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Volume 16, No 1 - 2015

Volume 16, No 1 - 2015

Table of Contents

Inhaled Nitric Oxide in Acute Pulmonary Embolism: A Systematic Review Systematic Review
Acute pulmonary embolism (PE) is usually a complication secondary to migration of a deep venous clot or thrombi to lungs, but other significant etiologies include air, amniotic fluid, fat, and bone marrow. Regardless of the underlying etiology, little progress has been made in finding an effective pharmacologic intervention for this serious complication. Among the wide spectrum of PE, massive PE is associated with considerable morbidity and mortality, primarily due to severely elevated pulmonary vascular resistance leading to right ventricular failure, hypoxemia, and cardiogenic shock. We currently have limited therapeutic options at our disposal. Inhaled nitric oxide (iNO) has been proposed as a potential therapeutic agent in cases of acute PE in which hemodynamic compromise secondary to increased pulmonary vascular resistance is present, based on iNO’s selective dilation of the pulmonary vasculature and antiplatelet activity. A systematic search of studies using the PubMed database was undertaken in order to assess the available literature. Although there are currently no published randomized controlled trials on the subject, except a recently publish phase I trial involving eight patients, several case reports and case series describe and document the use of iNO in acute PE. The majority of published reports have documented improvements in oxygenation and hemodynamic variables, often within minutes of administration of iNO. These reports, when taken together, raise the possibility that iNO may be a potential therapeutic agent in acute PE. However, based on the current literature, it is not possible to conclude definitively whether iNO is safe and effective. These case reports underscore the need for randomized controlled trials to establish the safety and efficacy of iNO in the treatment of massive acute PE. The purpose of this article is to review the current literature in the use of iNO in the setting of PE given how acute PE causes acute onset of pulmonary hypertension. [Rev Cardiovasc Med. 2015;16(1):1-8 doi: 10.3909/ricm0718] © 2015 MedReviews®, LLC
The Mystery of High-density Lipoprotein: Quantity or Quality? Update on Therapeutic Strategies Risk Stratification Review
This review summarizes the data challenging the concept that cardiovascular protection through high-density lipoprotein (HDL) is only associated with its serum concentration. This conventional impression about its protective role now appears obsolete. New aspects of its mechanisms are revealed and novel therapeutic strategies are based on them. However, data from long-term cost-effectiveness studies of treating HDL are still needed. There is a need for biomarkers that represent the functional characteristics of HDL in order to better quantify the total cardiovascular risk. [Rev Cardiovasc Med. 2015;16(1):9-19 doi: 10.3909/ricm0719] © 2015 MedReviews®, LLC
Heart Failure With Preserved Ejection Fraction: An Insight Into Its Prevalence, Predictors, and Implications of Early Detection Prevention Update
Heart failure with preserved ejection fraction (HFPEF) is common, and at least half of patients presenting with signs and symptoms of heart failure are found to have preserved left ventricular systolic function. They have high mortality and morbidity and exert a substantial impact on health care costs worldwide. A range of conditions has been shown to predispose individuals to development of diastolic dysfunction and HFPEF. Chronic hypertension is the most common cause; it has been suggested that up to 60% of patients with HFPEF are hypertensive. Coronary artery disease, obesity, and diabetes are some of the other common contributory factors. Early detection of asymptomatic patients identified as at risk of developing this syndrome has the potential to reduce the risk of subsequent heart failure; this may be of benefit to focus our attention on prevention and intervention strategies in this population. [Rev Cardiovasc Med. 2015;16(1):20-27 doi: 10.3909/ricm0725] © 2015 MedReviews®, LLC
Laboratory-induced Mental Stress, Cardiovascular Response, and Psychological Characteristics Systematic Review
Vulnerable populations, such as firefighters and patients with coronary artery disease, are susceptible to mental stress-induced cardiac events, including death. Mental stress tests are widely applied to investigate the mechanisms linking psychological stress to cardiovascular consequences and to predict the risk of death in those susceptible populations. However, some aspects of mental stress tests have not been thoroughly understood, which impairs their reliability and validity as a research and clinical tool. This review identifies types of mental stress tests applied in recent research and the exact cardiovascular responses induced by each mental stress test, along with the consideration of the influence of psychological characteristics on cardiovascular reactivity. [Rev Cardiovasc Med. 2015;16(1):28-35 doi: 10.3909/ricm0730] © 2015 MedReviews®, LLC
Current Advances in Endovascular Therapy for Infrapopliteal Artery Disease Treatment Update
Peripheral arterial disease (PAD) is a systemic disease with significant morbidity and mortality. A substantial number of patients with PAD have infrapopliteal disease; however, diagnosis based solely on symptoms and ankle-brachial index can lead to delayed or missed opportunities to provide improved quality of life and limb salvage, and potentially reduce mortality. Advances in techniques and devices, and modification of classification systems have shown that an endovascular approach should be the primary therapeutic option for critical limb ischemia resulting from infrapopliteal disease. [Rev Cardiovasc Med. 2015;16(1):36-50 doi: 10.3909/ricm0734] © 2015 MedReviews®, LLC
