Kumar, Gautam

Introduction: Obesity is a known risk factor and causes worse cardiovascular outcomes in obstructive sleep apnea. With the growing use of cannabis in the US, so we aimed to assess the impact of cannabis use disorder (CUD) on risk of atrial tachyarrhythmias (atrial fibrillation, AF; atrial fibrillation, AFL) and stroke in young patients with obesity-associated obstructive sleep apnea (OOSA). Methods: The National Inpatient Sample (2015Oct-2017) with relevant ICD-10 codes were used to identify admissions among young adults (18-44 years) with OOSA. We then matched (1:1) two cohorts of cannabis use disorder (CUD+) vs. without (CUD-) with controlling potential sociodemographic confounders. Primary outcomes of interest were frequency and risk of atrial tachyarrhythmias and stroke assessed by multivariable analysis. Results: Of 7470 demographically-matched OOSA admissions, CUD+ and CUD- cohorts had 3735 hospitalizations in each cohort. Both cohorts were comparable mean age of 38 years and CUD+ cohort more frequently included male (66.6% vs. 53.5%), African American (40.0% vs. 30.1%) patients admitted non-electively (92.3% vs. 84.5%). Rates of drug abuse, hypertension, smoking and chronic pulmonary disease were higher but diabetes mellitus, hyperlipidemia, and renal failure were lower in CUD+ cohort vs. CUD- cohort (p<0.001). The frequency of AF/AFL (5.7% vs 7.4%) related admissions were lower; however, the risk of AF/AFL (OR:1.64, 95%CI:1.17-2.30, p=0.004) and stroke (OR:4.41, 95%CI:1.41-13.77, p<0.011) admissions were significantly higher in the OOSA-CUD+ cohort vs. CUD- cohort in the multivariable analysis controlled for relevant cardiovascular/extracardiac comorbidities and concomitant alcohol/drug abuse and smoking. Conclusions: This propensity-matched analysis highlights that recreational cannabis use in young patients with OOSA may alarmingly increase emergency hospitalizations and independently increase the risk of AF/AFL and stroke.

Background: Bariatric surgery (BS) has been shown to be beneficial in improving co-morbid conditions in morbidly obese patients. Long-term cardiovascular complications remain undefined and warrant further investigation. We examined the prevalence and risk of atrial fibrillation (AF) in obese patients who underwent BS. Methods: PUBMED/Medline, SCOPUS, EMBASE databases were systematically reviewed using relevant keywords to search prospective and retrospective studies reporting AF with long-term (at least >1-year follow-up) follow-up in patients who had undergone BS. Random effects models were used for meta-analysis and subgroup analysis. I 2 statistics was used to identify substantial (>75%) heterogeneity. Results: Nine studies (3 USA, 2 UK, 4 Sweden) including 24,164 patients who had undergone BS (mean BMI cut off: 35, mean age 42 years) with 29,330 controls were included in the analysis with a median follow-up of 8 years. Pooled prevalence of AF was lower in BS arm (3.0%, 95%CI: 1.4%-5%) as compared to non-BS arm (3.8%, 95% CI: 1.8%-5.0%). The Forest Plot (Fig. 1) depicts significantly reduced odds of having AF in patients who have undergone BS vs controls (OR: 0.74, 95%CI: 0.60-0.91, I 2 =70.2%, p<0.01). Sensitivity analysis using the leave-one-out method did confirm equivalent results. On subgroup analysis, AF prevalence in the BS group was slightly higher in studies with a mean age of ≥50 years (4.8%, 0-12%) as compared to cohorts with mean age <50 (2.0%, 1.4-5.0%). The pooled rate of AF was low on short-term follow-up compared to long-term follow-up after BS: 1.5% (0.9-2.5%) in 1-5 years, 1.9% (0.2-4.5%) in 6-10 years, 5.4% (0-13.9%) ≥10 years of BS. Conclusions: Obese patients undergoing BS had nearly 25% lower risk and lower pooled rate of AF when compared to controls over 8 years of follow-up. The protective effect of BS on reduced risk of AF was seen to gradually wane over longer follow-up which warrants continued efforts to effectively control CVD risk factors.

