Post-Capillary Pulmonary Hypertension: Clinical Review.

Pulmonary hypertension (PH) caused by left heart disease, also known as post-capillary PH, is the most common etiology of PH. Left heart disease due to systolic dysfunction or heart failure with preserved ejection fraction, valvular heart disease, and left atrial myopathy due to atrial fibrillation are causes of post-capillary PH. Elevated left-sided filling pressures cause pulmonary venous congestion due to backward transmission of pressures and post-capillary PH. In advanced left-sided heart disease or valvular heart disease, chronic uncontrolled venous congestion may lead to remodeling of the pulmonary arterial system, causing combined pre-capillary and post-capillary PH. The hemodynamic definition of post-capillary PH includes a mean pulmonary arterial pressure > 20 mmHg, pulmonary vascular resistance < 3 Wood units, and pulmonary capillary wedge pressure > 15 mmHg. Echocardiography is important in the identification and management of the underlying cause of post-capillary PH. Management of post-capillary PH is focused on the treatment of the underlying condition. Strategies are geared towards pharmacotherapy and guideline-directed medical therapy for heart failure, surgical or percutaneous management of valvular disorders, and control of modifiable risk factors and comorbid conditions. Referral to centers with advanced heart and pulmonary teams has shown to improve morbidity and mortality. There is emerging interest in the use of targeted agents classically used in pulmonary arterial hypertension, but current data remain limited and conflicting. This review aims to serve as a comprehensive summary of postcapillary PH and its etiologies, pathophysiology, diagnosis, and management, particularly as it pertains to advanced heart failure.

Comparison of very high-power short-duration, high-power short-duration, and low-power long-duration radiofrequency ablation for atrial fibrillation: A systematic review and network meta-analysis.

BACKGROUND: The optimal power and duration settings for radiofrequency (RF) atrial fibrillation (AF) ablation to improve efficacy and safety is unclear. We compared low-power long-duration (LPLD), high-power short-duration (HPSD), and very HPSD (vHPSD) RF settings for AF ablation. METHODS: This network meta-analysis (NMA) was structured according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Medline, Scopus and Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies. Observational and randomized studies were included. Eligible studies compared outcomes in AF patients who underwent first-time RF ablation with the following settings: vHPSD (70-90 W, 3-10 s), HPSD (45-60 W, 5-10 s), or LPLD (20-40 W, 20-60 s). RESULTS: Thirty-six studies comprising 10,375 patients were included (33% female). Frequentist NMA showed LPLD tended toward a lower odds of freedom from arrhythmia (FFA) versus HPSD (OR 0.93, 95% CI 0.86-1.00). There was no difference in FFA between vHPSD versus HPSD. Splitwise interval estimates showed a lower odds of FFA in LPLD versus vHPSD on direct (OR 0.78, 95% CI 0.65-0.93) and network estimates (OR 0.85, 95% CI 0.73-0.98). Frequentist NMA showed less total procedural (TP) time with HPSD versus LPLD (generic variance 1.06, 95% CI 0.83 to 1.29) and no difference between HPSD versus vHPSD. CONCLUSION: This NMA shows improved procedural times in HPSD and vHPSD versus LPLD. Although HPSD tended toward improved odds of FFA compared to LPLD, the overall result was not statistically significant. The odds of FFA in LPLD was lower versus vHPSD on direct and network estimates on splitwise interval analysis. Large prospective head-to-head randomized trials are needed to validate HPSD and vHPSD settings.

Mobile electrocardiographic devices and healthcare utilization in post-atrial fibrillation ablation patients.

BACKGROUND: The use of mobile electrocardiogram (mECG) devices is becoming more prevalent. mECG devices allow instant access to recording arrhythmias and enable automatic rhythm interpretation. Providers can remotely evaluate patients and this may reduce in-person healthcare utilization. We sought to evaluate the utility of mECG devices in reducing healthcare utilization among patients who underwent atrial fibrillation (AF) ablation. METHODS: We identified a population of patients with paroxysmal or persistent AF presenting for their first AF ablation. Patients were divided into two groups: KardiaMobile (AliveCor, Mountain View, CA) mECG users and non-KardiaMobile users. Healthcare utilization was compared between the two groups for one year post-ablation. RESULTS: 184 patients were studied (76 KardiaMobile users, 108 non-KardiaMobile users). There was no difference in the number of office visits (p = 0.59), cardiac-specific emergency department visits (p = 0.26), cardiac-specific hospital admissions (p = 0.13), ablations or cardioversions completed (p = 0.24), telephone encounters (p = 0.05), patient electronic health record messages (p = 0.40), or cardiac imaging (transthoracic or transesophageal echocardiograms) tests ordered (p = 0.36). Exposure to the device was associated with a reduction in ambulatory cardiac monitor use (p = 0.04). There was no difference in sinus rhythm maintenance over 12 months by Kaplan-Meier survival analysis (log rank test p = 0.05) between groups. CONCLUSION: Mobile technology is available for heart rhythm monitoring and can give instant feedback to the user. mECG use is associated with a significant reduction in ambulatory cardiac monitor use in the post-ablation period. There was no difference in other AF-related healthcare utilization.

Review of Cardiovascular Risk of Androgen Deprivation Therapy and the Influence of Race in Men with Prostate Cancer.

Androgen deprivation therapy is the cornerstone of prostate cancer therapy. Recent studies have revealed an association between androgen deprivation therapy and cardiovascular adverse effects such as myocardial infarction and stroke. This review summarizes the available research on the cardiovascular risk of men using androgen deprivation therapy. We also discuss racial disparities surrounding both prostate cancer and cardiovascular disease, emphasizing the importance of biological/molecular and socioeconomic factors in assessing baseline risk in patients beginning androgen ablation. Based on the literature, we provide recommendations for monitoring patients who are at high risk for a cardiovascular adverse event while being treated on androgen deprivation therapy. This review aims to present the current research on androgen deprivation therapy and cardiovascular toxicity with an emphasis on racial disparities and provides a framework for clinicians to decrease the cardiovascular morbidity in men that are being treated with hormone therapy.