INTRODUCTION: Severe aortic regurgitation is a progressive condition that can lead to cardiogenic shock, a life-threatening emergency associated with high morbidity and mortality. AREAS COVERED: This article provides an...INTRODUCTION: Severe aortic regurgitation is a progressive condition that can lead to cardiogenic shock, a life-threatening emergency associated with high morbidity and mortality. AREAS COVERED: This article provides an updated review on how clinicians can diagnose, prevent, and manage aortic regurgitation presenting as cardiogenic shock, as well as discusses emerging technologies that have transformed the management of this condition. EXPERT OPINION: Clinicians can reduce the risk of aortic regurgitation manifesting as cardiogenic shock through a combination of early diagnosis, vigilant monitoring, optimized medical management, and timely intervention. Advanced imaging modalities, such as echocardiography and computed cardiac tomography, are essential for assessing valve function and identifying high-risk patients before decompensation occurs. For patients at risk, early referral to a multidisciplinary Heart Team is crucial for determining the optimal intervention, whether surgical or transcatheter. Future advancements in transcatheter therapies, including dedicated devices for aortic valve replacement, hold promise for expanding treatment options for high-risk patients.
INTRODUCTION: Twenty to twenty-five percent of patients with hypertrophic cardiomyopathy (HCM) have concurrent atrial fibrillation (AF). It is unclear whether direct oral anticoagulants (DOAC) are a safe and effective al...INTRODUCTION: Twenty to twenty-five percent of patients with hypertrophic cardiomyopathy (HCM) have concurrent atrial fibrillation (AF). It is unclear whether direct oral anticoagulants (DOAC) are a safe and effective alternative to vitamin K antagonists (VKA) in concurrent HCM and AF. METHODS: We performed a systematic review and meta-analysis of original reports comparing DOACs versus VKAs in concurrent HCM and AF. The protocol was published in PROSPERO -CRD42024575553. MEDLINE, Embase, and Cochrane Central were searched from inception to October 2024. RESULTS: From 1119 records retrieved by the search, we identified 8 different observational studies ( = 14,243). Compared to VKAs, DOACs were associated with a lower rate of thromboembolic events 318/8322 vs. 559/5921 (OR 0.44, 95% CI 0.23-0.83; = 0.0118; I = 84%; NNT = 18), and less major bleeds 289/8322 vs. 327/5921 (OR 0.54, 95% CI 0.36-0.80; = 0.0021; I = 76%; NNT = 49). Apixaban and dabigatran were associated with lower rate of thromboembolic events, major bleeding, all-cause death, and intracranial hemorrhage, and Rivaroxaban associated with less all-cause deaths and intracranial hemorrhages, compared to VKAs (all < 0.05). CONCLUSIONS: DOACs demonstrated good efficacy and a favorable safety profile in patients with HCM and AF compared to VKAs. The protocol for this meta-analysis was published in PROSPERO (CRD420245755530).
BACKGROUND: The impact of ventricular arrhythmia in patients with sarcoidosis has not been well studied. Our objective was to determine the association of ventricular arrhythmia with clinically relevant outcomes in sarco...BACKGROUND: The impact of ventricular arrhythmia in patients with sarcoidosis has not been well studied. Our objective was to determine the association of ventricular arrhythmia with clinically relevant outcomes in sarcoidosis patients. RESEARCH DESIGN AND METHODS: We included adult patients with sarcoidosis from a nationally representative database, the Nationwide Readmission Database, admitted between 1 January 2011 and 31 December 2018. We assessed whether ventricular tachycardia and fibrillation (VTVF) increases mortality risk, the need for automatic implantable cardioverter-defibrillator (AICD), or permanent pacemaker during hospitalization in sarcoidosis patients. Logistic and Cox regressions were performed. RESULTS: Out of 570,807 sarcoidosis patients 15,459 (2.71%) developed VTVF. In a multivariable-adjusted logistic regression, ventricular arrhythmias were significantly associated with mortality (aOR 2.98; 95% CI 2.66-3.34, < 0.001), AICD (aOR 17.69; 95% CI 14.8-21.2, < 0.001) or permanent pacemaker placement (aOR 3.41; 95% CI 2.87-4.06, < 0.001). In a multivariable-adjusted Cox regression, ventricular arrhythmias were not significantly associated with 30-day all cause readmission (aHR 0.94; 95% CI 0.84-1.05, = 0.251). CONCLUSIONS: VTVF in sarcoidosis patients was associated with increased mortality risk, AICD, and/or pacemaker placement but not readmissions. Aggressive monitoring of these patients to identify VTVF may improve outcomes.
