Association between rheumatoid arthritis and atrial fibrillation: A systematic review and meta-analysis.

Rheumatoid arthritis (RA) is an autoimmune disorder with a varying range of organs involved leading to adverse outcomes. However, very little is known, with conflicting results about the association between RA and atrial fibrillation (AF). We aim to evaluate the association between RA and AF, and other clinical outcomes. We performed a systematic literature search using PubMed, Embase, and Scopus for relevant articles from inception until September 10, 2023. Primary clinical outcomes were AF. Secondary outcomes were acute coronary syndrome (ACS), stroke, and all-cause mortality (ACM). A total of 4 679 930 patients were included in the analysis, with 81 677 patients in the RA group and 4 493 993 patients in the nonrheumatoid arthritis (NRA) group. The mean age of the patients was 57.2 years. Pooled analysis of primary outcomes shows that RA groups of patients had a significantly higher risk of AF (odds ratios [OR], 1.53; 95% confidence interval [CI]: [1.16-2.03], p < .001) compared with NRA groups. Secondary Outcomes show that the RA group of patients had significantly higher odds of ACS (OR, 1.39; 95% CI: [1.26-1.52], p < .001), and ACM (OR, 1.19; 95% CI: [1.03-1.37], p = .02) compared with the NRA groups. However, the likelihood of stroke (OR, 1.02; 95% CI: [0.94-1.11], p = .61) was comparable between both groups of patients. Our study shows that RA groups of patients are at increased risk of having AF, ACS, and ACM.

Safety and efficacy of direct oral anticoagulants in comparison to warfarin in obese patients with atrial fibrillation: A systematic review and meta-analysis.

Background and Aim: Obesity affects nearly 650 million adults worldwide, and the prevalence is steadily rising. This condition has significant adverse effects on cardiovascular health, increasing the risk of hypertension, coronary artery disease, heart failure, and atrial fibrillation (AF). While anticoagulation for obese patients with AF is a well-established therapy for the prevention of thromboembolism, the safety and efficacy of different anticoagulants in this specific population are not well explored. This meta-analysis aimed to compare direct oral anticoagulants (DOAC) to vitamin K antagonists in obese populations with AF. Methods: The PRISMA guidelines were followed for this meta-analysis, registered in PROSPERO (CRD42023392711). PubMed, PubMed Central, Embase, Cochrane Library, and Scopus databases were searched for relevant articles from inception through January 2023. Two independent authors screened titles and abstracts, followed by a full-text review in Covidence. Data were extracted in Microsoft Excel and analyzed using RevMan v5.4 using odds ratio as an effect measure. Results: Two thousand two hundred fifty-nine studies were identified from the database search, and 18 were included in the analysis. There were statistically significant reductions in the odds of ischemic and hemorrhagic stroke in the DOAC group compared with the VKA group (OR 0.70, CI 0.66-0.75) and (OR 0.47, CI 0.35-0.62), respectively. In addition, the DOAC group exhibited lower odds of systemic embolism (OR 0.67, CI 0.54-0.83), major bleeding (OR 0.62, CI 0.54-0.72), and composite outcome (OR 0.72, CI 0.63-0.81). Conclusion: Based on the findings from this meta-analysis, DOACs demonstrate superior safety and efficacy in obese patients with AF compared with VKAs. These results may have significant implications for guiding anticoagulation strategies in this patient population.

SGLT2 inhibitors among patients with heart failure with preserved ejection fraction: A meta-analysis of randomised controlled trials.

