Ventricular Tachycardia Storm in a Young Adult Post-ALCAPA Repair.

Anomalous left coronary artery to pulmonary artery (ALCAPA) is a leading cause of pediatric myocardial ischemia. This paper presents a case of a young man presenting with ventricular tachycardia storm 18 years after ALCAPA repair. Clinicians should recognize the risk of ventricular tachycardia in this patient population.

Exploring Armenian Ethnicity as an Independent Risk Factor for Cardiovascular Disease: Findings from a Prospective Cohort of Patients in a County Hospital.

OBJECTIVES: While several studies have examined the risk of cardiovascular disease (CVD) in larger racial and ethnic groups within the United States, limited information is available on smaller sub-populations, such as Armenians, with high rates of CVD in their home country. This study examined the association between Armenian ethnicity and a positive exercise treadmill test (ETT). DESIGN: Prospective cohort study of patients at a 377-bed county hospital in Los Angeles, California from 2008-2011. SETTING: All patients were interviewed at the time of ETT to assess their cardiovascular risk factors at the cardiac laboratory of the hospital. PARTICIPANTS: 5,006 patients between 18-89 years of age, of whom 12.6% were of Armenian ethnicity and 54.4% were female.Main Outcome Measure: ETT results as a proxy for CVD risk. RESULTS: After adjusting for cardiovascular risk factors, Armenian ethnicity was significantly associated with higher odds of positive ETT (OR = 1.40, p = 0.01). Known coronary artery disease CAD (OR = 2.28, p < 0.01), hyperlipidemia (OR = 1.37, p < 0.01), and hypertension (OR = 1.24, p = 0.05) were significantly associated with higher odds of a positive ETT. In subgroup analyses, hyperlipidemia was the only significant predictor of positive ETT (OR = 1.92, p = 0.02) among Armenians, while patient history of CAD (OR = 2.49, p < 0.01), hyperlipidemia (OR = 1.29, p = 0.03), and age (OR = 1.04, p < 0.01) were significant predictors among non-Armenians. Armenian ethnicity remained associated with higher odds of positive ETT (OR = 1.40, p < 0.01) when patients with CAD were excluded. CONCLUSION: Armenian ethnicity may be an independent risk factor for CVD, influenced by the uniformity of the genetic pool and cultural and dietary exposures.

Heterogeneity of treatment effect in SPRINT by age and baseline comorbidities: The greatest impact of intensive blood pressure treatment is observed among younger patients without CKD or CVD and in older patients with CKD or CVD.

The Systolic Blood Pressure Intervention Trial (SPRINT), a large randomized controlled trial funded by the National Institutes of Health, randomized 9361 patients with hypertension over 50 years of age and at least one cardiovascular risk factor to intensive (SBP < 120 mm Hg) or standard (SBP < 140 mm Hg) blood pressure treatment. The trial found a significant reduction in primary cardiovascular and mortality outcomes in the intensive treatment group. We performed an IRB-approved post hoc analysis of the SPRINT trial data, recently made available through the NEJM SPRINT Data Analysis Challenge. Our subgroup analysis stratified subjects by age (≥75 years vs. <75 years) and presence or absence of pre-existing chronic kidney disease (CKD) or cardiovascular disease (CVD). We found that intensive blood pressure control was associated with a significantly lower rate of the primary CVD outcome and all-cause mortality in subjects age <75 years with no prior CVD or CKD and in subjects age ≥75 years with pre-existing CVD or CKD.

Treatment of Chagas Disease in the United States.

PURPOSE OF REVIEW: Chagas disease (CD) is endemic to much of Latin America, but also present in the United States (U.S.). Following a lengthy asymptomatic period, CD produces serious cardiac or gastrointestinal complications in 30-40% of people. Less than 1% of the estimated six million cases in the Americas, including 326,000-347,000 in the U.S., are diagnosed. Infected persons are typically unaware and the bulk of clinicians are unfamiliar with current treatment guidelines. This review provides U.S. and other clinicians with the latest knowledge of CD treatment. RECENT FINDINGS: Chagas cardiomyopathy (CCM) causes severe fibrosis and autonomic damage in the myocardium. Eliminating the parasite through antitrypanosomal therapy with benznidazole, a nitroimidazole derivative or nifurtimox, a nitrofuran compound, potentially prevents heart failure and other sequelae of advanced CCM. Benznidazole, recently approved by the U.S. Food and Drug Administration (FDA) for children 2-12 years old, is the first-line therapy; optimal dosages are currently being studied. Antitrypanosomal therapy prevents congenital transmission; produces high cure rates for acute, congenital, and early chronic cases; and improves clinical outcomes in adult chronic indeterminate cases. However, this benefit was not observed in a large clinical trial that included patients with advanced CCM. SUMMARY: Treatment with antitrypanosomal drugs can cure CD in acute, congenital, and early chronic cases and provides improved clinical outcomes for chronic indeterminate cases. This treatment should be offered as early as possible, before advanced CCM develops.

"Cationic" Suzuki-Miyaura Coupling with Acutely Base-Sensitive Boronic Acids.

