Role of echocardiography in managing acute pulmonary embolism.

The role of echocardiography in acute pulmonary embolism (PE) remains incompletely defined. Echocardiography cannot reliably diagnose acute PE, and it does not improve prognostication of patients with low-risk acute PE who lack other clinical features of right ventricular (RV) dysfunction. Echocardiography, however, may yield additional prognostic information in higher risk patients and can aid in distinguishing acute from chronic RV dysfunction. Specific echocardiographic markers of RV dysfunction have the potential to enhance prognostication beyond existing risk models. Until these markers are subjected to rigorous prospective studies, the therapeutic utility and economic value of echocardiography in acute PE are uncertain.

Endovascular repair of delayed traumatic aortocaval fistula.

Aortocaval fistula (ACF) is an uncommon condition that can result in a number of adverse clinical sequelae. We describe a case of an ACF that occurred several years after open repair of a penetrating injury of the abdominal aorta and inferior vena cava. Whereas ACF can have sudden and catastrophic presentations, our patient had a subacute presentation of high-output heart failure. We were able to fully correct the vascular injury and heart failure physiology and symptoms with endovascular therapy.

Detection of Left Ventricular Hypertrophy Using Bayesian Additive Regression Trees: The MESA.

Background We developed a new left ventricular hypertrophy ( LVH ) criterion using a machine-learning technique called Bayesian Additive Regression Trees ( BART ). Methods and Results This analysis included 4714 participants from MESA (Multi-Ethnic Study of Atherosclerosis) free of clinically apparent cardiovascular disease at enrollment. We used BART to predict LV mass from ECG and participant characteristics using cardiac magnetic resonance imaging as the standard. Participants were randomly divided into a training set (n=3774) and a validation set (n=940). We compared the diagnostic/prognostic performance of our new BART - LVH criteria with traditional ECG - LVH criteria and cardiac magnetic resonance imaging- LVH . In the validation set, BART - LVH showed the highest sensitivity (29.0%; 95% CI , 18.3%-39.7%), followed by Sokolow-Lyon- LVH (21.7%; 95% CI , 12.0%-31.5%), Peguero-Lo Presti (14.5%; 95% CI , 6.2%-22.8%), Cornell voltage product (10.1%; 95% CI , 3.0%-17.3%), and Cornell voltage (5.8%; 95% CI , 0.3%-11.3%). The specificity was >93% for all criteria. During a median follow-up of 12.3 years, 591 deaths, 492 cardiovascular disease events, and 332 coronary heart disease events were observed. In adjusted Cox models, both BART - LVH and cardiac magnetic resonance imaging- LVH were associated with mortality (hazard ratio [95% CI ], 1.88 [1.45-2.44] and 2.21 [1.74-2.81], respectively), cardiovascular disease events (hazard ratio [95% CI ], 1.46 [1.08-1.98] and 1.91 [1.46-2.51], respectively), and coronary heart disease events (hazard ratio [95% CI ], 1.72 [1.20-2.47] and 1.96 [1.41-2.73], respectively). These associations were stronger than associations observed with traditional ECG - LVH criteria. Conclusions Our new BART - LVH criteria have superior diagnostic/prognostic ability to traditional ECG - LVH criteria and similar performance to cardiac magnetic resonance imaging- LVH for predicting events.

Palliative Care Training in Cardiology Fellowship: A National Survey of the Fellows.

