Monthly variations in acute coronary syndromes outcomes during the first year of the COVID-19 pandemic.

BACKGROUND: Cardiovascular disease, particularly acute coronary syndromes (ACS), is the leading cause of death in the United States. Minor fluctuations in hospital admissions for different conditions, including ACS, can be seen throughout the year. This study focuses on the impact of admission month on outcomes of acute coronary syndromes during the first year of the COVID-19 pandemic. METHODS: This was a retrospective observational study of patients hospitalized with ACS from the National Inpatient Sample, during the years 2020 (n = 779,895) and 2019 (n = 935,975). We compared the monthly outcomes for every month to the outcomes for the month of January of that same year. The primary outcomes of interest were in-hospital mortality and time from admission to PCI. RESULTS: Inpatient mortality for patients admitted with STEMI was significantly higher for admissions in the months of April, October and December of 2020 than January of that same year. For patients admitted with NSTEMI or UA, inpatient mortality was higher for admissions in April and December 2020 when compared to admissions in January 2020. Inpatient mortality for patients with STEMI, NSTEMI and UA was not different based on admission month in the year 2019. CONCLUSION: The month of admission significantly affected outcomes for patients admitted with ACS during the COVID-19 pandemic, with higher inpatient mortality and longer time from admission to PCI for certain months in 2020. Further studies should investigate disparities in monthly ACS outcomes for the year 2021 and onward, now that COVID-19 infections have been steadily declining.

Ventricular fibrillation arrest after blunt chest trauma in a 33-year-old man, commotio cordis?

BACKGROUND: Commotio cordis is an event in which a blunt, non-penetrating blow to the chest occurs, triggering a life-threatening arrhythmia and often sudden death. This phenomenon is often seen in young, male athletes and has become increasingly well-known over the past few decades. We present a unique case in which ventricular fibrillation occurs in an older male athlete after blunt trauma. CASE PRESENTATION: Patient with no known medical history was brought to the ER after being found unconscious after a soccer ball kick to the chest. He was found to be in ventricular fibrillation and successfully resuscitated on the soccer field. Patient was admitted to the hospital and lab workup and initial imaging were unremarkable, except elevated troponin and lactate, which returned to normal levels. An echocardiogram showed global left ventricular systolic dysfunction with a visually estimated ejection fraction of 45-50%. Coronary showed angiographically nonobstructive coronary arteries. The patient was diagnosed with commotio cordis and discharged from the hospital in stable condition. Follow-up echocardiogram continued to show low ejection fraction and event monitor demonstrated frequent polymorphic ventricular tachycardia with periods of asystole. CONCLUSION: This case is unique in that blunt trauma to the chest from a soccer ball immediately triggered ventricular fibrillation in a patient with a possible cardiomyopathy. It is possible that the blunt trauma caused primary commotio cordis that led to cardiomyopathy in a previous healthy man, or that an underlying cardiomyopathy made it more likely for this to occur. Overall, increased awareness and prevention efforts of blunt chest trauma are required to reduce the high mortality associated life-threatening arrhythmias. There is limited data regarding the interplay between these two entities.

Outcomes and Revascularization Strategies of ST-Elevation Myocardial Infarction in Patients With Hypertrophic Cardiomyopathy.

Myocardial ischemia is a known complication of HCM. Contemporary outcomes and care processes after STEMI are extensively examined; however, there are limited data on outcomes, and revascularization strategies of HCM patients with STEMI. The National Inpatient Sample 2004-2018 was queried to identify adult patients presenting with a primary diagnosis of STEMI, of whom a subset of patients with concomitant diagnosis of HCM were identified. Complex samples multivariable logistic and linear regression models were used to determine the association of HCM with in-hospital outcomes. HCM patients with STEMI who were revascularized were compared with their counterparts who were not revascularized. Of 3,049,068 primary STEMI hospitalizations, 2583 (0.8%) had an associated diagnosis of HCM. HCM patients were more likely to be elderly and female with less traditional cardiovascular risk factors compared to those without HCM. HCM patients were less likely to receive revascularization compared to those without HCM. STEMI with HCM was associated with similar in-hospital mortality (adjusted odds ratio [aOR] 1.09; 95% confidence interval [CI] 0.82-1.44; P = 0.561) compared to those without HCM. Notably, HCM patients who were revascularized had similar in-hospital mortality (aOR 0.69; 95% CI 0.36-1.33; P = 0.266) compared to HCM patients who did not receive revascularization. Despite lower rates of revascularization, STEMI in patients with HCM is associated with similar in-hospital mortality compared to those without HCM.

