Current Treatment Options In Cardiovascular Medicine[JOURNAL]
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200 papers
The "Extreme Exercise Hypothesis": Recent Findings and Cardiovascular Health Implications.
Eijsvogels TMH, Thompson PD, Franklin BA
Curr Treat Options Cardiovasc Med · 2018 Aug · PMID 30155804 · Full text
PURPOSE OF REVIEW: The "Extreme Exercise Hypothesis" is characterized by a U-shaped or reverse J-shaped, dose-response curve between physical activity volumes and cardiovascular health outcomes. In this review, we summar...
PURPOSE OF REVIEW: The "Extreme Exercise Hypothesis" is characterized by a U-shaped or reverse J-shaped, dose-response curve between physical activity volumes and cardiovascular health outcomes. In this review, we summarize recent findings that may support or refute the "Extreme Exercise Hypothesis." Furthermore, we discuss potential cardiovascular health implications of the cardiac anatomical, structural, contractility, and biomarker abnormalities that have been reported in some veteran endurance athletes. RECENT FINDINGS: Emerging evidence from epidemiological studies and observations in cohorts of endurance athletes suggest that potentially adverse cardiovascular manifestations may occur following high-volume and/or high-intensity long-term exercise training, which may attenuate the health benefits of a physically active lifestyle. Accelerated coronary artery calcification, exercise-induced cardiac biomarker release, myocardial fibrosis, atrial fibrillation, and even higher risk of sudden cardiac death have been reported in athletes. There is primarily circumstantial evidence that supports the "Extreme Exercise Hypothesis." Subclinical and atherosclerotic coronary artery disease (CAD) as well as structural cardiovascular abnormalities and arrhythmias are present in some of the most active veteran endurance athletes and need appropriate clinical follow-up to reduce the risk for adverse cardiovascular outcomes. Future studies are warranted to establish the long-term cardiovascular health effects of these findings in veteran endurance athletes.
Cardiac Screening of Young Athletes: a Practical Approach to Sudden Cardiac Death Prevention.
Dhutia H, MacLachlan H
Curr Treat Options Cardiovasc Med · 2018 Aug · PMID 30155696 · Full text
PURPOSE OF REVIEW: We aim to report on the current status of cardiovascular screening of athletes worldwide and review the up-to-date evidence for its efficacy in reducing sudden cardiac death in young athletes. RECENT F...
PURPOSE OF REVIEW: We aim to report on the current status of cardiovascular screening of athletes worldwide and review the up-to-date evidence for its efficacy in reducing sudden cardiac death in young athletes. RECENT FINDINGS: A large proportion of sudden cardiac death in young individuals and athletes occurs during rest with sudden arrhythmic death syndrome being recognised as the leading cause. The international recommendations for ECG interpretation have reduced the false-positive ECG rate to 3% and reduced the cost of screening by 25% without compromising the sensitivity to identify serious disease. There are some quality control issues that have been recently identified including the necessity for further training to guide physicians involved in screening young athletes. Improvements in our understanding of young sudden cardiac death and ECG interpretation guideline modification to further differentiate physiological ECG patterns from those that may represent underlying disease have significantly improved the efficacy of screening to levels that may make screening more attractive and feasible to sporting organisations as a complementary strategy to increased availability of automated external defibrillators to reduce the overall burden of young sudden cardiac death.
Sex Differences in Atrial Fibrillation-Update on Risk Assessment, Treatment, and Long-Term Risk.
Bai CJ, Madan N, Alshahrani S … +2 more , Aggarwal NT, Volgman AS
Curr Treat Options Cardiovasc Med · 2018 Aug · PMID 30146677 · Publisher ↗
PURPOSE OF REVIEW: Atrial fibrillation (AF) is a growing health problem worldwide. While the disease plagues both men and women, this arrhythmia does not affect both sexes equally. Women are more likely to have major adv...
