The latest medical research on Cardiology

The research magnet gathers the latest research from around the web, based on your specialty area. Below you will find a sample of some of the most recent articles from reputable medical journals about cardiology gathered by our medical AI research bot.

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Maternal Cardiovascular Complications at the Time of Delivery and Subsequent Re-Hospitalization in the United States, 2010 to 2016.

European Heart Journal

Cardiovascular (CV) complications are the leading cause of maternal morbidity and mortality. The objective was to estimate trends in incidence of peripartum CV complications in the United States between 2010-2016.

This was a retrospective analyses using data from the Healthcare Cost and Utilization Project. We included women with delivery codes consistent with delivery, weighted to a national estimate. The primary outcome was the age-adjusted incidence of CV complications among all deliveries, including complications that occurred during re-hospitalizations. Complications were identified using International Classification of Diseases (ICD) codes. Joinpoint regression was used to evaluate time trends and complications were stratified by type. The secondary outcome was in-hospital maternal death among women with a CV complication. We identified a weighted estimate of 27,408,652 women hospitalized for delivery from 2010 to 2016. Including all years, the complication incidence was 7.36/1,000 births (95% CI 7.18, 7.54), with an estimated annual percentage change of 5.8% (95% CI 3.7%, 7.8%). Cardiac dysrhythmia was the most common complication (3.98/1,000 births [95% CI 3.88, 4.08]) and acute myocardial infarction was the least common complication (0.11/1,000 births [95% CI 0.10, 0.11]). The incidence of hypertension, acute myocardial infarction, and cardiac arrest increased over time, the incidence of congestive heart failure and acute cerebrovascular disease remained stable, the incidence of pulmonary heart disease increased from 2015 onward, and the incidence of cardiac dysrhythmia decreased in 2016. Complications during re-hospitalization accounted for 13.6% (95% CI 13.2%, 14.1%) of all complications and was highest for acute myocardial infarction (28.1% [95% CI 23.2, 33.1]). Among women with any complication, the mortality rate was 1.20 (95% CI 1.11, 1.29) per 100 complications.

Our analyses suggest the rate of peripartum CV complications are increasing in the United States, which highlights the need for active efforts in research and prevention.

Cardiac power output accurately reflects external cardiac work over a wide range of inotropic states in pigs.

European Heart Journal

Cardiac power output (CPO), derived from the product of cardiac output and mean aortic pressure, is an important yet underexploited parameter for hemodynamic monitoring of critically ill patients in the intensive-care unit (ICU). The conductance catheter-derived pressure-volume loop area reflects left ventricular stroke work (LV SW). Dividing LV SW by time, a measure of LV SW min- 1 is obtained sharing the same unit as CPO (W). We aimed to validate CPO as a marker of LV SW min- 1 under various inotropic states.

We retrospectively analysed data obtained from experimental studies of the hemodynamic impact of mild hypothermia and hyperthermia on acute heart failure. Fifty-nine anaesthetized and mechanically ventilated closed-chest Landrace pigs (68 ± 1 kg) were instrumented with Swan-Ganz and LV pressure-volume catheters. Data were obtained at body temperatures of 33.0 °C, 38.0 °C and 40.5 °C; before and after: resuscitation, myocardial infarction, endotoxemia, sevoflurane-induced myocardial depression and beta-adrenergic stimulation. We plotted LVSW min- 1 against CPO by linear regression analysis, as well as against the following classical indices of LV function and work: LV ejection fraction (LV EF), rate-pressure product (RPP), triple product (TP), LV maximum pressure (LVPmax) and maximal rate of rise of LVP (LV dP/dtmax).

CPO showed the best correlation with LV SW min- 1 (r2 = 0.89; p < 0.05) while LV EF did not correlate at all (r2 = 0.01; p = 0.259). Further parameters correlated moderately with LV SW min- 1 (LVPmax r2 = 0.47, RPP r2 = 0.67; and TP r2 = 0.54). LV dP/dtmax correlated worst with LV SW min- 1 (r2 = 0.28).

