Trends of Hospitalizations and In-Hospital Outcomes for Traumatic Cardiac Injury in United States.

Introduction: Traumatic cardiac injury (TCI) poses a significant risk of morbidity and mortality, yet there is a lack of population-based outcomes data for these patients. Methods: The authors examined national yearly trends, demographics, and in-hospital outcomes of TCI using the National Inpatient Sample from 2007 to 2014. We focused on adult patients with a primary discharge diagnosis of TCI, categorizing them into blunt (BTCI) and penetrating (PTCI) cardiac injury. Results: A total of 11,510 cases of TCI were identified, with 7,155 (62.2%) classified as BTCI and 4,355 (37.8%) as PTCI. BTCI was predominantly caused by motor vehicle collisions (66.7%), while PTCI was mostly caused by piercing injuries (67.4%). The overall mortality rate was 11.3%, significantly higher in PTCI compared to BTCI (20.3% vs. 5.9%, χ2(1, N = 11,185) = 94.9, p <0.001). Additionally, 21.5% required blood transfusion, 19.6% developed hemopericardium, and 15.9% suffered from respiratory failure. Procedures such as heart and pericardial repair were more common in PTCI patients. Length of hospitalization and cost of care were also significantly higher for PTCI patients, W(1, N = 11,015) = 88.9, p <0.001). Conclusions: Patients with PTCI experienced higher mortality rates than those with BTCI. Within the PTCI group, young men from minority racial groups and low-income households had poorer outcomes. This highlights the need for early and specialized attention from emergency and cardiothoracic providers for patients in these demographic groups.

Sex Differences in Stress-Induced (Takotsubo) Cardiomyopathy.

Background: Takotsubo cardiomyopathy (TC) affects predominantly women. Prior studies have suggested that men might have worse short-term outcomes, but limited data are available regarding long-term outcomes. We hypothesized that men, compared to women, with TC have worse short- and long-term outcomes. Methods: A retrospective study of patients diagnosed with TC between 2005 and 2018 in the Veteran Affairs system was performed. Primary outcomes were in-hospital death, 30-day risk of stroke, death, and long-term mortality. Results: A total of 641 patients were included (444 men [69%]; 197 women [31%]). Men had a higher median age (65 vs 60 years; P < 0.001), and women were more likely to present with chest pain (68.7% vs 44.1%; P < 0.001). Physical triggers were more common in men (68.7% vs 44.1%, P < 0.001). Men had a higher in-hospital mortality rate (8.1% vs 1%; P < 0.001). On multivariable regression analysis, female sex was an independent predictor for improved in-hospital mortality, compared to men (odds ratio 0.25, 95% confidence interval 0.06-1.10; P = 0.04). On 30-day follow-up, no difference occurred in a combined outcome of stroke and death (3.9% vs 1.5%; P = 0.12). On long-term follow-up (3.7 ± 3.1 years), female sex was identified as an independent predictor of lower mortality (hazard ratio 0.71, 95% CI 0.51-0.97; P = 0.032). Women were more likely to have TC recurrence (3.6% vs 1.1%; P = 0.04). Conclusions: In our study with a predominantly male population, men had less-favourable short- and long-term outcomes after TC, compared to those of women.

