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The coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus-2 has affected the health of people across the globe. Cardiovascular diseases (CVDs) have a significant relationship with COVID-19, both as a risk factor and prognostic indicator, and as a complication of the disease itself. In addition to predisposing to CVD complications, the ongoing pandemic has severely affected the delivery of timely and appropriate care for cardiovascular conditions resulting in increased mortality. The etiology behind the cardiac injury associated with severe acute respiratory syndrome coronavirus-2 is likely varied, including coronary artery disease, microvascular thrombosis, myocarditis, and stress cardiomyopathy. Further large-scale investigations are needed to better determine the underlying mechanism of myocardial infarction and other cardiac injury in COVID-19 patients and to determine the incidence of each type of cardiac injury in this patient population. Telemedicine and remote monitoring technologies can play an important role in optimizing outcomes in patients with established CVD. In this article, we summarize the various impacts that COVID-19 has on the cardiovascular system, including myocardial infarction, myocarditis, stress cardiomyopathy, thrombosis, and stroke.

Despite widespread availability of plasmapheresis, the mortality in thrombotic thrombocytopenic purpura remains high. Cardiovascular complications have been reported as an important cause of morbidity in these patients. The burden and prognostic implications of these complications have not been well studied. We analyzed the rates of cardiovascular complications in thrombotic thrombocytopenic purpura, temporal trends, and studied its impact on in-hospital mortality.We analyzed the National Inpatient Sample (NIS) from January 2005 to September 2015 to identify adult patients with thrombotic thrombocytopenic purpura. This group was further refined by excluding patients who did not receive therapeutic plasmapheresis, and other conditions that can mimic thrombotic thrombocytopenic purpura. We identified the age- and sex-stratified rates of cardiac arrhythmias, cardiac conduction system disorders, heart failure, acute coronary syndrome, myocarditis, pericarditis, takotsubo cardiomyopathy, cardiogenic shock, cardiac arrest, and stroke. We also compared in-hospital mortality with and without cardiovascular complications.Among 15,054 thrombotic thrombocytopenic purpura hospitalizations (mean age 46.4 years, 69% in the 18- to 54-age group, 66.2% women, and 42.9% white), a cardiovascular complication was observed in 3802 (25.3%) hospitalizations. The following cardiovascular complications were identified: stroke (10.4%), heart failure (8.3%), acute coronary syndrome (6.4%), atrial tachyarrhythmia (5.9%), ventricular tachyarrhythmia (2.0%), cardiogenic shock (0.5%), takotsubo cardiomyopathy (0.1%), atrioventricular block (0.2%), myocarditis or pericarditis (0.3), and cardiac arrest (1.9%). Rates of several cardiovascular complications were significantly higher in patients 55 years or older compared to a younger age group, whereas males had higher rates of acute coronary syndrome and tachyarrhythmias compared to females. Overall, the cardiovascular complication rate was stable during the study period. The presence of a major cardiovascular complication was associated with a significantly higher in-hospital mortality (19.7%) as compared with no major cardiovascular complication (4.1%) (adjusted odds ratio 2.09, 95% confidence interval 1.41-3.09, P0.001). Results were generally consistent in age and sex subgroups.Cardiovascular complications were frequently observed at a rate of 1 in 4 in patients hospitalized for thrombotic thrombocytopenic purpura and were associated with substantially higher in-hospital mortality. These findings underscore the need to promptly identify and treat these complications to improve outcomes.

