Persistent Right Venous Valve: Insights From Multimodality Imaging.

Anatomic variants in the right atrium are under-recognized and under-reported phenomena in cardiac imaging. In the fetus, right atrium serves as a conduit for oxygenated blood to be delivered to the left heart bypassing the right ventricle and the nonfunctional lungs. The anatomy in the fetal right atrium is designed for such purposeful circulation. The right and left venous valves are prominent structures in the fetal heart that direct inferior vena caval flow towards the foramen ovale. These anatomic structures typically regress and the foramen ovale closes after birth. However, the venous valves can persist leading to a range of anatomic, physiological, and pathological consequences in the adult. We describe various presentations of persistent venous valves, focusing on the right venous valve in this illustrated multimodality imaging article.

Increased return of spontaneous circulation at the expense of neurologic outcomes: Is prehospital epinephrine for out-of-hospital cardiac arrest really worth it?

INTRODUCTION: Current guidelines for the management of out-of-hospital cardiac arrest (OHCA) recommend the use of prehospital epinephrine by initial responders. This recommendation was initially based on data from animal models of cardiac arrest and minimal human data, but since its inception, more human data regarding prehospital epinephrine in this setting are now available. Although out-of-hospital return of spontaneous circulation (ROSC) may be higher with the use of epinephrine, worse neurologic outcomes may be associated with its use. METHODS: A systematic review of the literature was conducted by search of databases including PubMed, Embase, and OVID to identify studies comparing patients with OHCA who had received epinephrine before arrival to the hospital with those who had not. Studies were assessed for quality and bias, and data were abstracted from studies deemed appropriate for inclusion. A meta-analysis was conducted using a Mantel-Haenszel model for dichotomous outcomes. Outcomes studied were prehospital ROSC, survival at 1 month, survival to discharge, and positive neurologic outcome. RESULTS: A total of 14 studies with 655853 patients were included for the meta-analysis. The use of epinephrine for OHCA before arrival to the hospital was associated with a significant increase in ROSC (odds ratio, 2.86; P<.001) and a significant increase in the risk of poor neurologic outcome at the time of discharge (odds ratio 0.51, P=.008). There was no significant difference in survival at 1 month or survival to discharge. CONCLUSION: Use of epinephrine before arrival to the hospital for OHCA does not increase survival to discharge but does make it more likely for those who are discharged to have poor neurologic outcome. There is a need for additional randomized controlled trials.

Associations between sleep duration and prevalence of cardiovascular events.

BACKGROUND: Data regarding the associations between sleep duration and clinical cardiovascular (CV) events are limited. We aimed to analyze any associations between self-reported sleep duration and CV events. HYPOTHESIS METHODS: This is a cross-sectional analysis of nationally representative population of noninstitutionalized US civilians recruited in the 2007 to 2008 National Health and Nutrition Examination Survey. This is a questionnaire-based study including only those subjects who answered questions on sleep duration and CV events. The main outcome measures were prevalence of congestive heart failure, myocardial infarction, stroke, coronary artery disease, and angina. RESULTS: After logistic regression analysis, significant associations between sleep duration and prevalence of stroke, myocardial infarction, congestive heart failure, coronary artery disease, and angina were found. There was a statistically significant increase in stroke in those with <6 hours of sleep (odds ratio [OR]: 2.0111, 95% confidence interval [CI]: 1.4356-2.8174), in myocardial infarction in those with <6 hours of sleep (OR: 2.0489, 95% CI: 1.4878-2.8216), in congestive heart failure in those with <6 hours of sleep (OR: 1.6702, 95% CI: 1.1555 to 2.4142), in coronary artery disease in those with >8 hours of sleep (OR: 1.1914, 95% CI: 1.0712-3.4231), and in angina in those with >8 hours of sleep (OR: 2.0717, 95% CI: 1.0497-4.0887). CONCLUSIONS: The results of this cross-sectional analysis suggest that sleep duration may be associated with the prevalence of various CV events.

Preventive aspects in peripheral artery disease.

The prevalence of peripheral artery disease is steadily increasing and is associated with significant morbidity, including a significant percentage of amputations. Peripheral artery disease often goes undiagnosed, making its prevention increasingly important. Patients with peripheral arterial disease are at increased risk of adverse cardiovascular outcomes which makes prevention even more important. Several risk factors have been identified in the pathophysiology of peripheral artery disease which should be modified to decrease risk. Smoking, hyperlipidemia, hypertension, and diabetes are among proven risk factors for the development of peripheral artery disease, thus smoking cessation, lipid control, blood pressure control, and glucose control have been tried and shown to be effective in preventing the morbidity associated with this disease. Pharmacologic agents such as aspirin and clopidogrel alone or in combination have been shown to be effective, though risk of bleeding might be increased with the combination. Anticoagulation use is recommended only for acute embolic cases. Other treatment modalities that have been tried or are under investigation are estrogen replacement, naftidrofuryl, pentoxifylline, hyperbaric oxygen, therapeutic angiogenesis, and advanced glycation inhibitors. The treatment for concomitant vascular diseases does not change in the presence of peripheral artery disease, but aggressive management of risk factors should be undertaken in such cases.

