The Harms of Unnecessary CT Pulmonary Angiography: A Case Report and Literature Review.

Pulmonary embolism (PE) poses a significant health risk in the United States, with high mortality rates. Clinicians maintain a low threshold for suspecting PE, potentially leading to deviation from guideline-recommended algorithms and unnecessary computed tomography pulmonary angiography (CTPA). This case discusses a 46-year-old woman who presented with symptoms suggestive of PE following a prolonged road trip. Despite a low Wells score and negative D-dimer results, she underwent CTPA, resulting in an unnecessary and harmful interventional radiology-guided thrombectomy. This highlights the importance of adhering to guidelines in PE diagnosis to mitigate potential harms associated with the overuse of available medical tools.

Landiolol for Treating Arrhythmias: A State-of-The-Art Review.

This article provides a state-of-the-art review on landiolol, a medication that was recently submitted for 7 approvals. Focusing on its pharmacology, pharmacokinetics, and pharmacodynamics, the analysis underscores landiolol's unique attributes compared to conventional beta-blockers, particularly esmolol. As a sympatholytic agent, landiolol exhibits a short half-life, high cardioselectivity, and minimal impact on blood pressure, setting it apart in the realm of arrhythmia treatment. The review explores landiolol's potential applications, emphasizing scenarios where other beta-blockers may be limited. A detailed examination of its efficacy in preventing postoperative atrial fibrillation reveals promising results from clinical trials, suggesting its utility in diverse surgical settings. Additionally, the article delves into landiolol's role in rate control for atrial fibrillation/flutter, treatment of ventricular tachycardia/fibrillation, and its use in managing sepsis-related tachyarrhythmias. The evolving landscape of landiolol's applications extends beyond cardiac care, including potential anti-inflammatory, antioxidative, analgesic, and anticancer effects. While the outcomes from various studies are promising, challenges persist, requiring further research to optimize dosing strategies, identify optimal patient populations, and elucidate mechanisms underlying its diverse effects. The potential expansion of landiolol's applications highlights the importance of ongoing clinical investigation, offering a promising avenue for enhancing arrhythmia management and addressing broader medical needs.

Unleashing an Underlying Serious Cardiac Arrhythmia: A Case of Coronary Vasospasm With Atypical Presentation.

This case report highlights the atypical presentation of coronary artery vasospasm in a 59-year-old patient presenting with syncope due to ventricular arrhythmia. Despite initially elevated troponin levels and non-significant lesions observed during left heart catheterization, the patient experienced recurrent chest pain and dizziness, prompting further evaluation. Ultimately, coronary vasospasm was identified as the likely differential diagnosis, supported by various diagnostic modalities including electrocardiogram, Zio patch monitoring, transthoracic echocardiogram, cardiac MRI, and CT angiography. Management involved the initiation of calcium channel blocker therapy, leading to a non-eventful follow-up in the cardiology clinic.

Relation between non-alcoholic fatty liver disease and carotid artery intimal media thickness as a surrogate for atherosclerosis: a systematic review and meta-analysis.

BACKGROUND AND OBJECTIVE: Non-alcoholic fatty liver disease (NAFLD), characterized by hepatic steatosis without heavy alcohol consumption or other chronic conditions, encompasses a spectrum from non-alcoholic fatty liver to non-alcoholic steatohepatitis leading to cirrhosis. This analysis aimed to investigate the correlation between NAFLD and carotid intimal media thickness (C-IMT), a non-invasive surrogate for atherosclerosis. METHODOLOGY: Database searches, including PubMed, EMBASE and Cochrane Library, yielded studies up to April 2023. Included were studies exploring the NAFLD-C-IMT relationship in populations aged >18 years. Exclusions comprised non-English papers, those involving animals or pediatric populations and studies lacking control groups. RESULTS: No statistical significance was noted between mild and moderate NAFLD compared to the control group regarding C-IMT [95% confidence intervals (CI): -0.03, 0.12] and (95% CI: -0.03, 0.21), respectively. There was a statistically significant difference only in the Severe NAFLD group ( P value 0.03). NAFLD with and without metabolic syndrome showed statistically significant differences compared to control regarding C-IMT (95% CI: 0.04, 0.12) and (95% CI: 0.01, 0.07), respectively. Fifty-nine studies were mentioned without classification of NAFLD severity and revealed a high statistically significant difference between NAFLD and controls regarding C-IMT with (95% CI: 0.09, 0.12, P < 0.00001). Stratified analysis according to sex was done in two studies and revealed statistical differences between NAFLD and control regarding C-IMT in both groups. CONCLUSION: This meta-analysis underscores a significant association between NAFLD and increased C-IMT, emphasizing the importance of assessing C-IMT in NAFLD patients to identify cardiovascular risk and tailor therapeutic interventions for improved patient outcomes.

