Contraceptive Strategies in Women With Heart Failure or With Cardiac Transplantation.

PURPOSE OF REVIEW: We describe contraception for two groups of women: (1) women with heart failure and (2) women with cardiac transplantation. RECENT FINDINGS: Medical Eligibility Criteria for contraceptive agents address women with peripartum cardiomyopathy and women with valvular heart disease (Curtis et al. MMWR Recomm Rep 65:1-103, 2016). Recommendations for women with other forms of heart failure are extrapolated from these populations. Recommendations for women with cardiac transplantation have shifted since the 1980s: use of long-acting reversible contraception has increased, and there is a better understanding of the interactions between contraceptive and immunosuppressive regimens. Women with heart failure may utilize long-acting reversible contraception and permanent sterilization. Modifications should be made according to the specific etiology of the heart failure. In women with cardiac transplantation, pregnancy is high risk and should be avoided altogether for 1-2 years after transplantation. In uncomplicated transplantation, almost all forms of contraception are allowable. In complicated transplantation, combined hormonal contraceptives are contraindicated, and de novo IUD insertion is not recommended.

Natriuretic peptide testing in high-risk pregnancy: a preventive opportunity?

Natriuretic peptide testing has been widely utilized in the heart failure and cardiac patient population, but there is limited utilization during pregnancy. Patients with hypertensive diseases of pregnancy have been shown to experience elevation of circulating natriuretic peptide levels compared to normal pregnancies, especially in the setting of preeclampsia. Natriuretic peptide testing can be utilized in patients presenting with signs and symptoms suspicious of heart failure in order to rule out underlying cardiac causes. Meanwhile, monitoring natriuretic peptide levels in those with established heart diseases (both congenital and acquired) may facilitate careful management of cardiac status during the course of pregnancy. Further investigations in the judicious use of selected medications (particularly loop diuretics) in the setting of elevated natriuretic peptide levels are warranted.

The concoction of cancer, catheter, and intracardiac clot: a case report describing a potential treatment strategy.

BACKGROUND: Patients with cancer often pose a unique challenge to anticoagulation, as they have a higher risk of bleeding and clotting than the general population. Patients with cancer and catheter-related intracardiac thrombus are a very specific subset of people who do not have specific recommendations guiding their treatment. This article aims to address the existing knowledge gaps in this scenario and provide a possible treatment approach for these patients. CASE SUMMARY: We describe the case of a 46-year-old lady with invasive breast cancer, who was on chemotherapy through a central venous catheter and was found to have a right atrial thrombus on routine echocardiography. Due to the paucity of data in this scenario and because the patient requested an oral anticoagulant which did not need frequent monitoring, we started her on apixaban for a total of 3 months. Echocardiogram was repeated at 4 and 8 weeks. In the 8-week echocardiogram, the right atrial thrombus was no longer visualized. DISCUSSION: Malignancy and central venous catheters significantly increase the risk of thrombosis. Although low molecular weight heparin is the preferred anticoagulant to manage thrombosis in patients with cancer, direct oral anticoagulants have been proven to be non-inferior. In patients with catheter-related intracardiac thrombus, anticoagulation should be continued for at least 3 months or until the catheter is removed, whichever is longer.

Broken Heart Syndrome Secondary To Liver Abscess.

Takotsubo cardiomyopathy is a well-known mimicker of acute coronary syndrome and is most often seen in postmenopausal women. Though it is most commonly observed after a stressful emotional episode, several infections have also been shown to precipitate this. Here, we describe a unique case of takotsubo cardiomyopathy that was precipitated by liver abscess induced sepsis.

Simultaneous Multifocal Paradoxical Embolism in an Elderly Patient with Patent Foramen Ovale: A Case Report.

About one-third of ischemic strokes may be associated with a patent foramen ovale (PFO). This article presents an unusual case of a 68-year-old woman with simultaneous paradoxical thrombo-embolization to different systemic sites. The patient presented initially with visual deficits and intracerebellar hemorrhage but was found to have concomitant saddle pulmonary embolism, sub-acute cerebral infarction with focal neurological deficits, and thromboembolism to the superior mesenteric artery (SMA) that resulted in an ischemic bowel. The unifying diagnosis was paradoxical embolism through a PFO and an atrial septal aneurysm with high-risk features. The patient underwent percutaneous closure of the PFO with an Amplatzer device.

Cardiac papillary fibroelastoma originating from the coumadin ridge and review of literature.