BACKGROUND: Sodium-glucose co-transporter 2 (SGLT2) inhibitors have been recommended in the practice guidelines for the treatment of patients with heart failure with reduced ejection fraction; however, their effects among patients with preserved ejection fraction have been debatable. OBJECTIVE: We aim to evaluate the SGLT2 inhibitor effect among patients with heart failure with reduced ejection fraction, including DELIVER and EMPEROR-Preserved trials. METHODS: We performed a systematic literature search using the PubMed, Embase, Scopus, and Cochrane libraries for relevant articles from inception until August 30th, 2022. Statistical analysis was performed by calculating hazard ratio (HR) using the random effect model with a 95% confidence interval (CI) and probability value (P). Statistical significance was met if 95% CI does not cross numeric "1" and P < .05. RESULTS: Six studies with a total of 15,989 total patients were included in the final analysis. The mean age of patients enrolled in SGLT2 inhibitors and placebo was 69.13 and 69.37 years, respectively. The median follow-up duration was 2.24 years. SGLT2 inhibitors reduced composite cardiovascular mortality or first hospitalization for heart failure (HR, 0.80 [95% CI: 0.74-0.87], P < .001, I2 = 0%), heart failure hospitalization (HR, 0.74 [95% CI: 0.67-0.82], P < .001, I2 = 0%) compared with placebo. However, all-cause mortality (HR, 0.97 [95% CI: 0.89-1.06], P = .54, I2 = 0%) and cardiovascular mortality (HR, 0.96 [95% CI: 0.82-1.13), P = .66, I2 = 35.09%] were comparable between both groups. CONCLUSION: Our study finding shows that SGLT2 inhibitors significantly reduced the risk of first HF hospitalization or cardiovascular death and HF hospitalization; however, all-cause mortality was comparable between the groups.

Amplatzer amulet versus watchman device for percutaneous left atrial appendage closure: A systematic review and meta-analysis.

BACKGROUND: The Amplatzer Amulet (AA) and Watchman devices (WD) are the 2 most frequently used devices for percutaneous LAA closure globally. OBJECTIVE: To evaluate the safety and clinical outcomes associated with these 2 devices in patients undergoing percutaneous LAA closure. METHOD: We systematically searched all electronic databases from inception until February 21, 2023. The primary endpoint was procedure related complications. Secondary endpoints were device related thrombus, stroke, cardiovascular mortality, peri device leak, systemic embolism, and all-cause mortality. RESULTS: A total of 3 randomized clinical trials with 2150 patients were included in this meta-analysis. The mean age was 75 and 76 years in the Amplatzer group and in the Watchman group, respectively. The odds of procedure-related complications (OR, 1.80 [95% CI: 1.21-2.67], P < .001) were significantly higher among patients with AA compared to the WD. However, the odds of all-cause mortality (OR, 0.75 (95% CI: 0.49-1.16), P = .20), stroke (OR, 0.79 [95% CI: 0.47-1.34], P = .39), systemic/pulmonary embolism (OR, 1.34 [95% CI: 0.30-6.04], P = .70), and major bleeding (OR, 1.10 [95% CI: 0.83-1.48], P = .50) were comparable between the two devices. The odds of device related thrombus (OR, 0.72 [95% CI: 0.46-1.14], P = .17) was comparable between both the group of patients, however the incidence of peri device leak was significantly lower in AA group (OR, 0.41 [95% CI: 0.26-0.66], P < .001) compared with WD group of patients. CONCLUSION: The AA was not superior to the Watchman device in terms of safety and efficacy. However, the Amulet occluder was associated with a higher incidence of procedure-related complications, and lower peri device leak.

Transcatheter vs Surgical Aortic Valve Replacement Outcomes Among Solid Organ Transplant Patients: A Systematic Review and Meta-Analysis.

The safety and clinical outcomes of transcatheter aortic valve replacement (TAVR) compared to surgical aortic valve replacement (SAVR) among patients with solid organ transplants is not well understood. This study aimed to evaluate the clinical outcomes of TAVR and SAVR among patients with a history of solid organ transplantation. We performed a systematic literature search of databases for relevant articles from inception until May 1st, 2022. Unadjusted odds ratios (OR) were pooled using a random-effect model, and a P-value of <0.05 was considered statistically significant. A total of 3240 studies were identified of which 3 studies with a total of 2960 patients were included in the final analysis. For solid organ transplants patients, the odds of in-hospital mortality (OR 0.37, 95% CI 0.20-0.71, P < 0.001), 30-day mortality (OR 0.51, 95% CI 0.35-0.74, P < 0.001), acute kidney injury (OR 0.45, 95% CI 0.35-0.59, P < 0.001), and bleeding (OR 0.35, 95% CI 0.27-0.46, P < 0.001) were significantly lower in patients undergoing TAVR compared to SAVR. In contrast, the odds of pacemaker implantation (OR 2.60, 95% CI 0.36-18.90, P = 0.34), postprocedural stroke (OR 0.36, 95% CI 0.13-1.03, P = 0.06) were similar between both groups of patients. Length of hospital stay was significantly lower in TAVR compared to SAVR patients (SMD -0.82, 95% CI -0.95 to -0.70, P < 0.001). In solid organ transplant patients, TAVR appeared to be a safe procedure with fewer postprocedure complications, shorter length of hospital stay, and lower in hospital mortality compared with SAVR.

