Low Skeletal Muscle Mass Independently Predicts Mortality in Patients with Chronic Heart Failure after an Acute Hospitalization.

BACKGROUND: Heart failure (HF) is a syndrome associated with exercise intolerance, and its symptoms are more common in patients with low skeletal muscle mass (SMM). Estimation of muscle mass can be cumbersome and unreliable, particularly in patients with varying body weight. The psoas muscle area (PMA) can be used as a surrogate of sarcopenia and has been associated with poor outcomes in other populations. OBJECTIVES: The aim of this study was to assess if sarcopenia is associated with the survival of patients with HF after an acute hospitalization. METHOD: We retrospectively studied a cohort of 160 patients with HF who had abdominopelvic computed tomography during an acute hospitalization. We obtained standardized measurements of their PMA and defined sarcopenia as the lowest gender-based tertile of the said area. The patients were followed until death or discontinuation of care. We used Kaplan-Meier estimates and Cox regression analysis to assess the relationship between sarcopenia and all-cause mortality. RESULTS: We found that the 52 patients with sarcopenia had 4.5 times the risk of all-cause mortality at 1 year compared to the rest of the cohort (CI 1.784-11.765; p = 0.0016) after adjusting for significant covariates. Stratification by age and sex revealed that this association could be limited to males and patients < 75 years old. CONCLUSION: The PMA, used as a surrogate of low SMM, is independently associated with an increased risk of late mortality after an acute hospitalization in patients with HF.

Gastrocardiac syndrome: A forgotten entity.

Symptomatic bradycardia due to gastric distension is a rarely reported entity in the field of medicine. The mechanism of gastrointestinal distention that contributes to bradycardia is complex. A 75-year-old female with recurrent episodes of dizziness in the setting of gastric distension was found to have severe sinus bradycardia which resolved upon resolution of gastric distension. No structural or functional abnormality of heart was found. The patient was treated with permanent pacemaker implantation due to recurrent episodes of dizziness in the setting of sinus bradycardia.

When a seizure is not a real seizure!

We report here 2 cases of methadone induced Torsades de Pointes with a clinical presentation mimicking convulsive seizures in a substance abuser. These cases highlight the importance of being aware of methadone-induced Torsades de Pointes and the occasional atypical clinical presentations of this condition.

Looking at diabetic ketoacidosis through electrocardiogram window!

BACKGROUND: Initial serum potassium (K+) in diabetic ketoacidosis (DKA) often does not reflect the true amount of total body K+ storage, and it is not a good predictor of subsequent hypokalemia. In this study, we tested the hypothesis that a deficiency of the total body K+ storage can be detected initially on surface electrocardiography (ECG). METHOD: Medical records of 350 patients with a diagnosis of DKA were reviewed. Data regarding serial basic metabolic panels, arterial blood gases, serum ketones, and total K+ replacement that patient received during admission were collected. We compared biochemical findings for patients with and without QTU corrected (QTUc) prolongation by using the t test. Patients who were taking medications known to affect QTUc or cause ST-T changes were excluded. RESULTS: After exclusion criteria, 61 patients were enrolled in this study. In 38 patients (62.9%), QTUc was more than or equal to 450 milliseconds. Patients with prolonged QTc received statistically more K+ supplementation during admission (P = .014). They also had lower serum K+ level during their hospital course (P = .002) compared to patients with normal QTUc intervals. No significant difference was found between initial serum K+, calcium, glucose, anion gap, acidosis, age, or heart rate between these 2 groups. CONCLUSION: The significant relationship between K+ depletion and the ECG changes observed in this study deserves further consideration. Our findings confirm the concept that the ECG is an easy and reliable tool for early diagnosis of hypokalemia in patients with DKA.

New oral anticoagulants in patients with cancer: current state of evidence.

