Prevalence of respiratory failure and use of mechanical ventilation in heart failure patients undergoing left atrial appendage occlusion device implantation.

BACKGROUND: We sought to evaluate respiratory complications in heart failure patients undergoing left atrial appendage occlusion (LAAO) for stroke prevention in atrial fibrillation. METHODS: Adult admissions (>18 years) undergoing LAAO during 2016-2020 were identified from the National Inpatient Sample. Heart failure (HF) was stratified into systolic (SHF) and diastolic heart failure (DHF) and were compared to those without HF. Outcomes of interested included acute respiratory failure, use of non-invasive and invasive mechanical ventilation, and in-hospital mortality. RESULTS: Of 74,440 admissions for atrial fibrillation undergoing LAAO, SHF and DHF were noted in 8335 (11.2%) and 10,925 (14.7%), respectively. The SHF cohort was predominantly male (78%) whereas DHF cohort were female (53%). Compared to those without HF, presence of SHF (2.3% vs. 0.6%; adjusted odds ratio [OR] 1.61 [95% confidence interval {CI} 1.10-2.36]; p = 0.01) and DHF (2.8% vs. 0.6%; adjusted OR 2.20 [95% CI 1.58-3.06]; p < 0.001) were associated with higher rates of acute respiratory failure. SHF (1.7% vs. 0.6%; adjusted OR 1.70 [95% CI 1.07-2.71]; p = 0.02) group but not DHF (1.2% vs. 0.6%; adjusted OR 1.21 [95% CI 0.78-1.89]; p = 0.39) was associated with higher rates of non-invasive ventilation, whereas the DHF group (0.9% vs. 0.2%; adjusted OR 1.91 [95% CI 1.08-3.34]; p = 0.02) but not SHF (0.8% vs. 0.2%; adjusted OR 1.54 [95% CI 0.83-2.84]; p = 0.17) was associated with higher rates of invasive mechanical ventilation use. In-hospital mortality was comparable between cohorts. CONCLUSION: Compared to those without HF, atrial fibrillation admissions with HF undergoing LAAO had higher rates of acute respiratory failure and mechanical ventilation rates without differences in in-hospital mortality.

Adding Pharmacist-Led Home Blood Pressure Telemonitoring to Usual Care for Blood Pressure Control: A Systematic Review and Meta-Analysis.

Health systems have been quickly adopting telemedicine throughout the United States, especially since the onset of the COVID-19 pandemic. However, there are limited data on whether adding pharmacist-led home blood pressure (BP) telemonitoring to office-based usual care improves BP. We searched PubMed/MEDLINE and Embase for randomized controlled trials from January 2000 until April 2022, comparing studies on pharmacist-led home BP telemonitoring with usual care. Six randomized controlled trials, including 1,550 participants, satisfied the inclusion criteria. There were 774 participants in the pharmacist-led telemonitoring group and 776 in the usual care group. The addition of pharmacist-led telemonitoring to usual care was associated with a significant decrease in systolic BP (mean difference -8.09, 95% confidence interval -11.15 to -5.04, p <0.001, I2 = 72%) and diastolic BP (mean difference -4.19, 95% confidence interval -5.58 to -2.81, p <0.001, I2 = 42%) compared with usual care. In conclusion, this meta-analysis showed that adding pharmacist-led home BP telemonitoring to usual care achieves better BP control than usual care alone.

Outcomes of Heart Failure Hospitalizations in Adult Patients With Coarctation of Aorta: Report From National Inpatient Sample.

Coarctation of aorta (CoA) is a common congenital anomaly which portends patients to early diastolic and systolic heart failure. In this retrospective cohort study, we aimed to evaluate the impact of CoA on heart failure hospitalization. Using the national inpatient sample, the study compared the outcomes of heart failure hospitalization between patients with and without CoA. We noted increasing prevalence of CoA related heart failure admissions over the last decade. Heart failure patients with CoA were younger (mean age 57 vs 71.6 years, P < 0.001), had a longer length of stay (7.4 vs 5.4 days, P < 0.001), and a higher incidence of cardiogenic shock (6.5% vs 2.1%, P = 0.001). However, there was no statistically significant difference in in-hospital mortality (OR 1.45, 95% CI: 0.58, 3.62, P = 0.421) between both groups. These findings demonstrate that CoA increase healthcare resource utilization in patients admitted with heart failure without any significant increase in in-hospital mortality.

