by Mark | Aug 26, 2015 | Cardiology
The Most Important Articles in Heart Failure Below are what I believe to be the most important articles in heart failure in mid-2015. Most of the ICD trials are actually covered in the EP trials section. Each trial is divided into categories, and each blue trial name is a link to the trial page. In many cases where the journal article is open access, the link will open the full article. Otherwise, a Pubmed or Abstract page will open. Enjoy! Beta Blockers CAPRICORN (carvedilol) CIBIS-I, CIBIS-II (bisoprolol) MERIT-HF (metoprolol XL) US-CARVEDILOL BEST (bucindolol) COPERNICUS (carvedilol) COMET (carvedilol vs. metoprolol) MOCHA (carvedilol) SENIORS (nevibolol) OPTIMIZE-HF (beta blockers) ACE Inhibitors HOPE (ramipril) SOLVD (enalapril) SAVE (captopril) ATLAS (lisinopril dosing) CONSENSUS (enalapril) OPTIMAAL (losartan vs. captopril) VALIANT (valsartan, captopril) Angiotensin Receptor Blockers CHARM, CHARM-ALTERNATIVE, CHARM-PEF (candesartan) I-PRESERVE (irbesartan, HFpEF) PEP-CHF (perindopril) TOPCAT (spironolactone, HFpEF) Aldo-DHF (spironolactone, HFpEF) VALHEFT, A-HEFT ELITE-I, ELITE-II (losartan) Other Therapies SCD-HeFT (amiodarone vs. ICD) ALLHAT (thiazide diuretics & HTN) DIG (digoxin) RALES (spironolactone) EPHESUS (eplerenone) EMPHASIS-HF (eplerenone) TREAT (darbapoietin-alpha) RED-HF (darbapoietin-alpha) DOSE (furosemide, bolus vs. continuous) ASCEND-HF (nesiritide) REMATCH (LVAD) RELAX WARCEF Guidelines Heart Failure Guidelines Disclaimer © 2015 www.markmccauleymd.com. All rights served. ...
by Mark | Aug 18, 2015 | Cardiology
The Most Important Articles in Ischemic Heart Disease, Coronary Artery Disease, and Myocardial Infarction (MI) Below are what I believe to be the most important articles in coronary heart disease in mid-2015. Each trial is divided into categories, and each blue trial name is a link to the trial page. In many cases where the journal article is open access, the link will open the full article. Otherwise, a Pubmed or Abstract page will open. Enjoy! Coronary Artery Bypass Grafting (CABG) VA-CABG CASS STICH CARP PCI COURAGE CARDia TACTICS/TIMI-18 TIMACS OAT APEX-AMI SIRIUS (sirolimus DES) TAXUS-IV (paclitaxel DES) REACT STREAM (rescue PCI) TRANSFER-AMI (rescue PCI) CARESS-IN-AMI BCIS-1 DEFER (FFR) FAME (FFR) CABG vs. PCI BARI SYNTAX FREEDOM SHOCK SHOCK-II Medical/Adjunctive Therapy for Ischemia/Infarct HOPE (ramipril) BARI-2D OASIS-V (enoxaparin vs. fondaparinux) SYNERGY (enoxaparin vs. unfractionated heparin) TIMI-11b (enoxaparin vs. unfractionated heparin in UA/NSTEMI) Antiplatelet Trialists’ Intervention: High Risk Low Risk CURRENT/OASIS-7 (aspirin & clopidogrel factorial) CURE (clopidogrel) TRITON/TIMI-38 (prasugrel vs. clopidogrel) TRILOGY-ACS (prasugrel vs. clopidogrel) PLATO (ticagrelor vs. clopidogrel) COGENT (clopidogrel/PPI) GRAVITAS (clopidogrel dosing) ACUITY (heparin+GPIIb/IIIa vs. bivalirudin+GPIIb/IIIa vs. bivalirudin) HORIZONS-AMI (bivalirudin) CAPTURE (abciximab) EARLY-ACS (eptifibatide) COMMIT (beta blocker, acute MI) POISE (toprol XL) DECREASE (bisoprolol, perioperative) TRIUMPH (tilarginine, shock) WOEST (clopidogrel without aspirin) CREDO (clopidogrel) GUSTO-1 GUSTO-3 (t-PA, streptokinase) GISSI-1 GISSI-2 (streptokinase, alteplase) ISIS-2 (streptokinase) INTIME-2 (lanoteplase) ASSENT-2 (tenecteplase vs. alteplase) Cholesterol-Lowering Drugs and Outcome ARIC / ARIC (rosuvastatin) JUPITER (rosuvastatin) PROVE-IT/TIMI-22 (pravastatin/atorvastatin) A-TO-Z (simvastatin) Acute Pericarditis ICAP (colchicine) COPE (colchicine) Scoring Systems in AMI GRACE Scoring System TIMI Risk Score UA/NSTEMI Guidelines Unstable Angina / NSTEMI STEMI PCI CABG Surgery Cholesterol Disclaimer © 2015 www.markmccauleymd.com. All rights...
