Cardiac arrest in the setting of probable catastrophic antiphospholipid syndrome in young patient with a history of COVID infection and polyglandular disorder-Case report.

Antiphospholipid syndrome is an autoimmune disorder characterized by arterial and venous thrombosis and recurrent spontaneous abortions due to the persistent presence of antiphospholipid antibodies. Probable Catastrophic antiphospholipid (Catastrophic antiphospholipid-like syndrome) is a life-threatening presentation of antiphospholipid syndrome which manifests as intravascular thrombosis, leading to rapid onset of symptoms and involvement of multiple organ systems. We present a case of a 28-year-old woman with a history of polyglandular autoimmune syndrome, systemic lupus erythematosus, provoked bilateral deep vein thrombosis in the setting of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection 2 years prior, and hypothyroidism who presents with a cardiac arrest in the setting of an acute ST-elevation myocardial infarction with thromboembolic occlusion of two coronary arteries simultaneously in the setting of noncompliance with anticoagulation for the past 1 week. Her presentation was further complicated by acute hypoxic respiratory failure due to diffuse alveolar hemorrhage during the hospital course with progressive multiorgan failure and eventual death. Catastrophic antiphospholipid is associated with high morbidity and mortality, thus a timely diagnosis and multidisciplinary approach to management is needed for evaluation and management.

A Case Report on Uremic Toxins and Their Effects on Cardiac Rhythm: Understanding Junctional Ventricular Escape Rhythm in Renal Failure.

Understanding the reasons behind junctional ventricular escape rhythm is crucial for guiding the clinical management of patients. Various factors such as acidosis, hyperkalemia, metabolic toxins, digoxin toxicity, and BRASH syndrome (comprising bradycardia, renal failure, atrioventricular (AV) nodal blockade, shock, and hyperkalemia) should be considered when dealing with a symptomatic unstable patient in a hospital. In this case, we present an example where metabolic toxins, specifically uremia, in combination with other factors, lead the patient to enter a ventricular escape rhythm, ultimately resulting in cardiogenic shock. The main objective of this case study is to illustrate how uremic metabolic acidosis contributes to AV nodal blockade, leading to a junctional ventricular escape rhythm within the context of BRASH.

Beyond Syncopal Episodes: A Complicated Hyperkalemic Emergency Manifesting As Complete Heart Block and Seizure Versus Convulsive Syncope Cascade.

We present a case involving an 87-year-old woman who had a hyperkalemic emergency. This condition was further complicated by complete heart block (CHB) and seizure-like activity. This case emphasizes the challenge of differentiating between seizures and convulsive syncope. Achieving an accurate diagnosis is essential for determining the appropriate medical treatment. This case report highlights the various symptoms and complications associated with hyperkalemia, emphasizing the importance of conducting a thorough examination to explore other potential causes. Additionally, it emphasizes the usefulness of the head-upright tilt test (HUTT) as a method to differentiate convulsive syncope from seizures, particularly in cases involving vagal stimulation.

The Implementation of Renal Denervation in the Management of Resistant Hypertension Despite Use of Multitherapy Antihypertensives at Maximally Tolerated Doses: A Contemporary Literature Review.

Refractory hypertension is highly prevalent among the hypertensive population, and current clinical management has failed to provide optimal control for these individuals. This subtype of arterial hypertension is defined as a persistently elevated systolic blood pressure reading of 140 mmHg, or higher, despite multiple antihypertensive use at maximally tolerated dosing. These patients have an elevated risk of cardiovascular and renal complications, urging for the need of more effective therapeutic management. Renal sympathetic efferent nerves have been noted to play an important role in volume and blood pressure homeostasis. Before the implementation of oral antihypertensives, the use of surgical lumbar sympathectomy for the reduction of persistent hypertension was considered a life-saving approach. However, individuals were left with debilitating side effects, such as postural hypotension, syncope, and impotence. A new and minimally invasive technique has been proposed, where the kidneys undergo selective denervation in hopes of providing decreased cardiovascular morbidity and mortality for patients with resistant hypertension. Some studies demonstrated promising outcomes with a reduction in blood pressure, a decrease in medication reliance, and a potential long-lasting effect of the procedure with an overall improvement in cardiovascular health. Unfortunately, most of the available data was obtained from observational, uncontrolled studies with short-term follow-up, small sample sizes, and high variability in blood pressure measurement. Therefore, further evidence is needed to determine whether renal denervation provides long-term benefits for blood pressure control and improves outcomes for mortality and cardiovascular events in this patient population.

Unraveling the Link Between Fibromuscular Dysplasia and Acute Coronary Syndrome: A Comprehensive Case Report and Analysis.

