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Introduction and importance: Chest pain is a frequent reason patients seek medical attention. The broad spectrum of potential etiologies makes determining the underlying cause of chest pain complex. Among cardiovascular etiologies, aortitis is a rare but life-threatening possibility that should be considered in the differential diagnosis. Case presentation: A 53-year-old female with a history of smoking presented with progressively worsening chest and epigastric pain over several weeks. She had seen multiple physicians previously for the same symptoms with unremarkable work-ups. Physical examination was notable for severe tenderness upon palpation of her lower abdomen. The electrocardiogram and troponins were unremarkable. Computed tomography of the abdomen revealed aneurysmal dilatation of the abdominal aorta, soft tissue thickening, and surrounding inflammatory stranding, consistent with aortitis. Infectious and autoimmune work-ups were unremarkable. Intravenous steroids were initiated, and her symptoms improved significantly. Her aortitis was attributed to inflammation secondary to chronic smoking. Clinical discussion: Aortitis is a rare condition with varied clinical presentations. Etiologies of aortitis include infection and non-infectious inflammation. Diagnosis of aortitis requires a thorough clinical assessment and prompt imaging of the aorta, with computed tomography being the preferred imaging modality. Conclusion: Evaluation for cardiovascular chest pain must extend beyond an electrocardiogram and troponin level. Imaging should be considered in patients with atypical symptoms. Aortitis is a rare but important diagnosis requiring immediate treatment.
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The incidence of takotsubo stress cardiomyopathy (TSCM) in males is low compared with females. Gender-based differences in clinical outcomes of TSCM are not well characterized. The aim of this meta-analysis was to analyze whether gender-based differences are observed in TSCM clinical outcomes. A comprehensive literature search of PubMed, Embase, Cochrane Library database, and Web of Science was performed from inception to June 20, 2022, for studies comparing the clinical outcomes between male and female patients with TSCM. The primary outcome of interest was in-hospital all-cause mortality and cardiogenic shock. The secondary outcomes were cardiovascular mortality, receipt of mechanical ventilation, intra-aortic balloon pump, occurrence of ventricular arrhythmia, and left ventricular thrombus. A random-effects model was used to calculate the risk ratios (RR) and confidence intervals (CI). Heterogenicity was assessed using the Higgins I2 index. Twelve observational studies involving 51,213 patients (4,869 males and 46,344 females) were included in the meta-analysis. Male gender was associated with statistically significant higher in-hospital all-cause mortality compared with females in patients with TSCM (RR 2.17, 95% CI 1.77 to 2.67, p <0.001). The rate of cardiogenic shock was significantly higher in males with TSCM compared with females (RR 1.66, 95% CI 1.29 to 2.12, p <0.001). Our meta-analysis showed a difference in the clinical outcomes of TSCM between men and women. Male gender was associated with a two-fold greater in-hospital all-cause mortality risk compared with female gender. The higher mortality risk associated with male gender deserves further study, particularly whether it represents later recognition of the condition and disparities in treatments.
Subject(s)
Shock, Cardiogenic , Takotsubo Cardiomyopathy , Female , Humans , Male , Incidence , Sex Characteristics , Sex Factors , Shock, Cardiogenic/etiologyABSTRACT
Cardiovascular complications contribute to approximately 40% of all COVID-19-related deaths. Thrombosis in COVID-19 infection is a well-known phenomenon, and the spectrum of thromboembolic diseases related to COVID-19 is wide, with venous thromboembolism being the most common manifestation. We describe a case of myocardial infarction with nonobstructive coronary arteries (MINOCA) that developed in the setting of mild COVID-19 infection. Our case illustrates how COVID-19 can present with MINOCA and highlights the importance of cardiac magnetic resonance imaging in identifying the underlying etiology.
