Cardiology in Review最新文献

Iron is an essential micronutrient for abounding physiological processes in the body, and its deficiency can be caused by various factors, such as low iron intake due to economic difficulties or loss of appetite, decreased iron absorption due to gastrointestinal issues, or increased iron loss due to hemorrhages or proteinuria. Iron deficiency is a prevalent issue among heart failure (HF) patients and is a significant contributor to anemia, affecting 30-50% of patients regardless of their gender, ethnicity, or left ventricular ejection fraction. Individuals with HF have high levels of pro-inflammatory cytokines, which can inhibit erythropoiesis by degrading the membrane iron exporter ferroportin, mediated by an increased release of hepcidin. In addition, elevated sympathetic and renin-angiotensin-aldosterone system activity retains salt and water, resulting in high cardiac output HF in people with normal left ventricular function. This review provides an overview of iron deficiency and HF.

Breast cancer is one of the leading causes of malignancy affecting women in the United States. Although many effective treatments are available, most come with notable side effects that providers and patients must take into consideration. Various classes of chemotherapeutic agents, including anthracyclines and human epidermal growth factor receptor-2 antagonists, are known to be toxic to myocardial tissue. In this review article, we discuss what is reported in the literature regarding the cardiotoxicity of these agents as well as how to monitor and prevent cardiac injury and dysfunction.

Acute decompensated heart failure (ADHF) is a multifactorial process that is associated with high morbidity and mortality. Treatment with inotropes can rapidly improve hemodynamic status; however, their use has been associated with increased mortality and incidence of arrhythmias. Istaroxime is a first-in-class intravenous agent currently undergoing clinical trials for acute heart failure. It has the unique mechanism of action of both Na + /K + ATPase inhibition and sarcoplasmic/endoplasmic reticulum Ca2+ ATPase 2a stimulation. Notably, its action on sarcoplasmic/endoplasmic reticulum Ca2+ ATPase 2a improves calcium handling, which is known to be abnormal in heart failure. Clinical trials have shown that istaroxime has beneficial hemodynamic effects; in particular, its ability to increase systolic blood pressure without causing significant increases in heart rate or clinically significant arrhythmias differentiates it from inotropes currently utilized for ADHF treatment, such as milrinone. While initial studies are encouraging, additional trials are needed to assess outcomes and to compare their performance to standard inotropes in patients hospitalized with ADHF. This article will review the relevant preclinical and clinical trials for istaroxime, as well as the relevant pharmacology.

Resistant hypertension (RH) is the state of uncontrolled blood pressure in the face of ostensibly optimal pharmacological intervention. It accounts for roughly one in six cases of hypertension, and is associated with more severe morbidity and mortality outcomes than is non-RH. The prevalence of RH implies a currently unmanaged pathology, which may involve the potent vasoconstrictor endothelin. Several endothelin receptor antagonists are currently marketed for pulmonary arterial hypertension, but none so far has been marketed for RH. Aprocitentan is currently in development, an endothelin receptor antagonist that effectively produces clinically significant and sustained decreases in systolic and diastolic blood pressure in the setting of RH.

Ischemic heart disease is the leading cause of mortality and morbidity in the Western world. Thus, coronary artery bypass graft is the most common cardiac procedure performed as it remains the gold standard for multiple vessel disease and left main disease. Long saphenous vein is the conduit of choice for coronary artery bypass graft as it is accessible and easy to harvest. Over the previous 4 decades, several techniques have emerged to optimize harvesting and reducing adverse clinical outcomes. The most cited techniques are open vein harvesting, no-touch technique, endoscopic vein harvesting, and standard bridging technique. In this literature review, we aim to summarize current literature for each of the 4 techniques in terms of: (A) graft patency and attrition, (B) myocardial infarction and revascularization, (C) wound infections, (D) postoperative pain, and (E) patient satisfaction.

The use of nondihydropyridine calcium channel blockers (NDCCBs) to achieve rate control in atrial fibrillation with the rapid ventricular rate (AF RVR) is not recommended in patients with comorbid heart failure with reduced ejection fraction (HFrEF) due to the concern for further blunting of contractility. However, these recommendations are extrapolated from data examining chronic NDCCB use in HFrEF patients, and comorbid AF was not analyzed. These recommendations also do not cite the hemodynamic effects or clinical outcomes of NDCCBs for acute rate control in HFrEF patients with AF RVR. It is our goal to open the discussion concerning the hemodynamic effects and safety profile of NDCCBs for acute rate control in this specific patient population. In the acute setting of AF RVR and HFrEF, there is a paucity of low-quality data on the safety and hemodynamic effects of NDCCBs, with mixed results. There has not been a clear signal toward adverse outcomes with NDCCBs, particularly for diltiazem. Data in this scenario is similarly limited for beta blockers, which provide the additional hemodynamic effect of the neurohormonal blockade, which provides a long-term mortality benefit to HFrEF patients. We support the cautious use of beta blockers as first-line therapy in clinical settings where an acute rate control strategy for AF RVR is warranted. We also support diltiazem as a reasonable second-line option, though the relative paucity of data calls for further research to validate this conclusion. Verapamil in this setting should be avoided until more data are available.