In-hospital mortality of heparin-induced thrombocytopenia in end-stage kidney disease. A retrospective national population-based cohort study.

AIM: Heparin induced thrombocytopenia (HIT) and end stage kidney disease (ESKD) are independent conditions associated with increased mortality and morbidity, however, whether ESKD is an independent risk factor for increased mortality in HIT admissions is not well studied. Therefore, we aimed to compare in-hospital mortality in HIT admissions based on their ESKD status. METHODS: This is a retrospective cohort study of HIT hospitalizations aged 18 and older using the 2016-2019 national inpatient sample (NIS) database. RESULTS: From 2016 to 2019 we had 12 161 admissions for HIT among 28 484 087 total hospitalizations. The annual incidence rate for HIT admissions per 100 000 admissions were: 47, 46, 41.1, and 36.6, respectively (p < .001) in 2016, 2017, 2018, and 2019 respectively. Among HIT admissions, the mean age was 64.3 years, 46.8% were females, 68% were Whites and 16% were Blacks. Black patients have a significantly higher likelihood of in-hospital mortality than White patients (aOR 1.25; 95% CI: 1.06, 1.48; p = .007). Patients who did not have any insurance or self-pay had higher mortality compared to Medicare (aOR 1.64; 95% CI: 1.13, 2.38; p = .009). ESKD status was not associated with higher or lower in-hospital mortality among HIT admissions (aOR 1.002; 95% CI: 0.84, 1.19; p = .981) after adjusting for age, sex, race, and insurance status. CONCLUSION: There are no higher or lower odds of in-hospital mortality in the ESKD subgroup in HIT admissions in adults. Decreasing incidence of HIT hospitalizations was seen over the years from 2016 to 2019.

Sex-based disparities and in-hospital outcomes of patients hospitalized with atrial fibrillation with and without dementia.

Study objective: We sought to evaluate the sex-based disparities and comparative in-hospital outcomes of principal AF hospitalizations in patients with and without dementia, which have not been well-studied. Design: This is a non-interventional retrospective cohort study. Setting and participants: We identified principal hospitalizations of AF in the National Inpatient Sample in adults (≥18 years old) between January 2016 and December 2019. Main outcome measure: In-hospital mortality. Results: Of 378,230 hospitalized patients with AF, 49.2 % (n = 186,039) were females and 6.1 % (n = 22,904) had dementia. The mean age (SD) was 71 (13) years. Patients with dementia had higher odds of in-hospital mortality {adjusted odds ratio (aOR): 1.48, 95 % confidence interval (CI): 1.34, 1.64, p < 0.001} and nontraumatic intracerebral hemorrhage (aOR: 1.60, 95 % CI: 1.04, 2.47, p = 0.032), but they had lower odds of catheter ablation (0.39, 95 % CI: 0.35, 0.43, p < 0.001) and electrical cardioversion (aOR: 0.33, 95 % CI: 0.31, 0.35, p < 0.001). In patients with AF and dementia, compared to males, females had similar in-hospital mortality (aOR: 1.00, 95 % CI: 0.93, 1.07, p = 0.960), fewer gastrointestinal bleeds (aOR: 0.92, 95 % CI: 0.85, 0.99, p = 0.033), lower odds of getting catheter ablation (aOR: 0.79, 95 % CI: 0.76, 0.81, p < 0.001), and less likelihood of getting electrical cardioversion (aOR: 0.78, 95 % CI: 0.76, 0.79, p < 0.001). Conclusions: Patients with AF and dementia have higher mortality and a lower likelihood of getting catheter ablation and electrical cardioversion.

All-cause and in-hospital mortality after aspirin use in patients hospitalized with COVID-19: a systematic review and meta-analysis.

