An Incidental Finding of Eagle Syndrome Post-Losartan-Induced Angioedema.

Eagle syndrome is a condition that can present with a wide range of clinical manifestations, including orofacial pain, altered sensation, dysphagia, tinnitus, and ear pain, and is caused by the abnormal elongation of the styloid process or the mineralization of the stylohyoid ligament. We present a case of an incidental finding of Eagle syndrome in a 48-year-old African American patient with losartan-induced angioedema. The patient complained of a foreign body sensation in his throat and mild dysphagia, and a computed tomography scan of his neck showed ossification of bilateral stylohyoid ligaments. This case report highlights the importance of being on the lookout for other pathologies when ordering imaging for primary diagnoses.

Losartan-Induced Angioedema: A Case Report.

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers are both classes of drugs used in the management of hypertension, heart failure, chronic kidney disease, and proteinuria. While angioedema induced by ACE inhibitors has been well-documented, angioedema induced by angiotensin receptor blockers (ARBs) has not. We present the case of losartan-induced angioedema requiring tracheostomy in a 48-year-old African American male. To our knowledge, there have only been twenty case reports published to date about losartan-induced angioedema. Although in the immediate short-term, our patient made a complete recovery, he had a sudden cardiac arrest a few months after the incident of angioedema and died.

Arrhythmogenic Right Ventricular Cardiomyopathy.

Arrhythmogenic right ventricular cardiomyopathy (ARVC), formerly called arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/ARVC), is a myocardial structural abnormality disease with clinical presentation of cardiac arrhythmia. It is characterized by the replacement of the myocardium with fibrofatty tissue. We present a case of a young male who met two major criteria for definite diagnosis of ARVC: early transition inverted t waves in lead V1-V4 and MRI showed right ventricle (RV) dyskinesia with RV ejection fraction (EF) < 40%, both satisfying the two major criteria of EKG and MRI required for definitive diagnosis.

Coronavirus Disease 2019 Associated Acute Myocardial Infarction and Atrial Fibrillation: A Case Report.

In the last two years since the inception of the Coronavirus pandemic, there have been a myriad of reports and studies related to Coronavirus disease 2019 (COVID-19). We present a unique case of COVID-19 associated with both acute myocardial infarction and new-onset atrial fibrillation (AFIB) in an elderly lady which is the first reported case to the best of our knowledge. The patient was symptomatic with acute COVID-19 and developed a type 2 myocardial infarction with new-onset AFIB. The patient also developed sepsis which may have contributed to the development of AFIB.

Acute COVID-19-Associated Cardiac Arrhythmia: A Case Series and Literature Review.

Coronavirus disease 2019 (COVID-19) is a highly contagious infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We report two cases of COVID-19-associated atrial fibrillation (AF) in two elderly females and a case of atrial flutter (AFlutter) in a middle-aged male patient. We believe this case series will contribute to the literature on new-onset AF and AFlutter in patients with acute COVID-19 infection. This case series illustrates various case scenarios of patients developing cardiac arrhythmia with acute COVID-19 infection without any prior history or other explicable cause of AF/AFlutter. The exact mechanism behind COVID-19 infection leading to AF or AFlutter is still unknown. Of the three patients reported, two converted to sinus rhythm following medical management, and one did not convert to sinus rhythm despite medical treatment.

Atrial Fibrillation With Myocardial Infarction Presenting as a Progressive Worsening Fatigue in a Young Male.

Atrial fibrillation (AF) is one of the most common arrhythmia exhibiting a dramatic rise in prevalence with associated increased risk of stroke, heart failure, and death. No standard symptoms have been categorized yet to set a gold standard in diagnosing this clinical attribute. A highly variable symptoms array has increased the challenges of management in terms of AF. An obvious relationship has not been established between symptoms and the onset or recurrence of arrhythmia. We present a case of a 43-year-old male patient who complained of chronic fatigue as a primary symptom and was diagnosed with AF with myocardial infarction.

Myocardial Bridging: Two Different Clinical Presentations in Young Males Involving Left Anterior Descending Coronary Artery.

