Age matters: association between age and depression severity at the time of OSA diagnosis and PAP adherence in adult patients.

STUDY OBJECTIVES: Numerous studies have shown an association and symptom overlaps between obstructive sleep apnea (OSA) and depression. However, data are limited on the association between age, sex, the severity of depression at the time of OSA diagnosis, and its impact on positive airway pressure (PAP) adherence. The Patient Health Questionnaire (PHQ-9) is a validated depression screening and severity scoring tool recommended by the Diagnostic and Statistical Manual of Mental Disorders (fifth edition). In this retrospective observational study, we evaluate the interrelationship between age at OSA diagnosis, depression severity, and PAP adherence. METHODS: Patients with new OSA diagnosis, seen at the University of California San Francisco-Fresno Sleep Center between February and October of 2022, were evaluated. PHQ-9 scores for depression severity uses a 1 to 5 scale (1 = none, 2 = mild, 3 = moderate, 4 moderately severe, 5 = severe). The PHQ-9 was administered at the time of OSA diagnosis and follow-up. Average daily PAP usage hours were obtained from PAP devices between 1 to 3 months after therapy initiation. IBM SPSS version 29.0.0 was used to calculate descriptive statistics, Pearson correlation, and Mann-Whitney test. RESULTS: Seventy-seven patients fit the inclusion criteria, of which 28 were women (36.4%). The average baseline apnea-hypopnea index was 34.5 (standard deviation 31.8), with a PHQ-9 mean of 8.3 with standard deviation ± 5.9. A Mann-Whitney comparison between the group with normal PHQ-9 scores and the group with PHQ-9 scores consistent with depression (score of 5 or greater) showed no statistically significant differences in apnea-hypopnea index (P = .470) or average night hour use (P = .195). There was a statistically significant difference in age between both groups (P = .031). Spearman correlation confirmed a negative, statistically significant correlation between PHQ-9 scores and age in patients with OSA. CONCLUSIONS: This study showed that PHQ-9 scores at the time of OSA diagnosis are moderately correlated with younger age, with those patients younger than 50 years old having more moderate to severe depression scores than older patients. We did not find a correlation between age and PAP adherence or between PHQ-9 scores and PAP adherence. Our findings can help identify high-risk depression patients early in the diagnosis of OSA and bring awareness that the young adult population can be particularly vulnerable. CITATION: Niraula R, Singh A, DelRosso LM, Meghpara S, Keenan L. Age matters: association between age and depression severity at the time of OSA diagnosis and PAP adherence in adult patients. J Clin Sleep Med. 2024;20(6):859-862.

Coronary flow abnormalities in chronic kidney disease: A systematic review and meta-analysis.

BACKGROUND: Coronary vasomotion abnormalities have been described in small studies but not studied systematically. We aimed to review the present literature and analyze it to improve our understanding of chronic kidney disease (CKD) related-coronary microvascular dysfunction. OBJECTIVE: Coronary flow reserve (CFR) is a well-known measure of coronary vasomotion. We aimed to assess the difference in CFR among participants with and without CKD. METHODS: PubMed, Embase, and Cochrane CENTRAL were systematically reviewed to identify studies that compared CFR in participants with and without CKD. We estimated standardized mean differences in mean CFR reported in these studies. We performed subgroup analyses according to imaging modality, and the presence of significant epicardial coronary artery disease. RESULTS: In 14 observational studies with 5966 and 1410 patients with and without CKD, the mean estimated glomerular filtration rate (eGFR) was 29 ± 04 and 87 ± 25 ml/min/1.73 m2 , respectively. Mean CFR was consistently lower in patients with CKD in all studies and the cumulative mean difference was statistically significant (2.1 ± .3 vs. 2.7 ± .5, standardized mean difference -.8, 95% CI -1.1, -.6, p < .05). The lower mean CFR was driven by both significantly higher mean resting flow velocity (.58 cm/s, 95% CI .17, .98) and lower mean stress flow velocity (-.94 cm/s, 95% CI -1.75, -.13) in studies with CKD. This difference remained significant across diagnostic modalities and even in absence of epicardial coronary artery disease. In meta-regression, there was a significant positive relationship between mean eGFR and mean CFR (p < .05). CONCLUSION: Patients with CKD have a significantly lower CFR versus those without CKD, even in absence of epicardial coronary artery disease. There is a linear association between eGFR and CFR. Future studies are required to understand the mechanisms and therapeutic implications of these findings. KEY POINTS: In this meta-analysis of observational studies, there was a significant reduction in coronary flow reserve in studies with chronic kidney disease versus those without. This difference was seen even in absence of epicardial coronary artery disease. In meta-regression, a lower estimate glomerular filtration rate was a significant predictor of lower coronary flow reserve. Coronary microvascular dysfunction, rather than atherosclerosis-related epicardial disease may underly increase cardiovascular risk in a patient with chronic kidney disease.

