RESUMO
Over the last decade, randomized clinical trials of several pharmacologic agents have demonstrated a reduction in cardiovascular mortality and other important secondary outcomes. Angiotensin-Neprilysin Inhibitors and Sodium-Glucose Co-transporter 2 inhibitors have now become pillars in the treatment of heart failure. Ivabradine is a negative chronotropic agent used as an adjunctive therapy in patients with heart failure. Two new hypertension therapies, zilebresiran and aprocitentan, are currently in investigational stages. Finally, mavacamten has emerged as a pharmacologic treatment for hypertrophic obstructive cardiomyopathy. Practitioners must be familiar with the indications and side effects of newer therapies as they are now frequently prescribed.
Assuntos
Doenças Cardiovasculares , Humanos , Doenças Cardiovasculares/tratamento farmacológico , Inibidores do Transportador 2 de Sódio-Glicose/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Fármacos Cardiovasculares/uso terapêutico , Hipertensão/tratamento farmacológico , Anti-Hipertensivos/uso terapêutico , Ivabradina/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Aminobutiratos/uso terapêutico , Antagonistas de Receptores de Angiotensina/uso terapêutico , Valsartana , Ácidos Dicarboxílicos , Ácidos Graxos , RNA Interferente PequenoRESUMO
OBJECTIVE: We sought to examine outcomes of ultrafiltration in real world community-based hospital settings. BACKGROUND: Ultrafiltration (UF) is an accepted therapeutic option for advanced decompensated heart failure (ADHF). the feasibility of UF in a community hospital setting, by general cardiologists in a start-up program had not been objectively evaluated. METHODS: We retrospectively analyzed the first-year cohort of ADHF patients treated with UF from 10/1/2019 to 10/1/2020, which totaled 30 patients, utilizing the CHF Solutions Aquadex FlexFlow™ System with active UF rate titration. RESULTS: Baseline patient characteristics were similar to RCTs: mean age 63, 73 % male; 27 % female; 53 % Caucasian; 47 % African American; 77 % had LVEF ≤ 40. The baseline mean serum creatinine (Cr) was 1.84 ±0.62 mg/dL, mean GFR of 36.95 ±9.60 ml/min. HF re-admission rates were not significantly different than prior studies (17.2 % at 30 d, 23.3 % at 60 d, but in our cohort, per patient HF re-admission rates were reduced significantly by 60 d (0.30 p = 0.017). CONCLUSION: Our analysis showed success with UF in mainstream setting with reproducible results of significant volume loss without adverse renal effect, mitigation of recurrent Hdmissions, and remarkable subjective clinical benefit.
Assuntos
Insuficiência Cardíaca , Hospitais Comunitários , Ultrafiltração , Humanos , Feminino , Masculino , Insuficiência Cardíaca/terapia , Insuficiência Cardíaca/fisiopatologia , Estudos Retrospectivos , Pessoa de Meia-Idade , Ultrafiltração/métodos , Resultado do Tratamento , IdosoRESUMO
Higher coronary artery calcium (CAC) scores and progression of CAC are associated with higher mortality. We previously reported that subjects with coronary artery disease randomly allocated to eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) supplementation or none had similar significant increases in CAC score over 30 months. Whether these findings are influenced by diabetes status is unknown. A total of 242 subjects with coronary artery disease who were on statin therapy were randomly allocated to to 1.86 g EPA and 1.5 g DHA daily or none (control). The CAC score was measured at baseline and 30-month follow-up using noncontrast, cardiac computed tomography. A significant interaction term between diabetes status and treatment arm was noted in the prediction of the CAC score (p <0.001). A total of 176 subjects (85.8% men) had no diabetes and 66 subjects (80.3% men) had diabetes. The mean age was 62.9 ± 7.9 versus 63.2 ± 7.1 years, respectively. The mean low-density lipoprotein cholesterol and median triglyceride levels were not significantly different between those without and with diabetes: 77.7 ± 25.9 versus 77.1 ± 30.2 mg/100 ml, respectively, and 117.0 (78.0 to 158.0) versus 119.0 (84.5 to 201.5) mg/100 ml, respectively. Subjects with diabetes on EPA+DHA had a greater increase in CAC score than subjects with diabetes in the control group (median 380.7 vs 183.5, respectively, p = 0.021). In contrast, no difference occurred between the EPA+DHA and control groups in subjects without diabetes (175.7 vs 201.1, respectively, p = 0.41). In conclusion, EPA+DHA supplementation was associated with greater CAC progression in subjects with diabetes than subjects with diabetes in the control group over a 30-month period; whether this indicates progression of the disease burden or plaque stabilization requires further study.
