Cardiovascular disease is prevalent in patients with chronic kidney disease (CKD) and responsible for approximately half of all CKD-related deaths. Unfortunately, the presence of CKD can lead to a challenging interpretation of cardiac biomarkers essential in accurate diagnosis and prompt management of heart failure and acute coronary syndrome. There is growing interest in novel cardiac biomarkers that may improve diagnostic accuracy reflecting myocardial injury, inflammation, and remodeling. Interpretation of these biomarkers in CKD can be complicated, since elevated levels may not reflect myocardial injury or wall tension but rather decreased urinary clearance with retention of solutes and/or overall CKD-associated chronic inflammation. In this review, we discuss the latest data on major and emerging cardiac biomarkers including B-type natriuretic peptide, troponin, suppression of tumorigenicity 2, growth and differentiation factor-15, galectin-3, and matrix gla protein, and their diagnostic and prognostic utility in the CKD population.

The left atrial septal pouch (LASP) occurs due to incomplete fusion of septa primum and secundum at the inter-atrial septum, creating an open flap that may serve as a thromboembolic source. Prior studies have demonstrated increased prevalence of LASP in cryptogenic strokes. The aim of the current study was to validate the above findings in a separate, larger group of stroke and non-stroke patients. We examined transesophageal echocardiograms (TEEs) performed between July 2011 and December 2018. LASP prevalence was determined in TEEs referred for ischemic stroke or transient ischemic attack (“stroke”) and compared with LASP prevalence in patients undergoing TEEs for other reasons (“non-stroke”). Stroke subtyping was performed using the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. There were 306 TEEs from 144 non-stroke and 162 stroke patients. Mean age and sex distribution were 56 ± 1 (mean ± SE) and 65% male in the non-stroke group and 58 ± 1 and 54% male in the stroke group. The overall prevalence of LASP was 31%. The prevalence of LASP was 28% (41/144) in non-stroke patients, 25% (24/95) in non-cryptogenic stroke patients, and 43% (29/67) in cryptogenic stroke patients. LASP prevalence was significantly higher in the cryptogenic subgroup compared with the non-cryptogenic subgroup (p = 0.02). These findings demonstrate a significant association of LASP with risk of cryptogenic stroke, suggesting that LASP may serve as a thromboembolic nidus. Additional studies are needed to determine the generalizability of these findings, and their therapeutic implications, supporting LASP as a stroke risk factor.

Familial hypercholesterolemia (FH) is a common heritable condition in which mutations of genes governing cholesterol metabolism result in elevated LDL levels and accelerated atherosclerosis. The treatment of FH focuses on lipid lowering drugs to decrease patients' cholesterol levels and reduce their risk of cardiovascular events. Even with optimal medical therapy, some FH patients will develop coronary atherosclerosis, suffer myocardial infarction, and require revascularization. Yet, the revascularization of FH patients has not been widely studied. Here we review FH, identify unanswered questions in the interventional management of FH patients, and explore barriers and opportunities for answering these questions. Further research is needed in this neglected but important topic in interventional cardiology.

Background: The left atrial septal pouch (LASP) is a common anatomic variant produced by the incomplete fusion of septa primum and secondum at the inter-atrial septum, thus creating a potential embolic source from an open flap or blind pouch in the left atrium. Our prior work demonstrated increased prevalence of LASP in cryptogenic strokes (Frontiers Neurology 3-24-15). The aim of the current study was to examine the prevalence of LASP in a separate, more recent group of stroke patients and control subjects who underwent transesophageal echocardiography (TEE). Methods: We examined consecutive TEE studies performed between July, 2011 and December, 2018 at UC Irvine Medical Center. Prevalence of LASP was determined in TEE studies referred for ischemic stroke or TIA (“stroke subjects”), and compared to LASP prevalence in patients undergoing TEE for other reasons (“control subjects”). Stroke subtyping was performed using TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria. Results: TEE studies were performed on 221 cerebrovascular cases and 164 control subjects. Age and sex were 57±1 years (mean±SE) and 53% male for stroke subjects, and 56±1 years and 62% male for control subjects. Prevalence of LASP was 24% (40/164) in control subjects, 17% (24/138) in non-cryptogenic stroke subjects, and 36% (30/83) in cryptogenic stroke subjects. LASP prevalence was significantly higher for cryptogenics compared to the other groups (p=0.007). There was no significant difference between LASP prevalence in controls vs non-cryptogenic stroke. Elimination from analysis of subjects with other inter-atrial septal abnormalities (ie, patent foramen ovale or atrial septal defect) did not significantly change results. Conclusions: These findings demonstrate an increased prevalence of LASP in cryptogenic stroke, confirming our prior published findings. Given the plausibility of LASP acting as a thromboembolic nidus, additional studies are needed to determine the generalizability of these findings and their therapeutic implications.