Emergency percutaneous balloon mitral valvotomy in a patient with septic shock

We report an 18-year-old patient with severe mitral stenosis complicated by right lower lobe pneumonia, sepsis, and shock. Intractable low cardiac output led to an emergency percutaneous balloon mitral valvotomy in a patient, resulting in immediately improved hemodynamic parameters. We are unaware of another report of percutaneous balloon mitral valvotomy performed in a patient with sepsis and shock. This ease supports previous isolated reports of the benefit from emergency percutaneous balloon mitral valvotomy in critical situations where thoracotomy is not possible due to coexisting medical problems

Acutely decompensated versus acute heart failure: two different entities

Heart failure (HF) has been classified in chronic HF (CHF) and acute HF (AHF). The latter has been subdivided in acutely decompensated chronic HF (ADCHF) defined as the deterioration of preexisting CHF and de novo AHF defined as the rapid development of new symptoms and signs of HF that requires urgent medical attention. However, ADCHF and de novo AHF have fundamental pathophysiological differences. Most importantly, the typical illness trajectory of HF, which is similar to that of other chronic organ diseases including lung, renal, and liver failure, features a gradual decline, with acute episodes usually related to disease evolution followed by partial recovery. Thus, ADCHF should be considered part of the natural history of CHF and renamed CHF exacerbation (CHFE) in accordance with the appropriate terminology used in chronic obstructive pulmonary disease. AHF, in turn, should include only acute de novo HF. The clinical implications of this paradigm shift will be in CHFE the change in focus from in-hospital to optimal ambulatory CHF management aiming at primary and secondary CHFE prevention, while in AHF, the institution of measures for in-hospital limitation of cardiac injury and prevention or retardation of symptomatic CHF development. © 2019, Springer Science+Business Media, LLC, part of Springer Nature

Current drugs and medical treatment algorithms in the management of acute decompensated heart failure

Background: Acute decompensated heart failure (ADHF) is associated with increased hospitalization rates and high in-hospital mortality, and has emerged as a major public health problem over the past decade. In recent years, several new drugs and therapeutic approaches have failed to reduce short- and long-term morbidity and mortality in ADHF patients. New agents and strategies are under investigation in order to effectively reduce the mortality and morbidity in these patients. Objective: To review the recent experimental and clinical evidence on existing therapeutic algorithms and investigational drugs used for the treatment of ADHF. Methods: A systematic search of peer-reviewed publications was performed on Medline and EMBASE from January 1995 to January 2009. The results of unpublished trials were obtained from presentations at national and international meetings. Results: Renal dysfunction and low systolic blood pressure (SBP) remain the main predictors of adverse clinical outcomes in ADHF patients. Thus, therapy should be tailored according to the level of SBP at admission, renal function and fluid retention. ADHF due to hypertensive disease should be treated with intravenous vasodilators and diuretics at low doses, while patients with low output syndrome need mainly inotropic support. However, few agents currently employed in the treatment of ADHF have been shown in large prospective randomized clinical trials to improve clinical outcomes. The calcium sensitizer levosimendan is superior than traditional inotropes in improving central hemodynamics and neurohormonal response in ADHF patients, without increasing their long-term survival. Vasopressin antagonists also seem to be promising and safe drugs in the treatment of ADHF patients, facilitating diuresis on top of standard-care therapy. Encouraging novel therapies include adenosine receptor antagonists, ularitide, istaroxime, cardiac myosin activators and relaxin. Conclusions: Clinical scenarios based on SBP are essential determinants of therapeutic approaches used for the management of ADHF. Traditional drugs (diuretics, dobutamine and milrinone) have several limitations in real clinical practice, and increase mortality rates. Investigational drugs targeting to novel pathophysiologic concepts are promising treatment approaches and ongoing trials will define their clinical efficacy and safety. © 2009 Informa UK Ltd. All rights reserved

Evaluating the role of Mediterranean diet and eating behaviors on the likelihood of having a non-fatal acute coronary syndrome, under the context of stress perception: A case-control study

