Current Cardiology Reviews - Volume 17, Issue 4, 2021

Coronavirus disease 2019 (COVID-19) first emerged in a group of patients who presented with severe pneumonia in Wuhan, China, in December 2019. A novel virus, now called SARSCoV- 2 (Severe Acute Respiratory Syndrome Coronavirus-2), was isolated from lower respiratory tract samples. The current outbreak of infection has spread to over 100 countries and killed more than 340,000 people as of 25^th May, 2020. The predominant clinical manifestation of COVID-19 is a respiratory disease- ranging from mild flu-like symptoms to fulminant pneumonia and Acute Respiratory Distress Syndrome (ARDS). Patients with pre-existing cardiovascular risk factors are considered more susceptible to the virus, and these conditions are often worsened by the infection. Furthermore, COVID-19 infection has led to de novo cardiac complications, like acute myocardial injury and arrhythmias. In this review, we have focused on the cardiovascular manifestations of COVID-19 infection that have been reported in the literature so far. We have also outlined the effect of pre-existing cardiovascular disease as well as risk factors on the clinical course and outcomes of COVID-19 infection.

Hypertension is one of the leading risk factors for stroke, myocardial infarction and untimely death. The prevalence of hypertension is extremely high among the global population, and many of them depend on modern medicines to manage their blood pressure. The modern antihypertensive medications include angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), calcium channel blockers (CCBs), diuretics, beta-adrenergic blockers, direct renin inhibitors, direct-acting vasodilators, alpha-adrenergic blockers and centrally acting drugs that are associated with many harmful and undesirable effects. The patients may consider traditional herbal medicines as a good strategy to manage chronic conditions due to the reasons such as perceived failure of allopathic medicines, relatively high cost of allopathic medicines, social-cultural practices and/or herbal knowledge, poor access to medical facilities and safety concerns about modern medicines. Nigella sativa (Black seeds) has been used to treat various conditions, including hypertension, obesity, diabetes, cancer, etc. Hence, the antihypertensive potential of N. sativa is analyzed in this review. The literature was searched in databases including Medline/PMC/PubMed, Google Scholar, ScienceDirect, Directory of Open Access Journals (DOAJ) and reference lists to identify articles associated with antihypertensive properties of N.sativa. Numerous randomized controlled trials and animal studies reported that N.sativa has potential antihypertensive effects. Hence, N. sativa could be used effectively to manage patients with stage 1 hypertension, and the patients using modern antihypertensive medications could reduce their doses by adding N. sativa into their regimen as adjuvant therapy.

In December 2019, a novel COVID-19 infection caused by SARS-CoV-2 has emerged as a global emergency. In a few months, the pathogen has infected millions of people in the world. Primarily SARS-CoV-2 infects the pulmonary system which ultimately leads to ARDS and lung failure. The majority of patients develop milder symptoms but the infection turns severe in a huge number of people, which ultimately results in enhanced mortality in COVID-19 patients. Co-morbid conditions, primarily cardiovascular complications and diabetes, have been reported to show a strong correlation with COVID-19 severity. Further, the onset of myocardial injury secondary to pulmonary damage has been observed in critically ill patients who have never reported heart-related ailments before. Due to drastic health risks associated with virus infection, the unprecedented disruption in normal business throughout the world has caused economic misery. Apparently, newer treatments are urgently needed to combat the virus particularly to reduce the severity burden. Therefore, understanding the crosstalk between lung and heart during COVID-19 might give us better clarity for early diagnosis followed by appropriate treatment in patients with the likelihood of developing severe symptoms. Accordingly, the present review highlights the potential mechanisms that may explain the crosstalk between lung and heart so that effective treatment/management strategies can be evolved swiftly in this direction.

