Acute Myopericarditis as the First Manifestation of Familial Mediterranean Fever: A Case Report.

Familial Mediterranean fever (FMF) is an autoinflammatory disorder, characterized by recurrent episodes of fever and polyserositis, and usually presents during the first two decades of life. Acute pericarditis is a rare manifestation of FMF and typically presents with other symptoms of the inflammatory disorder. A 27-year-old Arabian male presented to our hospital with pleuritic chest pain and shortness of breath while lying flat. His electrocardiogram showed changes suggestive of pericarditis, and his inflammatory markers and troponin were raised. His echocardiogram revealed a moderate-sized pericardial effusion with septa and a normal left ventricular function. He had a strong family history of FMF and consanguinity of the parents. He was treated for acute myopericarditis with colchicine and ibuprofen, and his symptoms improved gradually along with his inflammatory markers and troponin. Six weeks after discharge, he had a cardiac MRI, which revealed a thickened pericardium with profound enhancement (features suggestive of pericarditis) and no signs of myocarditis. He was asymptomatic, and his markers and troponin were within the normal range. His colchicine medication was continued indefinitely, and he was referred to a tertiary care hospital with a specialized periodic fever clinic for follow-up and genotype testing.

Hypertensive Subjects are More Likely to Develop Coronary Artery Lesions: A Study by Computerised Tomography Coronary Angiography.

Coronary Computed Tomography Angiography (CCTA) is commonly used to identify coronary artery disease. In this study, the indications for CCTA referrals are reviewed, to identify the strongest predictors of CAD, as seen on CCTA. A retrospective study, reviewing the electronic health records of consecutive patients who underwent CCTA between July and November 2020 at our Trust, was conducted. A total of 485 patient reports were reviewed. Of patients with moderate-to-severe CAD, 128 (73.6%) were hypertensive. Of those with severe CAD, 79 patients (76%) were hypertensive. Univariate analysis for comparison of patients with absent (n = 219), mild (n = 92), moderate (n = 70) and severe (n = 104) CAD revealed that hypertension (P < .001), diabetes mellitus (P < .001), gender (P < .001), dyslipidemia (P < .001) and smoking (P = .006), were each significantly associated with the presence of CAD on CCTA. However, multiple logistic regression analysis confirmed that hypertension has the strongest association with CAD (OR = 2.22, P < .001) Furthermore, the presence of typical chest pain in hypertensive patients was strongly associated with significant CAD, on CCTA. Among all risk factors, hypertension is the strongest independent predictor for the presence of CAD on CCTA. These results suggest that hypertension is a significant factor when considering referral for CCTA, particularly when associated with chest pain.

False-negative RT-PCR for COVID-19 and a diagnostic risk score: a retrospective cohort study among patients admitted to hospital.

OBJECTIVE: To describe the characteristics and outcomes of patients with a clinical diagnosis of COVID-19 and false-negative SARS-CoV-2 reverse transcription-PCR (RT-PCR), and develop and internally validate a diagnostic risk score to predict risk of COVID-19 (including RT-PCR-negative COVID-19) among medical admissions. DESIGN: Retrospective cohort study. SETTING: Two hospitals within an acute NHS Trust in London, UK. PARTICIPANTS: All patients admitted to medical wards between 2 March and 3 May 2020. OUTCOMES: Main outcomes were diagnosis of COVID-19, SARS-CoV-2 RT-PCR results, sensitivity of SARS-CoV-2 RT-PCR and mortality during hospital admission. For the diagnostic risk score, we report discrimination, calibration and diagnostic accuracy of the model and simplified risk score and internal validation. RESULTS: 4008 patients were admitted between 2 March and 3 May 2020. 1792 patients (44.8%) were diagnosed with COVID-19, of whom 1391 were SARS-CoV-2 RT-PCR positive and 283 had only negative RT-PCRs. Compared with a clinical reference standard, sensitivity of RT-PCR in hospital patients was 83.1% (95% CI 81.2%-84.8%). Broadly, patients with false-negative RT-PCR COVID-19 and those confirmed by positive PCR had similar demographic and clinical characteristics but lower risk of intensive care unit admission and lower in-hospital mortality (adjusted OR 0.41, 95% CI 0.27-0.61). A simple diagnostic risk score comprising of age, sex, ethnicity, cough, fever or shortness of breath, National Early Warning Score 2, C reactive protein and chest radiograph appearance had moderate discrimination (area under the receiver-operator curve 0.83, 95% CI 0.82 to 0.85), good calibration and was internally validated. CONCLUSION: RT-PCR-negative COVID-19 is common and is associated with lower mortality despite similar presentation. Diagnostic risk scores could potentially help triage patients requiring admission but need external validation.