Background: With the results of the largest randomized controlled trial (RECOVERY) and the most extensive retrospective cohort study on coronavirus disease 2019 (COVID-19) recently published, we performed a meta-analysis on the association of aspirin with mortality of COVID-19. We aimed to investigate the role of aspirin in COVID-19 hospitalizations. Materials and Methods: We searched PubMed, EMBASE and Cochrane databases for studies from 1 January 2020 until 20 July 2022, that compared aspirin versus non-aspirin use in hospitalized COVID-19 patients. We excluded case reports, review articles and studies on non-hospitalized COVID-19 infections. We used the inverse variance method and random effects model to pool the individual studies. Results: Ten observational studies and one randomized controlled trial met the criteria for inclusion. There were 136 695 total patients, of which 27 168 were in the aspirin group and 109 527 were in the non-aspirin group. Aspirin use was associated with a 14% decrease in all-cause mortality compared with non-aspirin use in patients hospitalized with COVID-19 [relative risk (RR) 0.86, confidence interval (95% CI) 0.76-0.97; P = 0.002; I 2 =64%]. Among subgroups of studies reporting in-hospital mortality in COVID-19 hospitalizations, aspirin use was associated with a 16% decrease in in-hospital mortality compared with non-aspirin use (RR 0.84, 95% CI 0.71-0.99; P = 0.007; I 2 =64%). Conclusion: Our study shows that aspirin decreases in-hospital mortality in patients hospitalized with COVID-19. Further studies are needed to assess which COVID-19 patient populations benefit most, such as patients on aspirin for primary versus secondary prevention of atherosclerotic disease. In addition, significant bleeding also needs to be considered when assessing the risk-benefit of aspirin use.

COVID-19 Positive Status is Associated with Increased In-hospital Mortality in Patients with Acute Myocardial Infarction: A Systematic Review and Meta-analysis.

Patients hospitalized for acute myocardial infarction (AMI) may have concomitant positive coronavirus disease 2019 (COVID-19). We aimed to compare the risk of in-hospital mortality in patients primarily hospitalized for AMI with or without concomitant COVID-19 positive status. Using the random-effects model, we conducted a systematic review and meta-analysis of published articles from December 1, 2019, to April 1, 2022. There were eight studies with 10,128 patients, including 612 patients with COVID and 9516 patients without COVID. A total of 261 patients (42.64%) with COVID-19 positive and 612 patients (6.43%) with negative COVID-19 status died in the hospital. Pooled data showed that patients with a primary diagnosis of AMI with COVID-19 infection had more than five times increased risk of in-hospital mortality compared to patients without COVID-19 (OR: 5.06, 95% CI: 3.61, 7.09; I2 = 35%, P < 0.001). However, pooled data from five studies with adjustment of baseline differences in patient demographics and characteristics, comorbidities, and in-hospital pharmacology revealed more than three times increased risk of in-hospital mortality compared to patients who had primary AMI without COVID-19 infection (aOR: 3.47, 95% CI: 2.21, 5.45; I2 = 0%, P < 0.001). In subgroup analysis, ST-elevation myocardial infarction (STEMI) had lower in-hospital mortality (OR 4.23, 95% CI: 3.31, 5.40; I2 = 0%, P < 0.001) compared to non-ST-segment elevation myocardial infarction (NSTEMI) (OR 9.97, 95% CI: 5.71, 17.41; I2 = 0%, P < 0.001) (p-value = 0.006). Our study shows that COVID-19 infection is associated with increased in-hospital mortality in patients with index hospitalization for AMI.

Meta-analysis examining phosphodiesterase-5 inhibitors in heart failure with preserved ejection fraction.

Patients with heart failure with preserved ejection fraction have reduced cyclic guanosine 3',5'-monophosphate (cGMP) levels compared to those with reduced ejection fraction. Phosphodiesterase-5 inhibitors may play a cardioprotective role by potentiating the cGMP pathway. To address this question, we conducted a systematic search for randomized trials using the electronic databases of PubMed, Embase, and Google Scholar and used RevMan (version 5.4) for the data analysis. We included 221 subjects in the phosphodiesterase group (mean age 69.2 ± 3.43 years; 58.82% male) and 202 subjects in the control group (mean age 70.4 ± 4.96 years; 53.46% male). The mean follow-up duration was 5.85 ± 3.43 months. The pooled results showed no significant differences in peak oxygen consumption, 6-minute walking distance, mitral annular E/e' ratio, left ventricular ejection fraction, mean pulmonary artery pressure, pulmonary artery systolic pressure, and pulmonary vascular resistance between the phosphodiesterase group and the control group.

A Case Report of Thromboembolic Stroke in a Patient with Holt-Oram Syndrome.

