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.

Novel Device Therapies for Heart Failure.

Heart failure (HF) therapeutics have advanced significantly over the past few years [...].

Hypertrophic Cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiomyopathy resulting from a mutation in one of several cardiac sarcomeric proteins [...].

The Roles of Coronary Computed Tomography Angiography in Characterizing Coronary Plaque: Screening, Treatment, and Prevention.

One of the major risk factors for coronary atherosclerosis is the gradual formation and maturation of coronary atherosclerotic plaque (CAP) [...].

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.

Meta-analysis comparing dexmedetomidine versus standard of care for sedation in patients with sepsis.

We aimed to evaluate the clinical benefits of dexmedetomidine (DEX) in comparison with the standard of care (SOC) sedation in critically ill, septic patients. Electronic databases (PubMed, EMBASE, Cochrane Central, Scopus, and Google Scholar) were systematically searched to identify only randomized clinical trials performed up until February 12, 2021. The primary outcomes were 28-day mortality, 90-day mortality, and intensive care unit (ICU) length of stay (LOS). We calculated risk ratios (RRs), 95% confidence intervals (CIs) for dichotomous data, and weighted mean differences (WMDs) for continuous data using a random-effects model. Seven randomized clinical trials were included, with a total of 529 patients in the DEX group and 520 patients in the SOC group. Compared with SOC, DEX was associated with a nonstatistically significant reduced 28-day mortality (RR = 0.76; 95% CI [0.51, 1.14]; P = 0.19), 90-day mortality (RR = 0.94; 95% CI [0.75, 1.18]; P = 0.60), and ICU LOS (WMD = -0.85; 95% CI [-2.60, 0.90]; P = 0.34). We conclude that among septic patients on sedation, the use of DEX in the ICU demonstrated no significant difference from SOC sedation protocols with respect to 28-day mortality, 90-day mortality, and total ICU LOS. Our findings suggest that DEX does not confer clinical benefit over SOC sedation in critically ill patients with sepsis.

Quality Improvement in Delirium Health Literacy in Older Adult Patients and Their Caregivers Attending a Geriatric Clinic.

Background: Delirium is a common medical condition that is highly prevalent in older adults who are at increased risk for its development with any illness, post-surgery or during hospitalization. The purpose of our study was to evaluate the health literacy of older adult patients and their caregivers about delirium, offer a brief educational intervention, and reevaluate their knowledge post intervention. Materials and Methods: We conducted a quality improvement project, focused on delirium health literacy in older adult patients ≥60 years and their caregivers. Delirium knowledge of participants was evaluated in a pre-education survey after which they were given a delirium education booklet to read. A post-education delirium survey was conducted within 2-3 weeks of the educational intervention. Chi-square test was used to analyze the knowledge base of older adults. Results: The study population consisted of a total of 70 older adults who participated in pre-education (n=35) and post-education (n=35) surveys. Older adult patients and their caregivers had significant knowledge gaps about the potential causes or etiologies, risk factors, symptomatology, and prevention of delirium in the pre-education survey. After the educational intervention, in the post-education survey, there were overall improvements in knowledge base of older adults in differentiating delirium with dementia (43% vs 94%, p<0.01) recognizing signs and symptoms (77% vs 94%, p<0.05), complications (76% vs 100%, p<0.01) and identifying the etiological factors associated with delirium. Conclusion: The quality improvement project demonstrated that older adults and caregivers have significant knowledge deficits about the common condition of delirium. This study also demonstrated that older adults were able to improve their health literacy regarding delirium after the intervention. Appropriate education on delirium for patients and caregivers might help in earlier identification, prevention, and better overall management of delirium.

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.

Ipilimumab and Nivolumab induced ventricular tachycardia in a patient with metastatic renal cell carcinoma.

The immune checkpoint inhibitor (ICIs) as Nivolumab and Ipilimumab is a novel class of medication used in the management of several metastatic malignancies. ICIs can cause immune-related adverse events due to autoreactive T cell activation. Cardiovascular complications comprised myocarditis, conduction abnormalities, ventricular storm, and cardiomyopathy. Cardiomyopathy is one of the significant side effects highlighted in some of the case reports. The physicians should include autoimmune toxicities as the potential differential diagnosis in patients presenting with an unusual presentation and receiving ICIs. We report a case of a 66-year-old female with advanced renal cell carcinoma who developed cardiomyopathy and ventricular tachycardia from nivolumab and ipilimumab therapy.

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.

In-hospital outcomes after percutaneous coronary interventions in cardiac allograft recipients.