With aging population and preponderance of severe aortic stenosis occurring in elderly patients, the number of transcatheter aortic valve implantations (TAVI) performed in the elderly are growing. Frailty is common in the elderly and is known to be associated with worse outcomes. We aimed to evaluate the impact of frailty on hospital readmissions rates after TAVI. We used the 2016 Nationwide Readmission Database and categorized patients who underwent TAVI low, intermediate, and high frailty status. The primary outcome was 6-months readmission rates across the 3 frailty categories. Secondary outcomes included causes of readmissions, in-hospital mortality and cost of care. STATA 16.0 was used for survey-specific statistical tests. Of 20,504 patients who underwent TAVI, 58.9% were low-, 39.6% were intermediate-, and 1.5% were in the high-frailty group. Overall in-hospital mortality was 1.9% (n = 396), and was 0.6%, 3.3%, and 16.8% (p0.01) with increasing frailty. Of the 20,108 patients who survived to discharge, 6,427 (32%) patients were readmitted within 6-months after TAVI. Readmission rates increased across the categories from 27.9% in low, 37.6% in intermediate and 51.1% in high frailty group (p0.01). While cardiac causes (mostly heart failure) were the predominant readmission etiologies across frailty categories (low: 51.2%, intermediate: 34.1%, high: 27.2%), rates of infectious and injury-related readmissions increased (low: 11%, intermediate: 30%, high: 45%). Mortality during readmissions also worsened from 0.8%, 5.3%, and 8.5% (p0.01). Over 40% of patients undergoing TAVI were of intermediate-high frailty. In conclusion, an increasing frailty was associated with significantly worse postprocedure mortality, readmissions, and related mortality.

Transcatheter mitral valve repair (TMVR) has shown comparable outcomes to surgical mitral valve replacement or repair (SMVR) in patients who are at a higher risk of surgical complications and therefore are not amenable to surgery. Elderly patients are considered poor surgical candidates due to their advanced age, and presence of comorbidities. A sub-analysis of EVEREST II (Endovascular Valve Edge-to-Edge Repair Study) trial identified patients of >70 years of age appear to have a similar risk-benefit profile for either approach of surgery or transcatheter. This finding does have some caveats considering the trial included surgical cohort with both repair and replacement. Utilizing the National Inpatient Sample, we identified a surgical cohort of ≥80 years of age that underwent mitral valve repair and used propensity matching to compare it with a similar cohort that underwent TMVR. In a well-balanced cohort, TMVR was associated with significantly lower in-patient mortality (0.7% vs 3.1%). TMVR was also associated with significantly decreased in-hospital complications such as acute kidney injury, cardiogenic shock, postoperative hemorrhage, transfusion, permanent pacemaker, and respiratory and vascular complications. Owing to this, the duration of hospital stay is approximately 6 days less with TMVR. Trend analysis has shown a paradigm shift in these elderly patients with 85% of all repairs in 2012 were performed surgically, whereas in 2016 almost 94% of all the repairs being performed via a transcatheter approach. In conclusion, in patients ≥80 years of age, the surgical MVR had 4-fold higher mortality compared to TMVR with higher cardiac, vascular, hemorrhagic and respiratory complications. Despite the limitations of being observational in nature, this data strongly supports the preferential use of the transcatheter approach for mitral valve repair in patients ≥80 years of age.

Atrial fibrillation (AF) is associated with a substantially higher risk of thromboembolism, particularly stroke events, resulting in significant morbidity and mortality. Oral anticoagulation (OAC), while effective in reducing embolic events in AF patients, is associated with an increased bleeding risk. Thus, not all patients with AF are candidates for OAC and some are only candidates for OAC in the short term. Of the available nonpharmacologic strategies for the management of AF, left atrial appendage occlusion (LAAO) has emerged as a potential approach for reducing the risk of systemic thromboembolism in AF patients eligible for OAC. LAAO can be achieved either surgically or percutaneously using an epicardial, endocardial, or a combined approach. Although available data are limited, currently available LAAO devices, and those being developed, have shown promise in reducing bleeding risk in AF patients because of the reduced overall need for anticoagulation, while maintaining efficacy in preventing thromboembolism. The optimal device will reduce both embolic and hemorrhagic strokes, and other bleeds, with a high implant success rate and a low complication rate. Until that time, anticoagulation remains the gold standard that these devices strive to surpass, and thus LAAO devices are currently indicated in patients with relative contraindication to OAC therapy.

