Efficacy of Pemafibrate Versus Fenofibrate Administration on Serum Lipid Levels in Patients with Dyslipidemia: Network Meta-Analysis and Systematic Review.

BACKGROUND: Pemafibrate is a novel fibrate class drug that is a highly potent and selective agonist of peroxisome proliferator-activated receptor α (PPARα). We performed the first ever network meta-analysis containing the largest ever group of patients to test the efficacy of pemafibrate in improving lipid levels compared with fenofibrate and placebo in patients with dyslipidemia. METHODS: Potentially relevant clinical trials were identified in Medline, PubMed, Embase, clinicaltrials.gov, and Cochrane Controlled Trials registry. Nine randomized controlled trials met the inclusion criteria out of 40 potentially available articles. The primary effect outcome was a change in the levels of triglycerides (TG), high-density lipoproteins (HDL), or low-density lipoproteins (LDL) before and after the treatment. RESULTS: A total of 12,359 subjects were included. The mean patient age was 54.73 (years), the mean ratio for female patients was 18.75%, and the mean examination period was 14.22 weeks. The dose for pemafibrate included in our study was 0.1, 0.2, or 0.4 mg twice daily, whereas the dose for fenofibrate was 100 mg/day. Data showed a significant reduction in TG and a mild increase in HDL levels across the pemafibrate group at different doses and fenofibrate 100 mg group (with greatest effect observed with pemafibrate 0.1 mg twice daily). A mild increase in LDL was also observed in all groups, but the increase in LDL in the 0.1 mg twice daily dose group was statistically insignificant. CONCLUSION: Pemafibrate 0.1 mg twice daily dose led to highest reduction in TG levels and the highest increase in HDL levels compared with other doses of pemafibrate, fenofibrate, and placebo.

Management of Right Atrial Thrombus During MitraClip Implantation: A Case Report and Review of Literature.

Transcatheter mitral valve repair (TMVR) is a relatively novel approach for treatment of symptomatic severe mitral regurgitation. Intra procedural thrombus formation is a rare but potential complication. Herein, we describe a case of large right atrial thrombus formation after transseptal puncture, that was successfully managed using aspiration thrombectomy.

A CABG Complication - LIMA Graft to Cardiac Venous System Anastomosis Rescued by Percutaneous Coronary Intervention.

Inadvertent graft anastomosis to the great anterior cardiac vein is a known but rare complication of coronary artery bypass graft surgery (CABG). This is usually managed with percutaneous embolization of the inadvertently anastomosed graft with stenting of underlying atherosclerotic coronary artery disease (CAD) or by surgical correction. We present a similar case of the inadvertent left internal mammary artery (LIMA) graft anastomosis to the cardiac venous system, managed with the less complicated percutaneous coronary intervention of the underlying coronary artery disease due to anginal symptoms without the need for surgical correction or embolization of the graft.

Impact of systemic lupus erythematosus on in-hospital outcomes of peripheral artery disease-insight from the National Inpatient Sample database.

Chronic inflammatory disorders like systemic lupus erythematosus (SLE) and rheumatoid arthritis are associated with worse outcomes in ischemic heart disease. However, there is a paucity of data regarding outcomes in patients with peripheral arterial disease (PAD) with concomitant SLE. The purpose of this study was to compare clinical features and in-hospital outcomes of PAD in patients with and without SLE from the general population using the Healthcare Cost and Utilization Project National Inpatient Sample database. We performed a cross-sectional analysis on 520,665 patients diagnosed with PAD from quarter 4 of 2015 to 2017. The primary endpoint was risk-adjusted in-hospital mortality. Of the total patient population, 3080 patients (0.6%) had SLE compared with 517,585 controls (99.4%). The observed in-hospital mortality was higher in patients with SLE (6.3% vs. 4.6%, P < 0.001). To the best of our knowledge, this is the largest population-based study investigating the impact of SLE in patients with PAD. Our analysis showed higher in-hospital mortality in SLE patients than in those without SLE. Early diagnosis and aggressive management of SLE and its complications in these patients have the potential to improve overall outcomes.

Comparison of In-Hospital Outcomes After Insertion of Watchman Device in Men Versus Women (from the National Inpatient Data).

