CMR tissue characterization provides effective risk stratification in patients with suspected myocarditis.

Heavy alcohol intake increases the risk of hypertension, but the relationship between light to moderate alcohol consumption and incident hypertension remains controversial. The authors sought to analyze the dose-response relationship between average daily alcohol consumption and the risk of hypertension via systematic review and meta-analysis. Electronic databases were searched for prospective control studies examining quantitative measurement of alcohol consumption and biological measurement of outcome. The primary endpoint was the risk of developing hypertension based on alcohol consumption. The level of alcohol consumption from each study was assigned to categorical groups based on the midpoint of their alcohol consumption classes to make possible the comparison of heterogeneous classification of alcohol intake. A total of 16 prospective studies (33,904 men and 193,752 women) were included in the analysis. Compared with nondrinkers, men with alcohol consumption with <10 g ⁄ d and 11 to 20 g ⁄ d had a trend toward increased risk of hypertension (relative risk [RR], 1.03; 95% confidence interval [CI], 0.94-1.13; P=.51) and (RR, 1.15; 95% CI, 0.99-1.33; P=.06), respectively, whereas a significantly increased risk of hypertension was found with heavy alcohol consumption of 31 to 40 g ⁄ d (RR, 1.77; 95% CI, 1.39-2.26; P<.001) and >50 g ⁄ d (RR, 1.61; 95% CI, 1.38-1.87; P<.001). Among women, the meta-analysis indicated protective effects at <10 g ⁄ d (RR, 0.87; 95% CI, 0.82-0.92; P<.001) and a trend toward decreased risk of hypertension with alcohol consumption 11 to 20 g ⁄ d (RR, 0.9; 95% CI, 0.87-1.04; P=.17), whereas a significantly increased risk of hypertension was indicated with heavy alcohol consumption of 21 to 30 g ⁄ d (RR, 1.16; 95% CI, 0.91-1.46; P=.23) and 31 to 40 g ⁄ d (RR, 1.19; 95% CI, 1.07-1.32; P=.002). In men, heavy alcohol consumption is associated with increased risk of hypertension, whereas there is a trend toward increased risk of hypertension with low and moderate alcohol consumption. The relationship between alcohol consumption and hypertension is J-shaped in women. Limiting alcohol intake should be advised for both men and women. J Clin Hypertens (Greenwich). 2012;14:792-798. Ó2012 Wiley Periodicals, Inc. Hypertension is a prevalent condition that affects approximately 65 million individuals in the UnitedStates based on a preliminary report from the National Health and Nutrition Examination Survey (NHANES) [2005][2006] and coincident US population estimates. 1 Due to its increasing clinical and public health importance, examining the risks or benefits of alcohol consumption in patients with hypertension is needed to assist clinicians in developing appropriate strategies of prevention. In observational studies, moderate alcohol consumption has been associated with lower incidence of cardiovascular diseases such as coronary artery disease, stroke, heart failure, and peripheral vascular disease. [2][3][4] Epidemiologic evidence suggests that heavy alcohol consumption is strongly associated ...

