Tejocote Root's Role in Symptomatic Mobitz Type 1 Heart Block: A Compelling Case Report.

The clinical presentation and diagnosis of Tejocote root toxicity causing Mobitz Type 1 remains a scarcely clinical phenomenon, often resulting in delayed diagnosis and treatment. This case report highlights a 30-year-old female presenting with a constellation of symptoms, including fatigue, dizziness, chest pressure, myalgias, nausea, vomiting, and peripheral tingling. Significantly, the patient had been using Tejocote root as an over-the-counter laxative acquired from Mexico. Laboratory findings revealed detectable Digoxin levels in her bloodstream, while an electrocardiogram (EKG) indicated sinus bradycardia with Mobitz Type 1 heart block. The patient was treated with a single dose of atropine 0.5 mg IV push. A repeat EKG before discharge showed resolution of the Mobitz type 1. This case underscores the potential cardiovascular repercussions of Tejocote root consumption and emphasizes the importance of heightened clinical awareness, especially in regions where such herbal supplement usage is prevalent.

The Clot Thickens: COVID-19-Related ST-Elevation Myocardial Infarction in the Setting of Recent Boosters.

The coronavirus disease of 2019 (COVID-19) has an array of pathological effects that continue to be discovered. Vaccines against COVID-19 have quickly emerged as our main tool. However, the thrombotic risk of both the virus and the vaccine is yet to be established, let alone together. In this case report, we present a case involving a recently diagnosed COVID-19 patient who developed an ST-elevated myocardial infarction (STEMI) after receiving his booster shot. Our aim is to highlight the standard of treatment outcomes in COVID-19-associated clots, familiarize ourselves with the complexity of the clot burden in a COVID-19-associated STEMI, and illustrate the potential role of the cumulative pro-thrombotic effects of a recent COVID-19 booster with a concomitant symptomatic COVID-19 infection.

SVEAT score outperforms HEART score in patients admitted to a chest pain observation unit.

BACKGROUND: Timely and accurate identification of subgroup at risk for major adverse cardiovascular events among patients presenting with acute chest pain remains a challenge. Currently available risk stratification scores are suboptimal. Recently, a new scoring system called the Symptoms, history of Vascular disease, Electrocardiography, Age, and Troponin (SVEAT) score has been shown to outperform the History, Electrocardiography, Age, Risk factors and Troponin (HEART) score, one of the most used risk scores in the United States. AIM: To assess the potential usefulness of the SVEAT score as a risk stratification tool by comparing its performance to HEART score in chest pain patients with low suspicion for acute coronary syndrome and admitted for overnight observation. METHODS: We retrospectively reviewed medical records of 330 consecutive patients admitted to our clinical decision unit for acute chest pain between January 1st to April 17th, 2019. To avoid potential biases, investigators assigned to calculate the SVEAT, and HEART scores were blinded to the results of 30-d combined endpoint of death, acute myocardial infarction or confirmed coronary artery disease requiring revascularization or medical therapy [30-d major adverse cardiovascular event (MACE)]. An area under receiving-operator characteristic curve (AUC) for each score was then calculated. C-statistic and logistic model were used to compare predictive performance of the two scores. RESULTS: A 30-d MACE was observed in 11 patients (3.33% of the subjects). The AUC of SVEAT score (0.8876, 95%CI: 0.82-0.96) was significantly higher than the AUC of HEART score (0.7962, 95%CI: 0.71-0.88), P = 0.03. Using logistic model, SVEAT score with cut-off of 4 or less significantly predicts 30-d MACE (odd ratio 1.52, 95%CI: 1.19-1.95, P = 0.001) but not the HEART score (odd ratio 1.29, 95%CI: 0.78-2.14, P = 0.32). CONCLUSION: The SVEAT score is superior to the HEART score as a risk stratification tool for acute chest pain in low to intermediate risk patients.

Resolution of Symptomatic Intermittent Sinoatrial Exit Block Associated With Unstable Angina Following Percutaneous Coronary Intervention.

