A case report: pitfalls in antibacterial therapy with rifampicin for mechanical valve endocarditis-the king of drug interactions.

Background: Rifampicin is a strong inducer of the hepatic cytochrome P450 (CYP) family and is known to interact with many clinical drugs. However, to our knowledge, no case of worsening heart failure (HF) due to the interaction between rifampicin and HF drugs has been reported. Case summary: A 32-year-old female, who had undergone intracardiac repair for an incomplete atrioventricular septal defect with dextrocardia and prosthetic valve replacements for right and left atrioventricular valve regurgitation, presented as an outpatient. Her medications included tolvaptan 15 mg and warfarin 1.25 mg. She had a slight fever and Osler nodes at her fingers. Blood culture bottles grew methicillin-resistant Staphylococcus epidermidis, and several vegetations were observed on the right atrioventricular mechanical valve with a transoesophageal echocardiogram. She was diagnosed with prosthetic valve endocarditis and treated with antibiotic agents including rifampicin. After a week, she developed systemic oedema and had a marked decrease in prothrombin time-international normalized ratio (PT-INR). Rifampicin was promptly discontinued due to a strong suspicion of a drug-drug interaction. Consequently, both her congestion and the PT-INR stabilized, and she was discharged after 8 weeks of antibiotic treatment. Discussion: The introduction of rifampicin induces CYP family members such as CYP3A4 and CYP2C9. Warfarin is metabolized by CYP2C9 and tolvaptan is also metabolized by CYP3A4, resulting in a notable reduction of their blood levels when co-administered with rifampicin. The clinical challenges arising from interactions between HF drugs and rifampicin can be categorized into two main groups: worsening HF and thrombotic complications. Clinicians should remain vigilant and informed about these potential issues.

99m Tc-PYP Uptake in an Insulin Ball.

ABSTRACT: Long-term subcutaneous insulin injection causes histopathological changes, such as insulin amyloidosis resulting in poor glycemic control, at the insulin injection site. Insulin amyloidosis often leads to the formation of a nodule called the "insulin ball." An insulin ball has not yet been documented on 99m Tc-PYP scintigraphy. Hereby, we describe the case of a 74-year-old man with insulin-requiring diabetes who developed heart failure with preserved ejection fraction due to new-onset atrial fibrillation. 99m Tc-PYP scintigraphy for cardiac amyloidosis screening showed no tracer uptake in the myocardium but did show uptake in the insulin ball suspected by CT and MRI scans.

Impact of Aromatase Inhibitors Treatment Duration on Coronary Artery Calcification in Postoperative Patients With Breast Cancer.

BACKGROUND: Aromatase inhibitors (AIs) are the standard therapeutic approach for hormone receptor-positive postmenopausal breast cancer. However, there are concerns about increased cardiovascular risk due to their antioestrogenic effects. This study aimed to investigate the potential association between duration of AI treatment and the severity of coronary artery calcification (CAC). METHODS: The study included outpatients who initiated adjuvant endocrine therapy with AIs for breast cancer from August 2010 to October 2022. CAC was quantified according to a visual ordinal scoring system. Patient characteristics were assessed based on the presence of CAC. Independent risk factors for elevated CAC scores were identified through a multivariable logistic regression model. RESULTS: Among 357 patients, 44.8% exhibited CAC. No significant difference in AI treatment duration was observed between groups (1268 d [interquartile range (IQR) 725-1743 d] vs 1104 d [IQR 685-1683.25 d]; P = 0.236). Patients with CAC were characterised by higher age (63.06 y [56.81-68.78 y] vs 74.39 y [68.98-80.03 y]; P < 0.001), lower hemoglobin levels (g/dL: 13.20L [IQR 12.60-13.70L] vs 12.60 [IQR 11.60-13.43]; P < 0.001), and reduced estimated glomerular filtration rate (mL/min/1.73 m2: 72.00 [IQR 61.80-81.50] vs 62.80 [IQR 51.27-71.90]; P < 0.001) compared with those without CAC. The prevalences of hypertension, diabetes mellitus, and dyslipidemia were significantly higher in patients with CAC. No correlation was found between the duration of AI treatment and CAC score (R = -0.02; P = 0.78). Independent risk factors for CAC included higher age, lower hemoglobin levels, and the presence of hypertension and diabetes mellitus in postoperative patients with breast cancer. CONCLUSIONS: The duration of AI treatment does not exert a significant influence on CAC in postoperative patients with breast cancer.

Remote dielectric sensing predicts elevated left atrial pressure in patients with atrial fibrillation.