Ischemic stroke associated with rare clinical syndromes represents less than 5% of etiologic factors. From those syndromes are Holt-Oram syndrome and Left ventricular non-compaction syndrome. We report a case of a 66 years old male with genetically confirmed Holt-Oram syndrome due to TBX5 mutation who presented with cryptogenic stroke most likely due to cardioembolic etiology. The patient has a history of moderate nonischemic cardiomyopathy due to an atypical pattern of left ventricular non-compaction confirmed by Cardiac Magnetic Resonance Imaging. The patient was treated appropriately with thrombolytic therapy and catheter-directed mechanical thrombectomy with minimal residual stroke symptoms. Holt-Oram syndrome is a genetic condition with variable clinical phenotypes, including cardiac manifestations. Left ventricular non-compaction syndrome is rare congenital cardiomyopathy defined as prominent left ventricular trabeculae, deep intertrabecular recesses, and a thin compacted layer. And only a few cases were reported with both conditions. Therefore, patients with the Holt-Oram Syndrome should get a comprehensive cardiac evaluation to exclude non-compaction cardiomyopathy, which may have significant prognostic implications.

In-hospital mortality and length of stay among patients with infective endocarditis and solid organ transplant: A study from National Inpatient Sample 2016-2019.

Infective endocarditis (IE) is a rare but serious complication following a Solid Organ Transplant (SOT). Due to the lack of sufficient studies, we aimed to compare in-hospital mortality and length of stay (LOS) of patients primarily admitted for IE (index or principal hospitalization) with history of SOT, including the subgroup of heart or lung transplant (HLT), to those without a history of SOT (non-SOT) or HLT (non-HLT). We used the 2016-2019 National Inpatient Sample, the largest all-payer inpatient hospital data from Healthcare Cost and Utilization Project (HCUP), including patients 18 years or older with IE, as a principal diagnosis for hospitalization. From 2016 to 2019, there were 56,330 principal or index hospitalizations for IE. Among them, 0.6 % (n = 327) were SOT recipients, 0.1% (n = 68) were HLT recipients, and 41.4% were females. The mean age was 51.9 ± 19.2 years. Compared to non-SOT controls, SOT recipients were older (mean age 59.3 vs. 51.8 years; P = 0.002) and had higher Charlson-comorbidity-index (CCI) of 3 or more (87.7% vs. 33.2%; p < 0.001). SOT status was not statistically significant for a higher or lower odds of in-hospital mortality (adjusted odds ratio (aOR) 0.7; 95% confidence interval (CI): 0.2, 2.4; p = 0.60) or increased or decreased LOS (coefficient: -0.1, 95% CI: -0.4, 0.1; p = 0.23) among index IE hospitalizations after controlling for age, sex, race, hospital-region, hospital-teaching status, income, insurance status, and CCI. HLT status was also not associated with higher or lower odds of in-hospital mortality (aOR 1.4; 95% CI: 0.2, 13.1; p = 0.77) or increased or decreased LOS (coefficient: -0.1, 95% CI: -0.3, 0.5; p = 0.59). From 2016 to 2019, the rate of index IE hospitalization trends from 37.8 to 41.4 per 100,000 overall hospitalizations (p = 0.001). We found the rate of index IE hospitalizations increasing with time. Among index IE hospitalizations, SOT, including a subgroup of HLT recipients, have similar in-hospital mortality and LOS compared to non-SOT or non-HLT groups. We need a larger sample size to comment on outcomes of IE hospitalizations with the HLT subgroup.

Safety and Efficacy of Ultra Short-duration Dual Antiplatelet Therapy After Percutaneous Coronary Interventions: A Meta-analysis of Randomized Controlled Trials.

