Myocardial Bridging-Induced Acute Coronary Syndrome: A Bridge Too Far.

Recent studies suggest a potential association between myocardial bridging (MB) and accelerated atherosclerotic plaque formation. We describe the case report of a 37-year-old South Asian male with no established risk factors for coronary artery disease (CAD) who presented with a non-ST-segment-elevation acute coronary syndrome (NSTE-ACS) with a coincident widowmaker lesion and severe MB. He was successfully managed with comprehensive guideline-directed medical therapy (GDMT) and urgent percutaneous coronary intervention (PCI) of the culprit lesion, sparing the MB segment. The clinician should be cognizant of MB implicating ACS as a major adverse cardiovascular event (MACE) and its key management strategies.

Pharmacodynamic Comparison of Two Aspirin Formulations in the Caribbean: The ARC Study.

INTRODUCTION: This prospective, single-arm, crossover pharmacodynamic study assessed the effect of Bayer® low-dose enteric-coated aspirin 81 mg tablets (LD EC-ASA) (Bayer AG, Leverkusen, North Rhine-Westphalia, Germany) compared to Vazalore® low-dose phospholipid-aspirin liquid-filled 81 mg capsules (LD PL-ASA) (PLx Pharma Inc., Sparta, NJ, USA) on platelet reactivity with respect to aspirin reaction units (ARU). METHODS: Forty-seven healthy volunteers were recruited. Platelet function was evaluated with the VerifyNow™ ARU assay (Werfen, Bedford, MA, USA) and assessed post-initiation of Bayer® LD EC-ASA daily for 14 days, with a washout period of 28 days, followed by Vazalore® LD PL-ASA daily for 14 days, again followed by ARU testing. RESULTS: Participants on LD EC-ASA had a mean ARU score of 426, with 19.1% of participants having an ARU > 550; patients on LD PL-ASA derived a mean ARU score of 435, with 14.9% achieving an ARU > 550. There were no significant differences in aspirin resistance (ARU > 550) according to the formulation (Bayer® LD EC-ASA vs. Vazalore® LD PL-ASA) used. Aspirin resistance was independent of ethnicity regardless of the formulation used. In addition, there were no significant associations between body surface area (BSA) and Bayer® LD EC-ASA ARU value (p value 0.788) or Vazalore® LD PL-ASA ARU value (p value 0.477). No patients experienced any serious adverse events or treatment-emergent adverse events. CONCLUSIONS: There were no significant differences in aspirin resistance between Bayer® LD EC-ASA and Vazalore® LD PL-ASA. This dedicated pharmacodynamic study could potentially be informative and applicable for Trinidadian patients on dual antiplatelet therapy (DAPT). Further studies are required to confirm these exploratory findings. TRIAL REGISTRATION: ClinicalTrials.gov identifier, NCT06228820, prospectively registered 1/18/2024.

Scorpion-Induced Acute Coronary Syndrome: A Stinging Complication.

The Tityus trinitatis, a black scorpion species endemic to the fauna of Trinidad, has been implicated in envenomation with devastating clinical sequelae such as acute pancreatitis and major adverse cardiovascular events. We present the first in-Caribbean case of a 59-year-old Caribbean South Asian male with human immunodeficiency virus who presented with a non-ST-segment-elevation acute coronary syndrome after being stung, which was managed with comprehensive, guideline-directed medical therapy. The clinician should be cognizant of scorpion-induced acute coronary syndrome (ACS) as a potential sequela of envenomation and its clinical management.

Effectiveness and Safety of Left Distal Transradial Access in Coronary Procedures in the Caribbean.

