Effusive-Constrictive Pericarditis in a Young Active Duty Male.

Effusive-constrictive pericarditis (ECP) is a rare clinical entity resulting from accumulating pericardial fluid within a stiff, non-compliant pericardium. There are a number of etiologies for ECP, which include malignancy, radiation, post-surgical causes, infectious, and collagen disorders. Clinically, ECP often presents as right-sided heart failure, or in advanced cases, cardiac tamponade. Symptoms may persist despite treatment with pericardiocentesis, and may warrant consideration for pericardiectomy for more definitive management. Invasive hemodynamic evaluation with cardiac catheterization remains the gold standard for diagnosis of ECP; however, echocardiography can provide a definitive diagnosis with high sensitivity and specificity. Echocardiographic features suggestive of ECP include ventricular septal motion abnormalities, such as interdependence, accentuated longitudinal motion of the heart, and altered respirophasic ventricular filling. While these features have been well established and can lead to the diagnosis of ECP, they are rarely observed in clinical practice. We present a case of ECP in a 25-year-old active duty male with a history of chest wall myoepithelial carcinoma who clearly demonstrated such echocardiographic findings of ECP.

Recurrent Takotsubo Cardiomyopathy: Getting to the Root of the Problem.

BACKGROUND While takotsubo cardiomyopathy (TC) is a rare cardiomyopathy, recurrent takotsubo cardiomyopathy (rTC) is even more so, occurring in only 4% of patients with TC. Treatment is based on expert opinion and includes standard heart failure treatment using beta blockers (BB) and angiotensin-converting enzyme inhibitors (ACEI). We present a case of rTC demonstrating how using a selective serotonin reuptake inhibitor (SSRI) with cognitive behavioral therapy (CBT) can successfully prevent recurrence. CASE REPORT A 64-year-old woman presented with ST-elevation myocardial infarction, and coronary angiography demonstrated non-obstructive coronary artery disease. Left heart catheterization showed apical hypokinesis with preserved function of the basal segments, consistent with TC. She reported having experienced multiple emotional stressors. The patient was started on BB and ACEI, and 5 months later repeat imaging showed resolution of her TC. One month after resolution, she was re-admitted for chest pressure, and imaging demonstrated rTC. This time, in addition to continued conventional therapy, she was started on an SSRI and CBT. Nearly 6 months later, her rTC had resolved. CONCLUSIONS Anxiety and depression are more common in patients with TC than in patients with STEMI, but there is little in the literature about the roles of SSRI and CBT in TC treatment. In fact, SSRIs are controversial since they can increase catecholamine concentration, which some experts believe contributes to TC. The positive response of our patient to combination SSRI-CBT therapy suggests that additional research is needed on the use of this approach for prevention and treatment of rTC.

Adoption of coronary artery disease - Reporting and Data System (CAD-RADS™) and observed impact on medical therapy and systolic blood pressure control.

BACKGROUND: CAD-RADS was developed to standardize communication of per-patient maximal stenosis on coronary CT angiography (CCTA) and provide treatment recommendations and may impact primary prevention care and resource utilization. The authors sought to evaluate CAD-RADS adoption on preventive medical therapy and risk factor control amongst a mixed provider population. METHODS: Statins, aspirin (ASA), systolic blood pressure and, when available, lipid panel changes were abstracted for 1796 total patients undergoing CCTA in the 12 months before (non-standard reporting, NSR, cohort) and after adoption of the CAD-RADS reporting template. Only initiation of a medication in a treatment naïve patient, escalation from baseline dose, or transition to a higher potency was considered an escalation/initiation in lipid therapy. RESULTS: The CAD-RADS reporting template was utilized in 83.7% (751/897) of CCTAs after the CAD-RADS adoption period. After adjusting for any coronary artery disease (CAD) on CCTA, statin initiation/escalation was more commonly observed in the CAD-RADS cohort (aOR 1.46; 95%CI 1.12-1.90, p = 0.005), driven by higher rates of new statin initiation (aOR 1.79; 95%CI 1.23-2.58, p = 0.002). This resulted in a higher observed rates of total cholesterol improvement in the CAD-RADS cohort (58% vs 49%, p = 0.016). New ASA initiation was similar between reporting templates after adjustment for CAD on CCTA (aOR 1.40; 95%CI 0.97-2.02, p = 0.069). The ordering provider's specialty (cardiology vs non-cardiology) did not significantly impact the observed differences in initiation/escalation of statins and ASA (pinteraction = NS). CONCLUSIONS: Adoption of CAD-RADS reporting was associated with increased utilization of preventive medications, regardless of ordering provider specialty.