Emerging Modalities for Temporary Mechanical Circulatory Support in Cardiogenic Shock

Cardiogenic shock (CS) is a life-threatening medical condition that requires prompt recognition and treatment. The use of standardized CS criteria, such as the Society for Cardiovascular Angiography and Interventions criteria, can categorize patients and guide therapeutic strategies. Temporary mechanical circulatory support (MCS) devices have become valuable tools in the treatment of CS, as they can provide cardiovascular support as a bridge to recovery, cardiac surgery, or advanced therapies such as cardiac transplant or durable ventricular assist devices. The use of MCS should be tailored to each individual patient, focused on a stepwise escalation of circulatory support to support both end-organ perfusion and myocardial recovery. As newer MCS devices reduce myocardial oxygen demand without increasing ischemia, the possibility of recovery is optimized. In this review, we discuss the different modalities of MCS focusing on the mechanism of support and the advantages and disadvantages of each device.

Role of the Electrocardiogram for Identifying the Development of Atrial Fibrillation

Atrial fibrillation (AF), a prevalent cardiac arrhythmia, is associated with increased morbidity and mortality worldwide. Stroke, the leading cause of serious disability in the United States, is among the important complications of this arrhythmia. Recent studies have demonstrated that certain clinical variables can be useful in the prediction of AF development in the future. The electrocardiogram (ECG) is a simple and cost-effective technology that is widely available in various healthcare settings. An emerging body of evidence has suggested that ECG tracings preceding the development of AF can be useful in predicting this arrhythmia in the future. Various variables on ECG especially different P wave parameters have been investigated in the prediction of new-onset AF and found to be useful. Several risk models were also introduced using these variables along with the patient's clinical data. However, current guidelines do not provide a clear consensus regarding implementing these prediction models in clinical practice for identifying patients at risk of AF. Also, the role of intensive screening via ECG or implantable devices based on this scoring system is unclear. The purpose of this review is to summarize AF and various related terminologies and explain the pathophysiology and electrocardiographic features of this tachyarrhythmia. We also discuss the predictive electrocardiographic features of AF, review some of the existing risk models and scoring system, and shed light on the role of monitoring device for screening purposes.

Inconsistent Benefits From Mobile Information Communication Technology in Adults With Peripheral Arterial Disease

INTRODUCTION

Quality of evidence regarding telemedicine in adults with peripheral arterial disease has not been systematically appraised.

OBJECTIVES

To explore benefits and harms from mobile information communication technology devices and applications in peripheral arterial disease.

METHODS

Systematic rapid evidence review and appraisal with the grading of recommendations assessment, development, and evaluation working group approach.

RESULTS

Sixteen randomized controlled clinical trials (RCT) examined various self-monitoring devices, telemedicine platforms, and individualized telephone counseling. Low-quality evidence suggested that the odds of treatment failure (pooled Peto odds ratio 0.8; 95% CI, 0.4-1.7; 5 RCTs), adverse effects (pooled Peto odds ratio 0.9; 95% CI, 0.5-1.5; 2 RCTs), and physical performance (standardized mean difference in 6-minute walking test 0.2; 95% CI, -0.3-0.7; 4 RCTs) did not differ between mobile interventions and usual care. Single RCTs suggested large but inconsistent improvement in the quality of life: EuroQol5D standardized mean difference = 5.0 (95% CI, 4.4-5.7; 1 RCT) after telehealth program for promoting patient self-management and standardized mean difference = 1.4 (95% CI, 0.4-2.3; 1 RCT) after structured rehabilitation with mobile self-monitoring. Inconsistent reporting of patient-centered outcomes and small sample sizes hampered the quality of evidence.

CONCLUSIONS

Improved quality of life after specific mobile applications should be confirmed in powered RCTs and large postmarketing studies.

Recovery From Left Ventricular Dysfunction

The treatment of heart failure is an evolving field of cardiology, with increasingly available therapeutics and significant disease burden. With the effective treatments available, we see a substantial patient population whose once reduced ejection fraction (EF) has normalized. Studies have assessed the natural history of these patients with improved EF and found improved mortality as compared with those patients with persistently reduced EF, with some evidence stating that each 5% increase in left ventricular EF correlates with a 4.9-fold decrease in the odds of mortality. This prognostic divergence has led to the recognition of this subset of patients as having a unique heart failure diagnosis, distinct from heart failure with reduced EF (HFrEF) or heart failure with preserved EF and to the adoption of the term heart failure with recovered EF. These patients, despite having improved mortality, do retain some of the molecular and histologic changes seen in HFrEF and are still at risk for decline in left ventricular function and adverse cardiac events, particularly when medical therapy is stopped. This distinction between recovery of EF and true myocardial recovery led to recent guidelines recommending continuation of guideline-directed medical therapy indefinitely, as well as surveillance echocardiography.

Lower Risk of Death and Kidney Failure Associated with Higher Target (vs Below-Target) Doses of RAS Inhibitors in Octogenarians with HFrEF

BACKGROUND

Renin-angiotensin system (RAS) inhibitors at higher target doses reduce the risk of death in patients with heart failure with reduced ejection fraction (HFrEF). Less is known about their effectiveness in octogenarians, the examination of which was the objective of this study.

