Hypertension is a leading cause of death and disability in the United States, affecting nearly half of all Americans, according to the NIH. Postpartum hypertension is a clinically important form of hypertension that can be preexisting or arise during or after pregnancy. While there are many medications available to manage it, many of them have side effects that can affect the patient, lactation, the nursing infant, or a combination of these factors. This review summarizes the available lactation safety data for commonly used antihypertensive medications, including breast milk concentrations, relative infant dose, infant serum levels, and reported maternal and infant outcomes. Based on the available evidence, medications are categorized according to their compatibility with breastfeeding, and a practical clinical framework is proposed to guide medication selection. Overall, calcium channel blockers, selected beta-blockers, and angiotensin-converting enzyme inhibitors demonstrated favorable safety profiles in lactating patients, whereas diuretics, clonidine, and angiotensin receptor blockers should be used with greater caution because of higher infant exposure, potential effects on lactation, reported adverse effects, or limited evidence. These data were mainly sourced from published pharmacokinetic and clinical studies, as summarized in LactMed, the NIH's Drugs and Lactation Database, which compiles lactation safety data for various medications.

Patients undergoing coronary artery bypass grafting (CABG) remain at high risk of major adverse cardiovascular events and death despite successful revascularization, and the role of renin-angiotensin system inhibitors (RASi), comprising angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, in this setting is not clearly defined. We systematically reviewed the effect of RASi initiated within 30 days after CABG on postoperative outcomes. PubMed, Web of Science, Scopus, and the Cochrane Library were searched through May 2025 for randomized controlled trials and observational studies comparing patients who received RASi after CABG, alone or with other cardiovascular medications, with those who did not. Five studies (3 RCTs and 2 retrospective cohorts) comprising 47,821 patients (28,917 RASi recipients and 18,904 controls) were included. RASi use after CABG was generally associated with a lower rate of major adverse cardiovascular events, with the largest reductions observed in patients with heart failure. The effect on all-cause mortality was inconsistent: 2 studies reported a reduced risk, whereas 2 reported no significant difference. Cardiovascular mortality findings were similarly variable, with 1 study showing a marked reduction, 1 an early increase in the composite endpoint that attenuated over longer follow-up, and 1 no significant change.

Systemic anticoagulation is the standard initial therapy for intermediate-risk pulmonary embolism (PE) but fails to reverse right ventricular (RV) overload rapidly. While full-dose systemic thrombolysis accelerates RV recovery, it carries an unacceptable risk of major hemorrhage. Catheter-directed thrombolysis (CDT) offers a targeted, low-dose alternative to improve hemodynamics safely. A comprehensive search of PubMed, Web of Science, CENTRAL, Scopus, and Embase was conducted up to May 2026. Mean differences (MD) and risk ratios (RR) were pooled using a random-effects model. PROSPERO ID: CRD420261402147. Six RCTs involving 886 patients were included. CDT was associated with a significantly greater reduction in the RV/LV ratio than anticoagulation alone (MD: -0.11, 95% CI: [-0.21, -0.00]; P < 0.05). Also, CDT significantly reduced the risk of early cardiorespiratory deterioration (RR: 0.36, 95% CI [0.19, 0.68]; P < 0.001). There was no significant increase in major bleeding (RR: 1.52, 95% CI [0.71, 3.24]; P = 0.28) or intracranial hemorrhage. However, CDT significantly increased the risk of any bleeding (P = 0.02) and vascular access-site complications/hematomas (P = 0.02). Mortality did not differ between the two groups. Adding CDT to standard systemic anticoagulation led to a statistically significant reduction in the RV/LV ratio compared with anticoagulation alone, with a significantly lower risk of early hemodynamic and cardiorespiratory deterioration, without increasing the risk of major bleeding or intracranial hemorrhage in patients with acute intermediate-risk PE. However, larger RCTs with longer follow-up are required to provide a clearer picture of its sustained effects on hard clinical outcomes.