PURPOSE OF REVIEW: Atrial fibrillation (AF) is a growing health problem worldwide. While the disease plagues both men and women, this arrhythmia does not affect both sexes equally. Women are more likely to have major adverse outcomes such as stroke and its sequela; however, recent data on stroke prevention show improving outcomes. The purpose of this review of the recent literature is to summarize important updates on risk scores and management of patients with AF. RECENT FINDINGS: It has been well known that women have a higher risk of strokes than men when untreated or when treated with warfarin. Current risk scores emphasizing new risk factors such as the higher risk of strokes in women have been incorporated into clinical guidelines. However, with the use of direct oral anticoagulants, this sex disparity on stroke is no longer seen and women have less major bleeding than men. The use of cardiac glycosides is associated with increased incidence of breast cancer, and this medication is used more in women. Procedural complications for the management of AF are higher in women. The study of the pathophysiology of AF and its management is a rapidly evolving area of cardiovascular medicine. Sex-specific data is necessary to achieve advances in the field and improve the outcomes in both men and women.
Assessment of the QT Interval in Athletes: Red Flags and Pitfalls.
Ahluwalia N, Raju H
Curr Treat Options Cardiovasc Med · 2018 Aug · PMID 30146672 · Publisher ↗
PURPOSE OF REVIEW: Pre-participation athlete screening has led to the referral of asymptomatic athletes with a prolonged QT interval warranting their evaluation for long QT syndrome (LQTS). Establishing a diagnosis of LQ...
PURPOSE OF REVIEW: Pre-participation athlete screening has led to the referral of asymptomatic athletes with a prolonged QT interval warranting their evaluation for long QT syndrome (LQTS). Establishing a diagnosis of LQTS can be difficult, particularly in asymptomatic athletes presenting with a prolonged QTc < 500 ms. This review examines the evaluatory pathway to ascertain the common pitfalls leading to mis- or overdiagnosis. We discuss the advanced ECG-based tools and consider their application in the diagnostic process. RECENT FINDINGS: Critical analysis of the ECG, symptom, and pedigree analysis has established value but relies on experienced interpretation. Protocolisation of the former has effectively reduced error. Exercise recovery ECG testing has demonstrated diagnostic value and provocation testing, reliant on QT hysteresis in LQTS, have shown reasonable sensitivity. Although it is becoming more established in experienced centres, its diagnostic value relies on effective risk stratification and subject selection. LQTS is a rare condition and the precision of any available test is greatly diluted if pre-test probability is low. Clinical and familial evaluation and exercise ECG testing are the foundation of the evaluatory process following referral. Adjunctive tests may have high sensitivity for LQTS but rely on high pre-test probability. Several pitfalls have been identified that can lead to misdiagnosis and thus informed evaluation at an experienced specialist centre is appropriate.
The Global Burden of Cardiovascular Disease in Women.
Sharma S, Wood MJ
Curr Treat Options Cardiovasc Med · 2018 Aug · PMID 30146670 · Publisher ↗
PURPOSE OF REVIEW: Cardiovascular disease (CVD) is the leading cause of mortality worldwide, accounting for one third of all deaths in 2015. Alarmingly, there has been slowing of the decline in age-standardized CVD morta...
PURPOSE OF REVIEW: Cardiovascular disease (CVD) is the leading cause of mortality worldwide, accounting for one third of all deaths in 2015. Alarmingly, there has been slowing of the decline in age-standardized CVD mortality over the last 5 years compared to the previous 25 years. RECENT FINDINGS: Given the increasing global CVD burden, in 2011, the United Nations declared the goal to reduce premature mortality from the four main non-communicable diseases by 25% from 2010 to 2025, abbreviated as the 25 × 25 goal. The United Nations has further created nine targets to achieve the 25 × 25 goal. These targets emphasize risk factor modification and strengthening of healthcare delivery systems. Achieving the nine targets and 25 × 25 goal set by the United Nations will undoubtedly benefit the world as a whole. However, women face additional, unacceptable, disproportionate CVD risk factors that need to be addressed, including psychological stressors contributing to ischemic heart disease, pregnancy-related CVD, environmental and infectious exposures in low socioeconomic settings, and limited healthcare access and delivery. This paper highlights global CVD gender disparities in order to stimulate awareness and discussion of potential interventions to address the rapidly growing burden of heart disease in women.
Speckle Tracking Echocardiography for the Assessment of the Athlete's Heart: Is It Ready for Daily Practice?
