Abhishek Jaiswal

Clinical Phenotypes in Heart Failure With Preserved Ejection Fraction

Over the past 2 decades, the syndrome of heart failure with preserved ejection fraction (HFpEF) received a lot of attention.[1][1]–[19][2] However, little therapeutic progress was made.[20][3]–[27][4] Among the issues that may account for the modest therapeutic progress, one appears to be

Pharmacologic and Endovascular Reversal of Left Ventricular Remodeling

Pathologic left ventricular (LV) remodeling as described by adverse changes in LV mass, volume, geometry, and composition in response to mechanical and systemic neurohormonal activation portends a poor prognosis in patients with underlying LV systolic dysfunction. Conversely, reversal of LV remodeling is associated with improved morbidity and mortality. Improvement in LV function and size may result from either change in loading conditions or reversal of remodeling (RR). When complete normalization of LV function and geometry occurs (ejection fraction >50% and indexed LV end-diastolic dimension <33 mm/m(2)), true reversal of LV alteration is likely to have occurred. Sustained improvement in function and dimensions after therapy withdrawal further supports RR. In the absence of complete RR one cannot readily differentiate incomplete RR from changes in loading conditions. In this review, we evaluate the role of renin-angiotensin-aldosterone system inhibition, beta-adrenergic receptor blockade, cardiac resynchronization therapy, and endovascular mitral repair on LVRR and improvement in LV geometry and function.

Intra-abdominal Hypertension: An Important Consideration for Diuretic Resistance in Acute Decompensated Heart Failure.

Fluid accumulation is the hallmark of heart failure decompensation. Fluid overload and congestion are associated with recurrent hospitalizations, poor quality of life, and increased mortality in heart failure. Despite the use of high‐dose intravenous loop diuretic therapy, acutely decompensated heart failure patients may develop diuretic resistance. Diuretic refractoriness can be a result of elevated intra‐abdominal pressure (IAP) in acutely decompensated heart failure. Increased renal venous and interstitial pressures in patients with elevated IAP may lead to renal impairment and diuretic resistance. Routine approaches such as sequential nephron blockade with a combination of loop and thiazide or thiazide‐like diuretics, continuous diuretic infusion, and ultrafiltration may not be sufficient. Presented here is a case illustrating the importance of recognizing intra‐abdominal hypertension in patients with diuretic resistance. Lowering IAP improves renal perfusion, renal filtration, and diuresis. When elevated, IAP is an easily reversible cause of diuretic resistance. Additionally, abdominal perfusion pressure can be used to guide therapy to reverse end‐organ damage and avoid permanent renal replacement therapy.

Obesity-Associated Hypertension: the Upcoming Phenotype in African-American Women

Purpose of ReviewThe present obesity epidemic particularly affects African-American women. Whether the obesity epidemic will alter the hypertension phenotype in African-American women is entertained.Recent FindingsThe prevalence of morbid obesity is steadily increasing in African-American women, who are prone to developing hypertension (HTN) even in the absence of obesity. The obesity-associated hypertension phenotype is characterized by marked sympathetic nervous system activation and resistance/refractoriness to antihypertensive therapy. Weight loss achieved through lifestyle interventions and pharmacotherapy has a modest and rarely sustained antihypertensive effect. In contrast, bariatric surgery has a sustained antihypertensive effect, as evidenced by normalization of hypertension or lessening of antihypertensive therapy.SummaryThe prevalence of HTN and its obesity-associated phenotype is likely to increase in African-American women over the next decades. Obese African-American women may be increasingly referred for bariatric surgery when hypertension remains uncontrolled despite lifestyle interventions and pharmacological therapy for weight loss and blood pressure (BP) control.

Impact of transesophageal echocardiography on clinical management of patients over age 50 with cryptogenic stroke and normal transthoracic echocardiogram.

BACKGROUND The utility of transesophageal echocardiography (TEE) subsequent to a normal transthoracic echocardiogram (TTE) in older patients with an unexplained stroke is uncertain. METHODS Two hundred sixty-three consecutive patients over the age of 50 years hospitalized with a clinical stroke confirmed with brain magnetic resonance imaging and a normal TTE were retrospectively analyzed. Patients with atrial fibrillation, atrial flutter, or any other causative reason for stroke were excluded. TEE was analyzed for findings that could explain the etiology of stroke as well as findings that would change therapy based on current guidelines. RESULTS Baseline characteristics included a mean age of 66.7 years (range, 50-91 years); 42.5% of patients were female. A possible etiology of stroke was discovered by TEE in 111 (42.2%) patients and included 1 or more of the following: complex plaque of the ascending aorta or arch, patent foramen ovale, atrial septal aneurysm, both atrial septal aneurysm and patent foramen ovale, or spontaneous contrast. Only 1 patient (0.4%) had a finding that changed immediate management, which was a thrombus in the left atrial appendage for which anticoagulation was prescribed. Follow-up was available at 6 months on 85 patients, of whom 13 (15%) had been discovered to have developed atrial fibrillation. CONCLUSION In our study population, when performed subsequent to a normal TTE in patients aged >50 years with cryptogenic stroke, TEE demonstrated a high diagnostic value, but had minimal incremental effect on patient management.

