Coronary Microvascular Dysfunction: A Guide for Clinicians.

Dysfunction of the coronary microvasculature has become increasingly recognized as an important mechanism of myocardial ischemia in patients without obstructive coronary artery disease. The causes and management of coronary microvascular dysfunction remain poorly understood and are still largely based on extrapolation of epicardial coronary artery disease data. Quantification of myocardial blood flow and flow reserve have improved diagnosis, though important questions remain. In this review, we explain current understanding of the spectrum of pathophysiology of coronary microvascular dysfunction, summarize current diagnostic techniques to assess for coronary microvascular dysfunction, and appraise the limited data on management options specifically for patients with coronary microvascular dysfunction.

National Trends, Mortality and Outcomes in Intravascular Imaging-Guided Versus Angiography-Guided Percutaneous Coronary Intervention in the United States.

Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) have become increasingly utilized in patients undergoing percutaneous coronary intervention (PCI). Despite these purported advantages, prior reports regarding the use of IVUS and OCT have indicated that contemporary use of intravascular imaging remains low with significant regional variation. Here, we present the findings of an updated contemporary analysis regarding the use of IVUS/OCT guided PCI vs. angiography-guided PCI in the United States. We also evaluated in-hospital mortality and clinical outcomes between IVUS/OCT-guided PCI versus angiography-guided PCI-only over million patients in the United States. There has been a significant decrease in the number of PCIs performed, while there has been increasing in trend of IVUS/OCT-guided PCI over this period. Most importantly, we found that IVUS/OCT guided PCI were associated with better clinical outcomes in terms of in-hospital mortality, compare with angiography guided PCI.

Trends in Transcatheter Aortic Valve Implantation Utilization, Outcomes, and Healthcare Resource Use in Patients with Liver Cirrhosis: A Decade of Insights (2011-2020).

It is well known that individuals with liver cirrhosis are considered high risk for cardiac surgery, with an increased risk for morbidity and mortality as the liver disease progresses. In the last decade, there have been considerable advances in transcatheter aortic valve implantation (TAVI) as an alternative to surgical aortic valve replacement (SAVR) in individuals deemed to high risk for surgery. However, research surrounding TAVI in the setting of liver cirrhosis has not been as widely studied. In this national population-based cohort study, we evaluated the trends of mortality, complications, and healthcare utilization in liver cirrhotic patients undergoing TAVI, as well as analyze the basic demographics of these individuals. We found that from 2011-2020, the amount of TAVI procedures conducted in cirrhotic patients was increasing annually while the mortality, procedural complications, and healthcare utilization trends in these cirrhotic patients undergoing TAVI decreased. Overall, TAVI does seem to be a reasonable management for aortic stenosis patients with liver cirrhosis who need aortic valve replacement.

Clinical Outcomes of Cardiogenic Shock due to Spontaneous Coronary Artery Dissection versus Cardiogenic Shock due to Coronary Artery Disease.

Spontaneous coronary artery dissection (SCAD) can be treated conservatively. However, some SCAD patients can develop cardiogenic shock (CS). We evaluated the outcomes of SCAD-related CS using data from a national population-based cohort study from January 1, 2016, to December 30, 2019. In our study of 32,640 patients with SCAD, about 10.6% of patients presented with cardiogenic shock. We found that SCAD patients with cardiogenic shock had higher mortality as well as greater complications including use of mechanical circulatory devices, arrythmias, respiratory support, and acute heart failure compared to those without cardiogenic shock. When comparing cardiogenic shock due to SCAD with that due to coronary artery disease (CAD), we found that while mortality rates were similar, those with cardiogenic shock due to SCAD were associated with higher risk of use of mechanical circulatory support, major bleeding, blood transfusion and respiratory failure.

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.

Postnatal acetaminophen exposure and neurodevelopmental outcomes at 18-21 months corrected gestational age in preterm infants <29 weeks gestation: a retrospective cohort study.

