Left Main Coronary Artery Disease: A Contemporary Review of Diagnosis and Management.

Significant left main coronary artery disease is a very high-risk subgroup of coronary artery disease that is a crucial indicator of heightened morbidity and mortality rates. Despite its clinical significance, uncertainties persist regarding the optimal management strategy for patients, particularly given its phenotypic variations. Existing evidence-based guidelines offer insights into revascularization options, yet questions remain regarding long-term prognoses and clinical outcomes when comparing percutaneous coronary intervention to coronary artery bypass grafting. This comprehensive review aims to provide an in-depth analysis of contemporary strategies for the diagnosis, assessment, and treatment of left main coronary artery disease. By synthesizing current literature and addressing the evolving landscape of revascularization modalities, this review seeks to contribute valuable insights for clinicians and researchers grappling with the complexities of managing left main coronary artery disease.

The Current State of Coronary Revascularization: Coronary Artery Bypass Graft Surgery Versus Percutaneous Coronary Interventions.

PURPOSE OF REVIEW: The optimal revascularization strategy for coronary artery disease depends on various factors, such as disease complexity, patient characteristics, and preferences. Including a heart team in complex cases is crucial to ensure optimal outcomes. Decision-making between percutaneous coronary intervention and coronary artery bypass grafting must consider each patient's clinical profile and coronary anatomy. While current practice guidelines offer some insight into the optimal revascularization approach for the various phenotypes of coronary artery disease, the evidence to support either strategy continues to evolve and grow. Given the large amount of contemporary data on revascularization, this review aims to comprehensively summarize the literature on coronary artery bypass grafting and percutaneous coronary intervention in patients across the spectrum of coronary artery disease phenotypes. RECENT FINDINGS: Contemporary evidence suggests that for patients with triple vessel disease, coronary artery bypass grafting is preferred over percutaneous coronary intervention due to better long-term outcomes, including lower rates of death, myocardial infarction, and target vessel revascularization. Similarly, for patients with left main coronary artery disease, both percutaneous coronary intervention and coronary artery bypass grafting can be considered, as they have shown similar efficacy in terms of major adverse cardiac events, but there may be a slightly higher risk of death with percutaneous coronary intervention. For proximal left anterior descending artery disease, both percutaneous coronary intervention and coronary artery bypass grafting are viable options, but coronary artery bypass grafting has shown lower rates of repeat revascularization and better relief from angina. The Synergy Between PCI with Taxus and Cardiac Surgery score can help in decision-making by predicting the risk of adverse events and guiding the choice between percutaneous coronary intervention and coronary artery bypass grafting. European and American guidelines both agree with including a heart team that can develop and lay out individualized, optimal treatment options with respect for patient preferences. The debate between coronary artery bypass grafting versus percutaneous coronary intervention in multiple different scenarios will continue to develop as technology and techniques improve for both procedures. Risk factors, pre, peri, and post-procedural complications involved in both revascularization strategies will continue to be mitigated to optimize outcomes for those patients for which coronary artery bypass grafting or percutaneous coronary intervention provide ultimate benefit. Methods to avoid unnecessary revascularization continue to develop as well as percutaneous technology that may allow patients to avoid surgical intervention when possible. With such changes, revascularization guidelines for specific patient populations may change in the coming years, which can serve as a limitation of this time-dated review.

ChatGPT: A Conceptual Review of Applications and Utility in the Field of Medicine.