A Case of Ruptured Giant Sinus of Valsalva Aneurysm Into the Right Ventricle in a Patient With Both Atrial and Ventricular Septal Defects.

Sinus of Valsalva aneurysm (SOVA) is a rare cardiac defect. In most cases, SOVA presents as an incidental finding during cardiac imaging. A dreadful complication of SOVA is spontaneous rupture, most commonly occurring into the right side of the heart resulting in an abrupt or insidiously progressive congestive heart failure. Ruptured SOVA is associated with poor prognosis with high mortality unless timely surgical intervention is deemed. We present a 23-year-old female who presented with a continuous heart murmur and exertional dyspnea. Transesophageal echocardiogram showed a ruptured 1.8 cm sinus of Valsalva aneurysm of the non-coronary cusp to the right ventricle, which resulted in a significant left-to-right shunt and pulmonary hypertension. Associated cardiac defects included ostium secundum atrial septal defect, peri-membranous ventricular septal defect, and moderate aortic and mitral valve insufficiency. The patient underwent successful surgical correction with significant resolution of the shunt and normalization of the pulmonary pressure. Despite being rare, SOVA can rupture spontaneously, resulting in decompensated heart failure. SOVA should be considered in the differential diagnosis of a continuous heart murmur. Early recognition and timely surgical intervention are pivotal in these cases to prevent further clinical deterioration or even death. LEARNING POINTS: Sinus of Valsalva aneurysms (SOVA) are usually silent until acute rupture. Rupture most commonly occurs into either the right ventricle or right atrium. A new continuous murmur is the most striking physical finding; it is always significant and must prompt urgent echocardiography to facilitate timely diagnosis and treatment. Ruptured SOVA has a poor prognosis with high mortality unless timely surgical intervention is deemed.

Outcomes of distal versus conventional transradial access for coronary angiography and intervention: An updated systematic review and meta-analysis.

INTRODUCTION: Distal transradial artery access (DTRA) has recently gained attention due to potential benefits in terms of local complications. In this meta-analysis, we aimed to evaluate the utility of DTRA compared to conventional transradial artery access (CTRA) for coronary angiography and intervention. METHOD: Multiple databases were searched from inception through May 2021 for all the studies that evaluated the efficacy and safety of DTRA in the coronary field. The primary outcome was the access success rate. The secondary outcomes were periprocedural local complications (site hematoma, radial artery occlusion, and spasm) and procedural characteristics (cannulation, fluoroscopy, procedure, and radial artery compression times). All meta-analyses were conducted using a random-effect model. RESULTS: A total of 12 studies (including four randomized control trials) with 1634 patients who underwent DTRA vs. 1657 with CTRA were included in the final analysis. The access success rate was similar between the two groups (odds ratio (OR):0.62; 95% confidence interval (CI):0.30-1.26; P = 0.18; I2 = 61%). DTRA was associated with a statistically significant lower rate of radial artery occlusion (OR:0.36; 95% CI: 0.22-0.59; P < 0.001; I2 = 0%) but similar rates of radial artery spasm and site hematoma when compared to CTRA. Regarding the procedural characteristics, despite having a longer canulation time (mean difference (min.) [MD] 0.89, 95% CI 0.36-1.42; P < 0.0001), DTRA was associated with shorter compression time and comparable fluoroscopy and procedure times. CONCLUSIONS: Our meta-analysis demonstrates that the DTRA is effective and safe with superiority in preventing radial artery occlusion when compared to CTRA.

Epidemiological and Clinical Characteristics of 217 COVID-19 Patients in Northwest Ohio, United States.