There has been ongoing debate about whether to continue or withhold angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in patients undergoing noncardiac surgery. With over 200 million surgeries performed annually worldwide and millions of patients on ACE inhibitors and ARBs, it is crucial to elucidate the best management strategy for patients undergoing noncardiac surgery while on these medications. Several large randomized controlled trials, the Stop-or-Not and the Perioperative Ischemic Evaluation-3 trials, were conducted to investigate this important issue. Both clinical trials demonstrated no difference in cardiovascular adverse events, including vascular death, myocardial injury, stroke, and cardiac arrest, with continuation versus discontinuation of ACE inhibitors or ARBs in patients undergoing noncardiac surgery. However, these clinical trials showed a higher incidence of intraoperative hypotension in patients who continued taking their ACE inhibitor or ARB through the surgery. Based on this evidence, the American College of Cardiology 2024 Perioperative Guidelines recommend that patients undergoing elevated-risk surgery should have their ACE inhibitor or ARB withheld 24 hours before the surgery; however, patients with heart failure with reduced ejection fraction undergoing noncardiac surgery should continue their regimen. Currently, while the evidence indicates no difference in adverse outcomes between continuing and discontinuing ACE inhibitors and ARBs in patients undergoing noncardiac surgery, the decision to continue or withhold these medications remains individualized. Clinicians must consider various patient and clinical factors when making this decision, including the type of surgery, the risk for intraoperative blood loss and hypotension, and the specific indication of the ACE inhibitor or ARB.

Sodium-glucose cotransporter-2 (SGLT2) inhibitors were originally approved for use in type 2 diabetes, but in recent years, these medications were found to also have significant cardiovascular benefits in patients with heart failure with reduced and preserved ejection fraction and chronic kidney disease. Part of the cardiovascular benefits of SGLT2 inhibitors likely comes from their antihypertensive effect in addition to other unknown effects, but the mechanism by which these medications reduce blood pressure has not been identified yet. Multiple mechanisms have been proposed to describe SGLT2 inhibitors' antihypertensive effect, including their associated weight loss and diuretic effect. However, studies have shown that these indirect mechanisms alone do not account for the antihypertensive effect seen with this medication, with more recent studies identifying a new potential mechanism by which SGLT2 inhibitors may derive their direct antihypertensive and cardiovascular benefits. In animal models, SGLT2 receptors were identified in parts of the brain responsible for regulating the sympathetic nervous system and adjusting blood pressure. In these studies, SGLT2 inhibitors suppressed the neuronal activity in these brain regions, reducing the sympathetic nervous system activity and blood pressure of the animals. Further investigation is needed to identify whether there are SGLT2 receptors in the central nervous system of humans and whether SGLT2 inhibitors can suppress neuronal activity in these brain regions. This information could be significant in learning more about the susceptibility and severity of primary hypertension in certain patient populations, as well as identifying whether SGLT2 inhibitors can be considered as a primary antihypertensive agent.

Syphilis is a disease caused by the spirochete bacterium Treponema pallidum, progressing in 4 stages: primary, secondary, latent, and tertiary syphilis. In the tertiary stage, patients may develop cardiovascular syphilis, which includes syphilitic aortitis, aortic aneurysm, aortic regurgitation, and coronary artery involvement. These cardiovascular manifestations increase morbidity and mortality during this late stage of syphilis. A recent large-scale, population-wide study has built on our knowledge of cardiovascular syphilis by identifying an increased risk for the development of acute myocardial infarction, heart failure, atrial fibrillation, ischemic stroke, hemorrhagic stroke, venous thromboembolism, and cardiovascular death in syphilis patients. This review discusses the incidence and pathophysiology of these various manifestations of cardiovascular syphilis, while also detailing the latest treatment options and the prognosis of these conditions. The clinical significance of this topic stems from the fact that the incidence of syphilis has spiked in recent years after previously reaching an all-time low in 1999. According to the Centers for Disease Control in the United States, from 2018 to 2022, the reported cases of syphilis increased by 80%. However, the incidence of cardiovascular syphilis has remained the same during this period, likely due to the efficacy of penicillin use early in the infection, preventing the progression of the disease to the tertiary stage. As a result, cardiovascular syphilis mostly remains a disease of the past, with only a few sporadic cases being reported in the literature in recent years.