Can Breaking Heroin Addiction Lead to a Broken Heart? A Case of Reverse Takotsubo Cardiomyopathy in a Patient With Heroin Withdrawal.

Reverse takotsubo cardiomyopathy is triggered by emotional or physical stress and has a presentation similar to that of acute coronary syndrome. A 39-year-old woman with a history of heroin use disorder presented with intractable nausea, vomiting, and diarrhea. She was diagnosed with heroin withdrawal and started on buprenorphine-naloxone. On day 2 of her hospitalization, she developed chest heaviness and had an elevated troponin I level of 3.2 ng/mL (reference range, 0.015-0.045 ng/mL); electrocardiography showed new T-wave inversions in the anterior and inferior leads. Emergent coronary angiography showed patent coronary arteries, and left ventriculography showed basal hypokinesis and apical hyperkinesis, consistent with reverse takotsubo cardiomyopathy secondary to heroin withdrawal. She was started on antihypertensive agents, and her buprenorphine-naloxone dose was increased. At her 3-month follow-up visit, she reported no symptoms consistent with angina or heart failure. This appears to be the first report of heroin withdrawal causing reverse takotsubo cardiomyopathy. Awareness of this association can lead to earlier recognition and treatment of reverse takotsubo cardiomyopathy.

Prevalence and outcomes of low ankle brachial index by atherosclerotic cardiovascular disease risk level: Insights from the National Health and Nutrition Examination Survey (NHANES).

BACKGROUND: Ankle brachial index (ABI) as a risk-enhancing factor in addition to the pooled cohort equation (PCE) in assessing cardiovascular risk for primary prevention of atherosclerotic cardiovascular disease (ASCVD) is uncertain. METHODS: We analyzed data from the 1999-2004 National Health and Nutrition Examination Survey (NHANES), for 5130 participants, aged 40 and older, without known cardiovascular disease or diabetes, with available data on standard ASCVD risk and ABI. Prevalence of low ABI (ABI<0.9) and all-cause mortality in persons with low, borderline and intermediate ASCVD risk categories using PCE was assessed. RESULTS: The overall prevalence of low ABI was 3.1%. The participants with low ABI were predominantly clustered in the intermediate (33%) and high (33%) ASCVD risk categories while most participants with a normal ABI were in the low (56%) and intermediate (23%) risk categories. All-cause mortality was higher among participants with low ABI compared to those with a normal ABI in both the intermediate/borderline and high-risk categories, p<0.001 but not in the low-risk ASCVD category, p = 0.323. CONCLUSIONS: Using the PCE, two-third of the participants with low ABI were classified as having a low, borderline or intermediate risk of ASCVD. Low ABI was associated with an increased all-cause mortality in the overall cohort and specifically among those with a borderline/intermediate or high risk of ASCVD but not in those with a low risk of ASCVD. Our study supports consideration of ABI as a risk enhancer for primary prevention among patients classified as borderline or intermediate risk of ASCVD.

Cranial Dislocation of Infrarenal Aortic Endoprostheses During Transcatheter Aortic Valve Replacement.

This report describes the complexity of transcatheter aortic valve replacement in which rare complications sometimes occur, even at experienced centers. This is a case of cranial migration of an infrarenal aortic aneurysm endograft while advancing the balloon-expandable prosthesis through the infrarenal aorta, which was subsequently successfully treated by deploying a thoracic endoprosthesis after deployment of the aortic valve bioprosthesis.

Temporal trends in atherosclerotic cardiovascular disease risk among U.S. adults. Analysis of the National Health and Nutrition Examination Survey, 1999-2018.

