Recent updates on asymptomatic and symptomatic aortic valve stenosis its diagnosis, pathogenesis, management and future perspectives.

Aortic stenosis (AS) is very common in mid-aged and elderly patients, and it has been reported to have a negative impact on both short and long-term survival with a high mortality rate. The current study identified methods of diagnosis, incidence, and causes of AS, pathogenesis, intervention and management and future perspectives of Asymptomatic and Symptomatic Aortic stenosis. A systematic literature search was conducted using PubMed, Scopus and CINAHL, using the Mesh terms and key words "Aortic stenosis", "diagnostic criteria", "pathogenesis", "incidence and causes of AS" and" intervention and management strategies". Studies were retained for review after meeting strict inclusion criteria that included studies evaluating Asymptomatic and Symptomatic AS. Studies were excluded if duplicate publication, overlap of patients, subgroup studies of a main study, lack of data on AS severity, case reports and letters to editors. Forty-five articles were selected for inclusion. Incidence of AS across the studies ranged from 3 % to 7 %. Many factors have been associated with incidence and increased risk of AS, highest incidence of AS was described after aortic valve calcification, rheumatic heart disease, degenerative aortic valve disease, bicuspid aortic valve and other factors. AS is common and can be predicted by aortic root calcification volume, rheumatic heart disease, degenerative aortic valve disease, bicuspid aortic valve. Intervention and management for AS patients is a complex decision that takes into consideration multiple factors. On the other hand, there is not enough progress in preventive pharmacotherapy to slow the progression of AS.

Right ventricle-pulmonary artery coupling in pulmonary artery hypertension its measurement and pharmacotherapy.

The right ventricular (RV) function correlates with prognosis in severe pulmonary artery hypertension (PAH) but which metric of it is most clinically relevant is still uncertain. Clinical methods to estimate RV function from simplified pressure volume loops correlate with disease severity but the clinical relevance has not been assessed. Evaluation of right ventricle pulmonary artery coupling in pulmonary hypertensive patients may help to elucidate the mechanisms of right ventricular failure and may also help to identify patients at risk or guide the timing of therapeutic interventions in pulmonary hypertension. Complete evaluation of RV failure requires echocardiographic or magnetic resonance imaging, and right heart catheterization measurements. Treatment of RV failure in PAH relies on decreasing afterload with drugs targeting pulmonary circulation; fluid management to optimize ventricular diastolic interactions; and inotropic interventions to reverse cardiogenic shock. The ability to relate quantitative metrics of RV function in pulmonary artery hypertension to clinical outcomes can provide a powerful tool for management. Such metrics could also be utilized in the future as surrogate endpoints for outcomes and evaluation of response to therapies. This review of literature gives an insight on RV-PA coupling associated with PAH, its types of measurement and pharmacological treatment.

An overview regarding the article 'clinical outcomes and mortality in patients with atrial fibrillation and recently diagnosed lung cancer in oncology outpatient settings'.

Cancer-related inflammation, anti-cancer treatment and other cancer-related comorbidities are proposed to affect atrial remodeling, increasing the susceptibility of lung cancer patients for developing atrial fibrillation. Moreover, cancer is assumed to modify the risk of thromboembolisms and bleeding. An association between AF and malignancy has been reported but incompletely defined. The earliest publications of cancer predisposing to AF came in the 1940s-50s with reports of neoplastic cardiac infiltration or mechanical pressure on the heart, and with oncologic thoracic surgery. Subsequently, multiple studies have reported an increased risk of AF after cancer therapy with surgery (particularly thoracic) and chemotherapy. However, the prevalence of AF appears to be higher in patients with cancer at the time of diagnosis even before undergoing therapy. The emerging field of cardio-oncology has revealed that these seemingly disparate disease processes are intertwined, owing to the cardiovascular sequelae of anticancer therapies, shared risk factors that predispose individuals to both cardiovascular disease and cancer, as well the possible potentiation of cancer growth by cardiac dysfunction. Although direct oral anticoagulants (DOAC) seem to represent a safe and effective option, compared to Vitamin K antagonists (VKA), in this population, this statement is based mainly on observational studies and sub analyses of pivotal trials of the DOAC.

