Prevalence and Prognostic Importance of Abnormal Positron Emission Tomography Among Asymptomatic Patients With Diabetes Mellitus.

BACKGROUND: Ischemia and reduced global myocardial blood flow reserve (MBFR) are associated with high cardiovascular risk among symptomatic patients with diabetes mellitus (DM). OBJECTIVES: This study aimed to assess the prevalence and prognostic importance of silent ischemia and reduced MBFR among asymptomatic patients with DM. METHODS: This study included 2,730 consecutive patients with DM, without known coronary artery disease (CAD) or cardiomyopathy, who underwent rubidium-82 rest/stress positron emission tomography (PET) myocardial perfusion imaging (MPI) from 2010 to 2016. These patients were followed up for all-cause mortality (n = 461) for a median follow-up of 3 years. Patients were considered asymptomatic if neither chest pain nor dyspnea was elicited. Rates of ischemia, reduced MBFR, and coronary microvascular dysfunction on PET were assessed in both groups. Cox regression was used to define the independent association of abnormal MPI markers with mortality. RESULTS: One-quarter of patients with DM (23.7%; n = 647) were asymptomatic; ischemia was present in 30.5% (n = 197), reduced MBFR in 62.3% (n = 361), and coronary microvascular dysfunction in 32.7% (n = 200). In adjusted analyses, reduced MBFR (HR per 0.1 unit decrease in MBFR: 1.08 [95% CI: 1.03-1.12]; P = 0.001) and reduced ejection fraction (HR per 5% decrease: 1.10 [95% CI: 1.01-1.18]; P = 0.02) were independently prognostic of mortality among asymptomatic patients, but ischemia was not. This was comparable to DM patients with symptoms. Insulin use and older age were significant predictors of reduced MBFR among asymptomatic patients with DM. CONCLUSIONS: In both symptomatic and asymptomatic patients with DM, impairment in MBFR is common and associated with greater mortality risk.

Treadmill Exercise Stress Test-Induced Takotsubo Cardiomyopathy: A Case Report and Review of Literature.

Noninvasive stress testing is routinely indicated and preferable in the diagnosis of coronary artery disease. We present the case of a patient who developed Takotsubo syndrome/cardiomyopathy (TTS) as a result of an exercise stress echocardiography, as well as a literature review of comparable cases. An abnormal stress test necessitated coronary angiography, which revealed nonobstructive coronaries with apical left ventricular ballooning and a decreased ejection fraction (EF), both of which are concerning for TTS. The patient was medically managed with metoprolol and lisinopril, with improvement in the EF on the follow-up echocardiogram.

An Overlooked Cause of Myocardial Infarction With Normal Coronaries Presenting as Stress Cardiomyopathy in Females.

Spontaneous coronary artery dissection (SCAD) should be considered in the differential diagnosis of patients with provisional Takotsubo cardiomyopathy (TTS). However, because of overlapping clinical features, SCAD with subtle angiographic findings and wall motion abnormality like TTS can be easily missed. Therefore, our case highlights the importance of further investigation for SCAD.

The Paleolithic Diet.

The promotion of healthy diets is likely one of the most cost-effective strategies for preventing a wide range of disorders, including cardiovascular disease, obesity, hypertension, and type 2 diabetes. The majority of present non-communicable chronic diseases are attributed to civilization, an abundance of food, and a lack of physical activity. According to the purported lifestyles of early humans, the paleolithic diet (PD) encourages the intake of wild animal and plant foods. In recent decades, the paleolithic diet has grown in popularity, particularly among younger populations and those with cardiometabolic syndrome and other chronic diseases. Due to the nutrition profile of the paleolithic diet, historical studies have postulated that hunter-gatherers (HGs) have slender physiques and were physically fit and devoid of chronic ailments such as cardiovascular diseases (CVDs). This review highlights the composition/constituent of the paleolithic diet along with an emphasis on current studies and evidence on the effectiveness of the paleolithic diet in mitigating chronic diseases.

A Case of Compartment Syndrome Due to Out-of-Hospital Intraosseous Misplacement During Cardiopulmonary Resuscitation.

Resuscitation relies heavily on gaining access to the circulatory system. During cardiopulmonary resuscitation (CPR), the biggest, most readily accessible vein that does not impede resuscitation is desired. Intraosseous (IO) access is designated for life-threatening emergencies and is a relatively safe procedure with fewer complications. We describe an intriguing and uncommon consequence of out-of-hospital IO placement: compartment syndrome resulting from the displacement of the IO needle by emergency medical services (EMS) workers in a diabetic woman with hypoglycemia. A few hours later, the patient had swelling, discomfort, and loss of motor and sensory sensations at the IO site, necessitating further examinations. The IO needle had traversed both the anterior and posterior cortices of the tibia and was located in the soft tissues along the posterior portion of the tibia as shown by imaging of the afflicted area. Immediate decompression fasciotomy was performed to preserve the patient's limb.

The Potential of F-18 Flurpiridaz PET/CT Myocardial Perfusion Imaging for Precision Imaging.