Assuntos
Doença da Artéria Coronariana , Suplementos Nutricionais , Progressão da Doença , Ácidos Docosa-Hexaenoicos , Ácido Eicosapentaenoico , Humanos , Masculino , Feminino , Ácido Eicosapentaenoico/uso terapêutico , Ácidos Docosa-Hexaenoicos/uso terapêutico , Ácidos Docosa-Hexaenoicos/administração & dosagem , Doença da Artéria Coronariana/diagnóstico por imagem , Pessoa de Meia-Idade , Calcificação Vascular/diagnóstico por imagem , Idoso , Seguimentos , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/metabolismo , Resultado do Tratamento , Diabetes Mellitus/epidemiologia , Tomografia Computadorizada por Raios X , Angiografia CoronáriaRESUMO
BACKGROUND AND AIMS: We previously reported that an omega-3 fatty acid index ≥4% with high-dose eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) prevented progression of noncalcified plaque. Higher coronary artery calcium (CAC) scores and progression of CAC are associated with increased cardiovascular events and mortality. We examined the effect of EPA + DHA on CAC score. METHODS: A total of 242 patients with coronary artery disease (CAD) on statin therapy were randomized to 1.86 g EPA and 1.5 g DHA daily or none (control) for 30 months. The CAC score was measured at baseline and 30-months with non-contrast, cardiac computed tomography. RESULTS: Both EPA + DHA and control groups had significant progression in CAC scores over 30 months (median change:183.5 vs 221.0, respectively, p < 0.001) despite a 13.6% reduction in triglyceride level with EPA + DHA. No significant difference was observed between groups for the total group, by baseline CAC scores of <100, 100-399, 400-999 and ≥1000 or quartiles of achieved levels of EPA, DHA and the omega-3 fatty acid index. Similar rates of CAC progression were noted in those on high-intensity statin compared to low- and moderate-intensity statin. CONCLUSIONS: EPA and DHA added to statin resulted in similar CAC progression over 30 months regardless of baseline CAC categories, statin intensity and achieved levels of EPA, DHA and the omega-3 fatty acid index.
Assuntos
Doença da Artéria Coronariana , Ácidos Graxos Ômega-3 , Inibidores de Hidroximetilglutaril-CoA Redutases , Humanos , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/tratamento farmacológico , Ácidos Docosa-Hexaenoicos , Cálcio , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Ácidos Graxos Ômega-3/uso terapêutico , Ácido Eicosapentaenoico/uso terapêutico , Cálcio da Dieta , Suplementos NutricionaisRESUMO
Background Residual risk of cardiovascular events and plaque progression remains despite reduction in low-density lipoprotein cholesterol. Factors contributing to residual risk remain unclear. The authors examined the role of eicosapentaenoic acid and docosahexaenoic acid in coronary plaque regression and its predictors. Methods and Results A total of 240 patients with stable coronary artery disease were randomized to eicosapentaenoic acid plus docosahexaenoic acid (3.36 g/d) or none for 30 months. Patients were stratified by regression or progression of coronary fatty plaque measured by coronary computed tomographic angiography. Cardiac events were ascertained. The mean±SD age was 63.0±7.7 years, mean low-density lipoprotein cholesterol level was <2.07 mmol/L, and median triglyceride level was <1.38 mmol/L. Regressors had a 14.9% reduction in triglycerides that correlated with fatty plaque regression (r=0.135; P=0.036). Compared with regressors, progressors had higher cardiac events (5% vs 22.3%, respectively; P<0.001) and a 2.89-fold increased risk of cardiac events (95% CI, 1.1-8.0; P=0.034). Baseline non-high-density lipoprotein cholesterol level <2.59 mmol/L (100 mg/dL) and systolic blood pressure <125 mm Hg were significant independent predictors of fatty plaque regression. Normotensive patients taking eicosapentaenoic acid plus docosahexaenoic acid had regression of noncalcified coronary plaque that correlated with triglyceride reduction (r=0.35; P=0.034) and a significant decrease in neutrophil/lymphocyte ratio. In contrast, hypertensive patients had no change in noncalcified coronary plaque or neutrophil/lymphocyte ratio. Conclusions Triglyceride reduction, systolic blood pressure <125 mm Hg, and non-high-density lipoprotein cholesterol <2.59 mmol/L were associated with coronary plaque regression and reduced cardiac events. Normotensive patients had greater benefit than hypertensive patients potentially due to lower levels of inflammation. Future studies should examine the role of inflammation in plaque regression. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01624727.
