Characteristics and Outcomes of Early vs Late Initiation of Mechanical Circulatory Support in Non-Acute Myocardial Infarction related Cardiogenic Shock: An Analysis of the National Inpatient Sample Database.

Cardiogenic shock (CS) is significant cause of mortality. The use of mechanical circulatory support (MCS) in patients with non-acute myocardial infarction (Non-AMI) CS is lacking. We inquired data regarding the trends and outcomes early vs late initiation of MCS in non-AMI CS. We investigated National Inpatient Sample database between October 2015-December 2018, identifying hospitalizations with CS, either complicated by AMI or Non-AMI. Patients were divided into 2 cohorts, early initiation of MCS (<48 hours) and late initiation of MCS (>48 hours). The primary analysis included death within first 24 hours. A secondary analysis was adjusted after excluding patients who died in first 24 hours. A total of 85,318 patients with non-AMI-related CS with MCS placement were identified. Among this cohort, 54.6% (n=46,579) underwent early initiation of MCS within 48 hours, and 45.4% (n=38,739) underwent late initiation of MCS after 48 hours. In primary analysis, early MCS initiation was associated with more in-hospital mortality in primary outcome of all-cause hospital mortality (35.72% vs 27.63%, P<0.0001, OR 1.44, 95% CI: 1.40-1.49, P<0.0001), however, adjusted secondary analysis showed a statistically significant decrease in all-cause hospital mortality (23.63% vs 27.63%, P<0.0001, OR 0.80, 95% CI: 0.78-0.83, P<0.0001). In non-AMI-related CS and based on survival to 24 hours after admission, early initiation of MCS had statistically significant decrease in all-cause hospital mortality, with less incidence of vascular and renal complications, and shorter hospital stay. Late initiation of MCS was associated with a higher incidence of advanced therapies, including LVAD and transplant.

Update on Wearable Cardioverter Defibrillator: A Comprehensive Review of Literature.

Despite the advancements in the prevention and treatment of cardiovascular diseases, sudden cardiac death (SCD) remains a leading cause of mortality and is accountable for approximately 15% of the total mortality in the USA. The prognosis after sudden cardiac arrest (SCA) varies significantly and depends largely on the underlying etiology and the rapidity and efficiency of resuscitation; however, the outcome remains poor for most of the patients. The main culprits for SCD are coronary heart disease (CHD) and heart failure with reduced ejection fraction (HFrEF). Patients with HFrEF and an ejection fraction (EF) of less than 35% are considered for an implantable cardioverter-defibrillator (ICD) placement if the EF does not improve. A wearable cardioverter defibrillator (WCD) commonly known as a life-vest is sometimes used as a bridging modality until an ICD is implanted. The indication and utility of WCD is still a controversial topic. The purpose of this article is to provide an up-to-date comprehensive review of literature for WCD utilization.

Percutaneous Repair of Mitral Regurgitation: A Comprehensive Review of Literature.

Mitral regurgitation is the most common valvular disease in the US and the second most common worldwide. Left untreated, it can lead to the development of heart failure, giving rise to increased mortality rates. Mitral valve intervention is usually indicated in severe mitral regurgitation at the onset of symptoms, even if the function of the left ventricle is preserved. A surgical approach is generally favored according to current guidelines, with excellent clinical outcomes. However, the emergence of novel data from contemporary trials indicates that percutaneous, catheter-based approach may have similar improvements in mortality outcomes while maintaining a superior safety profile when compared to the surgical approach. Here, we discuss transcatheter mitral valve repair as a treatment option for mitral regurgitation and summarize the major clinical trials which were recently conducted on transcatheter repair.

Perspectives on Heyde's Syndrome and Calcific Aortic Valve Disease.

Heyde's syndrome is a multisystem disorder describing the association between calcified aortic stenosis, gastrointestinal tract bleeding from arteriovenous malformations, and acquired von Willebrand syndrome. Several studies have reported an increase in prevalence of gastrointestinal arteriovenous malformation in patients with aortic stenosis and vice versa; however, the incidence of Heyde's syndrome remains controversial. In general, the syndrome is prevalent in the elderly population. The pathogenesis and management remain controversial as well. Our review, provides a unique case to highlight the diagnosis and management of Heyde's syndrome while also briefly describing the prevalence, etiology, diagnosis, and management of calcific aortic valve disease in general.

