Flecainide suppresses defibrillator-induced storming in catecholaminergic polymorphic ventricular tachycardia.

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is an inherited condition associated with ventricular tachycardia (VT) triggered by exercise or sympathetic stress. Incessant VT may develop due to defibrillator-induced storming-a condition where implantable cardioverter-defibrillator discharges result in a hyperadrenergic state, provoking further VT and defibrillator discharge. We describe the case of a 14-year-old boy with CPVT caused by a calsequestrin-2 mutation, who presented with defibrillator-induced storming refractory to ß-blockers, calcium-channel blockers, amiodarone, and dronedarone. Flecainide and ß-blocker use suppressed incessant VT and defibrillator-induced storming.

Public Compliance with Face Mask Use in Honolulu and Regional Variation.

Infections with the SARS-CoV-2 virus are increasing in Hawai'i at alarming rates. In the absence of a SARS-CoV-2 virus vaccine, the options for control include social distancing, improved hygiene, and face mask use. There is evidence that mask use may decrease the rates of viral transmission. The rate of effective face mask use has not yet been established in Hawai'i. The authors performed an observational study at 2 locations in Honolulu and evaluated outdoor face mask use compliance in 200 people. Simultaneous observations were performed in a downtown Honolulu business area and in Waikiki, an area focusing on tourism. Overall, 77% of all subjects used face masks in an appropriate fashion, covering their nose and mouth, while 23% were either incorrectly masked or not masked. The rate of compliance with correct public mask use in downtown Honolulu (88%) was significantly higher than in Waikiki (66%) (P=.0003, Odds Ratio [95% Confidence Interval]=3.78 [1.82, 7.85]) These findings suggest that there are opportunities for improvement in rates of public face mask use and a potential decrease in the spread of COVID-19 in our population. Four proposed actions are suggested, including a reassessment of the face mask exemption requirements, enhanced mask compliance education, non-threatening communication for non-compliance, and centralization of information of the public compliance with face mask use.

Perceptions on Diversity in Cardiology: A Survey of Cardiology Fellowship Training Program Directors.

Background The lack of diversity in the cardiovascular physician workforce is thought to be an important driver of racial and sex disparities in cardiac care. Cardiology fellowship program directors play a critical role in shaping the cardiology workforce. Methods and Results To assess program directors' perceptions about diversity and barriers to enhancing diversity, the authors conducted a survey of 513 fellowship program directors or associate directors from 193 unique adult cardiology fellowship training programs. The response rate was 21% of all individuals (110/513) representing 57% of US general adult cardiology training programs (110/193). While 69% of respondents endorsed the belief that diversity is a driver of excellence in health care, only 26% could quote 1 to 2 references to support this statement. Sixty-three percent of respondents agreed that "our program is diverse already so diversity does not need to be increased." Only 6% of respondents listed diversity as a top 3 priority when creating the cardiovascular fellowship rank list. Conclusions These findings suggest that while program directors generally believe that diversity enhances quality, they are less familiar with the literature that supports that contention and they may not share a unified definition of "diversity." This may result in diversity enhancement having a low priority. The authors propose several strategies to engage fellowship training program directors in efforts to diversify cardiology fellowship training programs.

Rheumatoid Arthritis and Cardiac Compression Caused by a Large Fibrotic Intrapericardial Mass and Effusion: A Case Report.

BACKGROUND Pericarditis is common in rheumatoid arthritis, mostly occurring as an extra-articular manifestation of the disease. We describe a patient with stable rheumatoid arthritis who presented with a large pericardial effusion and a compressive fibrotic pericardial mass. The patient had recently started treatment with a tumor necrosis factor-alpha (TNF-alpha) antagonist. CASE REPORT The patient was a 58-year-old woman with rheumatoid arthritis who presented with right ventricular compression caused by a pericardial fibrotic mass and a large pericardial effusion. The patient did not have active arthritis at the time of presentation. She had been started on treatment with a tumor necrosis factor-alpha (TNF-alpha) antagonist 4 months prior to this presentation. She was successfully treated with surgical pericardiectomy and resection of the pericardial mass. Pathologic analysis of the pericardial mass demonstrated fibrosis and no evidence of active inflammation, rheumatoid arthritis, opportunistic infection, or malignancy. CONCLUSIONS We describe a patient with stable rheumatoid arthritis who developed subacute right heart compression syndrome secondary to pericardial effusion and fibrous pericardial mass. The exact cause of pericarditis and the pericardial mass remain uncertain. There is a need for increased awareness of the association between use of TNF-alpha antagonists and the possible development of an intrapericardial fibrotic mass and effusion.

Cardiac transplantation in Hawai'i: a summary of the first 21 years.

Between 1987 and 2008, 45 patients have undergone cardiac transplantation in Hawai'i. This article summarizes the authors' experiences with cardiac transplantation over this 21-year period. The cumulative 1-, 3- and 5-year survival rates after transplantation have been 73.8%, 70.0%, and 63.2%, respectively. The corresponding survival rates have improved over the last eight years and are now 90.0%, 87.5%, and 83.3%, respectively. Despite clinical improvements, low patient volumes make the maintenance of a state-based program in Hawai'i difficult. Problems with financing and referral biases will need to be addressed if a local program is to continue.

