Cardiovascular disease associated with methamphetamine use: a review.

Methamphetamine abuse is a global epidemic associated with a wide-ranging array of adverse effects on the cardiovascular system including dilated cardiomyopathy, malignant and benign arrhythmias, coronary vasospasm, and atherosclerotic coronary artery disease. While the acute behavioral manifestations of amphetamine abuse are the most easily clinically identified, cardiovascular toxicity is common in this patient population and should be considered in this setting due to its high morbidity and mortality. The specific mechanisms for amphetamine cardiotoxicity have not been fully established, but new research implicates activation of several cellular targets including Sigma-1 receptors and trace amine-associated receptor 1 (TAAR1) leading to a myriad of negative downstream effects including increased reactive oxygenating species (ROS), mitochondrial dysfunction, and modulations of intracellular calcium. Additional pathologic effects are mediated by increased circulating catecholamines, which when chronically activated have well-established adverse effects on the cardiovascular system. In this article, we present a case report followed by a current review of the epidemiology, pathophysiology, diagnosis, and treatment modalities of amphetamine-induced cardiovascular disease.

Subcutaneous furosemide for the treatment of heart failure: a state-of-the art review.

The prevalence of heart failure (HF) is on the rise. By 2030, over eight million Americans (46% increase from current prevalence) will have heart failure. In the USA, approximately 30 billion dollars is spent annually on heart failure and this number will likely double in 2030. Thus, HF represents a significant economic burden. Acute decompensated heart failure (ADHF) is a clinical spectrum, which refers to increasing symptoms and signs of heart failure prompting an emergency room visit or hospitalization. In ADHF, inpatient administration of intravenous diuretic is the standard of care due to the variability in the absorption of oral diuretics. Within 30 days, 25-30% of these patients are readmitted with recurrent ADHF. Recent efforts have focused in reducing HF readmission, and thereby decreasing costs; hence, innovative outpatient treatment options have emerged. Subcutaneous furosemide use will potentially overcome the need to place intravenous lines, reduce associated expenses, and enable management of ADHF at home. This review presents data on the pharmacodynamics and pharmacokinetics of subcutaneous furosemide, scientific evidence on the use of this therapy in the palliative and hospice population, and its experimental use as an outpatient therapy and/or as a bridge from inpatient to home.

Implantable devices for heart failure monitoring and therapy.

Heart failure (HF), the cardiovascular epidemic of the twenty-first century, is associated with significant comorbidities and high mortality. The prevalence of HF is estimated around 6.5 million people and is expected to increase to 8 million by the year 2030. The associated costs to care for these patients continue to increase. Despite the advancement of pharmacologic therapy with significant improvement in morbidity and mortality, the 5-year survival for heart failure still stands at 61%. The challenges faced by HF patients include difficulty with lifestyle modifications, nonadherence to complex medical regimens, financial limitations, lack of access to medical care, and unfavorable side effects. The sickest HF patients, who are ACC/AHA stage D, have advanced therapeutic options such as left ventricular assist devices and orthotopic heart transplant; however, the majority of patients are ACC/AHA stage C and/or not candidates for such advanced care. With constraints placed on hospitals by Medicare on HF readmissions as well as the multiple comorbidities imposed by this disease, intense interest is focused on the development of implantable devices as add-on therapy. This review discusses the innovative devices under varying stages of investigation or approved for monitoring and treatment of HF.

Myocarditis Following Immune Checkpoint Inhibition With Pembrolizumab: Management in a Context of Steroid Intolerance.

Immune checkpoint inhibitors (ICIs) are a major advance in oncology and have become first- or second-line therapy for over 50% of oncology patients. ICI-associated myocarditis is a complication that, although rare, has a high mortality rate. We present a case of ICI-associated myocarditis presenting as complete heart block. Traditional treatment with high-dose steroids was abandoned in this case, owing to steroid-induced psychosis. Alternative treatment with immunomodulators was initiated with a good response. This case highlights the variable presentation of ICI-associated myocarditis. As use of ICIs continues to expand, an understanding of their adverse reactions and best treatments will be needed.

