Showing papers in "Expert Review of Cardiovascular Therapy in 2018"
TL;DR: A focused Medline search of the English language literature was conducted between 2010 and 2017 using the terms, homocysteine, risk factor, atherosclerosis, cardiovascular disease, stroke, treatment, and 38 papers with pertinent information were selected and there is a controversy regarding the significance of homocy steine as a risk factor for CVD and stroke.
Abstract: Introduction: Hyperhomocysteinemia has been considered as a risk factor for systemic atherosclerosis, cardiovascular disease (CVD) and stroke and many epidemiologic and case-controlled studies have...
112 citations
TL;DR: Hypertension is caused by increased cardiac output and/or increased peripheral resistance and its pathogenesis involves alteration in ANS (autonomic nervous system) and likely in cortical-hypothalamic connections.
Abstract: Introduction: Hypertension is caused by increased cardiac output and/or increased peripheral resistance.Areas covered: The various mechanisms affecting cardiac output/peripheral resistance involved...
93 citations
TL;DR: This work discusses POBA, why there was a need for BMS, the use of inhibiting drugs to create 1st generation DES, the change of components to 2nd generationDES, theUse of absorbable drug reservoirs and platforms, and possible future directions with Prohealing Endothelial Progenitor Cell Capture Stents.
Abstract: Introduction: Percutaneous coronary intervention (PCI) is 40 years old this year. From its humble beginnings of experimental work, PCI has transitioned over years with coronary artery stenting now ...
44 citations
TL;DR: The development of improved and standardized methods for detecting DD has shown promise in identifying early HFpEF, however, even with early detection, there are few treatment options shown to provide mortality benefit warranting further investigation.
Abstract: Introduction:
Heart failure with preserved ejection fraction (HFpEF) continues to be a major challenge for clinicians Many crucial aspects of the syndrome remain unclear, including the exact pathophysiology, early diagnosis, and treatment Patients with HFpEF are often asymptomatic late into the disease process, and treatment with medications commonly used in heart failure with reduced ejection fraction (HFrEF) has not been proven to be beneficial In addition, the confusion of similar terms with HFpEF, such as diastolic heart failure (DHF), and diastolic dysfunction (DD), has led to a misunderstanding of the true scope of HFpEF
37 citations
TL;DR: Treatment with volanesorsen has the potential to reduce disease burden in patients with FCS through modulation of multiple symptom domains and reduced interference of FCS with work/school responsibilities.
Abstract: Background: Volanesorsen, an investigational inhibitor of apoC-III synthesis, significantly reduced triglyceride levels in clinical trials in patients with familial chylomicronemia syndrome...
34 citations
TL;DR: Although further research is required, electroporation represents an appealing option for the ablation cardiac arrhythmias and has many advantages over current thermal based approaches.
Abstract: Introduction: Cardiac ablation is an established treatment modality for the management of patients with cardiac arrhythmias. Current approaches to cardiac ablation employ thermal based energy to achieve lesions (damage) within the heart. There are many shortcomings and limitations of thermal based approaches. Electroporation (DC energy) is a non-thermal alternative approach to ablation that has shown significant promise in animal studies.Areas covered: An extensive review of the literature on the application of electroporation for ablation (both cardiac and collateral cardiac tissue) was undertaken. This review explores irreversible electroporation as a cardiac ablation modality. Specifically, it focuses and explains the biophysics of electroporation, the limitations of current thermal based approaches and examines the current data published on electroporation cardiac ablation.Expert commentary: Electroporation is a fast-growing novel ablation modality that has many advantages over current thermal...
33 citations
TL;DR: Systematic review of the literature in the past 10 years was performed to identify manuscripts reporting both cardiac dosimetry and survival/cardiac endpoints, covering pediatrics, breast cancer, lung cancer, gastrointestinal diseases, and adult lymphoma.
Abstract: Introduction: Recent trials in radiotherapy have associated heart dose and survival, inadequately explained by the existing literature for radiation-related late cardiac effects. Authors aimed to ...
30 citations
TL;DR: This narrative review focuses on physical activity as a modifiable lifestyle factor that can modify aging processes as well as cardiovascular pathophysiology that is often exacerbated by aging.
Abstract: Introduction: The benefits of physical activity have long been recognized as powerful preventive opportunities for both prevention of cardiovascular disease and aging-related morbidity. However, ph...
29 citations
TL;DR: The aim of this review is to provide an overview of the current management of AF in young patients, and specific issues arise over diagnostic workup as well as antiarrhythmic and anticoagulation therapies.