We present a rare case of fibromuscular dysplasia (FMD) manifesting in the mid to distal segment of the left anterior descending (LAD) artery, which led to the development of acute coronary syndrome (ACS) in our patient, highlighting the severe consequences of this vascular disorder. During the investigation of the patient's clinical symptoms, an unexpected incidental finding emerged, indicating bilateral FMD involvement of the renal arteries. This serendipitous discovery underscores the importance of comprehensive evaluation and thorough exploration when managing patients with FMD. We aim to shed light on the intriguing nature of FMD and emphasize the need for vigilant assessment to identify potential multi-vessel abnormalities, even beyond the primary affected site. We also aim to highlight the coronary artery manifestation of FMD as ACS and discuss its medical management.

Tracheal Diverticulum Mimicking Pneumomediastinum: A Case Report Emphasizing the Importance of Differential Diagnosis in Chest Imaging Evaluation.

A tracheal diverticulum (TD) is a generally benign medical condition, where there is an outpouching of the tracheal wall. Additionally, it is generally asymptomatic but there have been reported cases of adverse outcomes linked to TD. Here we present a case of a tracheal diverticulum that was incidentally found during the workup for stroke in a patient. Moreover, due to its radiologic appearance, there was concern for pneumomediastinum. We highlight the presentation and clinical importance of TD owing to the complications one is predisposed to from having this condition.

The Liver-Heart Connection: A Literature Review of Liver Disease as a Risk Factor for Atrial Fibrillation.

Atrial fibrillation (AFib) is a common type of cardiac arrhythmia, characterized by disorganized atrial electrical activity with features of irregularly irregular heart rhythm and often with rapid ventricular response increasing the risk of stroke and heart failure due to tachyarrhythmia. The pathophysiology mechanism of AFib is either triggered by atrial distension, abnormality in conducting system, catecholamine excess, or increased atrial irritation or automaticity. Risk factors include uncontrolled diabetes, obesity, obstructive sleep apnea, hypothyroidism, and certain stimulants. Based on recent research, liver disease has recently been identified as a risk factor for AFib. Considering the progression of chronic liver disease, this literature review aims to investigate and summarize the relationship between liver disease and AFib and explore clinical interventions that can be utilized to prevent AFib aggravation.

An Unfortunate Miss of Undiagnosed Arterial Ischemic Stroke (AIS) in the Setting of Diabetic Ketoacidosis in an Adult: A Case Report.

We present the case of a 43-year-old male with a history of poorly controlled type II diabetes who presented with altered mental status, urinary incontinence, and diabetic ketoacidosis (DKA). Initial brain imaging studies were negative for acute intracranial pathology; however, the next day, the patient was found to have left-sided paralysis. Repeat imaging studies revealed a right middle cerebral artery infarct with hemorrhagic conversion. Given that the rate of reported strokes in the setting of DKA in adults is limited, this case report affirms to discuss the importance of prompt recognition, evaluation, and adequate treatment of DKA to prevent neurological complications, as well as the pathophysiology behind the etiology of DKA-induced stroke. This case also underscores the importance of early recognition and missed strokes in the emergency department (ED) and emphasizes the need for stroke evaluation in patients with altered mental status even though an alternative diagnosis is apparent to avoid anchor bias.

The Comparative Assessment of Wellens' Syndrome With Proximal Left Anterior Descending Artery (LAD) Stenosis Versus Right Coronary Artery (RCA) or Circumflex Coronary Artery Stenosis and Its Prevalence: A Systematic Review.

Wellens' syndrome is well-known for its critical stenosis of the proximal left anterior descending artery (LAD) with characteristic electrocardiographic findings of biphasic or deeply inverted T waves in V2-V6 under specific diagnostic criteria. Although the syndrome is known as a high-grade LAD lesion, its sequence of events can also be seen with the right coronary artery (RCA) and the left circumflex artery (LCX). This systemic review attempts to expand on these findings while analyzing the prevalence of Wellens' syndrome with the RCA and/or the circumflex artery. This study also comparatively indicated that Wellens' syndrome is seen in RCA and circumflex artery stenoses when present; the indication of the same medical management is warranted for effective treatment and survival. We extracted and analyzed 24 case reports each with an atypical presentation of acute coronary syndrome (ACS) and specific Wellens' syndrome pattern of electrocardiogram (ECG) presentation with critical stenosis in the LAD, RCA, and left circumflex artery. The risk of bias assessment was undertaken using internal risk analysis by utilizing medical libraries and certain search phrases to find research articles with the involvement of the LAD as opposed to the RCA and LCX in Wellens' syndrome. Based on the number of respective primary research articles found, a bias calculation was done on the reported respective coronary artery involvement. The finding of our systemic review confirms that Wellens' syndrome is a precordial lead disease with T wave abnormalities that present with critical stenosis of not only the LAD but also the RCA and circumflex artery. The result of our systemic review affirmed that although most Wellens' syndrome cases reported involve the stenosis of the LAD, the critical occlusion of the RCA and/or the circumflex artery was found with Wellens' syndrome pattern of ECG presentation, meaning that the sequence of events is not limited to the proximal LAD.

