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With increasing survival after cancer treatment, there is a need for long-term management of risk factors and chronic medical conditions to realize the full benefit of improvement of outcomes. Hypertension is a major risk factor for cardiovascular disease and has a higher prevalence in cancer survivors compared to the general population. In this review article, we discuss the burden of hypertension in cancer survivors and how this impacts their long-term outcomes and risk of cancer recurrence. We then discuss the latest concepts regarding the pathophysiology of hypertension in cancer survivors in detail. There is a focus on inflammation and the role it plays in cancer and hypertension followed by a brief discussion on clonal hematopoiesis of indeterminate potential (CHIP) and associated hypertension. There is a brief review of various cancer therapies associated with development and worsening of hypertension control and the underlying mechanisms behind this. We conclude the review article by giving recommendations on blood pressure control in this unique patient population.A lot of newer anti-cancer therapies have been implicated in the development or worsening of hypertension. We summarize the latest data, explore associations between these therapies and hypertension, and review the latest understanding of the underlying mechanisms driving this process. Hypertension is a major risk factor for cardiovascular disease in cancer survivors and must be recognized and treated promptly.

Atherosclerotic heart disease remains a major cause of morbidity and mortality worldwide. The past few decades have seen the emergence of chronic inflammation as a mediator of atherosclerosis. Although the heart and vascular system remain the organ systems most affected in the atherosclerotic process, chronic inflammation and ischemia trigger a systemic multi-organ response. The liver is a critical organ for systemic hemostasis and recent developments have established an important role of the liver in response to atherosclerosis and myocardial ischemia. In addition, the rapid emergence of systemic liver diseases has unraveled a pathophysiological link with heart disease with therapeutic implications. In this review, we explore the relationship between the liver and the heart in myocardial ischemia, describe epidemiological associations between various liver pathologies and coronary heart disease, and elucidate practical challenges in the clinical management of patients with concomitant coronary heart disease and hepatic abnormalities.

Massive pulmonary embolism (MPE) is associated with a 20-50% mortality rate with guideline directed therapy. MPE treatment with surgical embolectomy (SE) or venoarterial extracorporeal membrane oxygenation (VA-ECMO) have shown promising results. In the context of a surgical management strategy for MPE, a comparison of outcomes associated with VA-ECMO or SE was performed. A retrospective review of a single institution cardiac surgery database was performed, identifying MPE treated with SE or VA-ECMO between 2005-2020. Primary outcome was in-hospital survival. 59 MPE [27 (46.8%) VA-ECMO vs 32 (54.2%) SE] were identified. All presented with elevated cardiac biomarkers, tachycardia (mean heart rate 113 ± 20 beats/minute), hypotension (mean systolic blood pressure 85 ± 22 mm Hg) and vasopressors requirement, without significant differences between cohorts. Preoperative CPR was performed in 37.3% (22/59), without a significant difference between cohorts. More VA-ECMO presented with questionable neurologic status (GCS ≤ 4) [9/27 (33.3%) vs 2/32 (6.2%), P = 0.008] and more VA-ECMO failed thrombolysis [8/27 (29.6) vs 2/32 (6.3), P = 0.014]. All presented with severe RV dysfunction, by discharge all had normalization of echocardiographic RV function. Overall mortality was 10.2%, with a trend toward higher mortality among VA-ECMO [14.9% (4/27) vs 6.3% (2/32) P = 0.14]. CPR was independently associated with death (OR 10.8, P = 0.02) whereas treatment modality was not (OR 0.24). In an extremely unstable MPE population VA-ECMO and SE were safely performed with low mortality while achieving RV recovery. Adverse outcomes were more closely associated with preoperative CPR than with treatment modality.

Cardiac sympathetic denervation has been shown to reduce sustained ventricular arrhythmias and implantable cardioverter-defibrillator shocks by inhibiting sympathetic outflow to the heart. We describe the first case to our knowledge of cardiac sympathetic denervation in the left ventricular assist device population. (Level of Difficulty: Advanced.), Graphical abstract

With the growing need for donor hearts and longer transplant waiting lists, there is a growing interest in expanding the donor pool by reconsidering previously excluded donor candidates. There has been an increase in solid organ availability due to drug overdose deaths in the setting of the recent opioid epidemic. However, these donors often have transmissible infections such as hepatitis C. In this review, we discuss the challenges associated with heart transplantation from hepatitis C–infected donors as well as the recent advancements that are making the use of these organs possible. With the introduction and widespread use of nucleic acid testing (NAT), the ability to distinguish viremic donors and those that have cleared the virus has become a reality. In addition, with the emergence of direct antiviral agents, there is an increase in data showing the short-term outcomes and success of hepatitis C treatment for recipients of viremic donor hearts. As techniques to distinguish donor hepatitis C infection status and successful treatments emerge, the percentage of accepted hepatitis C donor hearts is increasing. A number of studies showing success with hepatitis C organ transplants present a promising new avenue for organ procurement essential to meet the increasing demand for donor hearts.

