Comprehensive echocardiographic and biomarker assessment of patients with diabetic ketoacidosis.

BACKGROUND: Systemic stress, inflammation, and hydroelectrolytic and acid‒base abnormalities observed during diabetic ketoacidosis (DKA) can cause changes in the heart and even induce cardiovascular damage. We aimed to evaluate the structure and function of the heart during and after a DKA episode via echocardiography and biomarker assessment. METHODS: We performed a transthoracic echocardiogram (TTE) in subjects with an episode of DKA in the first 4-6 h of treatment. We evaluated left ventricular wall thickness, diameters and volumes, as well as systolic and diastolic function using tissue Doppler imaging, pulsed wave Doppler and left ventricular ejection fraction (LVEF). Left ventricular function was also assessed with global longitudinal strain (GLS). We obtained cardiac troponin levels in the first 24 h after admission. A second TTE was performed following the same protocol 6-12 h after the resolution of the DKA episode. RESULTS: We included a total of 20 subjects. The mean age was 33 ± 13.6 years; 70% were female, and 70% had type 1 DM. 75% of the patients experienced severe episodes, and the rest experienced moderate episodes. Left ventricular isovolumetric contraction and ejection time were significantly shorter during DKA and prolonged after the resolution of the episodes (47.6 ± 9.9 vs. 62.2 ± 14.1, p = < 0.001) and (218.6 ± 37.9 vs. 265.06 ± 34.7). The isovolumetric relaxation time was also shorter during DKA, (41.72 ± 8.29 vs. 59.32 ± 17.98, p = < 0.001). Volumes and diameters of the left ventricle increased significantly after DKA resolution. We found no difference between LVEF or GLS during and after DKA resolution. 20% of the participants had troponin elevations, half of whom had moderate episodes and half of whom had severe episodes. 35% had LV dysfunction, 28.5% both in GLS and LVEF. 28.5% occurred after DKA resolution, with alterations in GLS. CONCLUSIONS: Diabetic ketoacidosis induces changes in the structure and function of the heart, which are mostly transient, reflect the presence of a hyperdynamic state and resolve after the resolution of the episode. Some subjects present with evidence of myocardial injury with elevated cardiac troponin and left ventricular dysfunction.

Echocardiographic Manifestations in COVID-19: A Review.

COVID-19 has rapidly spread around the world and threatened global health. Although this disease mainly affects the respiratory system, there is increasing evidence that SARS-CoV-2 also has effects on the cardiovascular system. Echocardiography is a valuable tool in the assessment of cardiovascular disease. It is cost-effective, widely available and provides information that can influence management. Given the risk of personnel infection and equipment contamination during echocardiography, leading world societies have recommended performing echocardiography only when a clinical benefit is likely, favouring focussed evaluations and using smaller portable equipment. In the past months, multiple reports have described a wide pattern of echocardiographic abnormalities in patients with COVID-19. This review summarises these findings and discusses the possible mechanisms involved.

Toluene toxicity presenting with hypokalemia, profound weakness and U waves in the electrocardiogram.

We present the case of a 25-year-old man with progressive limb weakness. His electrocardiogram showed prominent U waves which made us consider hypokalemia. The final diagnosis was toluene intoxication with severe hypokalemia and metabolic acidosis. Intravenous potassium administration and hydration effectively corrected the electrolyte and acid-base alterations; weakness resolved and the patient was discharged. The approach to a patient with acute weakness can be challenging. This case reminds us that the electrocardiogram can be a valuable tool in the evaluation and differential diagnosis of patients presenting to the emergency department with these conditions.

A tick beat in the electrocardiogram: Persistent third degree block as only manifestation of Lyme disease.

Lyme disease is the most common tick-borne illness in North America. A 23-year-old female presented to our emergency department with a chief complaint of sudden dyspnea and chest pain. An electrocardiogram revealed a third degree heart block. She was a resident of the Northeast region of Mexico and referred a recent travel to an endemic area for Borrelia burgdorferi in the center of Mexico in the past weeks. Lyme carditis was diagnosed after enzyme linked immunosorbent assay for IgM antibodies against B. burgdorferi was reported positive and corroborated by a confirmatory immunoblot analysis. Persistent AV block was the only manifestation in our patient, a presentation scarcely reported in literature.

