An Urgent Call for Studies That Address the Cardiovascular Consequences of Legalization of Marijuana.

In about a decade, half of the United States has legalized marijuana for recreational use. The drug has been associated with acute myocardial infarction, acute stroke, congestive heart failure, and various cardiac arrythmias. Data have shown that legalization of the drug led to an increase of its use as well as an increase in tetra hydro cannabinoid positive tests in patients admitted to emergency departments. In Colorado, one of the earlier states to implement legalization, there was an increase in traffic accidents, suicide rates, and even total mortality. However, there is a paucity of data on the effect of marijuana legalization on various cardiovascular events. It is prudent to have well-designed studies with enough power to provide consumers and health care providers the information they need to decide whether the risks of marijuana, especially on the cardiovascular front, are worth the "high" or potential benefits that have been described for other medical conditions.

Invasive versus Conservative Management in Coronary Artery Disease.

Background: In patients with ST-elevation myocardial infarction, immediate coronary angiography and intervention is the best practice, if an experienced laboratory is available. In non-Q-wave infarction most, but not all, studies suggest that early invasive strategy is superior to conservative management. Complete revascularization is preferred.Methods: A literature search regarding management of coronary artery disease was conducted in PubMed between January 1985 to January 2021. Articles published in English were reviewed, and those relevant were selected by both authors. Special focus was on the ISCHEMIA trial and related articles.Results: The utility of coronary angiography in patients with stable coronary artery disease is challenging. All patients should undergo optimal medical therapy. Patients with angina should not only receive approved anti-anginal agents but should also receive lifestyle modifications and pharmacologic therapy to control risk factors such as diabetes, hypertension, dyslipidemia, and smoking; and should consider organized physical activity programs. Low density lipoprotein should be reduced to 70 mg/dL or less. Non-invasive studies such as coronary computed tomography angiography (CCTA) are preferred. If expert CCTA is not available, then stress test, preferably with imaging, is recommended. If the results of CCTA show high risk, then coronary angiography and intervention are usually indicated. In patients with left main disease, left ventricular dysfunction, or symptoms of congestive heart failure, early invasive strategy is recommended. If none of these conditions exist, then initial medical therapy may be initiated, and invasive therapy should be utilized only if clinically indicated. In patients with chronic stable angina, continue with medical therapy and risk factor modification. If the frequency or severity of angina episodes change, coronary angiography and revascularization should be considered, as appropriate. In patients with significant renal dysfunction, angiogram may be indicated only if there is complete failure of medical therapy.Conclusion: Optimal medical therapy should be initially utilized in all patients. Early invasive management and revascularization should be utilized in patients with left ventricular dysfunction, congestive heart failure, and failure of medical therapy. A shared decision-making process should always be utilized.

ST Segment Elevation Myocardial Infarction in the COVID-19 Era: Appraisal of the Evidence.

The COVID-19 pandemic continues to present a public health challenge and has had a significant impact on the presentation, time-dependent management, and clinical outcomes of ST elevation myocardial infarction (STEMI). Patients with COVID-19 and pre-disposing cardiovascular risk factors like hypertension, hyperlipidemia, and diabetes mellitus are at a higher risk of developing STEMI, and global trends have highlighted delayed management of STEMI, which may contribute to worse clinical outcomes. Prolonged time to intervention has also resulted in an increased rate of no reflow, which is an independent risk factor for worse outcomes in these patients. Timely primary percutaneous coronary intervention (PCI) remains standard of care for STEMI and can be attained within the recommended 90 minutes timeline from hospital presentation. A coordinated, safe, standardized, algorithmic approach among emergency medical services, emergency departments, and cardiac catheterization laboratory is needed to ensure optimal patient outcome during and after the COVID-19 pandemic. The focus of this case report is to highlight the challenges of PCI for ST elevation myocardial infarction in the COVID-19 era.

Post-Acute Sequelae of SARS-COVID-2 Syndrome: Just the Beginning.

Viral diseases are some of the most common infections affecting humans. Despite the unpleasant symptoms, most people return to their normal lives without residual symptoms. Following the acute infectious phase of some viruses, however, in some individuals symptoms may linger to the extent they are unable to return to a normal lifestyle. Following coronavirus disease 2019 infection, significant numbers of patients continued to have symptoms that persisted for months after hospital discharge. Symptoms spanned many organ systems and were prominent in the pulmonary and cardiovascular systems. The exact mechanism is not clear. This group of patients represents a new challenge to our health care systems. An organized, multi-disciplinary approach and further research are warranted to be ready to deliver better care to these patients.

