Hyperkalemia-Induced T Wave Oversensing in an Implantable Cardioverter Defibrillator.

A 66-year-old female with end-stage renal disease and heart failure with reduced ejection fraction, status post implantable cardioverter defibrillator (ICD) presented to the emergency department with dizziness and fatigue. An electrocardiogram showed sinus rhythm, complete atrioventricular block, and ventricular paced rhythm at 30 beats per minute (bpm). Device interrogation revealed a programmed VVI mode with a lower rate limit of 40 bpm and evidence of T wave oversensing. Serologic studies were remarkable for hyperkalemia (7.9 mmol/dL). The device was initially reprogrammed to provide a higher pacing rate and symptomatic improvement. Both complete AV block and T wave oversensing resolved after correction of hyperkalemia. This case highlights the need for vigilant monitoring of electrolyte imbalances in ICD patients.

Discovery of non-HLA antibodies associated with cardiac allograft rejection and development and validation of a non-HLA antigen multiplex panel: From bench to bedside.

We analyzed humoral immune responses to nonhuman leukocyte antigen (HLA) after cardiac transplantation to identify antibodies associated with allograft rejection. Protein microarray identified 366 non-HLA antibodies (>1.5 fold, P < .5) from a discovery cohort of HLA antibody-negative, endothelial cell crossmatch-positive sera obtained from 12 cardiac allograft recipients at the time of biopsy-proven rejection. From these, 19 plasma membrane proteins and 10 autoantigens identified from gene ontology analysis were combined with 48 proteins identified through literature search to generate a multiplex bead array. Longitudinal sera from a multicenter cohort of adult cardiac allograft recipients (samples: n = 477 no rejection; n = 69 rejection) identified 18 non-HLA antibodies associated with rejection (P < .1) including 4 newly identified non-HLA antigenic targets (DEXI, EMCN, LPHN1, and SSB). CART analysis showed 5/18 non-HLA antibodies distinguished rejection vs nonrejection. Antibodies to 4/18 non-HLA antigens synergize with HLA donor-specific antibodies and significantly increase the odds of rejection (P < .1). The non-HLA panel was validated using an independent adult cardiac transplant cohort (n = 21 no rejection; n = 42 rejection, >1R) with an area under the curve of 0.87 (P < .05) with 92.86% sensitivity and 66.67% specificity. We conclude that multiplex bead array assessment of non-HLA antibodies identifies cardiac transplant recipients at risk of rejection.

Extended resuscitative endovascular balloon occlusion of the aorta (REBOA)-induced type 2 myocardial ischemia: a time-dependent penalty.

BACKGROUND: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) increases cardiac-afterload and is used for patients in hemorrhagic shock. The cardiac tolerance of prolonged afterload augmentation in this context is unknown. The aim of this study is to quantify cardiac injury, if any, following 2, 3 and 4 hours of REBOA. METHODS: Anesthetized swine (70-90 kg) underwent a 40% controlled hemorrhage, followed by supraceliac resuscitative endovascular balloon occlusion of the aorta (REBOA) for 2 (n=5), 3 (n=5), and 4 hours (n=5). High-fidelity arterial wave form data were collected, and signal processing techniques were used to extract key inflection points. The adjusted augmentation index (AIx@75; augmentation pressure/pulse pressure, normalized for heart rate) was derived for use as a measure of aortic compliance (higher ratio = less compliance). Endpoints consisted of electrocardiographic, biochemical, and histologic markers of myocardial injury/ischemia. Regression modeling was used to assess the trend against time. RESULTS: All animals tolerated instrumentation, hemorrhage, and REBOA. The mean (±SD) systolic blood pressure (mm Hg) increased from 65±11 to 212±39 (p<0.001) during REBOA. The AIx@75 was significantly higher during REBOA than baseline, hemorrhage, and resuscitation phases (p<0.05). A time-dependent rise in troponin (R2=0.95; p<0.001) and T-wave deflection (R2=0.64; p<0.001) was observed. The maximum mean troponin (ng/mL) occurred at 4 hours (14.6±15.4) and maximum T-wave deflection (mm) at 65 minutes (3.0±1.8). All animals demonstrated histologic evidence of acute injury with increasing degrees of cellular myocardial injury. DISCUSSION: Prolonged REBOA may result in type 2 myocardial ischemia, which is time-dependent. This has important implications for patients where prolonged REBOA may be considered beneficial, and strategies to mitigate this effect require further investigation. LEVEL OF EVIDENCE: II.

