Beyond the myocardium? SGLT2 inhibitors target peripheral components of reduced oxygen flux in the diabetic patient with heart failure with preserved ejection fraction.

Recent cardiovascular outcome trials have highlighted the propensity of the antidiabetic agents, SGLT2 inhibitors (SGLT2is or -flozin drugs), to exert positive clinical outcomes in patients with cardiovascular disease at risk for major adverse cardiovascular events (MACEs). Of interest in cardiac diabetology is the physiological status of the patient with T2DM and heart failure with preserved ejection fraction (HFpEF), a well-examined association. Underlying this pathologic tandem are the effects that long-standing hyperglycemia has on the ability of the HFpEF heart to adequately deliver oxygen. It is believed that shortcomings in oxygen diffusion or utilization and the resulting hypoxia thereafter may play a role in underlying the clinical sequelae of patients with T2DM and HFpEF, with implications in the long-term decline of extra-cardiac tissue. Oxygen consumption is one of the most critical factors in indexing heart failure disease burden, warranting a probe into the role of SGLT2i on oxygen utility in HFpEF and T2DM. We investigated the role of oxygen flux in the patient with T2DM and HFpEF extending beyond the heart with focuses on cellular metabolism, perivascular fibrosis with endothelial dysfunction, hematologic changes, and renal effects with neurohormonal considerations in the patient with HFpEF and T2DM. Moreover, we give a commentary on potential therapeutic targets of these components with SGLT2i to gain insight into disease burden amelioration in patients with HFpEF and T2DM.

Cardiogenic shock in autoimmune rheumatologic diseases: an insight on etiologies, management, and treatment outcomes.

Autoimmune rheumatological disorders are known to have an increased risk for cardiovascular diseases including coronary artery disease (CAD), myocarditis, pericarditis, valvulopathy, and in consequence cardiogenic shock. Data on cardiogenic shock in rheumatological diseases are scarce; however, several reports have highlighted this specific entity. We sought to review the available literature and highlight major outcomes and the management approaches in each disease. Systematic literature search, including PubMed, Ovid/Medline, Cochrane Library, and Web of Science, was conducted between January 2000 and December 2009. We reviewed all cases reporting cardiogenic shock with rheumatologic conditions, including systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), Takayasu's arteritis (TA), granulomatosis with polyangiitis (GPA), giant cell arteritis (GCA), and antiphospholipid syndrome (APS). We selected 45 papers reporting a total of 48 cases. Mean age was 39 ± 7.3 years and 68.8% were females. Most common rheumatologic conditions associated with cardiogenic shock were SLE (31%), GPA (23%), TA (14.6%), APA (10.4%), and RA (8.3%). Cardiogenic shock was found to be caused by eosinophilic myocarditis in 58% of cases, CAD in 19% of cases, and valvulopathy in 6% of cases. Most patient required high-dose steroids and second immunosuppressant therapy. Mechanical circulatory supported was required in 23 cases, IABP in 16 cases, and ECMO in 12 cases. Complete recovery occurred in 37 patients while 9 patients died and 2 required heart transplant. Responsible for two-thirds of cases, eosinophilic myocarditis should be suspected in young cardiogenic shock patients with underlying rheumatologic conditions. Lupus and GPA are the two most common conditions.

Neural tone and cardio-renal outcomes in patients with type 2 diabetes mellitus: a review of the literature with a focus on SGLT2 inhibitors.

Recent clinical trials involving the systemic effects of sodium-glucose cotransporter 2 inhibitors (SGLT2i) have revealed beneficial outcomes pertaining to the microvascular sequelae of type 2 diabetes mellitus (T2DM) such as nephropathy, as well as macrovascular effects such as major adverse cardiovascular effects (MACE). Such findings have spurred the elevation of these agents to level A-tiers of recommendation within clinical guidelines addressing the management of complicated T2DM. While the mechanisms of SGLTi (-flozin drugs) are still being elucidated, a paucity of data exists within the literature appraising the role of neuromodulation and associated mechanisms in the aforementioned outcome studies. Given the role of the nervous system in orchestrating the pathologic processes that hamper cardio-renal status, insight into this topic offers an expanded perspective on T2DM. In this review we investigate the mechanisms by which SGLTi improve cardio-renal function in T2DM patients with emphases on neural tone and nervous system physiology.