Background: There are currently no established non-invasive indices of echocardiography for elevated left atrial pressure (LAP) especially in patients with atrial fibrillation (AF). Remote dielectric sensing (ReDS) is a novel non-invasive electromagnetic energy-based technology that quantifies total lung fluid, enabling the monitoring of volume status in patients with heart failure. The utility of ReDS for estimating LAP in patients with AF remains unknown. Methods: We prospectively investigated patients with AF in whom LAP was directly measured during catheter ablation for AF, and ReDS measurements were conducted the day before ablation. Elevated LAP was defined as LAP ≥ 15 mmHg. Results: A total of 61 patients were included (median age 66 years, 38 % female). Among them, 26 patients had elevated LAP. There was a positive correlation between ReDS and LAP (r = 0.363, P = 0.004). Receiver operating characteristic curve analysis for the prediction of elevated LAP demonstrated that the best cut-off value of ReDS was 30 %, with a sensitivity of 65 %, specificity of 69 %, and an area under the curve of 0.703 (95 % confidence interval 0.568-0.837). Multivariate logistic regression analysis revealed that ReDS was an independent predictor of elevated LAP, among covariates including left ventricular ejection fraction, the ratio of early transmitral flow velocity to septal mitral annular early diastolic velocity, and left atrial volume index. Conclusions: Our results suggest ReDS could be a valuable marker of elevated LAP even in patients with AF. Further studies are needed to elucidate the effectiveness of a ReDS-guided decongestive strategy in patients with heart failure.

Left atrium as key player and essential biomarker in heart failure.

This article reviews roles of the left atrium as regulator of left ventricular filling, as compensatory reserve in left ventricular dysfunction and as diagnostic marker in patients with cardiovascular disorders. Application of novel imaging tools to assess left atrial function and their integration with conventional clinical methods are discussed. This includes a review of clinical applications of left atrial strain as a method to quantify the reservoir and booster pump components of left atrial function. Emerging methods for assessing left atrial wall stiffness and active work by pressure-strain loop analysis are discussed. Recommendations for how to apply left atrial strain in clinical routine to diagnose elevated left ventricular filling pressure are provided. Furthermore, a role for left atrial strain in the diagnostic work-up in patients suspected of pre-capillary pulmonary hypertension is proposed. The article also reviews how to implement parameters of atrial structure and function in clinical routine as recommended by recent international guidelines for imaging of heart failure.

Accidental Hypothermia-Induced J Wave Coupled With Giant R Wave Augmented by Premature Atrial Contraction: A Case Report.

The 12-lead electrocardiographic findings in hypothermia include the presence of J waves; prolongation of the PR, QRS, and QT intervals; and atrial and ventricular dysrhythmias. Among these findings, the J wave, known as the Osborn wave, is considered pathognomonic. In 1953, the J wave was reported as a specific response to hypothermia in dogs, representing the current at the site of injury instead of a widening of the QRS complex that occurs caused by a conduction delay. The J wave is often accompanied by ventricular fibrillation. For the past 28 years, it was assumed that the hypothermia-induced J wave was mediated by the transient outward current. However, it was recently been reported that the J waves in some patients with hypothermia can be considered delayed conduction-related waveforms. Here, we present a case of hypothermia-induced J waves together with giant R waves, which have not been previously reported during hypothermia, augmented by short RR intervals arising from premature atrial contractions. Our observations indicate that the underlying mechanism for the genesis of J waves is indeed conduction delay and not transient outward currents.

Feasibility of left atrial strain assessment using cardiac computed tomography in patients with paroxysmal atrial fibrillation.

PURPOSE: To evaluate the feasibility of left atrial strain (LAS) assessment using cardiac computed tomography (CT) in patients with paroxysmal atrial fibrillation (PAF). METHODS: This retrospective single-center study included 98 patients with PAF who underwent cardiac CT and echocardiography before the first catheter ablation. LAS was analyzed using cardiac CT (CT-LAS) and speckle-tracking echocardiography (STE; STE-LAS). LA reservoir (LASr), conduit (LASc), and pump strain (LASp) were calculated by averaging LAS measured in 4- and 2-chamber views. The results were compared using Pearson's correlation coefficients, paired t-tests, and Bland-Altman analysis. Intraclass correlation coefficients (ICCs) were used to evaluate reproducibility. RESULTS: CT-LAS could be analyzed in all patients, while STE-LAS could be analyzed in 53 (54%) patients. LASr, LASc, and LASp showed significant correlations between CT- and STE-LAS: LASr, r = 0.68, p < 0.001; LASc, r = 0.47, p < 0.001; LASp, r = 0.67, p < 0.001. LASr, LASc, and LASp of CT- and STE-LAS were 23.7 ± 6.0% and 22.1 ± 6.7%, 11.1 ± 3.6% and 11.1 ± 4.1%, and 12.6 ± 4.6% and 11.0 ± 4.1%, respectively. LASr and LASp were significantly higher in CT-LAS than that in STE-LAS (p = 0.023 for LASr and p = 0.001 for LASp). CT-LAS showed excellent reproducibility. The intra- and interobserver ICCs were 0.96 to 0.99 and 0.89 to 0.90, respectively. CONCLUSION: CT-LAS was successfully analyzed in more patients than STE-LAS and was highly reproducible. The findings suggest that CT-LAS is feasible for patients with PAF.