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BACKGROUND: Patients with diabetes mellitus (DM) have a high prevalence of coronary chronic total occlusions (CTOs). We conducted a systematic review and meta-analysis to characterize outcomes after CTO percutaneous coronary intervention (PCI) in patients without or with DM. METHODS: PubMed, EMBASE, Cochrane, and Google Scholar were queried for studies comparing non-DM vs. DM patients undergoing attempted CTO PCI. The primary outcome was all-cause mortality at longest follow-up (at least 6 months). Secondary outcomes were major adverse cardiovascular events (MACE) which is a composite endpoint including myocardial infarction, cardiac or all-cause mortality and any revascularization in patients after CTO PCI, target vessel revascularization (TVR), myocardial infarction (MI), Japanese chronic total occlusion (J-CTO) score and prevalence of multivessel (MV) CTO disease. We used a random effects model to calculate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Sixteen studies, including 2 randomized control trials and 14 observational studies, met inclusion criteria. At longest follow-up, all-cause mortality (OR 0.54 [95% CI 0.37-0.80], p < 0.0001) and MACE (OR 0.82 [95% CI 0.72-0.93], p < 0.00001) were significantly lower in non-DM CTO patients. MV CTO disease was less prevalent in patients without DM (OR 0.80 [95% CI 0.69-0.93], p = 0.004). However, there were no differences in MI, TVR and J-CTO score. CONCLUSIONS: Non-diabetics undergoing CTO PCI have lower all-cause mortality and MACE than diabetics. Future research may determine if DM control improves diabetics' CTO PCI outcomes.
Subject(s)
Coronary Occlusion , Diabetes Mellitus , Myocardial Infarction , Percutaneous Coronary Intervention , Chronic Disease , Coronary Occlusion/diagnostic imaging , Coronary Occlusion/etiology , Coronary Occlusion/therapy , Diabetes Mellitus/diagnosis , Diabetes Mellitus/epidemiology , Humans , Myocardial Infarction/etiology , Percutaneous Coronary Intervention/adverse effects , Risk Factors , Treatment OutcomeABSTRACT
BACKGROUND: Chylopericardium is the accumulation of lymphatic fluid in the pericardial cavity. It can be idiopathic or secondary to trauma, cardiothoracic surgery, neoplasm, radiation, tuberculosis, lymphatic duct dysfunction, thrombosis, or other causes. We present a case of chylopericardium due to subclavian vein thrombosis in a patient with protein S deficiency. Clinical Case. A 48-year-old man with a history of protein S deficiency presented to the emergency department with shortness of breath and a productive cough. CT of the chest showed pulmonary emboli, moderate pericardial effusion, and a large thrombus of the superior vena cava, brachiocephalic vein, and subclavian veins. He developed echocardiographic evidence of cardiac tamponade so he underwent pericardiocentesis with drainage of milky-appearing fluid. Analysis of the fluid showed elevated triglycerides consistent with chylopericardium. The pericardial effusion reaccumulated, likely secondary to lymphatic duct obstruction due to his subclavian vein thrombus. Catheter-assisted thrombolysis was performed with resolution of the patient's effusion and symptoms. CONCLUSION: Chylopericardium is a rare but important complication of subclavian vein thrombosis. Management is typically with surgical intervention, although our case represents successful treatment with catheter-assisted thrombolysis.
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Red cell distribution width (RDW) serves as an independent predictor towards the prognosis of coronary artery disease (CAD) in patients undergoing percutaneous coronary intervention (PCI). A systematic search of databases such as PubMed, Embase, Web of Science, and Cochrane library was performed on October 10th, 2019, to elaborate the relationship between RDW and in hospital and long term follow up, all-cause and cardiovascular mortality, major adverse cardiac events (MACE) and development of contrast-induced nephropathy (CIN) in patients with CAD undergoing PCI. Twenty-one studies qualified this strict selection criterion (number of patients = 56,425): one study was prospective, and the rest were retrospective cohorts. Our analysis showed that patients undergoing PCI with high RDW had a significantly higher risk of in-hospital all-cause mortality (OR 2.41), long-term all-cause mortality (OR 2.44), cardiac mortality (OR 2.65), MACE (OR: 2.16), and odds of developing CIN (OR: 1.42) when compared to the patients with low RDW. Therefore, incorporating RDW in the predictive models for the development of CIN, MACE, and mortality can help in triage to improve the outcomes in coronary artery disease patients who undergo PCI.