CPO reflects external cardiac work over a wide range of inotropic states. These data further support the use of CPO to monitor inotropic interventions in the ICU.

Predictors and prognosis of delirium among older subjects in cardiac intensive care unit: focus on potentially preventable forms.

European Heart Journal

Delirium is a common and potentially preventable condition in older individuals admitted to acute and intensive care wards, associated with negative prognostic effects. Its clinical relevance is being increasingly recognised also in cardiology settings. The aim of the present study was to assess the prevalence, incidence, predictors and prognostic role of delirium in older individuals admitted to two cardiology intensive care units.

All patients aged over 65 years consecutively admitted to the two participating cardiology intensive care units were enrolled. Assessment on admission included acute physiological derangement (modified rapid emergency medicine score, REMS), chronic comorbidity, premorbid disability and dementia. The Confusion Assessment Method-Intensive Care Unit was applied daily for delirium detection.

Of 497 patients (40% women, mean age 79 years), 18% had delirium over the entire cardiology intensive care unit course, half of whom more than 24 hours after admission (incident delirium). Advanced age, a main diagnosis of ST-segment elevation myocardial infarction or acute respiratory failure, modified REMS, comorbidity and dementia were independent predictors of delirium. Adjusting for patient's features on admission, incident delirium was predicted by invasive procedures (insertion of peripheral arterial catheter, urinary catheter, central venous catheter, naso-gastric tube and intra-aortic balloon pump). In a logistic regression model, delirium was an independent predictor of inhospital mortality (odds ratio 3.18, 95% confidence interval 1.02, 9.93).

Eighteen per cent of older cardiology intensive care unit patients had delirium, with half of the cases being incident, thus potentially preventable. Invasive procedures were independently associated with incident delirium. Delirium was an independent predictor of inhospital mortality. Awareness of delirium should be increased in the cardiology intensive care unit setting and prevention studies are warranted.

Recurrence of angina after ST-segment elevation myocardial infarction: the role of coronary microvascular obstruction.

European Heart Journal

The recurrence of angina after percutaneous coronary intervention affects 20-35% of patients with stable coronary artery disease; however, few data are available in the setting of ST-segment elevation myocardial infarction. We evaluated the relation between coronary microvascular obstruction and the recurrence of angina at follow-up.

We prospectively enrolled patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. Microvascular obstruction was defined as thrombolysis in myocardial infarction flow less than 3 or 3 with myocardial blush grade less than 2. The primary endpoint was the recurrence of angina at follow-up. Moreover, angina status was evaluated by the Seattle angina questionnaire summary score (SAQSS). Therapy at follow-up and the occurrence of major adverse cardiovascular events were also collected.

We enrolled 200 patients. Microvascular obstruction occurred in 52 (26%) of them. Follow-up (mean time 25.17±9.28 months) was performed in all patients. Recurrent angina occurred in 31 (15.5%) patients, with a higher prevalence in patients with microvascular obstruction compared with patients without microvascular obstruction (13 (25.0%) vs. 18 (12.2%), P=0.008). Accordingly, SAQSS was lower and the need for two or more anti-anginal drugs was higher in patients with microvascular obstruction compared with patients without microvascular obstruction. At multiple linear regression analysis a history of previous acute coronary syndrome and the occurrence of microvascular obstruction were the only independent predictors of a worse SAQSS. Finally, the occurrence of major adverse cardiovascular events was higher in patients with microvascular obstruction compared with patients without microvascular obstruction.

The recurrence of angina in ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention is an important clinical issue. The occurrence of microvascular obstruction portends a worse angina status and is associated with the use of more anti-anginal drugs.

Insights Into Myocardial Oxygen Consumption, Energetics, and Efficiency Under Left Ventricular Assist Device Support Using Noninvasive Pressure-Volume Loops.

