COVID-19 Infection and Arterial Thrombosis: Report of Three Cases.

Thrombotic complications associated with coronavirus disease 2019 (COVID-19) have been described; these have mainly included venous thromboembolic events. Limited literature is available regarding arterial thrombosis. Acute limb ischemia is associated with severe complications that can result in significant morbidity and mortality. Herein, we report 3 cases of COVID-19 infection complicated by arterial thrombosis in the form of acute limb ischemia. Our case series adds to the limited literature regarding arterial thrombosis.

The utility of bedside echocardiography in critically ill COVID-19 patients: Early observational findings from three Northern New Jersey hospitals.

INTRODUCTION: Cardiovascular complications related to coronavirus disease 2019 (COVID-19) have led to the need for echocardiographic services during the pandemic. The present study aimed to identify the echocardiographic findings in hospitalized COVID-19 patients and their utility in disease management. METHODS: We included patients who were diagnosed with COVID-19 using polymerase chain reaction and those who underwent echocardiographic examination during their hospitalization. RESULTS: Altogether, 45 patients were evaluated. The mean age was 61.4 ± 12.2 years. Hypertension (n = 29, 64%) and diabetes mellitus (n = 25, 55%) were the most common comorbidities followed by congestive heart failure (n = 11, 24%), coronary artery disease (n = 9, 20%), and valvular heart disease (n = 3, 7%). Eight patients (18%) showed evidence of myocardial injury, as suggested by elevated troponin levels. Brain natriuretic peptide was elevated in 14 patients (36%), and 14 patients had left ventricular dysfunction in the form of reduced ejection fraction (31%). Right ventricular (RV) dilatation was observed in six patients, and five patients had reduced RV ejection fraction. RV pressure and volume overload were observed in three patients. RV thrombus was observed in one patient. Pulmonary pressure was elevated in 10 patients (24%). CONCLUSION: Two-dimensional echocardiography can be an important bedside tool for the assessment of cardiovascular abnormalities and hemodynamic status of COVID-19 patients.

Brugada syndrome & AKAP9: Reconciling clinical findings with diagnostic uncertainty.

INTRODUCTION: Brugada Syndrome typically presents with sudden nocturnal arrhythmias. Diagnosis may be challenging due to variable and transient electrocardiogram patterns and nondiagnostic provocation studies. Genetic testing can establish the etiology, but results may be inconclusive with variants of uncertain significance. CASE: A 24-year-old male with family history of sudden cardiac death was found unresponsive due to seizure. He was hemodynamically stable. ECG showed saddle-back ST elevations in V1 and V2. Procainamide challenge was negative. We subsequently performed genetic testing, which demonstrated AKAP9 variant. DISCUSSION: AKAP9 is a scaffolding protein that facilitates phosphorylation of delayed-rectifier potassium channels. The AKAP9 variant alters potassium current causing disordered repolarization and ventricular reentry. It has been previously linked to other channelopathies, but its pathogenicity is fully undetermined. CONCLUSION: Genetic testing is a useful tool to determine the origin of channelopathy, but inconclusive results with variants of uncertain significance should be clinically correlated.

Isolated Pulmonary Valve Fungal Endocarditis with Candida parapsilosis: Management Considerations of a Rare Case.

Pulmonary valve infections without the involvement of other valves account for only 1.5- 2% of all infective endocarditis cases. Isolated pulmonary valve endocarditis due to fungus is extremely rare. The case is presented of a 36-year-old male who was found to have isolated pulmonary valve endocarditis caused by a very rare organism, Candida parapsilosis, and that was solely managed with medical therapy. The patient was evaluated for three weeks of lowgrade fever, generalized rash and fatigue, and found to have C. parapsilosis in the blood. Transesophageal echocardiography (TEE) demonstrated a 4.5 cm vegetation on the pulmonary valve, without involvement of other valves. The patient was deemed not to be a surgical candidate and was subsequently started on intravenous liposomal amphotericin B and 5-flucytosine, with excellent clinical outcome. Based on these case details, it must be emphasized that in selective cases and if there are no known complications, fungal endocarditis can be managed successfully using anti-fungal agents.

