Takotsubo Cardiomyopathy Precipitated by Tapering of Anxiolytic Medication: A Case Report.

Takotsubo cardiomyopathy is a transient apical ballooning of the left ventricle typically with electrocardiographic changes and enzyme release without evidence of obstructive coronary artery disease. It typically occurs in postmenopausal women and may have a predilection for patients with anxiety disorders. The following is a case in which we believe takotsubo cardiomyopathy was induced by the tapering of antianxiety medications. We feel that health care professionals should be aware of this possibility in such a patient population especially when they have demonstrated cardiovascular symptomatology.

Longest Event-Free Survival without Anticoagulation in a Mechanical Aortic Valve Replacement.

Sixty percent of the patients going for valve replacement opt for mechanical valves and the remaining 40% choose bioprosthetics. Mechanical valves are known to have a higher risk of thrombosis; this risk further varies depending on the type of valve, its position, and certain individual factors. According to current guidelines, long-term anticoagulation is indicated in patients with metallic prosthetic valve disease. We report two unique cases of patients who survived 27 and 37 years event free, respectively, after mechanical aortic valve replacement (AVR) without being on any form of anticoagulation. The latter case described the longest survival in a human with a prosthetic aortic valve without anticoagulation. A review of literature demonstrated few cases of prosthetic valves with no anticoagulation in the long term without significant embolic events reported as case reports. These cases have been summarized in this article. Some cases of long-term survival (in the absence of anticoagulation) were attributed to good luck, and others as the result of genetic variations. New mechanical prosthetic valves can be promising, such as microporus-surfaced valves that may be used without full anticoagulation. The use of dual antiplatelet agents alone can be currently recommended only when a patient cannot take oral anticoagulation after AVR, and it should be followed with measuring and monitoring of platelet reactivity.

Long-term Outcome after Percutaneous Coronary Intervention Compared with Minimally Invasive Coronary Artery Bypass Surgery in the Elderly.

BACKGROUND: Elderly patients with unstable coronary artery disease (CAD) have better outcomes with coronary revascularization than conservative treatment. With the improvement in percutaneous coronary intervention (PCI) techniques using drug eluting-stents, this became an attractive option in elderly. Minimally invasive coronary artery bypass grafting (MICS-CABG) is a safe and effective alternative to conventional CABG. We aimed to explore the long-term outcomes after PCI vs MICS-CABG in ≥75 year-old patients with severe CAD. METHODS: A total of 1454 elderly patients (≥75 year-old patients) underwent coronary artery revascularization between January 2005 and December 2009. Patients were selected in the study if they have one of the Class-I indications for CABG. Groups were divided according to the type of procedure, PCI or MICS-CABG, and 5 year follow-up. RESULTS: Among 175 elderly patients, 109 underwent PCI and 66 had MICS-CABG. There was no significant difference observed in both groups with long-term all-cause mortality (31 PCI vs 21% MICS-CABG, p=0.151) and the overall 5 year survival was similar on Kaplan-Meier curve (Log rank p=0.318). The average length of stay in hospital was significantly shorter in the PCI than in the MICS-CABG group (4.3 vs 7.8 days, p<0.001). Only 4.7% of the PCI group were discharged to rehabilitation facility compared with 43.9% of the MICS-CABG group (p<0.001). The rate of repeat revascularization was significantly higher in the PCI group than in the MICS-CABG group (15 vs 3%, p=0.014). CONCLUSION: Among elderly patients, long-term all-cause mortality is similar after PCI and MICS-CABG. However, there is a significantly higher rate of repeat revascularization after PCI.

Acute ST-segment elevation myocardial infarction in a young patient with essential thrombocythemia: a case with long-term follow-up report.

Essential thrombocythemia (ET) is a neoplastic proliferation of mature myeloid cells - in particular, megakaryocytes - leading to persistently elevated platelet count. Usual clinical presentation is related to an increase in the risk of hemorrhage and/or thrombosis. Management of ET consists of antiplatelet therapies - mainly aspirin and cytoreductive therapies. Coronary involvement in patients with ET is rare. The optimal treatment strategies for ET patients presenting with acute myocardial infarction remains unclear. Acute interventions like intracoronary thrombolytic therapy, angioplasty, and coronary-artery bypass grafting have been reported in such patients. However, several questions remain unanswered about the acute and long-term management of these patients. Herein, we report the case of a 47-year-old female who presented with acute myocardial infarction as the first clinical sign of ET, and also present the long-term follow-up of this patient.

