Sumeet S. Mitter

Contemporary Approaches to Patients with Heart Failure

Incident heart failure and the burden of hospitalization may be demonstrating a decline. However, as the population ages, the prevalence of heart failure continues to increase. Mortality among heart failure patients is increasingly due to non-cardiovascular causes. Current evidence-based therapy for heart failure has improved heart failure related mortality. Current efforts should be directed toward optimizing evidence based medical and device therapy, reducing morbidity, and increasing quality of life with heart failure. Future clinical trials should focus on therapies for heart failure with preserved ejection fraction, regenerative therapy for heart failure, and optimizing durable mechanical support for end-stage heart failure.

Spironolactone for Management of Heart Failure with Preserved Ejection Fraction: Whither to After TOPCAT?

Mineralocorticoid receptor antagonists (MRAs) represent an attractive class of drugs for the treatment of heart failure with preserved ejection fraction (HFpEF) because of the deleterious cardiovascular effects of aldosterone and because MRAs combat myocardial fibrosis and improve cardiac structure/function and vascular health. Recently, the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) study, a randomized, double-blind clinical trial of spironolactone versus placebo, was conducted in 3445 patients with symptomatic HFpEF. Although considered by some to be a negative trial, TOPCAT demonstrated that spironolactone decreases heart failure hospitalizations in patients with HFpEF. Furthermore, a pre-specified subgroup analysis of TOPCAT by geographic region uncovered concerning findings from Russia/Georgia, questioning (1) whether the correct patients were enrolled in this region and (2) whether enrolled patients actually received the study drug. In the Americas, spironolactone was clearly superior to placebo in reducing cardiovascular events. Given these data from TOPCAT, basic science evidence for the role of aldosterone in HFpEF, and results from other MRA clinical trials in HFpEF, we advocate using spironolactone in HFpEF with close monitoring of potassium and renal function.

HIV-Related Myocardial Vulnerability to Infarction and Coronary Artery Disease

Human immunodeficiency virus-infected (HIV+) persons have significantly greater risks for myocardial infarction (MI), heart failure, and sudden death than the general population [(1–3)][1]. HIV-related inflammation and immune dysfunction have been implicated in atherogenesis and MI, but the extent

Cardiac magnetic resonance imaging has limited additional yield in cryptogenic stroke evaluation after transesophageal echocardiography

Background The use of cardiac magnetic resonance imaging is increasing, but its role in the diagnostic work-up following ischemic stroke has received limited study. We aimed to explore the added yield of cardiac magnetic resonance imaging to identify cardio-aortic sources not detected by transesophageal echocardiography among patients with cryptogenic stroke. Methods A retrospective single-center cohort study was performed from 01 January 2009 to 01 March 2013. Consecutive patients who had both a stroke protocol cardiac magnetic resonance imaging and a transesophageal echocardiography preformed during a single hospitalization were included. All cardiac magnetic resonance imaging studies underwent independent, blinded review by two investigators. We applied the causative classification system for ischemic stroke to all patients, first blinded to cardiac magnetic resonance imaging results; we then reapplied the causative classification system using cardiac magnetic resonance imaging. Standard statistical tests to evaluate stroke subtype reclassification rates were used. Results Ninety-three patients were included in the final analysis; 68.8% were classified as cryptogenic stroke after initial diagnostic evaluation. Among patients with cryptogenic stroke, five (7.8%) were reclassified due to cardiac magnetic resonance imaging findings: one was reclassified as “cardio-aortic embolism evident” due to the presence of a patent foramen ovale and focal cardiac infarct and four were reclassified as “cardio-aortic embolism possible” due to mitral valve thickening (n = 1) or hypertensive cardiomyopathy (n = 3). Overall, findings on cardiac magnetic resonance imaging reduced the percentage of patients with cryptogenic stroke by slightly more than 1%. Conclusion Our stroke subtype reclassification rate after the addition of cardiac magnetic resonance imaging results to a diagnostic work-up which includes transesophageal echocardiography was very low. Prospective studies evaluating the role of cardiac magnetic resonance imaging and transesophageal echocardiography among patients with cryptogenic stroke should be considered.

MYOCARDIAL FIBROSIS FOLLOWING ISCHEMIA AND INFARCTION IS GREATER AMONG PERSONS WITH HUMAN IMMUNODEFICIENCY VIRUS THAN UNINFECTED CONTROLS

Persons with human immunodeficiency virus (HIV) have greater risks for myocardial infarction and sudden cardiac death (SCD) than the general population. Associations between coronary artery disease (CAD) and myocardial fibrosis - a mediator of SCD - in the setting of HIV are unknown. We hypothesized

Intraoperative Coronary Artery Dissection in Fibromuscular Dysplasia

A 61-year-old woman with bicuspid aortic stenosis, an ascending aortic aneurysm, and a remote history of renal fibromuscular dysplasia underwent aortic root replacement complicated by extensive dissection of the left circumflex artery extending retrograde into the left anterior descending artery. This was managed by coronary artery bypass grafting, left ventricular support, and percutaneous coronary intervention for propagation of the dissection. This case highlights the prevalence, diagnosis, and management of intraoperative coronary dissection secondary to fibromuscular dysplasia.