Assessing and improving radiation safety in cardiac catheterization: a study from Cairo University Hospital.

BACKGROUND: Catheter laboratories are high-radiation exposure environments, especially during X-ray procedures like percutaneous transluminal coronary angioplasty and electrophysiological studies. Radiation exposure poses risks of stochastic (e.g., cancer) and deterministic (e.g., skin changes) effects. This study assessed radiation safety and health practices in a cardiac catheterization unit to optimize radiation safety. A cross-sectional study in Cairo University Hospital (March-September 2019) evaluated 700 patients and healthcare workers. Real-time radiation measurements, educational lectures, and radiation protection measures were implemented in three phases. Data on radiation exposure, procedures, and compliance were collected and analyzed. RESULTS: The total procedure time and fluoroscopy time per cardiologist did not significantly differ between phases, but there was a statistically significant reduction in the mean total cumulative radiation doses between Phase I and Phase III for cardiologists (P = 0.013). Among nurses and technicians, there was no significant difference in radiation doses between the two phases. Significant correlations were found between operators' radiation doses, procedure time, and fluoroscopy time. Patients' radiation doses decreased significantly from Phase I to Phase III, with correlations between dose, procedure time, and gender. Compliance with radiation protection measures was suboptimal. CONCLUSIONS: Compliance with radiation safety standards in the cardiac catheterization unit at the Cairo University Hospital needs improvement. The study highlights the importance of adhering to radiation safety principles and optimizing protective measures to reduce radiation exposure for both patients and healthcare personnel. Despite low compliance, significant reductions in radiation doses were achieved with increased awareness and adherence to specific protection measures. Future efforts should focus on enhancing radiation safety protocols and organ-specific radiation impact assessments.

Association between non-alcoholic fatty liver disease and coronary artery disease outcomes: A systematic review and meta-analysis.

OBJECTIVES: To evaluate the association between non-alcoholic fatty liver disease (NAFLD) and cardiovascular outcomes, including angina, coronary artery disease (CAD), coronary artery calcification (CAC), myocardial infarction (MI), and calcified coronary plaques. METHODS: A comprehensive search of databases, including PubMed, EMBASE, and Cochrane Library, was conducted up to January 2023. Studies were included investigating the relationship between NAFLD and cardiovascular outcomes in adult populations. Exclusion criteria were studies on animals, pediatric populations, and those not published in English. Two reviewers assessed the risk of bias in the included studies using the Newcastle-Ottawa Scale. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using random-effects models. RESULTS: The meta-analysis included 32 studies with a total of 5,610,990 participants. NAFLD demonstrated significant associations with increased risks of angina (Relative Risk (RR): 1.45, 95% CI: 1.17, 1.79), CAD (RR: 1.21, 95% CI: 1.07, 1.38), CAC >0 (RR: 1.39, 95% CI: 1.15, 1.69), and calcified coronary plaques (RR: 1.55, 95% CI: 1.05, 2.27). However, no significant association was found between NAFLD and CAC >100 (RR: 1.16, 95% CI: 0.97, 1.38) or MI (RR: 1.70, 95% CI: 0.16, 18.32). CONCLUSION: The meta-analysis demonstrated a significant association between NAFLD and cardiovascular outcomes independent of conventional cardiovascular disease (CVD) risk factors. These findings emphasize the importance of prevention, early detection, and proper management of NAFLD.

Congenital Long QT Syndrome, Coinciding With Cavitary Mycobacterium avium Lung Infection, Led to Cardiac Arrest.