Worsening renal disease is known to be associated with increased valvular calcification, which is known to drive the progression of aortic stenosis and eventually worse outcomes. Almost 50% of patients with chronic kidney disease have concomitant aortic stenosis ([1][1]). Renal transplantation (RT

ObjectiveCurrent guidelines endorse the use of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation (AF). However, little is known about their safety and efficacy in valvular heart disease (VHD). Similarly, there is a paucity of data regarding NOACs use in patients with a bioprosthetic heart valve (BPHV). We, therefore, performed a network meta-analysis in the subgroups of VHD and meta-analysis in patients with a BPHV.MethodsPubMed, Cochrane and Embase were searched for randomised controlled trials. Summary effects were estimated by the random-effects model. The outcomes of interest were a stroke or systemic embolisation (SSE), myocardial infarction (MI), all-cause mortality, major adverse cardiac events, major bleeding and intracranial haemorrhage (ICH).ResultsIn patients with VHD, rivaroxaban was associated with more ICH and major bleeding than other NOACs, while edoxaban 30 mg was associated with least major bleeding. Data combining all NOACs showed a significant reduction in SSE, MI and ICH (0.70, [0.57 to 0.85; pConclusionsNOACs performed better than warfarin for a reduction in SSE, MI and ICH in patients with VHD. Individually NOACs performed similarly to each other except for an increased risk of ICH and major bleeding with rivaroxaban and a reduced risk of major bleeding with edoxaban 30 mg. In patients with a BPHV, results with NOACs seem similar to those with warfarin and this needs to be further explored in larger studies.

Acromegaly is a rare endocrine disorder that carries a significant burden of cardiovascular morbidity and mortality. Abnormalities of the growth hormone/insulin-like growth factor-1 axis in acromegaly lead to the characteristic cardiovascular manifestations of this disease. One hallmark feature of the disease is acromegalic cardiomyopathy, a syndrome of progressive cardiac dysfunction characterized by left ventricular hypertrophy, diastolic dysfunction, and combined systolic and diastolic dysfunction in the very advanced stage. In this article, we review the current concepts regarding the pathophysiology of acromegalic cardiomyopathy and discuss the various risk factors for its development. We also explore the question of whether the alterations in cardiac function are reversible with successful biochemical control of growth hormone excess either medically or surgically.

Ventricular tachycardia (VT) occurs most commonly in the presence of structural heart disease or myocardial scarring from prior infarction. It is associated with increased mortality, especially when it results in cardiac arrest outside of a hospital. When not due to reversible causes (such as acute ischemia/infarction), placement of an implantable cardioverter-defibrillator for prevention of future sudden death is indicated. The current standard of care for recurrent VT is medical management with antiarrhythmic agents followed by invasive catheter ablation for VT that persists despite appropriate medical therapy. Stereotactic arrhythmia radioablation (STAR) is a novel, noninvasive method of treating VT that has been shown to reduce VT burden for patients who are refractory to medical therapy and/or catheter ablation, or who are unable to tolerate catheter ablation. STAR is the term applied to the use of stereotactic body radiation therapy for the treatment of arrhythmogenic cardiac tissue and requires collaboration between an electrophysiologist and a radiation oncologist. The process involves identification of VT substrate through a combination of electroanatomic mapping and diagnostic imaging (computed tomography, magnetic resonance imaging, positron emission tomography) followed by carefully guided radiation therapy. In this article, we review currently available literature describing the utilization, efficacy, safety profile, and potential future applications of STAR for the management of VT.