Downsloping TP Segment in the Precordial Leads on a Standard 12-lead Electrocardiogram: Suspected Cardiac Impulse-tapping Artifact.

We herein report an 80-year-old man showing a downsloping TP segment together with an increase in the height of the T wave in the precordial leads on a standard 12-lead electrocardiogram (ECG). Separately, an 87-year-old woman showed only a downsloping TP segment in the precordial leads on a standard 12-lead ECG. Neither patient reported chest pain or dyspnea when ECGs was obtained. This downsloping TP segment in the precordial leads on the standard 12-lead ECG is thought to be due to a cardiac impulse-tapping artifact. Differential diagnoses are also discussed.

Right ventricular papillary muscle crossing the moderator band mimicked infective endocarditis: the utility of multimodal imaging.

Right-sided infective endocarditis (RSIE) generally carries a positive prognosis; however, it can result in complications such as heart failure, underscoring the importance of prompt diagnosis. While echocardiography serves as the standard diagnostic tool, it may occasionally face challenges in distinguishing between normal structures and vegetations. In this report, we present the case of a 60-year-old man diagnosed with pyogenic vertebral osteomyelitis, alongside suspected coexisting RSIE. During both transthoracic and transesophageal echocardiography, a rod-like mobile structure was observed adjacent to the right ventricular moderator band. However, confirming its nature as an infective vegetation proved challenging. Despite the inconclusive diagnosis of IE by echocardiography, the positron emission tomography/computed tomography (PET/CT) scan and cardiac magnetic resonance imaging (MRI) played a pivotal role in distinguishing between normal structures and vegetations. Since IE could develop life-threatening events, the role of multimodal imaging is of paramount importance. This case serves as a compelling example of the diagnostic value through the integration of PET/CT and MRI in ruling out IE.

Incremental value of tricuspid annular enlargement to progressive tricuspid regurgitation in patients with longstanding persistent atrial fibrillation.

Tricuspid annular enlargement in patients with atrial fibrillation (AF) can induce tricuspid regurgitation (TR). However, risk factors associated with TR progression in patients with AF have not been defined. This study aimed to clarify an association between tricuspid annular diameter (TAD) and TR progression in patients with longstanding persistent AF. We retrospectively analyzed data from 228 patients who had longstanding persistent AF for > 1 year and mild or less TR on baseline echocardiograms. We defined significant TR as moderate or greater TR, graded according to the jet area and vena contracta. The optimal cut-off value of the TAD index (TADI), based on body surface area for predicting progression to significant TR, was estimated using receiver operating characteristic (ROC) curves. The independence and incremental value of the TADI were evaluated using multivariate Cox proportional hazard regression analysis and likelihood ratio tests. Over a median follow-up of 3.7 years, 55 (24.1%) patients developed significant TR. The optimal cut-off value of 21.1 mm/m2 for the TADI at baseline and ROC curves predicted TR progression with 70.4% sensitivity and 86% specificity. Furthermore, TADI was an independent predictor of TR progression (hazard ratio, 1.32; 95% confidence interval, 1.17-1.49, P < 0.001) and had a significant incremental value that exceeded that of models constructed using clinical parameters. In conclusion, TADI was significantly associated with TR progression and was an independent predictor of TR progression in longstanding persistent AF.

A prediction model for estimating NT-proBNP in a general Japanese population: the Toon Health Study.