Inflammation, Obesity and the Metabolic Syndrome. Implications in Hispanics.

We report clinical and molecular mechanisms relating the process of inflammation involved in the progression of obesity and the metabolic syndrome, emphasizing the cardiovascular problems developed in Hispanic populations. Namely, the incidence, component characteristics and complications of obesity and metabolic syndrome in island Puerto Ricans are described and evidence is presented supporting the fact that the metabolic syndrome may be milder in Puerto Rico than in the mainland United States because it is characterized by less aggressive coronary artery disease and a relatively normal lipid profile. Moreover, data supports the fact that increased serum cholesterol levels produce less myocardial infarctions in Puerto Rico than in mainland Hispanics and Caucasians. In addition, the incidence of ventricular tachycardia, a complication caused by remodeling and ischemia of the heart, may be lower in Puerto Rico than in the United States, although the prevalence of the metabolic syndrome is higher in the island. On the other hand, there is evidence of a rising epidemic of obesity and vascular inflammation in Puerto Rico that suggests that cardiovascular morbidity and mortality in the island will continue to increase in the future decades.

Psoriasis and Coronary Artery Disease in Hispanics.

Psoriasis is an immune disorder characterized by chronic activation of systemic inflammation. Morbidity and mortality in patients with psoriasis is attributed mainly to cardiovascular disease. There are studies in Caucasians and African- Americans, but little is known about how psoriasis is associated to coronary artery disease (CAD) in Hispanics. We intend to describe the angiographic findings of a group of Puerto Rican patients with psoriasis. Retrospective cohort study of 46 patients with psoriasis were studied. Coronary angiographic reports were reviewed, and collected data was statistically analized. Population median age was 56, and 72% were males. Of the 46 patients, 27 had CAD by angiographic criteria (58.7%). Twelve patients were referred to bypass graft surgery, 8 underwent coronary stent placement, and 7 were treated medically. Whether psoriasis can be considered a risk factor for developing CAD is still on debate. More than 50% of our patients with psoriasis had angiographic evidence of CAD. Adjusting for traditional cardiovascular risk factors, we found no significant association (p>0.05) with CAD. We believe that inflammation plays a contributing role in the increased risk of CAD in these patients. The importance of this study relies on being the first retrospective analysis in a group of Hispanics trying to determine an association between coronary artery disease and psoriasis when in Puerto Rico, coronary artery disease is 30% less than in the United States.

Coronary levels of angiotensin-II and endothelin-I in diabetic patients with and without coronary artery disease.

Two groups of patients were studied to find out the levels of angiotensin-II and endothelin-I in the coronary and peripheral circulation. Group A consisted of eight patients with diabetes mellitus type 2 and coronary artery disease; and Group B with diabetes mellitus without coronary artery disease. Significant differences were found between Group A and B in the levels of both peptides peripherally and intracoronary. This shows the importance of these peptides in the origin of coronary artery disease and progression of the disease in diabetics with coronary artery disease.

Celiac trunk and branches dissection due to energy drink consumption and heavy resistance exercise: case report and review of literature.

Higher doses and consumption of energy drinks leads to cardiovascular effects and potential consequences. Principal components found in energy drinks such as caffeine, guarana and taurine has been related to dilatation, aneurysm formation, dissection and ruptures. There is no evidence showing an integration of these components and its effects in endothelium and aortic walls due to higher levels of pressure during exercises. We report a case of a 44 years male with celiac trunk and branches dissection due to long-term consumption of energy drinks and intense exercise routine. Our proposition relates cell and vessel walls alterations including elasticity in endothelial wall due to higher blood pressure, resistance by intense exercise routine and long-term consumption of energy drinks.

Metabolic Changes After Roux-N-Y Bariatric Surgery In Hispanics.