BackgroundIndividuals with cardiac sarcoidosis have an increased risk of ventricular arrhythmia and death. Several small cohort studies have evaluated the ability of late gadolinium enhancement (LGE) by cardiac magnetic resonance imaging (MRI) to predict adverse cardiovascular events. However, studies have yielded inconsistent results, and some analyses were underpowered. Therefore, we sought to systematically review and perform meta-analysis of the prognostic value of cardiac MRI for patients with known or suspected cardiac sarcoidosis.Methods and ResultsWe systematically searched for cohort studies of patients with known sarcoidosis with suspected cardiac involvement who underwent cardiac MRI with LGE with at least 12 months of either prospective or retrospective follow-up data regarding post-MRI adverse cardiovascular outcomes. We identified 7 studies of 694 subjects (mean age 53; 42% men). One hundred and ninety-nine patients (29%) were LGE positive. All-cause mortality occurred in 19 LGE-positive versus 17 LGE-negative subjects (annualized incidence, 3.1% versus 0.6%). The pooled relative risk was 3.38 (95% confidence interval, 1.07-10.7; P=0.04). Cardiovascular mortality occurred in 10 LGE-positive versus 2 LGE-negative subjects (annualized incidence, 1.9% versus 0.3%; relative risk 10.7 [95% confidence interval, 1.34–86.3]; P=0.03). Ventricular arrhythmia occurred in 41 LGE-positive versus 0 LGE-negative subjects (annualized incidence, 5.9% versus 0%; relative risk 19.5 [95% confidence interval, 2.68–143]; P=0.003). A combined end point of death or ventricular arrhythmia occurred in 64 LGE-positive versus 18 LGE-negative subjects (annualized incidence, 8.8% versus 0.6%; relative risk 6.20 [95% confidence interval, 2.47–15.6]; P<0.001). There was no significant heterogeneity for any outcomes.ConclusionsLGE is associated with future cardiovascular death and ventricular arrhythmia among patients referred to MRI for known or suspected cardiac sarcoidosis.

Allopurinol is a potent xanthine oxidase inhibitor that is used in hyperuricemic patients to prevent gout. It has also been shown to decrease cardiovascular complications in a myriad of cardiovascular conditions. However, studies have reported conflicting evidence on its effects on blood pressure (BP). A systematic review was conducted using Medline, PubMed, Embase, and the Cochrane Library for all the longitudinal studies that assessed the efficacy of allopurinol on systolic and diastolic BP. A total of 10 clinical studies with 738 participants were included in the analysis. Compared with the control group, systolic BP decreased by 3.3 mm Hg (95% confidence interval [CI], 1.4-5.3 mm Hg; P=.001) and diastolic BP decreased by 1.3 mm Hg (95% CI, 0.1-2.5 mm Hg; P=.03) in patients treated with allopurinol. When analysis was restricted to the higher-quality randomized controlled trials, similar changes in systolic and diastolic BPs were found: 3.3 mm Hg (95% CI, 0.8-5.8 mm Hg; P<.001) and 1.4 mm Hg (95% CI, 0.1-2.7 mm Hg; P=.04), respectively. Allopurinol is associated with a small but significant reduction in BP. This effect can be potentially exploited to aid in controlling BP in hypertensive patients with hyperuricemia. J Clin Hypertens (Greenwich). 2013;15:435-442. Ó2012 Wiley Periodicals, Inc.Uric acid (UA) is the end product of purine metabolism catalyzed by the enzyme xanthine oxidoreductase, which is frequently elevated in patients with gout. Hyperuricemia is commonly associated with hypertension 1,2 and is present in 25% of untreated patients with hypertension, in 50% of patients taking diuretics, and in >75% of patients with malignant hypertension. 1Hypertensive patients with hyperuricemia have a 3-to 5-fold increased risk of coronary or cerebrovascular disease compared with hypertensive patients with normal UA levels.3 Allopurinol is a potential inhibitor of the xanthine oxidoreductase enzyme, a key component in the production of UA pathway. Multiple studies examining the effects of allopurinol treatment on UA levels have documented conflicting results on its effects on blood pressure (BP). [4][5][6][7] The quandary regarding the use of allopurinol was pointed out in an editorial by Michael Alderman 8 in which he noted that while the present evidence does not justify the use of hypouricemic therapy for cardioprotection, there is also no evidence to show that lowering UA levels may be harmful. However, Feig and colleagues 9 found that allopurinol significantly lowered BP in adolescents with newly diagnosed hypertension. In view of these findings, we decided to conduct a systematic review of the existing literature to examine the effect of allopurinol on BP. MATERIALS AND METHODS Search StrategyWe systematically searched the electronic databases, Medline, PubMed, EMBASE, and the Cochrane Library for Central Register of Clinical Trials, using the MESH terms ''allopurinol,'' ''blood pressure,'' ''blood pressure monitoring, ambulatory,'' and ''hypertension,'' with the key words ''xanthine oxidase inhibitor,'' '...