Cardiac sarcoidosis (CS) is a widely underdiagnosed yet clinically significant form of granulomatous myocarditis associated with significant morbidity and mortality. Clinical presentation ranges from silent cardiac involvement detected on imaging to cardiomyopathy or sudden cardiac death. Diagnosis of CS remains challenging due to the lack of sensitivity and specificity of any single diagnostic method, underscoring the importance of elevated clinical suspicion and the use of multimodality imaging to guide diagnosis and treatment. In this review, we discuss the epidemiology, pathogenesis, clinical features, and diagnosis of this clinically evading and enigmatic disease.

OBJECTIVES: The purpose of this study was to examine whether peak oxygen uptake (pVO2) and other cardiopulmonary exercise test (CPET)-derived variables could predict intermediate-term mortality in stable continuous flow LVAD recipients. BACKGROUND: pVO2 is a cornerstone in the selection of patients for heart transplantation, but the prognostic power of pVO2 obtained in patients treated with a left ventricular assist device (LVAD) is unknown. METHODS: We collected data for pVO2 and outcomes in adult LVAD recipients in a retrospective, multicenter study and evaluated cutoff values for pVO2 including: 1) values above or below medians; 2) grouping patients in tertiles; and 3) pVO2 ≤14 ml/kg/min if the patient was not treated with beta-blockers (BB) or pVO2 ≤12 ml/kg/min if the patient was taking BB therapy. RESULTS: Nine centers contributed data from 450 patients. Patients were 53 ± 13 years of age; 78% were male; body mass index was 25 ± 5 kg/m2 with few comorbidities (stroke: 11%; diabetes: 18%; and peripheral artery disease: 4%). The cause of heart failure (HF) was most often nonischemic (66%). Devices included were the HeartMate II and 3 (Abbott); and Heartware ventricular assist devices Jarvik and Duraheart (Medtronic). The index CPET was performed at a median of 189 days (154-225 days) after LVAD implantation, and mean pVO2 was 14.1 ± 5 ml/kg/min (47% ± 14% of predicted value). Lower pVO2 values were strongly associated with poorer survival regardless of whether patients were analyzed for absolute pVO2 in ml/kg/min, pVO2 ≤12 BB/14 ml/kg/min, or as a percentage of predicted pVO2 values (P ≤ 0.001 for all). For patients with pVO2 >12 BB/14 and ventilation/carbon dioxide relationship (VE/VCO2) slope

Background Severe coronavirus disease 2019 (COVID‐19) is characterized by a proinflammatory state with high mortality. Statins have anti‐inflammatory effects and may attenuate the severity of COVID‐19. Methods and Results An observational study of all consecutive adult patients with COVID‐19 admitted to a single center located in Bronx, New York, was conducted from March 1, 2020, to May 2, 2020. Patients were grouped as those who did and those who did not receive a statin, and in‐hospital mortality was compared by competing events regression. In addition, propensity score matching and inverse probability treatment weighting were used in survival models to examine the association between statin use and death during hospitalization. A total of 4252 patients were admitted with COVID‐19. Diabetes mellitus modified the association between statin use and in‐hospital mortality. Patients with diabetes mellitus on a statin (n=983) were older (69±11 versus 67±14 years; P P P P =0.82). Propensity score matching (hazard ratio, 0.88; 95% CI, 0.83–0.94; P P Conclusions Statin use was associated with reduced in‐hospital mortality from COVID‐19 in patients with diabetes mellitus. These findings, if validated, may further reemphasize administration of statins to patients with diabetes mellitus during the COVID‐19 era.

