Hydroxychloroquine and Cardiovascular Events in Patients with Rheumatoid Arthritis.

INTRODUCTION: Cardiovascular disease (CVD) is the leading cause of mortality in patients with rheumatoid arthritis (RA). Some studies have reported a decrease in CVD in patients with RA using hydroxychloroquine (HCQ). Most of these have had fewer participants and have analyzed only composite outcomes. We aimed to identify the association between the use of HCQ in patients with RA and the incidence of major adverse cardiac events (MACEs), cerebral infarction, and AMI. METHODS: This was a retrospective observational study using the TriNetX Diamond Network. Propensity score matching (PSM) was used to equilibrate the cohorts. The dependent variables in our study were MACE, cerebral infarction, and AMI. RESULTS: A total of 2,261,643 patients with RA were identified. Approximately 6% had been prescribed HCQ. Of those prescribed HCQ, 80% (112,743) were females, while of those not prescribed HCQ, 72.5% (1,536,937) were females. HCQ was associated with lower rates of MACE (HR 0.827, 95%CI 0.8,0.86), cerebral infarction (HR 0.824, 95% CI 0.78,0.87), and AMI (HR 0.9, 95% CI 0.85,0.96). These associations were not seen in patients taking biologics. HCQ was associated with lower MACE in all other subgroups. CONCLUSION: In conclusion, HCQ was slightly beneficial in decreasing MACE and cerebral infarction in patients with RA. These associations were significantly lower in patients taking methotrexate or biologics. Although there was a significant decrease in the risk of AMI in all patients with RA, these results were not replicated in subgroup analyses, and there was an apparent increased risk of AMI with the use of HCQ in patients using biologics.

Peritoneal Dialysis and Inflammatory Demyelinating Polyneuropathy: A Correlation or Co-Incidence?

Uremic neuropathy (UN) is a sensorimotor polyneuropathy typically affecting the lower extremities due to length-dependent demyelination and axonal degeneration. Hemodialysis (HD) and peritoneal dialysis (PD) are the two widely used modalities for treating end-stage renal disease (ESRD) patients. Today, with the understanding of solute and water kinetics, PD is considered equivalent to in-center HD. Chronic inflammatory demyelinating polyneuropathy (CIDP) manifests as symmetric, motor-predominant neuropathy that results in both proximal and distal muscle weakness. It is treatable with immune modulatory therapies. Here, we present a series of three patients who developed CIDP following the initiation of PD. Patient A: 39-year-old male with ESRD secondary to renal dysplasia presented with new onset neuropathy four months after starting PD. Patient B: 30-year-old male with ESRD secondary to IgA nephropathy presented with a history of numbness in his feet gradually progressing to his legs 12 months after initiating PD. Patient C: 56-year-old female with ESRD and uncontrolled diabetes mellitus presented with progressive muscle weakness four months after initiating PD. These three patients were all on continuous cycling PD. They were followed at three different dialysis units and were initiated on CCPD at different times. All of these patients were found to have CIDP on electromyography. Patients A and B were treated with IV immunoglobulin (IVIG) and improved, while patient C received plasmapheresis and improved. It has been recognized that PD solution is not physiological and may lead to activation of the host immune system triggering an autoimmune demyelinating process. Immunologic pathogenesis is not clearly understood. Macrophage activation and cytokines may play a role in the demyelination process. With the recent initiative to increase the use of PD, more studies are warranted to understand this uncommon complication.

Right Heart Failure With Recurrent Pericardial Effusion Mimicking Effusive-Constrictive Pericarditis Several Years After Renal Transplantation.

Pericardial disease is a rare complication after renal transplantation. We present a patient who developed high-output cardiac failure from a large arteriovenous (AV) fistula with recurrent pericardial effusion resulting in a constrictive hemodynamic pattern that was revealed during cardiac catheterization. Pericardiectomy was considered for recurrent effusive pericarditis, but per cardiac surgery recommendations, closure of the AV fistula dramatically cured the patient's heart failure, and no recurrence of pericardial effusion was seen during follow-up almost a year later.

The association of hyponatremia and clinical outcomes in patients with acute myocardial infarction: a cross-sectional study.

INTRODUCTION: Hyponatremia is a common electrolyte abnormality that has been associated with poor outcomes in several conditions including acute myocardial infarction (AMI). However, those studies were performed in the era before percutaneous coronary intervention (PCI), focused mostly on ST-elevation myocardial infarction (STEMI), and sodium levels up to 72 h of admission. The purpose of this study was to identify the association between hyponatremia and clinical outcomes in patients with acute myocardial infarction. METHODS: We performed a retrospective analysis of patients with a diagnosis of non-ST-elevation myocardial infarction (NSTEMI) and STEMI presenting at our institution from March 2021 to September 2021. Our independent variables were sodium levels on the day of admission and up to 7 days later. Dependent variables were in-hospital mortality, 30-day mortality, length of hospital stay, intensive care admission, new heart failure diagnosis, and ejection fraction. RESULTS: 50.2% of patients had hyponatremia up to 7 days of admission. Intensive care admission was higher in patients with hyponatremia up to7 days (69.7% vs 54.3%, P 0.019, OR 1.9), they had worse 30-day mortality (12.7% vs to 2.2%, P 0.004, OR 6.5), in hospital mortality (9.9% vs 1.1%, P 0.006, OR 9.9), and new heart failure diagnosis (31.5% vs 17.9%, P < 0.043, OR 2.1). Hyponatremia on admission was associated with in-hopital mortality (16.3% vs 3.8%, P 0.004, OR 4.9), 30-day mortality (18.4% vs 5.9%, P 0.017, OR 3.5). CONCLUSIONS: This study suggests that hyponatremia on admission and at any point during the first seven days of hospitalization are associated with in-hospital and 30-day mortality.

