Sudden cardiac death from the perspective of coronary artery disease

Vericiguat suppresses ventricular tachyarrhythmias inducibility in a rabbit myocardial infarction model

BACKGROUND

The VICTORIA trial demonstrated a significant decrease in cardiovascular events through vericiguat therapy. This study aimed to assess the potential mechanisms responsible for the reduction of cardiovascular events with vericiguat therapy in a rabbit model of myocardial infarction (MI).

METHODS

A chronic MI rabbit model was created through coronary artery ligation. Following 4 weeks, the hearts were harvested and Langendorff perfused. Subsequently, electrophysiological examinations and dual voltage-calcium optical mapping studies were conducted at baseline and after administration of vericiguat at a dose of 5 μmol/L.

RESULTS

Acute vericiguat therapy demonstrated a significant reduction in premature ventricular beat burden and effectively suppressed ventricular arrhythmic inducibility. The electrophysiological influences of vericiguat therapy included an increased ventricular effective refractory period, prolonged action potential duration, and accelerated intracellular calcium (Cai) homeostasis, leading to the suppression of action potential and Cai alternans. The pacing-induced ventricular arrhythmias exhibited a reentrant pattern, attributed to fixed or functional conduction block in the peri-infarct zone. Vericiguat therapy effectively mitigated the formation of cardiac alternans as well as the development of reentrant impulses, providing additional anti-arrhythmic benefits.

CONCLUSIONS

In the MI rabbit model, vericiguat therapy demonstrates anti-ventricular arrhythmia effects. The vericiguat therapy reduces ventricular ectopic beats, inhibiting the initiation of ventricular arrhythmias. Furthermore, the therapy successfully suppresses cardiac alternans, preventing conduction block and, consequently, the formation of reentry circuits.

Risk stratifying individuals with zero, minimal, and mild coronary artery calcium for cardiovascular disease by determining coronary plaque burden

BACKGROUND AND AIMS

Use of coronary artery calcium (CAC) continues to expand, and several different categories of risk have been developed. Some categorize CAC as <10, 11-100 and ​> ​100, while others use CAC ​= ​0,1-10, 11-100 and ​> ​100 as categories. We sought to evaluate the plaque burden in patients with CAC 0, 1-10 and 11-100 to evaluate the best use of CAC scoring for risk assessment.

METHODS

Patients were recruited from existing prospective CCTA trials with CAC scores ≤100 and quantitative coronary plaque analysis (QAngio, Medis). CAC was categorized into three groups: zero (CAC ​= ​0), minimal (CAC 1-10), and mild (CAC 11-100). Plaque levels (low attenuated, fibrous, fibro-fatty, dense calcified, total non-calcified) were assessed using multivariable linear regression adjusted for cardiovascular risk factors (age, ethnicity, BMI, gender, hypertension, dyslipidemia, diabetes mellitus, past smoking).

RESULTS

378 subjects were included, with an average age of 53.9 ​± ​10.7 years and 53 ​% female. Among them, 51 ​% had 0 CAC, 16 ​% had minimal CAC (scores 1-10), and 33 ​% had mild CAC (scores 11-100). The minimal and mild CAC groups were significantly older, with higher rates of diabetes, hypertension, and hyperlipidemia. Multivariable analysis found no significant difference in low attenuated, fibro-fatty, and dense calcified plaque levels between the minimal and zero CAC groups. However, minimal CAC subjects had significantly higher fibrous, total non-calcified, and total plaque volumes than zero CAC. All plaque types were significantly higher in the mild group when comparing mild CAC to minimal CAC.

CONCLUSION

Individuals with minimal calcium scores (1-10) had greater noncalcified coronary plaque (NCAP) and total plaque volume than individuals with a calcium score of zero. The increased presence of NCAP and total plaque volume in the minimal CAC (1-10) is clinically significant and place those patients at higher coronary vascular disease (CVD) risk than individuals with absent CAC (CAC ​= ​zero). Therefore, the use of CAC ​= ​0, 1-10 and 11-100 is prudent to better categorize CVD risk.

[Forensic assessment of meteorological conditions as risk factors of sudden death from arterial hypertension]

Arterial hypertension is a disease that significantly increases the risk of sudden death in different age groups. It is of high scientific interest to study the relationship of arterial hypertension manifestations with different weather conditions. The article provides a review of literature data on the variability of arterial hypertension course depending on meteorological conditions as a risk factor for sudden death.

