Citations

Background: Antithrombotic regimens play a pivotal role in averting complications and ischemic incidents post-percutaneous coronary intervention (PCI) in MI (myocardial infarction) patients. Bivalirudin stands as a viable alternative to unfractionated heparin in this cohort, demonstrating the efficacy and safety profiles. Aim: We aimed to compare the efficacy and safety of bivalirudin versus unfractionated heparin in post-percutaneous coronary intervention (PCI) in MI (myocardial infarction) patients. Research Question : What is the efficacy and safety of Bivalirudin compared to unfractionated heparin in patients with MI undergoing PCI, specifically in terms of major bleeding, cardiovascular mortality, and other major adverse cardiovascular events? Methods: We systematically searched PubMed, including MEDLINE, Embase, Cochrane Library, Google Scholar, ClinicalTrials.gov, and EBSCOhost/CINAHL, from January 1, 2000, through May 29, 2024, for randomized controlled trials (RCTs) that evaluated Bivalirudin versus unfractionated heparin and with a study population of patients with MI undergoing PCI. Data extraction was done using a spreadsheet, and data analysis was done using RevMan 5.4.1 for meta-analysis. The primary efficacy and safety endpoints were major bleeding, major cardiovascular events, cardiovascular mortality, all-cause mortality, myocardial infarction, stent thrombosis, and stroke. Results: Our analysis included 11 RCTs, encompassing a total of 40,919 participants. When compared with unfractionated heparin, bivalirudin was associated with a significant reduction in major bleeding events (RR 0.66 [0.55 to 0.80]; p < 0.0001) and cardiovascular mortality (RR 0.79 [0.67 to 0.92]; p < 0.003). However, there were no significant differences between Bivalirudin and unfractionated heparin in terms of major adverse cardiovascular events (RR 1.02 [0.91 to 1.13]; p = 0.76), all-cause mortality (RR 0.89 [0.78 to 1.01]; p = 0.08), MI (RR 0.99 [0.85 to 1.15]; p = 0.90), stent thrombosis (RR 1.12 [0.53 to 2.40]; p = 0.76), or stroke (RR 0.96 [0.73 to 1.26]; p = 0.75). Conclusion: Our meta-analysis indicates that in patients with MI undergoing PCI, Bivalirudin is associated with lower rates of major bleeding and cardiovascular mortality compared to unfractionated heparin. However, there were no significant differences observed in major adverse cardiovascular events, all-cause mortality, MI, stroke, or stent thrombosis between the two treatment groups.

Background: We hypothesized that patients with coarctation of aorta (COA) and obesity would have more advanced cardiovascular remodeling and impaired aerobic capacity compared to COA patients without obesity. The purpose of this study was to assess the relationship between obesity, cardiovascular remodeling, and aerobic capacity in adults with repaired COA. Methods: The study comprised of 3 groups: (1) Obese COA group (n=177) (COA patients with body mass index [BMI] >30 kg/m2); (2) Non-obese COA group (n=572) (COA patients with BMI ≤30 kg/m2); (3) Control group (n=59) (subjects without structural heart disease and BMI ≤30 kg/m2). Cardiovascular remodeling was assessed using the following indices: (1) Arterial stiffness - total arterial compliance index (TACI). (2) Left ventricular hypertrophy - LV mass (LVM) and relative wall thickness (RWT). (3) LV diastolic function - Doppler-derived estimated LV end-diastolic pressure (LVEDP) and Tau. (4) Right ventricular-pulmonary artery coupling - RV free wall strain and right ventricle systolic pressure (RVFW/RVSP). Aerobic capacity was assessed using predicted peak oxygen consumption (VO2). Results: The obese COA group had higher LVM, RWT, LVEDP, and Tau, well as lower RVFWS/RVSP, TACI and peak VO2 compared to non-obese COA group and controls. There was a correlation between BMI and LVM (r=0.39, p<0.001), RWT (r=0.47, p<0.001), estimated LVEDP (r=0.43, p<0.001), tau (r=0.22, p=0.008), RVFWS/RVSP (r=- 0.24, p<0.001), and predicted peak VO2 (r= -0.48, p<0.001). Conclusions: These findings underscore the cardiovascular implications of obesity in the setting of COA, and provide opportunities for interventions to address obesity and improve outcomes in the COA population.