Bradyarrhythmia commonly occurs because of degenerative fibrosis in the conductive system. Ischemic disease is a rare etiology and limited cases have demonstrated direct evidence of ischemia to the sinus node vessels. We report a 62-year-old Hispanic male with a significant medical history of diabetes mellitus type II (DM II), hypertension, and dyslipidemia who was admitted to our hospital for symptomatic sinoatrial (SA) exit block. Patient had no electrolyte abnormalities and our differential included ischemic vs. fibrotic or infiltrative pathologies, giving symptomatic bradycardia, cardiac chest pain, and high-risk factors for coronary artery disease. We decided to take him for cardiac catheterization which revealed sluggish, pulsatile flow into the SA nodal artery due to severe stenosis of the ostial right coronary along with sever distal left circumflex (LCX) lesion. The flow into the sinus nodal artery (SNA) markedly improved post percutaneous coronary intervention (PCI) of the right coronary artery (RCA) and distal LCX and restoration of flow into SNA. Resolution of his bradyarrhythmia and symptoms post intervention confirmed our suspicious for reversible ischemic sinus node dysfunctions. Therefore, ischemic pathologies should be thought of when other common etiologies are less likely. Coronary angiogram should be considered prior to pacemaker evaluation in these setting to avoid missing reversible causes of bradyarrhythmia.

SVEAT Score, a Potential New and Improved Tool for Acute Chest Pain Risk Stratification.

Acute chest pain is one of the most common presenting symptoms to the emergency department. Currently available risk scores are suboptimal in identifying low-risk patients eligible for early and safe discharge. Various, initially obtained clinical data have valuable discriminating power but are not being fully utilized. We developed a new scoring system based on 5 sets of variables; characteristics of Symptoms, history of Vascular disease,  Electrocardiography,  Age, and Troponin (SVEAT score). A total of 321 subjects presenting to the emergency department or admitted to the clinical decision unit at our institution with chest pain from May 2017 to August 2018 were prospectively recruited. The subjects were followed for 30 days for any major cardiovascular events (MACE); acute myocardial infarction, confirmed coronary artery disease requiring revascularization or medical therapy or death. A 30-day MACE occurred in 19.6% of the subjects. Predictive ability of SVEAT score for a 30-day MACE was compared with HEART and TIMI risk score using receiving-operator characteristic curve. The area under the curve of SVEAT score (0.98, 95% confidence interval [CI] 0.97 to 0.99) is higher than HEART (0.92, 95% CI 0.88 to 0.96) and TIMI score (0.88, 95% CI 083 to 0.93). Using SVEAT score of 4 as a cut off, 0.8% of the subjects developed a 30-day MACE compared with 1.4% and 1.5% of those classified as low-risk based on the HEART and TIMI score respectively. SVEAT score additionally identified larger proportion of low-risk (73.8%) than the HEART (45.2%) and TIMI risk score (40.1%), (p <0.01, for both).

An Unusual Case of Left Atrial Mural Thrombus following Aortic Valve Replacement.

The left atrial thrombus is a well-known complication of atrial fibrillation and rheumatic mitral valve disease and carries a high risk for systemic thromboembolism. They are generally dissolved after a certain period of optimal anticoagulation. A large thrombus, on the other hand, may persist even with adequate anticoagulation. The surgical removal of a thrombus theoretically poses some risk of systemic embolization, making its management a clinical dilemma. Furthermore, a refractory thrombus is uncommon. Thus, an evidence-based guideline in selecting the optimal therapy is needed. We report a case of a 74-year-old male with atrial fibrillation and a history of unprovoked pulmonary embolism who was incidentally found to have a massive left atrial thrombus shortly after discontinuing warfarin about 4 months following bioprosthetic aortic valve replacement. The thrombus was refractory to anticoagulation posing a clinical management dilemma. This case is interesting in terms of presentation and the approach to diagnosis and treatment.

An Interesting Case and Literature Review of a Coronary Stent Fracture in a Current Generation Platinum Chromium Everolimus-Eluting Stent.

Coronary interventions are the mainstay of treatment for stenotic coronary vascular lesions. New stent designs are constantly being evaluated to improve stent performances and clinical outcomes. Coronary stent fracture is uncommon; however, it is associated with potential major consequences including acute coronary syndrome and the need for repeated target vessel revascularization due to in-stent restenosis or stent thrombosis. We report a case of a 66-year-old man with an extensive cardiac disease history, who presented with intractable angina and was found to have a fracture of a current generation, platinum chromium everolimus-eluting stent (Synergy, Boston Scientific Inc.).

