Archive for the ‘Frontiers in Cardiology and Cardiovascular Disorders’ Category

Subarachnoid hemorrhage care at Mayo Clinic in Rochester, Minn., ranks No. 1 for neurology and neurosurgery in the U.S. News & World Report Best Hospitals rankings

Reporter: Aviva Lev-Ari, PhD, RN


A Mayo Clinic study found that 63.3 percent of people treated for aneurysmal subarachnoid hemorrhages at Mayo Clinic in Rochester, Minnesota, from 2001 to 2013 had no or few lasting symptoms.

Mayo Clinic in Phoenix/Scottsdale, Ariz., and Mayo Clinic in Jacksonville, Fla., are ranked among the Best Hospitals for neurology and neurosurgery by U.S. News & World Report.




The term subarachnoid hemorrhage (SAH) refers to extravasation of blood into the subarachnoid space between the pial and arachnoid membranes (see the image below). It occurs in various clinical contexts, the most common being head trauma. However, the familiar use of the term SAH refers to nontraumatic (or spontaneous) hemorrhage, which usually occurs in the setting of a ruptured cerebral aneurysm or arteriovenous malformation (AVM).

The classic presentation can include the following:

  • Sudden onset of severe headache (the classic feature)
  • Accompanying nausea or vomiting
  • Symptoms of meningeal irritation
  • Photophobia and visual changes
  • Focal neurologic deficits
  • Sudden loss of consciousness at the ictus
  • Seizures during the acute phase

Physical examination findings may be normal or may include the following:

  • Mild to moderate BP elevation
  • Temperature elevation
  • Tachycardia
  • Papilledema
  • Retinal hemorrhage
  • Global or focal neurologic abnormalities

Complications of SAH include the following:

  • Hydrocephalus
  • Rebleeding
  • Vasospasm
  • Seizures
  • Cardiac dysfunction


Diagnosis of SAH usually depends on a high index of clinical suspicion combined with radiologic confirmation via urgent noncontrast CT, followed by lumbar puncture or CT angiography of the brain. After the diagnosis is established, further imaging should be performed to characterize the source of the hemorrhage.

Laboratory studies should include the following:

  • Serum chemistry panel
  • Complete blood count
  • Prothrombin time (PT)/activated partial thromboplastin time (aPTT)
  • Blood typing/screening
  • Cardiac enzymes
  • Arterial blood gas (ABG) determination

Imaging studies that may be helpful include the following:

  • CT (noncontrast, contrast, or infusion)
  • Digital subtraction cerebral angiography
  • Multidetector CT angiography
  • MRI (if no lesion is found on angiography)
  • Magnetic resonance angiography (MRA; investigational for SAH)

Other diagnostic studies that may be warranted are as follows:

  • Baseline chest radiograph
  • ECG on admission
  • Lumbar puncture and CSF analysis

See Workup for more detail.


Current treatment recommendations include the following:

  • Antihypertensive agents (eg, IV beta blockers) when mean arterial pressure exceeds 130 mm Hg
  • Avoidance of nitrates (which elevate ICP) when feasible
  • Hydralazine and calcium channel blockers
  • Angiotensin-converting enzyme (ACE) inhibitors (not first-line agents in acute SAH)
  • In patients with signs of increased ICP or herniation, intubation and hyperventilation

Other interventions for increased ICP are as follows:

  • Osmotic agents (eg, mannitol)
  • Loop diuretics (eg, furosemide)
  • IV steroids (controversial but recommended by some)

Surgical treatment to prevent rebleeding includes the following options:

  • Clipping the ruptured aneurysm
  • Endovascular treatment [1(ie, coiling)

The choice between coiling and clipping usually depends on the location of the lesion, the neck of the aneurysm, and the availability and experience of hospital staff.



Pharmaco-Therapy for SAH

  • Nimodipine is a drug used for SAH

Nimodipine is a second generation calcium channel blocker used in the treatment of cerebral vasospasm after subarachnoid hemorrhage.  Nimodipine is not widely used and has not been implicated in causing clinically apparent acute liver injury.