In-hospital outcomes of transcatheter versus surgical mitral valve repair in patients with chronic liver disease.

BACKGROUND: Mitral valve transcatheter edge-to-edge repair (TEER) using MitraClip is a treatment option for patients with moderate to severe mitral regurgitation who are not surgical candidate. Liver cirrhosis is associated with higher operative morbidity and mortality; however, it is not part of preoperative risk assessments calculators. We sought to evaluate the in-hospital outcomes in TEER and surgical mitral valve repair (SMVR) in liver cirrhosis. METHODS: National Inpatient Database from 2013 to 2017 was used to obtain all patients with cirrhosis who underwent TEER or SMVR using ICD-9-CM and ICD-10-CM codes. The primary outcome is to compare inpatient mortality between TEER and SMVR. Secondary outcomes were assessed including length of stay (LOS) and rate of complications including cardiogenic shock, blood transfusion and prolonged ventilation. RESULTS: A total of 875 patients with cirrhosis who underwent TEER (n = 123) or SMVR (n = 752) were identified in our analysis. Patients with TEER had significantly higher comorbidities such as congestive heart failure, coronary artery disease and chronic obstructive pulmonary disease. In-hospital mortality was lower in TEER group (8.2% vs 16%, P = .04). TEER was associated with lower rates of blood transfusion (30.3% vs 61.2%, P = .02) and reduced rates of prolonged mechanical ventilation (1.2% vs 17.2%, P = .042). In multivariate regression analysis, both blood transfusion and prolonged mechanical ventilation were significant predictors of mortality in liver cirrhosis. CONCLUSIONS: TEER was associated with lower rate of in-hospital mortality, LOS, blood transfusion and prolonged mechanical ventilation in cirrhosis patients. TEER can be considered as a viable option for cirrhosis patient with severe mitral regurgitation.

Cardiovascular, electrophysiologic, and hematologic effects of omega-3 fatty acids beyond reducing hypertriglyceridemia: as it pertains to the recently published REDUCE-IT trial.

Heart disease continues to affect health outcomes globally, accounting for a quarter of all deaths in the United States. Despite the improvement in the development and implementation of guideline-directed medical therapy, the risk of adverse cardiac events remains substantially high. Historically, it has been debated whether omega-3 polyunsaturated fatty acids provide clinical benefit in cardiac disease. The recently published REDUCE-IT trial demonstrated a statistically significant absolute risk reduction of 4.8% in its primary endpoint (cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, coronary revascularization, or unstable angina) with the use of icosapent ethyl, which is a highly purified eicosapentaenoic acid (EPA) ethyl ester. However, the mechanism of action of omega-3 fatty acids is not commonly discussed. Moreover, the use of EPA was not without risk, as the incidence of atrial fibrillation was increased along with a trend towards increased bleeding risk. Thus, our aim is to help explain the function of purified EPA ethyl ester, especially at the molecular level, which will ultimately lead to a better understanding of their clinically observable effects.

Prosthetic mitral inflow mimicking severe aortic regurgitation (revisited). An echocardiographic challenge.

Assessing aortic regurgitation (AR) severity in patients with mitral valve prosthesis may pose an echocardiographic challenge. We present a case of mild AR in whom difficulty occurred in judging its severity due to eccentric mitral prosthetic inflow signals filling practically completely the proximal left ventricular outflow tract in diastole mimicking severe AR. Frame-by-frame analysis of two-dimensional transthoracic echocardiographic images using a small sector depth and width was helpful in clarifying the true severity of AR.

Prominent pulmonary venous flow mimicking mitral regurgitation.