Forsythe L, George K, Oxborough D
Curr Treat Options Cardiovasc Med · 2018 Aug · PMID 30146663 · Full text
PURPOSE OF REVIEW: To describe the use of speckle tracking echocardiography (STE) in the biventricular assessment of athletes' heart (AH). Can STE aid differential diagnosis during pre-participation cardiac screening (PC...
PURPOSE OF REVIEW: To describe the use of speckle tracking echocardiography (STE) in the biventricular assessment of athletes' heart (AH). Can STE aid differential diagnosis during pre-participation cardiac screening (PCS) of athletes? RECENT FINDINGS: Data from recent patient, population and athlete studies suggest potential discriminatory value of STE, alongside standard echocardiographic measurements, in the early detection of clinically relevant systolic dysfunction. STE can also contribute to subsequent prognosis and risk stratification. Despite some heterogeneity in STE data in athletes, left ventricular global longitudinal strain (GLS) and right ventricular longitudinal strain (RV ɛ) indices can add to differential diagnostic protocols in PCS. STE should be used in addition to standard echocardiographic tools and be conducted by an experienced operator with significant knowledge of the AH. Other indices, including left ventricular circumferential strain and twist, may provide insight, but further research in clinical and athletic populations is warranted. This review also raises the potential role for STE measures performed during exercise as well as in serial follow-up as a method to improve diagnostic yield.
Imaging of the Postsurgical Aorta in Marfan Syndrome.
Groner LK, Lau C, Devereux RB … +1 more , Green DB
Curr Treat Options Cardiovasc Med · 2018 Aug · PMID 30146656 · Publisher ↗
Marfan syndrome is a heritable multisystem connective tissue disease and is the most common genetic cause of aortic disease. Guidelines for surgical repair and recommendations for surveillance imaging aim to prevent aneu...
Marfan syndrome is a heritable multisystem connective tissue disease and is the most common genetic cause of aortic disease. Guidelines for surgical repair and recommendations for surveillance imaging aim to prevent aneurysm rupture, aortic dissection, and death. Options for proximal aorta repair include the modified Bentall procedure and valve-sparing aortic root repairs. Hemiarch and total arch replacement are options for aortic arch repair, and the elephant trunk procedure is a special two-staged total arch repair facilitating future descending aorta repair. Endovascular repair is not currently considered an acceptable long-term treatment option in Marfan syndrome but may be performed when open repair is not feasible or in the acute setting as a bridge to definitive surgical treatment. After an initial surgery, patients remain at risk for new aortic dissection, propagation of a pre-existing aortic dissection, and new or enlarging aortic aneurysm. Anastomotic pseudoaneurysm is a potential postsurgical complication at multiple sites including proximal and distal aortic anastomoses, coronary anastomoses, and intercostal and visceral artery patches. Patients undergoing endovascular repair are at increased risk of endoleak and aortic dissection. CT and MR angiography are the main imaging modalities for surveillance of the aorta in Marfan syndrome and are capable of demonstrating these complications, as well as expected postsurgical appearances. 4D flow MRI is an emerging technique providing hemodynamic information that may risk-stratify aneurysms better than size alone and help predict future aortic events.
Cardiac Rehabilitation and Exercise Prescription in Symptomatic Patients with Non-Obstructive Coronary Artery Disease-a Systematic Review.
Kissel CK, Nikoletou D
Curr Treat Options Cardiovasc Med · 2018 Aug · PMID 30121850 · Full text
PURPOSE OF REVIEW: Non-obstructive coronary artery disease (NOCAD) on coronary angiography is a common finding in patients with stable angina. Angina in NOCAD patients is thought to be caused by endothelial dysfunction o...
