Dewaswala N, Mishra V, Bhopalwala H
… +2 more, Minhas AK, Keshavamurthy S
Int J Angiol
· 2022 Dec · PMID 36588873
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The population of elderly adults is increasing globally. It has been projected that the population of adults aged 65 years will increase by approximately 80% by 2050 in the United States. Similarly, the elderly populatio...The population of elderly adults is increasing globally. It has been projected that the population of adults aged 65 years will increase by approximately 80% by 2050 in the United States. Similarly, the elderly population is rising in other countries; a notable example being Japan where approximately 30% of the population are aged above 65 years. The pathophysiology and management of heart failure (HF) in this age group tend to have more intricacies than in younger age groups owing to the presence of multiple comorbidities. The normal aging biology includes progressive disruption at cellular and genetic levels and changes in molecular signaling and mechanical activities that contribute to myocardial abnormalities. Older adults with HF secondary to ischemic or valvular heart disease may benefit from surgical therapy, valve replacement or repair for valvular heart disease and coronary artery bypass grafting for coronary artery disease. While referring these patients for surgery, patient and family expectations and life expectations should be taken into account. In this review, we will cover the pathophysiology and the management of HF in the elderly, specifically discussing important geriatric domains such as frailty, cognitive impairment, delirium, polypharmacy, and multimorbidity.
Int J Angiol
· 2022 Dec · PMID 36588871
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Elderly patients over the age of ≥ 75 years are especially susceptible to coronary artery disease (CAD) as age is an important nonmodifiable risk factors for atherosclerosis and a predictor of poorer outcomes. In fact, C...Elderly patients over the age of ≥ 75 years are especially susceptible to coronary artery disease (CAD) as age is an important nonmodifiable risk factors for atherosclerosis and a predictor of poorer outcomes. In fact, CAD is a major cause of mortality and morbidity in this population. Due to concerns of functional frailty, comorbidities, and patient preference of conservative to no treatment have played a role in reducing the interest in pursuing prospective studies in this high-risk group. In this review, we provide an overview of the epidemiology, pathophysiology, and management of CAD in older adults.
Int J Angiol
· 2022 Dec · PMID 36588870
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Aortic stenosis is the most common valvular heart disease affecting the elderly. While most patients have a prolonged asymptomatic phase, the development of symptoms ushers in a phase clinical deterioration that often le...Aortic stenosis is the most common valvular heart disease affecting the elderly. While most patients have a prolonged asymptomatic phase, the development of symptoms ushers in a phase clinical deterioration that often leads to sudden death without an intervention. Treatment of aortic stenosis with valve replacement often relieves the symptoms but still leaves behind a remodeled left ventricle which may not recover. Understanding the pathophysiology of aortic stenosis and realizing that the disease process may be a more active biological entity rather than a passive degenerative process will help us prevent it. This review serves to summarize the latest literature on the pathophysiology of aortic stenosis in the elderly.
Int J Angiol
· 2022 Dec · PMID 36588869
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Aortic valvular disease, including aortic stenosis and aortic regurgitation, is increasingly common with age. Due to the aging population, more elderly patients are presenting with aortic valve pathology and expectations...Aortic valvular disease, including aortic stenosis and aortic regurgitation, is increasingly common with age. Due to the aging population, more elderly patients are presenting with aortic valve pathology and expectations for prompt diagnosis and efficacious treatment. The current paradigm for aortic valve disease is based on surgical or interventional therapy. In this review, we discuss the approach to diagnosing aortic valvular disease and the different options for treatment based on the most recent evidence.
