Current Cardiology Reviews - Volume 14, Issue 1, 2018

Context: Atherosclerosis is a progressive pathological process and a leading cause of mortality worldwide. Clinical research and epidemiological studies state that atherosclerosis is caused by an amalgamation of metabolic and inflammatory deregulation involving three important pathological events including Endothelial Dysfunction (ED), Foam Cell Formation (FCF), and Vascular Smooth Muscle Cells (VSMCs) proliferation and migration. Objectives: Research in recent years has identified Metabolic Syndrome (MS), which involves factors such as obesity, insulin resistance, dyslipidemia and diabetes, to be responsible for the pathophysiology of atherosclerosis. These factors elevate oxidative stress and inflammation-induced key signalling molecules and various microRNAs (miRs). In present study, we have reviewed recently identified molecular targets in the pathophysiology of atherosclerosis. Methods: Scientific literature obtained from databases such as university library, PubMed and Google along with evidences from published experimental work in relevant journals has been summarized in this review article. Results: The molecular events and cell signalling implicated in atherogenic processes of ED, FCF and VSMCs hyperplasia are sequential and progressive, and involve cross talks at many levels. Specific molecules such as transcription factors, inflammatory cytokines and chemokines and miRs have been identified playing crucial role in most of the events leading to atherosclerosis. Conclusion: Studies associated with MS induced oxidative stress- and inflammation- mediated signalling pathways along with critical miRs help in better understanding of the pathophysiology of atherosclerosis. Several key molecules discussed in this review could be potent target for the prevention and treatment of atherosclerosis.

Background: Mitral para-prosthetic leaks are rare but major complications of mitral heart valve replacements. When they must be re-operated, they are burdened with high mortality rates. We proposed to review our surgical experience in terms of approach and type of operation carried out. Methods: Demographic, preoperative, intraoperative and postoperative characteristics of 34 patients benefited from a surgical treatment of mitral paravalvular leak, at the Brugmann University Hospital between 1996 and 2016, have been analysed retrospectively. We analysed the data to identify the risk factors of postoperative mortality. We then compared the data depending on the approach and the type of surgical treatment in order to compare the morbidity-mortality. Results: The postoperative mortality rate was 11.7%. The presence of endocarditis and increase in lactate dehydrogenase were predictive factors of mortality. Cardiac complications and acute kidney failure were significantly more common in the decease population. Direct mitral paravalvular leak suturing was more frequently performed on early apparition, anterior and isolated leaks, whereas a mitral heart valve replacement was most often performed to cure active primary endocarditis. The incidence of complications and mortality rates were identical according to the approach and the type of operation performed. A mitral para-prosthetic leak recurrence was observed in 33% of the cases. Conclusion: Surgical treatment of mitral para-prosthetic leaks is accompanied by a high mortality rate. The operative strategy plays a major role and can influence the morbidity-mortality encountered in those patients.

Background: Since the introduction of Antiretroviral Therapy (ART), the life expectancy and health quality for patients infected with Human Immunodeficiency Virus (HIV) have significantly improved. Nevertheless, as a result of not only the deleterious effects of the virus itself and prolonged ART, but also the effects of aging, cardiovascular diseases have emerged as one of the most common causes of death among these patients. Objective: The purpose of this review is to explore the new insights on the spectrum of Cardiovascular Disease (CVD) in HIV infection, with emphasis on the factors that contribute to the atherosclerotic process and its role in the development of acute coronary syndrome in the setting of infection. Methods: A literature search using PubMed, ScienceDirect and Web of Science was performed. Articles up to Mar, 2017, were selected for inclusion. The search was conducted using MeSH terms, with the following key terms: [human immunodeficiency virus AND (cardiovascular disease OR coronary heart disease) AND (antiretroviral therapy AND (cardiovascular disease OR coronary heart disease))]. Results: Clinical cardiovascular disease tends to appear approximately 10 years before in infected individuals, when compared to the general population. The pathogenesis behind the cardiovascular, HIV-associated complications is complex and multifactorial, involving traditional CVD risk factors, as well as factors associated with the virus itself - immune activation and chronic inflammation – and the metabolic disorders related to ART regimens. Conclusion: Determining the cardiovascular risk among HIV-infected patients, as well as targeting and treating conditions that predispose to CVD, are now emerging concerns among physicians.

Background: Inappropriate Sinus Tachycardia (IST) is a clinical syndrome characterized by a sinus heart rate inexplicably higher than one hundred beats per minute at rest that is associated with symptoms like palpitations, dyspnea or dizziness in the absence of primary causes of tachycardia. The diagnosis requires exclusion of other causes of tachycardia including medications/substances (such as anti-cholinergic, beta-blocker withdrawal, caffeine, and alcohol) or medical conditions (such as panic attacks, pulmonary embolism, fever, hyperthyroidism, hypovolemia, anemia, and pain). Methods: Work up should include an EKG to differentiate other causes of tachycardia, 24 hour- Holter monitor if indicated, serum thyroid levels, hemoglobin levels and toxicology screen. Electrophysiological studies are not routinely recommended, but should be considered in certain patients in whom concurrent supraventricular tachycardia is suspected. Conclusion: The underlying pathology in IST is yet to be completely understood. However, it is thought that the causes of IST can be broadly classified into two groups; either as an intrinsic increase in sinus node automaticity or an extrinsic cause. Among extrinsic causes, there is evolving evidence that IgG anti-β receptor antibodies are found in IST causing tachycardia. Managing patients with IST includes lifestyle modification, non-pharmacological and pharmacological interventions. Ivabradine has recently emerged as an effective treatment of IST and was shown to be superior to beta-blockers.