Evaluation of research trends in the incidence of postoperative neurocognitive disorders in patients undergoing cardiac surgery.

Postoperative neurocognitive disorders (PNDs) are a kind of acute central nervous system syndrome, which is a common postoperative complication in cardiac elderly patients. The two most commonly used terms for PNDs are postoperative delirium (POD) and postoperative cognitive dysfunction (POCD). POD often leads to a series of adverse clinical outcomes and even death, so its prevention and treatment has become an important part of perioperative management in elderly patients. In the past decades, research has focused on the mechanism and progress of the pathogenesis of PNDs. Nonetheless, little research has been conducted on the research trends in the relevant field.

A review regarding the article 'Impact of previous cardiac operations in patients undergoing surgery for type A acute aortic dissection. Long-term follow up.'

Type A acute aortic dissection (TAAAD) still carries high rates of morbidity and mortality. Outcomes of patients presenting with TAAAD depend on several variables such as the site of intimal rupture, organ malperfusion and extension of surgical repair. Bleeding after surgery for TAAAD is one of the most common complications and it's also associated with worse postoperative outcomes. Previous cardiac operations have been associated with a higher rate of postoperative bleeding and also with worse postoperative outcomes in patients undergoing second elective cardiac operations. According to the Stanford system, the most commonly used system of anatomic classification, type A AAD (TA-AAD: DeBakey type I and II) involves the ascending aorta, irrespective of the site of the intimal tear while type B AAD (TB-AAD) does not involve the ascending aorta and propagates downwards distally from the isthmus. Despite recent substantial diagnostic and therapeutic progress, AAD morbidity and mortality remain still high. Blood malperfusion triggers the propagation of aortic dissection, resulting in the ischemia of involved organs. Meanwhile, an excessive inflammatory response occurs, contributing to the development of oxygen impairment. A recent study suggested that inflammation and coagulation are involved in AAD combined ALI. Endothelial and epithelial barriers are destroyed by increased alveolar-capillary barrier permeability, which is responsible for ALI. Furthermore, inflammatory and oxidative stress-related cellular and metabolic regulatory mechanisms might participate in the AAD course worsened by ALI.

A review regarding the article 'systematic review and meta-analysis of levothyroxine effect on blood pressure in patients with subclinical hypothyroidism'.

Subclinical hypothyroidism (SCH) is a biochemical condition defined by elevated serum thyroid stimulating hormone levels in the setting of normal levels of the peripheral thyroid hormones, thyroxine, and triiodothyronine. SCH is becoming increasingly prevalent in recent years especially among the elderly, and its prevalence ranges approximately from 5 to 20% in the general population. Clinical manifestations of SCH range from obvious symptoms to no signs or symptoms, and the most common symptoms of SCH include fatigue, mild depression, muscle weakness, cold intolerance, and weight gain. However, despite the clear biochemical pattern of mild thyroid failure, few patients with SCH have typical hypothyroid symptoms. Patients with SCH have elevated blood pressure, but the effect of levothyroxine (LT4) therapy on blood pressure among those patients is still unclear. Severe SCH or mild SCH with symptoms are generally recommended to be treated with levothyroxine (LT4), which requires monitoring of TSH level over several months and adjusting LT4 dosage accordingly. Oral LT4 administered daily is the treatment of choice for SCH, and the goal of LT4 treatment for SCH is to restore the TSH level within the reference range.

Letter regarding the article: Trends, and Outcomes of Transcatheter Aortic Valve Implantation in Aortic Insufficiency; A Nationwide Readmission Database Analysis.

With great interest, we have read the article "Trends, and Outcomes of Transcatheter Aortic Valve Implantation In Aortic Insufficiency; A Nationwide Readmission Database Analysis" by Ullah et al. For its clarity and conciseness, we applaud the author for his extensive research on this delicate topic. The authors have concisely written several scenarios including the current understanding of trends, and potential outcome of aortic insufficiency following transcatheter aortic valve implantation (TAVI). Nonetheless, we thought it would be helpful to add a few more things to the article's conclusion to strengthen it. The inclusion of the pathophysiology of coronary microcirculation disorder, and endothelial dysfunction in patients with aortic stenosis and then examine the impact of TAVI on these conditions can improve the results. Second, echocardiographic data regarding right and left ventricular dimensions and function or tricuspid regurgitation presence and its severity could lead to a better understanding of the mechanism.