Cardiorenal syndrome (CRS) has traditionally been conceptualized as a hemodynamic disorder characterized by bidirectional dysfunction between the heart and kidneys. However, recent advances have expanded this paradigm into a complex multisystem disorder involving intertwined cardiovascular, renal, metabolic, inflammatory, neurohormonal, and immunologic pathways. The emergence of sodium-glucose cotransporter-2 (SGLT2) inhibitors has accelerated this conceptual transformation by demonstrating profound cardiovascular and renal benefits extending beyond glycemic control. Contemporary evidence suggests that CRS is not solely driven by impaired perfusion and venous congestion but also by maladaptive neurohormonal activation, mitochondrial dysfunction, oxidative stress, endothelial injury, fibrosis, metabolic derangements, gut microbiota dysbiosis, and chronic low-grade inflammation. This evolving framework aligns closely with the newly proposed cardiovascular-kidney-metabolic syndrome model, emphasizing systemic pathophysiological interconnectedness. SGLT2 inhibitors have emerged as disease-modifying therapies capable of targeting multiple mechanistic pathways simultaneously through natriuresis, restoration of tubuloglomerular feedback, reduction of intraglomerular hypertension, attenuation of inflammatory signaling, improvement in myocardial energetics, modulation of sympathetic activity, and mitigation of oxidative stress. Landmark clinical trials have consistently demonstrated reductions in heart failure hospitalization, chronic kidney disease progression, and cardiovascular mortality across diabetic and non-diabetic populations. In this narrative review, we re-examine CRS through a modern multidimensional lens, highlighting evolving molecular mechanisms, novel biomarkers, inflammatory-metabolic interactions, and the transformative therapeutic implications of SGLT2 inhibitors. We further explore future directions, including precision medicine, multi-omics profiling, artificial intelligence-assisted phenotyping, and emerging cardiorenal therapeutics that may redefine CRS management in the coming decade.

Very-early discharge after transcatheter aortic valve replacement (TAVR) is increasingly incorporated into contemporary care pathways, but comparative outcomes remain vulnerable to clinical selection and reverse causation. We aimed to evaluate contemporary readmission and clinical outcomes associated with very-early versus later discharge after TAVR. The Medical Literature Analysis and Retrieval System Online via PubMed and the Cochrane Central Register of Controlled Trials were searched from inception through June 2026. Comparative studies evaluating same-day discharge, next-day discharge, discharge within 24 hours, hospital length of stay of 1 day or less, or corresponding institutional strategies were eligible. Odds ratios (ORs) and 95% confidence intervals (CIs) were pooled using inverse-variance random-effects models. Thirteen observational studies were included; 12 contributed crude binary data from up to 24,984 patients. Very-early discharge was associated with lower 30-day all-cause readmission (OR, 0.74; 95% CI, 0.67-0.82), early mortality (OR, 0.40; 95% CI, 0.30-0.54), and stroke or cerebrovascular events (OR, 0.58; 95% CI, 0.45-0.76). Delayed or post-discharge permanent pacemaker implantation was inconclusive. The readmission association became nonsignificant after the exclusion of the largest study. Certainty ranged from very low to low. Very-early discharge was associated with favorable outcomes in selected cohorts, but serious bias and influential studies preclude causal or universal conclusions. Structured, criteria-based pathways require rigorous prospective validation and standardized follow-up across diverse contemporary clinical settings.

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are a cornerstone of adult heart failure (HF) therapy and are increasingly prescribed off-label to children, yet pediatric outcomes have never been pooled. We searched PubMed/MEDLINE, Embase, Scopus, and Web of Science to 14 August 2026 for studies of any SGLT2 inhibitor in children or adolescents with HF and performed a single-arm meta-analysis of all exposed patients and a pairwise meta-analysis of the comparative studies with random-effects models. Nine studies contributed 599 exposed patients and 97 controls. Pooled rates were 3.8% (95% confidence interval [CI] 1.6-8.4) for mortality, 8.5% (6.2-11.5) for transplantation, 11.2% (8.2-15.1) for worsening HF, 0.2% (0.03-1.6) for ketoacidosis, 4.5% (1.2-14.9) for acute kidney injury, 3.7% (1.1-11.7) for urinary tract infection, and 4.1% (1.4-11.2) for discontinuation because of an adverse event. After initiation, left ventricular ejection fraction rose by 7.7 percentage points (3.6-11.8) and natriuretic peptide fell by 0.42 standard deviations (0.34-0.49). In the comparative synthesis (63 exposed, 97 unexposed), risk ratios were 0.80 (0.11-6.07) for mortality and 0.21 (0.03-1.68) for worsening HF; ejection fraction improved 3.34 percentage points more with SGLT2 inhibitors (0.22-6.46) whereas natriuretic peptide did not differ (standardized mean difference -0.09, -0.50 to 0.33).