Yeisley CD, Tafreshi S, Moirano J
… +2 more, Gandras E, Siegel D
Int J Angiol
· 2022 Dec · PMID 36588867
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Based on observations at angiography, it was hypothesized that angiomyolipomas (AMLs) associated with tuberous sclerosis complex (TSC) have a more robust parasitic blood supply and require more complex embolization invol...Based on observations at angiography, it was hypothesized that angiomyolipomas (AMLs) associated with tuberous sclerosis complex (TSC) have a more robust parasitic blood supply and require more complex embolization involving lower order vessels compared with the non-TSC patients' AMLs. This was a retrospective review of 71 patients who underwent angiography and embolization for renal AML at multiple centers within a single health system. All of the patients with TSC (11/11) were found to have "complex" tumor vascular supply. Of the patients with sporadic AML, 51/60 (85%) had "simple" tumor vascular supply. Sporadic cases with a complex tumor blood supply were larger tumors, with an average size of 11.5 cm. This study supports our hypothesis that AMLs associated with TSC have more complex tumor vascularity compared with sporadic lesions, and aims to better prepare interventionalists to deal with the complex cases.
Int J Angiol
· 2022 Dec · PMID 36588865
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This systematic review and meta-analysis aimed to evaluate patients with acute ST-segment elevation myocardial infarction (STEMI) who were admitted during off-hours and treated with primary angioplasty associated with an...This systematic review and meta-analysis aimed to evaluate patients with acute ST-segment elevation myocardial infarction (STEMI) who were admitted during off-hours and treated with primary angioplasty associated with an increased risk of mortality compared with those admitted during regular working hours. We performed a systematic literature search using PubMed, SCOPUS, Europe PMC, and Cochrane CENTRAL databases that was finalized on March 15, 2021. The primary outcome was mortality comprising early (in-hospital), midterm (30 days to 1 year), and long-term mortality (>1 year). A total of 384,452 patients from 56 studies were included. The overall mortality of acute STEMI patients admitted during off-hours and regular hours were 6.1 and 6.7%, respectively. Patients admitted during off-hours had similar risk of early, midterm, and long-term mortality compared to those admitted during regular working hours ([relative risk or RR = 1.07, 95% confidence interval or CI, 1.00-1.14, = 0.06; = 45%, = 0.0009], [RR = 1.00, 95% CI, 0.95-1.05, = 0.92; = 13%, = 0.26], and [RR = 0.95, 95% CI, 0.86-1.04, = 0.26; = 0%, = 0.76], respectively). Subgroup analyses indicated that the results were consistent across all subgroups ([women vs. men], [age >65 years vs. ≤65 years], and [Killip classification II to IV vs. Killip I]). Funnel plot was asymmetrical. However, Egger's test suggests no significance of small-study effects ( = 0.19). This meta-analysis showed that patients with acute STEMI who were admitted during off-hours and treated with primary angioplasty had similar risk of early, midterm, and long-term mortality compared with those admitted during regular working hours.
Int J Angiol
· 2022 Dec · PMID 36588864
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There is a high prevalence of systemic arterial hypertension in the elderly; 70% of adults >65 years have this disease. A key mechanism in the development of hypertension in the elderly is increased arterial stiffness. T...There is a high prevalence of systemic arterial hypertension in the elderly; 70% of adults >65 years have this disease. A key mechanism in the development of hypertension in the elderly is increased arterial stiffness. This accounts for the increase in systolic blood pressure and pulse pressure and fall in diastolic blood pressure (isolated systolic hypertension) that are commonly seen in the elderly, compared with younger persons. The diagnosis of hypertension is made on the basis of in-office blood pressure measurements together with ambulatory and home blood pressure recordings. Lifestyle changes are the cornerstone of management of hypertension. Comprehensive guidelines regarding blood pressure threshold at which to start pharmacotherapy as well as target blood pressure levels have been issued by both European and American professional bodies. In recent years, there has been considerable interest in intensive lowering of blood pressure in older patients with hypertension. Several large, randomized controlled trials have suggested that a strategy of aiming for a target systolic blood pressure of <120 mm Hg (intensive treatment) rather than a target of <140 mm Hg (standard treatment) results in significant reduction in the incidence of adverse cardiovascular events and total mortality. A systolic blood pressure treatment of <130 mm Hg should be considered favorably in non-institutionalized, ambulatory, free living older patients. In contrast, in the older patient with a high burden of comorbidities and limited life expectancy, an individualized team-based approach, based on clinical judgment and patient preference should be adopted. An increasing body of evidence for older adults with hypertension suggests that intensive blood pressure lowering may prevent or at least partially prevent cognitive decline.