INTRODUCTION: Prosthetic valve thrombosis (PVT) is a life-threatening complication of mechanical heart valve replacement. Management has evolved over decades, from urgent surgical intervention to low dose ultraslow throm...INTRODUCTION: Prosthetic valve thrombosis (PVT) is a life-threatening complication of mechanical heart valve replacement. Management has evolved over decades, from urgent surgical intervention to low dose ultraslow thrombolytic therapy. AREAS COVERED: This review provides a historical to present-day analysis of thrombolytic strategies in PVT, comparing accelerated dosing with slower infusion protocols. We synthesize clinical evidence and elucidate mechanistic insights into how infusion rate and dosage influence clot resolution and safety. We searched the PubMed database from inception to May 2025 using combinations of appropriate keywords. EXPERT OPINION: The development of lower dose, slower infusion protocols, notably using Alteplase without bolus, has dramatically improved outcomes. Clinical trials show comparable or superior thrombosis resolution rates with ultraslow infusion versus rapid infusion or surgery, but with markedly reduced complication rates. Mechanistically, ultraslow infusion may help to localize fibrinolysis to the thrombus site, minimizing systemic fibrinogen depletion and hemorrhagic risk. Ultraslow (25 hours) low-dose (25 mg) thrombolysis with Alteplase is a safe and effective first-line therapy for PVT patients, achieving high success in clot resolution while limiting bleeding and embolic complications. Ongoing evidence and mechanistic rationale suggest that, in the absence of contraindications, this strategy can often be preferable to traditional rapid high-dose thrombolysis or emergency surgery.
INTRODUCTION: Compelling evidence shows that unfavorably altered (prothrombotic) fibrin clot properties such as more compact and poorly lysable fibrin networks contribute to thrombo-embolic events in cardiovascular disea...INTRODUCTION: Compelling evidence shows that unfavorably altered (prothrombotic) fibrin clot properties such as more compact and poorly lysable fibrin networks contribute to thrombo-embolic events in cardiovascular disease. AREAS COVERED: Following a literature search in Medline, Embase, TRIP, and the Cochrane Database of Systematic Reviews, this review summarizes the current evidence on therapeutic strategies, that are currently used or tested in cardiovascular disease including coronary artery disease, peripheral artery disease, atrial fibrillation, heart failure, and their thrombotic manifestations, in particular myocardial infarction and ischemic stroke, in the context of altered plasma fibrin clot characteristics. EXPERT OPINION: Anticoagulants (heparins, vitamin K antagonists, and direct oral anticoagulants), aspirin, and statins favorably modify fibrin clot characteristics, which might contribute to their efficacy in various clinical settings. Encouraging results suggest that novel treatments not yet approved in cardiovascular disease, including factor XI inhibitors and lipoprotein (a) reducing agents, might be beneficial, in part through improved fibrin clot phenotype, which gives hope for reducing the residual risk of thromboembolism in cardiovascular disease, which persists despite the recommended management.
INTRODUCTION: With the substantial increase in direct oral anticoagulant (DOAC) usage, prescribers face complex decisions regarding the appropriate agent selection. This scoping review aimed to identify factors influenci...INTRODUCTION: With the substantial increase in direct oral anticoagulant (DOAC) usage, prescribers face complex decisions regarding the appropriate agent selection. This scoping review aimed to identify factors influencing oral anticoagulant choice in clinical practice over time. METHODS: Four databases (Medline, Embase, Scopus, Web of Science) were searched for quantitative observational studies on patients prescribed DOACs for any indication, focusing on factors affecting OAC choice. Studies published from January 2010 to March 2023 were included. RESULTS: Of the 4659 identified studies, 60 met selection criteria. Most (96%) examined the choice between DOACs and vitamin K antagonists (VKA); while (15%) evaluated factors affecting choice among DOACs. Age and gender were included in 77% and 70% of studies, respectively. Renal impairment (58%), heart failure (48%), previous stroke (43%), and thromboembolic risk (43%) were also commonly assessed. Older age had a significant negative association with DOAC prescribing in (50%) of the studies; renal impairment reduced DOAC initiation, favoring warfarin in (94%). CONCLUSIONS: Several significant key factors were identified as being associated with OAC choice, including demographic factors such as age, and clinical factors such as kidney function, prior stroke, and other comorbidities. Significant factors in the choice among DOACs were advanced age, and renal impairment. REGISTRATION: This systematic review was registered as a PURE protocol (https://pureportal.strath.ac.uk/en/projects/factors-associated-with-the-prescribing-of-direct-acting-oral-ant).
