Search

Several randomized controlled trials have studied the role of colchicine, a potent anti-inflammatory drug, to prevent adverse cardiovascular events in patients with coronary artery disease (CAD). In this meta-analysis, we aimed to determine the role of colchicine in patients with CAD in clinical outcomes and mortality. We searched PubMed, PubMed Central, Scopus, and Embase for randomized controlled trials/experimental studies evaluating the role of colchicine in patients with CAD. After assessing the eligibility for inclusion, risk-of-bias assessment, and data extraction from the included studies, a narrative synthesis was conducted. Of 17 studies included for the qualitative analysis, 11 studies reported that inflammatory markers such as C-reactive protein and cytokines were reduced in the colchicine group, suggesting an anti-inflammatory role of colchicine in CAD. Quantitative analysis with pooling of data from 9 studies using a fixed-effect model showed 28% lower odds of acute myocardial infarction [odds ratio (OR) 0.72, 95% CI 0.59-0.86; n = 11,712], 52% lower occurrence of stroke (OR 0.48, 95% CI 0.30-0.76), and 37% reduction in odds of coronary revascularization procedure in the colchicine group (OR 0.63, 95% CI 0.52-0.76; n= 11,258). However, the odds of gastrointestinal adverse events were 50% higher in the colchicine group (OR 1.50, 95% CI 1.01-2.23; n = 12,214). In conclusion, colchicine is associated with a lower risk of acute myocardial infarction, stroke, and coronary revascularization. However, there is some increased risk of gastrointestinal adverse events with the use of colchicine.

Sodium-glucose cotransporter-2 (SGLT-2) inhibitors showed benefit in patients with heart failure. In this updated meta-analysis, we evaluate the therapeutic efficacy and safety of SGLT-2 inhibitors in patients with heart failure. Different electronic databases were searched to find relevant articles. RevMan 5.4 was used for pooling data using a random/fixed-effects model, complemented by several sensitivity and subgroup analyses. A total of 13 randomized clinical trials including 14,618 patients with heart failure were included in analysis among 6797 studies screened. The overall mortality rate was 12.45% in the SGLT-2 group and 14.67% in the placebo group with 18% lower odds of overall mortality [odds ratio (OR), 0.82; confidence interval (CI), 0.75-0.91] in the SGLT-2 group. Odds of cardiovascular mortality was 18% lower (OR, 0.82; CI, 0.74-0.92) in the SGLT-2 group. The odds of hospitalization for heart failure (HHF) was 38% lower during the study period (OR, 0.62; CI, 0.56-0.68) in the SGLT-2 group. In addition, a benefit was seen for composite outcome HHF or mortality and considering subgrouping based on diabetes status, gender, and age groups. Although genital infection was significantly higher in the SGLT-2 group, the occurrence of severe adverse events, hypoglycemia, urinary tract infection, bone fracture, volume depletion, and other renal events did not differ between the 2 groups. Thus, SGLT-2 inhibitors improved cardiovascular outcomes among patients with heart failure with no significant difference in adverse events. Clinical benefit was comparable in diabetic and nondiabetic individuals, males and females, people in younger and older age groups with underlying heart failure, and HF with reduced ejection fraction.

Quadricuspid aortic valve, a rare congenital cardiac defect, manifests most commonly as aortic regurgitation. Clinical presentation mainly depends on the functional status of the aortic valve, myocardium and associated cardiovascular abnormalities. Aortic valve replacement or repair is usually warranted in the 5th or 6th decade.

(1) Background: The monkeypox virus (MPV) is a double-stranded DNA virus belonging to the Poxviridae family, Chordopoxvirinae subfamily, and Or-thopoxvirus genu. It was called monkeypox because it was first discovered in monkeys, in a Danish laboratory, in 1958. However, the actual reservoir for MPV is still unknown. (2) Methods & Results: We have reviewed the existing literature on the options for Monkeypox virus. There are three available vaccines for orthopoxviruses: ACAM2000, JYNNEOS, and LC16, with the first being a replicating vaccine and the latter being non or minimally replicating. (3) Conclusions: Smallpox vaccinations previously provided coincidental im-munity to MPV. ACAM2000(a live‐attenuated replicating vaccine) and JYNNEOS (a live‐attenuated, non-replicating vaccine) are two US FDA‐approved vaccines that can prevent monkeypox. However, ACAM2000 may cause serious side effects, including cardiac problems, whereas JYNNEOS is associated with fewer com-plications. The recent outbreaks across the globe have once again highlighted the need for constant monitoring and the development of novel prophylactic and therapeutic modalities. Based on available data, there is still a need to develop an effective and safe new generation of vaccines specific for monkeypox that are killed or mRNA before monkeypox is declared a pandemic.

