Coronary artery disease in patients with human immunodeficiency virus infection.

The life expectancy of people infected with human immunodeficiency virus (HIV) is rising due to better access to combination anti-retroviral therapy (ART). Although ART has reduced acquired immune deficiency syndrome (AIDS) related mortality and morbidity, there has been an increase in non-AIDS defining illnesses such as diabetes mellitus, hypercholesterolemia and coronary artery disease (CAD). HIV is a disease marked by inflammation which has been associated with specific biological vascular processes increasing the risk of premature atherosclerosis. The combination of pre-existing risk factors, atherosclerosis, ART, opportunistic infections and coagulopathy contributes to rising CAD incidence. The prevalence of CAD has emerged as a major contributor of morbidity in these patients due to longer life expectancy. However, ART has been associated with lipodystrophy, dyslipidemia, insulin resistance, diabetes mellitus and CAD. These adverse effects, along with drug-drug interactions when ART is combined with cardiovascular drugs, result in significant challenges in the care of this group of patients. Exercise tolerance testing, echocardiography, myocardial perfusion imaging, coronary computed tomography angiography and magnetic resonance imaging help in the diagnosis of CAD and heart failure and help predict cardiovascular outcomes in a manner similar to non-infected individuals. This review will highlight the pathogenesis and factors that link HIV to CAD, presentation and treatment of HIV-patients presenting with CAD and review briefly the cardiac imaging modalities used to identify this entity and help prognosticate future outcomes.

Limitations of Sacubitril/Valsartan in the Management of Heart Failure.

BACKGROUND: The PARADIGM-HF (Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure) trial was a double-blind trial that randomized 8442 patients with heart failure (HF) with reduced ejection fraction (HFrEF) to receive twice daily dosing of either 200 mg of LCZ696 or 10 mg of enalapril in addition to standard medical therapy for HF. AREAS OF UNCERTAINTY: Limitations of this trial include (1) sacubitril has not been tested by itself in the treatment of HFrEF; (2) the maximum recommended dose of valsartan for the treatment of HFrEF was used in this trial, but the maximum recommended dose of enalapril for the treatment of HFrEF was not used; (3) a run-in phase was used in this trial to test the tolerability of LCZ696, and patients who had adverse effects in this period were excluded from randomization; (4) the percent of blacks enrolled in this trial was only 5%; (5) LCZ696 caused a 14% incidence of hypotension; (6) neprilysin inhibition might favor the development of Alzheimer dementia, which was not assessed in the PARADIGM-HF trial; (7) patients with severe symptomatic HF were underrepresented in this trial; (8) major exclusions from this trial included an acute coronary event in the last 3 months, severe pulmonary disease, hepatic impairment, and an estimated glomerular filtration rate <30 mL per minute per 1.73 m. DATA SOURCES: Review of the PARADIGM-HF trial. RESULTS: At 27-month follow-up, the PARADIGM-HF trial showed that compared with enalapril, LCZ696 reduced the composite of cardiovascular death or hospitalization for HF 20% (absolute risk reduction 4.7%, P < 0.001). CONCLUSIONS: The numerous limitations discussed under the areas of uncertainty should be considered when prescribing LCZ696 for the treatment of HFrEF.

Embolic ST-Elevation Myocardial Infarction in Atrial Fibrillation: Report of Two Cases and Review of Literature.

Coronary artery plaque rupture, erosion, thrombosis, and dissection account for nearly all acute myocardial infarction (AMI). However, coronary artery embolism remains a significant cause of AMI that is essentially unaccounted for. In this report, we present two cases of acute coronary syndrome caused by coronary embolism. Both cases illustrate that patients with atrial fibrillation are at an increased risk of thromboembolic events of the coronary circulation. We highlight the clinical characteristics of atrial fibrillation associated with coronary embolism and present the therapeutic interventions based on our experience and a review of the literature. Given that AMI is a significant cause of morbidity and mortality among adults worldwide, it is imperative that practicing clinicians be aware of coronary embolism as a cause of AMI, particularly in high-risk populations such as those with atrial fibrillation.

Cardiotoxicity of Cancer Therapies.

Cardiotoxicity is a known complication of many cancer therapies. While the cardiotoxicity of established agents such as anthracyclines, antimetabolites, and alkylating agents is well known, it is important to realize that newer anticancer therapies such as tyrosine kinase inhibitors, angiogenesis inhibitors, and checkpoint inhibitors are also associated with significant adverse cardiovascular effects. Echocardiography, magnetic resonance imaging, and radionuclide imaging have been used to identify these complications early and prevent further consequences. We will discuss the different classes of cancer therapeutic agents that cause cardiotoxicity, the mechanisms that lead to these effects, and strategies that can be used to prevent the cardiac morbidity and mortality associated with their use.

National Landscape of Unplanned 30-Day Readmissions in Patients With Left Ventricular Assist Device Implantation.