Menopause is associated with changes consistent with cardiovascular aging. The effects of cardiac disease are multifaceted, affecting endothelial function, coronary artery physiology and metabolic dysfunction leading to structural changes in the coronary anatomy. A systematic review of literature from 1986 to 2019 was conducted using PubMed and Google Scholar. The search was directed to retrieve papers that addressed the changes in cardiovascular physiology in menopause and the current therapies available to treat cardiovascular manifestations of menopause. The metabolic and clinical factors secondary to menopause, such as dyslipidemia, insulin resistance, fat redistribution and systemic hypertension, contribute to the accelerated risk for cardiovascular aging and disease. Atherosclerosis appears to be the end result of the interaction between cardiovascular risk factors and their accentuation during the perimenopausal period. Additionally, complex interactions between oxidative stress and levels of L-arginine and ADMA may also influence endothelial dysfunction in menopause. The increased cardiovascular risk in menopause stems from the exaggerated effects of changing physiology on the cardiovascular system affecting peripheral, cardiac and cerebrovascular beds. The differential effects of menopause on cardiovascular disease at the subclinical, biochemical and molecular levels form the highlights of this review.

There is considerable evidence that autophagy in cardiomyocytes is activated by hypoxia/ reoxygenation (H/R) or in hearts by ischemia/reperfusion (I/R). Depending upon the experimental model and duration of ischemia, increases in autophagy in this setting maybe beneficial (cardioprotective) or deleterious (exacerbate I/R injury). Besides the conundrum as to whether or not autophagy is an adaptive process, it is clearly regulated by a number of diverse molecules, including reactive oxygen species (ROS), various kinases, hydrogen sulfide (H2S) and nitric oxide (NO). The purpose of this review was to address briefly the controversy regarding the role of autophagy in this setting and to examine a variety of disparate molecules that are involved in its regulation.

Radiofrequency ablation for atrial fibrillation is currently the most effective rhythm control strategy. These procedures, although safe, pose a risk for potential exposure to radiation and can be time consuming. Radiation exposure during ablation can increase the risk of serious complications in both patients as well as physicians. The overall procedure time also increases with use of fluoroscopy. Advances in mapping technology, such as electroanatomic mapping, use of contact force technology, intracardiac echocardiography and use of versatile sheaths and catheters has vastly enhanced our ability to both shorten the procedure duration and minimize or even eliminate radiation exposure. Use of near zero fluoroscopy technique is increasingly gaining acceptance in electrophysiology centers. At this point, there is no uniform technique and various centers use individual techniques based on their expertise and availability of various tools. There is need for a uniform technique that is workflow friendly and widely accepted. There is a learning curve associated with this technique and efforts should be made to incorporate zero fluoroscopic technique for ablation as an essential part of electrophysiology training programs. In this paper, we present the strategy being practiced at two centers, that involves a series of steps, to either decrease or eliminate the use of fluoroscopy during atrial fibrillation ablation.

Understanding the similarities and differences between myocardial infarction with or without ST-segment elevation is an essential step for proper patients’ management in current practice. Both syndromes are caused by critical stenosis or total occlusion of coronary arteries (mostly due to thrombosis on atherosclerotic plaque), and manifest with a similar clinical presentation. Recent epidemiologic studies show that the relative incidence of ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) moves in an opposite fashion (decreasing and increasing respectively), with a prognosis that is worse at short-term follow-up for STEMI but comparable at long-term. Current management differs, as for STEMIs, immediate reperfusion is recommended, while for NSTEMIs, risk stratification is mandatory in order to stratify patients’ risk, and then decide the timing for coronary angiography. Periprocedural and technical aspects of the interventional management, as well as antithrombotic medications, are for the most similarly implemented in the two types of MI, with routine radial access, DES implant, and novel P2Y12 inhibitors representing the standard of care in both cases. The following review article aims to compare the two types of MI, with and without persistent STsegment elevation. The main purpose is to explore their similarities and differences and address areas of uncertainty with regards to clinical presentation, therapeutic management, and prognosis. The identification of high-risk NSTEMI patients is important as they may require an individualised approach that can substantially overlap with current STEMI recommendations, and their mortality remains high if their management is delayed.

Despite the technological advancements in the last 40 years, conditions such as refractory cardiogenic shock and cardiac arrest still present a very high mortality rate in real-world clinical practice. In this light, we have reviewed the techniques, indications, contraindications, and results of the socalled Veno-Arterial Extracorporeal Circulatory Membrane Oxygenation (VA-ECMO) in the adult population to evaluate the current results of this temporary cardio-pulmonary support as salvage and/or bridge therapy in the patient suffering from refractory cardiogenic shock or cardio-circulatory arrest. The results are encouraging, especially in the setting of refractory cardiogenic shock and in-hospital cardiac arrest. Among a selected population, the prompt institution of a VA-ECMO may radically change the prognosis by sustaining vital functions while looking for the leading cause or waiting for the reversal of the temporary cardio-respiratory negative condition. The future directions aim to standardized and shared protocols, miniaturization of the machines, and possibly the institution of specialized “ECMO teams” for in and the out-of-hospital institution of the tool.

