Dr. Usman's Cardiology Notes

Eplerenone in patients with systolic heart failure and mild symptoms - The New England Journal of Medicine - 2011 Brief Summary: Eplerenone reduces the risk of death and hospitalization in patients with moderate systolic dysfunction and NYHA class II symptoms. Reference: http://www.ncbi.nlm.nih.gov/pubmed/21073363

Ultrafiltration in Decompensated Heart Failure with Cardio-renal Syndrome - The New England Journal of Medicine - 2012 Brief Summary: In patients with acute decompensated HF and cardio-renal syndrome, ultrafiltration is associated with more adverse events, worsening renal function, and no change in weight when compared to medical therapy. Reference: http://www.ncbi.nlm.nih.gov/pubmed/23131078

Effect of Phosphodiesterase-5 Inhibition on Exercise Capacity and Clinical Status in Heart Failure with Preserved Ejection Fraction – JAMA - 2013 Brief Summary: In patients with symptomatic HFpEF, sildenafil does not improve exercise capacity (measured by peak VO2) or clinical status at 24 weeks. Reference: http://www.ncbi.nlm.nih.gov/pubmed/23478662

Treatment of anemia with darbepoetin alfa in systolic heart failure - The New England Journal of Medicine - 2013 Brief Summary: Among patients with LV systolic dysfunction and mild to moderate anemia, the use of darbepoetin targeting a hemoglobin >13 g/dL does not reduce the composite outcome of all-cause mortality or first hospitalization for HF. Reference: http://www.ncbi.nlm.nih.gov/pubmed/23473338

Spironolactone for heart failure with preserved ejection fraction - The New England Journal of Medicine - 2014 Brief Summary: Among patients with heart failure with preserved ejection fraction, spironolactone does not reduce the composite endpoint of CV mortality, aborted cardiac arrest, or HF hospitalizations when compared to placebo. However, it is associated with small reduction in HF hospitalizations. Reference: http://www.ncbi.nlm.nih.gov/pubmed/24716680

Angiotensin-neprilysin inhibition versus enalapril in heart failure - The New England Journal of Medicine - 2014 Brief Summary: Among patients with HFrEF, treatment with an angiotensin receptor-neprilysin inhibitor reduces CV mortality or HF hospitalizations when compared to enalapril. It is also associated with a reduction in all-cause mortality. Reference: http://www.ncbi.nlm.nih.gov/pubmed/25176015

Isosorbide mononitrate in heart failure with preserved ejection fraction - New England Journal of Medicine - 2015 Brief Summary: In patients with HFpEF (LVEF ≥ 50%) and mild-moderate (NYHA II-III) symptoms, the addition of the long-acting nitrate isosorbide mononitrate appears to hinder rather than improve activity level. Patients on nitrate therapy had a borderline significant reduction in total activity units as well as about a 20-minute absolute reduction in activity time per day. There was no effect of nitrate therapy on 6-minute walk distance, quality of life, or clinical biomarkers. Reference: http://www.ncbi.nlm.nih.gov/pubmed/26549714

Ablation vs. Amiodarone for treatment of persistent atrial fibrillation in patients with congestive heart failure and an implanted device - Circulation - 2016 Brief Summary: In patients with symptomatic (NYHA II-III) heart failure with reduced ejection fraction (HFrEF, LVEF ≤40%) and persistent atrial fibrillation (AF) chosen for a rhythm control strategy, AF ablation was associated with a 36% absolute increase in AF-free survival at 24 months. There was also a 26% absolute reduction in unplanned hospitalizations and a 10% absolute reduction in overall mortality with AF ablation. Reference: http://www.ncbi.nlm.nih.gov/pubmed/27029350

Effect of oral iron repletion on exercise capacity in patients with heart failure with reduced ejection fraction and iron deficiency – JAMA - 2017 Brief Summary: In patients with iron deficiency (ferritin 15-100 or 100-299 with transferrin saturation < 20%) and symptomatic HFrEF (LVEF ≤ 40% with NYHA II-IV), oral iron replacement had no effect on exercise capacity as measured using change in peak oxygen uptake (VO2). Reference: http://www.ncbi.nlm.nih.gov/pubmed/28510680

Tafamidis Treatment for Patients with Transthyretin Amyloid Cardiomyopathy - The New England Journal of Medicine - 2018 Brief Summary: In patients with cardiac amyloidosis, the protein stabilizer tafamidis results in a 13.4% absolute reduction in overall mortality and a 22% absolute reduction in yearly cardiovascular hospitalization at 30 months compared to placebo. Tafamidis use was also associated with improvements in heart-failure related quality of life and functional status. Reference: http://www.ncbi.nlm.nih.gov/pubmed/30145929

Two-year Outcomes with a Magnetically Levitated Cardiac Pump in Heart Failure - The New England Journal of Medicine - 2018 Brief Summary: In patients with advanced heart failure refractory to medical management referred for durable left ventricular assist device (LVAD) placement, a magnetically levitated centrifugal-flow device was associated with 19.3% absolute reduction in reoperation for device malfunction or disabling stroke at 2 years. This was driven primarily by a 15.4% absolute reduction in the need for reoperation for device malfunction, although there was also a 9.1% absolute reduction in overall stroke (not disabling stroke). Reference: http://www.ncbi.nlm.nih.gov/pubmed/29526139

Angiotensin-Neprilysin Inhibition in Acute Decompensated Heart Failure - The New England Journal of Medicine - 2018 Brief Summary: Sacubitril-valsartan therapy decreased NT-proBNP concentration compared to enalapril therapy at 4 and 8 weeks, without significantly different rates of medication related adverse effects. Reference: http://www.ncbi.nlm.nih.gov/pubmed/30415601

Dapagliflozin in Patients With Heart Failure and Reduced Ejection Fraction - The New England Journal of Medicine - 2019 Brief Summary: Among individuals with HFrEF (NYHA II-IV, LVEF ≤40%) with or without T2DM, the addition of the SGLT-2 inhibitor dapagliflozin decreased rates of CV death or worsening HF, as well as all-cause mortality. Reference: http://www.ncbi.nlm.nih.gov/pubmed/31535829

