Spontaneous Coronary Artery Dissection With Systemic Lupus Erythematosus.

Background: Spontaneous coronary artery dissection (SCAD) has been reported to be a rare cause of acute coronary syndrome and sudden cardiac death. The clinical presentation of SCAD varies from asymptomatic to sudden death. Pregnancy is associated with SCAD, and autoimmune diseases, especially systemic lupus erythematosus (SLE), may play an important role in SCAD etiology. Case Report: A 37-year-old female with hypertension, SLE, a history of preeclampsia with 3 cesarean deliveries, and an active smoking habit presented to the emergency department with chest pain. On arrival, the patient was hypertensive with blood pressure of 152/122 mm Hg and a normal heart rate and respiratory rate. Given the patient's history of SLE and preeclampsia, antiphospholipid antibodies were tested. The anti-ß2-glycoprotein 1 immunoglobulin G concentration was elevated at 30 U/mL, and lupus anticoagulant was positive. Electrocardiogram showed minimum ST elevation in lead V2. Initial troponin was 0.1 ng/mL, with a peak of 54.5 ng/mL after 6 hours. Aspirin 325 mg was administered, and the patient underwent urgent cardiac catheterization. Intravascular angiography showed evidence of intimal flap (mid left anterior descending artery) spontaneous dissection with subintimal hematoma. The angioplasty resulted in successful stent placement in the mid left anterior descending artery. Conclusion: SCAD diagnosis is challenging and requires a high index of suspicion. This case shows the challenge of early diagnosis of SCAD and highlights its association with autoimmune diseases, specifically SLE. Early recognition of this pathology results in better outcomes.

Partial Anomalous Pulmonary Venous Return in Adults.

Partial anomalous pulmonary venous return (PAPVR) is a spectrum of congenital cardiovascular abnormalities. It is most commonly found as an incidental finding. However, it can lead to severe pulmonary hypertension depending on the magnitude of the shunt involved. We report a case of a 60-year-old female patient with PAPVR detected incidentally on imaging. We aim to highlight the incidence of PAPVR in adults and to elaborate on its unique association with a duplicated superior vena cava.

Sjogren Syndrome-Associated Autonomic Neuropathy.

Sjogren syndrome (SS) is one of the common autoimmune diseases characterized by dryness of the eyes and mouth described as "xerophthalmia" and "xerostomia," respectively. Affected patients may also experience complex neurological symptoms characterized by extremity paresthesia and pain as well as dizziness and presyncope. In fact, patients may present initially with pure neurological symptoms. Thus, the diagnosis of SS remains a clinical challenge. We report a case here of a patient with primary Sjogren syndrome (pSS) experiencing severe autonomic neuropathy symptoms. A 53-year-old female patient diagnosed with pSS at the age of 30 years presented with a four-month history of palpitations and dizziness. A tilt table test showed positive findings with significant symptomatic orthostatic hypotension. The patient was started on midodrine therapy followed by a beta-blocker with improvement in her symptoms. There was also augmentation of her SS disease management by introducing IV IgG therapy.  The diagnosis of neuropathy in SS is complex and requires a combination of clinical signs and symptoms. This case report focuses on the neurological manifestations of SS, especially the ones related to autonomic neuropathy. We aim to share awareness of the neurological manifestations of patients with pSS and alert physicians that it could be the initial presentation of this systemic disease.

Isolated Right Ventricular Air Embolism.

Vascular air embolism (VAE) is an uncommon but potentially life-threatening event often associated with various procedures and diagnostic tests. Understanding this challenging incident will enable physicians to evaluate, diagnose and manage this incident successfully. We present a case of a 73-year-old male who developed air in the right ventricle after intravenous contrast-enhanced computed tomography (CT) imaging. We aim at highlighting this challenging clinical scenario and emphasizing ways to assess the risks and implement means to prevent and treat accordingly.

Myocarditis on 18FDG-PET imaging.