Assuntos
Doença da Artéria Coronariana , Humanos , Pessoa de Meia-Idade , Idoso , Doença da Artéria Coronariana/diagnóstico por imagem , Pressão Sanguínea , Ácidos Docosa-Hexaenoicos , Ácido Eicosapentaenoico/uso terapêutico , LDL-Colesterol , Inflamação , Placa Amiloide , TriglicerídeosRESUMO
The practice of fasting before elective cardiac procedures including cardiac catheterization and transesophageal echocardiography is commonly implemented but evidence for these requirements is lacking. Fasting periods often exceed the intended length of time, increasing the risk of irritability, dehydration, acute kidney injury, hypoglycemia, and length of hospitalization. The practice of perioperative fasting relies on the premise that aspiration during general anesthesia can be mitigated by minimizing the volume of gastric contents, and stomach acidity. But the evidence has shown that fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines. Elective cardiac procedures are performed using procedural sedation, where the risk of serious aspiration is small. In most patients, we argue, that strict fasting requirements should be reduced, and a more nuanced fasting protocol based on individual patient characteristics and risk factors should be utilized given the overall low risk of aspiration with elective procedures utilizing procedural sedation. In this review, we examine the historical origins and current evidence relating to the practice of fasting as it relates to cardiac catheterization and transesophageal echocardiography.
Assuntos
Jejum , Hospitalização , Humanos , Fatores de Risco , Cooperação do PacienteRESUMO
Sudden cardiac death is a major cause of cardiovascular mortality in the United States with 250,000-450,000 deaths annually. Transvenous Implantable Cardioverter-Defibrillator (ICD) has been conventionally used for both primary and secondary prevention of ventricular tachycardia or fibrillation (VT/VF). It is also associated with a high risk of complications like hemothorax, pneumothorax, cardiac tamponade, lead failure, and increased risk for infections. Subcutaneous ICD (S-ICD) poses as a viable alternative with reduced chances of complications. This manuscript aims to review S-ICD as an alternative to conventional transvenous ICD and its efficacy. We conducted a Medline search of "Subcutaneous," "ICD," "transvenous," and "ventricular tachycardia or fibrillation (VT/VF)" to identify pivotal trials published before June 2021, for inclusion in this review. Major practice guidelines, trial bibliographies, and pertinent reviews were examined to ensure the inclusion of relevant trials. The following section reviews data from pivotal trials to review the efficacy of S-ICD for the termination of VT/VF. The S- ICD system consists of a pulse generator positioned over the sixth rib between the midaxillary and anterior axillary line and a tripolar parasternal electrode with the proximal and distal sensing electrodes positioned adjacent to the xiphoid process and manubriosternal junction, respectively. The conversion of the efficacy of the S-ICD after the first shock ranges from 88%-90.1% and 98.2%-100% after 5 shocks based on the current evidence. The device also has a 99% complication-free rate at 180 days with no increased complications even in ESRD patients. The PRAETORIAN trial showed non-inferiority of the S-ICD to transvenous ICD concerning device-related complications or inappropriate shocks in patients. S-ICD has several advantages including no need for fluoroscopy for implantation, decreased risk of infections, complications, and evidence of safety even in high-risk populations like ESRD. The limitations include the inherent lack of pacing abnormalities, the increase in inappropriate shocks compared to transvenous ICD, and non-reliability if there are baseline T wave abnormalities, especially in the inferior leads. Thus, S-ICD can be considered as an alternative to transvenous ICD in patients with an indication for defibrillator therapy but with no indication for pacing.
