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Cardiopulmonary exercise testing (CPET) provides important information for the assessment and management of patients with heart failure. This testing measures the respiratory and cardiac responses to exercise and allows measurement of the oxygen uptake (V˙O 2 ) max and the relationship between minute ventilation (V˙E) and carbon dioxide excretion (V˙CO 2 ). These two parameters help classify patients into categories that help predict prognosis, and patients with a V˙O 2 < 14 mL/kg/min and V˙E/V˙CO 2 slope >35 have a poor prognosis. This testing has been used in drug trials to determine complex physiologic responses to medications, such as angiotensin-converting enzyme inhibitors. For example, a study with enalapril demonstrated that the peak V˙O 2 was 14.6 ± 1.6 mL/kg/min on placebo and 15.8 ± 2.0 mL/kg/min on enalapril after 15 days of treatment. The V˙E/V˙CO 2 slopes were 43 ± 8 on placebo and 39 ± 7 on enalapril. Chronic heart failure and reduced physical activity measured by cardiopulmonary exercise testing are associated with increases in BNP, and several studies have demonstrated that cardiac rehabilitation is associated with reductions in BNP and increases in V˙O 2 . Therefore, BNP measurements can help determine the benefits of cardiac rehabilitation and provide indirect estimates of changes in V˙O 2 . In addition, measurement of microRNAs can determine the status of skeletal muscle used during physical activity and the changes associated with rehabilitation. However, CPET requires complicated technology, and simpler methods to measure physical activity could help clinicians to manage their patients. Recent advances in technology have led to the development of portable cardiopulmonary exercise testing equipment, which can be used in various routine physical activities, such as walking upstairs, sweeping the floor, and making the bed, to provide patients and clinicians a better understanding of the patient's current symptoms. Finally, current smart watches can provide important information about the cardiorespiratory system, identify unexpected clinical problems, and help monitor the response to treatment. The organized use of these devices could contribute to the management of certain aspects of these patients' care, such as monitoring the treatment of atrial fibrillation. This review article provides a comprehensive overview of the current use of CPET in heart failure patients and discusses exercise principles, methods, clinical applications, and prognostic implications.

Contrast-induced nephropathy (CIN) is a significant complication in patients undergoing coronary angiography, and its development is associated with increased morbidity and mortality. Left ventricular end-diastolic pressure (LVEDP) provides one index of left heart filling status. An elevated LVEDP can reflect volume overload or abnormal diastolic function and indicates a cardiac disorder. Data on the association between an elevated LVEDP and CIN are limited and have had conflicting results. We systematically searched the databases PubMed, Embase, and Scopus for full-text articles from database inception to May 2022. Studies were included if they evaluated the association between a high LVEDP and the incidence of CIN in patients undergoing coronary angiography. The study was registered in the PROSPERO CRD42022334070. A second search in PubMed identified randomized controlled trials using LVEDP to guide fluid administration during coronary procedures. Four studies were identified that used LVEDP to classify patients into groups to determine the association between the level and the development of CIN. In these studies, 240 patients of 2441 patients (9.8%) developed CIN. One study found no association between LVEDP levels and the development of CIN. Two studies found an increased frequency of CIN in patients with elevated levels using 2 cutoff points for LVEDP, ≥20 mm Hg and >30 mm Hg. One study found that lower LVEDP levels (5-14 mm Hg) were associated with the development of CIN. Three randomized control trials used LVDEP levels to manage fluid administration in patients undergoing coronary procedures; only one study found that the use of these levels to guide fluid administration resulted in better outcomes. In patients undergoing coronary angiography, an elevated LVEDP was not consistently associated with increased risk of CIN, and using LVEDP levels to guide fluid administration during these procedures did not always improve outcomes in comparison to other protocols. The use of LVEDP levels can help classify patients with cardiac disorders but does not necessarily provide an adequate description of the hemodynamic patterns in these patients to predict or prevent CIN in patients undergoing angiography., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Mitral valve prolapse (MVP) is associated with aggravated risk of ventricular tachycardia (VT), ventricular fibrillation (VF) and sudden cardiac death (SCD). There is a lack of specific guideline recommendation regarding risk stratification and management, despite multiple proposed high-risk phenotypes. We performed systematic review and meta-analysis to evaluate high-risk phenotypes for malignant arrhythmias in patients with MVP., Methods: We comprehensively searched the databases of MEDLINE, SCOPUS, and EMBASE from inception to April 2023. Included studies were cohort and case-control comparing between MVP patients with and without VT, VF, cardiac arrest, ICD placement, or SCD. Data from each study were combined using the random-effects. Pooled odds ratios (OR) and 95% confidence intervals (CI) were calculated., Results: Nine studies from 1985 to 2023 were included involving 2,279 patients with MVP. We found that T-wave inversion (OR 2.52; 95% CI: 1.90-3.33; p  < 0.001), bileaflet involvement (OR 2.28; 95% CI: 1.69-3.09; p  < 0.001), late gadolinium enhancement (OR 17.05; 95% CI: 3.41-85.22; p  < 0.001), mitral annular disjunction (OR 3.71; 95% CI: 1.63-8.41; p  < 0.002), and history of syncope (OR 6.96; 95% CI: 1.05-46.01; p  = 0.044), but not female (OR 0.96; 95% CI: 0.46-2.01; p  = 0.911), redundant leaflets (OR 4.30; 95% CI: 0.81-22.84; p  = 0.087), or moderate-to-severe mitral regurgitation (OR 1.24; 95% CI: 0.65-2.37; p  = 0.505), were associated with those events., Conclusion: Bileaflet prolapse, T-wave inversion, mitral annular disjunction, late gadolinium enhancement, and history of syncope are high-risk phenotypes among population with MVP. Further research is needed to validate the risk stratification model and justify the role of primary prophylaxis against malignant arrhythmias.