Acute pulmonary embolism (PE) is associated with high morbidity and mortality because of right ventricular (RV) failure. There is evidence suggesting surgical therapy (surgical embolectomy or venoarterial extracorporeal membrane oxygenation [ECMO]) is safe and effective.The aim of this study was to assess the safety and efficacy of surgical management of acute PE.Surgical embolectomy and/or venoarterial ECMO were compared, between 2005 and 2019, for massive PE (MPE) versus high-risk submassive PE (SMPE). RV recovery was defined as improvements in central venous pressure, pulmonary artery systolic pressure, RV/left ventricular ratio, and RV fractional area change.One hundred thirty-six patients with PE (92 with SMPE and 44 with MPE) were identified. Patients with MPE more often presented with syncope (59.1% [26 of 44] vs. 25.0% [23 of 92]; p = 0.0003), Glasgow Coma Scale score ≤4 (22.7% [10 of 44] vs. 0% [0 of 92]), and failed thrombolysis (18.2% [8 of 44] vs. 4.3% [3 of 92]; p = 0.008). Pre-operative cardiopulmonary resuscitation occurred in 43.2% of patients with MPE (19 of 44). Most patients with SMPE were treated with embolectomy (98.9% [91 of 92]), while ECMO was used more in those with MPE (ECMO in 40.9% [18 of 44], embolectomy in 59.1% [26 of 44]). RV function improved as measured by central venous pressure (from 23.4 ± 4.9 to 10.5 ± 3.1 mm Hg), pulmonary artery systolic pressure (from 60.6 ± 14.2 to 33.8 ± 10.7 mm Hg), RV/left ventricular ratio (from 1.19 ± 0.33 to 0.87 ± 0.23; p 0.005), and fractional area change (from 26.8 to 41.0; p 0.005). Mortality was 4.4% (6 of 136; SMPE, 1.1% [1 of 92]; MPE, 11.6% [5 of 44]). Subgroup analysis showed morbidity and mortality were highly associated with pre-operative cardiopulmonary resuscitation.Surgical management of patients with MPE and high-risk SMPE is safe and highly effective at achieving RV recovery.

Cardiovascular disease is a leading cause of mortality in the elderly. Hypertension is an important modifiable risk factor that contributes to cardiovascular morbidity and mortality. The prevalence of hypertension is known to increase with age, and hypertension has been associated with an increase in risk for cardiovascular disease in the elderly. There is a wealth of evidence that supports aggressive control of blood pressure to lower cardiovascular risk in the general population. However, there are limited data to guide management of hypertension in the elderly and frail patient subgroups. These subgroups are inadequately treated due to lack of clarity regarding blood pressure thresholds, treatment targets, comorbidities, frailty, drug interactions from polypharmacy, and high cost of care. Areas covered: We review the current evidence behind the definition, goals, and treatments for hypertension in the elderly and frail and outline a strategy that can be used to guide antihypertensive pharmacotherapy in this population. Expert commentary: Lower blood pressure to 130/80 mm Hg in elderly patients if tolerated and promote use of combination therapy if the blood pressure is 20/10 mm Hg over the goal blood pressure. Antihypertensive treatment regimens must be tailored to each individual based on their comorbidities, risk for adverse effects, and potential drug interactions ( Figure 1 ).

Dronedarone, a derivative of amiodarone with structural modifications, was designed to have similar electrophysiological properties with a less toxic profile. Areas covered: Brief overview of the pharmacology of dronedarone followed by a summary of randomized clinical trials testing the efficacy of dronedarone in maintaining normal sinus rhythm and clinical outcomes associated with these trials. In depth discussion and commentary on trial findings which may seem contradictory at first approach and brief discussion of post-marketing surveillance studies. Expert opinion: Dronedarone is a moderately efficacious anti-arrhythmic agent which is safe for use in a carefully selected patient population, maintained in normal sinus rhythm, without advanced congestive heart failure, structural heart disease, permanent atrial fibrillation, digoxin use. It is especially useful in younger patients who lack other risk factors for cardiovascular events and, who stand to gain the most by avoiding long-term pulmonary and thyroid toxicities associated with more effective, but also significantly more toxic agents such as amiodarone.

Diabetes mellitus (DM), a modern-day epidemic, is a significant risk factor for cardiovascular disease. It is believed that statins elevate the risk of incident DM. Multiple trials were suggestive of the hyperglycemic effect of long-term statin use. This has prompted the Food and Drug Administration to include the risk of DM in the product label of statins. New-onset DM with statin use is biologically plausible and can be explained based on the multiple pathways in glucose metabolism affected by statins. Most pivotal clinical trials on statins were not powered to adequately assess the risk of incident DM with statin use, and the results from multiple meta-analyses are mixed. Currently, the US Preventive Services Task Force recommend the use of statins for primary prevention in patients with at least 1 cardiovascular risk factor and a 10-year risk of >7.5%. With the new American College of Cardiology/American Heart Association guidelines, the number of patients eligible for statin therapy has increased exponentially, which also calls for caution and increased vigilance in prescribing physicians regarding the controversies surrounding statin use. This article aims to highlight the existing data on statin use for primary prevention in diabetics and nondiabetics and the association of statins use with new-onset DM and its postulated mechanisms.