Retraction notice to "Association between sarcoidosis and cardiovascular Outcomes: A systematic review and meta-analysis" [IJC Heart Vasculat. 41 (2022) 101073].

[This corrects the article DOI: 10.1016/j.ijcha.2022.101073.].

Echocardiographic predictors of presence of cardiac amyloidosis in aortic stenosis.

AIMS: Aortic stenosis (AS) and cardiac amyloidosis (CA) frequently coexist but the diagnosis of CA in AS patients remains a diagnostic challenge. We aim to evaluate the echocardiographic parameters that may aid in the detection of the presence of CA in AS patients. METHOD AND RESULTS: We performed a systematic literature search of electronic databases for peer-reviewed articles from inception until 10 January 2022. Of the 1449 patients included, 160 patients had both AS-CA whereas the remaining 1289 patients had AS-only. The result of our meta-analyses showed that interventricular septal thickness [standardized mean difference (SMD): 0.74, 95% CI: 0.36-1.12, P = 0.0001), relative wall thickness (SMD: 0.74, 95% CI: 0.17-1.30, P < 0.0001), posterior wall thickness (SMD: 0.74, 95% CI 0.51 to 0.97, P = 0.0011), LV mass index (SMD: 1.62, 95% CI: 0.63-2.62, P = 0.0014), E/A ratio (SMD: 4.18, 95% CI: 1.91-6.46, P = 0.0003), and LA dimension (SMD: 0.73, 95% CI: 0.43-1.02, P < 0.0001)] were found to be significantly higher in patients with AS-CA as compared with AS-only patients. In contrast, myocardial contraction fraction (SMD: -2.88, 95% CI: -5.70 to -0.06, P = 0.045), average mitral annular S' (SMD: -1.14, 95% CI: -1.86 to -0.43, P = 0.0017), tricuspid annular plane systolic excursion (SMD: -0.36, 95% CI: -0.62 to -0.09, P = 0.0081), and tricuspid annular S' (SMD: -0.77, 95% CI: -1.13 to -0.42, P < 0.0001) were found to be significantly lower in AS-CA patients. CONCLUSION: Parameters based on echocardiography showed great promise in detecting CA in patients with AS. Further studies should explore the optimal cut-offs for these echocardiographic variables for better diagnostic accuracy.

Association between sarcoidosis and cardiovascular Outcomes: A systematic review and Meta-analysis.

Background: Sarcoidosis is a chronic inflammatory disorder of unknown etiology associated with high morbidity and mortality. Its association with cardiovascular outcomes is under-documented. Aim: The aim of this study was to assess the adverse cardiovascular outcomes in patients with sarcoidosis compared with that of non-sarcoidosis. Methodology: Online databases including PubMed, Embase and Scopus were queried from inception until March 2022. The outcomes assessed included all-cause mortality (ACM) and incidence of ventricular tachycardia (VT), heart failure (HF) and atrial arrhythmias (AA). Result: A total of 6 studies with 22,539,096 participants (42,763 Sarcoidosis, 22,496,354 Non-Sarcoidosis) were included in this analysis. The pooled prevalence of sarcoidosis was 13.1% (95% CI 1% to 70%). The overall mean age was 47 years. The most common comorbidities were hypertension (12.7% vs 12.5%), and diabetes mellitus (5.5% vs 4%) respectively. The pooled analysis of primary endpoints showed that all-cause mortality (RR, 2.08; 95% CI: 1.17 to 3.08; p = 0.01) was significantly increased in sarcoidosis patients. The pooled analysis of secondary endpoints showed that the incidence of VT (RR, 15.3; 95% CI: 5.39 to 43.42); p < 0.001), HF (RR, 4.96; 95% CI: 2.02 to 12.14; p < 0.001) and AA (RR, 2.55; 95% CI: 1.47 to 4.44); p = 0.01) were significantly higher with sarcoidosis respectively compared to non-sarcoidosis. Conclusion: Incidence of VT, HF and AA was significantly higher in patients with CS. Clinicians should be aware of these adverse cardiovascular events associated with sarcoidosis.

