Clinical Medicine Insights. Cardiology最新文献

Uraemic Cardiomyopathy (UC) is recognised as an intricate and multifactorial disease which portends a significant burden in patients with End-Stage Renal Disease (ESRD). The cardiovascular morbidity and mortality associated with UC is significant and can be associated with the development of arrythmias, cardiac failure and sudden cardiac death (SCD). The pathophysiology of UC involves a complex interplay of traditional implicative factors such as haemodynamic overload and circulating uraemic toxins as well as our evolving understanding of the Chronic Kidney Disease-Mineral Bone Disease pathway. There is an instrumental role for multi-modality imaging in the diagnostic process; including transthoracic echocardiography and cardiac magnetic resonance imaging in identifying the hallmarks of left ventricular hypertrophy and myocardial fibrosis that characterise UC. The appropriate utilisation of the aforementioned diagnostics in the ESRD population may help guide therapeutic approaches, such as pharmacotherapy including beta-blockers and aldosterone-antagonists as well as haemodialysis and renal transplantation. Despite this, there remains limitations in effective therapeutic interventions for UC and ongoing research on a cellular level is vital in establishing further therapies.

Cardiovascular disease is one of the most common causes of death with social factors increasingly recognized as determinants of cardiovascular prognosis. Homelessness, transient or chronic, may be one of the factors which predict treatment access and eventual outcomes as socially and economically disadvantaged group has high prevalence of cardiovascular risk factors such as smoking, and delayed diagnosis and poor control of other risk factors such as diabetes and hypertension. This perspective article aims to discuss the issues associated with cardiovascular disease treatment, outcomes and future directions for homeless patients.

The impact of coronavirus disease, 2019 (COVID-19), has been profound. Though COVID-19 primarily affects the respiratory system, it has also been associated with a wide range of cardiovascular (CV) manifestations portending extremely poor prognosis. The principal hypothesis for CV involvement is through direct myocardial infection and systemic inflammation. We conducted a systematic review of the current literature to provide a foundation for understanding the CV manifestations and outcomes of COVID-19. PubMed and EMBASE databases were electronically searched from the inception of the databases through 27 April 2020. A second literature review was conducted to include major trials and guidelines that were published after the initial search but before submission. The inclusion criteria for studies to be eligible were case reports, case series, and observation studies reporting CV outcomes among patients with COVID-19 infection. This review of the current COVID-19 disease and CV outcomes literature revealed a myriad of CV manifestations with potential avenues for treatment and prevention. Future studies are required to understand on a more mechanistic level the effect of COVID-19 on the myocardium and thus provide avenues to improve mortality and morbidity.

Background: Inflammatory bowel diseases (IBD) associated-chronic inflammation and autonomic dysregulation may predispose to arrhythmias. However, its exact prevalence is unknown. Thus, we aimed to ascertain the prevalence of arrhythmias in patients with IBD.

Methods: We queried the Nationwide Inpatient Sample (the largest publicly available all-payer inpatient USA database) from 2012 to 2014. We used the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM) discharge codes to identify adult patients (⩾18 years) with IBD and dysrhythmias (supraventricular tachycardia (SVT), atrial fibrillation, atrial flutter, ventricular tachycardia (VT), or ventricular fibrillation). Furthermore, we identified risk factors for cardiovascular disease. We divided patients into 2 cohorts, IBD cohorts, and non-IBD cohort. The independent effect of a diagnosis of IBD on the risk of dysrhythmias was examined using a multivariable logistic regression model controlling for multiple confounders.

Results: We identified 847 235 and 84 757 349 weighted hospitalizations among patients with IBD and non-IBD cohorts, respectively. Patients with IBD were less likely to be hospitalized for dysrhythmias than the non-IBD (9.7% vs 14.2%, P < .001). The hospitalization odds for dysrhythmias among patients with IBD were less than the general population (OR 0.87; 95% CI 0.85-0.88). However, the prevalence of SVT and VT was indifferent between the 2 groups. Male sex, age of over 60, and white race were risk factors for dysrhythmias.

Conclusion: Despite prior reports of a higher prevalence of arrhythmias among patients with IBD, in a nationwide inpatient database, we found lower rates of hospitalization-related-arrhythmias in the IBD population compared to that of the general population.