Metabolic syndrome (MetS) represents a cluster of metabolic abnormalities that include hypertension, central obesity, insulin resistance, and atherogenic dyslipidemia, and is strongly associated with an increased risk for developing diabetes and atherosclerotic and nonatherosclerotic cardiovascular disease (CVD). The pathogenesis of MetS involves both genetic and acquired factors that contribute to the final pathway of inflammation that leads to CVD. MetS has gained significant importance recently due to the exponential increase in obesity worldwide. Early diagnosis is important in order to employ lifestyle and risk factor modification. Here, we review the epidemiology and pathogenesis of MetS, the role of inflammation in MetS, and summarize existing natural therapies for MetS.

Current guidelines for pharmacotherapy briefly describe a role for combination antihypertensive therapy. However, guidance on whether combination therapy should be used at the time of initiating therapy or as add on, and the choice of combination therapy is scarce. Areas covered: Current literature suggests that intensive blood pressure control is the key to managing cardiovascular risk. Along with lifestyle management, pharmacotherapy is an central component in the treatment of hypertension. Here, we aim to review the pathophysiology of hypertension, rationale for using combination therapy, and the different combinations of antihypertensive drug classes that are available in the market. Papers from 1967 through 2016 listed on PubMed on this topic were reviewed. Expert opinion: Based on the review of the literature, combination antihypertensive therapies are more effective than monotherapy and are also well tolerated, safe and cost effective for treatment of hypertension. Further research is needed to help guide the choice of combination antihypertensive therapy in different patient populations based on age, gender, race and comorbidities.

• Janeway lesions and Osler's nodes were clinical clues for the diagnosis of endocarditis.

Purpose Early acute cellular rejection (ACR) after orthotopic heart transplantation (OHT) is associated with adverse long-term outcomes. Data on whether the Mycophenolate mofetil (MMF) dose has any impact on rates of early ACR is lacking. The target MMF dose studied in clinical trials for immunosuppression with OHT has ranged from 2 to 3gm/day. In January of 2016 due to an increase in infectious complications, we modified our institutional policy whereby the target MMF dose was lowered from 3 gm/day to 2gm/day. In this analysis, we examined rates of early rejection stratified by target MMF dose. Methods We performed a retrospective analysis of consecutive OHT recipients at a single center from January 2015 to July 2019. Patients were divided into two groups based on the target MMF dose (3gm vs. 2 gm/day). The rates of ACR warranting a change in immunosuppressive regimen within 4 weeks of OHT (1R/1B or ≥ 2R) were compared between the two groups. Data on other factors that could impact early ACR such as age, gender, race, induction immunosuppression, and PRA was also collected. Univariate and multivariate-adjusted statistical analyses were performed. Results Of 169 OHT, mean age 53 years and 26% females, 67 patients were in the MMF 3gm/day group (Group 1) and 102 were in the 2 gm/day group (Group 2). Baseline characteristics were similar in both groups. The average daily dose of MMF for the first week after OHT was 2245 ± 724 mg in Group 1 and 1866 ± 525 mg in Group 2 (p Conclusion In this single-center study of OHT recipients comparing daily target MMF dose of 3gm with 2gm in the early post OHT period, there was a trend towards early ACR in the 2gm/day MMF dose group. This suggests that a higher MMF dose of 3gm/day, if tolerated, may help lower rates of early ACR. Further investigation in a larger sample is warranted to validate this finding.

Introduction: Heart failure (HF) affects over 6 million Americans and is the most common cause of hospital readmissions in the United States. Cardiac arrhythmias are common comorbidities seen in patients with HF and are associated with an increase in morbidity and mortality. Pharmacotherapeutic agents along with device and ablation therapies are the mainstays of treatment for cardiac arrhythmias in HF.Areas covered: An extensive literature review of articles and clinical trials on PUBMED on the topic of pharmacotherapy for cardiac arrhythmias in heart failure was conducted. This review article summarizes the above literature to describe the prevalence of the various types of arrhythmias in HF, the recommended pharmacotherapies for the treatment of these arrhythmias in HF and the evidence that supports these recommendations.Expert opinion: Cardiac arrhythmias are common in HF and are the leading cause of death in this patient population. The management of cardiac arrhythmias in HF is challenging. Pharmacotherapy is the primary though increasingly adjunctive therapy for most cardiac arrhythmias. Further, antiarrhythmic drugs must be used with caution in this patient population due to their potential adverse effects.

