Faculty Bibliography

To determine whether arterial responsiveness is impaired among patients with gout, and whether arterial responsiveness inversely correlates with serum urate and inflammatory measures. This is a cross-sectional study of untreated gout subjects (n = 34) and non-gout healthy controls (n = 64). High-resolution dynamic ultrasound-measured flow-mediated dilation (FMD) and nitroglycerin-mediated dilation (NMD) assessed endothelium-dependent and endothelium-independent arterial responsiveness respectively. Serum urate (sUA) and high-sensitivity C-reactive protein (hsCRP) were measured in the gout group, and correlated with FMD and NMD responses. Both FMD (2.20 ± 0.53 vs 3.56 ± 0.31, p = 0.021) and NMD (16.69 ± 1.54 vs 24.51 ± 0.90, p = 0.00002) were impaired in the gout versus control group. Stratification for individual comorbidities suggested that no single risk factor accounted for impaired FMD/NMD in the gout subjects. However, the degree of association between gout and FMD, but not NMD impairment, was dampened after multivariable adjustment (FMD unadjusted beta = - 1.36 (SE 0.58), p = 0.02; adjusted beta = - 1.16 (SE 0.78), p = 0.14 and NMD unadjusted beta = - 7.68 (SE 1.78), p < 0.0001; adjusted beta = - 5.33 (SE 2.46), p = 0.03). Within the gout group, there was an inverse correlation between FMD and sUA (R = - 0.5, p = 0.003), and between FMD and hsCRP (R = - 0.42, p = 0.017), but not between NMD and sUA or hsCRP. Compared with healthy controls, subjects with gout have reduced arterial function. Individual comorbidities are insufficient to account for differences between gout and control groups, but multiple comorbidities may collectively contribute to impairment in endothelium-dependent arterial responsiveness. Endothelial impairment is also related to sUA and hsCRP, markers of gout severity and inflammation respectively. Studies to determine whether gout therapy may improve arterial responsiveness are warranted.

Background: Use of a universal diagnostic catheter may decrease procedural time and catheter exchange-related spasm compared to a dual catheter strategy. The aim of this study is to identify demographic and clinical predictors of failure to complete an invasive coronary angiogram with a universal catheter alone. Methods: A retrospective review was performed of consecutive unique patients who underwent a right transradial or transulnar diagnostic coronary angiogram between January 2015 and June 13, 2017 by a transradial operator who routinely starts with a universal catheter (n=624). Patients were excluded if a universal catheter was not initially used (n=84). Multivariable predictors of failure to complete the procedure with a universal catheter alone were identified using logistic regression analysis and presented as odds ratio (OR) [95% confidence interval (CI)]. Results: Of patients who met study criteria, 317 (58.7%) underwent angiography with a universal catheter alone and 223 (41.3%) required exchange to a coronary-specific catheter (53.2% for right coronary artery alone, 20.1% for left coronary artery alone, 25.2% for both). Patients who required a catheter exchange were more likely to be age >75 years (24.7% vs 14.8%, p<0.005), female (34.4% vs 20.1%, p<0.005), height <64 inches (35.3% vs 25.5%, p=0.016), with diabetes mellitus (47.9% vs 36.7, p=0.010), with hypertension (85.2% vs 74.4%, p=0.003), or with chronic kidney disease (25.9% vs 17.2%, p=0.017). After multivariable adjustment, age >75 years (OR 2.02 [1.29-3.17]), female sex (OR 2.11 [1.42-3.15]), diabetes mellitus (OR 1.54 [1.06- 2.24]), and hypertension (OR 1.96 [1.23-3.12]) independently predicted failure of a universal catheter alone to complete angiography. Conclusion: In patients undergoing a right transradial or transulnar coronary angiogram, consideration may be made to use a dual catheter strategy over a universal catheter strategy if one or more of the following characteristics are present: elderly age, female sex, diabetes mellitus, hypertension. A prospective study is needed to determine if catheter selection based on these pre-procedural characteristics can decrease access crossover rate, procedural time, radiation exposure, and contrast use