The objective was to describe the metabolic outcomes 12 months after bariatric surgery (Roux-N-Y) in morbidly obese Hispanic patients, and evaluate the correlation between weight loss and the observed changes. Medical records from a hundred-and-two Hispanic obese patients who underwent bariatric surgery were identified at the University of Puerto Rico (UPR) Hospital. The following variables were obtained before and 12 months after surgery: Body Mass Index (BMI), body weight, total cholesterol (TC), triglycerides, high density lipoprotein (HDL), low density lipoprotein (LDL), and fasting blood sugar (FBS). Ninety-seven percent of patients underwent Roux-N-Y surgery; 79.4% were females and 44% were diabetics. We observed statistically significant reductions (p < 0.05) 12 months after surgery in: BMI -14.3 (± 6.2) kg/m2, weight -86.1 (± 34.4) Ibs, TC -17.9 (± 32.4) mg/dL, triglycerides -28.7(± 40.6) mg/dL, LDL-15.4 (± 30.6) mg/dL, and FBS -11.3 (± 23.5) mg/dL. HDL, instead increased +5.22 (± 12.9) mg/dL (p < 0.0006). Gastric bypass surgery of the Roux-N-Y significantly improves the lipid profile and FBS levels in obese Hispanic patients. The poor correlation factor between weight loss and these variables suggests that other mechanisms, independent from weight loss, are responsible for these changes.

Magnesium: the forgotten electrolyte.

UNLABELLED: Magnesium (Mg++), Potassium (K+) and Calcium (CA++) are important electrolytes in keeping a stable electrical status. The purpose of this study was to measure them in critically ill patients. METHODS: We evaluated the electrolytes in 28 consecutive patients. Eighteen were females and 10 males with mean age of 62 +/- 5 years. RESULTS: The admission diagnosis in 95% of the cases was congestive heart failure. Sixty-four percent of the patients had subnormal values of Mg++, 53% subnormal values of K+, and 28% subnormal values of CA++. Fourteen percent showed lower values of the three electrolytes and 35% only of Mg++ and K+ concomitantly. Twenty-eight percent showed prolonged QTC interval. All patients with prolonged QTC interval had low Mg++ and K+ levels. Twenty five percent of the patients showed atrial fibrillation, 25% ventricular tachycardia, and 3% junctional tachycardia. The ventricular tachycardia group had more electrolyte abnormalities than those with atrial fibrillation. None of the patients received Mg++ replacement during critical management while 50% received K+ replacement. CONCLUSION: This data shows physician overlook the Importance of Mg++ and K+ deficiency in critically ill patients.

Ethnicity and genetics are more important than diabetes mellitus and hypertension in producing cardiovascular events in patients with the metabolic syndrome: emphasis in the Puerto Rico population.

Metabolic syndrome is a cluster of risk factors for cardiovascular disease that affects an estimated 50 million Americans. The present article reviews the metabolic syndrome with respect to its definition, epidemiology, pathophysiology and management. A primary focus in research has been to elucidate the processes determined to cause insulin resistance, the fundamental mechanism underlying the metabolic syndrome. Namely, the incidence, component characteristics and complications of the metabolic syndrome in the island of Puerto Rico are described alongside the fact that the metabolic syndrome may be milder in Puerto Rico than in the mainland United States because it is characterized by less aggressive coronary disease and a relatively normal lipid profile. This suggests that the cardiovascular complications are more influenced by genetics and culture than diabetes mellitus and hypertension.

Incidence, in-hospital case-fatality rates, and management practices in Puerto Ricans hospitalized with acute myocardial infarction.