The Conundrum of Anticoagulation and Antiplatelet Therapy in Spontaneous Coronary Artery Dissection.

Spontaneous coronary artery dissection (SCAD) is a relatively rare and frequently misdiagnosed disease. The current knowledge of its pathophysiology and management is limited and based mostly on hypotheses. We present a patient with recurrent SCAD whose condition worsened soon after discontinuation of anticoagulation, prompting us to question the current management and review the evidence about pathophysiology, anticoagulation, and antiplatelet therapy.

Left Ventricular Global Longitudinal Strain in Patients With COVID-19 Infection.

Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2, is an ongoing pandemic that has affected millions globally. Many infected patients have been noted to have cardiovascular damage. Prior to the development of clinical symptoms, the use of transthoracic echocardiography, specifically with measurements of left ventricular global longitudinal strain (LVGLS), may provide an additional prognostic marker for patients infected with COVID-19. We sought to determine whether patients with COVID-19 and reduced LVGLS have an increased risk for mortality. The mean LVGLS was determined to be significantly lower in the non-survivors compared to the survivors (-11.6 ± 1.8 vs -15.4 ± 0.74, p<0.05). It should be noted, however, that even those that survived were found to have reduced LVGLS (<-18.5%). A multivariate logistic regression analysis was also performed that demonstrated a relationship between reduced LVGLS and an increased risk for mortality. Overall, our data indicate that COVID-19 patients may have subclinical left ventricular dysfunction, and that critically ill patients may have a greater decline in cardiac dysfunction.

Catheter-Directed Thrombectomy: An Alternative in Massive Pulmonary Embolism.

Massive pulmonary embolism (PE) is a life-threatening condition. The mainstay treatment is thrombolysis. Catheter-directed thrombectomy involves a group of new techniques that appear to have relatively low complications and mortality. These techniques have so far been studied mostly in submassive PE. We present a patient with massive PE that was successfully treated with catheter-directed thrombectomy.

The Importance of Early Pericardiectomy in Mulibrey Nanism Syndrome, a Case Report.

Mulibrey (Muscle-Liver-Brain-Eye) Nanism syndrome is an extremely rare genetic disorder with multiorgan involvement. Constrictive pericarditis and diastolic dysfunction are the most common causes of mortality. We present a case of a patient with Mulibrey nanism syndrome who underwent pericardiectomy at 12 years old and was able to live 44 years more with relatively stable and asymptomatic diastolic congestive heart failure (CHF). This case highlights the importance of early recognition and treatment of constrictive pericarditis in these patients.

A Rare Case of Ciprofloxacin-Induced Bradycardia Recognized by a Smartwatch.

Fluoroquinolones are known to cause cardiac side effects. The most common are ventricular arrhythmias and QT prolongation. We present a case of symptomatic bradycardia secondary to ciprofloxacin use in a patient who presented to the hospital after a smartwatch alert for bradycardia. We believe that the integration of wearable technology in the practice of medicine could provide valuable data and improve patient care in different settings.

A Rare Case of Restrictive Cardiomyopathy Presenting With Large, Recurrent Pericardial Effusions.

The association between large pericardial effusion and restrictive cardiomyopathy (RCM) is uncommon and has seldom been described. We describe an uncommon case of a 31-year-old male with RCM who presented with large, recurrent pericardial effusion, heart failure, and echocardiographic findings showing progressive worsening of diastolic function even after total pericardiectomy who was eventually transferred for cardiac transplant evaluation.

Diagnosing Spinal Gout: A Rare Case of Back Pain and Fever.

Gout is a common inflammatory arthritis that has a high prevalence worldwide. It is characterized by monosodium urate deposition, usually affecting the joints and soft tissue of the lower extremities. Urate deposition in the axial skeleton resulting in spinal gout is rare. However, it seems to be more prevalent than usually thought, largely because it is underdiagnosed. Imaging findings are, for the most part, nonspecific and often mimic infectious etiologies. Definitive diagnosis requires pathological examination. Thus, it can be easily missed. We present a 41-year-old male with a seven-year history of untreated gout who came in with severe back pain, fevers, and radiculopathy. He was initially diagnosed with vertebral osteomyelitis. However, after a biopsy, spinal gout was confirmed. Spinal gout can be misdiagnosed as vertebral osteomyelitis given the similarities in presentation and imaging findings. This case report highlights the importance of keeping spinal gout as a differential of vertebral osteomyelitis, especially in patients with long-standing or uncontrolled gout with tophi.