Abstract: Introduction: Atrial fibrillation (AF) is the most frequent arrhythmia worldwide. While mostly seen in elderly, it can also affect young adults (≤ 45 years of age), older adolescent, and children.A...
28 citations
TL;DR: The impact of COPD or HF on the pharmacological treatment of HF or COPD, respectively, is comprehensively discussed and how the non-pharmacological treatment can be tailored to the specific needs of patients with HF–COPD is outlined.
Abstract: Introduction: Heart failure (HF) with reduced ejection fraction and chronic obstructive pulmonary disease (COPD) frequently coexist, particularly in the elderly. Given their rising prevalen...
28 citations
TL;DR: This review discusses the particular challenges and limits in obtaining accurate measurements of RV anatomical and functional parameters and focuses primarily on the difficulties in proper interpretation of the highly load dependent RV ECHO-parameters which complicates the use of this valuable diagnostic and surveillance technique.
Abstract: Introduction: Compared with the left ventricle (LV), the right ventricle (RV) is less suited for evaluation by echocardiography (ECHO). Nevertheless, RV ECHO-assessment has currently emerged as an ...
TL;DR: Based on voluminous data available, the absence of coronary calcium serves as a factor to de-risk patients for cardiovascular risk stratification and management algorithms and is beneficial in slowing progression of atherosclerotic disease.
Abstract: Introduction: Coronary artery calcification (CAC) is reflective of atherosclerotic disease and incrementally predictive of future cardiovascular events (CVE), independent of traditional risk factor...
TL;DR: The prognosis associated with RVMI is worse in the short term, compared to non-RVMI, but those patients who survive hospitalization have a relatively good long-term prognosis.
Abstract: Acute right ventricular myocardial infarction (RVMI) is observed in 30-50% of patients presenting with inferior wall myocardial infarction (MI) and, occasionally, with anterior wall MI. The clinical consequences vary from no hemodynamic compromise to severe hypotension and cardiogenic shock depending on the extent of RV ischemia. Areas covered: The pathophysiological mechanisms, diagnostic steps, and novel therapeutic approaches of acute RVMI are described. Expert commentary: Diagnosis of acute RVMI is based on physical examination, cardiac biomarkers, electrocardiography, and coronary angiography, whereas noninvasive imaging modalities (echocardiography, cardiac magnetic resonance imaging) play a complementary role. Early revascularization, percutaneous or pharmacological, represents key step in the management of RMVI. Maintenance of reasonable heart rate and atrioventricular synchrony is essential to sustain adequate cardiac output in these patients. When conventional treatment is not successful, mechanical circulatory support, including right ventricle assist devices, percutaneous cardiopulmonary support, and intra-aortic balloon pump, might be considered. The prognosis associated with RVMI is worse in the short term, compared to non-RVMI, but those patients who survive hospitalization have a relatively good long-term prognosis.
TL;DR: Low SES was associated with poorer outcomes when AF was present and may imply that health-care professionals and policy interventions should focus on the promotion of AF-education and management among patients with AF and low SES.
Abstract: Background: Atrial fibrillation (AF) is a growing epidemic and evidence of a relationship to socioeconomic status (SES) is inconsistent. We aimed to summarize the literature about SES and AF and defined two objectives: (1) To examine the association between SES and the risk of AF; (2) To examine the association between SES and AF-related outcomes in an AF-population.Methods: We performed a separate search for each objective in Ovid-MEDLINE and Ovid-Embase. For objective 1, the population included was healthy participants and outcome of interest was AF. For objective 2, the population included were patients with AF and outcome of interest was mortality, treatment, ablation for AF, knowledge about AF, and morbidity.Results: For objective 1, 12 studies were included. No consistent pattern for an association between SES and the risk of AF was discovered. For objective 2, 39 studies comprising 42 outcomes were included. The majority of studies showed an association between low SES and increased mortali...
TL;DR: Radiofrequency ablation of the right ventricular outward flow tract epicardium is effective in suppressing arrhythmogenesis in BrS patients experiencing frequent appropriate ICD-shocks.
Abstract: Introduction: Brugada syndrome (BrS) is an inherited cardiac arrhythmia syndrome characterized by ST-segment elevation in right precordial ECG leads and associated with sudden cardiac death in young adults. The ECG manifestations of BrS are often concealed but can be unmasked by sodium channel blockers and fever.Areas covered: Implantation of a cardioverter defibrillator (ICD) is first-line therapy for BrS patients presenting with prior cardiac arrest or documented VT. A pharmacological approach to therapy is recommended in cases of electrical storm, as an adjunct to ICD and as preventative therapy. The goal of pharmacological therapy is to produce an inward shift to counter the genetically-induced outward shift of ion channel current flowing during the early phases of the ventricular epicardial action potential. This is accomplished by augmentation of ICa using □□adrenergic agents or phosphodiesterase III inhibitors or via inhibition of Ito. Radiofrequency ablation of the right ventricular outwar...
