Evaluating the efficacy and safety of mavacamten in hypertrophic cardiomyopathy: A systematic review and meta-analysis focusing on qualitative assessment, biomarkers, and cardiac imaging

BACKGROUND

Hypertrophic Cardiomyopathy (HCM) is a complex cardiac condition characterized by hypercontractility of cardiac muscle leading to a dynamic obstruction of left ventricular outlet tract (LVOT). Mavacamten, a first-in-class cardiac myosin inhibitor, is increasingly being studied in randomized controlled trials. In this meta-analysis, we aimed to analyse the efficacy and safety profile of Mavacamten compared to placebo in patients of HCM.

METHOD

We carried out a comprehensive search in PubMed, Cochrane, and clinicaltrials.gov to analyze the efficacy and safety of mavacamten compared to placebo from 2010 to 2023. To calculate pooled odds ratio (OR) or risk ratio (RR) at 95% confidence interval (CI), the Mantel-Haenszel formula with random effect was used and Generic Inverse Variance method assessed pooled mean difference value at a 95% CI. RevMan was used for analysis. P<0.05 was considered significant.

RESULTS

We analyzed five phase 3 RCTs including 609 patients to compare mavacamten with a placebo. New York Heart Association (NYHA) grade improvement and KCCQ score showed the odds ratio as 4.94 and 7.93 with p<0.00001 at random effect, respectively. Cardiac imaging which included LAVI, LVOT at rest, LVOT post valsalva, LVOT post-exercise, and reduction in LVEF showed the pooled mean differences for change as -5.29, -49.72, -57.45, -36.11, and -3.00 respectively. Changes in LVEDV and LVMI were not statistically significant. The pooled mean difference for change in NT-proBNP and Cardiac troponin-I showed 0.20 and 0.57 with p<0.00001. The efficacy was evaluated in 1) A composite score, which was defined as either 1·5 mL/kg per min or greater increase in peak oxygen consumption (pVO2) and at least one NYHA class reduction, or a 3·0 mL/kg per min or greater pVO2 increase without NYHA class worsening and 2) changes in pVO2, which was not statistically significant. Similarly, any treatment-associated emergent adverse effects (TEAE), treatment-associated serious adverse effects (TSAE), and cardiac-related adverse effects were not statistically significant.

CONCLUSION

Mavacamten influences diverse facets of HCM comprehensively. Notably, our study delved into the drug's impact on the heart's structural and functional aspects, providing insights that complement prior findings. Further large-scale trials are needed to evaluate the safety profile of Mavacamten.

Long-Term Outcomes of Women With Peripartum Cardiomyopathy Having Subsequent Pregnancies

BACKGROUND

Long-term maternal outcomes of subsequent pregnancies (SSPs) in patients with peripartum cardiomyopathy (PPCM) have not been analyzed.

OBJECTIVES

The goal of this study was to evaluate the long-term survival of SSPs in women with PPCM.

METHODS

We conducted a retrospective review of 137 PPCMs in the registry. The clinical and echocardiographic findings were compared between the recovery group (RG) and nonrecovery group (NRG), defined as left ventricular ejection fraction ≥50% and <50% after an index of pregnancy, respectively.

RESULTS

Forty-five patients with SSPs were included with a mean age of 27.0 ± 6.1 years, 80% were of African American descent, and 75.6% from a low socioeconomic background. Thirty (66.7%) women were in the RG. Overall, SSPs were associated with a decrease in mean left ventricular ejection fraction from 45.1% ± 13.7% to 41.2% ± 14.5% (P = 0.009). At 5 years, adverse outcomes were significantly higher in the NRG compared with the RG (53.3% vs 20%; P = 0.04), driven by relapse PPCM (53.3% vs 20.0%; P = 0.03). Five-year all-cause mortality was 13.33% in the NRG compared with 3.33% in the RG (P = 0.25). At a median follow-up of 8 years, adverse outcomes and all-cause mortality rates were similar in the NRG and RG (53.3% vs 33.3% [P = 0.20] and 20% vs 20%, respectively).

CONCLUSIONS

Subsequent pregnancies in women with PPCM are associated with adverse events. The normalization of left ventricular function does not guarantee a favorable outcome in the SSPs.

Filtering Crosstalk from Bath Non-Markovianity via Spacetime Classical Shadows

From an open system perspective non-Markovian effects due to a nearby bath or neighboring qubits are dynamically equivalent. However, there is a conceptual distinction to account for: neighboring qubits may be controlled. We combine recent advances in non-Markovian quantum process tomography with the framework of classical shadows to characterize spatiotemporal quantum correlations. Observables here constitute operations applied to the system, where the free operation is the maximally depolarizing channel. Using this as a causal break, we systematically erase causal pathways to narrow down the progenitors of temporal correlations. We show that one application of this is to filter out the effects of crosstalk and probe only non-Markovianity from an inaccessible bath. It also provides a lens on spatiotemporally spreading correlated noise throughout a lattice from common environments. We demonstrate both examples on synthetic data. Owing to the scaling of classical shadows, we can erase arbitrarily many neighboring qubits at no extra cost. Our procedure is thus efficient and amenable to systems even with all-to-all interactions.