Introduction Left ventricular assist devices (LVADs) have undergone technological advances over the past several years, however, device thrombosis remains a feared complication. We present a case of a HeartWare HVAD presenting with pump thrombosis which failed medical therapy and was exchanged for an Abbott HeartMate 3 pump. Case Report The patient is a 38-year-old male with end stage-systolic heart failure due to a HIV associated cardiomyopathy who underwent HVAD implantation six years prior to presentation. The patient was in his usual state of health when he presented to the hospital due to a "high watt" alarm. He was asymptomatic. The patient, who was maintained on aspirin and warfarin, had a presenting INR which was subtherapeutic (1.2). Interrogation of the device logs showed an abrupt increase in power up to 9W with flows >10 L/min (baseline ∼4.5W and ∼5.5 L/min) (Figure). Computed tomography (CT) angiogram did not reveal an outflow graft thrombosis but did note pulmonary edema. The patient was diagnosed with pump thrombosis and was initially treated with two doses of alteplase 20 mg (Figure arrows). The power and flow normalized. Multiple lactate dehydrogenase (LDH) specimens were hemolyzed, but the LDH 3 days after admission ultimately was 3,550 U/L (baseline 268 U/L). Two days later, power spikes recurred. The patient was given one dose of alteplase 50 mg without success. The patient underwent emergent exchange to a HeartMate 3 LVAD via a re-do sternotomy. Surgery was notable for the epicardial ring of the HVAD being firmly incorporated at the left ventricular apex. To minimize trauma, the epicardial ring of the HeartMate 3 was sutured directly onto the epicardial ring of the HVAD. The Heartmate 3 was then inserted through both epicardial rings while the outflow graft was anastomosed to the remnant outflow graft of the HVAD. The patient did well post-operatively and was discharged on post-operative day number 15. Summary A thrombosed HVAD can be successfully managed with exchange to a HeartMate 3 LVAD.

It is unknown whether pretreatment with clopidogrel in acute coronary syndrome (ACS) managed invasively, is superior to a strategy of administering clopidogrel in the cardiac catheterization laboratory at the time of percutaneous coronary intervention (PCI). Current practice guidelines do not endorse one strategy over the other.A comprehensive literature search was done to identify all relevant studies comparing pretreatment with clopidogrel to administration in the cardiac catheterization laboratory at the time of PCI (no pretreatment). A meta-analysis using a random effects model was used to calculate outcomes of interest.Our search identified 16 studies including 61,517 ACS patients undergoing cardiac catheterization. At 30days, clopidogrel pretreatment was associated with lower MACE 7.67% vs 9.46% (odds ratio (OR) 0.77, 95% confidence interval (CI) [0.68, 0.86]; P0.0001) and all-cause mortality 2.8% vs 4.1% (OR 0.70, 95% CI [0.58, 0.85]; P=0.0003). Mortality according to the longest follow up available was also significantly lower with pretreatment. No difference in major bleeding events was observed. These results were not significantly different between randomized vs observational studies or STEMI vs NSTEACS patients. Sensitivity analysis showed significantly lower MACE 7.98% vs 9.6% (OR 0.83, 95% CI [0.71, 0.96]; P=0.01) without increased major bleeding in NSTEACS patients undergoing PCI within 48h from pretreatment.In ACS patients undergoing PCI, clopidogrel pretreatment was associated with significantly lower 30day all-cause mortality and major adverse cardiovascular events without increased major bleeding events.

Acute pulmonary embolism (PE) is a common and highly lethal diagnosis. Surgical management has been marginalized despite recent promising outcomes. Survival and right ventricular (RV) recovery from the largest single center experience of surgically managed acute PE is reported. Surgical

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.

Data regarding the effects of intraprocedural thrombotic events (IPTE) are scarce. Hence we aim to perform a meta-analysis to examine the outcomes of IPTE compared to non-IPTE during PCI.We performed a literature search of all published full-length articles of studies that reported data on patients with IPTE compared with non-IPTE during PCI. We calculated odd ratios via random effects model.A total of 26,697 patients, of which 1572 patients had IPTE, were included in this analysis. In-hospital, IPTE was associated with higher mortality (odds ratio (OR) 5.36, 95% confidence interval (CI) [2.31, 12.41]; p0.0001), myocardial infarction (MI) and major bleeding compared to non-IPTE. At 30 days, IPTE was also associated with higher mortality (OR 4.57, 95% CI [2.43, 8.60]; p0.0001), MI, repeat revascularization, stent thrombosis and major bleeding compared to non-IPTE group. IPTE was also associated with higher long-term mortality (OR 2.19, 95% CI [1.35, 3.53]; p=0.001). Among IPTE patients, intraprocedural stent thrombosis was associated with greater odds of MI compared to both no reflow and distal embolization events.IPTE during PCI is associated with more adverse ischemic events, including mortality, during the index hospitalization, at 30 days and long-term.

