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Delineating phenotypes of Kawasaki disease and SARS-CoV-2-related inflammatory multisystem syndrome: a French study and literature review.
Cherqaoui, B, Koné-Paut, I, Yager, H, Bourgeois, FL, Piram, M
Rheumatology (Oxford, England). 2021;(10):4530-4537
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Abstract
OBJECTIVE To better define the clinical distinctions between the new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related paediatric inflammatory multisystem syndrome (PIMS) and Kawasaki disease (KD). METHODS We compared three groups of patients: group 1, cases from our national historic KD database (KD-HIS), before the SARS-CoV-2 pandemic; group 2, patients with KD admitted to an intensive care unit (KD-ICU) from both our original cohort and the literature, before the SARS-CoV-2 pandemic; and group 3, patients with PIMS from the literature. RESULTS KD-HIS included 425 patients [male:female ratio 1.3, mean age 2.8 years (s.d. 2.4)], KD-ICU 176 patients [male:female ratio 1.3, mean age 3.5 years (s.d. 3.1)] and PIMS 404 patients [male:female ratio 1.4, mean age 8.8 years (s.d. 3.7)]. As compared with KD-HIS patients, KD-ICU and PIMS patients had a higher proportion of cardiac failure, digestive and neurological signs. KD-ICU and PIMS patients also had a lower frequency of typical KD-mucocutaneous signs, lower platelet count, higher CRP and lower sodium level. As compared with KD-HIS and KD-ICU patients, PIMS patients were older and more frequently had myocarditis; they also had fewer coronary abnormalities and lower sodium levels. Unresponsiveness to IVIG was more frequent in KD-ICU than KD-HIS and PIMS patients. CONCLUSION On clinical grounds, KD-HIS, KD-ICU and PIMS might belong to a common spectrum of non-specific pathogen-triggered hyperinflammatory states. The causes of increasing inflammation severity within the three entities and the different effects on the heart remain to be determined.
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New pharmacotherapy for heart failure with reduced ejection fraction.
Sotirakos, S, Wheen, P, Spiers, J, Armstrong, R
Expert review of cardiovascular therapy. 2020;(7):405-414
Abstract
INTRODUCTION The European Society of Cardiology (ESC), Canadian Cardiovascular Society, and the American College of Cardiology Heart Failure (HF) guidelines all currently recommend the use of Angiotensin Converting Enzyme (ACE) inhibitors or Angiotensin Receptor Blockers (ARBs) and Beta Blockers (BB) in the treatment of HF with a reduced ejection fraction (HFrEF). Newer medications targeting combining an ARB with a neprilysin inhibitor (ARNI) sacubitril/valsartan have shown benefits in mortality and can be used in place of an ACE inhibitor or an ARB. Additionally, dapagliflozin, a medication targeting the sodium-glucose cotransporter 2 (SGLT2) can be used in addition to current therapies. AREAS COVERED This review provides a comprehensive analysis of the evidence around the new pharmacotherapies for HFrEF, specifically, sacubitril/valsartan and dapagliflozin. A comprehensive review of the literature using keywords such as heart failure with reduced ejection fraction, angiotensin receptor, neprilysin inhibitor, and sodium glucose transporter was conducted within the National Centre for Biotechnology Information (NCBI) and Google Scholar databases. The reference sections of articles were also examined to find additional articles. EXPERT OPINION Sacubitril/valsartan and dapagliflozin both show marked benefits on mortality in HFrEF patients. More research needs to be conducted on the mechanisms of action on disease modification.
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A meta-summary of case reports of non-vitamin K antagonist oral anticoagulant use in patients with left ventricular thrombus.
Leow, AS, Sia, CH, Tan, BY, Loh, JP
Journal of thrombosis and thrombolysis. 2018;(1):68-73
Abstract
Left ventricular (LV) thrombus is commonly seen in patients with extensive anterior ST-elevation myocardial infarction. The standard of care for LV thrombus is anticoagulation with warfarin. However, there has been an increasing trend of case reports using non-vitamin K antagonist oral anticoagulants (NOAC) for the treatment of LV thrombus. This study aimed to perform a meta-summary of the literature to characterise and evaluate the safety and feasibility of using NOAC in patients with LV thrombus. We searched for articles published in four electronic databases: PubMed, EMBASE, Scopus and Google Scholar using an appropriate keyword/MeSH term search strategy. Twenty-four studies comprising 36 patients were included in the analysis. Rivaroxaban was used in majority of patients (47.2%), whilst Apixaban and Dabigatran were prescribed in 25.0% and 27.8% of patients respectively. The most commonly associated risk factor found was post-acute myocardial infarction in 15 patients (41.7%). LV thrombus resolution was met by most patients (87.9%), and the median duration of treatment to resolution was 30.0 days (IQR = 22.5-47.0). One non-fatal bleeding event (3.0%) and no embolic events were reported. The use of NOAC may have a role in the treatment of LV thrombus in selected patients. Further randomized controlled trials are needed to evaluate this treatment strategy.