Circulation. Heart failure

Assessment of left ventricular (LV) recovery under continuous-flow LV assist device therapy is hampered by concomitant pump support. We describe derivation of noninvasive pressure-volume loops in continuous-flow LV assist device patients and demonstrate an application in the assessment of recovery.

Using pump controller parameters and noninvasive arterial pressure waveforms, central aortic pressure, outflow conduit pressure gradient, and instantaneous LV pressure were calculated. Instantaneous LV volumes were calculated from echocardiographic LV end-diastolic volume accounting for the integral of pump flow with respect to time and aortic ejection volume derived from the pump speed waveform. Pressure-volume loops were derived during pump speed adjustment and following bolus intravenous milrinone to assess changes in loading conditions and contractility, respectively. Fourteen patients were studied. Baseline noninvasive LV end-diastolic pressure correlated with invasive pulmonary arterial wedge pressure (r2=0.57, root mean square error 5.0 mm Hg, P=0.003). Measured noninvasively, milrinone significantly increased LV ejection fraction (40.3±13.6% versus 36.8±14.2%, P<0.0001), maximum dP/dt (623±126 versus 555±122 mm Hg/s, P=0.006), and end-systolic elastance (1.03±0.57 versus 0.89±0.38 mm Hg/mL, P=0.008), consistent with its expected inotropic effect. Milrinone reduced myocardial oxygen consumption (0.15±0.06 versus 0.16±0.07 mL/beat, P=0.003) and improved myocardial efficiency (43.7±14.0% versus 41.2±15.5%, P=0.001). Reduced pump speed caused increased LV end-diastolic volume (190±80 versus 165±71 mL, P<0.0001) and LV end-diastolic pressure (14.3±10.2 versus 9.9±9.3 mm Hg, P=0.024), consistent with a predictable increase in preload. There was increased myocardial oxygen consumption (0.16±0.07 versus 0.14±0.06 mL O2/beat, P<0.0001) despite unchanged stroke work (P=0.24), reflecting decreased myocardial efficiency (39.2±12.7% versus 45.2±17.0%, P=0.003).

Pressure-volume loops are able to be derived noninvasively in patients with the HeartWare HVAD and can detect induced changes in load and contractility.

Myocardial Energetics in Heart Failure With Preserved Ejection Fraction.

Circulation. Heart failure

The role of coronary microvascular disease and its impact on functional and energetic reserve in heart failure with preserved ejection fraction (HFpEF) remains unclear. We hypothesized that in response to submaximal pharmacologic stress (dobutamine), patients with HFpEF have impairment in left ventricular (LV) myocardial mechanical (external work [EW]), energetic (myocardial O2 consumption [MVO2]), and myocardial blood flow (MBF) reserve. We further assessed whether coupling of MBF to EW is impaired in HFpEF and associated with compensatory increases or pathological decreases in myocardial O2 extraction. Lastly, we assessed whether coupling of MVO2 to EW (mechanical efficiency) was impaired in HFpEF.

In prospectively enrolled patients with HFpEF (n=19) and age/sex-matched healthy controls (n=19), we performed 11C-acetate positron emission tomography assessing MVO2 and MBF at rest and during dobutamine infusion. EW was calculated as stroke volume (echo)×end-systolic pressure×heart rate. At rest, compared with controls, patients with HFpEF had higher LV EW, MVO2, and MBF. With dobutamine, LV EW, MVO2, and MBF increased in both HFpEF and controls; however, the magnitude of increases was significantly smaller in HFpEF. In both groups, MBF increased in relation to EW, but in HFpEF, the slope of the relationship was significantly smaller than in controls. Myocardial O2 extraction was increased in HFpEF. Mechanical efficiency was similar in HFpEF and controls. In a post hoc analysis, HFpEF patients with LV hypertrophy (n=10) had significant reductions in LV mechanical efficiency relative to controls.