Fast, base-promoted protodeboronation of polyfluoroaryl and heteroaryl boronic acids complicates their use in Suzuki-Miyaura coupling (SMC) because a base is generally required for catalysis. We report a "cationic" SMC method using a PAd3-Pd catalyst that proceeds at rt in the absence of a base or metal mediator. A wide range of sensitive boronic acids, particularly polyfluoroaryl substrates that are poorly compatible with classic SMC conditions, undergo clean coupling. Stoichiometric experiments implicate the intermediacy of organopalladium cations, which supports a long-postulated cationic pathway for transmetalation in SMC.

The Prevalence of Chagas Disease Among Latin American Immigrants with Pacemakers in Los Angeles, California.

AbstractChagas disease (CD), with associated conduction abnormalities, is a common indication for pacemaker implantation in Latin America. The prevalence of CD in Latin American immigrants with pacemakers residing in the United States has never been studied. This single-center cross-sectional study included pacemaker patients who were aged 18 years or more with a previous residence in Latin America for at least 6 months. Patients with an implantable cardioverter-defibrillator, cardiac resynchronization therapy, or iatrogenic and/or congenital heart block were excluded. Serological testing for Trypanosoma cruzi was performed at enrollment. A total of 80 patients were enrolled, and CD was diagnosed in six patients (7.5%). Patients with CD were more likely to be from El Salvador (P = 0.001). Other clinical, therapeutic, electrocardiographic, and echocardiographic variables were similar between the CD and non-CD groups. There is a high prevalence of CD among Latin American immigrants with pacemakers in Los Angeles.

Prevalence of Chagas Disease in a U.S. Population of Latin American Immigrants with Conduction Abnormalities on Electrocardiogram.

Chagas disease (CD) affects over six million people and is a leading cause of cardiomyopathy in Latin America. Given recent migration trends, there is a large population at risk in the United States (US). Early stage cardiac involvement from CD usually presents with conduction abnormalities on electrocardiogram (ECG) including right bundle branch block (RBBB), left anterior or posterior fascicular block (LAFB or LPFB, respectively), and rarely, left bundle branch block (LBBB). Identification of disease at this stage may lead to early treatment and potentially delay the progression to impaired systolic function. All ECGs performed in a Los Angeles County hospital and clinic system were screened for the presence of RBBB, LAFB, LPFB, or LBBB. Patients were contacted and enrolled in the study if they had previously resided in Latin America for at least 12 months and had no history of cardiac disease. Enzyme-linked immunosorbent assay (ELISA) and immunofluorescence assay (IFA) tests were utilized to screen for Trypanosoma cruzi seropositivity. A total of 327 consecutive patients were screened for CD from January 2007 to December 2010. The mean age was 46.3 years and the mean length of stay in the US was 21.2 years. Conduction abnormalities were as follows: RBBB 40.4%, LAFB 40.1%, LPFB 2.8%, LBBB 5.5%, RBBB and LAFB 8.6%, and RBBB and LPFB 2.8%. Seventeen patients were positive by both ELISA and IFA (5.2%). The highest prevalence rate was among those with RBBB and LAFB (17.9%). There is a significant prevalence of CD in Latin American immigrants residing in Los Angeles with conduction abnormalities on ECG. Clinicians should consider evaluating all Latin American immigrant patients with unexplained conduction disease for CD.

Autochthonous Transmission of Trypanosoma Cruzi in Southern California.

Trypanosoma cruzi usually infects humans via triatomine insects in Latin America. Vector-borne transmission in the United States is exceedingly rare. We describe (1) the first case of probable autochthonous transmission reported in California in more than 30 years and (2) the first ever reported case in the greater Los Angeles area.

Normal Variants in Echocardiography.

Echocardiography is a powerful and convenient tool used routinely in the cardiac evaluation of many patients. Improved resolution and visualization of cardiac anatomy has led to the discovery of many normal variant structures that have no known pathologic consequence. Importantly, these findings may masquerade as pathology prompting unnecessary further evaluation at the expense of anxiety, cost, or potential harm. This review provides an updated and comprehensive collection of normal anatomic variants on both transthoracic and transesophageal imaging.

Safety Profile of Nifurtimox for Treatment of Chagas Disease in the United States.