Les inhibiteurs des points de contrôle immunitaire (IPCI) constituent un progrès majeur dans le domaine de l'oncologie, et sont maintenant utilisés comme traitement de première ou de deuxième intention pour plus de 50 % des patients en oncologie. La myocardite associée aux IPCI est une complication rare, mais dont le taux de mortalité est élevé. Nous présentons ici un cas de myocardite associée aux IPCI caractérisé par un bloc cardiaque complet. Le traitement classique par doses élevées de stéroïdes a dû être abandonné en raison d'une psychose provoquée par les stéroïdes. Un autre traitement par des immunomodulateurs a été amorcé et a produit une réponse satisfaisante. Ce cas permet de souligner la variété des tableaux cliniques des myocardites associées aux IPCI. Alors que l'utilisation des IPCI continue d'augmenter, une meilleure compréhension des réactions indésirables et des options pour leur prise en charge seront nécessaires.

Myocarditis in the Setting of Recent COVID-19 Vaccination.

We report three patients who presented with chest pain after receiving either the BNT162b2 Pfizer/BioNTech or mRNA-1273 Moderna/NIH vaccine. Clinical presentation, biomarker, and cardiac MRI supported myocarditis. It is imperative that potential side effects of COVID-19 vaccine are reported to improve our knowledge about COVID-19 and mRNA vaccines.

Refractory Hypotension as an Initial Presentation of Bilateral Subclavian Artery Stenosis.

Bilateral subclavian stenosis is a rare clinical condition. An interbrachial pressure difference of 15 mm Hg can raise suspicion for unilateral subclavian artery stenosis, but the diagnosis of bilateral subclavian artery stenosis can be challenging. We present a case of a 75-year-old woman who presented with refractory hypotension after surgery. Initial vitals revealed blood pressure in the 60s/50s mm Hg in both arms. Cardiopulmonary examination was remarkable for diminished pulses in all 4 extremities and audible carotid bruits. She continued to be hypotensive despite aggressive fluid resuscitation. Troponin T peaked at 0.24 ng/mL (reference < 0.04), and an echocardiogram revealed a reduction in ejection fraction (37% from 50%). Left and right heart catheterization demonstrated normal filling pressures and cardiac output. During the procedure, however, it was noted that the patient's central blood pressure was 70-80 mm Hg higher than cuff pressures obtained in either arm. Selective angiography revealed 90% left subclavian ostial stenosis as well as 70% stenosis of the right subclavian artery.

Lyme Carditis: An Interesting Trip to Third-Degree Heart Block and Back.

Carditis is an uncommon presentation of the early disseminated phase of Lyme disease. We present the case of a young female who presented with erythema migrans and was found to have first-degree heart block which progressed to complete heart block within hours. After receiving ceftriaxone, there was complete resolution of the heart block in sequential fashion. Our case illustrates the importance of early recognition and anticipation of progressive cardiac conduction abnormalities in patients presenting with Lyme disease.

Influenza Induced Cardiomyopathy: An Unusual Cause of Hypoxemia.

Influenza has considerable burden on public health funds. The complications of influenza can be devastating. We present a case of a 42-year-old woman with history of asthma who presented to the emergency room in winter with shortness of breath and general malaise and was found to be in hypoxemic respiratory failure. She was diagnosed with influenza and workup revealed severely depressed systolic cardiac function (ejection fraction of 25%). She was treated with oseltamivir and diuresis and regained cardiac function within a week. We review the pathophysiology and management of influenza induced cardiomyopathy.

Hypertriglyceridemia-Induced Pancreatitis: A Decade of Experience in a Community-Based Teaching Hospital.

