Updates on New Therapies for Patients with CKD.

Individuals diagnosed with chronic kidney disease (CKD) continue to increase globally. This group of patients experience a disproportionately higher risk of cardiovascular (CV) events compared to the general population. Despite multiple guidelines-based medical management, patients with CKD continue to experience residual cardiorenal risk. Several potential mechanisms explain this excessive CV risk observed in individuals with CKD. Several new drugs have become available that could potentially transform CKD care, given their efficacy in this patient population. Nevertheless, use of these drugs presents certain benefits and challenges that are often underrecognized by prescribing these drugs. In this review, we aim to provide a brief discussion about CKD pathophysiology, limiting our discussion to recent published studies. We also explore benefits and limitations of newer drugs, including angiotensin receptor/neprilysin inhibitors (ARNI), sodium glucose transporter 2 inhibitors (SGLT2i), glucagon-like peptides-1 (GLP-1) agonists and finerenone in patients with CKD. Despite several articles covering this topic, our review provides an algorithm where subgroups of patients with CKD might benefit the most from such drugs based on the selection criteria of the landmark trials. Patients with CKD who have nephrotic range proteinuria beyond 5000 mg/g, or those with poorly controlled blood pressure (systolic ≥160 mm Hg or diastolic ≥100 mm Hg) remain understudied.

Mid- and long-term risk of atrial fibrillation among breast cancer surgery survivors.

BACKGROUND: The risk of incident atrial fibrillation (AF) among breast cancer survivors, especially for younger women, and cancer treatment effects on the association remain unclear. This study aimed to investigate the risk of AF among breast cancer survivors and evaluate the association by age group, length of follow-up, and cancer treatment. METHODS: Using data from the Korean Health Insurance Service database (2010-2017), 113,232 women newly diagnosed with breast cancer (aged ≥ 18 years) without prior AF history who underwent breast cancer surgery were individually matched 1:5 by birth year to a sample female population without cancer (n = 566,160) (mean[SD] follow-up, 5.1[2.1] years). Sub-distribution hazard ratios (sHRs) and 95% confidence intervals (CIs) considering death as a competing risk were estimated, adjusting for sociodemographic factors and cardiovascular/non-cardiovascular comorbidities. RESULTS: BCS had a slightly increased AF risk compared to their cancer-free counterparts (sHR 1.06; 95% CI 1.00-1.13), but the association disappeared over time. Younger BCS (age < 40 years) had more than a 2-fold increase in AF risk (sHR 2.79; 95% CI 1.98-3.94), with the association remaining similar over 5 years of follow-up. The increased risk was not observed among older BCS, especially those aged > 65 years. Use of anthracyclines was associated with increased AF risk among BCS (sHR 1.57; 95% CI 1.28-1.92), which was more robust in younger BCS (sHR 1.94; 95% CI 1.40-2.69 in those aged ≤ 50 years). CONCLUSIONS: Our findings suggest that younger BCS had an elevated risk of incident AF, regardless of the length of follow-up. Use of anthracyclines may be associated with increased mid-to-long-term AF risk among BCS.

Trends and cardiovascular outcomes of Takotsubo syndrome with cardiogenic shock vs. mixed cardiogenic and septic shock: a nationwide propensity matched analysis.

INTRODUCTION: Takotsubo syndrome (TTS), also known as stress-induced cardiomyopathy, can be complicated by shock. The outcomes of patients with TTS complicated with cardiogenic shock (CS) versus mixed cardiogenic and septic shock (MS) is not known. METHODS: We queried Nationwide Inpatient Sample (NIS) from 2009-2020 to compare TTS patients with CS and MS using International Classification of Disease, Ninth & Tenth Edition, Clinical Modification (ICD- 9 & 10-CM) coding. In-hospital outcomes were compared using one: one propensity score matched (PSM) analysis. The primary outcome was in-hospital mortality. RESULTS: Of 23,126 patients with TTS 17,132 (74%) had CS, and 6,269 (26%) had MS. The mean age was 67 years in CS and 66 years in MS, and majority of patients were female (n = 17,775, 77%). On adjusted multivariate analysis, MS patients had higher odds of in-hospital mortality (aOR 1.44, 95% CI 1.36-1.52), AKI (aOR 1.53, 95% CI 1.48-1.58), pressor requirement (aOR 1.37, 95% CI 1.25-1.50). However, had lower odds of MCS use (aOR 0.44, 95% CI 0.40-0.48) and cardiac arrest (aOR: 0.81, 95% CI 0.73-0.90) (p-value <0.0001). Mean LOS and inflation-adjusted hospital charges were higher in MS. CONCLUSION: MS in the setting of TTS have higher rates of in-hospital mortality, AKI, and pressor requirements.