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Current treatment of heart failure with reduction of left ventricular ejection fraction.
Aronow, WS
Expert review of clinical pharmacology. 2016;(12):1619-1631
Abstract
Heart failure is the commonest cause of hospitalization and of rehospitalization This review paper is a comprehensive review of current treatment of heart failure in 2016. The target of this review is all health care professionals who treat patients with heart failure. Areas covered: This article discusses stages of heart failure, treatment of heart failure with general measures, and drug therapy with diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta blockers, aldosterone antagonists, isosorbide dinitrate plus hydralazine, digoxin, other neurohormonal antagonists, sacubitril/valsartan, calcium channel blockers, and ivabradine. This article also discusses treatment of heart failure with use of cardiac resynchronization therapy, implantable cardioverter-defibrillators, and surgical therapy, and management of end-stage heart failure. This paper was written after an extensive Medline search reviewing articles written from 1970 through May, 2016. Expert commentary: Our approach as physicians must emphasize prevention of heart failure as well as treating it. Risk factors for developing heart failure, especially hypertension, must be better controlled starting in childhood. I concur with the current heart failure treatment guidelines (Tables 1 and 2 in this paper).
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The safety of mineralocorticoid receptor antagonists (MRAs) in patients with heart failure.
Pitt, B, Rossignol, P
Expert opinion on drug safety. 2016;(5):659-65
Abstract
INTRODUCTION Mineralocorticoid receptor antagonists (MRAs) have been accorded a class 1 indication for patients with chronic heart failure and a reduced left ventricular ejection fraction (HFREF) in both European and American guidelines. Uptake, however, has been less than optimal largely due to concerns about their safety, in particular the risk of hyperkalemia and renal dysfunction. AREAS COVERED This review presents the current state of affairs regarding the safety of MRAs in heart failure with reduced ejection fraction. EXPERT OPINION Careful patient selection and adherence to guideline-recommended inclusion and exclusion criteria, dosing, and serial monitoring of serum potassium and renal function, along with patient education regarding the potassium content of common foods, should minimize these risks and allow increased use of MRAs. Additionally, this may also result in a further reduction in cardiovascular mortality and hospitalizations for heart failure. The development of new non-steroidal MRAs, and especially new potassium binding molecules that are well tolerated and effective, hold the promise for increased safety and, therefore, increased and more prolonged use of MRAs in patients with heart failure, especially those with chronic kidney disease, diabetes mellitus, and the elderly.
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Echocardiographic examination of the posterior atrioventricular groove.
Silbiger, JJ
Echocardiography (Mount Kisco, N.Y.). 2014;(2):223-33
Abstract
Abnormalities of the posterior atrioventricular (AV) groove may be mischaracterized or overlooked in the course of routine echocardiographic imaging. Vascular abnormalities in this location include plethora of the coronary sinus and ectasia of the circumflex coronary artery. Excess accumulation of calcium (mitral annular calcification) and of fat (lipomatosis of the posterior AV groove) may also occur in this region. Masses (tumors or thrombus) arising from the floor of the left atrium or extrinsic to it (hiatal hernia, lymph nodes) may occupy the posterior AV groove. Abnormalities of the left ventricle, including aneurysms and pseudoaneurysms may present as masses in the posterior AV groove. This article discusses the echocardiographic features, differential diagnosis, and clinical significance of these abnormalities.
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[Vitamin D deficiency, left ventricular dysfunction and heart failure].
Cioffi, G, Gatti, D, Adami, S
Giornale italiano di cardiologia (2006). 2010;(9):645-53
Abstract
Epidemiologic data indicate that about one million people worldwide suffer from and should be treated for vitamin D deficiency. The clinical impact of vitamin D deficiency is very high if we consider the pivotal role that this condition plays in determining osteoporosis, fractures, cancers, diabetes, vascular inflammation, which can severely reduce functional capacity, quality of life and may often lead to disability. Vitamin D deficiency is a widely underdiagnosed pathological condition. Although many cardiovascular diseases such as arterial hypertension, myocardial ischemia, diabetic cardiomyopathy and heart failure, may arise from a low vitamin D status, cardiologists do not routinely search for this disease in clinical practice. Vitamin D, indeed, stimulates the synthesis of various contractile proteins and activates crucial intracellular mechanisms that manage calcium metabolism and energy production. These functions can be altered once vitamin D deficiency develops. This review focuses on the relationship between vitamin D deficiency, asymptomatic changes in left ventricular geometry and function, and heart failure syndrome through a recall of the myocardial metabolic processes regulated by vitamin D. The analysis of the available data from the literature leads to raise some questions that, at present, have no answer. Future prospective studies are needed to assess the effect of treatment of vitamin D deficiency on cardiac function.