Insights Regarding the Article "Exploring Transthyretin Amyloid Cardiomyopathy: A Comprehensive Review of the Disease and Upcoming Treatments".

Transthyretin amyloid cardiomyopathy (ATTR-CM) is an increasingly important but under-recognized cause of heart failure in persons over 60 years of age. Transthyretin amyloid cardiomyopathy (ATTR-CM) occurs when the disease affects the heart with or without the involvement of a more extensive systemic disorder. Both ATTRwt and less frequently hATTR are possibilities. Advances in diagnostics have identified specific populations in whom ATTR-CM is clinically important. The recent emergence of effective therapies that slow disease progression and improve clinical outcomes promises to render ATTR-CM a treatable disease. For such therapies to be most effective, early identification of affected individuals is critical. Treatments have been limited to supportive care, with no guideline-recommended treatment. In patients with transthyretin amyloid cardiomyopathy, tafamidis was associated with reductions in all-cause mortality and cardiovascular-related hospitalizations and reduced the decline in functional capacity and quality of life as compared with placebo. This commentary aims to afford providers the tools required to facilitate earlier diagnosis of ATTR-CM and delineate management strategies.

An Analysis Regarding the Article: Insight Into the Optimal Timing of Percutaneous Coronary Intervention and Transcatheter Aortic Valve Replacement.

Transcatheter aortic valve replacement (TAVR) is an emerging minimally invasive treatment modality that has been shown to reduce mortality significantly compared to medical therapy alone and is superior or noninferior to conventional surgical aortic valve replacement (SAVR) in patients with severe and symptomatic aortic stenosis (AS) deemed to have an intermediate or higher operative risk. AS patients at intermediate surgical risk, although complications of each procedure were different; with vascular complications and paravalvular leak (PVL) being more common in the TAVI group, whereas several other complications were more frequently found in the SAVR group, including new-onset atrial fibrillation, acute kidney injury and life-threatening bleeding. The risk factors associated with TAVR include larger annulus size (based on MSCT), pre-TAVI transvalvular Vmax, and aortic valve calcification; aortic valve calcification was found to be an independent predictor of PVL.

Feasibility of artificial intelligence its current status, clinical applications, and future direction in cardiovascular disease.

In routine clinical practice, the diagnosis and treatment of cardiovascular disease (CVD) rely on data in a variety of formats. These formats comprise invasive angiography, laboratory data, non-invasive imaging diagnostics, and patient history. Artificial intelligence (AI) is a field of computer science that aims to mimic human thought processes, learning capacity, and knowledge storage. In cardiovascular medicine, artificial intelligence (AI) algorithms have been used to discover novel genotypes and phenotypes in established diseases enhance patient care, enable cost effectiveness, and lower readmission and mortality rates. AI will lead to a paradigm change toward precision cardiovascular medicine in the near future. The promise application of AI in cardiovascular medicine is immense; however, failure to recognize and ignorance of the challenges may overshadow its potential clinical impact. AI can facilitate every stage in cardiology in the imaging process, from acquisition and reconstruction, to segmentation, measurement, interpretation, and subsequent clinical pathways. Along with new possibilities, new threats arise, acknowledging and understanding them is as important as understanding the machine learning (ML) methodology itself. Therefore, attention is also paid to the current opinions and guidelines regarding the validation and safety of AI. This paper provides a outline for clinicians on relevant aspects of AI and machine learning, selection of applications and methods in cardiology to date, and identifies how cardiovascular medicine could incorporate AI in the future. With progress continuing in this emerging technology, the impact for cardiovascular medicine is highlighted to provide insight for the practicing clinician and to identify potential patient benefits.

An editorial regarding the article 'A meta-analysis of atrial septal defect closure in patients with severe pulmonary hypertension: is there a room for poking holes amidst debate?'