Machine Learning in Cardiovascular Risk Prediction and Precision Preventive Approaches.

PURPOSE OF REVIEW: In this review, we sought to provide an overview of ML and focus on the contemporary applications of ML in cardiovascular risk prediction and precision preventive approaches. We end the review by highlighting the limitations of ML while projecting on the potential of ML in assimilating these multifaceted aspects of CAD in order to improve patient-level outcomes and further population health. RECENT FINDINGS: Coronary artery disease (CAD) is estimated to affect 20.5 million adults across the USA, while also impacting a significant burden at the socio-economic level. While the knowledge of the mechanistic pathways that govern the onset and progression of clinical CAD has improved over the past decade, contemporary patient-level risk models lag in accuracy and utility. Recently, there has been renewed interest in combining advanced analytic techniques that utilize artificial intelligence (AI) with a big data approach in order to improve risk prediction within the realm of CAD. By virtue of being able to combine diverse amounts of multidimensional horizontal data, machine learning has been employed to build models for improved risk prediction and personalized patient care approaches. The use of ML-based algorithms has been used to leverage individualized patient-specific data and the associated metabolic/genomic profile to improve CAD risk assessment. While the tool can be visualized to shift the paradigm toward a patient-specific care, it is crucial to acknowledge and address several challenges inherent to ML and its integration into healthcare before it can be significantly incorporated in the daily clinical practice.

Impact of SGLT2 Inhibitors on AF Recurrence After Catheter Ablation in Patients With Type 2 Diabetes.

BACKGROUND: The effects of sodium-glucose cotransporter 2 inhibitors (SGLT2-Is) on recurrent atrial fibrillation (AF) among patients undergoing catheter ablation is not well described. OBJECTIVES: This study sought to assess the impact of SGLT2-Is on the recurrence of AF among patients with type 2 diabetes mellitus (DM) after catheter ablation. METHODS: Using the TriNetX research network, we identified, by means of Current Procedural Terminology codes, patients ≥18 years of age with type 2 diabetes mellitus (DM) who had undergone AF ablation from April 1, 2014, to November 30, 2021. Patients were stratified based on the baseline SGLT2-I use. Propensity-score matching resulted in 2,225 patients in each cohort. The primary outcome was a composite of cardioversion, new antiarrhythmic drug (AAD) therapy, or re-do AF ablation after a blanking period after the index ablation. Additional outcomes included heart failure exacerbations, ischemic stroke, all-cause hospitalization, and death during 12 months of follow-up. RESULTS: SGLT2-I use in patients with type 2 DM undergoing AF ablation was associated with a significantly lower risk of cardioversion, new AAD therapy, and re-do AF ablation (adjusted OR: 0.68; 95% CI: 0.602-0.776; P < 0.0001). At 12 months, patients on SGLT2-Is had a higher probability of event-free survival (HR: 0.85, 95% CI: 0.77-0.95; log-rank test chi-square = 8.7; P = 0.003). All secondary outcomes were lower in the SGLT2I group; however, the ischemic stroke did not differ between groups. CONCLUSIONS: Use of SGLT2-Is in patients with type 2 DM is associated with a lower risk of arrhythmia recurrence after AF ablation and thence a reduced need for cardioversion, AAD therapy, or re-do AF ablation.

Cardiovascular outcomes of type 2 myocardial infarction among COVID-19 patients: a propensity matched national study.