Artificial Intelligence, specifically advanced language models such as ChatGPT, have the potential to revolutionize various aspects of healthcare, medical education, and research. In this narrative review, we evaluate the myriad applications of ChatGPT in diverse healthcare domains. We discuss its potential role in clinical decision-making, exploring how it can assist physicians by providing rapid, data-driven insights for diagnosis and treatment. We review the benefits of ChatGPT in personalized patient care, particularly in geriatric care, medication management, weight loss and nutrition, and physical activity guidance. We further delve into its potential to enhance medical research, through the analysis of large datasets, and the development of novel methodologies. In the realm of medical education, we investigate the utility of ChatGPT as an information retrieval tool and personalized learning resource for medical students and professionals. There are numerous promising applications of ChatGPT that will likely induce paradigm shifts in healthcare practice, education, and research. The use of ChatGPT may come with several benefits in areas such as clinical decision making, geriatric care, medication management, weight loss and nutrition, physical fitness, scientific research, and medical education. Nevertheless, it is important to note that issues surrounding ethics, data privacy, transparency, inaccuracy, and inadequacy persist. Prior to widespread use in medicine, it is imperative to objectively evaluate the impact of ChatGPT in a real-world setting using a risk-based approach.

NAFLD in Cardiovascular Diseases: A Contributor or Comorbidity?

Nonalcoholic fatty liver disease (NAFLD) and cardiovascular diseases are both highly prevalent conditions around the world, and emerging data have shown an association between them. This review found several longitudinal and cross-sectional studies showing that NAFLD was associated with coronary artery disease, cardiac remodeling, aortic valve remodeling, mitral annulus valve calcifications, diabetic cardiomyopathy, diastolic cardiac dysfunction, arrhythmias, and stroke. Although the specific underlying mechanisms are not clear, many hypotheses have been suggested, including that metabolic syndrome might act as an upstream metabolic defect, leading to end-organ manifestations in both the heart and liver. Management of NAFLD includes weight loss through lifestyle interventions or bariatric surgery, and pharmacological interventions, often targeting comorbidities. Although there are no Food and Drug Administration-approved nonalcoholic steatohepatitis-specific therapies, several drug candidates have demonstrated effect in the improvement in fibrosis or nonalcoholic steatohepatitis resolution. Further studies are needed to assess the effect of those interventions on cardiovascular outcomes, the major cause of mortality in patients with NAFLD. In conclusion, a more comprehensive, multidisciplinary approach to diagnosis and management of patients with NAFLD and cardiovascular diseases is needed to optimize clinical outcomes.

Robotic-assisted percutaneous coronary intervention in a COVID-19 patient.

Coronavirus disease-2019 (COVID-19) pandemic is the biggest global health threat in the 21st century. We describe a case of a patient with suspected COVID-19 who needed urgent coronary artery interrogation, in which we utilized robotic assistance to minimize the risk of exposure to COVID-19 and reduced personal protective equipment needed by the procedural team.

Predictors of 30-day re-admissions in patients with infective endocarditis: a national population based cohort study.

Infective endocarditis (IE) is a life threatening disease requiring lengthy hospitalizations, complex multidisciplinary management and high health care costs. In this study, we analyzed the National Readmissions' Database (NRD) to identify infective endocarditis cases and the causative organisms, clinical determinants, length of stay, in-hospital mortality, and 30-day hospital readmission rates. The study cohort was derived from Healthcare Cost and Utilization Project's National Readmission Database between 2010-15. We queried the National Readmissions' Database using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic code for infective endocarditis (421.0) and identified a total of 187,438 index admissions. SAS 9.4 (SAS Institute Inc., Cary, NC) was utilized for statistical analyses. A total of 187,438 patients with a primary diagnosis of IE were identified over 6 years (2010-2015). Twenty-four percent (44,151 patients) were readmitted within 30 days. Most common etiologies for readmission included sepsis (14%), acute heart failure (8%), acute kidney injury (6%), intracardiac device infection (5.6%) and recurrence of IE (2.7%). Predictors of increased readmissions included female sex, staphylococcus aureus infection, diabetes, chronic lung disease, chronic liver disease, acute kidney injury, acute heart failure and anemia. In-hospital mortality for the readmission of IE was 13%, and average length of stay during the re-admission was 12 days. IE is associated with high rates of index admission mortality and for 30-day readmissions of which are associated with a substantial risk of death.