BACKGROUND: Atherosclerotic cardiovascular diseases are a significant cause of disability and mortality. Study of trends in cardiovascular risk at a population level helps understand the overall cardiovascular health and the impact of primary prevention efforts. AIMS: To assess trends in the estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk among U.S. adults from 1999-2000 to 2017-18 with no established cardiovascular disease (CVD). METHODS AND RESULTS: Serial cross-sectional analysis of National Health and Nutrition Examination Survey (NHANES) data from 1999-2000 to 2017-18 (10 cycles), including 24 022 US adults aged 40-79 years with no reported ASCVD. ASCVD risk was assessed using the pooled cohort equations (PCEs). There was a significant temporal decline in the mean 10-year ASCVD risk from 13.5% (95% CI, 12.5-14.4) in 1999-2000 to 11.1% (10.5-11.7) in 2011-12 (Ptrend < 0.001) and to 12.0% (11.3-12.7) in 2017-2018 (overall Ptrend = 0.001), with the mean ASCVD risk score remaining stable from 2013-14 through 2017-2018 (Ptrend = 0.056). A declining trend in ASCVD risk was noted in females, non-Hispanic Blacks and those with income <3 times the poverty threshold with Ptrend of <0.001, 0.002, and 0.007, respectively. Mean total cholesterol and prevalence of smokers showed a downward trend (Ptrend <0.001 for both), whereas type 2 diabetes and mean BMI showed an upward trend (Ptrend < 0.001 for both). CONCLUSIONS: The 20-year trend of ASCVD risk among NHANES participants 40-79 years, as assessed by the use of PCE, showed a non-linear downward trend from 1999-2000 to 2017-18. The initial and significant decline in estimated ASCVD risk from 1999-2000 to 2011-12 subsequently stabilized, with no significant change from 2013-14 to 2017-18. Mean BMI and prevalence of diabetes mellitus increased while mean serum cholesterol levels and prevalence of smoking declined during the study period. Our findings support invigoration of efforts aimed at prevention of CVD, including primordial prevention of CVD risk factors.

Trends, Predictors, and Outcomes of 30-Day Readmission With Heart Failure After Transcatheter Aortic Valve Replacement: Insights From the US Nationwide Readmission Database.

BACKGROUND Data on trends, predictors, and outcomes of heart failure (HF) readmissions after transcatheter aortic valve replacement (TAVR) remain limited. Moreover, the relationship between hospital TAVR discharge volume and HF readmission outcomes has not been established. METHODS AND RESULTS The Nationwide Readmission Database was used to identify 30-day readmissions for HF after TAVR from October 1, 2015, to November 30, 2018, using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes. A total of 167 345 weighted discharges following TAVR were identified. The all-cause readmission rate within 30 days of discharge was 11.4% (19 016). Of all the causes of 30-day rehospitalizations, HF comprised 31.4% (5962) of all causes. The 30-day readmission rate for HF did not show a significant decline during the study period (Ptrend=0.06); however, all-cause readmission rates decreased significantly (Ptrend=0.03). HF readmissions were comparable between high- and low-volume TAVR centers. Charlson Comorbidity Index >8, length of stay >4 days during the index hospitalization, chronic obstructive pulmonary disease, atrial fibrillation, chronic HF, preexisting pacemaker, complete heart block during index hospitalization, paravalvular regurgitation, chronic kidney disease, and end-stage renal disease were independent predictors of 30-day HF readmission after TAVR. HF readmissions were associated with higher mortality rates when compared with non-HF readmissions (4.9% versus 3.3%; P<0.01). Each HF readmission within 30 days was associated with an average increased cost of $13 000 more than for each non-HF readmission. CONCLUSIONS During the study period from 2015 to 2018, 30-day HF readmissions after TAVR remained steady despite all-cause readmissions decreasing significantly. All-cause readmission mortality and HF readmission mortality also showed a nonsignificant downtrend. HF readmissions were comparable across low-, medium-, and high-volume TAVR centers. HF readmission was associated with increased mortality and resource use attributed to the increased costs of care compared with non-HF readmission. Further studies are needed to identify strategies to decrease the burden of HF readmissions and related mortality after TAVR.

Previously undiagnosed angina pectoris in individuals without established cardiovascular disease: Prevalence and prognosis in the United States.

BACKGROUND: The prevalence and prognosis of previously undiagnosed angina pectoris (AP) in the absence of established cardiovascular disease (CVD) are unknown. This study sought to determine the prevalence and prognosis of previously undiagnosed AP in the absence of established CVD in the United States. METHODS: Data derived from the National Health and Nutrition Examination Survey (2001-2018) and the Rose Angina Questionnaire (RAQ) were used to identify AP among participants ≥ 40 years without established CVD. Determinants of previously undiagnosed AP (AP undiagnosed prior to RAQ analysis) and predictors of all-cause mortality were identified using multivariable logistic regression analysis and the Cox proportional hazard model. RESULTS: Of the 27,506 participants eligible for analysis, 621 participants had previously undiagnosed AP. Thus, the prevalence of previously undiagnosed AP was 1.99% (95% CI 1.79-2.20). Female gender, poverty, < high school education, hypertension, cigarette smoking, and obesity were independent predictors of previously undiagnosed AP. All-cause mortality rates were 1.71 per 1000 person months for participants with previously undiagnosed AP and were 1.08 per 1000 person months to those without previously undiagnosed AP (p = 0.003). CONCLUSIONS: The prevalence of previously undiagnosed AP in the United States is 1.99% in persons ≥ 40 years of age without established CVD. Previously undiagnosed AP in those without established CVD was an independent predictor of all-cause mortality.