Background: Myocardial injury has been described in coronavirus-2019 (COVID-19). Few studies have reported cardiovascular imaging data with transthoracic echocardiography (TTE) and electrocardiography (ECG) findings in COVID-19 patients, and their correlation with mortality., Methods: We conducted a retrospective cohort study that included COVID-19 patients from March 2020 through February 2021 who had TTE and ECG during hospital admission. Myocardial injury was defined by an elevated high-sensitivity troponin T level > 20 ng/L. Bivariate analysis was used to compare patients with myocardial injury and those without. Multivariate logistic regression analysis was performed to identify the variables associated with mortality., Results: A total of 438 patients were included. The mean age was 62.1 ± 14.9 years, and 58.9% were male. A total of 149 patients died, with a mortality rate of 34%. A total of 260 patients (59.4%) had myocardial injury. The average left ventricular ejection fraction was 59.8% ± 11.2%, with 30 patients (6.8%) having an ejection fraction of < 40%. Patients with myocardial injury had higher mortality than those without ( P < 0.05, χ 2 test). A multiple regression analysis model indicated that age, race and/or ethnicity, the development of acute respiratory distress syndrome, shock, the need for vasopressors, mechanical ventilation, and hemodialysis were the variables significantly associated with mortality., Conclusion: COVID-19 patients with myocardial injury had higher mortality than those without. Age, race and/or ethnicity, acute respiratory distress syndrome, shock, the need for vasopressors, mechanical ventilation, and hemodialysis were the clinical variables associated with mortality. The TEE and ECG variables studied were not significantly associated with mortality., (© 2023 The Authors.)

Background: Promising results with the CHA 2 DS 2 -VASc risk score (CVRS) have been reported for the prediction of contrast-induced nephropathy (CIN). The aim of this study is to consolidate all the data available and examine the association between elevated CVRS and the incidence of CIN in patients undergoing percutaneous coronary intervention (PCI)., Methods: We systematically searched PubMed, Embase, and Scopus for abstracts and full-text articles from inception to May 2022. Studies were included if they evaluated the association between a high CVRS and the incidence of CIN in patients undergoing PCI. Data were integrated using the random-effects, generic inverse variance method of DerSimonian and Laird. Prospero registration: CRD42022334065., Results: Seven studies from 2016 to 2021 with a total of 7,401 patients were included. In patients undergoing PCI, a high CVRS (≥2: Odds ratio [OR]:2.98, 95% confidence interval [95% CI] 2.25-3.94, p  < .01, I 2 = 1%, ≥3: OR 4.46, 95% CI 2.27-8.78, p  < .01, I 2 =56% and ≥4: OR:2.75, 95% CI 1.76-4.30, p  < .01, I 2 = 11%) was significantly associated with an increase incidence for CIN. Subgroup analyses were done in patients with acute coronary syndrome, and association with CIN remained statistically significant (≥2: OR 2.93, 95% CI 2.11-4.07, p  < .01, I 2 =22%and ≥4: OR:2.24, 95% CI 1.36-3.69, p  < .01, I 2 = 0%,)., Conclusion: In patients undergoing PCI, an elevated CVRS is associated with an increased risk for CIN. More rigorous studies are needed to clarify this association and to identify strategies to reduce CIN.