Nimodipine is a second generation calcium channel blocker used in the treatment of cerebral vasospasm after subarachnoid hemorrhage.  Nimodipine is not widely used and has not been implicated in causing clinically apparent acute liver injury.



Nimodipine (nye moe’ di preen) belongs to the dihydropyridine class of calcium channel blockers (similar to amlopidine and felodipine) and is used to treat cerebral vasospasm after subarachnoid hemorrhage.  Like other calcium channel blockers, nimodipine acts by inhibition of the influx of calcium ions into smooth muscle cells during depolarization which results in vasodilation.  Nimodipine has high lipid solubility and was developed specifically to treat cerebral vasospasm.  Clinical trials have suggested that nimodipine reduces infarct size and complications after subarachnoid hemorrhage.  Nimodipine was approved for use in the United States in 1988 but is not widely used, largely because of its restricted indications.  Nimodipine is available in generic forms and under the commercial name Nimotop as capsules of 30 mg.  The recommend dose in adults is 60 mg every 4 hours for 21 days starting as soon as possible or within 96 hours of the diagnosis of subarachnoid hemorrhage.  Like most calcium channel blockers, nimodipine is generally well tolerated and side effects are largely due to its vasodilating activities and can include headache, dizziness, flushing, fatigue, nausea, diarrhea, peripheral edema, palpitations and rash.


Hepatotoxicity, Outcome and Management

Nimodipine has been associated with only rare reports of serum enzyme elevations during therapy.  These elevations are usually mild, transient and not associated with symptoms or need for dose modification.  Nimodipine is not widely used and has not been linked to instances of clinically apparent liver injury.  Thus, hepatotoxicity from nimodipine must be rare, if it occurs at all.


Likelihood score: E  (Unlikely cause of clinically apparent liver injury).


The reason why some calcium channel blockers cause liver injury (verapamil, diltiazem, amlodipine) while others (such as nimodipine) do not is not known. Because liver injury from calcium channel blockers is rare, those that are uncommonly used may just not have had enough exposures to manifest idiosyncratic cases of liver injury. Nimodipine is metabolized in the liver largely via CYP 3A4 and is susceptible to drug-drug interactions with agents that induce or inhibit CYP 3A4.


Drug Class:  Cardiovascular AgentsCalcium Channel Blockers


Other Drugs in the Subclass, Calcium Channel Blockers:  AmlodipineDiltiazemFelodipineIsradipineNicardipineNifedipineNisoldipineVerapamil




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Acute Coronary Syndrome (ACS): Strategies in Anticoagulant Selection: Diagnostics Approaches – Genetic Testing Aids vs. Biomarkers (Troponin types and BNP)

Curator: Aviva Lev-Ari, PhD, RN


UPDATED on 3/17/2018

An NT-proBNP <300 pg/ml strongly excludes the presence of acute HF.

J Am Coll Cardiol. 2018 Mar 20;71(11):1191-1200. doi: 10.1016/j.jacc.2018.01.021.

N-Terminal Pro-B-Type Natriuretic Peptide in the Emergency Department: The ICON-RELOADED Study


A breakthrough in emergence of

  • Genetic Testing Aids as a Personalized approach, genomics-based approach to selecting antiplatelet therapy, for reduction in ischemic and bleeding events, and
  • Biochemical Biomarker approaches for dosing anti-thrombotic drugs are presented here.

“This study fills in a part of the puzzle of genomic testing,” said Craig Beavers, PharmD, of the University of Kentucky in Lexington. “It shows we can use genomic information in clinical decision making. It was interesting that there appeared to be a change in prescribing based on genomics.”


At 12 months, 25.9% of patients receiving standard care had experienced the trial’s primary composite endpoint — cardiovascular death, non-fatal MI or stroke, and Bleeding Academic Research Consortium (BARC) 3-5 major bleeding — compared with 15.8% of patients receiving an anticoagulant drug on the basis of genetic testing (P<0.001), reported Diego Ardissino, MD, of Azienda Ospedaliero-Universitaria di Parma in Italy, and colleagues.

