The Impact of Long COVID-19 on the Cardiovascular System

Long coronavirus disease (COVID) is the development or persistence of symptoms after an acute SARS-CoV-2 (COVID-19) infection. Fewer patients are developing acute COVID-19 infections, but patients with long COVID continue to have alarming long-term sequelae. Many cardiac magnetic resonance imaging studies show significant changes in cardiac structure after a COVID-19 infection, suggestive of an increased burden of many cardiovascular diseases, notably myocarditis. The pathophysiology of COVID-19 requires viral binding to angiotensin-converting enzyme 2 protein receptors throughout the body, which are upregulated by inflammation. Consequently, the numerous preexisting conditions that worsen or prolong inflammation enhance this binding and have differing effects on patients based on their unique immune systems. These pathophysiological changes drive long COVID cardiac sequelae such as inappropriate sinus tachycardia, postural orthostatic tachycardia, and other types of orthostatic intolerance. Increased screening for long COVID and low-risk interventions such as exercise regimens could alleviate the suffering endured by patients with long COVID. Many studies such as the Researching COVID to Enhance Recovery Initiative (RECOVER) trials at the National Institutes of Health are exploring potential treatments for long COVID patients.

Ultrasound Guidance for Vascular Access for Coronary Angiogram: A Meta-Analysis of Randomized Controlled Trials

Obtaining vascular access during percutaneous coronary intervention is necessary to facilitate the procedure but carries procedural risks that impact patient outcomes. Historically, vascular access has been accomplished using anatomic landmarks, pulsation, and/or fluoroscopic guidance. Ultrasound (US) guidance has emerged as a modality for achieving vascular access in a multitude of interventional procedures including those in the cardiac catheterization laboratory. US use has been demonstrated in randomized controlled trials and meta-analyses to be associated with an increased success rate for vascular access with fewer complications, although the data are mixed. We aimed to re-evaluate the totality of evidence in an updated meta-analysis to compare the ease of access and complications rates between US-guided and manual vascular access. A meta-analysis of 8 randomized controlled trials including 5,170 patients was performed. The primary outcome evaluated was the rate of access failure, and the secondary outcomes included hematomas and access site bleeding. US-guided arterial access was associated with a significantly higher rate of first-attempt success and a decreased risk of venipuncture. US use had a trend toward a lower total number of attempts, but the results were not significant. This updated meta-analysis further supports the use of US for vascular access for coronary angiography because of higher rates of first-attempt success and reduced venipuncture. However, there was no significant difference in vascular complications such as hematoma, pseudoaneurysm, and bleeding complications. Because of the high morbidity of bleeding complications associated with coronary angiography, further research should be done to reduce these complications.

Treatment of Acute Heart Failure with Acetazolamide

The primary treatment for acute heart failure includes the use of intravenous loop diuretics to reduce congestion. Successful decongestion at the time of hospital discharge improves mortality and prevents rehospitalization in these patients. Loop diuretic therapy alone may not be enough for adequate decongestion, especially as diuretic resistance becomes more common. Other therapies include the addition of thiazide diuretics, though increasing evidence might suggest a better alternative to add-on therapy. In this review, we will discuss the new evidence for the use of the diuretic acetazolamide in acute heart failure.

Impella devices: a comprehensive review of their development, use, and impact on cardiogenic shock and high-risk percutaneous coronary intervention

INTRODUCTION

Impella devices have emerged as a critical tool for temporary mechanical circulatory support (TMCS) in the management of cardiogenic shock (CS) and high-risk percutaneous coronary interventions (PCI). The purpose of this review is to examine the history of the different Impella devices, their hemodynamic profiles, and how the data supports their use.

AREAS COVERED

This review covers the development and specifications of the Impella 2.5, Impella CP, Impella 5.0/Left Direct (LD), Impella RP, and Impella 5.5 devices. This review also covers the clinical trials that illuminate the Impella devices' use in their appropriate clinical contexts. These studies examine the effectiveness of Impella devices and have begun to yield promising results, demonstrating improved survival rates when compared to the historically high mortality rates associated with CS. It is important to weigh the benefits of Impella devices in light of their contraindications. A literature search was conducted by searching the PubMed database for reviews, meta-analyses, and clinical trials pertinent to Impella devices.