Modeling the Cost and Health Impacts of Diagnostic Strategies in Patients with Suspected Transthyretin Cardiac Amyloidosis.

Background Transthyretin cardiac amyloidosis (ATTR-CMP) is an increasingly recognized and treatable cause of heart failure with preserved ejection fraction. Multimodality cardiac imaging is recommended for ATTR-CMP diagnosis, but its cost-effectiveness in current clinical practice has not been well studied. Methods and Results Using a microsimulation model, we compared the cost-effectiveness of a combination of strategies involving 99mtechnetium pyrophosphate (PYP), cardiac magnetic resonance imaging, and endomyocardial biopsy for the diagnosis of ATTR-CMP. We developed a decision analytic model to project health care costs and lifetime quality-adjusted life years for symptomatic, older patients who present with congestive heart failure, with an increased left ventricular wall thickness and a 13% prevalence of ATTR-CMP. Rates of clinical events, costs, and quality-of-life values were estimated from published literature. The analysis was conducted from a US health care system perspective with health and cost outcomes discounted annually at 3%. In the base-case scenario, using a fixed tafamidis price of $16 000 annually (previously identified cost-effective price), total health care costs per person were lowest for the PYP-only strategy ($209 415) and highest for endomyocardial biopsy strategy ($215 881). Of the 7 strategies examined, the PYP-only strategy had the highest net monetary benefit using a willingness-to-pay threshold of $100 000/quality-adjusted life year. Results were sensitive to variations in model inputs for PYP and cardiac magnetic resonance imaging specificity, cost of tafamidis, and willingness-to-pay thresholds. Conclusions Our model-based analyses showed that a PYP-only strategy to diagnose ATTR-CMP is the most cost-effective strategy, at willingness-to-pay threshold of $100 000/quality-adjusted life year. At higher threshold ($150 000/quality-adjusted life year), sequential tests involving PYP and cardiac magnetic resonance imaging may be considered cost effective.

Paget-Schroetter Syndrome (PSS) and Adjunctive Treatment With Mechanical Aspiration Thrombectomy and Catheter Directed Thrombolysis: A Case Report and Review of Literature.

Paget-Schroetter syndrome, also known as venous thoracic outlet syndrome, is primarily an effort-induced thrombosis of the subclavian and axillary veins. Treatment modalities involve systemic anticoagulation, catheter-directed thrombolysis (CDT), and surgical decompression. Early endovascular intervention is noted to improve outcomes and result in symptomatic relief. Here we implore the usage of the novel mechanical aspiration thrombectomy device as an adjunct to CDT for the management of peripheral venous thrombosis and highlight it as a treatment option resulting in substantial radiological and symptomatic improvement.

Marijuana Use and Stress Cardiomyopathy in the Young.

