Chahal, Anwar A

ABSTRACT Objective Hypertension is a key risk factor for aortic dissection (AD). AD, if left untreated, carries significant mortality rates. Our aim is to analyse trends in mortality due to AD in adults with primary hypertension in the United States (US). Methods We used the CDC WONDER database to extract mortality data for patients with primary hypertension who died due to AD. Age‐adjusted mortality rates (AAMRs) and crude mortality rates (CMRs) were extracted per 100 000 persons. Annual percentage changes (APCs) and average APCs (AAPCs) in AAMRs and CMRs were calculated using Joinpoint regression. Results From 1999 to 2020, a total of 13 128 deaths due to AD were reported in patients with primary hypertension in the US. Males displayed a higher overall AAMR (0.3) than females (0.2) throughout the study period. Slight regional variations were observed, with the West showing the highest overall AAMR (0.4), followed by the Midwest (0.3), and the Northeast and South (0.2). In urban areas, AAMRs were higher than in rural areas until 2008. From 2009 to 2020, AAMRs remained stable in urban areas (0.3) but increased in rural areas from 2010 to 2020 (4.7). The highest state‐level AAMRs were observed in Hawaii, Oregon, and Oklahoma. Conclusion Significant differences were observed in AAPCs compared to AD‐related mortality trends in the general population. Mortality trends revealed an initial decline followed by a gradual rise. Clinicians should focus on high‐risk groups and raise awareness about the disease in these populations.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, contributing to significant morbidity and mortality worldwide. The relationship between physical exercise and AF is complex, with studies showing both beneficial and potentially adverse effects. Moreover, evidence suggests a U-shaped association between exercise intensity and AF risk. Moderate exercise has been shown to reduce AF burden by improving cardiovascular risk factors, enhancing autonomic regulation, and mitigating atrial fibrosis. In contrast, excessively high-intensity endurance exercise may increase AF risk, particularly in young athletes, due to atrial stretching, dilation, fibrosis, autonomic imbalances, and heightened inflammation. The current guidelines emphasize exercise as a core lifestyle intervention for AF management, recommending moderate-intensity aerobic activity for optimal outcomes. This review examines the current evidence on the effects of exercise on AF, identifies knowledge gaps, and proposes potential future research directions.

Abstract Arrhythmogenic cardiomyopathy (ACM) is addressed in international guidelines and expert consensus statements. To assist clinicians in their routine practice and support decision-making, we performed a systematic review of the most relevant guidelines and recommendations for ACM diagnosis and management. Our search, covering MEDLINE, EMBASE, and resources from scientific societies over the last 10 years, identified two guidelines and three consensus statements that met rigorous inclusion criteria for detailed analysis. In the examined documents, key areas of agreement included the critical role of cardiac imaging for initial diagnosis and ongoing monitoring, genetic testing in index patients, ventricular arrhythmia management, catheter ablation indications, heart failure treatment strategies, and exercise recommendations. However, significant differences were found in definitions and diagnostic criteria for ACM, interpretation of phenocopies, management of family members, and criteria for implantable cardioverter defibrillator implantation. Additional discrepancies emerged regarding the role of multidisciplinary teams, non-cardiac surgical considerations, atrial fibrillation management, and reproductive issues. Crucially, there remain considerable gaps in evidence, especially in areas such as the management and follow-up of patients with potential or borderline ACM diagnoses, as well as the care of their relatives. The clinical implications of genetic findings, along with the clinical management of left-dominant, biventricular phenotypes, and hot phases of disease, are also insufficiently addressed. Furthermore, a critical shortfall is the lack of externally validated risk assessment tools to guide clinical decision-making. Bridging these gaps could help guiding future research and guideline development towards improving patient outcomes.

