Vol 4-2 Review Article

Role of Monoamine Oxidase A (MAO-A) in Cardiac Aging

Chandreyee Datta, Ashish Bhattacharjee*

Department of Biotechnology, National Institute of Technology, Durgapur, India

Among different sources that contribute in the global oxidative stress, the vast majority of cellular reactive oxygen species (ROS) originate from mitochondrial compartments. Recently, monoamine oxidases (MAOs) are identified as a prominent source of ROS. Monoamine oxidases are localized in the outer membrane of mitochondria and exist as two different isoforms, MAO-A and MAO-B. MAOs are mitochondrial flavoenzymes responsible for oxidative deamination of biogenic amines and during this process, H2O2 and aldehydes are generated as intermediate products. The role of monoamine oxidase in cardiovascular pathophysiology has only recently gained some attention as it is demonstrated that H2O2 and aldehydes may target myocardial function and consequently cardiac function. Results obtained by different research groups showed that MAO-A plays a key role in the regulation of physiological cardiac function and in the development of acute and chronic heart diseases through two mechanisms: regulation of substrate concentration and intracellular production of ROS. In this review, we will focus on the role of MAO-A in the field of cardiac aging and related diseases.

ROS: Reactive oxygen species; MAO: Monoamine oxidase; H2O2: Hydrogen peroxide; WHO: World Health Organization; TAC: Transverse aortic constriction; CLG: Clorgyline; Tyr: Tyramine; HF: Heart failure.

DOI: 10.29245/2578-3025/2020/2.1189 View / Download Pdf
Vol 4-2 Original Research Article

Serious about C-ERAS (Cardiac ERAS)

Sanjeet Singh1*, Sudeep Das De1, Ahmad Al-Adhami1, Yasser Hegazy1, Kirsty Graham2, Giuseppe Bozzetti3, Fraser Sutherland1, Philip Curry1, Nawwar Al-Attar1, Zahid Mahmood1

1Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, UK

2Enhanced Recovery Nurse Practitioner, Golden Jubilee National Hospital, UK

3Department of Anaesthesia and Critical Care, Golden Jubilee National Hospital, UK

Enhanced Recovery After Surgery (ERAS) incorporates multi-modal interventions that synergistically improve patient outcome. Its goals include improving patients functionally pre-operatively, reducing the stress of surgery intra-operatively to facilitate early return to daily activities. We conducted a pilot study at our unit recruiting patients undergoing elective coronary artery bypass grafting (CABG) into the Cardiac ERAS (C-ERAS) pilot and compared them with the patients undergoing CABG meeting the ERAS criteria but who not included the C-ERAS pilot (Control).

Materials and Methods: 122 C-ERAS patients were compared to 91 control patients who underwent CABG only from the period of July 2015 to September 2016. All C-ERAS patients received pre-operative counselling by a dedicated ERAS Practitioner to manage expectations of the patient journey, health promotion and pre-operative optimisation advice. Emphasis was made on educating the patient on daily goals for recovery and patients were followed up daily by the ERAS practitioner post-operatively.

Results: There were 122 patients in the C-ERAS group and 91 patients in the control group. The mean age was 63.6±9.9 years. 181(85%) of the patients were males. After adjusting for the abovementioned confounders, C-ERAS patients had a shorter length of stay that was statistically significant. (2.36 days shorter (95% CI; 1.01-3.7 days; p<0.01). The difference in mean bed day costs was £1153.70 (95% CI, £553.70-£1753.7; p<0.01) less in the C-ERAS cohort.

Conclusion: This study highlighted that C-ERAS is a safe and feasible pathway to reduce in-hospital stay with no difference in complications and readmission rates compared to routine management of patients. There was also a significant cost saving with the C-ERAS pathway mimicking the results in enhanced recovery programmes in the other surgical specialities.

C-ERAS Cardiac Enhanced Recovery After Surgery

CABG Coronary Artery Bypass Grafting

BMI Body Mass Index

NYHA New York Heart Association Functional Classification of Symptoms

CCS Canadian Cardiovascular Society grading of angina pectoris

LV Left Ventricle

ICU Intensive Care Unit

DOI: 10.29245/2578-3025/2020/2.1192 View / Download Pdf
Vol 4-2 Mini Review Article

Cardiac Sarcoidosis: Role of Multimodality Imaging for Diagnosis and Treatment

Deepti Bhandare1*, Anupama Kottam2

1Department of Cardiology, AdventHealth Sebring, Florida

2Department of Cardiology, Detroit Medical Center, Michigan

The clinical presentation of cardiac sarcoidosis (CS) ranges from an incidentally discovered condition to heart failure and sudden death. The diagnosis of CS is tough, and as a result, CS is often under-recognized in clinical practice. CS is mostly noted in the setting of systemic sarcoidosis, though isolated CS can occur. Frequently clinical criteria require the diagnosis of extracardiac disease in order to establish the diagnosis of CS in the absence of having a positive endomyocardial biopsy. While endomyocardial biopsy provides a high specificity for diagnosing CS, this invasive test has a limited sensitivity. There is incomplete knowledge of disease development and a deficient consensus on the ideal methods for disease recognition. We discuss CS in general, the clinical disease, diagnostic algorithms, latest guidelines and management.