Embolized prostatic brachytherapy seeds mimicking acute chest pain syndromes.

A 59-year-old male with a history of nonobstructive coronary artery disease, diabetes mellitus, hypertension, and prostate cancer presented to the hospital with 1-day history of pleuritic chest pain. Initial workup for acute coronary event was unremarkable. Chest X-ray revealed multiple small radial densities which were linear and hyperdense, consistent with embolization of metallic seeds to the pulmonary circulation. The patient was noted to have had radioactive metallic seeds implanted for prostate cancer 6 months ago. Diagnosis of pulmonary embolization of prostatic seeds is challenging as they frequently present with chest pain mimicking acute coronary syndromes.

Infective Endocarditis in Hemodialysis Patients.

BACKGROUND AND AIM OF THE STUDY: Infective endocarditis (IE) is a major cause of morbidity and mortality in patients with end-stage renal disease (ESRD). The study aim was to evaluate the demographic, clinical, microbiological and inpatient mortality data of IE in hemodialysis patients. METHODS: Data were analyzed for all IE patients admitted to the authors' 800-bed tertiary care hospital between January 2001 and December 2014. These data included demographics, comorbidities, clinical and microbiological characteristics, echocardiographic findings, complications, outcomes, and in-patient mortality. RESULTS: A total of 296 patients, including 52 on hemodialysis, was admitted with a diagnosis of IE. The median age of patients with ESRD (28 females, 24 males) was 55.9 ± 15.47 years. The prevalences of comorbidities such as hypertension (80%) and diabetes mellitus (46%) were significantly higher in ESRD patients, whereas other comorbidities were similarly distributed in both groups. The mitral valve was the most commonly involved (55.8%), followed by aortic (21.7%), tricuspid (21.2%) and pulmonary (1.9%) valves. Staphylococcus aureus was the most common organism (40%), followed by Enterococcus sp. (13.7%), Gram-negative staphylococci (13.7%), coagulase-negative staphylococci (11.5%), and Streptococcus sp. (5.7%). Polymicrobes were found in 11.5% of patients and cultures were negative in 19%. The mean ejection fraction in these patients was 42 ± 4.19% and the mean area of vegetation was 63.5 ± 40 mm2. The in-hospital course of 11 patients was complicated by embolic events, while three patients had acute heart failure and one patient had heart block secondary to IE. A total of four patients (7.7%) died during the index hospitalization. CONCLUSIONS: IE in patients receiving chronic hemodialysis is a very frequent occurrence. Its diagnosis is complex and its presence should be considered in all hemodialysis patients with bacteremia. In the present study the etiology was shown to be multifactorial, with the mitral valve being the most commonly involved and S. aureus the most common organism.

Trends and disparities in prevalence of diagnosed hypertension among U.S. Adults from 2019 to 2022.

BACKGROUND: Hypertension (HTN) stands as a significant risk factor for cardiovascular diseases. Identifying trends and disparities in HTN prevalence is vital for developing public health policies. OBJECTIVE: Investigate the trends and disparities in HTN prevalence among U.S. adults from 2019 to 2022. METHODS: Data from the CDC's National Health Interview Survey were utilized, with regression analysis including Joinpoint and ARIMA models performed by ChatGPT-4 to predict future trends. RESULTS: The study observed fluctuations in the overall prevalence of diagnosed HTN starting at 27.0 % (95 % CI: 26.4-27.7, 2019), and reaching 27.2 % (95 % CI: 26.5-27.8, 2022). Males consistently showed higher HTN rates than females throughout the study period, with male prevalence increasing from 27.2 % (95 % CI: 26.3-28.1, 2019) to 27.9 % (95 % CI: 27.0-28.8, 2022), while females experienced decline from 26.9 % (95 % CI: 26.1-27.8, 2019) to 26.5 % (95 % CI: 25.7-27.3, 2022). Southern U.S. exhibited the highest prevalence at 30.1 % (95 % CI: 29.1-31.2, 2022), compared to the lowest in the West at 22.5 % (95 % CI: 21.4-23.8). Black adults showed a higher prevalence of 34.4 % (95 % CI: 32.4-36.4, 2022) compared to White adults at 27.4 % (95 % CI: 26.7-28.2), and significantly lower rates were observed in Asian adults at 14.5 % (95 % CI: 7.4-24.5). CONCLUSION: This study highlights stable trends in HTN prevalence among U.S. adults from 2019 to 2022, with significant disparities by gender, region, and race, underscoring the need for targeted public health interventions to address these inequalities.

