ABSTRACT:Unfractionated heparin is the most common anticoagulant used during percutaneous coronary intervention. Practice guidelines recommend an initial weight-based heparin bolus dose between 70 and 100 U/kg to achieve target activated clotting time (ACT) of 250-300 seconds. The impact of severe obesity on weight-based heparin dosing is not well studied. We performed a retrospective analysis of 424 patients undergoing percutaneous coronary intervention who received heparin for anticoagulation. We collected detailed data on cumulative heparin administration and measured ACT values in this cohort. We performed separate analyses to identify clinical predictors that may affect dose-response curves. There was significant variability in dosing with mean dose of 103.9 ± 32-U/kg heparin administered to achieve target ACT ≥ 250 seconds. Women received higher initial heparin doses when adjusted for weight than men (97.6 ± 31 vs. 89 ± 28 U/kg, P = 0.004), and only 49% of patients achieved ACT ≥ 250 s with the initial recommended heparin bolus dose (70-100 U/kg). Lower heparin dose (U/kg) was required in obese patients to achieve target ACT. In multivariate linear regression analysis with ACT as dependent variable, after inclusion of weight-based dosing for heparin, body mass index was the only significant covariate. In conclusion, there is significant variability in the therapeutic effect of heparin, with a lower weight-adjusted heparin dose required in obese patients.

Background:Femoral arterial access remains widely used despite recent increase in radial access for cardiac catheterization and percutaneous coronary intervention (PCI). Various femoral artery closure devices have been developed and are commonly used to shorten vascular closure times, with variable rates of vascular complications observed in clinical trials. We sought to examine the rates of contemporary outcomes during diagnostic catheterization and PCI with the most common femoral artery closure devices. Methods:We identified patients who had undergone either diagnostic catheterization alone (n = 14,401) or PCI (n = 11,712) through femoral artery access in the Indiana University Health Multicenter Cardiac Cath registry. We compared outcomes according to closure type: manual compression, Angio-Seal, Perclose, or Mynx. Access complications and bleeding outcomes were measured according to National Cardiovascular Data ​Registry standard definitions. Results:The use of any vascular closure device as compared to manual femoral arterial access hold was associated with a significant reduction in vascular access complications and bleeding events in patients who underwent PCI. No significant difference in access-site complications was observed for diagnostic catheterization alone. Among closure devices, Perclose and Angio-Seal had a lower rate of hematoma than Mynx. Conclusions:The use of femoral artery access closure devices is associated with a reduction in vascular access complication rates as compared to manual femoral artery compression in patients who undergo PCI.

Right ventricular infarction is often associated with significant morbidity and mortality. Here, we report a case of right ventricular infarction associated with persistent hypoxia due to acute right-to-left shunting through a patent foramen ovale. (Level of Difficulty: Intermediate.).

Bioprosthetic valve obstruction is a feared complication associated with considerable morbidity and mortality. High clinical suspicion is needed for prompt recognition and treatment. A 70-year-old female with a bioprosthetic valve for mitral prolapse placed nine years prior presented in atrial

Objective: This study examined whether body mass index (BMI) and access to fresh food affects heart failure outcomes. Methods: We identified patients admitted to a university hospital between 01/01/13 and 12/31/13 with a primary diagnosis of heart failure and extracted relevant data through a chart review. Using patient zip codes in the USDA Food Access Research Atlas we identified patients who lived in areas with low access to fresh food or food deserts. Low-access areas are defined as regions where ≥ 33% of the population live > 1 mile (in urban areas) or > 10 miles (in rural areas) from a supermarket. Food deserts have the additional stipulation of areas where median income is ≤ 80% of statewide median. We used the World Health Organization definitions of obesity to classify patients as obese (BMI ≥ 30) or non-obese (BMI < 29.9) and also further stratified as underweight (BMI < 18.5), normal (BMI 18.5–24.9), overweight (BMI 25–29.9) obesity class I (BMI 30–34.9), obesity class II (BMI 35–39.9), or obesity class III (BMI ≥ 40). Using regression analysis, we compared 30-day readmission, in-hospital mortality, and length of stay for obese or non-obese heart failure patients based on their access to fresh food. Results: There were 2063 patient encounters in our study (54.5% male, 43.7% African American, 47.2% heart failure with reduced ejection fraction, 39.9% obese) of which 1039 lived in adequate fresh food access areas and 1024 combined lived in low access or food desert areas with similar demographics within each group. Obesity was associated with living in a food desert (RR 1.26, P = .036). Living in a food desert was associated with a higher 30-day readmission rate for non-obese patients compared to obese patients (RR 1.96 vs. 0.51, P = .032). When stratified, patients of normal BMI patients had higher rates of 30-day readmissions in low access areas (RR 1.50, P = .032) and food deserts (RR 2.30, P = .005). There was a trend towards fewer readmissions with increasing obesity class but this was not statistically significant. No association for underweight or overweight patients and readmissions was present. There was no difference in in-patient mortality or length of stay between obese and non-obese patients regardless of food access. Conclusion: Living in a food desert is associated with higher rates of obesity for this heart failure sample. However, there appears to be an obesity paradox for heart failure in food deserts as obese patients have fewer 30-day readmissions than non-obese patients. Specifically, heart failure patients with normal BMI have the strongest association with 30-day readmissions. Further investigation is needed in a larger cohort with a broader geography.