A Genome-Wide Analysis of a Sudden Cardiac Death Cohort: Identifying Novel Target Variants in the Era of Molecular Autopsy

Sudden cardiac death (SCD) is an unexpected natural death due to cardiac causes, usually happening within one hour of symptom manifestation or in individuals in good health up to 24 h before the event. Genomic screening has been increasingly applied as a useful approach to detecting the genetic variants that potentially contribute to SCD and helping the evaluation of SCD cases in the post-mortem setting. Our aim was to identify the genetic markers associated with SCD, which might enable its target screening and prevention. In this scope, a case-control analysis through the post-mortem genome-wide screening of 30 autopsy cases was performed. We identified a high number of novel genetic variants associated with SCD, of which 25 polymorphisms were consistent with a previous link to cardiovascular diseases. We ascertained that many genes have been already linked to cardiovascular system functioning and diseases and that the metabolisms most implicated in SCD are the lipid, cholesterol, arachidonic acid, and drug metabolisms, suggesting their roles as potential risk factors. Overall, the genetic variants pinpointed herein might be useful markers of SCD, but the novelty of these results requires further investigations.

The expanding roles of neuronal nitric oxide synthase (NOS1)

The nitric oxide synthases (NOS; EC 1.14.13.39) use L-arginine as a substrate to produce nitric oxide (NO) as a by-product in the tissue microenvironment. NOS1 represents the predominant NO-producing enzyme highly enriched in the brain and known to mediate multiple functions, ranging from learning and memory development to maintaining synaptic plasticity and neuronal development, Alzheimer's disease (AD), psychiatric disorders and behavioral deficits. However, accumulating evidence indicate both canonical and non-canonical roles of NOS1-derived NO in several other tissues and chronic diseases. A better understanding of NOS1-derived NO signaling, and identification and characterization of NO-metabolites in non-neuronal tissues could become useful in diagnosis and prognosis of diseases associated with NOS1 expression. Continued investigation on the roles of NOS1, therefore, will synthesize new knowledge and aid in the discovery of small molecules which could be used to titrate the activities of NOS1-derived NO signaling and NO-metabolites. Here, we address the significance of NOS1 and its byproduct NO in modifying pathophysiological events, which could be beneficial in understanding both the disease mechanisms and therapeutics.

Regulatory variation within 3’UTR of STAT5A correlates with sudden cardiac death in Chinese populations

Definitive diagnosis to sudden cardiac death (SCD) is often challenging since the postmortem examination on SCD victims could hardly demonstrate an adequate cause of death. It is therefore important to uncover the inherited risk component to SCD. Signal transducer and activators of transcription 5 A (STAT5A) is a member of the STAT family and a transcription factor that is activated by many cell ligands and associated with various cardiovascular processes. In this study, we performed a systematic variant screening on the STAT5A to filter potential functional genetic variations. Based on the screening results, an insertion/deletion polymorphism (rs3833144) in 3'UTR of STAT5A was selected as the candidate variant. A total of 159 SCD cases and 668 SCD matched healthy controls was enrolled to perform a case-control study and evaluate the association between rs3833144 and SCD susceptibility in Chinese populations. Logistic regression analysis showed that the deletion allele of rs3833144 had significantly increased the SCD risk (odds ratio (OR) = 1.54; 95% confidence interval (CI) = 1.18-2.01; P = 0.000955). Further genotype-expression eQTL analysis showed that samples with deletion allele appeared to lower expression of STAT5A, and in silico prediction suggested the local 3 D structure changes of STAT5A mRNA caused by the variant. On the other hand, the bioinformatic analysis presented that promoters of RARA and PTGES3L-AARSD1 could interact with rs3833144, and eQTL analysis showed the higher expression of both genes in samples with deletion allele. Dual-luciferase activity assays also suggested the significant regulatory role of rs3833144 in gene transcription. Our current data thus suggested a possible involvement of rs3833144 to SCD predisposition in Chinese populations and rs3833144 with potential function roles may become a candidate marker for SCD diagnosis and prevention.

Sudden cardiac death: A comparative review of humans, dogs and cats

Sudden death is one of the most common causes of death in humans in Western countries. Approximately 85% of these cases are of cardiac origin. In dogs and cats, sudden cardiac death (SCD) also commonly occurs, but fewer pathophysiological and prevalence data are available. Both structural, primarily 'electrical' and ischemic heart diseases are known to cause SCD, many of which share similar underlying arrhythmogenic mechanisms between humans and companion animals. As for underlying genetics, numerous mutations on multiple loci have been related to SCD in humans, but only a few mutations associated with dilated cardiomyopathy and SCD have been identified in dogs, e.g. in the phospholamban and titin genes. Information published from human medicine can therefore inform future veterinary studies, but also dogs and cats could act as spontaneous models of SCD in humans. Further research in both fields is therefore warranted to better understand the pathophysiology, genetics, and prevention of SCD.

Clinical Impact of Reporting Coronary Artery Calcium Scores of Non-Gated Chest Computed Tomography on Statin Management

Introduction

Coronary artery calcium (CAC) scoring is used as a screening tool for patients with intermediate 10-year arteriosclerotic cardiovascular disease (ASCVD) risk. Results obtained on non-contrast non-gated chest CT (ngCCT) correlate well to those obtained on gated CTs. This paper aims to determine how the routine reporting of CAC scores on ngCCT scans with ASCVD risk of less than 12.5% would change statin management.

