Bridging Care Transition After Hospitalization for Atrial Fibrillation and Coronary Interventions

ABSTRACT

Treatment fragmentation between hospitals and the community can result in catastrophic outcomes; uninterrupted treatment with anticoagulant and platelet aggregation inhibitors is particularly important. We assessed the proportion and characteristics of patients who did not visit their primary community-based physician within 1 week of discharge from our department of cardiovascular medicine and the proportion that failed to procure essential drugs at the community pharmacy. We prospectively studied 423 patients who were discharged from our department. They were provided detailed explanations, tablets for 7 days, prescriptions, and a printed drug plan. We traced the time from discharge until a visit with a primary community-based physician, and the time until the procurement of medications, using our computerized community-hospital-integrated system. Complete data were available for 313 patients, of whom 220 were treated with anticoagulants or platelet aggregation inhibitors. For 175 patients, these drugs were initiated during index hospitalizations. Only 1 patient did not receive platelet aggregation inhibitors despite recommendations. Seventy-nine patients (25%) first visited their primary care physicians more than 1 week after discharge. Predictors for delayed visits were living alone (hazard ratio 1.91) and having an in-house caregiver (hazard ratio 2.01). In conclusion, all but 1 patient continued drug therapy after discharge from the hospital. The simple predischarge steps included patient education and provision of a 1-week supply of tablets and prescriptions. Treatment continuation was independent of visits to the community-based primary physician. Patients living alone or with an in-house caregiver more often delayed visits to primary physicians yet continued relevant drug therapy.

Causes of mortality in a department of cardiology over a 15-year period

Aims

Over the last four decades, in-hospital mortality from acute coronary syndromes (ACS) has declined. We characterized the patients who died in our cardiovascular intensive care unit (CICU) over a 15-year period. Based on these data, we described the changing patient population in the CICU.

Methods

This retrospective study compared characteristics of patients who died in our CICU in 2005–6, 2013–4 and 2019. During these 5 years, 13,931 patients were hospitalized; 251 (1.8%) died. The mean age of the patients who died was 76 years, 144 (57%) were men. ACS was the leading cause of admission (93 patients, 37%), and 145 (58%) patients had a history of heart failure prior to hospitalization. The leading cause of death was cardiogenic shock in 104 (41%) patients, septic shock in 48 (19%) patients, and combined cardiogenic and septic shock in 31 (12%). Patients hospitalized in the later years of the study were significantly older (67.7, 69.0 and 70.5 years, 2005–6, 2013–4 and 2019, respectively, p < 0.02) but their medical characteristics did not differ significantly between the years examined.

Conclusions

The profile of the patients who died did not change significantly over the 15-year study period. Age of admitted patients was higher in later years of the study. The leading cause of admission was ACS and the leading causes of death were cardiogenic and septic shock. Based on our observations, additional skills should be added to the curriculum of cardiology, including the management of patients with multiorgan failure.

Cardioversion of pre-excited atrial fibrillation leading to ventricular fibrillation- case report and review of literature

Pre-excited, fast conducting atrial fibrillation (AF) is a serious life-threatening arrhythmia that requires urgent pharmacological or electrical cardioversion. When anti-arrhythmic medications fail to restore sinus rhythm, biphasic, direct current (DC) cardioversion is required. Appropriate synchronization of the DC shock with the QRS is crucial, however not easily achieved. Since the QRS-T complexes in pre-excited AF are severely distorted, the diagnosis of inaccurate synchronization may be overlooked. Here, we report a unique case where during electrical cardioversion of pre-excited AF with inappropriate synchronization on the T wave inadvertently resulted in ventricular fibrillation (VF), and review the literature.