Introduction: Papillary fibroelastomas (PFEs) are the 3rd most common primary cardiac tumors with a prevalence of around 0.01% in patients with echocardiograms. The pathogenesis is controversial but endocardial trauma has been implicated. We hypothesized that increased turbulence in hypertrophic cardiomyopathy (HCM) would be a risk factor for PFE development and characterized PFEs in HCM. Around 5% of HCM patients had neurologic events. We postulated that patients with both PFE and HCM had a higher risk of neurologic events. Methods: We reviewed pathology records from 1990 –2006 and identified 129 subjects with PFEs and 2479 patients with HCM. We then identified the subjects who had both HCM and PFE (n = 19). All subjects signed release for use of their medical records for research. Results: 19 subjects (68.4% female) had both HCM and PFE. Mean age at diagnosis of HCM was 49 (range 21– 81) years. All had outflow tract obstruction with resting gradient >/=30 mm Hg except 2 who had resting gradients <30 mm Hg but elevated gradients on provocation. PFE diagnosis was after a mean of 9.7 years (SD 8.3) following HCM diagnosis. 5 subjects were diagnosed pre-operatively by transthoracic echocardiography, 2 subjects by transesophageal echocardiography and 12 subjects at surgery only. Most subjects had only 1 PFE (57.9%) but 1 subject had as many as 40 tumors. Most PFEs were on the aortic valve (47.4%) and the left ventricular side of the septum and left ventricular outflow tract (42.1%). Only 2 patients had right heart lesions that were presumably unrelated to HCM. 3 patients had previous septal myectomies and all 3 had PFEs near the previous resection. 5 of 19 subjects (26.3%) with PFE and HCM had neurologic events (either strokes or transient ischemic attacks) compared to 199 of 2261 subjects (8.8%) with HCM alone (OR = 4.1; 95% CI 1.4 –11.4, p < 0.05). Conclusion: Nearly 90% of PFEs in HCM are located in the septum, left ventricular outflow tract and aortic valve. This may be supportive of endocardial trauma as a risk factor for PFE development in HCM. About a quarter of patients with PFEs and HCM had neurologic events. This may indicate that these lesions are not innocuous and should perhaps be actively searched for in patients with HCM and unexplained neurologic events.

Objectives: Atrial fibrillation is frequently seen in sepsis-related hospitalizations. However, large-scale contemporary data from the United States comparing outcomes among sepsis-related hospitalizations with versus without atrial fibrillation are limited. The aim of our study was to assess the frequency of atrial fibrillation and its impact on outcomes of sepsis-related hospitalizations. Design: Retrospective cohort study. Setting: The National Inpatient Sample databases (2010–2014). Patients: Primary discharge diagnosis of sepsis with and without atrial fibrillation were identified using prior validated International Classification of Diseases, 9th Edition, Clinical Modification codes. Interventions: None. Measurements and Main Results: Overall, 5,808,166 hospitalizations with the primary diagnosis of sepsis, of which 19.4% (1,126,433) were associated with atrial fibrillation. The sepsis-atrial fibrillation cohort consisted of older (median [interquartile range] age of 79 yr [70–86 yr] vs 67 yr [53–79 yr]; p < 0.001) white (80.9% vs 68.8%; p < 0.001) male (51.1% vs 47.5%; p < 0.001) patients with an extended length of stay (median [interquartile range] 6 d [4–11 d] vs 5 d [3–9 d]; p < 0.001) and higher hospitalization charges (median [interquartile range] $44,765 [$23,234–$88,657] vs $35,737 [$18,767–$72,220]; p < 0.001) as compared with the nonatrial fibrillation cohort. The all-cause mortality rate in the sepsis-atrial fibrillation cohort was significantly higher (18.4% and 11.9%; p = 0.001) as compared with those without atrial fibrillation. Although all-cause mortality (20.4% vs 16.6%) and length of stay (median [interquartile range] 7 d [4–11 d] vs 6 d [4–10 d]) decreased between 2010 and 2014, hospitalization charges increased (median [interquartile range] $41,783 [$21,430–$84,465] vs $46,251 [$24,157–$89,995]) in the sepsis-atrial fibrillation cohort. The greatest predictors of mortality in the atrial fibrillation-sepsis cohort were African American race, female gender, advanced age, and the presence of medical comorbidities. Conclusions: The presence of atrial fibrillation among sepsis-related hospitalizations is a marker of poor prognosis and increased mortality. Although we observed rising trends in sepsis and sepsis-atrial fibrillation–related hospitalizations during the study period, the rate and odds of mortality progressively decreased.