Myocardial bridging is a rare anatomical variant that can lead to detrimental cardiac consequences when undiagnosed and untreated. This rare variant can induce anginal-type symptoms due to disrupted blood flow to the myocardium during systole. The patients presented in this report of two cases had previously undiagnosed myocardial bridging of the left anterior descending artery, however clinically, they presented quite differently. Here we present two cases discussing the course of diagnosis and treatment of myocardial bridging of these two patients. The goal of this case report is to highlight the significant cardiovascular injuries that can be a result of undiagnosed myocardial bridging.

Symptomatic Sinus Bradycardia in a Patient With Acute Calculous Cholecystitis Due to the Cardio-Biliary Reflex (Cope's Sign): A Case Report.

Acute cholecystitis may present cardiovascular manifestation like cardiac ischemia leading to detailed cardiac workup without any obvious cardiac pathology. Here we describe a case who presented with typical signs and symptoms of cholecystitis exhibiting sinus bradycardia. This reflexive bradycardia was a result of autonomic vagal innervation and was resolved after cholecystectomy. This case highlights the importance of the cardio-biliary reflex and recommends clinicians ensure expedited management of cholecystitis to avoid unnecessary extensive cardiac workup.

Prevalence and association of iron deficiency with anemia among patients with heart failure in the USA: NHANES 2017-2018.

Background: Heart failure (HF) is a major debilitating disease. HF patients with iron deficiency(ID) have poorer outcomes and treatment significantly improves outcomes. We set out to update the national prevalence of ID in the USA and its association with anemia using data from NHANES 2017-2018. Methods: Diagnosis of HF was self-reported. ID was defined as serum ferritin levels <100 ng/mL or a ferritin level between 100 and 299 ng/mL with transferrin saturation <20%. Anemia was defined as a hemoglobin level of <13 g/dl and <12 g/dl for men and women, respectively. Differences in prevalence of ID across various groups were assessed using Chi-squared test for categorical variables and equality of means for continuous variables with p-values <0.05 considered statistically significant. Results: A total of 187 persons ≥20 years, corresponding to a 5.57million had HF. The prevalence of ID was 48.17% (95% CI 36.84-59.69) and the prevalence of anemia was 12.08%(95% CI 8.16-17.53). Diabetics (61.03%) were more likely to have ID compared to nondiabetics (35.38%), p 0.022. The prevalence of ID was similar in persons with anemia (47.45%) and persons without anemia (48.27%), p-value 0.983. The prevalence of ID has been constant for at least the past 20 years, making ID in HF an underdiagnose and/or undertreated condition among patients with HF and should be addressed. Conclusions: One in every two persons with HF has ID. Also, prevalence of ID was similar in patients with anemia and without anemia. Anemia should not be considered a prerequisite for screening for ID in patients with HF.

Prevalence and control rates of hypertension in the USA: 2017-2018.

BACKGROUND: Recent review of hypertension guidelines requires fresh updates of prevalence and control rates. Though retrospective analysis provided burden estimates, control rates were grossly misleading. We set out to update the prevalence and control rates of hypertension in the USA using contemporary NHANES data. METHODS: Persons with mean systolic blood pressure (mSBP) ≥130 mmHg or mean diastolic blood pressure (mDBP) ≥80 mmHg or self-reported current use of antihypertensive medications were classified as hypertensives. Hypertensives on medications with mSBP <130 mmHg and mDBP <80 mmHg were classified as having well-controlled hypertension. Subgroup comparisons of hypertension prevalence were computed using Chi-square test. Predictors of hypertension and well-controlled BP were assessed using multivariable logistic regressions. Two tailed p-values <0.05 were considered statistically significant. RESULTS: The prevalence of hypertension in the USA in 2017-2018 was 49.64% (95% CI 46.67-52.61) corresponding to 115(95% CI 104-128) million persons. NH Blacks: 58.53% (95% CI 55.39-61.60); Men: 54.46% (95% CI 51.01-57.87); older persons and obese individuals: 61.03% (95% CI 57.31-64.63) as well as persons with diabetes and CKD, comparatively. The overall rate of well-controlled hypertension was 39.64% (95% CI 36.20-42.81). Persons with at least a college degree: OR 2.20(95% CI 1.02-5.04, p=0.049) and persons with incomes ≥3 times the poverty threshold; OR 1.88(95% CI 1.1.8-2.99, p=0.011) had higher rates of well-controlled hypertension when compared to lowest categories. CONCLUSION: One in every two persons ≥20 years in the USA has hypertension with only 39.64% on medications having well-controlled hypertension. Significant discrepancies exist in the burden and control rates in different subpopulation categories. Targeted interventions could help improve the prevalence and hypertension control rates in the USA.