Int J Angiol
· 2022 Dec · PMID 36588863
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Hypertension is a disease common in adults, with many risk factors and potentially life-threatening outcomes. Blood pressure is controlled by receptors that inform the brain about the amount of pressure inside the arteri...Hypertension is a disease common in adults, with many risk factors and potentially life-threatening outcomes. Blood pressure is controlled by receptors that inform the brain about the amount of pressure inside the arteries, and the amount of oxygen and carbon dioxide in the blood, respectively. Research has revealed that baroreflex sensitivity (BRS) decreases with increasing age and that there is a high correlation between hypertension and low BRS. However, various studies with differing results have indicated that high blood pressure is what causes BRS to decline, and vice versa. Several studies have shown very conflicting results on the correlation between chemoreflex and age; there have been indications of chemoreflex having a positive, negative, and zero correlation with age. In several experiments, the surgical removal of the chemoreceptors of hypertensive rats was followed by a decrease in blood pressure. These animal experiments, and an additional noninvasive human experiment in which the chemoreceptors were temporarily "shut off," are reasons why more attention should be given to chemoreceptors as a route of alleviating hypertension.
Zahidin AM, Alkatiri AA, Mangkuanom AS
… +2 more, Iryuza N, Firman D
Int J Angiol
· 2025 Jun · PMID 40365151
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Assessment of relationship between the angiographic stenosis severity and the coronary blood flow is complex. Coronary angiography has many limitations that may impair the judgment of stenosis severity and then affect de...Assessment of relationship between the angiographic stenosis severity and the coronary blood flow is complex. Coronary angiography has many limitations that may impair the judgment of stenosis severity and then affect decision-making regarding intervention. Myocardial perfusion imaging by single-photon emission tomography (MPI-SPECT) is used for a long time to help clinical decisions of interventions, but has limitations, such as issues with identification of extensive coronary artery disease (CAD). Fractional flow reserve (FFR) is a gold standard index for investigating the physiological significance of a coronary stenosis. The instantaneous wave-free ratio (iFR) is a hyperemia-free measurement and easier method to achieve physiological assessment to measure the severity of coronary stenosis. We present a case of multivessel coronary artery disease (MVCAD) patient who was treated with iFR-guided percutaneous coronary intervention (PCI) and emphasize the importance of physiological assessment in PCI. A 63-year-old male with multiple cardiovascular risk factors came to our center with chief complaint of stable angina since 1 year. He underwent MPI-SPECT and the result showed 2.5% of ischemia burden. Coronary angiography showed MVCAD. Surgical conference decided to do PCI. iFR-guided PCI was performed in this case. Our case highlights the importance of iFR as an important cardiology-physiology-based tool as a guide in management decisions for MVCAD. iFR as an alternative approach to physiological study is noninferior compared with FFR-guided PCI.
Junianto I, Zuhri E, Andriantoro H
… +3 more, Indriani S, Siddiq T, Adiarto S
Int J Angiol
· 2025 Jun · PMID 40365153
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May-Thurner syndrome (MTS) is a relatively rare vascular condition that is characterized by external compression of the left common iliac vein by the right common iliac artery against the fifth lumbar vertebra. This cond...May-Thurner syndrome (MTS) is a relatively rare vascular condition that is characterized by external compression of the left common iliac vein by the right common iliac artery against the fifth lumbar vertebra. This condition slows the blood flow and is a predisposing factor for deep vein thrombosis (DVT). The key to its successful treatment is to remove the clot and fix the anatomical lesion. If this MTS diagnosis is missed, the recurrence of thrombosis will lead to significant morbidity and mortality. We report a case of 70-year-old female who had left leg DVT caused by MTS and was treated with catheter-directed thrombolysis along with long-term anticoagulation.