Hepatitis C virus (HCV) infection is thought to be associated with an increased risk of coronary heart disease (CHD) events, perhaps secondary to increased inflammation. We sought to examine the angiographic burden of coronary artery disease (CAD) in patients with HCV compared to HCV-negative patients. All consecutive HCV RNA-positive patients (n = 61) who underwent coronary angiography at the University of Arkansas for Medical Sciences from 2001 to 2013 were identified. A parallel group of HCV-negative controls (n = 61), matched for age, gender, and indication for coronary angiography served as control. Angiographic burden of CAD was assessed by computing Gensini scores. Statistical analysis was performed using SPSS 21.0. Patients with HCV had significantly lower levels of total and low-density lipoprotein cholesterol. Preangiographic use of aspirin and statin was significantly lower in the HCV cohort. Number of patients with obstructive CAD was less in HCV group (23% vs 39%, p0.05). However, angiographic Gensini score was similar in both groups. There was no correlation between HCV RNA titers and Gensini score (p = 0.9, analysis of variance). In conclusion, patients with active HCV infection have similar angiographic CAD burden as HCV-negative patients. Furthermore, viral load does not appear to correlate with atherosclerosis burden. Patients with HCV have less-obstructive CAD and less-frequent use of aspirin and statins.

Cardiovascular disease represents a massive healthcare burden worldwide. Gender differences in the pathophysiology, presentation and prognosis of cardiovascular disease have been described in the literature. Metabolic syndrome, characterized by a cluster of metabolic abnormalities is associated with increased risk for type 2 diabetes mellitus and atherosclerotic cardiovascular disease. With the global obesity epidemic, the prevalence of metabolic syndrome is rising rapidly in the developed as well as developing world. However, there is considerable variation in the prevalence based on geography, age, sex and, definition used for diagnosis. Data on gender related differences in metabolic syndrome is relatively scarce. Here, we aim to review the gender differences in epidemiology and pathophysiology of metabolic syndrome as well as its individual components. Knowledge of gender differences in metabolic syndrome can help design gender specific preventative and therapeutic strategies that will have a positive impact on overall population health.

Cardiovascular disease is one of the leading causes of morbidity and mortality worldwide. Metabolic syndrome is a cluster of abnormalities, diagnosed using different combinations of metabolic abnormalities. Metabolic syndrome is associated with an increased risk of cardiovascular disease. Prevalence of metabolic syndrome varies based on age, sex, and geography similar to that of cardiovascular disease. Gender differences in pathophysiology, presentation and diagnosis of cardiovascular disease have been described in the literature, however, data on differences in metabolic syndrome in men and women is scarce. Through this chapter, we aim to discuss that gender differences in prevalence, pathophysiology, implications on cardiovascular disease risk, and management of metabolic syndrome. This knowledge will help further our understanding of the disease process and develop gender specific treatment strategies to help manage metabolic syndrome better and reduce the risk of cardiovascular disease and diabetes mellitus.

Background: Data on outcomes of ST-elevation myocardial infarction (STEMI) in patients with cancer are scarce. We investigated the nationwide trends in admissions for STEMI, utilization of percutaneous coronary intervention (PCI), and in-hospital outcomes in patients with the three most common cancer diagnoses (lung, breast, and colon) compared to patients without cancer. Methods: We conducted an administrative database study using the Nationwide Inpatient Sample (NIS). All in-patient hospitalizations for STEMI from 2001 to 2011 were identified. Patients with concomitant diagnosis of lung, breast or colon cancer were identified using appropriate International classification of diagnosis (ICD 9-CM) codes. Primary outcome was utilization of PCI and in-hospital mortality in patients with cancer compared to those without cancer. Results: Utilization of PCI was 30.8% (1,191/3,871), 20.2% (4,541/22,480) and 17.3% (1,716/9,944) in patients with breast, lung and colon cancer, respectively. Among patients without any of these cancers, use of PCI was 49.6%. In-hospital mortality was highest in patients with lung cancer (57.1%) and lowest in patients without cancer (25.7%). Conclusions: Patients with cancer have significantly worse in-hospital mortality compared to those without cancer, partly due to a relatively lower rate of PCI utilization in cancer patients with STEMI.

