William Howard Frishman

Orthopedic surgery is a major risk factor for thromboembolic events such as deep venous thrombosis and pulmonary embolism following a variety of surgeries such as total hip and knee replacements, fracture fixations, spinal surgeries, orthopedic traumas, and arthroscopic surgeries. Many other risk factors contribute, such as age, immobilization, combined oral contraceptive medications, genetic causes, cast immobilization, tourniquet use, and comorbidities. Prophylaxis can be done through chemoprophylaxis and/or mechanoprophylaxis. Diagnosis of deep venous thrombosis is made through ultrasonography, and pulmonary embolism diagnosis is made using risk stratification and a variety of possible tests including D-dimer levels, computed tomography pulmonary angiogram, and ventilation/perfusion scans. Treatment requires using anticoagulants for a minimum of 3 months or possibly inferior vena cava filters if anticoagulation therapy is contraindicated.

Preeclampsia is a multisystem hypertensive disorder of pregnancy that is defined by new-onset hypertension after 20 weeks of gestation along with proteinuria or evidence of end-organ dysfunction. Affecting 2–8% of pregnancies worldwide, preeclampsia remains a leading cause of maternal and perinatal morbidity and mortality. This disorder originates secondary to defective placentation during the first trimester, causing incomplete remodeling of the uterine spiral arteries, resulting in placental hypoperfusion, oxidative stress, and the release of anti-angiogenic factors into the maternal circulation. This pathophysiology provided researchers a rationale for the use of low-dose aspirin as a preventive strategy for preeclampsia. Early studies investigated low-dose aspirin initiated at variable gestational ages and failed to show significant reductions in the incidence of preeclampsia. However, over the years, multiple meta-analyses studying aspirin use for preeclampsia prevention revealed a consistent decrease in the incidence of preeclampsia with the use of low-dose aspirin initiated at or before 16 weeks of gestation, with the efficacy being largely dependent on the time of initiation. In 2017, a randomized controlled trial demonstrated a statistically and clinically significant reduction in the incidence of preeclampsia leading to preterm delivery with aspirin initiated before 16 weeks gestation in women identified as high risk by first-trimester algorithm-based screening. Based on the strong evidence in support of aspirin use for preeclampsia prevention, current guidelines recommend initiation of aspirin 81 mg after 12 weeks and ideally before 16 weeks for all pregnant women at increased risk for preeclampsia.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in clinical practice and an independent, well-established risk factor for ischemic stroke. However, restoring sinus rhythm via cardioversion does not eliminate this risk. Cardioversion itself transiently increases thromboembolic risk more than 10-fold, driven by atrial stunning, a state in which the left atrium and left atrial appendage remain mechanically dysfunctional despite normalized electrical activity seen on an electrocardiogram. Retrospective data show that thromboembolic events are clustered heavily within the first 2 weeks postcardioversion, supporting the near-universal recommendation of at least 4 weeks of continued therapeutic anticoagulation postcardioversion for AF duration more than 12 to 48 hours, regardless of baseline stroke risk score. Beyond this initial 4-week recommendation, the decision to continue anticoagulation is based on a comprehensive assessment of the patient’s thromboembolic risk profile, rather than rhythm status or cardioversion success. Multiple trials have demonstrated a significant increase in the incidence of ischemic strokes in patients who had a premature discontinuation of anticoagulation postcardioversion. Additionally, having a prior stroke, the heaviest weighted risk-stratification variable, favors indefinite anticoagulation regardless of postcardioversion rhythm outcome. Current guidelines provide a framework for approaching postcardioversion anticoagulation, including a fixed 4-week anticoagulation course encompassing the atrial stunning period, followed by individualized risk-stratification to determine the indication for continued anticoagulation. Nevertheless, future research is still required to better elucidate whether anticoagulation can be safely discontinued after completion of the recommended 4-week postcardioversion anticoagulation course in patients with a prior AF-related stroke.