INTRODUCTION: Hypertriglyceridemia is the third most common cause of acute pancreatitis. The current evidence on the management of hypertriglyceridemia-induced pancreatitis (HTGP) is mainly derived from case series. It has been suggested that insulin, and plasmapheresis have a role in the management of acute HTGP. We present a retrospective review of patients seen at a community-teaching hospital between 2005 and 2015. RESULTS: Out of the 549 admissions for acute pancreatitis, fourteen patients met our inclusion criteria. The mean age of presentation was 39± 8 years and there was a predominance of men (57%). More than two-thirds of the patients were admitted to the intensive care unit. The majority of the patients were treated with insulin drip (n=8), and the rest by subcutaneous insulin (n=3) and insulin drip + plasmapheresis (n=3). In the insulin drip group we noted a gradual decrease of the admission serum triglycerides by 50.6 ±16.0 % at 24 hours, 65.9±16.9% at 48 hours, and then 85.2± 7.1% at discharge. Serum triglycerides decreased by 79.8% and 92.6%, at discharge in the subcutaneous insulin and insulin + plasmapheresis cohorts, respectively. The insulin + plasmapheresis cohort stayed in the hospital longer (20.7±3.1 days) compared to the insulin drip (10.3±5.4 days) and subcutaneous insulin (5.7 ± 1.2 days) cohorts. CONCLUSION: Our study strengthens the evidence for using insulin (infusion or subcutaneous) with or without plasmapheresis in the treatment of hypertriglycerimia-induced pancreatitis.

Small Bowel Adenocarcinoma as the Cause of Gastrointestinal Bleeding in Celiac Disease: A Rare Malignancy in a Common Disease.

Introduction. Celiac disease is associated with an increased risk of small bowel malignancies, particularly lymphoma. Its association with small bowel carcinoma is less known. Case Description. We report a case of an 89-year-old woman with celiac disease who experienced recurrent episodes of gastrointestinal bleeding and was ultimately found to have adenocarcinoma of the small intestine. Discussion and Evaluation. Diagnosis of small bowel adenocarcinoma is often delayed because of the need for specialized modalities, which are often deferred in the inpatient setting. Although resection is the modality of choice for small bowel tumors, a majority is either locally advanced or metastatic at diagnosis, and even localized cancers have worse prognosis than stage-matched colorectal tumors. The role of adjuvant chemotherapy is uncertain, but it is often offered extrapolating data from other gastrointestinal cancers. Small bowel carcinomas occurring in the context of celiac disease appear to be associated with higher rates of microsatellite instability than sporadic tumors, although other specific genomic abnormalities and mechanisms of carcinogenesis in celiac disease remain unknown. Conclusion. Recurrent episodes of gastrointestinal bleeding in a patient with celiac disease should prompt an early evaluation of the small bowel to assure timely diagnosis of carcinoma at an early curable stage.

Evaluation of efficacy and dose response of different paclitaxel-coated balloon formulations in a novel swine model of iliofemoral in-stent restenosis.

OBJECTIVES: The authors aimed to validate a novel iliofemoral in-stent restenosis (ISR) model for the efficacy evaluation of paclitaxel-coated balloons (PCB) using the familial hypercholesterolemic swine (FHS). BACKGROUND: Most of the validation work regarding PCB technologies has been performed in the coronary territory of juvenile domestic swine. Although invaluable for safety evaluation, this model is not suited for the evaluation of the efficacy of peripheral PCB technologies. METHODS: Twenty-four iliofemoral segments in 12 FHS underwent balloon injury and self-expanding stent placement. After 21 days, the resulting ISR lesions were treated with either 1 µg/mm(2) dose (n = 8), or 3 µg/mm(2) dose (n = 8) PCB (Cotavance, Bayer Pharma AG/MEDRAD, Indianola, Pennsylvania), or with an identical uncoated control balloon (n = 8). RESULTS: At termination (28 days after treatment), the percent diameter stenosis by quantitative vascular analysis in the control group was higher (31.2 ± 13.7%) compared with the 1 µg/mm(2) (19.3 ± 14.0%, 38% reduction) and 3 µg/mm(2) (8.6 ± 10.7%, 72% reduction) PCB groups. Intravascular ultrasound analysis showed 36% (1 µg/mm(2) dose, p = 0.04) and 55% (3 µg/mm(2) dose, p < 0.01) reductions in neointimal volume stenosis. In the histological analysis, the control group showed the highest degree of percent area stenosis (65 ± 14.3%). The reductions in percent area stenosis was 13.2% (p = 0.5) and 26% (p = 0.04) in the 1 µg/mm(2) and 3 µg/mm(2) dose groups, respectively. CONCLUSIONS: The FHS model of iliofemoral ISR demonstrated a dose-dependent effect on the inhibition of neointimal proliferation of a clinically validated PCB technology. This model represents a positive step toward the efficacy evaluation of PCB in the peripheral vascular territory.