Sukhdeep S. Basra

The Percutaneous Ventricular Assist Device in Severe Refractory Cardiogenic Shock

OBJECTIVES We evaluated the efficacy and safety of the percutaneous ventricular assist device (pVAD) in patients in severe refractory cardiogenic shock (SRCS) despite intra-aortic balloon pump (IABP) and/or high-dose vasopressor support. BACKGROUND SRCS is associated with substantial mortality despite IABP counterpulsation. Until recently, there was no rapid, minimally invasive means of providing increased hemodynamic support in SRCS. METHODS A total of 117 patients with SRCS implanted with TandemHeart pVAD (CardiacAssist, Inc., Pittsburgh, Pennsylvania) were studied, of whom 56 patients (47.9%) underwent active cardiopulmonary resuscitation immediately before or at the time of implantation. Data was collected regarding clinical characteristics, hemodynamics, and laboratory values. RESULTS Eighty patients had ischemic and 37 patients had nonischemic cardiomyopathy. The average duration of support was 5.8 ± 4.75 days. After implantation, the cardiac index improved from median 0.52 (interquartile range [IQR]: 0.8) l/(min·m(2)) to 3.0 (IQR:0.9) l/(min·m(2)) (p < 0.001). The systolic blood pressure and mixed venous oxygen saturation increased from 75 (IQR:15) mm Hg to 100 (IQR:15) mm Hg (p < 0.001) and 49 (IQR:11.5) to 69.3 (IQR:10) (p < 0.001), respectively. The urine output increased from 70.7 (IQR: 70) ml/day to 1,200 (IQR: 1,620) ml/day (p < 0.001). The pulmonary capillary wedge pressure, lactic acid level, and creatinine level decreased, respectively, from 31.53 ± 10.2 mm Hg to 17.29 ± 10.82 mm Hg (p < 0.001), 24.5 (IQR: 74.25) mg/dl to 11 (IQR: 92) mg/dl (p < 0.001), and 1.5 (IQR: 0.95) mg/dl to 1.2 (IQR: 0.9) mg/dl (p = 0.009). The mortality rates at 30 days and 6 months were 40.2% and 45.3%, respectively. CONCLUSIONS The pVAD rapidly reversed the terminal hemodynamic compromise seen in patients with SRCS refractory to IABP and vasopressor support.

Percutaneous Circulatory Support in Cardiogenic Shock: Interventional Bridge to Recovery

Over the past 2 decades, innovation in the realm of mechanical ventricular assist devices (VADs) has altered the management of cardiogenic shock (CS). Percutaneous VADs (PVADs) allow emergent and effective ventricular unloading while providing sufficient systemic perfusion pressure to reverse end-organ dysfunction. Despite relatively few randomized trials evaluating these devices, some cardiovascular society guidelines recommend the use of PVADs in patients not responding to standard treatments for CS, including intra-aortic balloon pump (IABP) counterpulsation (Class IIa, Level of Evidence C).1 The purpose of this review is to highlight the spectrum of CS, to review modern PVADs as an interventional bridge to recovery, to discuss unique clinical issues related to PVAD support, and finally to offer a perspective on the future directions of acute mechanical circulatory support research. CS is a state of end-organ hypoperfusion caused by left ventricular (LV), right ventricular (RV), or biventricular myocardial injury resulting in systolic and/or diastolic myocardial pump failure. Myocardial infarction (MI) with LV failure remains the most common cause of CS. In general, CS complicates 8.6% of ST-segment elevation MIs (STEMI)2 and 2.5% of non–ST segment elevation MIs.3 Common causes of CS are listed in Table 1. View this table: Table 1. Common Causes of Cardiogenic Shock Clinically, CS is defined by both hemodynamic parameters (persistent hypotension [systolic blood pressure 18 mm Hg or RV end-diastolic pressure >10–15 mm Hg]) and clinical signs/symptoms of hypoperfusion (cool extremities, decreased urine output, and/or altered mental status). Inadequate systemic perfusion results in secondary lactic acidosis, catecholamine and neurohormone release, and activation of …