Heart and Lung Transplants from HCV-Infected Donors to Uninfected Recipients - The New England Journal of Medicine - 2019 Brief Summary: In patients with end-stage heart or lung disease requiring transplantation who are HCV negative, transplantation of HCV positive organs followed by immediate viral suppression with sofosbuvir/velpatasvir is feasible. At 6 months, all of 35 individuals (28 lung and 7 heart) transplanted had intact allograft function and undetectable HCV viral loads. In limited post-hoc analyses, overall transplant outcomes were similar to those observed with HCV- organs. Reference: http://www.ncbi.nlm.nih.gov/pubmed/30946553

Withdrawal of pharmacological treatment for heart failure in patients with recovered dilated cardiomyopathy (TRED-HF): an open-label, pilot, randomized trial - The Lancet - 2019 Brief Summary: Patients with dilated cardiomyopathy whose function recovers with treatment are at increased risk of relapse at 6 months if treatment is withdrawn. Reference: http://www.ncbi.nlm.nih.gov/pubmed/30429050

A 65 year old man known diabetic presented with chest pain. What is your diagnosis based on this ECG? Click the button below to view answer: Show Answer

Echocardiography showing Thrombus in Left Atrial Appendage (LAA) Thrombus in left atrial appendage (arrow). The corresponding Pulsed Doppler showing low emptying velocity in left atrial appendage (LAA)

Echocardiography showing Mediastinal Mass in Subcostal View, there is external compression of Left atrium by a mass.

Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S) - The Lancet – 1994 Brief Summary: In patients with prior MI or angina and hyperlipidemia, Simvastatin reduces all-cause mortality as well as CAD-related mortality. Reference: http://www.ncbi.nlm.nih.gov/pubmed/7968073

Prevention of Coronary Heart Disease with Pravastatin in Men with Hypercholesterolemia - The New England Journal of Medicine - 1995 Brief Summary: Among men with hyperlipidemia, pravastatin reduced the composite endpoint of nonfatal MI or death from CAD at 5 years. Reference: http://www.ncbi.nlm.nih.gov/pubmed/7566020

A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events - The Lancet - 1996 Brief Summary: Clopidogrel reduces CV outcomes more than aspirin when used as secondary prevention among patients with prior stroke or MI. Reference: http://www.ncbi.nlm.nih.gov/pubmed/8918275

Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients - The New England Journal of Medicine. 2000 Brief Summary: Ramipril reduces rates of death, MI, and stroke among patients with multiple CV risk factors and without heart failure. Reference: http://www.ncbi.nlm.nih.gov/pubmed/10639539

Efficacy of perindopril in reduction of cardiovascular events among patients with stable coronary artery disease - The Lancet -2003 Brief Summary: In patients with stable CAD without heart failure, perindopril reduces CV mortality, MI, or cardiac arrest, as compared to placebo. Reference: http://www.ncbi.nlm.nih.gov/pubmed/13678872

Coronary-artery revascularization before elective major vascular surgery - The New England Journal of Medicine - 2004 Brief Summary: In patients with stable CAD, there is no mortality benefit performing coronary artery revascularization before elective vascular surgery. Reference: http://www.ncbi.nlm.nih.gov/pubmed/15625331

Intensive lipid lowering with atorvastatin in patients with stable coronary disease - The New England Journal of Medicine - 2005 Brief Summary: In patients with stable CAD and hyperlipidemia, atorvastatin 80 mg PO daily is associated with a greater reduction in CAD mortality, non-fatal MI not related to procedures, resuscitation after cardiac arrest, or fatal or nonfatal stroke when compared to atorvastatin 10 mg PO daily. Reference: http://www.ncbi.nlm.nih.gov/pubmed/15755765

Optimal medical therapy with or without PCI for stable coronary disease - The New England Journal of Medicine - 2007 Brief Summary: In patients with stable CAD, there were no differences in death and MI between optimal medical therapy plus PCI vs. OMT alone. Reference: http://www.ncbi.nlm.nih.gov/pubmed/17387127

Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein - The New England Journal of Medicine - 2008 Brief Summary: Among patients with normal LDL but elevated HS-CRP, rosuvastatin reduces the incidence of CV events. Reference: http://www.ncbi.nlm.nih.gov/pubmed/18997196

A Randomized Trial of Therapies for Type 2 Diabetes and Coronary Artery Disease - The New England Journal of Medicine – 2009 Brief Summary: Among patients with T2DM and stable CAD that are CABG candidates, CABG and OMT reduced the rate of CV events compared to OMT alone. There was no difference in the PCI cohort. Reference: http://www.ncbi.nlm.nih.gov/pubmed/19502645

Effects of Extended-Release Metoprolol Succinate in Patients Undergoing Non-Cardiac Surgery: a Randomised Controlled Trial - The Lancet. 2008 Brief Summary: Although metoprolol reduced the risk of perioperative MI among patients undergoing non-cardiac surgery, this benefit was more than nullified by a higher rate of mortality and strokes. Reference: http://www.ncbi.nlm.nih.gov/pubmed/18479744

Fractional Flow Reserve versus Angiography for Guiding Percutaneous Coronary Intervention - The New England Journal of Medicine - 2009 Brief Summary: In patients with multivessel CAD, an FFR-guided approach reduces the composite of death, nonfatal MI, and repeat revascularization at one year compared to PCI alone. Reference: http://www.ncbi.nlm.nih.gov/pubmed/19144937

Percutaneous Coronary Intervention versus Coronary-Artery Bypass Grafting for Severe Coronary Artery Disease - The New England Journal of Medicine - 2009 Brief Summary: CABG resulted in fewer major CV events at 1 year compared with PCI among patients with 3-vessel and/or left main disease. Reference: http://www.ncbi.nlm.nih.gov/pubmed/19228612

Effects of combination lipid therapy in type 2 diabetes mellitus - The New England Journal of Medicine – 2010 Brief Summary: Among adults with T2DM on statin monotherapy, the addition of fenofibrate does not reduce CVD endpoints. Reference: http://www.ncbi.nlm.nih.gov/pubmed/20228404

Clopidogrel with or without omeprazole in coronary artery disease - The New England Journal of Medicine - 2010 Brief Summary: Among patients with CAD requiring aspirin and clopidogrel, there was no significantly increased risk in CV events when omeprazole was added. However, there was a significant reduction in GI events, particularly an 87% reduction in overt upper GI bleed. Reference: http://www.ncbi.nlm.nih.gov/pubmed/20925534