BACKGROUND/OBJECTIVES: Mediterranean diet and perceived stress have long been associated with the likelihood of having an acute coronary syndrome (ACS). The aim of this study was to evaluate whether the Mediterranean diet and other eating behaviors mediate and/or moderate the unfavorable impact of perceived stress on the likelihood of having a non-fatal ACS. SUBJECTS/METHODS: This is a case-control study with individuals matched by age and sex. A total of 250 consecutive patients (60 ± 11 years, 78% men) with a first ACS and 250 population-based, control subjects (60 ± 8.6 years, 77.6% men) were enrolled. Perceived stress levels were evaluated with the Perceived Stress Scale (PSS-14; range 0-14), and adherence to the Mediterranean diet was assessed by the MedDietScore (range 0-55). Stress eating, eating heavy meals and eating alone were also evaluated. RESULTS: For each unit increase in the PSS-14, the likelihood of having an ACS increased by 14% (95% confidence interval (CI) = 1.10, 1.18). Stratified analysis by Mediterranean diet adherence level revealed a similar association of PSS-14 with ACS likelihood between the low-to-moderate and moderate-to-high adherence groups (that is, odds ratio (OR) = 1.15, 95% CI = 1.09, 1.21 and OR = 1.13, 95% CI = 1.07, 1.80, respectively). Stress eating and eating alone were positively associated with the likelihood of having an ACS (OR = 1.31, 95% CI = 0.97, 1.77 and OR = 1.36, 95% CI = 1.08, 1.69, respectively). Eating heavy meals was not associated with ACS (OR = 1.08, 95% CI = 0.82, 1.41); no mediating or moderating effect of these behaviors on perceived stress ACS was observed. CONCLUSIONS: The highly significant impact of perceived stress on ACS likelihood was not mediated or moderated by the level of adherence to the Mediterranean diet or other eating behaviors, underlying the strong effect of this psychological disorder on ACS. © 2014 Macmillan Publishers Limited All rights reserved

Left ventricular hypertrophy and sudden cardiac death

Sudden cardiac death (SCD) is among the leading causes of death worldwide, and it remains a public health problem, as it involves young subjects. Current guideline-directed risk stratification for primary prevention is largely based on left ventricular (LV) ejection fraction (LVEF), and preventive strategies such as implantation of a cardiac defibrillator (ICD) are justified only for documented low LVEF (i.e., ≤ 35%). Unfortunately, only a small percentage of primary prevention ICDs, implanted on the basis of a low LVEF, will deliver life-saving therapies on an annual basis. On the other hand, the vast majority of patients that experience SCD have LVEF > 35%, which is clamoring for better understanding of the underlying mechanisms. It is mandatory that additional variables be considered, both independently and in combination with the EF, to improve SCD risk prediction. LV hypertrophy (LVH) is a strong independent risk factor for SCD regardless of the etiology and the severity of symptoms. Concentric and eccentric LV hypertrophy, and even earlier concentric remodeling without hypertrophy, are all associated with increased risk of SCD. In this paper, we summarize the physiology and physiopathology of LVH, review the epidemiological evidence supporting the association between LVH and SCD, briefly discuss the mechanisms linking LVH with SCD, and emphasize the need to evaluate LV geometry as a potential risk stratification tool regardless of the LVEF. © 2021, The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature

Current drugs and medical treatment algorithms in the management of acute decompensated heart failure

Background: Acute decompensated heart failure (ADHF) is associated with increased hospitalization rates and high in-hospital mortality, and has emerged as a major public health problem over the past decade. In recent years, several new drugs and therapeutic approaches have failed to reduce short- and long-term morbidity and mortality in ADHF patients. New agents and strategies are under investigation in order to effectively reduce the mortality and morbidity in these patients. Objective: To review the recent experimental and clinical evidence on existing therapeutic algorithms and investigational drugs used for the treatment of ADHF. Methods: A systematic search of peer-reviewed publications was performed on Medline and EMBASE from January 1995 to January 2009. The results of unpublished trials were obtained from presentations at national and international meetings. Results: Renal dysfunction and low systolic blood pressure (SBP) remain the main predictors of adverse clinical outcomes in ADHF patients. Thus, therapy should be tailored according to the level of SBP at admission, renal function and fluid retention. ADHF due to hypertensive disease should be treated with intravenous vasodilators and diuretics at low doses, while patients with low output syndrome need mainly inotropic support. However, few agents currently employed in the treatment of ADHF have been shown in large prospective randomized clinical trials to improve clinical outcomes. The calcium sensitizer levosimendan is superior than traditional inotropes in improving central hemodynamics and neurohormonal response in ADHF patients, without increasing their long-term survival. Vasopressin antagonists also seem to be promising and safe drugs in the treatment of ADHF patients, facilitating diuresis on top of standard-care therapy. Encouraging novel therapies include adenosine receptor antagonists, ularitide, istaroxime, cardiac myosin activators and relaxin. Conclusions: Clinical scenarios based on SBP are essential determinants of therapeutic approaches used for the management of ADHF. Traditional drugs (diuretics, dobutamine and milrinone) have several limitations in real clinical practice, and increase mortality rates. Investigational drugs targeting to novel pathophysiologic concepts are promising treatment approaches and ongoing trials will define their clinical efficacy and safety