The present case highlights a potential pitfall in assessing mitral regurgitation severity due to the presence of similar colored prominent pulmonary vein signals in the left atrium during color Doppler examination.

Role of Cardiac Biomarkers in Monitoring Cardiotoxicity in Chemotherapy Patients.

PURPOSE: This review aims to highlight the different types of chemotherapy-induced cardiotoxicity and will discuss the evidence base behind the use of different cardiac biomarkers to predict cardiovascular complications. Additionally, we will review the use of cardiac biomarkers to monitor cardiac outcomes and the role of cardioprotective medications in reducing cardiovascular side effects. RECENT FINDINGS: Chemotherapy has been linked to an increased risk of cardiotoxicity and heart failure. Currently, patients receiving chemotherapy undergo echocardiogram before starting chemotherapy and every 6 months to monitor for any decline in cardiac function. We reviewed the current evidence and practice guidelines of monitoring chemotherapy cardiotoxicity. SUMMARY: Cardio-oncology is a rapidly evolving subspecialty in cardiology, especially with the advent of new chemotherapeutic agents, which have cardiovascular side effects. Early detection of these effects is crucial to prevent life-threatening and irreversible cardiovascular outcomes. Monitoring troponin, pro-brain natriuretic peptide, and other cardiac biomarkers during chemotherapy will help to early detect cardiotoxicity.

Electrocardiogram changes as predictors for new imaging findings in repeat transthoracic echocardiography.

Aim: To determine if electrocardiogram (EKG) findings may be a useful tool to predict changes in repeat transthoracic echocardiogram (TTE). Methods: We evaluated patients who underwent TTE during hospitalization and their EKGs, and whether findings differed between studies. Results: Of 229 hospitalized patients who underwent repeat TTE, 183 (80%) were abnormal. Each minor and major EKG abnormality resulted in a 1.8 (1.2 to 2.6; p = 0.002) and 2.1 (1.3 to 3.3; p < 0.001) increased odds of abnormal imaging on TTE, respectively. The negative likelihood ratio for an unchanged EKG to predict an unchanged TTE was 0.68 (95% CI = 0.62 to 0.73). Conclusion: Among hospitalized patients with prior imaging results, an unchanged EKG predicts an unchanged TTE.

Iatrogenic Right Atrial Thrombus Complicated by Pulmonary Embolism: Management and Outcomes.

Right atrial thrombus can originate from distal venous sources or can be iatrogenic, secondary to the placement of central venous catheters, atrial devices, or surgeries. One of the most common complications of Central Venous Catheters (CVCs) is thromboembolism, which can be either fixed to the right atrium or can be free-floating. Device-related Right Atrial Thrombosis (RAT) can result in catheter occlusion, vascular occlusion, infection, and pulmonary embolism. The true incidence of these complications is unknown because the diagnosis may not be considered in asymptomatic patients, and it might be missed by Transthoracic Echocardiography (TTE). In this literature review, we discuss iatrogenic etiologies of RAT that is complicated by pulmonary embolism. We highlight the importance of maintaining a high index of suspicion of iatrogenic RAT, possible complications, and its management.

Hydralazine-Induced ANCA Associated Vasculitis (AAV) Presenting with Pulmonary-Renal Syndrome (PRS): A Case Report with Literature Review.

Hydralazine, an arterial vasodilator, is a widely used medication for the management of hypertension and heart failure, especially for patients who cannot tolerate the use of ACEIs or ARBs. It is generally well-tolerated and has a safe profile in pregnancy. However, hydralazine can induce immune-mediated side effects, such as hydralazine-induced lupus and less commonly hydralazine- induced ANCA vasculitis. The latter most commonly affects the kidneys with or without other organ involvement. There are several cases reported in the literature of hydralazine-induced ANCA associated vasculitis (AAV) that have pulmonary manifestations, also known as hydralazine- induced pulmonary-renal syndrome (PRS), a condition with a high risk of mortality. We are reporting a case of Hydralazine-induced ANCA associated glomerulonephritis with severe diffuse alveolar hemorrhage (DAH). In addition, we will review the current literature and discuss the importance of prompt diagnosis and early management to decrease mortality and morbidity associated with this serious condition.

