Δευτέρα, 19 Αυγούστου 2019

Sustainability of blood pressure reduction in black barbershops
Purpose of review The prevalence of hypertension (HTN) among non-Hispanic blacks increased from 41 to 55% with the release of the new 2017 ACC/AHA guidelines – the highest among any racial group. Non-Hispanic black men have less physician interaction and lower blood pressure (BP) treatment and control rates when compared with their female counterparts, necessitating community outreach. Here, we review the Los Angeles Barbershop Blood Pressure Study (LABBPS) which demonstrated a community-based approach involving pharmacists, physicians, and barbers could improve BP control rates among black men. Recent findings LABBPS was a cluster-randomized trial that evaluated both the efficacy and sustainability of a pharmacist-led HTN management program in which barbers promoted follow-up with pharmacists who prescribed antihypertensive therapy under collaborative practice agreements with intervention participant's primary care providers. After 6 months researchers observed a 21 mmHg greater fall in SBP among intervention group participants when compared with the control group participants who received ‘usual care.’ The 6-month extension phase of the study showed that the impressive BP reduction achieved was sustained with less pharmacist contact. Summary Multidisciplinary, community-based approaches to HTN management can be effective and are necessary to tackle the current disparity seen in BP control rates. The model developed in LABBPS represents one such approach. Correspondence to Ciantel A. Blyler, PharmD, Cedars-Sinai Medical Center, Smidt Heart Institute, 127 S. San Vicente Blvd., Ste. A3408, Los Angeles, CA 90048, USA. Tel: +1 310 425 2904; fax: +1 310 967 3818; e-mail: Ciantel.Blyler@cshs.org Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Vitamin D supplements and prevention of cardiovascular disease
Purpose of review The role of vitamin D supplementation for prevention of cardiovascular disease (CVD) outcomes has been rigorously studied only recently. This review briefly summarizes results from recent randomized controlled trials in the context of prior laboratory and epidemiologic data. Recent findings Randomized trials of vitamin D that included CVD outcomes, as well as two recently published large population-based trials that prespecified CVD as a primary endpoint (The Vitamin D Assessmentand The VITamin D and OmegA-3 TriaL), indicate that vitamin D supplementation does not decrease CVD incidence, when compared with placebo. Summary Evidence to date suggests that vitamin D supplementation in the general community does not reduce the risk of major cardiovascular events. Other trials are ongoing and future studies will explore additional CVD outcomes such as heart failure and assess high-risk populations such as those with chronic kidney disease. Correspondence to JoAnn E. Manson, MD, DrPH, Department of Medicine, Brigham and Women's Hospital, 900 Commonwealth Avenue, 3rd Fl, Boston, MA 02215, USA. Tel: +1 617 278 0871; fax: +1 617 731 3843; e-mail: jmanson@rics.bwh.harvard.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Genetic testing for aortopathies: primer for the nongeneticist
Purpose of review Although the majority of thoracic aortic aneurysms and dissections (TAD) in the overall population are mainly related to arterial hypertension and atherosclerosis, Heritable Thoracic Aortic Disease (HTAD) are increasingly recognized, especially in younger individuals. As fatal events in the setting of HTAD are preventable with timely detection and appropriate management, this review aims to provide an overview of the genetic basis of HTAD and practical recommendations for genetic evaluation in this setting. Recent findings Thanks in part to a number of important efforts to set up (inter)national networks and consortia for collecting clinical and genetic data from patients with these rare disorders, significant progress has been made in understanding the natural evolution of these disorders. These insights are now starting to enable the development of recommendations for the management of these patients. In addition, pathogenic variants in a number of new genes have been identified in HTAD patients. On the basis of more extensive genetic screening in cohorts of patients with TAD, it is becoming clear that there is no strict boundary between syndromal and nonsyndromal HTAD entities. It is, therefore, important to at least consider genetic evaluation, not only for patients presenting with syndromic forms but also for more isolated TAD. Finally, there are indications that we will -- up to a certain point -- soon be able to draw up a more precise policy for individual patients, based on the underlying genetic defects Summary Genetic evaluation in (young) patients with both syndromic and nonsyndromic forms of HTAD should be considered and is helpful for the development of more precise medicine. Correspondence to Julie De Backer, MD, PhD, Department of Cardiology and Center for Medical Genetics, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium. Tel: +32 9 332 56 27; e-mail: julie.debacker@ugent.be Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Type A aortic dissection complicated by malperfusion syndrome
Purpose of review Malperfusion is present in up to 40% of acute type A aortic dissections (ATAADs) and results in increased morbidity and mortality. This review presents different management strategies in patients with ATAAD and malperfusion to improve outcomes. Recent findings While the ideal management strategy of ATAAD complicated by malperfusion has yet to be determined, the literature provides evidence for additional techniques to be used in conjunction with central aortic repair to reduce mortality. Summary Recent findings support a role for initial reperfusion and delayed central aortic repair, although optimal management strategy remains debated. Correspondence to Bo Yang, MD, PhD, Department of Cardiac Surgery, University of Michigan, 1500 East Medical Center Drive, 5155 Frankel Cardiovascular Center, Ann Arbor, MI 48109, USA. E-mail: boya@med.umich.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Closing the gap between type A and type B aortic dissections