Coronary-Artery Bypass Surgery in Patients with Left Ventricular Dysfunction - The New England Journal of Medicine - 2011 Brief Summary: Among patients with ischemic cardiomyopathy with LVEF ≤35%, the addition of CABG to OMT does not significantly reduce all-cause mortality after 5 years but does reduce CV-related deaths and hospitalizations. After 10 years, there is a significant reduction in all-cause mortality with CABG. Reference: http://www.ncbi.nlm.nih.gov/pubmed/21463150

Strategies for multivessel revascularization in patients with diabetes - The New England Journal of Medicine - 2012 Brief Summary: Among diabetic patients with multivessel coronary artery disease (CAD), revascularization with CABG reduces the rates of death and myocardial infarction compared to PCI, but causes a modest increase in the rate of stroke. Reference: http://www.ncbi.nlm.nih.gov/pubmed/23121323

Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease - The New England Journal of Medicine - 2012 Brief Summary: Among patients with stable CAD with FFR ≤0.80, PCI reduces the composite rate of death, nonfatal MI, and urgent revascularization, compared to OMT alone, driven primarily by a reduction in urgent revascularization. Reference: http://www.ncbi.nlm.nih.gov/pubmed/22924638

n-3 fatty acids and cardiovascular outcomes in patients with dysglycemia - The New England Journal of Medicine - 2012 Brief Summary: Among those with prediabetes or diabetes, supplementation with n-3 polyunsaturated fatty acids (ie, fish oil) does not reduce CV mortality. Reference: http://www.ncbi.nlm.nih.gov/pubmed/22686415

Low dose colchicine for secondary prevention of cardiovascular disease - Journal of the American College of Cardiology - 2013 Brief Summary: The addition of colchicine 0.5 mg/day to standard secondary prevention treatment with aspirin/clopidogrel and high-dose statins decreased the risk of cardiovascular events in patients with stable coronary disease. However, this trial was limited by its poor design. Reference: http://www.ncbi.nlm.nih.gov/pubmed/23265346

Effect of Platelet Inhibition with Cangrelor during PCI on Ischemic Events - The New England Journal of Medicine - 2013 Brief Summary: Among patients undergoing urgent or elective PCI, cangrelor reduces the risk of ischemic events, as compared to clopidogrel. Reference: http://www.ncbi.nlm.nih.gov/pubmed/23473369

Primary prevention of cardiovascular disease with a mediterranean diet - The New England Journal of Medicine - 2013 Brief Summary: In the initial 2013 publication, a Mediterranean diet with extra-virgin olive oil or nuts was thought to reduce rates of MI, CVA, or CV death in those at high risk for CV disease. In 2018, this trial was retracted and replaced for abnormalities in randomization. The updated publication documented similar findings but the authors were unable to confirm adherence to randomization schemes given missing documentation. Reference: http://www.ncbi.nlm.nih.gov/pubmed/23432189

Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: An open-label, randomised, controlled trial - The Lancet - 2013 Brief Summary: In patients on oral anticoagulation undergoing PCI, use of clopidogrel alone (double therapy) was associated with a significant reduction in bleeding complications compared to patients receiving clopidogrel with aspirin (triple therapy). Reference: http://www.ncbi.nlm.nih.gov/pubmed/23415013

Effects of extended-release niacin with laropiprant in high-risk patients - The New England Journal of Medicine - 2014 Brief Summary: Among patients with atherosclerotic disease on statin therapy, niacin+laropiprant does not reduce incident major vascular events when compared to placebo. The therapy was poorly tolerated. Reference: http://www.ncbi.nlm.nih.gov/pubmed/25014686

Twelve or 30 months of dual antiplatelet therapy after drug-eluting stents - The New England Journal of Medicine - 2014 Brief Summary: Among patients who completed one year of dual antiplatelet therapy (DAPT) after drug-eluting stent PCI, continued DAPT (totaling 30 months) reduces the rate of stent thrombosis and death, MI, or stroke at the cost of increased bleeding. Reference: http://www.ncbi.nlm.nih.gov/pubmed/25399658

Aspirin in patients undergoing noncardiac surgery - The New England Journal of Medicine - 2014 Brief Summary: Among patients with elevated operative risk, perioperative aspirin does not reduce rate of all-cause mortality or non-fatal MI when compared to placebo. It is associated with increased risk of major bleeding. Reference: http://www.ncbi.nlm.nih.gov/pubmed/24679062

Trial of everolimus eluting stents or bypass surgery for coronary disease - The New England Journal of Medicine - 2015 Brief Summary: In patients with multivessel CAD undergoing revascularization, PCI with 2nd-generation DES is inferior to CABG and is associated with a 4.7% absolute increase in death, MI, or target-vessel revascularization at 4.6 years. The primary endpoint increase with PCI was driven primarily by a 3.3% absolute increase in target-vessel revascularization and a trend towards increased nonfatal MIs. Reference: http://www.ncbi.nlm.nih.gov/pubmed/25774645

Complete Revascularization Versus Treatment of the Culprit Lesion Only in Patients with ST-segment Elevation Myocardial Infarction and Multivessel Disease - The Lancet - 2015 Brief Summary: In patients undergoing PCI for STEMI found to have multivessel CAD, FFR-guided complete revascularization is associated with a 9% absolute reduction in major cardiovascular adverse events (death, MI, revascularization) at 27 months. This was driven primarily by an 12% absolute reduction in ischemia-driven revascularization. Reference: http://www.ncbi.nlm.nih.gov/pubmed/26347918

Randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and multivessel disease - J Am Coll Cardiol - 2015 Brief Summary: Among patients undergoing PCI for STEMI and found to have multivessel disease on angiography, complete revascularization is associated with an 11% absolute reduction in major adverse cardiovascular outcomes (MACE) at 12 months compared to culprit lesion-only revascularization, driven by symmetric modest reductions in each component of the primary composite outcome. Reference: http://www.ncbi.nlm.nih.gov/pubmed/25766941