CS: Cardiac Sarcoidosis; CMR: Cardiac MRI; PET: Positron Emission Tomography; EMB: Endomyocardial Biopsy; HRS: Heart Rhythm Society; ACC: American College of Cardiology; AHA: American Heart Association; LGE: Late Gadolinium Enhancement.

DOI: 10.29245/2578-3025/2020/2.1194 View / Download Pdf
Vol 4-2 Mini Review Article

Cardiac Disorders Associated with Cannabis: A Review of Literature

Deepti Bhandare1*, Christa Finer2

1Department of Cardiology, Advent Health Sebring, Sebring, Florida

2Medical Student, 4th year, Lake Erie College of Osteopathic Medicine, Bradenton, Florida

The leisure intake of cannabis has shortly amplified in the past years corresponding with its decriminalization and legalization. The natural cannabis has been substituted by synthetic cannabinoids and cannabimimetic in several formulae, which are stronger. In spite of irresistible public insight into the safety of these substances, a growing quantity of grave cardiovascular adverse events are reported in sequential relation to recreational cannabis intake. A multifaceted interface between the active ingredients, the endo-cannabinoid system, and the autonomic nervous system is responsible in the pathophysiology. Tolerance to the properties of cannabis can develop with repetitive contact due to receptor desensitization. Effects of cannabis may be heightened or transformed by affiliated use of other illicit drugs or drug treatment indicated for the treatment of cardiovascular diseases. Nonetheless, the recent cannabis epidemic would significantly increase global burden of cardiovascular diseases.

DOI: 10.29245/2578-3025/2020/2.1195 View / Download Pdf
Vol 4-2 Original Research Article

Acute Myocardial Readmission Reduction Program: “Never Discharge A Patient”

Deepti Bhandare1*, Thomas Shimshak2

1Department of Cardiology, Advent Health Sebring, Sebring, Florida

2Department of Interventional Cardiology, Advent Health Sebring, Florida

Readmission for Acute Myocardial Infarction [AMI] significantly contributes to preventable morbidity and healthcare costs. Nearly 1 in 6 patients hospitalized with AMI have an unplanned readmission within 30 days of discharge, accounting for over $1 billion of annual US healthcare costs. We developed a unique integrated product in our hospital called “Transition of Care” program [TOC] with the help of technology and services from Patient Engagement Advisors. The TOC program was based on the notion that engaging patients in their self-care journey by provision of extended set of products and facilities, nutrition, medications, and services to meet their care and recovery needs across the continuum of care.

The TOC program led to the subsequent reduction in the AMI readmission and significant cost savings by avoiding Medicare penalties. AMI readmission rates were reduced to less than 20% since implementation and have fallen below expected rates. This has translated to more than $ 400,000 savings in penalties as the actual readmission rate has been under the expected rate.

It also led to improved clinical follow up in the post AMI patients and improvement in clinical parameters in patients with chronic conditions like diabetes and hypertension. The TOC program extends health care beyond the four walls of the medical care facility and never truly discharges the patient.

AMI: Acute Myocardial Infarction; ACS: Acute coronary syndrome; TOC: Transition of Care; PEA: Patient Engagement Advisors; AHS: Advent Health Sebring; TS: Transition specialist; PNS: Patient Navigation System; SNF: Skilled nursing facility; ALF: Assisted Living facility; UDMI: Universal Definition of Myocardial Infraction

DOI: 10.29245/2578-3025/2020/2.1196 View / Download Pdf
Vol 4-2 Review Article

Left Atrial Appendage Occlusion in Patients with Non-Valvular Atrial Fibrillation and History of Intracranial Hemorrhage: A Review

