Sohaib Tariq

Use of Inotropic Agents in Treatment of Systolic Heart Failure

The most common use of inotropes is among hospitalized patients with acute decompensated heart failure, with reduced left ventricular ejection fraction and with signs of end-organ dysfunction in the setting of a low cardiac output. Inotropes can be used in patients with severe systolic heart failure awaiting heart transplant to maintain hemodynamic stability or as a bridge to decision. In cases where patients are unable to be weaned off inotropes, these agents can be used until a definite or escalated supportive therapy is planned, which can include coronary revascularization or mechanical circulatory support (intra-aortic balloon pump, extracorporeal membrane oxygenation, impella, left ventricular assist device, etc.). Use of inotropic drugs is associated with risks and adverse events. This review will discuss the use of the inotropes digoxin, dopamine, dobutamine, norepinephrine, milrinone, levosimendan, and omecamtiv mecarbil. Long-term inotropic therapy should be offered in selected patients. A detailed conversation with the patient and family shall be held, including a discussion on the risks and benefits of use of inotropes. Chronic heart failure patients awaiting heart transplants are candidates for intravenous inotropic support until the donor heart becomes available. This helps to maintain hemodynamic stability and keep the fluid status and pulmonary pressures optimized prior to the surgery. On the other hand, in patients with severe heart failure who are not candidates for advanced heart failure therapies, such as transplant and mechanical circulatory support, inotropic agents can be used for palliative therapy. Inotropes can help reduce frequency of hospitalizations and improve symptoms in these patients.

Update on pulmonary arterial hypertension pharmacotherapy.

ABSTRACT Pulmonary artery hypertension (PAH) refers to several subgroups of disease in which the mean pulmonary artery pressure (mPAP) is elevated to more than 25 mm Hg, pulmonary artery wedge pressure (PAWP) ≤ 15 mmHg, and an elevated pulmonary vascular resistance (PVR) > 3 Wood units as confirmed by right heart catheterization. The prevalence and geographic distribution of PAH vary depending on the type and etiology of the disease. Despite enormous efforts in the research and development of therapeutic agents in the last twenty years, the disease remains relatively incurable and the overall prognosis remains guarded. Median survival for an untreated patient is 2.8 years. In the last three decades, there have been dramatic advances in understanding the molecular mechanisms and signaling pathways involved in the disease, resulting in emerging new treatment strategies. In the following pages, we will review currently approved treatments for PAH, as well as a new generation of investigational drugs.

Ambulatory pulmonary artery pressure monitoring in advanced heart failure patients

Heart failure (HF) is an emerging epidemic associate with significant morbidity, mortality, and health care expenditure. Although there were major advances in pharmacologic and device based therapies for the management of HF, mortality of this condition remains high. Accurate monitoring of HF patients for exacerbations is very important to reduce recurrent hospitalizations and its associated complications. With the failure of clinical signs, tele-monitoring, and laboratory bio-markers to function as early markers of HF exacerbations, more sophisticated techniques were sought to accurately predict the circulatory status in HF patients in order to execute timely pharmacological intervention to reduce frequent hospitalizations. CardioMEMSTM (St. Jude Medical, Inc., Saint Paul, Minnesota) is an implantable, wireless pulmonary arterial pressure (PAP) monitoring system which transmits the patient’s continuous PAPs to the treating health care provider in the ambulatory setting. PAP-guided medical therapy modification has been shown to significantly reduce HF-related hospitalization and overall mortality. In advanced stages of HF, wireless access to hemodynamic information correlated with earlier left ventricular assist device implantation and shorter time to heart transplantation.

Advances in chemical pharmacotherapy for managing acute decompensated heart failure

ABSTRACT Introduction: Acute decompensated heart failure (ADHF) contributes largely to the burden of heart failure and is associated with a poorer prognosis. Although numerous clinical trials evaluated the benefit of newer medications for ADHF, most of them were not successful. Areas covered: This review focusses on the updates on recent developments in chemical pharmacotherapy for the management of ADHF. A MEDLINE search for relevant review articles and original investigations on newer drugs for ADHF provided us with necessary literature. Expert opinion: Currently, popular therapies like diuretics, vasodilators, and inotropes offer symptomatic relief but do not provide survival benefit. Although multiple medications targeting novel pathways in ADHF were studied extensively, they failed to show either symptomatic or mortality benefit in available randomized trials. Improving our understanding of the complex pathophysiology of ADHF along with designing studies which include patients who are more representative of the real-world heart failure population, standardizing methods for endpoint assessment, and evaluating the role on novel biomarkers of organ dysfunction is important to improve ADHF research. Enhancing preventive strategies like improving baseline therapy in chronic heart failure patients and developing strategies for early identification of ADHF are important as our quest for innovative ADHF pharmacotherapy continues.