(1) Background: The monkeypox virus (MPV) is a double-stranded DNA virus belonging to the Poxviridae family, Chordopoxvirinae subfamily, and Orthopoxvirus genus. It was called monkeypox because it was first discovered in monkeys, in a Danish laboratory, in 1958. However, the actual reservoir for MPV is still unknown. (2) Methods and Results: We have reviewed the existing literature on the options for Monkeypox virus. There are three available vaccines for orthopoxviruses—ACAM2000, JYNNEOS, and LC16—with the first being a replicating vaccine and the latter being non- or minimally replicating. (3) Conclusions: Smallpox vaccinations previously provided coincidental immunity to MPV. ACAM2000 (a live-attenuated replicating vaccine) and JYNNEOS (a live-attenuated, nonreplicating vaccine) are two US FDA-approved vaccines that can prevent monkeypox. However, ACAM2000 may cause serious side effects, including cardiac problems, whereas JYNNEOS is associated with fewer complications. The recent outbreaks across the globe have once again highlighted the need for constant monitoring and the development of novel prophylactic and therapeutic modalities. Based on available data, there is still a need to develop an effective and safe new generation of vaccines specific for monkeypox that are killed or developed into a mRNA vaccine before monkeypox is declared a pandemic.

Background: Outcomes following in-hospital cardiac arrest (IHCA) in patients with COVID-19 have been reported by several small single-institutional studies; however, there are no large studies contrasting COVID-19 IHCA with non-COVID-19 IHCA. The objective of this study was to compare the outcomes following IHCA between COVID-19 and non-COVID-19 patients. Methods: We searched databases using predefined search terms and appropriate Boolean operators. All the relevant articles published till August 2022 were included in the analyses. The systematic review and meta-analysis were conducted as per Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. An odds ratio with a 95% confidence interval (CI) was used to measure effects. Results: Among 855 studies screened, 6 studies with 27,453 IHCA patients (63.84% male) with COVID-19 and 20,766 (59.7% male) without COVID-19 were included in the analysis. IHCA among patients with COVID-19 has lower odds of achieving return of spontaneous circulation (ROSC) (OR: 0.66, 95% CI: 0.62–0.70). Similarly, patients with COVID-19 have higher odds of 30-day mortality following IHCA (OR: 2.26, 95% CI: 2.08–2.45) and have 45% lower odds of cardiac arrest because of a shockable rhythm (OR: 0.55, 95% CI: 0.50–0.60) (9.59% vs. 16.39%). COVID-19 patients less commonly underwent targeted temperature management (TTM) or coronary angiography; however, they were more commonly intubated and on vasopressor therapy as compared to patients who did not have a COVID-19 infection. Conclusions: This meta-analysis showed that IHCA with COVID-19 has a higher mortality and lower rates of ROSC compared with non-COVID-19 IHCA. COVID-19 is an independent risk factor for poor outcomes in IHCA patients.

Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia associated with high morbidity and mortality. AF treatment is guided by a patient–provider risk–benefit discussion regarding drug versus ablation or combination. Thermal ablation has a high rate of adverse events compared to pulsed field ablation (PFA). In this systematic review, we aimed to determine the safety and efficacy of PFA. Methods: The electronic search for relevant articles in English was completed in PubMed, PubMed Central, Cochrane library, Scopus, and Embase databases till July 2022. The screening was completed via the use of Covidence software. The risk of bias assessment and data extraction from the included studies was performed, and the narrative synthesis was performed accordingly. Results: A total of six studies were selected for review and 1897 patients receiving PFA were involved in these studies. Our review was focused on pulmonary vein isolation success, major adverse events, and arrhythmia recurrence. Successful pulmonary vein isolation (PVI) was completed in 100% of cases except in two studies. In one of them, six out of seven patients (86%) in the epicardial cohort had successful PVI. In the MANIFEST-PF survey, the acute PVI success rate was 99.9%. The major complications were rare and included pericardial tamponade, vascular complications requiring surgery, and stroke. The atrial arrhythmia recurrence was higher in the thermal group than in the PFA group (39% vs. 11%). Conclusions: The success rate of PVI by PFA is high, and major adverse events are low. PFA is found to decrease the recurrence of atrial arrhythmia compared to thermal ablation. Substantial randomized controlled trials (RCTs) are needed to validate the efficacy and safety of PFA over conventional methods.

Background: The preferred approach for secundum atrial septal defect (ASD) closure has evolved from surgical repair to the current standard of practice being percutaneous closure. Although ...

Introduction: Controlled clinical trials (CCTs) have traditionally been limited to urban academic clinical centers. Implementation of CCTs in rural setting is challenged by lack of resources, the inexperience of patient care team members in CCT conductance and workflow interruption, and global inexperience with remote data monitoring. Methods: We report our experience during the coronavirus disease 2019 (COVID-19) pandemic in activating through remote monitoring a multicenter clinical trial (the Study of Efficacy and Safety of Canakinumab Treatment for cytokine release syndrome (CRS) in Participants with COVID-19-induced Pneumonia [CAN-COVID] trial, ClinicalTrials.gov Identifier: NCT04362813) at a rural satellite hospital, the VCU Health Community Memorial Hospital (VCU-CMH) in South Hill, VA, that is part of the larger VCU Health network, with the lead institution being VCU Health Medical College of Virginia Hospital (VCU-MCV), Richmond, VA. We used the local resources at the facility and remote guidance and oversight from the VCU-MCV resources using a closed-loop communication network. Investigational pharmacy, pathology, and nursing were essential to operate the work in coordination with the lead institution. Results: Fifty-one patients with COVID-19 were enrolled from May to August 2020, 35 (69%) at VCU-MCV, and 16 (31%) at VCU-CMH. Among the patients enrolled at VCU-CMH, 37.5% were female, 62.5% Black, and had a median age of 60 (interquartile range 56–68) years. Conclusion: Local decentralization of this trial in our experience gave rural patients access to a novel treatment and also accelerated enrollment and more diverse participants’ representative of the target population.

Objective To analyse published literatures on prevalence, awareness, risk factors and control of hypertension in Nepal. Methods We used electronic databases to search relevant articles from January 2000 till October 2020. All relevant data from selected studies were extracted into a standardized form designed in Excel. Statistical analysis was conducted using Comprehensive Meta-Analysis Software (CMA) version 3. Proportions or Odds Ratio (OR) was used to estimate the outcome with 95% confidence interval (CI). The I-squared (I2) test was used for the assessment of heterogeneity. Results We identified a total of 3726 studies after comprehensive database searching. We performed qualitative and quantitative analysis of 40 studies. Pooling data showed 28.52% of patients with hypertension (CI: 26.40–30.75); 45.28% (CI: 38.89–51.83) aware of their high blood pressure; 31.66% (CI: 23.18–41.56) under treatment; 44.4% (CI: 36.17–53.04) had their blood pressure under optimum range. 27.4% (CI: 21.57–34.11) had pre-hypertensive range elevated blood pressure. 25.99% (CI: 21.81–30.65) of females and 34.25% (CI: 30.49–38.21) of male were hypertensive (p ​= ​0.007). The pooling of data showed smokers have 1.43 times (CI: 1.1429–1.7889); and alcohol users have 2.073 times (CI: 1.7154–2.5050) higher risk of having hypertension. Individuals with normal BMI have 53.15% (OR: 0.4685 CI: 0.3543–0.6195); with formal educated have 37.27% (OR: 0.6273, CI: 0.5485–0.7175); and with adequate exercise have 31.6% (OR: 0.6839, CI: 0.5203–0.8991) lower chance of having hypertension. Conclusion Our study shows the prevalence of hypertension in Nepal is high. However, awareness, treatment and subsequently control of high blood pressure are found to be alarmingly low. Hypertension was associated with male gender, smoking, alcohol use, high BMI, no education and inadequate exercise. It calls for more attention to address the burden of hypertension and associated risk factors in Nepal.