PHARMCLO is the first trial to combine clinical characteristics with genetic information to inform the choice of P2Y12 receptor antagonist in patients with ACS, Ardissino said in a presentation at the American College of Cardiology annual meeting. The study was simultaneously published in the Journal of the American College of Cardiology.

“Selecting treatment on the basis of genetic data in addition to considerations concerning the patients’ clinical characteristics may lead to a more personalized, and therefore more efficient, antiplatelet therapy, thus reducing both ischemic and bleeding risk,” he said. “PHARMCLO is the first step of a new approach that will see a shift in emphasis away from trying to discover ever-more potent anti-thrombotic drugs, and toward ensuring that the right therapy is given to each individual patient.”

However, PHARMCLO was halted after about a fourth of the intended population was recruited. The Ethics Committee of Modena (Italy) required the trial to be prematurely stopped because of a lack of in vitro diagnosis certification for the testing instruments. The original patients were still followed, Ardissino stated.

The authors enrolled 888 patients, and randomly assigned them to be tested for

  • three genes associated with resistance to clopidogrel (Plavix), and then were assigned a
  • treatment based on clinical data informed by the testing results.
  • Tested genes were ABCB1, 2C19*2 and 2C19*17 with the STQ3 system.
  • Another group was assigned to treatment without reference to genetic testing.
  • Standard of care treatment was with Clopidogrel, Ticagrelor (Brilinta), or Prasugrel (Effient).
  1. Clopidogrel was more frequently used in the standard arm (50.7% versus 43.3%), while
  2. Ticagrelor in the pharmacogenomic arm (42.6% versus 32.7%, P<0.05) and
  3. Prasugrel were used equally in both.

The primary endpoint hazard ratio was 0.58 versus the standard arm (95% CI 0.43-0.78, P<0.001).

Previous studies have shown Prasugrel and Ticagrelor to be superior to Clopidogrel at preventing ischemic events. However, prasugrel and ticagrelor, which are more potent, are also known to increase the risk of bleeding. The findings suggest that having more information about a specific patient’s likely response to clopidogrel can help doctors weigh this trade-off, Ardissino said.


The STANDARD OF CARE in Diagnosis of Acute Coronary Syndrome (ACS) using BioMarkers in serum blood relays of values of Troponin types and BNP for dosing anti-thrombotic drugs.

The team at LPBI Group published the following articles on this topic:

A search into our Journal Archive for “Acute Coronary Syndrome” yielded 210 articles

  1. High Sensitivity Troponin (hs cTn) Assays 

  • Previously undiscerned value of hs-troponin

Curators: Larry H. Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN

  • Recent Insights into the High Sensitivity Troponins for Acute Coronary Syndromes

Curator: Larry H Bernstein, MD, FCAP

  • Dealing with the Use of the High Sensitivity Troponin (hs cTn) Assays: Preparing the United States for High-Sensitivity Cardiac Troponin Assays

Author and Curator: Larry H Bernstein, MD, FCAP and Author and Curator: Aviva Lev-Ari, PhD, RD

  • Preparing the United States for High-Sensitivity Cardiac Troponin Assays

Curator: Larry H Bernstein, MD, FCAP


2. BNP and proBNP

Brain natriuretic peptide (BNP), also known as B-type natriuretic peptide, is a hormone secreted by cardiomyocytes in the heart ventricles in response to stretching caused by increased ventricular blood volume, decrease in systemic vascular resistance and central venous pressure as well as an increase in natriuresis. The net effect of these peptides is a decrease in blood pressure due to the decrease in systemic vascular resistance and, thus, afterload. Additionally, the actions of both BNP and ANP result in a decrease in cardiac output due to an overall decrease in central venous pressure and preload as a result of the reduction in blood volume that follows natriuresis and diuresis.


Maisel A, Krishnaswamy P, Nowak R, McCord J, Hollander J, Duc P, Omland T, Storrow A, Abraham W, Wu A, Clopton P, Steg P, Westheim A, Knudsen C, Perez A, Kazanegra R, Herrmann H, McCullough P (2002). “Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure“. N Engl J Med347 (3): 161–7. 