Contexte: La cardiomyopathie de Takotsubo (CT) touche majoritairement les femmes. Or, des études antérieures semblent indiquer que les hommes pourraient connaître de pires résultats à court terme, mais peu de données portent sur les résultats à long terme. Nous avons formulé l'hypothèse selon laquelle les hommes atteints de CT obtiennent de moins bons résultats à court et à long terme que les femmes qui en sont atteintes. Méthodologie: Nous avons réalisé une étude rétrospective auprès des patients qui étaient inscrits au système de soins de santé du département des Anciens Combattants des États-Unis et qui avaient reçu un diagnostic de CT entre 2005 et 2018. Les critères d'évaluations principaux étaient le taux de décès à l'hôpital, le risque d'AVC sur 30 jours, le taux de décès et le taux de mortalité à long terme. Résultats: Au total, 641 patients ont été inclus dans l'étude (444 hommes [69 %]; 197 femmes [31 %]). L'âge médian était plus élevé chez les hommes (65 c. 60 ans; p < 0,001), et les femmes étaient plus susceptibles de présenter des douleurs à la poitrine (68,7 % c. 44,1 %; p < 0,001). Les déclencheurs physiques étaient plus fréquents chez les hommes (68,7 % c. 44,1 %; p < 0,001). Le taux de mortalité des hommes à l'hôpital était plus élevé (8,1 % c. 1 %; p < 0,001). L'analyse par régression multivariée a permis de constater que le sexe féminin était un indicateur prévisionnel indépendant d'un taux de mortalité plus faible à l'hôpital (rapport des cotes : 0,25; intervalle de confiance [IC] à 95 % : 0,06 à 1,10; p = 0,04). Lors du suivi au jour 30, aucune différence n'a été notée dans les résultats combinés d'AVC et de décès (3,9 % c. 1,5 %; p = 0,12). Lors du suivi à long terme (3,7 ± 3,1 ans), le sexe féminin a été ciblé comme un indicateur prévisionnel d'un plus faible taux de mortalité (rapport de risques instantanés : 0,71; IC à 95 % : 0,51 à 0,97; p = 0,032). Enfin, les femmes étaient plus susceptibles de connaître une récurrence de la maladie (3,6 % c. 1,1 %; p = 0,04). Conclusions: Dans notre étude portant sur une population à prédominance masculine, les hommes atteints de CT ont obtenu des résultats à court et à long terme moins favorables que les femmes atteintes de ce syndrome.

A Rare Case of Pulmonary Emboli Presenting With ST Elevation on ECG.

Pulmonary embolism is a common medical emergency and often life threatening but can be misdiagnosed frequently leading to fatal outcomes. Changes in electrocardiogram (ECG) are common in pulmonary embolism and rarely they can present with ST elevation. We here describe a 79-year-old woman who presented after a cardiac arrest and was found have ST-segment elevation on ECG with normal coronary angiogram while CT scan revealing pulmonary embolism.

Eptifibatide-Induced Severe Thrombocytopenia After ST-Elevation Myocardial Infarction (STEMI): A Case Report.

Eptifibatide is a platelet glycoprotein (GP) IIb/IIIa inhibitor that is used in certain cases of acute coronary syndrome, including those with high thrombus burden or with no-reflow. It can rarely be associated with severe thrombocytopenia, which brings up a dilemma in managing those patients who require antiplatelet therapy. We discuss a patient who had ST-elevation myocardial infarction (STEMI) and developed severe thrombocytopenia after eptifibatide infusion. He was managed with platelet transfusion, stopping eptifibatide, and interrupting dual antiplatelet therapy (DAPT).

Unusual Presentation of Thrombotic Thrombocytopenic Purpura With Non-ST-Elevation Myocardial Infarction.

Thrombotic thrombocytopenic purpura (TTP) is a multisystem disease characterized by disseminated thrombus formation in the arterioles and capillaries. Patients usually present with weakness, subtle mental changes, fever, and acute kidney injury. Cardiac symptoms, such as chest pain or arrhythmia, have been reported but were rarely the sole presenting symptom. We report the case of a 68-year-old woman with acute non-ST-elevation myocardial infarction who was found to have TTP. Prompt diagnosis of TTP is essential because traditional approaches to manage an acute coronary event, inclusive of dual antiplatelet therapy and percutaneous coronary intervention, might be contraindicated due to an increased risk of bleeding. Early administration of steroids and urgent initiation of plasmapheresis to improve platelet count would be crucial initial steps in the management of these patients.

Cryoballoon vs radiofrequency ablation of atrial fibrillation: insights from the Veterans Healthcare System.

