A Case of Pulmonary Tumor Thrombotic Microangiopathy: A Rare and Fatal Phenomenon.

Pulmonary tumor thrombotic microangiopathy (PTTM) is a pulmonary hypertensive arteriopathy thought to be caused by activation of the coagulation cascade at the surface of circulating tumor microemboli along with intimal proliferation in small pulmonary arteries in patients with metastatic carcinomas. The subsequent stenosis of the pulmonary vasculature leads to pulmonary hypertension (PH) and, cor pulmonale with eventual respiratory compromise leading to respiratory failure. PTTM is always a nearly fatal disease with most cases diagnosed postmortem. Most cases reported on this condition are from Japan where the incidence of gastric malignancy is relatively higher than other parts of the world. We report a case of a Caucasian man with a classic presentation of PTTM to help make physicians aware of this rare, rapidly progressive and usually fatal phenomenon.

Catheter directed compared to systemically delivered thrombolysis for pulmonary embolism: a systematic review and meta-analysis.

To compare the efficacy and safety of systemic and catheter directed thrombolysis for patients with pulmonary embolism. Pubmed and Cochrane Central Register of Controlled Trials were systematically searched from inception to May 31st 2020 to identify relevant studies. Outcomes of interest were in-hospital mortality and major bleeding including intracranial hemorrhage. We included 8 observational studies comprising 11,932 patients with PE. Catheter directed thrombolysis was associated with lower in-hospital mortality [RR 0.52; 95% confidence interval (CI) 0.40-0.68]. Although there was no difference in major bleeding by treatment strategy (RR 0.80; 95% CI 0.37-1.76), intracranial hemorrhage was lower in patients receiving catheter directed therapy (RR 0.66; 95% CI, 0.47-0.94).The certainty in these estimates was low. Non-randomized studies suggest that catheter directed delivery of thrombolytic therapy may be associated with lower in-hospital mortality and intracranial hemorrhage rates. These results may help inform management strategies for health care and pulmonary embolism response teams (PERT) involved in the management of high risk patients with massive or submassive pulmonary emboli.

Platelet Anti-Aggregator Drowns the Heart.

BACKGROUND: Anagrelide is a drug used for treatment of essential thrombocytosis especially when conventional therapy is insufficient. Adverse effects associated with anagrelide are palpitation, liver toxicity, renal failure and in few cases pericardial effusion. We here report a rare case of anagrelide induced pericardial effusion. CASE PRESENTATION: A 76-year-old male with past medical history of hypertension, hyperlipidemia, chronic obstructive pulmonary disease, and myeloproliferative disorder presented to the emergency department with dyspnea on rest and exertion. He was initially treated with hydroxyurea for thrombocytosis but was later switched to anagrelide. On examination patient had muffled heart sounds. Lab investigations identified hyperkalemia and transaminitis. Transthoracic echocardiogram identified a moderate sized pericardial effusion. The pericardial effusion and transaminitis were attributed to anagrelide toxicity as other causes were ruled out. Pericardiocentesis was performed and anagrelide was discontinued. Patient was discharged in a well-compensated state with outpatient follow-up in two to three weeks. CONCLUSION: Anagrelide is considered to be very effective treatment for essential thrombocytosis. It is, however, associated with serious adverse effects such as pericardial effusion, liver toxicity and palpitations. The mechanisms of these adverse drug reactions are still not completely understood. We suggest that patient taking anagrelide presenting with shortness of breath should have a transthoracic echocardiogram performed to rule out pericardial effusion. Liver enzymes should also be monitored closely and anagrelide discontinued immediately if the above-mentioned adverse events are noted.

Efficacy and Safety of Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation Undergoing Elective Surgical Procedures: A Meta-analysis.

Objective: The study objective was to determine if peri-operative bridging anticoagulation in patients with atrial fibrillation is beneficial or harmful.Design: Systematic review and meta-analysis.Setting: Inpatient or in-hospital setting.Participants: Adults with atrial fibrillation having a CHADS2 score >1 undergoing elective surgical procedure on anticoagulation.Methods: A systemic search of multiple databases (Cochrane, Medline, PubMed) was performed regarding studies conducted on efficacy and safety of perioperative bridging anticoagulation in patients with atrial fibrillation. Studies identified were reviewed by two authors individually before inclusion. The results were then pooled using Review Manager to determine the combined effect. Stroke/systemic embolism was considered as the primary efficacy outcome. Major bleeding was the primary safety outcome.Results: The systematic search revealed 108 potential articles. The full texts of 28 articles were retrieved for assessment of eligibility. After full text review, 25 articles were excluded. Three articles met inclusion criteria. No significant difference in stroke/systemic embolism with bridging anticoagulation was noted (risk ratio, 1.25-95% confidence interval [CI], 0.55-2.85). Bridging was associated with significantly higher risk of major bleeding (risk ratio, 3.29-95% CI, 2.25-4.81).Conclusion: An individualized approach is required when initiating peri-operative bridging anticoagulation. There is certainly a higher risk of bleeding with bridging anticoagulation and no difference in stroke/systemic embolism. However, the results cannot be extrapolated to patients who have valvular atrial fibrillation or CHADS2 score of 5 or greater.

Myocardial Infarction Type 2: Avoiding Pitfalls and Preventing Adverse Outcomes.

