Interaction Between Risk Factors, Coronary Calcium, and CCTA Plaque Characteristics in Patients Age 18-45.

AIMS: The atherosclerotic profile and advanced plaque subtype burden in symptomatic patients ≤45 years old have not been established. This study aimed to assess the prevalence and predictors of coronary artery calcium (CAC), plaque subtypes, and plaque burden by coronary computed tomography angiography (CCTA) in symptomatic young patients. METHODS AND RESULTS: We included 907 symptomatic young patients (18-45 years) from Montefiore undergoing CCTA for chest pain evaluation. Prevalence and predictors of CAC, plaque subtypes, and burden were evaluated using semi-automated software. In the overall population (55% female and 44% Hispanic), 89% had CAC = 0. The likelihood of CAC or any plaque by CCTA increased with >3 risk factors (RF, OR 7.13 [2.14-23.7] and OR 10.26 [3.36-31.2], respectively). Any plaque by CCTA was present in 137 (15%); the strongest independent predictors were age ≥35 years (OR 3.62 [2.05-6.41]) and family history of premature CAD (FHx) (OR 2.76 [1.67-4.58]). Stenosis ≥50% was rare (1.8%), with 31% of those having CAC = 0. Significant non-calcified (NCP, 37.2%) and low-attenuation (LAP, 4.24%) plaque burdens were seen, even in those with non-obstructive stenosis. Among patients with CAC = 0, 5% had plaque, and the only predictor of exclusively non-calcified plaque was FHx (OR 2.29 [1.08-4.86]). CONCLUSIONS: In symptomatic young patients undergoing CCTA, the prevalence of CAC or any coronary atherosclerosis was not negligible, and the likelihood increased with RF burden. The presence of coronary stenosis ≥50% was rare and most often accompanied by CAC > 0 but there was a significant burden of NCP and LAP even within the non-obstructive group.

Impact of Hyperuricemia and Urate-Lowering Agents on Cardiovascular Diseases.

The association between hyperuricemia and cardiovascular diseases has been studied for many years. Research has shown a link between high uric acid levels and increased risk of including coronary artery disease hypertension and other cardiovascular conditions. Urate-lowering therapy, particularly with xanthine oxidase inhibitors like allopurinol, has shown promising results in reducing blood pressure in individuals with hyperuricemia and hypertension. Clinical trials and studies have demonstrated significant reductions in both systolic and diastolic blood pressure with urate-lowering treatment. Urate-lowering treatment has shown a favorable effect on reducing systolic blood pressure and major adverse cardiovascular events in patients with previous cardiovascular disease. In terms of cardiovascular safety, clinical trials have indicated that xanthine oxidase inhibitors such as febuxostat are non-inferior to allopurinol and do not increase the risk of death or serious adverse events. Overall, these findings highlight the importance of managing hyperuricemia and utilizing urate-lowering therapy to mitigate the adverse cardiovascular effects associated with elevated uric acid levels.

A Successful Treatment of COVID-Induced Acute Idiopathic Pancreatitis with an RNA-Polymerase Inhibitor Agent.

Acute idiopathic pancreatitis (AIP) has been rarely linked to SARS-CoV-2 and its mechanism is not completely understood. As a result, its management, due to the heterogeneity of the literature, may pose a challenge. This case report describes a 59-year-old female who presented to the emergency department with severe epigastric pain, fever, and a positive SARS-CoV-2 polymerase chain reaction (PCR) test. Imaging confirmed acute interstitial pancreatitis, which was successfully managed using the viral RNA polymerase inhibitor, remdesivir. Pancreatitis-associated complications, such as sepsis and shock, are recognized as significant factors contributing to extended hospitalization and increased mortality rates. The management of autoimmune pancreatitis poses a challenge due to the diverse existing literature, resulting in a lack of standardized approaches. Although the impact on inpatient mortality of remdesivir remains uncertain, early administration of RNA polymerase inhibitors could alleviate complications and positively impact the duration of hospitalization. Further research is important to create optimal management strategies for complications related to COVID-19-related pancreatitis.

Role of genetic polymorphisms in clopidogrel response variability: a systematic review.