The number of patients with advanced heart failure receiving left ventricular assist device (LVAD) implantation has increased dramatically over the last decade. There are limited data available about the nationwide trends of complications leading to readmissions after implantation of contemporary devices. Patients who underwent LVAD implantation from January 2013 to December 2013 were identified using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code 37.66 from the Healthcare Cost and Utilization Project's National Readmission Database. The top causes of unplanned 30-day readmission after LVAD implantation were determined. Survey logistic regression was used to analyze the significant predictors of readmission. In 2013, there were 2,235 patients with an LVAD implantation. Of them, 665 (29.7%) had at least 1 unplanned readmission within 30 days, out of which 289 (43.4%) occurred within 10 days after discharge. Implant complications (14.9%), congestive heart failure (11.7%), and gastrointestinal bleeding (8.4%) were the top 3 diagnoses for the first readmission and accounted for more than a third of all readmissions. Significant predictors of readmissions included a prolonged length of stay during the index admission, Medicare insurance, and discharge to short-term facility. In conclusion, despite increased experience with LVADs, unplanned readmissions within 30 days of implantation remain significantly high.

The evolution of natriuretic peptide augmentation in management of heart failure and the role of sacubitril/valsartan.

Heart failure (HF) is one of the leading causes of morbidity, mortality, and health care expenditures in the US and worldwide. For three decades, the pillars of treatment of HF with reduced ejection fraction (HFrEF) were medications that targeted the sympathetic nervous system (SNS) and the renin-angiotensin-aldosterone system (RAAS). Prior attempts to augment the natriuretic peptide system (NPS) for the management of HF failed either due to lack of significant clinical benefit or due to the unacceptable side effect profile. This review article will discuss the NPS, the failure of early drugs which targeted the NPS as therapies for HF, and the sequence of events which led to the development of sacubitril plus valsartan (Entresto; LCZ696; Novartis). LCZ696 has been shown to be superior to the standard of care available for treatment of HFrEF in several substantial hard endpoints including heart failure hospitalizations, cardiovascular mortality, and all-cause mortality.

Cardiac papillary fibroelastoma: The need for a timely diagnosis.

Cardiac papillary fibroelastomas (CPFs) are the second most common primary cardiac tumors and the most common cardiac valvular tumors. Although they are histologically benign and usually asymptomatic, CPFs can lead to serious and life-threatening complications like myocardial infarction, stroke, pulmonary embolus, cardiac arrest etc. CPFs represent a rare entity in clinical medicine and literature regarding their management is limited. We report two cases which illustrate such complications arising from undiagnosed CPFs on the aortic valve. We further stress on the importance of identifying CPFs early so that they can be managed appropriately based on recommendations from the available literature.

A rare presentation of acute heart failure secondary to aggressive uterine leiomyosarcoma metastatic to the myocardium initially diagnosed as hypertrophic obstructive cardiomyopathy.

Uterine sarcoma is the cause of 3-9% of all uterine malignant neoplasms and has a 2-fold higher incidence in black women as compared to white women. Cellular atypia and abundant mitoses (≥10 per 10 high power fields) as seen in this patient are associated with an increased risk for metastases. Metastases to the heart are infrequently reported with a handful of cases in the literature. We present a case of a 51-year-old woman with aggressively metastatic uterine leiomyosarcoma causing acute heart failure 4 months after initial presentation.

Relation of Obesity to Survival After In-Hospital Cardiac Arrest.

Previous studies have shown that obesity is paradoxically associated with improved outcomes in many cardiovascular (CV) disease states; however, whether obesity affects survival after in-hospital cardiac arrest (IHCA) has not been well examined. We queried the 2003 to 2011 Nationwide Inpatient Sample databases to identify all patients aged ≥18 years who underwent cardiopulmonary resuscitation for IHCA. Obese patients were identified using the co-morbidity variable for obesity, as defined in Nationwide Inpatient Sample databases. Survival to hospital discharge was compared between obese and nonobese patients using multivariate regression models. Of 836,289 patients with IHCA, 67,216 (8.0%) were obese. Obese patients were younger and more likely to be women compared with nonobese patients. Despite being younger, obese patients had significantly higher prevalence of most CV co-morbidities such as dyslipidemia, coronary artery disease, previous myocardial infarction, heart failure, diabetes mellitus, hypertension, peripheral vascular disease, and chronic renal failure (p <0.001 for all). Obese patients were more likely to have ventricular tachycardia or ventricular fibrillation as the initial cardiac arrest rhythm (22.3% vs 20.9%; p <0.001). After multivariate risk adjustment, obese patients had improved survival to hospital discharge compared with nonobese patients (31.4% vs 24.1%; unadjusted odds ratio 1.44, 95% CI 1.42 to 1.47, p <0.001; adjusted odds ratio 1.15, 95% CI 1.13 to 1.17, p <0.001). Similar results were seen in patients with CV or non-CV conditions as the primary diagnosis and in those with ventricular tachycardia/ventricular fibrillation or pulseless electrical activity/asystole as the cardiac arrest rhythm. In conclusion, this large retrospective analysis of a nationwide cohort of patients with IHCA demonstrated higher risk-adjusted odds of survival in obese patients, consistent with an "obesity paradox."