Background: We conducted a study to evaluate the risk of atrial fibrillation (AF) and atrial flutter (AFL) in periodontal disease (PD) patients., Methods: Cohort studies that evaluate the risk of AF or AFL in PD patients were included. The risk was expressed in the pooled odd ratio (OR) with 95% confidence interval (CI)., Results: A total of four cohort studies were included. We found that patients with PD have a significantly higher risk of AF/AFL compared to those without PD with the pooled OR of 1.33 (95% CI 1.29-1.38; p  = 0.357, I 2  = 3.0%)., Conclusions: PD increases the risk of AF and AFL., Competing Interests: All the authors declare no conflict of interest., (© 2023 The Authors. Journal of Arrhythmia published by John Wiley & Sons Australia, Ltd on behalf of Japanese Heart Rhythm Society.)

Pulmonary artery catheterization is a diagnostic procedure in which a catheter is inserted through a central vein and advanced toward the pulmonary artery to measure right atrial, right ventricular, and pulmonary artery pressures, estimate cardiac output, identify intracardiac shunts, and measure pulmonary vascular resistance. Hemodynamic measurements can provide a better understanding of the pathophysiology of heart failure and pulmonary hypertension, but their proper assessment and optimal use can be challenging due to differences in techniques that can lead to differences in conclusions and therapeutic management strategies. In this review, we will discuss right heart catheterization and its role in clinical practice (e.g., shunt evaluation, management of cardiogenic shock) and summarize important concerns related to measurement and interpretation., Competing Interests: None., (AJCD Copyright © 2023.)

This study hypothesized that elevated glycosylated hemoglobin (HbA1c) levels are associated with abnormal right heart catheterization (RHC) hemodynamic parameters in patients with heart failure with reduced ejection fraction (HFrEF) and no prior diagnosis of diabetes., Methods: Retrospective cohort study of adult patients with HFrEF and no prior diagnosis of diabetes who underwent RHC and had HbA1c levels measured 30 days before or after the RHC. This study excluded patients who had received blood transfusions within 90 days prior to HbA1c measurement and patients with known diabetes. Univariate and multivariate regression analyses adjusted for age, sex, and BMI were used to test for an association between RHC hemodynamic parameters and HbA1c levels., Results: A total of 136 patients were included with a mean age of 55 ± 15 years and mean HbA1c was 5.99 ± 0.64%. Unadjusted univariate models showed that HbA1c is significantly associated with cardiac index (CI) by the Fick method and thermodilution, right atrial pressure (RAP), and mean pulmonary arterial pressure (MPAP). After multivariate analysis, for every one unit increase in HbA1c, there was a 0.19 and 0.26 L/min/m 2 decrease in expected CI by thermodilution and by the Fick method ( P = 0.03 and P < 0.01), respectively. For every one unit increase in HbA1c, there was a 2.39 mmHg increase in expected RAP ( P = 0.01)., Conclusion: Elevated HbA1c levels measured within 30 days before or after the index RHC in patients with a left ventricular ejection fraction <40% were associated with congestive hemodynamic parameters., Competing Interests: There are no conflicts of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Competing Interests: Conflict of Interest: The authors have no financial conflicts of interest.

Competing Interests: Conflict of Interest: The authors have no financial conflicts of interest.

Introduction: Posttransplant anemia is a common finding after kidney transplantation. A previous meta-analysis reported an association between anemia and graft loss. However, data on cardiovascular outcomes have not yet been reported. Objective: We conducted an updated meta-analysis to examine the association between posttransplant anemia and outcomes after transplantation including cardiovascular mortality in adult kidney transplant recipients. Methods: We comprehensively searched the databases of MEDLINE and EMBASE from inception to November 2021. Data from each study were combined using the random-effects model. Generic inverse variance method of DerSimonian and Laird was employed to calculate the risk ratios and 95% CIs. Results: Seventeen studies from August 2006 to April 2019 were included (16 463 kidney transplantation recipients). Posttransplant anemia was associated with overall mortality (pooled risk ratio = 1.72 [1.39, 2.13], I 2  = 56%), graft loss (pooled risk ratio = 2.28 [1.77, 2.93], I 2  = 94%), cardiovascular death (pooled risk ratio = 2.06 [1.35, 3.16], I 2  = 0%), and cardiovascular events (pooled risk ratio = 1.33 [1.10, 1.61], I 2  = 0%). Early anemia (≤6 months), compared with late anemia (>6 months), has higher risk of overall mortality and graft loss with a pooled risk ratio of 2.63 (95% CI 1.79-3.86; I 2  = 0%) and 2.96 (95% CI 2.29-3.82; I 2  = 0%), respectively. Discussion: In addition to increased risk of graft loss, our updated meta-analysis demonstrated that posttransplant anemia was significantly associated with poor outcomes after kidney transplantation including overall mortality, graft loss, cardiovascular death, and cardiovascular events. Future studies are required to assess the effects of treatment strategies for posttransplant anemia on posttransplant outcomes including cardiovascular mortality.