BACKGROUND: Myocardial infarction Type II (T2MI) is a prevalent cause of troponin elevation secondary to a variety of conditions causing stress/demand mismatch. The impact of T2MI on outcomes in patients hospitalized with COVID-19 is not well studied. METHODS: The Nationwide Inpatient Sample database from the year 2020 was queried to identify COVID-19 patients with T2MI during the index hospitalization. Clinical Modification (ICD-10-CM) codes 'U07.1' and 'I21.A1' were used as disease identifiers for COVID-19 and T2MI respectively. Multivariate adjusted Odds ratio (aOR) and propensity score matching (PSM) was done to compare outcomes among COVID patients with and without T2MI. The primary outcome was in-hospital mortality. RESULTS: A total of 1,678,995 COVID-19-weighted hospitalizations were identified in the year 2020, of which 41,755 (2.48%) patients had T2MI compared to 1,637,165 (97.5%) without T2MI. Patients with T2MI had higher adjusted odds of in-hospital mortality (aOR 1.44, PSM 32.27%, 95% CI 1.34-1.54) sudden cardiac arrest (aOR 1.29, PSM 6.6%, 95% CI 1.17-1.43) and CS (aOR 2.16, PSM 2.73%, 95% CI 1.85-2.53) compared to patients without T2MI. The rate of coronary angiography (CA) in T2MI with COVID was 1.19%, with significant use of CA among patients with T2MI complicated by CS compared to those without CS (4% vs 1.1%, p < 0.001). Additionally, COVID-19 patients with T2MI had an increased prevalence of sepsis compared to COVID-19 without T2MI (48% vs 24.1%, p < 0.001). CONCLUSION: COVID-19 patients with T2MI had worse cardiovascular outcomes with significantly higher in-hospital mortality, SCA, and CS compared to those without T2MI. Long-term mortality and morbidity among COVID-19 patients who had T2MI will need to be clarified in future studies. [Figure: see text].

Artificial Intelligence, Wearables and Remote Monitoring for Heart Failure: Current and Future Applications.

Substantial milestones have been attained in the field of heart failure (HF) diagnostics and therapeutics in the past several years that have translated into decreased mortality but a paradoxical increase in HF-related hospitalizations. With increasing data digitalization and access, remote monitoring via wearables and implantables have the potential to transform ambulatory care workflow, with a particular focus on reducing HF hospitalizations. Additionally, artificial intelligence and machine learning (AI/ML) have been increasingly employed at multiple stages of healthcare due to their power in assimilating and integrating multidimensional multimodal data and the creation of accurate prediction models. With the ever-increasing troves of data, the implementation of AI/ML algorithms could help improve workflow and outcomes of HF patients, especially time series data collected via remote monitoring. In this review, we sought to describe the basics of AI/ML algorithms with a focus on time series forecasting and the current state of AI/ML within the context of wearable technology in HF, followed by a discussion of the present limitations, including data integration, privacy, and challenges specific to AI/ML application within healthcare.

First Report Of 50-Day Continuous Fasting in Symptomatic Multivessel Coronary Artery Disease and Heart Failure: Cardioprotection Through Natural Ketosis.

A 64-year-old man with angina and dyspnea due to severe two vessel coronary artery disease (CAD) was recommended for revascularization. The patient had recently learned Siddha fasting and self-inquiry meditative methods at Heartful Living, our eight-week physicianled cardiac wellness group clinic. He declined coronary artery bypass surgery and instead self-initiated a 50-day water-only fast and then switched to a vegan diet. During the fast, the patient experienced severe dehydration and electrolyte abnormalities, requiring IV fluids and electrolyte replacement. However, his hemodynamics remained stable and he had no angina, likely due to natural ketosis mediated cardioprotection. This is the first report of such a prolonged fast targeting cardiac resilience and clinical benefits in severe CAD.

A Case Report on Diagnostic Approach of a Complex Clinical Scenario: Differentiation Between Coronary Artery Disease and Apical Hypertrophic Cardiomyopathy as a Cause of Recurrent Debilitating Angina.

Apical hypertrophic cardiomyopathy (ApHCM) is a clinical challenge when presenting with symptoms of angina plus shortness of breath. An appropriate diagnosis of concurrent coronary artery disease (CAD) is needed for proper diagnosis, risk stratification, and management. We present a case of a 64-year-old gentleman with a history of ApHCM and CAD with previous percutaneous intervention presenting with recurrent angina. A repeat coronary angiography showed no new obstructive lesions. A stress cardiac magnetic resonance imaging was performed, which showed perfusion defect in the apex with apical scarring likely secondary to microvascular disease. The patient was managed medically with the improvement of symptoms. Diagnosis and management of CAD in patients with ApHCM are challenging. Multiple diagnostic modalities may be required for delineating the underlying pathology. Patients should be managed initially with medications. If symptoms are not controlled with medical management, a heart team approach with referral to an advanced center experienced in apical myectomy should be considered.