INTRODUCTION: Clopidogrel is a P2Y12 inhibitor that has become a mainstay treatment following percutaneous intervention with drug-eluting stent placement to decrease restenosis and its potential complications, including sudden cardiac death and ischaemic strokes in patients with significant vascular disease. AREAS COVERED: As a prodrug, the metabolism and efficacy of clopidogrel are contingent on the presence of wild-type CYP450 (CYP2C19) alleles. Genetic polymorphisms and variants are well known to impair its ability to prevent major adverse cardiovascular events in these patients, with inadequate response rates as high as 30% in previous publications. Patterns of allelic frequencies are expected to exhibit similarities between individuals of the same ancestry, ethnic group or geographic region. Accordingly, we seek to further elucidate worldwide prevalence rates for genetic polymorphisms in the CYP2C19-dependent metabolism of clopidogrel and review the potential of personalised CYP2C19 genotyping in clinical practice to mitigate this high treatment resistance and its associated burden on patients. EXPERTS' COMMENTARY: Our findings support the consideration of genotyping before initiation of therapy to guide adequate dosage or substitutions of other P2Y12 inhibitors to promote personalised, precision medicine and to prevent adverse events when these therapies may inevitably fail in patients with variants of the CYP450 (CYP2C19) system.

Crochetage, the Forgotten Electrocardiographic Sign.

Acquired complete heart block is a rare but severe arrhythmia caused by various factors such as infections, medications, and autoimmune conditions. Atrial septal defect (ASD) is a common congenital heart defect, with larger ASDs possibly causing symptoms such as fatigue, shortness of breath, and frequent respiratory infections. In some cases, high-grade atrioventricular block with ASD can occur; however, the exact incidence is not well established. We report a rare case of a 15-year-old male presenting with acute dizziness. Initial electrocardiogram (EKG) showed a complete heart block with a Crochetage sign. Patent foramen ovale (PFO) was confirmed by transthoracic and transesophageal echocardiograms. Closure of PFO and permanent pacemaker resulted in complete resolutions of symptoms and disappearance of Crochetage sign.

COVID-19-Induced Cardiac Tamponade: A Case Study and a Literature Review.

COVID-19 presentation is heterogeneous. As a viral illness, it could cause pericardial effusion leading to cardiac tamponade. We present a patient coursing with this viral illness that was found to have cardiac tamponade. We report a case of a 79-year-old female who presented with shortness of breath and dry cough for one week and resulted positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Her initial chest X-ray showed a bottle-shaped heart. Computed chest tomography showed pericardial effusion, and an echocardiogram confirmed moderated pericardial effusion with signs of tamponade. He improved with conservative therapy with colchicine, ibuprofen, cefepime, dexamethasone, dolutegravir, and apixaban for pulmonary emboli. An early approach in cardiac tamponade induced by COVID-19 is crucial to promptly address an aggressive directed therapy, avoiding potential complications or unnecessary procedures.

Interplay Between Zero CAC, Quantitative Plaque Analysis, and Adverse Events in a Diverse Patient Cohort.

BACKGROUND: Coronary artery calcium scoring (CAC) has garnered attention in the diagnostic approach to chest pain patients. However, little is known about the interplay between zero CAC, sex, race, ethnicity, and quantitative coronary plaque analysis. METHODS: We conducted a retrospective analysis from our computed tomography registry of patients with stable angina without prior myocardial infarction or revascularization undergoing coronary computed tomography angiography at Montefiore Healthcare System. Follow-up end points collected included invasive angiography, type-1 myocardial infarction, coronary revascularization, cardiovascular and all-cause death. RESULTS: A total of 2249 patients were included (66% female). The median follow-up was 5.5 years. The median age of those without CAC was 52 years (interquartile range, 44-59) and 60 years (interquartile range, 53-68) in those with CAC. Most patients were Hispanic (58%), and the rest were non-Hispanic Black (28%), non-Hispanic White (10%), and non-Hispanic Asian (5%). The majority had CAC=0 (55%). The negative predictive value of CAC=0 was 92.8%, 99.9%, and 99.9% for any plaque, obstructive coronary artery stenosis, and the composite outcome of all-cause death, myocardial infarction, or coronary revascularization, respectively. Among patients without CAC (n=1237), 89 patients (7%) had evidence of plaque on their coronary computed tomography angiography with a median low-attenuation noncalcified plaque burden of 4% (2-7). There were no significant differences in the negative predictive value for CAC=0 by sex, race, or ethnicity. Patients with ≥2 risk factors had higher odds of having plaque with zero CAC. CONCLUSIONS: In summary, no sex, race, or ethnicity differences were demonstrated in the negative predictive value of a zero CAC; however, patients with ≥2 risk factors had a higher prevalence of plaque. A small percentage (7%) of symptomatic patients undergoing coronary computed tomography angiography with zero CAC had noncalcified coronary plaque, with the implication that caution is needed for downscaling of preventive treatment in patients with zero CAC, chest pain, and multiple risk factors.