Myocarditis is the inflammation of the heart muscle with various clinical presentations and etiology. In this case, we demonstrate the utility of Fluorodeoxyglucose PET scan in identifying its etiology. A 28-year-old female with a history of undifferentiated connective tissue disease and sacroiliitis referred to the cardiology clinic for palpitations. Her symptoms started 3 years ago, were episodic, associated with fatigue, and impaired quality of her life. A resting electrocardiogram revealed sinus tachycardia. Medical workup for sinus tachycardia was unremarkable. Given suspicion for idiopathic myocarditis, a FDG PET using F18 was ordered and revealed diffuse myocardial uptake suggestive of myocarditis. Normal LV systolic function was noted on the echocardiogram. Her tachycardia was successfully treated with ivabradine and diltiazem. She was started on mycophenolate mofetil for myocarditis with improvement in symptoms of tachycardia and fatigue. A repeat FDG PET in follow-up revealed less diffuse uptake with the initiation of therapy. FDG-PET may add value in patients with inappropriate sinus tachycardia found especially if suspicion of underlying connective tissue disease exists. As illustrated in this case, a timely diagnosis could change management decisions as well as significantly impact the quality of life.

The Role of Imaging in Diagnosing Transthyretin Cardiac Amyloidosis.

Cardiac amyloidosis is a rare underdiagnosed condition with increasing morbidity and mortality. Its diagnosis is challenging and requires high clinical suspicion. Several diagnostic tools aid in the diagnosis of cardiac amyloidosis such as electrocardiogram, echocardiography, and, most importantly, cardiac MRI. A wide range of clinical symptoms is associated with cardiac amyloidosis, with shortness of breath and peripheral edema being the most common presenting complaints. Here, we report a case of transthyretin cardiac amyloidosis and discuss the importance of imaging in establishing the diagnosis.

Cardiac Mass: A Case of Cardiac Papillary Fibroelastoma.

Cardiac papillary fibroelastoma (CPF) is one of the most common neoplasms of the cardiac valvular structures that are associated with complications such as systemic stroke, embolism, and arrhythmias. We present a case of an incidentally discovered left ventricular mass in a 75-year-old Caucasian woman.

The kidney in heart failure: friend or foe?

Heart failure constitutes a significant source of morbidity and mortality in the United States and its incidence and prevalence continue to grow, increasing its burden on the health care system. Renal dysfunction in patients with heart failure is common and has been associated with adverse clinical outcomes. This complex interaction is characterized by a pathophysiological disequilibrium between the heart and the kidney, in which cardiac malfunction promotes renal impairment, which in turn feeds back for further deterioration of cardiovascular function. Multiple neurohumoral and hemodynamic mechanisms are involved in this cardiorenal dyshomeostasis, including the deficiency of and/or resistance to compensatory natriuretic peptides, leading to sodium retention, volume overload and organ remodeling. Management of patients with cardiorenal dysfunction can be challenging and should be individualized. Emerging therapies must address the impairment of both organs to secure better clinical outcomes. To this end, a multidisciplinary approach is warranted to achieve optimal results.

Angina pectoris in a patient with protein C deficiency and deep vein thrombosis: thrombus versus myxoma?

A 55-year-old Caucasian man with history of hypertension, diabetes mellitus, protein C deficiency, and deep vein thrombosis presented with typical angina. Both computed tomography and transesophageal echocardiography identified a mobile mass in left atrium but could not differentiate between thrombus and myxoma. A cardiac catheterization with coronary angiography demonstrated tumor neovascularization, suggestive of myxoma. Pathology examination after mass resection confirmed the diagnosis. Patients with myxoma could present with obstructive, embolic, or constitutional symptoms. However, typical angina has never been reported as the primary manifestation. Although being helpful, various noninvasive imaging modalities, including magnetic resonance image, often have limitations to help making a definitive diagnosis, before surgery decision, especially under hypercoagulable condition. In contrast, cardiac catheterization can help not only in differentiation diagnosis but also in detecting possible intracoronary embolization from myxoma. In patients with myxoma complicated with hypercoagulable disorders, anticoagulation will play essential role in long-term care.