Postinfarction ventricular septal rupture is a rare, frequently lethal mechanical complication of acute myocardial infarction, and the optimal timing of repair remains controversial. Early surgery is often unavoidable in refractory shock but is technically hazardous because necrotic, friable myocardium provides poor suture support. Delayed repair after tissue maturation is associated with lower operative mortality, although this apparent benefit is substantially inflated by survivorship and immortal time bias. Mechanical circulatory support, including intra-aortic balloon counterpulsation, venoarterial extracorporeal membrane oxygenation, and microaxial flow pumps, may stabilize selected patients, permit end-organ recovery, and bridge them to later repair. However, available evidence is almost entirely observational, and the certainty supporting major timing and device selection recommendations is low or very low. This narrative review synthesizes the biological basis of timing, diagnostic and anatomic considerations, surgical and transcatheter options, mechanical support strategies, and transplantation. We propose a practical Heart Team framework based on hemodynamic status, tissue maturation, rupture anatomy, and daily reassessment, with explicit clinical triggers for abandoning delay. Surgical timing should therefore be individualized according to physiology rather than dictated by a fixed chronological threshold, pending prospective multicenter validation.

Mental health disorders are linked with increased cardiovascular disease and mortality risk, yet national trends in cardiovascular mortality among US adults with mental health disorders remain incompletely characterized. We performed a nationwide multiple cause of death analysis using the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research Multiple Cause of Death database to evaluate long-term trends and demographic patterns in cardiovascular mortality among US adults aged 25 years or older with mental health disorders between 1999 and 2024. Adults with mental health disorders were identified using International Classification of Diseases, Tenth Revision codes F00-F99, and cardiovascular deaths were reported using circulatory system codes (I00-I99). Age-adjusted mortality rates and crude mortality rates were calculated, and Joinpoint regression was used to derive annual percentage change and average annual percent change (AAPC). Between 1999 and 2024, more than 7.2 million cardiovascular deaths occurred among US adults with mental health disorders. Cardiovascular mortality rose steadily through the study period, and across sex, race/ethnicity, age group, geographic region, and urbanization levels. The greatest increases were noted among adults ages 55-64 years (AAPC: 6.90%, P < 0.001), males (AAPC: 5.40%, P < 0.001), and individuals residing in rural counties and the Northeast. Cardiovascular mortality among US adults with mental health disorders increased significantly between 1999 and 2024, highlighting the persistent disparities in this vulnerable population. These findings reinforce the need for integrated cardiovascular and psychiatric care, targeted prevention strategies, and equitable access to healthcare.

Cyanotic congenital heart defects are malformations of the heart that affect its structure and function. The etiology of most of these defects is multifactorial, but some common causes include maternal conditions, genetic defects, and genetic mutations. Six of the most common cyanotic congenital heart defects include Tetralogy of Fallot, transposition of the great arteries, persistent truncus arteriosus, total anomalous pulmonary venous return, tricuspid atresia, and Ebstein's anomaly. These defects share several common features, however, each is distinguished by key cardiac abnormalities and effects on systemic circulation. Tetralogy of Fallot is the most common cause of early cyanosis in infants due to a ventricular septal defect, overriding aorta, right ventricular outflow tract obstruction, and right ventricular hypertrophy. In transposition of the great arteries, the aorta arises from the right ventricle, and the pulmonary artery arises from the left ventricle. Persistent truncus arteriosus presents with failure of truncus arteriosus separation, resulting in a single arterial trunk. In total anomalous pulmonary venous return, all pulmonary veins drain into systemic circulation rather than the left atrium, and tricuspid atresia patients lack a tricuspid valve and possess a hypoplastic right ventricle. Lastly, Ebstein's anomaly is a defect associated with apical displacement of a malformed tricuspid valve into the right ventricle.