Congenital long QT syndrome is a cardiac disorder leading to arrhythmias and sudden cardiac death. We present a case of a 55-year-old woman with altered mental status experiencing cardiac arrest caused by congenital long QT syndrome, coincidentally found with Mycobacterium avium complex lung infection. Genetic testing identified a pathogenic mutation in the KCNH2 gene. (Level of Difficulty: Intermediate.).

A Case Report of BRASH (Bradycardia, Renal Failure, Atrioventricular (AV) Blockage, Shock, and Hyperkalemia) Syndrome With a Challenging Diagnosis and Management Dilemma.

BRASH syndrome, characterized by bradycardia, renal failure, atrioventricular (AV) blockage, shock, and hyperkalemia, is an emerging clinical entity that challenges healthcare practitioners. This case report presents a unique instance of BRASH syndrome with an atypical presentation in a 56-year-old woman with a past medical history of hypertension, diabetes, and chronic kidney disease. Initial laboratory results revealed severe normocytic anemia, thrombocytopenia, renal dysfunction, acidosis, and hyponatremia, alongside hyperkalemia and hypothyroidism. An electrocardiogram depicted sinus arrest with atrial escape rhythms, indicative of severe bradycardia. Imaging studies revealed pleural effusion and ground glass opacities. Management involved anti-hyperkalemic measures, discontinuation of AV nodal-blocking agents, thyroid hormone replacement, and vasopressor support. The patient eventually improved following continuous renal replacement therapy (CRRT) and hemodialysis. The diagnosis of BRASH syndrome emerged as the most likely due to recurrent admissions with similar clinical features. BRASH syndrome represents a complex interplay between AV nodal block and hyperkalemia, leading to severe bradycardia and shock, often affecting older patients with limited renal reserve. While the current literature primarily consists of case reports, raising awareness of BRASH syndrome is crucial for timely intervention and improved patient outcomes. Further research is needed to better understand the mechanisms underlying this syndrome.

Point-of-Care Ultrasound Unveils Life-Threatening Conditions: A Case Series Highlighting Its Vital Diagnostic Role.

Point-of-care ultrasound (POCUS) has emerged as a powerful diagnostic tool in healthcare, offering rapid and cost-effective evaluation of cardiovascular and respiratory conditions. This case series highlights the vital role of POCUS in diagnosing life-threatening conditions and emphasizes the need for adequate training in its use. The first case describes a patient with chest pain, where POCUS revealed findings suggestive of thoracic aortic dissection, leading to timely transfer and surgical repair. The second case involves a patient with altered mental status and hypoxia, where POCUS identified a right atrial thrombus leading to thrombectomy. The discussion explores the expanding applications of POCUS in various medical specialties, including critical care and trauma, and its potential to improve patient outcomes. While POCUS has shown great promise, it remains a user-dependent technology, necessitating comprehensive training and collaboration among healthcare professionals to ensure its effective and safe use.

Pharmacotherapy of refractory pulmonary arterial hypertension.

INTRODUCTION: Treatment of refractory pulmonary arterial hypertension (PAH) is challenging and rarely the focus of reviews. The purpose of this review is to discuss current treatment options of refractory PAH, along with the state of research of several new medications. AREAS COVERED: We conducted a comprehensive PubMed search on the relevant literature on treating PAH, with a focus on approved and investigational interventions for high-risk patients. Our strategy used keywords 'Treatment' AND 'Pulmonary Hypertension,' without date restrictions, ensuring a thorough survey of available literature for our review. EXPERT OPINION: By utilizing serial risk assessment to identify patients remaining intermediate or high-risk, more patients are likely to survive longer. This is done by earlier use of combination or triple therapy with prostacyclin drugs. Current medications for PAH are all essentially vasodilators that improve physiology, but do not truly modify the disease process. The potential application of new investigational medications is exciting as they work by novel pathways likely to change the landscape of refractory PAH treatment.

Unusual Presentation of Multiple Lung Nodules in a Patient With Supraglottic Squamous Cancer: A Rare Infectious Cause Revealed.

