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Cardiovascular Diseases - Top 30 Publications

Trial of Tocilizumab in Giant-Cell Arteritis.

Trial of Tocilizumab in Giant-Cell Arteritis.

Trial of Tocilizumab in Giant-Cell Arteritis.

Trial of Tocilizumab in Giant-Cell Arteritis.

Prognostic Value of N-Terminal Pro-B-Type Natriuretic Peptide Levels in Heart Failure Patients With and Without Atrial Fibrillation.

Patients with heart failure (HF) and atrial fibrillation (AF) have higher circulating levels of NT-proBNP (N-terminal pro-B-type natriuretic peptide) than HF patients without AF. There is uncertainty about the prognostic importance of a given concentration of NT-proBNP in HF patients with and without AF. We investigated this question in a large cohort of patients with HF and reduced ejection fraction.

Catheter Ablation of the Superolateral Mitral Isthmus Line: A Novel Approach to Reduce the Need for Epicardial Ablation.

The mitral isthmus is a critical part of perimitral reentrant tachycardia, as well as an important substrate of persistent atrial fibrillation. Deployment of an endocardial mitral isthmus line (MIL) with the end point of bidirectional block may be challenging and often requires additional epicardial ablation within the coronary sinus.

Termination of Vernakalant-Resistant Atrial Fibrillation by Inhibition of Small-Conductance Ca(2+)-Activated K(+) Channels in Pigs.

Evidence has emerged that small-conductance Ca(2+)-activated K(+) (SK) channels constitute a new target for treatment of atrial fibrillation (AF). SK channels are predominantly expressed in the atria as compared with the ventricles. Various marketed antiarrhythmic drugs are limited by ventricular adverse effects and efficacy loss as AF progresses.

Characterization of a novel KCNJ2 sequence variant detected in Andersen-Tawil syndrome patients.

Mutations in the KCNJ2 gene encoding the ion channel Kir2.1 have been linked to the Andersen-Tawil syndrome (ATS). Molecular genetic screening performed in a family exhibiting clinical ATS phenotypes unmasked a novel sequence variant (c.434A > G, p.Y145C) in this gene. The aim of this study was to investigate the effect of this variant on Kir2.1 ion channel functionality.

Pulmonary Embolism Despite Rivaroxaban in an Obese Patient.

Introduction Rivaroxaban, an oral factor Xa inhibitor, is approved for therapy of venous thromboembolism. It is unclear whether the standard dose for patients with a body mass index (BMI) > 40 kg/m(2) is sufficient. History The 45-year-old patient was admitted because of increasing respiratory distress. She had a history of pulmonary embolism 30 months before the admission, a factor V Leiden mutation and several hospitalisations due to dermatomycoses. The patient briefly took phenprocoumon which was changed to 20 mg rivaroxaban due to a lack of adherence. Six months before admission, the patient paused the rivaroxaban therapy because of dental surgery and suffered a recurrent pulmonary embolism. Findings and Diagnosis The patient presented with increasing difficulty of breathing, morbid obesity with a BMI of 59.3 kg/m(2) and intertrigo of the lower extremities. The ECG showed a right axis deviation, a pulmonary P-wave and an incomplete right bundle branch block. Computed tomography showed pulmonary embolisms of the left lower lobe. The pulmonary artery was dilated, and the right atrium was enlarged. Venous thrombosis of the lower limb could not be certainly ruled out. The D-dimer was elevated with 5.895 mg/L (normal value up to 169 mg/L) and NT-pro-BNP was elevated at 5.580 ng/L (normal value up to 0.5 ng/L). Sixteen hours after the onset of symptoms, 22 hours after the last dose, the serum rivaroxaban level was 137 ng/ml. According to manufacturers, the therapeutic range of rivaroxaban after 2 - 4 hours is 22 - 535 ng/ml, and after 24 hours 6 - 239 ng/ml. Therapy and course After initiation of a therapy with low-molecular weight heparin and subsequent oral anticoagulation with phenprocoumon, the symptoms decreased. Conclusions It is highly probable that the pulmonary embolism occurred at a time when the rivaroxaban level was in the therapeutic range. Since there are only few data about safety and efficacy of rivaroxaban and other non-vitamin K-oral anticoagulants (NOACs) in severely obese patients, the recommendations of the "International Society for Thrombosis and Haemostasis" should be followed: Rivaroxaban and other NOACs should not be used in patients with a BMI > 40 kg/m(2) or weight > 120 kg, since only few data on this patient group are available. If NOACs are necessary in these patients, serum concentrations of NOACs should be measured.

Wine and Cardiovascular Health: A Comprehensive Review.

