Current Treatment Options In Cardiovascular Medicine[JOURNAL]
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200 papers
Virtual Care 2.0-a Vision for the Future of Data-Driven Technology-Enabled Healthcare.
Bhavnani SP, Sitapati AM
Curr Treat Options Cardiovasc Med · 2019 Apr · PMID 30989402 · Publisher ↗
A busy community cardiologist finished reading eight echocardiograms over lunch and started clinic at 1 pm. As three patients waited, "Jane," a 45-year-old graphic designer was seen for "skipped heart beat." She works ab...
A busy community cardiologist finished reading eight echocardiograms over lunch and started clinic at 1 pm. As three patients waited, "Jane," a 45-year-old graphic designer was seen for "skipped heart beat." She works about 50 h a week, exercises at the local gym, and enjoys eating a healthy diet. About 4 months ago Jane began experiencing her heart "skipping beats." She initially attributed the symptoms to long hours in the office and caffeine. But, over the holiday, her brother purchased a smart watch and she began digitally recording her cardiac rhythm. About a month ago, the device detected possible atrial fibrillation, so she called and scheduled this visit for a cardiology consultation. Upon that visitation, she and her physician reviewed the device readings. While it appeared to be an irregular rhythm, before either considered a treatment plan, they began to ask questions ranging from the following: "Is this an accurate diagnosis?" "What other data are available to better understand the risk of a cardiac arrhythmia?" "How is this data analyzed so that the best treatment plan can be made?" "And, what type of clinical decision support system is required to 'virtually' monitor people like me using digital health devices to improve the efficiency and quality of care delivered in population health?"
Treatment of Heart Failure With Preserved Ejection Fraction (HFpEF): the Phenotype-Guided Approach.
Silverman DN, Shah SJ
Curr Treat Options Cardiovasc Med · 2019 Apr · PMID 30982123 · Publisher ↗
The syndrome of heart failure with preserved ejection (HFpEF) continues to rise in prevalence without persuasive evidence of current pharmacologic interventions that can reduce mortality. Clinical trials thus far have ge...
The syndrome of heart failure with preserved ejection (HFpEF) continues to rise in prevalence without persuasive evidence of current pharmacologic interventions that can reduce mortality. Clinical trials thus far have generally enrolled "all-comers" with the clinical syndrome of heart failure and objective evidence of a preserved ejection fraction. However, HFpEF is increasingly understood to be a heterogeneous syndrome likely borne from the interplay of genetic predisposition, lifestyle factors, and high burden of associated comorbidities with each contributing to a variety of incompletely understood pathophysiologic abnormalities. Complicating management further, such abnormalities appear to be present to varying degrees among individual patients. Ongoing studies, along with the use of computational statistics/machine learning, offer the hope of clarifying the pathophysiological substrates giving rise to the syndrome of HFpEF in different patient subsets. With better understanding of the syndrome's underpinnings, there will be the potential for development of truly targeted therapies. However, for now, there is substantial evidence for the use of currently available pharmacologic device and lifestyle therapy for the optimized management of patients. Such therapy can be tailored to presently identifiable patient clusters-called "phenotypes"-distinguished by both the presence of predominant presenting symptoms and/or predominant comorbidity profiles. Examples of clinical presentation phenotypes include lung congestion, chronotropic incompetence, pulmonary hypertension, or skeletal muscle weakness as predominant features. Additionally, such patients may have underlying metabolic syndrome, systemic (arterial) hypertension, renal dysfunction, atrial fibrillation, and/or coronary artery disease as principal underlying comorbidities. Here, we review a "phenotype-guided" approach to the management of patients with HFpEF, based on a stepwise method of making the HFpEF diagnosis, identifying the prominent sources of organ dysfunction, and treating accordingly.
Dual Antiplatelet Therapy: How Long Is Long Enough?