Muscle-specific miRNAs, which are known as MyomiRs, are crucial regulatory elements for cardiovascular development. MyomiRs are abundantly expressed in the myocardium and regulate certain aspects of physiological and pathological processes in myocardiocytes, including cardiovascular development, myocardial remodeling, and arise for cardiovascular diseases through different mechanisms, such as epigenetic pathways. Clinical and experimental studies have confirmed the myomiRs as promising diagnostic biomarkers for the early diagnosis of cardiac disorders. In this review, we have summarized recent findings in the field of epigenetic modulations of myomiRs and cardiac regeneration associated with cardiac diseases.

Right atrial thrombus can originate from distal venous sources or can be iatrogenic, secondary to the placement of central venous catheters, atrial devices, or surgeries. One of the most common complications of Central Venous Catheters (CVCs) is thromboembolism, which can be either fixed to the right atrium or can be free-floating. Device-related Right Atrial Thrombosis (RAT) can result in catheter occlusion, vascular occlusion, infection, and pulmonary embolism. The true incidence of these complications is unknown because the diagnosis may not be considered in asymptomatic patients, and it might be missed by Transthoracic Echocardiography (TTE). In this literature review, we discuss iatrogenic etiologies of RAT that is complicated by pulmonary embolism. We highlight the importance of maintaining a high index of suspicion of iatrogenic RAT, possible complications, and its management.

Aortic dissection is an emergent medical condition, generally affecting the elderly, characterized by a separation of the aortic wall layers and subsequent creation of a pseudolumen that may compress the true aortic lumen. Predisposing factors mediate their risk by either increasing tension on the wall or by causing structural degeneration. They include hypertension, atherosclerosis, and a number of connective tissue diseases. If it goes undetected, aortic dissection carries a significant mortality risk; therefore, a high degree of clinical suspicion and a prompt diagnosis are required to maximize survival chances. Imaging methods, most commonly a CT scan, are essential for diagnosis; however, several studies have also investigated the effect of several biomarkers to aid in the detection of the condition. The choice of intervention varies depending on the type of dissection, with open surgical repair remaining of choice in those with type. In dissections, however, the role of conventional open surgery has considerably diminished in complicated type B dissections, with endovascular repair, a much less invasive technique, proving to be more effective. In uncomplicated type B dissections, where medical choice reigned supreme as the optimal intervention, endovascular repair is being explored as a viable option which may reduce long- term mortality outcomes, although the ideal intervention in this situation is far from settled.

Background: Aortic aneurysms are worrisome because of their predisposition to dissection and rupture. Beta-blockers are considered first-line therapy for aortic aneurysms. The following meta-analysis assesses if beta-blockers diminish aortic aneurysm growth. Methods: A literature search was performed to collect information on clinical trials that have assessed aortic aneurysm growth between beta-blockers and placebo. The primary endpoint was aortic aneurysm growth rate per year. A forest plot with a random-effects model was used for analysis. Results: Eight clinical trials were included in the analysis. Beta-blockers showed a statistically non-significant effect on aortic aneurysm growth (standard mean difference -0.44; 95% CI [-0.44, 0.00]). Conclusion: Beta-blockers do not significantly influence aortic aneurysm growth. Further studies are required to find a suitable medical therapy to reduce growth rates.

Background: Spontaneous coronary artery dissection (SCAD) is an under-recognized cause of acute coronary syndrome in women. Case Presentation: We present a 40-year-old female who presented with recurrent STEMI due to recurrent SCAD 10 days after the index presentation in a different coronary territory. She was successfully treated both times with drug eluting stents. MRI showed an evidence of transmural infarction but her ejection fraction was only mildly reduced. She had good short term outcome. Conclusion: High index of suspicion is crucial for early diagnosis and prompt medical and interventional management in patients with SCAD.