TL;DR: T1 and T2 mapping harbours a unique potential for an objective non-invasive disease recognition and treatment discovery in myocarditis and should enter independently into clinical experimentation, with a high priority for outcome and therapeutic studies.
Abstract: Introduction: Myocarditis and its sequelae remain an unconquered clinical problem, disproportionately affecting the young. Several hurdles beset myocarditis, including non-specific symptoms, hetero...
TL;DR: Cognitive assessment in cardiac rehabilitation as an outcome measure has the potential to improve clinical, functional and behavioral domains as well as help to reduce gaps in the quality of care in these patients.
Abstract: Introduction: Cardiac rehabilitation program is an evidence-based intervention and established model of exercise delivery following myocardial infarction and heart failure. Although it forms an imp...
TL;DR: QFR through a computational fluid dynamic analysis, proved to be useful in discriminating functionally significant stenosis, with an excellent correlation with FFR values, and considerable advantages in terms of acquisition time and costs.
Abstract: The assessment of coronary lesions severity has always been a relevant topic in the management of the patient undergoing coronary angiography. Fractional flow reserve (FFR) has been introduced as an objective index to determine the significance of a coronary stenosis with a positive impact on clinical outcomes has been demonstrated for FFR-guided coronary interventions. However, several technical drawbacks have been pointed out in clinical practice limiting the diffusion of FFR worldwide. To exceed these limits, other indices and the quantitative flow ratio (QFR) have been recently developed and tested in clinical studies. Areas covered: This review aims to provide a brief overview of functional assessment of coronary stenosis and a particular attention to the QFR, to its validation and application studies for its potential applicability in clinical practice. QFR through a computational fluid dynamic analysis, proved to be useful in discriminating functionally significant stenosis, with an excellent correlation with FFR values, and considerable advantages in terms of acquisition time and costs. Expert opinion/commentary: QFR is an innovative angiographic-based technique that uses modern software for three-dimensional vessel reconstruction, and flow models calculation. The significant technical benefits reported in the management of patients with intermediate coronary stenosis, make it a modern, effective and usable tool.
TL;DR: This review discusses technical, patient-level, and reader-level sources of variability in ASPECTS reading; relevant concepts in the psychology of medical image perception; and potential interventions likely to improve inter- and intra-rater reliability.
Abstract: Introduction: The Alberta Stroke Program Early CT Score on non-contrast CT is a key component of prognostication and treatment selection in acute stroke care. Previous findings show that the reliab...
TL;DR: This review will discuss the current surgical treatment modalities and emerging transcatheter interventions in the management of TR, the pathophysiology of functional tricuspid regurgitation (FTR), and the new 2017 ESC/EACTS guidelines for the Management of TR.
Abstract: Introduction: Tricuspid valve regurgitation (TR) is frequently encountered and is most often functional (FTR) in nature. Surgical tricuspid valve (TV) treatment is well established in specialized c...
TL;DR: This review discusses emerging roles for spectrin in cardiac myocytes and other metazoan cells and suggests that the integrity of the actin/spectrin cytoskeleton is critical for canonical signaling of pathways involved in cellular response to stress.
Abstract: INTRODUCTION In the heart, pathways that transduce extracellular environmental cues (e.g. mechanical force, inflammatory stress) into electrical and/or chemical signals at the cellular level are critical for the organ-level response to chronic biomechanical/neurohumoral stress. Specifically, a diverse array of membrane-bound receptors and stretch-activated proteins converge on a network of intracellular signaling cascades that control gene expression, protein translation, degradation and/or regulation. These cellular reprogramming events ultimately lead to changes in cell excitability, growth, proliferation, and/or survival. Areas covered: The actin/spectrin cytoskeleton has emerged as having important roles in not only providing structural support for organelle function but also in serving as a signaling 'superhighway,' linking signaling events at/near the membrane to distal cellular domains (e.g. nucleus, mitochondria). Furthermore, recent work suggests that the integrity of the actin/spectrin cytoskeleton is critical for canonical signaling of pathways involved in cellular response to stress. This review discusses these emerging roles for spectrin and consider implications for heart function and disease. Expert commentary: Despite growth in our understanding of the broader roles for spectrins in cardiac myocytes and other metazoan cells, there remain important unanswered questions, the answers to which may point the way to new therapies for human cardiac disease patients.