INTRODUCTION: This retrospective study investigated the effectiveness and safety of left distal transradial access (LDTRA) in patients with cardiovascular disease in Trinidad undergoing coronary angiography (CAG) or percutaneous coronary intervention (PCI). METHOD: Procedural parameters, including technical success and safety outcomes such as vascular complications and radial artery occlusion (RAO), were assessed in 111 consecutive patients undergoing CAG or PCI from January 2023 to June 2023 at the Eric Williams Medical Sciences Complex, Trinidad and Tobago. Eighty-eight patients underwent LDTRA, while 23 received left transradial access (LTRA). RESULTS: There was no difference in procedural success with LDTRA compared to LTRA, 90.9% vs. 100%, p-value 0.202, non-significant (ns). LDTRA was associated with shorter fluoroscopy times (8.4 ± 6.8 minutes vs. 12.4 ± 7.7 minutes, p-value = 0.02), procedural duration (26.7 ± 18 minutes vs. 35.8 ± 20 minutes, p-value = 0.04), and hemostasis time (142 ± 41 minutes vs. 186 ± 44 minutes, p-value < 0.05). There were no significant differences in procedural-related complications (8% for LDTRA vs. 4.3% for LTRA, p-value = 0.476, ns). There were no reported cases of RAO. In the subgroup of patients with prior coronary artery bypass grafting (CABG), the fluoroscopy and procedure times were similar for both access sites; however, LDTRA was associated with a shorter hemostasis time (128 ± 30 minutes vs. 194 ± 39 minutes, p-value = 0.01). CONCLUSIONS: LDTRA is effective and safe for coronary procedures and is associated with a shorter hemostasis time. This study may prove clinically pertinent in a limited-resource Caribbean setting.

The South African Flag Sign: An Electrocardiographic Flag for All Coronary Territories?

The South African flag sign (SAFS) is an acute, dynamic electrocardiographic (ECG) finding typically associated with first diagonal (D1) artery occlusion. We report the case of a 47-year-old woman who exhibited this pattern but subsequently revealed the dreaded "widow-maker" lesion (100% occluded proximal left anterior descending [LAD] artery) and severe multivessel disease (90% stenosis of the posterior left ventricular [PLV] artery and 80% stenosis of the left circumflex artery [LCx]).

Culture-Negative Endocarditis in an Immunocompromised Patient: A Case of Suspected Bartonella and Coxiella Co-Infection.

We present the case of a 23-year-old man with a previous deceased-donor renal transplant maintained on tacrolimus and prednisone who developed culture-negative endocarditis (CNE) of the mitral and aortic valves. He was suspected of being co-infected with Bartonella henselae and Coxiella burnetii, confirmed with serology testing. He was successfully managed with appropriate antibiotics and dual valve replacement.

Leptospirosis-Induced Myocarditis and Arrhythmias.

Cardiac manifestations in leptospirosis usually involve atrial arrhythmias, conduction abnormalities, and nonspecific ST-T changes, while left ventricular dysfunction is rare. We present the case of a 45-year-old male without a pre-existing cardiovascular history who developed atrial fibrillation and atrial and ventricular tachycardia, in addition to new-onset cardiomyopathy in the setting of fulminant leptospirosis infection.

Correlation of RETINAL Artery Diameter with Coronary Artery Disease: The RETINA CAD Pilot Study-Are the Eyes the Windows to the Heart?

INTRODUCTION: This study aimed to determine whether there was any correlation between coronary artery disease (CAD) and retinal artery diameter at an academic tertiary medical center in Trinidad and Tobago. METHODS: This prospective study evaluated patients (n = 77) with recent invasive coronary angiography (CAG) and the Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score who subsequently underwent optical coherence tomography-angiography (OCT-A) at the Eric Williams Medical Sciences Complex (EWMSC) from January 2021 to March 2021. Routine medical history and cardiovascular medications were also recorded. Spearman's rank correlation coefficient and Mann-Whitney U-tests were used to compare correlations and medians between groups. RESULTS: The average patient age was 57.8 years old, with the majority being male [n = 55 (71.4%)] and of South Asian ethnicity [n = 53 (68.8%)]. Retinal artery diameter was negatively correlated with the SYNTAX score (-0.332 for the right eye, p = 0.003 and -0.237 for the left eye, p = 0.038). A statistically significant relationship was also demonstrated in females and diabetic patients. There were no serious adverse events (SAEs). CONCLUSION: A significantly negative correlation was observed between retinal artery diameter and SYNTAX score. This study alludes to the practical use of optical coherence tomography-angiography (OCT-A) as a noninvasive diagnostic modality for patients with cardiovascular disease (CVD). Further large-scale, multicentric studies are required to confirm these exploratory findings. TRIAL REGISTRATION NUMBER: NCT04233619.