Papillary fibroelastomas represent the second most common benign cardiac tumour, secondary only to cardiac myxoma. A majority of patients are asymptomatic on presentation. The most common clinical manifestations include stroke, transient ischaemic attack, myocardial infarction and angina. Echocardiography remains the primary imaging modality for identification of these tumours. The majority of papillary fibroelastomas arise from the valves. Simple surgical excision is the mainstay of treatment, carrying an excellent prognosis. We present an unusual case of cardiac papillary fibroelastoma originating from the coumadin ridge (CR) in a 70-year-old woman. The patient exhibited increasing paroxysms of her atrial fibrillation and was pursuing a MAZE procedure. Preoperatively, a transesophageal echocardiogram revealed a 0.7×1 cm intracardiac mass that had echocardiographic appearance of a fibroelastoma. Surgical resection and MAZE procedures were performed. The gross specimen and histopathology findings were consistent with papillary fibroelastoma. This case reports the seventh documented case of fibroelastoma originating from the CR.

Metastatic Melanoma Presenting as a Ventricular Arrhythmia.

Melanoma is a highly aggressive disease with the risk of developing metastasis to virtually all organs including the heart, which can manifest as arrhythmia, right ventricular obstruction, heart failure, or pericardial effusion. Only a few reports are found in the literature of metastatic melanoma, causing ventricular arrhythmia. Prior to the advent of contemporary therapies, cardiac metastases implied a very poor prognosis. The use of immune checkpoint inhibitors and targeted therapy has greatly improved survival outcomes of metastatic melanoma. Aggressive therapy of cardiac metastasis including cardiac surgery can yield good outcomes. We present a case of a 57-year old gentleman with metastatic melanoma and cardiac involvement who initially presented as a ventricular arrhythmia and was successfully treated with immune checkpoint inhibitors and targeted therapy.

Two Intriguing Cases of Stanford Type A Acute Aortic Dissection.

Stanford type A acute aortic dissection (AAD) is a life-threatening illness that presents with chest pain and hemodynamic instability. Prompt and accurate evaluation and management are critical for survival as it is a cardiac surgical emergency. We aim to highlight the physicians about this potentially fatal condition, by reporting two cases of Stanford type A AAD, with atypical presentations that were initially misdiagnosed.

Myocardial and Pericardial Toxicity Associated With Immune Checkpoint Inhibitors in Cancer Patients.

We recount a single-center experience with cardiac immunity-related adverse effects in patients treated with immune checkpoint inhibitors. Of 2,830 patients, 9 patients (0.3%) developed cardiac immunity-related adverse effects (4 cases of cardiomyopathies, 2 of myocarditis, 2 of acute pericarditis, and 1 of large pericardial effusion). Disease profiles, hospital courses, and outcomes are reported. (Level of Difficulty: Advanced.).

Troponin levels after cardiac electrophysiology procedures: review of the literature.

Cardiac-specific Troponins (cTn) I and T have become markers of choice for myocardial injury. We reviewed the literature in order to understand the expected postprocedure cTn rise after electrophysiology procedures. A total of 34 studies and 1,608 patients were included. After external monophasic cardioversion, seven of 442 patients (1.6%) had minimal increase in cTnI (0.1-0.9 ng/mL), and only one of 368 (0.3%) had increase in cTnT (0.11 ng/mL). After internal cardioversion, 17 of 105 (16%) had increase in cTnI (0.7-2.4 ng/mL) but only three (2.9%) were above the cutoff for myocardial infarction (MI) (1.5 ng/mL). During implantable cardioverter-defibrillator (ICD) installation with a mean of 2-7 ICD shocks, 12 of 74 (16%) patients had cTnI >or=1.5 ng/mL (range 1.7-5.5 ng/mL) and 20 of 64 (32%) had cTnT >or=0.1 ng/mL (range 0.26-6.46 ng/mL) considered in the range of clinical MI. Radio frequency ablation (RFA) (n = 496) resulted in significant cTn elevation in 25-100% of patients with ventricular > atrial and linear > focal lesions. Average postprocedure peak cTnI ranged from 0.13 to 6 ng/mL (median: 2.36 ng/mL, max: 15 ng/mL) and cTnT 0.2 to 2.41 ng/mL (median: 0.44 ng/mL, max: 9 ng/mL). Early cTn peak at 2-8 hours was noted after RFA. External cardioversion should not cause a significant increase in cTn; RFA and ICD implantation with shocks often result in an increase in cTn. Interpretation of these markers can be difficult if acute coronary syndrome is suspected in the postprocedure period.

