ABSTRACTBackgroundIn-hospital management of out-of-hospital cardiac arrest (OHCA) is heavily influenced by the initial rhythm (shockable vs. non-shockable). The prevalence of discordance between initial rhythm determination reported by emergency medical services (EMS) versus hospital teams is not well described. It is unclear whether such documentation discrepancies in OHCA influence inpatient clinical care including subsequent left heart catheterization (LHC). We hypothesized that discordance between EMS and hospital team documentation of OHCA initial rhythm was common and associated with differences in LHC frequency.MethodsThis was a retrospective, single-center study. OHCA patients from the Cardiac Arrest Registry to Enhance Survival (CARES) hospital database were linked by demographic and arrest history to OHCA patients identified by inpatient hospital billing codes from 2009 to 2017. Patients who expired within 24 hours of hospital presentation were excluded. Hospital documentation of OHCA initial rhythm and occurrence of LHC were manually reviewed. The relationship between EMS versus hospital team documentation of OHCA initial rhythm and occurrence of LHC were assessed by relative risk ratios with 95% confidence intervals.ResultsOut of 164 patients for analysis, 140 (85.4%) had concordant EMS and hospital documentation of OHCA initial rhythm. For OHCA with an EMS-documented shockable rhythm, the relative risk of LHC when hospital-documented concordant shockable vs. discordant non-shockable rhythm was 2.12 (95% RR CI: 0.76-5.93). For OHCA with an EMS-documented non-shockable rhythm, the relative risk of LHC when hospital-documented concordant non-shockable vs discordant shockable rhythm was 0.19 (95% CI: 0.05-0.69).ConclusionsIn patients with OHCA, discrepancy between EMS and hospital team documentation of the initial arrest rhythm is prevalent. This discrepancy may influence the incidence of LHC. Further research is needed to understand the clinical impact of discrepancies in rhythm communication between EMS and hospital teams.

Psoriasis is a systemic inflammatory disease associated with increased cardiovascular risk and impaired cholesterol efflux. Cholesterol efflux capacity (CEC), the ability of HDL to accept cholesterol from macrophages has been shown to be associated with noncalcified coronary burden (NCB) in

Cardiovascular disease (CVD), especially ischemic heart disease and stroke, is the major cause of death worldwide, accounting for more than onethird of all deaths annually. Hypertension is the most prevalent and modifiable risk factor of CVD-related deaths. The same is true for obesity, which is currently being recognized as a major global epidemic. The prevalence of obesity in the United States has increased dramatically, from 13.4% in 1960 to 36.5% in 2014, with as much as 70.7% of the American adult population being overweight or obese (CDC). Epidemiological studies have shown that obesity predisposes to hypertension and CVD - with the relationship between markers of obesity and blood pressure being almost linear across different populations. In this review, we discuss systemic and pulmonary hypertension in the context of obesity.

BackgroundSarcoidosis is a multisystem granulomatous disease of unclear etiology characterized histologically by non-caseating granulomas. Lungs are the most common organs affected but sarcoidosis can affect almost any organ system. While clinically manifest cardiac involvement occurs in only about 5% of patients with sarcoidosis, a significant proportion have clinically silent disease. Symptomatic cardiac involvement portends a poorer prognosis with manifestations varying from heart failure and conduction abnormalities to ventricular arrhythmias including sudden death. Immunosuppression with corticosteroids and DMARDs such as methotrexate and mycophenolate mofetil has been the mainstay of treatment despite a paucity of data. There is a subset of patients that are either non-responders to these agents or in whom the side effect profile is prohibitive for their long term use. Biologic agents, mainly TNF alpha antagonists, have been used as salvage therapies in these patients. However, the evidence regarding their efficacy and safety is limited to a few case reports. In fact, there remains much apprehension regarding the use of TNF alpha antagonists in patients with systolic heart failure due to concerns that they can exacerbate heart failure.ObjectivesTo study the efficacy and safety of using biologics for the treatment of cardiac sarcoidosis.MethodsWe conducted a retrospective and prospective observational study of all adult patients with cardiac sarcoidosis treated with biologics at an academic medical center in Washington D.C, USA between 2013 and 2018.ResultsWe identified 9 patients (3 men and 6 women) diagnosed with cardiac sarcoidosis at our institution. The mean age at diagnosis was 49.9 (SD 8.6). 1 patient was Caucasian and the rest (n=8) were African American. Lungs were the most common extra cardiac organ involved (n=7) followed by CNS (n=4), liver (n=4) and skin (n=3). 5 of the patients presented with systolic heart failure (EF<50%), 3 with atrial and ventricular arrhythmias and 1 was found to have incidental abnormal myocardial uptake on PET imaging. 8 of the 9 patients had abnormal myocardial uptake on PET imaging. All but 1 patient had been initially treated with oral steroids (1 refused) and 7 of the 9 patients had also been given oral DMARDs; methotrexate (n=6), azathioprine (n=2), hydroxychloroquine (n=2) and mycophenolate mofetil (n=1). Biologics used were adalimumab (n=5), infliximab (n=3) and rituximab (n=1). The most common indication for biologics was progression of disease despite optimal doses of standard therapy, followed by intolerance or contraindication to standard therapy. 75% of the patients were noted to have marked clinical improvement with the addition of a biologic. 4 out of 9 patients had decreased myocardial uptake on PET following treatment with a biologic. One patient had no change on PET and 4 have not had repeat imaging done yet. None of the patients had worsening of left ventricular systolic function with the addition of a TNF alpha antagonist. There were no reported major infections or significant adverse events that were attributable to the use of biologics.ConclusionBased on our small cohort, biologics (mainly TNF alpha antagonists) appear to be safe and efficacious as salvage therapy for cardiac sarcoidosis. However, there is a need for prospective studies to further validate these findings as well as to identify the subset of patients that would benefit from early initiation of these therapies.References[1] Birnie, D. H., Nery, P. B., Ha, A. C., & Beanlands, R. S. B. (2016). Cardiac Sarcoidosis. Journal of the American College of Cardiology, 68(4), 411.Disclosure of InterestsNone declared