Background: Persistent atrial fibrillation (AF) presents a significant management challenge, particularly in patients with concurrent heart failure. The effectiveness of catheter ablation compared to medical therapy for these patients remains under debate. Aim: This meta-analysis aims to evaluate the outcomes of catheter ablation versus medical therapy for managing persistent AF. Research Question: How does catheter ablation compare to medical therapy in managing persistent AF considering outcomes like arrhythmia recurrence, hospitalizations, cardiac function, exercise capacity, and mortality? Methods: We performed a meta-analysis of randomized controlled trials (RCTs) comparing catheter ablation with medical therapy in patients with persistent AF. Data sources included PubMed, Embase, Cochrane Library, Clinicaltrial.gov, Google Scholar, and CINAHL/EBSCOHOST, with studies selected based on predefined inclusion criteria. Primary outcomes assessed were recurrence of atrial arrhythmias, hospitalizations, changes in left ventricular ejection fraction (LVEF), changes in 6-minute walk test (6MWT) distance, and all-cause mortality. The data extraction was done using a spreadsheet, and the data analysis was done using RevMan 5.4.1: for meta-analysis Results: A total of 10 RCTs involving 1812 patients were included in the analysis. Compared to medical therapy, catheter ablation significantly reduced the recurrence of atrial arrhythmias (risk ratio [RR] = 0.43, 95% confidence interval [CI]: 0.29-0.63, P < 0.0001). Hospitalization rates due to heart failure were also lower in the ablation group (RR = 0.57, 95% CI: 0.44-0.73, P < 0.001). Improvements in LVEF were observed with a mean difference (MD) of 5.98% (95% CI: 3.81% to 8.15%, P < 0.00001). The performance on the 6MWT was better in the catheter ablation group, with an MD of 28.83 meters (95% CI: 8.61 to 49.05 meters, P = 0.005). Additionally, catheter ablation was associated with a reduction in all-cause mortality (RR = 0.60, 95% CI: 0.45-0.80, P = 0.00006). Conclusion: This meta-analysis demonstrates that catheter ablation is superior to medical therapy in managing persistent atrial fibrillation. Catheter ablation offers significant benefits in reducing atrial arrhythmia recurrence, lowering hospitalization rates, improving cardiac function and exercise capacity, and reducing mortality. These findings support the consideration of catheter ablation as a preferred treatment strategy for patients with persistent AF.

Introduction: Atrial fibrillation is the most encountered arrhythmia in clinical settings, with an estimate of 6 million cases in the United States. A growing amount of evidence has been supporting the role of left atrial appendage in left sided atrial fibrillation with conflict results. We aim in this study to provide a more in-depth guide for optimal left sided atrial fibrillation ablation strategy. Methods: We searched PubMed, Web of Science, Cochrane and Scopus for published studies until May 2024. We included relevant studies that compared the left atrial appendage electrical isolation versus the standard ablation and reported our outcomes of interest. The main outcomes of the study were the recurrence of atrial arrhythmia and the incidence of stroke or transient ischemic attack during the follow-up period. Data were pooled as Mean difference (MD) or risk ratio (RR) with their 95% CI using a fixed-effect model. Results: Eleven studies with 3040 patients were included in the final analysis. Left atrial appendage electrical isolation was associated with a significant reduction in atrial arrhythmia recurrence compared to the standard ablation alone (OR: 0.41, 95% CI: 0.35 to 0.48). However, it was also associated with a significant increase in stroke or transient ischemic attack incidence (OR: 1.48, 95% CI: 1.09 to 3.12). Conclusion: Left atrial appendage electrical isolation led to a significantly lower atrial arrhythmia recurrence, but this was achieved with an increased risk of stroke and transient ischemic attack incidence during the follow-up period.