Left-Sided Intracardiac Tumors in a Case of Widespread Vulvar Cancer.

Metastatic cardiac tumors associated with gynecological malignancies are rare. This report describes the case of stage-4 vulvar carcinoma that metastasized to the left ventricle of the heart. (Level of Difficulty: Intermediate.).

An Interesting Case of Atherosclerotic Occlusion of the First Septal Perforator in a Physically Young and Fit Individual Causing Complete Heart Block.

Complete heart block (CHB) is an unfortunate complication of an anterior and inferior myocardial infarction (MI). We present a case of an atherosclerotic occlusion of the first septal perforator leading to CHB requiring permanent pacemaker placement in a young patient. A 33-year-old healthy white male presented to the emergency department with an episode of syncope. His vitals were stable, and his physical exam was unremarkable. His electrocardiogram (EKG) showed CHB and ST elevations in V1, V2, and V3 suggestive of septal MI. He underwent emergent left heart catheterization which revealed significant stenosis of the proximal left anterior descending (LAD) artery, proximal diagonal artery, and the first septal perforator. An intervention was done with stent placement in the LAD and insertion of a temporary pacemaker. After removal of the temporary pacemaker two days later, the patient developed asystole with alternating bundle branch block which prompted immediate reinsertion of the temporary pacemaker which was replaced later with a permanent pacemaker. The patient was stable afterward and discharged. The persistent atherosclerotic occlusion of the first septal perforator prevented adequate perfusion of the conduction system, even after revascularization of the proximal LAD. In conclusion, it is essential to acknowledge that difficulty to revascularize an occluded septal perforator raises the need for a permanent pacemaker to prevent a CHB.

Interventions to Decrease Overuse of Cardiac Monitoring (Telemetry) When Transitioning from the Intensive Care Unit to the Regular Nursing Floor.

Background Cardiac monitoring (telemetry) is a common over-utilized hospital resource in the United States. Previous studies have shown that telemetry does not improve outcomes for low-risk patients. Inappropriate utilization occurs because of lack of awareness of guideline-based indications or non-adherence to known indications. Objective A quality improvement study was conducted to reduce telemetry overutilization during the transition of care from the intensive care unit (ICU) by 15% through increasing awareness of indications for telemetry. Methods The study cohort included patients originally admitted to the ICU for sepsis who had improved and were stable for transfer to a non-ICU setting. Subjects were identified and included during pre-intervention (six weeks) and intervention (six weeks) periods. Resident physicians and nurse practitioners were targeted using multiple modalities of education: didactic lectures during week one, poster demonstrations during week three, and video presentations during week five. Results A total of 246 study subjects during the pre-intervention and 94 study subjects in the intervention period were studied; 187 of the 246 subjects in the pre-intervention arm (76%) and 58 of the 94 subjects in the intervention arm (61.7%) were transferred with telemetry. Telemetry utilization dropped by 23.1% at the end of the intervention period. Conclusion Educating the caregivers about the indications for telemetry led to a decrease in over-utilization of telemetry on the transition of care from the ICU to the regular nursing floor. Repetitive and multi-modality educational interventions were effective tools and associated with increased adherence to established guidelines for telemetry usage.

Circulating NT-proBNP but not soluble corin levels were associated with preeclampsia in pregnancy-associated hypertension.

BACKGROUND: Corin is a serine protease known to convert B-type natriuretic peptide (BNP) prohormone into BNP and its amino-terminal fragment (NT-proBNP). In mice lacking corin, high blood pressure and proteinuria were found at late gestational stages, with associated delayed trophoblast invasion and impaired spiral artery remodeling in the uterus. We hypothesize that both NT-proBNP and soluble corin elevation predict the presence of preeclampsia in pregnant patients with hypertension. METHODS: We prospectively enrolled 149 pregnant women with a history of chronic hypertension or gestational hypertension presenting at a tertiary-care hospital. We compared plasma NT-proBNP and soluble corin concentrations based on their preeclamptic status. RESULTS: In our study cohort, 62 patients with preeclampsia had lower gestational age than 87 patients without preeclampsia (33.3 ±â€¯3 versus 36.6 ±â€¯3 weeks; P < .001), otherwise the baseline characteristics were similar. We observed higher NT-proBNP concentrations in patients with preeclampsia compared to those without preeclampsia (304.3 [96.34, 570.4] vs. 60.8 [35.61, 136.8] ng/L, P < .001), with no differences between chronic and gestational hypertension. However, the concentration of corin was not statistically different between the two groups (1756 [1214, 2133] vs. 1571 [1171, 1961] ng/L, P = .1087). ROC curve analysis demonstrated stronger predictive value of NT-proBNP compared to soluble corin in predicting the presence of preeclampsia in our study population (AUC 0.7406 vs. 0.5789, P < .0001). CONCLUSION: While corin may contribute to mechanistic underpinnings of the development of preeclampsia in animal models, soluble corin likely has no diagnostic role in human pregnancies for preeclampsia beyond natriuretic peptide levels.

