Pretreatment identification of 90-day readmission among heart failure patients receiving aquapheresis treatment

BACKGROUND

The use of traditional models to predict heart failure (HF) has limitations in preventing HF hospitalizations. Artificial intelligence (AI) and machine learning (ML) in cardiovascular medicine only have limited data published regarding HF populations, with none assessing the favorability of decongestive therapy aquapheresis (AQ). AI and ML can be leveraged to design non-traditional models to identify those who are at high risk of HF readmissions.

OBJECTIVES

This study aimed to develop a model for pretreatment identification of risk for 90-day HF events among HF patients who have undergone AQ.

METHODS

Using data from the AVOID-HF (Aquapheresis versus Intravenous Diuretics and Hospitalization for Heart Failure) trial, we designed a ML-based predictive model that can be used before initiating AQ to anticipate who will respond well to AQ and who will be at high risk of future HF events.

RESULTS

Using ML we identified the top ten predictors for 90-day HF events. Interestingly, the variable for 'intimate relationships with loved ones' strongly predicted response to therapy. This ML-model was more successful in predicting the outcome in HF patients who were treated with AQ. In the original AVOID-HF trial, the overall 90-day HF event rate in the AQ arm was 32%. Our proposed predictive model was accurate in anticipating 90-day HF events with better statistical accuracy (area under curve 0.88, sensitivity 80%, specificity 75%, negative predictive value 90%, and positive predictive value 57%).

CONCLUSIONS

ML can help identify HF patients who will respond to AQ therapy. Our model can identify super-respondents to AQ therapy and predict 90-day HF events better than currently existing traditional models.

CONDENSED ABSTRACT

Utilizing data from the AVOID-HF trial, we designed a ML-predictive model that can be used before initiating AQ to anticipate who will respond well to AQ and who will be at high risk of future HF events. Using ML, we identified the top 10 predictors for 90-day HF events. Our model can identify super-respondents to ultrafiltration therapy and predict 90-day HF events better than currently existing traditional models.

Novel Cardiovascular and Pulmonary Findings in the Noninvasive Ischemic Assessment of Patients With Coronavirus 2019 (COVID-19)

In the past several years, the coronavirus pandemic has introduced multiple medical disciplines to various new forms of disease previously unknown and has shown us a unique presentation of already existing diseases. We continue to understand the long-term effects of the pandemic on the population's health and continue to find new unique features previously unknown. This paper presents the unique feature of lung uptake abnormalities discovered on nuclear stress testing for cardiac perfusion defects, a consistent finding in multiple individuals with recent COVID-19 or ongoing infection.

Novel Device Therapies for Heart Failure

Heart failure (HF) therapeutics have advanced significantly over the past few years [...].

Primary Cardiac Sarcoma: Angiosarcoma Compressing the Right Coronary Artery

Cardiac tumors are uncommon and can be classified as either primary benign, primary malignant, or metastatic. Cardiac tumors have a wide range of presentations, which can lead to delays in diagnosis and treatment. Primary cardiac tumors can also affect nearby structures, and there have been a few reported cases of coronary artery involvement with various underlying causes. In this case report, we describe a patient with a primary cardiac sarcoma (angiosarcoma) that had spread to other parts of the body and caused occlusion of the right coronary artery.

Prevalence of lymphedema among Anderson-Fabry disease patients: A report from the Fabry registry

BACKGROUND

Anderson-Fabry disease (AFD) is a rare X-linked lysosomal storage disease due to a genetic variation in the α-galactosidase A (GLA) gene. As a result, the activity of the α-galactosidase A (AGAL-A) enzyme is reduced or absent, which causes sphingolipid deposition within different body parts. AFD typically manifests with cardiovascular, renal, cerebrovascular, and dermatologic involvement. Lymphedema is caused by sphingolipid deposition within lymphatics. Lymphedema can cause intolerable pain and limit daily activities. Very limited data exist on lymphedema in AFD patients.

METHODS

Using data from the Fabry Registry (NCT00196742) with 7671 patients included (44% males and 56% females), we analyzed the prevalence of lymphedema among AFD patients who were ever assessed for lymphedema and studied the age of first reported lymphedema. Additionally, we assessed whether patients received AFD-specific treatment at some point during their clinical course. The data was stratified by gender and phenotype.

