When Does Primary Prevention Encroach on Secondary Prevention?

PURPOSE OF REVIEW: The risk of incident atherosclerotic cardiovascular disease (ASCVD) in primary prevention is typically lower than in secondary prevention. However, there is a spectrum of risk among individuals undergoing primary prevention with the risk in some individuals approaching those of secondary prevention. We review the clinical conditions wherein the risk in primary prevention is similar to that observed in secondary prevention. RECENT FINDINGS: Among individuals without established ASCVD, coronary artery calcium (CAC) scores ≥ 300 AU are associated with ASCVD event rates similar to secondary prevention populations. CAC score ≥ 1,000 AU are associated with an ASCVD risk seen in very high-risk secondary prevention populations. Interpretation of these observations must however consider differences in the risk reduction strategies. Current guidelines dichotomize ASCVD prevention into primary and secondary prevention, but certain primary prevention patients have an ASCVD risk equivalent to that of secondary prevention populations. Identifying higher risk primary prevention populations will allow for better risk mitigation strategies.

The Role and Implications of COVID-19 in Incident and Prevalent Heart Failure.

PURPOSE OF REVIEW: This review examines the pathophysiological interactions between COVID-19 and heart failure, highlighting the exacerbation of heart failure in COVID-19 patients. It focuses on the complex mechanisms driving worse outcomes in these patients. RECENT FINDINGS: Patients with pre-existing heart failure experience more severe symptoms and higher mortality rates due to mechanisms such as cytokine storms, myocardial infarction, myocarditis, microvascular dysfunction, thrombosis, and stress cardiomyopathy. Elevated biomarkers like troponin and natriuretic peptides correlate with severe disease. Long-term cardiovascular risks for COVID-19 survivors include increased incidence of heart failure, non-ischemic cardiomyopathy, cardiac arrest, and cardiogenic shock. COVID-19 significantly impacts patients with pre-existing heart failure, leading to severe symptoms and higher mortality. Elevated cardiac biomarkers are indicators of severe disease. Acute and long-term cardiovascular complications are common, calling for ongoing research into targeted therapies and improved management strategies to better prevent, diagnose, and treat heart failure in the context of COVID-19.

Outcomes in Patients with COVID-19 Infection Taking ACEI/ARB.

PURPOSE OF REVIEW: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus responsible for the aggressive coronavirus disease (COVID-19) pandemic. Recently, investigators have stipulated that COVID-19 patients receiving angiotensin-converting-enzyme inhibitors (ACEI) may be subject to poorer outcomes. This editorial presents the available evidence to guide treatment practices during this pandemic. RECENT FINDINGS: Recent studies from Wuhan cohorts provide valuable information about COVID-19. A cohort with 52 critically ill patients revealed cardiac injury in 12% of patients. Worse outcomes appear to be more prevalent in patients with hypertension and diabetes mellitus (DM), possibly due to overexpression of angiotensin-converting enzyme 2 (ACE2) receptor in airway alveolar epithelial cells. Investigators suspect that SARS-CoV-2 uses the ACE2 receptor to enter the lungs in a mechanism similar to SARS-CoV. Several hypotheses have been proposed to date regarding the net effect of ACEI/ARB on COVID-19 infections. Positive effects include ACE2 receptor blockade, disabling viral entry into the heart and lungs, and an overall decrease in inflammation secondary to ACEI/ARB. Negative effects include a possible retrograde feedback mechanism, by which ACE2 receptors are upregulated. Even though physiological models of SARS-CoV infection show a theoretical benefit of ACEI/ARB, these findings cannot be extrapolated to SARS-CoV-2 causing COVID-19. Major cardiology scientific associations, including ACC, HFSA, AHA, and ESC Hypertension Council, have rejected these correlation hypotheses. After an extensive literature review, we conclude that there is no significant evidence to support an association for now, but given the rapid evolvement of this pandemic, findings may change.

Mineralocorticoid Receptor Antagonists: a Comprehensive Review of Finerenone.

PURPOSE OF REVIEW: We aim to review the mechanism of action and safety profile of mineralocorticoid receptor antagonists (MRAs) and discuss the differences between selective and non-selective MRAs. More specifically, finerenone is a new medication that is currently under investigation for its promising cardiovascular and nephrological effects. RECENT FINDINGS: MRAs are well known for their utility in treating heart failure, refractory hypertension, and diverse nephropathies, namely, diabetic nephropathy. As their name denotes, MRAs inhibit the action of aldosterone at the mineralocorticoid receptor, preventing receptor activation. This prevents remodeling, decreases inflammation, and improves proteinuria. There are not significant differences in outcomes between selective and non-selective MRAs. A new selective MRA named finerenone (originally BAY 94-8862) has shown promising results in several trials (ARTS-HF and ARTS-DN) and smaller studies. Finerenone may have a dose-dependent benefit over older MRAs, decreasing rates of albuminuria and levels of BNP and NT-ProBNP without causing a significant increase in serum potassium levels. This medication is not yet approved as it is still in phase 3 clinical trials (FIGARO-DKD and FIDELIO-DKD trials). MRAs are beneficial in several disease states. Newer medications, such as finerenone, should be considered in patients with heart failure and diabetic nephropathy who may benefit from a reduction in albuminuria and BNP/NT-ProBNP. Data surrounding finerenone are limited to date. However, results from ongoing clinical trials, as well as new trials to evaluate use in other pathologies, could validate the implementation of this medication in daily practice.

The Role of Anticoagulation in COVID-19-Induced Hypercoagulability.