Tohme S, Newman JS, Gasparis C
… +1 more, Manetta F
Int J Angiol
· 2022 Sep · PMID 36157101
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Pulmonary embolism is the third most common cardiovascular syndrome with an estimated up to 25% of patients presenting with sudden death. For those who survive, a mainstay of management for patients with hemodynamic stab...Pulmonary embolism is the third most common cardiovascular syndrome with an estimated up to 25% of patients presenting with sudden death. For those who survive, a mainstay of management for patients with hemodynamic stability is anticoagulation; however, recommendations and options are rapidly changing for patients with submassive or massive pulmonary embolism with hemodynamic instability. Catheter-based and surgical approaches offer efficacious management options for unstable patients or patients with contraindications to anticoagulation; however, both approaches have inherent benefits and risk. This article seeks to offer a brief review on the recommendations and options for management of pulmonary embolism from both surgical and catheter-based perspectives.
Int J Angiol
· 2022 Sep · PMID 36157100
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Pulmonary embolectomy has a chequered history but the quest to surgically treat a patient diagnosed with pulmonary embolism effectively spurred the development of cardiopulmonary bypass and a new dawn for cardiac surgery...Pulmonary embolectomy has a chequered history but the quest to surgically treat a patient diagnosed with pulmonary embolism effectively spurred the development of cardiopulmonary bypass and a new dawn for cardiac surgery. The advent of cardiopulmonary bypass, extracorporeal membrane oxygenation, and computed tomography pulmonary angiogram has allowed rapid diagnosis and made surgical pulmonary embolectomy a relatively safe procedure that should be considered when indicated. Pulmonary emboli in donor lungs, often get rejected for transplantation. Ex vivo lung perfusion is among newly available technology with the ability to not only recondition marginal lungs but also treat donor lung pulmonary embolisms, effectively increasing the donor pool.
Int J Angiol
· 2022 Sep · PMID 36157099
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Pulmonary embolism (PE) is quite common and is associated with significant morbidity and mortality. It is estimated that it is the cause of approximately 100,000 annual deaths in the United States. With great variability...Pulmonary embolism (PE) is quite common and is associated with significant morbidity and mortality. It is estimated that it is the cause of approximately 100,000 annual deaths in the United States. With great variability in presenting symptoms of PE, poor recognition of PE can be fatal. As such, many risk scores have been created to identify the sickest patients. Choosing the appropriate imaging modality is also critical. Invasive pulmonary angiography was once the gold standard to establish the diagnosis. With the advent of nuclear imaging, V/Q scans, invasive angiography has been phased out for diagnosing acute PE. At present, the standard for diagnosis of acute PE is computed tomography pulmonary angiography. In select patient cohorts, nuclear studies remain the modality of choice. Once the diagnosis of acute PE is established, there is a broad spectrum of severity in outcome which has led to substantial focus and development of risk stratification prediction models. We will discuss making the proper diagnosis with contemporary diagnostic tools and risk stratifying patients with PE to receive the correct treatment.
Int J Angiol
· 2022 Sep · PMID 36157098
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Pulmonary embolism remains a leading cause of cardiovascular mortality. Presentation and outcomes are variable among patients and require rapid risk stratification for assessment and prognosis, as well as selection of ap...Pulmonary embolism remains a leading cause of cardiovascular mortality. Presentation and outcomes are variable among patients and require rapid risk stratification for assessment and prognosis, as well as selection of appropriate treatment. Over the past several decades, several different models and parameters have become available to assess risk and classify pulmonary embolism into different risk categories. Some patients may be candidates for early discharge or complete outpatient treatment, while some may require invasive diagnostics and intensive monitoring. In this review, we summarize contemporary guidelines and methods for classification and risk stratification in an effort to provide tools for physicians to use in their management of patients with acute pulmonary embolisms.