Radial Artery Versus Saphenous Vein Grafts in Coronary Artery Bypass Surgery: a Literature Review.

PURPOSE OF REVIEW: Coronary artery bypass grafting is a preferred strategy for complete coronary revascularization in patients who have multi-vessel coronary artery disease, left ventricular dysfunction, and/or diabetes. Both arterial (internal thoracic artery/radial artery) and venous grafts are utilized to bypass the obstruction in native vessels. Despite having radial arterial grafts as a preferred second conduit for bypass, venous grafts are more commonly used. RECENT FINDINGS: We review the existing literature and report the preferred conduit based on a recently published meta-analysis of 6 randomized controlled trials. The analysis concluded that radial artery grafts are associated with fewer adverse cardiac events and better graft patency at 5 years of follow-up. Although saphenous vein grafting is the most commonly used conduit in addition to ITA, current data suggests that total arterial bypass (using RA conduit in addition to ITA) may be the better strategy. Both the US and European consensus guidelines advocate for the use of arterial over SV grafting for most patients.

Therapeutic Options for In-Stent Restenosis.

PURPOSE OF REVIEW: In-stent restenosis (ISR) is a complex disease process that became apparent shortly after the introduction of stents into clinical practice. This review seeks to define in-stent restenosis (ISR) as well as to summarize the major treatment options that have been developed and studied over the past two decades. RECENT FINDINGS: Recent developments in drug-coated balloons and bioresorbable vascular scaffolds have added new potential treatments for ISR. Two recent network meta-analyses performed a head-to-head comparison of all the various treatment modalities in order to identify the best approach to management of ISR. Current data suggests that repeat stenting with second-generation drug-eluting stents is most likely to lead to the best angiographic and clinical outcomes. In situations where repeat stenting is not preferable, drug-coated balloon therapy seems to be a reasonably effective alternative.

Does Surgical Repair of Moderate Ischemic Mitral Regurgitation Improve Survival? A Systematic Review.

Mitral regurgitation (MR) is one of the common complications in myocardial infarction (MI) patients. Almost half of the post MI patients have MR (ischemic MR)(17) which is moderate to severe (grade II-IV). Whether there is a mortality benefit of performing mitral valve repair (MVR) along with coronary artery bypass grafting (CABG) in patients with post MI moderate MR remains inconclusive. Literature search was done from PubMed, Google scholar, Ovid, and Medline databases. Studies which included post MI patients with moderate ischemic MR and reported mortality outcomes of performing CABG and MVR were chosen for the systematic review. Our preliminary literature search identified 194 studies, of which 11 studies met our inclusion criteria. Nine studies showed no survival benefit of performing simultaneous MVR and CABG. One study demonstrated survival benefit of performing CABG plus MVR only in the New York Heart Association (NYHA) class III-IV, and one study suggested survival benefit of performing CABG plus MVR as compared to CABG alone in patient with ischemic MR irrespective of preoperative NYHA functional class. Review of current literature showed mixed results in terms of improvement in functional status but failed to show any survival benefit of performing MVR along with CABG. Limitations of studies include small sample size, difference in baseline demographic variables, and short follow-up period which might influence the outcome of the study. Prospective randomized studies are required to establish clear benefit of performing MVR simultaneously with CABG.

Advancements in Revascularization Strategies for Acute Mesenteric Ischemia: A Comprehensive Review.

Even with modern advancements in the management of acute mesenteric ischemia over the past decade, morbidity and mortality remain high, and the best primary treatment modality is still debated amongst interventionalists. Traditionally, interventionalists have favored an open surgical approach but are now trending for endovascular interventions due to apparent reduced mortality and complications. Newer studies suggest hybrid approaches, and intestinal stroke centers may be superior to either strategy alone. This narrative review will explore the natural history of acute mesenteric ischemia with the aim of increasing interventionalist awareness of modern advancements in revascularization strategies for this devastating disease.

