A Review of Commonly Prescribed Antiarrhythmics: Primer for Primary Care Providers, a Case Based Approach.

The incidence of atrial fibrillation has been steadily increasing as our average population continues to age. In addition, many patients with structural heart disease are on antiarrhythmic drugs for prevention of ventricular tachycardia. General practitioners have a large role in co-management of patients with cardiac disease. The general understanding of common antiarrhythmic drugs and underlying mechanism is pivotal to safely prescribe and follow up of patients as they have potent side effects and drug interactions that needs careful consideration. The decision of which antiarrhythmic medication to use should be personalized, as each patient has a variety of co-morbid conditions that may affect the selection of which drug therapy. The ideal use of antiarrhythmic drugs should focus on understanding the basic pharmacology of the medication. This manuscript is not meant to be an in-depth overview of antiarrhythmic therapy, but rather a review of the commonly used antiarrhythmic drugs to assist primary care practitioners on when to consider antiarrhythmic drugs best suited for their patients. Class I and class III antiarrhythmic drugs will be the focus in this manuscript.

Clinical factors associated with physician choice of femoral versus radial access: A real-world experience from a single academic center.

OBJECTIVES: To analyze clinical factors associated with operator's preference in selection of femoral versus radial access for angiography and percutaneous intervention (PCI) procedures. BACKGROUND: There has been an increase in radial access in cardiac catheterization and PCI in the last few decades. METHODS: Data from 11 226 consecutive cardiac catheterization procedures were collected from Sanford University Medical Center (University of South Dakota, Sanford School of Medicine) from 2011 to 2015. RESULTS: In the overall cases, clinical factors that favored upfront femoral access include patients presenting as ST-elevation myocardial infarction (STEMI) or emergent, coronary artery bypass graft, body mass index (BMI) <30 kg/m2 and age ≥70 years, whereas morbidly obese patients (BMI ≥35) and age <70 favored upfront radial access. Radial access in the overall group had lower fluoroscopy time (6.5 vs 8.4 min, P < 0.0001) and lower contrast use (68.8 vs 80.6 cc, P < 0.0001). In the PCI group, efficacy of upfront radial access is less evident with radial fluoroscopy time (10.1 vs 11.0 min, P < 0.0028) and contrast use being higher in radial group (113.8 vs 108.2 cc, P < 0.037). Interventional cardiologists were more efficient in diagnostic cases than non-interventional cardiologists. CONCLUSION: STEMI or emergent cases and elderly patients favor upfront femoral access. As BMI increases and age decreases, radial access is progressively favored. In diagnostic cases, radial access appears to be superior to femoral access in efficacy, but the distinction is less obvious in PCI and STEMI or emergent cases.

Single Coronary Artery Arising from the Right Sinus of Valsalva and the Role of Coronary Computed Tomography Angiography.

There are many variations of coronary anatomy encountered during coronary angiogram. Anatomy demonstrating a single coronary artery is a rare congenital coronary artery anomaly. The entire heart is supplied solely by a coronary artery with single coronary ostium. We present a rare case of single coronary artery arising from the right sinus of Valsalva. The patient had presented with atypical chest pain and a stress test was performed, which was abnormal. We proceeded with coronary angiography which showed a common ostium of the right and left coronary artery coming from the right coronary cusp. The coronary computed tomography angiography revealed the left main had a pre-pulmonic course, crossing the base of the heart and passing anterior to the pulmonary artery and then branching into the left anterior descending artery and left circumflex artery. Patients with single coronary artery usually has benign prognosis; however, a specific coronary anomaly may result in myocardial ischemia and sudden cardiac death if the anomalous coronary artery takes an intra-arterial course, running between the aorta and the pulmonary artery. Coronary computed tomography angiography is a useful imaging modality to identify anatomical course of coronary anomaly.

A Case of an Acute Myocardial Infarction Post Thrombolytic Treatment of Ischemic Stroke - A Management Dilemma.

Acute ischemic stroke and myocardial infarction are emergency clinical events that require prompt intervention. Concurrent occurrence of both events magnifies the complexity of the clinical management. We present a case of a patient who presented with acute ischemic stroke, complicated by acute myocardial infarction shortly after thrombolytic was administered. This case highlights the importance of individualization of management especially in complex cases where there are no clear specific guidelines to follow.

Simultaneous Onset of Deep Vein Thrombosis, Pulmonary Embolism, Cerebral Infarction, and Myocardial Infarction in a Patient with Patent Foramen Ovale.

Paradoxical embolism is a known complication with intra-cardiac shunts. It should be considered in the differential as the pathophysiologic mechanism of simultaneous thromboembolism in the venous and systemic vasculature. We present a case of simultaneous deep venous thrombosis, pulmonary embolism and myocardial infarction in the presence of a confirmed patent foramen ovale on echocardiography. Thrombolytic therapy was administered. Subsequent concerns of intracranial hemorrhage on imaging of the brain complicated the management and added to the challenge of co-managing the clot burden in our patient. This rare presentation highlights the importance of multisystem evaluation in making the best medical decision for the patient.

A Case of Fulminant Hepatic Failure Secondary to Congestive Heart Failure Without Evidence of Acute Cardiac Decompensation.