by Mark | Aug 8, 2015 | Cardiac Electrophysiology, Cardiology
The Most Important Articles in Electrophysiology (EP) Below are what I believe to be the most important articles in electrophysiology in mid-2015. Each trial is divided into categories, and each blue trial name is a link to the trial page. In many cases where the journal article is open access, the link will open the full article. Otherwise, a Pubmed or Abstract page will open. Enjoy! Atrial Fibrillation AFFIRM RACE RACE-II STOP AF ASSERT Crystal AF EURIDIS And ADONIS PALLAS ATHENA AVERROES ARREST-AF CTAF SAFE-T DIONYSOS Atrial Fibrillation – Stroke Prevention RE-LY Aristotle Rocket AF PROTECT-AF CHADS-VASC ACTIVE-W / ACTIVE-A Pacing and Implantable Cardioverter/Defibrillators (ICD) MADIT MADIT-II MADIT-RIT DINAMIT IRIS SCD-HeFT OPTIC CABG-PATCH DAVID AVID CASH CIDS ISSUE-3 Cardiac Resynchronization Therapy (CRT) MADIT-CRT Miracle ICD Miracle ICD II RAFT MUSTIC COMPANION Block-HF RethinQ CARE-HF PROSPECT EP Study Validation Trials MUSTT REVERSE ICD Remote Cardiac Monitoring CHAMPION CARISMA TRUST Heart Failure, Ventricular Tachycardia, and Mortality ANDROMEDA CAST SWORD Diamond-MI ALIVE GEISCA CHF-STAT EMIAT CAMIAT DIG Syncope VPS-1 VPS-2 Guidelines AF Guidelines SVT Guidelines VT Guidelines Device-Based Therapy Guidelines ICD and CRT Guidelines European Syncope Guidelines Disclaimer © 2015 www.markmccauleymd.com. All rights served. ...
by Mark | Aug 1, 2015 | Cardiology
Aortic Regurgitation (AR) Acute Aortic Regurgitation Acute AR Symptoms: Acute tachycardia Acute dyspnea Acute AR Signs: Tachycardia Severe HF Sx: rales, edema Soft S1 Hypotension Diastolic murmur may be short or inaudible S3/S4 Acute Severe AR Treatment: Urgent surgical replacement (AVR) or repair Nitroprusside IV, Inotropes DO NOT use Intra-Aortic Balloon Pump (IABP) DO NOT use beta blockers or pressors Chronic Aortic Regurgitation Chronic AR Symptoms: Prolonged asymptomatic stage, then dyspnea Chronic AR Signs: Loud decrescendo diastolic murmur at R upper sternal border (holodiastolic) +/- Austin Flint murmur Wide pulse pressure Bisferiens pulse Head nodding, capillary pulsations, pistol-shot femoral pulses, pulsatile uvula Chronic AR Etiology: Intrinsic valvular: degenerative, calcification, bicuspid, rheumatic, connective tissue Dz, IE, myxomatous, anorectic drugs Ascending aorta: degenerative, dissection, Marfan’s, Ehlers-Danlos, inflammatory/aortitis, giant cell arteritis A disease of LV volume and pressure overload Increased preload, Increased afterload –> often large LV (cor bovinatum) EF is relatively unchanged with corrective surgery Echocardiography in Chronic AR: Signs of severe AR: PHT < 200 msec, regurg vol > 60 mL, regurg fraction > 55%, color jet > 60% LVOT Premature MV closure Flow reversal in the proximal descending thoracic aorta Treadmill in Chronic AR: can do treadmill for estimation of exercise capacity, no need for LVEF changes Catheterization in Chronic AR: Do a cath if echo and Sx are discrepant LV pressure tracing shows gradual rise in diastole Wide pulse pressure Effacement of the dicrotic notch MRI If echo cannot diagnose AR severity, cardiac MRI (CMR) is the next modality Surgical Indications for Severe Chronic AR: Severe AR + any symptoms Severe AR + LVEF < 50%...