Purpose of review Given its rarity little is known about natural history, surgical indications, and results of acute non-A non-B dissections. With this review, we aim to review the current knowledge of this subject. Recent findings non-A non-B aortic dissections should be differentiated from type B aortic dissections. A strikingly high proportion of these patients have a complicate course requiring treatment and the mortality of patients treated with medical therapy is substantially higher compared to type B dissections. Surgical and endovascular treatment can be accomplished safety, with very good results in terms of mortality and morbidity also in the acute setting. Several treatments options are available including endovascular repair with thoracic endovascular aortic repair (TEVAR) associated with Chimney grafts or carotid to subclavian by pass, open arch replacement mainly by means of the frozen elephant trunk technique and hybrid arch repair with debranching of the supra-aortic vessel and zone 0 TEVAR. Summary considering the high rate of complication, the high mortality of patients managed medically and the safety of surgical and endovascular repair, early invasive treatment of non-A non-B dissections may be further considered. The treatment should be tailored to the morphology of the dissected aorta with TEVAR reserved to more distal lesions and open arch replacement with the FET technique for more proximal lesions. Correspondence to Davide Carino, MD, Department of Cardiovascular Surgery, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, Villarroel 170, 08036 Barcelona, Spain. Tel: +39 349 7207720; e-mail: davidecarino88@gmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Multiarterial coronary artery bypass grafting: is the radial artery fulfilling the unkept promise of the right internal thoracic artery?
Purpose of review The debate on the second best conduit for CABG is still intense. In this review, we discuss the role of the radial artery and the right internal thoracic artery (RITA) compared with saphenous vein grafts (SVG). Recent findings The recent RADIAL STUDY has been the first evidence based on randomized trials of a clinical benefit using a second arterial graft in CABG. On the other hand, the definitive 10-year results of the ART trial failed to show a clinical advantage associated with the use of bilateral internal thoracic artery (BITA). A thorough and contextualized analysis of this and other studies, however, may offer a different perspective. Summary Arterial conduits in CABG have shown better patency rates than SVG. Whether this leads to better clinical outcomes is still debated. In this setting, the radial artery and the RITA seem to offer a similar advantage, although with different indications and contraindications. Correspondence to Alessandro Affronti, MD, PhD, Division of Cardiac Surgery, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, Canada K1Y 4W7. Tel: +1 613 761 4893; fax: +1 613 761 5367; e-mail: alessandroaffronti@yahoo.it Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Thrombophilia evaluation in pulmonary embolism
Purpose of review Patients with pulmonary embolism commonly undergo thrombophilia evaluation for a variety of reasons including risk stratification for recurrent venous thromboembolism (VTE) and treatment planning. However, the utility of thrombophilia testing in many clinical scenarios remains unclear. This review evaluates current recommendations for thrombophilia testing described in consensus VTE guidelines, recent literature on the clinical application of these recommendations, novel genetic assessments for hereditary thrombophilias, and studies evaluating use of direct oral anticoagulants (DOACs) in VTE patients with thrombophilias. Recent findings Current VTE guidelines advise limited use of thrombophilia testing, recognizing that testing may be misinterpreted and frequently does not lead to a change in management. Testing and test results are not necessarily benign, are frequently misinterpreted, and can lead to increased anxiety in both patients and clinicians. Recent studies have offered innovative techniques to better align clinical practice with these recommendations as well as expanded genomic assessments to improve the scope and predictive value of thrombophilia testing. There is also emerging literature on the appropriateness of direct oral anticoagulant therapy for VTE patients with hereditary thrombophilias or antiphospholipid syndrome. Summary Thrombophilia testing in its current form does not significantly impact clinical management or improve outcomes for most VTE patients. Therefore, it should be employed judiciously and only in patients for whom it is likely to alter clinical management. Novel expanded genomic thrombophilia testing approaches and additional studies evaluating optimal anticoagulant treatment in various thrombophilia subpopulations will make thrombophilia testing more useful for patients moving forward. Correspondence to Jean M. Connors, MD, Hematology Division, Brigham and Women's Hospital, 75 Francis Street, SR322, Boston, MA 02115, USA. Tel: +1 617 732 5190; fax: +1 617 264 6388; e-mail: jconnors@partners.org Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

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