Dual antiplatelet therapy (DAPT) is required after percutaneous coronary intervention (PCI) to reduce stent thrombosis, but DAPT increases bleeding risks. The optimal duration of DAPT that provides the maximum protective ischemic effect along with the minimum bleeding risk is unclear. This is the first meta-analysis comparing outcomes for 1-month versus longer DAPT strategies following PCI.We searched PubMed, Cochrane, and ClinicalTrials.gov databases (from inception to October 2021) for randomized controlled trials that compared 1-month duration vs > 1-month duration of DAPT following PCI. We used a random-effects model to calculate risk ratio (RR) with 95% confidence interval (CI). The co-primary outcomes for study selection were all-cause mortality, major bleeding, and stent thrombosis. Secondary outcomes included myocardial infarction (MI), cardiovascular mortality, ischemic stroke and target vessel revascularization. A total of five randomized controlled trials were included [n = 29,355; 1-month DAPT(n = 14,662) vs > 1-month DAPT (n = 14,693)]. There was no statistically significant difference between the two groups in terms of all-cause mortality (RR 0.89; 95% CI 0.78-1.03; P = 0.12) and stent thrombosis (RR 1.07; 95% CI 0.80-1.43; P = 0.65). Similarly, there were no significant differences in MI, cardiovascular mortality, ischemic stroke, and target vessel revascularization. The rate of major bleeding was significantly lower in the group treated with DAPT for 1-month (RR 0.74; 95% CI 0.56-0.99, P = 0.04).There is no difference in all-cause mortality, cardiovascular mortality, MI, stent thrombosis, ischemic stroke, and target vessel revascularization with 1-month of DAPT following PCI with contemporary drug eluting stents compared to longer DAPT duration.

Effectiveness of Clinical Presentation (CP) Curriculum in teaching clinical medicine to undergraduate medical students: A cross-sectional study.

Introduction: The Clinical Presentation (CP) curriculum was first formulated in 1990 at the University of Calgary, Canada. Since then, it has been adopted at various medical schools, including Patan Academy of Health Sciences (PAHS), a state-funded medical school in a low-income country (LIC), Nepal. This study aims to evaluate the perceived effectiveness of the CP curriculum by students and faculty at PAHS, and test knowledge retention through a surprise non-routine exam administered to students.  Method: This is a cross-sectional study to evaluate the efficacy of the CP curriculum in teaching clinical medicine to the first batch of MBBS students of PAHS School of Medicine. Ethical approval was obtained from the Institutional Review Committee (IRC)-PAHS (Ref no std1505911069). Perceived effectiveness was evaluated using a set of questionnaires for faculty and students. A total of 33 students and 34 faculty filled the perception questionnaires. Subsequently, a questionnaire consisting of 50 Multiple Choice Questions (MCQs) from different clinical medicine disciplines was administered to test students' knowledge retention. Out of 49 students, 38 participated in the surprise non-routine exam.   Result: A significantly higher number of faculty preferred the CP curriculum compared to the traditional system of teaching clinical medicine (16 vs 11, Kruskal Wallis: 0.023, ie. P-value < 0.05). A significantly higher number of the students liked and recommended CP curriculum in the clinical year of medical education (20 vs. 13 with p-value < 0.05). In the non-routine surprise exam, two thirds of the students scored 60% or above.  Conclusion: Both faculty and students perceive that the CP curriculum system is an effective teaching and learning method in medical education, irrespective of their different demographic and positional characteristics. The students' overall performance was good in surprise, non-routine exams taken without scheduling or reminders.

The effects of curcumin as dietary supplement for patients with polycystic ovary syndrome: An updated systematic review and meta-analysis of randomized clinical trials.

This review aims to evaluate if there are clinical benefits of curcumin (CUR) in patients with polycystic ovary syndrome (PCOS). Electronic databases (PubMed, EMBASE, Scopus, Web of Science, Cochrane Central, and Google Scholar) were systematically searched to identify only randomized clinical trials (RCTs) that assessed CUR in patients with PCOS from inception to May 5, 2021. Five RCTs were included with a total of 296 patients, with 148 among the CUR groups and 148 patients among the control group. Revised Cochrane risk-of-bias tool for randomized trials was used to assess the risk of bias, three RCTs provided a low risk of bias and two provided a high risk of bias. Compared with the control group, CUR was associated with a statistically significant improvement in the glycemic control including fasting blood glucose (MD = -3.67; 95% CI = [-5.25, -2.08], p < .00001), insulin level (MD = -1.91; 95% CI = [-2.97, -0.84], p = .0005), homeostasis model assessment of insulin resistance (MD = -0.55; 95% CI = [-0.83, -0.27], p = .0001), and quantitative insulin sensitivity check index (MD = 0.01; 95% CI = [0.00, 0.02], p = .0005). The mean difference in total cholesterol was also statistically significant (MD = -15.55; 95% CI = [-30.33, -0.76], p < .04). The rest of the secondary outcomes, including LDL, HDL, sex hormone, body weight, and CRP, were not statistically significant. This review concluded that among patients with PCOS, the use of CUR demonstrated a significant difference from the control group for glycemic control. Those findings suggest that CUR confers clinical benefits in patients with PCOS. However, due to the limited number of the included studies, further high-quality studies are needed to establish the clinical efficacy of the CUR.