Thermal burn resulting from prolonged transcutaneous pacing in a patient with complete heart block.

Temporary transcutaneous pacing devices are used to treat symptomatic bradyarrhythmias that are unresponsive to medical therapy until it resolves or a more stable pacing device is established. Pain is the most common complication. Skin burns as a complication are uncommon. A female patient presented with a complete atrioventricular block that caused altered mental status and required orotracheal intubation. A temporary transcutaneous pacing device was used to treat the bradyarrhythmia and maintained for 12 h until a temporary transvenous pacemaker was placed. The patient developed a third degree skin burn in the area where the anterior pacing patch was placed. Bradycardia is a common complaint in the emergency department. Temporary transcutaneous cardiac pacing is a widely available treatment modality that serves as initial management for these cases and allows us to keep patients stable until a more stable pacing solution is available. Burns as a complication of transcutaneous pacing are uncommon.

Periodontal Disease, Systemic Inflammation and the Risk of Cardiovascular Disease.

Periodontal and cardiovascular disease are both major health issues. Poor oral health has long been associated with the development of systemic diseases, with the typical example being the risk of endocarditis posterior to dental procedures. Through the years, the association of periodontal disease with other non-infectious systemic diseases has been brought to attention. One of the most interesting associations is the one that exists with the development of cardiovascular disease. Many studies, including systematic reviews and meta-analyses, suggest an important association between periodontal disease and ischaemic heart disease, cerebrovascular disease, heart failure, atrial fibrillation and peripheral artery disease. Among the proposed mechanisms of this relationship, systemic inflammation appears to play a major role. Evidence suggests that periodontal inflammation triggers a systemic inflammatory state that, added to the damage mediated by antibodies that cross react between periodontal pathogens and components of the intimal wall, and the direct lesion of the intima by bacteria entering the circulation, promotes atheroma plaque development and progression. There are other studies that show a clear relationship between periodontal disease severity, elevations of inflammatory markers, and the presence of atherosclerosis. Here, we give a review of the available evidence supporting this association, and the possible mechanisms involved.

Initiation and Up-titration of Guideline-directed Medical Therapy for Patients with Heart Failure: Better, Faster, Stronger!

Treatment for heart failure has experienced a major revolution in recent years, and current evidence shows that a combination of four medications (angiotensin receptor-neprilysin inhibitors + ß-blockers + mineralocorticoid receptor antagonists + sodium.glucose cotransporter 2 inhibitors) offer the greatest benefit to our patients with significant reductions in cardiovascular mortality, heart failure hospitalisations and all-cause mortality. Unfortunately, despite their proven benefits, the implementation of these therapies is still low. Clinical inertia, and unfounded fear of using these drugs might contribute to this. Recently, evidence from randomised clinical trials has shown that intensive implementation of these therapies in patients with heart failure is safe and effective. In this review, we attempt to tackle some of these misconceptions/fears regarding medical therapy for heart failure and discuss the available evidence showing the best strategies for implementation of these therapies.

Pleural effusions identified by thoracic ultrasound predict poor quality of life in patients with acute decompensated heart failure.

INTRODUCTION: Pleural effusion (PE) is a common manifestation of acute decompensated heart failure (ADHF); however, its influence on the quality of life (QoL) is unknown. OBJECTIVES: To identify whether PE detected using thoracic ultrasound (TUS) is associated with poorer QoL in patients with ADHF and a reduced ejection fraction (≤40 %). METHODS: We conducted a prospective, longitudinal, descriptive, observational, single-center study at a university hospital in Mexico. We included participants with a reduced left ventricular ejection fraction who were admitted for ADHF. We performed TUS and the Minnesota Living with Heart Failure Questionnaire (MLHFQ) within the first 48 h of hospitalization. RESULTS: Forty patients with ADHF (30 males and 10 females; mean age, 51.24 ± 16.942 years) were included in this study. The participants were categorized into two groups: those with (n = 25, 62.5 %) or without (n = 15, 37.5 %) PE on TUS. We found a statistically significant association between the presence of PEs and a worse perception of QoL. The mean MLHFQ score in the group of patients with PEs was 40 points, compared to 12 points in the group without PEs (p < 0.001). Poorer QoL was associated with a higher quantity of pleural fluid, as evidenced by the greater number of intercostal spaces occupied by the PE (p < 0.001). CONCLUSIONS: Patients with ADHF and a reduced ejection fraction who present with PE have a worse perception of QoL than patients without PE.