TL;DR: In this study, intraoperative treatment of SVGs with DuraGraft was associated with a lower risk of long-term adverse events suggesting that efficient intraoperative SVG treatment may reduce VGF-related complications post-CABG.
Abstract: Background: Saphenous vein grafts (SVGs) remain the most often used conduits for coronary bypass grafting (CABG). Progressive intimal hyperplasia contributes to vein-graft disease and vein-graft failure (VGF). We compared the impact of intraoperative preservation of SVGs in a storage solution (DuraGraft®) versus heparinized saline on VGF-related outcomes after CABG.Methods: From 1996 to 2004, 2436 patients underwent isolated CABG with ≥ 1 SVG. SVGs were consecutively treated with DuraGraft in 1036 patients (2001−2004) and heparinized saline in 1400 patients (1996−1999). Short- (< 30 days) and long-term (≥ 1000 days) outcomes were assessed using repeat revascularization (primary end point), and major adverse cardiac events (MACE) consisting of the composite of death, nonfatal myocardial infarction, or repeat revascularization.Results: Mean follow-up in the DuraGraft group was 8.5 ± 4.2 years and 9.9 ± 5.6 years in controls. Short-term event rates were low and generally did not differ between groups...
TL;DR: Regular and adequate level of physical activity and/or exercise training, and sufficient nutritional intake or special nutritional supplementation may represent the best strategy for prevention or delay of sarcopenia and worsening physical performance in patients with HF.
Abstract: Sarcopenia is a common feature, and affects 20-47% of patients with heart failure (HF). Sarcopenia is also an independent predictor of impaired functional capacity, even after adjusting for clinical relevant variables, which is associated with adverse outcome in patients with HF. Areas covered: Several different pathophysiological pathways are involved in sarcopenic processes including altered nutrient intake and absorption, hormonal factor, inflammatory processes, oxidative stress, cellular proteolysis, and unhealthy lifestyle. Nutritional therapy, physical activity and/or exercise training have been associated with improved muscle mass or physical performance in HF. Few studies reported beneficial effects for muscle mass and physical performance, in those who received angiotensin-converting enzyme (ACE) inhibitors, or/and beta-blocker. In addition, testosterone, selective androgen receptor modulators, ghrelin agonist and myostatin inhibitors are currently under study as possible future therapeutic options. Expert commentary: Regular and adequate level of physical activity and/or exercise training, and sufficient nutritional intake or special nutritional supplementation may represent the best strategy for prevention or delay of sarcopenia and worsening physical performance in patients with HF. Maximal tolerated dosages of standard therapies for HF such as ACE-inhibitors or beta-blockers are first-line strategy, however it is difficult to recommend other pharmacological agents as part of routine treatment of sarcopenia.
TL;DR: P-wave duration is an ECG parameter that provides insight into the intricacies of the atria and could be a useful marker for assessing the risk for atrial fibrillation, but is not routinely reported on the printout of the electrocardiogram.
Abstract: Introduction: P-wave duration (PWD) is an electrocardiographic (ECG) marker reflecting atrial conduction, and studies have shown that its prolongation is associated with atrial fibrillation.Areas c...
TL;DR: Alternative transcatheter aortic valve implantation (TAVI) approaches offer the possibility of valve replacement in patients ineligible to the transfemoral route and comparative data to favor one approach over another is lacking and further research is warranted.
Abstract: INTRODUCTION Alternative transcatheter aortic valve implantation (TAVI) approaches offer the possibility of valve replacement in patients ineligible to the transfemoral route Authors provide an updated review of the existing alternative approaches Areas covered: A systematic review of alternative approaches for TAVI was undertaken The feasibility, safety, efficacy, and technical requirements of the transapical, transaortic, transcarotid, transsubclavian, and transcaval approaches have been compared A multislice computed tomography is often necessary for pre-operative planning Although the first developed, the transapical pathway tends to be abandoned because of its high morbidity Transaortic approach requires a mini-sternotomy or thoracotomy and general anesthesia limiting its' acceptance Transcarotid approach requires a mini-invasive surgical cutdown but is feasible under conscious sedation Registry data provided reassurance regarding the stroke risk with the transcarotid approach Transsubclavian pathway is recent and feasible percutaneously although necessitates additional complex maneuvers to avoid serious bleeding complications, which extends its' learning curve Transcaval approach is still experimental but may benefit from technological advances Expert commentary: The choice of the alternative approach dependents on patient anatomy and comorbidities, and local operator expertise and skills Transaortic, transcarotid and transsubclavian are nowadays used the most However, comparative data to favor one approach over another is lacking and further research is warranted
TL;DR: FFR-guided PCI has been demonstrated superior to an angiography- guided PCI and over medical therapy alone, and ongoing investigation will clarify whether it could perform better, or at least equalize the results of cardiac surgery in patients with severe multivessel disease.