Obesity remains a major modifiable driver of cardiovascular disease. Emerging antiobesity pharmacotherapies demonstrate substantial weight loss alongside improvements in multiple cardiometabolic parameters. This literature review summarizes the early clinical studies of eloralintide, a selective long-acting amylin receptor agonist, and evaluates whether its weight loss and cardiometabolic effects may be relevant to cardiovascular risk reduction. Early clinical studies suggest a potentially distinct and favorable cardiometabolic profile for eloralintide, including reductions in body weight, pulse rate, blood pressure, inflammatory markers, lipid parameters, and preferential fat mass loss. The reduction in pulse rate stands out as it contrasts with the increase in heart rate that is associated with glucagon-like peptide-1 receptor agonists. The favorable profile may be further supported by eloralintide’s preferential fat mass loss and improvements in both the high-sensitivity C-reactive protein and lipid markers. While these findings are promising, current evidence is limited as it is based on preclinical, phase 1, and phase 2 studies with relatively small sample sizes and short durations. No amylin receptor agonist, including eloralintide, has been evaluated in a dedicated cardiovascular outcomes trial, and their ability to reduce major adverse cardiovascular events remain to be studied. Therefore, epidemiological benchmarks should be viewed as contextual rather than predictive. Future clinical studies and dedicated cardiovascular outcomes trials will be essential to determine whether these early cardiometabolic improvements translate to clinically meaningful cardiovascular risk reduction.

The optimal strategy for long-term oral anticoagulation (OAC) after catheter ablation for atrial fibrillation (AF) remains uncertain. Although current guidelines recommend anticoagulation based on thromboembolic risk scores irrespective of rhythm status, this recommendation has not been validated by randomized controlled trials (RCTs). We included 3 RCTs, ODIn-AF (Prevention of Silent Cerebral Thromboembolism by Oral Anticoagulation With Dabigatran After Pulmonary Vein Isolation for Atrial Fibrillation), ALONE-AF (AnticoaguLation ONE Year After Ablation of Atrial Fibrillation in Patients With Atrial Fibrillation), and OCEAN (Optimal Anticoagulation for Higher-Risk Patients Post-Catheter Ablation for Atrial Fibrillation Trial), enrolling patients at least 6 months postablation with no recurrent atrial arrhythmias. Primary efficacy outcomes were all stroke and embolism (including cerebral emboli). The primary safety outcome was major bleeding. Secondary outcomes included clinically relevant nonmajor bleeding and other thromboembolic and bleeding events. Risk ratios (RR) with 95% confidence intervals (CI) were pooled using a random-effects model. In total, 2324 patients were included. Discontinuation of anticoagulation therapy did not significantly increase the risk of all stroke and embolism, at least 6 months postcatheter ablation [RR, 0.58 (0.11–3.12); I ² = 54%]. OAC discontinuation was associated with lower risk of major bleeding [RR, 0.33 (0.11–0.95); I ² = 0%] and clinically relevant nonmajor bleeding [RR, 0.40 (0.19–0.84); I ² = 0%]. No significant differences were observed for other thromboembolic and bleeding events. Sensitivity analyses using per-protocol populations were significant only for a reduction in clinically relevant nonmajor bleeding [RR, 0.33 (0.17–0.65); I ² = 0%]. In patients remaining arrhythmia-free for at least 6 months after AF ablation, discontinuation of OAC was associated with fewer bleeding events without a statistically significant increase in thromboembolic risk. These hypothesis-generating findings highlight the need for larger, well-powered RCTs to better inform postablation anticoagulation strategies.

Patent ductus arteriosus (PDA) is defined as a persistent communication between the pulmonary artery and the aorta that normally closes before birth. While the ductus arteriosus is an essential vascular shunt for a developing fetus, its failure to close can become pathologic. Most PDAs are repaired during infancy; however, some remain patent into adulthood, with presentations varying in clinical severity. Untreated PDA can lead to significant morbidity, with complications including left-heart volume overload, arrhythmia, pulmonary hypertension, and possible Eisenmenger syndrome. This review covers the management of PDA in adults, highlighting the pathophysiology, morphological classification, clinical presentation, and current approaches to closure. Transcatheter closure is currently the preferred approach, although surgical methods may be used in patients with distinct anatomy or other concomitant intracardiac pathology. While both methods come with different risk profiles, closure in adults has proven to be effective, resulting in considerable hemodynamic and clinical improvements.