The team at LPBI Group published the following articles on this topic:

  • Effect of Coronary Atherosclerosis and Myocardial Ischemia on Plasma Levels of High-Sensitivity Troponin T and NT-proBNP in Patients With Stable Angina

  • More on the Performance of High Sensitivity Troponin T and with Amino Terminal Pro BNP in Diabetes

Writer and Curator: Larry H. Bernstein, MD, FCAP

  • Erythropoietin (EPO) and Intravenous Iron (Fe) as Therapeutics for Anemia in Severe and Resistant CHF: The Elevated N-terminal proBNP Biomarker

Co-Author of the FIRST Article: Larry H. Bernstein, MD, FCAP. Reviewer and Curator of the SECOND and of the THIRD Articles: Larry H. Bernstein, MD, FCAP and Article Architecture Curator: Aviva Lev-Ari, PhD, RN

  • Highlights of LIVE Day 1: World Medical Innovation Forum – CARDIOVASCULAR • MAY 1-3, 2017  BOSTON, MA • UNITED STATES

Aviva Lev-Ari, PhD, RN


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 Cholesterol Lowering Novel PCSK9 drugs: Praluent [Sanofi and Regeneron] vs Repatha [Amgen] – which drug cuts CV risks enough to make it cost-effective?

Reporter: Aviva Lev-Ari, PhD, RN


Did Amgen’s Repatha cut CV risks enough to make it cost-effective? Analysts say no

Sanofi, Regeneron’s Praluent pulls off PCSK9 coup with 29% cut to death risks in most vulnerable patients
SEE our curations on PCSK9 drugs:

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Higher BMI (Obesity Marker): Earlier onset of incident CVD followed by Shorter overall Survival – Men and women of all ages

Reporter: Aviva Lev-Ari, PhD, RN


Men and women of all ages with a higher BMI were found to have both an earlier onset of incident CVD followed by shorter overall survival, Sadiya Khan, MD, of Northwestern University Feinberg School of Medicine in Chicago, and colleagues wrote in JAMA Cardiology.

Among middle-aged men, there were 13,457 incident CVD events total, with the highest percentage attributed to fatal or nonfatal myocardial infarctions. This incidence rate of CVD events increased accordingly with BMI range, with the highest seen in those who were morbidly obese. Compared with men who died due to non-CVD related causes — the most common of which was cancer — men who weighed more had a significantly higher rate of experiencing their first CVD event.

When compared to middle-aged men of normal weight, those in higher BMI categories had an increased incidence of CVD:

  • Overweight: adjusted competing HR 1.21 (95% CI 1.14-1.28)
  • Obese: 1.67 (95% CI 1.55-1.79)
  • Morbidly obese: 3.14 (95% CI 2.48-3.97)

Similar event rates were seen among middle-aged women of a higher BMI, as well:

  • Overweight: HR 1.32 (95% CI 1.24-1.40)
  • Obese 1.85 (95% CI 1.72-1.99)
  • Morbidly obese: 2.53 (95% CI 2.20-2.91)

Both men and women had a longer time to first CVD event if they were of normal weight by around 7.5 year and 7.1 years, respectively, when compared with people with morbid obesity.

The researchers noted that the morbidly obese category likely saw the highest rate of CVD events mainly due to a five-fold increase in the incidence of congestive heart failure events. These patterns were also seen in the younger and older age groups.

Although the notion of the “obesity paradox” — when people with a higher BMI might actually live longer after CVD onset compared to those of normal weight — has been described in some prior studies, the researchers noted that their findings suggest that “this occurs because of a trend toward earlier onset of disease in individuals who are overweight and obese.”



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ODYSSEY Outcomes trial evaluating the effects of a PCSK9 inhibitor, alirocumab, on major cardiovascular events in patients with an acute coronary syndrome to be presented at the American College of Cardiology meeting on March 10.

Reporter: Aviva Lev-Ari, PhD, RN


For PCSK9 inhibitors, the effect on major adverse cardiovascular events has always fallen short of expectations based on cholesterol lowering.