A Case of Diffuse Alveolar Hemorrhage as a Possible Complication of Bivalirudin Therapy.

BACKGROUND Diffuse alveolar hemorrhage (DAH) is a rare but potentially fatal complication of anticoagulant or antiplatelet therapy. Bivalirudin is a specific and reversible direct thrombin inhibitor (DTI). CASE REPORT We report a case of severe DAH, possibly related to bivalirudin use, in a 61-year-old patient undergoing coronary intervention. The patient had presented with an out-of-hospital cardiac arrest due to acute ST elevation myocardial infarction (STEMI). During the coronary intervention, shortly after receiving bivalirudin, the patient started having frank bleeding from the endotracheal tube and developed hemodynamic compromise. Despite aggressive intervention and intensive care, the patient died. CONCLUSIONS At this time, to our knowledge, there have been no reports of DAH associated with the use of bivalirudin.

A classic case of arrhythmogenic right ventricular cardiomyopathy (ARVC) and literature review.

Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) is a relatively under-recognized hereditary cardiomyopathy. It is characterized pathologically by fibro-fatty infiltration of right ventricular (RV) myocardium and clinically by consequences of RV electrical instability. Timely intervention with device therapy and pharmacotherapy may help reduce the risk of arrhythmic events or sudden cardiac death. Here, we describe a classic case of a young adult with ARVC and a brief literature review. The patient presented with exertional palpitations and ARVC was suspected after his routine electrocardiogram (EKG) revealed symmetric T wave inversions and possible epsilon waves in right precordial leads. Subsequent work up showed fatty infiltration of RV myocardium on cardiac magnetic resonance imaging and inducible ventricular tachycardia from the right ventricle during electrophysiologic study. Those findings confirmed the diagnosis of ARVC and warranted treatment with implantable cardioverter defibrillator. It is always exciting to encounter rare pathological entities with classic clinical findings, especially when they present as a diagnostic challenge.We were able to provide correct diagnosis and management, thereby preventing the potentially lethal consequences. Therefore, it is important to recognize the possible EKG findings of ARVC and to know when to pursue further investigations and to implement therapies.

A Case of Cardiac Calcified Amorphous Tumor Presenting with Concomitant ST-Elevation Myocardial Infarction and Occipital Stroke and a Brief Review of the Literature.

Cardiac calcified amorphous tumor (CAT) is an extremely rare benign intracavitary tumor of the heart. It may mimic other cardiac tumors and can present with signs or symptoms of systemic embolization. There are limited data regarding CAT in the literature. We report a case of a 68-year-old woman with a cardiac CAT and mitral annular calcification (MAC), who presented with acute ST-elevation myocardial infarction (STEMI) and occipital stroke. After extensive review of the literature, we believe that this case is possibly the first description of a cardiac CAT presenting with STEMI. The CAT was surgically removed, and the diagnosis was confirmed by histology. The patient tolerated the surgery and reported no events at 6-month follow-up.

Gender differences in platelet aggregation in healthy individuals.

This study evaluated gender variability in platelet aggregation in response to common agonists. Platelet aggregation was measured in 36 healthy men and women free of any antiplatelet medication, aged 22-36 years, of Caucasian (White not of Hispanic origin), Hispanic, and African-American not of Hispanic origin. In this ex-vivo study, we investigated platelet aggregation in response to adenosine-5'-diphosphate (ADP), epinephrine (EPI), arachidonic acid (AA) and collagen (COL), using a platelet ionized calcium aggregometer (Chrono-Log Co.). Platelet aggregation response to all tested agonists was higher in females than in males regardless of ethnicity. The most significant differences were observed with collagen (P < 0.01). Among the ethnic groups, Caucasian women were most prone to platelet aggregation. Gender is a determinant of agonist effects on platelet aggregability in healthy subjects.

Plasma carboxy-terminal peptide of procollagen type I is an independent predictor of diastolic function in patients with advanced systolic heart failure.