METHODS

Of the 32,964 veterans ≥ 80 years with HFrEF (ejection fraction ≤ 40%) receiving RAS inhibitors, 6655 received them at target doses. Using propensity scores for the receipts of target-dose, calculated for each of the 32,964 patients, we assembled a matched cohort of 13,284 patients balanced on 66 baseline characteristics. Hazard ratios (95% CI) for 5-year mortality and kidney failure associated with target (vs below-target) dose RAS inhibitor use were estimated in the matched cohort. Kidney failure was defined as receipt of kidney replacement therapy or estimated glomerular filtration rate (eGFR) < 15 mL/min/1.73m2 measured twice >30 days apart.

RESULTS

Patients had mean (±SD) age 84.5 (±3.4) years, EF 31.3 (±8.2) %, and eGFR 58.5 (±18.2) mL/min/1.73m2. All-cause mortality occurred in 71.2% and 69.5% of matched patients in below-target and target dose RAS inhibitor groups, respectively (HR associated with target-dose RAS inhibitor, 0.95; 95% CI, 0.91-0.99; P = .009). Respective rates for kidney failure were 1.8% and 1.5%, with a trend toward a lower risk in the target-dose group (HR, 0.80; 95% CI, 0.61-1.04; P = .094). Consequently, there was a lower risk of the composite endpoint of kidney failure or death (HR, 0.94; 95% CI, 0.91-0.98; P = .004).

CONCLUSIONS

These findings provide evidence that in octogenarians with HFrEF, the use of RAS inhibitors at higher target (vs below-target) doses is associated with lower risks of death and kidney failure.

A Review of Cardiac Preoperative Screening Guidelines for Liver Transplantation

Orthotopic liver transplant (OLT) medicine is a constantly evolving field, especially with the demographics of individuals with advanced liver disease drastically changing. OLT candidates are now older, and there is an increase of nonalcoholic steatohepatitis cirrhosis due to the epidemic of obesity, which has also resulted in an increase in cardiac comorbidities in this population. The pathophysiology of liver cirrhosis creates many complexities during the pre- and postoperative management of OLT. We discuss the role of screening for common co-existent cardiovascular comorbidities, including coronary artery disease, congestive heart failure, arrhythmias, and portopulmonary hypertension, as well as challenges in the standardization of pre-liver transplant cardiovascular care.

Cardiorenal outcomes associated with sodium-glucose co-transporter-2 inhibitors in chronic kidney disease stage 5 (CKD V): A propensity score-matched analysis

BACKGROUND

There remains a paucity of data regarding the cardio-renal benefits of sodium-glucose co-transporter-2 inhibitors (SGLT2i) in patients with chronic kidney disease stage 5 (CKD V) based on major clinical trials.

OBJECTIVE

This retrospective study aimed to identify potential cardiovascular and renal outcomes associated with SGLT2i use in CKD V patients.

METHODS

We queried the TriNetX Global collaborative network from Jan 2014 - Aug 2023 for patients ≥18 years diagnosed with CKD V but not on dialysis. Patients were stratified based on SGLT2i use. Propensity score matching for sociodemographics, comorbidities, and medication use resulted in 3465 patients in each cohort. The primary outcome was a composite of all-cause mortality, progression to end-stage renal disease (ESRD), or heart failure (HF). Secondary outcomes were ESRD, heart failure, all-cause mortality, acute myocardial infarction (AMI), ischemic stroke, cardiac arrest, hypertensive urgency, and hypertensive crisis. Cox proportional HRs were used to compare outcomes over a 5-year follow-up period.

RESULTS

The SGLT2i cohort was associated with a significantly lower risk of the primary composite outcome (HR 0.644; 95 % CI: 0.601-0.733, p < 0.0001). SGLT2i use was also associated with lower risks of some secondary outcomes including all-cause mortality (HR 0.649; 0.587-0.717, p < 0.0001), ESRD (HR 0.597; 0.547-0.652, p < 0.0001), heart failure (HR 0.726; 0.625-0.844, p < 0.0001), development of AMI (0.649; 0.542-0.776, p < 0.0001), cardiac arrest (HR 0.595; 0.462-0.766, p < 0.0001), hypertensive urgency (HR 0.578; 0.3451-0.740, p < 0.0001), and hypertensive crisis (HR 0.603; 0.481-0.755, p < 0.0001).

CONCLUSION

Among CKD V patients, SGLT2i was associated with a significantly slowed progression of CKD to ESRD and reduced cardiac morbidity and mortality.

Lead Extraction-Indications, Procedure, and Future Directions

Cardiac implantable electronic device (CIED) implantation has steadily increased in the United States owing to increased life expectancy, better access to health care, and the adoption of updated guidelines. Transvenous lead extraction (TLE) is an invasive technique for the removal of CIED devices, and the most common indications include device infections, lead failures, and venous occlusion. Although in-hospital and procedure-related deaths for patients undergoing TLE are low, the long-term mortality remains high with 10-year survival reported close to 50% after TLE. This is likely demonstrative of the increased burden of comorbidities with aging. There are guidelines provided by various professional societies, including the Heart Rhythm Society, regarding indications for lead extraction and management of these patients. In this paper, we will review the indications for CIED extraction, procedural considerations, and management of these patients based upon the latest guidelines.