Cardiovascular Outcomes With Anti-Inflammatory Therapies: Review of Literature.

Inflammation is a major contributing factor in the development of cardiovascular disease (CVD) and has been a popular topic of discussion as it provides a potential therapeutic target to reduce disease progression. Multiple inflammatory markers have been linked with progressive atherosclerosis which includes interleukin-6, tumor necrosis factor-α, C-reactive protein amongst others, this article aims to review current literature to evaluate the effectiveness of anti-inflammatory therapies in cardiovascular disease.

Outcomes in Hospitalization in Patients with Heart Failure Undergoing Remote Pulmonary Artery Pressure Monitoring: A Systematic Review and Meta-Analysis of Major Trials.

Heart failure is a leading global pandemic and a cause of economic burden. Although, treatments exist to help symptomatic alleviation, patient compliance and monitoring is the basis of ensuring efficacy. With devices that allow for remote wireless PA pressure monitoring such as CardioMEMS, the inconsistency in patient reporting and factors such as symptoms and hospitalizations can be reduced. A systematic review and meta-analysis utilizing the MEDLINE, Cochrane, and Scopus database was performed to identify randomized and non-randomized clinical trials evaluating baseline characteristics and hospitalizations. Five trials for the systematic review and 2 trials for the meta-analysis meeting the inclusion and exclusion criteria were included. Baseline characteristics included an average age of 64.6 years, male predominance, mean BMI of 29.6, predominance of HFrEF, hypertension the most prevalent comorbidity, and a mean PA pressure of 27.2 mm Hg. The follow-up periods ranged from 90 days to 12 months. There was a total of 64 adverse events, mostly non-serious. Patients who underwent remote PA monitoring were less likely to be hospitalized compared with patients who did not (Odds Ratio: 0.52; 95% Confidence Interval 0.39, 0.69). Remote PA pressure monitoring allows for reduced hospitalizations. With the recent and now resurging SARS-CoV-2 pandemic, devices such as CardioMEMS can allow for heart failure patients to be managed from home to not only reduce hospitalizations but for symptom prevention and management.

Update on the Cardiovascular Benefits of Sodium-Glucose Co-Transporter-2 Inhibitors: Mechanism of Action, Available Agents and Comprehensive Review of Literature.

Despite the currently established treatment for heart failure (HF), HF remains a growing public healthcare problem with an increasing burden. Therefore, novel therapeutic innovations are needed to overcome this issue and improve HF prognosis. Sodium-glucose co-transporter-2 inhibitors (SGLT2i) are state-of-the-art in type 2 diabetes mellitus management. They inhibit the reabsorption of glucose from the proximal renal tubules, leading to increased glycosuria and decreased plasma glucose levels. SGLT2i use is growing significantly, especially after recent clinical trials demonstrating favorable cardiovascular and renal protective effects independently of blood glucose-lowering. The mechanisms by which SGLT2i demonstrate their cardio-renal protective effects remain incompletely understood but are thought to be related to potential diuretic and natriuretic effects along with other mechanisms that will be discussed in this article. Over the past few years, there has been significant research on the safety, efficacy, and quality of this class of medications. Here, we review the current guideline-directed medical therapy for HF, focus on SGLT2i mechanism of action and potential role in HF patients, and finally summarize the cardiovascular clinical trials with SGLT2.

Incidence of Acute Ischemic Stroke in Hospitalized Patients With Atrial Fibrillation Who Had Anticoagulation Interruption: A Retrospective Study.