Background There is limited data on the clinical characteristics and predictors of mortality of coronavirus disease-2019 (COVID-19) in North West Ohio. We performed a retrospective review of patients hospitalized with COVID-19 in the ProMedica Health System in Northwest Ohio from March 25 to June 16, 2020. The study aims to identify epidemiological, clinical characteristics, and predictors of Mortality of COVID-19 patients in Northwest Ohio. Methods This study was conducted on 217 COVID-19 patients admitted to ProMedica Health System Hospitals in Northwest Ohio from March 25 to June 16, 2020. We collected data, including clinical signs, symptoms, and outcomes of the COVID-19 patients. We compared clinical signs and symptoms along with comorbidities of survivors and non-survivors. Results Of the 217 patients included in the study, the mean age of the population was 63.13 (SD 17.8), of which 194 (89.4%, mean age 61.7 years) survived while 23 (10.6%, mean age 74.6 years) died. Among them, 53% were females and 47% male. Common presenting symptoms were chest pain (91.71%), shortness of breath (79.7%), cough (71%), and fever (64%). Mortality was associated with age greater than 63 (p-value 0.0052) and hypertension (p-value: 0.0058) with marginal significance with gender (p-value: 0.0642), chest pain (p-value: 0.0944), and history of cancer (p-value: 0.0944). Conclusions Advanced age and hypertension (HTN) are independent predictors for increased mortality. History of cancer and chest pain are associated with increased mortality with marginal significance. Awareness among physicians about predictors of mortality is essential in dealing with COVID-19 patients. It is essential to educate the public about preventative strategies such as wearing masks to decrease mortality and morbidity from this pandemic.

Membranous nephropathy and autoimmune hepatitis in the setting of acute Helicobacter pylori infection: a case report.

BACKGROUND: Membranous nephropathy (MN) is the leading cause of nephrotic syndrome in adults worldwide. A growing body of evidence indicates a pathogenic and autoimmune correlation between Helicobacter pylori infection, MN, and autoimmune liver disease. CASE PRESENTATION: A 47-year-old African American woman presented to our institution with epigastric pain and vomiting. In-patient hospital workup included a thorough abdominal evaluation including esophagogastroduodenoscopy and liver biopsy, which revealed active H. pylori infection and autoimmune hepatitis. The patient was incidentally also found to have nephrotic-range proteinuria. Renal workup including kidney biopsy established the diagnosis of MN. Proteinuria improved after initiation of triple therapy for H. pylori infection. CONCLUSION: This case adds to the growing evidence of a correlation between H. pylori infection, MN, and autoimmune liver disease. This report demonstrates a unique case of a patient with MN, autoimmune hepatitis (AIH)/primary biliary cholangitis (PBC), and HP who underwent triple-eradication antibiotic treatment that resulted in an ultimate resolution of all these conditions.

Triple Valve Endocarditis With Aortic Root Abscess Presenting With Complete Heart Block and Distal Embolization.

Infective endocarditis (IE) carries a high mortality rate. Consequently, the prognosis is poorer in patients with multiple valve involvement. Due to poor prognosis of patients with endocarditis, early diagnosis and management of these patients can be challenging in the clinical setting. We describe a case of a 45-year-old man who came in with bacteremia secondary to a diabetic foot ulcer. Electrocardiogram (EKG) showed complete third-degree heart block which rose suspicion for possible valvular abscess formation. Transthoracic echocardiogram (TTE) was performed and revealed vegetations on the aortic and mitral valve. A follow-up transesophageal echocardiogram (TEE) showed an abscess on the aortic valve along with vegetations on the mitral and tricuspid valve, the latter which was missed on TTE. The prompt utilization of TEE in detecting early and late mechanical complications of endocarditis is imperative in facilitating rapid clinical decision-making and early intervention. Patients with multi-valve endocarditis are at extremely high risk of complications and should be evaluated for surgical intervention immediately.

Supraventricular Tachycardia and Postural Orthostatic Tachycardia Syndrome Overlap: A Retrospective Study.