INTRODUCTION: Heart failure is a clinical condition that notably affects the lives of patients in rural areas. Partnering of a rural satellite hospital with an urban academic medical center may provide geographically underrepresented populations with heart failure an opportunity to access to controlled clinical trials (CCTs). METHODS: We report our experience in screening, consenting and enrolling subjects at the VCU Health Community Memorial Hospital (VCU-CMH) in rural South Hill, Virginia, that is part of the larger VCU Health network, with the lead institution being VCU Health Medical College of Virginia Hospitals (VCU-MCV), Richmond, VA. Subjects were enrolled in a clinical trial sponsored by the National Institutes of Health and assigned to treatment with an anti-inflammatory drug for heart failure or placebo. We used the electronic health record and remote guidance and oversight from the VCU-MCV resources using a close-loop communication network to work with local resources at the facility to perform screening, consenting and enrollment. RESULTS: One hundred subjects with recently decompensated heart failure were screened between January 2019 and August 2021, of these 61 are enrolled to date: 52 (85%) at VCU-MCV and 9 (15%) at VCU-CMH. Of the subjects enrolled at VCU-CMH, 33% were female, 77% Black, with a mean age of 52 ± 10 years. CONCLUSION: The use of a combination of virtual/remote monitoring and guidance of local resources in this trial provides an opportunity for decentralization and access of CCTs for potential novel treatment of heart failure to underrepresented individuals from rural areas.

OBJECTIVES/GOALS: Heart failure (HF) is a clinical condition that notably affects the lives of patients in rural areas. The partnering of a rural satellite hospital with an urban academic medical center may provide geographically underrepresented populations with HF an opportunity to access controlled clinical trials (CCTs). METHODS/STUDY POPULATION: We report our experience in screening, consenting and enrolling subjects at the VCU Health Community Memorial Hospital (VCU-CMH) in rural South Hill, Virginia, that is part of the larger VCU Health network, with the lead institution being VCU Health Medical College of Virginia Hospitals (VCU-MCV), Richmond, VA. Subjects were enrolled in a clinical trial sponsored by the National Institutes of Health (ClinicalTrials.gov: NCT03797001) and assigned to treatment with an anti-inflammatory drug for HF or placebo. We used the electronic health record and remote guidance and oversight from the VCU-MCV resources using a closed-loop communication network to work with local resources at the facility to perform screening, consenting and enrollment. RESULTS/ANTICIPATED RESULTS: One hundred subjects with recently decompensated HF were screened between January 2019 and August 2021, of these 61 are enrolled to date: 52 (85 %) at VCU-MCV and 9 (15%) at VCU-CMH. Of the subjects enrolled at VCU-CMH, 33% were female, 77% Black, with a mean age of 5210 years. DISCUSSION/SIGNIFICANCE: The use of a combination of virtual/remote monitoring and guidance of local resources in this trial provides an opportunity for decentralization and access of CCTs for potential novel treatment of HF to underrepresented individuals from rural areas.

Importance Recent epidemiologic and therapeutic advances have transformed understanding of the role of and therapeutic approach to patent foramen ovale (PFO) in ischemic stroke. Patent foramen ovale is likely responsible for approximately 5% of all ischemic strokes and 10% of those occurring in young and middle-aged adults. Observations Randomized clinical trials have demonstrated that, to prevent recurrent ischemic stroke in patients with PFO and an otherwise-cryptogenic index ischemic stroke, PFO closure is superior to antiplatelet medical therapy alone; these trials have provided some evidence that, among medical therapy options, anticoagulants may be more effective than antiplatelet agents. Conclusions and Relevance These new data indicate a need to update classification schemes of causative mechanisms in stroke, developed in an era in which an association between PFO and stroke was viewed as uncertain. We propose a revised general nomenclature and classification framework for PFO-associated stroke and detailed revisions for the 3 major stroke subtyping algorithms in wide use.

