Wilbert S. Aronow

Pulmonary Nodule: A Comprehensive Review and Update

Abstract The incidental detection of solitary pulmonary nodules and ground-glass nodules has increased substantially with the use of computed tomography as a diagnostic modality and is expected to rise exponentially as lung cancer screening guidelines are more widely implemented by primary care physicians. The lesions should then be classified as low, indeterminate, or high risk for malignancy, depending on the clinical and radiological characteristics. Once classified, these lesions should be evaluated and managed as per expert consensus-based recommendations for performing follow-up computed tomography scans and tissue sampling depending on the pretest probability. When weighing the risks and benefits of further investigations, patient preference and suitability for surgery should be taken into consideration as well.

Total Arterial Revascularization in Coronary Artery Bypass Grafting Surgery

Coronary artery bypass graft (CABG) operations are one of the most commonly performed sur‐ gical procedures, with a worldwide prevalence of over 800,000 annually and more than 350,000 operations being performed in the United States each year [1]. The use of the left internal mam‐ mary artery (LIMA) is widely considered to be the gold standard for conventional CABG opera‐ tions. Its use has been shown to result in a lower incidence of reintervention, fewer myocardial infarctions, a lower incidence of angina, and lower associated mortality rates than with the use of saphenous vein grafts alone. Also when compared to saphenous vein grafts, LIMA use has been shown to have greater long-term patency results [1, 2]. For patients with multivessel coro‐ nary disease undergoing what is usually referred to as conventional CABG, the LIMA is typical‐ ly grafted to the left anterior descending (LAD) artery with saphenous vein grafts often used to bypass the remaining coronary occlusions. However, arterial conduits are now being more fre‐ quently used as choices for the second and third conduits in place of saphenous vein grafts to achieve total arterial revascularization (TAR) of the myocardium due to superior patency and long-term survival results. This article provides a review of TAR using the right internal mam‐ mary artery (RIMA) and radial artery as additional arterial conduits in conjunction with the LI‐ MA as a first choice conduit. The reported benefits of TAR when compared to conventional CABG procedures using the LIMA and saphenous vein grafts are discussed.

Interventional therapies for relief of obstruction in hypertrophic cardiomyopathy: discussion and proposed clinical algorithm

ABSTRACT Hypertrophic cardiomyopathy (HCM), a disease formerly thought rare in clinical practice, is now believed to affect as many as 1 in 300 individuals, regardless of race or gender. Rising awareness, coupled with advanced imaging and the development of dedicated HCM centers of excellence, has led to more patients coming to clinical presentation. While some are diagnosed at a young age, others are diagnosed in middle age or well into advanced age. Unfortunately, many such patients have progressed clinically to overt heart failure, or have some combination of advanced symptoms including dyspnea, angina, pre-syncope or syncope, palpitations, and edema. Anatomic subsets, including those with mid-ventricular obstruction or apical disease, with or without apical aneurysm, have also been seen in increasing frequency. Fortunately, both percutaneous and surgical invasive options are available across the spectrum of disease severity and anatomy, with outcomes continuing to improve as the techniques and experience evolve. Advances in both approaches allow targeted and individualized treatment of the majority of these patients. This review will focus on interventional approaches to relief of obstruction, and will provide a current clinical algorithm from our center for determining when an interventional approach may be recommended or optimal over a surgical approach, and vice versa.

Newer hormonal pharmacotherapies for heart failure

ABSTRACT Introduction: Heart failure (HF) is characterized by maladaptive neurohormonal activation of the cardiovascular and renal systems resulting in circulatory inadequacy and frequent acute exacerbations. The increasing burden of HF prompted investigation of underlying pathophysiological mechanisms and the design of pharmacotherapeutics that would target these pathways. Areas covered: A MEDLINE search for relevant original investigations and review articles of newer hormonal drugs for HF since the year 2005 till October 2017 provided us with necessary literature. Major trials and relevant clinical investigations were discussed. Expert commentary: A multitude of hormonal pathways central to HF were identified, including the natriuretic peptide system and neurohormones such as relaxin, arginine vasopressin, and endothelin. However, drugs targeting these novel pathways (aliskiren, tolvaptan, ularitide, serelaxin, bosentan, macitentan) failed to show mortality benefit. This emphasizes a tremendous unmet need in the pharmacotherapy for HF, especially for the subtypes of acute HF and HF with preserved ejection fraction. Sacubitril/valsartan demonstrated substantial mortality benefit in chronic systolic HF population and is endorsed by international HF guidelines. If proven to be efficacious in larger outcome trials, finerenone can be a valuable addition baseline HF therapy. More basic, translational, and phenotype specific clinical research is warranted to improve HF pharmacotherapy.

