses. Patients' perception of usefulness and performance of teleconsultation was graded on a 5-point Likert scale.RESULTS:Of the 330 patients who availed teleconsultation services, 231 (70%) completed the survey. Even though 91% of the respondents had access to a smartphone, only 10% received a video-based teleconsult. As per respondents, the challenges included poor network (7%), suboptimal communication/discussion (5.6%), lack of physical examination (6%), and misinterpretation of prescription by pharmacists/patients (6%). The majority of the respondents (58%) either agreed/strongly agreed that teleconsultation helped them tide over the medical exigency during the lockdown; however, the clinical diagnosis did not influence this response (P = 0.21). The vast majority of the respondents felt that teleconsultation is beneficial (97%), as it minimizes their exposure to COVID-19. One-third of the patients preferred this service over physical visits and 60% agreed to its continuation till resumption of routine care. Access to video-teleconsultation was the chief suggestion in 39 of 74 suggestions received.CONCLUSIONS:Telemedicine in neurosurgery offers favorable patient satisfaction during this pandemic and may be a satisfactory alternative to physical outpatient services in the future. Video-based teleconsults should be the preferred modality of communication for neurosurgery patients.

In this post-hoc analysis of the TOPCAT trial, we evaluated the prognostic role of anemia in adverse cardiovascular (CV) outcomes in heart failure with a preserved ejection fraction (HFpEF). Anemia was defined as hemoglobin of <12 g/dl in females and <13 g/dl in males. The primary outcome was a composite of CV mortality, aborted cardiac arrest (ACA), and heart failure (HF) hospitalization. Secondary outcomes were components of the primary outcome, all-cause, CV and non-CV mortality, cause-specific CV and non-CV mortality, all-cause and HF hospitalization, myocardial infarction, and stroke. Among 1,748 patients from TOPCAT-Americas, patients with anemia had a 52% higher risk of the primary outcome (hazard ratio [HR] 1.52, 95% confidence interval 1.27, 1.83, p<0.05) during a median follow up of 2.4 years. These patients were also at higher risk of all-cause and CV mortality with no difference in non-CV mortality. Among CV causes, patients with anemia had higher risk of sudden cardiac death (SCD)/ACA and presumed CV death with no difference in death due to pump failure. Among non-CV causes, patients with anemia had higher risk of death due to malignancy (HR 2.61, p<0.05). Patients with anemia had higher risk of all-cause and HF hospitalizations (HR 1.26 and 1.56, respectively, p<0.05 for both). There was no difference in the risk of myocardial infarction or stroke. In conclusion, patients with HFpEF and anemia are at higher risk of mortality and hospitalization. Anemia is a significant risk factor for SCD/ACA, death due to presumed CV causes and malignancy in HFpEF. Published by Elsevier Inc.

Introduction: Inflammation is associated with worse cardiovascular (CV) prognosis. We evaluated the impact of adding elevated monocyte lymphocyte ratio (MLR) to 10-year atherosclerotic CV disease (ASCVD) risk score. Hypothesis: Adding elevated MLR improves risk classification by 10-year ASCVD risk score. Methods: We used data from 6 cycles of NHANES (1999-2010) to identify ambulatory US adults aged ≥ 18 years without prevalent cardiovascular disease and total leukocyte count in normal range (4,000-11,000 cells/μL). Elevated MLR (≥0.3) was defined using optimal cutoff to predict CV mortality by Youden index. CV mortality was derived from linked National Center for Health Statistics data. We compared the change in reclassification of the 10-year ASCVD risk score at a pre-specified cutoff of 5% (low risk) and reported the net reclassification index (NRI). We further compared predictive value of the circulating immune with risk factors in ASCVD risk score using time-to-event and logistic models. Results: Among 21,599 eligible participants with median age 47 years (IQR, 34, 63; 49.2% women and 49.5% non-Hispanic White), there were 627 CV deaths with annual incidence rate of 0.3% over median follow-up of 9.6 years (IQR 6.8, 13.1). Median ASCVD risk score was 5% (IQR 1.6, 16.7). Adding elevated MLR to categorical 10-year ASCVD risk score correctly up classified 3.2% participants with CV mortality and incorrectly up classified 0.4% participants with no CV mortality. There was significant improvement in risk classification (NRI 2.7±1.4%, p=0.044, Panel A). Adding elevated CRP (≥0.3 mg/dL) did not change risk class (NRI -0.2±0.0%, p=827, Panel B). Among ASCVD components, MLR had higher predictive value than race, smoking, high-density lipoprotein, and total cholesterol in both time-to-event and logistic models. Conclusions: Elevated MLR significantly improves CV risk reclassification in ambulatory adults without prevalent CV disease and is better than CRP.