by Mark | Jul 31, 2015 | Cardiology
Mitral Valve Regurgitation (MR) Acute MR: Acute MR Symptoms: Acute severe shortness of breath “Bolt-upright” position in bed Apical tapping Chest discomfort Acute MR Signs: Hypotension, tachycardia, LV apical tapping Soft, subtle systolic murmur +S3, S4 Rales in lungs Echocardiography in Acute MR: TTE may fail to detect severe acute MR, progress to TEE or cath on clinical suspicion Treatment of Acute Symptomatic Severe MR: Vasodilators (sodium nitroprusside or nicardipine) Intra-aortic balloon pump (IABP) Surgical repair/replacement stat Papillary rupture Dehisced mitral prosthesis Infective endocarditis + heart failure Chordal rupture (soon if not stat) Chronic MR: Chronic MR Symptoms Prolonged asymptomatic period, followed by: Pulmonary congestion, dyspnea on exertion Palpitations Chronic MR Signs: Pulmonary rales S3 Tapping apical impulse High-pitched late holo-systolic murmur (sounds like wind in a microphone) Holo-systolic murmur best appreciated at apex in left-lateral decubitus position Loud P2 Possible mid-systolic click (MVP) Chronic MR Epidemiology: Primary MR (organic): #1 cause is degenerative disease, #2 rheumatic disease Secondary MR (functional): dilated CMP, ischemic CMP Chronic MR is pure volume overload –> increased preload, decreased afterload LV dysfunction occurs before symptoms, so surgical decision is based on LVEF, ESD rather than symptoms LVEF DROPS after repair/replacement surgery Hypertension aggravates MR Echocardiographic Findings of Chronic MR: Echocardiographic indications for surgery: LVEF < 60% or ESD > 40 mm Other signs of severe MR: regurg. vol > 60 mL, regurg. fraction > 55%, ERO > 0.4 cm(2), PV systolic reversal, VC > 0.5 cm Note: chronic MR cannot be severe with normal LVEF and normal LV dimensions Note: ERO is not accurate in late systolic prolapse of MV (assumes holosystolic...
by Mark | Jul 29, 2015 | Cardiology
Mitral Valve Stenosis Symptoms/History: Dyspnea at rest, dyspnea on exertion (DOE) Paroxysmal nocturnal dyspnea R-sided HF symptoms: slow progressive orthopnea, fatigue, edema Hemoptysis Atrial Fibrillation, palpitations, resultant emboli (stroke/TIA) Potential history of rheumatic fever as a child MS Physical Exam: Loud S1, loud P2 High pitched opening snap followed by a low-pitched holodiastolic rumble at the apex RV lift Liver edge may be palpable in R-HF Possible atrial fibrillation MS Etiology/Epidemiology: MS almost always results from rheumatic fever Prolonged inflammation causes commisural fusion, diastolic leaflet doming Resultant increase in LA pressure causes LA enlargement, pulmonary hypertension, R-HF, atrial arrhythmias LV is usually unaffected in pure MS; there is pressure overload in LA, RV, RA, and pulmonary circulation Differential Diagnosis for Mitral Stenosis: cor triatriatum, atrial myxoma, PV obstruction Mitral Stenosis Stages: A: At risk (mild valvular doming) B: Progressive C: Asymptomatic severe MS (MVA < 1.5 cm(2), PHT > 150 msec, very large LA, PASP > 30 mmHg) D: Symptomatic severe MS (above, with reduced exercise tolerance and DOE) Chest X-ray in MS: enlargement of left and right atria, pulmonary congestion, LV normal size Barium swallow study may show esophagus is “pushed-back” due to LA size Echocardiogram in MS: Echo Doppler of the mitral valve gradient is the gold standard for diagnosis of mitral stenosis & severity Findings of MS on echo: commisural fusion, increased LA size, diastolic doming, hockey stick appearance, candle-flame appearance of MS jet on Doppler, M-mode with A/P thickening and moves as one unit Severe mitral stenosis: gradient > 5-10 mmHg, MVA ≤ 1.5 cm(2), PHT > 150 msec Echo is better for evaluating MS, cath is limited by...
