Current Cardiology Reviews - Volume 18, Issue 5, 2022

Syncope is a common clinical presentation defined as a transient loss of consciousness (TLOC) due to cerebral hypoperfusion, characterized by a rapid onset, short duration, and spontaneous complete recovery. Different clinical decision rules (CDRs) and risk stratification scores have been developed to predict short- and long-term risks for adverse outcomes after syncope. The central theme of these prediction systems is consistent with the ESC syncope guidelines. Initial assessment according to the ESC guideline is essential until an optimal and well-validated risk score is available. The focus should be accurate risk stratification to allow prevention of adverse outcomes and optimize the use of limited healthcare resources. In this review article, we summarize and critically appraise the evidence regarding the CDRs for patients presenting with syncope.

Obesity, a chronic disease established as a global epidemic by the World Health Organization, is considered a risk factor for atrial fibrillation (AF), the most common sustained cardiac arrhythmia, which has high morbidity and mortality. Although both obesity and AF are diseases associated with negative outcomes, studies have shown the presence of an obesity paradox, in which patients with a high body mass index (BMI) and AF have a better prognosis than patients with a normal BMI. Despite the fact that the mechanisms that lead to this paradox are still uncertain, adequate anticoagulation in obese patients seems to play an important role in reducing adverse events in this group. In this perspective article, the authors discuss the relationship between new oral anticoagulants (NOACs), namely, apixaban, edoxaban and rivaroxaban (factor Xa inhibitors) and dabigatran (direct inhibitor of thrombin), and the obesity paradox, seeking to deepen the understanding of the mechanism that leads to this paradox.

In 2020, as the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) pandemic spread rapidly throughout the world, scientists worked relentlessly to develop and test the safety and effectiveness of potential vaccines. Usually, the vaccine development process involves years of investigation and testing prior to gaining approval for use in practice. A pathogenic PF4-dependent syndrome, unrelated to the use of heparin therapy, may be manifested following the administration of viral vector vaccines. It leads to severe clot formation at unusual sites approximately in 1 out of 110.000 vaccinated persons. This side effect, although rare, represents a newly devastating clotting phenomenon manifested in otherwise healthy young adults, who are often female. An in-depth description of the specific biological mechanisms implicated in the syndrome is here summarized.

The management of sepsis requires the rapid administration of fluid to support blood pressure and tissue perfusion. Guidelines suggest that patients should receive 30 ml per kg of fluid over the first one to three hours of management. The next concern is to determine which patients need additional fluid. This introduces the concept of fluid responsiveness, defined by an increase in cardiac output following the administration of a fluid bolus. Dynamic tests, measuring cardiac output, identify fluid responders better than static tests. Passive leg raising tests provide an alternative approach to determine fluid responsiveness without administering fluid. However, one small randomized trial demonstrated that patients managed with frequent passive leg raising tests had a smaller net fluid balance at 72 hours and reduced requirements for renal replacement therapy and mechanical ventilation, but no change in mortality. A meta-analysis including 4 randomized control trials reported that resuscitation guided by fluid responsiveness does not improve mortality outcomes in patients with sepsis. Recent studies have demonstrated that the early administration of norepinephrine may improve outcomes in patients with sepsis. The concept of fluid responsiveness helps clinicians analyze the clinical status of patients, but this information must be integrated into the overall management of the patient. This review considers the use and benefit of fluid responsiveness tests to direct fluid administration in patients with sepsis.

Adaptation of cardiac muscle to regular exercise results in morphological and structural changes known as physiological cardiac hypertrophy, to which the Hippo signaling pathway might have contributed. Two major terminal effectors in the Hippo signaling pathway are Yes-associated protein (YAP) and its homolog transcriptional coactivator with PDZ-binding motif (TAZ). The latest studies have reported the role of YAP and TAZ in different life stages, such as in fetal, neonatal, and adult hearts. Their regulation might involve several mechanisms and effectors. One of the possible coregulators is exercise. Exercise plays a role in cardiomyocyte hypertrophic changes during different stages of life, including in aged hearts. YAP/TAZ signaling pathway has a role in physiological cardiac hypertrophy induced by exercise and is associated with cardiac remodelling. Thus, it can be believed that exercise has roles in activating the signaling pathway of YAP and TAZ in aged cardiomyocytes. However, the studies regarding the roles of YAP and TAZ during cardiomyocyte aging are limited. The primary purpose of this review is to explore the response of cardiovascular aging to exercise via signaling pathway of YAP and TAZ.