Suspected COVID-19 mRNA Vaccine-Induced Postural Orthostatic Tachycardia Syndrome.

We present a case of a 15-year-old South Asian male who developed suspected postural orthostatic tachycardia syndrome (POTS) two weeks after receiving the Pfizer-BioNTech coronavirus disease 2019 (COVID-19) vaccine booster, which was successfully managed with low-dose fludrocortisone and ivabradine. Clinicians should be aware of the Pfizer-BioNTech COVID-19 vaccine being implicated with the onset of POTS.

Suspected Cannabis Vaping-Induced Pericardial Effusion.

Pericardial effusions refer to an excess accumulation of fluid within the pericardial cavity. The etiology is diverse, with most cases being idiopathic in nature. We report a case of suspected cannabis vaping-induced pericardial effusion in a 31-year-old South Asian patient, which was successfully managed with high-dose aspirin, colchicine therapy, and cannabis vaping cessation.Key Clinical Message: Clinicians should be aware of the possible cardiovascular complications of cannabis vaping.

Alcohol Binge Drinking-Induced ST-Segment-Elevation Acute Coronary Syndrome.

We present the case of a 26-year-old man, without any apparent cardiovascular risk factors, who experienced an ST-segment-elevation acute coronary syndrome after binge drinking high-proof alcohol, which was successfully managed with primary percutaneous coronary intervention and comprehensive, guideline-directed medical therapy.

Effect of cocoa (Theobroma cacao L.) on platelet function testing profiles in patients with coronary artery disease: ECLAIR pilot study.

INTRODUCTION: This prospective pharmacodynamic nutraceutical study assessed the effect of a 1-week trial of 30 g/day of 65% cocoa (dark chocolate) (Theobroma cacao L.) consumption intervention on platelet reactivity. METHODS: Patients with stable coronary artery disease (CAD) (n=20) who were on maintenance dual antiplatelet therapy of aspirin (ASA) 81 mg/day and clopidogrel 75 mg/day were recruited. Platelet function was evaluated with the VerifyNow P2Y12 reaction unit (PRU) and aspirin reaction unit (ARU) assays (Werfen, Bedford, Massachusetts, USA) and assessed prior to initiation of and after a 1-week trial of 30 g/day of 65% cocoa consumption intervention. Results were compared with a paired t-test. RESULTS: Cocoa augmented the inhibitory effect of clopidogrel, demonstrated by a reduction of 11.9% (95% CI 5.7% to 18.0%, p value 0.001), significantly decreasing the PRU by 26.85 (95% CI 12.22 to 41.48, p value 0.001). The inhibitory effect of ASA was not impacted by cocoa, reflected by a non-significant reduction in ARU of 17.65 (95% CI 21.00 to 56.3, p value 0.351). No patients experienced any serious adverse events. CONCLUSIONS: Cocoa augmented the inhibitory effect of clopidogrel but not ASA. This nutraceutical study could be potentially informative and applicable for patients with stable CAD. Further long-term studies are required to confirm these exploratory findings. TRIAL REGISTRATION NUMBER: NCT04554901.

Apixaban-Induced Pseudo-Ludwig's Angina.

Ludwig's angina describes fulminant cellulitis involving the oro- and hypopharynx, which typically stems from bacterial pathogens, whereas "pseudo-Ludwig's angina" is ascribed to sublingual swelling due to noninfectious causes. There is a paucity of case reports implicating warfarin as the culprit for sublingual hematoma mimicking Ludwig's angina; however, we describe a novel case of apixaban-induced pseudo-Ludwig's angina, which was successfully managed with urgent surgical intervention and supportive care with antibiotic and glucocorticoid therapy.