Introduction Over the last two decades, there has been a 24-fold rise in solid organ donation due to drug overdose deaths. One-year survival in recipients of a heart transplant from a drug overdose donor (DOD) has been reported to be similar to that of donor deaths from trauma or other medical causes (non-DOD). However, the incidence of primary graft dysfunction (PGD) requiring mechanical circulatory support (MCS) and early post-transplant mortality in these patients has not been established. Hypothesis Heart donation from a DOD results in higher rates of PGD and early post-transplant mortality than donation from a non-DOD. Methods We performed a retrospective analysis of consecutive orthotopic heart transplants (OHT) at a single center from January 2013 to December 2018. Patients with PGD requiring MCS in the form of extracorporeal membrane oxygenation (ECMO) within 48 hours of OHT were analyzed with respect to the cause of death of the donor. Patients on ECMO prior to transplant surgery were excluded. Baseline characteristics were compared using Chi-square test for categorical variables and t-test for continuous variables. Results Of 154 consecutive heart transplants, 5 were excluded due to pre-operative recipient ECMO support. Among the 149 analyzed transplants, 38 (25.5%) received a heart from a DOD. DOD had a lower initial pH (7.15 vs. 7.28, p=0.001), a higher rate of hepatitis C infection (15.8% vs. 1.8%, p=0.001) and were more likely to have received CPR (91.7% vs.32%, p Conclusions In this single-center study, there was a trend towards an increased risk of PGD when the donor had died from a drug overdose, possibly due to ischemic graft injury related to hypoxia. However, survival to hospital discharge was similar between the DOD and non-DOD groups. Given the rapid increase in the number of DODs, further investigation in larger populations is warranted as it may help inform donor selection.

Wolf Parkinson White syndrome is a pre-excitation syndrome due to an accessory conduction pathway. Electrocardiography demonstrates a short PR interval, long QRS interval and delta waves in normal sinus rhythm. Atrial fibrillation with underlying Wolf Parkinson White syndrome presents with irregular wide complex tachycardia, and can cause sudden cardiac death by precipitating ventricular fibrillation. Irregular wide complex tachycardia may be the first presentation of this underlying conduction abnormality in young patients. Emergency management for irregular wide complex tachycardia in hemodynamically unstable patients involves synchronized cardioversion, while intra-venous Procainamide can be used in hemodynamically stable patients. AV nodal blocking agents should be avoided. Treatment of choice for WPW syndrome is radiofrequency ablation.

Hydroxychloroquine (HCQ), a common anti-rheumatic medication, can be cardiotoxic and cause systolic or diastolic heart failure (HF). A 65 year old man presented with acute decompensated HF. He had a history of rheumatoid arthritis, and had been treated with hydroxychloroquine for the last 8 years.

Severe aortic stenosis (AS) can adversely affect right ventricular function (RVF). RVF is an important determinant of transcatheter aortic valve replacement (TAVR) outcomes. Immediate changes in echocardiographic parameters of RVF have not been previously reported. We report changes in

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

Late presentation of acute myocardial infarction (AMI) may be associated with complications such as cardiogenic shock (CS) and ventricular septal rupture (VSR). A 63 year old man presented several days after chest pain with an AMI complicated by CS, VSR and multiorgan failure. Coronary angiography

Background: Patients with active cancer represent an increasingly significant subset of patients presenting with acute coronary syndromes (ST elevation and Non ST elevation myocardial infarction). These patients are underrepresented in clinical trials. We sought to identify utilization of percutaneous coronary intervention (PCI) in patients with various cancers. Methods: We used the Nationwide inpatient sample to identify all patients that presented with STEMI and NSTEMI from the years 2002-2012. Patients with various cancers were identified with appropriate ICD-9 codes. Results: There were an estimated 3,120,957 STEMI admissions during the study period, of which 4.9% (140,008) had an associated cancer diagnosis. PCI was done in 48.3% of STEMI patients without cancer, but only in 32.9% of patients with cancer. We identified a total of 5,422,406 NSTEMI admissions during the same period. 5.6% (303,751) of NSTEMI patients had cancer. PCI utilization in NSTEMI patients without cancer was 27.8% and 19% in patients with cancer. Among individual cancers, patients with pancreatic, liver and gastric cancers had the lowest rates of PCI (table) Conclusion: Our study demonstrates significantly lower rates of PCI in patients with various cancers. Malignancies with a poor overall survival seem to be associated with lower PCI rates. With lack of clinical trial data on management of ACS in patients with various cancers and with improvements in cancer survivors overall, further studies are required to identify gaps in knowledge in appropriate selection of cancer patients for PCI.