The differential diagnosis of a lateral neck mass includes a number of possible etiologies. While jugular venous aneurysms and pseudoaneurysms are rare entities, they should be considered in the differential diagnosis of a pulsatile lateral neck mass. We present a case of an idiopathic jugular venous pseudoaneurysm and its association with worsening tricuspid regurgitation in a patient with heart failure with preserved ejection fraction.

Background: It has been hypothesized that lack of access to fresh food may be linked to poorer health outcomes. Objectives: This study sought to determine whether low access to food impacts health outcomes of heart failure patients. Methods: We identified patients admitted to a university hospital between 1/1/13 and 12/31/13 with a primary diagnosis of heart failure. We entered patients' zip codes into the USDA Food Access Research Atlas to identify those with and without access to fresh food. Low access areas were defined as regions where 33% or more of the population (of at least 500) lived more than 1 mile (in urban areas) or more than 10 miles (in rural areas) from a supermarket. We compared 30-day readmission rates, in-hospital mortality, and length of stay for low access and adequate access patients. Results: Of the 2100 patient encounters in our study, 321 (15.3%) were readmissions. There were 1620 unique patients (male 54.4%, Caucasian 49.8%, median age 65), of which 785 (48.5%) lived in low access areas and 835 (51.5%) lived in adequate access areas. There was an equal number of HFpEF and HFrEF patients (49.4% vs. 50.6%). A multiple Chi-squared regression was performed taking in to account age, gender, race, body mass index, ejection fraction, and access to food. HFrEF was the only variable associated with 30-day readmission (P = .003). Low access to fresh food did not predict 30-day readmission rates for this heart failure population, regardless of ejection fraction, BMI or location after discharge (see Table). In-hospital mortality for all patients was 3.9%, and patients with 30-day readmission and adequate access had higher mortality than those with 30-day readmission and low access (9.8% vs. 2.4%) (P = .173). Length of stay was similar for low access patients (9.93 days) and adequate access patients (9.86 days) (P = .615). Conclusion: Low access to fresh food is not correlated with 30-day readmission rates, in-hospital mortality, or length of stay for heart failure patients in this sample. Further investigation with a larger cohort and incorporating broader geography is needed.Table30-Day Readmission Rates According to Food Access, LVEF, BMI and Location After DischargeLow Access to FoodAdequate Access to FoodP-ValueLVEF < 40%7.4%7.9%.539LVEF ≥ 40%5.8%5.5%.85BMI < 306.8%6.8%.743BMI ≥ 306.2%6.5%1.0Patients discharged to home6.0%6.4%.71Patients discharged to skilled nursing facility8.2%8.7%.71 Open table in a new tab

Introduction: Limited access to healthy food has been linked to an unfavorable cardiovascular risk profile. This study sought to determine whether living in a food desert or an area with low access to fresh food impacts 30-day readmissions and total hospitalizations for heart failure patients. Hypothesis: Living in a food desert is associated with heart failure readmissions. Methods: We identified patients admitted to a university hospital between 01/01/2013 and 12/31/2013 with a primary diagnosis of heart failure. We entered patients’ zip codes into the USDA Food Access Research Atlas to identify patients who live in areas with low access to fresh food or food deserts. Low-access areas are defined as regions where ≥ 33% of the population live > 1 mile (in urban areas) or > 10 miles (in rural areas) from a supermarket. Food deserts have the additional stipulation of areas where median income is ≤ 80% of statewide median. We used regression analysis to compare 30-day readmissions and total hospitalizations for patients living in low-access or food deserts vs. living in adequate-access areas. Additional variables including poverty level, health insurance status, and education level were also examined for each zip code. Results: There was 2063 hospitalizations from 1598 unique patients in this sample (54% male, 41.1% African American, mean age 65±17 years, mean EF 41±19%). 789 (49.4%) patients lived in low-access areas and 318 (19.9%) lived in food deserts. 211 (13.2%) patients had at least one 30-day readmission. Living in a low-access area or a food desert was not associated with a 30-day readmission or the total number of heart failure-related hospitalizations (p > 0.05). Living in zip codes with levels of poverty, high school dropout rate, and uninsured status above the national average did not correlate with 30-day readmissions or total heart failure-related hospitalizations for our sample (p > 0.05). Conclusion: Living in a food desert or low-access area is not predictive of 30-day heart failure readmissions or total heart failure-related hospitalizations in this population. Further investigation examining additional outcome measures with a larger cohort and broader geography is necessary to substantiate these findings.

Diabetic ketoacidosis is a routinely encountered diagnosis in medicine. Physicians are trained early on to look for precipitants. Most clinicians assess for medication compliance, infection, ischemia, and the like. We present a case of pheochromocytoma presenting as “diabetic ketoacidosis.” The case serves as an example for broadening the differential diagnosis for patients with similar presentations. Additionally, the case helps inform our understanding of the so-called “stress reactions” that are commonly invoked in clinical rationale.