Qualitative and Quantitative Effects of PCSK9 Inhibitors in familial Hypercholesterolemia: a Synthetic Review

Familial hypercholesterolemia (FH) is an autosomal dominant disease caused most commonly by mutations in the gene coding for LDL receptors. This results in increased circulating cholesterol, and clinical consequences of premature stroke, myocardial infarction, etc. FH remains underdiagnosed and thus undertreated, leading to a high health care burden. A newer group of agents, the PCSK9 inhibitors, effectively reduces plasma cholesterol, especially when combined with other lipid lowering agents. The purpose of this narrative review is to synthesize all existing qualitative and quantitative data on the utility of PCSK9 inhibitors in familial hypercholesterolemia, in order to clarify standards of care and identify areas needing further research. Through PubMed/MEDLINE keyword searching, we identified 12 existing randomized controlled trials comparing PCSK9 inhibitor to placebo in FH patients, and pooled their outcomes across a total 2533 patients. We also reviewed quantitative effect on ASCVD outcomes and cost/benefit ratios. In FH patients, PCSK9 inhibitors caused a mean LDL reduction of -49.1%, compared to -3.5% with placebo (weighted average was calculated to account for different study sizes). These findings are comparable to trial results in the non-FH ASCVD population. However, there are no data on PCSK9 inhibitors' effect on hard cardiovascular outcomes in FH. Furthermore, in order for PCSK9 inhibitors to qualify as high-value care, price must be significantly reduced or LDL goals increased. PCSK9 inhibitors are potent reducers of LDL in FH patients. However, dedicated randomized trials are needed to assess whether this translates into statistically significant ASCVD prevention long-term.

Flow-driven right-to-left cardiac shunting in a patient with carcinoid heart disease and patent foramen ovale without elevated right atrial pressure: a case report and literature review

Background

Carcinoid heart disease is present in approximately 20% of the patients with carcinoid syndrome and is associated with poor prognosis. It usually manifests with right-sided valvular involvement including tricuspid insufficiency and pulmonary stenosis. Patent foramen ovale (PFO) is present in approximately 50% of the patients with carcinoid heart disease which is twice higher than the general population. Right-to-left shunting through a PFO can occur either due to higher right atrial pressure than left (pressure-driven) or when the venous flow is directed towards the PFO (flow-driven) in the setting of normal intracardiac pressures. We report a rare case of flow-driven right-to-left atrial shunting via PFO in a patient with carcinoid heart disease.

Case summary

A 54-year-old male with a metastatic neuroendocrine tumour to liver presented with progressive shortness of breath for 5 months. Patient was found to be hypoxic with oxygen saturation of 78% and examination revealed a holosystolic murmur. Arterial blood gas showed oxygen tension of 43 mmHg. A transthoracic and transoesophageal echocardiogram showed aneurysmal inter-atrial septum with a PFO, severe tricuspid regurgitation directed anteriorly towards the inter-atrial septum leading to a marked right-to-left shunt. Right heart catheterization showed right atrial pressure of 8 mmHg, mean pulmonary artery pressure of 12 mmHg, and normal oxygen saturations in the right atrium, right ventricle, and pulmonary arteries. The patient then underwent closure of the PFO along with tricuspid valve and pulmonary valve replacement at an experienced cardiovascular surgical centre and has been asymptomatic since.

Conclusion

Right-to-left shunting through a PFO in patients with normal right atrial pressure can be successfully treated with closure of the PFO. Thus, understanding the mechanism of intracardiac shunts is important to accurately diagnose and treat this rare and fatal condition.

Ischemic and bleeding outcomes of triple therapy in patients on chronic anticoagulation undergoing percutaneous coronary intervention: A meta-analysis of randomized trials

Background

Triple therapy (TT) that includes oral anticoagulation and dual antiplatelet therapy is recommended in patients who are on chronic anticoagulation and undergo percutaneous coronary intervention (PCI). The randomized clinical trials (RCTs) comparing the effectiveness and safety of TT compared to double therapy (DT), which consists of an oral anticoagulation and one of the P2Y12 inhibitors, have shown increased risk of bleeding; however, none of the individual studies were powered to show a difference in ischemic outcomes. To compare the clinical outcomes of TT and DT, we performed this meta-analysis of RCTs.

Methods

Electronic search of PubMed, EMBASE and Cochrane CENTRAL databases was performed for RCTs comparing TT and DT in patients who were on oral anticoagulation (Vitamin K antagonist or non-vitamin K antagonist oral anticoagulant) who underwent PCI. All-cause and cardiovascular mortality, myocardial infarction (MI), stroke, stent thrombosis (ST) and TIMI major and minor bleeding were the major outcomes.

Results

An analysis of 5 trials including 10,592 total patients showed that TT, compared to DT, resulted in non-significant difference in risk of all-cause [odds ratio (OR); 1.14;95% confidence interval (CI):(0.80–1.63); P = 0.46) and cardiovascular mortality [1.43(0.58–3.36); P = 0.44], MI [0.88 (0.64–1.21); P = 0.42], stroke [1.10(0.75–1.62); P = 0.63] and ST [0.82(0.46–1.45); P = 0.49]. TT, compared to DT resulted in higher risk of TIMI major bleeding [1.61(1.09–2.37); P = 0.02], TIMI minor bleeding [1.85(1.23–2.79); P = 0.003] and TIMI major and minor bleeding [1.81 (1.38–2.38); P < 0.0001; I² = 52%].