Effect of Pneumococcal Vaccine on Mortality and Cardiovascular Outcomes: A Systematic Review and Meta-Analysis.

Various studies have suggested the possible cardiovascular (CV) protective effects of the pneumococcal vaccine (PV). Therefore, we conducted a meta-analysis to assess the association between recipients of PV with mortality and CV outcomes among patients with and without established cardiovascular disease. We performed a systematic literature search in PubMed, Embase, and Scopus for studies evaluating the effect of PV on mortality and CV outcomes. A total of 15 studies with 347,444 patients were included in the meta-analysis: 111,784 patients received PV (32%) and 235,660 patients were in the unvaccinated group (68%). Recipients of PV were associated with decreased all-cause mortality (HR, 0.76 (95% CI: 0.66 to 0.87), p < 0.001). PV was associated with a decrease in the incidence of myocardial infarction (MI) (HR, 0.73 (95% CI: 0.56−0.96), p = 0.02), without significant reduction in CV mortality (HR, 0.87 (95% CI: 0.72−1.07), p = 0.18) and stroke (HR, 1.01 (95% CI: 0.93−1.10), p = 0.82). Our study found PV was associated with decreased risk of all-cause mortality and MI. Future RCTs will be necessary to confirm benefits associated with receipt of PV.

Cardioprotective effects of influenza vaccination among patients with established cardiovascular disease or at high cardiovascular risk: a systematic review and meta-analysis.

BACKGROUND: The clinical impact of the influenza vaccination on cardiovascular outcomes in people with established cardiovascular disease (CVD) is still debated. AIM: The aim of this meta-analysis was to estimate the effect of influenza vaccination on cardiovascular and cerebrovascular outcomes among patients with established CVD. METHODS: We systematically searched all electronic databases from inception until 15 April 2022. Primary clinical outcomes were all-cause mortality, and major adverse clinical events (MACEs). Secondary endpoints were heart failure, myocardial infarction, cardiovascular mortality, and stroke. RESULTS: Eighteen articles (five randomized trials and thirteen observational studies), with a total of 22 532 165 patients were included in the analysis. There were 217 072 participants included in the high cardiovascular risk or established CVD population (vaccinated n = 111 073 and unvaccinated n = 105 999). The mean age of the patients was 68 years old, without any difference between groups (69 vs. 71) years. At a mean follow-up of 1.5 years, the vaccinated group was associated with a lower risk of all-cause mortality [hazard ratio (HR), 0.71(95% CI, 0.63-0.80), P < 0.001], MACE [HR, 0.83(95% CI:0.72-0.96), P = 0.01], CV mortality [HR, 0.78(95% CI:0.68-0.90), P < 0.001], and MI [HR, 0.82 (95% CI:0.74-0.92), P < 0.001] compared to the unvaccinated group. While the incidence of stroke [HR, 1.03 (95% CI, 0.92-1.06), P = 0.61] and heart failure [HR, 0.74 (95% CI, 0.51-1.08), P = 0.12] did not differ between the two groups. CONCLUSION: Influenza vaccination reduced MACEs, all-cause mortality, CV mortality, and MI. These highlighted the importance of influenza vaccination in established CVD or high cardiovascular risk.

Simulation-based training in echocardiography.