Viral myocarditis: 1917-2020: From the Influenza A to the COVID-19 pandemics.

Myocarditis is common during viral infection with cases described as early as the influenza pandemic of 1917, and the current COVID-19 pandemic is no exception. The hallmark is elevated troponin, which occurs in 36% of COVID patients, with electrocardiogram, echocardiogram, and cardiac magnetic resonance being valuable tools to assist in diagnosis. Cardiac inflammation may occur secondary to direct cardiac invasion with the virus, or to intense cytokine storm, often encountered during the course of the disease. Angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and judicious use of beta-blockers are beneficial in management of myocarditis. Corticosteroids may be avoided during the very early phase of viral replication, but can be of clear benefit in hospitalized, critically ill patients. Statins are beneficial to shorten the course of the disease and may decrease mortality.

Aspirin in Primary Prevention of Cardiovascular Events.

Aspirin has demonstrated a clear benefit in secondary prevention of coronary syndrome, while aspirin's effect in primary prevention is unclear. This report will explore the role of aspirin as primary prevention for various vascular events. It strives to provide a clear guide for clinicians on whether or not to prescribe aspirin for their patients for primary prevention. Current guidelines and recent trials failed to show clear benefit against primary prevention, with risks outweighing benefits in moderate to high risk patients. A thoughtful discussion between patients and their doctors should be conducted before beginning aspirin use. More studies are needed to gain a better understanding of aspirin use in primary prevention.

The Cardiovascular Effects of Cocaine.

Cocaine is the leading cause for drug-abuse-related visits to emergency departments, most of which are due to cardiovascular complaints. Through its diverse pathophysiological mechanisms, cocaine exerts various adverse effects on the cardiovascular system, many times with grave results. Described here are the varied cardiovascular effects of cocaine, areas of controversy, and therapeutic options.

Management of No-Reflow Phenomenon in the Catheterization Laboratory.

At the conclusion of a primary percutaneous coronary intervention for ST-segment elevation myocardial infarction, and after the cardiologist makes certain that there is no residual stenosis following stenting, assessment of coronary flow becomes the top priority. The presence of no-reflow is a serious prognostic sign. No-reflow can result in poor healing of the infarct and adverse left ventricular remodeling, increasing the risk for major adverse cardiac events, including congestive heart failure and death. To achieve normal flow, features associated with a high incidence of no-reflow must be anticipated, and measures must be undertaken to prevent its occurrence. In this review, the authors discuss various preventive strategies for no-reflow as well as pharmacological and nonpharmacological interventions that improve coronary blood flow, such as intracoronary adenosine and nitroprusside. Nonpharmacological therapies, such as induced hypothermia, were successful in animal studies, but their effectiveness in reducing no-reflow in humans remains to be determined.

Cardiovascular consequences of cocaine use.

The cardiovascular consequences of cocaine use are numerous and can be severe, with mechanisms of cardiotoxicity unique to cocaine that include sympathomimetic effects, blockade of sodium and potassium channels, oxidative stress and mitochondrial damage, and disruption of excitation-contraction coupling. In combination, these effects increase myocardial oxygen demand while simultaneously decreasing oxygen supply. Cocaine-associated chest pain is particularly common and, in some instances, associated with a more severe cardiac syndrome, such as myocardial infarction, myocardial ischemia, arrhythmia, cardiomyopathy, aortic dissection, or endocarditis. Therapy for cocaine-associated chest pain and myocardial infarction is similar to treatment in non-cocaine users, except for differences in the use of benzodiazepines and phentolamine and avoidance of beta-blockers in the acute setting. In this review, we discuss the most up-to-date literature regarding the mechanisms of cocaine-associated cardiotoxicity and clinical consequences, diagnosis, and treatment; we also discuss relevant controversies while proposing several important areas for future research.

Outcome of early revascularization surgery in patients with ST-elevation myocardial infarction.