Assuntos
Desfibriladores Implantáveis , Falência Renal Crônica , Taquicardia Ventricular , Arritmias Cardíacas/etiologia , Morte Súbita Cardíaca/etiologia , Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis/efeitos adversos , Humanos , Falência Renal Crônica/etiologia , Taquicardia Ventricular/terapia , Resultado do TratamentoAssuntos
Cateterismo Cardíaco/métodos , Procedimentos Endovasculares/métodos , Cirurgia Assistida por Computador/métodos , Cateterismo Periférico/métodos , Hematoma/epidemiologia , Humanos , Complicações Pós-Operatórias/epidemiologia , Fatores de Tempo , Ultrassonografia , Ultrassonografia de IntervençãoRESUMO
Chronic systemic skin disease and cardiovascular disease are multisystem disorders which have been associated with each other for centuries. Recent research has strengthened this association, particularly in systemic inflammatory disease. Here we explore the current literature on psoriasis, hidradenitis suppurativa, lupus erythematosus, acanthosis nigricans, atopic dermatitis, and bullous pemphigoid. Psoriasis is a chronic inflammatory disorder that has been labeled as a risk-modifier for hyperlipidemia and coronary artery disease by the American College of Cardiology ACC lipid guidelines. Cardiovascular disease is also found at a significantly higher rate in patients with hidradenitis suppurativa and lupus erythematosus. Some associations have even been noted between cardiovascular disease and acanthosis nigricans, atopic dermatitis, and bullous pemphigoid. While many of these associations have been attributed to a shared underlying disease process such as chronic systemic inflammation and shared underlying risk factors, these dermatologic manifestations can help to identify patients at higher risk for cardiovascular disease.
Assuntos
Doenças Cardiovasculares , Hidradenite Supurativa , Psoríase , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/etiologia , Humanos , Fatores de Risco , PeleRESUMO
Targeted temperature management, also known as therapeutic hypothermia (TH), is recommended for out-of-hospital cardiac arrest (OHCA). Both internal or external methods of cooling can be applied. Individuals resuscitated from OHCA frequently develop postarrest myocardial dysfunction resulting in decreased cardiac output and left ventricular systolic function. This dysfunction is usually transient and improves with spontaneous recovery over time. Echocardiogram (ECHO) can be a vital tool for the assessment and management of these patients. This manuscript reviewed methods available for TH after OHCA and reviews role of ECHO in the diagnosis and prognosis in this setting.
Assuntos
Hipotermia Induzida , Parada Cardíaca Extra-Hospitalar , Humanos , Parada Cardíaca Extra-Hospitalar/diagnóstico por imagem , Parada Cardíaca Extra-Hospitalar/terapia , PrognósticoRESUMO
Obesity and diabetes are associated with chronic inflammation. Specialized pro-resolving lipid mediators (SPMs)-resolvins (Rv), protectins (PD) and maresins (MaR)-actively resolve inflammation. Bariatric surgery achieves remission of diabetes, but mechanisms are unclear. We measured SPMs and proinflammatory eicosanoid levels using liquid chromatography-tandem mass spectrometry in 29 morbidly obese subjects (13 with diabetes) and 15 nondiabetic, mildly obese subjects. Compared to the mildly obese, the morbidly obese had higher levels of SPMs-RvD3, RvD4 and PD1-and white blood cells (WBC) and platelets. Post-surgery, SPM and platelet levels decreased in morbidly obese nondiabetic subjects but not in diabetic subjects, suggesting continued inflammation. Despite similar weight reductions 1 year after surgery (44.6% vs. 46.6%), 8 diabetes remitters had significant reductions in WBC and platelet counts whereas five non-remitters did not. Remitters had a 58.2% decrease (p = 0.03) in 14-HDHA, a maresin pathway marker; non-remitters had an 875.7% increase in 14-HDHA but a 36.9% decrease in MaR1 to a median of 0. In conclusion, higher levels of RvD3, PD1 and their pathway marker, 17-HDHA, are markers of leukocyte activation and inflammation in morbid obesity and diabetes and diminish with weight loss in nondiabetic but not diabetic subjects, possibly representing sustained inflammation in the latter. Lack of diabetes remission after surgically-induced weight loss may be associated with reduced ability to produce MaR1 and sustained inflammation.