INTRODUCTION: The average age and survival of heart transplant recipients have improved significantly over the last 10 years. In these long-term survivors, coronary allograft vasculopathy is one of the most common causes of death. There is a paucity of large-data research highlighting the short-term outcomes of percutaneous coronary interventions in cardiac allograft recipients. METHODS: We compared the in-hospital outcomes of heart transplant recipient and non-transplant recipients following percutaneous coronary intervention using data from the National inpatient sample (NIS). All adult patients (age ⩾ 18 years) who had percutaneous coronary intervention in the index admissions from January of 2005 to December of 2014 were included in the analysis. They were then divided into two groups based on their heart transplant status. The primary outcome was in-hospital mortality. Secondary outcomes were stroke, cardiac arrest, duration of hospitalization, and total hospital charges. Logistic regression models were used to compare in-hospital outcomes between the two groups. RESULTS: Of 1,316,528 patients who had percutaneous coronary intervention, 618 (0.05%) were heart transplant recipients and 1,315,910 (99.95%) were not. The heart transplant recipient group was significantly younger with lower rates of obesity and peripheral vascular disease but higher rate of chronic kidney disease, iron deficiency anemia, and chronic liver disease. There was significantly higher in-hospital mortality in transplant recipients below 65 years of age (adjusted odds ration = 2.3, p value < 0.0001). Subjects in the heart transplant recipient group also had longer hospital stays (p value = 0.002). CONCLUSION: Heart transplant recipients younger than 65 years had higher in-hospital mortality. Subjects in the heart transplant recipient group were also younger and had longer duration of hospitalization than the non-transplant cohorts.

Coronary artery occlusion following low-power catheter ablation.

Myocardial infarction (MI) is an unusual but potentially serious complication of catheter ablation procedures. This case describes the occurrence of acute myocardial infarction following low-power ablation in a young patient and highlights the importance of maintaining high index of suspicion following catheter ablation irrespective of the ablation power used. A 22-year-old patient had low-power ablation of the right posteroseptal accessory pathway in the ostium of the coronary sinus on account of persistently symptomatic WPW syndrome with orthodromic re-entrant tachycardia. Two hours after the procedure, she developed moderately severe chest pain. Electrocardiogram showed ST elevation in the inferior leads. Coronary angiography showed 100% stenosis of the right coronary artery just beyond the posterior descending artery. She failed balloon angioplasty and a drug eluting stent was placed in the posterolateral branch of the right coronary artery. The symptoms resolved and follow up echocardiogram showed normal left ventricular systolic and diastolic functions with no regional wall motion abnormality. This case demonstrates the occurrence of MI following low-power catheter ablation. Patients should be monitored for this complication irrespective of the ablation power used.

Is rheumatoid arthritis an innocent bystander in female reproductive problems? A comparative study of fertility in Nigerian women with and without rheumatoid arthritis.

OBJECTIVE: Contrary to the old belief that rheumatoid arthritis (RA) is rare in sub-Saharan Africa, recent reports have increasingly recognized that the burden of the disease has probably been long under-appreciated in West Africa. Thus, fertility and other attributes of the reproductive lives among women with RA have not received research attention in Africa. We aimed to compare the fertility between married Nigerian women with and without RA. METHODS: A comparative study of 50 women with RA and 50 women without RA was conducted via the specialist rheumatology clinics at two teaching hospitals in Nigeria. The participants were aged 18 years or older. Patients with RA were recruited on the basis of the fulfillment of the 1987 American College of Rheumatology classification criteria for RA, whereas the control participants were age-matched to the patients. Using an interviewer-administered questionnaire, demographic and clinical information was collected from each participant. Clinical details at the time of diagnosis of RA were extracted from the hospital records of the patients. The patients were tested for rheumatoid factor and anti-cyclic citrullinated peptide antibody, and the disease activity was assessed using the Clinical Disease Activity Index. The functional status was determined using the Steinbrocker functional classification. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 20 (IBM Corp.; Armonk, NY, USA). The proportions of individuals with history of infertility, irregular menstruation, and menopausal states were compared between the two groups using χ2 and Fisher's exact tests, whereas the durations of infertility and parities were compared using Mann-Whitney U and independent t-tests, respectively. RESULTS: A positive history of infertility was found in 22 (44%) patients and 14 (28%) controls (p=0.096), while 17 (34%) patients and 23 (46%) controls were found to be postmenopausal (p=0.221). History of irregular menstruation was present in 15 (30%) patients and 4 (8%) controls (p=0.005). The median duration of infertility was 60 (range: 16-132) months among the patients and 36 (range: 12-72) months among the controls (p=0.036), while the mean parity was 2.85±1.8 among the patients and 3.77±2.2 among the controls (p=0.027). A significant association was found between infertility and functional class as well as methotrexate treatment. CONCLUSION: Infertility is not uncommon among patients with RA, and like many aspects of rheumatic diseases, it may have been under-recognized in the Nigerian patients.