OBJECTIVES: To compare morbidity and mortality of patients with ST-elevation myocardial infarction (MI) undergoing coronary artery bypass graft (CABG) surgery within 24 hours with those who had surgery delayed >24 hours. BACKGROUND: Patients with ST-elevation MI are currently managed by emergency percutaneous coronary intervention (PCI). If PCI is unsuccessful, or if there is severe coronary artery disease not amenable to PCI, CABG is considered. If the patient is clinically stable, surgeons wait several days before performing surgery, as very early surgery carries a prohibitive risk. METHODS: One hundred and eighty-four patients with acute ST elevation MI (STEMI) who had undergone CABG were divided into two groups based on their surgery timing (<24 hours vs. >24 hours). Mortality and complication rates were studied between the two groups by Fischer test. Time-to-event analyses were performed for five primary variables: all-cause mortality, cardiac events, congestive heart failure, stroke, and renal failure. RESULTS: At one month post-CABC, all-cause mortality was noted in 10.6% of patients who had CABG within 24 hours of STEMI diagnosis, compared with 8.9% in patients who had CABG after 24 hours (P = 0.3). Cardiac events including re-exploration, atrial fibrillation, graft occlusion, and arrhythmias requiring shock occurred in 17.1% versus 13.9% between the two groups, respectively (P = 0.68). One year post-coronary artery bypass surgery, there was no difference in individual or combined events between the two groups. CONCLUSIONS: In patients with ST-elevation myocardial infarction who required emergency coronary artery bypass surgery, there was no difference in procedure complications or mortality between early (within 24 hours) or later (more than 24 hours). That was noted at one month and one year after the index myocardial infarction.

Aspirin overutilization for the primary prevention of cardiovascular disease.

BACKGROUND: Aspirin is commonly used for the primary prevention of cardiovascular disease (CVD) in the US. Previous research has observed significant levels of inappropriate aspirin use for primary CVD prevention in some European populations, but the degree to which aspirin is overutilized in the US remains unknown. This study examined the association between regular aspirin use and demographic/clinical factors in a population-based sample of adults without a clinical indication for aspirin for primary prevention. METHODS: A cross-sectional analysis was performed using 2010-2012 data from individuals aged 30-79 years in the Marshfield Epidemiologic Study Area (WI, USA). Regular aspirin users included those who took aspirin at least every other day. RESULTS: There were 16,922 individuals who were not clinically indicated for aspirin therapy for primary CVD prevention. Of these, 19% were regular aspirin users. In the final adjusted model, participants who were older, male, lived in northern Wisconsin, had more frequent medical visits, and had greater body mass index had significantly higher odds of regular aspirin use (P<0.001 for all). Race/ethnicity, health insurance, smoking, blood pressure, and lipid levels had negligible influence on aspirin use. A sensitivity analysis found a significant interaction between age and number of medical visits, indicating progressively more aspirin use in older age groups who visited their provider frequently. CONCLUSION: There was evidence of aspirin overutilization in this US population without CVD. Older age and more frequent provider visits were the strongest predictors of inappropriate aspirin use. Obesity was the only significant clinical factor, suggesting misalignment between perceived aspirin benefits and cardiovascular risks in this subgroup of patients. Prospective studies that examine cardiac and bleeding events associated with regular aspirin use among obese samples (without CVD) are needed to refine clinical guidelines in this area.

The role of aspirin in the prevention of cardiovascular disease.

Aspirin therapy is well-accepted as an agent for the secondary prevention of cardiovascular events and current guidelines also define a role for aspirin in primary prevention. In this review, we describe the seminal trials of aspirin use in the context of current guidelines, discuss factors that may influence the effectiveness of aspirin therapy for cardiovascular disease prevention, and briefly examine patterns of use. The body of evidence supports a role for aspirin in both secondary and primary prevention of cardiovascular events in selected population groups, but practice patterns may be suboptimal. As a simple and inexpensive prophylactic measure for cardiovascular disease, aspirin use should be carefully considered in all at-risk adult patients, and further measures, including patient education, are necessary to ensure its proper use.

Remote ischemic preconditioning for coronary artery bypass graft operations.

Ischemia-reperfusion injury occurs during coronary artery bypass graft operations. Strategies are needed to lower the extent of damage. Attempts to find these strategies have been occurring for more than 40 years, with remote ischemic preconditioning being one method. This review provides a look at potential mechanisms involved in remote ischemic preconditioning, experimental evidence supporting it, clinical studies that support and negate it, and potential reasons for differences between clinical studies. With remote ischemic preconditioning having the potential to better clinical outcomes in patients undergoing coronary artery bypass graft operations, a large clinical trial needs to be undertaken to better assess its practical clinical application.

Swallow syncope: a case report and review of the literature.

Swallow or deglutition syncope is a relatively rare syndrome. It is a vagally mediated syncope induced by swallowing. Swallow syncope may occur in all age groups and, when diagnosed, is treatable. A woman, aged 60 years, presented with an episode of a syncopal attack associated with swallowing a sandwich. She had a 6-month history of recurrent episodes of lightheadedness while eating solid foods. Telemetry monitoring demonstrated several episodes of severe bradycardia and complete atrioventricular block with up to a 7.0 second pause associated with meals. Computed tomography of the head and neck revealed no significant findings, and barium esophagram was normal. Echocardiogram was within normal limits. Her symptoms resolved after permanent pacemaker placement. Herein, we review the diagnosis, mechanism, and management of swallow syncope.