Assuntos
Eicosanoides/sangue , Obesidade Mórbida/sangue , Obesidade Mórbida/cirurgia , Idoso , Cirurgia Bariátrica , Biomarcadores/sangue , Diabetes Mellitus Tipo 2/sangue , Dinoprostona/sangue , Ácidos Docosa-Hexaenoicos/sangue , Ácidos Graxos Insaturados/sangue , Feminino , Humanos , Contagem de Leucócitos , Metabolismo dos Lipídeos , Masculino , Pessoa de Meia-Idade , Obesidade/sangue , Cisto do Úraco/sangue , Redução de PesoAssuntos
Doenças Cardiovasculares/epidemiologia , Colesterol/sangue , Ácidos Dicarboxílicos/uso terapêutico , Ácidos Graxos/uso terapêutico , Hipercolesterolemia/tratamento farmacológico , Idoso , Doenças Cardiovasculares/sangue , Doenças Cardiovasculares/etiologia , Feminino , Saúde Global , Humanos , Hipercolesterolemia/sangue , Hipercolesterolemia/complicações , Hipolipemiantes/uso terapêutico , Incidência , Masculino , Metanálise como AssuntoRESUMO
BACKGROUND: Over the past decade, rates of cardiac implantable electronic device (CIED) related infections have increased and been associated with increased morbidity, mortality and financial burden on healthcare systems. METHODS: To examine the effect of an antibacterial envelope in reducing major CIED related infections, we performed a systematic review and meta-analysis by searching PubMed/MEDLINE, CENTRAL, Google scholar and Clinicaltrials.gov for studies that examined the effect of an antibiotic envelope in reducing major related CIED infections, comprising of device-related endocarditis, systemic infection requiring systemic antibiotics and or device extraction, compared to control up till February 15th, 2020. A random-effects meta-analysis was conducted by calculating risk ratios (RR) and respective 95% confidence intervals (CI). RESULTS: We include 6 studies that comprise of 11,897 patients, of which 5844 received an antibiotic envelope and 6053 did not. Compared with control, utilization of an antibiotic envelope at the time of procedure was associated with a significant 74% relative risk reduction in major CIED related infections among patients at high risk for infection (RR: 0.26 [95% CI, 0.08-0.85]; Pâ=â.03), while no significant reduction was observed among patients enrolled from studies with any risk for infection (RR: 0.53 [95% CI, 0.06-4.52]; Pâ=â.56). Additionally, no reduction in mortality among patients that received an envelope compared to control was observed (RR: 1.15 [95% CI, 0.53-2.50]; Pâ=â.72). CONCLUSION: The utilization of an antibiotic envelope at the time of device implantation or upgrade reduces major CIED infections, especially if used in patients perceived to be at higher risk for infection.
