Spontaneous coronary artery dissection: a case series illustrating current challenges in diagnosis and treatment.

Spontaneous coronary artery dissection (SCAD) has been increasingly recognized in recent years as an important cause of acute coronary syndrome, myocardial infarction, and sudden death, especially among young women. However, due to the lack of clinical trials on SCAD, evidence-based guidance on management is currently lacking. Presented are four case studies that illustrate the recent insights and challenges in SCAD diagnosis and treatment.

Spontaneous coronary artery dissection (SCAD) is a condition where the layers of a coronary artery tear without any apparent cause. In recent years, it has become more recognized as an important cause of chest pain, heart attacks, and sudden death, especially in younger women. However, because of the lack of clinical trials focused on SCAD, there is insufficient evidence-based guidance on managing the condition. This article shares four cases to show the current knowledge and challenges in diagnosing and treating SCAD.

Outcomes in transcatheter aortic valve replacement (TAVR) patients requiring red blood cell transfusion: A nationwide perspective.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) can be complicated by anemia due to periprocedural bleeding, hemolysis, vascular events, or significant bleeding associated with antiplatelet therapy. OBJECTIVE: We used the National Inpatient Sample (NIS) database to study the outcomes of patients who underwent TAVR and developed significant anemia requiring red blood cell (RBC) transfusion. METHODS: This is a retrospective cohort study utilizing the NIS database from 2016 to 2017. We identified patients who underwent TAVR and required RBC transfusion using ICD-10 and PCS-10 codes. The primary outcome was all-cause inpatient mortality, and the secondary outcomes were the cost of hospitalization and length of stay (LOS). Student t-test, Chi-square, and ANOVA were utilized for statistical analysis where applicable. Multivariate logistic regression was used to adjust for potential confounders. STATA 15.0 was utilized for data analysis. RESULTS: A total of 18,325 patients underwent TAVR in 2016-2017. Among them, 6.7 % of patients required RBC transfusion. Patients were relatively older in the transfusion group (81 yrs vs 79 yrs; p < 0.001). The mean cost of hospitalization was higher in the transfusion group (283,153 USD vs 208,939 USD; p < 0.001). The mean length of stay (LOS) was higher in the transfusion group (9.0 days vs 4.3 days; p < 0.001). Patients in the transfusion group had higher inpatient all-cause mortality compared to patients without transfusion (6.1 % vs 1.3 %; odds ratio 4.94; p < 0.001, 95 % CI 3.7-6.4). Inpatient mortality and LOS didn't differ by race or sex in the transfusion group. All-cause mortality, LOS, and cost of hospitalization were independently increased by transfusion after adjusting for potential confounders i.e. sex, race, hospital teaching status, hospital region, heart block, pacemaker, arrhythmias, heart failure, diabetes, pulmonary hypertension, CKD, and others using multivariate logistic regression. CONCLUSION: In patients undergoing TAVR, blood transfusion was associated with adverse outcomes including increased mortality, length of stay, and cost of hospitalization. The role of careful patient selection, judicious use of antiplatelets, anticoagulants, and pre-procedural optimization of anemia needs further investigation to optimize patient outcomes.

Sex-Based Outcomes in Patients Undergoing WATCHMAN Device Implantation.

Sex-based disparities in outcomes are reported for various cardiovascular procedures. This study aimed to assess the difference in outcomes in patients who underwent WATCHMAN device implant based on sex. Patients who underwent WATCHMAN device placement, from 2016 to 2018, were identified from the National Inpatient Sample database. The primary outcome was inpatient mortality, and the secondary outcomes were the length of stay (LOS), hospitalization cost (HOC), and periprocedural complications. A logistic regression model was built to perform an adjusted analysis for the outcomes. A total of 12,327 patients underwent WATCHMAN device placement. Female patients were older and more likely to have hypertension (p <0.01) and less likely to have peripheral arterial disease (5.6 vs 7.2, p <0.01), chronic kidney disease (21% vs 26%, p <0.01), and diabetes (18% vs 20%, p = 0.03) and were also at a higher risk for certain periprocedural complications, including pericardiocentesis and anemia requiring blood transfusion (p <0.01 for all). In the unadjusted analysis, the female sex was associated with longer LOS (1.5 vs 1.3 days, p <0.01) and inpatient mortality (0.23 vs 0.10, p = 0.05). The HOC was numerically higher in women but statistically nonsignificant ($120,791 vs $118,554, p = 0.1). In the stepwise, backward, multivariate regression analysis, the female sex  was an independent risk factor for higher LOS (1.5 vs 1.3 days, p <0.01, 95% confidence interval 1.3 to 1.4) after adjusting for potential confounders. The inpatient mortality and HOC were similar between 2 groups after adjusting for potential cofounders in the multivariate regression analysis. Our study suggests that the female sex is an independent risk factor for longer LOS among patients hospitalized for WATCHMAN device placement.