Obstructive sleep apnea and atrial fibrillation: a call for increased awareness and effective management.

Many studies have noted a correlation between obstructive sleep apnea (OSA) and atrial fibrillation (AF). Although there is a need for large randomized control trials, the present data are quite convincing and can be used to improve current treatment procedures. Reviews, randomized control trials, and meta-analyses were obtained using electronic search strategies such as Medline and Cochrane Library. References of electronically obtained studies were then used to conduct hand searches for additional relevant studies. Sources were deemed relevant if they discussed the relationship between AF and OSA in respect to incidence, mechanism, recurrence, or treatment. Selected sources were then stratified on the basis of quality. Correlations between OSA and AF are present, and OSA seems to lend itself to the development, progression, and post-ablation recurrence of AF. Treatment of OSA before ablation can help reduce AF recurrence, allowing for more efficient treatment of AF. It is thus important for physicians to monitor AF patients for OSA and monitor those with OSA for AF.

Short-term outcome comparison of Norwood procedures with right ventricle to pulmonary artery conduit versus modified Blalock-Taussig shunt: A meta-analysis.

A small number of nonrandomized and retrospective studies have compared outcomes of classical Norwood procedures for hypoplasticleft-heart syndrome and single ventricle lesions involving a Blalock-Taussig (BT) shunt to the modified procedure using a right ventricle to pulmonary artery conduit. Some of these studies reported data for the same outcomes and a meta-analysis was done to analyze pooled outcomes comparing in-hospital mortality, interstage mortality, cardiopulmonary bypass time, systolic and diastolic blood pressures 24 h postoperatively, length of intensive care and hospital stay, and need for postoperative extracorporeal membrane oxygenation. Right ventricle to pulmonary artery conduit was associated with an insignificant reduction of in-hospital mortality (odds ratio, 0.674, 95% confidence interval, 0.367 to 1.238), and in the length of hospital stay. There were significant reductions in cardiopulmonary bypass time, length of intensive care unit stay, and need for postoperative extracorporeal membrane oxygenation, postoperative ventilation times, and interstage mortality (odds ratio, 0.191, confidence interval, 0.0620 to 0.587). There was a significant increase in diastolic blood pressure and an insignificant increase in systolic blood pressure 24 h postoperatively. This pooled analysis demonstrates potential advantages associated with the right ventricle to pulmonary artery conduit when compared to the modified BT shunt in palliation and demonstrates the need for large randomized controlled trials that compare a number of outcomes in both procedures.

Prevention of cardiovascular disease utilizing fibrates--a pooled meta-analysis.

Dyslipidemia increases the risk of cardiovascular disease (CVD) risk which is a leading cause of mortality. This creates the need for therapies to effectively manage dyslipidemia to decrease the CVD risk associated with it. This meta-analysis evaluates fibrate therapy in respect to dealing with dyslipidemia and CVD risk. Fibrates significantly reduced plasma total cholesterol by 8% and significantly reduced triglyceride levels by 30%. High density lipoprotein cholesterol levels were raised by 9% with fibrates. All-cause mortality and noncardiovascular mortality were both significantly increased with fibrates but these significant changes no longer appeared after trials using clofibrate were removed from the analysis. There was no significant reduction in fatal myocardial infarction but there was a significant 22% reduction of nonfatal myocardial infarction. Fibrates can effectively reduce low density lipoprotein C (LDL-C) while also optimizing high-density lipoprotein and triglyceride levels as well, which statins do not. Negative effects of fibrates were not significant after clofibrate trials were removed from consideration in the study. It should be noted that gemfibrozil should not be used as well due to its adverse effects.

Hyperglycemia and acute coronary syndrome: a systematic review of hyperglycemia's impact on ACS.

The association between hyperglycemia and increased mortality associated with acute coronary syndrome (ACS) has been studied and affirmed. Although more studies are needed to explore how managing this hyperglycemia can affect ACS mortality, the need to educate regarding current data is urgent so that it can be clinically applied. Reviews, randomized controlled trials, and other studies were obtained by means of electronic search strategies, such as Medline and Cochrane Library, as well as hand selection. Sources selected were limited to those that discussed ACS and hyperglycemia, and specific emphasis was placed on sources that focused on ACS and hyperglycemia in conjunction with one another. Selected studies were then assessed for quality and relevance. Clear correlations between mean and persistent glucose levels and ACS mortality are found. Persistent glucose levels offer a better model to predict ACS mortality than on-admission glucose levels. However, findings concerning the effect on ACS-related mortality of controlling glucose levels have been conflicting.