But cardiovascular risk reduction is complicated. There is more to the puzzle than cholesterol. Some drugs lower both cholesterol and prevent cardiovascular events, but some people think that the two effects are actually not that closely related.

Milton Packer MD

In a previous trial (FOURIER), another PCSK9 inhibitor had only a modest benefit on its primary endpoint, and it did not reduce cardiovascular death, although the magnitude of cholesterol lowering was striking.

In another trial (SPIRE), a third PCSK9 inhibitor, the clinical trial was terminated prematurely by Pfizer because of reduction of the effect of the drug (a humanized but not fully humanized antibody) due to development of neutralizing antibodies in some of the patients. Actually, in patients treated for more than a year who did not develop neutralizing antibodies, a beneficial effect was seen.

The ODYSSEY Outcomes trial is evaluating the effects of a PCSK9 inhibitor,alirocumab, on major cardiovascular events in patients with an acute coronary syndrome within the prior year. The drug lowers serum cholesterol dramatically, and some are hopeful that that effect will translate into an important reduction in the risk of major adverse cardiovascular events. If you believe that cholesterol reduction inevitably leads to the prevention of cardiovascular death, myocardial infarction and stroke, then you would have high expectations for the ODYSSEY trial.

ODYSSEY. The trial uses a somewhat more aggressive treatment strategy and has a longer follow-up period than its predecessors. So maybe the benefit will be large. Maybe the drug will even reduce cardiovascular death or all-cause mortality.

In order to enrich the population for cardiovascular events, the trial enrolled patients with an acute coronary syndrome within the prior year. These patients are at high risk of having a recurrence. The problem is that risk is not necessarily related to changes in cholesterol, especially the events occurring early in the trial. And in this type of trial, the analysis tends to give extra weight to early events.

Trials like ODYSSEY are often designed to stop early if the results are unbelievably impressive. The ODYSSEY trial wasn’t stopped early.

the patients entering the ODYSSEY trial are starting out with a serum LDL <100 mg/dL or even <90 mg/dL. Is cholesterol really playing an important role at that level, especially when compared with noncholesterol factors?


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Cost per Inpatient Hospital Stay: Five cardiovascular issues ranked in the top 10 – #1 Heart valve disorders, #2 Acute myocardial infarction (heart attack), #4 Coronary atherosclerosis, #7 Septicemia, #10 Acute cerebrovascular disease

Reporter: Aviva Lev-Ari, PhD, RN

Cardiovascular conditions among most expensive per inpatient stay

Heart valve disorders are associated with the highest hospital costs per inpatient stay, according to the Healthcare Cost and Utilization Project (HCUP), running up an average tab of $41,878 per visit.

Business Insider crunched numbers from a 2016 HCUP report which identified the 20 most expensive conditions treated in U.S. hospitals. Septicemia led the way in terms of total costs, but it was also more common than several conditions lower on the list.

When broken down by cost per inpatient stay, five cardiovascular issues ranked in the top 10.

  1. Heart valve disorders — $41,878
  2. Acute myocardial infarction (heart attack) — $20,086
  1. Coronary atherosclerosis — $19,657
  1. Septicemia — $18,244
  1. Acute cerebrovascular disease — $15,111

Read Business Insider’s full rundown of the top 20 below:


The 20 most expensive reasons you might have to visit a hospital in the US — and how much it costs if you do


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Expanded Stroke Thrombectomy Guidelines: FDA expands treatment window for use (Up to 24 Hours Post-Stroke) of clot retrieval devices (Stryker’s Trevo Stent) in certain stroke patients

Reporter: Aviva Lev-Ari, PhD, RN


The stent retriever from Stryker was cleared for thrombectomy-eligible patients as initial therapy to reduce paralysis and other stroke disability only as an addition to tissue plasminogen activator (tPA). Previously, the device was approved only for use within 6 hours of ischemic stroke onset.