Background We aimed to compare the safety and efficacy of transradial vs transfemoral access for coronary angiography and intervention in patients presenting with ST-segment elevation myocardial infarction (STEMI) without cardiogenic shock. Methods PubMed, Embase and Cochrane Central were searched for randomized controlled trials (RCTs) comparing outcomes of STEMI patients who underwent transradial angiography (TRA) compared to transfemoral angiography (TFA). Our outcomes of interest were major adverse cardiac events (MACE), all-cause mortality, severe bleeding, access site bleeding, myocardial infarction, stroke, and major vascular complications. Summary statistics are reported as odds ratios (OR) with 95% confidence intervals (CI). Results In a pooled analysis of 17 RCTs with 12,118 randomized patients, the use of transradial compared to transfemoral approach in STEMI patients without cardiogenic shock was associated with a significant reduction in MACE [OR 0.85 (95% CI 0.73-0.99; p=0.04; NNT=111; I2=0%)] and all-cause mortality [OR 0.71 (95% CI 0.57-0.88; p Conclusions For coronary intervention in STEMI patients without cardiogenic shock, there is a clear mortality benefit with the TRA over TFA. Further studies are needed to see if this mortality benefit persists over the long-term.

The optimal duration of dual antiplatelet therapy (DAPT) in the era of second-generation drug-eluting stents is a matter of considerable debate with more data suggesting a shorter period of DAPT is feasible. We performed a meta-analysis to evaluate DAPT compared with monotherapy with a P2Y12 inhibitor after a percutaneous coronary intervention (PCI). PubMed, Embase, and Cochrane Central were searched from inception to October 2019 to identify randomized controlled trials that compared outcomes of patients treated with either DAPT or monotherapy with a P2Y12 inhibitor following PCI. Primary outcomes of interest included major bleeding, ischemic events (myocardial infarction, stroke, stent thrombosis, major adverse cardiac events), and both all-cause and cardiovascular mortality. Event rates were extracted, and the Mantel-Haenszel fixed-effects model was used to perform a meta-analysis. Summary statistics are reported as odds ratios with 95% confidence intervals. Subgroup analyses were performed using the generic inverse method. We identified four trials with 29,089 randomized patients. Use of P2Y12 monotherapy was associated with 30% lower odds of major bleeding 0.70 (0.60-0.81; p

Valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) for a failing prosthesis is an appealing alternative to redo surgical AVR. We utilized data from the US National Inpatient Sample for the period 2012 to 2016 to identify hospitalizations for either ViV-TAVI or redo-SAVR. The primary outcomes of interest were in-hospital adverse events composite outcome (comprising of mortality, myocardial infarction, stroke, or acute kidney injury) and all-cause mortality. We used propensity score matching to adjust for the baseline differences between ViV-TAVI and redo-SAVR cohorts. Survey techniques were employed to compare the 2 groups. Over 5 years, there has been a considerable increase in both interventions for prosthetic aortic valve failure, with significantly higher utilization of ViV-TAVI compared to redo-SAVR (p0.01). Out of the 3,305 hospitalizations for prosthetic aortic valve failure, 1,420 in matched pairs underwent either ViV-TAVI (n = 710) or redo-SAVR (n = 710). ViV-TAVI was associated with lower in-hospital composite adverse outcomes (14.1% vs 25.4%, p = 0.018), and numerically lower but statistically insignificant mortality (1.0% vs 5.2%; p = 0.06). ViV-TAVI was associated with a decreased length of hospitalization (mean 6.6 vs 9.7 days; p0.01). In the matched cohort, postoperative bleeding and transfusions were significantly lower for ViV-TAVI compared with redo-SAVR (17.6% vs 31.0% and 12% vs 31% respectively, p0.01 for both). Acute kidney injury, sepsis, permanent pacemaker implantation, and vascular complications, although numerically better, did not differ between 2 strategies. In conclusion, ViV-TAVI is associated with lower in-hospital MACE rates and reduced length of hospitalization compared with redo-SAVR.