Early revascularization is the gold standard for management of patients with ST-elevation myocardial infarction (STEMI) and cardiogenic shock (CS). The use of transradial artery access (TRA) in percutaneous coronary intervention (PCI) has increased in recent years and has emerged as a safe and effective approach to PCI in high-risk patients, with advantages in reduced major bleeding events, other peri-procedural complications, and all-cause mortality when compared with transfemoral artery access (TFA). Multiple randomized clinical trials have demonstrated these advantages of TRA vs. TFA PCI in STEMI patients. Although there remains a lack of dedicated randomized trials in CS, observational data suggest benefits on the same endpoints as in STEMI with TRA vs. TFA PCI in CS. This review summarizes the existing literature on the use of TRA compared to TFA for STEMI and CS patients; the reduction of major bleeding events, other peri-procedural complications, and mortality associated with TRA in STEMI and CS; and technical considerations and challenges in the care of these high-risk patient populations.

Colchicine is an ancient medication that is currently approved for the treatment of gout and FMF. However, colchicine has a wide range of anti-inflammatory activities, and studies indicate that it may be beneficial in a variety of other conditions. This paper reviews the evidence for the well-established use of colchicine in gout, as well as several other rheumatic diseases. In addition, we highlight the potential benefit of colchicine in cardiac disease, including coronary artery disease in patients both with and without gout.

BACKGROUND: Type 2 myocardial infarction (MI) is defined by a rise and fall of cardiac biomarkers and evidence of ischemia without unstable coronary artery disease (CAD) because of a mismatch in myocardial oxygen supply and demand. Myocardial injury is similar but does not fulfill the clinical criteria for MI. There is uncertainty in terms of the clinical characteristics, management, and outcomes of type 2 MI and myocardial injury in comparison with type 1 MI. PATIENTS AND METHODS: Patients admitted to a Veterans Affairs tertiary care hospital with a rise and fall in cardiac troponin were identified. MI and injury subtypes, presentation, management, and outcomes were determined. RESULTS: Type 1 MI, type 2 MI, and myocardial injury occurred in 137, 146, and 175 patients, respectively. Patients with type 2 MI were older (P=0.02), had lower peak cardiac troponin (P<0.001), and were less likely to receive aspirin and statin at discharge (P<0.001) than type 1 MI survivors. All-cause mortality (median follow-up: 1.8 years) was not different between patient groups (type 1 MI mortality: 29.9%, type 2 MI: 30.8%, myocardial injury: 29.7%; log rank P=0.94). A significant proportion of deaths were attributed to cardiovascular causes in all subgroups (type 1 MI: 34.1%, type 2 MI: 17.8%, myocardial injury: 30.8%). CONCLUSION: Patients with type 2 MI and myocardial injury were less likely to receive medical therapy for CAD than those with type 1 MI. No differences in all-cause mortality among MI subtypes were observed. Additional studies to determine optimal medical therapy and risk stratification strategies for these high-risk populations are warranted.

BACKGROUND: Diet is a modifiable risk factor for cardiovascular disease; however, dietary patterns are historically difficult to capture in the clinical setting. Healthcare providers need assessment tools that can quickly summarize dietary patterns. Research should evaluate the effectiveness of these tools, such as Rate Your Plate (RYP), in the clinical setting. HYPOTHESIS: RYP diet quality scores are associated with measures of body adiposity in patients referred for coronary angiography. METHODS: Patients without a history of coronary revascularization (n = 400) were prospectively approached at a tertiary medical center in New York City prior to coronary angiography. Height, weight, and waist circumference (WC) were measured; body mass index (BMI) and waist-to-height ratio (WHtR) were calculated. Participants completed a 24-question RYP diet survey. An overall score was computed, and participants were divided into high (>/=58) and low (