Heart failure with preserved ejection fraction (HFpEF) is a disease with a high prevalence. Accounting for more than 50% of all heart failure cases, it carries a significant mortality. There is a ...lack of therapeutic options that show improvement in morbidity and mortality. Certain novel therapies have shown a decrease in heart failure hospitalizations; however, this beneficial effect was more pronounced for heart failure patients with mildly reduced ejection fraction (EF).
This review summarizes the pathophysiology of the disease to help elucidate the differences between heart failure with reduced ejection fraction (HFrEF), and HFpEF, which could explain why therapies are successful in one (rather than the other). This review focuses on non-standardized nomenclature across major trials, the challenges of finding a therapeutic agent for such a heterogeneous population, and identification of specific phenotypes that have different outcomes and could be a target for future therapies.
Lack of standardized diagnostic criteria, associated with population heterogeneity, might explain why trials have failed to improve outcomes for patients with HFpEF. Standardizing phenotypes, recapitulating these phenotypes in animal models, and understanding the mechanisms of the disease at the molecular level could be the first steps in identifying promising therapeutic options.
Importance of the field: It is important to know which patients with hypertension will benefit from beta-blocker therapy and which beta-blockers should be used in the treatment of hypertension to ...reduce cardiovascular events and mortality.
Areas covered in this review: Studies between 1981 and 2009 using a Medline search are reported. Beta-blockers should be used to treat hypertension in patients with previous myocardial infarction, acute coronary syndromes, angina pectoris, congestive heart failure, ventricular arrhythmias, supraventricular tachyarrhythmias, diabetes mellitus, after coronary artery bypass graft surgery, and in patients who are pregnant, have thyrotoxicosis, glaucoma, migraine, essential tremor, perioperative hypertension, or an excessive blood pressure response after exercise.
What the reader will gain: The use of beta-blockers as first-line therapy in patients with primary hypertension has been controversial. However, the 2009 guidelines of the European Society of Hypertension state that large-scale meta-analyses of available data confirm that diuretics, beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and calcium channel blockers do not significantly differ in their ability to lower blood pressure and to exert cardiovascular protection both in elderly and in younger patients.
Take home message: The key message of this paper is that atenolol should not be used as an antihypertensive drug and that the degree of reduction of mortality, myocardial infarction, stroke and congestive heart failure by antihypertensive therapy is dependent on the degree of lowering of aortic blood pressure. Newer vasodilator beta-blockers such as carvedilol and nebivolol may be more effective in reducing cardiovascular events than traditional beta-blockers, but this needs to be investigated by controlled clinical trials.
The use of intravascular ultrasound (IVUS) guidance to facilitate stent implantation has been demonstrated to reduce major adverse cardiovascular events (MACE), predominantly due to a reduction in ...target lesion revascularization (TLR). The objectives of our meta-analysis are to assess the effect of IVUS on clinical outcomes, including cardiovascular mortality.
RCTs comparing drug-eluting stent (DES) implantation using IVUS plus angiography versus angiography alone were identified from a comprehensive search in PubMed, Embase, and Cochrane library. Pooled relative risks (RR) were obtained using DerSimonian and Laird estimator for the random effects model.
The search yielded 10 RCTs (5007 participants) in which the relevant data were available. Two trials were performed in patients with chronic total occlusion (CTO), whereas other trials included patients that either had stable ischemic heart disease (22–64%) or presented as an acute coronary syndrome (ACS) (36–78%). Routine use of IVUS was effective in reducing TLR (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.44, 0.80; p < 0.01), target vessel revascularization (TVR) (RR 0.59, 95% CI 0.43, 0.81; p < 0.01), and MACE (RR 0.63, 95% CI 0.51, 0.77; p < 0.01). Cardiovascular mortality was also significantly reduced (RR 0.51, 95% CI 0.27, 0.96; p = 0.04).
During DES implantation, the routine use of IVUS in addition to angiography improves clinical outcomes, including cardiovascular mortality. These findings reinforce the need for a broader implementation of IVUS-guidance during PCI. Since a significant proportion of patients studied presented as ACS, future trials should assess the benefit of IVUS-guidance in a more focused presentation setting.