Atorvastatin before percutaneous coronary intervention: A systematic review and meta-analysis.

Atorvastatin is widely recommended for long-term secondary prevention in STEMI patients with no contraindication. Although high-dose atorvastatin has been shown to reduce important patient outcomes such as MACE, there is still doubt that high-dose atorvastatin could have the same protective effect in patients undergoing PCI in the short and long term. We searched the following electronic databases: Scopus, Web of Science, MEDLINE, EMBASE, and Cochrane Central considering studies that enrolled adult patients with a confirmed diagnosis of STEMI or NSTEMI undergoing PCI. The intervention must have been atorvastatin alone compared to a placebo, standard care, or a different atorvastatin dose. A total of (n = 11) studies were included in the quantitative analysis. Information on (N = 5,399) patients was available; 2,654 were assigned to receive high-dose atorvastatin therapy, and 2,745 comprised the control group. High-dose atorvastatin pre-loading significantly reduced MACE at one month of follow-up (RR: 0.78; 95% CI: 0.67-0.91; p = 0.014) in both STEMI and NSTEMI. All-cause mortality was reduced in patients with STEMI (RR: 0.28; 95% CI: 0.10-0.81; p = 0.029). The quality of the body of evidence was rated overall as moderate. Patients presenting with STEMI or NSTEMI benefit from high-dose atorvastatin pre-loading before PCI by reducing MACE at 30 days. The use of high-dose atorvastatin in STEMI patients reduced all-cause mortality. The beneficial effects of atorvastatin pre-loading are limited to 30 days post-PCI.

Failing in reverse: a case report of reverse Takotsubo syndrome complicating peripartum.

Background: Pregnancy and the peripartum are states of stress for the cardiovascular system. These conditions can trigger different cardiomyopathies. Among these, Takotsubo cardiomyopathy (TC) has been increasingly recognized as a cause of transient left ventricular dysfunction associated with pregnancy. Case summary: We present the case of a 31-year-old multiparous woman with an unusual variant of TC after caesarean delivery. Discussion: Peripartum cardiomyopathy and TC are particularly interesting differential diagnoses for new systolic dysfunction in pregnancy. Some features, such as the time of presentation, regional or diffuse wall motion abnormalities, evolution, and biomarkers, can guide the clinician to the right diagnosis.

Echocardiographic manifestations during the first 3 months after an episode of COVID-19 and their relationship with disease severity and persistence of symptoms.

BACKGROUND: Cardiovascular manifestations in patients with COVID-19 are associated with dire outcomes. Long COVID syndrome is the persistence of symptoms after acute disease and is found in up to 40% of subjects. There is little information regarding subacute echocardiographic manifestations after COVID-19, and no study has included a Mexican mestizo population. METHODS: This cross-sectional study included subjects older than 18 with an episode of COVID-19 in the last 3 months. Those with previously known cardiovascular disease were excluded. The patient´s medical history and COVID-19 information were obtained from clinical charts. We performed a transthoracic echocardiogram in every subject and determined left ventricular (LV) index mass, LV ejection fraction (LVEF), left ventricular global longitudinal strain (LV GLS), right ventricular (RV) GLS, and tricuspid annular plane systolic excursion (TAPSE). A descriptive and comparative analysis was performed based on symptom severity and persistence. RESULTS: One hundred subjects were included; 63% were classified with mild and 37% with moderate to severe COVID-19. The median of LVEF was 60% (55-60), LV GLS and RV GLS was impaired in 34% and 74% of patients, respectively. Patients with moderate to severe disease had significantly lower LVEF (Mean Difference: -3.3), TAPSE (mean difference: -1.8), and higher (worse) LV GLS (Mean Difference: 2.5) and RV GLS (mean difference: 2.9). Persistent symptoms were associated with lower TAPSE and higher RVGLS. CONCLUSIONS: Patients who recover from COVID-19 have a high prevalence of subtle RV and LV dysfunction using GLS analysis. A moderate to severe episode was associated with worse RV and LV function measured by RV GLS, TAPSE, and LV GLS. Subjects with persistent symptoms had worse RVGLS and TAPSE.