Left atrial appendage occlusion with the Watchman device is approved to manage nonvalvular atrial fibrillation and prevent stroke in patients with contraindications to anticoagulation. This study aimed to analyze the National Inpatient Sample (NIS) data to evaluate gender disparities and further assess its impact on medical decision-making. The NIS data for 16,505 patients who underwent left atrial appendage occlusion with the Watchman device from 2016 to 2017 was used to perform a cross-sectional analysis. The primary end point was risk-adjusted in-hospital mortality. The study included 9,825 men and 6,680 women. Male patients were younger than female patients (mean age of 75.3 years vs 76.3 years, p <0.001). The observed in-hospital mortality was higher in female patients (0.3% vs 0.1%, p = 0.003). This remained significant after adjustment for baseline confounders (adjusted odds ratio 2.9, 95% confidence interval 1.4 to 6.3, p = 0.005). In conclusion, analysis of the large pool of NIS data reveals that female patients have relatively worse in-hospital outcomes in terms of mortality, length of stay, and total hospitalization cost than male patients who underwent Watchman device implantation. However, these disparities are not enough to impact the medical decision-making process and to defer the use of the Watchman device in female patients.

Risk factors and outcomes associated with Left Ventricular Thrombus in patients with Peripartum Cardiomyopathy: An insight from National Inpatient Sample Database.

BACKGROUND: : We sought to assess the prevalence and impact of left ventricular thrombus (LVT) in patients with peripartum cardiomyopathy (PPCM). METHODS: : We performed a retrospective cohort study of all admissions with PPCM as the primary diagnosis from the Nationwide Inpatient Sample database over a 11-year period. Univariate analysis of all risk factors and outcomes and multivariable logistic regression analysis of certain variables were performed and represented as odds ratio (OR) with 95% confidence interval (CI). A p value of < 0.05 was considered statistically significant. Statistical analysis was performed using epiDisplay in 'R' studio. RESULTS: : In the time frame spanning 2005 -2014, 43,986 admissions with PPCM were found which included 43,534 without LVT and 452 patients with LVT. Black race was associated with a higher incidence of LV thrombus, (p value <0.001). Comorbidities more prevalent in the LVT group were smoking, drug abuse, pregnancy induced hypertension, diabetes with complications, valvular heart disease, connective tissue disorders, coagulopathy, anemia and depression. Adverse outcomes such as congestive heart failure, arrhythmias and stroke were higher in LVT group. Conversely, Caucasian race, obesity, preeclampsia (p <0.005) were higher in those without LVT. Mean length of stay (9 vs 5 days, p <0.001), in hospital mortality (3.32% vs 1.41%, p = 0.001) and mean hospitalization charges ($85,390 vs $48,033) were higher in those with LVT. However, on multivariate logistic regression, although stroke was higher in the LVT group (adjusted OR 5.51, 95% CI, 2.2, 13.81, 5.05, p 0.002), in-hospital mortality was not significantly different between the two groups (adjusted OR 1.17, 95% CI,0.32, 4.23, p = 0.817). CONCLUSION: : Our study showed that PPCM patients with LV thrombus had worse outcomes with respect to stroke, length of stay and in hospital mortality. Higher prevalence in patients with black race, complicated diabetes, peripheral vascular disease, valvular disease, coagulopathy, smoking, drug abuse, depression and psychoses calls for special attention to such high-risk groups for aggressive risk factor modification.

Cardiovascular Events in Patients with Thyroid Storm.

CONTEXT: Thyroid storm can present as a multitude of symptoms, the most significant being cardiovascular (CV). It is associated with various manifestations such as cardiac arrhythmia, heart failure, and ischemia. However, the frequencies of events and characteristics associated with patients that experience these events are not known. METHODS: Study cohort was derived from the National Inpatient Sample database from January 2012 to September 2015. Total hospitalizations of thyroid storm were identified using appropriate ICD-9 diagnostic codes. The analysis was performed using SAS. OBJECTIVE: To better understand the frequency and characteristics CV occurrences associated with thyroid storm, through a retrospective analysis of thyroid storm hospital admissions. DESIGN: The study cohort was derived from the National Inpatient Sample database from January 2012 to September 2015. SETTING: Total hospitalizations of thyroid storm were identified using International Classification of Diseases (ICD)-9 diagnostic codes. The analysis was performed using Statistical Analysis System (SAS). RESULTS: A total of 6380 adult hospitalizations were included in the final analysis, which includes 3895 hospitalizations with CV events (CEs). Most frequently associated CEs were arrhythmia (N = 3770) followed by acute heart failure (N = 555) and ischemic events (N = 150). Inpatient mortality was significantly higher in patients with CEs compared with those without CEs (3.5% vs 0.2%, P < 0.005). The median length of stay was also higher in patients with CEs compared with those without CEs (4 days vs 3 days, P < 0.0005). Atrial fibrillation was the most common arrhythmia type, followed by nonspecified tachycardia. CONCLUSIONS: In patients who were hospitalized due to thyroid storm and associated CEs significantly increased in-hospital mortality, length of stay, and cost. Patients with obesity, alcohol abuse, chronic liver disease, and COPD were more likely to have CEs. Patients with CV complications were at higher risk for mortality. In-hospital mortality increased with ischemic events and acute heart failure. Further evaluation is needed to further classify the type of arrhythmias and associated mortality.