In-hospital outcomes of TAVR patients with a bundle branch block: Insights from the National Inpatient Sample 2011-2018.

INTRODUCTION: Data on the outcomes following transcatheter aortic valve replacement (TAVR) in patients with a bundle branch block (BBB) remains limited. METHODS: We studied the outcomes of TAVR patients with a BBB from the National Inpatient Sample (NIS) database between 2011 and 2018 using ICD-9-CM and ICD-10-CM codes. RESULTS: Between 2011 and 2018, 194,237 patients underwent TAVR, where 1.7% (n = 3,232) had a right BBB (RBBB) and 13.7% (n = 26,689) had a left BBB (LBBB). Patients with a RBBB and LBBB had a higher rate of new permanent pacemaker (PPM) implantation (31.5% - RBBB, 15.7% LBBB vs. 10.2% - no BBB). RBBB was associated with a significantly longer median length of stay (5 days) and total hospitalization cost ($53,669) compared with LBBB (3 days and $47,552) and no BBB (3 days and $47,171). Trend analysis revealed lower rates of PPM implantation and reduced lengths of stay and costs across all comparison groups. CONCLUSION: In conclusion, patients undergoing TAVR with a BBB are associated with higher new rates of PPM implantation. RBBB is the strongest independent predictor for new PPM implantation following TAVR. Rates of new PPM implantation in TAVR patients with and without a BBB have improved over time including reductions in length of stay and hospital costs. Further study is needed to reduce the risks of PPM implantation in TAVR patients.

Atrial Fibrillation Management: A Comprehensive Review with a Focus on Pharmacotherapy, Rate, and Rhythm Control Strategies.

Atrial fibrillation (AF) is an increasingly common arrhythmia encountered in clinical practice that leads to a substantial increase in utilization of healthcare services and a decrease in the quality of life of patients. The prevalence of AF will continue to increase as the population ages and develops cardiac comorbidities; thus, prompt and effective treatment is important to help mitigate systemic resource utilization. Treatment of AF involves two tenets: prevention of stroke and systemic embolism and symptom control with either a rate or a rhythm control strategy. Historically, due to the safe nature of medications like beta-blockers and non-dihydropyridine calcium channel blockers, used in rate control, it has been the initial strategy used for symptom control in AF. Newer data suggest that a rhythm control strategy with antiarrhythmic medications with or without catheter ablation may lead to a reduction in major adverse cardiovascular events, particularly in patients newly diagnosed with AF. Modulation of factors that promote AF or its complications is another important aspect of the overall holistic management of AF. This review provides a comprehensive focus on the management of patients with AF and an in-depth review of pharmacotherapy of AF in the rate and rhythm control strategies.

Use and outcomes of cerebral embolic protection for transcatheter aortic valve replacement: A US nationwide study.

BACKGROUND: Outcomes data on the use of cerebral embolic protection devices (CPDs) with transcatheter aortic valve replacement (TAVR) remain limited. Previous randomized trials were underpowered for primary outcomes of stroke prevention and mortality. METHODS: The National Inpatient Sample and Nationwide Readmissions Database were queried from 2017 to 2018 to study utilization and inpatient mortality, neurological complications (ischemic stroke, hemorrhagic stroke, and transient ischemic attack), procedural complications, resource utilization, and 30-day readmissions with and without use of CPD. A 1:3 ratio propensity score matched model was created. RESULTS: Among 108,315 weighted encounters, CPD was used in 4380 patients (4.0%). Adjusted mortality was lower in patients undergoing TAVR with CPD (1.3% vs. 0.5%, p < 0.01). Neurological complications (2.5% vs. 1.7%, p < 0.01), hemorrhagic stroke (0.2% vs. 0%, p < 0.01) and ischemic stroke (2.2% vs. 1.4%, p < 0.01) were also lower in TAVR with CPD. Multiple logistic regression showed CPD use was associated with lower adjusted mortality (odds ratio (OR], 0.34 [95% confidence interval [CI], 0.22-0.52), p < 0.01) and lower adjusted neurological complications (OR, 0.68 (95% CI, 0.54-0.85], p < 0.01). On adjusted analysis, 30-day all-cause readmissions (Hazard ratio, HR 0.839, [95% CI, 0.773-0.911], p < 0.01) and stroke (HR, 0.727 [95% CI, 0.554-0.955), p = 0.02) were less likely in TAVR with CPD. CONCLUSION: We report real-world data on utilization and in-hospital outcomes of CPD use in TAVR. CPD use is associated with lower inpatient mortality, neurological, and clinical complications as compared to TAVR without CPD.