BACKGROUND: Studies have reported prenatal acetaminophen exposure is associated with abnormal neurodevelopment. There is limited and conflicting data on neurodevelopmental outcomes following postnatal acetaminophen exposure. Our objective was to investigate the neurodevelopmental outcomes of preterm infants < 29 weeks gestation postnatally exposed to acetaminophen. METHODS: Retrospective cohort study of infants born between 2008 and 2017 at a tertiary care perinatal center. Exclusion criteria included chromosomal disorders, major congenital abnormalities, and congenital infections. The primary outcome was a composite score of <85 on the cognitive, language, or motor components of the Bayley Scales of Infant and Toddler Development, 3rd edition, assessed at 18 to 21 months corrected gestational age. Multivariate logistic regression was used to assess confounders. RESULTS: Of the 945 infants included in the study, 120 were in the acetaminophen group. There was no difference in any of Bayley-III cognitive, language or motor composite scores of < 85 between the two groups for postnatal acetaminophen exposure, adjusted odds ratios (aORs) 1.03, 95% CI 0.60-1.78, or days of acetaminophen use, aORs 1.10, 95% CI 0.93-1.29. CONCLUSIONS: There was no difference in neurodevelopmental outcome between the acetaminophen exposed and non-exposed groups. Our results need validation in larger cohorts. IMPACT: Animal research and cohort studies have suggested that prenatal acetaminophen exposure may be associated with an elevated risk of neurobehavioral abnormalities. However, there is limited and conflicting research on the impact of postnatal acetaminophen on neurodevelopment. The results of this study suggest that postnatal acetaminophen does not negatively impact neurodevelopment at 18 to 21 months in preterm infants born at <29 weeks gestational age. While these results need validation in larger and more longitudinal studies, this study provides reassurance for the use of postnatal acetaminophen in extremely preterm infants.

Contaminant Metals and Cardiovascular Health.

A growing body of research has begun to link exposure to environmental contaminants, such as heavy metals, with a variety of negative health outcomes. In this paper, we sought to review the current research describing the impact of certain common contaminant metals on cardiovascular (CV) health. We reviewed ten metals: lead, barium, nickel, chromium, cadmium, arsenic, mercury, selenium, zinc, and copper. After a literature review, we briefly summarized the routes of environmental exposure, pathophysiological mechanisms, CV health impacts, and exposure prevention and/or mitigation strategies for each metal. The resulting article discloses a broad spectrum of pathological significance, from relatively benign substances with little to no described effects on CV health, such as chromium and selenium, to substances with a wide-ranging and relatively severe spectrum of CV pathologies, such as arsenic, cadmium, and lead. It is our hope that this article will provide clinicians with a practical overview of the impact of these common environmental contaminants on CV health as well as highlight areas that require further investigation to better understand how these metals impact the incidence and progression of CV diseases.

PM2.5 and cardiovascular diseases: State-of-the-Art review.

Air pollution, especially exposure to particulate matter 2.5 (PM2.5), has been associated with an increase in morbidity and mortality around the world. Specifically, it seems that PM2.5 promotes the development of cardiovascular risk factors such as hypertension and atherosclerosis, while being associated with an increased risk of cardiovascular diseases, including myocardial infarction (MI), stroke, heart failure, and arrhythmias. In this review, we seek to elucidate the pathophysiological mechanisms by which exposure to PM2.5 can result in adverse cardiovascular outcomes, in addition to understanding the link between exposure to PM2.5 and cardiovascular events. It is hypothesized that PM2.5 functions via 3 mechanisms: increased oxidative stress, activation of the inflammatory pathway of the immune system, and stimulation of the autonomic nervous system which ultimately promote endothelial dysfunction, atherosclerosis, and systemic inflammation that can thus lead to cardiovascular events. It is important to note that the various cardiovascular associations of PM2.5 differ regarding the duration of exposure (short vs long) to PM2.5, the source of PM2.5, and regulations regarding air pollution in the area where PM2.5 is prominent. Current strategies to reduce PM2.5 exposure include personal strategies such as avoiding high PM2.5 areas such as highways or wearing masks outdoors, to governmental policies restricting the amount of PM2.5 produced by organizations. This review, by highlighting the significant impact between PM2.5 exposure and cardiovascular health will hopefully bring awareness and produce significant change regarding dealing with PM2.5 levels worldwide.

Clinical Outcomes Following Bifurcation Techniques for Percutaneous Coronary Intervention.

Bifurcation lesions account for 20% of all percutaneous coronary interventions and represent a complex subset which are associated with lower procedural success and higher rates of restenosis [...].

Noise Exposure and Cardiovascular Health.

Noise is considered an environmental stressor adversely affecting well-being and quality of life, inter-individual communications, and attention and cognitive function and inducing emotional responses, corresponding to noise annoyance. In addition, noise exposure is associated with nonauditory effects including worsening mental health, cognitive impairments, and adverse birth outcomes, sleep disorders, and increased annoyance. An accumulating body of evidence has indicated that traffic noise is also associated with CVD, through multiple pathways. It has been shown that psychological stress and mental health disorders such as depression and anxiety have a negative impact on the development of cardiovascular diseases and outcomes. Likewise, reduced sleep quality and/or duration has been reported to increase sympathetic nervous system activity, which can predispose to conditions like hypertension and diabetes mellitus, known risk factors for CVD. Finally, there seems to be a disruption in the hypothalamic-pituitary-axis secondary to noise pollution that also results in an increased risk of CVD. The World Health Organization has estimated that the number of DALYs (disability-adjusted life-years) lost resulting from environmental noise in Western Europe ranges from 1 to 1.6 million, making noise the second major contributor to the burden of disease in Europe, only after air pollution. Thus, we sought to explore the relationship between noise pollution and risk of CVD.