Seyedeh Maryam Hosseini1, Cristina Pecci2, Muhammad Ajmal3*

1Internal Medicine Resident, University of Arizona, Tucson, Arizona

2Cardiology Fellow, University of Arizona, Phoenix, Arizona

3Cardiology Fellow, University of Arizona, Tucson, Arizona

Atrial Fibrillation (AF) is associated with an increased risk of thromboembolism due to formation of intracardiac thrombus mostly in left atrial appendage. Anticoagulant agents are used to reduce the risk of thromboembolism but have concerning bleeding side effect, making their use very challenging particularly in patients with high HAS-BLED risk score. WATCHMAN device (Boston Scientific, St. Paul, Minnesota) is a Left Atrial Appendage Occlusion (LAAO) device, which was tested in two major randomized trials. PROTECT AF (Percutaneous Left Atrial Appendage Closure for Stroke Prophylaxis in Patients with Atrial Fibrillation) trial, and PREVAIL (Prospective Randomized Evaluation of the WATCHMAN Left Atrial Appendage Closure Device in Patients with Atrial Fibrillation versus Long Term warfarin Therapy) trial, both evaluated WATCHMAN device’s safety and efficacy compared to warfarin. These trials showed WATCHMAN device to be non-inferior to warfarin. However, patients with history of intracranial hemorrhage were excluded from these trials due to concern of increased recurrent bleeding in presence of perioperative use of anticoagulation. Purpose of this review is to evaluate existing evidence and share our experience of LAAO in this high-risk population.

DOI: 10.29245/2578-3025/2020/2.1197 View / Download Pdf
Vol 4-2 Mini Review Article

Understanding Noncompaction Cardiomyopathy: A Brief Comprehensive Review of A Controversial Entity

Luis Graca Santos*, Rita Ribeiro Carvalho, Sara Fernandes, Joao Morais

Department of Cardiology, Leiria Hospital Centre, Leiria, Portugal

Noncompaction cardiomyopathy is a heterogeneous and complex entity characterized by hypertrabeculation, typically of the left ventricle. Uncertainties regarding pathogenesis, classification as primary genetic or unclassified cardiomyopathy, diagnostic criteria, and risk stratification have contributed to fuel the discussion surrounding this disorder. Meanwhile, noncompaction phenotype is thought to be the morphological expression of different underlying pathophysiological mechanisms, genetics, and pathologies. Recent studies suggest that distinguishing genetic from nongenetic causes allows risk stratification and may support clinical management and counselling of patients and their relatives. Additionally, advanced cardiac imaging techniques have demonstrated a complementary role in outcome prediction. The purpose of this review is to provide a brief comprehensive review of this controversial entity.

DOI: 10.29245/2578-3025/2020/2.1198 View / Download Pdf
Vol 4-2 Original Research Article

Quantifying Relative Importance of Coronary Risk Factors on Patient Survival Following Coronary Artery Bypass Grafting: A Maximum Likelihood Analysis

G.M. Lindsay1*, N.A. Tayyib1, H. Asfour1,2, R. Pushpamala1, E. Nomani1, F.J. Alsolami1

1College of Nursing Studies, Umm Al-Qura University, Makkah, Saudi Arabia

2Faculty of Nursing, University of Alexandria, Alexandria, Egypt

Background: Coronary artery bypass grafting (CABG) is a major surgical intervention to relieve symptoms and promote survival for individuals with coronary heart disease (CHD). The benefits of the intervention are thought to be improved when underlying risk factors of CHD are ameliorated. However in current health care systems the long-term follow-up of patients following CABG is not centralized to allow for the determination of survival trends and their optimization. The survival of study participants who underwent CABG is compared with age and gender matched individuals from the general population. Differences in rates of survival are interpreted in terms of lifestyle choices and the impact of risk factors of CHD.

Method: Survival data were obtained from government records to 18 years post intervention on a cohort of patients underwent CABG and participated in a long-term follow-up program. Cardiac symptoms and risk factors of CHD were collected from consenting participants (44 women and 164 men) prior to CABG and at clinical assessments at one and eight-year follow-ups. Important clinical and lifestyle factors were identified and their impact on post-operative survival was quantified using a maximum likelihood technique. Male and female patients were investigated separately and a good fit between observed and simulated survival experiences was confirmed by Monte Carlo simulation.

Results: Cardiac symptoms were exhibited by 75.8% of women and 68.3% of men (χ2=0.712, p=0.3988) one-year post operation, and by 84.2% of women and 70.2% of men eight-years post operation (χ2=1.556, p=0.212). Male long-term survival at 54.3% after 18 years was significantly better than 36.4% for females (χ2=4.449, p=0.035), but both were worse than 73.0% and 71.5% (p=0.6114) respectively for gender and age-matched cohorts from the general population.

Important risk factors for women were post-operative smoking and post-operative hypertension reducing annual post-operative survival by 3.9% and 2.7% respectively and by 6.6% when both present. Equivalent important risk factors for men are post-operative smoking and unrelieved/recurring cardiac symptoms reducing annual survival rates by 2.4% and 1.2% respectively and by 3.6% when both present.