Anemia and the Risk of Life-threatening Ventricular Tachyarrhythmias from the Israeli Implantable Cardioverter Defibrillator Registry

Anemia was shown to be associated with increased risk for adverse events in patients with heart failure (HF). However, there are limited data on the association between anemia and the risk for ventricular arrhythmias (VAs) in patients with an implantable cardioverter defibrillator (ICD). The present study population comprised 2,352 patients who were enrolled and prospectively followed up in the Israeli ICD Registry. The risk for a first appropriate ICD shock for VA was assessed by the presence of anemia, categorized at the lower tertile of hemoglobin distribution (≤12 g/dL [n = 753]). Patients who had anemia displayed higher risk clinical characteristics including older age, more advanced HF symptoms, and atrial fibrillation (p <0.01 for all). Kaplan-Meier survival analysis showed that at 2.5 years of follow-up the rate of appropriate shocks was significantly higher in patients with low (11%) versus high (6%) hemoglobin (log-rank p <0.005). Multivariate analysis showed that anemia was independently associated with a significant 56% increased risk for first appropriate ICD shock (p <0.026). When hemoglobin was assessed as a continuous measure, each 1 g/dL reduction in hemoglobin was independently associated with a significant 8% increased risk for first appropriate shock (p <0.03). Anemia was also associated with increased risk for all-cause mortality (hazard ratio [HR] 1.78, 95% confidence interval [CI] 1.4 to 2.27], p <0.001), HF hospitalizations or death (HR 1.78, 95% CI 1.48 to 1.13, p <0.001), but not with inappropriate ICD shocks (HR 1.24, 95% CI 0.70 to 2.21, p = 0.47). In conclusion, our findings suggest that the presence of anemia in patients with ICD is associated with increased risk for VA during long-term follow-up.

A novel system for continuous, real-time monitoring of heart motion signals

BACKGROUND

Understanding cardiac mechanics is important for developing cardiac therapies. Current modalities for assessing cardiac mechanics sample patient's heart at specific heart rate, contractility, preload, and afterload. The objective of this study was to test the feasibility of a novel system composed of intra-cardiac leads equipped with an inertial module chip (3D accelerometers and 3D gyroscopes) in monitoring continuous heart motion.

METHODS

In this descriptive study, four healthy pigs were anesthetized and instrumented with motion-sensitive intra-cardiac leads; the temporal correlation between signals from motion sensors and tissue Doppler from the chest wall were studied; changes in real-time heart accelerations (ACC) and angular velocity (ANGV) were reported as percentages of change from baseline.

RESULTS

Heart motion signals were sensed continuously from the right ventricular apex (RVa) and coronary sinus (CS). Volume expansion did not produce significant changes in the ACC and ANGV signals. Increasing heart rate increased the peak systolic ACC signal recorded from RVa and CS by 94 and 76%, respectively, and increased both peak systolic (61% RVa and 27% CS) and diastolic ANGV (200% CS vs. 31% RVa). Epinephrine administration increased peak systolic ACC signals at both sites (246% RVa; 331% CS). Peak systolic and diastolic ANGV increased in response to epinephrine (systolic: 198% RVa and 175% CS; diastolic: 723% CS and 89% RVa) (p = 0.125 for all changes expressed in percent). Temporal correlation between the ANGV signal and tissue Doppler signal was detected throughout all interventions.

CONCLUSIONS

A novel system for continuously monitoring heart motion signals from within the heart was presented. Heart motion signals in response to physiologic manipulations were characterized.

Catheter ablation of atrial fibrillation is associated with reduced risk of stroke and mortality: A propensity score-matched analysis

BACKGROUND

Catheter ablation reduces recurrence of atrial fibrillation and improves quality of life. Only few studies have assessed the effect of catheter ablation on long-term outcomes.

OBJECTIVE

The purpose of this study was to assess the association between catheter ablation and risk of stroke and mortality in patients with atrial fibrillation.