Conclusion

Compared to DT, the patients receiving TT are at a higher risk of major and minor bleeding with no survival benefit or impact on thrombotic outcomes.

Acute De Novo Multivessel Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is an important cause of acute coronary syndrome, especially in young women. Recurrent SCAD can be due to extension of dissection or de novo dissection of unrelated vessel. The authors present a case of acute de novo recurrent SCAD treated conservatively and with coronary intervention. (Level of Difficulty: Intermediate.)

Quantum work statistics and resource theories: Bridging the gap through Rényi divergences

The work performed on or extracted from a nonautonomous quantum system described by means of a two-point projective-measurement approach is a stochastic variable. We show that the cumulant generating function of work can be recast in the form of quantum Rényi-α divergences, and by exploiting the convexity of this cumulant generating function, derive a single-parameter family of bounds for the first moment of work. Higher order moments of work can also be obtained from this result. In this way, we establish a link between quantum work statistics in stochastic approaches and resource theories for quantum thermodynamics, a theory in which Rényi-α divergences take a central role. To explore this connection further, we consider an extended framework involving a control switch and an auxiliary battery, which is instrumental to reconstructing the work statistics of the system. We compare and discuss our bounds on the work distribution to findings on deterministic work studied in resource-theoretic settings.

Who benefits from percutaneous closure of patent foramen ovale vs medical therapy for stroke prevention? In-depth and updated meta-analysis of randomized trials

BACKGROUND

A few randomized clinical trials (RCT) and their meta-analyses have found patent foramen ovale closure (PFOC) to be beneficial in prevention of stroke compared to medical therapy. Whether the benefit is extended across all groups of patients remains unclear.

AIM

To evaluate the efficacy and safety of PFOC vs medical therapy in different groups of patients presenting with stroke, we performed this meta-analysis of RCTs.

METHODS

Electronic search of PubMed, EMBASE, Cochrane Central, CINAHL and ProQuest Central and manual search were performed from inception through September 2018 for RCTs. Ischemic stroke (IS), transient ischemic attack (TIA), a composite of IS, TIA and systemic embolism (SE), mortality, major bleeding, atrial fibrillation (AF) and procedural complications were the major outcomes. Random-effects model was used to perform analyses.

RESULTS

Meta-analysis of 6 RCTs including 3560 patients showed that the PFOC, compared to medical therapy reduced the risk of IS [odds ratio: 0.34; 95% confidence interval: 0.15-0.78; P = 0.01] and the composite of IS, TIA and SE [0.55 (0.32-0.93); P = 0.02] and increased the AF risk [4.79 (2.35-9.77); P < 0.0001]. No statistical difference was observed in the risk of TIA [0.86 (0.54-1.38); P = 0.54], mortality [0.74 (0.28-1.93); P = 0.53] and major bleeding [0.81 (0.42-1.56); P = 0.53] between two strategies. Subgroup analyses showed that compared to medical therapy, PFOC reduced the risk of stroke in persons who were males, ≤ 45 years of age and had large shunt or atrial septal aneurysm.

CONCLUSION

In certain groups of patients presenting with stroke, PFOC is beneficial in preventing future stroke compared to medical therapy.

Electrocardiographic findings in peripartum cardiomyopathy

Background

There is limited data on electrocardiographic (ECG) abnormalities and their prognostic significance in women with peripartum cardiomyopathy (PPCM). We sought to characterize ECG findings in PPCM and explore the association of ECG findings with myocardial recovery and clinical outcomes.

Hypothesis

We hypothesized that ECG indicators of myocardial remodeling would portend worse systolic function and outcomes.

Methods

Standard 12‐lead ECGs were obtained at enrollment in the Investigations of Pregnancy‐Associated Cardiomyopathy study and analyzed for 88 women. Left ventricular ejection fraction (LVEF) was measured by echocardiography at baseline, 6 months, and 12 months. Women were followed for clinical events (death, mechanical circulatory support, and/or cardiac transplantation) until 1 year.

Results

Half of women had an “abnormal” ECG, defined as atrial abnormality, ventricular hypertrophy, ST‐segment deviation, and/or bundle branch block. Women with left atrial abnormality (LAA) had lower LVEF at 6 months (44% vs 52%, P = 0.02) and 12 months (46% vs 54%, P = 0.03). LAA also predicted decreased event‐free survival at 1 year (76% vs 97%, P = 0.008). Neither left ventricular hypertrophy by ECG nor T‐wave abnormalities predicted outcomes. A normal ECG was associated with recovery in LVEF to ≥50% (84% vs 49%, P = 0.001) and event‐free survival at 1 year (100% vs 85%, P = 0.01).

Conclusions

ECG abnormalities are common in women with PPCM, but a normal ECG does not rule out the presence of PPCM. LAA predicted lower likelihood of myocardial recovery and event‐free survival, and a normal ECG predicted favorable event‐free survival.

