Dapagliflozin in Heart Failure: A Comprehensive Meta-analysis on Functional Capacity, Symptoms, and Safety Outcomes.

OBJECTIVE: To evaluate the comparative effects of dapagliflozin versus placebo in patients with heart failure (HF), focusing on functional capacity, symptoms, and safety outcomes. BACKGROUND: Despite advancements in heart failure (HF) therapy, HF is still a significant cause of recurrent hospitalization and death worldwide. Dapagliflozin has demonstrated potential in lowering hospitalizations and mortality associated with heart failure; however, its impact on functional capacity, particularly the 6-min walk distance (6MWD), and the comprehensive assessment of safety outcomes in diverse HF populations, including those with preserved or reduced ejection fraction (HFpEF and HFrEF, respectively), requires further investigation. METHODS: PubMed, Web of Science, Cochrane Library, and Scopus databases were comprehensively searched to identify randomized controlled trials (RCTs) investigating the efficacy of dapagliflozin in comparison with control interventions for heart failure. The primary outcome was a change in the 6MWD, KCCQ score, and safety measures included hospitalization, all-cause mortality, and adverse events. RESULTS: In our meta-analysis of ten studies involving 12,695 patients with heart failure, dapagliflozin showed significantly improved Kansas City Cardiomyopathy Questionnaire (KCCQ) scores [risk ratio (RR) of 2.75, 95% confidence interval (CI) (1.95-3.569), p < 0.00001] and no significant differences in 6-min walk distance [6MWD; RR of 3.59, 95% CI (- 1.44 to 8.63), p = 0.16]. Dapagliflozin demonstrated a notable reduction in hospitalization for heart failure [RR of 0.76, 95% CI (0.68-0.84), p < 0.00001], significant overall reduction on the effect of any cause mortality [RR of 0.90, 95% CI (0.83-0.99), p = 0.03). There was, however, no significant effect on adverse events [RR of 0.96, 95% CI (0.98-1.03), p = 0.39). CONCLUSIONS: Our meta-analysis of ten trials concluded that dapagliflozin significantly improved KCCQ scores in both HFrEF and HFpEF. The improvement in 6MWD was not statistically significant but trended toward dapagliflozin. Dapagliflozin also showed a mortality benefit in patients with reduced ejection fraction; however, in patients with preserved ejection fraction, the result was not statistically significant. There was also a statistically significant reduction in heart failure hospitalizations across all classes.

Cardioembolic Stroke Three Days Post-Video-Assisted Thoracoscopic AtriClip in a Patient With Paroxysmal Atrial Fibrillation.

Atrial fibrillation is a global epidemic due to aging and chronic diseases. Treatment options are expanding to prevent thromboembolism in anticoagulant-ineligible patients. The left atrial appendage, implicated in 90% of embolic strokes, is increasingly managed with occlusion devices like the AtriClip. A 62-year-old woman with prior stroke, severe gastrointestinal bleeding on anticoagulation, and paroxysmal atrial fibrillation experienced sudden left-sided weakness and altered mental status three days post-AtriClip procedure. Brain MRI revealed acute infarcts in the right cerebellum and scattered punctate infarcts in both cerebral hemispheres. No further invasive investigations or interventions were recommended, as they would not influence management. Left-sided weakness improved, and the patient was discharged to a subacute rehabilitation center. Despite the AtriClip's ability to lower stroke incidence by occluding the left atrial appendage, there remains a residual risk of cerebrovascular events that can significantly impact morbidity and mortality. This case underscores persistent risks despite complete appendage closure, emphasizing the need for broader studies on post-AtriClip stroke risk.

Challenges and Insights: Severe Acute Right Ventricular Dysfunction in Pulmonary Hypertension.

Pulmonary hypertension (PH) is rarely a cause of syncope. We highlight an unusual presentation of pulmonary hypertension where management was a veritable challenge. We present a case report of a 35-year-old female with a history of stage 2 hypertension, polycystic ovarian syndrome, and obesity who presented to the hospital with a six-month history of progressive shortness of breath, lower extremity swelling, and recurrent syncope. Further evaluation with transthoracic echocardiography showed features consistent with severe pulmonary hypertension. This untreated severe pulmonary hypertension culminated in cardiogenic shock due to right ventricular (RV) failure. Successful care in this patient population entails preventing the acute downward spiral of decompensated right ventricular failure.