METHODS

Using the computerized database of the largest health maintenance organization in Israel, we identified all adults hospitalized with a primary diagnosis of atrial fibrillation between January 1, 2005, and December 31, 2015. Of them, a total of 969 individuals who underwent catheter ablation during the same admission were matched, on the basis of the propensity of having ablation, with 3772 individuals who did not undergo catheter ablation during the same period. The cohort was followed for the occurrence of stroke or transient ischemic attack (TIA) and mortality until June 30, 2016.

RESULTS

Overall, 3953 (83.4%) of patient in both groups had a CHA₂DS₂VASc score of 2 or greater. The incidence rate of stroke/TIA was 2.10 and 3.26 per 100 person-years in the ablation group and the nonablation group, respectively. The crude hazard ratio [HR] for stroke/TIA was 0.61 (95% confidence interval [CI] 0.48-0.79) in the ablation group compared with the nonablation group. The results were similar after controlling for CHA₂DS₂-VASc score (HR 0.58; 95% CI 0.43-0.72). The adjusted HRs for stroke alone, TIA alone, and mortality were 0.62 (95% CI 0.47-0.82), 0.47 (95% CI 0.20-0.78), and 0.57 (95% CI 0.47-0.66), respectively.

CONCLUSION

Catheter ablation of atrial fibrillation is associated with a decreased risk of stroke/TIA and mortality in predominantly patients with a high CHA₂DS₂-VASc score.

Contemporary evaluation of the causes of cardiac tamponade: Acute and long-term outcomes

BACKGROUND

Cardiac tamponade is a life-threatening state that complicates various medical conditions. The contemporary interventional era may have led to changes in clinical characteristics, causes and outcomes of cardiac tamponade.

METHODS

We investigated all patients diagnosed with cardiac tamponade, based on clinical and echocardiographic findings, at a single medical center between the years 2000 and 2013. Data on medical history, index hospitalizations, pericardial fluid etiologies, and acute and long-term outcomes were collected.

RESULTS

Cardiac tamponade was observed in 83 patients (52% females). Major etiologies included complications of percutaneous cardiac interventions (36%) and malignancies (primarily lung cancer; 23%), infectious/inflammatory causes (15%) and mechanical complications of myocardial infarction (12%). Sixteen (19%) patients died during the index hospitalization. Acute presentation of symptoms and lower quantity of effusion were associated with in-hospital mortality (p = 0.045 and p = 0.007). Tamponade secondary to malignancy was associated with the most substantial increment in post-discharge mortality (from 16% in-hospital to 68% 1-year mortality). During the mean follow-up of 45 months, 39 (45%) patients died. Malignancies, mechanical complications of myocardial infarction and bleeding/coagulation abnormalities were etiologies associated with poor survival (80% mortality during follow-up). Tamponade secondary to complications of percutaneous cardiac interventions or infectious/inflammatory causes were associated with significantly lower mortality (28% and 17%; log rank p < 0.001).

CONCLUSIONS

In a contemporary cohort, complications of percutaneous cardiac intervention replaced malignant diseases as the leading cause of cardiac tamponade. Nevertheless, these iatrogenic complications were associated with a relatively favorable outcome compared to tamponade induced by complications of myocardial infarction, coagulation abnormalities and malignant diseases.

Relation of reduced expression of MiR-150 in platelets to atrial fibrillation in patients with chronic systolic heart failure

Atrial fibrillation (AF) is associated with poor prognosis in patients with heart failure (HF). Although platelets play an important role in rendering a prothrombotic state in AF, the exact mechanism by which the effect is mediated is still debated. MicroRNAs (miRNAs), which have been shown to be involved in a variety of cardiovascular conditions, are abundant in platelets and in a cell-free form in the circulation. In the present study, we performed a genome-wide screen for miRNA expression in platelets of patients with systolic HF and in controls without cardiac disease, in pursuit of specific miRNAs that are associated with the presence of AF. MiRNA expression was measured in platelets from 50 patients with systolic HF and 50 controls, of which, samples from 41 patients with HF and 35 controls were used in the final analysis because of a quality control process. MiR-150 expression was 3.2-fold lower (p = 0.0003) in platelets of patients with HF with AF relative to those without AF. A similar effect was seen in serum samples from the same patients, in which miR-150 levels were 1.5-fold lower (p = 0.004) in patients with HF with AF. Furthermore, the serum levels of miR-150 were correlated to platelet levels in patients with AF (r = 0.65, p = 0.0087). In conclusion, miR-150 expression levels in platelets of patients with systolic HF with AF are significantly reduced and correlated to the cell-free circulating levels of this miRNA.