Neuroendocrine tumors (NETs, originally termed "carcinoids") create a relatively rare group of neoplasms with an approximate incidence rate of 2.5 to 5 cases per 100 000 persons. Roughly 30% to 40% of subjects with NETs develop carcinoid syndrome (CS), and 20% to 50% of subjects with CS are diagnosed with carcinoid heart disease (CaHD). The long-standing exposure to high serum serotonin concentration is one of the crucial factors in CaHD development. White plaque-like deposits on the endocardial surface of heart structures with valve leaflets and subvalvular apparatus thickening (fused and shortened chordae; thickened papillary muscles) are characteristic for CaHD. NT pro-BNP and 5-hydroxyindoleacetic acid are the 2 most useful screening markers. Long-acting somatostatin analogs are the standard of care in symptoms control. They are also the first-line treatment for tumor control in subjects with a metastatic somatostatin receptor avid disease. In cases refractory to somatostatin analogs, several options are available. We can increase a somatostatin analog to off-label doses, add telotristat ethyl or administer peptide receptor radionuclide therapy. Cardiac surgery, which mainly involves valve replacement, is presently the most efficient strategy in subjects with advanced CaHD and can relieve unmanageable symptoms or be partly responsible for better prognosis.

Cardiac Amyloidosis is an infiltrative cardiomyopathy which occurs secondary to deposition of mis-folded protein in the myocardium, with the two most common subtypes being AL amyloidosis and TTR amyloidosis. The pathogenesis of the disease is multifaceted and involves a variety of mechanisms including an inflammatory response cascade, oxidative stress and subsequent separation of myocyte fibrils. Cardiac Amyloidosis frequently results in congestive cardiac failure and arrhythmias, from a disruption in cardiac substrate with subsequent electro-mechanical remodelling. Disease progression is usually demonstrated by development of progressive pump failure, which may be seen with a high arrhythmic burden, usually portending a poor prognosis. There is a paucity of literature on the clinical implications of ventricular arrhythmias in the context of cardiac amyloidosis. The important diagnostic investigations for these patients include transthoracic echocardiography, cardiac magnetic resonance imaging and an electrophysiology study. Whilst there are no robust management guidelines, studies have indicated benefits from contemporary pharmacological therapy and case-by-case catheter ablation. There are novel directed therapies available for TTR amyloidosis that have shown to improve overall survival. The role of ICD therapy in cardiac amyloidosis is controversial, with benefits seen predominantly in early phases of the disease process. The only definitive surgical therapy includes heart transplantation, but is largely indicated for progressive decompensated heart failure (Figure 1). Further large-scale studies are required to better outline management paradigms for treating ventricular arrhythmias in cardiac amyloidosis.

Aortic valve replacement is the commonest cardiac surgical operation performed worldwide for infective endocarditis (IE). Long-term durability and avoidance of infection relapse are goals of the procedure. However, no detailed guidelines on prosthesis selection and surgical strategies guided by the comprehensive evaluation of the extension of the infection and its microbiological characteristics, clinical profile of the patient, and risk of infection recurrence are currently available. Conventional mechanical or stented xenografts are the preferred choice for localized aortic infection. However, in cases of complex IE with the involvement of the root or the aortomitral continuity, the use of homograft is suggested according to the surgeon and center experience. Homograft use should be counterbalanced against the risk of structural degeneration. Prosthetic bioroot or prosthetic valved conduit (mechanical and bioprosthetic) are also potentially suitable alternatives. Further development of preservation techniques enabling longer durability of allogenic substitutes is required. We evaluate the current evidence for the use of valve substitutes in aortic valve endocarditis and propose an evidence-based algorithm to guide the choice of therapy. We performed a systemic review to clarify the contemporary surgical management of aortic valve endocarditis.

Artificial intelligence (AI)-based applications have found widespread applications in many fields of science, technology, and medicine. The use of enhanced computing power of machines in clinical medicine and diagnostics has been under exploration since the 1960s. More recently, with the advent of advances in computing, algorithms enabling machine learning, especially deep learning networks that mimic the human brain in function, there has been renewed interest to use them in clinical medicine. In cardiovascular medicine, AI-based systems have found new applications in cardiovascular imaging, cardiovascular risk prediction, and newer drug targets. This article aims to describe different AI applications including machine learning and deep learning and their applications in cardiovascular medicine. AI-based applications have enhanced our understanding of different phenotypes of heart failure and congenital heart disease. These applications have led to newer treatment strategies for different types of cardiovascular diseases, newer approach to cardiovascular drug therapy and postmarketing survey of prescription drugs. However, there are several challenges in the clinical use of AI-based applications and interpretation of the results including data privacy, poorly selected/outdated data, selection bias, and unintentional continuance of historical biases/stereotypes in the data which can lead to erroneous conclusions. Still, AI is a transformative technology and has immense potential in health care.