Flannery L, Liu R, Elmariah S
Curr Treat Options Cardiovasc Med · 2019 Mar · PMID 30929096 · Publisher ↗
PURPOSE OF REVIEW: The optimal duration of dual antiplatelet therapy (DAPT) has been a topic of considerable interest in recent years, as the risk of stent thrombosis has decreased with newer generation stents and the im...
PURPOSE OF REVIEW: The optimal duration of dual antiplatelet therapy (DAPT) has been a topic of considerable interest in recent years, as the risk of stent thrombosis has decreased with newer generation stents and the impact of significant bleeding events on clinical outcomes is increasingly apparent. The purpose of this review is to highlight the landmark studies examining short-duration (6 months or less) and extended-duration (greater than 12 months) DAPT as well as provide information about prediction tools to help guide individualized patient treatment decisions. RECENT FINDINGS: Short-duration DAPT is acceptably safe when clinically necessary, though recent trials demonstrate non-significant trends towards increased risk of ischemic events with shorter durations. Extended-duration DAPT clearly confers a reduced risk of subsequent ischemic events but at an increased risk of bleeding. Understanding the perceived ischemic and bleeding risks for each individual patient is paramount in deciding targeted DAPT duration. For patients at a higher bleeding risk with a low ischemic risk, short-duration DAPT (6 months) is acceptable. For patients with continued ischemic risk factors and a low bleeding risk, extended-duration DAPT (up to 30 months) is recommended. The PRECISE DAPT and DAPT prediction tools are helpful in making this determination.
Extended Reality in Medical Practice.
Andrews C, Southworth MK, Silva JNA … +1 more , Silva JR
Curr Treat Options Cardiovasc Med · 2019 Mar · PMID 30929093 · Full text
PURPOSE OF REVIEW: Advances in display technology and computing have led to new devices capable of overlaying digital information onto the physical world or incorporating aspects of the physical world into virtual scenes...
PURPOSE OF REVIEW: Advances in display technology and computing have led to new devices capable of overlaying digital information onto the physical world or incorporating aspects of the physical world into virtual scenes. These combinations of digital and physical environments are referred to as extended realities. Extended reality (XR) devices offer many advantages for medical applications including realistic 3D visualization and touch-free interfaces that can be used in sterile environments. This review introduces extended reality and describes how it can be applied to medical practice. RECENT FINDINGS: The 3D displays of extended reality devices are valuable in situations where spatial information such as patient anatomy and medical instrument position is important. Applications that take advantage of these 3D capabilities include teaching and pre-operative planning. The utility of extended reality during interventional procedures has been demonstrated with through 3D visualizations of patient anatomy, scar visualization, and real-time catheter tracking with touch-free software control. Extended reality devices have been applied to education, pre-procedural planning, and cardiac interventions. These devices excel in settings where traditional devices are difficult to use, such as in the cardiac catheterization lab. New applications of extended reality in cardiology will continue to emerge as the technology improves.
Mitral Annular Calcification and Calcific Mitral Stenosis: Therapeutic Challenges and Considerations.
Bertrand PB, Mihos CG, Yucel E
Curr Treat Options Cardiovasc Med · 2019 Mar · PMID 30929092 · Publisher ↗
PURPOSE OF REVIEW: Mitral annular calcification (MAC) and associated calcific mitral stenosis (MS) are frequent in the aging population, although optimal management remains debated and outcomes are poor. This article sum...
PURPOSE OF REVIEW: Mitral annular calcification (MAC) and associated calcific mitral stenosis (MS) are frequent in the aging population, although optimal management remains debated and outcomes are poor. This article summarizes challenges in the diagnosis and therapy of calcific MS, the indications for valve intervention, procedural concerns, and emerging treatment options. RECENT FINDINGS: Surgical mitral valve replacement is the procedure of choice in symptomatic patients at acceptable surgical risk, with transcatheter mitral valve replacement (TMVR) being evaluated in clinical trials as an alternative for patients at prohibitive surgical risk. Significant challenges exist with the currently available technology and outcomes have been suboptimal. Optimizing the patient-selection process by using multimodality imaging tools has proven to be essential. MAC and calcific MS is an increasingly prevalent, challenging issue with poor outcomes. While surgical valve replacement can be performed in patients with acceptable surgical risk, TMVR can be considered for patients at higher risk. Clinical trials are underway to optimize outcomes. Dedicated device designs and techniques to minimize risk of left ventricular outflow tract obstruction, paravalvular leakage, and device embolization are to be awaited.
