Use of Lumason Contrast Echocardiography in Post-myocardial Infarction Ventricular Septal Defect.

We report herein the case of an elderly female who presented with myocardial infarction complicated by ventricular septal defect (VSD) that was evident on cardiac auscultation and contrast echocardiography using Lumason® (Bracco Diagnostics Inc, Monroe Township, USA). Patient underwent surgical repair for her VSD post-infarct along with coronary artery bypass grafting after being treated for cardiogenic shock. We also highlight the management strategies in patients with similar complications. In this report, we shed the light on the importance of using Lumason contrast for the identification of shunt and for the diagnosis of VSD. Lumason contrast is widely available and licensed.

Giant Coronary Artery Aneurysm: A Successful Diagnosis.

Coronary artery aneurysms (CAAs) are rare, with giant CAAs being even rarer. The precise pathophysiology of this phenomenon is still unknown. CAAs are seldom reported life-threatening abnormalities of the cardiovascular system. We herein present a case of a 74-year-old man who presented at the hospital complaining of chest pain. An adenosine thallium scan revealed a small, reversible defect in the inferior wall of the left ventricle extending into the apex, consistent with ischemia. Echocardiography uncovered a large right coronary artery (RCA) aneurysm, measuring 5.6 × 7.5 cm. Diagnostic coronary angiography confirmed the presence of a large RCA aneurysm and aneurysmal dilation of the left anterior descending and circumflex arteries with no flow-limiting lesions. A reversed saphenous vein interposition graft was placed from the ascending aorta to the right posterior descending artery. The RCA aneurysmal sac was resected and sent to pathology, which uncovered myxoid degeneration of the media as well as thrombus formation. No complications were encountered during the procedure. Early diagnosis is vital to avoid fatal complications of CAAs, and therapeutic approaches are currently individualized in view of absence of evidence-based management strategies.

Gender-related Disparities of Percutaneous Coronary Interventions in ST-elevation Myocardial Infarction: A Retrospective Chart Review of 500 Patients.

Door-to-balloon (DTB) time of primary percutaneous coronary intervention in ST-elevation myocardial infarction (STEMI) is a predictive indicator of outcomes and mortality. Traditional gender-related differences that existed in the provision of DTB in STEMI had been allegedly improving until recent controversial data showed re-emergence of longer DTB in females. The objective of our study was to compare circadian disparities in percutaneous coronary intervention for STEMI according to gender in our institution. We compared DTB and symptom-to-balloon (STB) as well as mortality outcomes in a registry of 514 patients. We studied 117 females and 397 males. Baseline characteristics and cardiovascular risk factors were similar among both populations. Men used more self-transportation (51% vs. 38%) compared with women. Both had similar DTB median times: males, 63 (47-79) min; and females, 61 (44-76) min. In addition, STB median times were also similar: males, 155 (116-264) min; and females, 165 (115-261) min. Mortality outcomes at 1 month were comparable at 3% in males versus 0.9% in females (P = 0.164). In a review of a tertiary care center in New York, we observed no gender differences in DTB and STB, endorsing the role of emergency medical service transportation in eliminating disparities.

Cardiovascular Complications of Androgen Deprivation Therapy for Prostate Cancer.

OPINION STATEMENT: Prostate cancer is a common hormone-sensitive malignancy, and androgen deprivation therapy (ADT) is a cornerstone of therapy in advanced disease. The most important and controversial of ADT side effects is cardiovascular (CV) toxicity. Prospective trials have demonstrated that ADT increases CV risk by lowering insulin sensitivity, causing dyslipidemia, and causing weight gain thus mimicking metabolic syndrome. Retrospective data suggests that ADT increases CV risk; however, data on cardiovascular mortality is equivocal. This discrepancy can be explained by study design limitations and selection bias inherent to post hoc analysis of trials not designed to study CV outcomes. Despite the adverse CV and metabolic sequelae of ADT, little data is available for optimal cardiac screening or management in these patients. The short-term CV risk is higher in patients who have had CV events in the year prior to starting ADT. A careful discussion of risk and benefit of ADT must take place with patients with pre-existing CV disease prior to initiating hormonal therapy. The duration of ADT must be considered. We recommend diligent pretherapy screening and optimization of cardiac risk factors and close surveillance especially within the first year of ADT.

Cardiorespiratory Fitness in Internal Medicine Residents: Are Future Physicians Becoming Deconditioned?