Postural orthostatic tachycardia syndrome (POTS) and supraventricular tachycardia (SVT) are disease states with distinctive features but overlapping clinical manifestations. Currently, studies on the presence of underlying SVT in patients with POTS are lacking. This retrospective study analyzed 64 patients [mean age: 43 years; 41 (61%) women] who had a POTS diagnosis and were found to have concomitant SVT during rhythm monitoring from September 1, 2013 to September 30, 2019 at our Syncope and Autonomic Disorders Clinic. The outcomes assessed were changes in disease severity, frequency of symptoms, heart rate, and blood pressure between before and after SVT ablation. The most frequent types of SVT noted on the electrophysiologic study were atrioventricular nodal reentrant tachycardia (57.81%), atrial flutter (29.68%), atrioventricular reentrant tachycardia (9.37%), atrial tachycardia (1.56%), and junctional tachycardia (1.56%). After SVT ablation, all 64 patients experienced an improvement in symptoms. Palpitations and lightheadedness experienced the most improvement after the procedure (72% vs. 31%; p < 0.001 and 63% vs. 22%; p < 0.001, respectively). There was a significant improvement in the resting heart rate (81.1 ± 12.8 vs. 75.8 ± 15.6 bpm; p < 0.002), but the orthostatic tachycardia on standing persisted (93.6 ± 16.5 vs. 77.3 ± 19.8 bpm; p = 0.14). Underlying SVT in patients with POTS can be missed easily. A strong suspicion and long-term ambulatory cardiac rhythm monitoring can help in diagnosing the condition.

Hospitalization and Post-hospitalization Outcomes Among Teaching Internal Medicine, Employed Hospitalist, and Locum Tenens Hospitalist Services in a Tertiary Center: a Prospective Cohort Study.

BACKGROUND: There are no prospective studies comparing hospitalization and post-hospitalization outcomes between teaching internal medicine services and non-teaching hospitalists, and no prospective studies comparing these outcomes between locum and employed hospitalists. OBJECTIVE: To compare the length of stay, hospital costs readmission rate, and mortality rate in patients treated by teaching internal medicine services vs. hospitalists and among patients treated by locum vs. employed hospitalists. DESIGN: Prospective cohort study. Propensity score was used to obtain weighted estimates. SETTING: Referral center. PATIENTS: All patients 18 years and older admitted to internal medicine services. INTERVENTION: Treatment by teaching internal medicine services vs. hospitalists. Treatment by locum hospitalists vs. employed hospitalists. MAIN MEASURES: Primary outcome was adjusted length of stay and secondary outcomes included hospital cost, inpatient mortality, 30-day all-cause readmission, and 30-day mortality. KEY RESULTS: A total of 1273 patients were admitted in the study period. The mean patient age was 61 ± 19 years, and the sample was 52% females. Teaching internal medicine physicians admitted 526 patients and non-teaching hospitalists admitted 747 patients. Being seen exclusively by teaching internal medicine physicians comports with a shorter adjusted hospital stay by 0.6 days (95% CI - 1.07 to - 0.22, P = .003) compared to non-teaching hospitalists. Adjusted length of stay was 1 day shorter in patients seen exclusively by locums compared to patients seen exclusively by employed services (95% CI - 1.6 to - 0.43, P < .001) with an adjusted average hospital cost saving of 1339 dollars (95% CI - 2037 to - 642, P < .001). There was no statistically significant difference in other outcomes. CONCLUSIONS: Teaching internal medicine services care was associated with a shorter stay but not with increased costs, readmission, or mortality compared to non-teaching services. In contrary to the "expected," patients treated by locums had shorter stays and decreased hospital costs but no increase in readmissions or mortality.

Predictors of mortality in 217 COVID-19 patients in Northwest Ohio, United States: A retrospective study.