AbstractBackgroundCardiac tamponade or pericardial tamponade (PT) can be a complication following invasive cardiac procedures.MethodsPatients who underwent various procedures in the cardiac catheterization lab (viz. coronary interventions) were identified using the International Classification of Diseases, Ninth and Tenth Edition, Clinical Modification (International classification of diseases [ICD]‐9‐Clinical modification [CM] and ICD‐10‐CM, respectively) from the Nationwide Inpatient Sample (NIS) database. Patient demographics, presence of comorbidities, PT‐related events, and in‐hospital death were also abstracted from the NIS database.ResultsThe frequency of PT‐related events in the patients undergoing CI from 2010 to 2017 ranged from 3.3% to 8.4%. Combined in‐hospital mortality/morbidity of PT‐related events were higher with increasing age (odds ratio [OR] [95% CI]: chronic total occlusion (CTO) = 1.19 [1.10‐1.29]; acute coronary syndrome (ACS) = 1.21 [1.11‐1.33], both p < 0.0001) and female sex (OR [95%CI]: CTO = 1.70 [1.45‐2.00]; ACS = 1.72 [1.44‐2.06], both p < 0.0001). In‐hospital mortality related to PT‐related events was found to be 8.5% for coronary procedures. In‐hospital mortality was highest amongst the patients undergoing percutaneous transluminal coronary angioplasty (PTCA) for ACS (ACS vs. non‐CTO PTCA vs. CTO PTCA: 15.7% vs. 10.4% and 14.4%, p < 0.0001 and ACS vs. non‐CTO PTCA vs. CTO PTCA: 12.1% vs. 8.1% and 5.6%, p = 0.0001, respectively).ConclusionsIn the real‐world setting, PT‐related events in CI were found to be 3.3%−8.4%, with in‐hospital mortality of 8.5%. The patients undergoing PTCA for ACS were found to have highest mortality. Older patients undergoing CTO PTCA independently predicted higher mortality.

Cardiovascular magnetic resonance (CMR) imaging is widely regarded as the gold-standard technique for myocardial tissue characterization, allowing for the detection of structural abnormalities such as myocardial fatty replacement, myocardial edema, myocardial necrosis, and/or fibrosis. Historically, the identification of abnormal myocardial regions relied on variations in tissue signal intensity, often necessitating the use of exogenous contrast agents. However, over the past two decades, innovative parametric mapping techniques have emerged, enabling the direct quantitative assessment of tissue magnetic resonance (MR) properties on a voxel-by-voxel basis. These mapping techniques offer significant advantages by providing comprehensive and precise information that can be translated into color-coded maps, facilitating the identification of subtle or diffuse myocardial abnormalities. As unlikely conventional methods, these techniques do not require a substantial amount of structurally altered tissue to be visually identifiable as an area of abnormal signal intensity, eliminating the reliance on contrast agents. Moreover, these parametric mapping techniques, such as T1, T2, and T2* mapping, have transitioned from being primarily research tools to becoming valuable assets in the clinical diagnosis and risk stratification of various cardiac disorders. In this review, we aim to elucidate the underlying physical principles of CMR parametric mapping, explore its current clinical applications, address potential pitfalls, and outline future directions for research and development in this field.

Abstract Multiple guidelines exist for the diagnosis and management of heart failure with preserved ejection fraction (HFpEF). We systematically reviewed current guidelines and recommendations, developed by national and international medical organizations, on the management of HFpEF in adults to aid clinical decision-making. We searched MEDLINE and EMBASE on 28 February 2024 for publications over the last 10 years as well as websites of organizations relevant to guideline development. Of the 10 guidelines and recommendations retrieved, 7 showed considerable rigour of development and were subsequently retained for analysis. There was consensus on the definition of HFpEF and the diagnostic role of serum natriuretic peptides and resting transthoracic echocardiography. Discrepancies were identified in the thresholds of serum natriuretic peptides and transthoracic echocardiography parameters used to diagnose HFpEF. There was agreement on the general pharmacological and supportive management of acute and chronic HFpEF. However, differences exist in strategies to identify and address specific phenotypes. Contemporary guidelines for HFpEF management agree on measures to avoid its development and the consideration of cardiac transplantation in advanced diseases. There were discrepancies in recommended frequency of surveillance for patients with HFpEF and sparse recommendations on screening for HFpEF in the general population, use of diagnostic scoring systems, and the role of newly emerging therapies.

