Full decongestion in acute heart failure therapy.

Incomplete decongestion is the main cause of readmission in the early post-discharge period of a hospitalization for acute heart failure. Recent heart failure guidelines have highlighted initiation and rapid up-titration of quadruple therapy with angiotensin receptor neprilysin inhibitor, beta adrenergic receptor blocker, mineralocorticoid receptor antagonist, and sodium glucose cotransporter 2 inhibitor to prevent hospitalizations for heart failure with reduced ejection fraction. However, full decongestion remains the foremost therapeutic goal of hospitalization for heart failure. While early addition of sodium glucose cotransporter 2 inhibitors and mineralocorticoid receptor antagonists may be helpful, the value of the other therapeutics comes after decongestion is complete.

Complex Left Atrial Appendage Morphology Is an Independent Risk Factor for Cryptogenic Ischemic Stroke.

Importance: Ischemic strokes pose a significant health burden. However, the etiology of between 20 and 40% of these events remains unknown. Left atrial appendage morphology may influence the occurrence of thromboembolic events. Design: A retrospective cross-sectional study was conducted to investigate the role of LAA morphology in patients with atrial fibrillation (AF) and cardioembolic-associated stroke and patients with cryptogenic stroke without atrial fibrillation. LAA morphology is classified into two groups: (1) simple (chicken-wing) vs. (2) complex (non-chicken wing) based on transesophageal echocardiography (TEE) findings. In addition to the LAA morphology, left atrial parameters, including orifice diameter, depth, emptying velocity, and filling velocity, were collected for both groups. Mathematical, computational models were constructed to investigate flow velocities in chicken-wing and non-chicken wing morphological patterns to assess LAA function further. Findings: TEE values for volume, size, emptying, and filling velocities were similar between simple and complex LAA morphology groups. Patients with cryptogenic stroke without coexisting AF were noted to have significantly higher rates of complex LAA morphology. Chicken-wing LAA morphology was associated with four-fold higher flow rate (kg/s) in computational simulations. Conclusions: Complex LAA morphology may be an independent contributing factor for cryptogenic strokes. Further studies are warranted to investigate the mechanism involved in LAA morphology and thromboembolic events.

Device Thrombosis During Destination Therapy.

BACKGROUND: Device thrombosis remains a complication of long-term mechanical circulatory support with HeartMate II. MATERIALS AND METHODS: Retrospective analysis of patients who underwent destination therapy (DT) with HeartMate II from January 2010-December 2013 at Tulane University Medical Center. RESULTS: Eighteen HeartMate II were implanted for DT. Survival rates were 72.2% at 1 year and 37% at 2 years. Device thrombosis in 7 of the 18 patients (39%) accounted for the low survival rate at 2 years. Known risk factors for device thrombosis were equally present in patients with and without device thrombosis. In contrast to patients without device thrombosis, all patients with device thrombosis had a pre-existing systemic inflammatory condition. CONCLUSIONS: Patients with pre-existing systemic inflammatory conditions are at risk of device thrombosis during DT.

Long-Term Anti-Hypertensive Therapy and Stroke Prevention: A Meta-Analysis.