EXPERT OPINION

Impella devices are a crucial tool for management of patients undergoing high-risk PCI and those with CS. There is evidence that early Impella implantation is beneficial in the treatment of patients presenting with CS. Further randomized controlled trials are needed to better elucidate the benefits of Impella devices in various clinical settings.

The Role of SGLT2 Inhibitors in Cardiovascular Management

Cardiovascular disease is a major cause of morbidity and mortality worldwide in patients with type 2 diabetes. Type 2 diabetes confers an elevated risk of developing heart failure and atherosclerotic cardiovascular disease. Until recently, there have been limited options to prevent and reduce the cardiovascular complications of type 2 diabetes. However, recent therapeutic advances have led to the adoption of sodium-glucose co-transporter 2 inhibitors (SGLT2i) in cardiovascular management. Though SGLT2i were originally used for antihyperglycemic treatment, a series of landmark trials found that SGLT2i may confer cardio-protective effects in patients with heart failure and atherosclerotic cardiovascular disease, particularly a reduction in cardiovascular mortality and hospitalizations for heart failure. The cardiovascular benefits of SGLT2i were similarly demonstrated in patients with and without type 2 diabetes. Though previous trials found SGLT2i to be cardio-protective in heart failure with reduced ejection fraction, recent trials demonstrated that SGLT2i may also provide cardiovascular benefits in heart failure with mildly reduced and preserved ejection fraction. These advances have led SGLT2i to become an instrumental component of cardiovascular therapy.

Emerging Modalities for Temporary Mechanical Circulatory Support in Cardiogenic Shock

Cardiogenic shock (CS) is a life-threatening medical condition that requires prompt recognition and treatment. The use of standardized CS criteria, such as the Society for Cardiovascular Angiography and Interventions criteria, can categorize patients and guide therapeutic strategies. Temporary mechanical circulatory support (MCS) devices have become valuable tools in the treatment of CS, as they can provide cardiovascular support as a bridge to recovery, cardiac surgery, or advanced therapies such as cardiac transplant or durable ventricular assist devices. The use of MCS should be tailored to each individual patient, focused on a stepwise escalation of circulatory support to support both end-organ perfusion and myocardial recovery. As newer MCS devices reduce myocardial oxygen demand without increasing ischemia, the possibility of recovery is optimized. In this review, we discuss the different modalities of MCS focusing on the mechanism of support and the advantages and disadvantages of each device.

Healthcare Disparities in Cardiovascular Medicine

There are significant healthcare disparities in cardiovascular medicine that represent a challenge for cardiologists and healthcare policy-makers who wish to provide equitable care. Disparities exist in both the management and outcomes of hypertension, coronary artery disease and its sequelae, and heart failure. These disparities are present along the lines of race, gender, and socioeconomic status. Despite recent efforts to reduce disparity, there are knowledge and research gaps among cardiologists with regards to both the scope of the problem and how to solve it. Solutions include increasing awareness of disparities in cardiovascular health, increasing research for optimal treatment of underserved communities, and public policy changes that reduce disparities in social determinants of health.

Review of the Metabolic Risk Factors for Increased Severity of Coronavirus Disease-2019

The coronavirus 2019 (COVID-19) pandemic has presented many new challenges to the healthcare community with the sheer number of individuals affected and the range of symptoms at presentation. Early findings have shown that increased age is an independent risk factor for COVID-19 severity. Diabetes and hypertension were also found to be strong independent risk factors for severe COVID-19. It was later discovered that obesity is a strong risk factor for severe disease as well. Possible mechanisms for the increased risk associated with metabolic disease include the increased prevalence of acute respiratory syndrome, immune cell dysfunction, and chronic inflammatory states associated with obesity and diabetes. Acknowledging these risk factors has consequences for addressing vaccination strategies as well as healthcare disparities.