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Volume 14, No 2-4 - 2013

Volume 14, No 2-4 - 2013

Table of Contents

Cardiometabolic Risk Factors and Atrial Fibrillation Disease State Review
Atrial fibrillation (AF) is the most common arrhythmia worldwide; it is a significant risk factor for stroke and embolization, and has an impact on cardiac function. Despite its impact on morbidity and mortality, our understanding of the etiology and pathophysiology of this disease process is still incomplete. Over the past several decades, there has been evidence to suggest that AF has a significant correlation with metabolic syndrome (MetS). Furthermore, AF appears to be more closely related to specific components of MetS compared with others. This article provides an overview of the various components of MetS and their impact on AF. [Rev Cardiovasc Med. 2013;14(2-4):e73-e81 doi: 10.3909/ricm0693] © 2013 MedReviews®, LLC
Role of Omega-3 Fatty Acids in the Prevention of Atrial Fibrillation Treatment Update
Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting more than 2.6 million people in the United States. It occurs frequently after myocardial infarction and is the most common arrhythmia following cardiac surgery. AF increases the risk of morbidity and mortality from stroke, thromboembolism, and death. AF may be caused by ectopic activity in one or more of the pulmonary veins. Focal ectopic activity can be generated by abnormal atrial automaticity, delayed afterdepolarizations from calcium overload, or early afterdepolarizations secondary to defective repolarization properties. Pathologic mechanisms may include autonomic dysfunction, inflammation, and fibrosis. Omega-3 fatty acids (polyunsaturated fatty acids [PUFAs]) have been shown to induce beneficial effects in the treatment of coronary artery disease. They may also reduce sudden cardiac death and the incidence of arrhythmias. Therefore, studies have been conducted to evaluate the benefits of PUFAs in arrhythmia prevention. This review describes the effects of PUFAs in AF and provides the current literature in the prevention of AF. [Rev Cardiovasc Med. 2013;14(2-4):e82-e91 doi: 10.3909/ricm0620] © 2013 MedReviews®, LLC
N-terminal Prohormone B-type Natriuretic Peptide and Cardiovascular Risk in Stable Coronary Artery Disease: A Meta-analysis of Nine Prospective Studies Risk Stratification Update
To evaluate the prognostic value of N-terminal prohormone B-type natriuretic peptide (NT-proBNP) for patients with stable coronary artery disease, we searched for all published English-language articles indexed in MEDLINE and PubMed through July 2011. Nine independent, prospective, cohort studies that assessed the association between NT-proBNP value and long-term prognosis were identified. The interested endpoints of this meta-analysis were all-cause mortality and cardiovascular mortality and cardiovascular events. A general variance-based method was used to pool the hazard ratio (HR). In a comparison of individuals in the top quartile with those in the bottom quartile of baseline values of NT-proBNP, the combined adjusted HR was 2.74 (95% confidence interval [CI], 1.85-3.62). The combined HRs for the second and third quartiles compared with the first quartile were 1.33 (95% CI, 0.83-1.82) and 1.85 (95% CI, 1.23-2.48), respectively. In a subanalysis grouped by the median value, per 1 standard deviation increase or per 1000 pg/mL increase of NT-proBNP, the overall effect also showed that poor prognosis was significantly increased with the elevation of NT-proBNP (HR, 1.58; 95% CI, 1.16-2.01). Available prospective studies indicated strong associations between the circulating concentration of NT-proBNP and long-term prognosis in patients with stable coronary artery disease. [Rev Cardiovasc Med. 2013;14(2-4):e92-e98 doi: 10.3909/ricm0644] © 2013 MedReviews®, LLC
An Update on Endovascular Management of Acute Thoracic Aortic Disease and Future Directions Management Update
Thoracic endovascular aortic repair (TEVAR) has become an alternative treatment option for acute thoracic aortic disease. This review focuses on current endovascular treatment of acute thoracic aortic disease and future directions of TEVAR. TEVAR is a promising alternative approach to open surgery, with lower early mortality and morbidity rates, especially in high-risk cohorts. Furthermore, with accumulating experience and improving device technology and imaging modalities, TEVAR has become safer and has potential to expand treatment options to include ascending and arch pathologies. [Rev Cardiovasc Med. 2013;14(2-4):e99-e106 doi: 10.3909/ricm0649] © 2013 MedReviews®, LLC
The Role of Early and Sufficient Isolated Venovenous Ultrafiltration in Heart Failure Patients With Pulmonary and Systemic Congestion Treatment Update
