RESUMEN
Patients with type 2 diabetes face an elevated risk of cardiovascular disease. This review centers on sodium-glucose cotransporter-2 (SGLT2) inhibitors, a class of drugs that, according to a growing body of evidence, may have major potential for managing cardiovascular disease in patients with type 2 diabetes. This review presents findings from multiple clinical trials suggesting that SGLT2 inhibitors can not only serve as preventive therapeutic agents but also play a role in the active management of heart failure. The discussion includes the mechanism of action of SGLT2 inhibitors, emphasizing that they enhance urinary glucose excretion, which could lead to improved glycemic control and contribute to metabolic shifts beneficial to cardiac function. Alongside these cardiometabolic effects, safety concerns and practical considerations for prescribing these agents are addressed, taking into account potential adverse effects such as genitourinary infections and diabetic ketoacidosis as well as the financial implications for patients. Despite these drawbacks, therapeutic indications for SGLT2 inhibitors continue to expand, including for kidney protection, although further research is necessary to fully understand the mechanisms driving the cardioprotective and kidney-protective effects of SGLT2 inhibitors. By synthesizing current knowledge, this review intends to inform and guide clinical decision-making, thereby enhancing cardiovascular disease outcomes in patients with type 2 diabetes.
Asunto(s)
Cardiología , Enfermedades Cardiovasculares , Diabetes Mellitus Tipo 2 , Inhibidores del Cotransportador de Sodio-Glucosa 2 , Humanos , Enfermedades Cardiovasculares/etiología , Enfermedades Cardiovasculares/prevención & control , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Glucosa/metabolismo , Hipoglucemiantes/efectos adversos , Sodio/metabolismo , Inhibidores del Cotransportador de Sodio-Glucosa 2/efectos adversosRESUMEN
Artificial intelligence in diagnostic cardiac-imaging platforms is advancing rapidly. In particular, artificial intelligence algorithms have increased the efficiency and accuracy of echocardiographic cardiovascular imaging, resulting in more complex echocardiographic imaging techniques and expanded use among noncardiologists. Here, we provide an overview of real-world applications of artificial intelligence in echocardiography including automatic high-quality computer-optimized image acquisition sequences, automated measurements, and algorithms for the rapid and accurate interpretation of cardiac physiology. These advances will not replace physicians but will improve their productivity, workflow, and diagnostic performance.
Asunto(s)
Inteligencia Artificial , Ecocardiografía , Algoritmos , HumanosRESUMEN
BACKGROUND: Chest radiation therapy (CRT) for malignant thoracic neoplasms is associated with development of valvular heart disease years later. As previous radiation exposure can complicate surgical treatment, transcatheter aortic valve replacement (TAVR) has emerged as an alternative. However, outcomes data are lacking for TAVR patients with a history of CRT. METHODS: We conducted a retrospective study of all patients who underwent a TAVR procedure at a single institution between September 2012 and November 2018. Among 1341 total patients, 50 had previous CRT. These were propensity-matched in a 1:2 ratio to 100 patients without history of CRT. Thirty-day adverse events were analyzed with generalized estimating equation models. Overall mortality was analyzed with stratified Cox regression modelling. RESULTS: Median clinical follow-up was 24 months (interquartile range [IQR], 12-44 months). There was no difference between CRT and non-CRT patients in overall mortality (hazard ratio [HR] 0.84 [0.37-1.90], P = 0.67), 30-day mortality (HR 3.1 [0.49-20.03], P = 0.23), or 30-day readmission rate (HR 1.0 [0.43-2.31], P = 1). There were no differences in the rates of most adverse events, but patients with CRT history had higher rates of postprocedural respiratory failure (HR 3.63 [1.32-10.02], P = 0.01) and permanent pacemaker implantation (HR 2.84 [1.15-7.01], P = 0.02). CONCLUSIONS: For patients with aortic valve stenosis and previous CRT, TAVR is safe and effective, with outcomes similar to those in the general aortic stenosis population. Patients with history of CRT are more likely to have postprocedural respiratory failure and to require permanent pacemaker implantation.
