Heart failure is a global public health problem that affects more than 26 million people worldwide. The global burden of heart failure is growing and is expected to increase substantially with the ageing of the population. Heart failure with reduced ejection fraction accounts for approximately 50% of all cases of heart failure in the United States and is associated with substantial morbidity and reduced quality of life. Several diseases, such as myocardial infarction, certain infectious diseases and endocrine disorders, can initiate a primary pathophysiological process that can lead to reduced ventricular function and to heart failure. Initially, ventricular impairment is compensated for by the activation of the sympathetic nervous system and the renin-angiotensin-aldosterone system, but chronic activation of these pathways leads to worsening cardiac function. The symptoms of heart failure can be associated with other conditions and include dyspnoea, fatigue, limitations in exercise tolerance and fluid accumulation, which can make diagnosis difficult. Management strategies include the use of pharmacological therapies and implantable devices to regulate cardiac function. Despite these available treatments, heart failure remains incurable, and patients have a poor prognosis and high mortality rate. Consequently, the development of new therapies is imperative and requires further research.
Advances in cancer therapy have resulted in significant improvement in long-term survival for many types of cancer, but have also resulted in untoward side effects associated with treatment. One such complication that has become increasingly recognized is the development of cardiomyopathy and heart failure. Whether a previously healthy person from a cardiovascular perspective develops cancer therapy related cardiac dysfunction or a high-risk cardiovascular patient requires cancer therapy, the team of oncologists and cardiologists must be better equipped with an evidence-based approach to care for these patients across the spectrum. Although the toxicities associated with various cancer therapies are well recognized, limitations to our understanding of the appropriate course of action remain. In this first of a 2-part review, we discuss the epidemiologic, pathophysiologic, risk factors, and imaging aspects of cancer therapy related cardiac dysfunction and heart failure. In a subsequent second part, we discuss the prevention and treatment aspects, concluding with a section on evidence gap and future directions. We focus on adult patients in all stages of cancer therapy from pre-treatment surveillance, to ongoing therapy, and long-term follow up.
BackgroundData regarding the benefits or harm associated with the continuation of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs), especially the effect on inflammation, in patients who are hypertensive and hospitalized with coronavirus disease 2019 (COVID-19) in the United States are unclear.MethodsThis is a single-center cohort study of patients sequentially hospitalized with COVID-19 at Stony Brook University Medical Center from March 7, 2020 to April 1, 2020, inclusive of these dates. Data collection included history of known comorbidities, medications, vital signs, and laboratory values (at admission and during the hospitalization). Outcomes include inflammatory burden (composite scores for multiple markers of inflammation), AKI, admission to the intensive care unit (ICU), need for invasive mechanical ventilation, and mortality.ResultsOf the 300 patients in the study cohort, 80 patients (27%) had history of ACEI or ARB use before admission, with 61% (49/80) of these patients continuing the medications during hospitalization. Multivariable analysis revealed that the history of ACEI or ARB use before hospitalization was not associated with worse outcomes. In addition, the continuation of these agents during hospitalization was not associated with an increase in adverse outcomes and predicted fewer ICU admissions (odds ratio, 0.25; 95% CI, 0.08 to 0.81) with a decrease in the severity of inflammatory burden (peak C-reactive protein, 6.9±3.1 mg/dl, P=0.03; peak inflammation score, 2.3±1.1 unit reduction, P=0.04).ConclusionsUse of ACEI or ARBs before hospitalization was not associated with adverse outcomes in COVID-19, and the therapeutic benefits of continuing ACEI or ARB in patients hospitalized with COVID-19 was not offset by adverse outcomes.
Background-Adverse events (AEs), such as intracranial hemorrhage, thromboembolic event, and progressive aortic insufficiency, create substantial morbidity and mortality during continuous flow left ventricular assist device support yet their relation to blood pressure control is underexplored.
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