Ticagrelor and primidone interaction masquerading as dual antiplatelet therapy noncompliance.

Ticagrelor and aspirin is a common dual antiplatelet therapy regimen for patients who undergo percutaneous coronary intervention. Despite its ability to significantly reduce cardiovascular complications, ticagrelor response may be altered by other medications causing subtherapeutic effects. Traditionally, ticagrelor is thought to have fewer drug-drug interactions compared to other thienopyridine antiplatelet medications such as clopidogrel. Primidone, metabolized into phenobarbital, is a strong CYP-3A inducer that can reduce serum concentrations of ticagrelor resulting in ineffective antiplatelet therapy. We present a 67-year-old male who suffered in-stent thrombosis after percutaneous intervention possibly due to the interaction between primidone and ticagrelor.

Ticagrelor and aspirin is a common antiplatelet regimen for patients who undergo coronary intervention and stent implantation. Ticagrelor is typically less associated with drug­drug interactions; however, our case illustrates an interaction between ticagrelor and primidone causing acute in-stent thrombosis to recently implanted drug-eluting stents.

Physicochemical characteristics of beverage emulsions containing crocetin as a functional ingredient of saffron.

This study aimed to investigate the physicochemical properties of beverage emulsions containing crocetin as a functional ingredient. The effect of different concentrations of gum Arabic (GA; 1-4%), various types of oils (10% sunflower or sesame oil containing 0.1% of crocetin) in the presence of xanthan gum (XG; 0.1%) were studied using a general full factorial design. The dependent variables were pH, opacity, size index, stability index (determined in accelerated and storage conditions), particle size, and steady shear rheological measurements. The main effects of GA concentration were significant (p < 0.001) on all of the physicochemical characteristics. However main effects of oil types were only significant (p < 0.001) on the mean diameter size, size index, and consistency coefficient (k) of prepared crocetin beverage emulsions. Results suggested sunflower oil may be more suitable for formulating a beverage emulsion containing crocetin because of the smaller mean particle size and lower size index.

Comparison of Outcomes for Non-ST Elevation Acute Myocardial Infarction in Weekday vs Weekend Admissions: The Weekend Effect.

Background: Recent literature shows that reduced staffing over the weekends in hospitals may compromise patient care with acute conditions like acute coronary syndrome (ACS). Objective: Our study evaluated differences in the outcomes between patients presenting with non-ST segment elevation acute coronary syndrome (NSTE-ACS) on weekends versus those coming on weekdays. Methods: A single-center retrospective study was performed on NSTE-ACS patients. Data were analyzed using SPSS version 22 to calculate an independent sample t-test value for significance between the two groups. Results: The mean DTB time for patients admitted over the weekend was significantly higher than those admitted over weekdays (p = 0.000). The mean peak troponin level and length of stay (LOS) for patients admitted over the weekends vs. weekdays was significantly higher by 5 ng/dL (9.71 ± 5.23 vs. 4.194 ± 2.60, p = 0.0001) and 24 h (72 ± 10 vs. 48 ± 6 h, p = 0.003), respectively. While the mean left ventricular ejection fraction (EF) of patients on discharge was lower by 5% for patients admitted over the weekend compared to patients admitted on weekdays (p = 0.001). Conclusion: NSTE-ACS patients admitted over the weekends have a significantly higher myocardial injury evidenced by an increased LOS, higher peak troponin levels, and reduced EF due to delayed PCI compared to weekday admissions.