BACKGROUND: Atrial fibrillation (AF) is one of the leading causes of acute ischemic stroke requiring anticoagulation. Many patients experience treatment interruption in the hospital setting. The aim of this study was to evaluate the effect of anticoagulation interruption on short-term risk of ischemic stroke in hospitalized patients with AF. METHODS: We performed a retrospective medical record review using the Hospital Corporation of America (HCA) database. We included patients admitted to our institution between December 2015 and December 2018 who had a prior history of AF. Patients were excluded if they had ischemic stroke, hemorrhagic stroke, history venous thromboembolism or mechanical valve on admission. We compared the incidence of ischemic stroke in patients in whom anticoagulation was interrupted for more than 48 h to those who continued anticoagulation. RESULTS: A total of 2,277 patients with history of AF were included in the study. In this cohort, 79 patients (3.47%) had anticoagulation interruption of more than 48 h during their hospital stay. There was no difference in incidence of stroke between the interruption and no interruption groups (1.27% (n = 1) vs. 0.23% (n = 5), P = 0.19). Interruption of anticoagulation did not associate with a significant increase in the risk of in-hospital ischemic stroke. CHA2DS2VASc score was a strong predictor of in-hospital stroke risk regardless of anticoagulation interruption (odds ratio: 7.199, 95% confidence interval: 2.920 - 17.751). CONCLUSION: In this study, the in-hospital incidence of ischemic stroke in patients with AF did not significantly increase by short-term anticoagulation interruption.

Southern Tick-Associated Rash Illness: Florida's Lyme Disease Variant.

Southern tick-associated rash illness (STARI) is an emerging zoonotic disease causing an annular rash with central clearing that is almost identical to erythema migrans seen in Lyme disease. It is spread by Amblyomma americanum tick bite. Although it is still debatable, this zoonotic disease is thought to be caused by Borrelia lonestari spirochete. At this time, there is no approved diagnostic modality nor approved treatment for such an illness. Here we describe a rare case of STARI in a 63-year-old female and shed light on the differences between STARI and Lyme disease.

Uncommon Pathogen in an Unexpected Host: A Rare Case of Rothia mucilaginosa Infective Endocarditis in an Immunocompetent Patient Without an Underlying Valvular Disease.

Rothia mucilaginosa is an infrequent opportunistic pathogen that affects immunocompromised patients, with a high affinity to prosthetic devices. Infections in immunocompetent individuals are extremely rare and usually related to pre-existing valvular heart disease. We report the first case of Rothia endocarditis in an immunocompetent patient without an underlying valve disease.

Atrial Fibrillation as a Possible Adverse Reaction to Evolocumab.

Evolocumab is a recently FDA-approved proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) that reduces the risk of myocardial infarction, stroke, and coronary revascularization in individuals with established atherosclerotic cardiovascular disease. We report an extremely rare possible side effect, atrial fibrillation (AF), encountered with evolocumab to increase the awareness among physicians of such a possibility.

A Case of Hypokalemic Periodic Paralysis in a Young Athlete.

Hypokalemic periodic paralysis (HPP) is one of the group muscle disorders that can cause sudden onset paresis or paralysis. It is a quite rare, yet, potentially life-threatening condition that, if appropriately and promptly diagnosed and treated, can be completely reversed. Other forms of periodic paralysis include thyrotoxic periodic paralysis, hyperkalemic periodic paralysis, and Anderson syndrome. We are presenting a case of a young male who presented to the emergency department (ED) with sudden paralysis to shed light on such a diagnosis and on other differential diagnoses.

A Rare Case of Statin-Induced Diplopia: An Often-Overlooked but Reported Side Effect.

Statins are a class of medications indicated for atherosclerotic cardiovascular diseases and dyslipidemia. Ever since their introduction, various side effects have been reported with their use. Statin-induced myopathy is a well-established side effect of the medication, ranging in severity from mild myotoxicity to fatal rhabdomyolysis, with or without an increase in creatine kinase levels. Statin-induced diplopia, ptosis, or ophthalmoplegia are very rare, but they have been reported as adverse events in a handful of cases. These adverse events typically result from the progressive weakening of the external ocular musculature or the levator palpebrae superioris muscle. In this report, we present a rare case of statin-induced diplopia in a patient who had been on atorvastatin therapy for years. We believe this report will increase awareness among physicians about such an adverse event related to statins.

Acute Multiple Cerebral Watershed Infarctions as the Initial Presentation of COVID-19 in a Young Male Patient: A Case Report.

Cerebrovascular diseases appear to be one of the most serious complications of coronavirus disease 2019 (COVID-19). In this report, we present a case of a 38-year-old male with a past medical history significant only for hypertension, who presented to the emergency department (ED) with confusion and multiple focal neurologic deficits. Brain imaging showed acute multiple cerebral watershed infarctions. Upon further investigation and laboratory workup, the hypercoagulability and vasculitis panels were found to be negative, and other differential diagnoses were ruled out. In light of a number of emerging reports of COVID-19-related ischemic stroke, our patient was also screened for the disease, and surprisingly the test came back positive. We believe this case report will highlight the importance of conducting neurological examinations in COVID-19 patients, since timely workup and prompt interventions may reduce morbidity and mortality.