PURPOSE OF THE REVIEW: Myocardial perfusion imaging (MPI) with single photon emission computed tomography (SPECT) has been the main method for assessing patients with known or suspected coronary artery disease (CAD) for decades. Based on a strong and growing evidence base, positron emission tomography (PET) MPI is increasingly favored when it is available. However, currently available PET perfusion tracers have limitations that have hampered broad utilization. RECENT FINDINGS: F-18 flurpiridaz is a novel PET MPI agent that is nearing completion of studies necessary to obtain regulatory approval. It has unique capabilities that will facilitate further expansion of PET MPI utilization. In addition, it has characteristics that may define it as the best MPI agent to date, in terms of the potential to equalize accuracy independent of patient size, gender, complexity, or ability to perform exercise stress. The combination of excellent image quality and accurate absolute blood flow quantification hold the potential of its being an ideal precision tool for non-invasive assessment of myocardial blood flow and entire spectrum of ischemic heart disease.

An Interesting Case of Serratia Endocarditis in a Patient With Chronic Myeloid Leukemia.

Serratia is a rare cause of infective endocarditis (IE) and usually occurs in patients with underlying risk factors, such as intravenous (IV) drug use, and human immunodeficiency virus patients. Gram-negative bacteria endocarditis is associated with high mortality when it involves the left side of the heart and often requires surgical intervention in addition to medical treatment. Although most gram-negative endocarditis cases are hospital-acquired, community cases have also been reported. Here, we present a case of Serratia endocarditis in an individual who was later diagnosed with chronic myeloid leukemia (CML) during the same hospitalization. The patient was treated with IV meropenem and started on targeted therapy for CML. CML is presumed to have likely predisposed the patient to bacteremia and IE.

Infective Endocarditis as a Complication of Crohn's Disease on Immunotherapy.

A patient with a history of Crohn's disease on infliximab presented to the hospital with sepsis and a new heart murmur. He was found to have native aortic valve infective endocarditis from a rare species of group D Streptococcusin his blood. The patient was also noted to be in an acute flare of Crohn's disease. The hospital course was complicated by florid heart failure from acute aortic insufficiency. He eventually improved after source control and appropriate antibiotic therapy. S. pasteuranis bacteremia and endocarditis are attributable to the patient's immunocompromised state as a result of infliximab treatment. While S. pasteuranis is infrequently grown in blood cultures, it is commonly found in normal gut flora. We hypothesize that it gained access to the bloodstream through the epithelium in the terminal ileum, which was inflamed due to an acute flare of Crohn's disease.

Nuts: Natural Pleiotropic Nutraceuticals.

Common nuts (tree nuts and peanuts) are energy-dense foods that nature has gifted with a complex matrix of beneficial nutrients and bioactives, including monounsaturated and polyunsaturated fatty acids, high-quality protein, fiber, non-sodium minerals, tocopherols, phytosterols, and antioxidant phenolics. These nut components synergize to favorably influence metabolic and vascular physiology pathways, ameliorate cardiovascular risk factors and improve cardiovascular prognosis. There is increasing evidence that nuts positively impact myriad other health outcomes as well. Nut consumption is correlated with lower cancer incidence and cancer mortality, and decreased all-cause mortality. Favorable effects on cognitive function and depression have also been reported. Randomized controlled trials consistently show nuts have a cholesterol-lowering effect. Nut consumption also confers modest improvements on glycemic control, blood pressure (BP), endothelial function, and inflammation. Although nuts are energy-dense foods, they do not predispose to obesity, and in fact may even help in weight loss. Tree nuts and peanuts, but not peanut butter, generally produce similar positive effects on outcomes. First level evidence from the PREDIMED trial shows that, in the context of a Mediterranean diet, consumption of 30 g/d of nuts (walnuts, almonds, and hazelnuts) significantly lowered the risk of a composite endpoint of major adverse cardiovascular events (myocardial infarction, stroke, and death from cardiovascular disease) by ≈30% after intervention for 5 y. Impressively, the nut-supplemented diet reduced stroke risk by 45%. As they are rich in salutary bioactive compounds and beneficially impact various health outcomes, nuts can be considered natural pleiotropic nutraceuticals.

Treatment of Metastatic Carcinoma of an Unknown Primary to the Heart with Checkpoint Inhibitor Therapy.

INTRODUCTION: Secondary cardiac malignancies are much more common than primary cancers. Metastatic cancers to the heart from other solid organs are well known and carry a poor prognosis. CASE PRESENTATION: An 83-year-old Hispanic veteran presented with breathlessness, cough, and weight loss. Imaging studies showed extensive pericardial effusion and multiple pericardial/epicardial masses. Biopsy showed poorly differentiated metastatic carcinoma with no definitive origin, based on lab, imaging, and extensive immunohistochemistry (IHC) studies. Gene panel testing showed microsatellite stable status. Programmed cell death 1 ligand (PD-L1) IHC was 100% in the tumor cells. He was started on pembrolizumab and had a complete resolution of symptoms. Subsequent imaging studies showed improvement in the multiple pericardial/epicardial masses. DISCUSSION: Immune checkpoint inhibitor (ICI) therapy has changed the treatment landscape of many malignancies since the approval of the first ICI, ipilimumab, for melanoma in 2011. To the best of our knowledge, this is the first reported case of successful treatment by ICI therapy in undifferentiated metastatic carcinoma of an unknown primary source to the heart.