Aldosterone Antagonist Therapy and Mortality in Patients With ST-Segment Elevation Myocardial Infarction Without Heart Failure: A Systematic Review and Meta-analysis

IMPORTANCE

Treatment with aldosterone antagonists is recommended and has been shown to have beneficial effects in patients with ST-segment elevation myocardial infarction (STEMI) and left ventricular ejection fraction (LVEF) less than 40%. However, the role of aldosterone antagonists in patients with ejection fraction greater than 40% or without congestive heart failure is not well known.

OBJECTIVES

To perform a systematic review and meta-analysis using standard techniques to determine the role of therapy with aldosterone antagonists in this patient population.

DATA SOURCES

PubMed, Embase, CINAHL, and Cochrane Central databases were searched and a manual search for relevant references from the selected articles and published reviews was performed from database inception through June 2017.

STUDY SELECTION

Randomized clinical trials that evaluated treatment with aldosterone antagonists in patients with STEMI without clinical heart failure or LVEF greater than 40% were included.

DATA EXTRACTION AND SYNTHESIS

Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used to conduct and report the meta-analysis, which used a random-effects model. Two investigators independently performed the database search and agreed on the final study selection. A manual search was performed for relevant references from the selected articles and published reviews.

MAIN OUTCOMES AND MEASURES

The outcomes analyzed were mortality, new congestive heart failure, recurrent myocardial infarction, ventricular arrhythmia, and changes in LVEF, serum potassium level, and creatinine level at follow-up.

RESULTS

In all, 10 randomized clinical trials with a total of 4147 unique patients were included in the meta-analysis. In patients who presented with STEMI without heart failure, treatment with aldosterone antagonists compared with control was associated with lower risk of mortality (2.4% vs 3.9%; odds ratio [OR], 0.62; 95% CI, 0.42-0.91; P = .01) and similar risks of myocardial infarction (1.6% vs 1.5%; OR, 1.03; 95% CI, 0.57-1.86; P = .91), new congestive heart failure (4.3% vs 5.4%; OR, 0.82; 95% CI, 0.56-1.20; P = .31), and ventricular arrhythmia (4.1% vs 5.1%; OR, 0.76; 95% CI, 0.45-1.31; P = .33). Similarly, treatment with aldosterone antagonists compared with control was associated with a small yet significant increase in LVEF (mean difference, 1.58%; 95% CI, 0.18%-2.97%; P = .03), a small increase in serum potassium level (mean difference, 0.07 mEq/L; 95% CI, 0.01-0.13 mEq/L; P = .02), and no change in serum creatinine level (standardized mean difference, 1.4; 95% CI, -0.43 to 3.24; P = .13).

CONCLUSIONS AND RELEVANCE

Treatment with aldosterone antagonists is associated with a mortality benefit in patients with STEMI with LVEF greater than 40% or without heart failure.

Reduction of vascular complication rates from femoral artery access in contemporary women undergoing cardiac catheterization

BACKGROUND

Femoral arterial access (FAA) during diagnostic coronary angiography (CAG) and percutaneous coronary interventions (PCI) are associated with several vascular complications (VC). VC rate in our experience a decade ago was 3.02% and higher in women (4.7% in women, and 1.67% in men, p < 0.0006), with an OR of 2.81 (95% CI: 1.51-5.22).

METHODS

Patients who underwent CAG and PCI utilizing FAA (n = 2617) were separated into Period 1 (2005 to 2008; 1970 patients; Male 1045; Female 925) and Period 2 (2016-2017; 647 patients; Male 357; Female 290). FA access was preceded by anatomic FA localization during Period 1 vs. additional fluoroscopic marking of femoral head during Period 2. Ultrasound guidance was not utilized during either period. VCs were defined as hematoma>3 cm, major bleeding requiring blood transfusion or hemoglobin drop >2 g, retroperitoneal bleed, pseudoaneurysm, AV fistula, arterial thrombosis, distal embolism, dissection, and transient limb ischemia.

RESULTS

Rate of VCs did not differ from Periods 1 to 2 (2.44% vs. 2.32%, p = 1.0). An elevated rate of VCs experienced by women in Period 1 (Female 3.68% vs. Male 1.34%, p < 0.05) is no longer noted in Period 2(Female 2.07% vs. Male 2.52%, p = 0.79). Vascular closure device (VCD) use was protective in both Periods 1 and 2.

CONCLUSIONS

The use of fluoroscopic marking of femoral head prior to access, smaller sheath size, and being a high femoral volume center may have contributed to the reduced incidence of VCs in women. VCD utilization is continuing to reduce VC rates in both men and women.