Sarcoidosis and Aortic Stenosis: A Role for Transcatheter Aortic Valve Replacement?

Sarcoidosis is an infiltrative disease known to affect multiple layers of the heart.1 Although rare, aortic valve involvement has been seen.17,18 The role of transcatheter aortic valve replacement (TAVR) has been described in amyloidosis,4 a well-known infiltrative disease, but not in sarcoidosis. As the awareness of cardiac sarcoidosis grows,17 as in amyloidosis, its impact on the aortic valve will grow too. Our review highlights the epidemiology, pathophysiology, and treatment of cardiac sarcoidosis with a discussion for TAVR in patients affected by aortic valve insult.

Cardio-oncology: Capecitabine Can Sometimes be Heatbreaking Capecitabine-Induced Takotsubo Cardiomyopathy Case Report and Literature Review.

Capecitabine has been more recognized for its cardiotoxicity with an incidence that varies widely. It demonstrates its toxicity in the forms of acute coronary syndrome, arrhythmias and, to a lesser extent, cardiomyopathy. There are several proposed theories including coronary vasospasm, endothelial injury, and oxidative stress. We present a case of capecitabine-induced cardiomyopathy in a patient with pancreatic cancer and mild coronary artery disease, and shed light on other cardio-toxic agents, their proposed mechanism of cardiotoxicity, and on cardiomyopathy in general.

Isolated Third Nerve Palsy as a Rare and Solo Presentation of Internal Carotid Artery Dissection in a Young Female - a Surprising Finding in the Angiogram.

Internal carotid artery dissection (ICAD) is a known but uncommon cause of ischemic stroke among young and middle-aged patients. A common presentation includes ipsilateral headache, unilateral oculosympathetic palsy (partial Horner syndrome), or ischemic stroke but some reported cases present with less common manifestations, such as lower cranial nerve syndrome (IX, X, XI, XII). However, third cranial nerve palsy is an extremely rare presentation of ICAD. We present a case of ICAD with pseudoaneurysm presenting with third nerve palsy, with ptosis, outward deviation, and binocular diplopia, emphasizing the importance of considering ICAD as a differential diagnosis in patients with third nerve palsy due to the anatomical proximity of ICA to third nerve within the cavernous sinus.

Use of Optical Coherence Tomography in Coronary Artery Disease: Review Article.

Optical coherence tomography is a catheter-based imaging modality in heart catheterizations, which provides a significantly higher resolution of intravascular pathology by means of using light as opposed to ultrasound. The applications of this modality may include a detailed assessment of atherosclerotic plaques, stent evaluation including coverage and restenosis and percutaneous coronary intervention optimization. In this article, we provide a review of current literature highlighting the advantages and disadvantages of the use of optical coherence tomography in the catheterization lab.

Aspiration Thrombectomy for Acute ST-Elevation Myocardial Infarction: Literature Review.

Over the years, aspiration thrombectomy for management of acute coronary syndrome was the center of discussion however due to multiple randomized control trials which did not provide sufficient evidence supporting use of this approach, this method is not routinely used. The benefit of this approach remains unknown, however, it is important to acknowledge the evolution of aspiration catheters and their potential in minimizing complications which were previously the set back of this approach. We provide a comprehensive review of the previous trials and how those catheters have since evolved significantly.

Evolution of Acute Pulmonary Embolism Management: Review Article.

Acute pulmonary emboli are a major cause of morbidity and mortality and require prompt evaluation, diagnosis, and treatment. To date, anticoagulation using low molecular weight heparin or non-Vitamin K oral anticoagulants has been the mainstay of treatment in the subset of patients in whom pulmonary embolism does not compromise hemodynamics. On the other hand however, patients with massive pulmonary embolism and shock, thrombolytic therapy is necessary. This raises the question whether ultrasound-assisted catheter directed thrombolytic delivery might be superior to systemic administration. This review article aims to consolidate recent literature to help achieve a better understanding toward the utility of catheter directed therapy.