We recently showed that Quantitative Perfusion SPECT (QPS), Emory Cardiac Toolbox (ECTb) and 4-Dimension-Myocardial SPECT (4DM) yielded discordant results in the assessment of perfusion defect size (PDS) in patients with known or suspected coronary artery disease. In this report, we examined the sources of variability in the measurement of PDS using ECTb (VarECTb), 4DM (Var4DM) and QPS (VarQPS) and found that gender is a source of variability in the assessment of PDS. In 120 patients, VarECTb was lower in men, compared with women, whereas Var4DM and VarQPS were similar between both genders. Among men, VarECTb was lowest, compared with VarQPS and Var4DM, whereas, VarECTb, VarQPS, and Var4DM were not different among women. Future studies should account for gender differences when comparing the 3 software programs.

Background The relative outcomes of intravascular ultrasound (IVUS) guided percutaneous coronary intervention (PCI) compared with angiography-guided PCI with drug-eluting stent (DES) in complex lesions have not been established. We sought to compare the efficacy and safety of IVUS-guided PCI with angiography-guided PCI in patients with complex coronary lesions treated with DES.Methods Electronic databases were searched to identify all randomized trials comparing IVUS-guided vs angiographyguided DES implantation. We evaluated major adverse cardiac events (MACE), all-cause and cardiovascular death, myocardial infarction, target lesion revascularization (TLR), target vessel revascularization (TVR), and stent thrombosis outcomes at the longest reported follow-up. Random-effects modeling was used to calculate pooled relative risk (RR) and 95% Cls.Results Eight trials comprising 3,276 patients (1,635 IVUS-guided and 1,641 angiography-guided) enrolling only patients with complex lesions were included. Mean follow-up was 1.4 +/- 0.5 years. Compared with angiography-guided PCI, patients undergoing IVUS-guided PCI had significantly lower MACE (RR 0.64, 95% CI 0.51-0.80, P = .0001), TLR (RR 0.62, 95% CI 0.45-0.86, P = .004), and TVR (RR 0.60, 95% CI 0.42-0.87, P = .007). There were no significant differences for stent thrombosis, cardiovascular death, or all-cause death. In meta-regression analysis, IVUS-guided PCI was of greatest benefit in reducing MACE in patients with acute coronary syndromes, diabetes, and long lesions.Conclusions The present meta-analysis demonstrates a significant reduction in MACE, TVR, and TLR with IVUS-guided DES implantation in complex coronary lesions.

Catheter-based treatment (CBT) is an evolving therapeutic strategy for acute pulmonary embolism (PE). We previously described in-hospital mortality rates among patients with acute PE undergoing CBT (1). Inferior vena caval (IVC) filters are often placed to prevent recurrent PE. We hypothesized that

There are conflicting data regarding the benefit of intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) over angiography-guided PCI in complex coronary interventions. Electronic databases were searched to identify all relevant trials published through October, 2015. We

The aim of this study was to compare the failure rates of crossing side branch (SB) with pressure guidewire vs. coronary guidewire after main vessel (MV) stenting in coronary bifurcation lesions (CBL).

Candidates for chronic warfarin therapy often have co-morbid conditions, such as heart failure, with reduced left ventricular ejection fraction. Previous reports have demonstrated an increased risk of over-anticoagulation due to reduced warfarin dose requirement in patients with decompensated heart failure. However, the influence of left ventricular systolic dysfunction (LVSD), defined as left ventricular ejection fraction <40%, on warfarin response has not been evaluated. Here, we assess the influence of LVSD on warfarin dose, anticoagulation control (percent time in target range), and risk of over-anticoagulation (international normalized ratio >4) and major hemorrhage. Of the 1,354 patients included in this prospective cohort study, 214 patients (16%) had LVSD. Patients with LVSD required 11% lower warfarin dose compared with those without LVSD (p <0.001) using multivariate linear regression analyses. Using multivariate Cox proportional hazards model, patients with LVSD experienced similar levels of anticoagulation control (percent time in target range: 51% vs 53% p = 0.15), risk of over-anticoagulation (international normalized ratio >4; hazard ratio 1.01, 95% confidence interval 0.82 to 1.25; p = 0.91), and risk of major hemorrhage (hazard ratio 1.11; 95% confidence interval 0.70 to 1.74; p = 0.66). Addition of LVSD variable in the model increased the variability explained from 35% to 36% for warfarin dose prediction. In conclusion, our results demonstrate that patients with LVSD require lower doses of warfarin. Whether warfarin dosing algorithms incorporating LVSD in determining initial doses improves outcomes needs to be evaluated.