by Mark | Jul 28, 2015 | Cardiology
Aortic Valve Stenosis (AS) Symptoms: dyspnea on exertion, dizziness/presyncope, angina, syncope (deadly) Prognosis: prognosis is worst for HF > syncope > angina Physical Exam: Late-peaking systolic ejection murmur (SEM), crescendo-decrescendo, may radiate to carotids, +/- thrill Single S2 (especially on inspiration) Carotid pulses attenuated (parvus) and delayed (tardus) +/- S4 heart sound in sinus rhythm +/- sustained apical impulse AS severity is worse with late-peaking AS increases with amyl nitrite (worsens gradient) AS decreases with standing and Valsalva maneuver (reduces preload) Causes: senile degenerative #1 (esp. > 70 yo); bicuspid, congenital, calcific, rheumatic Differential Dx: supervalvular stenosis, subvalvular stenosis, hypertrophic obstructive cardiomyopathy A note on Bicuspid AS: + AV ejection click, associated with coarcted aorta, you must image aorta (CT/MRI) and screen 1st degree relatives AS Stages: A: At risk B: Progressive AS C: Asymptomatic Severe AS: C1 = normal LVEF, C2 = LVEF < 50% D: Symptomatic Severe AS: D1 = high gradient, D2 = low flow/gradient/LVEF, D3 = nl EF, low gr&flow Echocardiography of AS: Severe AS: peak velocity > 4 m/s, mean gradient > 40 mmHg, AVA < 1 cm(2), LVOT:AV TVI < 0.25 AVA = CO / sqrt(gradient) AVA = (LVOT area x LVOT TVI) / AV TVI Echo can underestimate AS if sampling is not parallel to valve Echo can overestimate AS if pulse wave sampling volume is in the flow convergence zone Dobutamine stress echo (DSE) is indicated for symptomatic severe AS with low EF (<50%), AVA < 1, and discrepant velocity or pressure data (peak velocity < 4 m/s or mean gradient < 40...
by Mark | Jul 26, 2015 | Cardiology
With the flood of medical literature in Cardiology, it has become more and more difficult to identify the “most important” articles. Over the next few weeks, I will attempt to outline what I think are the most important articles in Cardiology, by sub-division. Obviously I can’t include every article, but I am going to narrow down a manageable set of articles that are highly cited by guidelines and thought leaders, and will try to include links for easy reference. I would encourage anyone who reads the blog to let me know what they think and maybe contribute a few of their own. Hopefully this will generate some good discussion! Category Links (continuing updates throughout August 2015): Ischemic Heart Disease, Coronary Artery Disease, and Myocardial Infarction Cardiac Electrophysiology (EP) Heart Failure Peripheral Arterial Disease Hypertension Disclaimer © 2015 www.markmccauleymd.com. All rights served....
by Mark | Mar 14, 2015 | Cardiology
Perioperative Guidelines 2014 Update – Synopsis Wait ≥ 60 days after MI prior to non cardiac surgery in the absence of coronary intervention. Age > 62 yo is an independent risk factor for perioperative stroke. Perioperative Valvular Disease Considerations: Patients with moderate-severe stenosis or regurgitation need an echo if none in the last year or changes in clinical status or physical exam. In patients that meet indications for valvular surgery, valvular intervention (replacement/repair) reduces perioperative risk. Asymptomatic severe AS may receive elective non-cardiac surgery (elevated risk). Asymptomatic severe MS may receive elective non-cardiac surgery (elevated risk), if balloon MV-plasty not possible. Asymptomatic severe AI with normal LVEF may receive elective non-cardiac surgery (elevated risk) Asymptomatic severe MR may receive elective non-cardiac surgery (elevated risk) ICD management plan should be discussed between surgeon and “clinician” prior to non-cardiac surgery. Patients with pulmonary HTN should have PH specialist, and should continue usual pulmonary vascular therapy. Pre-Surgical Cardiac Testing: Go to surgery: surgical emergency, low-risk surgery (< 1%), > 4 METS. Stress testing: < 4 METS, unknown functional capacity. Not useful for low risk surgery or > 4 METS. EKG: useful for CAD, arrhythmias, PAD, cerebrovascular disease, structural HD. Not useful for low-risk surgery & asymptomatic. LVEF: unknown dyspnea on exertion, HF with change of symptoms, HF with no echo for 1 year. Not useful for routine use. Cardiopulmonary Testing: elevated risk surgery & unknown functional capacity. Coronary Angiography: routine use not needed. Ok to revascularize if it is indicated anyways. Post-PCI Recommendations to Delay Surgery: Balloon angiography: 2 weeks Bare metal stent: 1 month DES / DAPT: 1 year...
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