BACKGROUND The PARADIGM-HF (Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure) trial was a double-blind trial that randomized 8442 patients with heart failure (HF) with reduced ejection fraction (HFrEF) to receive twice daily dosing of either 200 mg of LCZ696 or 10 mg of enalapril in addition to standard medical therapy for HF. AREAS OF UNCERTAINTY Limitations of this trial include (1) sacubitril has not been tested by itself in the treatment of HFrEF; (2) the maximum recommended dose of valsartan for the treatment of HFrEF was used in this trial, but the maximum recommended dose of enalapril for the treatment of HFrEF was not used; (3) a run-in phase was used in this trial to test the tolerability of LCZ696, and patients who had adverse effects in this period were excluded from randomization; (4) the percent of blacks enrolled in this trial was only 5%; (5) LCZ696 caused a 14% incidence of hypotension; (6) neprilysin inhibition might favor the development of Alzheimer dementia, which was not assessed in the PARADIGM-HF trial; (7) patients with severe symptomatic HF were underrepresented in this trial; (8) major exclusions from this trial included an acute coronary event in the last 3 months, severe pulmonary disease, hepatic impairment, and an estimated glomerular filtration rate

Heart failure (HF) is one of the leading causes of morbidity, mortality, and health care expenditures in the US and worldwide. For three decades, the pillars of treatment of HF with reduced ejection fraction (HFrEF) were medications that targeted the sympathetic nervous system (SNS) and the renin-angiotensin-aldosterone system (RAAS). Prior attempts to augment the natriuretic peptide system (NPS) for the management of HF failed either due to lack of significant clinical benefit or due to the unacceptable side effect profile. This review article will discuss the NPS, the failure of early drugs which targeted the NPS as therapies for HF, and the sequence of events which led to the development of sacubitril plus valsartan (Entresto; LCZ696; Novartis). LCZ696 has been shown to be superior to the standard of care available for treatment of HFrEF in several substantial hard endpoints including heart failure hospitalizations, cardiovascular mortality, and all-cause mortality.

Exercise induced complete atrioventricular block (EIAVB) is a relatively uncommon condition. This phenomenon is clinically important because it can mimic symptoms of other cardiovascular conditions and may be associated with exercise intolerance and subsequent syncope. A 76year old man with long-standing hypertension and diabetes mellitus presented with recurrent episodes of lightheadedness and syncope with physical activity. ECG showed sinus rhythm with first degree atrioventricular block. Echocardiography did not show any valvular disease causing his symptoms. Coronoary angiographic evaluation revealed non-obstructive coronary artery disease. Because of the exertional nature of his symptoms, a symptom-limited treadmill exercise test was performed which revealed EIAVB. A permanent dual chamber pacemaker was implanted and his symptoms resolved completely.

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.

Older patients with atrial fibrillation (AF) are at higher risk of thromboembolic events and oral anticoagulant (OAC)-related bleeding complications. This meta-analysis evaluates the efficacy and safety of direct-acting OACs (DOACs) compared with warfarin in older patients with nonvalvular AF. PubMed, Embase, and Cochrane Central databases were searched for randomized controlled trials assessing the efficacy and safety of DOACs compared with warfarin in AF patients who were >75 years old. Treatment effects and relevant standard errors were calculated from the available data. These values were imputed in software R to perform meta-analysis through generic inverse variance method. Additionally, we performed a network meta-analysis to compare the relative efficacy and safety of each OAC. Five substudies of randomized controlled trials, comprising 28,135 older participants, were included in the analysis. DOACs as a group were found to have superior efficacy compared with warfarin in reducing stroke or systemic embolization (hazard ratio 0.76, 95% confidence intervals 0.67 to 0.86, p

We assessed the impact of early ( 24 hours) revascularization with percutaneous coronary intervention (PCI) in patients with non-ST elevation myocardial infarction (NSTEMI) and cardiogenic shock (CS). Data from National Inpatient Sample 2005-16 were used to identify

Cardiogenic shock (HCM) in hypertrophic cardiomyopathy (HCM) is an under-studied clinical entity. We sought to study epidemiology of HCM-CS, utilization of mechanical circulatory support (MCS), and in-hospital mortality from CS among patients with HCM. We utilized the US National Inpatient Sample