BACKGROUND: Lipoprotein (Lp)(a) is a genetically inherited lipoprotein implicated in the progression of cardiovascular diseases and atherosclerosis. This study aims to examine whether elevated Lp(a) levels contribute to...BACKGROUND: Lipoprotein (Lp)(a) is a genetically inherited lipoprotein implicated in the progression of cardiovascular diseases and atherosclerosis. This study aims to examine whether elevated Lp(a) levels contribute to the development of subclinical atherosclerosis, compared to individuals with normal Lp(a) levels, using parameters such as coronary flow reserve (CFR). RESEARCH DESIGN AND METHODS: The study population included 25 patients with elevated Lp(a) levels and 30 subjects with normal Lp(a) levels, recruited prospectively. Conventional echocardiographic measurements were performed according to established guidelines. Main outcome measures included the comparison of CFR values between the groups. RESULTS: The CFR was found to be significantly decreased in the group with elevated Lp(a) levels compared to the control group (2.0 ± 0.5 vs. 2.5 ± 0.6, < 0.001). Additionally, a negative and statistically significant correlation was observed between Lp(a) levels and CFR, indicating that higher Lp(a) levels are associated with lower CFR values (r: -0.657, < 0.001). CONCLUSIONS: Our study demonstrates that elevated Lp(a) levels are significantly associated with subclinical atherosclerosis and impaired coronary vasomotor function. These findings suggest that lowering Lp(a) levels could effectively reduce the risk of atherosclerotic disease by targeting its role in atherosclerosis pathogenesis.
BACKGROUND: Exercise intolerance is a significant symptom of heart failure with reduced ejection fraction (HFrEF) and is associated with poor outcomes. While sodium-glucose cotransporter-2 inhibitors (SGLT2i) have demons...BACKGROUND: Exercise intolerance is a significant symptom of heart failure with reduced ejection fraction (HFrEF) and is associated with poor outcomes. While sodium-glucose cotransporter-2 inhibitors (SGLT2i) have demonstrated cardiovascular benefits, their impact on functional capacity remains debated. This study aimed to assess the effects of SGLT2i on exercise capacity and quality of life in patients with ischemic and non-ischemic HFrEF. RESEARCH DESIGN AND METHODS: Patients with a recent diagnosis of HFrEF and stable clinical status, referred to a heart failure unit, were prospectively enrolled. Exercise capacity was evaluated using the six-minute walk test (6MWT), and quality of life with the Minnesota Living with Heart Failure Questionnaire (MLHFQ) both at baseline and after 6 months. Patients were stratified by etiology and analyzed according to SGLT2i use. RESULTS: A total of 462 patients were included (275 non-ischemic, 187 ischemic); 86 (18.6%) received SGLT2i (45 non-ischemic, 41 ischemic). At 6 months, SGLT2i treatment significantly improved 6MWT in non-ischemic patients (+31.9 m, = 0.005), but not in ischemic patients (+9.0 m, = 0.411; ). MLHFQ scores improved similarly in both groups, with no significant differences related to SGLT2i use. CONCLUSIONS: SGLT2i improved exercise capacity only in non-ischemic HFrEF patients, suggesting a differential response based on etiology.
INTRODUCTION: In-stent calcification is recognized as a significant contributor to unfavorable clinical outcomes. Understanding the various types and underlying mechanisms of in-stent calcification can help interventiona...INTRODUCTION: In-stent calcification is recognized as a significant contributor to unfavorable clinical outcomes. Understanding the various types and underlying mechanisms of in-stent calcification can help interventional operators to make decisions. AREAS COVERED: This review will describe the distinct types of in-stent calcification, which are categorized into in-stent smooth calcification and in-stent calcified nodule. The mechanisms and characteristics of in-stent smooth calcification and calcified nodule will be summarized. Given the differences between these two types, treatment approaches will be discussed. This review will focus on histopathology and intracoronary imaging. For the purpose of this review, evidence was gathered from electronic literature searches via PubMed, with a particular focus on primary evidence published in the last 5 years. EXPERT OPINION: Several treatment devices are available such as conventional balloon, modified balloon, atherectomy device, and intravascular lithotripsy. In-stent smooth calcification and calcified nodule might result in different clinical courses after repeated target lesion revascularization. Understanding the mechanisms with the various types of in-stent calcification may assist operators in selecting appropriate treatment strategies.