Effectiveness of new oral anticoagulants (NOAC) in patients with cancer is not clearly defined. There remain concerns of doubtful benefit and chances of potential harm with newer agents. In this meta-analysis, we evaluated the efficacy and safety of NOAC in patients with cancer. PubMed, Cochrane Library, EMBASE, Web of Science, and CINAHL databases were searched from January 01, 2001 through February 28, 2013. Randomized controlled trials reporting efficacy and safety data of NOACs (rivaroxaban, dabigatran, and apixaban) with control (low-molecular-weight heparin/vitamin K antagonists/placebo) for patients with cancer were included. Primary efficacy outcome was venous thromboembolism (VTE) or VTE-related death, and primary safety outcome was clinically relevant bleeding. We used random-effects models. Six trials randomized 19,832 patients, and 1197 patients had cancer. Risk of VTE or VTE-related death was not significantly different with NOAC versus control [odds ratio (OR), 0.80; 95% confidence interval (CI), 0.39-1.65] in patients with cancer. Separate analysis for individual effects showed similar results for rivaroxaban (OR, 1.08; 95% CI, 0.60-1.94) and dabigatran (OR, 0.91; 95% CI, 0.21-3.91). Clinically relevant bleeding was not higher with NOAC compared with control (OR, 1.49; 95% CI, 0.82-2.71); individual effect of rivaroxaban showed similar results. No statistically significant difference of efficacy and safety with NOAC was found between patients with and without cancer. Rivaroxaban might be equally effective and safe as vitamin K antagonist in patients with cancer. Dabigatran is as effective as comparator; however, safety profile of dabigatran is unknown. Randomized trials of new anticoagulants specific to the cancer population are necessary, and NOAC also need to be evaluated against low-molecular-weight heparin.

Hazards with ordering troponin in patients with low pretest probability of acute coronary syndrome.

BACKGROUND: In clinical practice, we progressively rely on biomarkers, without estimating the pretest probability. There is not enough support for the use of cardiac troponin (cTn) I in the management of noncardiac patients. We studied the rate at which this test was ordered, the prevalence of detection of a positive result in noncardiac patients, and the impact of this incidental finding on clinical management. METHODOLOGY: Patients admitted from December 2011 to 2013 to our community hospital with diagnosis of noncardiac disease who had positive cTn were included. Data collected included final diagnosis, patient disposition, cardiac monitoring, cardiology consult, and cardiac biomarker testing. RESULTS: Cardiac troponin I was ordered for 1700 patients in our emergency department. Seven hundred fifty patients had a positive cTn. Of the 750 patients, 412 had a positive cTn without any clinical suspicion of an acute coronary syndrome. An incidental finding of a positive cTn leads to ordering of cTn on average 4 times during admission, cardiac monitoring of 379 (91.99%) patients for at least 1 day, and a cardiac consultation for 268 (63.65%) of these patients. None of these patients was candidates for an invasive cardiac intervention. Seventy-eight (19.17%) patients were admitted to the cardiac care unit and subsequently transferred to the medical intensive care unit. CONCLUSIONS: A positive cTn in patients diagnosed with a nonacute coronary syndrome was associated with increased cardiac biomarker testing, telemetry monitoring, and cardiology consults. This study supports adherence to national guidelines for the use of cTn, to reduce hospital cost and resource utilization.

Cangrelor for patients undergoing percutaneous coronary intervention: evidence from a meta-analysis of randomized trials.

Cangrelor is a new parenteral adenosine diphosphate P2Y12 receptor inhibitor with rapid, profound and reversible inhibition of platelet activity. The aim of this meta-analysis was to evaluate efficacy and safety of this new agent in patients undergoing percutaneous coronary intervention (PCI). We searched PubMed, Cochrane Library, EMBASE, Web of Science and CINAHL databases from the inception through April 2013. Randomized controlled trials (RCTs) comparing cangrelor with control (clopidogrel/placebo) were selected. We used the random-effects models to calculate the risk ratio. The primary efficacy outcome was risk of myocardial infarction, and the primary safety outcome was TIMI major bleeding at 48 h. Three RCTs included a total of 25,107 participants. Effects of Cangrelor were not different against comparators for myocardial infarction (MI) (Risk ratio [RR] 0.94, 95% confidence interval [CI] 0.78-1.13) and all-cause mortality (RR 0.72, 95% CI 0.36-1.43). However, cangrelor significantly reduced the risk of ischemia-driven revascularization (RR 0.72, 95% CI 0.52-0.98), stent thrombosis (RR 0.60, 95% CI 0.44-0.82) and Q wave MI (RR 0.53, 95% CI 0.30-0.92) without causing extra major bleeding (Thrombolysis in Myocardial infarction criteria) and severe or life-threatening bleeding (Global utilization of streptokinase and tissue plasminogen activator for occluded coronary arteries criteria). Separate analysis against only clopidogrel also showed similar findings except Q wave MI outcome. Use of cangrelor during PCI might reduce the risk of ischemia-driven revascularization and stent thrombosis, without causing extra major bleeding.