Diagnosis and Pathophysiological Mechanisms of Group 3 Hypoxia-Induced Pulmonary Hypertension.
Woo KV, Ornitz DM, Singh GK
Curr Treat Options Cardiovasc Med · 2019 Mar · PMID 30903302 · Publisher ↗
PURPOSE OF REVIEW: Group 3 hypoxia-induced pulmonary hypertension (PH) is an important and increasingly diagnosed condition in both the pediatric and adult population. The majority of pulmonary hypertension studies to da...
PURPOSE OF REVIEW: Group 3 hypoxia-induced pulmonary hypertension (PH) is an important and increasingly diagnosed condition in both the pediatric and adult population. The majority of pulmonary hypertension studies to date and all three classes of drug therapies were designed to focus on group 1 PH. There is a clear unmet medical need for understanding the molecular mechanisms of group 3 PH and a need for novel non-invasive methods of assessing PH in neonates. RECENT FINDINGS: Several growth factors are expressed in patients and in animal models of group 3 PH and are thought to contribute to the pathophysiology of this disease. Here, we review some of the findings on the roles of vascular endothelial growth factor A (VEGFA), platelet-derived growth factor B (PDGFB), transforming growth factor-beta (TGFB1), and fibroblast growth factors (FGF) in PH. Additionally, we discuss novel uses of echocardiographic parameters in assessing right ventricular form and function. FGF2, TGFB, PDGFB, and VEGFA may serve as biomarkers in group 3 PH along with echocardiographic methods to diagnose and follow right ventricle function. FGFs and VEGFs may also function in the pathophysiology of group 3 PH.
Cardiovascular Evaluation of Children With Malignancies.
Akam-Venkata J, Galas J, Aggarwal S
Curr Treat Options Cardiovasc Med · 2019 Mar · PMID 30854598 · Publisher ↗
PURPOSE OF REVIEW: The anthracycline (AC) group of drugs is widely used for cancer chemotherapy and has improved outcomes in many childhood malignancies. However, cardiovascular complications are major causes of morbidit...
PURPOSE OF REVIEW: The anthracycline (AC) group of drugs is widely used for cancer chemotherapy and has improved outcomes in many childhood malignancies. However, cardiovascular complications are major causes of morbidity and mortality in AC recipients, with the greatest risk factor being a higher cumulative dosage. The purpose of this review is to describe the etio-pathogenesis and risk factors of AC induced cardiotoxicity, with emphasis on currently available and emerging modalities of non-invasive imaging in its surveillance, and to review guidelines on its prevention and treatment. RECENT FINDINGS: Presently, ejection fraction and shortening fraction derived from two-dimensional echocardiography are the most widely used parameter for monitoring of cardiac function in childhood cancer survivors. The newer speckle tracking echocardiography has shown potential to detect abnormalities in ventricular function prior to the conventional measures such as ejection fraction and shortening fraction. When available, three-dimensional echocardiography should be used as it allows for more accurate estimation of ejection fraction. Newer magnetic resonance imaging (MRI) techniques, such as delayed enhancement and T1 mapping, are useful adjuncts for cardiac evaluation in cancer survivors, especially in patients with poor echocardiographic windows. Early detection and management of cardiovascular diseases is one of the major goals in the long-term follow-up of childhood cancer survivors. In addition to conventional two-dimensional echocardiography, newer techniques such as speckle tracking echocardiography and three-dimensional echocardiography should be incorporated due to its ability to detect early changes in anthracycline-induced cardiotoxicity. However further research are needed to guide changes in management due to abnormalities in speckle tracking echocardiography.