Background: Gastrointestinal bleeding is a major cause of morbidity that plagues the quality of life of patients supported on contemporary continuous-flow left ventricular assist devices (CF-LVADs). Despite benefits in survival and the nearly 50% reduction in complications provided by CF-LVADs, bleeding remains one of the most frequent adverse events with CF-LVAD implants. The CF-LVADs cause an increased risk of bleeding mainly due to the activation of the coagulation cascade., Methods: A literature search was done using PubMed and Google Scholar from Inception to February 2022. Qualitative analyses of the articles retrieved were used to construct this review. This review attempts to provide a comprehensive summary of the epidemiology, pathophysiology, risk stratification, and management of gastrointestinal bleeding as a complication of CF-LVAD as well as propose an algorithm for diagnosis and treatment., Results: Bleeding can occur at different sites in the gastrointestinal tract, the most common underlying pathology being arteriovenous malformations located in the upper gastrointestinal tract The increased prevalence of gastrointestinal (GI) bleeding in CF-LVAD patients has been attributed to the physiology of the LVAD itself, the use of anticoagulants, as well as patient comorbidities. Management involves pharmacologic and nonpharmacologic strategies., Conclusions: CF-LVAD-supported patients have a significant risk of GI bleeding that is mainly caused by arteriovenous malformations located in the upper GI tract. The increased prevalence of GI bleeding in CF-LVAD patients is attributed to several etiologies that include factors attributed to the device itself and extrinsic factors such as the use of anticoagulation., (© 2022 International Center for Artificial Organ and Transplantation (ICAOT) and Wiley Periodicals LLC.)

Congestive heart failure is an uncommon initial presentation for dystrophin-deficient muscular dystrophies. Cardiac manifestations may appear in late disease stages, although they classically present after musculoskeletal symptoms develop. This case report describes a patient who presented with heart failure and was newly diagnosed with Becker muscular dystrophy. The objective is to recognize Becker muscular dystrophy as a potential cause of dilated cardiomyopathy in young patients, even in the absence of clinically overt musculoskeletal symptoms., (© 2022 by the Texas Heart® Institute, Houston.)

Background: Optimal timing to initiate mechanical circulatory support (MCS) in patients with ST-elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS) remains unclear with studies showing conflicting results on whether to start before or after primary percutaneous coronary intervention (PPCI). This study aims to examine the association between mortality and MCS initiated before vs after PPCI in patients with STEMI complicated by CS., Methods: We systematically searched PubMed, Embase, and Scopus for abstracts and full-text articles from inception to October 2021. Studies were included if they evaluated the association of mortality in patients who initiated MCS (specifically intra-aortic balloon pump (IABP), Impella, and venoarterial extracorporeal membrane oxygenation (VA-ECMO)) before PPCI versus after PPCI, specifically in patients with STEMI complicated by CS. Data were integrated using the random-effects models., Results: Ten studies involving 1,352 patients (956, 203, and 193 patients underwent IABP, Impella, and VA-ECMO respectively) with STEMI complicated by CS were included. There was no difference in mortality using IABP before or after PPCI ([OR] 1.77, 95% CI 0.77-1.61, I2 = 27%, p = 0.57). Nevertheless, Impella and VA-ECMO started before PPCI were significantly associated with a reduced risk of mortality compared to that started after PPCI ([OR] 0.49, 95% CI 0.26-0.92, I2 = 0%, p = 0.03 and [OR] 0.29, 95% CI 0.14-0.62, I2 = 0%, p = 0.001, respectively)., Conclusions: In patients with STEMI complicated by CS undergoing PPCI, the use of IMPELLA or VA-ECMO prior to PPCI significantly decreased mortality, in contrast to IABP, in which no difference in mortality was found between using it before or after PPCI. More rigorous studies are needed to clarify this association., Competing Interests: Declaration of competing interest The authors report no conflict of interest or any source of financial support., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: Whether metformin exposure is associated with improved outcomes in patients with type 2 diabetes mellitus and sepsis., Design: Retrospective cohort study., Setting: Patients admitted to ICUs in 16 hospitals in Pennsylvania from October 2008 to December 2014., Patients: Adult critical ill patients with type 2 diabetes mellitus and sepsis., Interventions: None., Measurements and Main Results: We conducted a retrospective cohort study to compare 90-day mortality in diabetic patients with sepsis with and without exposure to metformin during hospitalization. Data were obtained from the electronic health record of a large healthcare system in Pennsylvania from October 2008 to December 2014, on patients admitted to the ICU at any of the 16 hospitals within the system. The primary outcome was mortality at 90 days. The absolute and adjusted odds ratio (OR) with 95% CI were calculated in a propensity score-matched cohort. Among 14,847 patients with type 2 diabetes mellitus and sepsis, 682 patients (4.6%) were exposed to metformin during hospitalization and 14,165 (95.4%) were not. Within a total of 2,691 patients subjected to propensity score-matching at a 1:4 ratio, exposure to metformin (n = 599) was associated with decreased 90-day mortality (71/599, 11.9% vs 475/2,092, 22.7%; OR, 0.46; 95% CI, 0.35-0.60), reduced severe acute kidney injury (50% vs 57%; OR, 0.75; 95% CI, 0.62-0.90), less Major Adverse Kidney Events at 1 year (OR, 0.27; 95% CI, 0.22-0.68), and increased renal recovery (95% vs 86%; OR, 6.43; 95% CI, 3.42-12.1)., Conclusions: Metformin exposure during hospitalization is associated with a decrease in 90-day mortality in patients with type 2 diabetes mellitus and sepsis., Competing Interests: Dr. Gomez reports support as principal investigator of the Limiting Acute Kidney Injury Progression in Sepsis (LAPIS) trial from Biomerieux. Drs. Gomez and Murugan report personal fees from AM-Pharma for enrolling patients in clinical trial of recombinant alkaline phosphatase in sepsis-associated acute kidney injury. Drs. Gomez’s, Zuckerbraun’s, and Angus’s institutions received funding from the National Institute of General Medical Sciences. Drs. Gomez, Zuckerbraun, Murugan, and Angus received support for article research from the National Institutes of Health (NIH). Dr. Priyanka disclosed work for hire. Dr. Zuckerbraun’s institution received funding from the Veteran’s Affairs; he disclosed government work. Dr. Murugan’s institution received funding from AM Pharma and Baxter; he received funding from the National Institute of Diabetes and Digestive and Kidney Diseases; and he disclosed the off-label product use of metformin of sepsis-associated acute kidney injury. Dr. Angus’ institution received funding from the NIH (R01 NR018434) and (R01 HS025146). The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2022 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

