The Brain–Heart Connection and the Northridge Earthquake No abstract available

Cardiovascular Effects of Drugs Used to Treat Attention-Deficit/Hyperactivity Disorder Part 2: Impact on Cardiovascular Events and Recommendations for Evaluation and Monitoring A variety of psychostimulant and nonpsychostimulant medications have proven to be successful in reducing inattention, impulsivity, and hyperactivity in individuals with attention-deficit/hyperactivity disorder (ADHD). Psychostimulants used to treat ADHD include methylphenidate and related drugs and various amphetamine preparations. Nonpsychostimulant medications used to treat ADHD include atomoxetine and 2 α-2 adrenergic agonists: guanfacine extended-release and clonidine extended-release. The psychostimulants and atomoxetine have been shown, on average, to increase heart rate by 3–10 beats/min, systolic blood pressure by 3–8 mm Hg, and diastolic BP by 2–14 mm Hg. These drugs may also delay ventricular repolarization. The α-2 adrenergic agonists may reduce heart rate and BP. For these reasons, there is concern about the safety of psychostimulant and nonpsychostimulant medications in patients with ADHD. Studies in healthy children adolescents and adults have not consistently shown a disproportionately high risk of major adverse cardiovascular (CV) outcomes, including sudden unexpected death. Those with underlying CV disease have, in general, tolerated these drugs well. Certain high-risk groups have been identified who may benefit from cardiology consultation prior to drug initiation. Several American and Canadian professional societies have published guidelines for CV evaluation, management, and monitoring of patients with ADHD who are candidates for pharmacotherapy.

Heart Transplantation for Hepatitis C Virus Non-Viremic Recipients From Hepatitis C Virus Viremic Donors Multiple strategies have been implemented to increase the donor pool to avoid transplant wait-list mortality. The approval of highly effective direct-acting antiviral regimens for the treatment of hepatitis C virus (HCV) has enabled expansion of the donor pool by allowing the transplantation of organs from HCV-viremic donors to HCV-negative recipients. Multiple centers have recently published data on outcomes of heart transplantation from HCV-viremic heart donors to HCV-negative recipients, with acceptable posttransplant outcomes. However, areas of uncertainty remain, particularly in the long-term risks of intentional HCV transmission, as well as the possibility that sustained virologic response may not be achieved. In this article, we review the literature illustrating both the risks and benefits of transplantation of organs from HCV-viremic donors to HCV-negative recipients. We also present the data collected at our institution regarding this special patient population.

Parathyroid Hormone and Cardiac Electrophysiology: A Review Calcium has long been known to be essential to cardiac electrical activity. Parathyroid hormone (PTH) is the main regulator of serum calcium and is central to calcium homeostasis. Although there are significant data linking parathyroid disease states with changes in cardiac electrophysiology, most data have focused on how PTH modulates serum calcium to produce these effects. Close scrutiny of early literature demonstrates that the relationship between PTH and electrocardiographic changes is not straightforward, and numerous studies have linked PTH to arrhythmia. Basic science research has demonstrated that there is a basis for a direct role of PTH on cardiac electrophysiology outside of its effect on serum calcium. Later studies in secondary hyperparathyroidism indicate that PTH disturbances could have important implications for broad categories of patients with cardiovascular disease. The current review summarizes the existing literature on PTH and electrophysiology based on clinical and basic science studies of various parathyroid states, providing directions for future study.

Predictors of Adverse Outcomes in Patients With Arrhythmogenic Right Ventricular Cardiomyopathy: A Meta-Analysis of Observational Studies Arrhythmogenic cardiomyopathy (AC) is a hereditary disorder characterized by degeneration of cardiac myocytes and their subsequent replacement by fat and fibrous tissue primarily in the right ventricle. Our study aimed to systematically evaluate the impact of significant demographic, clinical, electrocardiographic, and echocardiographic factors in arrhythmic events in AC patients. MEDLINE and Cochrane library databases were manually searched without year or language restriction or any other limits until July 31, 2017. A pooled odds ratio with 95% confidence intervals was calculated for each of the risk factors. Our search retrieved 26 studies (n = 2680 patients, mean age: 37.9 years old, males: 51.9%) which were included in the quantitative synthesis. The most reliable predicting factors/parameters are the following: (1) male gender, (2) presyncope, (3) left ventricular dysfunction, (4) T-wave inversions in inferior leads, (5) proband status, (6) late potentials, (7) syncope, (8) inducibility at electrophysiological study, (9) right ventricular dysfunction, (10) epsilon waves, and (11) premature ventricular contractions greater than 1000/24 h. On the contrary, family history of sudden cardiac death, palpitations, premature ventricular contractions greater than 500/24 h, and T-wave inversions in right precordial leads fail to determine the outcome in this meta-analysis. In conclusion, multiple risk factors have been associated with arrhythmic events in AC patients. However, larger studies are needed to discriminate those patients who will benefit from implantable cardioverter defibrillators.