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Estenosis de la Válvula Aórtica , Implantación de Prótesis de Válvulas Cardíacas , Reemplazo de la Válvula Aórtica Transcatéter , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/cirugía , Humanos , Readmisión del Paciente , Estudios Retrospectivos , Factores de Riesgo , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Resultado del TratamientoAsunto(s)
Antiinfecciosos/uso terapéutico , Presión Sanguínea/fisiología , Hipertensión , Complicaciones Cardiovasculares del Embarazo , Diagnóstico Prenatal , Congresos como Asunto , Femenino , Humanos , Hipertensión/tratamiento farmacológico , Hipertensión/epidemiología , Hipertensión/fisiopatología , EmbarazoAsunto(s)
Antihipertensivos/uso terapéutico , Presión Sanguínea/efectos de los fármacos , Hipertensión/tratamiento farmacológico , Adulto , Anciano , Antihipertensivos/efectos adversos , Comorbilidad , Quimioterapia Combinada , Femenino , Humanos , Hipertensión/diagnóstico , Hipertensión/epidemiología , Hipertensión/fisiopatología , Masculino , Persona de Mediana Edad , Prevalencia , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores de Riesgo , Resultado del Tratamiento , Adulto JovenAsunto(s)
Neoplasias Cardíacas/diagnóstico por imagen , Linfoma de Células B Grandes Difuso/diagnóstico por imagen , Imagen por Resonancia Magnética , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Neoplasias Cardíacas/tratamiento farmacológico , Neoplasias Cardíacas/patología , Humanos , Linfoma de Células B Grandes Difuso/tratamiento farmacológico , Linfoma de Células B Grandes Difuso/patología , Masculino , Persona de Mediana Edad , Miocardio/patología , Valor Predictivo de las Pruebas , Resultado del TratamientoRESUMEN
Why do we stay in prison when the door is wide open? - Jalal ad-Din Rumi. Depression is an independent risk factor for the development of CAD. Patients with CAD have a high rate of depression, which worsens their prognosis. Screening CAD patients with the 2-question PHQ-2 to identify those at greatest risk of depression is strongly recommended, as is referring patients for further evaluation and possible treatment when depression has been identified by the PHQ-9. Treating depression is likely to improve cardiovascular outcomes. The PHQs are in the public domain and free to use. To download and for more information, visit www. phqscreeners.com.
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Depresión/diagnóstico , Depresión/terapia , Cardiopatías/prevención & control , Depresión/epidemiología , Depresión/mortalidad , Medicina Basada en la Evidencia , Cardiopatías/diagnóstico , Cardiopatías/epidemiología , Cardiopatías/mortalidad , Humanos , Valor Predictivo de las Pruebas , Prevalencia , Pronóstico , Escalas de Valoración Psiquiátrica , Medición de Riesgo , Factores de Riesgo , Encuestas y CuestionariosRESUMEN
As public awareness and clinical use of CAC screening increases, physicians should, at a minimum, know the following information: 1) The presence of CAC indicates underlying CHD but does not predict luminal obstruction. 2) Non-contrast, prospectively ECG-gated cardiac EBCT and MDCT are sensitive, reproducible, rapid, and essentially equivalent imaging techniques commonly used to screen for CAC. 3) Currently, CAC screening is appropriate for all intermediate- risk patients and low-risk patients with a family history of premature CHD, and might be appropriate for all low-risk women. 4) The risks associated with CAC screening are a small but measurable excess risk of cancer and the risk of unnecessary downstream tests and procedures. 5) A CAC score of zero has a very high negative predictive value for CHD events. 6) Increasingly positive (non-zero) CAC scores are directly proportional to increased CHD event risk, and a CAC score >100 or greater than the 75th percentile indicates high risk. 7) Repeat screening to determine CAC progression or regression is not currently recommended.