Comparing Transcatheter Aortic Valve Replacement (AVR) With Surgical AVR in Lower Risk Patients: A Comprehensive Meta-Analysis and Systematic Review.

BACKGROUND: Transcutaneous aortic valve replacement (TAVR) is a novel percutaneous procedure for severe aortic stenosis and has been recently approved by Food and Drug Administration in lower risk patients. We performed the first ever meta-analysis and literature review of clinical trials comparing both 30-day and 1-year outcomes in lower risk patients undergoing TAVR vs. surgical aortic valve replacement (SAVR, having Society of Thoracic Surgeons score < 4% or equivalent). METHODS: Using predefined selection criteria as above, 68 articles were identified. Seven eligible articles were selected after extensive review. Primary effect outcomes were 30-day and 1-year all-cause mortality using risk ratio (RR) with significant P value of < 0.05. RESULTS: A total of 4,859 subjects were included. Risk of 30-day all-cause mortality was 40.1% less in TAVR group, RR 0.59 (95% confidence interval (CI): 0.38 - 0.92, P = 0.02) with no significant heterogeneity. Six studies except Schymik et al also reported 1-year risk. This was, however, not statistically significant with a 21% decrease in the TAVR group, RR 0.79 (95% CI: 0.57 - 1.09, P = 0.15). Six studies reported 30-day risk of secondary outcomes. The risk of 30-day stroke was 36% less in TAVR group, although this was not statistically significant, RR 0.64 (95% CI: 0.38 - 1.9, P = 0.10). The risk of acute kidney injury (AKI) stage 2 and above was 56% less in post-TAVR patients, RR 0.43 (95% CI: 0.35 - 0.54, P < 0.001) with no heterogeneity. For vascular complications, RR was high in TAVR group 4.62 (95% CI: 1.42-15.18, P = 0.01). Significant heterogeneity was demonstrated though (I2 = 81). The risks for permanent pacemaker (PPM) were also higher in the TAVR group, RR 3.30 (95% CI: 2.04 - 5.33, P < 0.001) and significant heterogeneity was observed. After removing Thyregod et al and Partner 3 trial from the analysis, heterogeneity was removed, but the RR was still high 3.21 (95% CI: 2.54 - 4.068, P < 0.001). Post-operative incidence of endocarditis among TAVR patients was low but not statistically significant. The 30-day risk for infective endocarditis was RR 0.67 (95% CI: 0.13 - 3.48, P = 0.63). The 1-year risk was similarly low but not significant, RR 0.73 (95% CI: 0.28 - 1.92, P = 0.53). CONCLUSIONS: Among low risk patients, TAVR was found to be superior in short-term all-cause mortality and 1-year stroke, a result that was statistically significant for TAVR and close to significance for stroke. TAVR patients were also less likely to have post-operative bleeding and AKI stage 2 and beyond. Post-operative incidence of endocarditis among TAVR patients was low but not statistically significant. However, the rates of PPM and vascular complications are higher in TAVR patients. The results of TAVR in low risk population are thus extremely encouraging. However, the issue of long-term valve durability in this group needs further studies. Also, caution needs to be exercised while extending the indications to extremely young patients due to lack of enough studies.

Meta-Analysis of Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Patients With Low Surgical Risk.