De-escalation from Prasugrel or Ticagrelor to Clopidogrel in Patients with Acute Coronary Syndrome Managed with Percutaneous Coronary Intervention: An Updated Meta-analysis of Randomized Clinical Trials.

INTRODUCTION: We aimed to evaluate the clinical benefits of a de-escalation strategy from prasugrel or ticagrelor to clopidogrel versus continuation of prasugrel or ticagrelor along with aspirin in both strategies for patients presenting with acute coronary syndrome (ACS) and treated with percutaneous coronary intervention (PCI), and to analyze the effect of the recently published randomized clinical trial (RCT) by Park et al., which included the largest sample size ever and the largest switched number of patients, on current guidelines and practices. DATA SOURCES: The PubMed, EMBASE, Scopus, Web of Science, Cochrane Central, and Google Scholar databases were searched systematically from inception to May 2021 by using the search terms ('de-escalation' OR 'switching') AND ('antiplatelet' OR 'clopidogrel' OR 'ticagrelor' OR 'prasugrel') AND ('percutaneous coronary intervention' OR 'PCI'' OR 'Acute coronary syndrome' OR 'ACS'). STUDY SELECTION AND DATA EXTRACTION: We included RCTs that reported the primary outcomes, i.e. net clinical benefits and Bleeding Academic Research Consortium (BARC) type 2 or higher bleeding. A combination of both ischemic and bleeding events was defined as a net clinical benefit. DATA SYNTHESIS: A total of four RCTs were included, with 5952 patients. A random-effects meta-analysis revealed that a de-escalation strategy was associated with lower ischemic and bleeding events (net clinical benefits; risk ratio [RR] 0.63, 95% confidence interval [CI] 0.47-0.85; p = 0.003), and lower BARC type 2 or higher bleeding (RR 0.51, 95% CI 0.29-0.91; p = 0.02) when compared with a continuation strategy. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: The current guidelines recommend potent P2Y12 prasugrel or ticagrelor for 12 months despite their association with a high risk of bleeding. Our meta-analysis updates cardiologists, providing them with the best available evidence in managing patients with ACS who underwent PCI. CONCLUSION: Among patients with ACS treated with PCI, a de-escalation strategy (prasugrel or ticagrelor to clopidogrel) is associated with lower ischemic and bleeding events (net clinical benefits) and lower BARC type 2 or higher bleeding; however, due to the limited number of included studies, further high-quality studies are needed to establish the clinical efficacy of the de-escalation strategy.

Hypothyroidism Is Associated With Longer Hospital Stay Following Implantation Of Left Ventricular Assist Device.

BACKGROUND: There has been a steady and consistent rise in the use of left ventricular assist devices in the management of patients with advanced heart failure. Hypothyroidism also remains one of the most common endocrine conditions with a significant impact on the development and overall outcomes of heart failure. The authors analyzed the National Inpatient Sample to evaluate the effect of hypothyroidism on the in-hospital outcomes of patients with end-stage heart failure following the placement of left ventricular assist device. METHODS: The national inpatient sample was queried to identify all adult patients who had LVAD placement from 2004 to 2014. They were subsequently divided into those with hypothyroidism and those without hypothyroidism. The primary outcome was in-hospital mortality. Other outcomes were acute kidney injury, length, and cost of hospitalization. Logistic regression models were created to determine the outcomes of interest. RESULTS: Of 2643 patients in the study, 5.4% had hypothyroidism, and 94.6% did not. The hypothyroid patients were significantly older compared to the non-hypothyroid patients (mean age 58.6 years vs 49.95 years, P-value <.0001). Both groups had similar gender composition. In-hospital mortality was similar across both groups. However, there was a higher incidence of acute kidney injury (AKI) in the hypothyroid group (adjusted odds ratio [aOR 1.83, P-value <.001]). Hypothyroid patients had longer hospital stays (adjusted mean difference [aMD] 5.19, P-value .0001). Hospital charges were also higher in the hypothyroid group. CONCLUSION: This study found that LVAD is associated with longer hospital stay in hypothyroid patients with heart failure.