10-Year trend in the prevalence and predictors of depression among patients with heart failure in the USA from 2007-2016.

BACKGROUND: Heart failure (HF) constitutes a major public health problem in the USA with self-management playing a key role in treatment. Depressed patients often have poor insights which correlates with increased rates of adverse events such as emergency room visits, admissions and readmissions, length of hospital stay and mortality. AIM: To determine the prevalence, trends, and predictors of depression among community-based patients with HF in the USA, and its association with self-perceived health status. METHODS: Using the 2007 through 2016 NHANES data, we identified patients with HF aged 20-80 years with completed PHQ-9 depression screening questionnaire. PHQ-9 scores ≥10 were considered diagnostic for depression. The Chi square test was used for comparison of prevalence of depression between subgroups with p < 0.05 considered statistically significant. RESULTS: The prevalence of depression among community-based patients with HF was 17.3% and remained stable from 2007 through 2016. Female participants, persons <60years, individuals with low socioeconomic status, and never married individuals were more likely to be depressed, comparatively. After controlling for confounders, living in poverty was the lone predictor of depression with OR 5.1 (95% CI 1.4-17.9), compared to those with incomes ≥3 times the poverty threshold. Depressed individuals were more likely to report a poor health status (76.4%) compared to non-depressed individuals (45.9%), p < 0.001. CONCLUSION: Over 1 in 6 community-based patients with HF suffers from depression with women, individuals <60years, never married, and persons with low socioeconomic status shouldering a disproportionately higher burden.

Ecstasy induced acute systolic heart failure and Non-Ischemic Cardiomyopathy in a young female: a rare case report and literature review.

Ecstasy or 3,4-methylenedioxymethamphetamine (MDMA) is an illicit recreational drug. Effects include euphoria, increased sensory awareness, and central stimulation. Although various arrhythmias, as well as dilated cardiomyopathy, have been previously noted to occur with chronic use, cardiac toxicities are seldom reported in an acute setting. Herein, we present a 28-year-old female patient with no prior medical condition that presented to the Emergency Department with chest pain following intake of MDMA. Electrocardiographic findings, as well as laboratories, were suggestive of possible Acute Non-ST elevation myocardial infarction. Upon admission, cardiac catheterization revealed patent coronary arteries. Stark regional wall motion abnormalities were observed along with reduced ejection fraction. Acute systolic heart failure was treated with standard medical management. Subsequent reassessment of ventricular function with Echocardiography revealed marked improvement. This article describes a case of MDMA induced heart failure, including details of evaluation, management, and monitoring of patient progress. It brings further attention to potential acute harmful effects of MDMA on cardiac function and viability.

Disparities and drivers of early age at diagnosis of congestive heart failure in the USA.

AIM: Heart failure (HF) constitutes a major public health problem in the USA due to its high morbidity and mortality. Age at diagnosis of HF would refine burden quantification, budgeting, disease surveillance and assessment of interventions. We set out to determine the median age at diagnosis of HF and drivers of young age at diagnosis among patients 20 years or older in the USA. METHODS AND RESULTS: We utilized NHANES data collected across five survey cycles (2007-2016). Included were individuals aged 20 to 80 years diagnosed of HF with valid entries for age at diagnosis. Differences in age at diagnosis between groups and major drivers for younger age at diagnosis were assessed using linear regression models with p-values <0.05 considered statistically significant. The prevalence of HF in the USA was 2.44% with a median age at diagnosis of 59 years (IQR 47-70). Non-Hispanic (NH) Blacks -4.94 years (95% CI -7.95 to -1.93), individuals living below the poverty line -5.79 years (95% CI -10.36 to -1.01), obese persons -5.63 years (95% CI -8.35 to -2.92), individuals without health insurance -4.31 years (95% CI -7.87 to -0.75) and those without hypertension -3.99 years (95% CI -7.19 to -0.78) were diagnosed at significantly younger ages than their respective counterparts. CONCLUSION: The median age at diagnosis of HF in the USA is 59 years. NH Blacks, living in poverty, lack of health insurance and obesity are the main drivers of early age at diagnosis of HF in the USA.