BACKGROUND: Nifurtimox is 1 of only 2 medications available for treating Chagas disease (CD) and currently the only drug available in the United States, but its safety and tolerance have not been extensively studied. This is the first study to evaluate tolerance of nifurtimox in US patients with CD. METHODS: This investigation assessed side effects in a sample of 53 patients with CD, all Latin American immigrants, who underwent treatment with nifurtimox (8-10 mg/kg in 3 daily doses for 12 weeks) from March 2008 to July 2012. The frequency and severity of adverse events (AEs) was recorded. RESULTS: A total of 435 AEs were recorded; 93.8% were mild, 3.0% moderate, and 3.2% severe. Patients experienced a mean of 8.2 AEs; the most frequent were anorexia (79.2%), nausea (75.5%), headache (60.4%), amnesia (58.5%), and >5% weight loss (52.8%). Eleven patients (20.8%) were unable to complete treatment. Experiencing a moderate or severe AE (odds ratio [OR], 3.82; P < .05) and Mexican nationality (OR, 2.29; P < .05) were significant predictors of treatment discontinuation, but sex and cardiac progression at baseline were not. Patients who did not complete treatment experienced nearly 3 times more AEs per 30-day period (P = .05). CONCLUSIONS: Nifurtimox produces frequent side effects, but the majority are mild and can be managed with dose reduction and/or temporary suspension of medication. The high frequency of gastrointestinal symptoms and weight loss mirrors results from prior investigations. Special attention should be paid during the early stages of treatment to potentially severe symptoms including depression, rash, and anxiety.

Prevalence and Impact of Chagas Disease Among Latin American Immigrants With Nonischemic Cardiomyopathy in Los Angeles, California.

BACKGROUND: Chagas disease is a well-known cause of cardiomyopathy in Latin America; however, 300 000 individuals are estimated to have Chagas disease in the United States. This study examined the prevalence and impact of Chagas cardiomyopathy (CCM) in a US population. We hypothesized that patients with CCM would have increased morbidity and mortality when compared with patients with non-CCM. METHODS AND RESULTS: This is a single-center, prospective cohort study. Enrollment criteria were new diagnosis of nonischemic cardiomyopathy (left ventricular ejection fraction ≤40%) and previous residence in Latin America for at least 12 months. Serological testing for Trypanosoma cruzi was performed at enrollment. The primary end point was all-cause mortality or heart transplantation. The secondary end point was heart failure-related hospitalization. A total of 135 patients were enrolled, with a median of 43 months of follow-up. Chagas disease was diagnosed in 25 (19%) patients. The primary end point occurred in 9 patients (36%) in the CCM group and in 11 patients (10%) in the non-CCM group (hazard ratio [HR], 4.46; 95% confidence interval, 1.8-10.8; P=0.001). The secondary end point occurred in 13 patients (52%) in the CCM group and in 35 patients (32%) in the non-CCM group (HR, 2.22; 95% confidence interval, 1.2-4.2; P=0.01). CONCLUSIONS: There is a high prevalence of Chagas disease among Latin American immigrants diagnosed with nonischemic cardiomyopathy in Los Angeles. Advanced CCM portends a poor prognosis and is associated with increased all-cause mortality/heart transplantation and heart failure-related hospitalization.

Chagas disease awareness among Latin American immigrants living in Los Angeles, California.

Approximately 300,000 persons have Chagas disease in the United States, although almost all persons acquired the disease in Latin America. We examined awareness of Chagas disease among Latin American immigrants living in Los Angeles, California. We surveyed 2,677 persons (age range = 18-60 years) in Los Angeles who resided in Latin America for at least six months. A total of 62% of the participants recalled seeing triatomines in Latin America, and 27% of the participants reported triatomine bites at least once per year while living abroad. A total of 86% of the participants had never heard of Chagas disease. Of persons who had heard of Chagas disease, 81% believed that it was not serious. More than 95% of those who had heard of Chagas disease would want to be tested and treated. Most Latin American immigrants living in Los Angeles recalled exposure to vectors of Chagas disease. However, they have little knowledge of this disease. Increasing awareness of Chagas disease is needed in this high-risk population.

Comparison of the racial/ethnic prevalence of regular aspirin use for the primary prevention of coronary heart disease from the multi-ethnic study of atherosclerosis.

In 2002, the United States Preventive Services Task Force and the American Heart Association recommended aspirin for the primary prevention of coronary heart disease in patients with Framingham risk scores ≥ 6% and ≥ 10%, respectively. The regular use of aspirin (≥ 3 days/week) was examined in a cohort of 6,452 White, Black, Hispanic, and Chinese patients without cardiovascular disease in 2000 to 2002 and 5,181 patients from the same cohort in 2005 to 2007. Framingham risk scores were stratified into low (<6%), increased (6% to 9.9%), and high (≥ 10%) risk. In 2000 to 2002 prevalences of aspirin use were 18% and 27% for those at increased and high risk, respectively. Whites (25%) used aspirin more than Blacks (14%), Hispanics (12%), or Chinese (14%) in the increased-risk group (p <0.001). Corresponding prevalences for the high-risk group were 38%, 25%, 17%, and 21%, respectively (p <0.001). In 2005 to 2007 prevalences of aspirin use were 31% and 44% for those at increased and high risk, respectively. Whites (41%) used aspirin more than Blacks (27%), Hispanics (24%), or Chinese (15%) in the increased-risk group (p <0.001). Corresponding prevalences for the high-risk group were 53%, 43%, 38%, and 28%, respectively (p <0.001). Racial/ethnic differences persisted after adjustment for age, gender, diabetes, income, and education. In conclusion, regular aspirin use in adults at increased and high risk for coronary heart disease remains suboptimal. Important racial/ethnic disparities exist for unclear reasons.