Advances in Management of Stable Coronary Artery Disease: the Role of Revascularization?
Voudris KV, Kavinsky CJ
Curr Treat Options Cardiovasc Med · 2019 Mar · PMID 30854580 · Publisher ↗
PURPOSE OF REVIEW: Coronary artery disease remains the most common cause of death worldwide. In patients with biomarker-positive acute coronary syndrome, the combination of guideline-directed medical therapy with routine...
PURPOSE OF REVIEW: Coronary artery disease remains the most common cause of death worldwide. In patients with biomarker-positive acute coronary syndrome, the combination of guideline-directed medical therapy with routine revascularization is associated with improved outcomes. However, the role of routine revascularization in stable ischemic heart disease, in addition to medical therapy, remains a matter of debate. In this review, we aimed to describe the role of revascularization in stable ischemic heart disease. RECENT FINDINGS: Revascularization is indicated in patients with stable ischemic heart disease and progressive or refractory symptoms, despite medical management. When guided by ischemia presence, revascularization has failed to show survival benefit, compared with medical therapy alone in multiple clinical trials. On the other hand, revascularization guided by coronary lesion severity, assessed by FFR or iFR, has been shown to offer survival benefit and improvement in symptom severity. PCI-revascularization of unprotected left main disease is feasible with comparable to surgical approach outcomes. Clinical decision to perform revascularization in stable ischemic heart disease necessitates a heart team approach, and no simple algorithm can guide this process. Further studies are required to assess the benefit of routine revascularization, in combination to medical therapy, in this population.
Atherectomy and Specialty Balloons in Percutaneous Coronary Intervention.
Allen DW, Kaul P
Curr Treat Options Cardiovasc Med · 2019 Mar · PMID 30830449 · Publisher ↗
PURPOSE OF REVIEW: Interventional cardiologists are increasingly being called upon to perform complex revascularization in patients who are deemed not to be candidates for surgical revascularization and, until recently,...
PURPOSE OF REVIEW: Interventional cardiologists are increasingly being called upon to perform complex revascularization in patients who are deemed not to be candidates for surgical revascularization and, until recently, many of these patients would have only been offered medical management. Further, changing demographics have resulted in an increasingly elderly and frail population with diabetes and chronic kidney disease being referred for revascularization. Owing to the increasing prevalence of coronary artery calcification and the importance of achieving complete revascularization, advanced tools and techniques are required to safely revascularize this patient population. RECENT FINDINGS: Coronary artery calcification is a marker for increased periprocedural complications and worse long-term outcomes in percutaneous intervention. Its presence may mandate advanced revascularization strategies to facilitate safe revascularization. Several studies have highlighted the importance of intracoronary imaging and there have been iterative changes and new devices that have been developed that can facilitate revascularization in the setting of significant coronary artery calcification. Successful coronary revascularization is increasingly dependent on the rational use of intraavascular imaging, specialized balloons and atherectomy to overcome complex coronary artery disease and calcification. A rational strategy for the safe use of advanced techniques and tools is presented here.
Management of Saphenous Vein Graft Disease in Patients with Prior Coronary Artery Bypass Surgery.
Dianati Maleki N, Ehteshami Afshar A, Parikh PB
Curr Treat Options Cardiovasc Med · 2019 Feb · PMID 30820682 · Publisher ↗
PURPOSE OF REVIEW: In this review, we summarize the pathogenesis of saphenous venous graft (SVG) failure in patients following coronary artery bypass graft (CABG) surgery. We also provide an update on various aspects of...