Clozapine-Induced Cardiotoxicity Presenting as Sepsis: A Case Report and Literature Review.

Clozapine is an atypical antipsychotic agent indicated in the treatment of medication-resistant schizophrenia. It is often reserved as a last line of treatment owing to the potential for serious and potentially life-threatening side effects, the most serious being agranulocytosis requiring close hematological monitoring and possible discontinuation of the medication from further use in the patient even when the agranulocytosis resolves. Other complications of clozapine include sedation, weight gain, elevated triglyceride levels, postural hypotension, and tachycardia. However, the potentially serious complication of myocarditis, though rare (with an incidence of 3%), may lead to cardiomyopathy as described in our present case. We present a 21-year-old patient who was started on clozapine for management of schizophrenia. He developed fever and tachycardia and was admitted to the medical unit on intravenous antibiotics for management of sepsis as he met the criteria for systemic inflammatory response syndrome. His labs revealed an elevated troponin and trending eosinophilia, which, in the context of clozapine use, raises the suspicion of clozapine cardiotoxicity. Echocardiogram showed reduced systolic function (45%). Clozapine was immediately discontinued, and his repeat echocardiogram showed normalization of his systolic function. In view of the increased prevalence of psychiatric illnesses, internists should be aware of rare but potentially life-threatening side effects.

Case Report: Diffuse T wave inversions as initial electrocardiographic evidence in acute pulmonary embolism.

Acute pulmonary embolism (PE) is a life-threatening condition and is typically diagnosed by a combination of symptoms, clinical signs and imaging. Electrocardiogram may be helpful in diagnosis, and the most widely described pattern of occurrence is the so-called S 1Q 3T 3 pattern. Here, we describe the case of an African-American male who presented with typical chest pain, diffuse T wave inversions with serial troponin elevation. There was initial concern for Wellen's syndrome but was finally diagnosed as acute PE. This case underscores the necessity of vigilance and a lower threshold for PE work up even in patients presenting as acute coronary syndrome.

Intramuscular Epinephrine-Induced Transient ST-Elevation Myocardial Infarction.

Introduction. Myocardial infarction in the setting of anaphylaxis may result from the anaphylaxis itself or from the epinephrine used to treat the anaphylaxis. While cases of myocardial infarction due to large doses of intravenous epinephrine have previously been reported, myocardial infarction after therapeutic doses of intramuscular epinephrine is rarely reported. Case Report. A 23-year-old male presented with sudden onset of difficulty in swallowing and speech after eating takeout food. He was treated with intramuscular epinephrine for presumed angioedema following which he immediately developed chest tightness associated with ST elevation on electrocardiogram and elevated serum troponin. His symptoms and electrocardiogram findings were transient and resolved within the next 10 minutes. Conclusion. Epinephrine is lifesaving during anaphylaxis and should be promptly used. Health care providers, however, need to be aware and vigilant of this rare complication of epinephrine.

Hypereosinophilic Syndrome Complicated by Eosinophilic Myocarditis With Dramatic Response to Steroid.