Localized Talaromyces marneffei infection presenting as a tonsillar mass mimicking malignancy.

Talaromyces marneffei is an opportunistic fungal infection seen in immunocompromised patients including those with HIV/AIDS. It is usually seen in patients who live in or are from tropical Asia. In HIV patients, oropharyngeal and laryngeal lesions are usually part of disseminated infection. We describe a case of 63-year-old Vietnamese male with history of HIV/AIDS who presented with localized T. marneffei tonsillar infection without disseminated disease. Imaging studies showed a right tonsillar mass with right cervical lymphadenopathy which was initially thought to be malignancy. The patient underwent biopsy of the mass and histology showed noncaseating granulomas on hematoxylin and eosin stain as well as yeast on Grocott methenamine silver stain. Fungal culture of the biopsy specimen grew suede-like grayish-white colonies with diffuse underlying deep red color pigment which was identified as Talaromyces marneffei. The patient was treated with intravenous liposomal amphotericin B and achieved resolution of symptoms and tonsillar mass. In HIV/AIDS patients who are either from endemic regions or with history of travel to endemic areas particularly Southeast Asia and China, T. marneffei infection should be considered in differential diagnoses of a tonsillar mass.

Recurrent ST Elevation Myocardial Infarction from Norepinephrine-induced Coronary Vasospasm.

Myocardial infarction with no obstructive coronary atherosclerosis (MINOCA) is a distinct clinical syndrome characterized by evidence of myocardial infarction with normal or near-normal coronary arteries on angiography (stenosis severity < 50%). Coronary artery spasm, as seen in "variant angina," usually occurs at a localized segment of an epicardial artery. Here, we present a case of a 58-year-old male who had norepinephrine-induced coronary vasospasm which resulted in ST elevation myocardial infarction on two consecutive admissions.

Global longitudinal strain assessment of the left ventricle by speckle tracking echocardiography detects acute cellular rejection in orthotopic heart transplant recipients: A systematic review and meta-analysis.

BACKGROUND: In orthotopic heart transplant recipients, surveillance with endomyocardial biopsy is crucial to detect acute cellular rejection (ACR) early. ACR is a common and serious complication of transplantation with substantial morbidity and mortality. Speckle tracking echocardiography with global longitudinal strain (GLS) assessment of the left ventricle has emerged as a possible noninvasive screening modality. We have conducted a systematic literature review and meta-analysis to evaluate the role of GLS in diagnosing ACR. METHODS: The following databases were queried: PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Embase. We compiled all articles evaluating changes in GLS in comparison to endomyocardial biopsy in ACR dated prior to September 2019. Weighted mean differences (WMD) and 95% confidence intervals (CIs) were pooled by using a random effects model. In order to determine the risk of bias, we used the revised version of the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. RESULTS: Twelve studies met inclusion criteria of which ten were chosen. These studies encompassed 511 patients and 1267 endomyocardial biopsies. There was a significant difference in GLS between patients who did and did not have ACR proven by biopsy (WMD = 2.18; 95% CI: 1.57-2.78, P = <.001; I2  = 76%). The overall sensitivity for GLS in detecting ACR was 78% (CI: 63%-90%, P = .123; I2  = 52.2%) while the overall specificity was 68% (CI: 50%-83%, P = <.001; I2  = 88.3%). CONCLUSION: Global longitudinal strain assessment of the left ventricle by speckle tracking echocardiography is useful in detecting ACR and could potentially reduce the burden of frequent endomyocardial biopsies in heart transplant recipients.

Importance of the Cardio-Obstetrics Team.

PURPOSE: In the USA, maternal mortality has been rising since the 1980s. Cardiovascular disease is recognized as the leading cause of this worrisome trend, and a multidisciplinary approach to the care of patients with cardiovascular conditions during pregnancy is becoming increasingly important. We outline the literature supporting this multidisciplinary approach, highlight our center's experience in building and expanding an integrated cardio-obstetrics practice, and provide guidance regarding patient selection and management within a combined practice. Antenatal management patterns and delivery planning for patients with cardiovascular disease during pregnancy vary substantially among cardiovascular and obstetric and maternal fetal medicine practices in the USA. The need for multidisciplinary care between cardiologists and obstetricians is evident and has been supported by best practice statements from the American Heart Association, the American College of Obstetrics and Gynecology, and the Cardiac Disease in Pregnancy Study (CARPREG) investigators, whose CARPREG II risk score included "late first antenatal visit" as a predictor of adverse outcomes of pregnancy. CONCLUSIONS: We have solid evidence supporting a multidisciplinary approach to the care of patients with cardiac conditions in pregnancy. This approach is optimal because it facilitates a consistent and clear message to the patient (and those caring for each patient) regarding management and risks associated with pregnancy, as well as subsequent risk and postpartum follow-up. We support the extension of clinical collaboration between obstetricians and cardiologists to the research realm and know that working together to investigate the outcomes of moms with heart conditions and their babies will provide clinically meaningful information to support the care of these unique patients.