Methods

Data of all patients scanned on a single CT scanner during a four-month window were reviewed. A total of 521 eligible scans were identified. After removing duplicate scans and scans from patients who were not in the age range of 40-75 years, 370 scans remained. Patients were excluded if they had documented ASCVD, type 2 diabetes mellitus, or low-density lipoprotein (LDL) > 190 mg/dL, or if they had ASCVD risk of greater than 12.5%. Ultimately, 36 scans were included in the study.

Results

Of the 36 patients who qualified, 10 were low-risk (ASCVD risk<5%), 13 were intermediate-risk (ASCVD risk 5-7.5%), and 13 were high-risk (ASCVD risk 7.5%-12.5%). A CAC score of 300 was used as a cutoff for recommending prescribing statins and 0 was used as a cutoff for recommending de-prescribing statins. In 63% of patients (23/36), CAC scoring altered statin recommendations. This included 11/13 (85%) intermediate-risk patients, 6/13 (46%) high-risk patients, and 6/10 (60%) low-risk patients.

Conclusions

Reporting CAC on ngCCTs obtained for other reasons can significantly impact statin prescribing practices. This may improve cost, patient satisfaction, and patient safety.

Role of mitochondrial quality surveillance in myocardial infarction: From bench to bedside

Myocardial infarction (MI) is the irreversible death of cardiomyocyte secondary to prolonged lack of oxygen or fresh blood supply. Historically considered as merely cardiomyocyte powerhouse that manufactures ATP and other metabolites, mitochondrion is recently being identified as a signal regulator that is implicated in the crosstalk and signal integration of cardiomyocyte contraction, metabolism, inflammation, and death. Mitochondria quality surveillance is an integrated network system modifying mitochondrial structure and function through the coordination of various processes including mitochondrial fission, fusion, biogenesis, bioenergetics, proteostasis, and degradation via mitophagy. Mitochondrial fission favors the elimination of depolarized mitochondria through mitophagy, whereas mitochondrial fusion preserves the mitochondrial network upon stress through integration of two or more small mitochondria into an interconnected phenotype. Mitochondrial biogenesis represents a regenerative program to replace old and damaged mitochondria with new and healthy ones. Mitochondrial bioenergetics is regulated by a metabolic switch between glucose and fatty acid usage, depending on oxygen availability. To maintain the diversity and function of mitochondrial proteins, a specialized protein quality control machinery regulates protein dynamics and function through the activity of chaperones and proteases, and induction of the mitochondrial unfolded protein response. In this review, we provide an overview of the molecular mechanisms governing mitochondrial quality surveillance and highlight the most recent preclinical and clinical therapeutic approaches to restore mitochondrial fitness during both MI and post-MI heart failure.

Association between ratio for diameters of pulmonary artery to ascending aorta bifurcation in chest CT scan and number of involved vessels in coronary angiography

Objective

Coronary artery disease (CAD) is an important cause of mortality and morbidity, therefore, recognizing its severity and related factors is important. This study was performed to evaluate the association between ratio for diameters of pulmonary artery to ascending aorta bifurcation in chest CT scan and number of involved vessels in coronary angiography. In this observational cross-sectional comparative study, 110 patients who were under coronary angiography in Firoozgar Hospital in 2017 were enrolled, and the association between ratio for diameters of pulmonary artery to ascending aorta bifurcation in their chest CT scan and number of involved vessels in angiography were assessed.

Results

In this study, number of involved vessels in angiography was related to PA/Ao ratio (P = 0.001) and further vessels were accompanied with higher ratio. It may be concluded that, a higher ratio for diameters of pulmonary artery to ascending aorta bifurcation in chest CT scan is related to higher number of involved vessels in coronary angiography, and it may have a predictive role.

Cardiac Screening for High Risk Sudden Cardiac Death in School-Aged Children

Background

Sudden cardiac death (SCD) is an uncommon but significant cause of death in the young. Citywide cardiac screening of school-aged children has been performed in Taipei since 1989. In this study, we investigate the efficacy of this screening method for identifying those at high risk of SCD.

Methods

This study analyzed the data from the results of cardiac screening for school-aged children in Taipei from 2003 to 2014. The cardiac screening included: Stage I, questionnaire surveys, simplified phonocardiography test and simplified electrocardiography (ECG) test; Stage II, physical examination and auscultation by a pediatric cardiologist for all children who had abnormal findings in stage I screening; Stage III, referral to a pediatric cardiologist for further examinations. Logistic regression and decision tree analyses were performed.