Risk stratification for patients undergoing nonurgent percutaneous coronary intervention using N-terminal pro-B-type natriuretic peptide: a Clopidogrel for the Reduction of Events During Observation (CREDO) substudy.

BACKGROUND: The utility of N-terminal pro-BNP (NT-proBNP) measurement as a prognostic marker during nonurgent percutaneous coronary intervention (PCI) has been suggested in several studies. The comparative prognostic values between NT-proBNP levels and left ventricular ejection fraction (LVEF) in the nonurgent PCI setting are unclear. METHODS: CREDO was a double blind, placebo-controlled, randomized trial comparing 2 clopidogrel regimens before and after nonurgent PCI. Baseline NT-proBNP levels and LVEF were measured in 1468 subjects using the Roche Elecsys proBNP assay (Roche Diagnostics, Indianapolis, IN), and the 1-year combined end point of death/myocardial infarction (MI)/stroke was analyzed according to NT-proBNP quartiles in impaired and preserved LVEF. RESULTS: In this patient cohort (mean age 61.6 +/- 10 years, 22% with LVEF < 50%), the median NT-proBNP level was 131 pg/mL. Increasing quartiles of NT-proBNP were associated with a higher rate of death, MI, and the combined end point (but not stroke) at 1 year, including those with LVEF > or = 50% (P < .001 for trend). This prognostic power for death and MI remained robust even when adjusted for other clinical or biochemical markers including cardiac troponin, creatinine clearance, and high-sensitive C-reactive protein (hazard ratio 1.249, P = .006). Despite its robust prognostic value, baseline NT-proBNP levels did not identify patients with enhanced benefit from pre-procedural and prolonged clopidogrel therapy. CONCLUSIONS: In patients undergoing a nonurgent PCI, NT-proBNP levels may provide important prognostic value for death and MI, even in patients with preserved cardiac function, However, NT-proBNP levels were unable to identify patients with enhanced benefit from pre-procedural and prolonged clopidogrel therapy.

Changing conduction abnormalities in a dialysis patient with fever.

A patient on hemodialysis with severe aortic valve disease and presumed arteriovenous fistula infection was found to have new-onset atrial fibrillation and alternating left and right bundle branch block patterns on serial electrocardiograms. These findings prompted transesophageal echocardiography, which revealed a large abscess involving the intervalvular fibrosa and the posterior cusp of the bicuspid aortic valve. Hence, basic bedside diagnostic skills remain important in the era of sophisticated imaging techniques and laboratory analyses.

Aldosterone receptor antagonists in the medical management of chronic heart failure.

The benefits of aldosterone receptor antagonists (spironolactone and eplerenone) for patients with heart failure were shown in 2 recent randomized controlled trials. Some of the proposed mechanisms of action of aldosterone antagonists are (1) inhibition of myocardial and vascular remodeling, (2) blood pressure reduction, (3) decreased collagen deposition, (4) decreased myocardial stiffness, (5) prevention of hypokalemia and arrhythmia, (6) modulation of nitric oxide synthesis, and (7) immunomodulation. Like many hormone receptors, the aldosterone receptor can be either nuclear or membrane bound. Most of the activities of the aldosterone receptor are subserved by the nuclear receptors and often lead to alterations in gene transcription. Although these agents are well tolerated in carefully selected patient populations that meet the inclusion criteria of large clinical trials, their use in unselected elderly patients with heart failure and multiple comorbidities has been associated with a significant risk of hyperkalemia and renal failure. Although no convincing data exist to predict which individual patients will respond to aldosterone inhibition, patients with more severe heart failure and those with acute myocardial infarction with concomitant heart failure or left ventricular dysfunction are most likely to respond. Theoretically, aldosterone receptor antagonists may also be beneficial in patients with more mild to moderate systolic heart failure or even in those with diastolic heart failure, although direct evidence is still lacking.