Severe diastolic dysfunction has important clinical implications in advanced systolic heart failure. The authors investigated whether a marker of fibrosis, serum carboxy-terminal peptide of procollagen type I (PICP) is a major determinant of diastolic function in 40 patients with heart failure and ejection fraction <35%. Patients with unstable heart failure or ischemic symptoms were excluded. The authors found PICP to be an independent predictor of diastolic function in addition to age and pulmonary artery systolic pressure. The authors' findings suggest that studies evaluating whether therapy that improves myocardial fibrosis could have a favorable impact on diastolic function in this population are warranted.

Transient left ventricular apical ballooning during dobutamine myocardial perfusion imaging.

The transient left ventricular apical ballooning is characterized by wall motion abnormalities involving the apex in the absence of obstructive coronary disease. It is precipitated by acute emotional or physical stress and is most often reported in post-menopausal women. We report a case of transient left ventricular "apical ballooning" without significant coronary artery disease precipitated by high dose dobutamine infusion during pharmacological stress myocardial perfusion imaging. The unique feature of our case was precipitation by chemical stress rather than emotional/physical stress.

Role of free hemoglobin in 8-iso prostaglandin F2-alpha synthesis in chronic renal failure and its impact on CD163-Hb scavenger receptor and on coronary artery endothelium.

Free hemoglobin (Hb) during autoxidation increases 8-iso-prostaglandin-F2-alpha (8-isoprostane) formation in vitro. Because 8-isoprostane and plasma Hb are elevated in chronic renal failure (CRF), we evaluated the role of Hb in this isoprostane synthesis in vivo. By monitoring correlations between Hb, haptoglobin (Hp), CD163-Hb-scavenger receptor, and 8-isoprostane that is known to induce CD163 shedding, we examined whether 8-isoprostane blocks Hb catabolism in CRF. Additionally, by studying the effect of 8-isoprostane on human coronary artery endothelium (HCAEC) in vitro and its impact on intercellular adhesion molecule-1 (ICAM-1) in vivo, we tested its role in promotion of cardiovascular events in CRF. Twenty-two never-dialyzed CRF patients and 18 control patients were screened for renal function, plasma and urine 8-isoprostane, and plasma Hb, Hp, thiobarbituric-acid-reactants (TBARS), C-reactive-protein (CRP), and soluble (s) ICAM-1 and sCD163. HCAEC exposed to 8-isoprostane were tested for ICAM-1 and apoptosis. In CRF, urine 8-isoprostane was significantly elevated and correlated with free-Hb and TBARS. The increased free-Hb, Hp, and sCD163 in CRF suggested 8-isoprostane-mediated suppression of Hb catabolism through CD163 receptor shedding. 8-Isoprostane enhanced ICAM-1 expression and apoptosis in HCAEC. CRF patients showed elevated sICAM-1. In conclusion, free-Hb, via 8-isoprostane, paradoxically blocks its own catabolism. Free-Hb and/or 8-isoprostane may intensify cardiovascular events in CRF.

Diastolic heart failure in the elderly and the potential role of aldosterone antagonists.

The overall incidence of heart failure increases with age, affecting up to 10% of people >65 years of age. Diastolic heart failure is also age-dependent, increasing from <15% in middle-aged patients to >40% in patients > or =70 years of age. Elderly patients usually have other co-morbid conditions such as hypertension, diabetes mellitus, coronary artery disease and atrial fibrillation that can adversely affect the diastolic properties of the heart. The clinical manifestations of diastolic heart failure are similar to those of systolic heart failure. In practice, the diagnosis is generally based on the finding of typical symptoms and signs of heart failure with preserved left ventricular ejection fraction and no valvular abnormalities on echocardiography. Altered ventricular relaxation and abnormal ventricular filling are the hallmarks of diastolic heart failure. Cardiac fibrosis and cellular disarray lead to the alterations in the diastolic properties of the heart. Diffuse foci of fibrosis in the myocardium have been reported with advancing age. Aldosterone has been shown to play a crucial role in the development of cardiac fibrosis via a direct effect on the mineralocorticoid receptors within the myocardium. Unlike the situation with treatment of systolic heart failure, few clinical trials are available to guide the management of patients with diastolic heart failure. In the absence of controlled clinical trials, patient management is based on control of the physiological factors (blood pressure, heart rate, blood volume and myocardial ischaemia) that are known to exert important effects on ventricular relaxation. Aldosterone antagonists inhibit the deposition of collagen matrix in the myocardium, thereby targeting the basic pathophysiological mechanism of diastolic dysfunction. Thus, they appear to represent a promising therapeutic approach for this condition. Currently, only small clinical trials supporting this therapy are available and large clinical trials evaluating long-term outcomes in diastolic dysfunction are therefore needed.