Results

A total of 566,447 students were screened, of whom 685 were identified as being at high risk of SCD. The most common causes of being at high risk of SCD included Wolff-Parkinson-White syndrome, long QT syndrome, cardiomyopathy and Marfan's syndrome. Using logistic regression analysis, the simplified ECG test was identified as being the most effective tool (odds ratio = 16.4, p < 0.001) and past history as the second most crucial factor (odds ratio = 3.95, p < 0.001) for detecting a high risk of SCD. Decision tree analysis showed that serial studies with a past history and the simplified ECG test could accurately identify those at high risk of SCD.

Conclusions

Questionnaire survey and simplified electrocardiography test-based cardiovascular screening in school-aged children can identify those at high risk of SCD.

Why do older workers with chronic health conditions prefer to retire early?

Background

older workers experiencing chronic health conditions (CHCs) are more likely to retire early. The different pathways through which CHCs stimulate retirement preferences, however, remain largely unexplored.

Objective

we present a more comprehensive model in which we test the different pathways through which four specific CHCs—arthritis, cardiovascular disease, sleep disorders and psychological disorders—influence early retirement preferences. We hypothesize that the association between CHCs and early retirement preferences is differentially mediated by subjective life expectancy (SLE), perceived health-related work limitations (HRWL) and vitality.

Methods

we collected data from 5,696 wage-employed older workers (60 to 64 years) in the Netherlands in 2015. Regression models were estimated to examine the associations between CHCs and early retirement preferences. Mediation analysis with the Karlson, Holm and Breen method was used to examine potential mediation pathways.

Results

SLE, HRWL and vitality mediated the association between CHCs and older workers’ early retirement preferences. The dominant mediator differed depending on the CHC. Severe HRWL predominantly guided the retirement preferences of older workers with arthritis and cardiovascular disease. Lower vitality mainly mediated retirement preferences of older workers with sleep and psychological disorders. Lower SLE was a significant mediation pathway for older workers with cardiovascular diseases.

Conclusions

HRWL and vitality play a major role in determining retirement preferences of older workers experiencing CHCs. Since both mediators are modifiable, targeted interventions may not only extend older workers’ working lives, but also improve the quality of their working lives.

Sudden Arrhythmic Death at the Higher End of the Heart Failure Spectrum

The risk of sudden cardiac death (SCD) is high in heart failure (HF) patients. Sudden arrhythmic death (SAD) is a frequent cause of exit in HF patients at the lower end of the HF spectrum, and implantable cardioverter–defibrillators have been recommended to prevent these life-threatening rhythm disturbances in select patients. However, less is known regarding the cause of SCD in patients at the upper end of the HF spectrum, despite the fact that the majority of out-of-hospital SCD victims have unknown or near-normal/normal left ventricular ejection fraction (LVEF). In this review, we report the epidemiology, summarize the mechanisms, discuss the diagnostic challenges, and propose a stepwise approach for the prevention of SAD in HF with near-normal/normal LVEF.

Sudden death in patients with Ebstein anomaly

Aims

Ventricular dysfunction or structural alteration of either ventricle is a well-established risk factor for sudden death (SD). Ebstein anomaly (EA) can present with both right and left heart abnormalities; however, predictors of SD have not been described. We therefore sought to characterize the incidence and risk factors of SD among a large cohort of patients with EA.

Methods and results

All EA patients who underwent evaluation at a high-volume institution over a 4-decade period were retrospectively reviewed. Clinical variables, cardiovascular surgical procedure(s), and cause of death were recorded. Sudden death incidence from birth and following tricuspid valve (TV) surgery were estimated using the Kaplan-Meier method. Cox regression analysis was used to identify clinical and surgical predictors of SD. The cohort comprised of 968 patients [mean age 25.3 years, 41.5% male; 79.8% severe EA, 18.6% accessory pathway, 0.74% implantable cardioverter-defibrillator (ICD) placement]. The 10-, 50-, and 70-year cumulative incidences of SD from birth were 0.8%, 8.3%, and 14.6%, respectively. Prior ventricular tachycardia [hazard ratio (HR) 6.37, P < 0.001)], heart failure (HR 5.64, P < 0.001), TV surgery (HR 5.94, P < 0.001), syncope (HR 2.03, P = 0.019), pulmonic stenosis (HR 3.42, P = 0.001), and haemoglobin > 15 g/dL (HR 2.05, P = 0.026) were multivariable predictors of SD. In a similar subgroup analysis of patients who underwent TV surgery, all of the above factors except syncope were significantly associated with post-operative SD on multivariable analysis.

Conclusion

Patients with EA are at significant risk for SD. Key clinical SD predictors identified can aid in risk stratification and potentially guide primary prevention ICD implantation.