Sudden Cardiac Arrest in Patient With Ventricular Septal Defect and Marijuana Consumption: A Case Report and Review of Literature.

This case report presents a detailed analysis of a 28-year-old woman who experienced sudden cardiac arrest (SCA). The patient had a history of marijuana consumption and was also diagnosed with a congenital ventricular septal defect (VSD) with no prior intervention or treatment. VSD is a common acyanotic congenital heart disease, which poses a constant risk of premature ventricular contractions (PVCs). During the evaluation, the patient's electrocardiogram PVCs and a prolonged QT interval were revealed. This study highlights the risk associated with the administration or consumption of drugs that can prolong the QT interval in patients with VSD. It also indicates that patients with VSD and who have a history of marijuana consumption should be cautioned about the risk of arrhythmias causing SCA due to prolonged QT interval caused by the cannabinoid. This case emphasizes the requirement of cardiac health monitoring in individuals with VSD and caution while prescribing medications that can affect the QT interval leading to life-threatening arrhythmias.

The Relevance of Preventive Implantable Cardioverter-Defibrillators (ICDs) in Non-Ischemic Cardiomyopathy in the Presence of Effective Quadruple Therapy for Heart Failure: A Review of Contemporary Medical Literature.

Cardiomyopathy is a disease of the cardiomyocytes that affects their structural function, leading to heart failure (HF). Non-ischemic cardiomyopathy (NICM) includes a subtype of dilated cardiomyopathy (DCM), restrictive cardiomyopathy (RCM), and hypertrophic cardiomyopathy (HCM). These types of cardiomyopathies have no coronary artery vessel involvement. The most common cause of NICM is DCM. In the ischemic cardiomyopathy (ICM) subtype, the utilization of implantable cardioverter-defibrillators (ICDs) has been effective in the prevention of sudden cardiac death (SCD). However, the relevance of ICDs in patients with NICM having an ejection fraction (EF) ≤35%, who are also receiving effective quadruple therapy (i.e., angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB), beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 (SGLT2) inhibitors) for HF has been a topic of debate. The purpose of this review is to analyze the benefits of preventive ICDs in NICM patients on adequate quadruple therapy for HF. The current guidelines recommend ICD implantation in patients with NICM who have a left ventricular ejection fraction of ≤35%, come under the New York Heart Association (NYHA) class II or III, and are in sinus rhythm with optimal medical therapy. The evidence supporting this recommendation is limited. Numerous clinical studies and meta-analyses have been conducted to look into this issue. While some have discovered a substantial decrease in mortality with the implantation of an ICD in patients with NICM, others have not found significant changes. Thereby, further investigations are required to define the function of ICDs in this population.

Benefit and Preference of Propranolol Over Metoprolol in Thyrotoxicosis-Induced Atrial Fibrillation: A Case Report and Review of Literature.

Atrial fibrillation is a common manifestation seen in patients with hyperthyroidism and thyroid storm. The presence of excess thyroid hormone (TH) alters adrenergic receptors in the heart and blood vessels, thereby causing an increase in sympathetic function and atrial fibrillation as a sequela of this excess circulating hormone. Excess thyroid hormone (T3) shortens the action potential of cardiomyocytes in the pulmonary vein, which facilitates the generation of reentrant circuits causing atrial fibrillation. Thyroid hormone can regulate cardiac beta-adrenergic receptor expression leading to enhanced catecholamine sensitivity of beta-adrenergic coupled cardiac response. We present a case of a 64-year-old female with a history of hypertension (HTN), nonobstructive coronary artery disease (CAD), congestive heart failure (CHF) [ejection fraction (EF) 35-40%], chronic obstructive pulmonary disease (COPD) on long-term oxygen therapy (LTO2), obstructive sleep apnea (OSA)/hypoventilation syndrome, atrial flutter/atrial fibrillation with a loop recorder on rivaroxaban, and obesity who presented to the emergency department (ED) with gastroenteritis symptoms precipitating difficulty breathing and atrial fibrillation with a rapid ventricular response (HR 140-150) requiring ICU admission for rate and rhythm control. During the course of hospitalization, she was treated with an amiodarone infusion, which induced thyrotoxicosis and increased the ectopic electrical activity in the atrium, worsening atrial fibrillation. On day 3, amiodarone was stopped, and IV esmolol and metoprolol tartrate PO were continued with no resolution of atrial fibrillation. The patient was transitioned to propranolol, which achieved adequate heart rate control prior to discharge. The aim of our review is to highlight that propranolol should be used over metoprolol in patients with hyperthyroidism-induced atrial fibrillation due to the effect of propranolol on blocking the activity of T4 conversion to active T3 and, as such, blocking its effect on cardiac myocytes, terminating reentrant atrial excitation.