Ejection fraction in patients with heart failure and preserved ejection fraction is greater than that in controls - a mechanism facilitating left ventricular filling and maximizing cardiac output

The absolute value of ejection fraction (EF) in patients with heart failure and preserved ejection fraction (HFpEF) is often observed to be greater than that in healthy, age- or risk-factor matched controls. Assuming this observation is true, we sought for a physiological explanation. It is hypothesized that an increased EF in HFpEF patients has a role in augmenting cardiac output (CO) especially during exercise. Normal mechanisms for increasing CO are restricted in HFpEF. For e.g., recruiting the Frank-Starling mechanism is limited by a thick left ventricle (LV) which is stiff and distends, however with greater than normal filling pressure. Increasing heart rate and decreasing systemic vascular resistance during exercise was shown to be significantly restricted in HFpEF. It is hypothesized that a "greater than normal" EF in HFpEF translates into a more forceful contraction, storing elastic energy (during systole) in the myocardial tissue. When systole terminates, as the contractile elements detach, the stored energy is utilized for rapid relengthening of the contractile elements of the myocardium, before mitral valve opening. The abrupt expansion of the LV decreases LV pressure to a minimum, thereby increasing the pressure gradient between the left atrium and LV. The latter pressure gradient accounts for an efficient early LV filling. Using the energy stored during systole in favor of early LV filling is referred to as elastic recoil (ER, also termed: diastolic suction). ER is especially important when heart rate is increased, resulting in a short time window for LV filling. The mechanism of ER is hypothesized to account for maximizing the potential for early LV filling. A systematic review of the literature is needed to verify that the observation is true, and further studies to support this hypothesis.

Autonomic remodeling in the left atrium and pulmonary veins in heart failure: creation of a dynamic substrate for atrial fibrillation

BACKGROUND

Atrial fibrillation (AF) is commonly associated with congestive heart failure (CHF). The autonomic nervous system is involved in the pathogenesis of both AF and CHF. We examined the role of autonomic remodeling in contributing to AF substrate in CHF.

METHODS AND RESULTS

Electrophysiological mapping was performed in the pulmonary veins and left atrium in 38 rapid ventricular-paced dogs (CHF group) and 39 control dogs under the following conditions: vagal stimulation, isoproterenol infusion, β-adrenergic blockade, acetylcholinesterase (AChE) inhibition (physostigmine), parasympathetic blockade, and double autonomic blockade. Explanted atria were examined for nerve density/distribution, muscarinic receptor and β-adrenergic receptor densities, and AChE activity. In CHF dogs, there was an increase in nerve bundle size, parasympathetic fibers/bundle, and density of sympathetic fibrils and cardiac ganglia, all preferentially in the posterior left atrium/pulmonary veins. Sympathetic hyperinnervation was accompanied by increases in β(1)-adrenergic receptor R density and in sympathetic effect on effective refractory periods and activation direction. β-Adrenergic blockade slowed AF dominant frequency. Parasympathetic remodeling was more complex, resulting in increased AChE activity, unchanged muscarinic receptor density, unchanged parasympathetic effect on activation direction and decreased effect of vagal stimulation on effective refractory period (restored by AChE inhibition). Parasympathetic blockade markedly decreased AF duration.