Transcatheter aortic valve implantation (TAVI) is the current standard of care for patients with severe aortic stenosis who are at high risk for surgery. However, several recent studies have demonstrated the comparable safety and efficacy of TAVI in low-risk patients as well. We sought to pool the existing data to further assert its comparability. MEDLINE, Cochrane, and Embase databases were evaluated for relevant articles published from January 2005 to June 2019. Studies comparing outcomes of TAVI versus surgical aortic valve replacement in patients who are at low risk for surgery were included. Twelve studies (5 randomized controlled trials and 7 observational studies) totaling 27,956 patients were included. Follow-up ranged from 3 months to 5 years. Short-term all-cause mortality, short-term, and 1-year cardiac mortality were significantly lower in the TAVI group. One-year all-cause mortality, short-term, and 1-year stroke and myocardial infarction were similar in both groups. Rate of acute kidney injury and new-onset atrial fibrillation were lower in the TAVI group, whereas permanent pacemaker implantation and major vascular complications were higher in the TAVI group. Subgroup analysis of randomized controlled trials showed significantly lower 1-year all-cause mortality in the TAVI group. In conclusion, in severe aortic stenosis patients at low surgical risk, TAVI when compared with surgical aortic valve replacement, demonstrated a lower rate of short-term all-cause mortality, short-term, and 1-year cardiac mortality and similar in terms of 1-year all-cause mortality. TAVI is emerging as a safe and efficacious alternative for low surgical risk patients.

Transient Complete Heart Block Secondary to Bed Bug Insecticide: A Case of Pyrethroid Cardiac Toxicity.

Pyrethroids are the major components of various commercially used insect repellants. These are less toxic to humans due to their slow absorption and rapid metabolism. However, cases of suicidal and accidental poisoning with household insecticides are not uncommon. We report a case of a 59-year-old female who presented with syncope after an accidental exposure to bed bug repellant spray at home. She was found to be in complete heart block and was treated conservatively. There was complete resolution of symptoms and atrioventricular conduction abnormality on day 2 of hospitalization. She was discharged in a stable condition with an uneventful follow-up course. Cardiac involvement in pyrethroid toxicity is rare. We describe various clinical manifestations and the pathophysiology of toxicity caused by pyrethroid-containing insecticides.

Clinical presentation and outcome of autosomal dominant polycystic kidney disease in Pakistan: a single center experience.

OBJECTIVE: To delineate clinical presentation and outcome of Autosomal Dominant Polycystic Kidney Disease (ADPKD) in terms of need for renal replacement therapy of kidney transplantation in Pakistani patients. METHODS: Patients with ADPKD were identified using strict clinical criteria. Medical charts were evaluated retrospectively for initial presenting complaints, co-morbids, family history of ADPKD, any palpable mass on abdominal examination, cardiac examination for any abnormal finding and use of any anti-hypertensive drugs. Laboratory parameters were assessed. Chi square and Logistic regression analyses at 95% CI were used for statistical significance. A p value of less 0.05 was considered statistically significant. RESULTS: A total of 56 patients fulfilled our criteria of ADPKD. There were 40 (71.4%) males and 16 (28.6%) females in our study. The mean age at the time of diagnosis of ADPKD was 47.0 +/- 14.5 years. Mean follow up period for all patients was 7.6 +/- 4.2 years. Most common form of presentation was hypertension in 38 (67.9%) patients. Kidneys were palpable in 33 (58.9%), liver in 16 (28.6%) and spleen in 6 patients (10.7%). Microscopic haematuria was observed in 38 (67.8%) patients while gross haematuria was present in 10 (17.9%) patients. The murmur of mitral valve prolapse was found in 10 patients on clinical examination which was later confirmed on transthoracic echocardiography (TEE). On MRI/MRA 2 (3.6%) patients each had berry aneurysm and AV malformations. Three patients (5.4%) received renal transplant and 19 (33.9%) patients were dialysis dependent at the end of study. A total 11 (20%) were lost to follow up. Two patients (3.5%) died during six years follow up. Male sex and uncontrolled hypertension were most important predictors of poor prognosis (p < 0.03 and < 0.048 respectively). CONCLUSION: Pre-symptomatic patients with ADPKD should be monitored with blood pressure measurements and assessment of their renal function. The advantages of such monitoring include the ability to prevent or control infection and hypertension, to identify potential kidney donors from among the family, to offer advice on marriage and childbearing, and to provide prenatal diagnosis.

Pre-operative renal function and selective renal vein renin levels as markers of favourable outcome in renovascular hypertension.