Total sulfane sulfur bioavailability reflects ethnic and gender disparities in cardiovascular disease

Hydrogen sulfide (H₂S) has emerged as an important physiological and pathophysiological signaling molecule in the cardiovascular system influencing vascular tone, cytoprotective responses, redox reactions, vascular adaptation, and mitochondrial respiration. However, bioavailable levels of H₂S in its various biochemical metabolite forms during clinical cardiovascular disease remain poorly understood. We performed a case-controlled study to quantify and compare the bioavailability of various biochemical forms of H₂S in patients with and without cardiovascular disease (CVD). In our study, we used the reverse-phase high performance liquid chromatography monobromobimane assay to analytically measure bioavailable pools of H₂S. Single nucleotide polymorphisms (SNPs) were also identified using DNA Pyrosequencing. We found that plasma acid labile sulfide levels were significantly reduced in Caucasian females with CVD compared with those without the disease. Conversely, plasma bound sulfane sulfur levels were significantly reduced in Caucasian males with CVD compared with those without the disease. Surprisingly, gender differences of H₂S bioavailability were not observed in African Americans, although H₂S bioavailability was significantly lower overall in this ethnic group compared to Caucasians. We also performed SNP analysis of H₂S synthesizing enzymes and found a significant increase in cystathionine gamma-lyase (CTH) 1364 G-T allele frequency in patients with CVD compared to controls. Lastly, plasma H₂S bioavailability was found to be predictive for cardiovascular disease in Caucasian subjects as determined by receiver operator characteristic analysis. These findings reveal that plasma H₂S bioavailability could be considered a biomarker for CVD in an ethnic and gender manner. Cystathionine gamma-lyase 1346 G-T SNP might also contribute to the risk of cardiovascular disease development.

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Baseline plasma sulfide metabolite levels are significantly different in an ethnic dependent manner.

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Reductions in sulfide metabolites are predictive of cardiovascular disease in an ethnic dependent manner.

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Differences in acid labile versus bound sulfane sulfur metabolites during cardiovascular disease are gender dependent.

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Single nucleotide polymorphism of CTH 1364 G>T is significantly associated with increased cardiovascular disease.

Acute cardiac disease in a patient with hyper-IgE syndrome

Summary

We describe the case of a 24-year-old male with hyper-IgE syndrome (HIES) which was diagnosed at 4 years of age and died from a very rare cardiac complication. He had typical clinical and laboratory manifestations of HIES, including total serum IgE as high as > 100,000 IU/mL. Stem cell transplantation was not available. During the 20-year follow-up, he suffered numerous various infections of the skin and deep organs, partial lung resection, as well as multiple bone fractures. At age 24, he developed acute decompensated heart failure associated with elevated serum troponin I and brain natriuretic protein. Two-dimensional echocardiogram revealed global hypokinesis of the left ventricle with estimated ejection fraction 20-25%, and catheterization revealed ectasia of multiple coronary arteries. Endomyocardial biopsy showed lymphocytic myocarditis, focal necrosis, mild fibrosis, and myxoid degeneration, but cultures were negative. The patient improved on corticosteroid therapy and was discharged on heart failure therapy and external defibrillator. Six weeks later, he developed supraventricular tachycardia and persistent global hypokinesis and was treated with amiodarone. A trial of intravenous immunoglobulin was initiated and was repeated as outpatient every four weeks for four times. However, his cardiac function did not improve and he developed severe hypotension and pulseless electrical activity arrest. Resuscitation was unsuccessful. To the best of our knowledge, this is the first reported case of HIES complicated with lymphocytic myocarditis. Both immunologists and cardiologists need to be aware of such a complication and practice caution in using immunosuppressants when the patient's immune status is markedly compromised.

Gender-based outcomes of bivalirudin versus heparin in patients undergoing percutaneous coronary interventions: Meta-analysis of randomized controlled trials

OBJECTIVES

We aimed to perform a gender-based meta-analysis of the outcome of bivalirudin versus heparin in patients undergoing percutaneous coronary interventions (PCI).

BACKGROUND

Bivalirudin has been shown to decrease major bleeding when compared to heparin ± glycoprotein IIb/IIIa inhibitors (GPI) in patients undergoing PCI. It is unclear, however, if those differences in outcomes are the same for men and women.

METHODS

We included randomized controlled trials (RCTs) that compared bivalirudin to heparin with or without GPI in patients undergoing PCI and reported outcome data that were stratified by gender. Random effect model was used to pool odds ratio (OR) and 95% confidence intervals (CI).

RESULTS

We included 9 trials with 33,224 patients. Bivalirudin decreased major bleeding when compared to heparin plus routine GPI in both men (OR: 0.51, P < 0.001) and women (OR: 0.55, P < 0.001). However, when GPI were used selectively with heparin, the bleeding lowering effect of bivalirudin was statistically significant in men (OR: 0.69, P = 0.02) but not in women (OR: 0.71, P = 0.21). When compared to heparin ± GPI, there was a nonstatistically significant trend toward lower all-cause mortality with bivalirudin in both men (OR: 0.76, P = 0.055) and women (OR: 0.79, P = 0.21). There were no significant differences in major adverse cardiovascular events between heparin and bivalirudin in both men and women.

CONCLUSION

Bivalirudin decreases major bleeding in both men and women when compared to heparin plus routine GPI. However, when compared to heparin alone, the bleeding lowering benefit of bivalirudin is less evident in women. © 2017 Wiley Periodicals, Inc.