Evaluation of Molecularly Imprinted Polymers for Point-of-Care Testing for Cardiovascular Disease

Molecular imprinting is a rapidly growing area of interest involving the synthesis of artificial recognition elements that enable the separation of analyte from a sample matrix and its determination. Traditionally, this approach can be successfully applied to small analyte (<1.5 kDa) separation/ extraction, but, more recently it is finding utility in biomimetic sensors. These sensors consist of a recognition element and a transducer similar to their biosensor counterparts, however, the fundamental distinction is that biomimetic sensors employ an artificial recognition element. Molecularly imprinted polymers (MIPs) employed as the recognition elements in biomimetic sensors contain binding sites complementary in shape and functionality to their target analyte. Despite the growing interest in molecularly imprinting techniques, the commercial adoption of this technology is yet to be widely realised for blood sample analysis. This review aims to assess the applicability of this technology for the point-of-care testing (POCT) of cardiovascular disease-related biomarkers. More specifically, molecular imprinting is critically evaluated with respect to the detection of cardiac biomarkers indicative of acute coronary syndrome (ACS), such as the cardiac troponins (cTns). The challenges associated with the synthesis of MIPs for protein detection are outlined, in addition to enhancement techniques that ultimately improve the analytical performance of biomimetic sensors. The mechanism of detection employed to convert the analyte concentration into a measurable signal in biomimetic sensors will be discussed. Furthermore, the analytical performance of these sensors will be compared with biosensors and their potential implementation within clinical settings will be considered. In addition, the most suitable application of these sensors for cardiovascular assessment will be presented.

The Role of the Cardioversion Defibrillator in Post Myocardial Infarction Sudden Cardiac Death: A Systematic Review of Clinical Trials and Observational Studies

Sudden cardiac death (SCD) accounts for approximately half of all the deaths attributed to cardiovascular disease in the United States. Survivors of an acute myocardial infarction (AMI) are at high risk of SCD, largely due to cardiac arrhythmias and severe left ventricular (LV) systolic dysfunction. The implantable cardioverter defibrillator (ICD) or automated implantable cardioverter defibrillator (AICD) is a device that is implantable inside the body, able to perform cardioversion, defibrillation, and (in modern versions) pacing of the heart. According to a study included in our review, patients who received an ICD contributed to an adjusted 44% reduction (hazard ratio [HR] 0.56, 95% CI: 0.32-1.01; P = 0.053) of all-cause mortality compared to those with a comparable baseline. Patients with an ICD implant three months after a myocardial infarction (MI) demonstrated a non-significantly higher mortality than patients who did not receive an ICD. The factors favoring ICD implantation were multiple MIs, increased resting heart rate, occurrence of non-sustained ventricular tachycardia, QRS duration = 120 ms, syncope events, anti-arrhythmic drug treatment (mostly Class III), and an index MI of more than one year. The likelihood of receiving an ICD diminished with the patient's age. Increased periodic repolarization dynamics were a significant predictor of mortality. It can be concluded that cardioverter defibrillators help reduce not only all-cause mortality but also sudden cardiac death. It is important to note that ICDs are only significant if implanted after a sufficient time-gap post-MI.

Gene polymorphism associated with TNF-α (G308A) IL-6 (C174G) and susceptibility to coronary atherosclerotic heart disease: A meta-analysis

To evaluate the association between gene polymorphisms of TNF-α G308A, IL-6 C174G, and coronary atherosclerotic heart disease (CHD) risk.We used computers to collect related case-control studies. After screening, a meta-analysis was conducted to assess the strength of association by Stata 12.0 software.Thirty-five articles were included. Among them, 17 studies were related to TNF-α (G308A) gene mutation and CHD, and 18 studies examined IL-6 (C174G) gene mutation. According to the results of subgroup analysis of ethnicity, it suggested that TNF-α (G308A) polymorphism was not significantly associated with CHD risk under all models in Asians (P > .05). There were no connected of IL-6 C174G polymorphism with CHD risk under all models in Caucasians after subgroup analysis (P > .05).The present evidence shows that TNF-α (G308A) have no connected with the risk of CHD in Asians; IL-6 (C174G) gene were not associated with the risk of CHD in Caucasians.

Risk of sudden cardiac death: Are coronary chronic total occlusions an additional risk factor?

Sudden arrhythmic cardiac death remains a significant, potentially reversible, cardiological challenge in terms of creating accurate risk prediction models. The current guidelines for implantable cardioverter defibrillator (ICD) therapy are mainly based on left ventricular ejection fraction despite its low sensitivity and specificity in predicting sudden cardiac death (SCD). Chronic total occlusions have been associated with increased mortality but further research is required to clarify if they should be incorporated in a risk model predicting SCD aiming to identify patients that would benefit from ICD therapy even with preserved ejection fraction.

Possible Predictive Factors for In-hospital Cardiac Arrest in Patients with Cancer: A Retrospective Single Center Study

BACKGROUND

Despite cancer being the second most common cause of death in the United States, more people are living longer after the diagnosis of cancer than before. Healthcare workers will be treating an increasing number of patients with cancer. Various studies have identified predictors of cardiac arrest in the general population, however, none have been done to identify such factors in cancer patients who form a more vulnerable group with lower survival rate following cardiac arrest.