PURPOSE OF REVIEW: Non-obstructive coronary artery disease (NOCAD) on coronary angiography is a common finding in patients with stable angina. Angina in NOCAD patients is thought to be caused by endothelial dysfunction of the epicardial coronary arteries and/or the microvasculature. Treatment is empiric, and 30% of patients remain symptomatic in spite of therapy. It is well known that physical exercise can improve endothelial function. The goal of this review was to assess the current literature on effects of physical exercise in NOCAD patients with angina. Therefore, a literature search was conducted to March 13, 2018 using the following search terms: syndrome X, microvascular angina, non-obstructive coronary artery disease and exercise training, cardiac rehabilitation, endothelial function. All original publications were included which examined the effect of a cardiac rehabilitation (CR) program or exercise training (ET) on patients with angina and NOCAD. RECENT FINDINGS: Eight studies, of which four were randomized controlled studies, examined 218 participants, 162 in an intervention and 56 in control groups. Most patients were women (97.7%). Exercise programs varied from 8 weeks to 4 months at moderate intensity and some included relaxation therapy. The studies examined the effect of CR on exercise capacity, quality of life (QoL), and perfusion defects. CR increased exercise capacity, oxygen uptake, symptom severity, and QoL. Myocardial perfusion improved. CR appears to be beneficial in symptomatic patients with NOCAD, improving exercise capacity and QoL and reducing severity of symptoms and myocardial perfusion defects. Data is limited to a small number of predominantly female patients. Further larger trials are warranted to determine the optimal rehabilitation protocols and define its long-term benefits.
Multi-Modality Imaging in the Evaluation and Treatment of Tricuspid Regurgitation.
Kim SM, Singh HS, Nati J … +1 more , Ginns JN
Curr Treat Options Cardiovasc Med · 2018 Aug · PMID 30094651 · Publisher ↗
PURPOSE OF REVIEW: The goal of this review is to cover the epidemiology of tricuspid regurgitation (TR), anatomy of the tricuspid valve (TV), and the mechanisms and modern treatment of TR. The focus will be on the role o...
PURPOSE OF REVIEW: The goal of this review is to cover the epidemiology of tricuspid regurgitation (TR), anatomy of the tricuspid valve (TV), and the mechanisms and modern treatment of TR. The focus will be on the role of echocardiography, cardiac CT, and MRI to determine the mechanism, severity, and management strategies of TR. RECENT FINDINGS: The evaluation and management of TR is a rapidly growing field with significant advances in both imaging and interventions. Important advances have been made to understand TV anatomy and physiology in 3D echo, CT, and MRI. Additional understanding of the abnormal outcomes in both primary TR and secondary TR have been appreciated. Multiple transcatheter devices have reached the stage of early trials in high surgical risk cohorts with favorable initial findings. TR is a significant cardiovascular problem and vastly undertreated in the present era. There has been tremendous growth in knowledge of mechanisms of TR, its prognostic implications, timing of intervention, and development of novel treatment strategies. Multimodality imaging plays a key role in evaluation and treatment of this condition.
Specialized Care for Women: the Impact of Women's Heart Centers.
Lundberg GP, Mehta LS, Volgman AS
Curr Treat Options Cardiovasc Med · 2018 Aug · PMID 30091012 · Publisher ↗
PURPOSE OF THE REVIEW: Cardiovascular disease (CVD) has been and remains the leading cause of mortality in women in the United States. For decades, more women died every year of CVD compared to men. Heart centers for wom...
PURPOSE OF THE REVIEW: Cardiovascular disease (CVD) has been and remains the leading cause of mortality in women in the United States. For decades, more women died every year of CVD compared to men. Heart centers for women (HCW) are developed in response to the need for greater patient and physician awareness of CVD in women and to conduct sex-specific research in women. Today, many HCW provide multispecialty and focused areas of cardiovascular care for women. HCW provide their female patients with expertise over the many stages of a woman's life. And HCW partner with national organizations to advance research and education through specialized and focused care for women. The purpose of this review is to review the historical development of heart centers for women and discuss the types of care they provide for women. RECENT FINDINGS: Mortality rates from cardiovascular disease in women are finally reaching the levels of men after decades of focus on awareness, prevention, and evidence-based guideline-directed care for women. Heart centers for women have evolved to provide subspecialty and comprehensive care for women that includes education and research. Heart centers for women are partnering with many other disease-based and patient advocacy organizations to provide care for all women at all stages of life. Alarmingly, there has been increasing CVD mortality in both men and women recently.
DVT Intervention in the Post-ATTRACT Era.