The coronavirus disease 2019 (COVID-19) pandemic continues to cause significant morbidity and mortality worldwide. This study aims to identify specific lab markers, complications, and treatments that may be associated with increased mortality in COVID-19 patients. This study is retrospective in nature; it included 217 COVID-19 positive patients who were admitted to a ProMedica Health System hospital in Northwest Ohio, United States, between March 25 and June 16, 2020. We collected various laboratory values, complications, and treatment courses. T test and χ2 analyses were used to predict mortality. COVID-19 test was confirmed via polymerase chain reaction. Of 217 patients included in the study, the mean age of the population was 63.13 (SD, 17.8), of which 194 (89.4%, mean age 61.7 years) survived while 23 (10.6%, mean age 74.6 years) died. Among them, 53% were females and 47% male. Laboratory values that were associated with mortality were low hemoglobin (p = .0046), elevated INR (p = .0005), low platelets (p = .0246) and elevated procalcitonin (p = .0472). Marginally significant laboratory values included elevated troponin (p = .0661), and elevated creatinine (p = .0741). Treatment with either antibiotic, antifungals, antivirals, blood transfusion, steroids, and intubation were all statistically significant for mortality. COVID-19 related complications with either ARDS, myocarditis, elevated INR, septic shock, or age greater than 63 were significant predictors of mortality. Low hemoglobin, elevated INR, Low platelet, elevated procalcitonin, treated with either antibiotic, antifungal, antiviral, blood transfusion, steroids, and intubation are associated with high mortality related to COVID-19 infection. Healthcare professionals must be aware of these predictors.

A single, shared origin for all three coronary arteries from the right coronary cusp: a case report.

BACKGROUND: Anomalous coronary arteries occur in less than 1% of the population and have been implicated in sudden cardiac and exercise-related death. The most common variant involves the left circumflex artery arising from a separate ostium than the left coronary artery. This case demonstrates a rare variation in which all three coronary arteries arise from a shared, single, ostium originating from the right coronary cusp. CASE PRESENTATION: We report the case of a 63-year-old Caucasian man with a history of myocardial infarction, congestive heart failure, and atrial fibrillation who presented for syncope. Inpatient ischemic workup, including coronary angiography, demonstrated a rare coronary anomaly which included all three coronary arteries arising from a shared, single, ostium originating from the right coronary cusp. Our patient was treated conservatively with an option for coronary bypass if symptomatic. CONCLUSION: Surgical management is indicated in high-risk patients, but the optimal management for a nonmalignant, shared origin for all three coronary arteries has not been explored in detail.

Bupropion in the treatment of postural orthostatic tachycardia syndrome (POTS): a single-center experience.

Postural orthostatic tachycardia syndrome (POTS) is estimated to impact millions of people each year. However, there is no established gold standard for its treatment. Bupropion is a norepinephrine and a dopamine reuptake inhibitor and has been implicated as a potential treatment for POTS. We performed a non-randomized retrospective chart review on 47 patients with POTS with statistical analysis evaluating for significant findings including reduced orthostasis and improvement of symptoms with the use of bupropion. Bupropion was not associated with a statistically significant improvement in orthostatic vitals but there was an overall reduction in reported syncope. While the use of bupropion does not show a statistically significant impact on orthostatic vitals in patients with POTS, it did show a degree of improvement in syncope and as such might be useful in patients with syncope-predominant POTS.

CardioMEMSTM System in the Daily Management of Heart Failure: Review of Current Data and Technique of Implantation.

INTRODUCTION: Heart failure (HF) leads to significant morbidity and mortality and imposes a large economic burden. Although there have been several advances in HF monitoring and management, HF-rehospitalization remains a significant problem. Remote monitoring of HF to detect early signs of decompensation has emerged in past years as an option to prevent or reduce the incidence of HF rehospitalization. The CardioMEMSTM HF system is a wireless pulmonary artery (PA) pressure monitoring system that detects changes in PA pressure and transmits data to the healthcare provider. Since changes in PA pressure happen early in the course of HF decompensation, the CardioMEMSTM system allows the provider to institute timely intensification of HF therapies to alter the course. In trial and registry data, the use of the CardioMEMSTM HF system has been associated with reduction in HF hospitalization, improvement in quality of life, symptoms, and physical activity. AREAS COVERED: This review will focus on the available data supporting its utilization in patients with HF. EXPERT OPINION: CardioMEMSTM is relatively safe and cost-effective, reduces heart failure hospitalization rates, and fits into intermediate to high-value medical care.