Int J Angiol
· 2022 Sep · PMID 36157097
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Pulmonary embolism is a potentially lethal manifestation of venous thromboembolic disease. It is one of the three main causes of cardiovascular morbidity and mortality in developed countries. Over the years, better diagn...Pulmonary embolism is a potentially lethal manifestation of venous thromboembolic disease. It is one of the three main causes of cardiovascular morbidity and mortality in developed countries. Over the years, better diagnostic and risk stratification measures were implemented. A generous range of new treatment options is becoming available, particularly for management of massive pulmonary embolism. Nonetheless, clinicians often face uncertainty in clinical practice due to lack of scientific support for available treatment options. The aim of this article is to review management of massive pulmonary embolism.
Kerrigan J, Morse M, Haddad E
… +2 more, Willers E, Ramaiah C
Int J Angiol
· 2022 Sep · PMID 36157096
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Acute pulmonary embolism (PE) is a leading cause of morbidity and mortality worldwide. Systemic anticoagulation remains the recommended treatment for low-risk PE. Systemic thrombolysis is the recommended treatment for PE...Acute pulmonary embolism (PE) is a leading cause of morbidity and mortality worldwide. Systemic anticoagulation remains the recommended treatment for low-risk PE. Systemic thrombolysis is the recommended treatment for PE with hemodynamic compromise (massive/high-risk PE). A significant number of patients are not candidates for systemic thrombolysis due to the bleeding risk associated with thrombolytics. Historically, surgical pulmonary embolectomy (SPE) was recommended for massive PE with hemodynamic compromise for these patients. In the last decade, catheter-directed thrombolysis (CDT) has largely replaced SPE in the patient population with intermediate risk PE (submassive), defined as right heart strain (as evidenced by right ventricle enlargement on echocardiogram and/or computed tomography, usually along with elevation of troponin or B-type natriuretic peptide). Use of CDT increased in the last few years due to high incidence of PE in hospitalized patients with coronavirus disease 2019 pneumonia, and the use of mechanical thrombectomy (initially reserved for those with contraindications to thrombolysis) has also grown. In this article, we discuss the value of the PE response team, our approach to management of submassive (intermediate risk) and massive (high risk) PE with systemic thrombolytics, CDT, mechanical thrombectomy, and surgical embolectomy.
Int J Angiol
· 2022 Sep · PMID 36157095
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The pulmonary embolism response team (PERT) is an institutionally based multidisciplinary team that is able to rapidly assess and provide treatment for patients with acute pulmonary embolism (PE). Intrinsic to the team's...The pulmonary embolism response team (PERT) is an institutionally based multidisciplinary team that is able to rapidly assess and provide treatment for patients with acute pulmonary embolism (PE). Intrinsic to the team's structure is a formal mechanism to execute a full range of medical, endovascular, and surgical therapies. In addition, the PERT provides appropriate multidisciplinary follow-up of patients. In the 10 years since the PERT was first introduced, it has gained acceptance in many centers in the United States and around the world. These PERTs have joined together to form an international association, called the PERT Consortium. The mission of this consortium is to advance the diagnosis, treatment, and outcomes of patients with PE. There is considerable evidence that the PERT model improves delivery and standardization of care of PE patients, particularly those patients with massive and submassive PE. However, it is not yet clear whether PERTs improve clinical outcomes. A large prospective database is currently being compiled by the PERT Consortium. Analysis of this database will likely further delineate the role of PERTs in the management of intermediate-to-high risk PE patients and, importantly, help determine in which PE patients PERT may improve clinical outcomes.