Left ventricular assist devices (LVADs) have emerged as an attractive option in patients with advance heart failure. Nationwide readmission database 2013 to 2014 was utilized to identify LVAD recipients using ICD-9 procedure code 37.66. The primary outcome was 90-day readmission. Readmission causes were identified using ICD-9 codes in primary diagnosis field. The secondary outcomes were LVAD associated with hospital complications. Hierarchic 2-level logistic models were used to evaluate study outcomes. We identified 4,693 LVAD recipients (mean age 57 years, 76.2% males). Of which 53.9% were readmitted in first 90 days of discharge. Cardiac causes (33.3%), bleeding (21.3%), and infections (12.4%) were leading etiologies of 90-day readmissions. Significant predictors (odds ratio, 95% confidence interval, p value) of readmission were disposition to nursing facilities (1.33, 1.09 to 1.63, p = 0.01) and longer length of stay (1.01, 1.00 to 1.01, p

We read with interest the recent article by Lee et al. [(1)][1] on the efficacy and safety of percutaneous patent foramen ovale (PFO) closure for prevention of recurrent ischemic cerebrovascular events in patients experiencing cryptogenic stroke in the DEFENSE-PFO (Cryptogenic Stroke and High-Risk

Peripheral arterial disease (PAD) is a common atherosclerotic disease approximately affecting 8.5 million Americans above age 40 and is associated with significant functional impairment, morbidity and mortality from both cardiovascular and non-cardiovascular causes. PAD has increasing prevalence in females contrary to previous findings. Compared to men, women with PAD are more asymptomatic or have atypical symptoms. Women with PAD have increased quality of life impairment, increased risk of depression and increased cardiovascular mortality. The intent of this review is to provide an update on gender differences in PAD that can help in timely diagnosis and appropriate management through intensive cardiovascular risk factor modification, exercise program and guideline directed therapy to improve cardiovascular outcomes.

Paradoxical embolism from a patent foramen ovale (PFO) mediated right-to-left shunt is a well-described mechanism of ischemic stroke [(1)][1]. In a patient level meta-analysis of the earlier 3 randomized trials, percutaneous PFO closure was superior to medical therapy for secondary prevention of

We read with interest the recent article by Ntaios et al.1 In a meta-analysis of randomized trials, the authors reported the efficacy and safety of transcatheter patent foramen ovale (PFO) closure for prevention of recurrent stroke, in patients with an index cryptogenic stroke/transient ischemic attack. Among 3627 patients (5 trials), there was a significantly lower rate of recurrent stroke in patients randomized to a PFO-occluding device compared with medical therapy (0.53 versus 1.1 per 100 patient-years; odds ratio, 0.43; 95% confidence interval, 0.21–0.90) at a mean follow-up of 3.7 years. In the discussion, the authors mention the important role of non-vitamin K antagonists in the prevention of venous thromboembolism, given venous thromboembolism seems to be the main issue in PFO-mediated stroke. …

Patent foramen ovale (PFO), an embryonic remnant of the fetal circulation, is present in 20-25% of adults. Although recent observational studies and clinical trials have established the link between PFO-mediated right-to-left shunting with cryptogenic stroke and migraine with aura, the role of a PFO in exacerbating hypoxemic medical conditions (ie, sleep apnea, chronic obstructive pulmonary disease, pulmonary hypertension, platypnea-orthodeoxia, pulmonary arteriovenous malformation, high-altitude pulmonary edema, and exercise desaturation) remains less understood. PFO-mediated hypoxemia occurs when deoxygenated venous blood from the right atrium enters and mixes with oxygenated arterial blood in the left atrium. Patients with an intracardiac right-to-left shunt may have profound hypoxemia out of proportion to underlying primary lung disease, even in the presence of normal right-sided pressures. The presence of right-to-left cardiac shunting can exacerbate the degree of hypoxemia in patients with underlying pulmonary disorders. In a subset of these patients, percutaneous PFO closure may result in marked improvement in dyspnea and hypoxemia. This review discusses the association between PFO-mediated right-to-left shunting with medical conditions associated with hypoxemia and explores the role of percutaneous PFO closure in alleviating the hypoxemia.