•Pooled analysis of latest randomized trials shows that IVUS-guided stent implantation reduces cardiovascular mortality•IVUS seems to be beneficial when instituted as an all-comers strategy•Role of IVUS-guided stenting needs to be assessed in angiographically low-risk coronary lesions
There has been strong evidence of myocardial injury in COVID-19 patients with significantly elevated serum cardiac troponin (cTn). While the exact mechanism of injury is unclear, possible suggested ...pathological mechanisms of injury are discussed. These include increased susceptibility of the myocardium and endothelium to viral invasion, underlying hyperinflammatory state and subsequent cytokine storm, a hypercoagulable and prothrombotic state, and indirect myocardial injury due to hypoxemia. As a result of these pathological mechanisms in COVID-19 patients, cTn may be elevated largely due to myocarditis, microangiopathy or myocardial infarction. The utility of cTn as a biomarker for measuring myocardial injury in these patients and assessing its ability as a prognostic factor for clinical outcome is also discussed.
Nonvalvular atrial fibrillation (AF) is a common rhythm disorder of middle-aged to older adults that can cause ischemic strokes and systemic embolism. Stroke prevention is a crucial aspect of ...management, considering the increasing AF population and the associated morbidity and mortality. The left atrial appendage (LAA) has been identified as a predominant source of AF-associated thrombus and stroke, with at least 90% of the thrombi originating from this anatomical structure. Lifelong use of oral anticoagulants reduces the risk of these ischemic events but increases the risk of major and clinically relevant hemorrhages. In addition, these medications also require strict compliance for efficacy and have high failure rates in higher-risk patients. LAA occlusion (LAAO) has emerged as an alternative strategy for stroke prevention with encompassing various percutaneous and surgical techniques. Randomized controlled trials evaluating this intervention have shown promising results in stroke reduction replacing anticoagulation therapy. In this review, we aim to provide a comprehensive overview on the anatomy of the LAA and its role in thrombus formation, the emergence of various LAAO techniques and devices, and provide evidence on the role of LAAO in the reduction of stroke risk among patients with nonvalvular AF.
Mineralocorticoid receptor stimulation by aldosterone can cause various cardiovascular and renal disease complications. Finerenone is a new oral nonsteroidal mineralocorticoid receptor antagonist ...that has been approved for clinical use by the Federal Drug Aministration, and has been shown in clinical trials to reduce the risk of sustained estimated glomerular filtration rate decline, end-stage renal disease, nonfatal myocardial infarction, hospitalization for heart failure and cardiovascular death in adult patients with chronic kidney disease associated with type 2 diabetes. The drug has also been shown to have fewer side effects than the steroidal mineralocorticoid receptor antagonists like spironolactone and eplerenone. In this review article, the authors will discuss the clinical pharmacology of finerenone, its clinical application and the additional studies that are now underway to further assess the efficacy of the drug in diabetic patients having cardiac and renal disease.
National guidelines recommend that systolic blood pressure (SBP) in patients with heart failure with reduced ejection fraction (HFrEF) and hypertension be maintained below 130 mm Hg.
This study ...sought to determine associations of SBP <130 mm Hg with outcomes in patients with HFrEF.
Of the 25,345 patients in the Medicare-linked OPTIMIZE-HF registry, 10,535 had an ejection fraction (EF) ≤40%. Of these, 5,615 had stable SBP (≤20 mm Hg admission to discharge variation), and 3,805 (68%) had a discharge SBP <130 mm Hg. Propensity scores for SBP <130 mm Hg, estimated for each of the 5,615 patients, were used to assemble a matched cohort of 1,189 pairs of patients with SBP <130 versus ≥130 mm Hg, balanced on 58 baseline characteristics (mean age 76 years; mean EF 28%, 45% women, 13% African American). This process was repeated in 3,946 patients, after excluding 1,669 patients (30% of 5,615) with a discharge SBP <110 mm Hg and assembled a second matched balanced cohort of 1,099 pairs of patients with SBP 110 to 129 mm Hg versus ≥130 mm Hg.