Pulmonary nodules are commonly encountered in medical practice, necessitating thorough evaluation due to their diverse etiologies. Identifying the underlying cause is of utmost importance, particularly in patients with a history of extrapulmonary cancer, to differentiate between metastasis and other etiologies. We present a rare case of a 24-year-old male with supraglottic squamous cancer who developed multiple pulmonary nodules, which surprisingly were caused by a rare infectious agent. The patient presented with bilateral infiltrates on imaging, raising strong suspicion of metastatic disease from primary cancer. However, bronchoscopy and biopsy revealed no malignancy but confirmed the presence of Corynebacterium amycolatum, leading to a change in the treatment approach from palliative to curative. This case highlights the importance of considering other etiologies, especially infections, in patients with cancer and pulmonary nodules. Accurate diagnosis is crucial to guide appropriate management decisions and optimize patient outcomes.

An Acute Large Pericardial Effusion in a Scleroderma Renal Crisis.

This case report describes a patient with systemic sclerosis (SSc) who presented with a large pericardial effusion and a scleroderma renal crisis (SRC). The patient's clinical presentation, diagnostic workup, and treatment plans are reviewed. The coexistence of these complications presents a challenging clinical scenario requiring an interdisciplinary approach. The management of pericardial effusion in SSc and SRC is discussed, emphasizing the need for early detection and prompt treatment. Further research is needed to better understand and manage these complex complications in SSc patients.

Cardiac Sarcoidosis Presented With Hiccups: A Case Report and Literature Review.

Sarcoidosis is a multisystem disorder of unknown etiology commonly associated with hilar lymphadenopathy and granulomas. Cardiac involvement is less common; however, sarcoidosis is a known cause of restrictive cardiomyopathy. It typically presents as new-onset arrhythmias or heart failure, although cases of sudden cardiac death have been reported. We present a case of a 56-year-old male with a known history of pulmonary sarcoidosis, not on active treatment, who presented to the emergency department with a week of continuous hiccups every few seconds associated with non-exertional dyspnea. An initial computed tomography (CT) scan of the chest showed multiple stellate-like ground-glass opacities and the progression of bronchiectasis. Troponins were negative. On the initial electrocardiogram (EKG), he was found to be in atrial flutter and was admitted to the medical floor. Cardiology was consulted for suspected cardiac sarcoidosis, and they recommended transfer to the tertiary care center for further evaluation. Upon arrival, the patient underwent catheter ablation for atrial flutter and returned to sinus rhythm after the procedure. The initial nuclear scan with gallium was not suggestive of cardiac sarcoidosis. However, subsequent cardiac magnetic resonance imaging (MRI) showed cardiac involvement. Due to the high risk of arrhythmias, the patient was scheduled for implantable cardioverter defibrillator placement before discharge. The patient was given oral prednisone. The patient was discharged in stable condition, and interrogation of the device found it well functioning, and no significant arrhythmias were noted. Presentation of cardiac sarcoidosis can be variable, and any should be considered in any patient with a known history of sarcoidosis who presents with atypical symptoms above the diaphragm, such as hiccups or with new-onset arrhythmias.

Heart Block and Sinus Pause Following Abdominal Surgery: A Case Requiring Temporary Pacemaker Insertion.

This case report presents the clinical course of a 70-year-old female with a history of hypertension who developed sinus pauses following abdominal surgery, ultimately requiring the placement of a pacemaker. The patient initially presented with altered mental status preceded by abdominal pain, which progressed to confusion and obtundation. Examination revealed signs of toxicity, tachycardia, tachypnea, and a distended abdomen with absent bowel sounds. A computed tomography (CT) scan of the abdomen indicated closed-loop small bowel obstruction with free air and ascites. The patient underwent exploratory laparotomy, revealing purulent fluid and a necrotic, perforated appendix, leading to appendectomy and peritoneal irrigation. Subsequent surgeries addressed the coagulative necrosis of the omentum and wound closure. During the recovery period, the patient exhibited bradycardia with sinus pauses, including episodes of complete heart block. Cardiology consultation attributed this to increased parasympathetic tone following surgery and recommended the placement of a temporary transvenous pacemaker. As the patient's condition improved, the sinus pacing function progressively returned, leading to the removal of the pacemaker. This case underscores the potential development of sinus pauses after abdominal surgery and highlights the importance of prompt recognition, appropriate management, and collaboration between surgical and cardiology teams to ensure patient recovery.