BACKGROUND: Previous studies have shown a falloff in physicians' physical activity from medical school to residency. Poor fitness may result in stress, increase resident burnout, and contribute to mortality from cardiovascular disease and other causes. Physicians with poor exercise habits are also less likely to counsel patients about exercise. Prior studies have reported resident physical activity but not cardiorespiratory fitness age. OBJECTIVE: The study was conducted in 2 residency programs (3 hospitals) to assess internal medicine residents' exercise habits as well as their cardiorespiratory fitness age. METHODS: Data regarding physical fitness levels and exercise habits were collected in an anonymous cross-sectional survey. Cardiopulmonary fitness age was determined using fitness calculator based on the Nord-Trøndelag Health Study (HUNT). RESULTS: Of 199 eligible physicians, 125 (63%) responded to the survey. Of respondents, 11 (9%) reported never having exercised prior to residency and 45 (36%) reported not exercising during residency (P < .001). In addition, 42 (34%) reported exercising every day prior to residency, while only 5 (4%) reported exercising daily during residency (P < .001), with 99 (79%) participants indicating residency obligations as their main barrier to exercise. We found residents' calculated mean fitness age to be 5.6 years higher than their mean chronological age (P < .001). CONCLUSIONS: Internal medicine residents reported significant decreases in physical activity and fitness. Residents attributed time constraints due to training as a key barrier to physical activity.

Acute kidney injury adjusted to volume status in critically ill patients: recognition of delayed diagnosis, restaging, and associated outcomes.

Critically ill patients receive a significant amount of fluids leading to a positive fluid balance; this dilutes serum creatinine resulting in an overestimated glomerular filtration rate. The goal of our study is to identify undiagnosed or underestimated acute kidney injury (AKI) in the intensive care unit (ICU). It will also identify the morbidity and mortality associated with an underestimated AKI. We reviewed records of patients admitted to our institution (Staten Island University Hospital) between 2012 and 2013 for more than 2 days. Patients with end stage renal disease were excluded. AKI was defined using the Acute Kidney Injury Network criteria. The following formula was used to identify and restage patients with AKI: adjusted creatinine = serum creatinine × [(hospital admission weight (kg) 0.6 + Σ (daily cumulative fluid balance (L))/hospital admission weight × 0.6]. The primary outcome identified newly diagnosed AKI and those who were restaged. The secondary outcome identified associated morbidities. Seven-hundred and thirty-three out of 1,982 ICU records reviewed, were used. Two-hundred and fifty-seven (mean age 69.8±14.9) had AKI, out of which 15.9% were restaged using the equation. Comparison of mean by Student's t-test showed no difference between patients who were restaged. Similarly, chi-square revealed no differences between both arms, except mean admission weight (lower in patients who were restaged), fluid balance on days 1, 2, and 3 (higher in the restaged arm), and the presence of congestive heart failure (more prevalent in the restaged arm). Of note, the mean cost of stay was US$150,562.82 vs $197,174.63 for same stage vs restaged, respectively, however, without statistical significance (P=0.74). Applying the adjustment equation showed a modest (15.9%) increase in the AKI staging slightly impacting outcomes (mortality, length, and cost of stay) without statistical significance.

Longest Event-Free Survival without Anticoagulation in a Mechanical Aortic Valve Replacement.

Sixty percent of the patients going for valve replacement opt for mechanical valves and the remaining 40% choose bioprosthetics. Mechanical valves are known to have a higher risk of thrombosis; this risk further varies depending on the type of valve, its position, and certain individual factors. According to current guidelines, long-term anticoagulation is indicated in patients with metallic prosthetic valve disease. We report two unique cases of patients who survived 27 and 37 years event free, respectively, after mechanical aortic valve replacement (AVR) without being on any form of anticoagulation. The latter case described the longest survival in a human with a prosthetic aortic valve without anticoagulation. A review of literature demonstrated few cases of prosthetic valves with no anticoagulation in the long term without significant embolic events reported as case reports. These cases have been summarized in this article. Some cases of long-term survival (in the absence of anticoagulation) were attributed to good luck, and others as the result of genetic variations. New mechanical prosthetic valves can be promising, such as microporus-surfaced valves that may be used without full anticoagulation. The use of dual antiplatelet agents alone can be currently recommended only when a patient cannot take oral anticoagulation after AVR, and it should be followed with measuring and monitoring of platelet reactivity.