Variant Angina and Aborted Sudden Cardiac Death

Purpose of ReviewVariant angina, which is characterized by recurrent chest pain and transient ECG changes along with angiographic evidence of coronary artery spasm, generally has a favorable prognosis. However, episodes of ischemia caused by vasospasm may lead to potentially life-threatening ventricular arrhythmias and cardiac arrest, even in patients with no history of prior cardiac disease. This review describes the epidemiology, pathogenesis, clinical spectrum, and management of variant angina, as well as outcomes in patients who present with aborted sudden cardiac death (ASCD).Recent FindingsContrary to prior opinions, evidence from recent observational studies indicate that patients with variant angina presenting with ASCD face a worse prognosis than those without this type of presentation. Predictors of ASCD include age, hypertension, hyperlipidemia, family history of sudden cardiac death, multi-vessel spasm, and left anterior descending artery spasm. Medical therapy alone with calcium channel blockers and nitrates may not be sufficiently protective in these patients and there is lack of concrete data on the optimal management strategy. Current guidelines recommend implantable cardiac defibrillator (ICD) therapy in patients who are survivors of cardiac arrest caused by ventricular fibrillation or unstable ventricular tachycardia after reversible causes are excluded, and should strongly be considered in these patients.SummaryAlthough medical therapy is absolutely imperative for patients with variant angina and a history of ASCD, ICD therapy in these patients is justified. Further large-scale studies are required to determine whether ICD therapy can improve survival in this high-risk group of patients.

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.nnMethods: 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.nnMethods: Using the U. S. Nationwide Inpatient Sample databases 2003 through

Impact of intraprocedural thrombotic events on short- and long-term outcomes following percutaneous coronary intervention. Evidence from a meta-analysis

BACKGROUNDnData regarding the effects of intraprocedural thrombotic events (IPTE) are scarce. Hence we aim to perform a meta-analysis to examine the outcomes of IPTE compared to non-IPTE during PCI.nnnMETHODSnWe performed a literature search of all published full-length articles of studies that reported data on patients with IPTE compared with non-IPTE during PCI. We calculated odd ratios via random effects model.nnnRESULTSnA total of 26,697 patients, of which 1572 patients had IPTE, were included in this analysis. In-hospital, IPTE was associated with higher mortality (odds ratio (OR) 5.36, 95% confidence interval (CI) [2.31, 12.41]; p<0.0001), myocardial infarction (MI) and major bleeding compared to non-IPTE. At 30 days, IPTE was also associated with higher mortality (OR 4.57, 95% CI [2.43, 8.60]; p<0.0001), MI, repeat revascularization, stent thrombosis and major bleeding compared to non-IPTE group. IPTE was also associated with higher long-term mortality (OR 2.19, 95% CI [1.35, 3.53]; p=0.001). Among IPTE patients, intraprocedural stent thrombosis was associated with greater odds of MI compared to both no reflow and distal embolization events.nnnCONCLUSIONnIPTE during PCI is associated with more adverse ischemic events, including mortality, during the index hospitalization, at 30 days and long-term.

LOW PLATELET COUNT AND FATAL MYOCARDIAL INFARCTION: A POPULATION BASED ANALYSIS

High platelet count has been causally linked to increased risk of fatal myocardial infarction (MI). However, the data on the possible association of low platelet count with fatal MI are limited.nnThis cohort study used data from the Third National Health and Nutrition Examination survey, 1988-94 (