OBJECTIVES: To address perspectives of cardiology fellows on the current state of palliative education and palliative and hospice resource utilization within their fellowship experiences. METHODS: We conducted an online national survey of cardiology fellows during the 2015 to 2016 academic year. Survey questions aimed to assess perceived importance of palliative care education, level of palliative care education during fellowship, and the structure of palliative care support at respondent institutions. Responses were collected anonymously. A total of 519 programs, including subspecialty programs, were contacted. RESULTS: We received 365 responses, a number that represents roughly 14% of all cardiology fellows nationwide during the 2015 to 2016 academic year. Fellows reported discordance in the quality of education between general cardiology and palliative care principles as it relates to care of the patient approaching the end of life. Fellows infrequently received explicit training nor were observed or mentored in delivering end-of-life discussions. Respondents reported an underutilization of palliative care and hospice resources during fellowship training and also a perception that attending faculty were not routinely addressing goals of care. CONCLUSIONS: Our survey results highlight a need for enhanced palliative care and end-of-life training experiences for cardiology fellows and also suggest underutilization of hospice and palliative care resources for patients with advanced cardiac diseases. These findings create a platform for future work that might: (1) confirm this training deficit, (2) lead to exploration of educational models that could reconcile this deficit, and (3) potentially help improve palliative care support for patients and families facing advanced heart disease.

Future therapies for chronic hepatitis C.

Therapy for hepatitis C has been fairly stagnant for the past decade, but the past few years have seen major progress and evolution, beginning with the approval of two HCV protease inhibitors in 2011. In spite of considerable improvements in response rates with these agents, a need for additional agents with improved potency and tolerability remains. Toward this goal and over the course of just a few months, the HCV therapy pipeline has already become crowded with direct-acting antivirals, host-targeted agents and unique interferons, all of which are positioned to be part of the next wave of therapeutic options. The ultimate goal of this push for new agents is to achieve a safe and straight forward yet highly effective therapy for hepatitis C that is widely embraced and readily available. Particularly among the 'baby boomer' population, it is predicted that over the next few years, more patients with currently quiescent infections will be newly diagnosed, and those currently diagnosed will be at increased risk of long-term complications of infection, and thus in need of treatment. A simple and safe treatment paradigm will become a necessity. This Review chronicles the latest developments in hepatitis C therapy and the potential effect these new treatments could have on delivery of care to patients infected with HCV.

Cocaine mediated apoptosis of vascular cells as a mechanism for carotid artery dissection leading to ischemic stroke.

In arterial dissection, blood may enter the arterial wall through an intimal tear, splitting the arterial wall and activating the coagulation cascade at the site of endothelial damage. Dissection of extracranial and intracranial vessels may lead to ischemic stroke through thromboembolic or hemodynamic mechanisms. Major blunt trauma or rapid acceleration-deceleration may cause dissection, but in patients with inherent arterial wall weakness, dissection can occur spontaneously or as a result of minor neck movement. Cocaine use has been associated with dissection of the aortic arch and coronary and renal arteries through cocaine-mediated hypertension. Recent preclinical studies have suggested, however, that cocaine may cause apoptosis of cells in the vascular wall. In this article, we postulate that cocaine may cause apoptosis of vascular endothelial and/or smooth muscle cells, thus weakening the vascular wall and resulting in a dissection-prone state. We review the literature and propose a biological basis for vasculopathy, vascular dissection, and ischemic stroke in the setting of cocaine use. Further research studies on vascular cells, as well as focused analysis of human pathological material, will be important in providing evidence for or against our hypotheses.

Interactions with the Abelson tyrosine kinase reveal compartmentalization of eyes absent function between nucleus and cytoplasm.

Eyes absent (Eya), named for its role in Drosophila eye development but broadly conserved in metazoa, possesses dual functions as a transcriptional coactivator and protein tyrosine phosphatase. Although Eya's transcriptional activity has been extensively characterized, the physiological requirements for its phosphatase activity remain obscure. In this study, we provide insight into Eya's participation in phosphotyrosine-mediated signaling networks by demonstrating cooperative interactions between Eya and the Abelson (Abl) tyrosine kinase during development of the Drosophila larval visual system. Mechanistically, Abl-mediated phosphorylation recruits Eya to the cytoplasm, where in vivo studies reveal a requirement for its phosphatase function. Thus, we propose a model in which, in addition to its role as a transcription factor, Eya functions as a cytoplasmic protein tyrosine phosphatase.