Duration of triple therapy in patients requiring oral anticoagulation after drug-eluting stent implantation - J Am Coll Cardiol - 2015 Brief Summary: In patients requiring oral anticoagulation (OAC) for a separate indication undergoing drug-eluting stent (DES) placement after coronary intervention, six weeks of clopidogrel therapy in addition to aspirin and OAC is not associated with improved net clinical outcomes compared to 6 months of clopidogrel therapy after 9 months. Both major bleeding risk and thrombotic risk appeared to be similar with either the shorter or longer duration of "triple therapy" over this limited period of follow-up. Reference: http://www.ncbi.nlm.nih.gov/pubmed/25908066

Drug-Eluting or Bare-Metal Stents for Coronary Artery Disease - The New England Journal of Medicine - 2016 Brief Summary: In patients with stable or unstable CAD undergoing PCI, contemporary second-generation DES are not superior to contemporary BMS in regards to a primary endpoint of all-cause mortality or nonfatal MI at 6 years. DES was associated with a 3% absolute reduction in any repeat revascularization as well as a 0.4% absolute reduction in stent thrombosis over this period. Reference: http://www.ncbi.nlm.nih.gov/pubmed/27572953

Cardiovascular safety of celecoxib, naproxen, or ibuprofen for arthritis - The New England Journal of Medicine - 2016 Brief Summary: Among patients with RA and osteoarthritis and elevated CV risk requiring daily NSAID therapy, celecoxib is noninferior to ibuprofen and naproxen with regard to a primary safety outcome of cardiovascular death, nonfatal MI, and nonfatal stroke after mean follow up of nearly 3 years. Primary outcome events were low (approximately 2-3%) and similar among the three NSAIDs. GI events were significantly lower with celecoxib versus either naproxen or ibuprofen. Renal events were significantly lower with celecoxib versus ibuprofen. Reference: http://www.ncbi.nlm.nih.gov/pubmed/27959716

Everolimus-eluting stents or bypass surgery for left main coronary artery disease - The New England Journal of Medicine - 2016 Brief Summary: Patients with left main CAD and low-intermediate anatomic complexity, PCI with 2nd generation DES is noninferior to CABG with respect to a primary outcome of death, stroke, or myocardial infarction at 3 years, though with a nonsignificant trend towards increased mortality. Reference: http://www.ncbi.nlm.nih.gov/pubmed/27797291

Prevention of bleeding in patients with AF undergoing PCI - The New England Journal of Medicine - 2016 Brief Summary: Among patients with nonvalvular AF undergoing PCI with stent placement, the use of low dose rivaroxaban plus either single or dual antiplatelet therapy reduces the risk of bleeding when compared to warfarin plus DAPT at 1 year. Reference: http://www.ncbi.nlm.nih.gov/pubmed/27959713

Percutaneous coronary intervention in stable angina – Lancet -2017 Brief Summary: In patients with stable angina despite medical therapy, PCI does not improve angina as measured by treadmill exercise time compared to placebo procedure, with both arms receiving anti-anginal therapy. PCI also failed to improve angina as assessed by validated questionnaires or improve overall quality of life. Reference: http://www.ncbi.nlm.nih.gov/pubmed/29103656

Evolocumab and clinical outcomes in patients with cardiovascular disease - The New England Journal of Medicine - 2017 Brief Summary: Among patients with clinical atherosclerotic disease and LDL > 70 despite high- or moderate-intensity statin therapy (70% high intensity), the addition of evolocumab resulted in an absolute 1.5% reduction in major cardiovascular events (cardiovascular death, MI, stroke, hospitalization for unstable angina, or coronary revascularization) at median follow-up 26 months, driven primarily by reductions in nonfatal MI, stroke, and revascularization. There was no overall or CV-specific mortality benefit with evolocumab. Other than a modest 2% incidence in injection-site reactions, there was no increase in key adverse events including new-onset diabetes or neurocognitive effects in patients receiving evolocumab. Reference: http://www.ncbi.nlm.nih.gov/pubmed/28304224

PCI strategies in patients with acute myocardial infarction and cardiogenic shock - New England Journal of Medicine. 2017 Brief Summary: In patients with acute MI complicated by cardiogenic shock found to have multivessel CAD on coronary angiography, culprit-only PCI is associated with 9.5% absolute reduction in the rate of death or renal replacement therapy at 30 days. This was driven primarily by a 7.3% absolute reduction in all-cause mortality with culprit-lesion only PCI. Reference: http://www.ncbi.nlm.nih.gov/pubmed/29083953

Anti-inflammatory Therapy with Canakinumab for Atherosclerotic Disease - The New England Journal of Medicine - 2017 Brief Summary: Anti-inflammatory therapy targeting the interleukin-1β innate immunity pathway with canakinumab at a dose of 150 mg every 3 months was associated with 0.6% absolute reduction in cardiovascular events, driven by a comparable reduction in nonfatal MI. Use of canakinumab was also associated with 0.13% absolute increase in fatal infection. Reference: http://www.ncbi.nlm.nih.gov/pubmed/28845751

Rivaroxaban with or without aspirin in stable cardiovascular disease - The New England Journal of Medicine - 2017 Brief Summary: In patients with established stable atherosclerotic disease, rivaroxaban plus aspirin resulted in a modest 1.3% absolute risk reduction in cardiovascular death, stroke, or nonfatal MI, with a trend toward improved mortality. This benefit was offset by a 1.2% increased absolute risk in major bleeding. Reference: http://www.ncbi.nlm.nih.gov/pubmed/28844192

Fractional Flow Reserve-Guided Multivessel Angioplasty in Myocardial Infarction - The New England Journal of Medicine - 2017 Brief Summary: In patients with multivessel coronary disease presenting with STEMI, FFR-guided complete revascularization is associated with a 12.7% absolute reduction in major cardiovascular adverse events (death, MI, revascularization, stroke). This was driven primarily by an 11.4% absolute reduction in the need for revascularization as well as a trend toward fewer MIs. Reference: http://www.ncbi.nlm.nih.gov/pubmed/28745981

Bioresorbable scaffolds versus metallic stents in routine PCI - The New England Journal of Medicine – 2017 Brief Summary: In patients with stable or unstable CAD undergoing PCI, bioresorbable scaffolds are associated with similar rates of target-vessel failure (defined as death, target-vessel MI, target-vessel revascularization) as DES at 2 years. Importantly, scaffolds were associated with a 2.6% absolute increase in probable or definite device thrombosis compared to DES. Reference: http://www.ncbi.nlm.nih.gov/pubmed/28402237