Heart failure (HF) is characterized by maladaptive neurohormonal activation of the cardiovascular and renal systems resulting in circulatory inadequacy and frequent acute exacerbations. The increasing burden of HF prompted investigation of underlying pathophysiological mechanisms and the design of pharmacotherapeutics that would target these pathways.A MEDLINE search for relevant original investigations and review articles of newer hormonal drugs for HF since the year 2005 till October 2017 provided us with necessary literature. Major trials and relevant clinical investigations were discussed.A multitude of hormonal pathways central to HF were identified, including the natriuretic peptide system and neurohormones such as relaxin, arginine vasopressin, and endothelin. However, drugs targeting these novel pathways (aliskiren, tolvaptan, ularitide, serelaxin, bosentan, macitentan) failed to show mortality benefit. This emphasizes a tremendous unmet need in the pharmacotherapy for HF, especially for the subtypes of acute HF and HF with preserved ejection fraction. Sacubitril/valsartan demonstrated substantial mortality benefit in chronic systolic HF population and is endorsed by international HF guidelines. If proven to be efficacious in larger outcome trials, finerenone can be a valuable addition baseline HF therapy. More basic, translational, and phenotype specific clinical research is warranted to improve HF pharmacotherapy.

Cardiovascular (CV) disease is a major cause of morbidity and mortality in the developing and the developed world. Mortality from CV disease had plateaued in the recent years raising concerning alarms about the sustained efficacy of available preventive and treatment options. Heart failure (HF) is among the major contributors to the CV-related health care burden, a persisting concern despite the use of clinically proven guideline-directed therapies. A requirement for more efficient medical therapies coupled with recent advances in bio-innovation led to the creation of sacubitril/valsartan, an angiotensin receptor-neprilysin inhibitor (ARNI), which demonstrated substantial CV benefit when compared with the standard of care, enalapril, in patients with HF and reduced ejection fraction. Further investigations of this novel combination ARNI at the tissue level shed light into the anti-remodeling and cardioprotective effects of sacubitril/valsartan, while clinical studies in the phenotypes of HF with preserved ejection fraction, hypertension and subsets, coronary outcomes, postmyocardial infarction, and renal disease suggested that this combination could be beneficial across a wide spectrum of CV disease. Sacubitril/valsartan is a much-needed therapeutic advance in the avenue of CV disease.

Catheter ablation is proven to be an effective strategy for drug refractory ventricular tachycardia (VT) in ischemic cardiomyopathy. However, the appropriate timing of VT ablation and identifying the group of patients that may receive the greatest benefit remains uncertain. There is limited data on the effect on prophylactic catheter ablation (PCA) in the prevention of implantable cardioverter defibrillator (ICD) therapy, electrical storm, and mortality. We performed a comprehensive literature search through November 1, 2017, for all eligible studies comparing PCA + ICD versus ICD only in eligible patients with ischemic cardiomyopathy. Clinical outcomes included all ICD therapies including ICD shocks and electrical storm. Additional outcomes included all-cause mortality, cardiovascular mortality, and complications. Three randomized controlled trials (RCTs) (N = 346) met inclusion criteria. PCA was associated with a significantly lower ICD therapies (OR 0.49; CI 0.28 to 0.87; p = 0.01) including ICD shocks [OR 0.38; CI 0.22 to 0.64; p = 0.0003) and electrical storm (OR 0.55; CI 0.30 to 1.01; p = 0.05) when compared with ICD only. There was no significant difference in all-cause mortality (OR 0.77; CI 0.41 to 1.46; p = 0.42), cardiovascular mortality (OR 0.49; CI 0.16 to 1.50; p = 0.21), and major adverse events (OR 1.45; CI 0.52 to 4.01; p = 0.47) between two groups. These results suggest prophylactic catheter ablation decreases ICD therapies, including shocks and electrical storm with no improvement in overall mortality. There is a need for future carefully designed randomized clinical trials.