Revascularization Strategies for Acute and Chronic Mesenteric Ischemia: A Narrative Review.

Mesenteric ischemia is a challenging condition characterized by insufficient blood perfusion to the mesentery and, consequently, intestinal tissues that continues to perplex clinicians. Despite its low prevalence, the condition's variable clinical presentation and elusive radiographic diagnosis can delay life-saving interventions in the acute setting and deteriorate the quality of life of patients when left undiagnosed or misdiagnosed. PURPOSE: Review and summarize recent diagnostic updates and emergent intervention strategies for acute and chronic mesenteric ischemia. METHODS: A narrative review of all relevant studies from January 2022 through September 2023. RESULTS: A total of 11 studies from MEDLINE, supplemented with 44 studies from Google Scholar, were included in the review. CONCLUSIONS: Both acute and chronic mesenteric ischemia propose diagnostic and therapeutic challenges for interventionalists. Computed tomographic angiography remains the diagnostic modality of choice for both. Open surgical intervention remains the gold standard for acute mesenteric ischemia, while endovascular techniques are preferred for chronic mesenteric ischemia.

Lifestyle Approach and Medical Therapy of Lower Extremity Peripheral Artery Disease.

Lower extremity peripheral artery disease (PAD) is common among patients with several risk factors, such as elderly, smoking, hypertension, and diabetes mellitus. Notably, PAD is associated with a higher risk of cardiovascular complications. Non-invasive interventions are beneficial to improve morbidity and mortality among patients with PAD. Traditional risk factors like smoking, diabetes mellitus, hypertension, and dyslipidemia play a significant role in the development of PAD. Still, additional factors such as mental health, glycemic control, diet, exercise, obesity management, lipid-lowering therapy, and antiplatelet therapy have emerged as important considerations. Managing these factors can help improve outcomes and reduce complications in PAD patients. Antiplatelet therapy with aspirin or clopidogrel is recommended in PAD patients, with clopidogrel showing more significant benefits in symptomatic PAD individuals. Managing several risk factors is crucial for improving outcomes and reducing complications in patients with PAD. Further research is also needed to explore the potential benefits of novel therapies. Ultimately, a comprehensive approach to PAD management is essential for improving morbidity and mortality among patients with this condition.

Complications of Radial vs Femoral Access for Coronary Angiography and Intervention: What Do the Data Tell Us?

In the last decades, radial access, as an alternative to femoral access, has rapidly evolved and emerged as the preferred vascular access for coronary angiography and percutaneous coronary intervention (PCI). The use of radial access for PCI can reduce access-site bleeding, particularly retroperitoneal bleeding, and risk of developing pseudoaneurysm, while also improving patient comfort after procedure (eg, early ambulation). However, radial access requires a longer learning curve to develop technical skills, and the data on radial artery graft for coronary artery bypass graft after radial access remain insufficient. Further, recent clinical trials have shown conflicts regarding whether radial access is associated with lower mortality in patients with ST-elevation myocardial infarction. Despite these recent investigations, it is still debated whether there are benefits associated with radial access over femoral access for PCI. In this review, we will evaluate radial access compared with femoral access for PCI on clinical outcomes and further discuss the usefulness of radial access.

Artificial intelligence in preventive cardiology.

Artificial intelligence (AI) is a field of study that strives to replicate aspects of human intelligence into machines. Preventive cardiology, a subspeciality of cardiovascular (CV) medicine, aims to target and mitigate known risk factors for CV disease (CVD). AI's integration into preventive cardiology may introduce novel treatment interventions and AI-centered clinician assistive tools to reduce the risk of CVD. AI's role in nutrition, weight loss, physical activity, sleep hygiene, blood pressure, dyslipidemia, smoking, alcohol, recreational drugs, and mental health has been investigated. AI has immense potential to be used for the screening, detection, and monitoring of the mentioned risk factors. However, the current literature must be supplemented with future clinical trials to evaluate the capabilities of AI interventions for preventive cardiology. This review discusses present examples, potentials, and limitations of AI's role for the primary and secondary prevention of CVD.