Elevated carboxy-terminal peptide of procollagen type I in elderly patients with diastolic dysfunction.

BACKGROUND: Diastolic dysfunction (DD) is common in elderly people. Myocardial fibrosis is a major determinant of diastolic function. Increased myocardial fibrosis has been observed with advancing age. We hypothesized that plasma levels of carboxy-terminal peptide of procollagen type I (PICP), a marker of fibrosis, is elevated in elderly subjects with DD compared to healthy control subjects. METHODS: PICP levels were measured in 29 elderly subjects with DD and 25 healthy control subjects. The relationship between PICP levels and age, gender, hypertension, and the presence of left ventricular hypertrophy were then assessed. RESULTS: PICP levels were significantly higher in elderly subjects with DD than in healthy control subjects (301.0 +/- 52.0 vs. 262.9 +/- 45.3 ng/mL; P = .006). PICP levels were higher in elderly with DD regardless of the presence of left ventricular hypertrophy. Additionally, PICP levels were not found to correlate with age. CONCLUSIONS: PICP levels are elevated in elderly people with DD. PICP may be a useful marker to determine the level of fibrotic activity in this population.

Spironolactone improves diastolic function in the elderly.

BACKGROUND: Diastolic dysfunction is common in the elderly. Increased myocardial fibrosis, a major determinant of diastolic function, has been observed with advancing age. Spironolactone prevents age-related increases in myocardial fibrosis in old normotensive rats. HYPOTHESIS: Spironolactone, via its antifibrotic activity, can improve diastolic function in the elderly with isolated diastolic dysfunction. METHODS: The study was a prospective, double-blind, randomized, placebo-controlled trial. Thirty elderly subjects between 60 and 85 years of age with isolated diastolic dysfunction and no contraindications for spironolactone were randomized to 25 mg/day of spironolactone or placebo for 4 months. Mitral E/A and deceleration time, plasma levels of carboxy-terminal of procollagen type I (PICP), and brain natriuretic peptide (BNP) were measured at baseline and at the end of 4 months. Plasma level of potassium was also monitored to prevent clinically significant hyperkalemia. RESULTS: There was no serious adverse event or clinically significant hyperkalemia in the spironolactone group. Compared with baseline values, spironolactone significantly improved mitral E/A ratio (0.71 +/- 0.08 vs. 0.84 +/- 0.19, p = 0.025) and deceleration time (285.5 +/- 73.1 vs. 230.0 +/- 54.7, p = 0.035). There were no significant differences in the magnitude of change in the levels of PICP and BNP between the two treatment groups. CONCLUSION: Spironolactone may improve diastolic function in the elderly.

Troponin I elevation in a patient with acute severe bronchospasm.

Right ventricular strain is a source of troponin elevation in some patients with acute pulmonary embolism. Acute and/or severe obstructive airway disease could lead to a sudden increase in pulmonary arterial pressure and right ventricular afterload. We report a case of troponin I elevation in a 40-year-old woman who presented with acute severe bronchospasm and had a negative evaluation for coronary artery disease.

Brain natriuretic peptide and diastolic dysfunction in the elderly: influence of gender.

Diastolic heart failure is common in the elderly, particularly women. Previous studies on the value of brain natriuretic peptide in diastolic dysfunction have been largely limited to male subjects. The authors found that female gender, in addition to diastolic function, is an independent predictor of brain natriuretic peptide levels in the elderly without systolic ventricular dysfunction. The authors' data indicate that an optimal threshold of brain natriuretic peptide for detecting diastolic dysfunction should be gender-specific.

Common causes of troponin elevations in the absence of acute myocardial infarction: incidence and clinical significance.

Cardiac troponin is a preferred biomarker of acute myocardial infarction (MI). Unfortunately, elevation of troponin can be detected in a variety of conditions other than acute MI. This review focuses on the incidence and clinical significance of increased troponin in conditions commonly associated with troponin elevations, particularly in those that may resemble acute MI.