Subject(s)
Coronary Artery Disease , Percutaneous Coronary Intervention , Coronary Artery Disease/diagnostic imaging , Coronary Artery Disease/surgery , Erythrocyte Indices , Humans , Percutaneous Coronary Intervention/adverse effects , Prognosis , Prospective Studies , Retrospective Studies , Risk FactorsABSTRACT
BACKGROUND: Thrombocytopenia (TP) is associated with higher incidence of bleeding in the setting of percutaneous coronary intervention (PCI) leading to increased morbidity and mortality. Herein, we report a meta-analysis evaluating the effects of baseline thrombocytopenia (bTP) on cardiovascular outcomes in patients undergoing PCI. METHODS: Literature search was performed using PubMed, Embase, Cochrane library and clinicaltrials.gov from inception till October 2019. Patients were divided into two groups: Patients with (a) no Thrombocytopenia (nTP) (b) bTP before PCI. Primary endpoints were in-hospital, and all-cause mortality rates at the longest follow-up. The main summary estimate was random effects risk ratio (RR) with 95% confidence intervals (CIs). RESULTS: A total of 6,51,543 patients from 10 retrospective studies were included. There was increased in-hospital all-cause mortality (RR 2.58 [1.7-3.8], p < .001) and bleeding (RR 2.37 [1.41-3.98], p < .005), in the bTP group compared to the nTP group. There was no difference for in-hopsital major adverse cardiovascular outcomes (MACE) (RR 1.38 [0.94-2.0], p < .10), post-PCI MI (RR 1.17 [0.9-1.5], p = .19) and TVR (RR 1.65 [0.8-3.6], p = .21), respectively. Outcomes at longest follow-up showed increased incidence of all-cause mortality (RR 1.86 [1.2-2.9], p < .006) and bleeding (RR 1.72 [1.1-2.9], p = .04) in bTP group, while there was no significant difference for post-PCI MI (RR 1.07 [0.91-1.3], p = .42), MACE (RR 1.86 [0.69-1.8], p = .68) and TVR (RR 1.1 [0.9-1.2], p = .93) between both groups. CONCLUSIONS: bTP in patients undergoing PCI is associated with increased mortality and predicts risk of bleeding.
Subject(s)
Myocardial Infarction , Percutaneous Coronary Intervention , Thrombocytopenia , Humans , Percutaneous Coronary Intervention/adverse effects , Retrospective Studies , Thrombocytopenia/diagnosis , Treatment OutcomeABSTRACT
Life expectancy in the United States has increased due to advances in health care. Despite increased utilization of percutaneous coronary intervention (PCI), octogenarian patients are less likely to be referred to the catheterization laboratory for coronary interventions. This is in part due to multiple patient co-morbidities and lack of established guidelines. We examined in-hospital clinical outcomes of octogenarian and nonoctogenarian patients who underwent PCI in the United States. Using the National Inpatient Sampling database, we identified all adult patients who are older than 18 years and underwent PCI. Patient were stratified by age into 2 groups, ≥80 years old and <80 years old and in-hospital adverse outcome rates were determined. A total of 11,056,559 patients underwent PCI between the years of 2002 and 2014 and 1,544,563 patients were ≥80 years old (14%). After multivariable adjustment, patients who are ≥80 years old had higher in-hospital mortality (3.3% vs 1.3%, adjusted Odds Ratio, 1.624; 95% confidence interval, 1.602 to 1.647, p <0.0001) and longer length of stay (median length of stay days 3, range 2 to 8 days vs median 2 days, range 1 to 4 days) (p <0.0001). Patients ≥80 years old had a higher rate of cardiopulmonary complications, postprocedural stroke, acute kidney injury, postprocedural thromboembolic complications, and hemorrhage requiring transfusion. There was no difference in vascular complications between the 2 groups. In conclusion, octogenarians who underwent PCI were at increased risk for in-hospital mortality and morbidity compared with nonoctogenarians. The decision to proceed with PCI in this patient population should be individualized, taking into consideration known risk factors and patient's wishes.