Early-Stage Loeffler's Endocarditis with Isolated Right Ventricular Involvement: Management, Long-Term Follow-Up, and Review of Literature

Loeffler's endocarditis is a clinical condition characterized by combination of three key findings: unexplained prolonged and marked eosinophilia (>1500 eosinophils/mm(3) ), absence of a primary cause of hypereosinophilia, and evidence of eosinophil-mediated organ damage. We report a case of a 55-year-old African American male with symptoms of heart failure. Hematology showed white blood cell count of 17 670/mm(3) with 63% eosinophils and an absolute eosinophil count of 11 133/mm(3) . Echocardiogram and computed tomography showed near complete obliteration of right ventricular cavity. Endomyocardial biopsy showed diffuse myocyte necrosis with extensive eosinophilic infiltration without fibrosis consistent with early Loeffler's endocarditis. Molecular and cytogenetic analyses of bone marrow cells were negative for FIP1L1-PDGFRA fusion, PDGFRB mutation, abnormal myeloid maturation, or a lymphoproliferative disorder. Flow cytometry showed no clonality excluding chronic eosinophilic leukemia. There was a complete resolution of symptoms and eosinophilia after 1 month of steroid therapy.

Experimental demonstration of information to energy conversion in a quantum system at the Landauer limit

Landauer's principle sets fundamental thermodynamical constraints for classical and quantum information processing, thus affecting not only various branches of physics, but also of computer science and engineering. Despite its importance, this principle was only recently experimentally considered for classical systems. Here we employ a nuclear magnetic resonance set-up to experimentally address the information to energy conversion in a quantum system. Specifically, we consider a three nuclear spins [Formula: see text] (qubits) molecule-the system, the reservoir and the ancilla-to measure the heat dissipated during the implementation of a global system-reservoir unitary interaction that changes the information content of the system. By employing an interferometric technique, we were able to reconstruct the heat distribution associated with the unitary interaction. Then, through quantum state tomography, we measured the relative change in the entropy of the system. In this way, we were able to verify that an operation that changes the information content of the system must necessarily generate heat in the reservoir, exactly as predicted by Landauer's principle. The scheme presented here allows for the detailed study of irreversible entropy production in quantum information processors.

Clinical Outcomes for Peripartum Cardiomyopathy in North America: Results of the IPAC Study (Investigations of Pregnancy-Associated Cardiomyopathy)

BACKGROUND

Peripartum cardiomyopathy (PPCM) remains a major cause of maternal morbidity and mortality.

OBJECTIVES

This study sought to prospectively evaluate recovery of the left ventricular ejection fraction (LVEF) and clinical outcomes in the multicenter IPAC (Investigations of Pregnancy Associated Cardiomyopathy) study.

METHODS

We enrolled and followed 100 women with PPCM through 1 year post-partum. The LVEF was assessed by echocardiography at baseline and at 2, 6, and 12 months post-partum. Survival free from major cardiovascular events (death, transplantation, or left ventricular [LV] assist device) was determined. Predictors of outcome, particularly race, parameters of LV dysfunction (LVEF), and remodeling (left ventricular end-diastolic diameter [LVEDD]) at presentation, were assessed by univariate and multivariate analyses.

RESULTS

The cohort was 30% black, 65% white, 5% other; the mean patient age was 30 ± 6 years; and 88% were receiving beta-blockers and 81% angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. The LVEF at study entry was 0.35 ± 0.10, 0.51 ± 0.11 at 6 months, and 0.53 ± 0.10 at 12 months. By 1 year, 13% had experienced major events or had persistent severe cardiomyopathy with an LVEF <0.35, and 72% achieved an LVEF ≥0.50. An initial LVEF <0.30 (p = 0.001), an LVEDD ≥6.0 cm (p < 0.001), black race (p = 0.001), and presentation after 6 weeks post-partum (p = 0.02) were associated with a lower LVEF at 12 months. No subjects with both a baseline LVEF <0.30 and an LVEDD ≥6.0 cm recovered by 1 year post-partum, whereas 91% with both a baseline LVEF ≥0.30 and an LVEDD <6.0 cm recovered (p < 0.00001).

CONCLUSIONS

In a prospective cohort with PPCM, most women recovered; however, 13% had major events or persistent severe cardiomyopathy. Black women had more LV dysfunction at presentation and at 6 and 12 months post-partum. Severe LV dysfunction and greater remodeling at study entry were associated with less recovery. (Investigations of Pregnancy Associated Cardiomyopathy [IPAC]; NCT01085955).

Abstract 596: Platelet inhibition by Ticagrelor in African American versus Caucasian patients after Percutaneous Coronary Intervention