Cancer-Related Non-Bacterial Thrombotic Endocarditis Presenting as Acute Ischemic Stroke.

Non-bacterial thrombotic endocarditis (NBTE), also known as marantic endocarditis, is a rare form of noninfectious endocarditis presenting with thromboembolism including ischemic cerebral stroke. It is mostly associated with advanced malignancy and characterized by the presence of sterile vegetation on heart valves. The diagnosis is usually based on vegetations seen on an echocardiogram, with negative blood cultures suggesting a noninfectious etiology. The treatment for this condition includes systemic anticoagulation. In this report, we discuss the case of a 61-year-old Caucasian female who presented to our facility with an ischemic stroke. She was found to have vegetations on the mitral valve with negative blood cultures. Further studies revealed metastatic pancreatic cancer. The patient's condition improved following in-hospital management, and she was discharged home for outpatient follow-up and treatment. Through this report, we highlight the importance of considering a search for malignancy in patients presenting with these clinical features. Early diagnosis and prompt management are critical to reduce the complications of NBTE and improve the patients' quality of life.

Systematic Review and Meta-Analysis: Can We Compare Direct Oral Anticoagulants to Warfarin in Patients With Atrial Fibrillation and Bio-Prosthetic Valves?

Background There are no clear consensus guidelines on the indications and types of anticoagulation therapies in patients with bio-prosthetic valves either with concomitant atrial fibrillation (AF) or sinus rhythm. In our meta-analysis, we assessed the safety and efficacy of DOACs as compared to the standard treatment with warfarin in patients with AF and bioprosthetic valves. Methods We included randomized controlled trials (RCTs), cohort studies in the English language, and studies reporting patients with valvular heart disease that included bioprosthetic valvular disease. A systematic literature review using Embase, PubMed, and Web of Science was performed using the terms "Direct Acting Oral Anticoagulant," "Oral Anticoagulants," "Non-Vitamin K Antagonist Oral Anticoagulant," "Atrial Fibrillation," "Bioprosthetic Valve" for literature published prior to January 2021. Extraction of data from included studies was carried out independently by three reviewers from Covidence. We assessed the methodical rigor of the included studies using the modified Downs and Black checklist. Results Four RCTs and one observational study (n=1776) were included in our study. A random-effect model using RevMan (version 5.4; The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen) was used for data analysis. The pooled data showed that there was a non-significant reduction in the incidence of stroke and systemic embolism in the patients taking DOACs as compared to warfarin (HR 0.69; 95% CI, 0.29, 1.67; I2 = 50%). The incidence of major bleeding was lower in the DOACs group; the difference was statistically significant (HR 0.42; 95% CI, 0.26, 0.67; I2 = 7%). The difference was not statistically significant for all-cause mortality in both groups (HR 1.24; 95% CI, 0.91, 1.67; I2 = 0%). Conclusion Our results showed that there was no difference in the outcomes of stroke and systemic embolism between DOACs and warfarin but there were statistically significantly lower major bleeding events. We conclude that larger clinical trials are needed to assess the true safety and efficacy of DOACs in patients with AF and bioprosthetic valves.

Pharmacotherapies in Heart Failure With Preserved Ejection Fraction: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Heart failure (HF) with preserved ejection fraction (HFpEF) causes significant cardiovascular morbidity and mortality. It is a growing problem in the developed world, especially, in the aging population. There is a paucity of data on the treatment of patients with HFpEF. We aimed to identify pharmacotherapies that improve peak oxygen consumption (peak VO2), cardiovascular mortality, and HF hospitalizations in patients with HFpEF. METHODS: We conducted a systematic literature search for English studies in PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, Scopus, and Google scholar. We searched databases using terms relating to or describing HFpEF, stage C HFpEF, and diastolic HF and included only randomized controlled trials (RCTs). RevMan 5.4 (The Cochrane Collaboration, 2020, London, UK) was used for data analysis, and two independent investigators performed literature retrieval and data-extraction. We used PRISMA guidelines to report the outcomes. We included 14 articles in our systematic review and six studies in meta-analysis. RESULTS: We calculated the pooled mean difference (MD) of peak VO2 between placebo and pharmacotherapies. Our meta-analysis showed that the peak VO2 was comparable between pharmacotherapies and placebo in HFpEF (MD = 0.09, 95% CI: -0.11, 0.30, I2 =28%). Our systematic review highlights that statins and spironolactone use should be further studied in larger RCTs due to their potential beneficial effect on all-cause mortality and hospitalizations, respectively. CONCLUSION: Compared to placebo, none of the pharmacotherapies significantly improved peak VO2 in HFpEF except ivabradine. In our meta-analysis, the pooled improvement in peak VO2 is non-significant. This needs validation with larger studies. We are lacking larger studies on pharmacotherapies that improve peak VO2 in HFpEF. Statin and spironolactone should be further studied in patients with HFpEF as few trials have shown improvement in all-cause mortality and reduction in HF hospitalizations in selected patients, respectively.

