Case Report of Multiembolic Cerebrovascular Event Associated with Ramp Study Echocardiogram

The incidence of ramp test echocardiogram-associated embolic events in the setting of therapeutic anticoagulation is likely rare and has not been reported. We present such a case in a patient with a HeartMate II left ventricular assist device (LVAD) whose serial head computed tomography images, deteriorating clinical course, and the multiembolic nature of the event suggest causality. If the pretest probability of pump thrombosis in an individual LVAD patient is sufficiently high, the potential risks of performing a ramp study echocardiogram may not be warranted, even in the setting of adequate anticoagulation

Point-of-Care Technologies for Precision Cardiovascular Care and Clinical Research

Point-of-care technologies (POC or POCT) are enabling innovative cardiovascular diagnostics that promise to improve patient care across diverse clinical settings. The National Heart, Lung, and Blood Institute convened a working group to discuss POCT in cardiovascular medicine. The multidisciplinary working group, which included clinicians, scientists, engineers, device manufacturers, regulatory officials, and program staff, reviewed the state of the POCT field; discussed opportunities for POCT to improve cardiovascular care, realize the promise of precision medicine, and advance the clinical research enterprise; and identified barriers facing translation and integration of POCT with existing clinical systems. A POCT development roadmap emerged to guide multidisciplinary teams of biomarker scientists, technologists, health care providers, and clinical trialists as they: 1) formulate needs assessments; 2) define device design specifications; 3) develop component technologies and integrated systems; 4) perform iterative pilot testing; and 5) conduct rigorous prospective clinical testing to ensure that POCT solutions have substantial effects on cardiovascular care

Role of Apoptosis in Heart Failure

Investigators have identified biochemical and morphologic hallmarks of apoptosis in a wide variety of heart diseases; however, delineating the functional and anatomic contribution of apoptosis to the pathogenesis of heart disease has been challenging. Studies in cardiomyocytes and genetically engineered mice suggest that this contribution is likely to be substantial and may be greater than initially anticipated because of the observation that common signaling mechanisms regulate not only cardiomyocyte apoptosis but also the function of surviving cardiomyocytes. This article reviews mechanisms and implications of apoptotic signaling and evidence that these pathways contribute to cardiac dysfunction and heart failure. Consideration is given to whether these pathways represent an opportunity for therapeutic intervention

Untimely Trial Publication: A Sin of Omission?

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Case Report of Multiembolic Cerebrovascular Event Associated with Ramp Study Echocardiogram

The incidence of ramp test echocardiogram-associated embolic events in the setting of therapeutic anticoagulation is likely rare and has not been reported. We present such a case in a patient with a HeartMate II left ventricular assist device (LVAD) whose serial head computed tomography images, deteriorating clinical course, and the multiembolic nature of the event suggest causality. If the pretest probability of pump thrombosis in an individual LVAD patient is sufficiently high, the potential risks of performing a ramp study echocardiogram may not be warranted, even in the setting of adequate anticoagulation

Prognostic Value of Soluble ST2 Measurements for Morbidity and Mortality in Ambulatory Patients with HFrEF

Soluble ST2 (sST2) has emerged as a powerful prognostic marker in chronic systolic heart failure with reduced ejection fraction (HFrEF). Elevated levels of sST2 are associated with adverse cardiac remodeling and fibrosis. However, few studies have demonstrated the relative prognostic value of sST2 collected from stable patients in the ambulatory setting and correlated it with long term clinical outcomes. In our study, we sought to determine the prognostic utility of a baseline sST2 partition value in the ambulatory setting as it related to subsequent risk for heart failure hospitalization and all-cause mortality. Single-center, retrospective observational study of subjects presenting to an ambulatory heart failure (HF) clinic from July 2014 to December 2016. There were 156 subjects with stage C heart failure and a baseline sST2 level. For purposes of this analysis in HFrEF, we excluded patients with EF > 40% resulting in a study cohort of 103 subjects. The mean follow-up was 2.20 years ± 1.53 years. Analysis was performed with IBM SPSS Statistics 26 software package. Discrete variables were expressed as counts (percentage) and were compared using the Chi-squared test. Mean differences of continuous variables were expressed as a mean ± standard deviation and compared using the unpaired Student's t-test. The log-rank test (Mantel-Cox) was used to compare survival times on Kaplan-Meier curves. To determine the diagnostic and prognostic accuracies of sST2 and BNP, receiver operating characteristic (ROC) plots were analyzed, and areas under the curve (AUC) were calculated. Patients who had baseline sST2 ≥ 35 ng/ml were at increased risk for heart failure hospitalization and all-cause mortality compared to patients who had sST2 < 35 ng/ml. Patients with sST2 ≥ 35 ng/ml had a mean of 1.76 HF hospitalizations, 44.0% of this group had ≥ 2 HF hospitalizations and 50.0% all-cause mortality. Patients with sST2 < 35 ng/ml had a mean of 0.80 HF hospitalizations, 15.0% had ≥ 2 HF hospitalizations and 18.0% all-cause mortality. We also found that sST2 ≥ 35 ng/ml was associated with increased risk for atrial arrhythmias (39.0% vs. 20.5%), lower hemoglobin (11.5 vs 13.0), and lower systolic blood pressure (109.6 vs 124.8). Subjects with sST2 levels ≥ 35 ng/ml were at increased risk of recurrent hospitalization and all-cause mortality. Additionally, we saw that elevated sST2 was associated with increased atrial arrhythmia, hypotension, and anemia. The results of this study highlight the value of sST2 concentrations as a prognostic biomarker for identifying patients with HFrEF that are at increased risk for morbidity and mortality in the ambulatory setting. Key words: Soluble ST2, cardiac remodeling, biomarkers, heart failur