CONCLUSIONS

In this heart failure model, autonomic and electrophysiological remodeling occurs, involving the posterior left atrium and pulmonary veins. Despite synaptic compensation, parasympathetic hyperinnervation contributes significantly to AF maintenance. Parasympathetic and/or sympathetic signaling may be possible therapeutic targets for AF in CHF.

Use of a custom-designed adapter to manage ICD lead fracture

We report the case of a 72-year-old patient with ischemic cardiomyopathy who was found to have a lead fracture in the RV coil DF-1 connector of an integrated bipolar implantable cardioverter-defibrillator (ICD) lead system at the time of upgrade to a biventricular ICD. Due to the redundant connection of the RV coil to the DF-1 connector and the ring on the IS-1 connector, a custom-designed adapter was used to exclude the site of fracture. This novel solution spared the patient the potential risks of lead extraction or abandoning the fractured ICD lead. In this way, pacing and defibrillating capabilities were fully restored, providing the patient 6 years of optimal device functioning.

Usefulness and predictive value of circulating NT-proBNP levels to stratify patients for referral and priority treatment in a specialized outpatient heart failure center

BACKGROUND

Serum natriuretic peptide levels are useful diagnostic and prognostic markers in patients with acute decompensated heart failure, but have been little used to stratify urgency of treatment in the outpatient situation.

OBJECTIVES

To examine the use of natriuretic peptide to guide priority of patient referral to a heart failure center.

METHODS

We analyzed data from 70 consecutive patients with chronic heart failure (NYHA class 2-4) referred for first evaluation in a specialized outpatient heart failure center. Serum NT-proBNP was measured at the initial patient visit. We examined correlates and predictive value of mid- and upper tertile NT-proBNP for mortality in comparison with other known prognostic indicators using univariate and multivariate logistic regression analysis.

RESULTS

Mortality at 6 months was 26.0% in patients with upper tertile (> 1958 pg/ml) NT-proBNP, 8.7% in the middle tertile group and 0% in the lowest tertile (P=0.017). Patients with upper tertile serum NT-proBNP levels (group 3) had lower left ventricular ejection fraction, were more often in atrial fibrillation (P=0.04) and more often had renal failure (P=0.03). Age-adjusted logistic regression analysis identified upper tertile serum NT-proBNP level as the strongest independent predictor of 6 month mortality with a sixfold risk of early death (adjusted odds ratio 6.08, 95% confidence interval 1.58-47.13, P=0.04). NT-proBNP was a more powerful predictor of prognosis than ejection fraction and other traditional outcome markers.

CONCLUSIONS

In heart failure patients referred to an outpatient specialized heart failure center, an upper tertile NT-proBNP level identified patients at high risk for mortality. A single high > 550 pg/ml NT-proBNP measurement appears to be useful for selecting patients for care in a heart failure center, and a level > 2000 pg/ml for assigning patients to high priority management.

Taenia cordis

Free-floating right heart thrombi are rare echocardiographic findings usually encountered in patients with massive pulmonary embolism and associated with poor prognosis. We report a case of a large free-floating right heart thrombus without clinically significant pulmonary embolism. The patient was treated conservatively with heparin and warfarin, and the thrombus resolved uneventfully.

High frequency of vitamin B12 deficiency in asymptomatic individuals homozygous to MTHFR C677T mutation is associated with endothelial dysfunction and homocysteinemia