Assuntos
Antibioticoprofilaxia/instrumentação , Antibioticoprofilaxia/normas , Infecções Relacionadas à Prótese/prevenção & controle , Antibacterianos/uso terapêutico , Antibioticoprofilaxia/métodos , Humanos , Infecções Relacionadas à Prótese/tratamento farmacológico , Fatores de RiscoAssuntos
Doenças Cardiovasculares/mortalidade , Hipercolesterolemia/tratamento farmacológico , Infarto do Miocárdio/epidemiologia , RNA Interferente Pequeno/uso terapêutico , Acidente Vascular Cerebral/epidemiologia , LDL-Colesterol/metabolismo , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Hipercolesterolemia/metabolismo , Infarto do Miocárdio/mortalidade , Pró-Proteína Convertase 9/metabolismo , Acidente Vascular Cerebral/mortalidade , Resultado do TratamentoRESUMO
Background Aerobic exercise capacity is inversely associated with cardiovascular and all-cause mortality in men and women without coronary artery disease (CAD); however, a higher amount of vigorous exercise is associated with a J-shaped relationship in CAD patients. Therefore, the optimal type and amount of exercise for CAD patients is unclear. Coronary artery calcification (CAC) is associated with increased cardiovascular disease (CVD) events and mortality. Fatty plaque is more likely to rupture and cause coronary events than other types. We examined the association between exercise capacity, fatty plaque, CAC score and CVD events in CAD patients. Methods and Results A total of 270 subjects with stable CAD were divided into tertiles based on metabolic equivalents of task (METs) calculated from exercise treadmill testing. Self-reported exercise was obtained. Coronary computed tomographic angiography measured coronary plaque volume and CAC score. After adjustment, fatty plaque volume was not different among the 3 MET groups. For each 1 MET increase, CAC was 66.2 units lower (P=0.017). Those with CAC >400 and ≥8.2 METs had fewer CVD events over 30 months compared to <8.2 METs (P=0.037). Of moderate intensity exercisers (median, 240 min/wk; 78% walking only), 62.4% achieved ≥8.2 METs and lower CAC scores (P=0.07). Intensity and duration of exercise had no adverse impact on coronary plaque or CVD events. Conclusions Achieving ≥8.2 METs with moderate exercise intensity and volume as walking resulted in lower CAC scores and fewer CVD events. Therefore, vigorous exercise intensity and volume may not be needed for CAD patients to derive benefit. Registration URL: https://www.clinicaltrials.gov; Unique Identifier: NCT01624727.
Assuntos
Aptidão Cardiorrespiratória , Doença da Artéria Coronariana/fisiopatologia , Tolerância ao Exercício , Placa Aterosclerótica , Calcificação Vascular/fisiopatologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiografia por Tomografia Computadorizada , Angiografia Coronária , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/diagnóstico por imagem , Estudos Transversais , Teste de Esforço , Feminino , Fatores de Risco de Doenças Cardíacas , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Ruptura Espontânea , Índice de Gravidade de Doença , Calcificação Vascular/complicações , Calcificação Vascular/diagnóstico por imagemRESUMO
The Middle East and North Africa regions, including Lebanon, have recently witnessed rapid urbanization and modernization over the last couple of decades that has led to a dramatic transformation affecting lifestyle and diet. The World Health Organization reports that the leading cause of death in Lebanon is due to cardiovascular disease (CVD) at 47% of all-cause mortality. Over the last 30 years, especially the last 10, the population of Lebanon has changed dramatically due to the effect of wars in the region and refugees seeking asylum. With a population of around 4.5 million and a relatively high rate of consanguinity in Lebanon, a variety of novel mutations have been discovered explaining several familial causes of hypercholesterolemia, diabetes mellitus, congenital heart disease, and cardiomyopathies. Due to the Syrian civil war, 1.5 million Syrian refugees now reside in Lebanon in either low-income housing or tented settlements. A National Institutes of Health study is examining diabetes and CVD in Syrian refugees in comparison to native Lebanese. We provide the first review of CVD in Lebanon in its metabolic component including coronary artery disease and its risk factors, mainly hyperlipidemia and diabetes mellitus, and its structural component, including congenital heart disease, valvular heart disease, cardiomyopathies, and heart failure. The knowledge in this review has been compiled to guide clinicians and assist researchers in efforts to recognize risk factors for disease, improve delivery of health care, and prevent and treat CVDs in Lebanon, both for the native Lebanese and Syrian refugees.