PURPOSE OF REVIEW: We aim to provide a comprehensive analysis of hypercoagulability in individuals affected by COVID-19. Our goal is to describe the hypercoagulable state related to the infection and provide guidance regarding the possible benefits of anti-coagulation with the support of evidence from current literature. RECENT FINDINGS: The incidence of thrombotic disease in individuals affected by COVID-19 is reported as high as 31%. A significant mortality benefit has been observed with the use of therapeutic anticoagulation in high-risk individuals. Literature supports the use of scoring systems, such as the sepsis-induced coagulopathy score, to risk-stratify individuals who might benefit from anticoagulation. COVID-19-induced hypercoagulability has been demonstrated to play a significant role in overall COVID-19 outcomes. Current literature shows promising evidence with the use of therapeutic anticoagulation in high-risk individuals. Further studies are needed to better analyze the risks and benefits of anticoagulation in this specific patient population.

Cases and etiologies of suspected COVID-19 reactivation.

Our article outlines a perspective on COVID-19 reactivation with considerations of implored commentary on behalf of the medical community regarding open discourse about this subject. Such a topic is paramount in elucidating parameters that pertain to testing, and subsequent public health population dynamics once uneventful cases pass. We argue that what some may refer to as a reinfection or reactivation of the virus, is actually a result of prolonged shedding of the virus complemented with occasional false positives/negatives and lab errors. This article was written with the perspective of informing in addition to engage discussions that distill salient, evidence-based characterization of COVID-19. We hope to recruit fellow academics in medicine who see trends in their own respective communities about people who re-test, and to explore their clinical outcomes.

Positive Pressure Ventilation in Cardiogenic Shock: Review of the Evidence and Practical Advice for Patients With Mechanical Circulatory Support.

Cardiogenic shock (CS) is often complicated by respiratory failure, and more than 80% of patients with CS require respiratory support. Elevated filling pressures from left-ventricular (LV) dysfunction lead to alveolar pulmonary edema, which impairs both oxygenation and ventilation. The implementation of positive pressure ventilation (PPV) improves gas exchange and can improve cardiovascular hemodynamics by reducing preload and afterload of the LV, reducing mitral regurgitation and decreasing myocardial oxygen demand, all of which can help augment cardiac output and improve tissue perfusion. In right ventricular (RV) failure, however, PPV can potentially decrease preload and increase afterload, which can potentially lead to hemodynamic deterioration. Thus, a working understanding of cardiopulmonary interactions during PPV in LV and RV dominant CS states is required to safely treat this complex and high-acuity group of patients with respiratory failure. Herein, we provide a review of the published literature with a comprehensive discussion of the available evidence on the use of PPV in CS. Furthermore, we provide a practical framework for the selection of ventilator settings in patients with and without mechanical circulatory support, induction, and sedation methods, and an algorithm for liberation from PPV in patients with CS.

Sarcoidosis y amiloidosis secundaria, una rara asociación / Sarcoidosis and secondary Amyloidosis, an uncommon association

Resumen La sarcoidosis es una enfermedad granulomatosa crónica relacionada frecuentemente con antígenos ambientales e infecciones. Sin embargo, no se ha logrado identificar una causa clara en todos los escenarios. Por su parte, la amiloidosis secundaria se caracteriza por el depósito de proteína amiloide AA en los diferentes tejidos, la cual se asocia a procesos inflamatorios crónicos. Es supremamente infrecuente coincidir con estas dos enfermedades ya que no existe una relación de causalidad directa. A continuación presentamos un caso de un paciente con hallazgos de esta rara asociación.

Abstract Sarcoidosis is a chronic granulomatous disease, frequently attributed to environmental antigens (organic and inorganic) and infections. However, it is quite common not to find a clear cause behind this pathology. Alternatively, secondary amyloidosis is characterized my Amyloid AA protein deposition in different tissues, which is associated with chronic inflammation. Nonetheless, it is extremely uncommon to find both sarcoidosis and secondary AA amyloidosis simultaneously provided that there is no a clear causality relationship between both. We present an interesting case of a patient with this uncommon duality.

Subcutaneous implantable defibrillator: a therapeutic alternative for prevention of sudden cardiac death / Desfibrilador implantable subcutáneo: una alternativa terapéutica para la prevención de la muerte súbita cardiaca

Abstract: The transvenous implantable cardiac defibrillator (T-ICD) is currently considered the standard of care for prevention of sudden cardiac death in patients with structural cardiac disease or channelopathies. However, the use of these devices is associated with a significant increase of short and long-term complications, mostly related to intravascular leads. The subcutaneous implantable cardiac defibrillator (S-ICD) is a novel alternative for high-risk patients susceptible to intravascular lead complications, with a similar efficacy as T-ICD. Multiple ongoing clinical trials involving the S-ICD are expected to provide additional information about safety, use and benefits in the clinical setting.

Resumen: El desfibrilador cardiaco implantable transvenoso (DCI-T) se considera actualmente el tratamiento estándar para la prevención de la muerte súbita cardiaca en pacientes con enfermedad cardiaca estructural o canalopatías. Sin embargo, el uso de estos dispositivos se asocia con un aumento significativo de complicaciones a corto y largo plazo, principalmente relacionadas con derivaciones intravasculares. El desfibrilador cardiaco implantable subcutáneo (DCI-S) es una alternativa novedosa para pacientes de alto riesgo susceptibles a complicaciones intravasculares, con una eficacia similar al DCI-T. Se espera que varios ensayos clínicos en curso que involucran al DCI-S brinden información adicional sobre seguridad, uso y beneficios en el entorno clínico.