Complications of Cardiac Resynchronization Therapy: Comparison of Safety Outcomes from Real-world Studies and Clinical Trials.

Cardiac resynchronization therapy (CRT) is an important intervention in heart failure. Whether real-world complication rates mirror those reported in randomized clinical trials (RCTs) is unknown. We sought to compare rates of procedural complications between major RCTs of CRT with "real-world" complication rates reported in registries and administrative claims database studies. We conducted a PubMed search to identify all relevant publications on CRT and classified them into RCTs and registry studies. Pooled procedural complication rates were analyzed. Differences between groups were compared using the chi-squared test. We identified a total of 6 RCTs, 2 administrative claims database studies, and 4 CRT registry studies. RCTs included a total of 4,442 patients and "real-world" studies included a total of 72,554 patients. The overall rates of procedural complications with CRT were significantly higher in RCTs compared to the real world (8.1% vs. 6.9%, P = .002). Lead-related complications were higher in the real-world studies compared to RCTs (11.3% vs. 6.5%, P = .0001). This could represent a follow-up bias with patients in registries being followed up for longer durations that would compound lead complication rates. Interestingly, RCTs had a higher incidence of pocket hematomas (2.1% vs. 0.4%, P = .001). In conclusion, real-world procedural complication rates of CRT appear to be significantly lower than those reported in RCTs.

Hepatic Interactions in Atherosclerotic Heart Disease.

Atherosclerotic heart disease remains a major cause of morbidity and mortality worldwide. The past few decades have seen the emergence of chronic inflammation as a mediator of atherosclerosis. Although the heart and vascular system remain the organ systems most affected in the atherosclerotic process, chronic inflammation and ischemia trigger a systemic multi-organ response. The liver is a critical organ for systemic hemostasis and recent developments have established an important role of the liver in response to atherosclerosis and myocardial ischemia. In addition, the rapid emergence of systemic liver diseases has unraveled a pathophysiological link with heart disease with therapeutic implications. In this review, we explore the relationship between the liver and the heart in myocardial ischemia, describe epidemiological associations between various liver pathologies and coronary heart disease, and elucidate practical challenges in the clinical management of patients with concomitant coronary heart disease and hepatic abnormalities.

Utility of Inferior Lead Q-waveforms in diagnosing Ventricular Tachycardia.

BACKGROUND: Electrocardiogram (ECG) differentiation of wide complex tachycardia (WCT) into ventricular tachycardia (VT) and supraventricular tachycardia with aberration (SVT-A) is often challenging. OBJECTIVE: To determine if the presence of Q-waveforms (QS, Qr, QRs) in the inferior leads (II, III, aVF) can differentiate VT from SVT-A in a WCT compared to Brugada algorithm. We studied 2 inferior lead criteria namely QWC-A where all the inferior leads had a similar Q wave pattern and QWC-B where only lead aVF had a Q-waveform. METHODS: A total of 181 consecutive cases of WCT were identified, digitally separated into precordial leads and inferior leads and independently reviewed by 2 electrophysiologists. An electrocardiographic diagnosis of VT or SVT-A was assigned based on Brugada and inferior lead algorithms. Results were compared to the final clinical diagnosis. RESULTS: VT was the final clinical diagnosis in 24.9% of ECG cohort (45/181); 75.1% (136/181) were SVT-A. QWC-A and QWC-B had a high specificity (93.3% and 82.8%) and accuracy (78.2% and 71.0%), but low sensitivity (33.3% and 35.6%) in differentiating VT from SVT-A. The Brugada algorithm yielded a sensitivity of 82.2% and specificity of 68.4%. Area under the curve in ROC analysis was highest with Brugada algorithm (0.75, 95% CI 0.69-0.81) followed by QWC-A (0.63, 95% CI 0.56-0.70) and QWC-B (0.59, 95% CI 0.52-0.67). CONCLUSION: QWC-A and QWC-B criteria had poor sensitivity but high specificity in diagnosing VT in patients presenting with WCT. Further research combining this simple criterion with other newer diagnostic algorithms can potentially improve the accuracy of the overall diagnostic algorithm.

Subacute stent thrombosis in a patient with COVID-19 pneumonia.

