Congenital Long QT Syndrome and Cardiac Arrest in a Military Tactical Athlete.

We present a case of a U.S. marine who experienced cardiac arrest during military Special Forces underwater diving exercises whose evaluation revealed congenital long QT syndrome. This case highlights the expanding role for systematic electrocardiogram screening in target athletic and military populations given their stress and tactical exposures. (Level of Difficulty: Advanced.).

Temporal trends in anticoagulation management for US active duty personnel with atrial fibrillation.

ObjectivesThis study aims to investigate US active duty (AD) military members diagnosed with atrial fibrillation (AF) and the temporal trends of systemic anticoagulation (AC). Our secondary objective is to study the AC prescriptions in AD military members diagnosed with AF and associated military dispositions and deployment rates. DESIGN AND SETTING: A retrospective investigation of Tricare pharmacy AC prescriptions within the San Antonio Military Health System from January 2004 to July 2019 for AD individuals diagnosed with AF was performed. PARTICIPANTS: 386 AD personnel with non-valvular AF were analysed (mean age 35.0±9.4 years; mean body mass index, 28.3±4.3 kg/m2; 93% male; 57% Caucasian, 94% paroxysmal AF). OUTCOMES: The temporal trends of systemic AC prescriptions were the primary outcome measures. The association between AC prescriptions and military dispositions and deployments were secondary outcomes of interest. STATISTICAL ANALYSIS: The association between AC management, future deployments and military disposition was analysed using χ2 and Fisher's exact test for categorical variables. The t-test was used for comparison of continuous variables. RESULTS: CHA2DS2-VASc and HAS-BLED scores were low (0.39±0.65 and 0.86±0.63, respectively). 127 (33%) members received warfarin and 58 (15%) received direct oral anticoagulants (DOACs). Rates of military retention were not different between AC histories (no AC (64%) vs warfarin (75%) vs DOAC (65%); p=0.425). There was a significant trend of more recent utilisation of DOACs compared with warfarin (p<0.0001). When adjusted for temporal changes in deployment rates, there was no significant difference in deployment between AC groups (no AC (39%) vs warfarin (49%) vs DOAC (27%); p=0.9472). CONCLUSIONS: This is the first report describing AC utilisation in US AD military members with AF. Young AD personnel with low stroke and bleeding risks do not commonly receive AC prescriptions. DOAC prescription rates are increasing and predominate over warfarin for AC indications.

Characteristics of United States military pilots with atrial fibrillation and deployment and retention rates.

INTRODUCTION: Atrial fibrillation (AF) is an arrhythmia that impacts deployment and retention rates for United States military pilots. This study aims to characterize United States active duty (AD) pilots with AF and review deployment and retention rates associated with medical and ablative therapies. METHODS: An observational analysis was performed to assess AD pilots diagnosed with AF in the largest military regional healthcare system from 2004 to 2019. Baseline characteristics and AF management were reviewed. RESULTS: 27 AD pilots (mean age, 37.3 ± 7.9 years; mean BMI, 27.3 ± 3.1 kg/m2; 100% male sex) were diagnosed with AF during the study dates. 17 (63%) were Air Force branch pilots with hypertension as the most common risk factor (26%). There were overall low CHA2DS2-VASc scores (mean 0.29 ± 0.47). 22 (82%) pilots were equally treated with medical rate and rhythm strategies (41% and 41%, respectively). 16 (59%) underwent pulmonary vein isolation (PVI) with zero complications. 11 (41%) pilots received warfarin and 5 (19%) received a direct oral anticoagulant for stroke prevention. After diagnosis, 12 (44%) pilots deployed and 25 (93%) were retained in military. PVI was not associated with a change in subsequent deployments rates (PVI, 38% vs no PVI, 55%; p = 0.3809) or retention rates (PVI, 94% vs no PVI, 91%; p = 0.7835). CONCLUSIONS: United States military pilots diagnosed with AF are younger patients with few traditional AF risk factors and  they receive medical rate and rhythm strategies equally. Many pilots maintain deployment eligibility and most remain on AD status after diagnosis. PVI is not associated with differences in retention or deployment rates. Further prospective study is needed to further evaluate these findings.

Primary Cardiac Lymphoma Manifesting as Complete Heart Block.

Primary cardiac tumors are exceedingly rare with variable clinical manifestations. This case involves a patient presentation of symptomatic complete heart block and cardiac imaging revealing a right atrial mass invading the myocardium consistent with Burkitt lymphoma on histopathology. The patient received definitive bradytherapy with a pacemaker and chemotherapy for the primary cardiac lymphoma. After three cycles of chemotherapy, the right atrial mass regressed significantly with restoration of atrioventricular conduction and no pacing burden. Primary cardiac lymphomas infrequently manifest as atrioventricular block and this case highlights cardiac masses as a potential etiology when evaluating new conduction disturbances and bradyarrhythmias.