The knowledge gained from echocardiography is paramount for the clinician in diagnosing, interpreting, and treating various forms of disease. While cardiologists traditionally have undergone training in this imaging modality during their fellowship, many other specialties are beginning to show interest as well, including intensive care, anesthesia, and primary care trainees, in both transesophageal and transthoracic echocardiography. Advances in technology have led to the development of simulation programs accessible to trainees to help gain proficiency in the nuances of obtaining quality images, in a low stress, pressure free environment, often with a functioning ultrasound probe and mannequin that can mimic many of the pathologies seen in living patients. Although there are various training simulation programs each with their own benefits and drawbacks, it is clear that these programs are a powerful tool in educating the trainee and likely will lead to improved patient outcomes.

Cardiovascular outcomes of sodium-glucose cotransporter 2 inhibitors: A comprehensive review of clinical and preclinical studies.

Diabetes is a leading cause of morbidity and mortality worldwide. Management of diabetes is changing at a rapid pace. Three new classes of antidiabetic drugs including GLP-1 (Glucagon-like peptide 1), DPP-IV (Dipeptidyl peptidase IV) and SGLT2 (Sodium glucose cotransporter 2) inhibitors have been approved in the last few years. Treating diabetes with the antidiabetic drug does not always reduce the cardiovascular complications of diabetes. On the contrary, there was a huge controversy regarding the effect of rosiglitazone on cardiovascular risk reduction a few years ago. Since then, submission of postmarketing cardiovascular outcome study data has been mandated by US FDA and other drug regulatory agencies for newer antidiabetic medications. This is to avoid further premature claims regarding cardiovascular harm or safety of the newer classes. We already have some cardiovascular safety data available on DPP-IV and GLP-1 groups of medications. Dapagliflozin, canagliflozin, and empagliflozin are currently approved SGLT2 inhibitors. We do not have sufficient cardiovascular outcome data available for this novel class. However, this group of drugs, which act by increasing renal glucose excretion, have also shown some non-glycemic benefits including weight reduction, blood pressure control, diuretic action, renal protection, decrease in arterial stiffness and uric acid reduction. Empagliflozin, a new member of SGLT2 class, showed significant cardiovascular morbidity and mortality benefit in recently published EMPA-REG OUTCOME trial. The authors summarize all the published clinical and preclinical cardiovascular outcome data of SGLT2 inhibitors, including recently completed and ongoing major clinical trials in this comprehensive review.

Aspiration Thrombectomy in Patients Undergoing Primary Angioplasty for ST Elevation Myocardial Infarction: An Updated Meta-Analysis.

BACKGROUND: The Trial of Routine Aspiration Thrombectomy with PCI versus PCI alone in patients with STEMI (TOTAL trial) refuted the salutary effect of routine aspiration thrombectomy (AT) in PPCI for patients with ST-elevation myocardial infarction (STEMI). OBJECTIVES: We performed an updated meta-analysis to assess clinical outcomes with AT prior to PPCI compared with conventional PPCI alone including the additional trial data. METHODS AND RESULTS: Clinical trials (n = 20) that randomized patients (n = 21,281) with STEMI between Routine AT (n = 10,619) and PPCI (n = 10,662) were pooled. There was no difference in all-cause mortality between the 2 groups (RR: 0.89, 95%CI: 0.78-1.01, P = 0.08). Stratifying by follow up at 1-month (RR: 0.87, 95%CI: 0.69-1.10, P = 0.25), up to 6 months (RR: 0.91, 95%CI: 0.74-1.13, P = 0.39 and beyond 6 months (RR: 0.88, 95%CI: 0.74-1.05, P = 0.16) yielded similar results. There was a statistically significant increase risk of stoke rate in the AT arm (RR: 1.51, 95%CI: 1.01-2.25, P = 0.04). The 2 groups were similar with regards to target vessel revascularization (0.94, 95%CI: 0.83-1.06, P = 0.28) recurrent MI (RR: 0.96, 95%CI: 0.80-1.16, P = 0.68, MACE events (RR: 0.91 95%CI: 0.81-1.02, P = 0.11), early (0.59, 95%CI: 0.23-1.50, P = 0.27) and late (RR: 0.91, 95%CI: 0.69-1.18, P = 0.47) stent thrombosis and net clinical benefit (RR 0.99, 95%CI: 0.91-1.07, P = 0.76). CONCLUSION: Routine AT prior to PPCI in STEMI is associated with higher risk of stroke. There is no statistical difference in clinical outcome parameters of mortality, major adverse cardiac events, target vessel revascularization, stent thrombosis, and net clinical benefit between AT and PCI alone.