Newer Modalities for Imaging Nonischemic Cardiomyopathy Diagnostic and Imaging Update
Cardiomyopathies are practically classified as either ischemic or nonischemic based on the presence or absence of coronary artery disease. Although conventional two-dimensional echocardiography can assess left ventricular ejection fraction, wall motion, and diastolic function, it does not fully capture myocardial mechanics or tissue characterization, and does not accurately identify patients with nonischemic cardiomyopathy (NICMP) at risk for sudden cardiac death. This article discusses advanced imaging modalities for assessment of NICMP, namely, three-dimensional echocardiography, strain imaging, cardiac magnetic resonance, cardiac computed tomography, and sympathetic innervation imaging. [Rev Cardiovasc Med. 2015;16(1):51-67 doi: 10.3909/ricm0748] © 2015 MedReviews®, LLC
A Novel Inhibitor of Protease-activated Receptor 1: A Review of Chemical Structure and Mode of Action Treatment Update
Limitations of current antiplatelet therapies have led to the discovery of new antiplatelet agents with new modes of action. Vorapaxar has been developed as a thrombin receptor antagonist. This drug works against the protease-activated receptor 1 (PAR1) and inhibits platelet aggregation mediated by PAR1. This article reviews this new class of antiplatelet therapy in detail with an acute focus on the TRACER (Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome) and TRA 2°P-TIMI 50 (Trial to Assess the Effects of Vorapaxar in Preventing Heart Attack and Stroke in Patients With Atherosclerosis-Thrombolysis In Myocardial Infarction 50) trials. Vorapaxar has proven to be beneficial when administered to stable atherosclerotic patients. However, it has been shown to increase risk of intracranial hemorrhage in patients with known, previous history of cerebrovascular incidence. Despite these limitations, TRA 2°P-TIMI 50 results showed that vorapaxar appears to have a definitive therapeutic benefit when administered alongside aspirin or when it is used as an addition to dual antiplatelet therapy for patients with stable atherosclerosis. [Rev Cardiovasc Med. 2015;16(1):68-73 doi: 10.3909/ricm0754] © 2015 MedReviews®, LLC
Best of the 2014 TCT Annual Meeting
Highlights From the Transcatheter Cardiovascular Therapeutics Conference, September 13-17, 2014, Washington DC [Rev Cardiovasc Med. 2015;16(1):74-80 doi: 10.3909/ricm0787] © 2015 MedReviews®, LLC
The Clot Thickens: Unusual Presentation of a Left Atrial Thrombus
Left atrial thrombi are a significant cause of cardioembolic morbidity and mortality. Transesophageal echocardiography is the preferred method for complete visualization of atrial thrombi, and has a sensitivity and specificity of up to 100% and 99%, respectively. Cardiac magnetic resonance imaging has been shown to be useful in identifying tissue characteristics that may aid in differentiating between atrial myxoma and thrombi. This is an unusual case of a large, free-floating atrial thrombus with a cystic appearance that was surgically removed. The echocardiographic appearance of the cystic atrial mass led to the consideration of another potential etiology for a cardiac mass, namely, atrial myxoma. Histopathologic analyses of the mass led to the final diagnosis of an atrial thrombus. [Rev Cardiovasc Med. 2015;16(1):81-83 doi: 10.3909/ricm0745] © 2015 MedReviews®, LLC
An Example of the Deleterious Effects of Right Ventricular Apical Pacing
Pacemaker implantation remains the mainstay of treatment in patients with symptomatic sinus node disease or severe heart block. Despite the dramatic benefits of this therapy, a high burden of ventricular pacing is known to have its disadvantages. Reported is the case of an 85-year-old woman with a history of sick sinus syndrome who presented with congestive heart failure after her atrioventricular sequential pacemaker defaulted to ventricular pacing mode as a result of battery depletion. After replacement of her generator and reinstitution of atrial pacing, dramatic improvements in her symptoms and echocardiographic findings were observed. Although it is difficult to predict which patients will ultimately develop cardiac decompensation as a result of ventricular pacing, closer follow-up and early recognition of these complications is essential to prevent adverse outcomes. [Rev Cardiovasc Med. 2015;16(1):84-89 doi: 10.3909/ricm0752] © 2015 MedReviews®, LLC
Pulmonary Valve Papillary Fibroelastoma: A Rare Tumor and Rare Location
Although rare, papillary fibroelastomas (PFEs) are considered the third most common cause of primary cardiac neoplasm. They are usually asymptomatic and are found during routine echocardiography. PFEs of the pulmonary valve are extremely rare. They are usually benign; however, because of their potential to embolize to the pulmonary circulation, it is often recommended that they be removed. This article reviews a case of an asymptomatic PFE of the pulmonary valve, incidentally found in a patient who presented with three-vessel coronary artery disease. [Rev Cardiovasc Med. 2015;16(1):90-93 doi: 10.3909/ricm0757] © 2015 MedReviews®, LLC
Correction to “The Potential Role of Anti-PCSK9 Monoclonal Antibodies in the Management of Hypercholesterolemia”
[Rev Cardiovasc Med. 2015;16(1):94 doi:10.3909/ricm0773corr] © 2015 MedReviews®, LLC