Cryotherapy for the Treatment of Tracheal Stenosis: A Systematic Review.

Tracheal stenosis (TS) is an iatrogenic sequela after intubation or tracheostomy that is increasing despite technological improvement and skilled respiratory care in the ICU. According to the studies, the rate of TS varies from 10 to 22%, but only 1-2% of these stenoses are severe and present with inspiratory dyspnea that does not respond to medical management. Bronchoscopy is considered the most appropriate diagnostic test, and laser surgery and tracheobronchial stenting are the most commonly performed procedures for tracheal stenosis. However, alternative treatment options, including cryotherapy for inoperable patients, have yet to be studied widely. As the number of patients requiring ICU admission with mechanical intubation is increasing, it is crucial to acknowledge this complication and consider alternative management options. Here we present a review of the use of cryotherapy for post-intubation tracheal stenosis.  Pubmed, Cochrane, and EMBASE databases were inquired for studies performed using the keywords 'airway stricture' OR 'airway obstruction' AND 'post-intubation' OR 'post-extubation' OR 'tracheostomy' AND 'cryotherapy'. After the primary and secondary screening, five studies were included in the analysis.  We included 67 patients were included in the analysis, with a mean age of 50.2 (range: 42-55) years. Tracheal stenosis and subglottic stricture were the most common sites of stenosis. Twenty-nine patients were treated with cryotherapy only, while the rest 38 patients had cryotherapy followed by balloon dilation. After the intervention, 48 patients experienced improvement, five experienced no change in the symptoms, 13 patients were asymptomatic before the treatment, and one died. No complication was reported in 65 patients, with only minor complications reported in rest.  Although, there is no clear treatment protocol for patients with inoperable tracheal stenosis. Our review demonstrates that cryotherapy for inoperable tracheal stenosis can be an acceptable alternative treatment with significant clinical improvement. Additionally, cryotherapy has fewer adverse effects compared to other treatment options.

Cardiac Arrest as the Initial Presentation of Undiagnosed Kawasaki Disease: A Case Report and Literature Review.

Kawasaki Disease (KD) is a self-limited acute vasculitis that mainly affects medium-sized arteries in childhood, with the coronary arteries being one of the main targets. A well-known complication is a coronary aneurysm with myocardial ischemia. We report the case of a 29-year-old female with an insignificant past medical history who presented with sudden cardiac arrest. Labs were significant for elevated troponin, consistent with non-ST elevation myocardial infarction, given diffuse ST depression on the electrocardiogram. The patient underwent a coronary angiogram that revealed diffuse coronary artery disease with multiple ulcerations, aneurysms, and occlusions consistent with KD, despite denying prior history. Cardiac arrest may be the initial presentation of undiagnosed KD and should be considered as one of the differential diagnoses.

Severe Disseminated Intravascular Coagulopathy Associated With Biventricular Massive Mural Thrombi in Newly Diagnosed Non-ischemic Cardiomyopathy.

Hemostatic system abnormalities have been previously associated with congestive heart failure (CHF). Here, we report a rare case of disseminated intravascular coagulopathy (DIC) in the setting of non-ischemic cardiomyopathy with right atrial and biventricular thrombus. We present a 55-year-old female with a past medical history of bronchial asthma who presented with a six-day history of bilateral leg swelling and dry cough. Her physical examination on admission was significant for signs of biventricular heart failure. Initial workup was significant for elevated pro-brain natriuretic peptide (ProBNP), elevated transaminases, marked thrombocytopenia (19,000/mcL), and coagulopathy with international normalized ratio (INR) of 2.5 and D-dimer of 15,585 ng/mL. Transthoracic echocardiogram (TTE) showed a large mobile right atrial thrombus protruding into the right ventricle and a more adherent left ventricular (LV) thrombus with severely reduced biventricular contractility. Pan CT was done and was significant for multifocal multilobar pulmonary emboli. A lower limb venous duplex was done and revealed extensive bilateral lower limb deep venous thrombosis (DVT). This rare case demonstrates an unusual association between DIC with non-ischemic cardiomyopathy, biventricular thrombus, extensive deep vein thrombosis, and pulmonary embolism (PE). In comparison, there are multiple prior reports for DIC with CHF and LV thrombus. However, our case differs from prior reports in terms of the presence of right atrial and biventricular thrombus. The patient received antibiotics, diuretics, and cryoprecipitate in the setting of persistent low fibrinogen levels. The patient underwent Interventional radiology-guided thrombectomy for extensive pulmonary emboli followed by inferior vena cava (IVC) filter insertion, resulting in the resolution of the right atrial thrombus and extensive decrease of the pulmonary emboli burden. The patient was then given apixaban after normalization of the platelet count and fibrinogen level. Hypercoagulability workup was inconclusive. The patient was then discharged after improvement of symptoms. Early recognition of DIC and cardiac thrombi in patients with new-onset heart failure is crucial for the implementation of the correct management by thrombectomy, optimizing heart failure medications, and anticoagulation to achieve better outcomes.