Nearly one-half of patients with cryptogenic stroke have a patent foramen ovale (PFO). The dilemma of whether to close these PFOs percutaneously, in an effort to reduce the risk of recurrent paradoxical embolism, has been a matter of ongoing debate for more than a decade. Early randomized clinical trials failed to demonstrate a significant benefit of percutaneous PFO closure for secondary prevention of cryptogenic stroke in an intention-to-treat analysis. The long-term follow-up data from the RESPECT trial and 2 new randomized trials (CLOSE and REDUCE) have clarified these findings. They showed that with good patient selection, transcatheter PFO closure significantly reduces the risk of recurrent stroke compared with medical therapy in patients with cryptogenic stroke, with no increased risk of serious adverse events or influence on major bleeding.

We read with interest the recent article by Merkler et al.1 In a retrospective cohort study, the authors investigated the safety of transcatheter patent foramen ovale (PFO) closure in patients with ischemic stroke/transient ischemic attack who underwent PFO closure within 1 year. The study concluded that closure was associated with adverse events in 7% of patients; the rate of events was higher in patients >60 years old compared with those aged ≤60 years (10.9% versus 4.9%; P

Although aspirin monotherapy is considered the standard of care after coronary artery bypass grafting (CABG), more recent evidence has suggested a benefit with dual antiplatelet therapy (DAPT) after CABG. We performed a meta-analysis of observational studies and randomized controlled trials comparing outcomes of aspirin monotherapy with DAPT in patients after CABG. Subgroup analyses were conducted according to surgical technique (i.e., on vs off pump) and clinical presentation (acute coronary syndrome vs no acute coronary syndrome). Random effects overall risk ratios (RR) were calculated using the DerSimonian and Laird model. Eight randomized control trials and 9 observational studies with a total of 11,135 patients were included. At a mean follow-up of 23 months, major adverse cardiac events (10.3% vs 12.1%, RR 0.84, confidence interval [CI] 0.71 to 0.99), all-cause mortality (5.7% vs 7.0%, RR 0.67, CI 0.48 to 0.94), and graft occlusion (11.3% vs 14.2%, RR 0.79, CI 0.63 to 0.98) were less with DAPT than with aspirin monotherapy. There was no difference in myocardial infarction, stroke, or major bleeding between the 2 groups. In conclusion, DAPT appears to be associated with a reduction in graft occlusion, major adverse cardiac events, and all-cause mortality, without significantly increasing major bleeding compared with aspirin monotherapy in patients undergoing CABG.

Background Complete revascularization of patients with ST-elevation myocardial infarction and multivessel coronary artery disease reduces adverse events compared to infarct-related artery only revascularization. Whether complete revascularization should be done as multivessel intervention during index procedure or as a staged procedure remains controversial. Method We performed a meta-analysis of randomized controlled trials comparing outcomes of multivessel intervention in patients with ST-elevation myocardial infarction and multivessel coronary artery disease as staged procedure versus at the time of index procedure. Composite of death or myocardial infarction was the primary outcome. Mantel-Haenszel risk ratios were calculated using random effect model. Results Six randomized studies with a total of 1126 patients met our selection criteria. At a mean follow-up of 13 months, composite of myocardial infarction or death (7.2% vs 11.7%, RR: 1.66, 95%CI: 1.09-2.52, P = 0.02), all cause mortality (RR: 2.55, 95%CI: 1.42-4.58, P