PURPOSE OF REVIEW: In this review, we summarize the pathogenesis of saphenous venous graft (SVG) failure in patients following coronary artery bypass graft (CABG) surgery. We also provide an update on various aspects of prevention and management of SVG failure. RECENT FINDINGS: Application of perioperative measures and medical therapies to promote SVG patency is crucial to optimize clinical outcomes in patients following CABG. Percutaneous coronary intervention (PCI) of SVG disease is fraught with complications, with the highest risk being no-reflow and periprocedural myocardial infarction due to distal embolization of microemboli. Minimizing this risk with use of distal embolic protection when feasible and understanding the role of adjunctive pharmacotherapies is critical in reducing the risk of adverse cardiac events. The long-term patency of SVGs remains a contemporary challenge and is adversely affected by thrombotic occlusion, intimal fibrosis, and accelerated atherosclerosis. Prevention of SVG failure is multifactorial. Use of perioperative measures, medical therapies, and PCI techniques to promote SVG patency is vital to optimize outcomes in patients following CABG. Further prospective trials are needed to define the optimal medical and surgical therapy to maintain short- and long term SVG patency.
Evaluation and Monitoring of Pulmonary Hypertension in Neonates With Congenital Diaphragmatic Hernia.
Sanchez Mejia AA, Rodgers NJ
Curr Treat Options Cardiovasc Med · 2019 Feb · PMID 30767157 · Publisher ↗
PURPOSE OF REVIEW: This review aims to describe the assessment of pulmonary hypertension and ventricular function in neonates with congenital diaphragmatic hernia and the long-term follow-up of their pulmonary vascular d...
PURPOSE OF REVIEW: This review aims to describe the assessment of pulmonary hypertension and ventricular function in neonates with congenital diaphragmatic hernia and the long-term follow-up of their pulmonary vascular disease. RECENT FINDINGS: In 2015, the pediatric pulmonary hypertension guidelines from the American Heart Association and American Thoracic Society suggested class I level of evidence B guidelines for routine evaluation of patients with congenital diaphragmatic hernia, including longitudinal care in an interdisciplinary pulmonary hypertension program and following the recommendations offered for all children with pulmonary hypertension. Congenital diaphragmatic hernia causes compression of the lungs during critical stages of fetal development and results in lung hypoplasia. As a result, there is abnormal development of pulmonary vasculature that leads to post-natal pulmonary hypertension and increased afterload to the right ventricle. Left ventricular filling is affected by decreased pre-load and mechanical compression by abdominal content leading to decreased systemic perfusion. Persistent pulmonary hypertension after surgical repair of congenital diaphragmatic hernia is associated with increased mortality. Assessment and monitoring of pulmonary hypertension and ventricular function in this population of neonates is crucial to determine response to medical treatment, the need for extracorporeal membrane oxygenation, and the timing of surgical repair.
Comprehensive Evaluation of Right Heart Performance and Pulmonary Hemodynamics in Neonatal Pulmonary Hypertension : Evaluation of cardiopulmonary performance in neonatal pulmonary hypertension.
Bhattacharya S, Sen S, Levy PT … +1 more , Rios DR
Curr Treat Options Cardiovasc Med · 2019 Feb · PMID 30767138 · Full text
PURPOSE OF REVIEW: Pulmonary hypertension is characterized by an elevation of pulmonary artery pressures and prolonged exposure of the right ventricle to high afterload that collectively contribute to morbidity and morta...
PURPOSE OF REVIEW: Pulmonary hypertension is characterized by an elevation of pulmonary artery pressures and prolonged exposure of the right ventricle to high afterload that collectively contribute to morbidity and mortality in both the term and preterm infants. This review summarizes the pathogenesis, etiologies, and hemodynamic profiles of the conditions that result in pulmonary hypertension in neonates. We explore the application of echocardiographic techniques for the assessment of right ventricular performance and pulmonary hemodynamics that enhance and guide the diagnosis and management strategies in neonates. RECENT FINDINGS: Clinical assessments based on the determinants of mean pulmonary artery pressures (pulmonary vascular resistance, pulmonary blood flow, and pulmonary capillary wedge pressure) provide a physiologic approach in determining the acute and chronic etiologies of pulmonary hypertension in neonates. In addition, advances in neonatal echocardiography now afford the capability to obtain quantitative information that often precedes the qualitative information acquired by conventional methods and also provide sensitive markers of right ventricle performance for prognostic information based on the determinants of mean pulmonary artery pressures. Neonatal pulmonary hypertension represents a physiologic spectrum that accounts for the variance in clinical presentation and response to therapies. Physiology-based approaches to etiological identification, coupled with the emerging echocardiographic methods for the assessment of pulmonary hypertension in neonates will likely help to identify cardiovascular compromise earlier, guide therapeutic intervention, monitor therapeutic effectiveness, and improve overall outcome.