Contemporary trends in the incidence of spontaneous coronary artery dissection (SCAD) - ethnic and household income disparities.

OBJECTIVES: Spontaneous coronary artery dissection (SCAD) may contribute to 35% of acute coronary syndrome among women ≤50 years of age. We aimed to investigate the overall incidence, as well as the trends of SCAD incidence based on race, household income, and the U.S. census regions utilizing the National Inpatient Sample. METHODS: In this retrospective cohort study the discharge data were extracted from the NIS using 9th and 10th revisions of the International Classification Disease for SCAD. RESULTS: We found that the incidence of SCAD is rising in all U.S. census regions, and patients were predominantly females. Overall crude incidence of SCAD per 1,000,000 discharges per year was found to be 4.95 (2010), 5.73 (2011), 5.34 (2012), 6.18 (2013), 7.64 (2014), 8.11 (2015), 14.58 (2016), and 14.81 (2017). There was a higher incidence of SCAD in white population and higher-income groups. Among U.S. census regions, West has had the highest incidence followed by the Northeast, Midwest, and South. Statistically significant differences were observed in year-to-year SCAD incidence among racial groups, household income quintiles, and U.S. census regions (P < 0.0001). CONCLUSION: Recent trends indicate that the incidence is highest among White race, highest household income quintile, and in U.S. CENS-R4 (Census Region 4: West). These findings defy classic racial trends in cardiovascular disease burden which need further discovery.

Heart Failure Patients and Implications of Obesity: A Single-Center Retrospective Study.

Background and objective The prevalence of heart failure (HF) is on the rise; currently, it affects around five million people in the United States (US) and the prevalence is expected to rise from 2.42% in 2012 to 2.97% in 2030. HF is a leading cause of hospitalizations and readmissions, accounting for a major economic burden to the US healthcare system. Obesity is a widely accepted risk factor of HF; however, data regarding its independent association with HF mortality and morbidity is heterogeneous. Globally, more than two-thirds of deaths attributable to high body mass index (BMI) are due to cardiovascular diseases (CVD). This study aimed to investigate the potential role of obesity (BMI >30 Kg/m2) in HF patients in terms of 30-day readmissions, in-hospital mortality, and the use of noninvasive positive pressure ventilation (NIPPV). Methods In this single-center, retrospective study, all adult (age: >18 years) patients who were hospitalized with a primary diagnosis of HF at the Abington Jefferson Hospital from January 2015 to January 2018 were included. Demographic characteristics were collected manually from electronic medical records. Outcomes were 30-day readmission due to HF, all-cause in-hospital mortality, and requirement for NIPPV. Multivariable logistic regression analysis was conducted to investigate the association of obesity with HF outcomes. Results A total of 1,000 patients were initially studied, of these 800 patients were included in the final analysis based on the inclusion criteria. Obese patients showed higher odds for 30-day readmissions and the use of NIPPV compared to non-obese patients. There was no significant difference in in-hospital mortality in obese vs. non-obese patients. Conclusions Based on our findings, BMI >30 Kg/m2 is an independent risk factor for HF readmissions. Additionally, our results highlight the importance of guidelines-directed medical therapy (GDMT) for HF exacerbation, a low threshold for use of NIPPV in obese patients, promotion of lifestyle modifications including weight loss, and early follow-up after discharge to prevent HF readmissions in the obese population.

The contemporary trends and geographic variation in premature mortality due to heart failure from 1999 to 2018 in the United States.