With an estimated prevalence of 5.8 million in the USA and over 23 million people worldwide, heart failure (HF) is growing in epidemic proportions. Despite the use of guideline-directed medical therapies such as angiotensin-converting enzyme inhibitors, beta-adrenergic blockers, angiotensin receptor blockers, and mineralocorticoid receptor antagonists for chronic systolic HF for almost two decades, HF remains a leading cause of morbidity, mortality, and health care expenditures. The Prospective Comparison of Angiotensin Receptor-Neprilysin Inhibitor with Angiotensin-Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial provided compelling evidence for the cardiovascular and mortality benefit of sacubitril/valsartan when compared to enalapril in patients with heart failure and reduced ejection fraction (HFrEF). Sacubitril/valsartan performed better than enalapril across various HFrEF patient characteristics and showed substantial benefit in patients with other common comorbidities. Following the trial, the US Food and Drug Administration approved this drug for the treatment of HF. Various international HF consensus guidelines endorse sacubitril/valsartan as a class I recommendation for the management of symptomatic HFrEF. Although this high-quality clinical study is the largest and the most globally represented trial in HFrEF patients, concerns have been raised regarding the generalizability of the trial results in real-world HF population. The gaps in US Food and Drug Administration labeling and guideline recommendations might lead to this medication being used in a larger population than it was studied in. In this review, we will discuss the current role of sacubitril/valsartan in the management of HF, concerns related to PARADIGM-HF and answers, shortcomings of this novel drug, effects on patient characteristics, real-world eligibility, and the role of ongoing and further investigations to clarify the profile of sacubitril/valsartan in the management of HF.

Background: Correlation of ST-segment elevation on the 12-lead electrocardiogram (ECG) with the expected affected coronary territory is established in patients with ST-elevation myocardial infarction (STEMI). In patients with non-ST-elevation myocardial infarction (NSTEMI), correlation of ischemic ECG abnormalities with the affected coronary territory has not been well-established. We sought to investigate the correlation of electrocardiographic abnormalities with the location of 1-vessel obstructive coronary artery disease (CAD) in patients with both STEMI and NSTEMI. Methods: In this retrospective study, the charts of all patients referred for coronary angiography in 2012 were reviewed. Patients with a single obstructive coronary artery plus angina-equivalent symptoms and an elevated cardiac troponin I was included. Available ECGs were interpreted by an experienced cardiologist (WSA) blinded to the result of angiography. Patients with complete bundle branch block or ventricular pacing were excluded. Ischemic ECG changes were correlated to a coronary territory based on predefined criteria. Results: Of 131 included patients (mean age 64±13 years; 74% male), 29 had STEMI and 102 had NSTEMI. Eleven of 11 patients (100%) with anterior STEMI had left anterior descending artery (LAD) obstructive CAD. Of 18 patients with inferior STEMI, 14 (78%) had right coronary artery (RCA) obstructive CAD, 3 (17%) had left circumflex artery (LCX) artery obstructive CAD, and 1 (5%) had LAD obstructive CAD. Of 102 NSTEMI patients, 53 (52%) had definite ECG ischemic abnormalities. Of 31 patients with anterior definite ECG ischemic abnormalities, 30 (97%) had LAD obstructive CAD, and 1 (3%) had RCA obstructive CAD. Of 22 patients with inferior definite ECG ischemic abnormalities, 14 (64%) had RCA obstructive CAD, 5 (23%) had LCX obstructive CAD, and 3 (14%) had LAD obstructive CAD. Conclusions: Patients with anterior STEMI had LAD obstructive CAD. Patients with inferior STEMI were highly likely to have RCA or LCX obstructive CAD. Only half of NSTEMI patients had definite ischemic ECG abnormalities. When present, anterior ischemic ECG changes in patients with single vessel CAD with NSTEMI were predictive of LAD obstructive CAD.