BackgroundObesity can lead to increased oxidative stress which is one of the proposed mechanisms in the etiopathogenesis of takotsubo cardiomyopathy (TCM).HypothesisThe presence of obesity adversely impacts clinical outcomes in TCM patients.MethodsWe queried the Nationwide Inpatient Sample database (2010‐2014) to identify adult patients admitted with a principal diagnosis of TCM with and without obesity. We compared the categorical and continuous variables by Pearson χ2 and Student t test, respectively, in propensity‐score matched cohorts.ResultsThe study cohort comprised 612 obese TCM (weighted n = 3034) and 5696 nonobese TCM (weighted n = 28 186) patients. Obese TCM patients were more often younger and private‐insurance enrollees. Cardiac complications including acute myocardial infarction (9.0% vs 7.4%; P = 0.04), cardiac arrest (2.3% vs. 0.4%; P < 0.001), cardiogenic shock (4.3% vs. 3.2%; P = 0.03), congestive heart failure (5.0% vs. 3.8%; P = 0.02), respiratory failure (12.9% vs. 11.0%; P = 0.021) and use of mechanical hemodynamic support (Impella; 0.2% vs. 0.0%, P = 0.02) were significantly higher among obese TCM patients. There were no significant differences between the 2 groups in all‐cause mortality (1.0% vs. 0.8%; P = 0.35), arrhythmia (24.5% vs. 22.7%, P = 0.123), length of stay (3.7 ±3.5 vs. 3.7 ±3.6 days; P = 0.68), and total hospital charges ($40 780.16 vs. $42 575.14; P = 0.08).ConclusionsObese TCM patients were more susceptible to developing TCM‐related cardiac complications than were nonobese TCM patients, without any impact on all‐cause in‐hospital mortality, LOS, and hospital charges.

Objective Cardiac angiosarcoma is the most common primary malignant cardiac tumor. The dismal prognosis and nonspecific symptomatology underscore the need for an accurate and cost‐effective approach to the identification and characterization of this rare tumor. Methods Mayo Clinic tissue registry archives were queried for all histologically confirmed cases of cardiac angiosarcoma (1976–2013) with available imaging data. Echocardiograms were retrospectively reviewed. Results Thirty‐three cases of cardiac angiosarcoma were identified; of these, 17 had echocardiograms available (mean age, 46 years; six men). Transthoracic echocardiography ( TTE ) as the initial diagnostic test had 75% sensitivity for visualizing primary cardiac angiosarcoma (9/12 patients). Tumor extension into the pericardium was common and pericardial effusion was present in 15 patients (88%); however, pericardial fluid cytology was negative for malignancy in all tested patients (n = 15). Left ventricular ejection fraction ( LVEF ) was preserved in 16 patients (94%) (average LVEF , 62%). Right ventricular function was mildly reduced in two patients (12%) at initial presentation. Tricuspid valve obstruction was present in three patients (18%; mean diastolic gradient, 6.3 mmHg [range, 3–11 mmHg]). Conclusion The sensitivity of TTE as the first diagnostic imaging modality compared favorably with computed tomography. Pericardial effusion was common, but pericardial fluid cytology was negative in all patients who underwent pericardiocentesis. The absence of a stalk was a universal finding that may help distinguish angiosarcoma from benign, primarily pedunculated tumors such as myxoma and papillary fibroelastoma.