Sudden Cardiac Death and Sudden Cardiac Arrest in Patients with Human Immunodeficiency Virus: A Systematic Review.

The importance of this review lies in its study of the risk of sudden cardiac death (SCD) and sudden cardiac arrest (SCA) in people living with the human immunodeficiency virus (PLWH). To the best of our knowledge, this is the first review investigating the effect of the human immunodeficiency virus (HIV) on SCD and SCA. The review's objective was to determine the risk of SCD and SCA in PLWH. To do this, the electronic databases Ovid MEDLINE, EMBASE, Cochrane Central, Scopus, and Google Scholar were systematically searched to identify eligible studies published before January 31, 2021. Reference lists of the included studies were searched for further identification of relevant studies. The search terms included: "Sudden Cardiac Death," "Sudden Cardiac Arrest," "Human Immunodeficiency virus," "HIV," "Acquired immunodeficiency syndrome," and "AIDS." Only observational studies that assessed the association between SCD and SCA in PWLH were selected.  Data were extracted by two independent authors who screened titles, abstracts, and articles to meet the inclusion criterion. Quality assessment was done by using modified Downs and Black checklist. A total of seven studies were included in this review. Five studies revealed a higher incidence of SCD in PLWH, two of which focused on patients with HIV and low left ventricular ejection fraction (LVEF). The other two studies were about the association of HIV and SCA. Studies reported that PLWH had a three- to five-fold higher incidence of SCD as compared to non-HIV patients. HIV patients with low LVEF had a higher incidence of SCD than HIV patients with normal LVEF. PLWH had a higher incidence of SCA and less successful cardiopulmonary resuscitation (CPR) as compared to patients without HIV. After adjusting for various confounders in multiple studies, all the studies reported a higher incidence of SCD in PLWH. To conclude, PLWH is at an increased risk of SCD and SCA. Some risk factors for this include LVEF, viral load (VL), and the cluster of differentiation 4 (CD4) count. There is a paucity of data on the mechanisms involved, although a higher prevalence of cardiac fibrosis and interstitial fibrosis in PLWH may play a role. Because of the general suboptimal quality of the heterogeneous nature of the current evidence, further, rigorous studies are needed to determine the association of increased risk of SCD and SCA in PLWH.

A Case Report of Sick Sinus Syndrome as an Initial Presentation of Primary Amyloidosis.

Primary light chain amyloidosis (AL amyloidosis) rarely presents as sick sinus syndrome (SSS), and only a few cases have been reported in the literature. A higher index of suspicion is needed to diagnose AL amyloidosis in patients presenting with SSS. Recognizing the electrocardiography (ECG) and transthoracic echocardiogram (TTE) findings for amyloidosis are crucial for early recognition, proper management, and to improve the patients' quality of life. A 79-year-old female initially presented with dyspnea and was diagnosed with SSS that required a pacemaker insertion. Ten days later, the patient had complained of dysphagia and difficulty swallowing. She underwent an esophagogastroduodenoscopy (EGD) to investigate further, and it revealed esophageal and duodenal ulcers, and biopsy was positive for amyloidosis. The patient was worked up for amyloidosis, including bone marrow biopsy, renal biopsy, frees light chains, and serum electrophoresis, which all confirmed the diagnosis of primary amyloidosis. Unfortunately, due to the terminal nature of her condition, the patient was discharged with comfort measures to hospice care.