RESULTS

Our study showed that lymphedema occurred in 16.5% of the Fabry Registry patients who were ever assessed for lymphedema (n = 5487). Male patients when compared to female patient have higher prevalence (21.7% vs 12.7%) and experienced lymphedema at a younger age (median age at first reported lymphedema of 43.7 vs 51.7 years). When compared to other phenotypes, classic phenotype has the highest prevalence of lymphedema with the earliest reported lymphedema. Among those who reported lymphedema, 84.5% received AFD-specific treatment during their clinical course.

CONCLUSIONS

Lymphedema is a common manifestation of AFD in both genders, with a tendency to present later in female patients. Recognition of lymphedema can offer an important opportunity for intervention and potential impact on associated morbidity. Additional future studies are needed to characterize the clinical implications of lymphedema in AFD patients and identify additional treatment options for this growing population.

The Roles of Coronary Computed Tomography Angiography in Characterizing Coronary Plaque: Screening, Treatment, and Prevention

One of the major risk factors for coronary atherosclerosis is the gradual formation and maturation of coronary atherosclerotic plaque (CAP) [...].

A Review of Cardiac amyloidosis: Presentation, Diagnosis, and Treatment

Amyloidosis is a group of disorders that can affect almost any organ due to the misfolding of proteins with their subsequent deposition in various tissues, leading to various disease manifestations based on the location. When the heart is involved, amyloidosis can manifest with a multitude of presentations such as heart failure, arrhythmias, orthostatic hypotension, syncope, and pre-syncope. Diagnosis of cardiac amyloidosis can be difficult due to the non-specific nature of symptoms and the relative rarity of the disease. Amyloidosis can remain undiagnosed for years, leading to its high morbidity and mortality due to this delay in diagnosis. Newer imaging modalities, such as cardiac magnetic resonance imaging, advanced echocardiography, and biomarkers, make a timely cardiac amyloidosis diagnosis more feasible. Many treatment options are available, which have provided new hope for this patient population. This manuscript will review the pathology, diagnosis, and treatment options available for cardiac amyloidosis and provide a comprehensive overview of this complicated disease process.

Beyond Ejection Fraction: Novel Clinical Approaches Towards Sudden Cardiac Death Risk Stratification in Patients with Dilated Cardiomyopathy

Implantable Cardioverter-Defibrillator (ICD) therapy is indicated for patients at risk for sudden cardiac death due to ventricular tachyarrhythmia. The most commonly used risk stratification algorithms use Left Ventricular Ejection Fraction (LVEF) to determine which patients qualify for ICD therapy, even though LVEF is a better marker of total mortality than ventricular tachyarrhythmias mortality. This review evaluates imaging tools and novel biomarkers proposed for better risk stratifying arrhythmic substrate, thereby identifying optimal ICD therapy candidates.

Emerging Technologies in Cardiac Pacing From Leadless Pacers to Stem Cells

Modern pacemakers can sense and pace multiple chambers of the heart. These pacemakers have different modes and features to optimize atrioventricular synchrony and promote intrinsic conduction. Despite recent advancements, current pacemakers have several drawbacks that limit their feasibility. In this review article, we discuss several of these limitations and detail several emerging technologies in cardiac pacing aimed to solve some of these limitations. We present several technological advancements in cardiac pacing, including the use of leadless pacemakers, physiologic pacing, battery improvements, and bioartificial pacemakers. More research still needs to be done in testing the safety and efficacy of these new developments.

Invasive Strategies for the Treatment of Pulmonary Embolism. Where Are We in 2020?