Obesity hypertension: the regulatory role of leptin.

Leptin is a 16-kDa-peptide hormone that is primarily synthesized and secreted by adipose tissue. One of the major actions of this hormone is the control of energy balance by binding to receptors in the hypothalamus, leading to reduction in food intake and elevation in temperature and energy expenditure. In addition, increasing evidence suggests that leptin, through both direct and indirect mechanisms, may play an important role in cardiovascular and renal regulation. While the relevance of endogenous leptin needs further clarification, it appears to function as a pressure and volume-regulating factor under conditions of health. However, in abnormal situations characterized by chronic hyperleptinemia such as obesity, it may function pathophysiologically for the development of hypertension and possibly also for direct renal, vascular, and cardiac damage.

El síndrome cardiorenal en insuficiencia cardíaca: un paradigma en evolución / The cardiorenal syndrome in heart failure: an envolving paradigm

Background: Heart failure constitutes a significant source of morbidity and mortality in the United States and its incidence and prevalence continue to grow, increasing its burden on the health care system. Renal dysfunction in patients with heart failure is common and has been associated with adverse clinical outcomes. This interaction, termed the cardiorenal syndrome, is a complex phenomenon characterized by a pathophysiological disequilibrium between the heart and the kidney, in which malfunction of one organ subsequently promotes the impairment of the other. Multiple neuro-humoral mechanisms are involved in this cardiorenal interaction, including the deficiency of and/or resistance to compensatory natriuretic peptides, leading to sodium retention, volume overload and organ remodeling. Management of patients with the cardiorenal syndrome can be challenging and should be individualized. Emerging therapies must address the function of both organs in order to secure better clinical outcomes. To this end, a multidisciplinary approach is recommended to achieve optimal results.

The cardiorenal syndrome in heart failure: an evolving paradigm.

Heart failure constitutes a significant source of morbidity and mortality in the United States, and its incidence and prevalence continue to grow, increasing its burden on the healthcare system. Renal dysfunction in patients with heart failure is common and has been associated with adverse clinical outcomes. This interaction, termed the cardiorenal syndrome, is a complex phenomenon characterized by a pathophysiologic disequilibrium between the heart and the kidney, in which malfunction of 1 organ consequently promotes the impairment of the other. Multiple neurohumoral mechanisms are involved in this cardiorenal interaction, including the deficiency of and/or resistance to compensatory natriuretic peptides, leading to sodium retention, volume overload and organ remodeling. Management of patients with the cardiorenal syndrome can be challenging and should be individualized. Emerging therapies must address the function of both organs to secure better clinical outcomes. To this end, a multidisciplinary approach is recommended to achieve optimal results.

Obesity hypertension: the emerging role of leptin in renal and cardiovascular dyshomeostasis.

PURPOSE OF REVIEW: Adipose tissue is now considered to be an active physiologic system operating in concert with multiple other organs. Leptin is a peptide hormone that is primarily synthesized and secreted by adipose tissue whose principal action is the control of appetite and energy balance. However, current information suggests that leptin exerts pleiotropic effects on several organ systems. Herein, we review the potential role of leptin in cardiovascular and renal physiological conditions as well as pathophysiological situations including obesity and hypertension. RECENT FINDINGS: Increasing evidence suggests that leptin may function as a pressure and volume-regulating factor under conditions of health; however, in situations characterized by chronic hyperleptinemia such as obesity, it may function pathophysiologically for the development of hypertension and possibly also for adverse renal, vascular and cardiac remodeling. SUMMARY: Adipose tissue should be regarded as a potentially important mediator of cardiorenal physiology. Further research awaits the characterization of additional mechanisms of action of leptin, including its interface with other important endocrine and hemodynamic sodium-volume regulatory systems, in both health and disease, particularly in obesity and related comorbidities. This information could lead to the development of leptin analogues as well as leptin receptor blockers that given specific circumstances could optimize the beneficial actions of the hormone and minimize its deleterious effects.