Pulmonary arterial hypertension (PAH) related to an atrial septal defect (ASD) poses a challenge to transcatheter closure of an ASD. In patients with untreated ASDs, chronic pulmonary over-circulation due to shunt flow can cause pulmonary vascular remodeling and increased pulmonary vascular resistance. PAH is one of the difficult situations to treat. Complex pathophysiology, association of the multiple comorbidities make clinical scenario challenging. The closure of ASD in patients with PAH improves PAH severity and cardiac functional capacity and reduces atrial arrhythmias. However, some patients show remaining PAH or aggravation of PAH post-ASD closure. PAH is a strong predictor of mortality in older patients who undergo ASD closure. Hence, the decision to opt for ASD closure should be carefully considered in high-risk patients with PAH. As per the American Heart Association/American College of Cardiology 2018 guidelines, ASD with elevated pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) more than two-thirds systemic is considered to be a contraindication for closure. However, it is difficult to determine the outcomes for ASD closure in patients with moderately-to-severely elevated PVR. A "treat and repair strategy" might be an option. In addition, the patient should be carefully selected by the observation of PVR change through vasoreactivity and balloon occlusion tests, and then closure should be considered. For patients with a predictable poor prognosis, research on the risk assessment of ASD closure in patients with PAH will be needed for a more individualized treatment plan.

A review regarding the article 'Dose-response association between cardiovascular health and mortality in cancer survivors'.

Cardiovascular disease (CVD) and cancer are the two leading causes of morbidity and mortality in the world. The emerging field of cardio-oncology has revealed that these seemingly disparate disease processes are intertwined, owing to the cardiovascular sequelae of anticancer therapies, shared risk factors that predispose individuals to both cardiovascular disease and cancer, as well the possible potentiation of cancer growth by cardiac dysfunction. As a result, interest has increased in understanding the fundamental biological mechanisms that are central to the relationship between CVD and cancer. CVD and cancer frequently coincide in the same patient and often complicate each other. To date, much of the focus in cardio-oncology has been on the cardiovascular complications developed during cancer progression and as a result of cancer treatment. However, the reverse can also be true, and patients with CVD have been shown to be at increased risk of developing cancer (reverse cardio-oncology), as reviewed previously. Recently, the American Heart Association (AHA) updated the Life's Essential 8 (LE8) score, which captures modifiable risk factors, including smoking, body mass index, physical activity, sleep, dietary habits, blood pressure, fasting glucose, and total cholesterol levels, to assess CVH. Many studies have demonstrated a robust association between LE8 and CVD and all-cause mortality in the general population. Beyond assessment and monitoring, using metrics such as LE8 has the unique advantage to identify modifiable risk factors and refers cancer survivors for targeted interventions to manage their CVD risk. Future research in larger study samples is needed to investigate whether the optimal CVD defined by LE8 may differ in population subgroups and implement and evaluate CVD promotion interventions in the high-risk cancer survivor population.

Comment on: Smart Technologies Used as Smart Tools in the Management of Cardiovascular Disease and Their Future Perspective.

With keen interest and seriousness, we have read the article "Smart Technologies used as Smart Tools in the Management of Cardiovascular Disease and their Future Perspective" by Muneeb Ullah et al. and writing to provide a critique. For its clarity and conciseness, we applaud the author for his extensive research on this delicate topic. The authors have concisely written several scenarios of using smart technologies used as smart tools in the management of cardiovascular disease, such as wearable devices, mobile applications,3D printing technologies, artificial intelligence, remote monitoring systems, and electronic health records. Nonetheless, While the study addresses an important topic in the field of cardiology, we believe there are certain aspects that require further consideration and exploration.

A Comment on: Anxiety and Depression in Heart Failure: An Updated Review.

With great interest, we have read the article "Anxiety and depression in heart failure: An updated review" by Sarim Rashid et al. For its clarity and conciseness, we applaud the author for his extensive research on this delicate topic. The authors have concisely written several scenarios including the risk factors that contribute to the development and exacerbation of anxiety and depression in individuals with heart conditions, including biological, psychological, and social factors. Nonetheless, we thought it would be helpful to add a few more things to the article's conclusion to strengthen it. Exploring the pathogenesis and pathophysiology of post-sepsis related depression is of positive significance for reducing the occurrence of long-term depression and improving the prognosis of sepsis patients.