Severe Liver Injury Secondary to COVID-19-Induced Rhabdomyolysis in McArdle Disease.

Severe liver injury is an uncommon condition caused by non-traumatic rhabdomyolysis. This rare correlation is more commonly seen in the aspartate aminotransferase (AST) than in the alanine transaminase (ALT) level elevation. We report a case of a 27-year-old male with a history of McArdle disease who presented with generalized muscle aches associated with dark urine. His workup showed SARS-CoV-2 positive, severe rhabdomyolysis (creatinine kinase [CK] > 40000 U/L) and acute kidney injury (AKI) followed by severe liver injury (AST/ALT: 2122/383 U/L). He was started on aggressive intravenous hydration. After multiple boluses, he became overloaded, fluids were re-adjusted and continued, his renal function, CK, and liver enzymes improved, and the patient was discharged; during his visit at the post-discharge, the patient was asymptomatic and no clinical or laboratory abnormalities were found. The glycogen storage diseases are challenging, but prompt and accurate assessment is determinant in recognizing potential life-threatening complications of SARS-CoV-2. The failure to identify complicated rhabdomyolysis could lead to the patient's rapid deterioration, ending in multiorgan failure.

COVID-19 therapy and vaccination: a clinical narrative review.

The SARS-CoV-2 pandemic is the most globally impacting health issue our world has faced over the last century. As of January 7, 2022, around 300 million cases have been reported worldwide, with over 5 million deaths. The SARS-CoV-2 infection causes a hyperactive host immune response leading to an excessive inflammatory reaction with the release of many cytokines - cytokine storm - commonly noticed in acute respiratory distress syndrome, sepsis and fulminant multiorgan failure. Since the beginning of the pandemic, the scientific medical community has worked on therapeutic procedures that interfere with the exaggerated immune response. Thromboembolic complications are widespread in patients who are critically ill with COVID-19. Anticoagulant therapy was initially considered a cornerstone in hospitalized patients and even in the early post-discharge period; however, later trials have aborted the clinical benefits except for suspicion of or confirmed thrombosis. Immunomodulatory therapies are still crucial in moderate to severe COVID-19. Immunomodulator therapies include various medications from steroids to hydroxychloroquine, tocilizumab and Anakinra. Anti-inflammatory agents, vitamin supplements and antimicrobial therapy had initial encouraging evidence, but there are limited data to review. Convalescent plasma, immunoglobulins, eculizumab, neutralizing IgG1 monoclonal antibodies and remdesivir have positively impacted inpatient mortality and hospital length of stay. Eventually, wide population vaccination was proven to be the best tool to overcome the SARS-CoV-2 pandemic and help humanity return to regular life. Many vaccines and various strategies have been used since December 2020. This review discusses how the SARS-CoV-2 pandemic has progressed and surged, and summarizes the safety and efficacy of the most used therapies and vaccines in the light of recent evidence.

Pre-workout Induced Demand Ischemia.

Pre-workout supplement use has increased in recent years. Multiple side effects and off-labeled substances have been reported. We report a case of a 35-year-old patient who recently started a pre-workout and was found to have sinus tachycardia, elevated troponin, and subclinical hyperthyroidism. The echocardiogram showed normal ejection fraction and no wall motion abnormality. Beta-blockade therapy with propranolol was offered, but she refused, and her symptoms and troponin levels improved after proper hydration within 36 hours. A cautious and accurate assessment of young, fitness-enthusiastic patients experiencing unusual chest pain is essential to identify a reversible cardiac injury and possible off-label substances in over-the-counter supplements.