Takotsubo Cardiomyopathy and COVID-19: A Case Report and Literature Review.

BACKGROUND: Takotsubo cardiomyopathy is characterized by transient regional ventricular abnormalities in the absence of coronary artery disease and is reported as a complication of COVID-19. CASE PRESENTATION: It can have a diverse clinical presentation, occasionally resembling an acute coronary syndrome, and progress to acute heart failure and cardiogenic shock, adversely affecting patients' prognosis. A high index of suspicion and a thorough diagnostic approach supported by ancillary studies like echocardiography and coronary angiography is key for an accurate diagnosis and correct medical treatment. Herein, we report a patient with severe COVID-19 who developed Takotsubo cardiomyopathy. CONCLUSION: We also present a detailed literature review regarding the relationship between COVID-19 and Takotsubo cardiomyopathy.

Flecainide toxicity associated with the use of goji berries: a case report.

BACKGROUND: Goji berries (GB), usually marketed as a 'superfruit', are a widely used herbal supplement. As with other herbal remedies, the use of GB might be associated with herb-drug interactions, increasing plasma levels of other drugs and causing adverse events. Here, we present the case of a patient that developed flecainide toxicity secondary to an herb-drug interaction, associated with the use of GB to prevent COVID-19. CASE SUMMARY: A 75-year-old female presented to the emergency department with fainting. She was taking flecainide for the treatment of atrial extrasystoles diagnosed 2 years previously, and she was using a tea of GB for the prevention of COVID-19. The admission electrocardiogram showed a wide complex polymorphic tachycardia that was considered and treated as flecainide toxicity. The patient had a favourable evolution and was discharged 48 h after admission. DISCUSSION: Flecainide toxicity is uncommon and needs timely recognition and treatment; it is usually secondary to overdose and renal or hepatic failure. In our case, toxicity was associated with GB use, probably by inhibition of CYP2D6 which is the main enzyme associated with the metabolism of flecainide. Clinicians need to be aware of the possible interactions between herbal remedies (in this case used for the prevention of COVID-19) and cardiovascular drugs that are used to treat chronic cardiovascular diseases.

The Heart in Diabetic Ketoacidosis: A Narrative Review Focusing on the Acute Cardiac Effects and Electrocardiographic Abnormalities.

Diabetic ketoacidosis (DKA) is a serious complication of diabetes mellitus. Hyperglycemia, acidosis, and electrolyte imbalances can directly affect the heart by inducing toxicity, impairing myocardial blood flow, autonomic dysfunction, and altering activation and conduction of electrical impulses throughout the heart, increasing the risk of arrhythmias and ischemia. The electrocardiogram is useful in monitoring patients during and after an episode of DKA, as it allows the detection of arrhythmias and guides metabolic correction. Unfortunately, reports on electrocardiographic abnormalities in patients with DKA are lacking. We found two electrocardiographic patterns that are frequently reported in the literature: a pseudo-myocardial infarction and a Brugada Phenocopy. Both are associated with DKA metabolic anomalies and they resolve after treatment. Because of their clinical relevance and the challenge they represent for clinicians, we analyzed the clinical characteristics of these patients and the mechanisms involved in these electrocardiographic findings.

A case of round pneumonia due to Enterobacter hormaechei: the need for a standardized diagnosis and treatment approach in adults.

Round pneumonia is an unusual radiological manifestation of a bacterial lung infection. We present the case of an elderly male patient who arrived at the emergency room with a productive cough and exertional dyspnea. His chest x-ray and CT showed a round opacity and air bronchograms in the right upper lobe. Taken together, the patient's symptoms and images strongly suggest a pulmonary infection. Empirical antibiotic therapy with ceftriaxone and clarithromycin was started. The sputum culture was positive for Enterobacter hormaechei and the bacterium was sensitive to levofloxacin; therefore, the antibiotic therapy was changed. Despite the treatment, the patient progressed to respiratory failure and septic shock, dying six days after admission. Although round pneumonia is uncommon, it is a potentially curable disease and clinicians should always consider it in their differential diagnosis.