Thirty-day all-cause mortality occurred in 7% and 4% of matched patients with SBP <130 mm Hg versus ≥130 mm Hg, respectively (hazard ratio HR: 1.76; 95% confidence interval CI: 1.24 to 2.48; p = 0.001). HRs (95% CIs) for all-cause mortality, all-cause readmission, and HF readmission at 1 year, associated with SBP <130 mm Hg, were 1.32 (1.15 to 1.53; p < 0.001), 1.11 (1.01 to 1.23; p = 0.030), and 1.24 (1.09 to 1.42; p = 0.001), respectively. HRs (95% CIs) for 30-day and 1-year all-cause mortality associated with SBP 110 to 129 mm Hg (vs. ≥130 mm Hg) were 1.50 (1.03 to 2.19; p = 0.035), and 1.19 (1.02 to 1.39; p = 0.029), respectively.
Among hospitalized older patients with HFrEF, SBP <130 mm Hg is associated with poor outcomes. This association persisted when the analyses were repeated after excluding patients with SBP <110 mm Hg. There is an urgent need for randomized controlled trials to evaluate optimal SBP reduction goals in patients with HFrEF.
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The advancement of medical treatment and surgical technique, along with the invention of cardiopulmonary bypass, has allowed for long-term survival of patients with cyanotic congenital heart disease ...(CHD)-with many women with CHD now reaching child-bearing age and wishing to become pregnant. Pregnancy in these women is a major concern as the physiologic adaptations of pregnancy, including an increased circulating volume, increased cardiac output, reduced systemic vascular resistance, and decreased blood pressure, place a substantial load on the cardiovascular system. These changes are essential to meet the increased maternal and fetal metabolic demands and allow for sufficient placental circulation during gestation. However, in women with underlying structural heart conditions, they place an additional hemodynamic burden on the maternal body. Overall, with appropriate risk stratification, pre-conception counseling, and management by specialized cardiologists and high-risk obstetricians, most women with surgically corrected CHDs are expected to carry healthy pregnancies to term with optimization of both maternal and fetal risks. In this article, we describe the current understanding of 5 cyanotic CHDs-Tetralogy of Fallot, Transposition of the Great Arteries, Truncus Arteriosus, Ebstein's Anomaly, and Eisenmenger Syndrome-and explore the specific hemodynamic consequences, maternal and fetal risks, current guidelines, and outcomes of pregnancy in women with these conditions.
Severe tricuspid regurgitation (TR) is an underrated, common pathology that affects over 70 million individuals worldwide. Traditionally, TR has been managed with diuretic therapies without any ...significant mortality benefit. The underlying cause of TR can be primary, coming from structural issues with tricuspid valve and more commonly secondary, arising from conditions affecting the right ventricle or the pulmonary circulation. Management of TR has seen few improvements until recently. Traditionally, valve replacement and surgical repair were the therapeutic options available. Tricuspid valve is a complex cardiac structure with many technical challenges for surgical intervention. Transcatheter valve interventions have proven to be safe and effective novel therapeutic options for severe TR, which reduce the severity of TR with associated improvement in quality of life. In this review, we will provide an overview of the management of severe TR utilizing transcatheter edge-to-edge repair with the TriClip device (Abbott, Santa Clara, CA).
Atrial fibrillation (AF) is the most common cardiac arrhythmia responsible for significant morbidity and mortality. Its burden on patients and the health care system is only expected to increase. ...Several studies have established a dose-response relationship between the amount and frequency of alcohol consumption and the incidence of new onset AF independent of sex, age, and other risk factors. This causal relationship is mediated by the impact alcohol consumption has on conduction properties of the atrium, structural and cellular effect on cardiac myocytes, and dysregulation of the autonomic nervous system. This article reviews the current literature supporting the link between alcohol consumption and AF while attempting to provide an insight into pathophysiological mechanisms.
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