Conclusion: Eighteen year survival post CABG was significantly better for men than women, but both were worse than that for the general population. Post-operative smoking was the most significant risk factor associated with decreased rates of survival followed by unrelieved/recurring cardiac symptoms for men and persisting hypertension for women.

DOI: 10.29245/2578-3025/2020/2.1193 View / Download Pdf
Vol 4-2 Mini Review Article

Endovascular Treatment of Type A Aortic Dissection

Ivo Petrov*, Zoran Stankov, Gloria Adam

ACIBADEM City Clinic Cardiovascular Center, Sofia, Bulgaria

DOI: 10.29245/2578-3025/2020/2.1191 View / Download Pdf
Vol 4-2 Mini Review Article

Regulation of SCN5A by Non-coding RNAs in the Brugada Syndrome Context

Houria Daimi1, Diego Franco2*

1Biochemistry and Molecular Biology Laboratory, Faculty of Pharmacy, University of Monastir, Monastir, Tunisia

2Department of Experimental Biology University of Jaen, Spain

In the human heart, the action potential (AP) is initiated and maintained thanks to a fast-activating fast-inactivating Na+ current carried by Nav1.5 channels. The pivotal physiological role of Nav1.5 in the heart is reflected by the important consequences of its coding SCN5A gene mutations. These mutations may lead to an impaired functional expression (including expression level, subcellular localization, trafficking, and/or current density), and are generally correlated with severe cardiac rhythm disorders such as Long QT (LQT) and Brugada syndrome (BrS). In BrS, loss of function mutations in SCN5A account for 35-40% of clinically affected patients and around 400 mutations in the SCN5A gene were identified in probands with BrS. Emerging electrophysiological techniques such as patch clamp along with transgenic animal technologies improved our understanding of the pathogenic mechanisms underlying BrS due to SCN5A variants. However, despite significant advances in defining the pathophysiology of Nav1.5, the molecular mechanisms underlying its regulation and contribution to the disease are poorly understood. It is well established that functional expression of Nav1.5 may be under modulation by post-transcriptional regulators, defining thus its transcript levels in the cell and also the penetrance on its associated diseases. Recently, non-coding RNA (ncRNAs) molecules have been identified as key transcriptional regulators of SCN5A expression in the heart. The present mini-review provides a summary of the role of ncRNAs, especially microRNAs (miRNAs), in the regulation of SCN5A. It mainly focuses on their role in the BrS context and discusses the recent updates and the major gaps still to be elucidated.

AP: Action potential; LQT: Long QT; BrS: Brugada syndrome; ncRNAs: non-coding RNA; miRNAs: microRNAs; lncRNAs: long non coding RNAs; 3′UTR: 3′ untranslated region; SNPs: Single-nucleotide polymorphisms.

DOI: 10.29245/2578-3025/2020/2.1201 View / Download Pdf
Vol 4-2 Review Article

Diagnostic and Treatment Challenges in Acute Myocardial Infarction: Perspectives from a Community Hospital

François M.A. Paris1*, Gillian J. Jessurun2, Rutger L. Anthonio2, Massimo A. Mariani3

1House officer cardiology, Department of Cardiology, Treant Zorggroep Scheper Ziekenhuis Emmen, The Netherlands

2Intervention cardiologist, Department of Cardiology, Treant Zorggroep Scheper Ziekenhuis Emmen, The Netherlands

3Cardiothoracic surgeon Heart, Center University Medical Center Groningen, The Netherlands

One of the most important causes of death in Western society, following cancer, is myocardial infarction (MI). Although acute MI occurs at an older age, the incidence of acute MI in younger adults has increased.

Essentially, treatment of acute MI is reperfusion therapy, which should preferably be performed within 12 hours of onset of the symptoms. Time is imperative and shorter intervals between symptoms an reperfusion leads to lower mortality. Conversely, a longer interval results in higher mortality, more mechanical complications and morbidity.

At our institution, located in the middle of a thinly populated rural area, patients used to be treated with thrombolysis until 2005. The nearest centers for percutaneous coronary interventions (PCI) and cardiothoracic surgery, had a travelling distance of 60 minutes. Since the introduction of interventional cardiology in the province of Drenthe, we managed to reduce the symptom to needle time.

Recently, we have been confronted with the COVID-19 pandemic, led to an increase in patient’s and doctor’s delay. This unfolded new challenges in treating acute MI.

This overview addresses the general clinical approach of acute MI and highlights the diagnostic approach and treatment options of both premature atherosclerosis and non-atherosclerotic causes of MI from our clinical perspective. We would like to argue that a personalized clinical approach remains of utmost importance in each patient treated by protocolized medicine.

DOI: 10.29245/2578-3025/2020/2.1200 View / Download Pdf