Clinical outcomes of PCSK9Is: a meta-analysis of randomized clinical trials.

BACKGROUND: Previous studies of proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9Is) were not designed to detect clinical benefit and were underpowered for this outcome. However, recently published trials reported improvement in clinical outcomes. The aim of this meta-analysis to assess the impact of PCSK9Is on clinical outcomes. METHODS: Medline, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) were queried from January 2000 through March 2017. Only randomized controlled trials (RCTs) comparing clinical outcomes in patients treated with PCSK9I versus control group were included. Two independent reviewers selected the studies and extracted data in duplicate. Random-effects meta-analysis was used to pool outcomes across studies. Study endpoints included: major adverse cardiovascular events (MACE), myocardial infarction (MI), stroke, coronary revascularization, cardiovascular (CV) mortality and all-cause mortality. RESULTS: A total of 62,776 patients (mean age 61 years, 73% were males) were included from six randomized clinical trials. In comparison to control group, PCSK9I use was associated with lower MACE (RR =0.81, 95% CI, 0.70-0.93, P=0.003), MI (RR =0.78, 95% CI, 0.63-0.97, P=0.03), stroke (RR =0.74, 95% CI, 0.64-0.87, P=0.0002) and coronary revascularization (RR =0.79, 95% CI, 0.73-0.86, P<0.00001). There was no statistically significant difference between both groups in terms of all-cause mortality (RR =1.01, 95% CI, 0.86-1.20, P=0.86) or CV mortality (RR =0.98, 95% CI, 0.78-1.22, P=0.83). CONCLUSIONS: PCSK9Is should be strongly considered to improve clinical outcomes in patients at high risk for atherosclerotic CVD.

Fatal anaphylactoid reaction associated with heparin-induced thrombocytopenia.

Acute systemic (anaphylaxis and anaphylactoid) reactions have been well described in patients with heparin-induced thrombocytopenia (HIT). Both necrotizing and non-necrotizing skin lesions at heparin injection sites have been reported and may occur in 10-20% of patients with HIT. We report herein a patient treated with subcutaneous enoxaparin sodium who developed non-necrotizing erythematous skin lesions at enoxaparin sodium injection sites. A subsequent intravenous bolus of unfractionated heparin produced a fatal anaphylactoid reaction. This suggests that caution should be exercised in the administration of intravenous heparin to patients with non-necrotizing erythematous skin lesions at prior heparin injection sites.

Protamine-induced immune thrombocytopenia.

BACKGROUND: Protamine is widely used to reverse the anticoagulant effects of heparin. Although mild thrombocytopenia is common in patients given protamine after cardiac procedures, acute severe thrombocytopenia has not been described. We encountered a patient who experienced profound thrombocytopenia and bleeding shortly after administration of protamine and performed studies to characterize the responsible mechanism. STUDY DESIGN AND METHODS: Patient serum was studied for antibodies that recognize protamine, heparin-protamine complexes, and platelets (PLTs) treated with protamine using flow cytometry, enzyme-linked immunosorbent assay, and serotonin release from labeled PLTs. RESULTS: A high-titer immunoglobulin G antibody was detected in patient serum that recognizes protamine in a complex with heparin or PLT surface glycosaminoglycans (GAGs) and activates PLTs treated with protamine at concentrations achieved in vivo after protamine infusion. The antibody is distinctly different from those found in patients with heparin-induced thrombocytopenia on the basis of its failure to recognize heparin in a complex with PLT factor 4 (PF4) and to release serotonin from labeled PLTs in the absence of protamine. CONCLUSIONS: Findings made suggest that the patient's antibody is specific for conformational changes induced in protamine when it reacts with heparin or a PLT surface GAG. Development of severe thrombocytopenia after treatment of this patient with protamine defines a previously undescribed mechanism of drug-induced immune thrombocytopenia. Patients given protamine who produce this type of antibody may be at risk of experiencing thrombocytopenia if given the drug a second time while antibody is still present.

Does reduced lung diffusing capacity for carbon monoxide predict the presence of pulmonary hypertension?