Cardiac Adrenergic Nervous System and Left Ventricular Remodeling.

Abstract:Heightened cardiac adrenergic nervous system (ANS) activity and progression of left ventricular (LV) remodeling are temporally related in patients with systolic heart failure. Whether cardiac ANS activation directly contributes to or merely accompanies LV remodeling remains an unresolved issue. Human and experimental data that directly link cardiac ANS activation to LV remodeling and worsening heart failure are first reviewed, including cardiac norepinephrine spillover. Alterations of beta adrenergic receptor signaling pathways are then addressed with emphasis on the mechanisms that may mediate the beneficial effect of beta adrenergic receptor blockade on LV remodeling. Lastly, alternative approaches to beta adrenergic receptor blockade for lessening cardiac ANS activation and reversing cardiac ANS-induced LV remodeling are discussed. A large body of work now links LV remodeling to cardiac ANS activation. However, the precise mechanisms that link cardiac ANS activation to LV remodeling are still to be fully understood. Fully understanding of these mechanisms may uncover new therapeutic approaches.

Pathophysiology and Potential Non-Pharmacologic Treatments of Obesity or Kidney Disease Associated Refractory Hypertension

Purpose of ReviewThe review assesses the role of non-pharmacologic therapy for obesity and chronic kidney disease (CKD) associated refractory hypertension (rf HTN).Recent FindingsHypertensive patients with markedly heightened sympathetic nervous system (SNS) activity are prone to develop refractory hypertension (rfHTN). Patients with obesity and chronic kidney disease (CKD)-associated HTN have particularly heightened SNS activity and are at high risk of rfHTN. The role of bariatric surgery is increasingly recognized in treatment of obesity.SummaryCurrent evidence advocates for a greater role of bariatric surgery in the management of obesity-associated HTN. In contrast, renal denervation does not appear have a role in the management of obesity or CKD-associated HTN. The role of baroreflex activation as adjunctive anti-hypertensive therapy remains to be defined.

Regression of Left Ventricular Mass After Bariatric Surgery

Notwithstanding the presence of hypertension, obstructive sleep apnea, or both, obesity is associated with increased left ventricular (LV) mass. The effects of bariatric surgery on LV mass have been sparsely investigated by M-mode and two-dimensional (2D) echocardiography. Overall, Roux-en-Y gastric bypass, adjustable gastric banding, and sleeve gastrectomy reduce LV mass. However, the reduction in LV mass is extremely variable. Besides duration and severity of obesity, presence of hypertension, obstructive sleep apnea or both, and type of surgical procedures, the inaccuracy of M-mode and 2D echocardiography for assessment of LV mass contributes to the variable effects of bariatric surgery on LV mass. Three-dimensional (3D) echocardiography may obviate the limitations of M-mode 2D echocardiography for assessment of LV mass and allow an accurate appraisal of the effects of bariatric surgery on LV mass.

Novel role of phosphodiesterase inhibitors in the management of end-stage heart failure

In advanced heart failure (HF), chronic inotropic therapy with intravenous milrinone, a phosphodiesterase III inhibitor, is used as a bridge to advanced management that includes transplantation, ventricular assist device implantation, or palliation. This is especially true when repeated attempts to wean off inotropic support result in symptomatic hypotension, worsened symptoms, and/or progressive organ dysfunction. Unfortunately, patients in this clinical predicament are considered hemodynamically labile and may escape the benefits of guideline-directed HF therapy. In this scenario, chronic milrinone infusion may be beneficial as a bridge to introduction of evidence based HF therapy. However, this strategy is not well studied, and in general, chronic inotropic infusion is discouraged due to potential cardiotoxicity that accelerates disease progression and proarrhythmic effects that increase sudden death. Alternatively, chronic inotropic support with milrinone infusion is a unique opportunity in advanced HF. This review discusses evidence that long-term intravenous milrinone support may allow introduction of beta blocker (BB) therapy. When used together, milrinone does not attenuate the clinical benefits of BB therapy while BB mitigates cardiotoxic effects of milrinone. In addition, BB therapy decreases the risk of adverse arrhythmias associated with milrinone. We propose that advanced HF patients who are intolerant to BB therapy may benefit from a trial of intravenous milrinone as a bridge to BB initiation. The discussed clinical scenarios demonstrate that concomitant treatment with milrinone infusion and BB therapy does not adversely impact standard HF therapy and may improve left ventricular function and morbidity associated with advanced HF.

Device Thrombosis During Destination Therapy.

Background: Device thrombosis remains a complication of long‐term mechanical circulatory support with HeartMate II. Materials and Methods: Retrospective analysis of patients who underwent destination therapy (DT) with HeartMate II from January 2010‐December 2013 at Tulane University Medical Center. Results: Eighteen HeartMate II were implanted for DT. Survival rates were 72.2% at 1 year and 37% at 2 years. Device thrombosis in 7 of the 18 patients (39%) accounted for the low survival rate at 2 years. Known risk factors for device thrombosis were equally present in patients with and without device thrombosis. In contrast to patients without device thrombosis, all patients with device thrombosis had a pre‐existing systemic inflammatory condition. Conclusions: Patients with pre‐existing systemic inflammatory conditions are at risk of device thrombosis during DT.