Association of Depression and Cardiovascular Disease.

BACKGROUND: Cardiovascular disease remains the leading worldwide cause of mortality. There has been increased awareness of the impact of psychological health on cardiovascular disease. In particular, major depression has been linked to increased all-cause mortality, development of cardiovascular disease, and worse outcomes in those with existing cardiovascular disease. METHODS: We conducted a meta-analysis assessing the incidence of cardiovascular disease and cardiovascular disease outcomes among those with major depressive disorder. RESULTS: Among 26 studies of 1,957,621 individuals, depression was associated with increased risk of incident stroke (hazard ratio [HR] 1.13; 95% confidence interval [CI], 1.00-1.28), myocardial infarction (HR 1.28; 95% CI, 1.14-1.45), congestive heart failure (HR 1.04; 95% CI, 1.00-1.09), or any cardiovascular disease (HR 1.16; 95% CI, 1.04-1.30). Depression was associated with increased risk of all-cause mortality (HR 1.43; 95% CI, 1.27-1.60), cardiovascular disease mortality (HR 1.44; 95% CI, 1.27-1.63), and congestive heart failure mortality (HR 3.20; 95% CI, 1.29-7.94). CONCLUSION: Depression has a significant negative impact on development of cardiovascular disease and on cardiovascular disease outcomes. Further efforts to understand and mitigate these impacts are prudent.

Enteral long-chain polyunsaturated fatty acids and necrotizing enterocolitis: A systematic review and meta-analysis.

BACKGROUND: Preterm infants are at risk of long-chain polyunsaturated fatty acid (LCPUFA) deficiency. Recent studies on high-dose DHA; n-3 LCPUFA in preterm infants suggested potential positive effects on cognitive outcomes but raised concerns about some increased neonatal morbidities. These studies and recent recommendations for DHA supplementation generated controversy owing to the lack of balance between DHA and arachidonic acid (ARA; n-6 LCPUFA). OBJECTIVES: To identify the effect of enteral supplementation of DHA, with and without ARA, on necrotizing enterocolitis (NEC) in very preterm infants. METHODS: A systematic review of randomized and controlled trials compared enteral LCPUFAs with placebo or no supplementation in very preterm infants. We searched PubMed, Ovid-MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and CINHAL databases from inception to July 2022. Data were extracted in duplicate using a structured proforma. A meta-analysis and metaregression with random-effects models were used. The interventions evaluated were DHA alone vs. that combined with ARA, source of DHA, dose, and supplement delivery methods. Methodological qualities and risk of bias were assessed using the Cochrane risk-of-bias tool. RESULTS: Fifteen randomized clinical trials (RCTs) included 3963 very preterm infants with 217 cases of NEC. Supplementation with DHA alone increased NEC (2620 infants; RR: 1.56; 95% CI: 1.02, 2.39) with no evidence of heterogeneity (I2 = 0.0%, P = 0.46). Multiple metaregression revealed significant reduction in NEC when ARA was supplemented with DHA (aRR 0.42; 95% CI: 0.21, 0.88). The source of DHA, dose, and feeding type revealed no associations with NEC. Two RCTs supplemented high-dose DHA to lactating mothers. There was a significant increase in risk of NEC with this approach (1148 infants; RR: 1.92; 95% CI: 1.02, 3.61) with no evidence of heterogeneity (I2 = 0.0, P = 0.81). CONCLUSIONS: Supplementation with DHA alone may increase risk of NEC. Concurrent supplementation with ARA needs to be considered when adding DHA to preterm infants' diet.

Comparing Three Methods of Therapeutic Hypothermia Among Transported Neonates with Hypoxic-Ischemic Encephalopathy.