Winokur RS, Sista AK
Curr Treat Options Cardiovasc Med · 2018 Aug · PMID 30084056 · Publisher ↗
PURPOSE OF REVIEW: Patients suffering from acute lower extremity deep vein thrombosis (DVT) are at risk for developing chronic limb pain, heaviness, and fatigue, known as the post-thrombotic syndrome (PTS). RECENT FINDIN...
PURPOSE OF REVIEW: Patients suffering from acute lower extremity deep vein thrombosis (DVT) are at risk for developing chronic limb pain, heaviness, and fatigue, known as the post-thrombotic syndrome (PTS). RECENT FINDINGS: Although several studies have shown that catheter-directed therapy reduces clot burden and may improve clinical outcomes, the multicenter randomized controlled ATTRACT trial showed no difference in PTS or quality of life at 2 years between patients treated with pharmacomechanical catheter-directed thrombolysis (PCDT) and those treated with anticoagulation alone, and a higher major bleeding rate in the PCDT group. PCDT is not indicated for most patients diagnosed with lower extremity DVT. Since PCDT may benefit patients with iliofemoral DVT, intervention can be considered in this subset of patients if they are at low risk of bleeding.
Updates on the Role of Imaging in Cardiac Sarcoidosis.
Yatsynovich Y, Valencia D, Petrov M … +3 more , Linares JD, Rahman MM, Dittoe N
Curr Treat Options Cardiovasc Med · 2018 Aug · PMID 30084045 · Publisher ↗
PURPOSE OF REVIEW: The non-specific symptom profile and subclinical nature of disease along with variable region of cardiac involvement in systemic sarcoidosis make the diagnosis particularly challenging. The yield of en...
PURPOSE OF REVIEW: The non-specific symptom profile and subclinical nature of disease along with variable region of cardiac involvement in systemic sarcoidosis make the diagnosis particularly challenging. The yield of endomyocardial biopsy, a gold standard for diagnosis, is not high unless coupled with additional imaging modalities to detect regional involvement. This review is focused on highlighting the major recent advances in imaging modalities and diagnosis of cardiac sarcoidosis. RECENT FINDINGS: There has been much interest and increasing research focused on developing newer and improved imaging modalities to establish diagnosis. CMR and F- FDG-PET are now considered imaging modalities of choice in most centers worldwide, but the data comparing both methodologies head-to-head is limited. Nevertheless, novel radiotracers (i.e. Ga-DOTANOC, F-Flurpiridaz, N-Ammonia) and hybrid combination PET/CMR imaging are coming to spotlight with improved sensitivity and specificity for earlier detection of myocardial sarcoid. As CMR and PET are showing increased utilization in cardiac sarcoidosis, Th-SPECT, Tc MDP SPECT, Ga Scintigraphy, and Rb PET are falling out of favor. Newer imaging modalities, radionuclide tracers, and hybrid PET/CMR combinations have been promising in better detecting cardiac sarcoidosis and are currently being evaluated in larger trials.
State-of-the-Art Imaging for the Evaluation of Pulmonary Embolism.
Roshkovan L, Litt H
Curr Treat Options Cardiovasc Med · 2018 Aug · PMID 30084035 · Publisher ↗
PURPOSE OF REVIEW: CT angiography has become the gold standard for evaluation of suspected pulmonary embolism; however, continuous evolution in radiology has led to new imaging approaches that offer improved options for...
PURPOSE OF REVIEW: CT angiography has become the gold standard for evaluation of suspected pulmonary embolism; however, continuous evolution in radiology has led to new imaging approaches that offer improved options for detection and characterization of pulmonary embolism while exposing patients to lower contrast and radiation dose. The purpose of this review is to summarize state of the art imaging approaches for the evaluation of pulmonary embolism, focusing on technical innovations in this field. RECENT FINDINGS: The introduction of dual-energy CT has resulted in the ability to add functional and prognostic information beyond the morphologic assessment of the pulmonary arteries and potentially offer improved image quality without additional radiation burden. New approaches and strategies in CT scanning have resulted in decreased radiation exposure as well as a significant decrease in contrast material used without decreasing the sensitivity for detection of pulmonary embolism. Continuous developments and improvements in MR angiography techniques offer a valuable and efficient option for certain patient populations without the risk of radiation exposure. Improvements in the technical success rate and reliability of this modality will mean more widespread use in the future. Moving beyond planar ventilation/perfusion (V/Q) scintigraphy, nuclear imaging offers several new approaches, including the use of single photon emission computed tomography (SPECT) and SPECT/CT resulting in superior diagnostic performance and a decrease in nondiagnostic studies, potentially surpassing the diagnostic capabilities of computed tomography pulmonary angiography. Ongoing research in the use of V/Q PET/CT demonstrates superior temporal and spatial resolution and quantitative capabilities compared to SPECT-CT; this modality will likely play an increasing role in the detection and characterization of pulmonary embolism. The field of pulmonary embolism imaging has demonstrated continuous evolution in both development of novel techniques and improvement in current technologies, resulting in better detection, decreased radiation exposure, and enhanced functional information beyond morphologic characterization of the pulmonary vasculature.