Current status of percutaneous ventricular assist devices for cardiogenic shock

Purpose of review Percutaneous ventricular assist devices (pVADs) are being increasingly used in patients with cardiogenic shock. They offer a means of instituting rapid and adequate cardiac support in patients with cardiogenic shock unresponsive to inotropes/vasopressors and intraaortic balloon pumps (IABPs). However, there is considerable debate on the appropriate use of these devices given the difficulty of conducting randomized trials in patients with cardiogenic shock, lack of clear guidelines on indications, device selection, and cost-effective care of patients implanted with these devices. Recent findings Several centers have recently reported data on the use of these devices for cardiogenic shock in a variety of different settings, including myocardial ischemia and its complications, high-risk percutaneous coronary intervention, myocarditis, and refractory arrhythmias. Recent randomized trials have compared the use of IABP with different pVADs evaluating hemodynamic outcomes as well as short-term mortality. Summary We review the current evidence on the use of pVADs (Tandemheart pVAD, Impella, percutaneous extracorporeal membrane oxygenation), their indications, relative merits, and adverse effects, and discuss the current approach to the appropriate use of pVADs in patients with cardiogenic shock. We also propose an algorithm for device selection tailored to each patients needs based on severity of cardiogenic shock, amount of support needed, and the overall clinical scenario.

Safety and Efficacy of Antiplatelet and Antithrombotic Therapy in Acute Coronary Syndrome Patients With Chronic Kidney Disease

Chronic kidney disease (CKD) is prevalent and affects an ever-increasing proportion of patients presenting with acute coronary syndrome (ACS). Patients with CKD have a higher risk of ACS and significantly higher mortality, and are also predisposed to increased bleeding complications. Antiplatelet and antithrombotic drugs form the bedrock of management of patients with ACS. Most randomized trials of these drugs exclude patients with CKD, and current guidelines for management of these patients are largely based on these trials. We aim to review the safety and efficacy of these drugs in patients with CKD presenting with ACS.

Frequency and Practice-Level Variation in Inappropriate Aspirin Use for the Primary Prevention of Cardiovascular Disease: Insights From the National Cardiovascular Disease Registry’s Practice Innovation and Clinical Excellence Registry

BACKGROUND Among patients without cardiovascular disease (CVD) and low 10-year CVD risk, the risks of gastrointestinal bleeding and hemorrhagic strokes associated with aspirin use outweigh any potential atheroprotective benefit. According to the guidelines on primary prevention of CVD, aspirin use is considered appropriate only in patients with 10-year CVD risk ≥6% and inappropriate in patients with 10-year CVD risk <6%. OBJECTIVES The goal of this study was to examine the frequency and practice-level variation in inappropriate aspirin use for primary prevention in a large U.S. nationwide registry. METHODS Within the National Cardiovascular Disease Registrys Practice Innovation and Clinical Excellence registry, we assessed 68,808 unique patients receiving aspirin for primary prevention from 119 U.S. practices. The frequency of inappropriate aspirin use was determined for primary prevention (aspirin use in those with 10-year CVD risk <6%). Using hierarchical regression models, the extent of practice-level variation using the median rate ratio (MRR) was assessed. RESULTS Inappropriate aspirin use frequency was 11.6% (7,972 of 68,808) in the overall cohort. There was significant practice-level variation in inappropriate use (range 0% to 71.8%; median 10.1%; interquartile range 6.4%) for practices; adjusted MRR was 1.63 (95% confidence interval [CI]: 1.47 to 1.77). Results remained consistent after excluding 21,052 women age ≥65 years (inappropriate aspirin use 15.2%; median practice-level inappropriate aspirin use 13.8%; interquartile range 8.2%; adjusted MRR 1.61 [95% CI: 1.46 to 1.75]) and after excluding patients with diabetes (inappropriate aspirin use 13.9%; median practice-level inappropriate aspirin use 12.4%; interquartile range 7.6%; adjusted MRR 1.55 [95% CI: 1.41 to 1.67]). CONCLUSIONS More than 1 in 10 patients in this national registry were receiving inappropriate aspirin therapy for primary prevention, with significant practice-level variations. Our findings suggest that there are important opportunities to improve evidence-based aspirin use for the primary prevention of CVD.