In HFpEF during submaximal dobutamine stress, there is myocardial mechanical-, energetic- and flow-reserve dysfunction with impaired coupling of blood flow to demand and slight increases in myocardial O2 extraction. These findings provide evidence that coronary microvascular dysfunction is present in HFpEF, limits O2 supply relative to demand, and is associated with reserve dysfunction.

Improvements of right ventricular function and hemodynamics after balloon pulmonary angioplasty in patients with chronic thromboembolic pulmonary hypertension.

Echocardiography

Right ventricular (RV) function is an important factor in the prognosis of chronic thromboembolic pulmonary hypertension (CTEPH) in patients. In our study, we aimed to evaluate the timing and magnitude of regional RV function before and after balloon pulmonary angioplasty (BPA) using speckle tracking echocardiography (STE) and their relation to clinical and hemodynamic parameters in patients with CTEPH.

We enrolled 20 CTEPH patients and 19 healthy subjects in our study. Enrolled patients underwent echocardiography, right heart catheterization (RHC), and 6-minute walk distance (6MWD) test at baseline and after the BPA.

In hemodynamic RHC measurements and clinical evaluations, mean pulmonary artery pressure (median: 53.5 mm Hg vs 37.0 mm Hg, P = .001) and pulmonary vascular resistance (median: 12 Wood units [WU] vs 7 WU, P = .001) and pro-brain natriuretic peptide level decreased and 6MWD increased after BPA sessions. There was no statistically significant difference between before and after the BPA sessions in conventional echocardiographic measurements. In STE analysis, the electromechanical delay (EMD) between RV free wall (RVF) and LV lateral wall (LVL) (median: 65 ms vs 47.5 ms, P = .01) and RV peak systolic strain dispersion index (52 ms vs 29 ms, P = .001) were higher in patients with CTEPH than healthy controls before the BPA. Both these parameters decreased significantly after BPA.

Chronic thromboembolic pulmonary hypertension was associated with RV electromechanical delay and dispersion based on the STE analysis. Balloon pulmonary angioplasty might have an important impact on the improvement of both RV function and hemodynamics.

Biatrial and right ventricular deformation imaging: Implications of the recent EACVI consensus document in the clinics and beyond.

Echocardiography

In this review, right ventricular (RV), right atrial (RA), and left atrial (LA) strain in some selected clinical situations has been discussed in l...

Survival Outcomes After Heart Transplantation: Does Recipient Sex Matter?

Circulation. Heart failure

Currently, women represent <25% of heart transplant recipients. Reasons for this female underrepresentation have been attributed to selection and referral bias and potentially poorer outcomes in female recipients. The aim of this study was to compare long-term posttransplant survival between men and women, when matched for recipient and donor characteristics.

Using the International Society for Heart and Lung Transplantation Registry, we performed descriptive analyses and estimated overall freedom from posttransplant death stratified by sex using Kaplan-Meier survival methods. Male and female recipients were matched according to the Index for Mortality Prediction After Cardiac Transplantation and Donor Risk Index score using 1:1 propensity score matching. The study cohort comprised 34 198 heart transplant recipients (76.3% men, 23.7% women) between 2004 and 2014. Compared with men, women were more likely younger (51 [39-59] versus 55 [46-61] years; P<0.001) and had a different distribution of heart failure etiology (P<0.001). In general, the prevalence of comorbidities was lower in women than in men. Women were less likely to have diabetes mellitus (19.1% versus 26.2%; P<0.001), hypertension (40.7% versus 47.9%; P<0.001), peripheral vascular disease (2.4% versus 3.3%; P=0.002), tobacco use (36.5% versus 52.3%; P<0.001), and prior cardiovascular surgery (38.6% versus 50.7%; P<0.001). Women were more likely to have a history of malignancy (10.5% versus 5.3%; P<0.001), require intravenous inotropes (41.4% versus 37.2%; P<0.001), and were less likely supported by an intra-aortic balloon pump (3.3% versus 3.8%; P=0.03) or durable ventricular assist device (22% versus 31.5%; P<0.001). Transplanted male recipients had a higher Index for Mortality Prediction After Cardiac Transplantation score (5 [2-7] versus 4 [1-6]; P<0.001). When male and female heart transplant recipients were matched for recipient and donor characteristics, there was no significant survival difference (P=0.57).