Stable Ischemic Heart Disease in Women.
Schmidt KMT, Nan J, Scantlebury DC … +1 more , Aggarwal NR
Curr Treat Options Cardiovasc Med · 2018 Aug · PMID 30084006 · Publisher ↗
PURPOSE OF THE REVIEW: Paradoxically, although women have a lower burden of coronary atherosclerosis, they experience more symptoms, more frequent hospitalizations, and a worse prognosis compared to men. This is in part...
PURPOSE OF THE REVIEW: Paradoxically, although women have a lower burden of coronary atherosclerosis, they experience more symptoms, more frequent hospitalizations, and a worse prognosis compared to men. This is in part due to biological variations in pathophysiology between the two sexes, and in part related to inadequate understanding of these differences, subconscious referral bias, and suboptimal application of existing women-specific guidelines. We sought to review the contemporary literature and provide an update on risk assessment, diagnosis, and management of IHD in women. RECENT FINDINGS: IHD in women is often secondary to diffuse non-obstructive atherosclerosis, coronary spasm, inflammation, and endothelial and microvascular dysfunction, and less commonly due to the male pattern of flow-limiting epicardial stenosis. Both IHD patterns likely represent sex-specific manifestations of the same disease process. Additionally, there is a differential expression of risk factors and symptoms between men and women. Application of male-pattern IHD risk factors and presentation to women contributes to under-recognition, under-testing, and under-treatment of IHD in women compared to men. Traditional diagnostic evaluation has focused on detection of epicardial disease, amenable to revascularization. Our improved understanding of sex-specific pathophysiology of IHD has enabled us to also develop tools for detection of microvascular disease. Advances in stress MRI, flow quantification on stress PET, and provocative invasive angiography have filled this void and offer important diagnostic and prognostic information. Despite our improved understanding of sex-specific differences in presentation, risk factors, pathophysiology, diagnostic testing, and management strategies of IHD, women with IHD continue to experience worse outcomes than men. This disparity underscores the need for improved research and understanding of biological sex differences, elimination of subconscious gender bias in referral patterns, and improved application of existing research into clinical practice.
Advances in Mitral Valve Surgery.
Meier S, Seeburger J, Borger MA
Curr Treat Options Cardiovasc Med · 2018 Aug · PMID 30083865 · Publisher ↗
Mitral valve (MV) insufficiency, classified as primary and secondary mitral regurgitation (MR), is a common cause of morbidity and mortality. In industrialized countries, degenerative forms are the predominant cause of M...
Mitral valve (MV) insufficiency, classified as primary and secondary mitral regurgitation (MR), is a common cause of morbidity and mortality. In industrialized countries, degenerative forms are the predominant cause of MR; however, an increasing number of patients present with secondary MR (Iung et al. EHJ 24:1231-1243, 2003). During the last decades, MV surgery experienced substantial advancements. Alain Carpentier pioneered the field of reconstructive valve surgery in the beginning of the 1970s and, since then, a plethora of innovations have led to today's landscape of MV surgery. Modern MV repair techniques including minimally invasive approaches represent the gold standard for primary MR with reconstruction rates of > 97% in high-volume reference centers (Castillo et al. JTCS 144(2):308-312, 2012). Although there is a clear strategy for treatment of primary MR with established high-quality results, the optimal course for treatment of secondary MR remains controversial. Results for a variety of MV repair techniques for secondary MR have been uniformly disappointing and there has been a recent resurgence in interest for MV replacement surgery. Innovations in equipment and imaging have led to the development of new techniques for patients with MV disease. High-risk patients who are poor candidates for surgery have been the focus for most of these techniques, usually within the construct of a multidisciplinary heart team. Efforts have been predominantly focused on less invasive strategies, usually transcatheter technologies, in these high-risk patients. This article aims to give an overview about current surgical treatment options for primary and for secondary MR with special focus on new surgical and transcatheter developments.