Carotid and Renal Vascular Disease.

This article review covers carotid artery disease, abdominal aortic aneurysm, and atherosclerotic renal artery disease. It overviews each condition's clinical presentation, diagnosis, medical management, and interventional approach. Carotid artery disease is characterized by hemispheric and neuropsychological manifestations, which can help detect this condition. Screening for carotid artery stenosis is recommended in high-risk individuals and can be performed using different methods, with carotid duplex ultrasonography being the preferred option. Carotid endarterectomy and carotid artery stenting are indicated based on specific criteria and patient characteristics. An abdominal aortic aneurysm is often asymptomatic, but abdominal, back, or flank pain may sometimes be present. Ultrasonography is an effective method for screening and monitoring abdominal aortic aneurysms, with high sensitivity and specificity. Smoking cessation is a crucial intervention for preventing further enlargement of small aortic aneurysms. Repair of abdominal aortic aneurysm is recommended based on the aneurysm size, growth rate, and the presence of symptoms. Endovascular repair is preferred when suitable anatomy is present. Atherosclerotic renal artery disease is associated with resistant hypertension, renal failure, and occasionally pulmonary edema. Doppler ultrasonography is a valuable diagnostic tool for detecting it, while the renal resistive index provides additional insights into disease severity and treatment response. Revascularization is not routinely recommended for atherosclerotic renal artery disease, but it may be considered in specific cases, such as renal arterial fibromuscular dysplasia or unexplained congestive heart failure.

Acute Myocardial Infarction in Pregnancy.

Pregnancy-associated myocardial infarction is an overall uncommon event, but can be associated with significant maternal and fetal morbidity and mortality. In contrast to myocardial infarction in the general nonpregnant population, the mechanism of pregnancy-associated myocardial infarction is most commonly due to nonatherosclerotic mechanisms such as coronary dissection, vasospasm, or thromboembolism. The diagnosis of pregnancy-associated myocardial infarction can be challenging, requiring a high index of suspicion for prompt recognition and management. Furthermore, the management of pregnancy-associated myocardial infarction can be complex due to maternal and fetal considerations and may vary based on the specific underlying mechanism of the myocardial infarction. This review aims to review the recent literature on pregnancy-associated myocardial infarction and summarize the epidemiology, mechanisms, diagnosis, and treatment strategies for this uncommon entity.

Temporal Trends and Outcomes of Peripheral Artery Disease and Critical Limb Ischemia in the United States.

INTRODUCTION: Peripheral arterial disease (PAD) is a progressive, systemic atherosclerotic disease that is associated with an increased risk of coronary artery disease (CAD), cerebrovascular disease (CVD), and critical limb ischemia (CLI). CLI represents the most severe stage of PAD, characterized by progressive endothelial dysfunction and arterial narrowing. We hypothesized that the incidence of CLI and PAD would increase over the study period and that the rates of in-hospital mortality and major amputations among patients admitted with CLI would rise correspondingly. METHODS: We utilized the National Inpatient Sample (NIS) database from year 2016 to 2021 using the ICD-10-CM codes. Patients with a primary or secondary diagnoses of PAD were initially selected and subsequently hospitalization with CLI were appropriately identified. Cochran Armitage test was used to describe the trend of outcomes across the years. All statistical analyses were conducted using the software Stata version 17.0. RESULTS: From 2016-2021, there were 2,930,639 admissions for critical limb ischemia. 65% of these patients were over the age of 60 and 35.8% of these patients were women. Most of these individuals were white (64.7%), followed by African Americans (15.8%) and Hispanics (12.6%). In-hospital mortality rates varied by revascularization method, with hybrid revascularization showing the highest rate at 2.6%, followed by endovascular revascularization at 1.8%, and surgical revascularization at 1.6%. Additionally, hospitalization costs were highest for patients undergoing hybrid revascularization ($46,257 ± $36,417), compared to endovascular ($36,924 ± $27,945) and surgical revascularization ($35,672 ± $27,127). Endovascular revascularization rates seemed to increase while surgical revascularization rates decreased during this time period. CONCLUSION: PAD is a progressive, systemic atherosclerotic disease that is associated with an increased risk of CAD, CVD, and CLI. Our data showed that the rates of PAD and CLI hospitalizations has remained relatively stable from 2016-2021, but there seems to be a trend towards doing more revascularization via an endovascular approach as compared to a surgical approach.