Routine screening for CYP2C19 polymorphisms for patients being treated with clopidogrel is not recommended.

Recent efforts directed at potential litigation in Hawai'i have resulted in a renewed interest for genetic screening for cytochrome P450 2C19 (CYP2C19) polymorphisms in patients treated with clopidogrel. Clopidogrel is an antiplatelet agent, frequently used in combination with aspirin, for the prevention of thrombotic complications with acute coronary syndrome and in patients undergoing percutaneous coronary interventions. Cytochrome P-450 (CYP) 2C19 is an enzyme involved in the bioactivation of clopidogrel from a pro-drug to an active inhibitor of platelet action. Patients of Asian and Pacific Island background have been reported to have an increase in CYP2C19 polymorphisms associated with loss-of-function of this enzyme when compared to other ethnicities. This has created an interest in genetic testing for CYP2C19 polymorphisms in Hawai'i. Based upon our review of the current literature, we do not feel that there is support for the routine screening for CYP2C19 polymorphisms in patients being treated with clopidogrel; furthermore, the results of genetic testing may not be helpful in guiding therapeutic decisions. We recommend that decisions on the type of antiplatelet treatment be made based upon clinical evidence of potential differential outcomes associated with the use of these agents rather than on the basis of genetic testing.

Methamphetamine-associated cardiomyopathy.

Methamphetamine and related compounds are now the second most commonly used illicit substance worldwide, after cannabis. Reports of methamphetamine-associated cardiomyopathy (MAC) are increasing, but MAC has not been well reviewed. This analysis of MAC will provide an overview of the pharmacology of methamphetamine, historical perspective and epidemiology, a review of case and clinical studies, and a summary of the proposed mechanisms for MAC. Clinically, many questions remain, including the appropriate therapeutic interventions for MAC, the incidence and prevalence of cardiac pathology in methamphetamine users, risk factors for developing MAC, and prognosis of these patients. In conclusion, recognition of the significance of MAC among physicians and other medical caregivers is important given the growing use of methamphetamine and related stimulants worldwide.

Door-to-balloon time in acute ST segment elevation myocardial infarction--further experience.

Early coronary reperfusion has been established as the optimal treatment for acute ST segment elevation myocardial infarction. A treatment protocol, previously described, has been designed to reduce delay in achieving recanalization of the culprit coronary artery. Over a period of about 4 years, Door-to-Balloon time has been analyzed for patients arriving in the Emergency Department with this condition. During that time the process was enhanced by the ability of ambulance personnel to transmit 12 lead EKG's from the field. Door-to-Balloon times have been analyzed and compared to the American College of Cardiology target of 90 minutes. After just over one year of gradually improving results, 100% compliance was achieved. From that time on, this was achieved during the period under consideration in 97% of cases.

Cardio-oncology/onco-cardiology.

An understanding of onco-cardiology or cardio-oncology is critical for the effective care of cancer patients. Virtually all antineoplastic agents are associated with cardiotoxicity, which can be divided into 5 categories: direct cytotoxic effects of chemotherapy and associated cardiac systolic dysfunction, cardiac ischemia, arrhythmias, pericarditis, and chemotherapy-induced repolarization abnormalities. Radiation therapy can also lead to coronary artery disease and fibrotic changes to the valves, pericardium, and myocardium. All patients being considered for chemotherapy, especially those who have prior cardiac history, should undergo detailed cardiovascular evaluation to optimize the treatment. Serial assessment of left ventricular systolic function and cardiac biomarkers might also be considered in selected patient populations. Cardiotoxic effects of chemotherapy might be decreased by the concurrent use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or beta-blockers. Antiplatelet or anticoagulation therapy might be considered in patients with a potential hypercoagulable state associated with chemotherapy or cancer. Open dialogue between both cardiologists and oncologists will be required for optimal patient care.

Orthotopic cardiac transplantation for the treatment of progressive heart failure caused by idiopathic giant cell myocarditis.

We describe a patient with idiopathic giant cell myocarditis who underwent orthotopic cardiac transplantation. On triple immunosuppressive therapy including prednisone, cyclosporine and mycophenolate, the patient has not had recurrence of idiopathic giant cell myocarditis in the transplanted heart in 48 months of follow-up.

ST-segment elevation myocardial infarction: recommendations on triage of patients to heart attack centers: is it time for a national policy for the treatment of ST-segment elevation myocardial infarction?

Despite substantial progress in the diagnosis and treatment of acute ST-segment elevation myocardial infarction (STEMI), implementation of this knowledge into routine clinical practice has been variable. It has become increasing clear that primary percutaneous coronary intervention (PCI) is the preferred method of reperfusion if it can be performed in a timely manner. Recent European data suggest that transfer for direct PCI may also be preferable to fibrinolytic therapy. We believe it is time to establish a national policy for treatment of patients with STEMI to develop a coordinated system of care similar to that of the level 1 trauma system.