Overall survival does not differ between men and women after cardiac transplantation. Women who survive to heart transplantation appear to have lower risk features than male recipients but receive hearts from higher risk donors.

Shared Decision-Making About End-of-Life Care Scenarios Compared Among Implantable Cardioverter Defibrillator Patients: A National Cohort Study.

Circulation. Heart failure

Authors of expert guidelines and consensus statements recommend that decisions at the end-of-life (EOL) be discussed before and after implantation of an implantable cardioverter defibrillator (ICD) and include promotion of shared decision-making. The purpose of this study was to describe experiences, attitudes, and knowledge about the ICD at EOL in ICD recipients and to compare experiences, attitudes, and knowledge in ICD recipients with and without heart failure (HF). We further sought to determine factors associated with having discussions about EOL.

Using a national registry in Sweden of all ICD recipients (n=5355) in 2012, an EOL questionnaire, along with other ICD-related measures, was completed by 2403 ICD recipients. Of the participants, 1275 (n=53%) had HF. Their responses in the knowledge, experience, and attitude domains were almost identical to those without HF. Forty percent of patients with and without HF did not want to discuss their illness trajectory or deactivation of their ICD ever. In logistic regression analyses, we found that having had an ICD shock (OR, 2.05; CI, 1.64-2.56), having high levels of anxiety (OR, 1.41; CI, 1.04-1.92), and having high levels of ICD concerns (OR, 1.53; CI, 1.22-1.92) were the only significant predictors of having discussions with providers about EOL scenarios (P<0.001 for full model).

HF was not a predictor of having an EOL conversation. Further research is needed to determine if attitudes related to not wanting to discuss EOL interfere with good quality of life and of death, or if shared decision-making should be encouraged in these individuals.

Mechanisms of the Multitasking Endothelial Protein NRG-1 as a Compensatory Factor During Chronic Heart Failure.

Circulation. Heart failure

Heart failure is a complex syndrome whose phenotypic presentation and disease progression depends on a complex network of adaptive and maladaptive ...

Utility of the modified myocardial performance index in growth-restricted fetuses.

Echocardiography

The modified myocardial performance index (Mod-MPI) can be used to assess myocardial function. Fetal growth restriction can affect fetal myocardial function, thereby altering the Mod-MPI. The results of previous studies on the utility of the Mod-MPI in growth-restricted fetuses are conflicting. The aim of this study was to calculate the left modified-MPI in growth-restricted fetuses and to compare the results with those of healthy fetuses.

This was a prospective cross-sectional case-control study. In total, 40 women with growth-restricted fetuses and 40 women with fetuses of normal weight (controls) at 29-39 gestational weeks were enrolled in the study. An experienced obstetrician calculated the Mod-MPI for each fetus. Women with systemic diseases or fetuses with chromosomal/structural abnormalities were excluded from the study. The results of Mod-MPI measurements of the two groups were compared.

The mean single deepest vertical pocket (SDVP) of amniotic fluid, estimated fetal weight (EFW), and isovolumetric relaxation time (IRT) was significantly lower in the fetal growth restriction (FGR) group as compared with these parameters in the control group (P < .05). The uterine artery (UtA) pulsatility index (PI) was significantly higher in the FGR group as compared with that in the control group (P < .05). There were six cases of absent end-diastolic flow (AED) in the FGR group. There were no statistically significant between-group differences in the Mod-MPI, isovolumetric contraction time (ICT), and ejection time (ET) (P > .05). There was also no statistically significant correlation between the Mod-MPI in the fetuses with AED and the control group for Mod-MPI (P > .05).

The utility of the Mod-MPI in FGR remains unclear. Future studies with larger populations are needed to determine the utility of the Mod-MPI as a predictor of cardiac compromise in FGR.