The most common use of inotropes is among hospitalized patients with acute decompensated heart failure, with reduced left ventricular ejection fraction and with signs of end-organ dysfunction in the ...setting of a low cardiac output. Inotropes can be used in patients with severe systolic heart failure awaiting heart transplant to maintain hemodynamic stability or as a bridge to decision. In cases where patients are unable to be weaned off inotropes, these agents can be used until a definite or escalated supportive therapy is planned, which can include coronary revascularization or mechanical circulatory support (intra-aortic balloon pump, extracorporeal membrane oxygenation, impella, left ventricular assist device, etc.). Use of inotropic drugs is associated with risks and adverse events. This review will discuss the use of the inotropes digoxin, dopamine, dobutamine, norepinephrine, milrinone, levosimendan, and omecamtiv mecarbil. Long-term inotropic therapy should be offered in selected patients. A detailed conversation with the patient and family shall be held, including a discussion on the risks and benefits of use of inotropes. Chronic heart failure patients awaiting heart transplants are candidates for intravenous inotropic support until the donor heart becomes available. This helps to maintain hemodynamic stability and keep the fluid status and pulmonary pressures optimized prior to the surgery. On the other hand, in patients with severe heart failure who are not candidates for advanced heart failure therapies, such as transplant and mechanical circulatory support, inotropic agents can be used for palliative therapy. Inotropes can help reduce frequency of hospitalizations and improve symptoms in these patients.
Modifiable risk factors (RFs) play an important role in the development and prognosis of acute myocardial infarction (AMI).
This study sought to study the prevalence rates of modifiable RFs during a ...first AMI, sex/race differences, and temporal trends in U.S. young adults.
This was a retrospective cohort analysis of the U.S. National Inpatient Sample years 2005 and 2015 to identify adults 18 to 59 years of age hospitalized for a first AMI. Prevalence rates, race and sex differences, and temporal trends of hypertension, diabetes mellitus, obesity, smoking, dyslipidemia, and drug abuse were analyzed in these patients.
The authors’ study included 1,462,168 young adults with a first AMI (mean age 50 ± 7 years, 71.5% men, 58.3% white) of whom 19.2% were 18 to 44 years of age, and 80.8% were 45 to 59 years of age. In the 18- to 44-year group, smoking (56.8%), dyslipidemia (51.7%), and hypertension (49.8%) were most prevalent, and 90.3% of patients had at least 1 RF. In the 45- to 59-year group, hypertension (59.8%), dyslipidemia (57.5%), and smoking (51.9%) were most prevalent, and 92% patients had at least 1 RF. Significant sex and racial disparities were observed in the prevalence of individual RFs. Women had a higher prevalence of diabetes mellitus, hypertension, and obesity, and men had a higher prevalence of dyslipidemia, drug abuse, and smoking. The prevalence of all these RFs increased temporally except for the rate of dyslipidemia, which decreased more recently. Trends were generally consistent across sex and racial groups.
During a first AMI in young adults in whom preventive measures are more likely to be effective, modifiable RFs were highly prevalent and progressively increased over time. Significant sex and racial disparities were observed for individual RFs.
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Interest in evaluation of the right ventricle (RV) has increased recently. With the growth of new echocardiographic techniques and technology, there has been a corresponding increase in the ability ...to evaluate the RV, both qualitatively and quantitatively. Older echocardiographic techniques, such as right ventricular fractional area of change, tricuspid annular plane systolic excursion, and tissue S′, and newer echocardiographic techniques including 3‐dimensional evaluation and global longitudinal strain, can improve our evaluation of RV function. These techniques provide both diagnostic and prognostic data on a large variety of clinical diseases including pulmonary hypertension and congestive heart failure. With the continuing and exponential advances in technology, echocardiography is well poised to become the primary modality to evaluate the RV.
Background
Limited information is available on the contemporary and potentially changing trends in the incidence, management, and outcomes of cardiogenic shock complicating ST‐elevation myocardial ...infarction (STEMI).
Methods and Results
We queried the 2003–2010 Nationwide Inpatient Sample databases to identify all patients ≥40 years of age with STEMI and cardiogenic shock. Overall and age‐, sex‐, and race/ethnicity‐specific trends in incidence of cardiogenic shock, early mechanical revascularization, and intra‐aortic balloon pump use, and inhospital mortality were analyzed. From 2003 to 2010, among 1 990 486 patients aged ≥40 years with STEMI, 157 892 (7.9%) had cardiogenic shock. The overall incidence rate of cardiogenic shock in patients with STEMI increased from 6.5% in 2003 to 10.1% in 2010 (Ptrend<0.001). There was an increase in early mechanical revascularization (30.4% to 50.7%, Ptrend<0.001) and intra‐aortic balloon pump use (44.8% to 53.7%, Ptrend<0.001) in these patients over the 8‐year period. Inhospital mortality decreased significantly, from 44.6% to 33.8% (Ptrend<0.001; adjusted OR, 0.71; 95% CI, 0.68 to 0.75), whereas the average total hospital cost increased from $35 892 to $45 625 (Ptrend<0.001) during the study period. There was no change in the average length of stay (Ptrend=0.394). These temporal trends were similar in patients <75 and ≥75 years of age, men and women, and across each racial/ethnic group.
Conclusions
The incidence of cardiogenic shock complicating STEMI has increased during the past 8 years together with increased use of early mechanical revascularization and intra‐aortic balloon pumps. There has been a concomitant decrease in risk‐adjusted inhospital mortality, but an increase in total hospital costs during this period.
Immune checkpoint inhibitors (ICIs) have been an important therapeutic advance in the field of cancer medicine, resulting in a significant improvement in survival of patients with advanced ...malignancies. Recent reports provided greater insights into the incidence of cardiovascular adverse events (CVAEs) with ICI use. Myocarditis is the most common CVAE associated with ICI. Pericardial diseases, Takotsubo syndrome, arrhythmias, and vasculitis constitute other significant AEs. Physicians should be aware of these infrequent, but potentially fatal toxicities associated with ICIs as their therapeutic use becomes widespread with a myriad of approvals by the U.S. Food and Drug Administration. Management involves prompt administration of high-dose corticosteroids and discontinuation of ICIs in severe myocarditis. This review summarizes the most updated evidence on epidemiology, pathophysiological mechanisms, and management strategies of various CVAEs associated with ICIs. Highlights from recent guidelines published by National Comprehensive Cancer Network on ICI-related CV toxicities have also been incorporated.
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