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Recognition and treatment of anemia in the setting of heart failure due to systolic left ventricular dysfunction.
Howlett, JG
Expert review of cardiovascular therapy. 2008;(2):199-208
Abstract
Anemia is increasingly recognized as a common, important and treatable condition in patients with congestive heart failure. Despite increasing knowledge of anemia, as well as its co-association with chronic renal disease, advanced New York Heart Association class and worse prognosis, there are very few evidence-based recommendations for treatment. The use of supplemental iron, especially intravenous forms, for the treatment of iron-deficiency anemia in heart failure patients is associated with improved symptoms, cardiac size and function, and possibly improved outcomes. However, many patients with heart failure suffer from anemia due to other causes, including renal failure (so-called cardiorenal syndrome), erythropoietin resistance, possible ACE inhibitor use and extracellular fluid expansion. The association between anemia and adequate iron stores has led to interest in the use of erythrocyte-stimulating agents, such as erythropoietin and darbepoetin. While early data are promising, recent evidence in non-heart failure trials has led to caution in their use and given way to anticipation of results of ongoing definitive randomized trials of this therapy, such as the Trial to Reduce Cardiovascular Events with Aranesp Therapy (TREAT) and Reduction of Events with Darbepoetin-alpha in Heart Failure (RED-HF) studies.
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Aldosterone receptor blockade in patients with left ventricular systolic dysfunction following acute myocardial infarction.
Brandimarte, F, Blair, JE, Manuchehry, A, Fedele, F, Gheorghiade, M
Cardiology clinics. 2008;(1):91-105, vii
Abstract
Left ventricular systolic dysfunction (LVSD) is a common complication of acute myocardial infarction (AMI) that occurs in approximately 30% of post-AMI patients, and results in a threefold increase in in-hospital and 6-month mortality, regardless of type of AMI. Post-AMI care has evolved to include early reperfusion, antiplatelet therapy, hydroxymethylglutaryl coenzyme A reductase inhibitors (stains), beta blockers, angiotentsin-converting enzyme inhibitors, and angiotensin receptor blockers. Despite these therapies, however, there is still an excess of sudden cardiac death (SCD), especially in patients with severe LVSD and in the first 30 days post-AMI. Aldosterone has been shown to be elevated in patients with post-AMI LVSD and to have deleterious effects on the myocardium, including endothelial dysfunction, collagen deposition, inflammation, apoptosis, and autonomic instability, leading to left ventricular remodeling and SCD. Aldosterone blockade with eplerenone has been shown to reduce mortality even in the presence of optimal post-AMI therapy in patients with post-AMI LVSD. Despite this, eplerenone is underutilized in real-world clinical practice. Care must be taken to follow renal function and potassium balance in patients treated with eplerenone.
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Valsartan in the treatment of heart failure or left ventricular dysfunction after myocardial infarction.
Bissessor, N, White, H
Vascular health and risk management. 2007;(4):425-30
Abstract
The physiological role of the renin angiotensin aldosterone system (RAAS) is to maintain the integrity of the cardiovascular system. The effect of angiotensin II is mediated via the angiotensin type I receptor (AT1 ) resulting in vasoconstriction, sodium retention and myocyte growth changes. This causes myocardial remodeling which eventually leads to left ventricular hypertrophy, dilation and dysfunction. Inhibition of the RAAS with angiotensin converting enzyme (ACE) inhibitors after acute myocardial infarction has been shown to reduce cardiovascular morbidity and mortality. Angiotensin receptor blockers (ARBs) specifically inhibit the AT1 receptor. It has not been known until the performance of the VALIANT (valsartan in acute myocardial infarction trial) whether blockade of the angiotensin receptor with an ARB or combination of an ACE inhibitor and ARB leads to similar outcomes as an ACE inhibitor. The VALIANT trial demonstrated equal efficacy and non-inferiority of the ARB valsartan 160 mg bid compared with captopril 50 mg tds, when administered to high risk patients with left ventricular dysfunction or heart failure in the immediate post myocardial infarction period. The combination therapy showed no incremental benefit over ACE inhibition or an ARB alone and resulted in increased adverse effects. This review examines the role of valsartan in left ventricular dysfunction post myocardial infarction. We also discuss pharmacokinetics, dosing, side effects, and usage in the elderly.