OBJECTIVE: There are extremely limited data on minority populations, especially Hispanics, describing the clinical epidemiology of acute coronary disease. The aim of this study is to examine the incidence rate of acute myocardial infarction (AMI), in-hospital case-fatality rate (CFR), and management practices among residents of greater San Juan (Puerto Rico) who were hospitalized with an initial AMI. METHODS: Our trained study staff reviewed and independently validated the medical records of patients who had been hospitalized with possible AMI at any of the twelve hospitals located in greater San Juan during calendar year 2007. RESULTS: The incidence rate (# per 100,000 population) of 1,415 patients hospitalized with AMI increased with advancing age and were significantly higher for older patients for men (198) than they were for women (134). The average age of the study population was 64 years, and women comprised 45% of the study sample. Evidence-based cardiac therapies, e.g., aspirin, beta blockers, ACE inhibitors/angiotensin receptor blockers, and statins, were used with 60% of the hospitalized patients, and women were less likely than men to have received these therapies (59% vs. 65%) or to have undergone interventional cardiac procedures (47% vs. 59%) (p<0.05). The in-hospital CFR increased with advancing age and were higher for women (8.6%) than they were for men (6.0%) (p<0.05). CONCLUSION: Efforts are needed to reduce the magnitude of AMI, enhance the use of evidence-based cardiac therapies, reduce possible gender disparities, and improve the short-term prognoses of Puerto Rican patients hospitalized with an initial AMI.

Heart tumors in Puerto Rico de novo atrial fibrillation as clinical presentation in a subgroup of patients.

OBJECTIVE: Primary cardiac tumors are rare neoplasms in humans, of which the most common is the atrial Myxoma. The objective of this study was to find the incidence of these tumors at the Heart Center of Puerto Rico and the Caribbean. METHODS: This study was approved by the Institutional Review Board of the Medical Sciences Campus University of Puerto Rico to review the records at the Heart Center of patients with heart tumors in the last 14 years. RESULTS: The sample consists of 55 patients (78.9% were females and 24.1% were male) with a median age of 52 years. Sixty-five percent of patients lived in rural areas. Clinical presentations included shortness of breath (43.1%), chest pain (37.9%), asymptomatic (25%), palpitations (20.7%), neurologic symptoms (10.3%) and dizziness (6.9%). Electrocardiographic findings included normal sinus rhythm (53.4%), non-specific ST-T changes (32.8%), sinus tachycardia (20.7%), left atrial enlargement (10.3%) and atrial fibrillation (8.6%). A subgroup presenting with atrial fibrillation prior to diagnosis had left atrial myxoma. The tumors found, in descending order of frequency are: left atrial myxoma, right atrial myxoma, papillary fibroelastoma, hamartoma, lipoma and rhabdomyoma. We found a correlation between large left atrial myxoma and atrial fibrillation. CONCLUSION: The most frequent heart tumor was atrial myxoma. The larger myxomas were associated with atrial fibrillation.

Gender disparities in Puerto Ricans hospitalized with an initial acute myocardial infarction: A population-based perspective.

OBJECTIVE: The published literature suggests differences in presenting symptoms for acute myocardial infarction (AMI), management, and outcomes according to gender and age. However, limited information exists on this topic among Hispanics. METHODS: In Puerto Rican patients hospitalized with an initial AMI, we examined differences in presenting symptoms, effective cardiac therapies, and in-hospital mortality as a function of gender and age groups. We reviewed the medical records of patients hospitalized with a validated AMI in 12 greater San Juan, Puerto Rico hospitals during 2007. RESULTS: The average age of 1,415 patients hospitalized with a first AMI was 66 years and 45 % were women. Chest pain (81%) was the most prevalent acute presenting symptom with significant differences in its frequency between women (77%) and men (85%)(p<0.001). Right arm pain, shortness-of-breath/dyspnea, and sweating/ diaphoresis were most prevalent in patients 55-64 years old (45%), compared with patients 75 years and older (29%)(p<0.005). Relative to men and patients < 55 years old, coronary angiography/thrombolytic therapy and percutaneous coronary interventions were used less frequently in women and older patients (>75 years old). During hospitalization for AMI the in-hospital death rate was higher in women (8.6%) than men (6.0%), and increased with advancing age (p<0.05). CONCLUSION: These findings suggest significant gender and age differences in presenting symptoms, management, and early mortality in Puerto Ricans hospitalized with an initial AMI. It remains of considerable importance that health care personnel become aware of these gender and age differences to improve the management and outcomes of these patients.

Metabolic syndrome among Puerto Ricans and other Hispanic populations.