There are scarce publications regarding the presentation and outcome of Becker muscular dystrophy in adulthood when idiopathic dilated cardiomyopathy is the initial disease manifestation. We performed a systematic review using Medline, Embase, Cochrane, and Scopus to identify cases of adults with idiopathic dilated cardiomyopathy who were subsequently diagnosed with Becker muscular dystrophy from inception through August 2020. Six cases were found. We identified young males (Median age: 26 years) with Becker muscular dystrophy who first presented with dilated cardiomyopathy. Most patients initially presented with congestive heart failure symptoms (5/6, 83%), and had a median left ventricular ejection fraction of 23%. One case did have calf pseudohypertrophy. Musculoskeletal symptoms later appeared one to six years after the initial dilated cardiomyopathy presentation. Heart transplantation was the most common management strategy (4/6, 67%). A left ventricular assist device was used in one case as a bridge to heart transplant. Dilated cardiomyopathy can be the initial presentation of Becker muscular dystrophy in the third to fourth decades of life in adult patients, and musculoskeletal symptoms can be subclinical., (© 2022. The Author(s).)

Importance: The 23rd Acute Disease Quality Initiative (ADQI-23) consensus conference proposed a framework to integrate biomarkers into the staging of acute kidney injury (AKI). It is unknown whether tissue inhibitor of metalloproteinases 2 (TIMP-2) and insulinlike growth factor binding protein 7 (IGFBP7) could be used for staging., Objective: To test whether higher levels of urinary [TIMP-2] × [IGFBP7] are associated with lower survival among patients with the same functional stage of AKI., Design, Setting, and Participants: This cohort study was performed using data from the Protocolized Care for Early Septic Shock (ProCESS) trial, which enrolled critically ill patients with septic shock who presented at academic and community emergency departments and intensive care units in the US from March 2008 to May 2013. Patients with end-stage kidney disease, a reference serum creatinine level of 4 mg/dL or greater (to convert to μmol/L, multiply by 76.25), or missing data on serum creatinine levels or urinary levels of [TIMP-2] × [IGFBP7] were excluded. Data were analyzed from October 2020 to October 2021., Exposures: The presence of AKI, assessed using Kidney Disease: Improving Global Outcomes criteria within 24 hours after enrollment and the highest AKI stage as well as urinary [TIMP-2] × [IGFBP7] level at 6 hours after enrollment. A previously reported high-specificity cutoff level for [TIMP-2] × [IGFBP7] of 2.0 (ng/mL)2/1000 was used to categorize patients (including those without functional criteria of AKI) according to the new staging system proposed by the ADQI-23 as biomarker negative (urinary [TIMP-2] × [IGFBP7] level ≤2.0 [ng/mL]2/1000) or biomarker positive ([TIMP-2] × [IGFBP7] >2.0 [ng/mL]2/1000)., Main Outcomes and Measures: Survival (assessed using Kaplan-Meier plots and the log-rank test) and mortality (assessed using relative risk [RR] 30 days after enrollment)., Results: The analysis included 999 patients with a median age of 61 years (IQR, 50-73 years); 554 (55.5%) were male. Biomarker-positive patients had lower survival and higher mortality at 30 days in the groups with AKI stage 1 (RR, 2.20; 95% CI, 1.02-4.72), stage 2 (RR, 1.53; 95% CI, 1.04-2.27), and stage 3 (RR, 1.61; 95% CI, 1.00-2.60). The associations were specific to patients with AKI. No difference in 30-day survival was found between biomarker-positive and biomarker-negative patients in the absence of functional criteria for AKI (RR, 1.16; 95% CI, 0.45-3.01)., Conclusions and Relevance: The findings suggest that assessment of the cell-cycle arrest biomarkers TIMP-2 and IGFBP7 may augment AKI staging for patients with functional criteria for AKI.