BNP and obesity in acute decompensated heart failure with preserved vs. reduced ejection fraction: The Atherosclerosis Risk in Communities Surveillance Study

BACKGROUND Levels of B-type natriuretic peptide (BNP), a prognostic marker in patients with heart failure (HF), are lower among HF patients with obesity or preserved Left Ventricular Ejection Fraction (LVEF). We examined the distribution and prognostic value of BNP across BMI categories in acute decompensated heart failure (ADHF) patients with preserved vs. reduced LVEF. METHODS We analyzed data from the Atherosclerosis Risk in Communities (ARIC) HF surveillance study which sampled and adjudicated ADHF hospitalizations in patients aged ≥55years from 4 US communities (2005-2009). We examined 5 BMI categories: underweight (<18.5kg/m2), normal weight (18.5-<25), overweight (25-<30), obese (30-<40) and morbidly obese (≥40) in HF with preserved LVEF (HFpEF) and reduced LVEF (HFrEF). The outcome was 1-year mortality from admission. We used ANCOVA to model log BNP and logistic regression for 1-year mortality, both adjusted for demographics and clinical characteristics. RESULTS The cohort included 9820 weighted ADHF hospitalizations (58% HFrEF; 42% HFpEF). BNP levels were lower in HFpEF compared to HFrEF (p<0.001) and decreased as BMI increased within the LVEF groups (p<0.001). After adjustment for covariates, log10 BNP independently predicted 1-year mortality (adjusted OR 1.62 (95% CI 1.17-2.24)) with no significant interaction by BMI or LVEF groups. CONCLUSIONS BNP levels correlated inversely with BMI, and were higher in HFrEF compared to HFpEF. Obese patients with HFpEF and ADHF had a significant proportion with BNP levels below clinically accepted thresholds. Nevertheless, BNP was a predictor of mortality in ADHF across groups of BMI in HFpEF and HFrEF.

Acute Coronary Syndromes: Unstable Angina and Non–ST Elevation Myocardial Infarction

Non-ST elevation acute coronary syndromes (NSTE-ACS) encompass the clinical entities of unstable angina and non-ST elevation myocardial infarction. Several advances have occurred over the past decade, including the emergence of new antiplatelet and antithrombotic therapies and novel treatment strategies, leading to marked improvements in mortality. However, there has also been an increased incidence in NSTE-ACS as a result of the use of high-sensitivity troponins and the increase in cardiovascular risk factors. This article provides a focused update on contemporary management strategies pertaining to antiplatelet, antithrombotic, and anti-ischemic therapies and to revascularization strategies in patients with ACS.

Abnormal rhythms in patients without known cardiac disease after a first dose of fingolimod

BACKGROUND Fingolimod is used to reduce the rates of relapse and slow the progression of disability in relapsing-remitting multiple sclerosis (RRMS). In-office monitoring of patients for 6h after the first dose of fingolimod is currently recommended due to rare cardiac rhythm disturbances. The objective of this paper is to describe our experience with continuous electrocardiographic monitoring of patients with RRMS starting on fingolimod. METHODS Since changes to the FDA recommendations for first dose observation, a total of 59 patients with RRMS began treatment with fingolimod. After the first dose, all patients were observed for 6h with continuous electrocardiographic telemetry, vital signs were checked every hour, and 12 lead ECG performed before and after the 6-h period. RESULTS Three out of 59 (5%) patients developed arrhythmia that led to discontinuation of fingolimod. The first patient had a sinus bradycardia with idioventricular escape rhythm that lasted 45s and two patients developed second-degree atrio-ventricular block Mobitz type I. None of the patients had a history of prior cardiacc disease or was taking other medications that may cause arrhythmia or bradycardia. CONCLUSION Continuous on-line electrocardiographic telemetry may detect abnormal rhythms in a small number of patients started on fingolimod. The clinical significance of these is unclear and warrants further study.

Incident cancer in patients with heart failure: causation or mere association?

Heart failure (HF) and cancer are becoming increasingly prevalent as our population ages. Both conditions are associated with significant mortality and morbidity. Although the increased risk of incident HF in patients with cancer receiving chemotherapy has been well documented [(1)][1], little is

Are There Any New Pharmacologic Therapies on the Horizon to Better Treat Hypertension? A State-of-the-Art Paper

Hypertension is the most important cardiovascular risk factor. We have witnessed a significant improvement in hypertension treatment and control and an impressive growth in the pharmacologic options available to clinicians and hypertension specialists. With up to a third of patients with hypertension not at the recommended goal blood pressures, it is critically important to develop novel therapeutic approaches to better treat hypertension. This review will explore the ever-expanding horizon of antihypertensive treatment and will focus on 2 major areas of drug development. First, we will review novel targets for pharmacologic treatment and novel molecules and classes of drugs in various phases of development and recognize the limitations we face in their transition from research and development to clinical practice. Then, we will discuss an expanding array of combination strategies to better treat hypertension with the goal of minimizing the burden of cardiovascular and renal complications of hypertension.