Monmouth Medical Center

Abstract Purpose Angiotensin receptor-neprilysin inhibitors (ARNI) are well-established for chronic heart failure (HF) with reduced ejection fraction. However, their efficacy and safety when initiated in acute decompensation (ADHF) remain less well characterized. This meta-analysis evaluates the efficacy and safety of ARNI compared to angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) for ADHF. Methods A meta-analysis of randomized controlled trials (RCTs) retrieved from PubMed, Scopus, WOS, Embase, and CENTRAL till November 2024. Risk ratios (RR) were applied for dichotomous outcomes and standardized mean differences (SMD) for continuous outcomes, both with 95% confidence intervals (CI). Results Three RCTs with 1,741 patients were included. Use of ARNI after stabilization of ADHF resulted in a significant reduction of HF rehospitalization/all-cause mortality (RR: 0.71; 95% CI: 0.57 to 0.88; p < 0.01), HF rehospitalization (RR: 0.73; 95% CI: 0.57 to 0.93; p = 0.01), worsening renal function (RR: 0.80; 95% CI: 0.64 to 1.00; p = 0.048), and NT-proBNP at 4 weeks (SMD: -0.24; 95% CI: -0.34 to -0.14; p < 0.0001) or 8 weeks (SMD: -0.21; 95% CI: -0.31 to -0.10; p = 0.0001). However, ARNI was associated with a higher risk of symptomatic hypotension (RR: 1.33; 95% CI: 1.04 to 1.71; p = 0.024). Conclusion Pooled data demonstrate that the initiation of ARNI post-ADHF can be effective compared with ACEIs/ARBs for both cardiovascular and renal benefits at the expense of increased risk for symptomatic hypotension.

Age and Gender Disparities in Burden of Hypertensive Heart Disease Attributable to Lead Exposure from 1990 to 2021: A Global Benchmarking Analysis Background: Hypertensive heart disease (HHD) remains a major global contributor to cardiovascular mortality and morbidity. Lead exposure is a recognized environmental risk factor that exacerbates hypertension and its complications. This study aims to evaluate the age-specific burden of HHD attributable to lead exposure across the years 1990, 2000, and 2021, focusing on trends in mortality, disability-adjusted life years (DALYs), and years lived with disability (YLDs). Methods: We estimated deaths, DALYs, and YLDs due to HHD attributable to lead exposure, stratified by 5-year age group, sex, year and location across the 204 countries and territories from 1990-2021 using standardized global burden of disease study 2021 methodology. Annualized percentage changes (APC) were calculated for multiple time intervals to assess temporal and sex-specific trends. Result: From 1990 to 2021, deaths due to hypertensive heart disease attributable to lead exposure increased by 83% (95% UI: 6%–137%), DALYs rose by 50% (4%–92%), and YLDs surged by 150% (27%–176%). Regionally, the greatest increase in total percentage change (TPC) in deaths occurred in South Asia (146%), followed closely by Central Europe, Eastern Europe, and Central Asia (139%), Latin America and the Caribbean (81%), and North Africa and the Middle East (79%). Stratified by socio-demographic index (SDI), the most pronounced rise in deaths was observed in high SDI regions (146%), with notable increases also recorded in low-middle SDI (97%), high-middle SDI (96%), low SDI (76%), and middle SDI (63%). Age-specific trends revealed minimal change in individuals aged 20–54 years (1% increase), while those aged 55 years and above exhibited a substantial 94% rise in DALYs. In the same older age group, YLDs increased by 65% during the study period. Gender-disaggregated analysis showed a disproportionately greater increase among females compared to males: deaths rose by 92% vs. 74%, DALYs by 57% vs. 43%, and YLDs by 170% vs. 134%, respectively. Conclusion: The burden of hypertensive heart disease attributable to lead exposure has significantly increased over the past three decades, with disproportionately higher impacts among older adults, high-SDI regions, and females, underscoring the need for targeted environmental and cardiovascular interventions.

Background: Heart failure (HF) remains a leading cause of morbidity and mortality in the U.S. Concurrently, amphetamine use disorder has emerged as an increasingly recognized contributor to cardiovascular fatalities. While the broader stimulant-overdose mortality trends have been documented, specific trends in HF mortality involving amphetamine use require elucidation to guide targeted interventions. Methods: Mortality data (2003–2022) were extracted from the CDC’s National Vital Statistics System, identifying HF-listed deaths with amphetamine-type stimulants noted as a contributing cause. Absolute counts and age-adjusted rates were computed annually. Annual Average Percent Change (AAPC) was calculated for both absolute death counts and age-standardized mortality. Trends were stratified by census region, state, 2013 urbanization categories, age group, sex, race, and Hispanic origin. Results: Between 2003 and 2022, HF deaths involving amphetamine use as a contributing cause rose substantially in the U.S., with total deaths increasing from 150 to 1,500 and an overall AAPC of +12.1%. The age-adjusted mortality rate rose from 0.05 to 0.35 per 100,000 (AAPC +11.3%). Regionally, the West had the steepest rise (AAPC +13.8%), followed by the Midwest, South, and Northeast. West Virginia showed the highest state-level increase (AAPC +14.9%), with Colorado and California also showing significant growth. Non-metropolitan areas experienced the fastest rise in age-adjusted mortality (AAPC +14.2%), while large metros had a slower increase. Adults aged 25–44 years had the highest AAPC (+13.5%), followed by those aged 45–64; older adults had a smaller increase. Males were more affected, with an AAPC of +12.8% versus +9.0% in females. Among racial groups, American Indian/Alaska Native individuals had the highest burden (0.50 per 100,000 in 2022, AAPC +14.9%), followed by Black, Hispanic, and White populations, all with AAPCs above +10%. Conclusion: Deaths in which amphetamine use disorder contributes to HF have surged significantly across all demographic and geographic sectors, with disproportionate increases in young adults, rural populations, and racial minorities. The especially steep trends in non metro regions and among American Indian/Alaska Native communities signal urgent need for tailored public health initiatives, focusing on stimulant use prevention, cardiovascular screening, and substance use rehabilitation integrated with cardiac care.