Rare case of coronary to pulmonary vein fistula with coronary steal phenomenon.

Coronary artery fistulas are abnormal connections between coronary artery territories and cardiac chambers or major vessels, most of them are congenital. Patients with coronary artery fistula can be asymptomatic or present with different symptoms like angina. Cardiac computed tomography (CT) is one of the best modalities for diagnosis. We present an elderly patient that presented with angina symptoms, non invasive stress test was positive for ischemic heart disease, coronary angiogram could not reveal any obstructive lesions, but an abnormal branch of the left descending coronary artery (LAD), cardiac CT showed fistula that connect left anterior descending coronary artery to left superior pulmonary vein. Our case is extremely rare as most of the reported cases were fistulas between LAD and pulmonary artery, but in our case the fistula between LAD and left superior pulmonary vein. In addition, our patients' symptoms resolved with anti-ischemic medical treatment without any surgical intervention.

A rare case of silent transmural myocardial infarction with diffuse ST elevations complicated by concomitant severe hyperkalemia.

It is well described that certain group of patients do not display the typical symptoms of myocardial infarction (MI). Elderly patients, diabetics and those with previous coronary artery bypass graft surgery are at high risk for silent MI. The diagnosis of Acute MI in the emergency room (ER) is mainly based on the electrocardiogram (EKG) findings of ST elevations or new onset left bundle branch block which is supported by the clinical presentation and positive biomarkers when present. The diagnoses can sometimes become challenging when the patient is asymptomatic and has coincidental finding of hyperkalemia with diffuse ST segment elevations simulating that seen with electrolyte disturbance. Despite the well known pseudoinfarction pattern of hyperkalemia, acute MI should be ruled out first. A high index of suspicion is needed, especially in high risk patients. We think that in rare clinical situation when the diagnosis is in doubt, MI should be ruled out, as time has a high impact on patient mortality. An urgent bedside echocardiogram is very beneficial in excluding regional wall motion abnormalities and preventing any delay in destination therapy for transmural MI. We present a 67 years old female with history of diabetes and chronic kidney disease sent by her nephrologist to the ER for severe hyperkalemia (Potassium 7.2 milliequivalent/L). She was found to have ST elevations on EKG despite having no chest pain or distress. On cardiac catheterization she had a total occlusion of the proximal left circumflex artery, with a filling defect consistent with large thrombus.

Persistent thebesian vessels involving the right and left ventricles leading to coronary steal phenomena and ischemia.

We report an extremely rare case of thebesian vein microfistulae to both ventricles. A 65-year-old woman, with no major cardiovascular risk factors, presented with multiple episodes of chest pain. The resting electrocardiogram showed T-wave inversion in leads V(1) -V(4). A Dipyridamole myocardial perfusion imaging revealed large and severe inferior defect with complete reversibility. Coronary angiography showed no coronary artery disease. On contrast injection, an exaggerated capillary blush from the distal portions of the right and left coronary artery systems was seen in both ventricles, mimicking the image of ventriculography. This appearance suggests prominent thebesian vessels, a congenital communication between the coronaries and the two ventricles. The clinical relevance of these myocardial sinusoids is still not well established. Although the majority of these fistulas are small in size and with no clinical significance, they can rarely present with chest pain, cardiac arrhythmia, syncope, myocardial infarction, and/or pulmonary hypertension. These fistulae when excessive can cause significant shunting of blood to the ventricles, leading to coronary steal phenomena and ischemia. This phenomenon is facilitated by the low resistance in these microfistulae as opposed to the higher resistance in the normal coronary circulation. Due to the diffuse nature of these microfistulae, neither surgery nor transcatheter therapy is feasible. This condition can only be managed medically; however, it should be noted that vasodilator agents, such as nitrates, can worsen the coronary steal phenomenon. Our patient was treated with ranolazine with significant improvement in her symptoms, which was not reported previously. Multiple coronary artery microfistulae could be an underestimated condition of angina in patient with normal coronaries.

Two cases and review of the literature: primary percutaneous angiography and antiplatelet management in patients with immune thrombocytopenic purpura.