Statin therapy and aortic stenosis: a systematic review of the effects of statin therapy on aortic stenosis.

Aortic stenosis is a condition that is inflicting an increasing number of the elderly in North America and Europe. Current treatment for aortic stenosis is aortic valve replacement. An expanding pool of knowledge regarding the mechanism of aortic stenosis has led to the testing of statins to reduce the progression of aortic stenosis. Reviews, randomized, controlled trials and other studies pertaining to the topic were searched for using Medline, Cochrane Library, and ScienceDirect. Search terms used were "HMG-CoA reductase inhibitors" and "aortic stenosis." Studies found were then searched for relevant data and ranked using a rating system to determine the validity and quality of the study's results by evaluating the methodology used to include patients, clinical end points examined, and the methodology used to analyze data. Hand searches for referenced studies were also carried out. Studies with relevant results of acceptable quality were then incorporated. Statins have been found to be generally ineffective in delaying the progression of aortic stenosis, although some cohort studies found improvements in valve hemodynamics. Aortic stenosis lesions are characterized by calcific and lipoproteinacous deposits and end-stage aortic stenosis results in valve ossification. Although retrospective and prospective cohort studies show that statins do delay progression of aortic stenosis and improve hemodynamics of the affected valve, randomized, controlled study data do not reinforce these findings. Simvastatin and Ezetimibe in Aortic Stenosis (SEAS), a large randomized, controlled trial, not only found that statins have no significant effect on progression of aortic stenosis, but that statin therapy in those with aortic stenosis may lead to a higher incidence of cancer.

ST elevation myocardial infarction guidelines today: a systematic review exploring updated ACC/AHA STEMI guidelines and their applications.

With new study findings becoming available, the American College of Cardiology (ACC) and the American Heart Association (AHA) have made additions and revisions to their guidelines for treating patients with ST elevation myocardial infarctions (STEMI). It is important for clinicians to be familiar with these changes so that they may be applied and assist in the treatment of patients. Electronic searches on databases such as PubMed, Cochrane Library, and Medline were conducted using specific keywords pertaining to the ACC/AHA guidelines and the specific topics discussed in these guidelines to find randomized controlled trials, meta-analyses, and systematic reviews. Additional studies were then found via hand search for referenced sources. All sources were then stratified on quality and relevance. The ACC/AHA have made several additions and revisions to the 2004 STEMI guidelines. These include recommendations focusing on reperfusion and antithrombotic therapy, ancillary anticoagulation, fibrinolytic therapy, and primary percutaneous intervention (PCI). Goal times for interventions such as fibrinolytic therapy and PCI are also set forth in new guidelines, which stress prompt response to STEMI for better outcomes. Changes deal with all aspects of care such as care provided by emergency medical systems (EMS) en route to the hospital, in-hospital fibrinolysis and PCI, post-hospitalization measures, and secondary prevention. It is of great importance that clinicians who deal with STEMI become familiar with the latest guidelines so that the quality of care they provide is of the highest caliber and that patients experience the highest quality of life after STEMI treatment.

Prevention of coronary heart disease in women.

OBJECTIVE: Coronary heart disease (CHD) mortality is higher in women than in men and misdiagnosis of CHD in women is one of the reasons for this, with differences in the presentation of CHD between men and women being a cause for the misdiagnosis. This review discusses the need for evidence-based guidelines to diagnose and treat CHD in women. METHODS: Reviews, randomized controlled trials, and other studies pertinent to the topic were obtained using electronic search strategies, such as MEDLINE and Cochran Library, as well as manual selection. Sources selected were limited to those that discussed CHD, with specific emphasis placed on sources that focused on CHD in women. Selected studies were then assessed for quality of data and relevance via analysis of the study's methodology, results, and data. Results of selected studies were then stratified using a rating system devised to determine the quality of results using the scientific evidence provided for them. The references of the selected studies were then used to obtain and analyze additional studies in the same manner. RESULTS: Control of lifestyle factors such as smoking, physical activity, diet, and weight are all necessary in women to control CHD, as is the maintenance of healthy lipid levels and blood pressure. Angiotensin-converting enzyme inhibitors and antiplatelets can help aid lifestyle changes in CHD management for women while hormone therapy and vitamin E have no proven benefits in CHD management. CONCLUSIONS: New gender- and evidence-based guidelines for the prevention of CHD in women need to be developed and adopted by physicians so that prevention, diagnosis, and treatment of CHD is made more effective.