Anjli Maroo

Lack of significant renal tubular injury despite acute kidney injury in acute decompensated heart failure

Acute kidney injury (AKI) is a strong predictor of adverse events with an incompletely understood pathophysiology. Neutrophil gelatinase‐associated lipocalin (NGAL) is proposed as an early marker of renal tubular injury. Our aim is to determine whether AKI during treatment of acute decompensated heart failure (ADHF) is accompanied by renal tubular injury.

PPARγ agonists: safety issues in heart failure

PPARγ agonists (or thiazolidinediones, TZD) are popular oral drugs for glycaemic control in patients with diabetes mellitus. However, side‐effects of fluid retention, oedema and congestive heart failure have been reported in the literature as well as observed in clinical registries and trials. Concerns regarding the safety of TZD use in patients with underlying heart failure have been implicated by its propensity to cause fluid retention. There is relatively good documentation in the literature that TZDs do not produce adverse haemodynamic consequences. TZD‐induced fluid retention is often sub‐acute in nature, developed over weeks to months following initiation, and primarily located in the periphery. Drug withdrawal may lead to complete resolution of fluid retention. Current approval of TZD use in patients with mild (NYHA class I – II) and stable heart failure is supported by existing literature and clinical experience. There have been few reports of severe adverse consequences following drug withdrawal, and emerging data are suggesting potential benefits of TZDs in the diabetic population with or without underlying heart failure. Future research should therefore be directed at better understanding PPARγ‐related mechanisms of renal sodium retention and endothelial vascular permeability of the periphery, as well as development of newer compounds without this side‐effect.

Aldosterone Receptor Antagonists in the Medical Management of Chronic Heart Failure

The benefits of aldosterone receptor antagonists (spironolactone and eplerenone) for patients with heart failure were shown in 2 recent randomized controlled trials. Some of the proposed mechanisms of action of aldosterone antagonists are (1) inhibition of myocardial and vascular remodeling, (2) blood pressure reduction, (3) decreased collagen deposition, (4) decreased myocardial stiffness, (5) prevention of hypokalemia and arrhythmia, (6) modulation of nitric oxide synthesis, and (7) immunomodulation. Like many hormone receptors, the aldosterone receptor can be either nuclear or membrane bound. Most of the activities of the aldosterone receptor are subserved by the nuclear receptors and often lead to alterations in gene transcription. Although these agents are well tolerated in carefully selected patient populations that meet the inclusion criteria of large clinical trials, their use in unselected elderly patients with heart failure and multiple comorbidities has been associated with a significant risk of hyperkalemia and renal failure. Although no convincing data exist to predict which individual patients will respond to aldosterone inhibition, patients with more severe heart failure and those with acute myocardial infarction with concomitant heart failure or left ventricular dysfunction are most likely to respond. Theoretically, aldosterone receptor antagonists may also be beneficial in patients with more mild to moderate systolic heart failure or even in those with diastolic heart failure, although direct evidence is still lacking.

The early history and development of thrombolysis in acute myocardial infarction

Fibrinolytic therapy has been a major advance in the treatment of acute myocardial infarction (AMI), leading to improved early survival, less heart failure, less ventricular remodeling, and fewer arrhythmias [1]. The thrombolytic era was founded on a fundamental concept: that most cases of AMI are the result of sudden obstruction of an epicardial coronary artery by intracoronary thrombus superimposed on a ruptured or fissured atherosclerotic plaque. Physicians trained after the advent of thrombolytic therapy may find it difficult to believe that this concept was one of the most intensely debated pathophysiologic tenets of the 20th century. Yet, the development of thrombolytic agents for treatment of AMI remained a tortuous and stuttering process until this concept achieved widespread acceptance.Wewill review the interesting history of coronary artery thrombosis and its foundation of the thrombolytic era.

Stent-assisted detachable coil embolization of pseudoaneurysms in the coronary circulation

Pseudoaneurysms in the coronary circulation are an uncommon occurrence that can develop spontaneously in the setting of atherosclerosis or can develop after catheter‐based coronary interventions. The natural history, clinical outcome, and optimal therapy for pseudoaneurysms in the coronary circulation are not clearly established. Recent advances in the techniques and technologies used for endovascular treatment of intracranial aneurysms may be applicable to the management of coronary aneurysms and pseudoaneurysms. We present a case of spontaneous coronary pseudoaneurysm formation after paclitaxel drug‐eluting stent implantation and a case of pseudoaneurysm formation in a saphenous vein graft that were both successfully treated with stent‐assisted detachable coil embolization.

Natriuretic Peptide Testing in High-Risk Pregnancy: A Preventive Opportunity?

Natriuretic peptide testing has been widely utilized in the heart failure and cardiac patient population, but there is limited utilization during pregnancy. Patients with hypertensive diseases of pregnancy have been shown to experience elevation of circulating natriuretic peptide levels compared to normal pregnancies, especially in the setting of preeclampsia. Natriuretic peptide testing can be utilized in patients presenting with signs and symptoms suspicious of heart failure in order to rule out underlying cardiac causes. Meanwhile, monitoring natriuretic peptide levels in those with established heart diseases (both congenital and acquired) may facilitate careful management of cardiac status during the course of pregnancy. Further investigations in the judicious use of selected medications (particularly loop diuretics) in the setting of elevated natriuretic peptide levels are warranted.