The aim of this study was to examine the association of homozygosity for the methylenetetrahydrofolate reductase (MTHFR) C677T mutation and vitamin B12 deficiency in 360 asymptomatic individuals and to investigate forearm endothelial function in C677T homozygotes. MTHFR C677T mutation and levels of vitamin B12, folic acid, and homocysteine were measured in study participants. Frequency of homozygosity for the C677T mutation was 67/360 (18.6%). Homocysteine levels were elevated in homozygous compared with heterozygous subjects or those without the mutation (20.6 +/- 18.8 vs. 9.4 +/- 3.2 mumol/l; P < 0.0001). The number of subjects with vitamin B12 deficiency (<150 pmol/l) was significantly higher among the homozygote than the heterozygote subjects or subjects without mutation [20/67 (29.8%) vs. 27/293 (9.2%); P < 0.0001]. Homozygote subjects had 4.2 times higher probability of having B12 deficiency (95% confidence interval = 2.1-8.3). Forearm endothelial function was assessed in 33 homozygote and 12 control subjects. Abnormal endothelial function was observed in homozygous subjects and was worse in homozygote subjects with vitamin B12 deficiency. Endothelial function was normalized after B12 and folic acid treatment. We found that homozygosity for the C677T mutation is strongly associated with B12 deficiency. Coexistence of homozygosity for the C677T mutation and B12 deficiency is associated with endothelial dysfunction and can be corrected with vitamin B12 and folic acid treatment.

Usefulness of 64-slice multidetector computed tomography in diagnostic triage of patients with chest pain and negative or nondiagnostic exercise treadmill test result

The usefulness of 64-slice multidetector coronary computed tomography (MDCT) in a diagnostic triage of 100 consecutive patients (age 55.8+/-11.6 years; 57% men) with chest pain suspected to be ischemic in origin and a negative or nondiagnostic exercise treadmill test (ETT) result was examined. None of the patients had previously known coronary artery disease (CAD). MDCT showed obstructive (>or=50%) CAD in 29 patients; 13 of 59 patients (22%) with a negative and 16 of 41 patients (39%) with a nondiagnostic ETT result. High-risk (left main and/or 3-vessel) CAD was present in 3.3% of patients with a negative and 4.9% with a nondiagnostic ETT result. The 29 patients with obstructive CAD on MDCT had a higher mean Agatston calcium score (221+/-402 vs 40+/-77 U, p<0.001). Invasive coronary angiography confirmed MDCT findings in 26 of 29 patients (positive predictive value 90%) and 45 of 54 stenotic segments (83%) in a per-segment analysis. For the 71 patients without obstructive CAD on MDCT, clinically driven invasive angiography detected CAD in 1 of 15 patients (1 false-negative MDCT result) and 2 of another 5 patients who were referred for invasive angiography later during a 12-month follow-up period. In the remaining 51 patients, MDCT findings effectively allowed exclusion of obstructive CAD, and there were no major adverse clinical events during follow-up. In conclusion, in patients with chest pain possibly ischemic in origin, no previously known CAD, and a negative or nondiagnostic ETT result, contrast-enhanced 64-slice MDCT scanning was a useful tool to provide direct noninvasive coronary angiography and rapidly advance diagnostic triage.

Ineffectiveness of Precordial Thump for Cardioversion of Malignant Ventricular Tachyarrhythmias

BACKGROUND

The Precordial Thump (PT) is commonly used for cardiopulmonary resuscitations both in and out of hospitals. However, the support for its efficiency relies mainly on sporadic cases. In this current prospective large study, we tested the effectiveness and safety of PT in a wide range of malignant ventricular tachyarrhythmias.

METHODS

The study included 80 patients who underwent electrophysiological study and/or implantation of a cardiodefibrillator device. During these procedures, once a malignant ventricular tachyarrhythmia was induced, PT was used as the first treatment option. If the PT failed, other means were used to discontinue the arrhythmia.

RESULTS

Polymorphic ventricular tachycardia occurred in 32 (40%) patients, ventricular fibrillation in 28 (35%) patients, and 20 (25%) patients had sustained monomorphic ventricular tachycardia. Except in one patient with monomorphic ventricular tachycardia, the PT was unsuccessful in terminating any of the other malignant tachyarrhythmias, and internal or external defibrillation was eventually required in all other 79 (99%) patients. The PT was not associated with any damage either to the sternal bone, ribs, or to the cardiodefibrillator device.

CONCLUSIONS

PT is not effective in terminating malignant ventricular tachyarrhythmia and should be reserved to a situation in which a defibrillator is not available.