Hypervolemia, present in at least 70% of patients with decompensated heart failure, results in renal dysfunction due to increased renal venous pressure, impaired renal autoregulation, and decreased renal blood flow that are associated with increased morbidity and mortality. Loop diuretics, widely used in congested patients, result in the production of hypotonic urine and neurohormonal activation. In contrast, ultrafiltration (UF) removes isotonic fluid without increasing renin secretion by the macula densa. Simplified devices that permit us to perform UF with peripheral venous access, adjustable blood flows, and small extracorporeal blood volumes make this therapy feasible at most hospitals and in less acute care settings. Conflicting results on the effects of UF in heart failure patients underscore the challenges of patient selection and choice of fluid removal rates. Unfavorable outcomes in patients undergoing UF in the midst of cardiorenal syndrome type 1 are in contrast with the sustained benefits of UF initiated before unsuccessful use of high-dose intravenous (IV) diuretics. UF rates should be based on a precise knowledge of the degree of hypervolemia and careful assessment of blood volume changes, so that extracellular fluid gradually refills the intravascular space and volume depletion is avoided. Poor outcomes are likely to occur if fluid removal rates are not tailored to individual patients’ clinical characteristics. A large trial is ongoing to determine if a strategy of early UF, initiated before renal function is worsened by other therapies, is superior to IV diuretics in reducing 90-day heart–failure–related hospitalizations in patients with pulmonary and systemic congestion. [Rev Cardiovasc Med. 2013;14(2-4):e123-e133 doi:10.3909/ricm0685] © 2013 MedReviews®, LLC
Choosing Wisely
[Rev Cardiovasc Med. 2013;14(2-4):e134-e135 doi: 10.3909/ricm14023CAACC] © 2013 MedReviews®, LLC
Contemporary Diagnosis of Carotid Fibromuscular Dysplasia: Role of Power Doppler and a Review of Other Diagnostic Modalities
Fibromuscular dysplasia (FMD) is a nonatheromatous, noninflammatory arteriopathy with segmental involvement of medium-sized arteries in multiple vascular beds. It most commonly involves the renal and carotid arteries. The etiology is unknown, although various hormonal and mechanical factors have been suggested. The disease can occur at any age but is usually diagnosed in middle-aged individuals, predominantly women. FMD is much more common than previously thought, perhaps affecting as many as 4% of adult women. Clinical manifestations of the internal carotid artery involvement are transitory ischemic attacks or cerebral infarction, as well as nonspecific symptoms such as headache and vertigo. In cases of cerebrovascular events, endovascular or surgical treatment is recommended; therefore, detection of FMD is of considerable importance. The gold standard for diagnosing FMD is catheter angiography (with the classic “string of beads” pattern), but this invasive procedure is only used for patients in whom it is clinically pertinent to proceed with revascularization. The optimal noninvasive modality for diagnosis and quantification for FMD is not known and little information has been recently published about new diagnostic modalities. Although angiography, computed tomography angiography, and magnetic resonance angiography are excellent in confirming the morphologic diagnosis of FMD, they are less accurate in assessing the hemodynamic significance of the lesions. Ultrasonography is useful in assessing the degree of carotid artery stenosis. Use of power Doppler ultrasound improves the ability to detect the morphologic features of carotid FMD. [Rev Cardiovasc Med. 2013;14(2-4):e136-e143 doi: 10.3909/ricm0653] © 2013 MedReviews®, LLC
The Use of Percutaneous Left Ventricular Assist Device in High-risk Percutaneous Coronary Intervention and Cardiogenic Shock
Patients with high-risk coronary lesions may be denied coronary artery bypass grafting due to excessive comorbidities. Percutaneous coronary intervention (PCI) may be a feasible revascularization strategy in high-risk patients who present with ST-elevation myocardial infarction and cardiogenic shock. Historically, the use if intra-aortic balloon pump (IABP) has been used in high-risk PCI and cardiogenic shock. However, recent data has shown that elective IABP insertion did not reduce the incidence of major cardiovascular events following PCI. The use of a left ventricular assist device is a reasonable and safe alternative compared with IABP counterpulsation, giving greater cardiac output and hemodynamic support in patients undergoing high-risk PCI and in those with severe cardiogenic shock. This review outlines a case of severe cardiogenic shock and hemodynamic instability where high-risk PCI is a reasonable option. [Rev Cardiovasc Med. 2013;14(2-4):e144-e149 doi: 10.3909/ricm0675] © 2013 MedReviews®, LLC