Percutaneous assist devices in acute myocardial infarction with cardiogenic shock: Review, meta-analysis

AIM: To assess the impact of percutaneous cardiac support in cardiogenic shock(CS) complicating acute myocardial infarction(AMI), treated with percutaneous coronary intervention. METHODS: We selected all of the studies published from January 1st, 1997 to May 15 st, 2015 that compared the following percutaneous mechanical support in patients with CS due to AMI undergoing myocardial revascularization:(1) intra-aortic balloon pump(IABP) vs Medical therapy;(2) percutaneous left ventricular assist devices(PLVADs) vs IABP;(3) complete extracorporeal life support with extracorporeal membrane oxygenation(ECMO) plus IABP vs IABP alone; and(4) ECMO plus IABP vs ECMO alone, in patients with AMI and CS undergoing myocardial revascularization. We evaluated the impact of the support devices on primary and secondary endpoints. Primary endpoint was the inhospital mortality due to any cause during the same hospital stay and secondary endpoint late mortality at 6-12 moof follow-up. RESULTS: One thousand two hundred and seventytwo studies met the initial screening criteria. After detailed review, only 30 were selected. There were 6 eligible randomized controlled trials and 24 eligible observational studies totaling 15799 patients. We found that the inhospital mortality was:(1) significantly higher with IABP support vs medical therapy(RR = +15%, P = 0.0002);(2) was higher, although not significantly, with PLVADs compared to IABP(RR = +14%, P = 0.21); and(3) significantly lower in patients treated with ECMO plus IABP vs IABP(RR =-44%, P = 0.0008) or ECMO(RR =-20%, P = 0.006) alone. In addition, Trial Sequential Analysis showed that in the comparison of IABP vs medical therapy, the sample size was adequate to demonstrate a significant increase in risk due to IABP. CONCLUSION: Inhospital mortality was significantly higher with IABP vs medical therapy. PLVADs did not reduce early mortality. ECMO plus IABP significantly reduced inhospital mortality compared to IABP.

Role of genomics in cardiovascular medicine

As all branches of science grow and new experimental techniques become readily accessible,our knowledge of medicine is likely to increase exponentially in the coming years.Recently developed technologies have revolutionized our analytical capacities,leading to vast knowledge of many genes or genomic regions involved in the pathogenesis of congenital heart diseases,which are often associated with other genetic syndromes,coronary artery disease and non-ischemic cardiomyopathies and channelopathies.The knowledge-base of the genesis of cardiovascular diseases is likely going to be further revolutionized in this new era of genomic medicine.Here,we review the advances that have been made over the last several years in this field and discuss different genetic mechanisms that have been shown to underlie a variety of cardiovascular diseases.

Present concepts in management of atrial fibrillation:From drug therapy to ablation

Atrial fibrillation(AF) management requires knowledge of its pattern of presentation,underlying conditions,and decisions about restoration and maintenance of sinus rhythm,control of the ventricular rate,and antithrombotic therapy.Maintenance of sinus rhythm is a desirable goal in AF patients because the prevention of recurrence may improve cardiac function,relieve symptoms and reduce the likelihood of adverse events.Anti-arrhythmic drug therapy is the first-line treatment for patients with paroxysmal and persistent AF based on current guidelines.However,currently used drugs have limited efficacy and cause cardiac and extracardiac toxicity.Thus,there is a continued need to develop new drugs,device and ablative approaches to rhythm management.Additionally,simpler and safer stroke prevention regimens are needed for AF patients on life-long anticoagulation,including occlusion of the left atrial appendage.The results of the Randomized Evaluation of Long-Term Anticoagulant Therapy study are encouraging in these settings.Knowledge on the pathophysiology of AF is rapidly expanding and identification of focally localized triggers has led to the development of new treatment options for this arrhythmia.Conversely,the clinical decision whether to restore and maintain sinus rhythm or simply control the ventricular rate has remained a matter of intense debate.In the minority of patients in whom AF cannot be adequately managed by pharmacological therapy,the most appropriate type of non-pharmacological therapy must be selected on an individualized basis.Curative treatment of AF with catheter ablation is now a legitimate option for a large number of patients.The evolution of hybrid therapy,in which two or more different strategies are employed in the same patient,may be an effective approach to management of AF.In any case,planning a treatment regimen for AF should include evaluation of the risks inherent in the use of various drugs as well as more invasive strategies.

The Effect of Bergamot-Derived Polyphenolic Fraction on LDL Small Dense Particles and Non Alcoholic Fatty Liver Disease in Patients with Metabolic Syndrome

The occurrence of Metabolic Syndrome (MS) represents an independent risk factor for developing cardiovascular disease states in patients suffering from type 2 diabetes mellitus. Moreover, both the size of LDL particles and liver dysfunction identified as non alcoholic fatty liver disease (NAFLD) represent important biomarkers for the development of cardiometabolic risk in patients with MS. Here we studied the effect of bergamot polyphenolic fraction (BPF) in patients with MS and NAFLD. 107 patients were enrolled at the San Raffaele IRCCS (Rome). All of them showed ultrasonografic evidences of NAFLD and at least three out of five previous identified criteria for the diagnosis of MS. Patients were divided into two groups: one receiving placebo and the second receiving BPF 650 mg twice a day for 120 consecutive days. In the group receiving BPF 650 mg twice a day, a significant reduction of fasting plasma glucose, serum LDL cholesterol and triglycerides alongside with an increase of HDL cholesterol was found. This effect was accompanied by significant reduction of both ultrasonographic and metabolic biomarkers of NAFLD. Moreover, a significant reduction of small dense LDL particles, as detected via proton NMR Spectroscopy, was found after BPF treatment. In conclusion, our data confirm the beneficial effect of bergamot-extract in patients with MS an effect highlighted by significant reduction of small dense LDL particles and by improvement of NAFLD biomarkers. This suggests a potential preventive role of bergamot derivatives in reducing cardiometabolic risk.