Choosing an antithrombotic regimen after coronary intervention in patients with concomitant indication for anticoagulation is a challenge commonly encountered by clinicians.We performed a meta-analysis of observational studies and randomized, controlled trials comparing outcomes of triple therapy (dual antiplatelet therapy and anticoagulant) with dual therapy (single antiplatelet therapy and anticoagulant) in patients taking long-term anticoagulants after percutaneous coronary intervention. Major bleeding was the primary outcome. Random effects overall risk ratios (RRs) were calculated using the DerSimonian and Laird model.Nine observational studies and 2 randomized controlled trials with a total of 7276 patients met our selection criteria. At a mean follow-up of 10.8 months major bleeding was higher in the triple therapy cohort compared with dual therapy (6.6% vs 3.8%; RR 1.54; 95% confidence interval [CI], 1.2-1.98; P .01). No difference was observed between the 2 groups for all-cause mortality (RR 0.98; 95% CI, 0.68-1.43; P = .93), major adverse cardiac events (RR 1.03; 95% CI, 0.8-1.32; P = .83), thromboembolic events (RR 1.02; 95% CI, 0.49-2.10; P = .96), myocardial infarction (RR 0.85; 95% CI, 0.67-1.09; P = .21), stent thrombosis (RR 0.77; 95% CI, 0.46-1.3; P = .33), and target vessel revascularization (RR 0.87; 95% CI, 0.66-1.15; P = .33).In patients receiving anticoagulant therapy, a strategy of single antiplatelet therapy confers a benefit of less major bleeding with no difference in all-cause mortality, cardiovascular mortality, major adverse cardiac events, myocardial infarction, stent thrombosis, or thromboembolic event rate compared with dual antiplatelet therapy.

Thromboembolism and atherothrombosis are the 2 predominant mechanisms associating atrial fibrillation (AF) with cardiovascular outcomes. Recent evidence has shown that insulin use in patients with DM probably increases risk of thromboembolic outcomes like ischemic stroke in patients with AF. It

Hypertension (HTN) is a modifiable, highly prevalent risk factor for cardiovascular morbidity and renal dysfunction worldwide. In the United States, HTN affects one in three adults, contributes to one out of every seven deaths and to nearly half of all cardiovascular disease-related deaths. HTN is considered resistant when the blood pressure remains above goal despite lifestyle modification and administration of three antihypertensive agents of different classes including a diuretic. Large population-based studies have suggested that obstructive sleep apnea (OSA) is a risk factor for resistant HTN. The mechanism proposed is a pattern of intermittent hypoxia associated with hyperaldosteronism, increased sympathetic tone, endothelial dysfunction, and inflammation. In this review we discuss the association between OSA and resistant HTN, the physiologic mechanisms linking OSA with resistant HTN, and the effect of continuous positive airway pressure therapy (CPAP) on blood pressure in patients with resistant HTN. While the reduction in blood pressure with CPAP is usually modest in patients with OSA, a decrease of only a few mmHg in blood pressure can significantly reduce cardiovascular risk. Patients presenting to a center specializing in management of hypertension should be screened and treated for OSA as a potentially modifiable risk factor.

Pulmonary involvement due to leptospirosis carries high case fatality rate and is the commonest cause of death due to leptospirosis. Immune mechanisms play a key role in the pathogenesis of leptospiral pulmonary haemorrhage. As other immune pulmonary haemorrhages due to non leptospiral causes are treated with plasma exchange and cyclophosphamide we evaluated their efficacy in patient with leptospiral pulmonary haemorrhage.Of the 602 confirmed patients of leptospirosis, 236 (39.2%) had pulmonary haemorrhage. Of these,144 had mild haemorrhage (acute lung injury score2.5) and were included in the study. One hundred and fourteen patients were given two cycles of plasma exchange, 24 h apart, 25 ml/kg body weight of plasma was removed in each cycle. Cyclophosphamide (20 mg/kg body weight) was given after the first plasma exchange cycle. The remaining 30 patients were not given this treatment, and used as control.In the control group only 5 (16.6%) patients survived while in the treatment group 70 (61.40%) patients survived. Thrombocytopenia was observed in 111 (77.08%) patients. Renal and hepatic involvement was seen but did not account for mortality. Minor complications were seen in group I patients after plasma exchange and cyclophosphamide treatment, but none were serious.Our findings showed that plasma exchange with immunosuppression improved survival in patients of pulmonary alveolar haemorrhage due to leptospirosis, suggesting that immune mechanisms play a key role in the pathogenesis of the disease.