Metabolic syndrome is a cluster of risk factors for cardiovascular disease that affects an estimated 50 million Americans. The present article reviews this syndrome with respect to its definition, epidemiology, pathophysiology, and management. A primary focus in research has been to elucidate the processes that have been determined to cause insulin resistance, the fundamental mechanism underlying metabolic syndrome; these processes are reviewed here along with the interplay of the syndrome with the renin-angiotensin system, circadian rhythm, and atherosclerosis. Lifestyle changes promoting exercise and a healthy diet can reduce the incidence and prevent the progression of metabolic syndrome; however, refractory cases may warrant drug therapy. Recent emphasis has been placed on targeting obesity and insulin resistance as new therapeutic modalities are developed. In this manuscript, the incidence, component characteristics, and complications of metabolic syndrome in island-living Puerto Ricans and other Hispanic populations are described. The fact that island patients suffering from the syndrome tend to have less aggressive coronary disease and relatively normal lipid profile compared to their stateside counterparts is also discussed.

Higher incidence of atrial fibrillation in the metabolic syndrome: a Hispanic population study.

UNLABELLED: The metabolic syndrome is probably one of the main medical problems in developing countries. Purpose of this investigation was to study the metabolic syndrome at the Puerto Rico and Caribbean Cardiovascular Center with emphasis on the cardiovascular complications. MATERIALS/METHODS: The medical charts in the last six years of the metabolic syndrome were evaluated at the PRCCC. RESULTS: One Hundred and Seventy-Three patients met the consensus criteria of the metabolic syndrome. The mean age was 60 years. Fifty-seven percent were males and 42% females. The mean body mass was 30 kg/m. The ejection fraction was subnormal (49 +/- 8%). The end systolic dimension of the left atrium was increased (45 +/- 10mm) when compared to normal. The incidence of atrial fibrillation was 16%. CONCLUSIONS: The metabolic syndrome in this sub-group of Hispanics, showed a higher incidence of atrial fibrillation without ventricular tachycardia. This is probably related to abnormal left ventricular and atrial function.

Basiliximab and heart transplantation in Hispanics: the experience in Puerto Rico.

BACKGROUND: Induction immunotherapy in addition to standard triple therapy at the time of cardiac transplantation with cytolytic antibodies has been used in recipients with pre transplant renal impairment, and to prevent rejection. Recently, anti-interlukin-2 receptor monoclonal antibodies have been used for these purposes. A retrospective study of 58 heart transplant recipients was conducted to assess the effect of basiliximab, a chimeric anti-interlukin-2 receptor monoclonal antibody on biopsy proven acute rejection, serum creatinine, creatinine clearance, hospitalizations due to infection and mortality one year after transplantation. METHODS: A total of 58 heart transplant patient's charts were reviewed. All patients received triple immunosuppressive therapy with cyclosporine or tacrolimus, mycophenolate mofetil and prednisone post transplant. Basiliximab 20 mg on day 0 and day 4 was administered as induction therapy in a subgroup of patients. Both groups had similar pre transplant characteristics. Analysis was performed at intervals of 0-17 weeks, 18-34 weeks, 35-52 weeks, and one year overall. The incidence of acute rejection episodes, post-transplant renal function, patient survival and hospitalizations due to infection was analyzed. RESULTS: Twenty-seven patients received induction therapy with basiliximab and 31 patients did not. Basiliximab induction helped reduce acute rejection overall during the first year, with 22 episodes of rejection in the induction group, and 67 episodes in the no induction group. In the 0-17 weeks following transplantation there were 20 reported rejection episodes in the induction group versus 58 rejection episodes in the no-induction group, demonstrating also reduction of rejection by induction in this group. Basiliximab induction group had preserved renal function, with higher creatinine clearance at 1 year when compared to the no induction group. There were no differences between groups in terms of hospitalizations due to infections or mortality. CONCLUSION: Induction therapy with basiliximab significantly reduced the number of acute rejection within the first year after heart transplantation, without a negative impact on patient's renal function, risk of infection or mortality.

Syncope in Puerto Rico.

