Cardiac Catheterization and Outcomes for Elderly Patients Hospitalized With Heart Failure.

Background: Heart failure affects over 6 million people in the United States (US) with limited evidence to support the use of cardiac catheterization. The benefit of its use remains mostly as expert opinion. This study intends to assess the benefits and risks of cardiac catheterization in elderly patients admitted for heart failure. Methods: This was a retrospective study using data from the National Inpatient Sample, including admissions 65 years and older hospitalized for heart failure, between 2008 and 2016. The outcomes analyzed were in-hospital mortality, total hospital costs, and length of stay. Results: After controlling for covariates, cardiac catheterization was found to have a protective association with mortality (OR 0.87, 95% CI 0.833-0.912, P < .0001), an increased hospital length of stay by 2.88 days (95% CI: 2.84-2.92 days, P < .0001) and approximately $16 255 increase in cost. Conclusions: Cardiac catheterization was associated with decreased in-hospital mortality, longer length of stay and higher total costs in admissions with heart failure aged 65 years or older.

Insights into elastic fiber fragmentation: Mechanisms and treatment of aortic aneurysm in Marfan syndrome.

Marfan syndrome (MFS) is an autosomal dominant connective tissue disorder caused by mutations in fibrillin 1 (FBN1) gene. These mutations result in defects in the skeletal, ocular, and cardiovascular systems. Aortic aneurysm is the leading cause of premature mortality in untreated MFS patients. Elastic fiber fragmentation in the aortic vessel wall is a hallmark of MFS-associated aortic aneurysms. FBN1 mutations result in FBN1 fragments that also contribute to elastic fiber fragmentation. Although recent research has advanced our understanding of MFS, the contribution of elastic fiber fragmentation to the pathogenesis of aneurysm formation remains poorly understood. This review provides a comprehensive overview of the molecular mechanisms of elastic fiber fragmentation and its role in the pathogenesis of aortic aneurysm progression. Increased comprehension of elastic fragmentation has significant clinical implications for developing targeted interventions to block aneurysm progression, which would benefit not only individuals with Marfan syndrome but also other patients with aneurysms. Moreover, this review highlights an overlooked connection between inhibiting aneurysm and the restoration of elastic fibers in the vessel wall with various aneurysm inhibitors, including drugs and chemicals. Investigating the underlying molecular mechanisms could uncover innovative therapeutic strategies to inhibit elastin fragmentation and prevent the progression of aneurysms.

Symptomatic Myocarditis Post COVID-19 Vaccination.

There are few major adverse events after the coronavirus disease 2019 (COVID-19) vaccination. However, increasing cases of myocarditis and pericarditis are being reported to the Vaccine Adverse Event Reporting System (VAERS) in young people, primarily after the second dose of messenger RNA (mRNA) COVID-19 vaccines. We present a case series of myopericarditis post mRNA (Moderna) and myocarditis post vector-based (Johnson & Johnson) COVID-19 vaccines. We intend to highlight the importance of early diagnosis and treatment of vaccine-related myocarditis to reduce mortality and morbidity.

Recognizing Rare Sequelae of Epstein-Barr Virus Myocarditis Leading to Dilated Cardiomyopathy and Acute Congestive Heart Failure With Multivalvular Regurgitation.

Myocarditis is associated with a wide range of infections, most commonly viral (cytomegalovirus), bacterial, and parasitic (Trypanosoma cruzi). Epstein-Barr virus (EBV) rarely causes myocarditis, which is a life-threatening complication. Autoantibodies against cardiac myocytes activate the complement system and cause diffuse myocyte necrosis. Myocarditis has a variable presentation from asymptomatic to cardiogenic shock. Over time, untreated myocarditis can progress and result in dilated ventricles. Continued dilation of ventricles leads to systolic dysfunction, conduction abnormalities, ventricular arrhythmia, heart failure, valvular abnormalities, and thromboembolism. So, we are emphasizing the importance of early diagnosis and treatment of EBV to prevent mortality. This case study represents a rare case of mortality secondary to EBV infection with resultant DCM and congestive heart failure (CHF).

Hypertensive Emergency in a Young Patient With Unilateral Adrenal Hyperplasia: A Case of Conn's Syndrome.