Correction: Austrian Syndrome: The Forgotten Triad of a Complex Condition in an Antibiotic Era.

[This corrects the article DOI: 10.7759/cureus.32106.].

Diuretic resistance and the role of albumin in congestive heart failure.

Diuresis with loop diuretics is the mainstay treatment for volume optimization in patients with congestive heart failure, in which perfusion and volume expansion play a crucial role. There are robust guidelines with extensive evidence for the management of heart failure; however, clear guidance is needed for patients who do not respond to standard diuretic treatment. Diuretic resistance (DR) can be defined as an insufficient quantity of natriuresis with proper diuretic therapy. A combination of diuretic regimens is used to overcome DR and, more recently, SGLT2 inhibitors have been shown to improve diuresis. Despite DR being relatively common, it is challenging to treat and there remains a notable lack of substantial data guiding its management. Moreover, DR has been linked with poor prognosis. This review aims to expose the multiple approaches for treatment of patients with DR and the importance of intravascular volume expansion in the response to therapy.

A Successfully Treated COVID-19 Vaccine Induced Immune Thrombocytopenic Purpura.

Immune Thrombocytopenic Purpura (ITP) is a life-threatening condition where an accurate initial assessment is essential to be able to offer the proper therapy in a timely matter to improve the outcome of the patient. Here, we present a case of ITP secondary to the coronavirus disease 2019 (COVID-19) vaccine (BioNTech, Pfizer vaccine). A 61-year-old obese African American female presented to the emergency room (ER) from a clinic with a platelet count of 11k/ul 21 days after she received the second dose of the BioNTech, Pfizer vaccine. The patient was immediately started on intravenous immunoglobulin (IVIG) 1g/kg twice daily (bid) and dexamethasone 20 mg IV every 12 hrs (q12h). The next day, the platelet count increased to 63 k/ul, and after the second dose of IVIG, the platelet count improved to 122 k/ul and trended up. The early detection of ITP induced by the mRNA COVID-19 vaccine is determinant to guide the early and proper therapy with immunoglobulins and steroids to improve the outcome of our patients.

Bovine Aortic Arch, A High-Risk Variant.

The bovine aortic arch is a vascular variant related to an increased incidence of vascular and neurological complications. It should be ruled out in patients with vague neurological symptoms without a clear etiology. Our case is of a 72-year-old female patient who presented with a syncopal episode; the workup incidentally showed the aortic arch bovine variant with evidence of ischemic white matter disease more than expected for age. After reviewing the related literature, we suggest that this aortic variant is likely an independent risk factor for multiple vascular complications. A close follow-up is essential, and screening should be considered for symptomatic family members.

Anomalous Origin of the Right Coronary Artery: An Uncommon Presentation.

The anomalous origin of the coronary artery is a relatively uncommon condition with a variant incidence depending on the modality of the imaging techniques such as transesophageal echocardiography (TEE), computed tomography angiography (CTA), magnetic resonance angiography (MRA), or invasive coronary angiography (ICA). The importance of diagnosing ectopic coronary artery origin comes from its possible relation to sudden cardiac death (SCD) cases in young populations. The anomalous origin of the coronary artery could cause myocardial ischemia and fibrosis; this would, in turn, increase the chances of fatal ventricular arrhythmias. In this report, we present a 40-year-old male, incidentally found to have persistent tachycardia and a gradually decreasing left ventricular ejection fraction (LVEF). He denied any symptoms or changes in his baseline, unlimited, functional capacity. However, his records were remarkable for persistent tachycardia over more than six months, raising concerns about tachyarrhythmia-induced cardiomyopathy related to his anatomical variations. We also discussed the guideline-directed therapeutic option for the abnormal origin of the coronary artery as per current guidelines.

Acute Hydronephrosis Secondary to Methadone-Induced Constipation.

