Comparison of transvalvular flow rate in aortic stenosis subtypes.

OBJECTIVES: Evaluate ET and TVFR in normal patients, PLFLGAS, LGLFAS, and classic pre and post TAVR. BACKGROUND: Severe aortic stenosis (AS) is defined echocardiographically. Generating a pressure gradient to meet diagnostic criteria is dependent on left ventricular contractility, stroke volume, and ejection time.  Abnormalities in these decrease the mean pressure gradient across the valve creating pathology termed low flow, low gradient AS. This occurs in two subtypes, low ejection fraction LFLGAS and paradoxical LFLGAS (PLFLGAS), in which EF is normal but stroke volume is < 35 ml/m2 . Paradoxical LFLGAS is difficult to diagnose and does not have a confirmatory echocardiographic parameter. Transvalvular flow rate (TVFR), which is defined as stroke volume divided by the ejection time, provides a direct measure of flow across the aortic valve. METHODS: A retrospective study of patients who underwent transcatheter aortic valve replacement (TAVR) at the University of Cincinnati Medical Center between 2016 and 2019 was performed. Patients were classified by AS subtype. ET and TVFR were measured pre and post TAVR and statistically compared using SPSS statistics software and ANOVA analysis. RESULTS: Pre TAVR TVFR in the normal population, severe AS population, and LFLGAS were not significantly different. The pre TAVR TVFR in paradoxical LFLGAS patients was significantly lower than other groups. TVFR improved to the greatest degree post TAVR in PLFLGAS but did not meet statistical significance. CONCLUSIONS: The significantly lower TVFR demonstrated in PLFLGAS provides a comprehensive, direct measurement of aortic valve hemodynamics and PLFLGAS pathology and can aid in diagnosis.

Review of Cardiovascular Drugs in Pregnancy.

Cardiovascular disease is now the leading cause of pregnancy-related deaths in the United States. Increasing maternal mortality in the United States underscores the importance of proper cardiovascular management. Significant physiological changes during pregnancy affect the heart's ability to respond to pathological processes such as hypertension and heart failure. These physiological changes further affect the pharmacokinetic and pharmacodynamic properties of cardiac medications. During pregnancy, these changes can significantly alter medication efficacy and metabolism. This article systematically reviews the literature on safety, efficacy, pharmacokinetics, and pharmacodynamics of cardiovascular drugs used for hypertension and heart failure during pregnancy and lactation. The 2017 American College of Cardiology/American Heart Association hypertension guidelines recommend transitioning pregnant patients to methyldopa, nifedipine, or labetalol. Heart failure medications, including beta-blockers, furosemide, and digoxin, are relatively safe and can be used effectively. Medications that block the renin angiotensin-aldosterone system have been shown to be beneficial in the general population; however, they are teratogenic and, therefore, contraindicated in pregnancy. Cardiovascular medications can also enter breast milk and, therefore, care must be taken when selecting drugs during the lactation period. A summary of the safety of drugs during pregnancy and lactation from an online resource, LactMed by the National Library of Medicine's TOXNET database, is included. High-risk pregnant patients with cardiovascular disease require a multispecialty team of doctors, including health care providers from obstetrics and gynecology, maternal fetal medicine, internal medicine, cardiovascular disease specialists, and specialized pharmacology expertise.

Duration of Dual Antiplatelet Therapy in Coronary Artery Disease: a Review Article.

Dual antiplatelet therapy (DAPT) following an acute coronary syndrome or after placement of a coronary artery stent is superior to aspirin alone for prevention of atherothrombotic events but carries an increased bleeding risk. DAPT should be continued for at least 12 months based on current guidelines. Recent randomized trials demonstrate reduced ischemic events including myocardial infarction (MI), stroke, and death with continued DAPT for up to 30 months or longer, particularly in the post-MI population. However, this clinical benefit is accompanied by an increased risk of bleeding. Additional trials show mixed safety and efficacy with duration of DAPT of less than 12 months. The current data emphasizes the need to individualize DAPT duration at the patient level to balance the clinical benefits of a reduced risk of cardiovascular ischemic events with the greater risk of clinically significant bleeding. Patients at an increased risk of ischemic events and a lower risk of bleeding should be strongly considered for prolonged DAPT beyond the 1 year currently recommended in the practice guidelines.