Ivabradine in children with postural orthostatic tachycardia syndrome: a retrospective study.

BACKGROUND: Ivabradine is a unique medication that reduces the intrinsic heart rate by specifically blocking the inward funny current that controls the pacemaker activity of the sinus node. We conducted a retrospective cohort study to assess the efficacy of ivabradine in children suffering from postural orthostatic tachycardia syndrome. METHODS: A chart review was conducted of patients less than 18 years of age who were diagnosed with postural orthostatic tachycardia syndrome who had received ivabradine as treatment from January 2015 to February 2019 at our institution. Twenty-seven patients (25 females, 92.5%) were identified for the study. The outcomes which were assessed included a change in the severity and frequency of symptoms, heart rate, and blood pressure before and after starting ivabradine. RESULTS: There was an improvement in the symptoms of 18 (67%) out of 27 patients. The most notable symptom affected was syncope/presyncope with a reduction in 90%, followed by lightheadedness (85%) and fatigue (81%). The vital signs of the patients showed an overall significant lowering of the heart rate during sitting (89.7 ± 17.9 versus 73.2 ± 12.1; p-value <0.05) and standing (100.5 ± 18.1 versus 80.9 ± 10.1; p-value <0.05) without a significant change in the blood pressure. Two patients had visual disturbances (luminous phenomena). Severe bradycardia and excessive flushing were seen in two patients, respectively. Another one patient reported joint pain and fatigue. CONCLUSION: This study indicates that 67% of children treated with ivabradine report an improvement in symptoms.

Severe radial artery spasm causing entrapment of the Terumo radial to peripheral destination slender sheath: a case report.

BACKGROUND: Radial access for lower-extremity peripheral vascular interventions (PVIs) has been limited due to inadequate equipment lengths. The Terumo R2P Destination Slender sheath is a relatively new sheath designed for these interventions. However, complications related to this sheath or access strategy for lower-extremity PVI have not been reported. CASE SUMMARY: A 69-year-old woman presented with purple discolouration of her 1st and 5th toes of the left foot for approximately 1 month. Lower-extremity arterial duplex ultrasound showed mid left superficial femoral artery (SFA) greater than 90% stenosis. Peripheral angiogram was performed via the left radial artery and this confirmed the presence of severe left SFA stenosis. Intra-arterial vasodilators including verapamil and nitroglycerine were administered to prevent radial artery spasm. Next, we attempted to deliver the Terumo 6-Fr R2P Destination Slender 119 cm sheath for the interventional procedure. However, the sheath became stuck at the level of mid axillary artery due to severe radial artery spasm. Despite use of intra-arterial vasodilators, deep sedation with propofol, and gentle retraction, the sheath could not be removed and eventually broke requiring surgical removal. DISCUSSION: This case demonstrates severe radial artery spasm causing sheath entrapment that required emergency surgery for sheath removal. Unfortunately, the sheath could not be removed despite typical manoeuvres for severe spasm including intra-arterial vasodilators and deep sedation with propofol. Physicians performing PVIs via radial access need to be aware of this potentially serious complication.

Obstructing Pancreatic Ductal Calculus: A Case Report and Literature Review.

Pancreatic calculi are typically a sequela of chronic pancreatitis. Here, we present a patient who was found to have an obstructing one-centimeter pancreatic calculus secondary to recurrent gallstone pancreatitis. Recent retrospective studies have focused on the optimal treatment of large pancreatic calculi that were defined as greater than five millimeters. But most studies fail to comment on much larger stone as in this case report. Further guidelines and investigation need to be done aiming toward the optimal treatment of relatively large pancreatic stones.

A Case of Acute Massive Bioprosthetic Mitral Valve Thrombosis Leading to Fulminant Heart Failure.

Bioprosthetic valve thrombosis has been considered to be extremely unlikely, typically freeing patients from the potential complications of long-term anticoagulation. However, there have been several documented cases of bioprosthetic valve thrombosis and there are concerns that its incidence may be underreported. Experience with diagnosis and management of this condition is limited. Here, we present a case of acute massive bioprosthetic mitral thrombosis manifesting as fulminant heart failure.