Proteomic analysis of human plasma in chronic rheumatic mitral stenosis reveals proteins involved in the complement and coagulation cascade.

BACKGROUND: Rheumatic fever in childhood is the most common cause of Mitral Stenosis in developing countries. The disease is characterized by damaged and deformed mitral valves predisposing them to scarring and narrowing (stenosis) that results in left atrial hypertrophy followed by heart failure. Presently, echocardiography is the main imaging technique used to diagnose Mitral Stenosis. Despite the high prevalence and increased morbidity, no biochemical indicators are available for prediction, diagnosis and management of the disease. Adopting a proteomic approach to study Rheumatic Mitral Stenosis may therefore throw some light in this direction. In our study, we undertook plasma proteomics of human subjects suffering from Rheumatic Mitral Stenosis (n = 6) and Control subjects (n = 6). Six plasma samples, three each from the control and patient groups were pooled and subjected to low abundance protein enrichment. Pooled plasma samples (crude and equalized) were then subjected to in-solution trypsin digestion separately. Digests were analyzed using nano LC-MS(E). Data was acquired with the Protein Lynx Global Server v2.5.2 software and searches made against reviewed Homo sapiens database (UniProtKB) for protein identification. Label-free protein quantification was performed in crude plasma only. RESULTS: A total of 130 proteins spanning 9-192 kDa were identified. Of these 83 proteins were common to both groups and 34 were differentially regulated. Functional annotation of overlapping and differential proteins revealed that more than 50% proteins are involved in inflammation and immune response. This was corroborated by findings from pathway analysis and histopathological studies on excised tissue sections of stenotic mitral valves. Verification of selected protein candidates by immunotechniques in crude plasma corroborated our findings from label-free protein quantification. CONCLUSIONS: We propose that this protein profile of blood plasma, or any of the individual proteins, could serve as a focal point for future mechanistic studies on Mitral Stenosis. In addition, some of the proteins associated with this disorder may be candidate biomarkers for disease diagnosis and prognosis. Our findings might help to enrich existing knowledge on the molecular mechanisms involved in Mitral Stenosis and improve the current diagnostic tools in the long run.

Clinical significance of markers of collagen metabolism in rheumatic mitral valve disease.

BACKGROUND: Rheumatic Heart Disease (RHD), a chronic acquired heart disorder results from Acute Rheumatic Fever. It is a major public health concern in developing countries. In RHD, mostly the valves get affected. The present study investigated whether extracellular matrix remodelling in rheumatic valve leads to altered levels of collagen metabolism markers and if such markers can be clinically used to diagnose or monitor disease progression. METHODOLOGY: This is a case control study comprising 118 subjects. It included 77 cases and 41 healthy controls. Cases were classified into two groups- Mitral Stenosis (MS) and Mitral Regurgitation (MR). Carboxy-terminal propeptide of type I procollagen (PICP), amino-terminal propeptide of type III procollagen (PIIINP), total Matrix Metalloproteinase-1(MMP-1) and Tissue Inhibitor of Metalloproteinase-1 (TIMP-1) were assessed. Histopathology studies were performed on excised mitral valve leaflets. A p value <0.05 was considered statistically significant. RESULTS: Plasma PICP and PIIINP concentrations increased significantly (p<0.01) in MS and MR subjects compared to controls but decreased gradually over a one year period post mitral valve replacement (p<0.05). In MS, PICP level and MMP-1/TIMP-1 ratio strongly correlated with mitral valve area (r = -0.40; r = 0.49 respectively) and pulmonary artery systolic pressure (r = 0.49; r = -0.49 respectively); while in MR they correlated with left ventricular internal diastolic (r = 0.68; r = -0.48 respectively) and systolic diameters (r = 0.65; r = -0.55 respectively). Receiver operating characteristic curve analysis established PICP as a better marker (AUC = 0.95; 95% CI = 0.91-0.99; p<0.0001). A cut-off >459 ng/mL for PICP provided 91% sensitivity, 90% specificity and a likelihood ratio of 9 in diagnosing RHD. Histopathology analysis revealed inflammation, scarring, neovascularisation and extensive leaflet fibrosis in diseased mitral valve. CONCLUSIONS: Levels of collagen metabolism markers correlated with echocardiographic parameters for RHD diagnosis.