Workup and Management of Native and Prosthetic Valve Endocarditis.
Bin Abdulhak AA, Qazi AH, Tleyjeh IM
Curr Treat Options Cardiovasc Med · 2018 Aug · PMID 30083823 · Publisher ↗
Infective endocarditis (IE) is associated with significant serious adverse outcomes including death. IE usually presents with diverse clinical picture and syndromic diagnoses including heart failure, stroke, and peripher...
Infective endocarditis (IE) is associated with significant serious adverse outcomes including death. IE usually presents with diverse clinical picture and syndromic diagnoses including heart failure, stroke, and peripheral embolization. Given variable, vague, and syndromic presentations, the diagnosis of IE may be delayed for days to weeks. Maintaining a high index of suspicion among clinicians is the key to early recognition of the disease and prompt initiation of antimicrobial therapy to prevent IE-associated mortality and morbidity. Blood culture and echocardiography remain essential tools in the diagnosis of infective endocarditis. However, advances in molecular techniques, serology testing, computed tomography scan, and nuclear medicine have led to growth in the available tools that may aid in early diagnosis of infective endocarditis. Antimicrobial agents are the mainstay of IE therapy; however, as many as 50% of endocarditis cases will undergo valve surgery, even on an urgent or emergent basis.
Management of Venous Thromboembolism in Pregnancy.
Fogerty AE
Curr Treat Options Cardiovasc Med · 2018 Jul · PMID 30039233 · Publisher ↗
PURPOSE OF REVIEW: This manuscript addresses the risks for venous thromboembolism (VTE) during pregnancy and the associated challenges of both diagnosis and treatment. RECENT FINDINGS: The obstacles to diagnosis given la...
PURPOSE OF REVIEW: This manuscript addresses the risks for venous thromboembolism (VTE) during pregnancy and the associated challenges of both diagnosis and treatment. RECENT FINDINGS: The obstacles to diagnosis given lack of specificity of typical biomarkers to predict VTE in pregnancy, as well as the unique fetal and bleeding risks introduced by managing massive pulmonary embolism (PE) with thrombolytics or thrombectomy are highlighted. VTE during pregnancy and the postpartum window occurs at a 6-10-fold higher rate compared with age-matched peers and is a major cause of morbidity and mortality. Hypercoagulability persists for 6-8 weeks after delivery with the highest risk of PE being postpartum. The lack of randomized trials in pregnant women leads to variability in practice, which are largely based on expert consensus or extrapolation from non-pregnant cohorts. The standard treatment of VTE in pregnancy is anticoagulation with low molecular weight heparin (LMWH), which like unfractionated heparin does not cross the placenta and is not teratogenic. LMWH is preferred given the negligible risk for heparin-induced thrombocytopenia and osteoporosis, better bioavailability, and a predictive dose response. Depending on the severity of the VTE, additional treatments including thrombolysis, thrombectomy, inferior vena cava filter placement, or venous stenting may be used. Management requires balancing the competing bleeding and thrombotic risks during labor and delivery and factoring the impact of treatment on the fetus. A multidisciplinary team involving hematology, obstetrics, anesthesia, vascular medicine, and cardiology is critical for safe and timely management. The design and execution of prospective, randomized trials to specifically address optimal diagnosis and management are a top priority in obstetric hematology.
Cardiac Adaption to Exercise Training: the Female Athlete.
Petek BJ, Wasfy MM
Curr Treat Options Cardiovasc Med · 2018 Jul · PMID 30019289 · Publisher ↗
PURPOSE OF REVIEW: The number of female athletes participating in sports has increased exponentially over the past century. While cardiac adaptations to exercise have been well described, female athletes have been underr...