Background: The Fontan procedure is currently the mainstay therapy for single functional ventricles. However, with prolonged follow-up duration, various complications have been observed that seriously influence the quality of life of patients. Objectives: The aim of this meta-analysis is to compare the effectiveness of pharmacologic agents in improving exercise capacity in patients with Fontan circulation. Methods: This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement and has been registered in the International Prospective Register for Systematic Reviews database with registration no. 282352. Quality assessments of the included studies were assessed using the Strengthening Reporting of Observational Studies in Epidemiology (STROBE) statement. Results: Twelve studies met the predetermined inclusion criteria and were included in this metaanalysis. This meta-analysis found that treatment with bosentan significantly improved New York Heart Association Functional Class (NYHA FC) in Fontan patients (standard mean difference - 0.59, 95% CI -0.94 – -0.25; P=0.0008; I² = 1%). However, the use of bosentan (P=0.66) and sildenafil (P=0.13) did not show a significant improvement in the maximum rate of oxygen consumption (VO2 max). Conclusion: This meta-analysis shows that people with Fontan circulation may benefit from using bosentan as it decreases postexercise heart rate and improves NYHA FC and 6-minute walking test results. Therefore, indirectly improving exercise capacity. Nonetheless, considerable work is required to strengthen our knowledge in improving the exercise capacity of Fontan patients.

Background: Idiopathic pulmonary artery aneurysm is a rare disorder that has been reported in less than 50 cases. This complication is often asymptomatic, while the first manifestation can be severe hemoptysis or death. Case Presentation: A 36-year-old man presented to our institute with hemoptysis and fever. Dilated pulmonary artery trunk (5.5 cm) and the left pulmonary artery branch (6.90 cm) were discovered during a computed tomography angiogram scan in the patient's chest region. Therefore, the patient was diagnosed with a pulmonary artery aneurysm. According to the results of the tests requested for the patient, the cause of the patient's pulmonary artery aneurysm was not determined. Therefore, an idiopathic pulmonary artery aneurysm was proposed for the patient. Conclusion: Idiopathic pulmonary artery aneurysm poses a double diagnostic and therapeutic problem. The rarity of the disease, and the absence of specific clinical signs make diagnosis difficult.

Acute coronary syndrome is the main cause of mortality and morbidity worldwide and early diagnosis is a challenge for clinicians. Though cardiac Troponin, the most commonly used biomarker, is the gold standard for myocardial necrosis, it is blind for ischemia without necrosis. Therefore, ideal biomarkers are essential in the care of patients presenting with symptoms suggestive of cardiac ischemia. The ideal biomarker or group of biomarkers of atheromatous plaque formation, rupture and thrombosis for timely and accurate diagnosis of acute coronary syndrome is a current need. Therefore, we discuss the existing understanding and future of biomarkers of atheromatous plaque formation, rupture and thrombosis of acute coronary syndrome in this review. Keywords were searched from Medline, ISI, IBSS and Google Scholar databases. Further, the authors conducted a manual search of other relevant journals and reference lists of primary articles. The development of high-sensitivity troponin assays facilitates earlier exclusion of acute coronary syndrome, contributing to a reduced length of stay at the emergency department, and earlier treatment resulting in better outcomes. Although researchers have investigated biomarkers of atheromatous plaque formation, rupture and thrombosis to help early diagnosis of cardiac ischemia, most of them necessitate validation from further analysis. Among these biomarkers, pregnancy-associated plasma protein-A, intercellular adhesion molecule-1, and endothelial cell-specific molecule- 1(endocan) have shown promising results in the early diagnosis of acute coronary syndrome but need further evaluation. However, the use of a combination of biomarkers representing varying pathophysiological mechanisms of cardiac ischemia will support risk assessment, diagnosis and prognosis in these patients and this is the way forward.

It has been documented that Ca²⁺ overload and increased production of reactive oxygen species play a significant role in reperfusion injury (RI) of cardiomyocytes. Ischemia/reperfusion induces cell death as a result of necrosis, necroptosis, apoptosis, and possibly autophagy, pyroptosis and ferroptosis. It has also been demonstrated that the NLRP3 inflammasome is involved in RI of the heart. An increase in adrenergic system activity during the restoration of coronary perfusion negatively affected cardiac resistance to RI. Toll-like receptors are involved in RI of the heart. Angiotensin II and endothelin-1 aggravated ischemic/reperfusion injury of the heart. Activation of neutrophils, monocytes, CD4+ T-cells and platelets contributes to cardiac ischemia/reperfusion injury. Our review outlines the role of these factors in reperfusion cardiac injury.

Endothelial dysfunction, impaired implantation and placental insufficiency have been identified as mechanisms behind the development of pre-eclampsia, resulting in angiogenic factors’ alteration. Angiogenic imbalance is also associated with congenital heart defects, and this common physiologic pathway may explain the association between them and pre-eclampsia. This review aims to understand the physiology shared by these two entities and whether women with pre-eclampsia have an increased risk of fetal congenital heart defects (or the opposite). The present research has highlighted multiple vasculogenic pathways associated with heart defects and preeclampsia, but also epigenetic and environmental factors, contributing both. It is also known that fetuses with a prenatal diagnosis of congenital heart disease have an increased risk of several comorbidities, including intrauterine growth restriction. Moreover, the impact of pre-eclampsia goes beyond pregnancy as it increases the risk for following pregnancies and for diseases later in life in both offspring and mothers. Given the morbidity and mortality associated with these conditions, it is of foremost importance to understand how they are related and its causative mechanisms. This knowledge may allow earlier diagnosis, an adequate surveillance or even the implementation of preventive strategies.