Early Initiation of Guideline-Directed Medical Therapy for Heart Failure After Cardiac Surgery.

There is an evolving role for guideline-directed medical therapy (GDMT) in managing heart failure with reduced ejection fraction after cardiac surgery. GDMT is based on the use of pharmacologic agents from each of 4 distinct drug classes, also known as the 4 pillars of heart failure therapy: ß-blockers, renin-angiotensin system inhibitors, often paired with neprilysin inhibitors, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors. Despite the demonstrated benefits of GDMT in reducing mortality and hospitalization rates in the nonsurgical literature, there is conspicuous underuse of GDMT after cardiac surgery. The lack of published literature and practical challenges surrounding the timing for initiation of GDMT in the immediate postoperative period has limited standardized implementation strategies. A multidisciplinary approach will be necessary to assist in initiating, titrating, and monitoring the response to these therapies in patients with heart failure with reduced ejection fraction after cardiac surgery.

Predictors of outcomes following catheter-based therapy for acute stroke.

BACKGROUND: Timely reperfusion directly impacts favorable neurologic outcomes in acute ischemic stroke (AIS) patients. Most strokes present outside the 3-4.5 h window for intravenous thrombolysis (IV-tPA). Catheter-based therapy (CBT) is commonly used in patients not eligible for timely IV-tPa, but variables that predict good neurologic outcomes are poorly understood. METHODS: Results of 124 consecutive AIS patients who received CBT at Ochsner Medical Center from 2006 and 2012 are reported. A modified Rankin score (mRs) of ≤ 2 at 90 day post-CBT was used as the primary measurement of a good neurologic outcome. All-cause mortality during the index hospitalization, ≤30 days from treatment, and at 1 year were reported. Results are reported as those treated by Interventional Cardiologists (IC) or by Neurointerventionalists (NI). RESULTS: The mean age was 65 ± 16 years of which 48% (n = 52) were male. The mean NIHSS was 15.0 ± 7.5. Thrombolysis in cerebral infarction (TICI) ≥2 flow was achieved in 80% (n = 100). Good neurologic outcome was observed in 64% (n = 37 of 58) of patients 65 years or younger while in those older than 65, only 36% (n = 24 of 66) had the same outcome (P = 0.002). Mortality at 30 days for the two age groups were 21% (n = 12) vs. 50% (n = 33) (P = <0.001) respectively. A good neurologic outcome at 90 days was seen in 57% of patients with restoration of TICI ≥ 2 flow compared to 17% with TICI < 2 flow (P = <0.001). Those with failed reperfusion (TICI<2 flow) had 30-day mortality rate of 54% (13 of 24) vs. 20% (19 of 97) in those with TICI ≥ 2 flow (P = <0.001). At 90 days, there was no significant differences in patient outcomes between IC (n = 58) and NI (n = 66) treated patients. CONCLUSION: Successful revascularization with CBT leads to a good neurologic outcome in selected stroke patients. Medical co-morbidities and increased age > 65 years contributed to poor outcomes. To support broadening the number of physicians qualified to perform catheter-based stroke interventions, this study demonstrates that IC participating on a stroke team achieve comparable outcomes to NI.

Cardiac resynchronization therapy: history, present status, and future directions.

BACKGROUND: Cardiac resynchronization therapy (CRT) is one of the most exciting recent advancements in heart failure (HF) treatment. METHODS: This review surveys the available literature regarding the effectiveness of CRT in treating patients with HF. RESULTS: By targeting ventricular dyssynchrony, CRT attempts to give the failing heart a mechanical advantage that can substantially improve both symptoms and mortality. CONCLUSION: CRT results in short-term and long-term improvement in cardiac structure and function, often leading to enhanced quality of life and, for some patients, enhanced survival.

Importance and management of chronic sleep apnoea in cardiology.

Sleep apnoea is a common, yet underestimated, chronic disorder with a major impact on morbidity and mortality in the general population. It is quickly becoming recognized as an independent risk factor for cardiovascular impairment. Hypertension, coronary artery disease, diabetes, cardiovascular rhythm and conduction abnormalities, cerebrovascular disease, and heart failure have all been linked to this syndrome. This review will explore the critical connection between sleep apnoea and chronic cardiovascular diseases while highlighting established and emerging diagnostic and treatment strategies.