Background: Severe mitral regurgitation (MR) in cardiogenic shock (CS) presents unique therapeutic challenges, especially in patients with prohibitive surgical risk. Transcatheter edge-to-edge repair (TEER) with MitraClip offers a less invasive alternative, yet optimal strategies for hemodynamic support in this setting remain unclear. Methods: We conducted a retrospective study of patients undergoing MitraClip implantation for severe MR and CS between 2018 and 2024 at a tertiary academic center. Of 440 screened cases, 47 met CS criteria and were stratified based on receipt of periprocedural Impella support. Clinical, procedural, and survival outcomes were compared between Impella-supported and unsupported cohorts using appropriate statistical methods. Results: Among the 47 patients, 24 received Impella support and 23 did not. The Impella group had greater illness severity, including higher rates of preprocedural intubation (75.0% vs. 43.5%) and SCAI stage D shock (50.0% vs. 13.0%). Despite these differences, procedural success was 100% in both groups. In-hospital (8.3% vs. 8.7%), 30-day (12.5% vs. 8.7%), and 1-year mortality (25.0% vs. 26.0%) were similar between Impella and non-Impella patients, respectively. Impella recipients had longer hospital stays (median 18 vs. 11 days; p=0.032) and higher 1-year readmission rates (55.0% vs. 21.7%; p=0.024), reflecting baseline acuity. There were no differences in major procedural complications or re-intervention rates. Conclusions: MitraClip implantation in CS patients supported with Impella is feasible and safe. Despite significantly worse hemodynamic profiles, outcomes were comparable to those without mechanical support. These findings suggest a potential role for tailored Impella use in expanding TEER to critically ill patients and underscore the need for prospective studies to guide support strategies in high-risk MR intervention.

Background: Congenital circulatory anomalies remain a significant cause of mortality in the United States, especially among infants and young children. Understanding long-term mortality trends and disparities across demographics and geography is crucial for targeted public health interventions. Methods: Mortality data for congenital circulatory anomalies were extracted from CDC WONDER for the years 1999 to 2020. Annualized Percentage Change (APC) in absolute death counts was calculated using log-linear regression models, stratified by state, census region, urbanization, sex, age group, race, and Hispanic origin. Results: Nationally, deaths declined from 4,436 in 1999 to 3,011 in 2020, reflecting an APC of –2.14%. Among census regions, the Northeast experienced the steepest decline (APC: –2.37%), followed by the Midwest (–2.25%), South (–2.05%), and West (–2.02%). Urbanization-wise, the greatest reduction was noted in NonCore (–2.53%) and Large Fringe Metro areas (–2.01%), while Small Metro areas had a milder decline (–1.44%). State-level analysis showed that Alaska had an increasing trend (APC: +4.66%), while several states showed moderate-to-high declines, with California (–3.12%) and Texas (–2.84%) among the top. Age-specific trends revealed significant reductions in the 1–4 year age group (APC: –1.70%) and 75–84 year group (–1.56%), with relatively stable trends among those aged 55–64 (–0.04%). Sex-stratified analysis showed a sharper decline in females (–2.33%) compared to males (–1.97%). Racial disparities were evident: White individuals experienced the highest decline (–2.36%), followed by Black or African American (–1.82%), American Indian or Alaska Native (–0.60%), while Asian or Pacific Islanders showed a slight increase (APC: +1.02%). By Hispanic origin, deaths among Hispanic or Latino populations declined with an APC of –1.20%, while those not of Hispanic origin declined more steeply (–2.29%). The "Not Stated" category also declined (–2.13%). Conclusion: Despite overall declining mortality from congenital circulatory anomalies in the U.S. from 1999 to 2020, marked disparities persist across race, state, age, and urbanization level. Targeted efforts are needed to reduce the widening gaps and address the concerning upward trends observed in specific states and ethnic groups.