Active Duty Personnel With ST Elevation Myocardial Infarctions Are Deployment Ineligible Despite Receiving Standard Management.

INTRODUCTION: ST elevation myocardial infarction (STEMI) is a high acuity diagnosis that requires prompt recognition and developed system responses to reduce morbidity and mortality. There is a paucity of literature describing active duty (AD) military personnel with STEMI syndromes at military treatment facilities (MTFs). This study aims to describe AD military members with STEMI diagnoses, military treatment facility management, and subsequent military dispositions observed. MATERIALS AND METHODS: We performed a single-center, retrospective review of all STEMI diagnoses at San Antonio Military Medical Center (SAMMC) from January 2008 to June 2018. Patients met inclusion in the analysis if they were (1) AD personnel in the United States Air Force (USAF) or United States Army (USA) and (2) presented with electrocardiogram findings and cardiac biomarkers diagnostic of a STEMI diagnosis. ASCVD and STEMI diagnoses were confirmed by board certified interventional cardiologists with coronary angiography. The 2017 American College of Cardiology (ACC) STEMI clinical performance and quality measures were used as the standard of care metrics for our case reviews. RESULTS: A total of 236 patients were treated for STEMI at SAMMC during the study period. Eight (3.4%) of these cases met inclusion criteria of being AD status at the time of diagnosis. Five (63%) of the AD STEMI diagnoses were USA members, three (37%) were USAF members, 50% were Caucasian, and 100% were male sex. The average age and body mass index were 46.3 ± 5.5 years old and 28.5 ± 3.1 kg/m 2, respectively. Preexisting cardiovascular risk factors were present in six (75%) of the individuals with hypertension being most common (63%). The eight patients had a baseline average low-density lipoprotein cholesterol of 110 ± 39 mg/dL, total cholesterol of 180 ± 49 mg/dL and calculated 10-year risk of atherosclerotic cardiovascular disease (ASCVD) 3.9 ± 1.6%. 100% of patients underwent primary percutaneous coronary intervention (PCI) within 90 minutes of presentation (average door-to-balloon time 59.3 ± 24 min). Single-vessel disease was found in all eight patients and seven of them underwent drug-eluting stent placement (average number of stents 2 ± 1.5). Performance and quality measures were met in all applicable categories including door-to-balloon times, discharge medical therapies, and cardiac rehabilitation enrollments for 100% AD personnel. Reported adverse events included two stent thromboses and two vascular complications. Three of eight individuals (37.5%) were diagnosed with behavioral health disorders secondary to their acute coronary syndrome. Medical retirement secondary to STEMI diagnosis occurred in 87.5% of subjects and all study personnel medically retired within 24 months (average 12.8 ± 7.9 months). CONCLUSIONS: AD personnel represent a small minority of MTF STEMI diagnoses and present with lower risk cardiovascular profiles. AD personnel received standard STEMI management compared to national performance measures, and were deployment ineligible after STEMI diagnoses. Further studies are needed to definitively explore the appropriate military dispositions for members with STEMI diagnoses and acute coronary syndromes.

Right Ventricular Failure Following Patent Foramen Ovale Closure on Venovenous-Extracorporeal Membrane Oxygenation.

We present a patient with pulmonary arterial hypertension requiring venovenous-extracorporeal membrane oxygenation for acute respiratory distress syndrome. Refractory hypoxemia secondary to right-to-left interatrial shunting via a patent foramen ovale was discovered. Right heart catheterization with invasive occlusion test heralded worsening right heart failure so closure was aborted. (Level of Difficulty: Intermediate.).

Association of Endothelial Dysfunction and Antiretroviral Therapy in Early HIV Infection.