Acute and subacute stent thromboses are rare but life-threatening complications of primary coronary intervention and stenting. We present a case of a patient with COVID-19 infection who presented with pneumonia, acute respiratory failure, and non-ST elevation myocardial infarction. Reperfusion was achieved with coronary angioplasty and drug-eluting stent placement, and the patient was started on aspirin and clopidogrel. However, 72 hours later, the patient experienced an episode of subacute stent thrombosis. This raises concerns about a possible association between stent thrombosis and increased thrombogenicity and platelet aggregability triggered by COVID-19 infection.

Coronary Artery Calcium Scoring in Young Adults: Evidence and Challenges.

PURPOSE OF REVIEW: This review aims to summarize the evidence and challenges of coronary artery calcium (CAC) scoring as a screening tool for coronary artery disease (CAD) in young adults. RECENT FINDINGS: Several cohort studies have highlighted the value of CAC scoring in CAD risk assessment in young adults. The largest study to date is the Coronary Artery Risk Development in Young Adults (CARDIA) study. The study examined patients at 18-30 years of age and demonstrated that the presence of any degree of CAC was associated with a higher risk of coronary events compared to zero CAC, with an incremental increase in the risk of events with higher scores. However, it is important to note that 70% of patients screened had CAC = 0 at the age of 56. Despite the evidence that higher CAC score cutoff used in guidelines for predicting cardiovascular risk may be "falsely reassuring," however, mass screening of young adults using CAC score may be challenging. The development of prediction tools and scoring systems to identify patients at higher risk of developing CAC based on known CAD risk factors may help reduce the number needed to screen to detect patients with positive CAC.

The Current Focus of Heart Failure Clinical Trials.

BACKGROUND: Heart failure (HF) is a major global health problem. Clinical trials test efficacy, effectiveness, and safety of novel and emerging therapies in HF. We sought to determine the salient features of ongoing interventional clinical trials in HF. METHODS AND RESULTS: We accessed the ClinicalTrials.gov registry of the National Institutes of Health (NIH) and the International Clinical Trials Registry Platform of the World Health Organization on January 1, 2017, and extracted pertinent information on current HF clinical trials for systematic review. Of 794 HF trials that met our inclusion criteria, almost one-half (49.1%) evaluated clinical end points and one-third (32.8%) examined imaging end points as primary outcomes. One-fourth (24.8%) were industry sponsored and one-third (35.6%) were university sponsored. The NIH and other United States federal agencies funded only 14 trials (1.8% of all trials; 10.7% of trials in the US). Among 536 HF trials with specified left ventricular ejection fraction status, 434 (81.0%) focused on HF with reduced ejection fraction (HFrEF) and only 102 (19.0%) trials targeted HF with preserved ejection fraction (HFpEF). CONCLUSIONS: Ongoing HF trials are predominantly sponsored by nongovernmental funding agencies. Although HFpEF occurs as commonly as HFrEF in the community, the number of clinical trials targeting HFpEF is substantially lower compared with HFrEF.

Long-Term Outcomes With Transcatheter Aortic Valve Replacement in Women Compared With Men: Evidence From a Meta-Analysis.

OBJECTIVES: This study sought to examine long-term outcomes with transcatheter aortic valve replacement (TAVR) in women versus men. BACKGROUND: TAVR is commonly performed in women. Previous studies have shown conflicting results with respect to sex differences in outcomes with TAVR. In addition, short-term outcomes have primarily been reported. METHODS: Electronic search was performed until March 2017 for studies reporting outcomes with TAVR in women versus men. Random effects DerSimonian-Laird risk ratios were calculated. Outcomes included all-cause mortality and major cardiovascular events at short- (30 days) and long-term (>1 year) follow-up. RESULTS: Seventeen studies (8 TAVR registries; 47,188 patients; 49.4% women) were analyzed. Women were older but exhibited fewer comorbidities. At 30 days, women had more bleeding (p < 0.001), vascular complications (p < 0.001), and stroke/transient ischemic attack (p = 0.02), without difference in all-cause (p = 0.19) or cardiovascular mortality (p = 0.91) compared with men. However, female sex was associated with lower all-cause mortality at 1 year (risk ratio: 0.85; 95% confidence interval: 0.79 to 0.91; p < 0.001), and longest available follow-up (mean 3.28 ± 1.04 years; risk ratio: 0.86; 95% confidence interval: 0.81 to 0.92; p < 0.001), potentially caused by less moderate/severe aortic insufficiency (p = 0.001), and lower cardiovascular mortality (p = 0.009). The female survival advantage remained consistent across multiple secondary analyses. The risk of stroke, moderate/severe aortic insufficiency, and all-cause mortality seemed to vary based on the type of valve used; however, without significant subgroup interactions. CONCLUSIONS: Despite a higher upfront risk of complications, women derive a better long-term survival after TAVR compared with men.