State-of-the-Art Review of Current Therapies for HFpEF: An Overview of Interatrial Septal Device Therapy in Heart Failure.

Heart failure (HF) affects an increasing number of geriatric patients. The condition is classified according to whether the left ventricular ejection fraction (EF) is reduced or preserved. Many patients have heart failure with preserved ejection fraction (HFpEF) and face a shortage of effective therapeutic strategies. However, an emerging mechanical strategy for treatment is gaining momentum. Interatrial septal connection devices, i.e. V-wave device and Interatrial septal device, are new devices for patients with heart failure with preserved ejection fraction. We review the function of these systems and the data from the recent clinical trials. Interatrial septal connection device therapy provided favorable efficacy and safety profile applicable to a wide range of patients with HFpEF. However, the long-term effects of these devices on morbidity.

Spontaneous Biliary Pericardial Tamponade: A Case Report and Literature Review.

BACKGROUND: Biliary pericardial tamponade (BPT) is a rare form of pericardial tamponade, characterized by yellowish-greenish pericardial fluid upon pericardiocentesis. Historically, BPT reported to occur in the setting of an associated pericardiobiliary fistula. However, BPT in the absence of a detectable fistula is extremely rare. LEARNING OBJECTIVE: A biliary pericardial tamponade is a rare form of tamponade warranting a prompt workup (e.g., MRCP or HIDA scan) for a potential fistula between the biliary system and the pericardial space. A pericardio-biliary fistula can be iatrogenic or traumatic. People with a history of chest wall trauma, abdominal surgery, or chest surgery are at increased risk. The use of HIDA scanning plays a salient role in effectively surveilling for the presence of a fistula - especially when MRCP is contraindicated. CASE PRESENTATION: A 75-year-old Hispanic male presenting with dyspnea and diagnosed with cardiac tamponade is the subject of the study. Subsequent pericardiocentesis revealed biliary pericardial fluid (bilirubin of 7.6 mg/dl). The patient underwent extensive workup to identify a potential fistula between the hepatobiliary system and the pericardial space, which was non-revealing. The mechanism of bile entry into the pericardial space remains to be unidentified. LITERATURE REVIEW: A total of six previously published BPT were identified: all were males, with a mean age of 53.3 years (range: 31-73). Mortality was reported in two out of the six cases. The underlying etiology for pericardial tamponade varied across the cases: incidental pericardio-biliary fistula, traumatic pericardial injury, and presence of associated malignancy. - Conclusion: Biliary pericardial tamponade is a rare form of tamponade that warrants a prompt workup (e.g., Hepatobiliary Iminodiacetic Acid - HIDA scan) for an iatrogenic vs. traumatic pericardio- biliary fistula. As a first case in the literature, our case exhibits a biliary tamponade in the absence of an identifiable fistula.

Concurring hypertrophic cardiomyopathy and takotsubo cardiomyopathy: Assessment and management.

The prevalence of takotsubo cardiomyopathy (TCM) has been on the rise, but co-occurrence with hypertrophic cardiomyopathy (HOCM) remains rare. Although presenting patient demographics were similar to those in TCM, the potential for hemodynamic compromise was significantly compounded by the presence of underlying HOCM. Management was similar to standalone TCM, although use of inotropic agents and mechanical support appears to be more prevalent. Despite the increased potential for complications and the paucity of data regarding management, outcomes appear to be mostly favorable in both the hospitalization period and at follow-up. Interestingly, despite a new diagnosis of HOCM in about half the cases described, which signifies no significant left ventricular outflow tract (LVOT) gradient prior to TCM, half of those patients had a persistently elevated LVOT gradient after resolution of TCM. This poses a question of whether or not TCM can predispose to LVOT obstruction in HOCM patients even after its resolution.