Spontaneous wave-free ratio versus fractional flow reserve to guide PCI - The New England Journal of Medicine - 2017 Brief Summary: In patients with stable or unstable coronary artery disease (CAD) undergoing revascularization with intermediate coronary lesions, iFR is noninferior to FFR for PCI guidance, with similar rates of all-cause mortality, nonfatal MI, or unplanned revascularization in both groups at 12 months. Reference: http://www.ncbi.nlm.nih.gov/pubmed/28317438

Dual antithrombotic therapy with dabigatran after PCI in atrial fibrillation - The New England Journal of Medicine - 2017 Brief Summary: In patients with nonvalvular AF undergoing PCI for coronary artery disease, dual therapy with a thienopyridine antiplatelet and dabigatran is associated with an 11.5% absolute reduction in major and clinically relevant non-major bleeding when compared to triple therapy. Dual therapy was also associated with overall similar rates of thrombosis, although a pooled analysis including both doses of dabigatran dual therapy revealed a modest and non-significant 1.1% absolute increase in thromboembolic events or death. Reference: http://www.ncbi.nlm.nih.gov/pubmed/28844193

Effect of aspirin on disability-free survival in the healthy elderly - The New England Journal of Medicine - 2018 Brief Summary: Among healthy, community-dwelling seniors, does low-dose aspirin did not reduce incident death, dementia, or persistent physical disability when compared with placebo. Aspirin was associated with increased risk of major hemorrhage. Reference: http://www.ncbi.nlm.nih.gov/pubmed/30221596

Drug-eluting stents versus bare-metal stents in saphenous vein grafts: a double-blind, randomised trial – Lancet - 2018 Brief Summary: In patients with a history of coronary artery bypass grafting undergoing percutaneous coronary intervention (PCI) of a saphenous vein graft, bare-metal stents (BMS) result in similar rates of target-vessel failure (defined as cardiac death, target vessel myocardial infarction, and target vessel revascularization) as drug-eluting stents (DES). At 12 months, the target-vessel failure rate was 19% in the BMS group and 17% in the DES group. Adverse event rates were similar in each group. Reference: http://www.ncbi.nlm.nih.gov/pubmed/29759512

Cardiovascular Risk Reduction with Icosapent Ethyl for Hypertriglyceridemia - The New England Journal of Medicine - 2018 Brief Summary: In patients with established atherosclerotic heart disease, or diabetes and an additional risk factor, on pre-existing statin therapy with residual hypertriglyceridemia (fasting triglyceride level 135-499 mg/dL), icosapent ethyl was associated with an absolute 4.8% reduction in cardiovascular events (cardiovascular death, nonfatal MI, nonfatal stroke, coronary revascularization, or unstable angina), with a 0.9% absolute reduction in cardiovascular death, at 4.9 years. Reference: http://www.ncbi.nlm.nih.gov/pubmed/30415628

Low-dose methotrexate for the prevention of atherosclerotic events - The New England Journal of Medicine - 2018 Brief Summary: In patients with established atherosclerotic heart disease (previous MI or multivessel coronary disease plus either type 2 diabetes or metabolic syndrome), low-dose methotrexate failed to reduce the primary endpoint of nonfatal MI, nonfatal stroke, hospitalization for unstable angina leading to revascularization, or cardiovascular death after 2.3 years. Reference: http://www.ncbi.nlm.nih.gov/pubmed/30415610

Bilateral versus Single Internal Thoracic Artery Grafts at 10 Years - The New England Journal of Medicine - 2019 Brief Summary: In patients with multi-vessel coronary disease selected for surgical revascularization, bilateral internal mammary artery (BIMA) grafting resulted in similar 10 year mortality as compared to single IMA grafting. There was a 1.6% absolute increase in sternal wound complications using BIMA. Reference: http://www.ncbi.nlm.nih.gov/pubmed/30699314

Apical four chamber view of echocardiography of a patient with Thoracic Aortic Aneurysm , the descending aorta distorts the left atrial shape creating appearance of a mass within left atrium.

A 65 year old man with a history of severe de-compensated chronic renal failure and advanced coronary disease, What are the ECG findings? Click the button below to view answer: Show Answer

A 32 year old man with no significant past medical history presented with chest pain, fever, and dyspnea on exertion. His laboratory evaluation revealed elevated cardiac enzymes, elevated liver function tests, and pancytopenia. What is your likely diagnosis based on these images?Click the button below to view answer: Show Answer

A 67 year old woman with a history of lupus presented with dyspnea and chest pain. What are the findings shown in above MR images? Click the button below to view answer: Show Answer

A 22 year old woman with Behçet’s syndrome and myelodysplastic syndrome status post recent bone marrow transplant presented with dyspnea, fatigue, and lower extremity swelling. What are the key findings in above MR images? Click the button below to view answer: Show Answer

 Gadolinium enhanced MRA, Sagittal Oblique View A 57 year old woman with hypertension presented with sudden onset of severe chest pain radiating to the back. MRA was done, identify the structures marked with arrows. Click the button below to view answer: Show Answer

A 55 year old male smoker presented in Emergency Department with one hour chest pain, What is your diagnosis based on this EKG? Click the button below to view answer: Show Answer

ECG Case: A 77 year old man presented with palpitations, What is the rhythm? Click the button below to view answer: Show Answer

A 50 year old man history of NIDDM, renal artery stenosis and longstanding hypertension now presented with CHF. You have to evaluate him for ischemia. SPECT myocardial perfusion studies were performed using Tc-99m-Sestamibi and Persantine. Images representing myocardial perfusion were obtained at rest and peak stress. Stress protocol = Persantine Duration of stress = 4 min Peak heart rate (basal --> peak) = 72 --> 87 (85%=144 ) Systolic BP (basal --> peak) = 166 --> 120 Double product (peak rate x BP) = 10,520 Reason for termination = Protocol achieved. No chest pain ECG findings = No ST changes Figure 1 Figure 2: Labelled for easy identification Subsequent Echocardiography: LV dilatation with severe reduction in systolic function EF=15-20% Mild mitral regurgitation (1+) Left atrial enlargement Click the button below to view answer: Show Answer

What is the main finding in these images? Click the button below to view answer: Show Answer

A 50 year old man diagnosed case of dilated cardiomyopathy (DCM) presented with dyspnea. What are the ECG findings? Click the button below to view answer: Show Answer

A young female presented to the emergency department with vague chest discomfort. What is the most likely diagnosis based on this ECG? Click the button below to view answer: Show Answer

A 34 year old man admitted with pyelonephritis, What is the rhythm? Click the button below to view answer: Show Answer

A 54 year old female smoker presented with palpitations, What is your diagnosis based on this ECG? Click the button below to view answer: Show Answer

This video is showing echocardiographic features in a patient with amyloidosis. There is shiny, speckled appearance of myocardium , concentric left ventricle hypertrophy, right ventricle hypertrophy with reduced systolic function, biatrial enlargement and pericardial effusion.