Prelude to "Pediatric and Congenital Heart Disease".
Singh GK
Curr Treat Options Cardiovasc Med · 2019 Feb · PMID 30767074 · Publisher ↗
Abstract loading — click title to view on PubMed.
Preterm Birth Is a Novel, Independent Risk Factor for Altered Cardiac Remodeling and Early Heart Failure: Is it Time for a New Cardiomyopathy?
Burchert H, Lewandowski AJ
Curr Treat Options Cardiovasc Med · 2019 Feb · PMID 30762137 · Publisher ↗
PURPOSE OF REVIEW: Around 10% of the global population is born preterm (< 37 weeks' gestation). Preterm birth is associated with an increased risk of cardiovascular events, with preterm-born individuals demonstrating a d...
PURPOSE OF REVIEW: Around 10% of the global population is born preterm (< 37 weeks' gestation). Preterm birth is associated with an increased risk of cardiovascular events, with preterm-born individuals demonstrating a distinct cardiac phenotype. This review aims to summarize the main phenotypic features of the preterm heart and directions for future research to develop novel intervention strategies. RECENT FINDINGS: Being born between 28 and 31 weeks' gestation results in a 4-fold higher risk of heart failure in childhood and adolescence and 17-fold increased risk when born less than 28 weeks' gestation. In support of this being due to a reduction in myocardial functional reserve, preterm-born young adults have an impaired left ventricular cardiac systolic response to moderate and high intensity physiological stress, despite having a preserved resting left ventricular ejection fraction. Similar impairments under physiological stress were also recently reported regarding the right ventricle in young adults born preterm. Preterm birth relates to a unique cardiac phenotype with an impaired response to stress conditions. These data, combined with the work in animal models, suggest that being born preterm may lead to a novel form of cardiomyopathy. Understanding the driving mechanisms leading to this unique cardiac phenotype is important to reduce risk of future heart failure and cardiovascular events.
Renal Artery Denervation for Hypertension.
Ranard LS, Swaminathan RV
Curr Treat Options Cardiovasc Med · 2019 Feb · PMID 30762119 · Publisher ↗
PURPOSE OF REVIEW: Hypertension (HTN) has a growing impact, already affecting over 1 billion people. An estimated 2-16% of those with HTN have resistant HTN. The sympathetic nervous system (SNS) is a recognized contribut...
PURPOSE OF REVIEW: Hypertension (HTN) has a growing impact, already affecting over 1 billion people. An estimated 2-16% of those with HTN have resistant HTN. The sympathetic nervous system (SNS) is a recognized contributor to the pathophysiology of resistant HTN. Current hypertensive pharmacotherapy has not fully targeted the SNS; therefore, the SNS has become a prominent research therapeutic target. This review summarizes the evidence and rationale behind renal denervation (RDN) therapy and the technology available. RECENT FINDINGS: Prior to the SYMPLICITY HTN-3 clinical trial, trials found RDN to be an effective procedure to control resistant hypertension. The failure of SYMPLICITY HTN-3 to meet its primary efficacy endpoint sparked further studies to address potential shortcomings. The subsequent SPYRAL program trials demonstrated efficacy of RDN therapy in a controlled manner; however, they were not adequately powered. Ongoing research is examining new, innovative RDN technology as well as defining appropriate patients to target for treatment. The data currently available for RDN in HTN and other states of SNS activation suffer from potential biases and limitations, highlighting the need for continued exploration. Contemporary studies are more promising and hypothesis-generating. Future trials and continued device innovation will be crucial for understanding the clinical applications of RDN therapy.