Background: Cardiovascular disease (CVD) remains the leading cause of death among women in the United States. Understanding temporal and demographic trends in mortality is essential to inform targeted public health strategies and equitable interventions. Methods: We analyzed female mortality due to cardiovascular disease in the U.S. from 1999 to 2020 using national death certificate data. Age-adjusted mortality rates (AAMRs) were calculated per 100,000 population. Annualized Percentage Change (APC) in AAMRs and absolute deaths was assessed using log-linear regression models. Analyses were stratified by census region, state, urbanization level, age group, race, and Hispanic origin. Results: Between 1999 and 2020, total cardiovascular deaths among U.S. women declined from 510,798 to 441,532, with an APC of -0.69%. The AAMR decreased markedly from 297.9 to 183.1 per 100,000, reflecting an APC of -2.29%. Regionally, the greatest declines were seen in the West (-2.53%), followed by the Northeast (-2.49%), South (-2.21%), and Midwest (-2.07%). At the state level, the sharpest reductions were observed in California (-2.85%), Alaska (-2.29%), and Arizona (-2.04%). Urban-rural disparities were evident: Large Central Metro areas experienced the steepest decline (-2.49%), followed by Large Fringe Metro (-2.44%), Medium Metro (-2.22%), Micropolitan (-1.93%), and NonCore rural areas (-1.81%). Age-stratified analysis showed the greatest mortality reduction in the 1–4 years group (-1.26%), whereas rising trends were noted among women aged 25–34 (+0.98%) and 45–54 years (+0.29%). Racial disparities were observed, with the largest AAMR decline in American Indian or Alaska Native women (-2.89%), followed by Asian or Pacific Islander (-2.44%), White (-2.29%), and Black or African American women (-2.10%). By Hispanic origin, Hispanic or Latino women showed a greater decline (228.8 to 139.0; APC: -2.35%) compared to Non-Hispanic women (300.3 to 187.9; APC: -2.21%). Conclusion: Cardiovascular mortality in U.S. women has declined substantially over the past two decades, with notable geographic, racial, ethnic, age, and urbanization-based disparities. The growing burden in younger women and persistent racial differences warrant tailored prevention strategies to sustain and equitably advance cardiovascular health gains.

Eosinophilic esophagitis results in a chronic immune-mediated condition of the esophagus characterized by esophageal dysfunction and eosinophil-predominant inflammation. While food-based oral immunity therapy (OIT) is a recognized trigger for eosinophilic esophagitis, the impact of sublingual immunotherapy (SLIT) for aeroallergens is less well established. We present an unusual case of eosinophilic esophagitis in a 14-year-old male induced by SLIT and resolved after discontinuing SLIT with Timothy grass pollen allergy extract (GRASTEK®, ALK-Abelló, Inc., Bedminster, USA), which, to our knowledge, has not been previously reported.

Abstract Introduction: Hepatic artery aneurysm (HAA) is a rare condition, accounting for 0.1% of all arterial aneurysms, and is the most prevalent visceral pseudoaneurysm with a prevalence of 20%. HAA in infective endocarditis is rarely implicated, arising from microbial infiltration and subsequent damage to arterial wall. While HAA is associated with life-threatening morbidity, its incidence has declined due to widespread use of antibiotics. Case Presentation: A 73 year old female with history of coronary artery disease, atrial fibrillation, mitral valve prolapse with repair and on warfarin presented with sudden onset left lower quadrant abdominal pain. Examination revealed periumbilical tenderness. Vitals were unstable with blood pressure of 60/45. Labs showed white count 18000, hemoglobin 7.7, platelets 1023, AST 509, ALT 313, and positive SARS-COV2. Non contrast CT abdomen and pelvis (CTAP) showed moderate hemoperitoneum, large rectus sheath hematoma, hypodense lesion in left hepatic lobe. CTAP with IV contrast revealed stable rectus sheath hematoma, pseudo aneurysm in left hepatic lobe, confirmed by Doppler ultrasound of liver. Coil embolization of left hepatic artery pseudo aneurysm stabilized her vitals. Blood cultures grew Staphylococcus epidermidis, and she was started on meropenem and vancomycin due to her prosthetic mitral valve. 2D echocardiogram showed vegetation on the prosthetic mitral leaflet. Repeat imaging showed stable thromboses left hepatic artery pseudoaneurysm. She remained stable and was transferred to a tertiary center for mitral valve replacement. Transesophageal echocardiogram revealed no evidence of vegetation, with clear mitral valve leaflets. Repeat blood cultures remained negative, but antibiotics were continued for six weeks due to high suspicion of infective endocarditis. Warfarin was resumed and no new hematoma or bleeding was noted. Conclusion: Hepatic artery aneurysms, often mycotic, are rare but life-threatening complications of infective endocarditis, especially in patients with bioprosthetic valves on anticoagulation therapy, which raises bleeding risk and worsens the severity of these cases. These aneurysms pose significant diagnostic and therapeutic challenges, as they are often asymptomatic until rupture, which may be the first and only indicator of underlying infective endocarditis. Given the high rupture rate and substantial mortality risk, it is critical to maintain a low diagnostic threshold. Patients with hepatic artery aneurysms or rupture, especially those presenting with unexplained fever, prosthetic valves, dialysis catheters, or IV drug use, should undergo prompt screening for infective endocarditis. Immediate management should focus on hemodynamic stabilization, utilizing appropriate vascular interventions and initiating antibiotic therapy without delay.