METHODS

We retrospectively analysed charts of all patients with active cancer who experienced in-hospital cardiac arrest (IHCA) and underwent cardio-pulmonary resuscitation (CPR) from January 2015 to December 2017 at our hospital (n=44, group A). We compared this group to 44 consecutive patients with active cancer admitted to the oncology unit who did not experience cardiac arrest (n=44, group B). We excluded patients in remission.

RESULTS

Both the groups were comparable in terms of age (69 ± 14 vs 68 ± 15, p=0.776) and gender distribution (50% vs 56% males, p=0.521). Prevalence of coronary artery disease (CAD) (25% vs 11%, p=0.097), hypertension (68% vs 66%, p=0.821), hyperlipidaemia (34% in both groups, p=1.000), tobacco abuse (18% vs 27%, p=0.308), and diabetes mellitus (34% vs 23%, p=0.237) was not significantly different between the two groups. Group with cardiac arrest had significantly higher alanine aminotransferase (100 U/L ± 150 vs 47 U/L ± 87, p=0.043), alkaline phosphatase (288 U/L ± 512 vs 118 U/L ± 80, p=0.032), creatinine (1.8 mg/dl ± 1.74 vs 1.1 mg/dl ± 0.76, p=0.023), international normalised ratio (INR) (2.1 ± 1.5 vs 1.2 ± 0.5, p=0.005), and lower estimated -glomerular filtration rate (43 mL/min/1.73m2 ± 17 vs 51 mL/min/1.73m2 ± 15, p=0.022) on admission. Group A also had significantly higher incidence of sepsis during the hospital course as compared to group B (30% vs 2%, p<0.001). In group A, 11.4% survived to discharge as compared to 95.5% in group B. Significantly higher number of patients in group B were taking chemotherapy (77.27% vs 34.09%, p=0.000046) and radiation therapy (65.9% vs 22.72%, p=0.000046) as compared to group A.

CONCLUSION

Cancer patients who experienced IHCA had worse renal and hepatic function; they were frequently diagnosed with sepsis and had similar cardiovascular risk factors as compared to cancer patients who did not experience cardiac arrest. Furthermore, a higher number of patients with active cancer who did not experience cardiac arrest were on chemotherapy, immunotherapy or radiation therapy.

Variability of extracorporeal cardiopulmonary resuscitation utilization for refractory adult out-of-hospital cardiac arrest: an international survey study

Objective

A growing interest in extracorporeal cardiopulmonary resuscitation (ECPR) as a rescue strategy for refractory adult out-of-hospital cardiac arrest (OHCA) currently exists. This study aims to determine current standards of care and practice variation for ECPR patients in the USA and Korea.

Methods

In December 2015, we surveyed centers from the Korean Hypothermia Network (KORHN) Investigators and the US National Post-Arrest Research Consortium (NPARC) on current targeted temperature management and ECPR practices. This project analyzes the subsection of questions addressing ECPR practices. We summarized survey.

Results

using descriptive statistics.

Results

Overall, 9 KORHN and 4 NPARC centers reported having ECPR programs and had complete survey data available. Two KORHN centers utilized extracorporeal membrane oxygenation only for postarrest circulatory support in patients with refractory shock and were excluded from further analysis. Centers with available ECPR generally saw a high volume of OHCA patients (10/11 centers care for &gt;75 OHCA a year). Location of, and providers trained for cannulation varied across centers. All centers in both countries (KORHN 7/7, NPARC 4/4) treated comatose ECPR patients with targeted temperature management. All NPARC centers and four of seven KORHN centers reported having a standardized hospital protocol for ECPR. Upper age cutoff for eligibility ranged from 60 to 75 years. No absolute contraindications were unanimous among centers.

Conclusion

A wide variability in practice patterns exist between centers performing ECPR for refractory OHCA in the US and Korea. Standardized protocols and shared research databases might inform best practices, improve outcomes, and provide a foundation for prospective studies.

Twenty-First Century Diseases: Commonly Rare and Rarely Common?

Alzheimer's drugs are failing at a rate of 99.6%, and success rate for drugs designed to help patients with this form of dementia is 47 times less than for drugs designed to help patients with cancers ( www.scientificamerican.com/article/why-alzheimer-s-drugs-keep-failing/2014 ). How can it be so difficult to produce a valuable drug for Alzheimer's disease? Each human has a unique genetic and epigenetic makeup, thus endowing individuals with a highly unique complement of genes, polymorphisms, mutations, RNAs, proteins, lipids, and complex sugars, resulting in distinct genome, proteome, metabolome, and also microbiome identity. This editorial is taking into account the uniqueness of each individual and surrounding environment, and stresses the point that a more accurate definition of a "common" disorder could be simply the amalgamation of a myriad of "rare" diseases. These rare diseases are being grouped together because they share a rather constant complement of common features and, indeed, generally respond to empirically developed treatments, leading to a positive outcome consistently. We make the case that it is highly unlikely that such treatments, despite their statistical success measured with large cohorts using standardized clinical research, will be effective on all patients until we increase the depth and fidelity of our understanding of the individual "rare" diseases that are grouped together in the "buckets" of common illnesses. Antioxid. Redox Signal. 27, 511-516.