PURPOSE: Catheter ablation is considered the mainstay treatment for drug-refractory atrial fibrillation (AF). The aims of our study were to compare the efficacy and safety of the most two currently approved approaches (point-by-point radiofrequency ablation (RFA), either with contact force (CF) or without contact force (nCF) catheters, and cryoballoon ablation (CBA)) in the Veterans Healthcare System. METHODS: We performed a retrospective study of patients who underwent ablation for treatment of AF at the veterans affairs healthcare system between 2013 and 2018. Only the first reported ablation procedure was included. RESULTS: We included 956 patients in the study (97.4% males, 91.5% Caucasians, 67% paroxysmal AF), with 682 patients in RFA-nCF, 139 in RFA-CF, and 135 in CBA. Thirty-day complication rates were comparable between the three groups with the exception of higher incidence of phrenic nerve injury in CBA group when compared to RFA-nCF (2.2% vs 0.0%, p < 0.01). Long-term recurrence rate of AF was significantly lower in the CBA group when compared to RFA-nCF (33.3% vs 47.7%, adjusted HR 0.60, 95% CI 0.44-0.83, p < 0.01). On the other hand, it was similar between RFA-CF and RFA-nCF groups (43.9% vs 47.7%, adjusted HR 1.01, 95% CI 0.76-1.33, p 0.97). After stratifying patients based on AF type, these findings were only present in patients with paroxysmal AF. CONCLUSION: CBA for paroxysmal AF, in male dominant patients' population, was associated with lower incidence of AF recurrence rate while having a comparable safety profile to RFA independent of the use of CF catheters.

Nivolumab-induced immune-mediated neurotoxicity in Hodgkin lymphoma.

Nivolumab, a monoclonal antibody against programmed cell death-1 used to treat multiple cancers, has fewer side effects than traditional chemotherapy but has displayed a propensity to cause a host of immune-related adverse events. We describe a case of nivolumab immune-mediated neurotoxicity in a 42-year-old Hispanic man with relapsed Hodgkin lymphoma who presented with unilateral facial droop, dysarthria, and dysphagia 1 week after receiving nivolumab. His symptoms rapidly improved with steroids, intravenous immunoglobulin, and infliximab.

Cocaine Use and Pulmonary Hypertension.

Evidence linking cocaine to the risk of pulmonary hypertension (PH) is limited and inconsistent. We examined whether cocaine use, in the absence of other known causes of PH, was associated with elevated systolic pulmonary artery pressure (sPAP) and increased probability of PH. We compared patients with documented cocaine use to a randomly selected age, sex, and race-matched control group without history of cocaine use. All participants had no known causes of PH and underwent echocardiography for noninvasive estimation of sPAP. We used routinely reported echocardiographic parameters and contemporary guidelines to grade the probability of PH. In 88 patients with documented cocaine use (mean age ± standard deviation 51.7 ± 9.5 years), 33% were women and 89% were of Black race. The commonest route of cocaine use was smoking (74%). Cocaine users compared with the control group had significantly higher sPAP (mean ± standard deviation, 30.1 ± 13.1 vs 22.0 ± 9.8 mm Hg, p <0.001) and greater likelihood of PH (25% vs 10%, p = 0.012). In multivariable analyses adjusted for potential confounders including left ventricular diastolic dysfunction, cocaine use conferred a fivefold greater odds of echocardiographic PH (p = 0.006). Additionally, a stepwise increase in the likelihood of PH was noted across cocaine users with negative or no drug screen on the day of echocardiography to cocaine users with a positive drug screen (multivariable p for trend = 0.008). In conclusion, cocaine use was associated with a higher sPAP and an increased likelihood of echocardiographic PH with a probable acute-on-chronic effect.

A comparison of anti-arrhythmic efficacy of carvedilol vs metoprolol succinate in patients with implantable cardioverter-defibrillators.