Pulmonary Embolism (PE) is the third most common cause of cardiovascular mortality in the United States, with 60,000-100,000 deaths per year following myocardial infarction and stroke. During the past 5 years, there has been an introduction of novel interventions as a result of a renewed interest in optimizing PE management, particularly among those individuals with more severe disease of hemodynamic significance. The cornerstone treatment for PE is anticoagulation. More aggressive alternatives have been considered for patients with intermediate and high-risk PE. In general, these options can be grouped into 3 different categories: systemic thrombolysis, catheter-directed interventions, and surgical embolectomy. Systemic thrombolysis has shown statistical benefit in several randomized trials for intermediate- and high-risk PE, however, this benefit has been offset by an elevated risk of major bleeding and intracerebral hemorrhage, limiting their use in clinical practice. Catheter-directed thrombolysis refers to catheter-directed injection of a thrombolytic drug directly into the pulmonary artery. Three interventional devices (EKOSonic endovascular system, FlowTriever embolectomy device and the Indigo thrombectomy system) have recently been cleared by the US Food and Drug Administration for marketing, and several others are in various stages of development. As of today, catheter-based interventions are limited to small randomized trials and single arm-prospective studies focused on short-term surrogate endpoints. Although single arm studies carry some value establishing the preliminary safety and effectiveness of these devices, they are not sufficient to stratify risk and guide clinical practice. Furthermore, no trials have been performed with enough power to assess potential mortality benefit with the use of catheter-directed thrombolysis or catheter-based embolectomy devices, hence treatment decisions continue to be influenced by individual risk of bleeding, the location of thrombus and operator expertise until additional evidence becomes available.

Is early invasive management as ST elevation myocardial infarction warranted in de Winter's sign?-a "peak" into the widow-maker

de Winter's sign was first described by de Winter et al. in 2008 as a new electrocardiographic (EKG) pattern of acute proximal left anterior descending coronary artery (LAD) occlusion. Instead of the normal presentation of ST elevation, it is described as depression of ST segment at the J point in the precordial leads V1-V6, which are upsloping leading to hyper-acute T waves, with ST elevation in aVR. The initial retrospective systematic analysis proved this sign to be present in about 2% of anterior myocardial infarction. This review aims to address the important question of mode and urgency of intervention, on detection of de Winter's sign. In this review, we take a look at the de Winter's sign EKG characteristics, accuracy in diagnosis, typical patient presentation, and the outcomes of early intervention. We conducted a Medline search using various combinations of "de Winter's sign," "STEMI equivalent," "cardiac catheterization," and "thrombolysis" to identify pivotal research articles published before June 1, 2019, for inclusion in this review. Concurrently, major practice guidelines, trial bibliographies, and pertinent reviews were examined to ensure inclusion of relevant trials. A consensus among the authors was used to choose items for narrative inclusion. The following section reviews data from pivotal trials to determine the need for early invasive management in de Winter's sign. Research articles reviewed evaluating cardiac catheterization in de Winter's sign. de Winter's sign, although rare (~2%), should be promptly recognized, as it reveals underlying severe coronary artery pathology, frequently involving the LAD which is associated with a high rate of mortality. This systematic review emphasizes awareness and strong consideration of early activation of the cardiac catheterization lab with PPCI; which may yield better treatment outcomes. The evidence suggests that de Winter's sign, presenting with ST depression and T wave elevation, should indeed be treated as ST-elevation myocardial infarction (STEMI) equivalent, with prompt recognition and early intervention.

Transcatheter aortic valve replacement with a focus on transcarotid: a review of the current literature

Valve replacement in high-risk patients with severe aortic stenosis has undergone a huge paradigm shift in the recent years in terms of procedural details and vascular access site for patients who have poor peripheral access. Carotid artery is one of the more promising access sites which has been proven to provide a good alternative site with comparable outcomes to transfemoral approach. In this manuscript, we will provide a review of the current literature on transaortic, transapical, transaxillary and transcarotid approaches to transcatheter aortic valve replacement (TAVR) while focusing on the transcarotid approach.

Accuracy of non-invasive and minimally invasive hemodynamic monitoring: where do we stand?

One of the most important variables in assessing hemodynamic status in the intensive care unit (ICU) is the cardiac function and blood pressure. Invasive methods such as pulmonary artery catheter and arterial line allow monitoring of blood pressure and cardiac function accurately and reliably. However, their use is not without drawbacks, especially when the invasive nature of these procedures and complications associated with them are considered. There are several newer methods of noninvasive and minimally invasive hemodynamic monitoring available. In this manuscript, we will review these different methods of minimally invasive and non-invasive hemodynamic monitoring and will discuss their advantages, drawbacks and limitations.