The Impact of Cocaine Use and the Obesity Paradox in Patients With Heart Failure With Reduced Ejection Fraction Due to Non-ischemic Cardiomyopathy.

Background Obesity and illicit drugs are independent risk factors for developing heart failure (HF). However, recent studies have suggested that patients who already have HF and are obese have better clinical outcomes. We aim to study the effect of cocaine use on this obesity paradox phenomenon as it pertains to HF readmissions. Methodology In a retrospective chart analysis, we reviewed patients with a diagnosis of HF with reduced ejection fraction (HFrEF) admitted to Metropolitan Hospital in New York. We studied the association between body mass index (BMI) categories, namely, non-obese (<30 kg/m2) and obese (≥30 kg/m2), cocaine use, and the primary outcome (time to readmission for HF within 30 days after discharge). The interaction between cocaine and obesity status and its association with the primary outcome was also assessed. Results A total of 261 patients were identified. Non-obese status and cocaine use were associated with an increased hazard of readmission in 30 days (hazard ratio (HR) = 2.28, p = 0.049 and HR = 3.12, p = 0.004, respectively). Furthermore, cocaine users who were non-obese were over six times more likely to be re-admitted in 30 days compared to non-cocaine users who were obese (HR = 6.45, p = 0.0002). Conclusions Non-obese status and continued use of cocaine have a negative additive effect in impacting HF readmissions.

Lyme Carditis: A Reversible Cause of Acquired Third-Degree AV Block.

BACKGROUND Lyme borreliosis, caused by spirochetes of the Borrelia burgdorferi genospecies complex, is the most commonly reported tickborne infection in North America and those infected may present with cutaneous, cardiac, articular, and neuropsychiatric abnormalities. The protean nature of many of its clinical manifestations presents a diagnostic conundrum. Lyme disease can affect the heart, albeit rarely, with cardiac abnormalities usually manifesting as varying degrees of heart block or arrhythmias. CASE REPORT We present a case of complete heart block in a young man who participated in outdoor activities in a Lyme-endemic area and developed fatigue and palpitations weeks after a flu-like illness. He noticed that his heart rate was low; he had an intermediate suspicious index in Lyme carditis (SILC) score with positive Lyme serologies. His initial electrocardiogram when he presented to the emergency department showed a complete heart block. In this case, he was successfully managed with intravenous ceftriaxone, amoxicillin, and a transcutaneous pacemaker, obviating the need for a permanent pacemaker. CONCLUSIONS Electrocardiographic changes such as heart block and arrhythmias with or without symptoms may be the initial manifestation of Lyme carditis in a patient who may or may not remember a tick bite or have a typical skin rash. The SILC score may assist in recognizing these cases and prompt initiation of antibiotics usually leads to the resolution of these electrocardiographic abnormalities and symptoms that may be present.

A 61-Year-Old Man with SARS-CoV-2 Infection and Venous Thrombosis Presenting with Painful Swelling and Gangrene of the Lower Limb Consistent with Phlegmasia Cerulea Dolens.