Background: Balloon angioplasty revolutionised percutaneous treatment for coronary artery disease four decades ago, but vessel-threatening dissections, elastic recoil and restenosis were major drawbacks to an otherwise successful long-lasting intervention. Subsequent advances with bare metal stents and then drug eluting stents followed, aiming to mitigate the risks of acute vessel closure and restenosis. However, stent implantation often necessitates dual antiplatelet therapy for a prolonged period of time, which in itself can lead to adverse outcomes, especially in the frail elderly population at higher risk of bleeding. More recently, bioabsorbable stents have been implemented in clinical practice enabling earlier intimal coverage of the stent and apposition. However, another addition to the armamentarium of percutaneous coronary intervention is the use of drug-coated balloons without the need for deploying any coronary stents or scaffolds. Drugcoated balloons are semi-compliant balloons coated with an antiproliferative agent that is rapidly released on contact with the vessel intima exerting an anti-restenotic effect. The absence of a metallic scaffold means that the need for antiplatelet therapy can potentially be negated in the longer term if required. In this article, we will review the history of percutaneous coronary intervention and the available evidence for the appropriate use of drug-coated balloons especially in the elderly population. Conclusion: We will conclude this review by demonstrating the potential use of drug-coated balloon rather percutaneous stenting through case examples.

Background: A common phenotype associated with heart failure is the development of cardiac hypertrophy. Cardiac hypertrophy occurs in response to stress, such as hypertension, coronary vascular disease, or myocardial infarction. The most critical pathophysiological conditions involved may include dilated hypertrophy, fibrosis and contractile malfunction. The intricate pathophysiological mechanisms of cardiac hypertrophy have been the core of several scientific studies, which may help in opening a new avenue in preventive and curative procedures. Objectives: To our knowledge from the literature, the development of cardiac remodeling and hypertrophy is multifactorial. Thus, in this review, we will focus and summarize the potential role of oxidative stress in cardiac hypertrophy development. Conclusion: Oxidative stress is considered a major stimulant for the signal transduction in cardiac cells pathological conditions, including inflammatory cytokines, and MAP kinase. The understanding of the pathophysiological mechanisms which are involved in cardiac hypertrophy and remodeling process is crucial for the development of new therapeutic plans, especially that the mortality rates related to cardiac remodeling/dysfunction remain high.

Background: Several risk factors including Ischemic heart disease, uncontrolled hypertension, high output Heart Failure (HF) from shunting through vascular hemodialysis access, and anemia, contribute to development of HF in patients with End-Stage Renal Disease (ESRD). Guidelinedirected medical and device therapy for Heart Failure with Reduced Ejection Fraction (HFrEF) has not been extensively studied and may have limited safety and efficacy in patients with ESRD. Results: Maintenance of interdialytic and intradialytic euvolemia is a key component of HF management in these patients but often difficult to achieve. Beta-blockers, especially carvedilol which is poorly dialyzed is associated with cardiovascular benefit in this population. Despite paucity of data, Angiotensin-converting Enzyme Inhibitors (ACEI) or Angiotensin II Receptor Blockers (ARBs) when appropriately adjusted by dose and with close monitoring of serum potassium can also be administered to these patients who tolerate beta-blockers. Mineralocorticoid receptors in patients with HFrEF and ESRD have been shown to reduce mortality in a large randomized controlled trial without any significantly increased risk of hyperkalemia. Implantable Cardiac-defibrillators (ICDs) should be considered for primary prevention of sudden cardiac death in patients with HFrEF and ESRD who meet the implant indications. Furthermore in anemic iron-deficient patients, intravenous iron infusion may improve functional status. Finally, mechanical circulatory support with leftventricular assist devices may be related to increased mortality risk and the presence of ESRD poses a relative contraindication to further evaluation of these devices.

Background: Prevention and treatment of dyslipidemias represent the key issues of Cardiovascular Disease (CVD) prophylaxis. Consequently, the effective management of different types of lipid disorders, including hypertriglyceridemia, should be a priority for the healthcare practitioners (e.g.: cardiology and endocrinology specialists, primary care physicians, dietitians, and pharmacists), who provide medical care, as well as for the patients, who receive this care, and need to be directly engaged in it, in order to improve their outcomes. The aim of this review is to facilitate the translation of current trends in hypertriglyceridemia management into a daily practice. The article focuses on the common causes and consequences of hypertriglyceridemia, and discusses diagnostic evaluation and therapeutic options for patients with high Triglyceride (TG) levels and CVD risk. Conclusion: This review presents the main practice-related strategies, based on the current guidelines for the management of dyslipidemias and CVD risk, according to the European Society of Cardiology (ESC), the European Atherosclerosis Society (EAS), and the American College of Cardiology (ACC)/American Heart Association (AHA), including both non-pharmacological, and pharmacological approaches. It also addresses the beneficial impact of pharmaceutical Care (PC) interventions on clinical outcomes of patients with lipid disorders and CVD risk (in light of Randomized Controlled Trials (RCT) data), and underlines the importance of close cooperation between physicians and pharmacists, who manage such patients.