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Angiografía Coronaria/métodos , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Tomografía Computarizada Multidetector , Tomografía Computarizada por Rayos X , Calcificación Vascular/diagnóstico por imagen , Enfermedades Asintomáticas , Angiografía Coronaria/efectos adversos , Angiografía Coronaria/economía , Enfermedad de la Arteria Coronaria/economía , Medicina Basada en la Evidencia , Femenino , Costos de la Atención en Salud , Humanos , Masculino , Tomografía Computarizada Multidetector/efectos adversos , Tomografía Computarizada Multidetector/economía , Selección de Paciente , Guías de Práctica Clínica como Asunto , Valor Predictivo de las Pruebas , Pronóstico , Dosis de Radiación , Medición de Riesgo , Factores de Riesgo , Tomografía Computarizada por Rayos X/efectos adversos , Tomografía Computarizada por Rayos X/economía , Calcificación Vascular/economíaRESUMEN
BACKGROUND: The optimal type of stem cell for use in patients with ischemic heart disease has not been determined. A primitive population of bone marrow-derived hematopoietic cells has been isolated by the presence of the enzyme aldehyde dehydrogenase and comprises a multilineage mix of stem and progenitor cells. Aldehyde dehydrogenase-bright (ALDH(br)) cells have shown promise in promoting angiogenesis and providing perfusion benefits in preclinical ischemia studies. We hypothesize that ALDH(br) cells may be beneficial in treating ischemic heart disease and thus conducted the first randomized, controlled, double-blind study to assess the safety of the transendocardial injection of autologous ALDH(br) cells isolated from the bone marrow in patients with advanced ischemic heart failure. METHODS: Aldehyde dehydrogenase-bright cells were isolated from patients' bone marrow on the basis of the expression of a functional (aldehyde dehydrogenase) marker. We enrolled 20 patients (treatment, n = 10; control, n = 10). Safety (primary end point) and efficacy (secondary end point) were assessed at 6 months. RESULTS: No major adverse cardiovascular or cerebrovascular events occurred in ALDH(br)-treated patients in the periprocedural period (up to 1 month); electromechanical mapping-related ventricular tachycardia (n = 2) and fibrillation (n = 1) occurred in control patients. Aldehyde dehydrogenase-bright-treated patients showed a significant decrease in left ventricular end-systolic volume at 6 months (P = .04) and a trend toward improved maximal oxygen consumption. The single photon emission computed tomography delta analysis showed a trend toward significant improvement in reversibility in cell-treated patients (P = .053). CONCLUSIONS: We provide preliminary evidence that treatment with the novel cell population, ALDH(br) cells, is safe and may provide perfusion and functional benefits in patients with chronic myocardial ischemia.
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Aldehído Deshidrogenasa/farmacología , Insuficiencia Cardíaca/terapia , Isquemia Miocárdica/terapia , Trasplante de Células Madre/métodos , Mapeo del Potencial de Superficie Corporal , Método Doble Ciego , Endocardio , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/complicaciones , Insuficiencia Cardíaca/diagnóstico , Humanos , Inyecciones , Masculino , Persona de Mediana Edad , Isquemia Miocárdica/complicaciones , Isquemia Miocárdica/diagnóstico , Proyectos Piloto , Tomografía Computarizada de Emisión de Fotón Único , Trasplante Autólogo , Resultado del TratamientoRESUMEN
BACKGROUND: Autologous bone marrow mononuclear cell (ABMMNC) therapy has shown promise in patients with heart failure (HF). Cell function analysis may be important in interpreting trial results. METHODS: In this prospective study, we evaluated the safety and efficacy of the transendocardial delivery of ABMMNCs in no-option patients with chronic HF. Efficacy was assessed by maximal myocardial oxygen consumption, single photon emission computed tomography, 2-dimensional echocardiography, and quality-of-life assessment (Minnesota Living with Heart Failure and Short Form 36). We also characterized patients' bone marrow cells by flow cytometry, colony-forming unit, and proliferative assays. RESULTS: Cell-treated (n = 20) and control patients (n = 10) were similar at baseline. The procedure was safe; adverse events were similar in both groups. Canadian Cardiovascular Society angina score improved significantly (P = .001) in cell-treated patients, but function was not affected. Quality-of-life scores improved significantly at 6 months (P = .009 Minnesota Living with Heart Failure and P = .002 physical component of Short Form 36) over baseline in cell-treated but not control patients. Single photon emission computed tomography data suggested a trend toward improved perfusion in cell-treated patients. The proportion of fixed defects significantly increased in control (P = .02) but not in treated patients (P = .16). Function of patients' bone marrow mononuclear cells was severely impaired. Stratifying cell results by age showed that younger patients (≤60 years) had significantly more mesenchymal progenitor cells (colony-forming unit fibroblasts) than patients >60 years (20.16 ± 14.6 vs 10.92 ± 7.8, P = .04). Furthermore, cell-treated younger patients had significantly improved maximal myocardial oxygen consumption (15 ± 5.8, 18.6 ± 2.7, and 17 ± 3.7 mL/kg per minute at baseline, 3 months, and 6 months, respectively) compared with similarly aged control patients (14.3 ± 2.5, 13.7 ± 3.7, and 14.6 ± 4.7 mL/kg per minute, P = .04). CONCLUSIONS: ABMMNC therapy is safe and improves symptoms, quality of life, and possibly perfusion in patients with chronic HF.