We report two cases of immune thrombocytopenic purpura (ITP) associated with acute coronary artery syndrome highlighting the interventions done in every case along with the medications used during intervention and as outpatient. The first case is that of a woman with ITP exacerbation while on dual antiplatelet therapy and the second case is that of a male presenting with non-ST elevation myocardial infarction (NSTEMI) while in a thrombocytopenic crisis. In both cases antiplatelet therapy was held and thrombopoietic therapy was initiated before resuming full anticoagulation and coronary intervention. Given the paucity of data on ITP and antiplatelets treatment in the setting of acute coronary syndrome, no strict recommendations can be proposed, but antiplatelets appear to be safe acutely and in the long term in this category of patients as long as few measures are undertaken to minimize the risks of bleeding and thrombosis.

Aortic pulse pressure is associated with the localization of coronary artery disease based on coronary flow lateralization.

BACKGROUND: Aortic pulse pressure (APP) is related to arterial stiffness and associated with the presence and extent of coronary artery disease (CAD). Besides, the left coronary artery (LCA) has a predominantly diastolic flow while the right coronary artery (RCA) receives systolic and diastolic flow. Thus, we hypothesized that increased systolic-diastolic pressure difference had a greater atherogenic effect on the RCA than on the LCA. METHODS: A random sample of 433 CAD patients (145 females, 288 males, mean age 65.0 ± 11.1 years) undergoing coronary angiography at Staten Island University Hospital between January 2005 and May 2008 was studied. Coronary lesion was defined as a ≥50% luminal stenosis. Patients were divided into three groups, with isolated LCA lesions (n = 154), isolated RCA lesions (n = 36) or mixed LCA and RCA lesions (n = 243). RESULTS: APP differed significantly between groups, being highest when the RCA alone was affected (67.6 ± 20.3 mm Hg for LCA vs. 78.8 ± 22.0 for RCA vs. 72.7 ± 22.6 for mixed, P = 0.008 for analysis of variance (ANOVA)). Age and gender were not associated with CAD location. Heart rate was associated with CAD location, lowest in RCA group, and negatively correlated with APP. However, left ventricular ejection fraction (LVEF) was lower in the mixed CAD group and positively correlated with APP. The association between APP and right-sided CAD persisted in multivariate logistic regression adjusting for confounders, including heart rate, LVEF and medication use. A similar but less significant pattern was seen with brachial arterial pressures. CONCLUSIONS: Aortic pulse pressure may affect CAD along with coronary flow phasic patterns.

Usefulness of red cell distribution width in predicting all-cause long-term mortality after non-ST-elevation myocardial infarction.

BACKGROUND: Red blood cell distribution width (RDW) is a strong predictor of adverse outcomes in patients with heart failure, stable coronary artery disease, stroke and acute myocardial infarction. The aim of our study was to explore the predictive value of RDW on all-cause mortality in patients with non-ST-segment elevation myocardial infarction (NSTEMI). METHOD: This observational study includes 619 NSTEMI patients, discharged from Staten Island University Hospital between September 2004 and December 2006. Patients were divided into equal RDW tertiles and survival was evaluated in each tertile. RESULT: Patients in the highest RDW tertile (RDW >14) had higher in-patient (7 vs. 1%) and 4-year (30 vs. 7%) mortality rates compared to those in the lowest tertile (RDW <13) (Wilcoxon χ(2) = 34.64, p < 0.0001). After controlling for Global Registry of Acute Coronary Events risk profile scores and other confounding variables, the RDW adjusted hazard ratio for 4-year all-cause mortality increased by 1.10 for each one unit increase in RDW (confidence interval 1.004-1.213, p = 0.042). CONCLUSION: RDW is an independent predictor of all-cause long-term mortality in NSTEMI patients. Further studies are needed to clarify the mechanisms of this association between RDW and adverse outcomes in patients with coronary artery disease.

Serum lipoprotein levels in takotsubo cardiomyopathy vs. myocardial infarction.