CardioMEMS: where we are and where can we go?

The prevalence of heart failure (HF) has been on the rise with associated increase in hospitalizations, morbidity and mortality. These hospitalizations have led to increasingly more cost on and decreased quality of life for patients. CardioMEMS is one of the newer devices designed to help tackle this issue by allowing for better monitoring of HF patients. This device also allows for accurate recording of pulmonary artery pressures (PAPs) and has also been applied in various other areas, such as aneurysmal tears, for monitoring pressures. In this manuscript we will review the current state of CardioMEMS HF system and investigate some of the other areas for its promising use in the field.

Apple Watch, Wearables, and Heart Rhythm: where do we stand?

Atrial fibrillation (AF) poses a major health concern in the United States by affecting over 5 million people accounting for at least 15% to 25% of strokes. It can be asymptomatic or subclinical with its first presentation being stroke in 18%, and AF being only detected at the time of stroke. With evidence of subclinical AF associated with increased risk of ischemic stroke, recent developments indeed point towards wearables, especially smart watches, being quite effective and representing a novel method for screening for silent AF in the general population, and thereby reducing mortality and morbidity associated with it. This manuscript aims to review whether the photoplethysmography (PPG) technology, employed in the wearables to monitor heart rate, is accurate enough to aid in the diagnosis of AF that may remain asymptomatic or paroxysmal. It also explores the option of actually employing this method in the general population, the feasibility of this mode of diagnosis, sensitivity and specificity of this method compared to the conventional electrocardiogram (EKG), and the actual follow up with a practitioner and subsequent treatment of AF, if diagnosed. We conducted a Medline search using various combinations of "smart watch" "atrial fibrillation" "wearables", and "Kardia" to identify pivotal randomized trials published before June 1, 2019, for inclusion in this review. Concurrently, major practice guidelines, trial bibliographies, and pertinent reviews were examined to ensure inclusion of relevant trials. A consensus among the authors was used to choose items for narrative inclusion. The following section reviews data from pivotal trials to determine the effectiveness of smart watch technology in detecting AF in the general population. Trials reviewed evaluated apple watch, Kardia, Samsung wearables in diagnosis of AF. The fact that there is an increase in consumer use of wearables, smart devices, which can serve as health monitoring devices that can be used as a non-invasive, ambulatory assessment of heart rate and rhythm, is definitely novel. Intermittent short EKG recordings repeated over a longer-term period produced significantly better sensitivity for AF detection, with 4 times as many cases diagnosed compared with a single time-point measurement. Since there are limitations and further research into this new field is required, the wearable technology may not serve as the ultimate tool for diagnosis of AF, rather a nidus for the general population to seek medical advice for confirmation on being notified of having an irregular rhythm leading to prevention of morbidity and mortality associated with it.

Levamisole-induced Vasculitis in a Hepatitis C Patient: A General Medicine Ward Perspective on Diagnosis and Management

Purpura in hepatitis C patients has a wide range of possible etiologies, some of which include mixed cryoglobulinemia and idiopathic thrombocytopenic purpura. Levamisole is a common chemical used as a lacing agent for cocaine. It is believed to enhance the addictive properties of cocaine, but it has been associated with a vasculitis syndrome that most commonly presents with purpura and leukopenia. We report a case of a patient with hepatitis C and cocaine abuse who presented with vasculitis, thrombocytopenia, and bloody sputum. A punch biopsy was performed, which confirmed the diagnosis of levamisole-induced vasculitis. A comprehensive rheumatology workup could result in variable serology and does not provide a definitive diagnosis. We suggest performing a punch biopsy as part of the initial workup for these patients, as it can provide rapid diagnosis and is associated with a lower cost.