BACKGROUND Coronavirus disease 2019 (COVID-19) is a novel infectious disease with an evolving understanding of its clinical manifestations, complications, and therapeutic implications. Thromboembolic disease and coagulopathy are common and have been seen in COVID-19 patients. Phlegmasia cerulea dolens had been reported in previous cases associated with malignancy which is a known cause of a procoagulable state. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may also induce a procoagulable state and be associated with PCD. CASE REPORT A 61-year-old man presented with a painful, swollen limb and gangrene, findings consistent with a diagnosis of PCD due to venous thrombosis. The patient tested positive for SARS-CoV-2 infection after a nasopharyngeal swab sample using the XPRSARS-COV2-10 reverse transcription polymerase chain reaction kit. He had bilateral leg swelling with a gangrenous left fourth digit in the presence of a palpable peripheral pulse. His venous duplex showed bilateral acute deep venous thrombosis, whereas his arterial Doppler scan was normal and his skin biopsy was negative for vasculitis. One of our screening blood tests was suggestive of an antiphospholipid-like syndrome. These clinical and radiologic findings were consistent with PCD. This patient was promptly anticoagulated; other supportive treatments were also initiated. He had a significant resolution of his pedal swelling with the associated revitalization of his previously gangrenous toe. CONCLUSIONS This case report shows the importance of testing for SARS-CoV-2 infection in patients who present with unusual thrombotic symptoms and signs and highlights the potential severity of these thrombotic complications.

Beta Blocker Therapy in Heart Failure Patients with Active Cocaine Use: A Systematic Review.

BACKGROUND: Cocaine use is associated with multiple cardiovascular complications including heart failure. The use of different types of beta blockers in heart failure patients with active cocaine use is still a matter of debate. In this review, our objective is to systematically review the available literature regarding the use of beta blockers in the treatment of heart failure patients with concurrent cocaine use. METHODS: PubMed, EMBASE, Web of Science, and Clinical Trials.gov were searched from inception to March 2019 using the Medical Subject Headings (MeSH) terms "cocaine", "heart failure", "beta blocker," and "cardiomyopathy". Only studies containing the outcomes of heart failure patients with active cocaine use who were treated with beta blockers were included. RESULTS: The search resulted in 2072 articles out of which 12 were finally included in the review. A total number of participants were 1994 with a median sample size of 111. Most of the studies were retrospective in nature with Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence from 3 to 5. The main primary outcomes included readmission rates, mortality, left ventricular ejection fraction (LVEF) improvement, New York Heart Association (NYHA) functional class, and major adverse cardiovascular events (MACEs). In the studies analyzed, beta blockers were found to have either a beneficial or a neutral effect on primary outcomes in heart failure patients with active cocaine use. CONCLUSION: The use of beta blocker therapy appears to be safe and beneficial in heart failure patients with active cocaine use, although the evidence is not robust. Furthermore, large-scale studies are required to confirm this finding.

Rare Association of Takotsubo Cardiomyopathy with Right Bundle Branch Block in the Dual Setting of Asthma Exacerbation and Psychiatric Illness.

BACKGROUND Takotsubo cardiomyopathy is characterized by a transient left ventricular dysfunction without obstructive coronary artery disease that mimics an acute myocardial infarction. The electrocardiogram findings of Takotsubo cardiomyopathy usually present with ST-segment elevation or depression, T-wave inversion, left bundle branch block or high-grade atrioventricular block. CASE REPORT This is a report of a case of a 58-year-old male diagnosed with Takotsubo cardiomyopathy that occurred in the setting of an acute asthma exacerbation and psychiatric exacerbation with novel electrocardiogram findings of right bundle branch block. Transthoracic echocardiogram showed a preserved ejection fraction with left ventricular apical ballooning and hyperkinesis of the basal segments. The nuclear stress test showed a fixed perfusion defect at the apical segment, but the patient refused further testing such as coronary angiography. The patient was managed medically, and a repeat echocardiogram done after 8 weeks from discharge showed a complete resolution of the apical ballooning. CONCLUSIONS It is important to recognize that patients with psychiatric illness and asthma exacerbation are predisposed to develop Takotsubo cardiomyopathy. It is also reasonable to suspect Takotsubo cardiomyopathy in the presence of new electrocardiogram findings aside from those typically seen in acute myocardial infarction, especially if it is associated with apical ballooning.

Heart Failure and Cognitive Impairment: Clinical Relevance and Therapeutic Considerations.