Alcoholic beverages have been consumed for thousands of years, attracting great human interest for social, personal, and religious occasions. In addition, they have long been debated to confer cardioprotective benefits. The French Paradox is an observation of a low prevalence of ischemic heart disease, with high intakes of saturated fat, a phenomenon accredited to the consumption of red wine. Although many epidemiological investigations have supported this view, others have attributed it to beer or spirits, with many suggesting that the drink type is not important. Although excessive consumption of alcoholic beverages is commonly regarded to be detrimental to cardiovascular health, there is a debate as to whether light-to-moderate intake is cardioprotective. Although there is extensive epidemiological support for this drinking pattern, a consensus has not been reached. On the basis of published work, we describe the composition of wine and the effects of constituent polyphenols on chronic cardiovascular diseases.

Points to consider-Raynaud's phenomenon in systemic sclerosis.

RP is an exaggerated vasospastic response to cold or emotion. Randomized, double-blind, placebo-controlled trials with either parallel group or cross-over trials should be mainly considered. Cross-over design, which is good for early phase trials of immediate or very short-term outcomes, is important in a condition as heterogeneous as RP: a wash-out period between treatment arms should always be included to minimize the possibility of a period (carry-over) effect. Duration of RP trials is usually constrained by the need to complete these over a single season, usually winter when the weather is colder. For cross-over trials, each treatment arm tends to be 4 weeks or less. Frequency and duration of attacks, and the Raynaud's Condition Score are widely used outcome measures. There is increasing interest in physiological laboratory endpoints, for example laser Doppler imaging at least for early phase trials.

Points to consider when doing a trial primarily involving the heart.

Cardiac involvement contributes to the severity of SSc and should carefully be investigated and managed in SSc patients. Although it is commonly sub-clinical, once symptomatic it has a poor prognosis. Several complementary tools (circulating biomarkers, electrocardiography, echocardiography, scintigraphy or MRI) allow the assessment of all the various cardiac structures (endocardium, myocardium and pericardium) and heart function. Treatment remains empirical but cardiac trials in SSc can add data to the treatment of this complication.

Retained Needle Following Transanal Hemorrhoidal Dearterialization.

A needle was retained during transanal hemorrhoidal dearterialization. This rare complication has not been described before.

Ischemic Stroke: Advances in Diagnosis and Management.

Acute ischemic stroke carries the risk of morbidity and mortality. Since the advent of intravenous thrombolysis, there have been improvements in stroke care and functional outcomes. Studies of populations once excluded from thrombolysis have begun to elucidate candidates who might benefit and thus should be engaged in the process of shared decision-making. Imaging is evolving to better target the ischemic penumbra salvageable with prompt reperfusion. Availability and use of computed tomography angiography identifies large-vessel occlusions, and new-generation endovascular therapy devices are improving outcomes in these patients. With this progress in stroke treatment, risk stratification tools and shared decision-making are fundamental.

Mesenteric Ischemia: A Deadly Miss.

Mesenteric ischemia has 4 etiologies: arterial embolus, arterial thrombosis, venous thrombosis, and nonocclusive. No history or physical examination finding can definitively diagnose the condition. A wide variety of presentations occur. Pain out of proportion and gut emptying may occur early, with minimal tenderness. Once transmural infarction occurs, peritoneal findings and tenderness to palpation may occur. Physicians must be suspicious of pain out of proportion and scrutinize risk factors. Computed tomography angiography is the best imaging modality. Treatment requires surgery and interventional radiology consultation, intravenous antibiotics and fluids, and anticoagulation. The physician at the bedside is the best diagnostic tool.

Cerebral Venous Thrombosis: A Challenging Neurologic Diagnosis.

Headache is a common emergency department chief complaint. Although most are benign, emergency physicians must rapidly identify and manage the uncommon, sometimes subtle, presentation of headache from a life-threatening cause. Cerebral venous thrombosis imparts significant morbidity and mortality, and can be a challenging diagnosis. It most commonly occurs in those under 50 years of age with thrombosis of the cerebral veins/sinuses. Diagnosis is frequently delayed. The disease can present with 1 or more clinical syndromes, including intracranial hypertension with headaches, focal neurologic deficits, seizures, and encephalopathy. Diagnosis requires imaging. Treatment includes stabilization, management of complications, and anticoagulation.

Abdominal Aortic Emergencies.

This article discusses abdominal aortic emergencies. There is a common thread of risk factors and causes of these diseases, including age, male gender, hypertension, dyslipidemia, and connective tissue disorders. The most common presenting symptom of these disorders is pain, usually in the chest, flank, abdomen, or back. Computed tomography scan is the gold standard for diagnosis of pathologic conditions of the aorta in the hemodynamically stable patient. Treatment consists of a combination of blood pressure and heart rate control and, in many cases, emergent surgical intervention.