Torsades De Pointes in a 71-Year-Old Female With Normal Qt Interval After Azithromycin Use.

A 71-year-old female visiting from Colombia presented to the emergency room with a productive cough, subjective fever, and chills for the past three days. Baseline EKG demonstrated a QT interval of 385 milliseconds with left ventricular hypertrophy and T wave inversions in leads V4, V5, and V6. Azithromycin was administered, and she was subsequently found to have torsades de pointes (TdP) on telemetry. In high-risk individuals, medications with reduced effects on cardiac conduction should be considered to avoid potentially lethal reactions. This case highlights the importance of clinical history prior to the administration of medications that have a propensity to cause abnormalities in cardiac conduction. Our patient had a grossly normal QT interval prior to the administration of azithromycin; however, she subsequently developed torsades de pointes. The patient was on telemetry monitoring, and cardiopulmonary resuscitation was quickly initiated as she was in a hospitalized setting; however, in an outpatient community setting, she likely would not have survived. By examining all the elements which contribute to QT prolongation, clinicians can have a deeper understanding of the complexities, particularly in individuals with multiple co-morbid conditions prior to the administration of medications that have a propensity to affect the QT interval.

Reverse Takotsubo Cardiomyopathy in a Critically Ill Patient in the ICU: A Case Report With Literature Review.

Takotsubo, or stress cardiomyopathy (SC), is described as a transient systolic dysfunction of the apical segments of the left ventricle mainly triggered by emotional or physical stress resembling the presentation of an acute coronary syndrome in the absence of obstructive coronary artery disease. Reverse Takotsubo SC is a rare variant of SC that presents with basal ballooning instead of apical ballooning seen in classic SC. We present a case of a 74-year-old male who was admitted to the ICU with septic shock. Laboratory test results showed elevated troponin. An echocardiogram showed reduced cardiac contractility and relative hypokinesis of the basal and mid segments compared to the apical segments, consistent with reverse Takotsubo SC, which recovered after 10 days. It can happen in critically ill patients in the ICU secondary to severe sepsis and could contribute to hemodynamic worsening, affecting the final clinical outcomes.

A Rare Case of Transient Second-Degree Mobitz Type II Heart Block Complicating a Saddle Pulmonary Embolism.

Presentations of pulmonary embolism (PE) are often associated with various cardiac arrhythmias and conduction abnormalities detected on electrocardiograms (EKG). We describe a 65-year-old female with no known history of heart disease or arrhythmias who presented with an acute onset of shortness of breath. Initial EKG showed right bundle branch block (RBBB), and first-degree atrioventricular (AV) block with subsequent development of second-degree Mobitz type II AV block. The patient's clinical appearance was highly suggestive of a massive pulmonary embolism with hemodynamic instability, and treatment with alteplase (tPA) was given, followed by heparinization. A CT pulmonary angiography confirmed the provisional diagnosis and revealed a large saddle embolus within the right and left main pulmonary arteries. Subsequent EKG showed resolution of the RBBB, first-degree AV block, and second-degree AV block. The patient improved clinically and was discharged to a subacute rehab facility with follow-up appointments. This case highlights that pulmonary embolism may present with many EKG changes, including RBBB, first-degree, second-degree, or complete heart block. Early recognition of PE and thrombolytic treatment can improve cardiac function and restore heart rhythms. Further evaluation for underlying conduction abnormalities can later be performed.