AIMS: As part of the Toon Health Study, which is an ongoing population-based cohort study, we aimed to develop a prediction model for N-terminal pro-brain natriuretic peptide (NT-proBNP) in a general Japanese population. We sought to explore the influence of various demographic and clinical factors on NT-proBNP levels and assess the model's performance. In addition, our objectives included internal validation and investigation of the diagnostic potential of the observed-to-predicted NT-proBNP ratio (OPR) at baseline for predicting the risk of heart failure with preserved ejection fraction (HFpEF). METHODS AND RESULTS: In this prospective cohort study, participants were recruited from Toon City, Japan, as part of the larger Toon Health Study, focusing on cardiovascular risk factors. We measured the NT-proBNP levels and used linear regression with penalization (ridge regression) to develop the model. The model incorporated 10 prespecified predictors (age, gender, body mass index, diastolic blood pressure, heart rate, haemoglobin, albumin, total cholesterol, haemoglobin A1c, and estimated glomerular filtration rate) and underwent assessment using R2 and root mean squared error (RMSE). Internal validation was conducted through bootstrapping. In a post hoc analysis, we explored the OPR's diagnostic potential using 5 year follow-up data (n = 636) to predict the elevation of NT-proBNP > 125 pg/mL at the 5 year follow-up as the risk of HFpEF. A total of 2505 participants (age: 60.4 ± 12.9 years, men: 35%) were enrolled in this study. There was a linear relationship between the observed and predicted values of NT-proBNP in which the logarithm of observed NT-proBNP was <6, which corresponds to 403 pg/mL in NT-proBNP. The prediction model demonstrated satisfactory performance (R2: 0.291, RMSE: 0.688), with age identified as a dominant predictor. The stability of the model was underscored by the internal validation. The OPR at baseline predicted NT-proBNP > 125 pg/mL at the 5 year follow-up with an area under the curve of 0.793. CONCLUSIONS: This study introduces the first prediction model for NT-proBNP in a general Japanese population. Although the model has acceptable performance, ongoing refinement is essential. Our transparent approach to model development, alongside a web-based interactive tool, lays the groundwork for further improvements and external validation. The OPR holds potential for predicting the future risk of HFpEF. This research contributes to understanding the nuanced influence of patient backgrounds on levels of NT-proBNP in asymptomatic individuals within the context of a broader population-based cohort study.

Distinctive left ventricular-arterial and right ventricular-pulmonary arterial coupling observed in patients with heart failure and a higher left ventricular ejection fraction range.

AIMS: Higher left ventricular (LV) ejection fraction (EF) is related to unfavourable prognosis in patients with heart failure (HF) with preserved ejection fraction (HFpEF). The cause of this finding needs to be haemodynamically explained. Thus, we investigated this crucial issue from the perspective of LV-arterial (A) and right ventricular (RV)-pulmonary arterial (PA) coupling. METHODS AND RESULTS: Study patients were derived from our prospective cohort study of patients hospitalized due to acute decompensated HF and LVEF > 40%. We divided the 255 patients into three groups: HF with mildly reduced EF (HFmrEF), HFpEF with 50% ≤ LVEF < 60%, and HFpEF with LVEF ≥ 60%. We compared LV end-systolic elastance (Ees), effective arterial elastance (Ea), and Ees/Ea as a representative of LV-A coupling among groups and compared the ratio of tricuspid annular plane excursion to peak pulmonary arterial systolic pressure (TAPSE/PASP) as a representative of RV-PA coupling. All-cause death and readmission due to HF-free survival was worse in the group with a higher LVEF range. Ees/Ea was greater in HFpEF patients with LVEF ≥ 60% (2.12 ± 0.57) than in those with 50% ≤ LVEF < 60% (1.20 ± 0.14) and those with HFmrEF (0.82 ± 0.09) (P < 0.001). PASP was increased in the groups with higher LVEF; however, TAPSE/PASP did not differ among groups (n = 168, P = 0.17). In a multivariate Cox proportional hazard model, TAPSE/PASP but not PASP was significantly related to event-free survival independent of LVEF. CONCLUSION: HFpEF patients with higher LVEF have unfavourable prognosis and distinctive LV-A coupling: Ees/Ea is elevated up to 2.0 or more. Impaired RV-PA coupling also worsens prognosis in such patients. CLINICAL TRIAL REGISTRATION: URL: https://www.umin.ac.jp/ctr/index.htm Unique identifier: UMIN000017725.

Adenosine triphosphate-induced life-threatening arrhythmia.

A 68-year-old woman with idiopathic dilated cardiomyopathy presented with a wide QRS complex regular tachycardia five days after mitral valve replacement. Adenosine triphosphate (ATP) was administered to make the correct diagnosis; however, tachycardia eventually transitioned to ventricular fibrillation, which required cardioversion. Although ATP is considered a relatively safe drug, it can cause unexpected, life-threatening arrhythmias. Careful monitoring and preparation are advised during ATP administration in the event of a regular wide QRS complex tachycardia in patients with irritable conditions. Learning objective: Adenosine triphosphate (ATP) is considered a safe drug that is often used to manage wide QRS complex tachycardia. Herein, we present a case of regular, wide QRS complex tachycardia in a patient who underwent mitral valve replacement. Tachycardia degenerated into ventricular fibrillation soon after ATP administration, probably because of sympathetic overdrive secondary to the ATP infusion. It is advisable to use ATP with caution, especially in irritable cases such as in the early post-cardiac surgery period.