Background: Air pollution is a leading cause of cardiovascular diseases including ischemic heart disease and stroke contributing to millions of deaths, with elevated blood pressure, endothelial dysfunction, and systemic inflammation being some of the most important underlying mechanisms. Various studies showed a promising beneficial effect of indoor air purification on various health outcomes, including blood pressure. We aimed to assess the effect of indoor air purification on systolic blood pressure (SBP) and Diastolic blood pressure (DBP) and provide a rationale for home use of these filters. Methods: We searched PubMed, Web of Science, Cochrane and Scopus for published literature up to May 2024. We included studies that assessed air purification, including HEPA filters or electrostatic air filters, as an intervention compared to no intervention. The primary outcome of interest was mean changes in blood pressure both systolic and diastolic. Secondary outcomes were biomarkers of inflammation and oxidative stress. Mean difference (MD) and 95% CI was used in a fixed-effect model to analyze the data. Results: A total of 21 studies were included in our meta-analysis with a total of 1955 participants. Air purification was associated with a significant reduction in systolic blood pressure (SBP) (MD: -2.42, 95% CI: -3.42, -1.41), and diastolic blood pressure (DBP) (MD: -1.11, 95% CI: -1.76, -0.46). However, there was no significant changes in levels of inflammatory biomarkers or oxidative stress. Conclusion: Indoor air purification was associated with significant reductions in systolic and diastolic blood pressure levels, but questions arise whether these reductions are clinically relevant or not. Further studies should assess these findings. Conclusion: Indoor air purification was associated with significant reductions in systolic and diastolic blood pressure levels, but questions arise whether these reductions are clinically relevant or not. Further studies should assess these findings.

Background: Coronary microvascular disease (CMD) may be endothelium-independent (coronary flow reserve, CFR<2.5) or endothelium-dependent (<50% increase in coronary blood flow in response to acetylcholine). Endothelium-independent CMD has been subclassified into structural and functional groups based on hyperemic microvascular resistance (hMR, mmHg/cm/s). We hypothesized that endothelium-dependent CMD also has these subtypes. Methods: Patients with non-obstructive coronary artery disease who underwent coronary catheterization of the left anterior descending artery were included (n=112). Pressure and flow were recorded at rest, with adenosine, and with acetylcholine. Patients were classified by endothelial type and functional CMD (hMR<2.5) or structural CMD (hMR>2.5). Wave intensity analysis was performed and cumulative separated wave intensity (Joules/m 2 ) was calculated by standard formulae. Three dominant waves were analyzed (forward compression wave, FCW; backward compression wave, BCW; backward expansion wave, BEW). Results: Seventy-four of 109 patients had CMD, of which 59 had endothelium-independent and 38 had endothelium-dependent CMD (23 had both). Functional and structural subgroups were identified (Figure 1). All CMD subtypes had significantly different wave intensities at rest, adenosine, and acetylcholine (p<0.05). Comparing subtypes, there was no difference in wave intensities at rest. However, wave intensities significantly differed between all CMD subtypes with adenosine and acetylcholine, with higher energy waves in the endothelium-independent and functional groups (p<0.05, Figure 2). Conclusions: CMD is a heterogenous condition with distinct subtypes. Functional and structural groups exist in both endothelium-dependent and endothelium-independent CMD. These subgroups have distinct hemodynamic profiles as measured by wave intensity. A patient-specific approach to first line medical therapy may be improved by subgroup classification.