PLATO study showed that in acute coronary syndromes, treatment with Ticagrelor as compared with Clopidogrel significantly reduced the rate of death, myocardial infarction or stroke. In subgroup analysis based on race, no significant difference in primary end point was noted. However, African Americans (AA) comprised only 1.1% of study population. AA have greater mortality from coronary artery disease (CAD) and more likely to have high on-treatment platelet reactivity. Aim of our study is to compare the extent of platelet inhibition achieved by Ticagrelor and Clopidogrel in AA versus Caucasian patients undergoing percutaneous coronary intervention (PCI). Methods: 72 patients undergoing PCI during September to November 2014 were included in this study. All received Aspirin 325mg loading dose (LD) followed by 81mg maintenance dose, along with either Ticagrelor 180 mg LD followed by 90 mg twice-daily MD or Clopidogrel 600 mg LD followed by 75 mg once-daily MD. Platelet reactivity (PRU) was measured using the VerifyNow P2Y12 function assay 12-24h following MD and the average values calculated for each group. Results: 40 African American (55%) and 32 Caucasian (45%) patients were included. Ticagrelor was used in 45 (62.5%) and Clopidogrel was used in 27 patients (37.5%). Among Caucasians, 16 (50%) received Ticagrelor and 16 (50%) received Clopidogrel. Among AA, 27 patients (67%) received Ticagrelor, 13 patients (33%) received Clopidogrel. In the total study population, the average PRU achieved was lower for Ticagrelor (44) compared with Clopidogrel (183). Among patients who received Ticagrelor, significantly lower average PRU was seen in AA (33) compared to Caucasians (63). Among patients who received Clopidogrel, similar average PRU was seen in AA (181) and Caucasian (185) groups. After combining Ticagrelor and Clopidogrel groups, lower average PRU was achieved in AA (76) compared to Caucasians (126), the difference primarily attributable to Ticagrelor. Conclusion: Ticagrelor achieved greater platelet inhibition in AAs compared to Caucasians, while Clopidogrel achieved similar platelet inhibition in both racial groups. This potentially greater platelet inhibition by Ticagrelor in high risk AA group merits investigation in large-scale studies.

Characterizing quantum dynamics with initial system-environment correlations

We fully characterize the reduced dynamics of an open quantum system initially correlated with its environment. Using a photonic qubit coupled to a simulated environment, we tomographically reconstruct a superchannel-a generalized channel that treats preparation procedures as inputs-from measurement of the system alone. We introduce novel quantitative measures for determining the strength of initial correlations, and to allow an experiment to be optimized in regard to its environment.

Work and quantum phase transitions: quantum latency

We study the physics of quantum phase transitions from the perspective of nonequilibrium thermodynamics. For first-order quantum phase transitions, we find that the average work done per quench in crossing the critical point is discontinuous. This leads us to introduce the quantum latent work in analogy with the classical latent heat of first order classical phase transitions. For second order quantum phase transitions the irreversible work is closely related to the fidelity susceptibility for weak sudden quenches of the system Hamiltonian. We demonstrate our ideas with numerical simulations of first, second, and infinite order phase transitions in various spin chain models.

Differences in clinical profile of African-American women with peripartum cardiomyopathy in the United States

BACKGROUND

Peripartum cardiomyopathy (PPCM) is a rare and heterogeneous disease with a higher prevalence in African Americans (AAs) in the USA. The clinical features and prognosis of PPCM in AAs have not been sufficiently characterized.

METHODS

We studied 52 AA patients with PPCM and compared clinical characteristics and outcome with those of 104 white patients.

RESULTS

AA patients were significantly younger (26 ± 7 vs 30 ± 6 years; P < .001), had a higher prevalence of gestational hypertension (61% vs 41%; P = .03), and were diagnosed more commonly postpartum rather then antepartum (83% vs 64%; P = .03). The rate of left ventricular (LV) recovery (LV ejection fraction [LVEF] ≥50%) was significantly lower in AAs (40% vs 61%; P = .02). AA women also had a larger LV end-diastolic diameter (57 ± 10 vs 51 ± 6 mm; P = .004) as well as lower LVEF (40% ± 16.7% vs 46% ± 14%; P = .002) at the last follow-up. Moreover, AA patients had a significantly higher incidence of the combined end points of mortality and cardiac transplantation (P = .03) and showed a strong trend (P = .09) for increased mortality.

CONCLUSIONS

AA patients with PPCM in the USA have a different clinical profile and worse prognosis compared with white patients. Further research to evaluate potentially correctable causes for these differences is warranted.

Cocaine-induced postpartum coronary artery dissection: a case report and 80-year review of literature

The incidence of cocaine-induced myocardial infarction (MI) in pregnancy is unknown. During the peripartum period, cocaine-abusing women are highly susceptible to MI caused by the effect of cocaine on a heart that is already stressed by hemodynamic changes of pregnancy. MI is an infrequent event during pregnancy and the peripartum period, with an estimated rate of 1 in 16,000 patients. Spontaneous coronary artery dissection (SCAD) can account for up to 27% of pregnancy-related MIs. We describe a case of MI diagnosed by increased troponin I levels in a postpartum patient with recent crack cocaine use in the setting of SCAD that required percutaneous coronary intervention of the left anterior descending and diagonal arteries. We also provide a comprehensive review of published literature related to this clinical entity.

Leucas aspera: A review

Leucas aspera commonly known as ‘Thumbai’ is distributed throughout India from the Himalayas down to Ceylon. The plant is used traditionally as an antipyretic and insecticide. Medicinally, it has been proven to possess various pharmacological activities like antifungal, antioxidant, antimicrobial, antinociceptive and cytotoxic activity. Further, studies reveal the presence of various phytochemical constituents mainly triterpenoids, oleanolic acid, ursolic acid and b-sitosterol, nicotine, sterols, glucoside, diterpenes, phenolic compounds (4-(24-hydroxy-1-oxo-5-n-propyltetracosanyl)-phenol). These studies reveal that L. aspera is a source of medicinally active compounds and have various pharmacological effects; hence, this drug encourage finding its new therapeutic uses.