PURPOSE OF REVIEW: The number of female athletes participating in sports has increased exponentially over the past century. While cardiac adaptations to exercise have been well described, female athletes have been underrepresented in many prior studies. More recently, important research has embraced gender as an important biologic variable. We will review this work in order to examine how gender influences the impact of exercise on the heart. RECENT FINDINGS: Exercise-induced cardiac remodeling (EICR) manifests slightly differently in male and female athletes. Specifically, female athletes have fewer signs of EICR on the electrocardiogram than male athletes, though are more likely to have anterior T wave inversions in the absence of cardiac disease. Cardiac enlargement due to exercise follows a different pattern in female versus male athletes, with females having similar chamber size when adjusted for body size but lower left ventricular mass. Recent research also suggests that female masters athletes may be less likely to have excess coronary disease, atrial fibrillation, and myocardial fibrosis, all of which have been posited though not proven to be sequelae of long-term endurance exercise in males. Gender appears to be an important modifier of the relationship between exercise and associated cardiac remodeling. The biological mechanisms underlying gender-based differences in EICR are poorly understood and will be an important area of future research.
Arteriovenous Malformations: Syndrome Identification and Vascular Management.
Conway AM, Rosen RJ
Curr Treat Options Cardiovasc Med · 2018 Jul · PMID 30019284 · Publisher ↗
PURPOSE OF REVIEW: Vascular malformations represent a poorly understood set of conditions that create considerable diagnostic and therapeutic confusion. Historically, extensive surgical resections yielded poor results. M...
PURPOSE OF REVIEW: Vascular malformations represent a poorly understood set of conditions that create considerable diagnostic and therapeutic confusion. Historically, extensive surgical resections yielded poor results. More recently, the treatment paradigm has shifted to endovascular therapy such that embolization and sclerotherapy are now considered the first line of treatment. Although there is still a role for traditional surgical techniques, it is now most commonly integrated with endovascular therapies in a hybrid fashion. The goal of this review is to provide a greater understanding of the diagnosis and treatment of vascular malformations. RECENT FINDINGS: Vascular malformations can be high-flow (arteriovenous shunting) or low-flow (venous or lymphatic). Clinical presentation and treatment is different for each. Treatment of high-flow lesions must be directed at reducing or eliminating the nidus, usually via super-selective catheterization and embolization. Low-flow lesions are usually treated by direct injection of sclerosing agents under fluoroscopic or ultrasound guidance. The cornerstone of managing patients with vascular malformations is making the proper diagnosis, which is often challenging. Even after a diagnosis is made, therapy itself may be challenging and generate frustration among patients and providers. Frequently, the treatment of vascular malformations is characterized by only slow and incremental improvements without complete lesion eradication. By combining a thorough understanding of the vascular malformation disease process with an array of endovascular techniques, vascular interventionalists may contribute greatly to the care of these patients.
Iron Deficiency in Heart Failure: to Treat or Not to Treat?
Pope M, Kalra PR
Curr Treat Options Cardiovasc Med · 2018 Jul · PMID 30019227 · Publisher ↗
PURPOSE OF REVIEW: This review will highlight the frequency and prognostic importance of iron deficiency in patients with chronic heart failure. An overview of the evidence surrounding the use of both oral and intravenou...
PURPOSE OF REVIEW: This review will highlight the frequency and prognostic importance of iron deficiency in patients with chronic heart failure. An overview of the evidence surrounding the use of both oral and intravenous iron will be presented together with discussion around what further data are required to establish what is the optimal long-term treatment strategy. RECENT FINDINGS: Several recent randomised controlled studies have suggested that intravenous iron therapy in iron deficient patients with chronic heart failure and reduced ejection fraction can improve symptoms and quality of life, at least in the short term. There is no evidence of benefit from oral iron. Iron deficiency is common in patients with chronic heart failure and is associated with a worse prognosis. Whilst oral iron therapy has been shown to be of no benefit, randomised controlled trials suggest significant improvement in symptoms and quality of life with intravenous iron treatment over 6-12 months. Data are lacking on long-term efficacy, safety and impact on hard outcomes such as death and hospitalisation. Four large trials are currently recruiting patients and will provide definitive answers to these outstanding questions.
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