Background: Arrhythmogenic cardiomyopathy (ACM) is a genetic heart disease characterized by proclivity for ventricular arrhythmias and systolic dysfunction. Rarely, sudden cardiac arrest (SCA) is the presenting event in ACM. These individuals may have concealed disease with no appreciable structural manifestations on imaging. Aims: To determine the prevalence, clinical features, and outcomes of patients with genotype-positive ACM who presented with a sentinel SCA. Methods: In this retrospective study, 445 genotype-positive ACM patients evaluated from 1/2015-4/2024 were analyzed to identify those whose initial presentation was SCA. Pertinent demographic, clinical, genetic, and outcome data were extracted from the electronic medical record. Structural manifestations were defined by having one of the following on baseline TTE: EF < 50%, LVEDV >56 mL (male) or >51 mL (female), or regional RV akinesia, dyskinesia, or aneurysm. Categorical variables are presented as number (%), and continuous variables as median (IQR). Statistical analysis was done using Fisher’s exact test (categorical), t-test (continuous), and Logrank test (survival). Patients were censored at time of transplant, death, or last followup. Results: Overall, 14/445 (3%) ACM patients presented with sentinel SCA [71% male; median age at SCA 39 (IQR 30-46)]. The most common genetic substrates were DSP -encoded desmoplakin (n=4; 29%), LMNA -encoded lamin A/C (n=3; 21%), and PKP2 -encoded plakophilin-2 (n=3; 21%). During a median followup of 8.4 years, 12 (86%) experienced appropriate ICD shocks, 8 (57%) required catheter ablation for ventricular arrhythmias, 6 (42%) underwent transplant, and 2 (14%) died of cardiac causes. Notably, 5 (35%) patients did not have evidence of structural disease during baseline evaluation. Compared to those with structural disease, this group was younger [median age 28 (IQR 21-29) vs 45 (IQR 41-48), p = 0.002] and less likely to undergo transplant [0 (0%) vs 6 (42%), p = 0.03]. Conclusions: Sentinel SCA is a rare presentation in ACM and may precede overt structural cardiac changes in a subset of younger patients. This population remains at increased risk for recurrent ventricular arrhythmias and often require advanced therapies.

Introduction: Pulmonary hypertension (PHTN) is common in patients with chronic kidney disease (CKD), however categorization as precapillary or postcapillary is challenging due to the need for invasive right heart catheterization (RHC). Studies have validated transthoracic echocardiography (TTE) to characterize PHTN and ECG-artificial intelligence (AI) to predict diastolic dysfunction risk. The utility of these noninvasive tools in patients with CKD is unknown. Methods: Retrospective analysis of patients with end stage CKD who underwent RHC between 2011 and 2021. Patients with PHTN (pulmonary artery pressure >20mmHg on RHC) were categorized as having precapillary (pulmonary capillary wedge pressure, PCWP, ≤15mmHg and pulmonary vascular resistance, PVR, >2WU) or postcapillary PHTN (PCWP >15mmHg and PVR ≤2WU for isolated postcapillary or PVR >2WU for combined). TTE and ECG within 3 months of RHC were obtained. TTE measurements were used to calculate ePLAR (echocardiographic pulmonary to left atrial ratio); tricuspid regurgitant peak velocity (TRV max ) divided by mitral E/e’. ECGs were analyzed with an AI risk tool for diastolic dysfunction (score 0-3, increasing with increasing risk). Receiver operating curves (ROC) evaluated the performance of these tests. Results: 60 patients were included; 16 (27%) with precapillary and 44 (73%) with postcapillary PHTN. ROC analysis found good accuracy for both ECG-AI diastolic dysfunction risk score to predict precapillary PHTN with AUC 0.724 (sensitivity=60% and specificity=88% for an ECG score value ≤1) and ePLAR with AUC 0.715 (sensitivity=75% and specificity=70% for ePLAR >0.17m/sec). Highest accuracy for detection of precapillary PHTN was reached by combination of ePLAR and ECG-AI tool, with AUC 0.756 (sensitivity=73%, accuracy of 86% for a value ≤1.17). Conclusions: ECG-AI generated diastolic risk score of 0-1 (low risk) and high ePLAR showed good accuracy in characterizing precapillary PHTN in patients with end stage CKD. The combination of these noninvasive tools further increased the diagnostic accuracy, reflecting its potential utility in classification of patients with CKD and PHTN, a crucial determinant of the ideal therapeutic plan in kidney transplant candidates.