OBJECTIVE: To evaluate factors that affect outcome following revascularization in patients with renovascular hypertension. METHODS: This study was conducted at the Aga Khan University Hospital. It included all the patients diagnosed to have Renovascular hypertension confirmed by renal angiography between July 1996 to September 2000. Using ANOVA (Analysis of variance) and paired-sample t-test, several preoperative factors were evaluated for their ability to predict postoperative improvement of blood pressure and renal function. For descriptive purpose patients were divided into cured, improved and failure groups. RESULTS: Of the total 15 patients, 9 were males and 6 were females. Before the surgical procedure, 13 patients were on 3 or more antihypertensive drugs. Eleven patients received vein grafts, three patients had PTFE (polytetraflouroethyline) grafts while one patient underwent angioplasty and stenting. The patients had a median follow-up period of nine months with a range of 2 to 84 months. Five were completely cured, as they became normotensive without antihypertensive therapy after operation, whereas four showed marked improvement in BP control postoperatively, requiring two antihypertensive drugs. Six patients showed no improvement requiring 3 or more drugs. Extended cure or improvement of renovascular hypertension was achieved in nine patients. Normal preoperative serum creatinine level, high preoperative unstimulated peripheral renin levels and renal vein renin ratio of at least 1.75:1 were the most significant predictive factors for favorable outcome. CONCLUSION: This study confirms the long term effectiveness and safety of renovascular reconstruction in the relief of severe hypertension. The results further suggest that normal preoperative renal function, high renal vein renin ratio and high preoperative unstimulated peripheral renin levels are associated with the most favourable postoperative outcome (p <0.01). Preoperative severity and duration of hypertension and degree of disparity in kidney sizes do not affect the overall results in terms of postoperative improvement in renal function and blood pressure control (p=0.734).

Outcome of triple procedure in older children with developmental dysplasia of hip (DDH).

OBJECTIVE: To evaluate the radiographic and functional results of the triple procedure (open reduction, femoral shortening and Salter's Osteotomy) in the treatment of Developmental Dysplasia of the Hip (DDH) disease in older children. METHODS: This case-series comprising 23 patients (29 hips) underwent the triple procedure of open reduction, femoral shortening and Salter osteotomy, at Aga Khan University Hospital between June 1995 and June 2005. Patients were classified pre-operatively according to the Tonnis class. Postoperative functional evaluation was performed using Modified MacKay's scoring system and radiographic assessment using Severin's scoring method. RESULTS: The mean age of patients at presentation was 6.84 years and the average follow-up was 19.6 months. The MacKay score was 'Good' to 'Excellent' in 25 hips; we had a failure in 1 hip joint. The Severin's class was I in 15 (51.7%) hips at the time of final evaluation as compared to none at the time of presentation. Patients younger than 5.6 years of age had a better radiological and clinical outcome as compared to older patients (p-value < 0.05). CONCLUSIONS: The triple procedure of open reduction, femoral shortening and Salter osteotomy gives best results in younger children. Early diagnosis and intervention is therefore imperative in the successful treatment of patients suffering from DDH.

Do clinical manifestations of Systemic Lupus Erythematosus in Pakistan correlate with rest of Asia?

OBJECTIVE: Systemic Lupus Erythematosus (SLE) is known to be different among people with different racial, geographical and socio-economic back grounds. Asia has diverse ethnic groups broadly, Orientals in the East and Southeast Asia, Indians in South Asia and Arabs in the Middle East. These regions differ significantly from the Caucasians with reference to SLE. The purpose of this study was, therefore, to delineate the clinical pattern and disease course in Pakistani patients with SLE and compare it with Asian data. METHODS: Patients with SLE fulfilling the clinical and laboratory criteria of the American Rheumatism Association admitted at the Aga Khan University Hospital between 1986 and 2001 were studied by means of a retrospective review of their records. The results were compared with various studies in different regions of Asia. RESULTS: Demographically, it was seen that SLE is a disease predominantly of females in their third decade, which is generally consistent with Asian data. There was less cutaneous manifestations, arthritis, serositis, haematological and renal involvement compared to various regions in Asia. The neurological manifestations of SLE, however, place Pakistani patients in the middle of a spectrum between South Asians and other Asian races. CONCLUSION: This study has shown that the clinical characteristics of SLE patients in our country may be different to those of other Asian races. Although our population is similar to South Asians, but clinical manifestations of our SLE patients are considerably different, suggesting some unknown etiology. Further studies are required to confirm the above results and to find statistically sounder associations.