Uses and limitations of 40 slice multi-detector row spiral computed tomography for diagnosing coronary lesions in unselected patients referred for routine invasive coronary angiography

BACKGROUND AND AIMS

The value of multi-detector row computed tomography (MDCT) in routine cardiology practice is uncertain. We examined the applicability of MDCT imaging for the diagnosis of obstructive coronary artery disease in a routine clinical setting.

METHODS

MDCT scanning (40 slice) was performed in 111 unselected patients referred for invasive coronary angiography (ICA) and findings were compared to an independent quantitative assessment of the ICA on a segmental, vessel and patient basis.

RESULTS

Sensitivity and positive predictive value for segmental disease (72.2 and 70.9% respectively, overall) were higher in patients aged > or = 60 years and history of disease > or = 1 year, whereas specificity and negative predictive value were high in all groups. In the patient-based analysis, sensitivity and positive predictive value (84.7 and 87.8%, respectively) were higher, the latter in keeping with the high-patient prevalence of disease, but specificity and negative predictive value (61.5 and 55.2%) were low.

CONCLUSIONS

Usefulness of MDCT was significantly influenced by age, duration of coronary artery disease and female gender, and on a patient-based analysis its diagnostic accuracy was not sufficient to replace ICA in a routine clinical setting.

Diagnosis of Coronary In-Stent Restenosis With Multidetector Row Spiral Computed Tomography

OBJECTIVES

The purpose of this study was to assess the accuracy of a new generation spiral multidetector computed tomography (MDCT) scanner (Brilliance 40, Philips Medical Systems, Cleveland, Ohio) in the diagnosis of coronary in-stent restenosis (ISR).

BACKGROUND

Noninvasive imaging of ISR would be clinically useful, but artifacts caused by metallic stent struts have limited the role of early generation MDCT scanners.

METHODS

We examined 65 patients (age 63 +/- 12 years, 48 [73.8%] men) with 111 implanted coronary stents who were referred for repeat invasive coronary angiography (ICA). Patients underwent 40-slice MDCT one to three days before scheduled ICA, using intravenous contrast enhancement. Images were reconstructed in multiple formats using retrospective electrocardiographic gating. Stents were viewed in their long and short axes and luminal contrast attenuation graded from MDCT grade 1 (minimal restenosis) to 4 (severe restenosis) by consensus of two observers.

RESULTS

In-stent restenosis (>/=60% luminal narrowing by quantitative coronary angiography) was found on ICA in 18 (16.2%) of the stented segments and in 16 (24.6%) patients. The MDCT findings correlated with ICA restenosis, with restenosis in only 1 of 59 (1.6%) MDCT grade 1 segments, but in more than three-quarters (12 of 15, 80%) of MDCT grade 4 segments (sensitivity 72.2%, specificity 92.5%, positive predictive value [PPV] 65.0%, negative predictive value [NPV] 94.5% [five stents not assessable by MDCT considered as restenosis]). Using MDCT grades 3 or 4 combined for restenosis, sensitivity of MDCT was 88.9%, specificity 80.6%, PPV 47.1%, and NPV 97.4%.

CONCLUSIONS

In-stent restenosis can be diagnosed with moderate sensitivity using a new generation 40-slice MDCT scanner. The high NPV implies a significant role for MDCT in excluding ISR.

Brachial artery endothelial function in residents and fellows working night shifts

Brachial artery endothelial function, which is measured as responsiveness to reactive hyperemia (flow-mediated dilation [FMD]) was abnormal in residents and house staff after a 24-hour shift, including night duty. The greatest decrease in FMD was observed in physicians with a longer history of night-shift duty and in those reporting fewer sleeping hours during the shift. The finding that FMD is decreased after night duty raises the issue of the effects of shift duty on cardiovascular function in healthcare personnel, particularly in those undertaking night duty for a prolonged period of time.