Heart failure (HF) is a devastating condition characterized by poor quality of life, numerous complications, high rate of readmission and increased mortality. HF is the most common cause of hospitalization in the United States especially among people over the age of 64 years. The number of people grappling with the ill effects of HF is on the rise as the number of people living to an old age is also on the increase. Several factors have been attributed to these high readmission and mortality rates among which are; poor adherence with therapy, inability to keep up with clinic appointments and even failure to recognize early symptoms of HF deterioration which may be a result of cognitive impairment. Therefore, this review seeks to compile the most recent information about the links between HF and dementia or cognitive impairment. We also assessed the prognostic consequences of cognitive impairment complicating HF, therapeutic strategies among patients with HF and focus on future areas of research that would reduce the prevalence of cognitive impairment, reduce its severity and also ameliorate the effect of cognitive impairment coexisting with HF.

Prognostic Utility of Troponin I and N Terminal-ProBNP among Patients with Heart Failure due to Non-Ischemic Cardiomyopathy and Important Correlations.

BACKGROUND: Heart Failure (HF) is accompanied by a high cost of care and gloomy prognosis despite recent advances in its management. Therefore, efforts to minimize HF rehospitalizations is a major focus of several studies. METHODS: We conducted a retrospective cohort study of 140 patients 18 years and above who had baseline clinical parameters, echocardiography, NT-ProBNP, troponin I and other laboratory parameters following a 3-year electronic medical record review. Patients with coronary artery disease, preserved ejection fraction, pulmonary embolism, cancer, and end-stage renal disease were excluded. RESULTS: Of the 140 patients admitted with HF with reduced Ejection Fraction (HFrEF) secondary to non-ischemic cardiomyopathy, 15 were re-hospitalized within 30 days of discharge while 42 were rehospitalized within 6 months after discharge for decompensated HF. Receiver operating characteristic (ROC) cutoff points were obtained for NT-ProBNP at 5178 pg/ml and serum troponin I at 0.045 ng/ml. After Cox regression analysis, patients with HFrEF who had higher hemoglobin levels had reduced odds of re-hospitalization (p = 0.007) within 30 days after discharge. NT-ProBNP and troponin I were independent predictors of re-hospitalization at 6 months after discharge (p = 0.047 and p = 0.02), respectively, after Cox regression analysis. CONCLUSION: Troponin I and NT-ProBNP at admission are the best predictors of re-hospitalization 6 months after discharge among patients with HFrEF. Hemoglobin is the only predictor of 30 -day rehospitalization among HFrEF patients in this study. High-risk patients may require aggressive therapy to improve outcomes.

The relevance of serum albumin among elderly patients with acute decompensated heart failure.

OBJECTIVE: To assess the prognostic utility of serum albumin among elderly patients admitted for acute decompensated heart failure (ADHF) in terms of all-cause mortality and also to identify the predictors of hypoalbuminemia. METHODS: Retrospective cohort study of 119 elderly patients admitted for ADHF. Elderly patients were defined as patients over the age of 65 years. The patients were followed up for approximately 11 years. Patients with advanced renal failure, liver disease not due to HF, cancer and other causes of low life expectancy were excluded. Hypoalbuminemia was defined as serum albumin ≤ 2.9 g/dL. RESULTS: The study was made up of 65 females and 54 males with age ranging from 65 to 96 years. Of the 119 elderly patients with ADHF, there were 26 deaths. A significantly higher proportion of patients in the mortality group had an admission serum albumin level of ≤ 2.9 g/dL than those surviving (P = 0.011). After Cox's logistic regression, low albumin (P = 0.016), elevated direct bilirubin (P = 0.03), age greater than 85 (P = 0.008), lack of use of beta blockers (P = 0.0001) and left ventricular ejection fraction less than 35% (P = 0.005) increased the risk of death. Elevated serum creatinine (P = 0.0357) was the only predictor of hypoalbuminemia following multiple linear regression. CONCLUSIONS: Hypoalbuminemia may be an unrecognized marker of death in elderly patients with ADHF.