Hypoxic-ischemic encephalopathy (HIE) and associated multiorgan injury are significant causes of morbidity and mortality in term and near-term neonates. Therapeutic hypothermia (TH) is the current standard of care for neuroprotection in neonates with HIE. In our experience, the majority of babies born with HIE were found in nontertiary care facilities in our region, where effective methods of cooling during transport to tertiary care centers are desirable. Most centers initiate passive TH at referral hospitals, while active cooling is typically initiated during transport. The objective of this study was to evaluate the effectiveness of three methods of cooling during transport of neonates with HIE in southern Alberta. In this prospective cohort study, 186 neonates with HIE were transported between January 2013 and December 2021. Among the 186 neonates, 47 were passively cooled, 36 actively cooled with gel packs, and 103 cooled with a servo-controlled cooling device. The clinical characteristics were comparable for the three groups, with no difference in adverse events. Fifteen neonates (8%) died and 54 neonates (29%) suffered radiologically determined brain injury. Servo-controlled cooling was found to be superior to other methods in maintaining a target temperature without significant fluctuation during transport and with temperature in the target range on arrival at tertiary care facilities. The rate of overcooling was also lower in the servo-controlled group compared with other groups. There were no statistically significant differences between the groups in relation to mortality and brain MRI changes associated with HIE. Adjusting for GA, 10-minute Apgar score, base excess, HIE stage, and need for intubation during transport, passive cooling increased the odds of temperature fluctuation outside the range by 12-fold and gel pack cooling by 13-fold compared with servo-controlled cooling. The use of servo-controlled TH devices should be the preferred practice wherever feasible. (REB17-1334_REN3).

Hindmilk as a Rescue Therapy in Very Preterm Infants with Suboptimal Growth Velocity.

Despite advances in neonatal nutrition, very preterm infants remain at increased risk of extrauterine growth faltering. This prospective study aimed to examine the effect of hindmilk, the milk at the end of a breast expression session, on growth and plasma fatty acids (FAs) of infants born <30 weeks' gestation who had been on full enteral feeds for ≥2 weeks and had a weight gain of <15 g/kg/day despite optimizing energy and protein intakes. Weight and plasma FAs were assessed before and two weeks after feeding hindmilk. Growth anthropometrics were assessed weekly for four weeks. Paired t-tests and multiple linear regression were used for statistical analyses of data from 34 infants and their 29 mothers. There was a significant increase in weight gain in the two weeks after feeding hindmilk (MD 3.9, 95%CI 1.2-6.5 g/kg/day). Weight Z-scores were larger at two weeks (MD 0.61, 95%CI 0.02-1.20) and onwards. Head circumference Z-scores were larger at three weeks (MD 0.83, 95%CI 0.20-1.47) and onwards. Plasma linoleic acid (LA) and α-linolenic acid (ALA) increased after feeding hindmilk. In conclusion, hindmilk may improve weight and head growth and increase LA and ALA in very preterm infants with suboptimal growth. A large randomized controlled trial is required to examine and validate the potential benefits of hindmilk.

PM2.5 and Cardiovascular Health Risks.

PM2.5 is a frequently studied particulate matter metric, due to its wide range of identified overall adverse health effects, particularly cardiovascular health risks. However, there are no clear clinical practice guidelines for air pollution in regard to the prevention of cardiovascular health risks, since most of the current medical guidelines for CVD focus on metabolic risk factors such as hyperlipidemia or diabetes. We sought to determine the relationship between PM2.5 and cardiovascular disease, cardiovascular events, and all-cause mortality by performing a systematic review and meta-analysis. We searched Ovid MEDLINE, Ovid Embase, Ovid Cochrane Database of Systematic Reviews, Scopus, and Web of Science from the database inception to December 2022 for studies that reported an association between PM2.5 and cardiovascular disease, cardiovascular events, and all-cause mortality. We used the DerSimonian & Laird random-effects method to pool hazard ratios or risk ratios separately from the included studies. Of the total 18 prospective studies, 7,300,591 individuals were followed for a median follow-up of 9 years. Compared to low long-term exposure to PM 2.5 levels, an increase in exposure to PM 2.5 levels resulted in an increase in all-cause mortality (HR 1.08 95% CI of 1.05-1.11, P < 0.05). Similarly, when compared to a low long-term exposure to PM 2.5 levels, an increase in exposure to PM 2.5 levels resulted in an increase in cardiovascular disease (HR 1.09, 95% CI of 1.00-1.18, P < 0.05) and an increase in cardiovascular disease mortality (HR 1.12, 95% CI of 1.07-1.18, P < 0.05). Increased exposure to PM 2.5 levels is significantly associated with an increased risk of all-cause mortality, cardiovascular disease, and cardiovascular disease mortality. Although federal primary and secondary standards are in place, those standards are not low enough to prevent CVD health effects. Clinicians should emphasize PM2.5 as a modifiable CV risk factors for their patients to potentially reduce the development of CV complications. A clinical action guideline is needed specifically for air pollution effects on CVD, and how to mitigate them.