BACKGROUND: Stroke causes approximately 6.7 million deaths worldwide per year and is the second leading cause of death. Pharmacotherapy for hypertension, an independent risk factor for stroke, significantly reduces the incidence of stroke. Although prior meta-analyses demonstrate various antihypertensive classes are superior to placebo in reducing stroke risk, which class is most effective is unclear. METHODS: We conducted a systematic MEDLINE search including only randomized controlled trials (RCT) of antihypertensive medications published between 1999 and 2014 in adults with stroke as a primary or secondary outcome. Five classes compared against all others were angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), ß-adrenoceptor antagonists (ß-blockers), calcium channel blockers (CCBs), and thiazide or thiazide-like diuretics (T-TLDs). Among 17 RCTs with 31 comparative arms, risk ratio was used to assess effect size, and a fixed- and random-effect model was used to calculate summary effect size, utilizing comprehensive meta-analysis statistical software version 2.0. RESULTS: The 251,853 subjects (46 ± 11.4 % female; mean age 67.2 ± 6.8 years), were grouped as follows: ACEI 52,887; ARB 7278; ACEI/ARB 60,165; ß-blocker 24,099; CCB 98,950; and T-TLD 68,639. The mean follow-up was 42.9 ± 15 months. A random-effect model was used to assess for summary effect size in ACEI, ACEI/ARB, ARB, and T-TLD groups. The summary risk ratio for stroke occurrence in the different antihypertensive drug classes were as follows: ACEIs 1.01 (95 % confidence interval [CI] 0.81-1.27; p = 0.92); ACEIs/ARBs 0.94 (95 % CI 0.78-1.13; p = 0.51); T-TLDs 0.90 (95 % CI 0.75-1.08; p = 0.25); ARBs 0.83 (95 % CI 0.59-1.18; p = 0.30); ß-blockers 1.42 (95 % CI 1.26-1.61; p < 0.01); and CCBs 0.83 (95 % CI 0.79-0.89; p < 0.01). CONCLUSION: Among the antihypertensive classes, CCBs were most effective in reducing the long-term incidence of stroke, whereas ß-blockers were associated with significantly increased risk.

Overview of transesophageal echocardiography for the chest physician.

Transesophageal echocardiography (TEE) is a growing technology that is frequently utilized in the critical care setting by intensivists, surgeons, anesthesiologists as well as specialists in cardiovascular diseases. The clinical application of TEE continues to emerge, and the indications and diagnostic utility of this technology as currently available are summarized in this review.

Use of multidetector computed tomography for evaluation of global and regional left ventricular function.

Left ventricular (LV) function was shown to play a paramount role in the evaluation, management, and prognosis of patients with cardiac pathology. With the advent of multidetector computed tomography (MDCT), a novel tool for cardiac function assessment became available. This comes at no additional cost to the patient undergoing coronary CT angiography in terms of radiation exposure or contrast material delivery. The accuracy of LV function assessment by retrospective electrocardiographic gating intimately depends on the level of spatial and temporal resolution achievable during scanning. With the aid of today's fast-advancing technology, MDCT is now capable of acquiring data with isotropic submillimeter voxels that allow true 3-dimensional threshold-based chamber segmentation for accurate volumetric analysis. The challenge, however, continues to involve optimizing temporal resolution through various reconstruction techniques and technologic innovations. MDCT-determined global LV function variables were shown to strongly correlate with those of standard imaging methods. Regional function assessment has now become feasible with today's latest scanners. Its accuracy, however, still awaits a major breakthrough in temporal resolution to approach or possibly surpass that of echocardiography or magnetic resonance imaging.

Benefits of Cardiac Rehabilitation and Exercise Training in Older Persons.

Despite the well-proved benefits of cardiac rehabilitation and exercise training, older persons are frequently not referred to or vigorously encouraged to pursue this therapy after major coronary heart disease (CHD) events. Therefore, we determined the effects of this therapy on plasma lipids, indices of obesity, and exercise capacity in older CHD patients compared with the benefits obtained in a younger cohort. At baseline, the older persons had lower body mass indices (BMI), triglycerides levels, and estimated metabolic equivalent (METs), and the elderly had higher levels of high-density lipoprotein cholesterol (HDL-C). Most other parameters were statistically similar in the older and younger patients. After cardiac rehabilitation, the elderly had significant improvements in METs, BMI, percent body fat, HDL-C, and low-density lipoprotein cholesterol (LDL-C)/HDL-C but not in total cholesterol or LDL-C. However, improvements in all of these parameters were statistically similar in older and younger patients. We conclude that despite baseline differences, improvements in exercise capacity, obesity indices, and lipid levels were statistically similar in older and younger patients enrolled in formal, phase II, cardiac rehabilitation and exercise training programs. Therefore, our data emphasized that the elderly should not be categorically denied the benefits of vigorous secondary CHD prevention, including formal cardiac rehabilitation and exercise training programs.