There is accumulating evidence for the existence of a phenotype of isolated cardiac sarcoidosis (ICS), or sarcoidosis that only involves the heart. In the absence of biopsy-confirmed cardiac sarcoidosis (CS), existing diagnostic criteria require the presence of extra-cardiac sarcoidosis as an inclusion criterion for the diagnosis of CS. Consequently, in the absence of a positive endomyocardial biopsy, ICS is not diagnosable by current guidelines. Therefore, there is uncertainty regarding the epidemiology, pathobiology, clinical characteristics, prognosis, and optimal treatment of ICS. This review will summarize the available data related to the prevalence and prognosis of ICS and will discuss challenges surrounding the diagnosis and management of this under-recognized entity.

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Although very useful agents, fluoroquinolones are associated with a number of adverse events, some with considerable clinical significance. Prolongation of the QT interval, for example, is an adverse effect associated with the use of fluoroquinolones. Fluoroquinolones prolong the QT interval by blocking voltage-gated potassium channels, especially the rapid component of the delayed rectifier potassium current I_Kr, expressed by HERG (the human ether-a-go-go-related gene). According to the available case reports and clinical studies, moxifloxacin carries the greatest risk of QT prolongation from all available quinolones in clinical practice and it should be used with caution in patients with predisposing factors for Torsades de pointes (TdP). Although gemifloxacin, levofloxacin, and ofloxacin are associated with a lower risk of QT prolongation compared with moxifloxacin, they should also be used with caution in patients at risk for QT prolongation. Ciprofloxacin appears to be associated with the lowest risk for QT prolongation and the lowest TdP rate. The overall risk of TdP is small with the use of fluoroquinolones. Clinicians can minimize that risk by avoiding prescriptions of multiple medications associated with QT-interval prolongation, especially in high-risk patients.

Background Although the presence of late gadolinium enhancement (LGE) using cardiovascular magnetic resonance imaging (CMR) is a significant discriminator of events in patients with suspected myocarditis, no data are available on the optimal LGE quantification method. Methods Six hundred seventy consecutive patients (48 ± 16 years, 59% male) with suspected myocarditis were enrolled between 2002 and 2015. We performed LGE quantitation using seven different signal intensity thresholding methods based either on 2, 3, 4, 5, 6, 7 standard deviations (SD) above remote myocardium or full width at half maximum (FWHM). In addition, a LGE visual presence score (LGE-VPS) (LGE present/absent in each segment) was assessed. For each of these methods, the strength of association of LGE results with major adverse cardiac events (MACE) was determined. Inter-and intra-rater variability using intraclass-correlation coefficient (ICC) was performed for all methods. Results Ninety-eight (15%) patients experienced a MACE at a medium follow-up of 4.7 years. LGE quantification by FWHM, 2- and 3-SD demonstrated univariable association with MACE (hazard ratio [HR] 1.05, 95% confidence interval [CI]:1.02–1.08, p = 0.001; HR 1.02, 95%CI:1.00–1.04; p = 0.001; HR 1.02, 95%CI: 1.00–1.05, p = 0.035, respectively), whereas 4-SD through 7-SD methods did not reach significant association. LGE-VPS also demonstrated association with MACE (HR 1.09, 95%CI: 1.04–1.15, p < 0.001). In the multivariable model, FWHM, 2-SD methods, and LGE-VPS each demonstrated significant association with MACE adjusted to age, sex, BMI and LVEF (adjusted HR of 1.04, 1.02, and 1.07; p = 0.009, p = 0.035; and p = 0.005, respectively). In these, FWHM and LGE-VPS had the highest degrees of inter and intra-rater reproducibility based on their high ICC values. Conclusions FWHM is the optimal semi-automated quantification method in risk-stratifying patients with suspected myocarditis, demonstrating the strongest association with MACE and the highest technical consistency. Visual LGE scoring is a reliable alternative method and is associated with a comparable association with MACE and reproducibility in these patients. Trial registration number NCT03470571 . Registered 13th March 2018. Retrospectively registered.