Two- and three-dimensional speckle tracking echocardiography: clinical applications and future directions.

Two-dimensional speckle tracking echocardiography (2D STE) is a novel technique of cardiac imaging for quantifying complex cardiac motion based on frame-to-frame tracking of ultrasonic speckles in gray scale 2D images. Two-dimensional STE is a relatively angle independent technology that can measure global and regional strain, strain rate, displacement, and velocity in longitudinal, radial, and circumferential directions. It can also quantify rotational movements such as rotation, twist, and torsion of the myocardium. Two-dimensional STE has been validated against hemodynamics, tissue Doppler, tagged magnetic resonance imaging, and sonomicrometry studies. Two-dimensional STE has been found clinically useful in the assessment of cardiac systolic and diastolic function as well as providing new insights in deciphering cardiac physiology and mechanics in cardiomyopathies, and identifying early subclinical changes in various pathologies. A large number of studies have evaluated the role of 2D STE in predicting response to cardiac resynchronization therapy in patients with severe heart failure. However, the clinical utility of 2D STE in the above mentioned conditions remains controversial because of conflicting reports from different studies. Emerging areas of application include prediction of rejection in heart transplant patients, early detection of cardiotoxicity in patients receiving chemotherapy for cancer, and effect of intracoronary injection of bone marrow stem cells on left ventricular function in patients with acute myocardial infarction. The emerging technique of three-dimensional STE may further extend its clinical usefulness.

Early, structured disease modifying anti-rheumatic drug (DMARD) therapy reduces cardiovascular risk in rheumatoid arthritis--a single centre study using non-biologic drugs.

BACKGROUND: Rheumatoid arthritis, being a chronic disease requires long-term management of patients with drugs. The increasing cost of biologics in this era of disease management led us to devise a treatment regime, optimal for use in a developing country like India, which was economical as well as effective in controlling disease activity. OBJECTIVE: To investigate if combination therapy with DMARDs can reduce cardiovascular risk in early Rheumatoid Arthritis, besides controlling disease activity. METHODS: A small cohort of early Rheumatoid subjects with disease duration less than 1 year were treated with a structured DMARD regime and were followed up over a year. Disease activity score, C-reactive protein (CRP) and cardiac risk markers like lipid panel and carotid intima-medial thickness were monitored at 6 months and 1 year. RESULTS: A significant reduction (p < 0.001) of disease activity as well as cardiac risk parameters were observed. CONCLUSION: Our study showed that treatment of early rheumatoid arthritis with a combination regime of traditional DMARDs is highly effective in controlling disease activity as well as cardiovascular risk.

A conservative surgical approach for management of iatrogenic pulmonary artery perforation.

Accidental malposition of a chest tube in the pulmonary artery is a potentially fatal complication. Here we describe a 66 year-old obese woman with prior cardiac transplantation, intubated for respiratory failure and felt to have a large left pleural effusion. A chest tube was inserted using a trocar tube, and resulted in near-exsanguinating hemorrhage immediately, with development of hypovolemic shock. Prompt clamping of the tube proved life-saving, and CT scan confirmed placement of the tube in the main pulmonary artery. Initial stabilization, followed by a planned surgical approach, resulted in successful removal of the tube.

Spontaneous coronary artery dissection: case report and review of literature.

Spontaneous coronary artery dissection (SCAD) is an unusual cause of acute coronary syndrome or sudden cardiac death. SCAD has most frequently been described as presenting as an acute coronary syndrome in females during the peripartum period. It may also be associated with autoimmune and collagen vascular diseases, Marfan's syndrome, chest trauma, and intense physical exercise. The most common presentation of SCAD is the acute onset of severe chest pain associated with autonomic symptoms. This condition has a high mortality rate if not identified and treated promptly. Here, we present a case of SCAD presenting with stroke, followed by a brief review.