BackgroundMultiple novel oral anticoagulants and left atrial appendage closure devices (WATCHMAN) have been tested against dose-adjusted vitamin K antagonists in randomized controlled trials for stroke prophylaxis in non-valvular atrial fibrillation. No direct comparisons of these strategies are available from randomized controlled trials. We conducted the current analyses by combining efficacy and safety characteristics of all FDA approved stroke prophylaxis treatment strategies for patients with non-valvular atrial fibrillation.Materials and MethodsWe searched SCOPUS from 1945 till October 2015 for randomized controlled trials comparing these strategies and reporting efficacy and safety outcomes. Six randomized controlled trials were identified and included in the final analyses and review. We followed PRISMA guidelines for network meta-analyses while reporting the current analyses. We collected data on ischemic stroke, major bleeding, and the composite primary safety end-point as defined by various randomized controlled trials. Network meta-analyses were conducted using consistency and inconsistency models for efficacy and safety outcomes. Surface under the cumulative ranking curve were then utilized to cluster rank these treatments for safety and efficacy.ResultsSix randomized controlled trials with 59,627 patients comparing six treatment strategies were eligible for the analyses. All prophylaxis strategies had comparable rates of ischemic stroke. Apixaban was associated with the least number of primary safety endpoint events as compared with all other treatments. In the cluster analyses assessing safety and efficacy, apixaban, edoxaban and dabigatran ranked best followed by vitamin K antagonists and rivaroxaban, whereas the WATCHMAN left atrial appendage closure device ranked last.ConclusionsDose-adjusted vitamin K antagonists, novel oral anticoagulants, and the WATCHMAN left atrial appendage closure devices are equally efficacious for ischemic stroke prevention but these treatments have different safety profiles. More randomized controlled trials are needed to directly compare these strategies.

Untreated high-risk pulmonary embolism (PE) is associated with a mortality rate as high as 60%. Surgical pulmonary embolectomy (SPE) is an efficacious treatment but outcomes data regarding this approach are limited. We sought to characterize mortality outcomes for patients with high-risk PE

We thank Drs. Huang et al. for their interest and comments [ [1] Huang Y. Huang W. Hu Y. Digoxin in patients with atrial fibrillation and heart failure: a risk factor or a marker of increased mortality?. Int. J. Cardiol. 2015; (Manuscript Number: IJC-D-15-04581) Google Scholar ] on our recent review entitled “Digoxin in patients with Atrial fibrillation and Heart Failure: A meta-analysis” [ [2] Bavishi C. Khan A.R. Ather S. Digoxin in patients with atrial fibrillation and heart failure: a meta-analysis. Int. J. Cardiol. Jun 1 2015; 188: 99-101 Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar ]. The authors raise several questions about the limitations of the analyses because of the observational design of the included studies in the review and advocate the use of digoxin in patients with heart failure and atrial fibrillation (AF). We agree with the opinion that evidence from observational studies should be interpreted with caution due to residual confounding and inherent biases despite the use of appropriate statistical measures, which has been duly acknowledged in our study. Moreover, the concern underlines the need for a randomized control trial assessing use of digoxin in patients with HF and AF. In the absence of a randomized control trial, observational studies could provide important clinical data and insights into the “real world” practices. Digoxin in patients with atrial fibrillation and heart failure: A risk factor or a marker of increased mortality?International Journal of CardiologyVol. 206PreviewWe read the recent article by Bavishi et al. [1] with great interest. In this study, the authors performed a meta-analysis on the association of digoxin treatment and all-cause mortality in patients with atrial fibrillation (AF) and heart failure (HF). Ten studies, including 4 registry studies, 4 single-center cohort studies, and 2 post-hoc analysis of randomized control trials (RCTs) with a total of 76,100 patients were included for analysis. The results showed that digoxin treatment in patients with both HF and AF was associated with 15% more risk of all-cause mortality. Full-Text PDF