The Latest Evidence on Bempedoic Acid: Meta-Analysis of Safety and Efficacy in High Cardiovascular Risk Patients With Hypercholesterolemia⋆.

Background: Bempedoic Acid (BA) is a novel drug that has a potential to serve as an alternative to statins to decrease lipid levels and improve cardiovascular disease (CVD) outcomes, particularly for statin-intolerant individuals. However, insufficient statistical power has limited our understanding of the efficacy and safety of BA. This meta-analysis utilizes the latest data to improve our knowledge of BA's effects on lipids and CVD with increased statistical power. Methods: MEDLINE, Embase, Cochrane Central, Clinicaltrials.gov, abstracts of national and international conferences, and reference lists of studies were searched for relevant studies. Rayyan was used to screen the search results, and Revman 5.3 was used for the meta-analysis and sensitivity analysis. Results: Our final analysis included seven randomized control trials (RCTs) with 17,782 participants, 53.6 % in the BA group (n = 9535) and 46.4 % in the placebo group (n = 8247). BA significantly decreased major adverse cardiovascular events (MACE) (OR: 0.86; 95 % CI 0.78-0.95; p = 0.03), non-fatal myocardial infarction (OR 0.72; 95 % CI 0.61-0.85; p = 0.0001), and new onset/worsening diabetes (OR:0.55; 95 % CI 0.30-0.98, p = 0.04), while reducing low-density lipoprotein cholesterol (LDL-C) levels by 22.5 % (MD: -22.53 %; 95 % CI -25.54 to -19.52, p < 0.00001). Conclusion: The findings of this meta-analysis suggest that BA is a promising and effective alternative to statin therapy, particularly for statin-intolerant and high CVD-risk patients. However, further studies with diverse populations are needed to quantify the long-term efficacy and safety endpoints.

Clinical outcomes of MANTA vs suture-based vascular closure devices after transcatheter aortic valve replacement: An updated meta-analysis.

OBJECTIVE: A recently published randomized control trial showed different results with suture-based vascular closure device (VCD) than plug-based VCD in patients undergoing transfemoral transcatheter aortic valve replacement (TAVR). The learning curve for MANTA device is steep, while the learning curve for suture based VCD is shallow as the devices are quite different. In this meta-analysis, we have compared suture-based (ProGlide and Prostar XL) vs plug-based VCDs (MANTA). METHODS: We performed a meta-analysis of all published studies (using PubMed/Medline and Cochrane databases) reporting the clinical outcome of plug-based vs suture-based VCDs in transfemoral TAVR patients. RESULTS: We included nine studies with a total of 2865 patients (plug-based n = 1631, suture-based n = 1234). There was no significant difference in primary outcome of all bleeding when using plug-based as opposed to suture-based VCDs (RR 1.14 [0.62-2.06] I2 = 72%). There was no significant difference in the incidence of secondary outcomes between two groups including major life threatening bleeding (RR 1.16 [0.38-3.58] I2 = 65%), major vascular complications (RR 0.84 [0.35-2.00] I2 = 55%), minor vascular complications (RR 1.05 [0.56-1.95] I2 = 42%), pseudo aneurysm (RR 1.84 [0.11-29.98] I2 = 44%), stenosis-dissection (RR 0.98 [0.66-1.47] I2 = 0%), VCD failure (RR 1.71 [0.96-3.04] I2 = 0%), and blood transfusion (RR 1.01 [0.38-2.71], I2 = 61%). CONCLUSION: Large bore arteriotomy closure with plug-based VCD was not superior to suture-based VCDs in this transfemoral TAVR population. There was very frequent use of secondary VCDs in suture-based VCD group which is not practical when using MANTA. Additional high-powered studies are required to determine the safety and efficacy of MANTA device.