Influenza-related viral myocarditis.

Seasonal influenza outbreak is responsible for significant morbidity and mortality around the world. The disease can be severe, leading to rapid worsening of breathing and culminating in death. The pulmonary manifestations are prominent and may mask the involvement of other organs, such as the heart. This paper will discuss the incidence, clinical manifestations, and management of viral myocarditis in a modest attempt to heighten awareness of acute viral myocarditis for early recognition and prompt management during seasonal episodes of influenza infection.

No-reflow phenomenon following percutaneous coronary intervention for acute myocardial infarction: incidence, outcome, and effect of pharmacologic therapy.

BACKGROUND: No-reflow (NR) phenomenon is a well-known problem, often accompanying percutaneous coronary intervention for acute ST elevation myocardial infarction (STEMI). There are little data on effects of pharmacologic therapy on the resolution, outcome, and long-term natural history of NR. OBJECTIVE: Retrospectively assess incidence, management, and prognosis of NR in a tertiary referral hospital. METHODS: Study included patients with STEMI, treated with percutaneous coronary intervention (PCI). Effect of pharmacologic therapy and long-term outcome were assessed. NR was defined by thrombolysis in myocardial infarction (TIMI) < 3 or myocardial blush grade (MBG) < 3. RESULTS: Of 347 identified subjects, NR occurred in 110 (32%) by TIMI and 198 (57%) by MBG. Higher incidence was identified in men versus women (34% vs. 25% by TIMI, P = 0.08; and 60% vs. 48% by MBG, P = 0.04). Pharmacologic therapy was equally effective in restoring normal flow, increasing TIMI score from 1.62 ± 0.07 to 2.78 ± 0.06 (P < 0.0001) and MBG score from 0.43 ± 0.08 to 2.09 ± 0.11 (P < 0.0001). Twenty-three percent who did not receive pharmacologic therapy developed clinical composite of congestive heart failure, cardiogenic shock, and/or death; only 9% of patients who received pharmacologic therapy developed this composite. Patients with severe NR despite treatment had poorer prognosis. Sixty-five percent of patients who survived and had repeat angiogram about 1.5 years later had spontaneous improvement in coronary flow by MBG. CONCLUSION: NR is common in STEMI. Treatment with nicardipine, nitroprusside, and verapamil are equally effective in improving flow. If not treated, prognosis is poor.

Coronary no-reflow phenomenon: from the experimental laboratory to the cardiac catheterization laboratory.

Coronary no-reflow occurs commonly during acute percutaneous coronary intervention, particularly in patients with acute myocardial infarction and those with degenerated vein grafts. It is associated with a guarded prognosis, and thus needs to be recognized and treated promptly. The pathophysiology originates during the ischemic phase and is characterized by localized and diffuse capillary swelling and arteriolar endothelial dysfunction. In addition, leukocytes become activated and are attracted to the lumen of the capillaries, exhibit diapedesis and may contribute to cellular and intracellular edema and clogging of vessels. At the moment of perfusion, the sudden rush of leukocytes and distal atheroemboli further contributes to impaired tissue perfusion. Shortening the door-to-balloon time, use of glycoprotein IIb/IIIa platelet receptor inhibitors and distal protection devices are predicted to limit the development of no-reflow during percutaneous interventions. Distal intracoronary injection of verapamil, nicardipine, adenosine, and nitroprusside may improve coronary flow in the majority of patients. Hemodynamic support of the patient may be needed in some cases until coronary flow improves.

Cocaine-induced acute myocardial infarction.

Acute myocardial infarction may occur following cocaine use. Cocaine-induced infarction is particularly common in younger patients aged 18 to 45 years old. Patients may or may not have angiographic evidence of coronary artery disease at the time of their acute event. Previous studies have shown that coronary artery spasm occurs with cocaine use, and perhaps platelet activation, both contributing to a process that may culminate in coronary artery occlusion. Primary coronary intervention should be the preferred revascularization modality by an experienced team. Thrombolytic therapy needs to be instituted if this intervention is unavailable. Beta blockers should be utilized with caution since they may increase coronary spasm or cause a paradoxical rise in blood pressure. They should be avoided in the early hours of the infarction, but be instituted prior to patient discharge. Interruption of cocaine abuse is the cornerstone of secondary prevention in cocaine-related myocardial infarction.