This echocardiography video is showing Amplatzer Septal Occluder in situ, there is also evidence of dilated right ventricle.

Transcatheter Aortic Valve implantation for aortic stenosis in patients who cannot undergo surgery - The New England Journal of Medicine - 2010 Brief Summary: In patients with severe AS who are poor surgical candidates, transcatheter aortic-valve implantation reduces all-cause mortality and rates of rehospitalization for valve or procedure-related deterioration when compared to standard therapy, at the expense of more strokes. Reference: http://www.ncbi.nlm.nih.gov/pubmed/20961243

Transcatheter versus Surgical Aortic-Valve Replacement in High-Risk Patients - The New England Journal of Medicine - 2011 Brief Summary: In patients with symptomatic severe AS who are high-risk surgical candidates (expected peri - procedural mortality ~ 15%), TAVI was associated with similar all-cause mortality to surgical AVR at 1 year. Reference: http://www.ncbi.nlm.nih.gov/pubmed/21639811

Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients - The New England Journal of Medicine - 2016 Brief Summary: In patients with symptomatic severe AS who are intermediate-risk surgical candidates (expected periprocedural mortality ~ 4-8%), TAVI was noninferior to surgical AVR with respect to all-cause mortality and disabling stroke at 2 years. Reference: http://www.ncbi.nlm.nih.gov/pubmed/27040324

Surgical or Transcatheter Aortic-valve replacement in intermediate-risk patients - The New England Journal of Medicine - 2017 Brief Summary: In patients with severe, symptomatic AS at intermediate surgical risk (3-15% risk of surgical death at 30 days per STS-PROM score), transcatheter aortic valve replacement (TAVR) was found to be non-inferior to surgical aortic valve replacement (SAVR) with respect to all-cause mortality and disabling stroke at 2 years. SAVR was associated with a marginally higher peri-operative stroke rate while TAVR was associated with a modest increase in hospitalizations related to aortic valvular disease at 2 years. Reference: http://www.ncbi.nlm.nih.gov/pubmed/28304219

Transcatheter Aortic-Valve Replacement with a Balloon-Expandable Valve in Low-Risk Patients - The New England Journal of Medicine – 2019 Brief Summary: In patients with symptomatic, severe aortic stenosis who are low-risk surgical candidates, TAVR was associated with a 6.6% absolute reduction in death, stroke, or re-hospitalization at 1 year when compared to SAVR. The superiority of TAVR was driven by symmetric reductions in each component of the primary endpoint, including a 1.5% absolute reduction in overall mortality. Reference: http://www.ncbi.nlm.nih.gov/pubmed/30883058

Protective Effects of Aspirin against Acute Myocardial Infarction and Death in Men with Unstable Angina - Results of a Veterans Administration Cooperative Study - The New England Journal of Medicine - 1983 Brief Summary: Aspirin reduces the risk of death or Myocardial Infarction at 12 weeks by 50% among patients with Unstable Angina. Reference: http://www.ncbi.nlm.nih.gov/pubmed/6135989

Randomized Trial of Intravenous Streptokinase, Oral Aspirin, Both, or Neither among 17187 Cases of Suspected Acute Myocardial Infarction - The Lancet - 1988 Brief Summary: Among patients with acute MI, aspirin and streptokinase reduced 5-week vascular mortality by 20% and 23%, respectively, when compared to placebo. The combination of aspirin and streptokinase reduced the same outcome by 40%. Reference: http://www.ncbi.nlm.nih.gov/pubmed/2899772

Effect of Captopril on Mortality and Morbidity in Patients with Left Ventricular Dysfunction after Myocardial Infarction - Results of the Survival and Ventricular Enlargement Trial - The New England Journal of Medicine - 1992 Brief Summary: In patients with acute MI complicated by asymptomatic LV dysfunction, captopril led to a 19% reduction in all-cause mortality. Reference: http://www.ncbi.nlm.nih.gov/pubmed/1386652

An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction - The New England Journal of Medicine - 1993 Brief Summary: Among patients with ACS, rapidly administered tPA in addition to heparin and ASA reduces all-cause mortality at 30 days when compared ASA and heparin with either streptokinase or slowly-administered tPA and streptokinase. Reference: http://www.ncbi.nlm.nih.gov/pubmed/8204123

Effects of lisinopril and transdermal glyceryl trinitrate singly and together on 6-week mortality and ventricular function after acute myocardial infarction - The Lancet - 1994 Brief Summary: Lisinopril reduces the odds of 6-week mortality by 11% when administered within 24 hours of acute Myocardial Infarction. Reference: http://www.ncbi.nlm.nih.gov/pubmed/7910229

A Comparison of Low-Molecular-Weight Heparin with Unfractionated Heparin for Unstable Coronary Artery Disease - The New England Journal of Medicine - 1997 Brief Summary: Enoxaparin reduces the composite endpoint of death, MI, or recurrent angina at 14 days when compared to unfractionated heparin in the treatment of UA/NSTEMI. Reference: http://www.ncbi.nlm.nih.gov/pubmed/9250846

Early Re-vascularization in Acute Myocardial Infarction Complicated by Cardiogenic Shock - The New England Journal of Medicine - 1999 Brief Summary: Compared to initial medical stabilization, early revascularization was associated with a nonsignificant trend towards improved survival at 30 days among patients who developed cardiogenic shock during acute MI. However, early revascularization did confer a significant benefit by 6 months. Reference: http://www.ncbi.nlm.nih.gov/pubmed/10460813