Spontaneous Intracerebral Hemorrhage.

Although commonly arising from poorly controlled hypertension, spontaneous intracerebral hemorrhage may occur secondary to several other etiologies. Clinical presentation to the emergency department ranges from headache with vomiting to coma. In addition to managing the ABCs, the crux of emergency management lies in stopping hematoma expansion and other complications to prevent clinical deterioration. This may be achieved primarily through anticoagulation reversal, blood pressure, empiric management of intracranial pressure, and early neurosurgical consultation for posterior fossa hemorrhage. Patients must be admitted to intensive care. The effects of intracerebral hemorrhage are potentially devastating with very poor prognoses for functional outcome and mortality.

Subarachnoid Hemorrhage: Updates in Diagnosis and Management.

Subarachnoid hemorrhage (SAH) is a neurologic emergency due to bleeding into the subarachnoid space. Mortality can reach 50%. The clinical presentation is most often in the form of headache, classically defined as maximal at onset and worst of life. The most common cause is traumatic; approximately 80% of nontraumatic SAH are due to aneurysmal rupture, with the remainder from idiopathic peri-mesencephalic hemorrhage or other less common causes. Noncontrast brain computed tomography (CT) performed within 6 hours of symptom onset has sensitivity approaching 100%. Lumbar puncture may be considered after this period for definitive diagnosis if initial CT is normal.

Penetrating Vascular Injury: Diagnosis and Management Updates.

Penetrating vascular injury is becoming increasingly common in the United States and abroad. Much of the current research and treatment is derived from wartime and translation to the civilian sector has been lacking. Penetrating vascular injury can be classified as extremity, junctional, or noncompressible. Diagnosis can be obvious but at other times subtle and difficult to diagnose. Although there are numerous modalities, computed tomography angiography is the diagnostic study of choice. It is hoped that care will be improved by using an algorithmic approach integrating experience from military and civilian research.

Deep Venous Thrombosis.

Deep venous thrombosis (DVT) is a frequently encountered condition that is often diagnosed and treated in the outpatient setting. Risk stratification is helpful and recommended in the evaluation of DVT. An evidence-based diagnostic approach is discussed here. Once diagnosed, the mainstay of DVT treatment is anticoagulation. The specific type and duration of anticoagulation depend upon the suspected etiology of the venous thromboembolism, as well as risks of bleeding and other patient comorbidities. Both specific details and a standardized approach to this vast treatment landscape are presented.

Extracranial Cervical Artery Dissections.

Cervical artery dissections (CeAD) include both internal carotid and vertebral artery dissections. They are rare but important causes of stroke, especially in younger patients. CeAD should be considered in patients with strokelike symptoms, a new-onset headache and/or neck pain, and/or other risk factors. Early imaging with computed tomography (CT) or magnetic resonance imaging (MRI) is key to making the diagnosis. Treatment may vary depending on the extent of the dissection, timing of the dissection, and other comorbidities. The overall prognosis is good, but does depend on the initial severity of symptoms.

Thoracic Aortic Syndromes.

Aortic dissection (AD) is a lethal, treatable disruption of the aortic vessel wall. It often presents without classic features, mimicking symptoms of other conditions, and diagnosis is often delayed. Established high-risk markers of AD should be sought and indicate advanced aortic imaging with CT, MRI, or TEE. Treatment is immediate surgical evaluation, aggressive symptom relief, and reduction of the force of blood against the aortic wall by control of heart rate, followed by blood pressure.

Gender differences in the prevalence of congenital heart disease in Down's syndrome: a brief meta-analysis.

Down's syndrome (DS) affects one per 700 live births and congenital heart disease (CHD) occurs in 40-60% of these patients. Contributing factors to the association between DS and CHD are being unraveled. Gender could be one of them.

Mendelian Randomization Analysis Identifies CpG Sites as Putative Mediators for Genetic Influences on Cardiovascular Disease Risk.

The extent to which genetic influences on cardiovascular disease risk are mediated by changes in DNA methylation levels has not been systematically explored. We developed an analytical framework that integrates genetic fine mapping and Mendelian randomization with epigenome-wide association studies to evaluate the causal relationships between methylation levels and 14 cardiovascular disease traits. We identified ten genetic loci known to influence proximal DNA methylation which were also associated with cardiovascular traits after multiple-testing correction. Bivariate fine mapping provided evidence that the individual variants responsible for the observed effects on cardiovascular traits at the ADCY3 and ADIPOQ loci were potentially mediated through changes in DNA methylation, although we highlight that we are unable to reliably separate causality from horizontal pleiotropy. Estimates of causal effects were replicated with results from large-scale consortia. Genetic variants and CpG sites identified in this study were enriched for histone mark peaks in relevant tissue types and gene promoter regions. Integrating our results with expression quantitative trait loci data, we provide evidence that variation at these regulatory regions is likely to also influence gene expression levels at these loci.