Subject(s)
Coronary Artery Disease/surgery , Forecasting , Percutaneous Coronary Intervention/adverse effects , Postoperative Complications/epidemiology , Risk Assessment/methods , Age Factors , Aged , Aged, 80 and over , Female , Follow-Up Studies , Hospital Mortality/trends , Humans , Male , Middle Aged , Retrospective Studies , Risk Factors , United States/epidemiologySubject(s)
Arrhythmias, Cardiac/diagnosis , Asymptomatic Diseases/epidemiology , Death, Sudden, Cardiac/prevention & control , Electrocardiography/methods , Arrhythmias, Cardiac/physiopathology , Arrhythmias, Cardiac/prevention & control , Diagnosis, Differential , Heart Conduction System/physiopathology , Humans , Incidental Findings , Medical History Taking/methods , Patient Care Management/methods , PrevalenceABSTRACT
Amitriptyline is a widely prescribed tricyclic antidepressant (TCA) with a very concerning cardiotoxicity profile, but it is one that has not been discussed much in literature. Here, we present a case of amitriptyline toxicity presenting as myocarditis with pericardial involvement. A 21-year-old male with no previous cardiac history presented to the emergency department (ED) with a decreased level of consciousness after an amitriptyline overdose as a suicidal attempt. For concerns with airway protection, the patient was intubated and subsequently admitted to the intensive care unit (ICU). An electrocardiogram (EKG) showed sinus tachycardia, prolonged QRS complex, prolonged QTc interval, and nonspecific ST-T wave changes. Intravenous fluid resuscitation and sodium bicarbonate were administered with a target blood pH of 7.5 to 7.55. Two days later, the patient was taken off mechanical ventilation and improved clinically. However, troponin levels began to rise with a peak level of 4.08 µg/L. He then began having fevers, elevated white blood cell counts (WBCs), and elevated inflammatory markers. Transthoracic echo (TTE) revealed an ejection fraction (EF) of 45%-50%, no wall segment motion abnormalities, and a mild-to-moderate pericardial effusion. Cardiac magnetic resonance (CMR) was done, which revealed changes indicative of acute myocarditis, moderate pericardial effusion, a calculated EF of 45% with a moderate left ventricular dilation, and no coronary artery stenosis or anomalous coronary artery origin. Given the patient's age, the absence of cardiac risk factors, and the presence of an amitriptyline overdose along with his EKG, TTE, and CMR findings, we hypothesize that this myocarditis with pericardial involvement is due to amitriptyline-induced direct toxicity.
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BACKGROUND: Electrical disturbances following blunt cardiac injuries are rare but can be caused by electrical or structural damage to the heart. We present the case of a patient who had conduction abnormalities following blunt traumatic injury that were incidentally detected on telemetry. CASE REPORT: A 64-year-old female with no history of cardiac disease was brought to the emergency department after a motor vehicle collision that resulted in chest wall bruising. The patient was found to have L-spine fractures and was admitted for observation. During her hospitalization, the patient had multiple episodes of heart block. A temporary pacemaker was inserted because of the recurrent episodes, and a dual-chamber permanent pacemaker was placed on day 4 of her hospitalization. CONCLUSION: Heart block as a consequence of blunt cardiac injury is rare; however, it needs to be recognized as early as possible. Permanent pacemaker placement is usually indicated for patients with prolonged or recurrent episodes.
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BACKGROUND: The role of catheter ablation (CA) is increasingly recognized as a reasonable therapeutic option in patients with atrial fibrillation (AF) and heart failure (HF). HYPOTHESIS: We aimed to compare CA to medical therapy in AF patients with HF with reduced ejection fraction (HFrEF). METHODS: We searched the literature for randomized clinical trials comparing CA to medical therapy in this population. RESULTS: Six trials with a total of 775 patients were included. AF was persistent in 95% of patients with a mean duration of 18.5 ± 23 months prior enrollment. The mean age was 62.2 ± 7.8 years, mostly males (83%) with mean left ventricular ejection fraction (LVEF) of 31.2 ± 6.7%. Compared to medical therapy, CA has significantly improved LVEF by 5.9% (Mean difference [MD] 5.93, confidence interval [CI] 3.59-8.27, P < 0.00001, I2 = 87%), quality of life, (MD -9.01, CI -15.56, -2.45, P = 0.007, I2 = 47%), and functional capacity (MD 25.82, CI 5.46-46.18, P = 0.01, I2 = 90%). CA has less HF hospital readmissions (odds ratio [OR] 0.5, CI 0.32-0.78, P = 0.002, I2 = 0%) and death from any cause (OR 0.46, CI 0.29-0.73, P = 0.0009, I2 = 0%). Freedom from AF during follow-up was higher in patients who had CA (OR 24.2, CI 6.94-84.41, P < 0.00001, I2 = 81%. CONCLUSION: CA was superior to medical therapy in patients with AF and HFrEF in terms of symptoms, hemodynamic response, and clinical outcomes by reducing AF burden. However, these findings are applicable to the very specific patients enrolled in these trials.