Importance: Human immunodeficiency virus (HIV) infection is associated with increased cardiovascular disease (CVD) events. Endothelial dysfunction (EDF) is involved in CVD pathogenesis; however, EDF onset after HIV acquisition and the potential for reversibility with antiretroviral therapy (ART) have not been evaluated to date. Objective: To evaluate endothelial function with noninvasive reactive hyperemia index (RHI) in patients with early HIV infection at baseline and after ART initiation. Design, Setting, and Participants: Cohort study in which 61 members of the United States Air Force diagnosed with HIV infection from September 1, 2015, through September 30, 2017, were evaluated for baseline EDF. Natural log-transformed RHI values (lnRHI) of less than 0.51 and at least 0.51 were defined as abnormal and normal, respectively. The RHI interval changes were evaluated in a subgroup of 40 patients. Data were analyzed from September 30, 2017, through January 30, 2018. Exposure: Early HIV infection. Main Outcomes and Measures: Baseline EDF at HIV diagnosis and interval changes associated with ART initiation. Results: The 61 patients included in the analysis were predominantly male (58 [95%]) and mostly African American (35 [57%]), with a mean (SD) age of 28.1 (6.7) years at HIV diagnosis. Median time from estimated date of HIV seroconversion to RHI assessment was 10.6 months (interquartile range [IQR], 5.1-13.2 months), and the median CD4 lymphocyte count was 552/µL (IQR, 449/µL-674/µL). Patients had a mean (SD) body mass index of 26.2 (4.0), median (IQR) low-density lipoprotein cholesterol level of 97 (80-126) mg/dL, median (IQR) total cholesterol level of 163 (146-195) mg/dL, and no diabetes diagnoses. Overall mean (SD) lnRHI was 0.70 (0.29) at HIV diagnosis. Baseline RHI was normal in 47 patients (77%; mean [SD] lnRHI, 0.82 [0.20]) and was abnormal in 14 patients (23%; mean [SD] lnRHI, 0.30 [0.18]). Age (per 10-year increase) was not associated with an abnormal lnRHI (odds ratio, 2.15; 95% CI, 0.89-5.19; P = .09). Of the 41 patients with follow-up RHI assessments, 40 started ART immediately and repeated the RHI assessments at a median (IQR) of 6.4 (6.0-7.8) months. Use of ART was associated with an overall significan increase in mean (SD) lnRHI (0.13 [0.33]; P = .02). A greater increase in mean (SD) lnRHI was associated with abnormal (n = 11) compared with normal (n = 29) lnRHI at HIV diagnosis (0.33 [0.34]; P = .01 vs 0.04 [0.30]; P = .38). Among those with abnormal baseline lnRHI, 8 (73%) showed improved endothelial function after ART. The patient who declined ART converted from having a normal lnRHI (0.60) to an abnormal lnRHI (0.11) lnRHI after 8.3 months. Conclusions and Relevance: In this study, EDF was common in early HIV infection, with associated reversal in most patients taking ART. Results suggest that persistent EDF and CVD complications may be associated with delayed ART. Further studies are necessary to define the role of noninvasive endothelial function testing in patients with HIV infection.

Prevalence of colonic adenomas in patients with nonalcoholic fatty liver disease.

BACKGROUND: Epidemiologic data suggest that colonic adenomas have an increased tendency to occur in patients who are obese, African American, or have a positive family history of colon cancer, or diabetes mellitus. Recent data suggest that impaired glucose tolerance, dyslipidemia, and metabolic syndrome are associated with a higher risk for colonic adenomas. Patients with nonalcoholic fatty liver disease (NAFLD) often share several of the aforementioned risk factors for colonic adenomas. However, data are lacking about the relationship between NAFLD and colonic adenomas. The aim of this study was to systematically evaluate whether NAFLD is an independent risk factor for colonic adenomas. METHODS: We performed a retrospective cohort observational study on 233 patients who underwent screening colonoscopies at Brooke Army Medical Center from November 2007 to March 2010 to assess for the association between NAFLD and colonic adenomas. Patients who had previously been found to have biopsy-proven simple steatosis (n = 65) or nonalcoholic steatohepatitis (NASH) (n = 29) were compared with a control group without fatty liver disease on sonographic imaging (n = 139). Patients were stratified based on gender, race, body mass index (BMI), and family history and adjusted for variables previously known to be associated with increased adenoma risk. RESULTS: The mean age was 54.7 ± 6.0 years (48.5% women). Racial demographics were: 62.7% White, 18.5% Hispanic, 13.7%, African American, and 5.2% other. The mean BMI was 29.7 ± 5.8. The prevalence of colonic adenomas was 25.1% in the control group and 24.4% in the NAFLD group to include simple steatosis and NASH (p = 1.00). Furthermore, when adjusting for known confounders to include race, BMI, and family history no significant differences were found (p = 0.33). However, the ultrasound-negative patients ranked lower in the number of adenomas per person (p = 0.016). CONCLUSIONS: There was no difference in the prevalence of colonic adenomas when comparing the NAFLD group who had undergone colonoscopy with a group of control patients without NAFLD who had undergone colonoscopy. However, patients with negative ultrasounds appeared to have a lower polyp burden.