Int J Angiol
· 2022 Sep · PMID 36157094
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Heart failure with preserved ejection fraction (HFpEF) encompasses nearly half of heart failure (HF) worldwide, and still remains a poor prognostic indicator. It commonly coexists in patients with vascular disease and ne...Heart failure with preserved ejection fraction (HFpEF) encompasses nearly half of heart failure (HF) worldwide, and still remains a poor prognostic indicator. It commonly coexists in patients with vascular disease and needs to be recognized and managed appropriately to reduce morbidity and mortality. Due to the heterogeneity of HFpEF as a disease process, targeted pharmacotherapy to this date has not shown a survival benefit among this population. This article serves as a comprehensive historical review focusing on the management of HFpEF by reviewing past, present, and future randomized controlled trials that attempt to uncover a therapeutic value. With a paradigm shift in the pathophysiology of HFpEF as an inflammatory, neurohormonal, and interstitial process, a phenotypic approach has increased in popularity focusing on the treatment of HFpEF as a systemic disease. This article also addresses common comorbidities associated with HFpEF as well as current and ongoing clinical trials looking to further elucidate such links.
Int J Angiol
· 2022 Sep · PMID 36157093
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Pulmonary embolus (PE) is defined as obstruction of the pulmonary artery or one of its branches by material (e.g., thrombus, tumor, air, or fat) but most commonly due to thrombus originating from the lower extremity deep...Pulmonary embolus (PE) is defined as obstruction of the pulmonary artery or one of its branches by material (e.g., thrombus, tumor, air, or fat) but most commonly due to thrombus originating from the lower extremity deep veins. We reviewed the current literature describing the optimal medical treatment and management of PE. Databases (PubMed, the Cochrane Library, Embase, EBSCO, Web of Science, and CINAHL) were searched for relevant studies and guidelines for management of patients with PE. The initial approach to patients with suspected PE should focus upon stabilizing the patient while further workup for risk stratification is in progress. In most cases, anticoagulation should ideally be started even prior to confirming PE, if risk-benefit regarding suspicion of PE and bleeding risk is favorable. Once the diagnosis is confirmed, risk stratification will guide further therapies consisting of anticoagulation, thrombolysis, or catheter-directed interventions. Data for initial, long-term, and indefinite anticoagulation, and factors that determine whether or not a patient can be treated in the outpatient setting, are reviewed and discussed.
Int J Angiol
· 2022 Sep · PMID 36157092
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Pulmonary embolism (PE) is one of the most common etiologies of cardiovascular mortality. It could be linked to several risk factors including advanced age. The pathogenesis of PE is dictated by the Virchow's triad that...Pulmonary embolism (PE) is one of the most common etiologies of cardiovascular mortality. It could be linked to several risk factors including advanced age. The pathogenesis of PE is dictated by the Virchow's triad that includes venous stasis, endothelial injury, and a hypercoagulable state. The diagnosis of PE is difficult and is often missed due to the nonspecific symptomatology. Hypoxia is common in the setting of PE, and the degree of respiratory compromise is multifactorial and influenced by underlying cardiac function, clot location, and ability to compensate with respiratory mechanics. Right ventricular dysfunction/failure is the more profound cardiovascular impact of acute PE and occurs due to sudden increase in afterload. This is also the primary cause of death in PE. High clinical suspicion is required in those with risk factors and presenting signs or symptoms of venous thromboembolic disease, with validated clinical risk scores such as the Wells, Geneva, and pulmonary embolism rule out criteria in estimating the likelihood for PE. Advancement in capture time and wider availability of computed tomographic pulmonary angiography and D-dimer testing have further facilitated the rapid evaluation and diagnosis of suspected PE. Treatment is dependent on clinical presentation and initially involves providing adequate oxygenation and stabilizing hemodynamics. Anticoagulant therapy is indicated for the treatment of PE. Treatment is guided by presence or absence of shock and ranges from therapeutic anticoagulation to pharmacologic versus mechanical thrombectomy. The prognosis of patients can vary considerably depending on the cardiac and pulmonary status of patient and the size of the embolus.