Subject(s)
Atrial Fibrillation/surgery , Catheter Ablation , Heart Failure/physiopathology , Stroke Volume , Ventricular Function, Left , Aged , Anti-Arrhythmia Agents/therapeutic use , Atrial Fibrillation/diagnosis , Atrial Fibrillation/mortality , Atrial Fibrillation/physiopathology , Catheter Ablation/adverse effects , Comorbidity , Female , Heart Failure/diagnosis , Heart Failure/mortality , Heart Failure/therapy , Humans , Male , Middle Aged , Randomized Controlled Trials as Topic , Risk Factors , Treatment OutcomeABSTRACT
BACKGROUND: The current guidelines recommend empirical therapy with DAPT of aspirin and clopidogrel for six months after TAVR. This recommendation is based on expert consensus only. Giving the lack of clear consensus on treatment strategy following TAVR. Goal of this meta-analysis is to assess the efficacy and safety of mono-antiplatelet therapy (MAPT) versus dual antiplatelet therapy (DAPT) following transcatheter aortic valve replacement (TAVR). METHODS AND MATERIALS: We performed a meta-analysis from randomized clinical trials (RCTs) and prospective studies that tested DAPT vs. MAPT for all-cause mortality and major bleeding of 603 patients. The primary efficacy outcomes were 30â¯days mortality and stroke. The primary safety outcomes were major bleeding and major vascular complications. RESULTS: We included 603 patients from 4 studies. The use of MAPT was associated with similar mortality rate (5.9% vs. 6.6%; RRâ¯=â¯0.92; 95% CI 0.49-1.71; Pâ¯=â¯0.68) and stroke rate compared with DAPT (1.3% vs. 1.3%; RR 1.04; 95% CI 0.27 to 4.04; Pâ¯=â¯0.81). There was no difference in major vascular complication (4.2% vs. 8.9%; RR 0.52; 95% CI 0.23 to 1.18; Pâ¯=â¯0.17) or minor vascular complication (4.2% vs. 7.3%; RR 0.58; 95% CI 0.25 to 1.34; Pâ¯=â¯0.14). However, MAPT was associated with significantly less risk of major bleeding (4.9% vs. 14.5%; RR 0.37; 95% CI 0.20 to 0.70; Pâ¯<â¯0.01) but no difference in minor bleeding (4.2% vs. 3.6%; RR 1.16; 95% CI 0.43 to 3.10; Pâ¯=â¯0.85). CONCLUSION: MAPT use after TAVR is associated with lower rates of major bleeding compared with DAPT with no significant difference in mortality, stroke or vascular complications.
Subject(s)
Platelet Aggregation Inhibitors/administration & dosage , Transcatheter Aortic Valve Replacement , Aged , Aged, 80 and over , Drug Therapy, Combination , Female , Hemorrhage/chemically induced , Humans , Male , Platelet Aggregation Inhibitors/adverse effects , Randomized Controlled Trials as Topic , Risk Factors , Stroke/epidemiology , Time Factors , Transcatheter Aortic Valve Replacement/adverse effects , Transcatheter Aortic Valve Replacement/mortality , Treatment Outcome , Vascular Diseases/epidemiologySubject(s)
Esophagus/pathology , Hematemesis/etiology , Rare Diseases , Superior Mesenteric Artery Syndrome/complications , Superior Mesenteric Artery Syndrome/diagnostic imaging , Tomography, X-Ray Computed , Duodenum/pathology , Endoscopy, Digestive System , Female , Humans , Middle Aged , Radiography, Abdominal , Rare Diseases/diagnostic imaging , Ulcer/diagnosisABSTRACT
[This corrects the article DOI: 10.1155/2015/927438.].