Metabolic syndrome: pathophysiology, management, and modulation by natural compounds.

Metabolic syndrome (MetS) represents a cluster of metabolic abnormalities that include hypertension, central obesity, insulin resistance, and atherogenic dyslipidemia, and is strongly associated with an increased risk for developing diabetes and atherosclerotic and nonatherosclerotic cardiovascular disease (CVD). The pathogenesis of MetS involves both genetic and acquired factors that contribute to the final pathway of inflammation that leads to CVD. MetS has gained significant importance recently due to the exponential increase in obesity worldwide. Early diagnosis is important in order to employ lifestyle and risk factor modification. Here, we review the epidemiology and pathogenesis of MetS, the role of inflammation in MetS, and summarize existing natural therapies for MetS.

Tension pneumothorax presenting as ST segment elevation: Look, Listen, Act!

We present a unique case of a patient with a tension pneumothorax that presented with electrocardiogram (ECG) characteristics typical for ST segment elevation myocardial infarction. The clinical diagnosis was clinched by focused physical examination. Treatment of the pneumothorax lead to resolution of the electrocardiographic abnormalities. Our experience from this unique case is useful for cardiologists and critical care physicians who encounter these patients routinely.

Temporal trends and outcomes of acute myocardial infarction in patients with cancer.

BACKGROUND: Data on outcomes of ST-elevation myocardial infarction (STEMI) in patients with cancer are scarce. We investigated the nationwide trends in admissions for STEMI, utilization of percutaneous coronary intervention (PCI), and in-hospital outcomes in patients with the three most common cancer diagnoses (lung, breast, and colon) compared to patients without cancer. METHODS: We conducted an administrative database study using the Nationwide Inpatient Sample (NIS). All in-patient hospitalizations for STEMI from 2001 to 2011 were identified. Patients with concomitant diagnosis of lung, breast or colon cancer were identified using appropriate International classification of diagnosis (ICD 9-CM) codes. Primary outcome was utilization of PCI and in-hospital mortality in patients with cancer compared to those without cancer. RESULTS: Utilization of PCI was 30.8% (1,191/3,871), 20.2% (4,541/22,480) and 17.3% (1,716/9,944) in patients with breast, lung and colon cancer, respectively. Among patients without any of these cancers, use of PCI was 49.6%. In-hospital mortality was highest in patients with lung cancer (57.1%) and lowest in patients without cancer (25.7%). CONCLUSIONS: Patients with cancer have significantly worse in-hospital mortality compared to those without cancer, partly due to a relatively lower rate of PCI utilization in cancer patients with STEMI.

Comparison of Angiographic Burden of Coronary Artery Disease in Patients With Versus Without Hepatitis C Infection.

Hepatitis C virus (HCV) infection is thought to be associated with an increased risk of coronary heart disease (CHD) events, perhaps secondary to increased inflammation. We sought to examine the angiographic burden of coronary artery disease (CAD) in patients with HCV compared to HCV-negative patients. All consecutive HCV RNA-positive patients (n = 61) who underwent coronary angiography at the University of Arkansas for Medical Sciences from 2001 to 2013 were identified. A parallel group of HCV-negative controls (n = 61), matched for age, gender, and indication for coronary angiography served as control. Angiographic burden of CAD was assessed by computing Gensini scores. Statistical analysis was performed using SPSS 21.0. Patients with HCV had significantly lower levels of total and low-density lipoprotein cholesterol. Preangiographic use of aspirin and statin was significantly lower in the HCV cohort. Number of patients with obstructive CAD was less in HCV group (23% vs 39%, p <0.05). However, angiographic Gensini score was similar in both groups. There was no correlation between HCV RNA titers and Gensini score (p = 0.9, analysis of variance). In conclusion, patients with active HCV infection have similar angiographic CAD burden as HCV-negative patients. Furthermore, viral load does not appear to correlate with atherosclerosis burden. Patients with HCV have less-obstructive CAD and less-frequent use of aspirin and statins.