The Vaccine Adverse Event Reporting System database has been used to report adverse events following several vaccines. We studied the patient population predisposed to such reactions and how these reactions differ with respect to the vaccine type. We searched the electronic databases PubMed, EMBASE, and Scopus up to 9 July 2021 for any study describing cardiac adverse events attributed to the vaccination. A total of 56 studies met the criteria comprising 340 patients. There were 20 studies describing cardiac adverse events following smallpox vaccination, 11 studies describing adverse events after influenza vaccination, and 18 studies describing adverse events after COVID-19 vaccination. There was a total of six studies describing cardiac adverse events after the pneumococcal vaccine, tetanus toxoid, cholera vaccine, and rabies vaccine. Adverse events following influenza vaccination occurred more commonly in older females within an average duration of four days from vaccination. Pericardial involvement was the most reported adverse event. Adverse events following COVID-19 vaccination happened at a mean age of 42.7 years, more commonly in males, and mostly after a second dose. Adverse events following smallpox vaccination occurred more commonly in younger males, with an average onset of symptoms from vaccination around 16.6 days. Adverse events were mostly myopericarditis; however, the acute coronary syndrome has been reported with some vaccines.

Cases of rhabdomyolysis causing myoglobinuria in post-COVID-19 patients have been seen, and exact mechanisms behind it seem multifactorial. Some patients have severe myoglobinuria with highly elevated creatinine phosphokinase levels requiring urgent hemodialysis to keep creatinine and blood urea nitrogen levels under control and protect the kidneys from long-term damage. Here, we present a case of a 34-year-old man with a history notable for autism and hypertension who was admitted to the hospital for COVID-19 viral pneumonia and discharged without major complications. After 3 weeks, he came to the emergency room with decreased mental status and asterixis. He had red-colored urine and acute kidney injury secondary to rhabdomyolysis. His creatinine phosphokinase was 289,500 mcg/L-a level never reported before. The patient did not respond to aggressive intravenous fluids, so he was started on hemodialysis. After 1 week, he showed clinical improvement, and he was taken off dialysis in 2 weeks., (Copyright © 2022 Baylor University Medical Center.)

Objectives: The aim of this study is to examine the association between vascular access sites and the incidence of AKI in patients with STEMI undergoing primary PCI., Background: Emerging evidence has suggested that transradial access (TRA) may be associated with lower rates of acute kidney injury (AKI) as compared with transfemoral access (TFA). However, most of these studies have included a nonselected study population undergoing diagnostic cardiac catheterization or percutaneous coronary intervention (PCI). Data on the association between TRA and AKI in this setting of STEMI are limited and with conflicting results., Methods: We systematically searched PubMed, Embase, and Scopus for abstracts and full-text articles from inception to July 13 th of 2021. Studies included were randomized controlled trials (RCTs) and propensity-score-matched (PSM) studies evaluating the association of TRA versus TFA access with AKI in patients undergoing primary PCI for STEMI. Data were integrated using the random effects model and generic inverse-variance method of DerSimonian and Laird., Results: A total of 10,093 studies were found. After applying our inclusion criteria, 5 studies from 2014 to 2021 with a total of 8,536 STEMI patients were included. TRA was not significantly associated with a reduced risk for AKI compared with TFA (odds ratio 0.85, 95% CI 0.71-1.01, p 0.07, I 2  = 40%)., Conclusions: Transradial access was not significantly associated with lower risk of AKI in patients undergoing primary PCI for STEMI compared with TFA. Larger studies are needed to clarify this outcome., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2022 Gaspar Del Rio-Pertuz et al.)

Hypertrophic cardiomyopathy (HCM) is a hereditary disease with an autosomal dominant pattern of inheritance, that is caused by a mutation in one of several sarcomere genes that encodes components of the contractile system of the heart. Hypertrophic cardiomyopathy has been described as a disease that is more heavily diagnosed in the second decade of life, that may present with abnormal syncopal episodes or sudden cardiac death. However, with a better understanding of the genetic changes that occur in HCM and with improved imaging techniques, there has now been an increased recognition of a late-onset disease that can occur in the elderly population. We report a case of a 73-year-old woman who was found to have HCM after various clinical events took place.