The Curious Case of Pseudo-Wellens' Syndrome and Myocardial Bridging.

Wellens' syndrome is an electrocardiographic harbinger of a critical left anterior descending (LAD) coronary artery stenosis in acute coronary syndromes (ACS), whereas pseudo-Wellens' syndrome typically has angiographically normal coronary arteries. Myocardial bridging (MB) occurs when an epicardial coronary artery segment takes a tunneled intramuscular course. We describe a rare case of MB-induced pseudo-Wellens' syndrome in a young patient presenting with unstable angina (USA).

The Effect of Dapagliflozin on Platelet Function Testing Profiles in Diabetic Patients: The EDGE Pilot Study.

INTRODUCTION: This prospective pharmacodynamic (PD) study assessed the effect of the sodium-glucose co-transporter-2 inhibitor (SGLT2i), dapagliflozin, on platelet reactivity. METHODS: Patients with stable coronary artery disease (CAD) and type 2 diabetes mellitus (T2DM) (n = 27) who were on maintenance dual antiplatelet therapy (DAPT) of aspirin 81 mg daily, and clopidogrel 75 mg daily were recruited. Platelet function was evaluated with the VerifyNow™ P2Y12 assay (Werfen, Bedford, MA, USA) and assessed prior to initiation of and after 10 days of treatment with dapagliflozin 10 mg once-daily dose regimen. Results were compared with a paired t test. RESULTS: Treatment with dapagliflozin significantly decreased P2Y12 reaction units (PRU) by 20%, (95% confidence interval (CI) 8.5-32.6%, p value 0.002). The mean difference in PRU was 36.70 (95% CI 16.66-56.75). No patients experienced any serious adverse events (SAEs). CONCLUSIONS: Significantly diminished platelet reactivity was observed on dapagliflozin as compared to without dapagliflozin. This dedicated pharmacodynamic study could be potentially informative and applicable for Trinidadian stable CAD patients with T2DM on DAPT. Further studies are required to confirm these exploratory findings. CLINICAL TRIAL REGISTRATION: EDGE ClinicalTrials.gov number NCT04400760.

Africanized Honey Bee Sting-Induced Stress-Related Cardiomyopathy: A Bee or Octopus Trap.

The Africanized honey bee commonly referred to as the "killer bee," is a hybrid of the East African lowland honey bee with various European honey bees. These bees tend to be more hostile as compared to other bee species. Their stings may have devastating clinical sequelae, including cardiovascular, cerebrovascular events, and fatalities. We report the first-in-Caribbean case of a middle-aged woman who experienced stress-related, Takotsubo cardiomyopathy (also known as stress-related cardiomyopathy [SRC]) after being afflicted with innumerable Africanized honey bee stings. Key clinical message: The clinician should be cognizant of Takotsubo's cardiomyopathy as a potential sequela of Hymenoptera envenomation and anaphylaxis.

Presyncope in a Patient Status Post Pectus Excavatum Repair.

Pectus excavatum (PEX) is an anterior chest wall deformity with sternal depression relative to the costal cartilages. We describe a patient status post remote PEX repair who presented with presyncope attributed to bifascicular block, partial right ventricular outflow tract (RVOT) obstruction, and right coronary artery (RCA) ischemia. Key Clinical Message: The clinician should be cognizant of the hemodynamic impact and electrocardiographic changes in a symptomatic patient status post pectus excavatum repair.

Isolated Right Ventricular Noncompaction Cardiomyopathy Causing Pulmonary Embolism.

Ventricular noncompaction is a rare, heterogeneous cardiomyopathy characterized by marked trabeculations and deep intertrabecular spaces with clinical sequelae of heart failure, arrhythmias, and cardioembolic events. In this article, we describe a patient with isolated right ventricular noncompaction who presented with submassive pulmonary embolism, which was managed with long-term direct oral anticoagulation.