Masquerading bundle branch block: an often missed electrophysiological event.

Masquerading bundle branch block is an easily overlooked pattern on the ECG that indicates severe disease of the atrioventricular nodal conduction pathway. It is often caused by coronary artery disease, infiltrative diseases of the heart and idiopathic degeneration of the atrioventricular nodal conduction pathways. The diagnosis is easily missed as it needs a detailed interpretation of the ECG in addition to the clinical presentation of the patient. The presence of this specific bundle branch block pattern on the ECG indicates severe degeneration of the conduction system requiring intervention. Given its rarity, this clinical entity risks misdiagnosis and inappropriate management. This case highlights two diagnostic challenges for clinicians: the rarely described masquerading bundle branch block and the art of clinically differentiating between epilepsy and convulsive syncope.

Recurrent thromboembolism due to direct oral anticoagulation interruption postpericardial window for a hemopericardium.

We present a female patient with a history of systolic heart failure with an ejection fraction of 25-30%, and unprovoked pulmonary embolism on extended anticoagulation therapy with rivaroxaban who underwent a pericardial window for cardiac tamponade due to hemopericardium in the setting of direct oral anticoagulant (DOAC). The rivaroxaban was held following the pericardial window, and she experienced another episode of pulmonary embolism before the rivaroxaban could be restarted. Currently, there are no guidelines on when to restart anticoagulation postpericardial window for DOAC-associated hemopericardium. Studies are needed to help solve this dilemma.

We present a female patient with a history of systolic heart failure which means their left ventricle was unable to pump blood efficiently. They also have a history of an unprovoked disruption in the flow of blood in the pulmonary arteries or its branches, known as a pulmonary embolism. The patient was on direct oral anticoagulation medication to thin their blood, promoting efficient blood flow and minimizing the risk of clots and blockages. While on this medication, the patient developed a significant collection of blood around the heart, so the medication was withheld and the blood collection was drained. She developed another episode of pulmonary embolism before the medication could be restarted. Healthcare providers need guidance on when to restart anticoagulation medications in these types of patients.

The Thyroid Forecast: A Case of a Thyroid Storm Diagnosed Under Unforeseen Circumstances.

Hyperthyroidism and thyrotoxicosis are common conditions in clinical practice. Untreated, they are associated with several co-morbidities. One of these conditions, and arguably the most lethal, is the thyroid storm. Our case presentation is one of a young female who had previously been diagnosed with thyroid illness but was lost to follow-up, subsequently given a clean bill of health, and emerged with what would eventually be diagnosed as a thyroid storm. While the thyroid storm may pose some diagnostic challenges, it has come a long way in securing diagnostic tools. What remains is a tool for physicians and patients to stratify patients by their risk of developing a storm in the outpatient setting.

Diagnostic dilemma: COVID-19 related cardiomyopathy or peripartum cardiomyopathy?

Peripartum cardiomyopathy is a relatively rare condition, that usually presents with features of heart failure in the peripartum period. The ongoing pandemic caused by coronavirus disease 2019 (COVID-19) has been reported to be associated with myocarditis, with progression to dilated cardiomyopathy and heart failure. Dilated cardiomyopathy in a peripartum patient with COVID-19 infection may present a diagnostic dilemma. We report a case of dilated cardiomyopathy in a peripartum patient with COVID-19 infection. She presented with shortness of breath in the peripartum period. Chest X-ray showed a grossly enlarged heart with bilateral pulmonary infiltrates consistent with congestive heart failure or viral pneumonia. Echocardiography revealed dilated chambers with 22% left ventricular ejection fraction (LVEF) and global hypokinesis. Despite completing 5 days of remdesivir and dexamethasone, she had worsening dyspnea on postpartum day 10, a repeat echocardiogram showed further reduction in LVEF to 10-15% and was discharged with a life-vest after acute management. She had multiple hospital admissions for decompensated heart failure. Myocardial core biopsy showed marked acute inflammation and necrosis. She had an intra-aortic balloon pump, left ventricular and right ventricular assist devices placed on account of persistent hemodynamic instability, and is now scheduled to have a cardiac transplant. .