Spontaneous coronary artery dissection (SCAD) is an infrequent cause of acute coronary syndrome (ACS) caused by a nontraumatic tear in the coronary artery wall. The true incidence is thought to be underestimated owing to its diagnostic difficulty as coronary angiography is insensitive in assessing the arterial wall structure, thereby warranting additional diagnostic modalities such as intravascular ultrasound. We report a case of a young woman who had been taking oral contraceptives, and presented with acute non-ST segment elevation myocardial infarction due to SCAD with superimposed thrombosis.

Background: Transthyretin amyloid cardiomyopathy (ATTR-CM) is one of the most common types of cardiac amyloidosis. Amyloid cardiomyopathy more commonly affects men, elderly, and 3% to 4% of the African-American population. ATTR-CM suspicion and diagnosis is challenging; however, awareness of the disease is increasing, and best practices to identify it are being proposed. The approach to suspected cases of ATTR-CM relies on the presence of heart failure, red flag signs and symptoms, and age >65 or >70 for men and women respectively. Little is known about cases when it presents in early ages. Case: We report a 62-year-old African American male with past medical history of hyperlipidemia, prostate cancer, hypertension, bilateral carpal tunnel surgery that had debuted with a cardiac arrhythmia at age 55 and was diagnosed with heart failure several years later. Restrictive cardiomyopathy was suspected, and genetic screening was sent for ATTRm which confirmed a pathogenic trasnthyretin gene mutation. Endomyocardial biopsy was performed which confirmed cardiac amyloid deposition. Discussion: ATTR-CM is a rare disease with an increasing prevalence. Cases with out of proportion signs and symptoms of heart failure with preserved ejection fractions should raise the suspicion of ATTR-CM despite age.

The majority of acute coronary syndromes are caused by coronary artery thrombotic occlusions secondary to atherosclerotic plaque erosion or rupture. Coronary embolism is an important yet forgotten underlying cause of acute coronary syndrome. We present a case of a young patient who presented with ST elevation myocardial infarction suspected to be secondary to coronary embolization originating from a left ventricular thrombus.

Aims: We sought to investigate the relationship between macrohemodynamic resuscitation and microcirculatory parameters with the response of microcirculatory flow, tissue-specific parameters of metabolic stress and injury. We hypothesized that early resuscitation based on macrohemodynamic parameters does not prevent the development of organ dysfunction in a porcine model of endotoxemic shock, and that sublingual microcirculatory parameters are associated with markers of tissue metabolic stress and injury. Results: Both resuscitation groups had significant increases in creatinine and neutrophil gelatinase-associated lipocalin as compared with baseline. Neither the macrovascular response to endotoxemia or resuscitation, nor group allocation predicted the development of acute kidney injury (AKI). Only a microvascular flow index (MFI) <2.5 was associated with the development of renal tubular injury and AKI, and with increased renal, liver, peritoneal, and sublingual lactate/pyruvate (L/P) ratio and lactate. Among systemic parameters, only partial pressure of carbon dioxide (PCO 2 ) gap >6 and P(a-v)CO 2 /C(v-a)O 2 >1.8 were associated with increased organ L/P ratio and AKI. Innovation and Conclusion: Our findings demonstrate that targeting macrohemodynamics to guide resuscitation during endotoxemic shock failed to predict tissue metabolic stress and the response of the microvasculature to resuscitation, and was unsuccessful in preventing tubular injury and AKI. Mechanistically, our data suggest that loss of hemodynamic coherence and decoupling of microvascular flow from tissue metabolic demand during endotoxemia may explain the lack of association between macrohemodynamics and perfusion goals. Finally, we demonstrate that MFI, PCO 2 gap, and P(v-a)CO 2 /C(a-v)O 2 ratio outperformed macrohemodynamic parameters at predicting the development of renal metabolic stress and tubular injury, and therefore, that these indices merit further validation as promising resuscitation targets. Antioxid. Redox Signal . 35, 1407-1425.