A 76 year old man presented with Chest pain and dyspnea, What is your diagnosis based on this ECG? Click the button below to view answer: Show Answer

A 65 year old man with history of CAD and Diabetes presented with palpitations, What are the findings in this ECG? Click the button below to view answer: Show Answer

Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomized multicenter study - The Lancet. 1999 Brief Summary: Among intermediate- to high-risk patients with UA/NSTEMI, an early invasive strategy is associated with fewer recurrent MIs and improved long-term survival compared to a non-invasive strategy. Reference: http://www.ncbi.nlm.nih.gov/pubmed/10475181

Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes - Journal of the American Medical Association - 2001 Brief Summary: Early initiation of atorvastatin post-UA/NSTEMI reduced the combined endpoint of death, nonfatal MI, cardiac arrest, and ACS requiring hospitalization at 16 weeks, when compared to placebo. Reference: http://www.ncbi.nlm.nih.gov/pubmed/11277825

Effects of Clopidogrel in Addition to Aspirin in Patients with Acute Coronary Syndromes without ST-Segment Elevation - The New England Journal of Medicine - 2001 Brief Summary: In patients with UA/NSTEMI, dual antiplatelet therapy with clopidogrel and aspirin reduced CV mortality, non-fatal MI, or stroke but increased the rate of major bleeding. Reference: http://www.ncbi.nlm.nih.gov/pubmed/11519503

Prophylactic Implantation of a Defibrillator in Patients with Myocardial Infarction and Reduced Ejection Fraction - The New England Journal of Medicine - 2002 Brief Summary: In post-MI patients with systolic dysfunction (EF ≤30%), prophylactic ICD reduced all-cause mortality compared to standard medical therapy. Reference: http://www.ncbi.nlm.nih.gov/pubmed/11907286

Sertraline treatment of major depression in patients with acute MI or unstable angina - Journal of the American Medical Association - 2002 Brief Summary: Sertraline is a safe treatment for recurrent depression among patients recently hospitalized for ACS. Reference: http://www.ncbi.nlm.nih.gov/pubmed/12169073

Valsartan, Captopril, or Both in Myocardial Infarction Complicated by Heart Failure, Left Ventricular Dysfunction, or Both - The New England Journal of Medicine - 2003 Brief Summary: Valsartan was as effective as captopril in improving survival among patients with HF and/or LV dysfunction in the post-MI period. Reference: http://www.ncbi.nlm.nih.gov/pubmed/12921816

Eplerenone, a selective Aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction - The New England Journal of Medicine. 2003 Brief Summary: Eplerenone reduced the rate of mortality among patients with acute MI complicated by LV dysfunction and HF symptoms. Reference: http://www.ncbi.nlm.nih.gov/pubmed/12668699

Intensive versus Moderate Lipid Lowering with Statins after Acute Coronary Syndromes - The New England Journal of Medicine - 2004 Brief Summary: After recent ACS, high-dose atorvastatin reduces the rate of CV events compared to moderate-dose pravastatin. Reference: http://www.ncbi.nlm.nih.gov/pubmed/15007110

Early intravenous then oral metoprolol in 45852 patients with acute myocardial infarction: randomised placebo-controlled trial - The Lancet - 2005 Brief Summary: Among patients with acute MI not undergoing PCI, a regimen of IV metoprolol followed by high-dose oral metoprolol succinate does not reduce the composite rate of death, reinfarction, or cardiac arrest, but does increase rates of cardiogenic shock. Reference: http://www.ncbi.nlm.nih.gov/pubmed/16271643

Comparison of fondaparinux and enoxaparin in acute coronary syndromes - The New England Journal of Medicine - 2006 Brief Summary: Among patients with NSTE-ACS, fondaparinux is non-inferior to enoxaparin in preventing death, myocardial infarction, or refractory ischemia. Reference: http://www.ncbi.nlm.nih.gov/pubmed/16537663

Clopidogrel and aspirin versus aspirin alone for the prevention of Atherothrombotic events - The New England Journal of Medicine - 2006 Brief Summary: Among patients at high risk for cardiovascular events, combination aspirin plus clopidogrel did not significantly reduce the rates of MI, stroke, or death from CV causes. There was increased bleeding with combination therapy. Reference: http://www.ncbi.nlm.nih.gov/pubmed/16531616

Prasugrel versus Clopidogrel in Patients with Acute Coronary Syndromes - The New England Journal of Medicine - 2007 Brief Summary: In patients with ACS and scheduled PCI, prasugrel reduces CV morbidity and mortality but increases bleeding when compared to clopidogrel. Reference: http://www.ncbi.nlm.nih.gov/pubmed/17982182

Ticagrelor versus clopidogrel in patients with acute coronary syndromes - The New England Journal of Medicine - 2009 Brief Summary: Compared to clopidogrel, ticagrelor significantly reduced the rate of CV death, MI, or stroke without an increase in the rate of overall major bleeding. Reference: http://www.ncbi.nlm.nih.gov/pubmed/19717846

Early versus Delayed Invasive Intervention in Acute Coronary Syndromes - The New England Journal of Medicine - 2009 Brief Summary: Among patients with unstable angina or NSTEMI, early intervention (≤24 h) does not result in a decrease in the composite of death, MI, or stroke at 6 months compared to delayed intervention (≥36 h) except in patients at high-risk (GRACE score >140). Reference: http://www.ncbi.nlm.nih.gov/pubmed/19458363  

Effect of Platelet Inhibition with Cangrelor during PCI on Ischemic Events - The New England Journal of Medicine - 2013 Brief Summary: Among patients undergoing urgent or elective PCI, cangrelor reduces the risk of ischemic events, as compared to clopidogrel. Reference: http://www.ncbi.nlm.nih.gov/pubmed/23473369

Intraaortic Balloon Support for Myocardial Infarction with Cardiogenic Shock - The New England Journal of Medicine - 2012 Brief Summary: In patients with acute MI complicated by cardiogenic shock, there was no difference in 30-day mortality with IABP placement. Reference: http://www.ncbi.nlm.nih.gov/pubmed/22920912