FDA Clears Trevo Stent Retriever for Up to 24 Hours Post-Stroke

FDA move follows expanded stroke thrombectomy guidelines

by Nicole Lou, Reporter, MedPage Today/

“Time is critical following the onset of stroke symptoms. Expanding the treatment window from 6 to 24 hours will significantly increase the number of stroke patients who may benefit from treatment,” said Carlos Peña, PhD, director of the division of neurological and physical medicine devices at the FDA’s Center for Devices and Radiological Health, in a statement. “Healthcare providers and their patients now have better tools for treating stroke and potentially preventing long-term disability.”

The American Heart Association and American Stroke Association recently revised their guidelines to recommend stent retriever use up to 24 hours after symptom onset. This was announced at the International Stroke Conference in January, where the DEFUSE 3 trial added to the evidence from DAWN in demonstrating benefits to relatively late endovascular thrombectomy.

In particular, DAWN data were used to support the FDA’s latest decision. Trial investigators had reported more functional independence when patients were randomized to Trevo thrombectomy over medical management alone.



FDA expands treatment window for use of clot retrieval devices in certain stroke patients

For Immediate Release

February 15, 2018


FDA expands treatment window for use of clot retrieval devices in certain stroke patients


The U.S. Food and Drug Administration today cleared the use of the Trevo clot retrieval device to treat certain stroke patients up to 24 hours after symptom onset, expanding the device’s indication to a broader group of patients. This device is cleared for use as an initial therapy for strokes due to blood clots (also known as an acute ischemic stroke) to reduce paralysis, speech difficulties and other stroke disabilities and only as an addition to treatment with a medication that dissolves blood blots called tissue plasminogen activator (t-PA). The device was previously cleared for use in patients six hours after symptom onset.

“Time is critical following the onset of stroke symptoms. Expanding the treatment window from 6 to 24 hours will significantly increase the number of stroke patients who may benefit from treatment,” said Carlos Peña, Ph.D., director of the division of neurological and physical medicine devices at the FDA’s Center for Devices and Radiological Health. “Health care providers and their patients now have better tools for treating stroke and potentially preventing long-term disability.”

A stroke is a serious medical condition that requires emergency care and can cause lasting brain damage, long-term disability or even death. According to the Centers for Disease Control and Prevention, stroke is the fifth leading cause of death in the U.S. and is a major cause of serious disability for adults. About 795,000 people in the U.S. have a stroke each year. Ischemic strokes represent about 87 percent of all strokes.

The Trevo device was first cleared by the FDA in 2012 to remove a blood clot and restore blood flow in stroke patients who could not receive t-PA or for those patients who did not respond to t-PA therapy. In 2016, the FDA allowed expanded marketing of the device for certain patients in addition to treatment with t-PA if used within six hours of the onset of symptoms. Today’s expanded indication increases the amount of time that the device can be used once the symptoms are present.

Trevo is a clot removal device that is inserted through a catheter up into the blood vessel to the site of the blood clot. When the shaped section at the end of the device is fully expanded (up to three to six millimeters in diameter), it grips the clot, allowing the physician to retrieve the clot by pulling it back through the blood vessel along with the device for removal through a catheter or sheath.

The FDA evaluated data from a clinical trial comparing 107 patients treated with the Trevo device and medical management to 99 patients who had only medical management. About 48 percent of patients treated with the Trevo device were functionally independent (ranging from no symptoms to slight disability) three months after their stroke compared to 13 percent of patients who were not treated with the Trevo device.

Risks associated with using the Trevo device include a failure to retrieve the blood clot, embolization (blockage) to new territories in the brain, arterial dissections and vascular perforations, and access site complications at the femoral (thigh) artery entry point.

Trevo was reviewed through the premarket notification (510(k)) pathway. A 510(k) is a premarket submission made by device manufacturers to the FDA to demonstrate that the new device is substantially equivalent to a legally marketed predicate device. The FDA granted premarket clearance of the Trevo device to Concentric Medical Inc.

The FDA, an agency within the U.S. Department of Health and Human Services, protects the public health by assuring the safety, effectiveness, and security of human and veterinary drugs, vaccines and other biological products for human use, and medical devices. The agency also is responsible for the safety and security of our nation’s food supply, cosmetics, dietary supplements, products that give off electronic radiation, and for regulating tobacco products.


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