Rare Association of Non-Bacterial Thrombotic Endocarditis, Myocardial Infarction, and Acute Limb Ischemia Secondary to Rheumatoid Arthritis: Comprehensive Case Series With Literature Review.

Most cases of non-bacterial thrombotic endocarditis (NBTE) tend to be related to malignancy or rheumatologic and autoimmune disorders like systemic lupus erythematosus. Rheumatoid arthritis (RA) itself has been associated with increased atherosclerosis, coronary artery plaque formation, and endothelial damage. However, it is rare to see NBTE in RA, simultaneously presenting with the acute coronary syndrome and acute limb ischemia due to distant embolization. Here we present a case of a 46-year-old female presenting with chest pain and right leg numbness, found to have ST-elevation myocardial infarction (STEMI) and occlusion of a peripheral artery due to embolization of vegetation present in the aortic valve. We also provide an extensive literature review of the relationship between NBTE and MI. One must be extra vigilant in managing these patients, especially if the size of vegetation is large as it has a tendency to embolize causing devastating complications.

Spontaneous coronary artery dissection associated with incidental finding of left ventricular thrombus.

Spontaneous Coronary Artery Dissection (SCAD) is one of the nonatherosclerotic causes of Acute Coronary Syndrome. It's extremely rare for SCAD to present in an asymptomatic male, with incidental finding of Left Ventricular (LV) thrombus on echocardiogram. This report presents the case of a 36-year-old male with such an atypical presentation of Spontaneous Coronary Artery Dissection with Left Ventricular apical thrombus as a complication. The patient received successful medical management, with excellent clinical outcomes. This case highlights the importance of an early recognition and treatment strategy for both conditions using medical therapy.

Gadolinium-based coronary angiography in a patient with prior known anaphylaxis to iodine-based dye.

Gadodiamide is a gadolinium-based chemical element that is considered safe and well tolerated in patients without renal dysfunction and is therefore routinely used as a contrast agent in magnetic resonance imaging. Although radio-opaque, it is not frequently used for coronary angiography due to its less than optimal image quality and prohibitive cost. Our center's previous experience was less than satisfactory but the addition of a power injection system yielded good quality diagnostic images. We report a case of 63 years old male with a known history of severe, life-threatening anaphylactic reaction to previous iodinated dye presenting with persistent angina despite optimal medical therapy. Coronary and bypass graft angiography was performed using 24 cc of undiluted Gadodiamide (OMNISCAN) with a power injector (ACIST®) without any incidents or premedication with an interpretable angiogram.

A Case of STEMI Masquerading Brugada Syndrome: Emphasizing the Importance of Clinical Decision Making in Emergencies.

Brugada syndrome is a rare arrhythmogenic syndrome that is associated with an increased risk of ventricular fibrillation and sudden cardiac death. Electrocardiographic findings include patterns similar to a right bundle branch block (RBBB) and persistent ST-segment elevation in precordial leads (V1 and V2). There are numerous reports of Brugada syndrome mimicking ST-segment elevation myocardial infraction (STEMI); however, we describe a case of 47-year-old male who presented with STEMI mimics Brugada syndrome with preexisting RBBB. The patient developed polymorphic ventricular tachycardia generating into ventricular fibrillation right before catheterization making the diagnosis more challenging. The patient, eventually, was found to have obstructive coronary artery disease and no evidence of abnormal sodium channelopathy on further testing. This case highlights the importance of meticulous history taking and appropriate diagnostic test in establishing proper diagnosis of STEMI in a patient with preexisting RBBB, which can mimic Brugada syndrome.

Does Baseline Diuretics Use Affect Prognosis in Patients With COVID-19?

