Guideline-Directed Medical Therapy and the Risk of Death in Primary Prevention Defibrillator Recipients.

BACKGROUND: Contemporary guideline-directed medical therapy (GDMT) confers a significant mortality benefit for patients with heart failure with reduced ejection fraction (HFrEF), as compared to GDMT prevalent at the time of landmark primary prevention implantable cardioverter-defibrillator (ICD) trials. The impact of modern era GDMT on survival in this population is unknown. OBJECTIVES: This study sought to investigate the impact of number of GDMT medications prescribed for HFrEF on all-cause mortality in recipients of primary prevention ICD. METHODS: A cohort of 4,972 recipients with primary prevention ICD (n = 3,210) or cardiac resynchronization therapy-defibrillator (CRT-D) (n = 1,762) was studied. The association of number of GDMT medications prescribed at the time of device implantation and all-cause mortality at 2 years post implantation was examined. RESULTS: In our primary prevention cohort, 5%, 20%, 52%, and 23% of patients were prescribed 0, 1, 2, or 3-4 GDMT medications, respectively. After risk adjustment for age, sex, ejection fraction, body mass index, the Elixhauser comorbidity score, the type of cardiomyopathy, and the year of device implantation, each additional GDMT conferred a reduction in the risk of death of 36% in recipients of ICD (HR: 0.64; P < 0.001) and 30% in recipients of CRT-D (HR: 0.70; P < 0.001). CONCLUSIONS: A higher number of prescribed GDMT medications is associated with an incremental 1-year survival in recipients of primary prevention ICD with or without CRT. Initiation of maximum number of tolerated GDMT medications should therefore be the goal for all patients with HFrEF. In the setting of robust GDMT, the risk versus benefit of a primary prevention ICD warrants re-examination in future studies.

Atypical de Winter Presentation of Critical Left Anterior Descending Coronary Artery Occlusion.

A 69-year-old male presented with substernal chest pain that started a few hours earlier. On arrival, the patient was hemodynamically stable, and the physical examination was unrevealing. Laboratory workup revealed an elevated high-sensitivity troponin, and an initial electrocardiogram (ECG) revealed tall, symmetric T-waves with preceding minor concave ST-segment elevations less than 1 mm in the precordial leads (V1-V6) and 0.5 mm ST elevation in the aVR. Due to concerning ECG changes, the patient was treated for a possible non-ST-segment elevation myocardial infarction. A loading dose of aspirin and clopidogrel was given and a heparin drip was initiated. However, the patient's chest pain persisted requiring multiple sublingual nitroglycerin tablets. Later, on further review of the ECGs, the presence of de Winter T-waves was noted and led to activation of the catheterization laboratory, and an urgent left heart catheterization (LHC) was done. LHC revealed a critical 90% occlusion of the left anterior descending artery, and a drug-eluting stent was placed. The patient had a good recovery thereafter. This case emphasizes the rarity of the case and lack of awareness about the atypical de Winter pattern that is considered to be an ST-segment elevation myocardial infarction equivalent. Failure to recognize this can potentially lead to delayed intervention.

Myocardial Infarction With Non-obstructive Coronary Arteries: An Updated Overview of Pathophysiology, Diagnosis, and Management.

Myocardial infarction with non-obstructive coronary arteries (MINOCA) refers to acute myocardial infarction with normal or near-normal coronary arteries. The MINOCA is a heterogeneous group of conditions, and possible etiologies are coronary artery spasm, spontaneous coronary artery dissection, coronary thromboembolism, coronary plaque disruption, coronary microvascular dysfunction, supply and demand mismatch. It is more common in young adults, with women having a higher chance of getting MINOCA than men. Considering MINOCA as a clinically dynamic working diagnostic that needs further investigation rather than a "true" diagnosis is proposed. Optical coherence tomography (OCT), intravenous ultrasound (IVUS), cardiac MRI may be required to stratify the underlying mechanism. Due to the lack of evidence-based literature and prospective randomized controlled studies, therapeutic management is limited. Consequently, the strategy is patient-specific. The prognosis of MINOCA patients remains unclear and depends upon the underlying etiology. This article aims to review the literature about various aspects of MINOCA, including pathophysiology, diagnosis, prognosis, and treatment.

Charge transport mechanisms in sol-gel grown La0.7Pb0.3MnO3/LaAlO3 manganite films.

In this communication, structural, microstructural, transport and magnetotransport properties are reported for La0.7Pb0.3MnO3/LaAlO3 (LPMO/LAO) manganite films having different thicknesses. All the films were irradiated with 200 MeV Ag+15 swift heavy ions (SHI). Films were grown using the sol-gel method by employing the acetate precursor route. Structural measurements were carried out using the X-ray diffraction (XRD) method at room temperature, while atomic force microscopy (AFM) was performed for the surface morphology. Temperature dependent resistivity under different applied magnetic fields for all the films shows metal to insulator transition at temperature TP. In addition to the metal to insulator transition at TP, the films also exhibit low temperature resistivity upturn behavior. Resistivity, TP and upturn behavior are highly influenced by the film thickness, applied magnetic field and irradiation. To understand the nature of charge transport for the low temperature resistivity behavior and metallic and insulating (semiconducting) regions, various models and mechanisms have been verified and the most suitable mechanism has been found for each region in the resistivity curves. Magnetoresistance (MR) is affected by temperature, film thickness and irradiation. MR behavior has been understood in terms of combined and separate contributions from grains and grain boundaries in the films.

Correction: Charge transport mechanisms in sol-gel grown La0.7Pb0.3MnO3/LaAlO3 manganite films.

Correction for 'Charge transport mechanisms in sol-gel grown La0.7Pb0.3MnO3/LaAlO3 manganite films' by Eesh Vaghela et al., Phys. Chem. Chem. Phys., 2017, DOI: 10.1039/c6cp07730g.

Transport properties and electroresistance of a manganite based heterostructure: role of the manganite-manganite interface.

In this paper, we report the results of the investigations on the transport properties performed across the manganite-manganite interface in the LaMnO3-δ/La0.7Ca0.3MnO3/LaAlO3 (LMO/LCMO/LAO) heterostructure. The bilayered heterostructure was synthesized by a low cost and simple chemical solution deposition (CSD) method by employing the acetate precursor route. The same LMO/LCMO/LAO heterostructure was also grown using the dry metal oxide chemical vapor deposition (CVD) method and the results of transport characterization have been compared on the basis of wet and dry chemical methods used. XRD Φ-scan measurements were carried out to verify the structural quality and crystallographic orientations of LMO and LCMO manganite layers, for both wet and dry chemical method grown heterostructures. For wet and dry chemical methods, the temperature dependent resistance of the LMO/LCMO interface suggests the metallic nature. The asymmetric I-V curves collected at different temperatures show normal diode characteristics which get transformed to backward diode characteristics at high temperatures under high applied voltages at Vtr for both the methods. The values of Vtr are strongly dependent on the chemical method used. I-V data have been fitted using the Simmons model at different temperatures and discussed in terms of the spin-flip scattering mechanism for both wet and dry chemical method grown heterostructures. The electric field dependent electroresistance (ER) behavior of the presently studied LMO/LCMO manganite-manganite interface, grown using wet and dry chemical methods, has been understood on the basis of complex mechanisms including charge injection, formation of the depletion region, the tunneling effect, thermal processes and junction breakdown and their dependence on the applied electric field, field polarity and temperature studied.