Two-dimensional myocardial deformation in coronary vasospasm-related Takotsubo cardiomyopathy: A case report of a serial echocardiographic study.

Although transient reduction in the left ventricular ejection fraction is characteristic of Takotsubo cardiomyopathy, little is known about the time-course changes of myocardial deformation in coronary vasospasm-related Takotsubo cardiomyopathy.

Intralesional versus intracoronary administration of glycoprotein IIb/IIIa inhibitors during percutaneous coronary intervention in patients with acute coronary syndromes: A meta-analysis of randomized controlled trials.

Glycoprotein IIb/IIIa inhibitors (GPIs) have been regarded as an adjuvant regimen to deal with no-reflow. However, whether intralesional (IL) administration of GPIs improves myocardial reperfusion without increasing bleeding in patients with acute coronary syndrome (ACS) compared with intracoronary (IC) administration has not been well addressed. Our meta-analysis aimed to evaluate the efficacy and safety of IL versus IC administration of GPIs for patients with ACS during percutaneous coronary intervention.

Management of iatrogenic renal arteriovenous fistula and renal arterial pseudoaneurysm by transarterial embolization: A single center analysis and outcomes.

The purpose of this study was to evaluate the efficacy and safety of transarterial embolization (TAE) for iatrogenic renal arterial pseudoaneurysm and arteriovenous fistula at our center.Our retrospective analysis included 27 patients who received TAE for iatrogenic renal arterial pseudoaneurysm and arteriovenous fistula between January 2006 and January 2016. Data on demographics, type of minimally invasive renal procedures, clinical manifestation, imaging features, embolization procedure, and perioperative details were collected. The technical and clinical success rates were analyzed. Furthermore, the changes in serum creatinine and eGFR before and after embolization were recorded and compared by t test.The median time between iatrogenic renal injury and TAE was 3 days (range, 0-110 days), with most patients (24/27, 88.9%) receiving TAE within 14 days. Only 1 patient was diagnosed with renal artery pseudoaneurysm 110 days after laproscopic partial nephrectomy. The technical and clinical success rates were 100% and 96.3%, respectively, with 1 patient requiring a second embolotherapy at the third postoperative day. No other patient required additional endovascular or surgical intervention due to recurrent hemorrhage. The mean serum creatinine before TAE was 92.8 ± 25.3 μmol/L and after TAE, 96.1 ± 27.7 μmol/L (P = .095). The eGFR of pre- and postembolization was 75.2 ± 26.5 mL/min/1.73 m and 72.5 ± 26.2 mL/min/1.73 m (P = .16). No severe complications were observed during follow-up.This retrospective review demonstrated that TAE for the treatment of iatrogenic renal artery pseudoaneurysm and/or arteriovenous fistula was safe and associated with high technical and clinical success rate.

The safety and feasibility of guidezilla catheter in complex coronary interventions and an observational study.

The monorail Guidezilla guide extension catheter was designed to provide additional backup and facilitate device delivery in percutaneous coronary intervention (PCI) for complex coronary anatomy such as chronic total occlusion (CTO), extreme vessel tortuosity, diseased bypass grafts, and anomalous coronary arteries, among others.The present retrospective, single-center study included 188 consecutive patients who underwent PCI using the Guidezilla catheter from March 2015 to August 2016. Study outcomes were rates of target lesion crossing success, procedural success, and complications.The Guidezilla catheter was used most commonly in PCI of CTOs (45%) and heavy proximal calcification (37%), followed by tortuosity (10%), previously deployed proximal stents (4%), and coronary artery anomaly (4%). The right coronary artery (48%) was most commonly intervened followed by the left ascending (35%) and left circumflex (17%) arteries. Rates of target lesion crossing success and procedural success were both 99%, with one device-related periprocedural complication, namely proximal vessel dissection secondary to deep insertion which was successfully treated with stent implantation. Ninety percent of PCI were performed and completed successfully by radial access.In a single center with experienced operators, the use of the Guidezilla guide extension catheter in PCI of complex coronary anatomy performed mostly via radial artery access appeared safe and efficacious, and greatly facilitated device delivery.

Ivabradine has a neutral effect on mortality in randomized controlled trials.

It has long been a controversial hotspot whether resting heart rate (RHR) is a risk factor or a marker for death. Ivabradine, a specific inhibitor of the If current in the sinoatrial node, is a pure RHR lowering agent. The study was aimed to investigate whether ivabradine would reduce more RHR, cardiovascular disease (CVD) mortality, and all-cause mortality than those placebo or beta-blockers.