Opioid-induced constipation is a significant medical problem accounting for over 40% to 60% of patients without cancer receiving opioids. We report a unique case of a 71-year-old male with a history of opioid use disorder now on methadone maintenance presenting with severe opioid-induced constipation and fecal impaction causing extrinsic compression on the right-sided ureter resulting in right hydronephrosis and hydroureter that improved with aggressive bowel regime with the stool softener, laxatives and enemas. Methadone alone can predispose to hydroureter with hydronephrosis due to external compression from the severe intestinal dilation secondary to opioid-induced constipation.

Reversible Autoimmune Cardiomyopathy Secondary to a Vaccine-Induced Multisystem Inflammatory Syndrome.

The Dominican government started an early booster protocol, including a heterogeneous vaccination sequence needed based on availability. We report a case of a 25-year-old male who presented with jaundice, and vomiting for 6 days, associated with maculopapular rash (Mucocutaneous features), elevated pro-B-type natriuretic peptide (pro-BNP), erythrocyte sedimentation rate (ESR), transaminitis (> 1000 U/L), thrombocytopenia, echocardiogram evidenced stigmata of heart failure after his third dose of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. He was started on steroids and immunoglobulin therapy for multisystemic organ failure syndrome. A significant improvement was noticed, then was discharge; in the post-discharge clinic, he was asymptomatic, inflammatory markers improved, and the echocardiogram showed a recovered ejection fraction. An accurate anamnesis, including a proper chronologic gathering of the events, is essential to recognize a vaccine-multisystem inflammatory syndrome; its prompt assessment and therapy would directly improve the outcome.

Left Main Coronary Artery Fusiform Aneurysm.

Aneurysm of the coronary artery is an uncommon condition that is usually found incidentally. The left coronary aneurysm is the least common. We report the case of a young patient with a history of vasculitis who was found to have a left fusiform coronary aneurysm. This is a 20-year-old female who has a history of polyarteritis nodosa and who came due to shortness of breath associated with chest discomfort. The physical exam was only relevant for multiple joint pains and tenderness. An echocardiogram showed a possible coronary aneurysm that was confirmed on the angio-tomography. The patient was discharged without complications. The left main coronary artery aneurysm is a rare condition and the least common of the coronary aneurysms. There is no established guideline for screening and therapy of these aneurysms, but invasive methods are not a preferred method for follow-up on this condition.

COVID-Induced Fulminant Myocarditis.

Viral-induced myocarditis has different presentations, from being asymptomatic to fatal arrhythmias. It is crucial to recognize and treat this condition early to improve morbidity and mortality. We report a case of a 56-year-old male who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) three days ago and presented with syncope. The physical exam was relevant for right eyebrow laceration, tachycardia, and hypotension that responded to intravenous fluid, but two hours later, he had mental status changes, bradycardia, hypotension, and cardiac arrest. His repeated electrocardiogram (ECG) showed diffuse ST-segment elevation. Troponemia was evident in his blood work. Point-of-care ultrasound (POCUS) at the bedside showed dilated cardiomyopathy. Unfortunately, the patient re-arrested and needed advanced cardiovascular life support (ACLS). The initial assessment of SARS-CoV-2, serial ECGs, and cardiac markers are essential for a prompt approach and therapy in COVID-19-induced myocarditis.

Austrian Syndrome: The Forgotten Triad of a Complex Condition in an Antibiotic Era.

Osler's triad, an alternative term for Austrian syndrome, has a complex pathology comprising of pneumonia, meningitis, and endocarditis, all of which are caused by the hematogenous dissemination of Streptococcus pneumoniae. It can affect multiple organ systems, resulting in this rare but complex triad. With the advent of antibiotics, the incidence and severity of the disease have reduced remarkably. However, it still remains a lethal disease requiring early diagnosis and prompt treatment. We present the case of a 58-year-old male, with a past medical history of cerebrovascular accident and alcohol dependency, who presented with altered mental status, flu-like symptoms, fever, and vomiting. The patient was initially diagnosed with meningoencephalitis and pneumonia from Streptococcus pneumoniae, and despite adequate antibiotic treatment, he subsequently developed bacterial endocarditis, requiring valve replacement. Austrian syndrome is an uncommon life-threatening condition with a high mortality rate. Its outcome depends on an early diagnosis to establish antimicrobial therapy and to define potential surgical approach in order to improve the outcome of the patient.