Background Increased accessibility, recreational use, and regional legalization of marijuana (cannabis) have been paralleled by widespread recognition of its serious cardiovascular complications (acute myocardial infarction, stroke, sudden death) particularly in the young. We aimed to examine trends in hospital admissions and outcomes of adults with stress cardiomyopathy (SC) in temporal relation to marijuana use. Methods and results A search of the 2003-2011 Nationwide Inpatient Sample (NIIS) database identified 33,343 admissions for SC of which 210 (0.06%) were temporally related to marijuana use. Demographics, clinical characteristics, and outcomes of marijuana users (MU) and non-marijuana users (NMU) with SC were compared. MU were younger (44±14 vs. 66±13 years), more often male (36% vs. 8%), and had lower prevalence of hypertension (38% vs. 62%), diabetes (2.4% vs. 17.6%), and hyperlipidemia (16% vs. 52%) while more often suffered from depression (33% vs. 15%), psychosis (12% vs. 4%), anxiety disorder (28% vs. 16%), alcohol use disorder (13% vs. 3%), tobacco use (73% vs. 29%), and polysubstance abuse (11% vs. 0.3%) [all p<0.001]. In addition, MU more often suffered a cardiac arrest and required placement of a defibrillator while congestive heart failure was more frequent in NMU. Logistic regression analysis on the entire database (n=71,753,900), adjusted for known risk factors for SC, identified marijuana use as an independent predictor of SC (OR=1.83; 95% CI=1.57-2.12, p<0.0001). Among MU, older age (>48 years) was a strong predictor of any major adverse cardiac event (OR=7.8; 95% CI=2.88-21.13; p<0.0001). Conclusions Marijuana use is linked to SC in younger individuals and is associated with significant morbidity despite being younger in age and having a more favorable cardiac risk factor profile in affected individuals.

Treatment Considerations for Obstructive Sleep Apnea in Pediatric Down Syndrome.

Children with Down syndrome (DS) are at high risk for developing obstructive sleep apnea (OSA) compared to children without DS. The negative impact of OSA on health, behavior, and cognitive development in children with DS highlights the importance of timely and effective treatment. Due to the higher prevalence of craniofacial and airway abnormalities, obesity, and hypotonia in patients with DS, residual OSA can still occur after exhausting first-line options. While treatment commonly includes adenotonsillectomy (AT) and continuous positive airway pressure (CPAP) therapy, additional therapy such as medical management and/or adjuvant surgical procedures need to be considered in refractory OSA. Given the significant comorbidities secondary to untreated OSA in children with DS, such as cardiovascular and neurobehavioral consequences, more robust randomized trials in this patient population are needed to produce treatment guidelines separate from those for the general pediatric population of otherwise healthy children with OSA. Further studies are also needed to look at desensitization and optimization of CPAP use in patients with DS and OSA.

Evaluation of Shear Peel Bond Strength of Different Adhesive Cements Used for Fixed Space Maintainer Cementation: An In Vitro Study.

AIM AND OBJECTIVE: This study aims to compare the retentive strength of different adhesive cements used for band cementation of fixed space maintainer by comparing the shear peel bond strength and mode of failure for each adhesive material using three different adhesive cements. MATERIALS AND METHODS: Eighty intact extracted teeth were used to assess the shear peel bond strength. Preformed bands were adapted to each tooth. Three cements compared in this in vitro study are glass ionomer cement [Ketac Cem radiopaque (3M ESPE)], resin-modified glass ionomer cement [RelyX luting 2(3M ESPE)], and self-adhesive resin cement [RelyX U200 (3M ESPE)]. The teeth were randomly divided to four groups of 20 samples each. All samples were stored at 37°C for 24 hours before testing. All specimens were tested in a tensile mode using a universal testing machine to determine shear peel bond. After debonding procedure, each specimen was visually assessed at the site of cement. RESULTS: The results of our study showed that the greatest resistance to decementation was shown by self-adhesive resin cement (256.85 N) followed by resin-modified GIC (165.40 N) and GIC (127.40 N) (p < 0.001). Self-adhesive resin cement has the greatest shear peel bond strength (2.36 MPa) followed by resin-modified GIC (1.53 MPa), conventional GIC (1.22 MPa), and bands without cementation (0.29 MPa) (p < 0.001). In terms of adhesive remnant index (ARI) scores, it was seen that the decementation of bands of both conventional GIC and self-adhesive resin cements occurred at the band/enamel interface. However, resin-modified GIC showed varied results in the ARI scores. CONCLUSION: The findings of our study suggest that self-adhesive resin cements can be used for cementation of bands of fixed space maintainers. However, further research with short-term and long-term data is required to evaluate the ability of these cements for its application in vivo. HOW TO CITE THIS ARTICLE: Kaur J, Singh A, Sadana G, et al. Evaluation of Shear Peel Bond Strength of Different Adhesive Cements Used for Fixed Space Maintainer Cementation: An In Vitro Study. Int J Clin Pediatr Dent 2021;14(2):175-179.