Comprehensive Noninvasive Evaluation of Right Ventricle-Pulmonary Circulation Axis in Pediatric Patients with Pulmonary Hypertension.
Jone PN, Ivy DD
Curr Treat Options Cardiovasc Med · 2019 Feb · PMID 30739224 · Publisher ↗
PURPOSE OF REVIEW: The purpose of this review is to detail the advanced echocardiographic studies that evaluated outcomes in pediatric PH using these advanced imaging techniques: (1) right heart size and function (using...
PURPOSE OF REVIEW: The purpose of this review is to detail the advanced echocardiographic studies that evaluated outcomes in pediatric PH using these advanced imaging techniques: (1) right heart size and function (using 2D and 3D echocardiography), (2) myocardial mechanics, and (3) right ventricular (RV) to pulmonary arterial coupling. RECENT FINDINGS: Advanced echocardiographic imaging tools in pediatric PH include RV/left ventricular ratio, 3D echocardiographic assessment of RV volumes and ejection fraction, right atrial and RV strain, and RV-pulmonary arterial coupling ratio that allow for evaluation of clinical outcomes in this patient population. The right atrial to RV axis provides insights to RV diastolic function that has been poorly understood in pediatrics. The RV-pulmonary arterial coupling ratio helps us understand the mechanics of the RV response to afterload. The advanced imaging tools provide clinical outcome evaluation in pediatric PH patients and provide insight into the RA-RV axis and the RV-pulmonary circulatory unit.
Coronary Revascularization in High-Risk Stable Patients With Significant Comorbidities: Challenges in Decision-Making.
Schulman-Marcus J, Peterson K, Banerjee R … +2 more , Samy S, Yager N
Curr Treat Options Cardiovasc Med · 2019 Feb · PMID 30739215 · Publisher ↗
PURPOSE OF REVIEW: There is a growing cohort of complex high-risk patients with stable ischemic heart disease (SIHD) who present for coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI...
PURPOSE OF REVIEW: There is a growing cohort of complex high-risk patients with stable ischemic heart disease (SIHD) who present for coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI). These patients are older, have complex coronary disease, and a substantial comorbidity burden including frailty. The procedural risks and outcomes of CABG and PCI in these patients are more difficult to assess based on the available literature, which has generally studied a younger population with a lower comorbidity burden. RECENT FINDINGS: There have been initiatives to recalibrate and expand risk models derived from procedural registries to inform the care of complex higher-risk patients, including patients "turned down" for CABG. There is greater recognition of the need for improved assessment of risk, quality, and benefits of coronary revascularization in higher-risk SIHD patients with a substantial comorbidity burden. Clinicians and patients should be aware that there are significant evidence gaps regarding revascularization in complex high-risk patients. The limitations of procedural-derived risk scores should be understood when presenting treatment options. Future randomized controlled trials and expanded registries are greatly desired and should be achievable. Meanwhile, a multidisciplinary heart team approach should be employed for proper decision-making.
Revascularization in Cardiogenic Shock and Advanced Heart Failure.
Rahban Y, Davila CD, Natov PS … +1 more , Kapur NK
Curr Treat Options Cardiovasc Med · 2019 Feb · PMID 30729357 · Publisher ↗
PURPOSE OF REVIEW: Ischemic heart disease is the most common cause of heart failure with systolic dysfunction. The progressive course of heart failure characterized by increasing levels of care and worsening quality of l...