Cardiovascular Disease in Clozapine-Treated Patients: Evidence, Mechanisms and Management

Myocarditis occurs in about 3% of those initiated on clozapine but monitoring reduces the risk of serious outcome. Cardiomyopathy may develop after myocarditis, or from prolonged tachycardia. Monitoring using echocardiography is not deemed cost effective. Tachycardia, orthostatic hypotension and reduced heart rate variability are a group of clozapine-related adverse effects associated with autonomic dysfunction and may have serious consequences in the long term. Elevated heart rate and poor heart rate variability can be treated with a β-blocker or a non-dihydropyridine calcium channel blocker, while orthostatic hypotension can be alleviated by increased fluid intake and abdominal binding, but may require pharmacological intervention. Adequate correction for heart rate may show that clozapine does not prolong the QT interval. Other cardiovascular effects, pulmonary embolism, metabolic syndrome, sudden cardiac death and particularly the excessive mortality from cardiovascular disease events may be more strongly associated with the combination of mental illness, lifestyle factors and poor treatment of cardiovascular disease and its risk factors than with clozapine treatment. In view of the efficacy of clozapine and the evidence of reduced mortality relative to other antipsychotics, clozapine should be prescribed when indicated and recipients should be enrolled in lifestyle programmes to increase exercise and improve diet, and referred for diagnosis and treatment of cardiovascular disease and its risk factors.

Factors associated with performing urgent coronary angiography in out-of-hospital cardiac arrest patients

OBJECTIVES

Factors associated with performing urgent coronary angiography (UCA) in patients with out-of-hospital cardiac arrest (OHCA) were identified.

BACKGROUND

Current guidelines for resuscitated OHCA patients recommend UCA if there is ST-elevation on post-arrest electrocardiogram or high suspicion of acute myocardial infarction. Some have advocated for UCA in all OHCA regardless of suspected etiology. The reasons for variations in performing UCA are not well understood.

METHODS

A retrospective analysis of subjects presenting with resuscitated OHCA to a single academic medical center from 12/15/2007 to 8/31/2014 was conducted. Demographic and clinical characteristics of patients undergoing UCA, defined as angiography within 6 hr of presentation, were compared with those not undergoing UCA. Logistic regression was used to determine predictors of UCA.

RESULTS

A total of 323 resuscitated OHCA patients (mean age, 64 years; women, 35%) were included in the analysis; 107 (33.1%) underwent coronary angiography during their hospitalization and 66 (20.4%) underwent UCA. Multivariable adjusted factors associated with UCA were ST-elevation [odds ratio (OR) 14.66, 95% confidence interval (CI) 6.28-34.24, P < 0.001], initial shockable rhythm (OR 3.69, 95% CI 1.52-8.97, P = 0.004), and history of coronary artery disease (CAD) (OR 3.37, 95% CI 1.43-7.95, P = 0.005). Higher age (OR 0.71 per decade, 95% CI 0.55-0.92, P = 0.01) and obvious non-cardiac cause of arrest (OR 0.08, 95% CI 0.02-0.38, P = 0.001) were negatively associated with UCA.

CONCLUSIONS

In resuscitated out-of-hospital cardiac arrest patients, ST-elevation, shockable rhythm, and history of CAD were associated with performing urgent coronary angiography; older patients and those with obvious non-cardiac causes of arrest were negatively associated.

Pathophysiology and prevention of sudden cardiac death

Sudden cardiac death (SCD) is known to occur in individuals with diverse diseases. Each disease state has a specific etiology and pathophysiology, and is diagnosed and treated differently. Etiologies for SCD include cardiac arrhythmias, coronary artery disease, congenital coronary artery anomalies, hypertrophic cardiomyopathy, arrhythmogenic right ventricular dysplasia, dilated cardiomyopathy, and aortic valve stenosis. A potential unifying mechanism of SCD in these diseases involves a massive stimulation of the sympathetic nervous system’s stress response and the subsequent elevation of circulating catecholamines. The diagnosis of cardiac diseases that contribute to an increased risk for SCD is accomplished by a combination of different techniques including electrocardiography, echocardiography, magnetic resonance imaging, and invasive cardiac catheterization. Several therapies including anti-arrhythmic drugs, β-blockers, and antiplatelet agents may be used as medical treatment in patients for the prevention of SCD. Invasive therapies including percutaneous angioplasty, coronary artery bypass surgery, and implantable cardioverter-defibrillators are also used in the clinical management of SCD.