Research article expression of surfactant protein-A and D, and CD9 in lungs of 1 and 30 day old foals.

BACKGROUND: Respiratory diseases are a major cause of morbidity and mortality in the horses of all ages including foals. There is limited understanding of the expression of immune molecules such as tetraspanins and surfactant proteins (SP) and the regulation of the immune responses in the lungs of the foals. Therefore, the expression of CD9, SP-A and SP-D in foal lungs was examined. RESULTS: Lungs from one day old (n = 6) and 30 days old (n = 5) foals were examined for the expression of CD9, SP-A, and SP-D with immunohistology and Western blots. Western blot data showed significant increase in the amount of CD9 protein (p = 0.0397) but not of SP-A and SP-D at 30 days of age compared to one day. Immunohistology detected CD9 in the alveolar septa and vascular endothelium but not the bronchiolar epithelium in the lungs of the foals in both age groups. SP-A and SP-D expression was localized throughout the alveolar septa including type II alveolar epithelial cells and the vascular endothelium of the lungs in all the foals. Compared to one day old foals, the expression of SP-A and SP-D appeared to be increased in the bronchiolar epithelium of 30 day old foals. Pulmonary intravascular macrophages were also positive for SP-A and SP-D in 30 days old foals and these cells are not developed in the day old foals. CONCLUSIONS: This is the first data on the expression of CD9, SP-A and SP-D in the lungs of foals.

Multimodality Imaging Assessment of Myocardial Fibrosis.

Myocardial fibrosis, seen in ischemic and nonischemic cardiomyopathies, is associated with adverse cardiac outcomes. Noninvasive imaging plays a key role in early identification and quantification of myocardial fibrosis with the use of an expanding array of techniques including cardiac magnetic resonance, computed tomography, and nuclear imaging. This review discusses currently available noninvasive imaging techniques, provides insights into their strengths and limitations, and examines novel developments that will affect the future of noninvasive imaging of myocardial fibrosis.

Statin-Induced Triad of Autoimmune Myocarditis, Myositis, and Transaminitis.

Despite well-established cardiovascular benefits, statins have been associated with myopathic side effects ranging from myalgias to rhabdomyolysis and autoimmune necrotizing myositis. Statins have not been previously shown to cause myocarditis. Our case highlights this rare entity.

Native valve emphysematous enterococcal endocarditis: expanding the differential diagnosis.

INTRODUCTION: Emphysematous endocarditis is caused by the gas-forming organisms Citrobacter koseri, Escherichia coli, Clostridium species, and Finegoldia magna. We report the first case of emphysematous endocarditis caused by Enterococcus faecalis. CASE REPORT: An 82-year-old man presented with fever and rapidly progressive shortness of breath. He was found to be in atrial fibrillation with rapid ventricular rates. Two-dimensional transthoracic echocardiography demonstrated severe mitral regurgitation. Subsequent two- and three-dimensional transesophageal echocardiogram revealed a large, highly mobile vegetation on the atrial surface of the anterior mitral leaflet with aneurysmal destruction of the lateral scallop requiring mitral valve replacement. Sequencing of the vegetation revealed Enterococcus faecalis, an anaerobic gram-positive coccus that, in rare cases, produces gas using a heme-dependent catalase. Histopathological analysis of the infected valve suggested interstitial gas accumulation, leading to the diagnosis of emphysematous endocarditis. CONCLUSIONS: E. faecalis-associated emphysematous endocarditis should be included in the differential diagnosis of valvular vegetation in patients with a rapidly progressing clinical course. When possible, histopathological analysis should be used alongside other imaging techniques to confirm the diagnosis of emphysematous endocarditis. This case also highlights the importance of collecting blood cultures prior to initiating antibiotic treatment.