Systematic Review of COVID-19 Related Myocarditis: Insights on Management and Outcome.

INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also referred to as COVID-19, was declared a pandemic by the World Health Organization in March 2020. The manifestations of COVID-19 are widely variable and range from asymptomatic infection to multi-organ failure and death. Like other viral illnesses, acute myocarditis has been reported to be associated with COVID-19 infection. However, guidelines for the diagnosis of COVID-19 myocarditis have not been established. METHODS: Using a combination of search terms in the PubMed/Medline, Ovid Medline and the Cochrane Library databases and manual searches on Google Scholar and the bibliographies of articles identified, we reviewed all cases reported in the English language citing myocarditis associated with COVID-19 infection. RESULTS: Fourteen records comprising a total of fourteen cases that report myocarditis/myopericarditis secondary to COVID-19 infection were identified. There was a male predominance (58%), with the median age of the cases described being 50.4 years. The majority of patients did not have a previously identified comorbid condition (50%), but of those with a past medical history, hypertension was most prevalent (33%). Electrocardiogram findings were variable, and troponin was elevated in 91% of cases. Echocardiography was performed in 83% of cases reduced function was identified in 60%. Endotracheal intubation was performed in the majority of cases. Glucocorticoids were most commonly used in treatment of myocarditis (58%). Majority of patients survived to discharge (81%) and 85% of those that received steroids survived to discharge. CONCLUSION: Guidelines for diagnosis and management of COVID-19 myocarditis have not been established and our knowledge on management is rapidly changing. The use of glucocorticoids and other agents including IL-6 inhibitors, IVIG and colchicine in COVID-19 myocarditis is debatable. In our review, there appears to be favorable outcomes related to myocarditis treated with steroid therapy. However, until larger scale studies are conducted, treatment approaches have to be made on an individualized case-by-case basis.

Outcomes of MitraClip Placement in Patients With Liver Cirrhosis.

INTRODUCTION: Liver cirrhosis is associated with increased morbidity and mortality. Many preoperative risk assessment tools do not take into account the presence or degree of liver cirrhosis prior to surgery. Over recent years, percutaneous mitral valve repair using MitraClip has emerged as an option for patients at high risk of surgical intervention. However, the safety, efficacy and outcomes of this procedure in patients with liver cirrhosis have not yet been evaluated. METHODS: This is a retrospective cohort study using the 2013-2017 National Inpatient Sample database of adults who were hospitalized for MitraClip repair of mitral valve. All patients were divided into patients with cirrhosis and those without cirrhosis. The primary outcome was all-cause mortality in patient with cirrhosis who underwent MitraClip. The secondary outcomes were to assess length of stay (LOS) and total hospital cost per year in cirrhotic patients compared to non-cirrhotic patients. RESULTS: In-hospital mortality was higher in cirrhosis group compared to non-cirrhosis however not statistically significant (8.1% vs 3.2%, OR: 2.59 [95% CI: 0.47-14.28, p-value 0.27). Additionally, neither of the secondary outcomes, LOS and total cost, were found to be statistically significant. However, the incidence of cardiogenic shock was significantly higher in the cirrhosis group 13.3% versus 3.9% (p-value 0.032). CONCLUSION: Patients with liver cirrhosis who underwent MitraClip repair of MV were at higher risk of developing cardiogenic shock, without any significant increase in in-hospital mortality, LOS or total cost. However, this study showed a trend toward higher rates of mortality, requirement of blood transfusion, mechanical ventilation, length of stay, and cost of care in cirrhosis patients.

A focused review of cardiovascular guideline related recommendations for the primary care physician in the USA.