Sepsis-associated acute kidney injury (S-AKI) is a common and life-threatening complication in hospitalized and critically ill patients. It is characterized by rapid deterioration of renal function associated with sepsis. The pathophysiology of S-AKI remains incompletely understood, so most therapies remain reactive and nonspecific. Possible pathogenic mechanisms to explain S-AKI include microcirculatory dysfunction, a dysregulated inflammatory response, and cellular metabolic reprogramming. In addition, several biomarkers have been developed in an attempt to improve diagnostic sensitivity and specificity of S-AKI. This article discusses the current understanding of S-AKI, recent advances in pathophysiology and biomarker development, and current preventive and therapeutic approaches., Competing Interests: Disclosure H. Gomez received a research grant from TES pharma to study mechanisms of AKI in sepsis, and is site principal investigator of an industry-sponsored grant (AM Pharma) to study the effect of recombinant alkaline phosphatase in sepsis-induced AKI., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Acute kidney injury (AKI) and cardiorenal syndrome (CRS) are increasingly prevalent in hospitalized patients with cardiovascular disease and remain associated with poor short- and long-term outcomes. There are no specific therapies to reduce mortality related to either AKI or CRS, apart from supportive care and volume status management. Acute renal replacement therapies (RRTs), including ultrafiltration, intermittent hemodialysis, and continuous RRT are used to manage complications of medically refractory AKI and CRS and may restore normal electrolyte, acid-base, and fluid balance before renal recovery. Patients who require acute RRT have a significant risk of mortality and long-term dialysis dependence, emphasizing the importance of appropriate patient selection. Despite the growing use of RRT in the cardiac intensive care unit, there are few resources for the cardiovascular specialist that integrate the epidemiology, diagnostic workup, and medical management of AKI and CRS with an overview of indications, multidisciplinary team management, and transition off of RRT., (Copyright © 2020 American College of Cardiology Foundation. All rights reserved.)

Objective: The aim of this study was to appraise the methodological quality of published clinical practice guidelines (CPGs) of community-acquired pneumonia (CAP) using AGREE II instrument for further enhancing the CAP CPG development., Methods: We performed a systematic review of published CPGs on CAP from January 2007 to May 2019. All reviewers independently assessed each CPG using the AGREE II instrument. A standardised score was calculated for each of the six domains., Results: Our search strategy identified 4125 citations but just 18 met our inclusion criteria. Agreement among reviewers was very good: 0.98. The domains that scored better were: "scope and purpose" and "clarity and presentation". Those that scored worse were "editorial independence", and "applicability". According to the AGREE II evaluation for each Guideline, the NICE, IDSA, BTS, SWAB, Korea, Consensur II, Colombian and Peruvian CPGs were the only recommended with no further modifications. In addition, ERS and SEPAR CPGs were recommended with modifications, with lower scores regarding the editorial independence and applicability., Conclusion: In conclusion, published CPGs for CAP management vary in quality with a need to improve the methodological and applicability rigour. This could be achieved following the standards for guidelines development and a better emphasis on how to apply CPGs recommendations in clinical practice., (© 2020 John Wiley & Sons Ltd.)

Hemolytic uremic syndrome is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. Disseminated intravascular coagulation, thrombotic thrombocytopenic purpura, and hemolytic uremic syndrome have a similar clinical presentation. Diagnostic needs to be prompt to decrease mortality, because identifying the different disorders can help to tailor specific, effective therapies. However, diagnosis is challenging and morbidity and mortality remain high, especially in the critically ill population. Development of clinical prediction scores and rapid diagnostic tests for hemolytic uremic syndrome based on mechanistic knowledge are needed to facilitate early diagnosis and assign timely specific treatments to patients with hemolytic uremic syndrome variants., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Implementation of sputum Gram stain in the initial assessment of community-acquired pneumonia (CAP) patients is still controversial. We performed a systematic review and meta-analysis to investigate the usefulness of sputum Gram stain for defining the etiologic diagnosis of CAP in adult patients., Methods: We systematically searched the Medline, Embase, Science Direct, Scopus and LILACS databases for full-text articles. Relevant studies were reviewed by at least three investigators who extracted the data, pooled them using a random effects model, and carried out quality assessment. For each bacterium (Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, and Gram-negative bacilli), pooled sensitivity, specificity, positive and negative likelihood ratios were reported., Results: After a review of 3539 abstracts, 20 articles were included in the present meta-analysis. The studies included yielded 5619 patients with CAP. Pooled sensitivity and pooled specificity of sputum Gram stain were 0.59 (95% CI, 0.56-0.62) and 0.87 (95% CI, 0.86-0.89) respectively for S. pneumoniae, 0.78 (95% CI, 0.72-0.84) and 0.96 (95% CI, 0.94-0.97) for H. influenzae, 0.72 (95% CI, 0.53-0.87) and 0.97 (95% CI, 0.95-0.99) for S. aureus, and 0.64 (95% CI, 0.49-0.77) and 0.99 (95% CI, 0.97-0.99) for Gram-negative bacilli., Conclusion: Sputum Gram stain test is sensitive and highly specific for identifying the main causative pathogens in adult patients with CAP., Trial Registration: This study has been registered at PROSPERO International prospective register of systematic reviews under registration no. CRD42015015337 .