There are so far only a few reported cases of acute fulminant hepatic failure resulting from acute cardiomyopathy. This is a rare occurrence, especially in patients that do not exhibit any signs and symptoms of acute cardiac decompensation. We report a case of fulminant liver failure with nondiagnostic work up for the common causes of liver failure. This patient had concurrent history of congestive heart failure, but did not have acute decompensation. Right upper quadrant sonogram revealed hepatomegaly of 15 cm, trace amount of perihepatic ascites, pericholecystic fluid, and also thickened edematous gallbladder wall with no stones, no common bile duct stones, and no portal vein thrombosis. Echocardiogram revealed dilated left atrium and ventricle, severe mitral regurgitation, severe tricuspid regurgitation, grade 4 diastolic dysfunction, diffuse hypokinesis of left ventricle, and severely and newly reduced systolic function with an ejection fraction of 10 percent (decreased from 25 percent on last ECHO 18 months prior). Liver biopsy demonstrated marked centrilobular hepatocyte necrosis and dropout accompanied by congestion, some areas of bridging necrosis and focal confluent necrosis which was suggestive of severe congestive hepatopathy. With initiation of heart failure medications, liver function improved significantly.

A Primer on Bleeding Risk and Management Strategies of Newer Oral Anti Platelet Agents in Cardiovascular Disease.

Aspirin, the first antiplatelet agent, has been around since the 19th century, and is one of the most established drugs in history. With the improvement of coronary interventions in the past few decades, there has been more reliance on oral antiplatelet agents to reduce complications of in-stent restenosis/thrombosis. Clopidogrel was initially introduced in 1997, and within the past seven years, two additional oral antiplatelet agents have been approved by the U.S. Food and Drug Administration. With more potent antiplatelet agents comes increased risks of adverse effects. Physicians of all fields should be aware of the common antiplatelet agents used today, and the basic landmark trials that allowed them to be on the market today. The focus of this review article is to evaluate each oral antiplatelet drug, its brief history, relevant trials, indications and management of complications through evidence based guidelines.

Acute Stent Fracture During Balloon Post Dilation of an Everolimus Eluting Stent.

Coronary artery stent fracture is a well described complication during percutaneous intervention, with rates ranging from 0.84 to 8.4 percent in first generation drug eluting stents. Complications of stent fractures usually present with symptoms of acute coronary syndrome or progressive angina days, months to years after initial implantation. We present a case of an acute stent fracture during post balloon dilation of an everolimus eluting stent at a critical stenosis junction of a saphenous vein graft to the first diagonal of the left anterior descending artery. A shorter oversized drug eluting stent was placed to cover the stent fracture with good angiographic results. To our knowledge, this is the first incidence in literature of an acute stent fracture in a saphenous vein graft.

Review of Acute Coronary Syndromes: Diagnosis and Management of ST-Elevation Myocardial Infarction.

Acute coronary syndrome is a life-threatening event that affects millions of people each year and accounts for a big portion of hospital visits. With an ever-growing elderly patient population, ischemic heart disease is more prevalent than ever before. It is paramount that physicians of all fields are cognizant of the various presentations of acute coronary syndrome (ACS), as its prompt diagnosis and treatment profoundly decreases mortality and morbidity. Under the American College of Cardiology Foundation and the American Heart Association, guidelines are published for the optimal management of patients with acute coronary syndromes. Guidelines are continuously evolving as more multicenter randomized trials, new medications and new technologies continue to change the way we treat acute coronary syndromes. The focus of this review is ST-elevation myocardial infarction and it provides answers to some of the fundamental questions through evidence-based guidelines.

Review of acute coronary syndromes: diagnosis and management of unstable angina and non ST-elevation myocardial infarction.

Coronary artery disease (CAD) is the leading cause of death in the U.S. Acute coronary syndrome (ACS), in specific, unstable angina (UA) and a non ST-elevation myocardial infarction (NSTEMI) are life threatening conditions that need prompt diagnosis and treatment. This is the second part of a two-part review series that aims to discuss the different types of ACS. The focus of this review is UA/NSTEMI, and it provides answers to some of the fundamental questions through evidence-based guidelines.

Mechanical Valve Thrombosis on Rivaroxaban: Are Novel Anticoagulants Really an Option?

This is a case of a 54-year-old female with a history of mechanical aortic valve replacement who presented in cardiogenic shock. Her primary care provider started her on rivaroxaban for anticoagulation therapy. An urgent transesophageal echocardiogram revealed a significant gradient and thrombosis on one leaflet of the valve that was immobile. Given that she was not a surgical candidate, she underwent thrombolysis. However, she later died due to complications from the thrombotic valve. The utility of target-specific oral anticoagulants has yet to be established in clinical practice.

Sinus Venosus Atrial Septal Defect Complicated by Eisenmenger Syndrome and the Role of Vasodilator Therapy.

Sinus venosus atrial septal defect is a rare congenital, interatrial communication defect at the junction of the right atrium and the vena cava. It accounts for 5-10% of cases of all atrial septal defects. Due to the rare prevalence and anatomical complexity, diagnosing sinus venous atrial septal defects poses clinical challenges which may delay diagnosis and treatment. Advanced cardiac imaging studies are useful tools to diagnose this clinical entity and to delineate the anatomy and any associated communications. Surgical correction of the anomaly is the primary treatment. We discuss a 43-year-old Hispanic female patient who presented with dyspnea and hypoxia following a laparoscopic myomectomy. She had been diagnosed with peripartum cardiomyopathy nine years ago at another hospital. Transesophageal echocardiography and computed tomographic angiography of the chest confirmed a diagnosis of sinus venosus atrial septal defect. She was also found to have pulmonary arterial hypertension and Eisenmenger syndrome. During a hemodynamic study, she responded to vasodilator and she was treated with Ambrisentan and Tadalafil. After six months, her symptoms improved and her pulmonary arterial hypertension decreased. We also observed progressive reversal of the right-to-left shunt. This case illustrates the potential benefit of vasodilator therapy in reversing Eisenmenger physiology, which may lead to surgical repair of the atrial septal defect as the primary treatment.