Amiodarone versus other pharmacological interventions for prevention of sudden cardiac death

BACKGROUND

Sudden cardiac death (SCD) is one of the main causes of cardiac death. There are two main strategies to prevent it: managing cardiovascular risk factors and reducing the risk of ventricular arrhythmias. Implantable cardiac defibrillators (ICDs) constitute the standard therapy for both primary and secondary prevention; however, they are not widely available in settings with limited resources. The antiarrhythmic amiodarone has been proposed as an alternative to ICD.

OBJECTIVES

To evaluate the effectiveness of amiodarone for primary or secondary prevention in SCD compared with placebo or no intervention or any other antiarrhythmic drugs in participants at high risk (primary prevention) or who have recovered from a cardiac arrest or a syncope due to Ventricular Tachycardia/Ventricular Fibrillation, or VT/VF (secondary prevention).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), EMBASE (OVID), CINAHL (EBSCO) and LILACS on 26 March 2015. We reviewed reference lists of included studies and selected reviews on the topic, contacted authors of included studies, screened relevant meetings and searched in registers for ongoing trials. We applied no language restrictions.

SELECTION CRITERIA

Randomised and quasi-randomised trials assessing the efficacy of amiodarone versus placebo, no intervention, or other antiarrhythmics in adults. For primary prevention we considered participants at high risk for SCD. For secondary prevention we considered participants recovered from cardiac arrest or syncope due to ventricular arrhythmias.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the trials for inclusion and extracted relevant data. We contacted trial authors for missing data. We performed meta-analyses using a random-effects model. We calculated risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CIs). Three studies included more than one comparison.

MAIN RESULTS

We included 24 studies (9,997 participants). Seventeen studies evaluated amiodarone for primary prevention and six for secondary prevention. Only three studies used an ICD concomitantly with amiodarone for the comparison (all of them for secondary prevention).For primary prevention, amiodarone compared to placebo or no intervention (17 studies, 8383 participants) reduced SCD (RR 0.76; 95% CI 0.66 to 0.88), cardiac mortality (RR 0.86; 95% CI 0.77 to 0.96) and all-cause mortality (RR 0.88; 95% CI 0.78 to 1.00). The quality of the evidence was low.Compared to other antiarrhythmics (three studies, 540 participants), amiodarone reduced SCD (RR 0.44; 95% CI 0.19 to 1.00), cardiac mortality (RR 0.41; 95% CI 0.20 to 0.86) and all-cause mortality (RR 0.37; 95% CI 0.18 to 0.76). The quality of the evidence was moderate.For secondary prevention, amiodarone compared to placebo or no intervention (two studies, 440 participants) appeared to increase the risk of SCD (RR 4.32; 95% CI 0.87 to 21.49) and all-cause mortality (RR 3.05; 1.33 to 7.01). However, the quality of the evidence was very low. Compared to other antiarrhythmics (four studies, 839 participants) amiodarone appeared to increase the risk of SCD (RR 1.40; 95% CI 0.56 to 3.52; very low quality of evidence), but there was no effect in all-cause mortality (RR 1.03; 95% CI 0.75 to 1.42; low quality evidence).Amiodarone was associated with an increase in pulmonary and thyroid adverse events.

AUTHORS' CONCLUSIONS

There is low to moderate quality evidence that amiodarone reduces SCD, cardiac and all-cause mortality when compared to placebo or no intervention for primary prevention, and its effects are superior to other antiarrhythmics.It is uncertain if amiodarone reduces or increases SCD and mortality for secondary prevention because the quality of the evidence was very low.

Long Non-Coding RNAs as Master Regulators in Cardiovascular Diseases

Cardiovascular disease is the leading cause of death in the United States, accounting for nearly one in every seven deaths. Over the last decade, various targeted therapeutics have been introduced, but there has been no corresponding improvement in patient survival. Since the mortality rate of cardiovascular disease has not been significantly decreased, efforts have been made to understand the link between heart disease and novel therapeutic targets such as non-coding RNAs. Among multiple non-coding RNAs, long non-coding RNA (lncRNA) has emerged as a novel therapeutic in cardiovascular medicine. LncRNAs are endogenous RNAs that contain over 200 nucleotides and regulate gene expression. Recent studies suggest critical roles of lncRNAs in modulating the initiation and progression of cardiovascular diseases. For example, aberrant lncRNA expression has been associated with the pathogenesis of ischemic heart failure. In this article, we present a synopsis of recent discoveries that link the roles and molecular interactions of lncRNAs to cardiovascular diseases. Moreover, we describe the prevalence of circulating lncRNAs and assess their potential utilities as biomarkers for diagnosis and prognosis of heart disease.