SummaryObjectiveWe aimed to determine the frequency of probable obstructive sleep apnea (pOSA) in refractory epilepsy monitoring unit inpatients and clinical features associated with pOSA, including risk for sudden unexpected death in epilepsy (SUDEP).MethodsWe prospectively recruited 49 consecutive adult patients admitted to the Mayo Clinic Epilepsy Monitoring Unit with focal, generalized, or unclassified epilepsy syndromes. pOSA was identified using oximetric oxyhemoglobin desaturation index (ODI) and the Sleep Apnea–Sleep Disorders Questionnaire (SA‐SDQ) and STOP‐BAG screening tools. Revised SUDEP Risk Inventory (rSUDEP‐7) scores were calculated, and epilepsy patients with and without pOSA were compared with Wilcoxon signed‐rank tests. Correlation and regression analyses were utilized to determine relationships between pOSA and rSUDEP‐7 scores.ResultsThirty‐five percent of patients had pOSA, with a mean ODI of 11.3 ± 5.1/h (range = 5.1‐22.8). Patients with pOSA were older and heavier, and more frequently had a focal epilepsy syndrome and longer epilepsy duration, with higher SA‐SDQ and STOP‐BAG scores (all P < 0.05). Median rSUDEP‐7 score was 3 ± 1.4 (range = 0‐6). Higher rSUDEP‐7 scores were positively correlated with higher ODI (P = 0.036). rSUDEP‐7 score ≥ 5 was associated with pOSA by ODI, SA‐SDQ, and STOP‐BAG questionnaire criteria (P < 0.05).SignificanceOur pilot study identified a high frequency of pOSA in refractory epilepsy monitoring patients, finding that pOSA patients were older and heavier, with higher screening symptoms for sleep apnea and more frequent focal seizures with a longer epilepsy duration. We also found a possible association between OSA and SUDEP risk. Identification and treatment of OSA in patients with epilepsy could conceivably provide a novel approach toward preventing the risk of SUDEP. Future studies with polysomnography are needed to confirm predictive features for OSA in epilepsy populations, and to determine whether OSA is associated with SUDEP risk.

AbstractBackgroundCardiovascular implantable electronic devices (CIEDs) can be life‐saving. However, complications from CIED infection can be life‐threatening, often requiring device removal. Despite publication of CIED infection management guidelines, there remains marked variation in clinical practice.ObjectiveTo better understand and quantify these differences, we conducted a multinational survey of practitioners of CIED management.MethodsAn electronic survey was sent to Heart Rhythm Society members, spanning 70 countries across six continents. All responses were collected anonymously.Results227 out of 3,600 (6.3%) responded to the survey. The majority of surveys were completed by practitioners from the United States (168; 68.3%) and 53.8% of these practiced in academic medical centers. The large majority (92.7%) of sites had protocols to ensure appropriate timing of prophylactic antibiotics. Superficial (incisional) site infections were treated with antibiotics alone 52.5% of the time (consistent with guidelines); in contrast, deep pocket infections were treated with antibiotics (with device removal) in accordance to guidelines only 37.4% of the time. Almost all providers (98.7%) were inclined to perform complete hardware removal in cases of CIED‐related endocarditis. In contrast, 82.2% of survey participants suggested complete CIED system removal in patients with an occult Gram‐positive bacteremia, 65.5% with occult Gram‐negative bacteremia, and 59.3% with prolonged bacteremia due to a source other than CIED.ConclusionsThese data suggest wide variability in clinical practice in managing CIED infection with significant deviations from published guidelines. There is critical need to increase awareness and develop institutional protocols to ensure adherence with evidence‐based guidelines to optimize outcomes.