Primary care physicians in the USA serve the critical role of first contact for undiagnosed or mismanaged pathologies as well as providers of continuous care in multiple communities. Their scope of practice is broad from medication reconciliation to coordinating specialty care and even performing office procedures. Primary care physicians in the USA commonly encounter patients with diabetes and associated comorbidities related to prolonged insulin resistance. Mainly these include heart failure exacerbation or major adverse cardiovascular events. The demanding roles primary care physicians serve may render these providers encumbered to navigate through long, verbose and dynamic guidelines related to managing diabetes and cardiac diabetology sequelae. Our aim is to compose current, prominent evidence-based points from American medical societies such as the American College of Cardiology/American Heart Association and the American Diabetes Association central to lifestyle modifications, antiplatelet therapy, anti-hyperglycemic and SGLT2-inhibitor utilization, hypertension, dyslipidemia, and heart failure screening in a way that is both succinct and valuable to primary care physicians.

Cutaneous Fusariosis in a Patient with Job's (Hyper-IgE) Syndrome.

Fusarium is a filamentous fungus that is ubiquitous in nature and can cause severe opportunistic infections in immunocompromised hosts. The association between Fusarium and hyper-IgE syndrome is exceedingly rare and has only been documented in a single report previously. A 44-year-old male, working as marijuana grower, with prior diagnosis of hyper-IgE syndrome and recurrent infections presented with enlarging right knee ulcer that did not respond to antimicrobial treatment. The patient was diagnosed with cutaneous fusariosis, confirmed with punch biopsy and positive wound cultures. The patient was managed with extended antifungal therapy (i.e., posaconazole) and surgical debridement resulting in remarkable improvement with wound healing leaving a pale scar. Fusarium should be considered in differential for cutaneous and invasive fungal infections in presence of cutaneous manifestations. Exposure to Cannabis plants is a noticeable risk factor. Multimodal approach involving systemic antifungals and wound debridement is essential for favorable outcome. Posaconazole was demonstrated to be a highly efficacious antifungal choice.

Coronary Fistula Between Left Anterior Descending Artery (LAD) and Pulmonary Artery (PA) Leading to Sudden Cardiac Death: Case Report with Literature Review.

Coronary Artery Fistulas (CAF) are inappropriate connections between a coronary artery and a major vessel or a cardiac chamber. These fistulas may or may not present with symptoms, but they need to be detected as early as possible in order to decide the most appropriate treatment methodology (i.e. surgery vs. conservative management). We report the case of a 67-year-old female with no modifiable cardiovascular risk factors who had an unwitnessed sudden death at home during her ongoing evaluation of a fistula detected incidentally between the Left Anterior Descending Artery (LAD) and the Pulmonary Artery (PA). This case highlights that early diagnosis and treatment of symptomatic CAF are crucial to minimize the risk of sudden cardiac death. Although the symptomatic fistula of LAD to PA has been reported in the literature multiple times, it has been rarely reported that this fistula can result in sudden cardiac death.

Acute Myocardial Infarction in Systemic Mastocytosis: Case Report With Literature Review on the Role of Inflammatory Process in Acute Coronary Syndrome.

BACKGROUND: Systemic Mastocytosis (SM) is a disorder of excessive mast cell infiltration in multiple organ tissues. Atherosclerosis is a major risk factor for developing acute coronary syndrome. In addition to lipid accumulation in the arterial wall, inflammation plays an important role in the pathogenesis of plaque rupture and activating the thrombosis cascade. The Mast cells contribution to plaque destabilization has been well established in multiple animal and human studies. In a recent study, SM has been proven to be associated with a higher incidence of acute coronary syndrome even with lower plasma lipids levels. The study showed that 20% of patients with SM had cardiovascular events compared to only 6% in the control group with adjustment to all cardiac risk factors. CASE: We presented a patient with no risk factors for heart disease other than old age and history of SM who developed acute myocardial infarction. CONCLUSION: SM can be life-threatening and can result in ACS, anaphylactic reaction, syncope, or cardiac arrest. Clinicians should have a high index of suspicion of acute coronary syndrome (ACS) occurrence in the setting of inflammatory conditions, such as SM and KS, and vice versa, where SM should be considered or ruled out in patients who suffer from anaphylaxis and cardiac arrest or myocardial infarction.