BACKGROUND:We sought to estimate the efficacy and safety outcomes of catheter-directed treatment (CDT) for patients with acute pulmonary embolism (PE). METHODS:We searched SCOPUS for studies reporting outcomes after CDT for acute PE. Studies were categorized in three groups for analyses due to heterogeneity in the classification of acute PE: 1) patients with PE causing right ventricular dysfunction and haemodynamic instability: unstable haemodynamic status, 2) patients with PE causing right ventricular dysfunction where study outcomes were not stratified by haemodynamic status: stable and unstable haemodynamic status, and 3) patients with PE causing right ventricular dysfunction who remained haemodynamically stable: stable haemodynamic status. Efficacy and safety outcomes were estimated and presented as point estimates with 95% confidence intervals. RESULTS:In 35 studies with 1253 patients, 1277 CDTs were performed. The in-hospital mortality rates for the unstable haemodynamic status, stable and unstable haemodynamic status, and stable haemodynamic status groups were 18.1% (7.3-38.2%), 7.1% (5.0-10.1%), and 2.6% (0.8-7.3%), respectively. The major bleeding rates across the groups were estimated to be 4.5, 8.5 and 3.9 per 100 CDTs, respectively. Minor bleeding occurred in 6.2, 11.9 and 9.1 per 100 CDTs, respectively. After CDT, all groups had improvements in mean pulmonary artery pressure and right ventricular function. CONCLUSIONS:We provide descriptive measures of efficacy and safety for patients who underwent CDT for acute PE.

Acute massive pulmonary embolism (PE) is associated with a high mortality rate.Catheter-based treatments (CBT) may provide effective immediate treatment without the inherent bleeding risks of systemic thrombolysis, but comparative data for the two approaches are limited. We searched SCOPUS since

Background and propose: In coronary bifurcation lesions ( CBL), hydrophilic guidewires used for side-branch ( SB) protection can be withdrawn from underneath the stent easier than other wires. However, the safety of which has not been investigated.Methods/materials: We performed scanning electron microscopic ( SEM) examination of hydrophilic wires - the Whisper and Runthrough wires -used for SB protection during stenting and proximal optimization technique ( POT) in 30 patients with CBL. The distal 15 cm of the wire was examined every 1 mm by SEM and 4500 segments were analyzed to investigate for wire fracture, polymer shearing ( PS), and its correlations with post-stenting creatine kinase ( CK)-MB release.Results: SEM examination showed no evidence for wire fracture. The total area of PS and the largest defect on the wire were significantly larger with the Whisper wire versus the Runthrough wire ( 0.15 +/- 0.04mm(2) vs. 0.026 +/- 0.01mm(2) and 0.04 +/- 0.05 mm(2) vs. 0.01 +/- 0.01 mm(2); P < 0.05, respectively). The total length of PS and the longest defect on the wire were significantly longer with the Whisper wire vs. the Runthrough wire ( 12.1 +/- 14.5mm vs. 2.7 +/- 3.0mm and 2.9 +/- 4.2mm vs. 1.0 +/- 1.2mm; P < 0.05, respectively), but there were weak correlations between the extents of PS with CK-MB release.Conclusions: Hydrophilic guidewires may be safely used for SB protection during stenting and POT in CBLs. The extent of PS was significantly greater with the Whisper wire than with the Runthrough wire, but its correlation with post-stenting CK-MB release was weak. (C) 2016 Elsevier Inc. All rights reserved.

Background Significant controversy exists regarding the best approach for nonculprit vessel revascularization in patients with multivessel coronary artery disease presenting with ST‐segment elevation myocardial infarction. We conducted a systematic investigation to pool data from current randomized controlled trials (RCTs) to assess optimal treatment strategies in this patient population. Methods and Results A comprehensive search of SCOPUS from inception through May 2015 was performed using predefined criteria. We compared efficacy and safety outcomes of different approaches by categorizing the studies into 3 groups: (1) complete revascularization (CR) versus culprit lesion revascularization (CL) at index hospitalization, (2) CR at index hospitalization versus staged revascularization (SR) of nonculprit vessels at a separate hospitalization, and (3) comparison of SR versus CL. Eight eligible RCTs met the inclusion criteria: (1) CR versus CL (6 RCTs, n=1727) (2) CR versus SR (3 RCTs, n=311), and (3) SR versus CL (1 RCT, n=149). We observed significantly lower rates of major adverse cardiovascular events, revascularization, and repeat percutaneous coronary interventions among patients treated with CR and SR compared with a CL approach (P<0.05). The rates of all‐cause mortality, cause‐specific mortality, major bleeding, reinfarction, stroke, and contrast‐induced nephropathy did not differ in the CR arm compared with the CL arm. The rates of these outcomes were similar in the CR and SR arms. Conclusion Results suggest that CR and SR compared with CL reduce major adverse cardiovascular event and revascularization rates primarily by lowering repeated percutaneous coronary intervention rates. We did not observe any increase in the rate of adverse events while using a CR or SR strategy compared with a CL approach. Current guidelines discouraging CR need to be reevaluated, and clinical judgment should prevail in treating multivessel coronary artery disease patients with ST‐segment elevation myocardial infarction as data from larger RCTs accumulate.