Bivalirudin versus heparin in patients undergoing percutaneous coronary intervention in acute coronary syndromes.

INTRODUCTION: Data on outcomes between unfractionated heparin and bivalirudin anticoagulation during percutaneous coronary intervention (PCI) in acute coronary syndromes (ACS) remains inconclusive. We aimed to systematically analyze PCI outcomes comparing unfractionated heparin and bivalirudin. METHODS: We systematically searched Ovid MEDLINE, Ovid Embase, Ovid Cochrane Database of Systematic Reviews, Scopus, and Web of Science from database inception in 1966 through January 2024 for studies evaluating PCI outcomes comparing unfractionated heparin and bivalirudin. Two investigators independently reviewed data. Conflicts were resolved through consensus. Random-effects meta-analyses were used. RESULTS: Ten prospective trials were identified that enrolled 42,253 individuals who presented with an acute coronary syndrome. Our analysis found that heparin when compared to bivalirudin was associated with an increased risk of trial-based definition of major bleeding (RR 1.68, 95% CI 1.29-2.20), non-access site complications (RR 4.6, 95% CI 1.75-12.09), TIMI major bleeding (RR 1.70, 95% CI 1.20-2.41), major bleeding risks (RR 1.87, 95% CI 1.49-2.36), cardiovascular disease death (RR 1.26, 95% CI 1.02-1.57), and thrombocytopenia (RR 1.67, 95% CI 1.07-2.62). There were no statistically significant differences between heparin and bivalirudin for all-cause mortality, MACE, stroke, reinfarction, target vessel revascularization, acute or stent thrombosis. CONCLUSIONS: The present meta-analysis demonstrates bivalirudin reduces major bleeding when used for anticoagulation during PCI in patients with acute coronary syndromes and is not associated with an increased risk of stent thrombosis or MACE.

Clinical implications of combination proton pump inhibitor and triple therapies in patients with atrial fibrillation following percutaneous intervention: a guide for clinicians.

INTRODUCTION: Patients on systemic oral anticoagulation with vitamin K antagonists (VKA) or non-vitamin K oral anticoagulants (NOAC) often require triple therapy following percutaneous coronary intervention, substantially increasing the risk of bleeding. Gastroprotective agents like proton pump inhibitors (PPI) are often employed to mitigate this risk, despite potential competitive inhibition between P2Y12-receptor inhibitors, NOACs, and VKAs. While the interactions and clinical outcomes of PPIs and DAPT have been frequently explored in literature, not many studies have evaluated the same outcomes for triple therapy. AREAS COVERED: This comprehensive narrative review of three studies on PPIs and triple from the PubMed/MEDLINE database supplemented by 23 other relevant studies aims to use the available literature to analyze the potential interactions between PPIs and triple therapy while shedding light on their mechanisms, clinical implications, and areas for optimization. EXPERT OPINION: If triple therapy is indicated following PCI, then patients at high-risk for bleeding may benefit from transition to apixaban and a PPI to lower the risk of gastrointestinal bleeding. More research is needed to determine the role of PPIs in triple therapies in prevention of gastrointestinal bleeding or potentiation of other adverse outcomes.