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Trasplante de Médula Ósea/métodos , Insuficiencia Cardíaca/terapia , Anciano , Tomografía Computarizada por Emisión de Fotón Único Sincronizada Cardíaca , Proliferación Celular , Ensayo de Unidades Formadoras de Colonias , Femenino , Citometría de Flujo , Insuficiencia Cardíaca/etiología , Humanos , Masculino , Células Madre Mesenquimatosas , Persona de Mediana Edad , Isquemia Miocárdica/complicaciones , Estudios Prospectivos , Calidad de Vida , Método Simple CiegoAsunto(s)
Envejecimiento , Terapia de Reemplazo de Estrógeno , Cardiopatías/prevención & control , Salud de la Mujer , Factores de Edad , Anciano , Ensayos Clínicos como Asunto , Terapia de Reemplazo de Estrógeno/efectos adversos , Medicina Basada en la Evidencia , Femenino , Cardiopatías/etiología , Cardiopatías/mortalidad , Humanos , Persona de Mediana Edad , Selección de Paciente , Posmenopausia , Prevención Primaria , Medición de Riesgo , Factores de Riesgo , Prevención Secundaria , Factores Sexuales , Resultado del TratamientoAsunto(s)
Enfermedades Cardiovasculares/epidemiología , Salud de la Mujer , Factores de Edad , Anciano , Enfermedades Cardiovasculares/mortalidad , Enfermedades Cardiovasculares/prevención & control , Femenino , Humanos , Persona de Mediana Edad , Servicios Preventivos de Salud , Pronóstico , Medición de Riesgo , Factores de Riesgo , Conducta de Reducción del Riesgo , Factores Sexuales , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: We sought to examine the relationship between the degree of prosthesis-patient mismatch and long-term survival after mechanical aortic valve replacement. METHODS: Prospectively collected long-term follow-up data from 469 consecutive patients who underwent aortic valve replacement between 1995 and 1998 were reviewed. The indexed effective orifice area was derived from the reference normal values of effective orifice area divided by the patient's body surface area. Outcome was stratified according to the severity of prosthesis-patient mismatch: moderate mismatch was defined as 0.65 to 0.85 cm(2)/m(2) and severe mismatch as less than 0.65 cm(2)/m(2). The Cox proportional-hazards model with propensity score adjustment was used to adjust for the observed differences in baseline characteristics between the mismatch groups. RESULTS: The degree of prosthesis-patient mismatch was minimal in 57% of patients, moderate in 39%, and severe in 4%. Predictors of clinically significant mismatch included small aortic valve sizes (19 and 21 mm), obesity, age greater than 65 years, and class III or IV heart failure. During a median follow-up period of approximately 7.9 years, overall survival was 77% in patients with minimal mismatch, 63% in those with moderate mismatch, and only 47% in those with severe mismatch (P < .001). Moderate or severe mismatch was a significant predictor of poorer survival (hazard ratio, 1.6; 95% confidence interval, 1.4-2.3; P < .01), even after adjustment for all significant clinical predictors (ie, propensity score; hazard ratio, 1.2; 95% confidence interval, 1.0-1.5; P = .05). CONCLUSIONS: In a large aortic valve surgery population, prosthesis-patient mismatch occurred in 43% of patients, and those with significant mismatch had worse long-term outcomes than those with minimal mismatch.
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Estenosis de la Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Prótesis Valvulares Cardíacas/efectos adversos , Adulto , Anciano , Válvula Aórtica/anatomía & histología , Tamaño Corporal , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis de SupervivenciaRESUMEN
A right-to-left shunt in the presence of normal pulmonary artery pressure is an unusual cause of hypoxemia in an adult who has a patent foramen ovale. We report a rare case of such a shunt-the result of a right atrial thrombus that formed in a hypercoagulable patient after placement of an indwelling central venous catheter for chemotherapy. In order to ascertain the nature of the right atrial mass and to decrease the risk of systemic embolization, the thrombus was surgically removed with the patient on cardiopulmonary bypass.