OBJECTIVE: The objective of this study was to determine whether reduced lung diffusing capacity for carbon monoxide (DLCO) predicts the presence of pulmonary hypertension (PH) in heterogeneous group of patients. METHODS: Consecutive patients who underwent pulmonary function and transthoracic echocardiographic testing within a 6-month period were retrospectively identified by chart review. Right ventricular systolic pressure (RVSP) was measured using Doppler echocardiography. PH was defined as a RVSP >30 mm Hg. Patients were divided into 2 major groups: those whose RVSP was < or =30 mm Hg and those whose RVSP was >30 mm Hg. PH was classified as mild (RVSP = 31-40 mm Hg), moderate (RSVP = 41-60 mm Hg) and severe (RVSP >60 mm Hg). RESULTS: A total of 398 patients were entered into the study: 264 (66.3%) with PH and 134 (33.7%) without PH. Patients with PH were older, had a lower mean percentage of predicted values for forced vital capacity (%FVC), for DLCO (%DLCO) and for DLCO corrected for alveolar volume (%DLCO/VA) than those without PH. Multivariate analysis identified age and %FVC as independent predictors of PH [odds ratios and 95% confidence intervals of 1.038 (1.020-1.056) and 0.972 (0.955-0.988), respectively]. There was a weak, but significant negative correlation between RVSP and %DLCO (r = -0.205, P = 0.001), but there was no correlation between RVSP and %DLCO/VA. Neither %DLCO nor %DLCO/VA was found to be independent predictors of PH. CONCLUSION: In a heterogeneous group of patients, %DLCO and %DLCO/VA do not independently predict the presence of PH.

Uncommon Cause of Acute Drug-induced Liver Injury Following Mammoplasty.

Cephalexin is a well tolerated antimicrobial and hepatic injury is an infrequent occurrence with its use. We here describe a 21-year-old female who presented with jaundice and elevated liver enzymes after 4 weeks completion of 10 day course of cephalexin, prescribed prophylactically after mammoplasty. Extensive work up including all causes of hepatitis was within normal limits and she improved with conservative management. This case highlights the need to suspect drug induced liver injury in cases of jaundice and cephalexin use.

Small Bowel Obstruction Caused by Carcinoid Tumor and Incidental Capsule Retention.

Capsule endoscopy (CE) is a sensitive modality for examining the small bowel and is commonly employed to identify a variety of small bowel pathologies. We report a case of capsule retention leading to diagnosis of a chronic condition. A 60-year-old female presented with abdominal pain, nausea, and weight loss for 3 years. Physical exam revealed a mildly tender abdomen with hypoactive bowel sounds. Laboratory was normal. Abdominal radiographs showed a partial small bowel obstruction with retained capsule. Abdominal computed tomography (CT) demonstrated a retained capsule in the mid-portion of the jejunum, dilated small bowel, and terminal ileal mass. She underwent exploratory laparotomy showing an ileal mass with hepatic metastasis. A right hemicolectomy, reanastomosis, and removal of the retained capsule were performed. Pathology showed well-differentiated carcinoid tumor. She was discharged home for further treatment with oncology. Carcinoid tumors of the small bowel usually present with abdominal pain or small bowel obstruction. Our patient had intermittent small bowel obstruction due to a carcinoid tumor and retained capsule causing her symptoms. CE is a valuable tool but requires extensive consideration and possible patency capsule prior to use in patients presenting with symptoms consistent with Crohn's disease or small bowel tumor.

Prevalence of appropriate cardioverter-defibrillator shocks in 1038 consecutive patients with implantable cardioverter-defibrillators.

During a 33-month follow-up of 1038 consecutive patients who had implantable cardioverter-defibrillators, appropriate shocks occurred in 329 of 1038 patients (32%). Appropriate shocks occurred in 101 of 380 patients (27%) treated with beta-adrenergic blockers alone; in 31 of 95 patients (33%) treated with amiodarone alone; in 39 of 149 patients (26%) treated with beta-blockers plus amiodarone; in 11 of 28 patients (39%) treated with sotalol alone; and in 147 of 386 patients (38%) treated with no beta-blockers, amiodarone, or sotalol (P < 0.001 comparing patients treated with beta-adrenergic blockers alone with patients treated with no beta-blockers, amiodarone, or sotalol; and P < 0.01 comparing patients treated with beta-blockers plus amiodarone with patients treated with no beta-blockers, amiodarone, or sotalol). In conclusion, patients having implantable cardioverter-defibrillators should also be treated with beta-adrenergic blockers to reduce the frequency of appropriate shocks.

Giant sporadic renal angiomyolipoma treated with nephron-sparing surgery.

Angiomyolipoma is a benign renal tumor that tends to grow with time and can be associated with complications, such as hemorrhage and pain, requiring active intervention. Nephron-sparing surgery for sporadic renal angiomyolipomas offers preservation of renal function and is associated with acceptable complication and recurrence rates. Preoperative embolization of the large tumors is recommended to avoid excess blood loss during surgery. We report a case of giant renal angiomyolipoma treated with preoperative embolization, followed by partial nephrectomy without complications.