Niacinamide May Be Associated with Improved Outcomes in COVID-19-Related Acute Kidney Injury: An Observational Study.

Background: AKI is a significant complication of coronavirus disease 2019 (COVID-19), with no effective therapy. Niacinamide, a vitamin B3 analogue, has some evidence of efficacy in non-COVID-19-related AKI. The objective of this study is to evaluate the association between niacinamide therapy and outcomes in patients with COVID-19-related AKI. Methods: We implemented a quasi-experimental design with nonrandom, prospective allocation of niacinamide in 201 hospitalized adult patients, excluding those with baseline eGFR <15 ml/min per 1.73 m2 on or off dialysis, with COVID-19-related AKI by Kidney Disease Improving Global Outcomes (KDIGO) criteria, in two hospitals with identical COVID-19 care algorithms, one of which additionally implemented treatment with niacinamide for COVID-19-related AKI. Patients on the niacinamide protocol (B3 patients) were compared against patients at the same institution before protocol commencement and contemporaneous patients at the non-niacinamide hospital (collectively, non-B3 patients). The primary outcome was a composite of death or RRT. Results: A total of 38 out of 90 B3 patients and 62 out of 111 non-B3 patients died or received RRT. Using multivariable Cox proportional hazard modeling, niacinamide was associated with a lower risk of RRT or death (HR, 0.64; 95% CI, 0.40 to 1.00; P=0.05), an association driven by patients with KDIGO stage-2/3 AKI (HR, 0.29; 95% CI, 0.13 to 0.65; P=0.03; P interaction with KDIGO stage=0.03). Total mortality also followed this pattern (HR, 0.17; 95% CI, 0.05 to 0.52; in patients with KDIGO stage-2/3 AKI, P=0.002). Serum creatinine after AKI increased by 0.20 (SEM, 0.08) mg/dl per day among non-B3 patients with KDIGO stage-2/3 AKI, but was stable among comparable B3 patients (+0.01 [SEM, 0.06] mg/dl per day; P interaction=0.03). Conclusions: Niacinamide was associated with lower risk of RRT/death and improved creatinine trajectory among patients with severe COVID-19-related AKI. Larger randomized studies are necessary to establish a causal relationship.

Stress cardiomyopathy induced during dobutamine stress echocardiography.

BACKGROUND: Catecholamines play a central role in pathogenesis of stress cardiomyopathy (SC). We aimed to review the clinical characteristics, procedural details and outcomes of patients with SC during dobutamine stress echocardiography (DSE). METHODS/RESULTS: A total of 20 adults [age 64±15 years, 80% women, 67% hypertension, 20% diabetes, 33% hypercholesterolemia, 19% chronic kidney disease, 13% known anxiety disorder] with SC during DSE were identified from local digital archives of our laboratory (n=3) or reports in English literature (n=17). Indication for DSE was suspected coronary artery disease (CAD) in all patients. Left ventricular (LV) ejection fraction was normal at baseline. SC developed at a blood pressure of 154±47/86±24 mmHg, heart rate of 130±17 bpm (88±10% predicted maximum) and peak rate-pressure product of 20559±3898 mmHg*bpm. ST segment elevation was seen in 65%. SC occurred at peak dobutamine infusion rate of 38±6 µg/kg/min in 85% and during recovery in 15%. Atropine [0.7±0.6 (0.25-2) mg] was given to 7 patients. LV ejection fraction dropped to 30±6% with apical (40%), apical and mid (45%) or basal and mid (10%) circumferential LV ballooning. One patient (5%) had a mixed pattern of wall motion abnormality. LV outflow tract obstruction developed in 15%. Major adverse cardiac events occurred in 7 (35%) and included death (n=1), congestive heart failure (n=2), hypotension (n=3) and atrial fibrillation with heart failure (n=1). At a mean follow up duration of 19±19 days, complete or partial recovery of LV wall motion abnormality was seen in 18 and 1 patient, respectively. CONCLUSION: SC uncommonly occurs during DSE. However, death and other adverse events (hypotension, heart failure and atrial fibrillation) may occur and require urgent attention. Once managed, complete recovery is expected in most patients.