Evaluating the role of Mediterranean diet and eating behaviors on the likelihood of having a non-fatal acute coronary syndrome, under the context of stress perception: a case-control study

BACKGROUND/OBJECTIVES: Mediterranean diet and perceived stress have long been associated with the likelihood of having an acute coronary syndrome (ACS). The aim of this study was to evaluate whether the Mediterranean diet and other eating behaviors mediate and/or moderate the unfavorable impact of perceived stress on the likelihood of having a non-fatal ACS. SUBJECTS/METHODS: This is a case control study with individuals matched by age and sex. A total of 250 consecutive patients (60 +/- 11 years, 78% men) with a first ACS and 250 population-based, control subjects (60 +/- 8.6 years, 77.6% men) were enrolled. Perceived stress levels were evaluated with the Perceived Stress Scale (PSS-14; range 0-14), and adherence to the Mediterranean diet was assessed by the MedDietScore (range 0-55). Stress eating, eating heavy meals and eating alone were also evaluated. RESULTS: For each unit increase in the P55-14, the likelihood of having an ACS increased by 14% (95% confidence interval (CI) = 1.10, 1.18). Stratified analysis by Mediterranean diet adherence level revealed a similar association of PSS-14 with ACS likelihood between the low-to-moderate and moderate-to-high adherence groups (that is, odds ratio (OR) = 1.15, 95% CI = 1.09, 1.21 and OR = 1.13, 95% CI = 1.07, 1.80, respectively). Stress eating and eating alone were positively associated with the likelihood of having an ACS (OR = 1.31, 95% CI = 0.97, 1.77 and OR = 1.36, 95% CI = 1.08, 1.69, respectively). Eating heavy meals was not associated with ACS (OR = 1.08, 95% CI = 0.82, 1.41); no mediating or moderating effect of these behaviors on perceived stress ACS was observed. CONCLUSIONS: The highly significant impact of perceived stress On ACS likelihood was not mediated or moderated by the level of adherence to the Mediterranean diet or other eating behaviors, underlying the strong effect of this psychological disorder on ACS

Carotid plaque composition in stable and unstable coronary artery disease

Background Several pieces of evidence suggest that formation of complex atheromatous plaques may be influenced not only by local but also by systemic factors. Methods Twenty-five patients (16 men/9 women, age 63 +/- 10 years) with stable coronary artery disease (sCAD) and 61 (41 men/20 women, age 66 +/- 16 years) with acute coronary syndromes (ACSs) underwent carotid ultrasonography within 2 days of cardiac catheterization. Complex coronary plaques were associated with intraluminal filling defect consistent with thrombus, ulceration, or irregularity. Complex carotid plaques had one or more of the following features: (a) ulceration, (b) irregular surface, (c) mobile thrombi on plaque surface, (cl) predominant echolucency, and (e) heterogeneity with introplaque echolucent areas. Results Carotid intimamedia thickness and luminal diameter were not significantly different between patients with sCAD and those with ACS (0.95 +/- 0.22 vs 1.0 +/- 0. 15 mm [P=.23] and 6.1 +/- 0.89 vs 6.20 +/- 0.77 min [P=.60], respectively), whereas the interadventitial diameter was slightly greater in the latter (7.93 +/- 1.05 vs 8.40 +/- 0.97 mm, P=.0496). Both complex coronary plaques and complex carotid plaques were more common in patients with ACS than in those with sCAD (n=52 [85.2%] vs n=6 [24%] [P6-fold in patients with ACS compared with those with sCAD (OR 6.61, 95% CI 2.24-19.32). Conclusions Complex coronary plaques are associated with complex carotid plaques and the high prevalence of both plaque types in patients with ACS is indicative of a systemic process contributing to complex plaque formation and instability