Abstract: Introduction: The presence and extent of myocardial ischemia are the major determinants of prognosis in patients with coronary artery disease (CAD). Unlike coronary angiography alone, fractional fl...
TL;DR: Considering major bleeding as the predominant complication following LAAO, evidence suggests that short-term DAPT (6 weeks) or single antiplatelet therapy using aspirin may be a viable option.
Abstract: INTRODUCTION Interventional left atrial appendage occlusion (LAAO) has emerged as a valid alternative to oral anticoagulation (OAC) therapy for the prevention of ischemic stroke and systemic embolism in patients with non-valvular atrial fibrillation (AF). Areas covered: Antithrombotic therapy following interventional LAAO is critical in balancing the risk of thromboembolism and bleeding during the endothelialization of the implanted devices. In this article, the most recent clinical trials are reviewed and the current real-world antithrombotic strategies following LAAO device implantation are discussed. Expert commentary: For patients eligible for OAC and receiving a Watchman device, the most solid scientific evidence exists for warfarin plus aspirin for 45 days followed by dual antiplatelet therapy (DAPT) for 6 months and a lifelong aspirin therapy. In real-world most patients are being treated with DAPT for 3-6 months. Alternatively, the Watchman was approved for 3 months of novel OAC (NOAC) therapy in conjunction with aspirin. For all other devices, DAPT for 1-6 months has been used in the vast majority of cases. Considering major bleeding as the predominant complication following LAAO, evidence suggests that short-term DAPT (6 weeks) or single antiplatelet therapy using aspirin may be a viable option.
TL;DR: An up-to-date, evidence-based review of the understanding of Idiopathic systemic capillary leak syndrome and its management in the light of currently available evidence is provided.
Abstract: Introduction Idiopathic systemic capillary leak syndrome (SCLS) is a unique disorder characterized by episodes of massive systemic leak of intravascular fluid leading to volume depletion and shock. A typical attack of SCLS consists of prodromal, leak and post-leak phases. Complications, such as compartment syndrome and pulmonary edema, usually develop during the leak and post-leak phases respectively. Judicious intravenous hydration and early use of vasopressors is the cornerstone of management in such cases. Areas covered: The purpose of the present review is to provide an up-to-date, evidence-based review of our understanding of SCLS and its management in the light of currently available evidence. Commentary Idiopathic SCLS was first described in 1960 and, since then, more than 250 cases have been reported. A large number of cases have been reported over the past one decade, most likely due to improved recognition. In the acute care setting, most patients with SCLS are managed as per the Surviving Sepsis guidelines and receive aggressive volume resuscitation - which is not the optimal management strategy for such patients. There is a need to raise awareness amongst physicians and clinicians in order to improve recognition of this disorder and ensure its appropriate management.
TL;DR: It is found that significant numbers of moderate to high risk patients with AF are either undertreated or untreated placing them at increased risk of complications such as stroke.
Abstract: Introduction: Atrial fibrillation (AF) is the commonest persistent cardiac arrhythmia with an estimated incidence rate of between 1.5–2% and an important cause of strokes. Few epidemiological studi...
TL;DR: This review will discuss the current evidence and future development of hybrid aortic arch and frozen elephant trunk reconstruction, and the potential exists for hybrid approaches to arch pathology to completely supplant conventional surgery, while avoiding the potential deleterious complications of total endovascular repair.
Abstract: Introduction: Novel endovascular techniques hope to offer patients aortic arch repair with reduced morbidity compared to conventional arch surgery; however, current endovascular strategies remain challenged by the proximal seal zone, higher stroke rates, long-term durability and select anatomy. Hybrid arch repair offers patients a less invasive alternative that can treat more distal aorta than conventional arch repair yet still be performed via standard sternotomy.Areas covered: This review will discuss the current evidence and future development of hybrid aortic arch and frozen elephant trunk reconstruction. Several approaches to hybrid arch repair are summarized, including the off-label use of thoracic endovascular stent-grafts and commercially manufactured hybrid grafts. Technical considerations and clinical outcomes with each approach will be addressed along with advantages and disadvantages.Expert commentary: Hybrid arch repair will undergo continued refinement as our ability to provide a les...