Precardiogenic Shock: A New Clinical Entity The pathogenesis of cardiogenic shock (CS) has evolved from an acute event due to a large myocardial infarction to a semiacute event due to rapid hemodynamic deterioration on a background of preexisting left ventricular systolic dysfunction. Pre-CS refers to the period of rapid hemodynamic deterioration that precedes overt CS with hypotension, inflammatory response, and end-organ failure. Mortality remains extremely high in CS and has not improved over the past decades. Pre-CS offers a unique opportunity to initiate early treatment that may result in better clinical outcomes. The present review addresses the definition, recognition, and management of pre-CS with the pharmacologic or mechanical support of the failing left ventricle.

Hearts and Minds: Stress, Anxiety, and Depression: Unsung Risk Factors for Cardiovascular Disease Anxiety, depression, and stress are exceedingly common in patients with cardiovascular disease (CVD). They increase the risk of cardiac events and are associated with much worse outcomes. A causal relationships exists between anxiety/depression and adverse cardiac events such as acute myocardial infarction and sudden cardiac death. Various treatments, including psychologic therapies and pharmacotherapy, can used to treat patients with these disorders. This review discusses the epidemiology, pathogenesis, and treatment options for patients with CVD who suffer from these conditions and argues that they should be treated as concomitant risk factors for CVD.

Cardiac Applications of Dual-Energy Computed Tomography Computed tomography is an established tool in the assessment of cardiac anatomy and function. As demonstrated by single photon emission computed tomography, positron emission tomography, and magnetic resonance, the noninvasive evaluation of coronary hemodynamics is an important step in guiding clinical management. Nevertheless, no single modality has been shown to accurately quantify coronary artery stenosis, evaluate an atherosclerotic plaque’s composition for embolic risk stratification, and assess myocardial perfusion. Although not a novel technology, dual-energy computed tomography has undergone significant advancements that have increased interest in this modality’s potential clinical cardiac applications. Albeit still in the early stages of development, one can expect additional clinical studies to further develop this important tool for cardiac imaging as more institutions acquire dual-energy compatible scanners.

Angiopoietin-Like 3 Protein Inhibition: A New Frontier in Lipid-Lowering Treatment Angiopoietin-like 3 protein (ANGPTL3) is an inhibitor of both lipoprotein lipase and endothelial lipase in humans. Population studies indicate a relationship between loss of function mutations in ANGPTL3 and favorable reductions in triglycerides and non- high-density lipoprotein cholesterol. In addition, loss of function mutations is associated with a reduced risk of coronary artery disease. Whereas ANGPTL3’s role in human lipid metabolism has yet to be fully clarified, it is unlikely that ANGPTL3 impacts cholesterol uptake via the low-density lipoprotein-receptor, unlike the proprotein convertase subtilisin/kexin9 inhibitors. In contrast to other forms of lipid-lowering therapy, ANGPTL3 inhibition may improve insulin sensitivity. The promise of this new therapy, particularly its independence from the low-density lipoprotein-receptor, has prompted the creation of a monoclonal antibody inhibitor; evinacumab. Evinacumab has shown favorable lipid-lowering action in both human and mouse models. Efficacy trials are currently ongoing and will be completed in the near future. In addition, ANGPTL3 inhibition via an antisense oligonucleotide was performed in healthy human subjects, which resulted in a dose-dependent reduction in circulating ANGPTL3 levels and an antiatherogenic lipid profile. When tested in mouse models, administration of the antisense oligonucleotide caused a reduction in progression of atherosclerosis. Further investigation is required to evaluate the efficacy, safety and net benefit of clinical ANGPTL3 inhibition before it can be accepted into clinical practice.