The rapid emergence of coronavirus disease 2019 (COVID-19) has become the biggest healthcare crisis of the last century, resulting in thousands of deaths worldwide. There have been studies that evaluated the role of angiotensin-converting enzyme (ACE) inhibitors (ACEi) and angiotensin receptor blockers (ARBs) in treating patients with COVID-19. However, the prior use of diuretics and their effect on mortality in this setting remains unknown. The aim of the study was to evaluate the effect of diuretics in patients admitted with COVID-19. The current study was conducted between March 15, 2020, and April 30, 2020, during the COVID-19 pandemic in three different hospitals in Northern New Jersey, USA. The primary outcome was survival or in-hospital mortality from COVID-19 from the day of admission. The secondary outcome was severe or non-severe illness from COVID-19. This retrospective study included a total of 313 patients with a median age of 61.3 ± 14.6 years. There was a total of 68 patients taking diuretics at home and 245 patients who were not taking diuretics. There was a total of 39 (57.35%) deaths in patients taking diuretics as compared to 93 (37.96%) deaths in patients not taking diuretics (p-value 0.0042). Also, 54 (79.41%) patients who took diuretics had severe COVID-19 illness as compared to 116 (47.35%) who did not take diuretics (p-value <.0001). However, after adjusting for the confounding factors, there was no difference in mortality or severity of illness in COVID-19 patients taking diuretics at the time of admission. In conclusion, there was no effect of the baseline use of diuretics in the prognosis of COVID-19.

A Rare Case of Myocarditis Mimicking ST-Elevation Myocardial Infarction.

Myocarditis is caused by acute injury and inflammation of cardiac myocytes and is most commonly caused by a viral infection. Myocarditis remains a rare diagnosis and manifests with a wide spectrum of non-specific symptoms that include chest pain, dyspnea, and palpitations associated with electrocardiographic abnormalities that resemble that of ST-elevation myocardial infarction (STEMI). Therefore, clinical diagnosis is often challenging and is often misdiagnosed. We present a case of a 22-year-old male who presented with left-sided non-radiating chest pain associated with shortness of breath, elevated troponin of 3.2 ng/ml (<0.03 ng/ml). Electrocardiogram (ECG) and cardiac echocardiogram revealed ST-segment elevations in the anterolateral leads and an ejection fraction of 35%, respectively. The patient was initially suspected of having a STEMI; however, cardiac catheterization revealed non-obstructed coronary arteries. Due to elevated inflammatory markers, the patient was then started on colchicine for suspected myocarditis and had complete resolution of symptoms one week after. This case highlights that a high index of clinical suspicion and prompt diagnosis is necessary to prevent any delays in appropriate therapy for myocarditis.

Gender differences in the revascularization rates and in-hospital outcomes in hospitalizations with ST segment elevation myocardial infarction.

BACKGROUND: Gender differences have been noted in patients presenting with ST segment elevated myocardial infarction (STEMI) but the reason remained poorly defined. We hypothesize that women presenting with STEMI are associated with poor reperfusion strategies which leads to worse in-hospital outcomes. Our goal is to identify age-stratified gender differences in revascularizations and in-hospital outcomes in patients presented with STEMI. METHODS: We used the 2012 to 2015 Nation Inpatient Sample databases to identify all patients ≥ 18 years of age hospitalized with STEMI. Resource utilization including revascularization strategies and in-hospital outcomes were compared in propensity-matched women and men in the overall cohort as well as two major age groups (< 65 years and ≥ 65 years). RESULTS: Less women presented with STEMI (32.3%). After propensity matching, women were less likely to receive revascularization compared to men. These disparities were seen in both age groups. The in-hospital mortality in the overall cohort was significantly higher in women (10.6% vs 8.9%, P < 0.001). In-hospital mortality was higher in women in both age groups (5.8% vs 4.4% and 14% vs 12.2% in groups 1 and 2, respectively, P < 0.001 for both). The length of stay was higher in women in both age groups compared to men (group 1-4.6 vs 4.3 days, P < 0.001; group 2-5.4 vs 5.3 days, P < 0.01). CONCLUSIONS: Regardless of age, women presenting with STEMI are less likely to receive revascularization and have higher in-hospital mortality, longer length of stay, and more likely to be discharged to other acute care facility.