BACKGROUND: We assessed the sex and racial/ethnic disparities on in-hospital outcomes in patients undergoing transcatheter aortic valve replacement (TAVR). RESEARCH DESIGN AND METHODS: This retrospective study analyzed T...BACKGROUND: We assessed the sex and racial/ethnic disparities on in-hospital outcomes in patients undergoing transcatheter aortic valve replacement (TAVR). RESEARCH DESIGN AND METHODS: This retrospective study analyzed TAVR procedures performed during 2016-2019. Data from the National Inpatient Sample database identified 155,610 patients who underwent TAVR. Outcomes included in-hospital mortality, stroke, major bleeding, and other complications, assessed separately by sex and race/ethnicity (White, Black, and Hispanic). Logistic regression was used to estimate odds ratio (OR) with its 95% confidence interval (CI). RESULTS: Women had higher odds of in-hospital mortality (OR 1.33, 95% CI 1.07-1.64), bleeding, and vascular complications, but lower odds of pacemaker implantation and renal replacement therapy compared with men. Hispanic patients had increased mortality (OR 1.86, 95% CI 1.26-2.75) and black patients had increased odds of stroke (OR 2.06, 95% CI 1.24-3.44). Subgroup analysis showed that Hispanic women had the highest mortality odds (OR 2.42, 95% CI 1.46-4.01). CONCLUSIONS: There are significant sex and racial/ethnic disparities in TAVR outcomes, particularly among minority women. Women had a higher odds of mortality, major bleeding, and vascular complications compared to men. Racial disparities were also seen, with Hispanic patients having an increased odds of mortality and black patients having an increased odds of stroke.
INTRODUCTION: The optimal management of elderly patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) remains uncertain. This systematic review assessed routine invasive versus conservative strategies...INTRODUCTION: The optimal management of elderly patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) remains uncertain. This systematic review assessed routine invasive versus conservative strategies in this population. METHODS: PubMed, Embase, and Scopus were searched through September 2024 for randomized controlled trials comparing both strategies. The primary outcome was major adverse cardiovascular events (MACE); secondary outcomes included all-cause mortality, cardiovascular mortality, non-cardiovascular mortality, myocardial infarction, revascularization, stroke, and bleeding. Evidence certainty was evaluated using GRADE, and meta-analyses applied random-effects models. RESULTS: Seven RCTs ( = 2,997; mean age 81-86 years; 49% female) were included. Invasive strategy reduced MACE risk (HR 0.77, 95% CI 0.65-0.92), with consistent point estimate direction across trials. Myocardial infarction (HR 0.70, 95% CI 0.59-0.84) and revascularization (HR 0.45, 95% CI 0.23-0.90) were also significantly reduced. No significant differences were observed for all-cause mortality (HR1.04, 95% CI 0.90-1.19), cardiovascular mortality (HR 1.10, 95% CI 0.86-1.41), stroke (HR 0.78, 95% CI 0.53-1.16), or bleeding (RR1.23, 95% CI 0.90-1.69). Evidence certainty was moderate for most outcomes. CONCLUSIONS: In elderly NSTE-ACS patients, routine invasive strategy reduces cardiovascular events without significantly increasing bleeding, supporting individualized treatment decisions. REGISTRATION: The protocol for this study was registered in the PROSPERO repository (CRD42024600769).
BACKGROUND: Acute limb ischemia (ALI) is a critical vascular emergency marked by a sudden reduction in blood flow to the limb, significantly increasing amputation risk. Revascularization outcomes in urban versus rural ar...BACKGROUND: Acute limb ischemia (ALI) is a critical vascular emergency marked by a sudden reduction in blood flow to the limb, significantly increasing amputation risk. Revascularization outcomes in urban versus rural areas have not been examined. RESEARCH DESIGN AND METHODS: The National Inpatient Sample from 2016 to 2021 identified patients with ALI who underwent revascularization. Propensity score matching compared outcomes, analyzed using STATA version 18. RESULTS: Of 85,760 hospitalizations for ALI receiving percutaneous revascularization 81,880 (95.5%) were in urban centers and 3,880 (4.5%) in rural facilities. Patients in urban hospitals showed higher mortality (4% vs. 2.7%), myocardial infarction (MI) (3.4% vs. 2.7%), cardiogenic shock (1.6% vs. 0.6%), cardiac arrest (6.5% vs. 5.9%), major adverse cardiovascular and cerebrovascular events (MACCE) (7.5% vs. 5.3%), mechanical circulatory support (1.1% vs. 0.5%), and acute kidney injury (18.5% vs. 15.4%). However, urban patients had lower intravascular ultrasound (IVUS) (3.4% vs. 6.5%), major amputation (6.3% vs. 7.8%), fasciotomy (1.8% vs. 2.2%), and major adverse limb events (MALE) (46.4% vs. 49.1%), with a significant difference of < 0.01 compared to rural hospitals. CONCLUSIONS: Urban hospitals in the United States report elevated mortality rates and significant cardiovascular events in comparison to their rural counterparts.