Introduction: Sleep duration is now recognized as an important determinant of cardiovascular (CV) health. Recently, the CV implications of day-to-day variability in sleep duration have become apparent, with irregular sleep duration associated with increased risk of CV disease, including hypertension. However, the relationship between sleep duration variability and ambulatory blood pressure (BP) patterns in the general population or in patients with CV disease is unknown. Research Questions: We sought to investigate whether irregular sleep duration is associated with aberrant ambulatory BP or heart rate (HR) profiles in patients undergoing cardiac rehabilitation (CR). Methods: We recruited a sample of 42 patients with coronary artery disease enrolled in CR at Mayo Clinic Rochester. Participants underwent 24-hour ambulatory BP monitoring and sleep assessment including one week of wrist actigraphy and sleep diary prior to entering CR. Twenty-four hour, awake, and asleep averages were calculated for systolic BP, diastolic BP, and HR. Nocturnal dipping and morning surge were also computed for BP and HR. Sleep regularity was quantified by SD of actigraphy-derived sleep duration and irregular sleep duration was defined as SD >1 hour. Chi-square tests and Mann-Whitney U tests were used to compare groups. Results: Thirty-six participants (22% females, median age [25 th ,75 th IQR] 66.5 [61,75.8] years, body mass index 31.7 [26.9,35.1] kg/m 2 ) had valid actigraphy and ambulatory BP recordings. We found sleep duration SD >1 hour in 36% of them. Demographics and average sleep duration were similar between those with irregular and regular sleep duration (all Ps>0.11). Twenty-four-hour, awake and asleep HR values were comparable between groups (all Ps>0.26). Participants with irregular sleep duration exhibited lower nocturnal HR dipping (9.2 [3.1,11.6] % vs 12.9 [8.9,18.2] %, P=0.019) than their counterparts with regular sleep. Morning HR surge was also attenuated in patients with irregular sleep duration (3 [-1,9] bpm vs 10 [7,14] bpm, P=0.006). Ambulatory SBP and DBP measures did not differ significantly between groups (all Ps>0.17). Conclusions: High day-to-day variability in sleep duration is linked to blunted nocturnal dipping and morning surge in HR in patients with coronary artery disease enrolled in CR. Because altered ambulatory HR profile predicts unfavorable CV outcomes, evaluation of sleep patterns in the CR setting may yield important prognostic information.

Introduction: Hyponatremia is a common electrolyte abnormality that has been associated with poor outcomes in several conditions including acute myocardial infarction (AMI). However, those studies were performed in the era before percutaneous coronary intervention (PCI), focused mostly on ST-elevation myocardial infarction (STEMI), and sodium levels up to 72 h of admission. Aim: The purpose of this study was to identify the prognostic importance of hyponatremia in patients with acute myocardial infarction. Methods: We performed a cross sectional and retrospective analysis of 100 patients with a diagnosis of non-ST-elevation myocardial infarction (NSTEMI) and STEMI presenting at PSH, Vadodara, Gujarat, India from January 2022 to May 2024. Our independent variables were sodium levels on the day of admission. Dependent variables were in-hospital mortality, 30-day mortality, length of hospital stay, intensive care admission, new heart failure diagnosis, and ejection fraction. Infarct size was determined by echocardiographic examination that was performed on admission, day 2 or 3 of hospitalization Results: Hyponatremia, defined as a plasma sodium level <135 mmol/L (<135 mEq/L). 32% of patients had hyponatremia up to 7 days of admission. Intensive care admission was higher in patients with hyponatremia up to7 days (70% vs 383%), they had worse 30-day mortality (15% vs to 3%), in hospital mortality (12% vs 2%), and new heart failure diagnosis (32% vs 16%). Hyponatremia on admission was associated with in-hospital mortality (15% vs 4%), 30-day mortality (19% vs 6 %). Conclusions: This study suggests that hyponatremia on admission and at any point during the first seven days of hospitalization are associated with in-hospital and 30-day mortality and prognosis worsens with the severity of hyponatremia. Further studies are required to determine if plasma sodium levels may serve as a simple marker to identify patients at high risk.