Faculty Bibliography

BACKGROUND: Diabetes mellitus (DM) and metabolic syndrome are important targets for secondary prevention in cardiovascular disease. However, the prevalence in patients undergoing elective percutaneous coronary intervention (PCI) is not well defined. We aimed to analyze the prevalence and characteristics of patients undergoing PCI with previously unrecognized prediabetes, diabetes and metabolic syndrome. METHODS: Data were collected from 740 patients undergoing elective PCI between November 2010 and March 2013 at a tertiary referral center. Prevalence of DM and prediabetes was evaluated using Hemoglobin A1c (A1c >/= 6.5% for DM, A1c 5.7-6.4% for prediabetes). A modified definition was used for metabolic syndrome [3 or more of the following criteria: body mass index (BMI) >/=30 kg/m2; triglycerides >/= 150 mg/dL; high density lipoprotein <40 mg/dL in men and <50 mg/dL in women; systolic blood pressure >/= 130 mmHg and/or diastolic >/= 85 mmHg; A1c >/= 5.7% or on therapy]. RESULTS: Mean age was 67 years, median BMI was 28.2 kg/m2 , and 39% had known DM. Of those without known DM, 8.3% and 58.5% met A1c criteria for DM and for prediabetes at time of PCI. Overall, 54.9% met criteria for metabolic syndrome (69.2% of patients with DM and 45.8% of patients without DM). CONCLUSION: Among patients undergoing elective PCI, a substantial number were identified with new DM, prediabetes, and/or metabolic syndrome. Routine screening for an abnormal glucometabolic state at the time of revascularization may be useful for identifying patients who may benefit from additional targeting of modifiable risk factors

Despite increasing use of the transradial approach (TRA) for coronary angiography, TRA failure and subsequent access site crossover remain a barrier to TRA adoption. The aim of this study was to elucidate patient and procedural characteristics associated with TRA to transfemoral approach (TFA) crossover and examine TRA to TFA crossover by operator experience over time. This retrospective analysis identified 1,600 patients who underwent coronary angiography with possible percutaneous coronary intervention through TRA by operators with varied TRA experience in an urban tertiary care center from October 2010 to August 2013. Univariate and multivariable logistic regression were used to identify independent predictors of access site crossover, from TRA to TFA, and strength of association is presented as odds ratio (OR, 95% confidence interval [CI]). Access site crossover was noted in 166 patients (10.4%). Multivariable predictors of access site crossover included age >75 years (OR 1.90, 95% CI 1.23 to 2.91, p = 0.004) and operator experience (OR 2.98, 95% CI 1.96 to 4.52, p <0.0001). Less experienced operators (5 years TRA experience) had no significant change in proportion of access site crossover over time (quartile 1: 2.8%, quartile 2: 6.4%, quartile 3: 5.6%, quartile 4: 5.8%, p = 0.54). In conclusion, rate of access site crossover in the contemporary era is relatively low and can be mitigated with operator experience.

Although colchicine has been a focus of research, debate and controversy for thousands of years, it was only approved by the United States Food and Drug Administration in 2009. Over the past decade, advances in the knowledge of colchicine pharmacology, drug safety and mechanisms of action have led to changes in colchicine dosing and to potential new uses for this very old drug. In this review, we discuss the pharmacologic properties of colchicine and summarize what is currently known about its mechanisms of action. We then discuss and update the use of colchicine in a variety of illnesses, including rheumatic and, most recently cardiovascular diseases.

Since the advent of percutaneous coronary intervention, enormous advances have been made in the treatment of coronary artery disease. Angioplasty and bare metal stents were plagued by high rates of restenosis leading to repeat revascularization procedures. Examination of the underlying pathophysiology of restenosis led to the development of drug-eluting stents to reduce neointimal hyperplasia. However, as restenosis rates declined, length of dual antiplatelet therapy use and risk of long-term stent thrombosis associated with drug-eluting stents increased. Subsequent generations have improved each facet of stent design. Novel alloys maintain durability and reduce strut thickness to increase deliverability, biocompatible polymers decrease the inflammatory response and improve drug elution kinetics, and new generations of drugs predictably inhibit restenosis. Developments on the horizon include stents with bioabsorbable polymers and platforms. The purpose of this review is to assess the evolution of stent design and the evidence behind each generation and to peer into the future of stent technology.

Background: Type 2 myocardial infarction (MI) is defined as myocardial necrosis due to an imbalance in supply and demand. Clinical characteristics predisposing to Type 2 MI and medical therapy use remain uncertain. Methods: Charts of patients admitted to NYU Langone Medical Center in 2013 with a diagnosis of secondary myocardial ischemia (ICD9 411.89) or non-primary diagnosis of non-ST-elevation MI (ICD9 410.71) were retrospectively reviewed, following hospital standardization of acute MI ICD9 coding. Cases with suspected/confirmed Type 1 MI or without rise and fall of troponin were excluded. Results: Charts of 104 inpatients with Type 2 MI have been reviewed to date, with evaluation of additional cases ongoing. Conditions associated with and possibly provoking Type 2 MI included sepsis (defined as SIRS with an infectious source, 39%), surgery (37%), anemia (Hgb < 7 mg/dL), bleeding, or transfusion >1 PRBCs (34%), respiratory failure (28%), tachyarrhythmia (21%), hypotension (17%), hypertensive crisis (8%), and bradycardia (2%). Multiple provoking conditions were identified in 74% of cases. See Table for risk factors, procedure use and results and in-hospital outcomes. Inpatient mortality was 3%. Among 92 patients discharged alive and not to hospice, medical regimens included aspirin (65%), statin (66%), ACE inhibition (ACEi) (38%), and beta blocker (65%). Patients with a peak troponin >1.0 ng/mL (35%) were more likely to be discharged on aspirin (p=0.004) and beta-blocker (p=0.027), but not statin or ACEi. Conclusions: Type 2 MI occurs most frequently in the setting of sepsis, surgery, and/or anemia in patients with cardiovascular risk factors, but mechanisms of Type 2 MI remain poorly understood. Rates of outpatient antiplatelet and statin prescription are low at hospital discharge, reflecting physician uncertainty about the role of secondary prevention. Further research into mechanisms is needed to inform management of patients with Type 2 MI