A case report on transient cardiomyopathy with cytokine storm in SARS-CoV-2.

BACKGROUND: Cardiac manifestations during Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2) pandemic have included acute coronary syndrome, arrhythmias, myocarditis, and stress cardiomyopathy. However, the combination of cardiomyopathy and negative cardiac biomarkers has not yet been reported. CASE SUMMARY: A 49-year-old man admitted for respiratory failure secondary to SARS-CoV-2 developed new-onset cardiomyopathy with negative cardiac biomarkers. Left ventricular ejection fraction and strain improved 7 days after the initial echocardiogram, after administration of Tocilizumab, coinciding with clinical recovery, and improvement in inflammatory markers. DISCUSSION: As experience of cardiovascular manifestations of SARS-CoV-2 increases, more patients will likely present with cardiovascular manifestations; the recognition and proper management of these may improve patient outcomes.

Acute retinal necrosis secondary to Varicella Zoster Virus.

A 54 year old female presented to the ophthalmology clinic with pain and decreased vision in her left eye. No past medical history other than primary varicella zoster infection, in her childhood. The eye exam revealed a macular region with scattered areas of retinal opacity along with patches of necrosis on the periphery. She was started on valganciclovir and referred to the infectious disease clinic. Cell Count, blood chemistry and HIV were negative. Serum was sent for polymerase chain reaction (PCR) for Varicella Zoster Virus (VZV), Herpes Simplex Virus (HSV) and Cytomegalovirus (CMV). The VZV PCR was positive. She had decreased vision on the right eye two days later, and exam revealed peripheral retinal whitening. She was admitted and started on intravenous acyclovir. VZV is one of the most common causes of ARN and has been described in both immunocompetent and immunocompromised persons. Visual changes are usually noted weeks to months after the antecedent herpes zoster. Retinal involvement is bilateral in over half of cases, suggesting that VZV reaches the central nervous system hematogenously. The retinal exam reveals multifocal necrotizing lesions, often initially involving the peripheral retina. Therapy includes intravenous acyclovir with consideration of intravitreal foscarnet and other antivirals for progressing disease.

Novel Use of N-Acetylcysteine in Management of Tyrosine Kinase Inhibitor Induced Acute Liver Injury.

Tyrosine kinase inhibitors (TKIs) have been adopted in the treatment of a variety of malignancies. Despite their popularity, the underlying mechanism of the adverse effects seen with the use of TKIs is not completely understood. Acute liver injury is a known side effect of many of these drugs. Some papers have demonstrated that N-acetylcysteine may have a role in non-acetaminophen induced acute liver failure (NAI-ALF). There is little evidence supporting the use of N-acetylcysteine in the treatment of tyrosine kinase inhibitor-induced acute liver injury. This case report adds to the limited body of existing knowledge. We present a 67-year-old Caucasian female with a past medical history of anxiety, hyperlipidemia, in utero exposure to diethylstilbestrol (DES), and well-differentiated angiosarcoma of the right breast. She achieved remission for approximately six years after mastectomy with adjuvant chemotherapy and radiation. Subsequent surveillance imaging revealed new hepatic and cervical lesions. Further investigation with cutaneous biopsy near the occipital region confirmed recurrent metastatic angiosarcoma. The patient was started on high-dose pazopanib and initially tolerated the TKI without any adverse effects. However, after approximately two weeks of therapy, she began to experience dark colored urine, myalgias, and fatigue. These symptoms, along with significant elevations in liver enzymes (alanine transaminase of 1377 units/L, aspartate transaminase of 1212 units/L), prompted admission for evaluation of acute liver injury. The etiology of the acute liver injury was suspected to be secondary to TKI therapy. Treatment with intravenous N-acetylcysteine was initiated for non-acetaminophen induced acute liver failure (NAI-ALF) and resulted in a dramatic improvement in transaminases before discharge. Evidence suggests that there is a beneficial role for N-acetylcysteine in the management of NAI-ALF. However, when it comes specifically to the management of TKI induced acute liver injury, there is limited evidence to support its use. This case report highlights a possible use of N-acetylcysteine in the management of TKI mediated acute liver injury. Additional studies should be conducted to determine the role N-acetylcysteine plays in the management of TKI mediated liver injury.