Aldosterone is a mineralocorticoid hormone that maintains sodium and potassium homeostasis. Excess aldosterone secretion causes sodium influx and potassium outflow, leading to hypertension and in some cases hypokalemia. Conn's syndrome, or primary aldosteronism, is the most common cause of secondary hypertension, accounting for 20% or more of people with resistant hypertension. We present a young male with hypertension, blurry vision in the right eye, and hypokalemia who was on further investigation found to have an aldosterone-secreting adrenal adenoma. He was treated with retroperitoneoscopic right-sided adrenalectomy and his blood pressure improved. Conn's syndrome should be suspected in any hypertensive patient with hypokalemia. Adrenal venous sampling is the best investigation to measure aldosterone levels and also to lateralize the source. Surgical resection is the treatment of choice.

The Epidemiology and Clinical Manifestations of Takayasu Arteritis: A Descriptive Study of Case Reports.

Takayasu's arteritis is a rare form of chronic inflammatory disorder involving large vessels, with an unclear etiology. Common early signs and symptoms are weakness, malaise, and fever. Takayasu's arteritis mainly involves the aorta and its branches as well as the subclavian and carotid arteries. While radiologic methods can identify diseased vessels, they can't tell the difference between active and chronic lesions. This study reviews the characteristics of Takayasu's arteritis to identify any possible changes in the prevalence of symptoms of the disease. We conducted a literature review of case reports on Takayasu arteritis from PubMed and Google Scholar. Variables of interest were age, gender, symptoms, blood pressure (BP) measurement, diminished pulses, and radiological findings. Data were transferred to an Excel spreadsheet (Microsoft Corporation, Redmond, WA), and mean, median, and standard deviation, frequencies, and proportions were calculated using R version 1.1.456 (RStudio: Integrated Development for R. RStudio, PBC, Boston, MA). There were 43 cases, and females accounted for 88.3% of the presentations. The average age was 25 years, SD 12.5 years. Fever was the most frequent symptom (20.93%), followed by chest pain (13.95%), claudication (13.95%), and headache (13.95%). Less frequent complaints included shortness of breath (11.62%), weight loss (9.30%), syncope (6.98%), and night sweats (4.65%). On the right side, the average BP was 142/87 mmHg, and the left-sided finding averaged 115/72 mmHg. Decreased pulses were primarily seen in the radial artery with 15 cases. Radiological findings showed narrowing of the vessels in the following order: aorta (22), carotid (11), renal (10), subclavian (9), celiac (2), mesenteric (2), axillary (2), and tibial (1). The characteristics of Takayasu's arteritis were analyzed in this study. It identified several findings, ranging from fever symptoms to the signs of claudication, as well as the involvement of major vessels, such as the aorta and its branches, and a summary of radiological findings. This depicts the picture of Takayasu's arteritis and what physicians should expect when dealing with the disease.

The Great Impostor Did It Again: Syphilitic Arthritis.

Syphilis-related bone and joint involvement is commonly found in congenital form, but it can also be seen in adults with acquired syphilis as a rare sequela of infectious syphilis. We report a case of syphilitic arthritis where the patient presented with multiple problems over the course of several visits and was eventually diagnosed with tertiary syphilis as the source of his musculoskeletal complaints. The clinical manifestations of syphilis can be diverse and challenging, as evidenced by our case. Unusual clinical manifestations might be seen in syphilis, and clinicians may not be familiar with these clinical presentations while diagnosing. Being aware of arthropathy in syphilis and including it in the differential diagnoses will help improve patient outcomes and avoid unfavorable consequences, particularly in the high-risk group.

Pseudohyponatremia Leading to a Fatal Outcome in a Patient With Familial Hypertriglyceridemia.

Serum sodium assay is a commonly performed laboratory test in a clinical setting and the results are taken for granted without being aware of the actual methods involved. In conditions like hyperlipidemia and hyperproteinemia, excessive lipids in serum dilute the water component of the serum. Since sodium is dissolved only in the aqueous phase of serum, the sodium content per unit volume of plasma is reduced. Currently, most of the laboratories use the indirect ion-selective electrode method (ISE), where the plasma sample is diluted before the measurement. Indirect ISE may not give accurate results in conditions with higher serum lipid and protein levels. Overcorrection of the serum sodium levels in pseudohyponatremia may cause serious complications. We report a case of a 26-year-old Asian male with a past medical history of chronic pancreatitis, familial hypertriglyceridemia, and fatty liver who presented to the emergency department with acute pancreatitis. Initially, the patient was found to have hyponatremia and he was started on hypertonic saline for one day. Later the patient's condition deteriorated and then it was determined that serum sodium results were a measurement artifact since the patient had extremely high levels of triglycerides. After realizing that it was a measurement artifact, the saline infusion was stopped and he was started on desmopressin. However, the patient deteriorated neurologically and expired later. As this patient had normal sodium levels, administration of hypertonic saline led to a fatal outcome.