Cryptogenic Stroke and Significance of the Patent Foramen Ovale: A Case Series

Stroke is the second leading cause of death globally and can lead to significant adverse outcomes in patients following the acute illness. Due to this high morbidity and mortality, adequate interventions can play a significant role in health outcomes. Patent foramen ovale is one of the major proposed causes of cryptogenic strokes and can be present in up to 25% of general population. In cryptogenic strokes, the relation of this structural heart defect is inversely proportional to age of patient. Here, we present three cases of cryptogenic strokes in patients with patent foramen ovale where it possibly plays a significant role. We demonstrate that in the younger age spectrum, patent foramen ovale plays a more significant role and treatment could prevent future stroke episodes.

Incidence and predictors of acute coronary syndrome within a year following a negative stress test-a false sense of security: is routine screening any useful?

One of the major issues in management of the acute coronary syndrome (ACS) is classification of patients with atypical presentation who have low risk of having a coronary episode at presentation. There have been multiple studies on the stratification of high risk patients and medical management of such cases, however, there is a sub-class of patients who do not fit any category. In this paper, we have looked at the current literature on stratification of patients based on the study tools available and the risk of having a coronary episode during the following year. In our overview, we have found that the current methods in place namely, cardiac stress test and stress echocardiogram have a good prognostic factor in terms of mortality in the next one year and can safely stratify the patients at low risk when correlated with clinical presentation and laboratory studies. However, such data are limited for computerized tomography or magnetic resonant imaging and their application might be limited due to accessibility and cost of studies. Current guidelines for classification of high risk patient do an excellent job and we believe that proper application of stress tests together with other imaging modalities together with laboratory, clinical judgment, and proper use of medical management can help with safe discharge of patients from the emergency department (ED) and reduction of burden from healthcare.

Permanent pacemaker insertion in patients with conduction abnormalities post transcatheter aortic valve replacement: a review and proposed guidelines

Conduction abnormalities are a common and serious complication of transcatheter aortic valve replacement (TAVR) with well-established predictive factors. Current guidelines are not concrete, leaving several questions unanswered about indications, timing and risks of pacemaker implantation post-TAVR. In this review article, we discuss current guidelines, predictors of pacemaker implantation, clinical implications of this procedure and our recommendations for reducing the pacemaker implantation rate post-TAVR.

Cyclophilin D regulates lifespan and protein expression of aging markers in the brain of mice

Cyclophilin D (cypD) modulates the properties of the permeability transition pore, a phenomenon implicated in the manifestation of many diseases including aging. Here, we examined the effects of partial or complete deletion of cypD on i) lifespan, ii) forebrain protein expression of 18 aging markers as well as regional expression of GFAP, mGluR1, and alpha-synuclein, and iii) behaviour of aged (>24month) male and female mice. Both male and female cypD heterozygous but not KO mice exhibited increased lifespans compared to WT littermates, associated with alterations in the protein expression of some markers, albeit without exhibiting changes in behaviour.

Mitochondrial diaphorases as NAD⁺ donors to segments of the citric acid cycle that support substrate-level phosphorylation yielding ATP during respiratory inhibition

Substrate-level phosphorylation mediated by succinyl-CoA ligase in the mitochondrial matrix produces high-energy phosphates in the absence of oxidative phosphorylation. Furthermore, when the electron transport chain is dysfunctional, provision of succinyl-CoA by the α-ketoglutarate dehydrogenase complex (KGDHC) is crucial for maintaining the function of succinyl-CoA ligase yielding ATP, preventing the adenine nucleotide translocase from reversing. We addressed the source of the NAD(+) supply for KGDHC under anoxic conditions and inhibition of complex I. Using pharmacologic tools and specific substrates and by examining tissues from pigeon liver exhibiting no diaphorase activity, we showed that mitochondrial diaphorases in the mouse liver contribute up to 81% to the NAD(+) pool during respiratory inhibition. Under these conditions, KGDHC's function, essential for the provision of succinyl-CoA to succinyl-CoA ligase, is supported by NAD(+) derived from diaphorases. Through this process, diaphorases contribute to the maintenance of substrate-level phosphorylation during respiratory inhibition, which is manifested in the forward operation of adenine nucleotide translocase. Finally, we show that reoxidation of the reducible substrates for the diaphorases is mediated by complex III of the respiratory chain.