OBJECTIVES: We aimed to examine the contemporary trends and regional variations in premature mortality due to heart failure across the U.S. from 1999 to 2018. BACKGROUND: For most U.S. census regions, it is unknown whether premature mortality (deaths among persons under age 65) due to heart failure is increasing -or decreasing. METHODS: In this descriptive study, the death certificate data were retrieved from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (WONDER) database and examined from 1999 to 2018 for the underlying cause of death. Age-adjusted mortality rates (AAMR) per 100,000 persons and annual percent change (APC) in rates stratified by census region were calculated using Joinpoint trend analysis software. RESULTS: There were 118,116 premature deaths due to heart failure from 1999 to 2018 across the U.S. Of these 52.40% of deaths were reported in the South, 20.30% in the Midwest, 15.10% in the West, and 12.20% in the Northeast. The AAMRs were the highest in the South region (range: 3.1-4.9) and the lowest in the Northeast region (range: 1.5-1.9). There was an overall decline in mortality across all regions from 1999 till 2011-2012. However, mortality has an upward trajectory throughout all the census regions after 2012. CONCLUSIONS: This study on nationwide data showed that overall premature mortality due to heart failure declined from 1999 to 2011-2012 followed by an upward trajectory from 2012 to 2018; the explanation for this merits further discovery.

Wrapped Left Anterior Descending Artery Presenting As Inferior Myocardial Infarction: Case Report and Review of the Literature.

Acute occlusion of the left anterior descending (LAD) coronary artery generally results in ST-segment elevation in the anterior leads of the electrocardiogram and reciprocal ST-segment depression in the inferior leads. We present a case of LAD occlusion presenting as inferior wall ST-segment elevation myocardial infarction.

Percutaneous repair of post-myocardial infarction ventricular septal rupture presenting with cardiogenic shock.

Ventricular septal rupture (VSR) is an uncommon and devastating complication with a high mortality rate due to limited available interventions required by expert hands in a small window of opportunity. Most commonly seen following delayed myocardial infarctions (MI), the rate of VSR has decreased partly from protocol driven reperfusion therapy; however, cases are still present, particularly when diagnosis is delayed. We present a case of a critically ill patient in cardiogenic shock following a large anterolateral wall ST-elevation MI complicated by a large VSR whom was transferred to our academic institution for percutaneous repair. Of note, such intervention was initially performed by Lock in 1988 and a comprehensive review published in 2016 noted only 273 such cases. This review noted patient cases since that initial percutaneous closure by Lock with a majority of cases utilizing an Amplatzer system; others being Clamshell and CardioSEAL. Our patient underwent the percutaneous VSR closure utilizing an Amplatzer Occluder delivery system with successful insertion of an 18 mm muscular VSD Amplatzer closure device. Although the rarely performed procedure was successful and provided invaluable insights into the treatment and management of VSR, the patient succumbed to multiple critical disease processes in the following days post intervention. Patient consent and ethics committee approval for publication, as per Saint Louis University case publication guidelines, were confirmed and approved.

The role of echocardiography in diagnostic evaluation of patients with syncope-a retrospective analysis.

BACKGROUND: Syncope is a symptom complex comprising of a brief loss of consciousness leading to a transient decrease in cerebral blood flow that resolves completely. 2D-transthoracic echocardiography (TTE) is a useful tool to detect underlying structural heart disease, which can lead to syncope, e.g., aortic stenosis, atrial masses. This study aimed to find the subgroups of patients with syncope who would benefit the most from a TEE. METHODS: We did a retrospective chart review of all patients aged 18 years or older, admitted to our hospital with a primary diagnosis of syncope between January 2015 and January 2017 to determine the frequency and findings of echo in all these patients. The baseline characteristics, demographics were taken into account for the inclusion of these patients into the study. RESULTS: A total of 369 patients were initially studied, but only 139 patients were included in the final analysis based on inclusion criteria. Among the high-risk patients (i.e., abnormal Physical exam and/or abnormal EKG, population), 43.75% had significant echocardiographic finding. While among low-risk patients (i.e., normal EKG and exam), 10% (9/91) had a significant finding. Patients with abnormal EKG or examination findings were 7.08 times (95% CI = 2.89-17.3) more likely to have an abnormal echocardiogram (P < 0.001). CONCLUSION: Our study suggests that the diagnostic yield of 2D-TTE in the absence of abnormal physical exam and/or abnormal EKG is very limited and may add an extra burden on the finances and resources of both the patient and the hospital.

Weight Loss: A Significant Cue To The Diagnosis of Chronic Mesenteric Ischemia.