An Overview of Outcomes Associated With Early Versus Late Tracheostomy From a National Standpoint.

Tracheostomy is a procedure that is commonly used in critically ill patients who require prolonged mechanical ventilation due to acute respiratory failure or airway problems. The best tracheostomy timing (early vs. late) and techniques (percutaneous dilatational, other new percutaneous procedures, open surgery) have been hotly debated. This research aimed to evaluate the outcome of early versus late tracheostomy in terms of in-hospital mortality, patient length of stay in the hospital, and cost after a detailed analysis and review using National Inpatient Survey (NIS) data. This study indicates that early tracheostomy greatly reduces in-hospital mortality, the need to transfer to skilled nursing facilities as well as direct variables, length of stay, and potentially overall hospital cost in the ICU.

How Much Is Too Much? Exploring Pseudohyperaldosteronism in Glycyrrhizic Acid Toxicity From Chronic Licorice Root Consumption.

Licorice has been around for centuries and has been commercialized in the food, tobacco, and healthcare industry. Historically, its therapeutic benefits have been reaped in countless ways, including as a thirst sensation suppressor in battlefields, flavoring agent in medicinal preparations, antacid for gastric discomfort and peptic ulcers, and even as an estrogenic agent in postmenopausal women. Licorice and its derivatives are recognized safe by the US Food and Drug Administration (FDA). Though FDA recognized the licorice to be a food additive in certain concentrations, it has issued warnings against its use in at-risk group and in larger amount. However, it is a lesser known fact that glycyrrhizic acid, the active component in licorice, can cause a metabolic syndrome presenting as pseudohyperaldosteronism. Chronic consumption leads to the development of hypertension, metabolic alkalosis, and hypokalemia. We present a patient who developed a sinus pause on telemetry and subsequent syncope after presenting for evaluation of hypertension and hypokalemia. The patient had been ingesting a significant quantity of deglycyrrhizinated licorice for many years to alleviate postprandial epigastric pain. Although seemingly benign electrolyte disturbance, it is crucial to recognize that chronic consumption of licorice without strict regulation can lead to supraventricular and ventricular ectopics and tachyarrhythmias with the potential to develop life-threatening arrhythmias including ventricular tachycardia, ventricular fibrillation, and Torsades de Pointes.

Cheating Death: A Rare Case Presentation of Kratom Toxicity.

Kratom is a psychoactive herb that has been gaining widespread popularity due to its ease of availability and opiate-like effects. While it has been used beneficially as a method of weaning off opiate addictions, it does have a host of toxic effects when misused or abused. There has been a wide spectrum of negative effects including renal failure, liver failure, and cardiac toxicity. While some adverse effects have been reversed with medical intervention, others left more of a detrimental long-term impact not amenable to even the most invasive therapies. We present the case of a patient who was admitted to the intensive care unit after presenting with unresponsiveness secondary to a cerebrovascular accident, rhabdomyolysis, and renal failure. The patient had begun using kratom, initially for recreational purposes, and later escalating it to abusive doses. The patient survived the episode after suffering many complications including transient reversible nonischemic cardiomyopathy and was discharged in a neurologically stable state; however, he ended up being hemodialysis-dependent at such an early age. Rhabdomyolysis is a rare complication of this herb that has not been well documented.

Transient Complete Heart Block in a Patient With COVID-19.

SARS-CoV-2, also known as COVID-19, was first identified in Wuhan, China. Symptoms of COVID-19 are fevers, dry cough and less commonly gastrointestinal (GI) symptoms such as diarrhea that occur in 2 to 14 days of exposure. Infection with COVID-19 leads to hospitalizations due to respiratory compromise. Secondary manifestations of this virus should warrant further investigation since little is known about COVID-19 and its role in the cardiac circuit. We present a patient with COVID-19 who developed transient third-degree AV block initially hospitalized for septic shock. The patient presented with mild symptoms and the transient nature of the complete heart block could be a matter of low viral load in his circulation. He recovered from COVID-19 with no long-term cardiac sequelae. The long-term effects of COVID-19 are still unknown; this case presents the cardiac manifestations of the virus.