Background: Cardiac sarcoidosis (CS) is an increasingly recognized cause of cardiomyopathy; however, data on immunosuppressive strategies are limited. Treatment with tumor necrosis factor (TNF) alpha inhibitors is not well described; moreover, there may be heart failure-related safety concerns. Methods: Retrospective multicenter study of patients with CS treated with TNF alpha inhibitors. Baseline characteristics, treatments, and outcomes were adjudicated. Results: Thirty-eight patients with CS (mean age 49.9 years, 42% women, 53% African American) were treated with TNF alpha inhibitor (30 infliximab, 8 adalimumab). Prednisone dose decreased from time of TNF alpha inhibitor initiation (21.7 +/- 17.5 mg) to 6 months (10.4 +/- 6.1 mg, P = .001) and 12 months (7.3 +/- 7.3 mg, P = .002) after treatment. On pre-TNF alpha inhibitor treatment positron emission tomography with 18-flourodoxyglucose (FDG-PET), 84% of patients had cardiac FDG uptake. After treatment, there was a significant decrease in number of segments involved (3.5 +/- 3.8 to 1.0 +/- 2.5, P = .008) and maximum standardized uptake value (3.59 +/- 3.70 to 0.57 +/- 1.60, P = .0005), with 73% of patients demonstrating complete resolution or improvement of cardiac FDG uptake. The left ventricular ejection fraction remained stable (45.0 +/- 16.5% to 47.0 +/- 15.0%, P = .10). Four patients required inpatient heart failure treatment, and 8 had infections; 2 required treatment cessation. Conclusions: TNF alpha inhibitor treatment guided by FDG-PET imaging may minimize corticosteroid use and effectively reduce cardiac inflammation without significant adverse effect on cardiac function. However, infections were common, some of which were serious, and therefore patients require close monitoring for both infection and cardiac symptoms.

Permanent pacemaker (PPM) implantation remains common after transcatheter aortic valve implantation (TAVI). Invasive electrophysiology studies (EPSs) may reduce PPM implantation rates by identifying patients who do not require long-term pacing. At our institution, a new strategy in which patients with equivocal indications for pacing underwent EPSs to determine the need for PPM implantation was adopted. We compared baseline demographics, TAVI procedural details, and outcomes in patients without any conduction disturbance after TAVI, patients with new PPM implantation, and patients with EPS ± new PPM implantation. After exclusion for preexisting PPMs, of a total of 614 consecutive TAVI patients, 117 (19.1%) required new PPM implantation for unequivocal pacing indications, and 95 (15.5%) underwent EPSs. Of those patients who underwent EPSs, 28 (29.5%) required PPM implantation and 67 (70.5%) did not. The overall rate of new PPM implantation was higher for self-expanding versus balloon-expandable valves (34.0% vs 19.9%, p = 0.0011). PPM implantation increased intensive care and hospital length of stay compared with patients without any conduction disturbance (10.7 ± 8.3 vs 8.5 ± 6.4 days, p = 0.003). A negative EPS did not prolong length of stay. There were no significant differences in 30-day and 1-year mortality between groups. In conclusion, among TAVI patients with new-onset conduction disturbance, EPS is a safe strategy to identify those who require PPM implantation and those in whom PPMs can be avoided.

•We present two cases of advanced uterine cancer that were treated with the combination of metronomic cyclophosphamide and bevacizumab.•Targeting angiogenesis can provide disease control in patients with advanced uterine cancer.•Randomized controlled trials comparing metronomic and conventional regimens in advanced uterine cancer are required.

INTRODUCTION:Despite the undeniable clinical efficacy of drug-eluting stents with durable polymers, concerns regarding their long-term safety have been raised, especially in more complex subsets. The Manipal-S Registry was designed to evaluate the safety and effectiveness of the biodegradable polymer coated Supralimus(®) Sirolimus-Eluting Coronary Stent for the treatment of coronary artery disease, across a wide range of patients who are treated in real-life clinical practice.METHODS:All the consecutive 116 patients who underwent single-vessel or multiple vessel percutaneous coronary interventions with the use of Supralimus(®) sirolimus-eluting stents between September 2009 and December 2010, were included in this study. Patients were clinically followed-up at 1, 9, 12 and 24 months post-procedure. All clinical, procedural, and follow-up information were collected and analysed.RESULTS:In total 116 patients, 126 lesions were implanted with 144 stents which had an average stent length of 25.8±8.0 mm. The incidences of any major adverse cardiac and cerebral events at 1, 9, 12 and 24 months were 0, 5 (4.3%), 8 (6.9%), and 10 (8.6%) respectively.CONCLUSION:These 24-month results clearly provide evidence for safety and effectiveness of the Supralimus(®) Sirolimus-eluting coronary stent system with the biodegradable polymer in real-life patients, even in those with acute myocardial infarctions.