Introduction Diffuse alveolar hemorrhage (DAH) is frequently a life-threatening complication of a variety of conditions. Thrombotic thrombocytopenic purpura (TTP) is a disorder of blood-coagulation system whose mortality rate exceeds 90% in the absence of rapid appropriate treatment. We report a case with DAH as initial presentation of TTP. Case presentation A 68-year-old male with a history of polymyositis was admitted to a community hospital with chief complaints of progressive shortness of breath at rest and with minimal exertion for one week. On physical examination, he was afebrile and hemodynamically stable. Oxygen saturation on room air was 98%. On physical exam breath sounds were diminished at the bases of the lungs bilaterally. Laboratory studies revealed WBC-11.39×109/L, hemoglobin-8.9 g/dL, platelets-106×109/L, BUN-109 mg/dL and creatinine-4.8 mg/dL. Chest radiograph showed a left lower lobe infiltrate with small bilateral pleural effusions. The patient developed a progressive respiratory distress with associated hemoptysis on the second day of admission. Repeat chest radiograph showed extensive interstitial densities bilaterally. CT scan of chest showed diffuse interstitial and air space opacification, predominantly with pleural effusions bilaterally. The patient was subsequently required intubation/mechanical ventilation. Bronchoscopy was performed and showed profuse bloody airway secretions in both lung fields with bloody return in the bronchoalveolar lavage, consistent with DAH. Repeat laboratory data revealed hemoglobin -6.0 g/dL, platelets- 34 ×109/L, BUN-119 mg/dL, creatinine -5.6 mg/dL, LDH-3269 units/L with haptoglobin Discussion DAH is a life-threatening complication of a variety of clinical conditions. Most cases of DAH are caused by capillaritis associated with systemic autoimmune diseases such as antineutrophil cytoplasmic antibodies-associated vasculitis, anti-glomerular basement membrane disease, and systemic lupus erythematosus. TTP is a critical, frequently life-threatening disease that is characterized by thrombotic microangiopathy with the formation of thrombi in small blood vessels throughout the body. The classic pentad is hemolytic anemia with associated schistocytosis, thrombocytopenia, fevers, neurological sequelae, and renal dysfunction. Recent clinical data shows that about 80% of patients with TTP have abnormal chest X-ray findings including diffuse, local infiltrates, pleural effusions, or atelectatic change. More than 50% of patients developed acute respiratory distress that necessitates mechanical ventilation. Cases have been published where intrapulmonary hemorrhage is the initial presentation of TTP similar to our case report. Autopsies have shown that in patients with TTP and associated pulmonary hemorrhage, thrombi within small vessels of the lung can be identified. Potential pathophysiology of TTP that results in DAH is thought to be related to capillary injury followed by adherence of platelets and fibrin to the vascular endothelial cells which leads to increased permeability and noncardiogenic pulmonary edema. Conclusion This case confirms that DAH can be the initial clinical manifestation of TTP. Since both diagnoses are associated with high mortality rates, prompt diagnosis is crucial to improving survival. Similar reports may provide the authors with a better understanding of the clinical scenario and help elucidate the best treatment options for patients who present with DAH associated with TTP. Disclosures: No relevant conflicts of interest to declare.

Background/Aims Several prognostic markers for heart failure (HF) have been determined but the importance of liver function tests (LFTs) remains unknown. The aim of this study was to determine the prognostic significance, if any, of abnormal LFTs in acute decompensated HF. Methods All adult patients (> 18 years of age) who were admitted to a community hospital with a diagnosis of acute decompensated HF during the period January 2008 to December 2009 were identified. Exclusion criteria included acute coronary syndrome, active hepatobiliary disease, renal failure (serum creatinine ≥ 2 mg/dL), and malignancy. The primary end point was readmission secondary to acute exacerbation of HF. The Cox proportional hazard model was used for statistical analyses. Results Univariate analysis showed that serum total bilirubin (TB, p < 0.01), serum B-type natriuretic peptide (p < 0.05), ejection fraction (EF, p < 0.05), and heart rate (p < 0.05) were significant predictors of hospital readmission secondary to acute decompensated HF. Multivariate analysis showed that high serum TB (> 1.3 mg/dL) on admission was an independent predictor (p < 0.05) of hospital readmission secondary to HF. The 'at-risk' group-patients with serum TB > 1.3 mg/dL and/or EF < 35% on admission-had a readmission rate that was 87% ± 20% (p < 0.05) higher than those with neither criterion. Conclusions In patients with acute decompensated HF, elevated serum TB on admission with or without low EF (< 35%) predicts a worse prognosis and early future readmission, secondary to HF.