Current cardiology reports
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Ventricular tachycardia occurrence in implantable cardioverter defibrillator (ICD) patients may result in shock delivery and is associated with increased morbidity and mortality. In addition, shocks may have deleterious mechanical and psychological effects. Prevention of ventricular tachycardia (VT) recurrence with the use of antiarrhythmic drugs or catheter ablation may be warranted. Antiarrhythmic drugs are limited by incomplete efficacy and an unfavorable adverse effect profile. Catheter ablation can be effective but acute complications and long-term VT recurrence risk necessitating repeat ablation should be recognized. A shared clinical decision process accounting for patients' cardiac status, comorbidities, and goals of care is often required. ⋯ There are four published randomized trials of catheter ablation for sustained monomorphic VT (SMVT) in the setting of ischemic heart disease; there are no randomized studies for non-ischemic ventricular substrates. The most recent trial is the VANISH trial which randomly allocated patients with ICD, prior infarction, and SMVT despite first-line antiarrhythmic drug therapy to catheter ablation or more aggressive antiarrhythmic drug therapy. During 28 months of follow-up, catheter ablation resulted in a 28% relative risk reduction in the composite endpoint of death, VT storm, and appropriate ICD shock (p = 0.04). In a subgroup analysis, patients having VT despite amiodarone had better outcomes with ablation as compared to increasing amiodarone dose or adding mexiletine. There is evidence for the effectiveness of both catheter ablation and antiarrhythmic drug therapy for patients with myocardial infarction, an implantable defibrillator, and VT. If sotalol is ineffective in suppressing VT, either catheter ablation or initiation of amiodarone is a reasonable option. If VT occurs despite amiodarone therapy, there is evidence that catheter ablation is superior to administration of more aggressive antiarrhythmic drug therapy. Early catheter ablation may be appropriate in some clinical situations such as patients presenting with relatively slow VT below ICD detection, electrical storms, hemodynamically stable VT, or in very selected patients with left ventricular assist devices. The optimal first-line suppressive therapy for VT, after ICD implantation and appropriate programming, remains to be determined. Thus far, there has not been a randomized controlled trial to compare catheter ablation to antiarrhythmic drug therapy as a first-line treatment; the VANISH-2 study has been initiated as a pilot to examine this question.
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The prevalence of hypertension and erectile dysfunction has steadily increased, and greater than 40% of men with erectile dysfunction concurrently share a diagnosis of hypertension. The treatment of the patient with both diseases poses a clinical challenge as both are closely correlated and share multiple overlapping risk factors.To address the recognized knowledge gap among clinicians who care for these patients, we will review the current literature on the diagnosis and treatment of erectile dysfunction in the hypertensive patient and will provide recommendations for the management of this challenging patient population. ⋯ The pharmacological treatment of hypertension may adversely affect sexual function, and certain treatments for erectile dysfunction are contraindicated or cautioned against with certain antihypertensive agents. In review of the literature, we find that the clinician should opt to use an angiotensin-receptor blocker followed by an angiotensin-converting enzyme inhibitor or calcium channel blocker for the treatment of hypertension in patients with erectile dysfunction. Other agents require careful consideration for adverse effects on sexual function. Men with erectile dysfunction should be assessed for cardiovascular fitness for sexual activity, and PDE-5 inhibitors remain the first-line treatment for erectile dysfunction.
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The purpose of this study is to review the current evidence on the relationship between diet and heart, giving practical recommendations for cardiovascular prevention. ⋯ A heart-healthy diet should maximize the consumption of whole grains, vegetables, fruit, and legumes and discourage the consumption of meat and meat products as well as refined and processed foods. Plant-based diets fully meet these criteria, and the evidence supporting the protective effect of these dietary patterns evolved rapidly in recent years. Among plant-based diets, the Mediterranean and vegetarian diets gained the greater interest, having been associated with numerous health benefits such as reduced levels of traditional and novel risk factors and lower risk of cardiovascular disease. These positive effects may be explained by their high content of dietary fiber, complex carbohydrate, vitamins, minerals, polyunsaturated fatty acids, and phytochemicals. Current evidence suggests that both Mediterranean and vegetarian diets are consistently beneficial with respect to cardiovascular disease.
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Since identification of aspartate aminotransferase as the first cardiac biomarker in the 1950s, there have been a number of new markers used for myocardial damage detection over the decades. There have also been several generations of troponin assays, each with progressively increasing sensitivity for troponin detection. Accordingly, the "standard of care" for myocardial damage detection continues to change. The purpose of this paper is to review the clinical utility, biological mechanisms, and predictive value of these various biomarkers in contemporary clinical studies. ⋯ As of this writing, a fifth "next" generation troponin assay has now been cleared by the US Food and Drug Administration for clinical use in the USA for subjects presenting with suspected acute coronary syndromes. Use of these high-sensitivity assays has allowed for earlier detection of myocardial damage as well as greater negative predictive value for infarction after only one or two serial measurements. Recent algorithms utilizing these assays have allowed for more rapid rule-out of myocardial infarction in emergency department settings. In this review, we discuss novel assays available for the risk assessment of subjects presenting with chest pain, including both the "next generation" cardiac troponin assays as well as other novel biomarkers. We review the biological mechanisms for these markers, and explore the positive and negative predictive value of the assays in clinical studies, where reported. We also discuss the potential use of these new markers within the context of future clinical care in the modern era of higher sensitivity troponin testing. Finally, we discuss advances in new platforms (e.g., mass spectrometry) that historically have not been considered for rapid in vitro diagnostic capabilities, but that are taking a larger role in clinical diagnostics, and whose prognostic value and power promise to usher in new markers with potential for future clinical utility in acute coronary syndrome.
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Review Case Reports
Endovascular Management of Massive and Submassive Acute Pulmonary Embolism: Current Trends in Risk Stratification and Catheter-Directed Therapies.
Acute pulmonary embolism (PE) is a common condition associated with high morbidity and mortality. Prior studies have evaluated the role of systemic fibrinolysis and catheter-directed therapy (CDT) in the management of PE. In this review, we examine current data on risk stratification and the appropriate allocation of systemic fibrinolysis and CDT in acute PE patients with elevated risk of adverse outcomes. ⋯ Classification of pulmonary embolism is based on risk of adverse events, and relies on clinical parameters, imaging findings, and biomarkers. The synthesis of this data permits appropriate risk stratification of acute PE patients, and is the foundation upon which treatment decisions are made. While systemic thrombolytics remain the frontline therapy for hemodynamically unstable PE patients, studies have suggested that CDT has a significant promise as the primary modality for treating hemodynamically stable patients at increased risk for clinical decompensation and as an alternative therapy for hemodynamically unstable patients who may not tolerate systemic thrombolytics. The appropriate use of CDT in patients with acute PE is dependent on accurate risk stratification. CDT offers the potential to reduce excessive bleeding while maintaining the efficacy of systemic thrombolytics, but will require data from larger randomized trials to support its use prior to widespread adoption as the frontline therapy for PE in patients at elevated risk of adverse outcomes.