Chronic Thromboembolic Pulmonary Hypertension: Epidemiology, Diagnosis, and Management

Chronic thromboembolic pulmonary hypertension (CTEPH), classified as World Health Organization (WHO) group 4 pulmonary hypertension (PH), is an interesting and rare pulmonary vascular disorder secondary to mechanical obstruction of the pulmonary vasculature from thromboembolism resulting in PH. The pathophysiology is complex, beginning with mechanical obstruction of the pulmonary arteries, which eventually leads to arteriopathic changes and vascular remodeling in the nonoccluded arteries and in the distal segments of the occluded arteries mediated by thrombus nonresolution, abnormal angiogenesis, endothelial dysfunction, and various local growth factors. Based on available data, CTEPH is a rare disease entity occurring in a small proportion (0.5–3%) of patients after acute pulmonary embolism with an annual incidence ranging anywhere between 1 and 7 cases per million population. It is often underdiagnosed or misdiagnosed as idiopathic pulmonary arterial hypertension due to a lack of clinical suspicion or the under-utilization of radionuclide ventilation/perfusion scan. Although the current standard remains planar ventilation/perfusion scintigraphy as the initial imaging study to screen for CTEPH, and invasive pulmonary angiography with right heart catheterization as confirmatory modalities, they are likely to be replaced by modalities that can provide both anatomic and functional data while minimizing radiation exposure. Surgery is the gold standard treatment and offers better improvements in clinical and hemodynamic parameters compared with medical therapy. The management of CTEPH requires a multidisciplinary team, operability assessment, experienced surgical center, and the consideration of medical PH-directed therapies in patients who have inoperable disease, in addition to supportive therapies. Although, balloon pulmonary angioplasty is gaining interest to improve pulmonary hemodynamics and symptoms in CTEPH patients not amenable to surgery, further investigative randomized studies are needed to validate its use. It is very important for the present-day physician to be familiar with the disease entity and its appropriate evaluation to facilitate early diagnosis and appropriate management.

Use of Stem Cells in Ischemic Heart Disease

Summary/Abstract Heart disease continues be one of the major causes of morbidity and mortality in the United States largely due to increasing life expectancy, increasing prevalence of cardiovascular risk factors, and changing life style. Significant advances have been made in the diagnosis and treatment of ischemic heart disease as well as cardiomyopathy in the past few decades. While these therapies which include pharmacological intervention, percutaneous coronary intervention, cardioverter-defibrillators, and mechanical circulatory support increase longevity by preventing further damage, they have a somewhat limited role in healing cardiac damage and have variable adverse effects. In recent years, considerable meaningful research has been done with stem cells with the goal of repairing cardiac cells. In this chapter, we review the data regarding the techniques and clinical applications of stem cell therapy.

Use of Extracorporeal Membrane Oxygenation in Refractory Cardiogenic Shock.

Cardiogenic shock is a condition marked by low cardiac output and end-organ hypoperfusion frequently requiring hemodynamic support, and it carries a high mortality. Extracorporeal membrane oxygenation (ECMO) is an effective tool in providing mechanical circulatory support in patients with cardiogenic shock refractory to conventional medical therapies. ECMO can be an essential bridge to recovery, ventricular assist device implantation or transplant. A multidisciplinary team approach is needed in managing such patients and intensive monitoring is required to avoid complications from ECMO. Nevertheless, randomized clinic trials are warranted to prove a survival benefit.

Prevalence and In-Hospital Outcomes of Uremic and Dialysis Pericarditis: A United States National Study

Background: In the modern dialysis era, uremic and dialysis pericarditis (UDP) are less frequently encountered in clinical practice. We sought to determine the secular variation and in-hospital outcomes of UDP. Methods: Using the U.S. Nationwide Inpatient Sample databases 2003 through 2012, we

IN-HOSPITAL OUTCOMES AND HOSPITALIZATIONS FOR ACUTE RHEUMATIC HEART DISEASE: A UNITED STATES NATIONAL STUDY

Background: Acute rheumatic heart disease (ARHD) is a serious manifestation of acute rheumatic fever (ARF) and can result in long-term cardiac complications. Literature suggests that the incidence of ARF is declining in the United States (US). However, the secular variation of ARHD has not been

ARRHYTHMIAS IN HOSPITALIZED HEART TRANSPLANTED PATIENTS: A UNITED STATES NATIONAL STUDY

Background: Abnormal anatomy, sympathetic denervation, rejection, and infection may increase the risk for arrhythmias in heart transplant (HT) recipients. Data are limited regarding arrhythmias in hospitalized HT patients. Methods: Using the U. S. Nationwide Inpatient Sample databases 2003 through