Bilateral breast enlargement due to Trichophyton rubrum.

Gynecomastia is the most common cause of breast enlargement in males. Trichophyton rubrum is a common dermatophyte, is responsible for a variety of infections, and may rarely manifest as a dermatophytic pseudomycetoma. We report the case of a 52-year-old man who presented with progressive bilateral breast enlargement. This is the first reported case of bilateral breast pseudomycetoma due to T. rubrum. Long-term antifungal therapy with itraconazole was successful.

Who should pay for home monitoring of heart failure?

Despite the recent advancement in medical therapy for heart failure, morbidity associated with heart failure continues to be excessive, with rising hospitalization rates and costs. Disease management models have been instituted successfully for several chronic disease states, and observational trials have shown different models to be beneficial. A multidisciplinary approach to management of heart failure improves outcomes. Multiple recent trials involving various models of integrated and comprehensive disease management have demonstrated promising results, such as reduction in mortality and hospitalizations. Future models for disease monitoring may include implantable devices that directly monitor hemodynamics combined with multidisciplinary care.

Patient expectations from an emergency medical service.

BACKGROUND: Patient expectation survey at the Emergency Medical Services can improve patient satisfaction. A need was established to conduct such a survey in order to recommend its use as a quality improvement tool. METHODS: The study was conducted on patients visiting the Emergency Medical Services, Aga Khan University, Karachi. A questionnaire was used to collect information on the demographic profile, and expectations of patients. The ethical requirements for conducting the study were met. RESULTS: A hundred patients were surveyed. The majority was relatively young, married men and women, well educated and better socio-economically placed. The majority of the patients expected a waiting time and a consultation time of less than 30 minutes and 20 minutes, respectively. The majority of respondents expected and agreed to be examined by a trainee but there were reluctant to be examined by the students. There was an expectation that the consultant will examine patients and not advice the attending team over the phone. The majority of the patients expected intravenous fluid therapy. There was a desire to have patient attendant present during the consultation process. The majority of the patients expected to pay less than three thousand rupees for the visit. An expectation exists for investigations and hospitalization. Involvement of patients in decisions concerning their treatment and written feedback on their visit was expected. CONCLUSIONS: We have documented the need and value of patient expectation survey at the Emergency Medical Services department. The use of such a tool is recommended in order to improve the satisfaction levels of patients visiting such facilities.

Healing during physician-patient consultation.

OBJECTIVE: To determine the patient perceptions regarding healing during a physician-patient consultation. DESIGN: A questionnaire-based survey. PLACE AND DURATION OF STUDY: Family Practice Center of the Aga Khan University Hospital, Karachi, Pakistan, in June 2004. PATIENTS AND METHODS: A questionnaire was designed that included the demographic profile of patients comprising age, gender, education and occupation as well as questions in line with the study objective. It was administered to 111 patients, visiting outpatient department of the hospital. Participants were explained the study objective, a written consent was taken and full confidentiality was assured. RESULTS: The mean age of the study population was 27.86 years. Majority of the subjects were males with 68% having graduate or more education. A physician-patient consultation has healing properties for patients and physicians, according to 99 (89%) and 67 (65%) respondents respectively, with 65 (58%) having had experienced healing during the consultation process. The competence of a physician, individual attention given by a physician and a cool and calm attitude of a physician, were reported to increase healing in a physician-patient consultation according to 34 (30%), 32 (29%) and 13 (11%) respondents respectively. The unhelpful physician behavior, incorrect diagnosis and physician's rude and arrogant attitude were reported to decrease healing according to 42 (37%), 15 (14%) and 14 (13%) respondents respectively. CONCLUSION: The study shows that a majority of the patients believe a physician-patient consultation has healing properties on its own, based on healing potential in the consultation process itself. Physicians must try to find ways to improve their ability to act as healers during consultation with patients.

Human granulocytic anaplasmosis affecting the myocardium.

A case of 65-year-old male is reported who presented with myalgias, headache, and fever. He subsequently developed myocarditis and was diagnosed to have anaplasmosis on peripheral blood smear. He was treated with doxycycline for 30 days. A coronary angiogram done after recovery showed normal epicardial arteries. The case illustrates the importance of a careful examination of the peripheral smear, with a high index of clinical suspicion, which led to prompt treatment and complete recovery of the patient.