Microvascular disease of the eye encompasses both structural and functional changes to the retinal vessels. Cardiometabolic disorders, such as hypertension and diabetes, are associated with early, measurable abnormalities in the retinal microvascular network that often emerge before cardiovascular disease becomes detectable. These features can be directly, noninvasively assessed with a multitude of evolving imaging techniques. Furthermore, these vascular changes can be used to predict future cardiac events, making them promising biomarkers for systemic disease. Early detection is essential, as retinal microvascular pathology not only reflects systemic health but, in certain conditions, can be detrimental to vision. Therefore, clinical evaluation requires a combination of ocular-specific strategies and a focus on underlying metabolic risk factors. As screening techniques advance, integrating assessment of the ocular microcirculation into broader cardiovascular care may become increasingly valuable.

Chronic wounds are a major source of patient morbidity and healthcare expenditure, with impaired tissue oxygenation recognized as a notable obstacle to successful repair. Supersaturated oxygen (SSO ₂ ) therapies have gained increasing traction as adjunctive treatments to improve the local wound environment and support the healing process. This review examines the current research and applications of SSO ₂ therapy in wound healing, including its proposed biological effects, methods of administration, clinical outcomes, and safety considerations. Current research suggests that oxygen-enriched therapies may support tissue regeneration through multiple mechanisms, including the promotion of vascularization, support of extracellular matrix formation, optimization of cellular energy production, and modulation of host inflammatory and antimicrobial processes. Clinical studies have also reported improved outcomes in chronic wounds, particularly diabetic foot ulcers, with additional positive findings in venous leg ulcers, pressure ulcers, and select postoperative wounds. Although limitations remain regarding ideal patient selection and long-term financial impacts, current data support SSO ₂ therapy as a promising adjunctive therapy within comprehensive wound management.

As the global burden of heart failure continues to rise, heart transplantation—the only definitive therapy for heart failure—has become a major focus of clinical research aimed at increasing the availability of suitable donor allografts. Historically, heart transplantation has been limited to the availability of hearts obtained from donors after brain death within relatively short distances. The TransMedics Organ Care System (OCS) Heart is a novel technology that allows for portable extracorporeal nonischemic perfusion of the heart after the circulatory death of the donor. Often referred to as “Heart in a Box,” the OCS Heart is a potential major advancement in heart transplantation because of its ability to preserve the heart in a metabolically active state after the circulatory death of the donor, allowing for longer-distance transport compared to traditional cold storage methods. Numerous randomized controlled trials studying the efficacy of the OCS Heart technology from donors after circulatory death compared to traditional cold storage methods from donors after brain death demonstrated noninferiority. By allowing for preservation after circulatory death and for longer transport times, the OCS Heart can potentially significantly expand the donor pool and increase the number of heart transplants. The major limitations of its use include the expensive costs of operation, the increased level of training required for personnel, and the risk of technological malfunctions compared to traditional cold storage methods. Nevertheless, the OCS Heart is poised as a critical development in the field of heart transplantation, with an expectation that adoption rates for its use will increase in the coming years.

Pacemaker insertion in children presents unique challenges because of their small size and developing anatomy. Since pacemaker insertion is relatively uncommon in pediatric patients, and as a result, specialized technologies for this population remain limited and under-researched. The most common indication for pacemaker insertion in children is congenital or acquired heart block. Congenital heart block is often associated with maternal autoimmune disease, in which autoantibodies damage the developing cardiac conduction system. It may also occur in association with congenital heart disease. Acquired heart block can result from several causes, including postoperative conductive abnormalities and complications of myocarditis. Several types of pacemakers have been studied in pediatric patients, including leadless, transvenous, and epicardial pacemakers. Smaller devices designed specifically for neonates are also being investigated. In addition, temporary pacemakers may be used in acute settings or as a bridge to permanent therapy because they can be implanted more rapidly.