Outcomes of COVID-19 in Patients With a History of Cancer and Comorbid Cardiovascular Disease.

BACKGROUND: Cancer and cardiovascular disease (CVD) are independently associated with adverse outcomes in patients with COVID-19. However, outcomes in patients with COVID-19 with both cancer and comorbid CVD are unknown. METHODS: This retrospective study included 2,476 patients who tested positive for SARS-CoV-2 at 4 Massachusetts hospitals between March 11 and May 21, 2020. Patients were stratified by a history of either cancer (n=195) or CVD (n=414) and subsequently by the presence of both cancer and CVD (n=82). We compared outcomes between patients with and without cancer and patients with both cancer and CVD compared with patients with either condition alone. The primary endpoint was COVID-19-associated severe disease, defined as a composite of the need for mechanical ventilation, shock, or death. Secondary endpoints included death, shock, need for mechanical ventilation, need for supplemental oxygen, arrhythmia, venous thromboembolism, encephalopathy, abnormal troponin level, and length of stay. RESULTS: Multivariable analysis identified cancer as an independent predictor of COVID-19-associated severe disease among all infected patients. Patients with cancer were more likely to develop COVID-19-associated severe disease than were those without cancer (hazard ratio [HR], 2.02; 95% CI, 1.53-2.68; P<.001). Furthermore, patients with both cancer and CVD had a higher likelihood of COVID-19-associated severe disease compared with those with either cancer (HR, 1.86; 95% CI, 1.11-3.10; P=.02) or CVD (HR, 1.79; 95% CI, 1.21-2.66; P=.004) alone. Patients died more frequently if they had both cancer and CVD compared with either cancer (35% vs 17%; P=.004) or CVD (35% vs 21%; P=.009) alone. Arrhythmias and encephalopathy were also more frequent in patients with both cancer and CVD compared with those with cancer alone. CONCLUSIONS: Patients with a history of both cancer and CVD are at significantly higher risk of experiencing COVID-19-associated adverse outcomes. Aggressive public health measures are needed to mitigate the risks of COVID-19 infection in this vulnerable patient population.

The protective effects of human milk-derived peptides on the pancreatic islet biology.

Several epidemiological studies support the protective role of breastfeeding in reducing the risk for type 1 diabetes. Human breast milk is the perfect nutrition for infants and contains many complex proteins, lipids and carbohydrates. In this study, we examined the physiological effects of human milk-derived opioid peptides, ß-casomorphins (BCM), and compared them with bovine-milk-derived opioid peptides on pancreatic hormone regulation and ß-cell regeneration. Exposure of wild-type zebrafish embryos to 50 µg/ml of human BCM-5 and -7 from 3 days post fertilisation until 6 days post fertilisation resulted in an increased insulin domain of expression while exposure to bovine BCM-5 and -7 significantly reduced the insulin domain of expression as analysed by whole-mount in situ hybridisation. These changes may be accounted for by reduced insulin expression or ß-cell number and were mitigated by the µ-opioid receptor antagonist, naloxone. The effect of BCM on ß-cell regeneration was assessed following ablation of ß-cells in Tg (ins: CFP-NTR) zebrafish from 3 days post fertilisation to 4 days post fertilisation, followed by exposure of bovine and human BCM-5 and -7 (50 µg/ml) from 4 days post fertilisation until 7 days post fertilisation. The regenerative capacity of ß-cells was not impeded following exposure to human BCM-5 and -7, whereas the capacity of ß-cells to regenerate following bovine BCM-5 and -7 exposure was reduced. Our data suggest that human BCM-5 and -7 may promote ß-cell development and enable the regeneration of ß-cells, while the bovine-milk-derived peptides, BCM-5 and -7, play an opposite role. These data may provide some biological explanation for the protective effect of breastfeeding on the development of type 1 diabetes.