Comparison of left ventricular mechanical dyssynchrony parameters between exercise and adenosine triphosphate stress tests using gated single-photon emission computed tomography myocardial perfusion imaging.

BACKGROUND: Left ventricular mechanical dyssynchrony (LVMD) can be induced after stress test. However, no studies have compared the influence of different stress­inducing methods on LVMD parameters. AIMS: The aim of the study was to determine whether there is a difference between exercise and adenosine triphosphate (ATP) stress tests in terms of changes in LVMD parameters assessed using gated single­photon emission computed tomography myocardial perfusion imaging (GSPECT MPI). METHODS: A total of190 patients who underwent 99mTc ­sestamibi GSPECT MPI were consecutively enrolled. Treadmill exercise and ATP stress tests were performed in 95 patients each. Normal myocardial perfusion was defined as the summed stress score (SSS) ≤3 and summed rest score (SRS) ≤3, myocardial ischemia as SSS >3 and SRS ≤3, and myocardial infarction as SSS >3 and SRS >3. Parameters of LVMD, including phase standard deviation (PSD), phase bandwidth (PBW), skewness, and kurtosis were compared. Subtraction was made between values during stress and rest phases to acquire ∆PSD, ∆PBW, ∆skewness, and ∆kurtosis Results: There were no differences in LVMD parameters between the exercise and ATP groups. The same results were obtained in the normal perfusion, ischemia, and infarction subgroups. Furthermore, no differences were observed in ∆PSD (median [interquartile range, IQR], 0.25 [-2.3 to 3.1] vs 0.42 (-1.7 to 3.1]; P = 0.73), ∆PBW (median [IQR], 1 [-7 to 11] vs 1 [-6 to 11]; P = 0.95), ∆skewness (mean [SD], -0.06 [0.63] vs 0 [0.81]; P = 0.53), and ∆kurtosis (median [IQR], -0.47 [-4.2 to 4.3] vs -0.42 [-4.8 to 5.2]; P = 0.73) between the exercise and ATP stress­inducing methods. CONCLUSIONS: There are no differences between the exercise and ATP stress tests in terms of changes in LVMD parameters. Thus, the 2 methods can be used alternatively.

A Rare Case of Pelvic Organ Prolapse in a Nulliparous Female With Autosomal Dominant Polycystic Kidney Disease (ADPKD) and Polycystic Liver Disease (PLD).

Polycystic liver disease (PLD) is a condition that most often occurs in patients with autosomal dominant polycystic kidney disease (ADPKD) and less commonly as isolated liver disease. The presence of both conditions has proven to be a therapeutic challenge. Patients with ADPKD can suffer from significant renal and extra-renal complications and symptoms as a result of space-occupying cysts from polycystic kidney and liver enlargement. We present a case of ADPKD in a 56-year-old Caucasian female who developed pelvic organ prolapse, a rare complication, while also dealing with multiple other complications of ADPKD. Despite the high prevalence of ADPKD, complications such as pelvic organ prolapse have seldom been reported and discussed in the literature. The care team should do a prompt gynecological examination when they realize the burden of cysts becomes so large.

A Rare Case of Delayed Onset Multi-Drug Interaction Resulting in Rhabdomyolysis in a 66-Year-Old Male.

Drug-drug interactions in medications metabolized by cytochrome P450 enzymes can lead to multi-organ complications. An uncommon but serious potential adverse effect of statins is rhabdomyolysis, most commonly triggered by drug interactions. Rhabdomyolysis presents with markedly elevated creatine kinase levels, dark urine, and often myoglobinuria. The breakdown of the muscles during rhabdomyolysis can be toxic to the kidneys, often precipitating acute kidney injury (AKI) and can also damage the liver, causing transaminitis. This study presents a case of a 66-year-old male with delayed onset complex pharmacological interaction between ticagrelor, rosuvastatin, and amiodarone resulting in rhabdomyolysis, AKI, and transaminitis.