Despite significant breakthroughs in preventative medicine, atherosclerotic cardiovascular disease (ASCVD) is still the primary cause of morbidity and death worldwide. In this context, 2 apoB-containing particles-LDL and lipoprotein(a) [Lp(a)] have emerged as important but mechanistically separate causes of atherothrombotic illness. This review synthesizes current knowledge in lipid biology, epidemiology, measurement, and therapeutics to address 3 key questions: (1) how LDL-C/apoB and Lp(a) differ in structure, pathophysiology, and clinical risk; (2) what the evidence shows about the safety and efficacy of driving LDL-C to very low or near-zero levels; and (3) where PCSK9-based therapies and soon, dedicated Lp(a) -lowering agents-fit into modern prevention strategies. Randomized trials, MR studies, and population-level cohort data all contribute to a clear and convincing picture: LDL-C/apoB and Lp(a) are separate causative drivers of cardiovascular risk, with Lp(a) introducing an orthogonal risk axis determined by genetics rather than lifestyle. By combining both viewpoints, we propose a feasible, dual-axis strategy to ASCVD prevention that addresses both cumulative apoB load and genetically driven Lp(a) risk.

Preexisting atrial fibrillation (AF) or atrial flutter may impair cardiovascular reserve during septic shock, potentially leading to worse clinical outcomes; however, its independent association with short-term outcomes remains uncertain. Using the TriNetX U.S. Collaborative Network, we identified adults with septic shock and compared patients with preexisting AF/flutter, documented at least 1 month before the index event, with those without prior AF/flutter. Clinical outcomes were compared after 1:1 propensity score matching for demographic characteristics, comorbidities, and baseline cardiovascular medication use. Outcomes included 30-day all-cause mortality, cerebral infarction, renal replacement therapy, invasive mechanical ventilation, acute-care utilization, and vasopressor/inotrope use. Effect estimates were reported as relative risks (RRs) with 95% confidence intervals. After propensity score matching, 76,295 patients were included in each cohort. Preexisting AF/flutter was associated with significantly higher risks of all-cause mortality (RR 1.07, 95% CI, 1.06-1.09; P<0.001), renal replacement therapy (RR 1.30, 95% CI, 1.25-1.35; P<0.001), invasive mechanical ventilation (RR 1.14, 95% CI, 1.12-1.16; P<0.001), acute-care utilization (RR 1.06, 95% CI, 1.05-1.06; P<0.001), and vasopressor/inotrope use (RR 1.09, 95% CI, 1.08-1.10; P<0.001). There was no significant difference in cerebral infarction (RR 1.11, 95% CI, 1.00-1.24; P=0.054). Among patients with septic shock, preexisting AF/flutter was associated with higher mortality and greater use of organ-supportive therapies, including renal replacement therapy, invasive mechanical ventilation, and vasopressor/inotrope use, but not with a significant increase in cerebral infarction. Preexisting AF/flutter may serve as an important prognostic marker for early risk stratification in septic shock.

Transcatheter aortic valve replacement (TAVR) has transformed the treatment of severe aortic stenosis across all surgical risk profiles. However, as TAVR expands into younger, lower-risk populations with longer life expectancies, the management of late bioprosthetic failure has emerged as a critical clinical challenge. While valve-in-valve TAVR offers a less-invasive reintervention strategy, absolute anatomical contraindications frequently render it infeasible, necessitating surgical explantation. Driven primarily by structural valve deterioration, acute device failure, and prosthetic valve infective endocarditis, TAVR explantation presents a uniquely hostile operative field. Unlike traditional redo-surgical aortic valve replacement, the endothelialized and fibrotic integration of transcatheter stent frames into the aortic root and subvalvular apparatus significantly complicates extraction. These procedures often require complex, unplanned concomitant reconstructive procedures. Consequently, explantation carries a substantial morbidity and mortality burden that significantly eclipses native redo-surgical aortic valve replacement, with a stark volume-outcome relationship highlighting the necessity of institutional expertise. This review synthesizes contemporary data from high-volume international registries to evaluate the evolving landscape of TAVR explantation, detailing the primary indications, anatomical hurdles, and clinical outcomes. Ultimately, we emphasize the necessity of rigorous, computed tomography-based lifetime management protocols at the time of the index procedure and the regionalization of explant operations to specialized multidisciplinary structural heart centers to mitigate the severe surgical risks of transcatheter valve failure.