Prevalence of obstructive coronary artery disease and prognosis in patients with stable symptoms and a zero-coronary calcium score.

AIMS: CT calcium scoring (CTCS) and CT cardiac angiography (CTCA) are widely used in patients with stable chest pain to exclude significant coronary artery disease (CAD). We aimed to resolve uncertainty about the prevalence of obstructive coronary artery disease and long-term outcomes in patients with a zero-calcium score (ZCS). METHODS AND RESULTS: Consecutive patients with stable cardiac symptoms referred for CTCS or CTCS and CTCA from chest pain clinics to a tertiary cardiothoracic centre were prospectively enrolled. In those with a ZCS, the prevalence of obstructive CAD on CTCA was determined. A follow-up for all-cause mortality was obtained from the NHS tracer service. A total of 3914 patients underwent CTCS of whom 2730 (69.7%) also had a CTCA. Half of the patients were men (50.3%) with a mean age of 56.9 years. Among patients who had both procedures, a ZCS was present in 52.2%, with a negative predictive value of 99.5% for excluding ≥70% stenosis on CTCA. During a mean follow-up of 5.2 years, the annual event rate was 0.3% for those with ZCS compared with 1.2% for CS ≥1. The presence of non-calcified atheroma on CTCA in patients with ZCS did not affect the prognostic value (P = 0.98). CONCLUSION: In patients with stable symptoms and a ZCS, obstructive CAD is rare, and prognosis over the long-term is excellent, regardless of whether non-calcified atheroma is identified. A ZCS could reliably be used as a 'gatekeeper' in this patient cohort, obviating the need for further more expensive tests.

Diagnostic accuracy of cardiothoracic ratio on admission chest radiography to detect left or right ventricular systolic dysfunction: a retrospective study.

OBJECTIVES: To determine the diagnostic accuracy of the cardiothoracic ratio on postero-anterior or antero-posterior chest radiographs in predicting left ventricular or right ventricular dysfunction on echocardiography in an inpatient population. DESIGN: Retrospective study. SETTING: Two secondary care hospitals in the United Kingdom. PARTICIPANTS: Four hundred consecutive inpatient echocardiograms were screened for inclusion along with chest radiographs (both postero-anterior and antero-posterior). The cardiothoracic ratio was calculated from chest radiographs along with quantitative and qualitative measures of left ventricular or right ventricular dysfunction on echocardiography. MAIN OUTCOME MEASURES: Sensitivity and specificity of cardiothoracic ratio across a range of values to detect moderate/severe left ventricular and/or right ventricular dysfunction on echocardiography. RESULTS: Overall, 272 records met inclusion criteria. The prevalence of left ventricular/right ventricular dysfunction on echocardiography was 26% in an inpatient population with high clinical suspicion of cardiac disease referred for echocardiography. Over a range of cardiothoracic ratio values on postero-anterior films, a value of >0.55 yielded the best sensitivity (62.5%) and specificity (76.5%) for diagnosing left ventricular/right ventricular impairment (positive likelihood ratio 2.56), with a positive predictive value of 29.5%. Cardiothoracic ratio on antero-posterior film was not predictive of left ventricular/right ventricular impairment on echocardiography. CONCLUSIONS: In conclusion, in the context of an acute admission, cardiothoracic ratio measured on postero-anterior or antero-posterior films has limited value in detecting moderate left ventricular and/or right ventricular systolic dysfunction. Previously established absolute values may be unreliable by modern standards.