Introduction. Eosinophilic myocarditis is an infiltrative disease that affects the myocardium leading to various presentations. It can be precipitated by medications, helminthiasis, or hypereosinophilic syndrome. Case. We present the case of a young, male patient who presented with palpitations and dyspnea and was found to have heart failure with reduced ejection fracture of 12%. His past medical history was significant for recent lung problem treated with steroids. Based on his history and laboratory findings, he was started on intravenous steroids for treatment of eosinophilic myocarditis. Within 3 days, his ejection fracture improved to 35%. Conclusion. Given the nonspecific clinical presentations, mimicking other diseases, high index of suspicion is warranted to diagnose eosinophilic myocarditis. This is crucial as early detection and treatment with steroids can lead to a dramatic response.

Type 1 Brugada pattern ECG due to supra-therapeutic phenytoin level.

Brugada syndrome is an inherited arrhythmogenic disease, characterised by a coved-type ST segment elevation in right precordial leads and an increased risk of sudden cardiac death due to ventricular arrhythmia. To unmask or exacerbate a Brugada ECG pattern, class IA or IC antiarrhythmic agents are used, and clinicians can predict sudden cardiac death in a high-risk patient. However, phenytoin, one of the class IB agents, may induce a Brugada pattern ECG at a supra-therapeutic level and this association has rarely been reported. We describe a case of a patient with a phenytoin level about twice as high as the therapeutic level, which led to the emergence of a type 1 Brugada pattern ECG. Awareness should be made between this important association of supra-therapeutic phenytoin level and type 1 Brugada pattern ECG because symptomatic Brugada syndrome can lead to sudden cardiac death.

Arrhythmias and Electrocardiographic Changes in Systolic Heart Failure.

BACKGROUND: Heart failure is a common condition that that leads to hospitalization. It is associated with various atrial and ventricular arrhythmias. AIM: The aim of this study is to find common arrhythmias and electrocardiographic changes in hospitalized patients who have systolic heart failure. MATERIALS AND METHODS: This is a retrospective study of medical records, and electrocardiograms (EKGs) of 157 patients admitted to our hospital who had systolic heart failure with ejection fraction (EF) <50% on echocardiogram. Based on EF, the patients were divided into two groups; one with EF ≤ 35% and the other with EF > 35%. Twelve-lead EKG of these patients was studied to identify common arrhythmia and demographic variables; laboratory results were compared to identify the differences. RESULTS: A total of 157 patients with systolic heart failure, 63.7% had an EF ≤ 35%. Hypertension 82.8%, diabetes 49%, coronary artery disease 40.8%, chronic obstructive pulmonary disease or bronchial asthma 22.3%, and stroke 12.1% were common associated co-morbidities. On analysis of EKG, 28.6% had tachycardia, 21.9% had prolonged PR > 200 ms, 16.3% had wide QRS > 120 ms, 70.7% had prolonged corrected QT (QTc), and 42.2% had left axis deviation. The most common arrhythmias were sinus tachycardia and atrial fibrillation/flutter which were found in 14.6% and 13.4%, respectively. The left ventricular hypertrophy was a common abnormality found in 22.4% followed by ventricular premature contractions 18.4%, atrial premature contractions 9.5%, and left bundle branch block 6.1%. Patients with severe systolic heart failure had prolonged QRS (P = 0.02) and prolonged QTc (P = 0.01) as compared to the other group. CONCLUSIONS: Sinus tachycardia and atrial fibrillation/flutter were common arrhythmias in patients with systolic heart failure. Patients with severe systolic heart failure had statistically significant prolongation of the QRS duration and QTc interval.

Tricuspid valve endocarditis complicated by Mobitz type II heart block - a case report and literature review.

We present a case of a middle-aged male who manifested with low-grade fever and lower back pain. MRI and bone scan of the spine were suggestive of vertebral osteomyelitis. Blood cultures were persistently positive for Enterococcus faecalis and echocardiogram revealed tricuspid valve endocarditis. There was no history of IV drug use and urine toxicology was negative. EKG showed Mobitz type II AV block and a transesophageal echocardiogram revealed no valve ring or septal abscesses. The heart block persisted despite antibiotic therapy and an epicardial pacemaker was placed. This is a rare presentation of high-grade AV block with tricuspid endocarditis in the absence of echocardiographic evidence of perivalvular extension of infection. Also, unique in this case is the finding of E. faecalis hematogenous vertebral osteomyelitis.