Sedentary behavior and physical inactivity are distinct but interrelated risk factors that independently influence cardiovascular health. This narrative review synthesizes current evidence on the association between sedentary behavior and early cardiovascular markers in young adults, particularly university students. Epidemiological data indicate high levels of sedentary time (7-10 hours/day) alongside low adherence to physical activity guidelines in this population. Mechanistic evidence suggests that prolonged sitting impairs endothelial function, reduces nitric oxide bioavailability, alters autonomic balance by decreasing heart rate variability, and promotes arterial stiffness and metabolic dysfunction. Evidence from randomized and controlled trials demonstrates that uninterrupted sitting can induce acute adverse changes in glucose metabolism and autonomic regulation, while frequent light-intensity activity breaks may mitigate these effects. However, findings remain heterogeneous, with limited long-term improvements in structural cardiovascular outcomes. Observational studies further support associations between sedentary time and elevated blood pressure, arterial stiffness, and impaired heart rate recovery. Despite growing evidence, limitations include small sample sizes, short intervention durations, and lack of diverse populations. Overall, reducing sedentary time through feasible behavioral and institutional strategies may represent an effective early intervention to prevent future cardiovascular disease in young adults.

Vascular calcification complicates endovascular intervention by reducing vessel compliance, impairing device delivery and expansion, and increasing the risk of suboptimal procedural outcomes. Intravascular lithotripsy (IVL) has emerged as a calcium-modification strategy that uses acoustic pressure waves to fracture vascular calcium while minimizing injury to surrounding tissue. This paper reviews the mechanisms, procedural applications, clinical evidence, and evolving role of IVL in calcified coronary and peripheral arterial disease. We summarize evidence from pivotal prospective trials, randomized studies, registries, observational cohorts, imaging studies, and expert consensus, with particular emphasis on complex coronary and peripheral applications. IVL has demonstrated high procedural success and a favorable acute safety profile in severely calcified coronary lesions, with randomized evidence also supporting its use in calcified femoropopliteal disease. Expanding observational evidence supports its feasibility in complex coronary subsets, including left main and bifurcation lesions, as well as iliac and common femoral disease. Evidence remains more limited for chronic total occlusions, calcified nodules, stent underexpansion, and infrapopliteal disease. Emerging technologies and applications may further broaden the role of lithotripsy, but randomized comparative studies and longer-term outcome data are needed to define its optimal use.

Drug-coated balloons (DCBs) represent an accepted approach for in-stent restenosis (ISR); however, post-procedural predictors for risk stratification remain limited. Angiography-based physiological parameters, including quantitative flow ratio (QFR), microvascular QFR (μQFR), and coronary angiography-derived fractional flow reserve (caFFR), enable noninvasive functional assessment, but their clinical implications after DCB intervention for ISR are not well established. A comprehensive literature search of PubMed, Embase, and the Cochrane Library from inception to May 2026 was conducted to identify studies evaluating post-procedural angiography-based physiological parameters in ISR patients treated with DCB. Pooled relative risks (RRs) with 95% confidence intervals (CIs) were calculated using random-effects models, and heterogeneity was assessed using the I2 statistic. Five studies comprising 1702 patients were included. Mean age ranged from 59 to 75 years, with 75-78% males. Patients with lower post-procedural physiological index values had a significantly higher risk of vessel-oriented composite outcomes (a composite of cardiac death, target vessel myocardial infarction, and target vessel revascularization) compared with those with higher values (28.0% vs 10.3%; RR 4.65, 95% CI 1.67-12.91; P = 0.014; 5 studies). Similarly, target vessel revascularization was more frequent in the lower-value group (28.8% vs 7.5%; RR 4.88, 95% CI 1.26-18.91; P = 0.034; 4 studies). No significant associations were observed for myocardial infarction, target lesion revascularization, or cardiovascular death. Post-procedural angiography-derived physiological indices provide important prognostic information after DCB treatment for ISR. Lower values are associated with an increased risk of adverse clinical outcomes, supporting their role in risk stratification.