Objective: To compare the efficacy and safety of dual antiplatelet therapy (DAPT) and triple therapy (TT, dual antiplatelet plus warfarin) in patients with myocardial infarction (MI) or PCI with stenting (PCI-S) who also require chronic oral anticoagulation. Background: Recommendations for the optimal antiplatelet/anticoagulant treatment regimen for patients undergoing PCI-S or MI who also require oral anticoagulation are largely based on evidence from observational studies and expert opinions. Methods: A systematic search was performed for studies comparing TT vs. DAPT in patients post PCI-S or MI and requiring chronic anticoagulation. Primary outcome was all-cause mortality. Secondary outcomes were ischemic stroke, major bleeding, MI, and stent thrombosis. Pooled relative risks (RR) were calculated using random effects model. Results: A total of 17 studies were included, with 14,921 patients [TT: 5,819(39%) and DAPT: 9,102(61%)] and a mean follow-up of 1.6 years. The majority of patients required oral anticoagulation for atrial fibrillation. Compared to DAPT, patients treated with TT had no significant difference in all-cause mortality [RR: 0.81, 95% confidence interval (CI): 0.61-1.08, P = 0.15], MI [RR 0.74, 95% CI: 0.51-1.06, P = 0.10], and stent thrombosis [RR 0.67, 95% CI: 0.35-1.30, P = 0.24]. Patients treated with TT had significantly increased risk of major bleeding [RR 1.20, 95% CI: 1.03-1.39, P = 0.02], whereas the risk for ischemic stroke was significantly lower [RR 0.59, 95% CI: 0.38-0.92, P = 0.02]. Conclusions: All-cause mortality appears similar in patients treated with TT or DAPT although TT was associated with higher rates of major bleeding and a lower risk for ischemic stroke. (C) 2015 Wiley Periodicals, Inc.

Introduction: The efficacy of drug-eluting stents (DES) compared to bare-metal stents (BMS) in patients with Non-ST-segment Elevation Myocardial Infarction (NSTE-ACS) is unclear. Methods: Pubmed, Scopus and Clinical trials.gov databases were searched to identify all studies that compared DES with BMS in patients with NSTE-ACS. We evaluated the following efficacy and safety outcomes: all-cause mortality, cardiovascular mortality, myocardial infarction, stent thrombosis, target vessel revascularization and major advance cardiovascular events (MACE) at the longest reported follow-up times. Random-effects model was used to pool study results. Results: A total of 11 cohort studies with 44,123 patients were included. The mean follow-up duration was 2.3 years. Of note, all studies compared first generation DES with BMS. Patients receiving DES had significantly lower all-cause mortality (Relative risk [RR]: 0.74, 95% confidence interval [CI]: 0.64 - 0.86, p<0.001), cardiovascular mortality (RR: 0.73, 95% CI: 0.54 - 0.99, p=0.02), MACE (RR: 0.71, 95% CI: 0.54 - 0.94, p=0.02) and target vessel revascularization (RR: 0.64, 95% CI: 0.49 - 0.82, p=0.001). There was no significant difference in the incidence of myocardial infarction (RR: 0.88, 95% CI: 0.67 - 1.15, p=0.34) and stent thrombosis (RR: 0.98, 95% CI: 0.71 - 1.35, p=0.89). Conclusions: Compared to BMS, DES is associated with improved outcomes with non-significant differences in myocardial infarction and stent thrombosis. Further randomized controlled trials including studies with newer DES, are required to evaluate the efficacy and safety of DES in patients with NSTE-ACS.