Hemodynamic effects of sildenafil in patients with congestive heart failure and pulmonary hypertension: combined administration with inhaled nitric oxide.

STUDY OBJECTIVES: In patients with pulmonary hypertension (PH) secondary to congestive heart failure, inhaled nitric oxide (NO) increases pulmonary vascular smooth-muscle intracellular cyclic guanosine monophosphate (cGMP) concentration, thereby decreasing pulmonary vascular resistance (PVR) and increasing cardiac index (CI). However, these beneficial effects of inhaled NO are limited in magnitude and duration, at least in part due to cGMP hydrolysis by the type 5 isoform of phosphodiesterase (PDE5). The goal of this study was to determine the acute pulmonary and systemic hemodynamic effects of the selective PDE5 inhibitor, sildenafil, administered alone or in combination with inhaled NO in patients with congestive heart failure and PH. DESIGN: Single center, case series, pharmacohemodynamic study. SETTING: Cardiac catheterization laboratory of a tertiary care academic teaching hospital. PATIENTS: We studied 11 patients with left ventricular systolic dysfunction due to coronary artery disease or idiopathic dilated cardiomyopathy who had PH. INTERVENTIONS: We administered oral sildenafil (50 mg), inhaled NO (80 ppm), and the combination of sildenafil and inhaled NO during right-heart and micromanometer left-heart catheterization. MEASUREMENTS AND RESULTS: Sildenafil administered alone decreased mean pulmonary artery pressure by 12 +/- 5%, PVR by 12 +/- 5%, systemic vascular resistance (SVR) by 13 +/- 6%, and pulmonary capillary wedge pressure by 12 +/- 7%, and increased CI by 14 +/- 5% (all p < 0.05) [+/- SEM]. The combination of inhaled NO and sildenafil decreased PVR by 50 +/- 4%, decreased SVR by 24 +/- 3%, and increased CI by 30 +/- 4% (all p < 0.01). These effects were greater than those observed with either agent alone (p < 0.05). In addition, sildenafil prolonged the pulmonary vasodilator effect of inhaled NO. Administration of sildenafil alone or in combination with inhaled NO did not change systemic arterial pressure or indexes of myocardial systolic or diastolic function. CONCLUSIONS: PDE5 inhibition with sildenafil improves cardiac output by balanced pulmonary and systemic vasodilation, and augments and prolongs the hemodynamic effects of inhaled NO in patients with chronic congestive heart failure and PH.

Ischemic heart disease and congestive heart failure in diabetic patients.

Ischemic heart disease and heart failure are major contributors to the morbidity and mortality associated with diabetes mellitus. With growing knowledge of how the metabolic derangements of diabetes contribute to the pathogenesis of cardiovascular disease, we must continuously refine our understanding of optimal screening and strategies for prevention and treatment for these interlinked disorders. This article summarizes our current understanding of ischemic heart disease and heart failure in patients with diabetes mellitus, highlighting gaps in our knowledge about the relationship between diabetes and cardiovascular disease. Special consideration is given to new strategies for treating the adverse effects of abnormal glucose metabolism on the cardiovascular system.

Current practice and future promise for clinical noninvasive measurements of subclinical atherosclerotic disease in the elderly.

The detection, treatment, and follow-up of subclinical vascular disease are becoming clinically essential components of cardiovascular disease prevention in the elderly. Noninvasive measurements are available for different vascular beds, including carotid, coronary, aortic, and peripheral arterial circulation. Current interest in these measures is aimed at improving the accuracy of risk prediction for coronary heart disease and cardiovascular disease. Indirect physical examination and imaging evaluations detect significant obstruction of flow in the peripheral arteries. Doppler measures of ankle-arm blood pressure index represent a simple, indirect test that has been shown to be predictive of incident cardiovascular disease independent of risk factors. Newer, high-resolution tests allow direct detection and quantitation of the burden of atherosclerosis and vascular disease within the arterial wall, independent of flow obstruction. Carotid intimal-medial thickness predicts incident coronary heart disease and stroke in the elderly, even after adjustment for traditional risk factors. Coronary calcium can be accurately detected by computed tomography and is a strong predictor of the incidence of coronary heart disease events. Evidence is accruing that coronary calcium screening will play a role in prevention in the elderly. Magnetic resonance imaging is currently under study as a promising modality for detection and quantification of aortic and carotid plaque. Ongoing studies will provide important information regarding the appropriate role of the many newer, high-resolution tests of subclinical atherosclerosis in disease prediction, treatment, and tracking of disease progression in the elderly.