Chronic mesenteric ischemia (CMI) is a condition defined by a state of attenuated blood circulation in the mesenteric vasculature affecting one or more abdominal viscera, and is more common in the female and elderly populations. Amongst the many causes, it occurs most frequently in connection with diffuse atherosclerosis. Its presentation is variable with symptoms such as weight loss, nausea, vomiting, diarrhea and/or constipation, with postprandial pain classically present in the majority of the cases; this, in addition to the chronic course of the disease, makes timely diagnosis a challenge. Physical examination may reveal signs of malnutrition and other findings usually linked with the underlying medical condition. It can have grave consequences if not managed promptly. In our case, an 81-year-old woman came in with loss of appetite, nausea, vomiting, diarrhea and/or constipation, and weight loss. Computed tomography angiography (CTA) of the abdomen/pelvis confirmed chronic occlusion of the mesenteric vessels. She was treated surgically. This discussion is based on chronic mesenteric ischemia and its nonspecific symptomatology, particularly its association with weight loss.

Acute mesenteric ischemia in an African American patient with heterozygous factor V Leiden deficiency.

It is well documented that factor V Leiden mutation (FVL) is a common hypercoagulable risk factor in the Caucasian population. Patients with homozygous FVL mutation have an increased risk for venous thromboembolism. However, there have been few cases of heterozygous FVL mutation associated with arterial thrombosis described in the literature. Our case report presents an African American (AA) female with heterozygous FVL mutation who presented with acute arterial mesenteric ischemia.

Tetralogy of Fallot with isolated levocardia in a young female.

Tetralogy of Fallot is the most common cyanotic congenital heart disease. It consists of right ventricular outflow tract obstruction, a ventricular septal defect, abnormally located aorta and right ventricular hypertrophy. It usually occurs as an isolated anomaly with a normally placed heart and abdominal viscera. We present a case of a 19 years old female who presented with a prolonged history of shortness of breath (SOB) and cyanosis. After undergoing echocardiography and cardiac computed tomography angiogram (CTA), she was diagnosed to be a case of Tetrology of Fallot (TOF) in association with situs inversus with levocardia also termed 'isolated levocardia'. The patient underwent surgical correction and she was asymptomatic with no residual cardiac defects on follow up after 6 months. Isolated levocardia is a rare condition that is usually associated with severe cardiac defects and a low life expectancy in untreated patients. It is unusual for it to be diagnosed in adults as in our case.

"Singultus" uncloaking potentially fatal vascular dissections.

Aortic dissection (AD) is a serious condition in which the intimal layer of aorta tears and blood surges in between the intimal and medial layers of aorta causing it to separate (dissect). It usually presents with excruciating pain radiating to the back. Here we present a unique presentation of AD where an old-aged Caucasian male presented with a chronic history of intractable hiccups. His computed tomography (CAT scan) revealed the dissection of the descending thoracic aorta. He was managed conservatively and was discharged home in stable condition. The purpose of this report is to highlight this unusual presentation of AD and unmask the possible etiology of hiccups in such cases.

What is the cause of death, when alcohol dependent persons die prematurely?

BACKGROUND: Although individuals with alcohol use disorder (AUD) have a significantly shorter lifespan than the general population, there is sparse evidence on cause of death when alcohol dependent people die prematurely. Especially the somatic causes of death are shed less light on. AIM: To determine the cause of premature death in individuals with AUD based on recent studies. METHODS: This systematic review summarizes evidence from the last 10 years with cohort studies consisting of AUD patients with the subsequent outcome of cause of death and with at least two years of follow-up. RESULTS: Nine studies were included of which only two were assessed to be of good quality. Furthermore, two studies were of moderately good and acceptable quality, respectively. This review found increased mortality in AUD individuals with the main causes of death being malignancy, and problems of the cardiovascular- and the digestive system. CONCLUSION: Malignancy was the most common cause of death in the included AUD cohorts, but the overall quality of the included studies in this review is low. There is a need for high-quality studies to better understand cause-specific mortality among AUD individuals.

Clinical Approach to Manage Gastrointestinal Bleeding with a Left Ventricular Assist Device (LVAD).