INTRODUCTION: Atherosclerotic cardiovascular disease (ASCVD) and cancer are the leading causes of death globally. While traditionally viewed as distinct, growing evidence reveals significant overlap in their risk factors...INTRODUCTION: Atherosclerotic cardiovascular disease (ASCVD) and cancer are the leading causes of death globally. While traditionally viewed as distinct, growing evidence reveals significant overlap in their risk factors and pathophysiology, suggesting a shared biological basis that warrants closer clinical and research attention. AREAS COVERED: This review explores modifiable lifestyle and pathological risk factors that contribute to both ASCVD and cancer, including tobacco use, poor diet, physical inactivity, environmental toxins, hypertension, hyperlipidemia, obesity, insulin resistance, and sex hormone dysregulation. Mechanistically, these factors converge on common pathways such as chronic inflammation, oxidative stress, and hormonal imbalance, facilitating both atherogenesis and tumorigenesis. The paper also highlights how these shared mechanisms offer opportunities for unified prevention and treatment strategies. EXPERT OPINION: Understanding these connections is critical for dual-risk stratification, prevention, and management strategies. Emerging approaches such as personalized medicine, leveraging genomic and biomarker data, and multidisciplinary care models that integrate cardiology and oncology expertise offer opportunities to optimize outcomes. Advances in multi-omics and targeted therapies promise to further elucidate the shared mechanisms, paving the way for innovative interventions. This comprehensive understanding highlights the need for integrated care to address the dual burden of ASCVD and cancer and improve patient outcomes.
INTRODUCTION: Bleeding risk assessment plays a critical role in the anticoagulation management for atrial fibrillation (AF), to balance stroke prevention with risk of major hemorrhage. Traditional bleeding risk models, s...INTRODUCTION: Bleeding risk assessment plays a critical role in the anticoagulation management for atrial fibrillation (AF), to balance stroke prevention with risk of major hemorrhage. Traditional bleeding risk models, such as HAS-BLED, ORBIT, and ATRIA, offer valuable insights but have limitations in predictive accuracy and clinical applicability. Recent advances in risk stratification have introduced novel models integrating biomarkers, genetic data, and artificial intelligence (AI)-driven algorithms to improve precision and individualized patient care. AREAS COVERED: This review evaluates strengths and limitations of established bleeding risk assessment tools and explores emerging trends in predictive modeling. It discusses novel risk stratification models- DOAC Score, GARFIELD-AF, and HEMORR₂HAGES, which incorporate renal function markers, hematologic parameters, and genetic polymorphisms to enhance predictive accuracy. Integration of machine learning and digital health tools, such as the Universal Clinician Device (UCD) and the mAFA-II mobile application, was also examined for their role in improving anticoagulation safety and adherence. EXPERT OPINION: The future of bleeding risk assessment lies in AI-driven, real-time risk prediction models adapting to dynamic patient profiles. Enhanced integration of digital health solutions and learning health systems will minimize adverse events while optimizing stroke prevention. Future research should prioritize the validation and standardization of these novel tools.
BACKGROUND: Patients with surgically repaired tetralogy of Fallot (rTOF) often develop chronic pulmonary regurgitation (PR), necessitating pulmonary valve replacement (PVR). While cardiac MRI is crucial for PVR timing, i...BACKGROUND: Patients with surgically repaired tetralogy of Fallot (rTOF) often develop chronic pulmonary regurgitation (PR), necessitating pulmonary valve replacement (PVR). While cardiac MRI is crucial for PVR timing, its availability is limited. This study evaluates electrocardiographic (ECG) findings - specifically the R-wave amplitude in lead V1 (V1R) and the sum of the R-wave amplitude in lead V1 and the deepest S-wave amplitude in lead V5 or V6 (V1R + V5S or V6S) - as predictors of cardiac MRI findings. PATIENTS AND METHODS: We retrospectively analyzed 35 rTOF patients (mean age 34 ± 9 years; 60% male) who underwent cardiac MRI from 2019 to 2022, assessing correlations between ECG parameters (V1R, V1R + V5S or V6S, and QRS duration) and MRI findings (RVESVI and RVEDVI). RESULTS: V1R showed significant correlation with RVESVI ( = 0.486, = 0.003) and was notably higher in patients with RVESVI ≥ 80 mL/m. A V1R cutoff of 20 mm identified RVESVI ≥ 80 mL/m with 67% sensitivity and 77% specificity. CONCLUSIONS: V1R on ECG may help predict the need for cardiac MRI, aiding in the timely PVR planning for rTOF patients.