Management of Cardiovascular Disease During Coronavirus Disease (COVID-19) Pandemic.

Patients with pre-existing cardiovascular disease and risk factors are more likely to experience adverse outcomes associated with the novel coronavirus disease-2019 (COVID-19). Additionally, consistent reports of cardiac injury and de novo cardiac complications, including possible myocarditis, arrhythmia, and heart failure in patients without prior cardiovascular disease or significant risk factors, are emerging, possibly due to an accentuated host immune response and cytokine release syndrome. As the spread of the virus increases exponentially, many patients will require medical care either for COVID-19 related or traditional cardiovascular issues. While the COVID-19 pandemic is dominating the attention of the healthcare system, there is an unmet need for a standardized approach to deal with COVID-19 associated and other traditional cardiovascular issues during this period. We provide consensus guidance for the management of various cardiovascular conditions during the ongoing COVID-19 pandemic with the goal of providing the best care to all patients and minimizing the risk of exposure to frontline healthcare workers.

Marijuana Use in Patients With Cardiovascular Disease: JACC Review Topic of the Week.

Marijuana use is increasing as more states are legalizing cannabis for both medicinal and recreational purposes. National survey data estimate that >2 million Americans with established cardiovascular diseases currently use or have used marijuana in its variety of forms, including inhalation and vaping. Cannabinoid receptors are distributed in multiple tissue beds and cells, including platelets, adipose tissue, and myocytes. Observational data suggest associations between marijuana and a broad range of adverse cardiovascular risks. Marijuana is becoming increasingly potent, and smoking marijuana carries many of the same cardiovascular health hazards as smoking tobacco. Synthetic cannabinoids have been linked to more sustained and deleterious pharmacodynamic effects. Marijuana is classified as a Schedule I substance, thus limiting its rigorous study for cardiovascular health effects. This review summarizes cardiovascular considerations related to marijuana use, pharmacological interactions, and future steps to provide clearer guidance regarding its cardiovascular safety. Screening for marijuana use is encouraged, especially in young patients presenting with cardiovascular disease.

Recent trends in hospital admissions and outcomes of cardiac Chagas disease in the United States.

BACKGROUND: Chagas disease (CD), caused by Trypanosoma cruzi, has been increasingly encountered as a cause of cardiovascular disease in the United States. We aimed to examine trends of hospital admissions and cardiovascular outcomes of cardiac CD (CCD). METHODS: Search of 2003-2011 Nationwide Inpatient Sample database identified 949 (age 57±16 years, 51% male, 72.5% Hispanic) admissions for CCD. RESULTS: A significant increase in the number of admissions for CCD was noted during the study period (OR=1.054; 95% CI=1.028-1.081; P< 0.0001); 72% were admitted to Southern and Western hospitals. Comorbidities included hypertension (40%), coronary artery disease (28%), hyperlipidemia (26%), tobacco use (12%), diabetes (9%), heart failure (5%) and obesity (2.2%). Cardiac abnormalities noted during hospitalization included atrial fibrillation (27%), ventricular tachycardia (23%), sinoatrial node dysfunction (5%), complete heart block (4%), valvular heart disease (6%)] and left ventricular aneurysms (5%). In-hospital mortality was 3.2%. Other major adverse events included cardiogenic shock in 54 (5.7%), cardiac arrest in 30 (3.2%), acute heart failure in 88 (9.3%), use of mechanical circulatory support in 29 (3.1%), and acute stroke in 34 (3.5%). Overall, 63% suffered at least one adverse event. Temporary (2%) and permanent (3.5%) pacemakers, implantable cardioverter defibrillators (10%), and cardiac transplant (2.1%) were needed for in-hospital management. CONCLUSIONS: Despite the remaining concerns about lack of awareness of CCD in the US, an increasing number of hospital admissions were reported from 2003-2011. Serious cardiovascular abnormalities were highly prevalent in these patients and were frequently associated with fatal and nonfatal complications.