Chronic thromboembolic pulmonary hypertension (CTEPH), classified as World Health Organization (WHO) group 4 pulmonary hypertension (PH), is an interesting and rare pulmonary vascular disorder secondary to mechanical obstruction of the pulmonary vasculature from thromboembolism resulting in PH. The pathophysiology is complex, beginning with mechanical obstruction of the pulmonary arteries, which eventually leads to arteriopathic changes and vascular remodeling in the nonoccluded arteries and in the distal segments of the occluded arteries mediated by thrombus nonresolution, abnormal angiogenesis, endothelial dysfunction, and various local growth factors. Based on available data, CTEPH is a rare disease entity occurring in a small proportion (0.5-3%) of patients after acute pulmonary embolism with an annual incidence ranging anywhere between 1 and 7 cases per million population. It is often underdiagnosed or misdiagnosed as idiopathic pulmonary arterial hypertension due to a lack of clinical suspicion or the under-utilization of radionuclide ventilation/perfusion scan. Although the current standard remains planar ventilation/perfusion scintigraphy as the initial imaging study to screen for CTEPH, and invasive pulmonary angiography with right heart catheterization as confirmatory modalities, they are likely to be replaced by modalities that can provide both anatomic and functional data while minimizing radiation exposure. Surgery is the gold standard treatment and offers better improvements in clinical and hemodynamic parameters compared with medical therapy. The management of CTEPH requires a multidisciplinary team, operability assessment, experienced surgical center, and the consideration of medical PH-directed therapies in patients who have inoperable disease, in addition to supportive therapies. Although, balloon pulmonary angioplasty is gaining interest to improve pulmonary hemodynamics and symptoms in CTEPH patients not amenable to surgery, further investigative randomized studies are needed to validate its use. It is very important for the present-day physician to be familiar with the disease entity and its appropriate evaluation to facilitate early diagnosis and appropriate management.

Recent guidelines have allowed consideration of multi-vessel percutaneous coronary intervention (MVPCI) in ST elevation myocardial infarction (STEMI). National Readmissions Data (NRD) 2010-14 was utilized to select study cohort. Appropriate International Classification of Diseases, 9th Revision (

Acute myocardial infarction (AMI) is the most common cause of cardiogenic shock (CS). Sepsis can predispose to the development of AMI and is also a known cause of CS. The incidence and outcomes of CS with the clinical phenotype of sepsis-AMI are not well studied. We analyzed the United States

Choice of septal reduction procedure with either alcohol septal ablation (ASA) or septal myectomy (SM) for hypertrophic cardiomyopathy (HCM) is largely guided by patient age, anatomy, and comorbidity status. Given clinical equipoise in a subset of patients who are candidates for both procedures

Data regarding the utilization and outcomes of percutaneous closure of ventricular septal rupture (VSR) complicating ST-segment elevation myocardial infarction (STEMI) in the United States are lacking. We queried the National Inpatient Sample 2006-2014 to identify STEMI hospitalizations in adult

With the growing use of imaging to aid in both diagnosis and treatment of patients presenting with a myriad of clinical presentations, incidental findings on imaging have become commonplace. Partial anomalous pulmonary venous connection (PAPVC) is a rare congenital cardiovascular condition that often goes undiagnosed due to lack of symptoms early in life. In adulthood, it can manifest clinically as right-sided heart failure or pulmonary hypertension. We present a case of PAPVC, which, like most cases, was discovered incidentally on chest X-ray.

Cardiogenic shock can lead to dysfunction of multiple organ systems. Signs and symptoms from secondary organ dysfunction can mask the primary role of cardiac dysfunction. A 59 year-old man with a history of coronary artery disease presented with several days of progressive abdominal pain and

Hemodynamic instability immediately post heart transplant (OHT) could be due to primary graft dysfunction (PGD). Extracorporeal membrane oxygenation (ECMO) is increasingly utilized as temporary mechanical circulatory support in PGD until graft function normalizes. We aim to study the donor and

Hemodynamic instability in orthotropic heart transplant (OHT) recipients in the peri-transplant period is deleterious and not infrequent. Mechanical circulatory support (MCS) devices have been used to provide temporary hemodynamic support. We aim to study the trends in utilization of MCS use in OHT