Myocardial infarction type 2 (MI type 2) is an elevation of cardiac biomarkers in a physiologically stressful state leading to demand-supply mismatch of oxygen. This type of myocardial infarction is commonly seen in hospitalized patients. Since the introduction of clear definition, diagnostic criteria and International Classification of Disease (ICD) codes, the diagnosis has become increasingly common. There still remains plenty to learn about MI type 2 especially prevention and treatment strategies. Studies have shown that there is increased mortality and morbidity associated with MI type 2 when compared to MI type 1, and there may be benefit in having a multi-disciplinary approach including cardiology when treating such patients. Secondary prevention therapies may also play a role in decreasing adverse events from MI type 2. However, randomized control trials are insufficient, and results of studies are cautiously interpreted. In this article we have assessed the current evidence on MI type 2 and the gap in literature that will potentially be the focus of future analyses.

Severe Pulmonary Hypertension as Initial Presentation of SLE: A Case Report and Literature Review.

Severe pulmonary artery hypertension (PAH) is a rare initial presentation of systemic lupus erythematosus (SLE). SLE associated with PAH carries worse prognosis that isolated SLE. However, there has been improvement in mortality of the patients in the recent years owing to newer treatment options available. Early recognition remains of prime importance. We present here a case of young female who presented with severe pulmonary hypertension with right heart failure leading to cardiogenic shock and was found to have SLE. She was started on appropriate treatment; however, given the severity of her illness, the patient did not survive. This case highlights the importance of early recognition and prompt treatment of SLE-associated PAH, which might improve the survival rate in the patients.

Utility of Endoscopic Ultrasound in the Work Up for Solitary Hepatobiliary Neuroendocrine Lesions.

A 43-year-old woman, with an unremarkable past medical history, presented with a three-week history of generalized itching, jaundice, and abdominal pain. Initial workup showed amorphous, regionally invasive, and obstructing soft tissue mass in the region of the hepatic hilum. The middle third of the main bile duct was subsequently found to harbor a polypoid mass on endoscopic retrograde cholangiopancreatograph. Biopsy revealed nests of neoplastic cells that was subsequently identified as well-differentiated neuroendocrine tumor. A search for a possible primary neuroendocrine tumor was performed and included imaging of the chest, abdomen, and pelvis, a colonoscopy, capsule endoscopy, and an octreotide scan; however, no primary tumor outside of the liver was identified. Surgical debulking was performed, during which intraoperative exploration and ultrasound failed to reveal any extra-hepatic tumor sanctuaries. A few months later, patient underwent endoscopic ultrasound (EUS) for evaluation of recurrent abdominal pain which revealed a small lesion in the pancreas. It was unclear, however, whether it was primary or a metastatic lesion. This case represents a diagnostic challenge and emphasizes the potential utility of EUS in the preoperative work up for any presumable primary hepatobiliary neuroendocrine tumor.

Temporal Pattern of CABG and PCI after Non-ST Elevation Myocardial Infarction Among Elderly Patients from NHDS.

Background Management of elderly patients with Non-ST Elevation Myocardial Infarction (NSTEMI) continues to be a source of controversy due to underrepresentation in large-scale clinical trials and the increased risk of adverse outcomes after both invasive (Percutaneous coronary intervention and Coronary artery bypass grafting) and non-invasive therapies. Recent randomized clinical trials have shown improved short term and intermediate term outcomes among high risk NSTEMI patients receiving early invasive management versus conservative medical management. However, how this is reflected in U.S. clinical practice for elderly patients has not been reported. Objective To identify the trend of invasive management in patients with NSTEMI, particularly among elderly population. Methods We used data from National Hospital Discharge Survey to identify all adult patients with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for NSTEMI from the years 2005 to 2009. The goal was to investigate the trends in time of invasive therapy for patients diagnosed with NSTEMI. We then stratified the patients according to age >65 and ≤65, and compared the temporal trends between two age groups. Results Among 21,306 patients diagnosed with NSTEMI between 2005 and 2009, the median age was 73 years (IQR: 61-82 years), 54% were males and 57% were White. The proportions of patients age>65 years receiving invasive management (21%, N=13978) was significantly lower than those age≤65 (41%, N=7328) (p<0.001). Moreover, in both age groups, the proportion of patients receiving early invasive management decreased substantially over time (p<0.001). Conclusion Despite numerous studies promoting the use of early invasive management for NSTEMI patients, the proportion of patients receiving invasive intervention gradually decreased from 2005-2009, more so in elderly population. The decrease seen in overall proportion of patients receiving invasive therapy could be associated with older median age of NSTEMI patients; 73 years (IQR: 61-82). Our future analyses will investigate if this trend maintains after adjusting for other factors (sex, co-morbid conditions, insurance status, year of procedure, hospital region, and hospital bed-size) thought to be associated with the management of NSTEMI in elderly patients.

Massive Prosthetic Valve Thrombosis of a Mechanical Mitral Valve - A Report of an Interesting Case Illustrating the Importance of Effective Anticoagulation.

Contemporary medicine saw rapid development of artificial valves, as well as evolution of surgical techniques allowing their implantation in a growing number of patients. Primary care and cardiology offices are providing ongoing care for an increasing number of patients post valve surgery. One of the most crucial aspects of this ongoing care is prevention of prosthetic valve thrombosis (PVT). Our case report illustrates the importance of maintaining effective anticoagulation at all times by presenting a case of massive prosthetic valve thrombosis of a mechanical mitral valve.