Quantum discord bounds the amount of distributed entanglement

The ability to distribute quantum entanglement is a prerequisite for many fundamental tests of quantum theory and numerous quantum information protocols. Two distant parties can increase the amount of entanglement between them by means of quantum communication encoded in a carrier that is sent from one party to the other. Intriguingly, entanglement can be increased even when the exchanged carrier is not entangled with the parties. However, in light of the defining property of entanglement stating that it cannot increase under classical communication, the carrier must be quantum. Here we show that, in general, the increase of relative entropy of entanglement between two remote parties is bounded by the amount of nonclassical correlations of the carrier with the parties as quantified by the relative entropy of discord. We study implications of this bound, provide new examples of entanglement distribution via unentangled states, and put further limits on this phenomenon.

Histiocytosis: An Uncommon Presentation with Hypopituitarism

Langerhans cell histiocytosis is a multi system disorder with a certain predilection for involving hypothalamic pituitary axis. We hereby report a 7 year old girl presenting with polyuria, polydipsia and growth retardation. The girl had a past history of pain in right hip joint and nodular region over chest. Water deprivation test confirmed the diagnosis of central diabetes inspidus. Other investigations revealed Growth hormone deficiency and central hypothyroidism. X-ray and MRI hip revealed absent right inferior pubic ramus with bone marrow biopsy confirming the diagnosis of histiocytosis. Patient was treated with nasal Arginine Vasopressin spray, subcutaneous growth hormone and oral thyroxine. Key words: Histiocytosis; Diabetes inspidus; Growth hormone deficiency; Central hypothyroidism DOI: http://dx.doi.org/10.3126/jnps.v32i1.5343 J. Nepal Paediatr. Soc. Vol.32(1) 2012 81-84

Evaluation of the clinical relevance of baseline left ventricular ejection fraction as a predictor of recovery or persistence of severe dysfunction in women in the United States with peripartum cardiomyopathy

BACKGROUND

Baseline left ventricular ejection fraction (LVEF) has been shown to be associated with likelihood of recovery in patients with peripartum cardiomyopathy (PPCM). The clinical relevance of this association for individual patients is unclear.

METHODS AND RESULTS

We analyzed baseline parameters of LVEF in 187 PPCM patients with ≥6 months follow-up data in an attempt to detect the value of baseline LVEF as a predictor of early recovery or persistence of severe LV dysfunction. Recovery of LV function (LVEF ≥50%) at 6 months after diagnosis was found in 115 patients (61%). Multivariate analysis identified baseline LVEF >30% as a significant predictor for recovery (odds ratio 5.2, 95% confidence interval 1.96-7.70; P > .0001). Recovery of LV function was 6.4-fold higher in women with baseline LVEF ≥ 30% (group III) and 3.9-fold higher in women with LVEF 20%-29% (group II) compared with those with LVEF 10%-19% (group I). Failure to achieve full recovery was seen in 63% of group I patients, 32% of group II (P = .03), and 21% of group III (P = .02 vs group I). Failure to achieve LVEF ≥30% was seen in 30% of group I patients and 13% of group II (P = .09).

CONCLUSIONS

Early recovery in patients with PPCM is significantly related to the degree of myocardial insult at time of diagnosis. Baseline LVEF however, has a limited sensitivity for prediction of failure to improve in individual patients and can not be used as an indication for premature use of aggressive therapy including devices or cardiac transplantation.

Nerve, muscle or bone disease? Look before you leap

Severe muscle weakness in osteomalacia may mimic a primary neuromuscular disorder like spinal muscular atrophy. A 32-year-old woman, initially diagnosed as a case of spinal muscular atrophy based on clinical presentation, electromyography and muscle biopsy, was later found to have osteomalacic myopathy due to primary hyperparathyroidism complicated by vitamin D deficiency. Before diagnosing a progressive, inevitably fatal degenerative condition like spinal muscular atrophy, one must rule out all possible treatable conditions with a similar presentation.

Diagnosis of a very rare variant of cor triatriatum dexter by contrast echocardiography: a case report

Cor triatriatum dexter is a rare congenital abnormality in which the right atrium is divided into two chambers by a membrane. A rare variant of cor triatriatum dexter where the membrane is attached to the left of the superior vena cava at one end and to the right of inferior vena cava and coronary sinus at the other end has been described only once before. We describe here a case of this very rare variant of cor triatriatum dexter that was diagnosed using contrast echocardiography.

Superior vena cava and right atrial thrombus detected on lung perfusion scintigraphy

Ventilation and perfusion scanning is still used as the first modality for evaluating pulmonary embolism in pregnant and renal failure patients and those who are allergic to radiographic contrast. Hot spots in the right atrial area on perfusion scan are the result of the presence of thrombi. These thrombi are of 2 varieties. One type is a free-floating thrombus, which needs emergency thrombectomy, and another type is thrombus formation in the atria, predisposed by the presence of catheters. We report a study showing essentially normal perfusion but intense tracer uptake in the superior vena cava and right atrium. Noncontrast computed tomography confirmed the thrombus.