PURPOSE OF REVIEW: Ischemic heart disease is the most common cause of heart failure with systolic dysfunction. The progressive course of heart failure characterized by increasing levels of care and worsening quality of life often indicates an advanced stage. Similarly, cardiogenic shock remains a major clinical problem with prohibitively high mortality rates despite major advances in clinical care. Here, we review the current treatment options and available data for revascularization in patients with ischemic cardiomyopathy, advanced heart failure, and cardiogenic shock. We also explore the emerging role of Interventional Heart Failure specialist within the Heart Team. RECENT FINDINGS: Although guideline-directed medical therapy remains the cornerstone treatment strategy for patients with advanced heart failure, coronary revascularization is sometimes indicated. There is a relatively paucity of evidence regarding different revascularization strategies and the use of acute mechanical circulatory support in patients with advanced heart failure and in those presenting with cardiogenic shock. A deep understating of the physiologic and hemodynamic effects of different acute mechanical support platforms is of paramount importance in preparation for revascularization in these patients. The decision regarding revascularization in patients with coronary artery disease in the setting of left ventricular dysfunction remains challenging. Clinical decision-making in these cases requires interdisciplinary discussion and assessment of the potential long-term survival derived from surgical revascularization against its higher perioperative risk.
Antithrombotic Strategies in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention.
Rajagopalan B, Madias C
Curr Treat Options Cardiovasc Med · 2019 Feb · PMID 30729324 · Publisher ↗
PURPOSE OF REVIEW: The choice of appropriate antithrombotic therapy in patients with atrial fibrillation (AF) undergoing percutaneous coronary interventions (PCI) should be approached prudently. Careful consideration is...
PURPOSE OF REVIEW: The choice of appropriate antithrombotic therapy in patients with atrial fibrillation (AF) undergoing percutaneous coronary interventions (PCI) should be approached prudently. Careful consideration is necessary, balancing the ischemic and bleeding risk. Traditionally, triple antithrombotic therapy comprising of aspirin, a P2Y12 inhibitor, and an oral anticoagulant is associated with high bleeding rates. RECENT FINDINGS: Recent trials have evaluated the safety and effectiveness of dual antithrombotic therapy in AF patients undergoing PCI. These studies have shown a significant reduction in bleeding with no increase in ischemic events. Clopidogrel is the preferred P2Y12 agent in the dual antithrombotic regimens. The novel oral anticoagulants (NOAC) rivaroxaban and dabigatran have been evaluated as part of dual antithrombotic therapy and are preferred options for oral anticoagulation in AF patients undergoing PCI. Studies are in progress to evaluate the role of alternate NOACs in this clinical scenario. This review explores the contemporary management of antithrombotic therapy in AF patients undergoing PCI.
Radial Percutaneous Coronary Intervention in Complex Arm and Chest Vasculature: Tips and Tricks.
Parikh DS, Gandhi K, Shroff A
Curr Treat Options Cardiovasc Med · 2019 Jan · PMID 30685799 · Publisher ↗
PURPOSE OF REVIEW: The purpose of this review is to identify the anatomical difficulties an operator may encounter during the transradial approach for cardiac catheterization and to offer tips and tricks to overcome thos...
PURPOSE OF REVIEW: The purpose of this review is to identify the anatomical difficulties an operator may encounter during the transradial approach for cardiac catheterization and to offer tips and tricks to overcome those challenges. RECENT FINDINGS: With increasing implementation of the transradial approach for cardiac catheterization, many new techniques have been utilized to overcome anatomical challenges. This article also discusses the difficulties faced during transradial approach in patients with prior coronary artery bypass grafting (CABG). Numerous large randomized trials have demonstrated the value of the transradial approach over the transfemoral approach during cardiac catheterization. However, this technique is routinely avoided or aborted due to anatomical variations in the upper arm and chest. These obstacles have delayed adoption of transradial access by operators despite the apparent benefits. This article reviews some of the available tips and tricks described in the literature to overcome anatomical obstacles. By implementing some of these tools into practice, an operator may realize improved procedural success, decreased procedure time, and improved patient comfort with the transradial approach.
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