Syncope is defined as a transient loss of consciousness with an inability to maintain postural tone that is followed by spontaneous recovery. Syncope is a prevalent disorder, accounting for 1-3% of emergency department visits and up to 6% of hospital admissions each year in the United States. The medical records of patients admitted at the Cardiovascular Center of Puerto Rico and the Caribbean after an episode of syncope were reviewed. The characteristics of this population and the etiologies of syncope were analyzed. One hundred and eighty six patients were identified with a primary diagnosis of syncope. A specific etiology was identified in 77.5% of the population studied whereas 22.6% had an unknown or unidentifiable cause. Cardiac syncope is associated with an increased mortality. Cardiac syncope was diagnosed in 60.8% of the evaluated patients. Although many etiologies for syncope exist, recent studies suggest categorization into cardiac, noncardiac, and unknown groupings for the purposes of future risk stratification.

Coronary artery abnormalities in Puerto Rico.

A retrospective study was done to determine the frequency of coronary artery anomalies in terms of their origin, course, and structure. The clinical history, catheterization data and surgical reports of patients undergoing coronary angiography at the Cardiovascular Center of Puerto Rico and the Caribbean, from 1999 to 2004, were analyzed. Thirty-eight patients were identified with a coronary artery anomaly in this population. These anomalies were classified according to their clinical consequences and the need for surgical intervention.

Heart transplantation in females: the experience in Puerto Rico.

BACKGROUND: Heart transplantation is the procedure of choice for a selected group of patients with end stage heart disease. Gender related differences have been observed in the heart transplant field: less women than men are recipients of heart transplants, more risk of rejection in female recipients, and a perception toward reduced survival in women. We report our experience of heart transplantation in females in Puerto Rico. METHODS: We studied the data bank of 69 heart transplant recipients in the Puerto Rico Heart Transplant Program from June 1999 to June 2005. Gender related differences in the number of recipients: males or females, incidence of rejection, survival, and other outcomes were analyzed. RESULTS: 69 patients received an orthotopic heart transplant from June 1999 to June 2005, in a single center in Puerto Rico. The mean age of the patients was 47 (11-62) years. Fifty patients (72%) were men, and 19 patients (28%), were women. Survival in the female group at 3 months, 1, 2, 3, 4, and 5 years was 100%, 100%, 100%, 100%, 90%, and 90% respectively. The survival in the male group at 3 months, 1, 2, 3, 4 and 5 years was 97%, 97%, 97%, 94%, 86 and 79% respectively. There was an early, higher incidence of rejection in women during the first three months post transplant; 1.5 vs. 0.75, (P=0.04) episodes per patient in the female, and male group respectively. After the third month post transplant there was no significant difference in rejection incidence. The incidence of infectious episodes was significantly more frequent in female than in male recipients, 2.8 vs. 1 (P=0.02) per patient respectively. CONCLUSIONS: There were more male than female heart transplant recipients at a ratio of 3:1, without a significant gender difference in survival. The risk of rejection was higher in females in the early period post transplantation, but thereafter this risk showed no signinificant statistical difference. The incidence of infection was more frequent in female than in male recipients.

Effects of Enalaprilat on Regional Wall Stress in Patients with Angina Pectoris.

Left ventricle (LV) cineventriculograms silhouettes in the right anterior oblique projection with simultaneous pressure micromanometry were assessed before and 10 min after administration of 1.25 mg enalaprilat intravenously to 10 patients with angina pectoris undergoing diagnostic cardiac catheterization. Cineventriculograms were divided into 20 areas using a modified Leighton's method for segmentalization of the LV and computed by the Janz's method for regional wall stress. Enalaprilat reduced preload and afterload in all cases. There was significant reduction in regional wall stress in 15 of the 20 segments after enalaprilat administration compared with baseline analysis. Segments without significant reduction in wall stress wee apical. There was significant reduction in global wall stress after enalaprilat. Thus, enalaprilat, in addition to improve hemodynamics decreasing both preload and afterload, reduces LV wall stress both regional and global. Clinical implications of these findings are in agreement with the wall stress reduction for prevention of ventricular remodeling with this agent in postinfarction patients.