Multiple myeloma (MM) is associated with development of cardiac amyloidosis. Data on arrhythmic burden in this population is lacking. We sought to assess the burden of arrhythmias in patients with MM. Patients with a diagnosis of MM and various cardiac arrhythmias (CA) at discharge were identified

We describe a diagnostic dilemma in a middle-aged man presenting with dyspnoea and bilateral pedal oedema who had been diagnosed with right heart failure based on clinical evidence. The evaluation for aetiology eventually led to discovery of an unusual extrathoracic cause, a left-to-right communication in the renal vasculature. Renal arteriovenous fistulae are rare and can be congenital, acquired or idiopathic. A left-to-right shunt typically presents with high-output cardiac failure involving the left and right sides of the heart. An atypical feature of this case was the finding of overt right heart failure in the setting of a normal left heart. Such a presentation has only been described in a few isolated case reports. Diagnostic approaches include CT angiography and cardiac catheterisation for haemodynamic measurements. The primary treatment options for arteriovenous fistulae are medical management, arterial embolisation and surgical repair.

Postoperative hypoxemia can result from a variety of causes. We describe a case of platypnea-orthodeoxia caused by shunting across a patent foramen ovale in a 72-year-old woman immediately after a laparoscopic Nissen fundoplication procedure. This was diagnosed by echocardiography and treated successfully with percutaneous device closure. An intracardiac shunt should always be considered as a potential cause of refractory postoperative hypoxemia after procedures on the thorax and upper abdomen.

Fractional flow reserve (FFR) of intermediate coronary stenosis is a highly accurate, reproducible, and cost-effective modality with powerful prognostic value. Results of the FAME (Fractional Flow Reserve versus Angiography for Multivessel Evaluation) [(1)][1] and FAME-2 trials [(2)][2] have shown a

Oesophageal ultrasound with bronchoscope (EUS-B) is designed to evaluate mediastinal structures. We describe a case of a 78-year-old woman who presented with altered mental status for 2 weeks. CT head revealed a subacute infarct in the right middle cerebral artery distribution. She was also found to have a lung mass on chest imaging. EUS-B-guided fine needle aspiration demonstrated the presence of adenocarcinoma in station 7 lymph node and in the mass. Immunohistochemistry confirmed it to be a lung primary as the Thyroid Transcription Factor-1 (TTF-1) was strongly positive. During the procedure, the cardiac valves were evaluated, and a mitral valve vegetation was noted. Formal echocardiography confirmed the presence of the vegetation. During hospital stay, the patient developed fever. Her blood cultures grew oxacillin-resistant Staphylococcus aureus. She was subsequently treated for infective endocarditis. We suggest that the use of EUS-B to routinely scan adjacent structures during a procedure may help obtain additional clinical information that may be critical to patient management.

Myasthenia gravis (MG) is a neuromuscular disorder that typically affects the ocular, bulbar, neck, proximal limbs and respiratory muscles. Dysphagia can occasionally be the only presenting symptom leading to extensive but ultimately futile gastrointestinal workup. Delay in diagnosis and use of certain pharmacological agents in the interim can lead to a myasthenic crisis, which though diagnostic is life threatening. We document a case of dysphagia as the only symptom of myasthenia, diagnosed after a magnesium infusion precipitated myasthenic crisis. A 70-year-old Caucasian woman who had had progressive dysphagia for 2 years, for which multiple oesophageal dilations were performed. During a hosptalisation for further gastrointestinal workup, she went into myasthenic crisis (respiratory failure) after receiving magnesium replacement. She required ventilatory support and received five plasma exchange (PLEX) treatments after myasthenia was confirmed by the detection of high antiacetylcholine receptor antibody. Though her symptoms improved, she had a prolonged hospital stay (25 days) and required 18 days of mechanical ventilation. This underscores the morbidity associated with a delay in diagnosis of this condition. This case report suggests that neuromuscular causes should be considered early in elderly patients presenting with dysphagia. Timely diagnosis, initiation of management and avoidance of drugs that affect neuromuscular transmission may help reduce the morbidity and mortality associated with myasthenic crisis.

Surgery is the treatment of choice for prosthetic mechanical mitral valve thrombosis (PMVT) with heart failure. We present a case where two-dose thrombolysis was successful in PMVT. A 35-year-old woman with history of mechanical mitral valve for rheumatic mitral stenosis presented with dyspnea