Left ventricular assist devices (LVADs) are an exceedingly important form of mechanical support for patients with end-stage heart failure. LVADs can be utilized both as a bridge to cardiac transplant and also as a definitive treatment. However, a few complications are associated with LVAD placement, the most common and cumbersome of which is gastrointestinal (GI) bleeding with an incidence of about 30%. These bleeding events often require transfusion therapy, but they are rarely fatal. The etiologies of GI bleeding following LVAD are multifactorial and include unstable hemodynamics, an acquired von Willebrand factor (vWf) deficiency, impaired platelet aggregation, and activation of fibrinolytic systems. The treatment of choice in LVAD implantation-associated GI bleeding is endoscopy, which plays a vital role in both its diagnosis and management. Even so, its effectiveness in controlling post-LVAD implantation GI bleeding is still poorly ascertained. In this article, we will review the use of medication and alterations in the LVAD setting to prevent the occurrence of GI bleeding, as well as the findings of previously reported literature on LVAD implantation-associated GI bleeding.

Tilting the balance: hemidiaphragm paralysis leading to right to left cardiac shunt.

Patent foramen ovale (PFO) is a congenital abnormality present in 25%-30% of healthy adults and rarely leads to any sequelae. 1 2 It is associated with a left-to-right shunt which usually does not lead to any haemodynamic compromise. Occasionally, the shunt can get reversed; that is, right-to-left shunt occurs due to worsening pulmonary hypertension and can lead to persistent hypoxia. It is rare for the shunt reversal to happen in the absence of pulmonary hypertension. Here, we present an exceedingly rare case in a 61-year-old man presenting with hypoxia, was found to have shunt reversal due to unilateral diaphragmatic paralysis. He was successfully treated with PFO closure. The purpose of this report is to consider rare possibilities of PFO shunt reversal when the right-sided heart pressure is normal and to highlight that a simple chest X-ray can be a clue to the diagnosis.

The Effects of Geography on Outcomes of Routine Early Versus Selective Late Revascularization Strategy in the Treatment of Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction: A Meta-Analysis of Transatlantic Randomized Controlled Trials.

BACKGROUND: The optimal timing of revascularization in unstable angina (UA) or non-ST-segment elevation myocardial infarction (NSTEMI) remains uncertain. We compared routine early revascularization (REV) versus selective late revascularization (SLR) strategies and divergence in the approach of cardiologists in the United States and Europe. METHODS: Seventeen randomized controlled trials (RCTs) (15,812 patients) were extracted from PubMed, Cochrane Library, EMBASE and Web of Science databases. The data were pooled using the Der Simonian and Laird random-effect models and expressed as pooled risk ratios (RR) with 95% confidence intervals (95% CIs). RESULTS: Overall, there was no difference in all-cause mortality (RR: 1.01, 95% CI: 0.95 - 1.08, P = 0.7), myocardial infarction (MI) (RR: 0.98, 95% CI: 0.79 - 1.22, P = 0.85) or coronary artery bypass grafting (CABG) (RR: 1.33, 95% CI: 0.92 - 1.91, P = 0.12) between REV and SLR strategy. There were trends of decreased incidence of MI in REV, 13.3% (1,029/7,704) vs. 15.1% (1,108/7,314) in SLR (P = 0.007), and rate of CABG was higher in REV, 4.9% (140/2,831) vs. 3.7% (105/2,819) in SLR (P = 0.031). There were trends of lower all-cause mortality in the combined US/international trials in both REV 8.4% (390/4,624) vs. 22.8% (908/3,975) (P < 0.001) and SLR 8% (359/4,421) vs. 24% (910/3,808) (P < 0.001) compared to the European trials. There were also trends of lower rates of MI in the European trials in the REV group 20% (623/3,080) vs. 25% (712/2,893) in SLR (P = 0.001) and higher rates of CABG in REV 8.3% (96/1,144) vs. 5.7% (67/1,165) in SLR (P = 0.02); however, there were no significant effects in the pooled RR ratios even after subgroup analysis between US/international trials and European trials. CONCLUSIONS: Despite having contemporary differences in the management approach towards UA/NSTEMI patients, no significant differences in trends were observed with REV strategy in US/international trials vs. European trials.