Undetectable high-sensitivity cardiac troponin T level in the emergency department and risk of myocardial infarction - Journal of the American College of Cardiology - 2014 Brief Summary: Among patients with chest pain presenting to one of two Emergency Departments in Sweden, 30 day incidence of MI was low (0.17%) for those with a high-sensitivity troponin-T <5 ng/L and no ECG changes. Reference: http://www.ncbi.nlm.nih.gov/pubmed/24694529

Ezetimibe Added to Statin Therapy after Acute Coronary Syndromes - The New England Journal of Medicine - 2015 Brief Summary: Among individuals with recent ACS, the addition of ezetimibe to moderate-intensity statin therapy is associated with a reduction in CV mortality, major CV event, or nonfatal stroke when compared to statin therapy alone. Reference: http://www.ncbi.nlm.nih.gov/pubmed/26039521

Prevention of bleeding in patients with AF undergoing PCI - The New England Journal of Medicine - 2016 Brief Summary: Among patients with nonvalvular AF undergoing PCI with stent placement, the use of low dose rivaroxaban plus either single or dual antiplatelet therapy reduces the risk of bleeding when compared to warfarin plus DAPT at 1 year. Reference: http://www.ncbi.nlm.nih.gov/pubmed/27959713

Efficacy and safety of low-dose colchicine after myocardial infarction - The New England Journal of Medicine – 2019 Brief Summary: In patients with MI in the last 30 days, colchicine was associated with a 1.6% absolute reduction in the primary composite endpoint of death from cardiovascular causes, resuscitated cardiac arrest, recurrent MI, stroke, or urgent hospitalization for angina leading to coronary revascularization at median 22.6 months. Reference: http://www.ncbi.nlm.nih.gov/pubmed/31733140

Elderly man, known diabetic and smoker, presented with chest pain. What is your diagnosis? Click the button below to view answer: Show Answer

A 88 year old man man with a history of atrial fibrillation, his medications include Atenolol and dofetilide. What are the ECG findings? Click the button below to view answer: Show Answer

A 90 year old man presented with palpitations, What is your diagnosis? Click the button below to view answer: Show Answer

Acetylcysteine for Prevention of Renal Outcomes in Patients Undergoing Coronary and Peripheral Vascular Angiography - Main Results from the Randomized Acetylcysteine for Contrast-Induced Nephropathy Trial – Circulation - 2011 Brief Summary:  Acetylcysteine does not prevent contrast-induced acute kidney injury in patients undergoing angiography. The study drugs were administered orally twice daily for 2 doses before and 2 doses after the procedure. Reference: http://www.ncbi.nlm.nih.gov/pubmed/21859972

Effect of Carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction: the CAPRICORN randomized trial - The Lancet – 2001 Brief Summary: In patients with acute MI and evidence of LV systolic dysfunction (EF < 40%), treatment with carvedilol is associated with decreased mortality. Reference: http://www.ncbi.nlm.nih.gov/pubmed/11356434

Rivaroxaban in Patients with Recent Acute Coronary Syndrome - The New England Journal of Medicine - 2012 Brief Summary: In patients with recent ACS, the addition of rivaroxaban to standard dual antiplatelet therapy reduced the composite of CV mortality, recurrent MI, or stroke, but increased the risk of nonfatal bleeding. Reference: http://www.ncbi.nlm.nih.gov/pubmed/22077192

A 67-year-old woman with a past medical history of paroxysmal atrial fibrillation for the last 10 years is brought to the hospital with episodes of syncope. Her medications include metoprolol, flecainide, and rivaroxaban. Baseline electrocardiogram showing sinus bradycardia with heart rate 40/min. Which of the following is the next best step in the management of this patient? A. Hold metoprolol and flecainide B. Permanent pacemaker placement C. Observation only D. Switch flecainide to dofetilide Click the button below to view answer: Show Answer

A 67-year-old man presents to the clinic for a follow-up appointment after being treated for an ST-elevation myocardial infarction. He developed ventricular arrhythmia while he was admitted to the intensive care unit and was twice defibrillated and received an amiodarone infusion. The patient also has mild persistent asthma and is on albuterol and fluticasone. He also just completed a 5-day course of oral azithromycin for community-acquired pneumonia. He is concerned about the bluish discoloration of his lips that was first noticed by his wife a few days ago. Which of the patient's recent medications is mot likely to have caused this clinical condition? A. Albuterol B. Fluticasone C. Azithromycin D. Amiodarone Click the button below to view answer: Show Answer

A 71-year-old woman with a past medical history of poorly controlled diabetes and coronary artery disease presents to the hospital with chest pain, diaphoresis, and hypotension. He is found to have anterolateral ST-elevation myocardial infarction (STEMI). Emergent percutaneous coronary intervention (PCI) is performed and Impella 2.5 is placed in the cath lab due to cardiogenic shock. 2 hours later, her urine noticed to be bloody in the urine bag. Which of the following indices is most likely to be elevated in this patient? A. Hematocrit B. Haptoglobin C. Chloride D. HCO3 Click the button below to view answer: Show Answer

An asymptomatic 20-year-old woman is incidentally found to have a bicuspid aortic valve. Fusion of the left and right coronary cusps is noted and there is moderate stenosis with a peak echocardiogram gradient of 3.2 meters/second. There is also mild aortic insufficiency. The left ventricular size is normal and the ejection fraction is 62%. The ascending aorta measures 3.8 cm. Her past history is significant for hypothyroidism and short stature. Which of the following is the next best step in the management of this patient? A. Cardiac MRI B. Exercise testing C. Chromosome analysis with a karyotype D. Cardiac catheterization Click the button below to view answer: Show Answer

A 67-year-old male presents to the emergency department with substernal chest pain. After initial investigations, the medical team decides whether to proceed with angioplasty or thrombolytics. Based on the results of the PAMI-1 (Primary Angioplasty in Myocardial Infarction) trial, when compared to thrombolytics in ST-segment elevation myocardial infarction (STEMI), percutaneous balloon angioplasty was associated with which of the following? A. Higher in-hospital mortality B. Similar rates of cerebral vascular accidents C. Similar rates of repeat re-vascularization D. Higher event-free survival Click the button below to view answer: Show Answer

ECG Case: A 80 year old woman, with coronary artery disease, pulmonary hypertension and bi-ventricular heart failure presented with nausea. What are the ECG findings? Click the button below to view answer: Show Answer