BACKGROUND: The effects of carvedilol and metoprolol succinate on appropriate and inappropriate implantable cardioverter defibrillator (ICD) therapy in patients with heart failure with reduced ejection fraction (HFrEF) are not fully understood. HYPOTHESIS: The hypothesis of our study is possible carvedilol superiority over metoprolol in patients with ICD. METHODS: All patients with ICD registered to a single device clinic between 1/2012 and 6/2017 (n = 569) were identified. Patients with systolic heart failure (left ventricular ejection fraction ≤40%) treated with carvedilol vs metoprolol succinate were compared. Primary endpoint was difference in survival free of appropriate device therapy (shock or anti-tachycardia pacing, ATP). Secondary endpoints were freedom from inappropriate therapy (shock or ATP) and all cause death. RESULTS: A total of 225 patients were included in the analysis with median follow up of 57 months (IQR 33.7-90). The 2 groups were comparable in the baseline characteristics. Carvedilol was superior to metoprolol succinate in improving survival free of appropriate ICD therapy (HR 0.42; 95% CI 0.24-0.72, P = 0.01). This difference was driven by reduction in survival free of appropriate shocks (HR 0.30; 95% CI 0.15-0.63, P = -0.01) while there was no significant difference in appropriate ATP (HR 0.55; 95% CI 0.28-1.1, P = 0.12). There was no significant difference in time to inappropriate shocks (HR 1.02; 95% CI 0.19-5.6, P = 0.97), inappropriate ATP (HR 0.93, OR 0.24-3.5, p value 0.9) or all cause death (HR 0.8; 95% CI 0.42-1.5, P = 0.52). CONCLUSIONS: This study suggests that carvedilol use was associated with improved survival free of appropriate ICD therapy compared to metoprolol succinate in patients with HFrEF.

Multiple admissions to the coronary care unit due to falsely elevated cardiac troponin.

The measurement of cardiac troponin, released from injured cardiomyocytes, is of paramount importance in the diagnosis of acute myocardial infarction. Elevated troponin can be encountered, however, in patients with cardiomyopathy, significant cardiac arrhythmias, vasculitis, right-sided heart strain, critical systemic illnesses, stroke, drug toxicity (such as Adriamycin), poisons (such as snake venoms), renal failure, seizure, and rhabdomyolysis. If the clinical picture is not consistent with any of these causes, a false-positive result should be considered. We herein describe a 94-year-old man with a prior history of coronary artery disease who presented with altered mental status and was found to have a persistently high troponin level resulting in three admissions to the coronary care unit for various noncardiac complaints. Because of discordance between clinical and laboratory data, immunological interference due to heterophile antibodies in the locally used assay (AccuTnI+3, Beckman Coulter) was suspected. The same serum sample tested on a different assay (Elecsys Troponin I Assay, Roche) resulted in an undetectable cardiac troponin I level, thus confirming the diagnosis.

Predetermined Anti-Diabetic Drug Regimen Adjustments during Ramadan Fasting: An Observational Study of Safety.

BACKGROUND: Many Muslim type 2 diabetes mellitus (T2DM) patients choose to fast the month of Ramadan despite the possible adverse health effects brought about by the change in dietary habits, among other things. Clinical data regarding the safety of multi-drug regimens during fasting are particularly scarce. The aim of the study was to evaluate the safety of a drug protocol devised by the authors to accommodate Ramadan's dietary changes, involving dose adjustments of four anti-diabetic drug regimens in T2DM patients fasting Ramadan. METHODS: In this prospective, observational, open-label study, 301 T2DM patients who wished to fast Ramadan were followed during Ramadan and the preceding month. The incidence of hypoglycemia, diabetic ketoacidosis (DKA) and non-ketotic hyperosmolar state (NKHS) was monitored. Patients were classified into four groups: A group (those taking metformin, sulfonylurea and insulin [n=33]); B group (metformin and sulfonylurea [n=89]); C group (metformin and insulin [n=96]); and D group (premixed 70/30, glargine or regular insulin [n=82]). During Ramadan, drug doses were adjusted as percentages of their pre-Ramadan values: 75% for sulfonylureas, 75% for glargine, 75% for premixed insulin 70/30 in two doses, and 75% for regular insulin. Metformin was adjusted to a twice-daily regimen. RESULTS: No cases of DKA or NKHS were reported. Hypoglycemia occurred at a lower rate than pre-Ramadan values in groups C, and D; and a similar rate in groups A, and B. CONCLUSION: The data suggested that using the above protocol to adjust the doses of anti-diabetic drugs is safe in T2DM patients in regards to hypoglycemia, DKA, and NKHS.