BACKGROUND: In the setting of myocardial infarction (MI) or acute coronary syndrome (ACS), current guidelines recommend early and aggressive lipid lowering therapy with statins, irrespective of the baseline lipoprotein levels. Takotsubo cardiomyopathy (TCM) patients have a clinical presentation similar to myocardial infarction and thus receive early and aggressive statin therapy during their initial hospitalization. However, the pathology of TCM is not atherosclerotic coronary artery disease and hence we assumed the lipid profiles in TCM would be healthier than coronary artery disease patients. METHODS: In this retrospective study, we assessed fasting serum lipoprotein levels of ten TCM patients and compared them with forty, age and sex-matched myocardial infarction (MI) patients. RESULTS: Comparing serum lipoprotein levels of TCM with MI group, there was no significant difference in mean total cholesterol between the two groups (174.5 mg/dL vs. 197.6 mg/dL, p = 0.12). However, in the TCM group, mean HDL-C was significantly higher (66.87 mg/dL vs. 36.5 mg/dL, p = 0.008), the mean LDL-C was significantly lower (89.7 mg/dL vs. 128.9 mg/dL, p = 0.0002), and mean triglycerides was also significantly lower (65.2 mg/dL vs. 166.8 mg/dL, p < 0.0001). CONCLUSIONS: In this study, TCM patients in comparison to MI patients had significantly higher levels of HDL-C, lower levels of LDL-C levels and triglycerides. The lipid profiles in TCM were consistent with the underlying pathology of non-atherosclerotic, non-obstructive coronary artery disease. As lipoproteins in most TCM patients were within the optimal range, we recommend an individual assessment of lipid profiles along with their coronary heart disease risk factors for considering long term lipid-lowering therapy. A finding of hyperalphalipoproteinemia or hypotriglyceridemia in 40% of TCM patients is novel but this association needs to be confirmed in future studies with larger sample sizes. These findings may provide clues in understanding the pathogenesis of takotsubo cardiomyopathy.

Proximal atherosclerotic lesion as a cause of very late stent thrombosis.

Very late stent thrombosis is defined as in-stent thrombosis occurring after 1 year of an intra-coronary artery stent placement. Drug eluting stents have lately been criticized for increased reports of very late stent thrombosis. The exact cause of these very late stent thromboses is not clearly understood. Virchow's triad describes the three main factors of thrombus formation to be stasis of blood flow, endothelial injury and hypercoagulability. Based on Virchow's triad, we propose the cause of very late stent thrombosis to be formation of a de novo atherosclerotic lesion in the proximal segment of a stented artery. The de novo atherosclerotic lesion narrows the vessel lumen and causes stasis of blood flow in the distal stent. The de novo lesion can also cause myocardial ischemia creating a prothrombotic environment in the stented region. Stasis of blood flow and prothrombotic environment in the stented region can lead to the formation of very late stent thrombosis. Since atherosclerosis is a dynamic aging process in humans, we propose de novo proximal lesions in the coronary arteries can predispose to very late stent thrombosis.

Usefulness of neutrophil to lymphocyte ratio in predicting short- and long-term mortality after non-ST-elevation myocardial infarction.

Neutrophil/lymphocyte ratio (NLR) is the strongest white blood cell predictor of adverse outcomes in stable and unstable coronary artery syndromes. The aim of our study was to explore the utility of NLR in predicting long-term mortality in patients with non-ST-segment elevation myocardial infarction (NSTEMI). Consecutive patients with NSTEMI at Staten Island University Hospital were evaluated for study inclusion. Of the 1,345 patients with NSTEMI admitted from September 2004 to September 2006, 619 qualified for study inclusion. Survival analysis, stratified by NLR tertiles, was used to evaluate the predictive value of average inpatient NLR levels. Four-year vital status was accessed with electronic medical records and Social Security Death Index. Patients in the highest NLR tertile (NLR >4.7) had a higher 4-year mortality rate (29.8% vs 8.4%) compared to those in the lowest tertile (NLR <3, Wilcoxon chi-square 34.64, p <0.0001). After controlling for Global Registry of Acute Coronary Events risk profile scores, average NLR level remained a significant predictor of inpatient and 4-year mortality. Hazard ratios per unit increase of average NLR (log) increased by 1.06 (p = 0.0133) and 1.09 (p = 0.0006), respectively. In conclusion, NLR is an independent predictor of short-term and long-term mortalities in patients with NSTEMI with an average NLR >4.7. We strongly suggest the use of NLR rather than other leukocyte parameters (e.g., total white blood cell count) in risk stratification of the NSTEMI population.