Non-ischemic cardiomyopathy with focal segmental glomerulosclerosis.

Focal segmental glomerulosclerosis (FSGS) is a common cause of nephrotic syndrome, accounting for 40% of nephrotic syndrome in adults. FSGS has diverse clinical and morphological features and underlying pathogenesis. We present a case of a 33-year-old male presenting with acute systolic heart failure complicated with left ventricular thrombus with embolism to coronary circulation and bilateral deep vein thrombosis. He was found to have nephrotic range proteinuria with kidney biopsy showing FSGS. Association of FSGS with cardiomyopathy has been reported in children. However, in adults, according to our best knowledge, there have not been any report of FSGS and non-ischemic cardiomyopathy or it is at least underreported. ABBREVIATIONS: FSGS: Focal segmental glomerulosclerosis; ESRD: End-stage renal disease; NOS: Not otherwise specified; LV: Left ventricle.

Coronary vasospasm complicating atrial fibrillation ablation: a case report and review of the literature.

Radiofrequency ablation is one of the alternative treatment strategies in patients with atrial fibrillation. With the increasing number of such ablation procedures being performed it is important for the physicians to be aware of the associated complications. We present a very rare case of severe triple coronary vessel spasm during radiofrequency catheter ablation. The procedure was complicated by cardiac arrest secondary to ventricular fibrillation and cardiogenic shock requiring subsequent management with a temporary mechanical circulatory support device. Multi-vessel spasm is a rare and life-threatening complication leading to ventricular fibrillation and cardiac arrest. One should be extra vigilant in monitoring patients during extensive ablations and the procedure should be terminated at the earliest signs of ischemia in order to prevent this rare but fatal complication.

Should Bangladeshi Race Be Considered as an Independent Risk Factor for Multi Vessel Coronary Artery Disease?

INTRODUCTION: Coronary Artery Disease (CAD) continues to be on the rise not only in the Western developed world but also affecting the South Asian race, particularly Bangladeshis. The objectives of this study were as follows: To determine whether or not risk factors of Bangladeshis differ from non-Bangladeshis, whether there is any difference in the extent of CAD for both groups, and if there are risk factors that can significantly affect the extent of CAD. METHODS: All patients with a diagnosis of CAD admitted to our 800-bed tertiary care hospital between January 2001 and December 2015 were retrospectively analyzed. We reviewed the age, sex, body-mass index (BMI), cardiac risk factors such as family history of CAD, dyslipidemia, hypertension, diabetes and smoking. We also reviewed coronary angiographic findings of these consecutive 150 Bangladeshis and a randomly selected group of 193 non-Bangladeshis. RESULTS: A total of 343 medical records were evaluated, this included two groups: 193 non-Bangladeshis and 150 Bangladeshi subjects. The Bangladeshi group was older than the non-Bangladeshi group (63.49 vs 59.22, p-value=0.001), and included a larger proportion of males than the non-Bangladeshi group (28.7% vs 15.68%, p-value=0.0116). Bangladeshi subjects are more likely to be smokers than non-Bangladeshi (11.75% vs 6.67%, χ2=12.7, p-value=0.0004). Non-obstructive, 1-vessel, 2-vessel and 3-vessel accounts for 13.33%, 36.67%, 22%, and 28% for Bangladeshis, and 16.39%, 20.77% 34.43% and 28.42% for non-Bangladeshis, respectively. The difference of extent of CAD is significant between two groups (χ2 =12.397, p-value=0.0061). The findings suggest that Bangladeshi ethnicity has almost 2 times the likelihood of having 1-vessel CAD at coronary angiography (OR=2.361, 95% CI 1.452-3.839, p=0.0005). CONCLUSION: This study is a pivotal starting point for further evaluating the link between Bangladeshis and CAD. In our study we found that being Bangladeshi increases the risk of having CAD and may be an independent risk factor for multi-vessel CAD.