Thyrotoxicosis-Related Left Main Coronary Artery Spasm Presenting As Acute Coronary Syndrome.

Thyrotoxicosis can cause acute chest pain without ST changes in EKG due to coronary artery spasm. Its diagnosis can be particularly challenging as the symptoms may mimic acute coronary syndrome. The diagnosis of coronary artery spasm is confirmed by coronary angiography. The use of intracoronary nitroglycerin can relieve spasms and reveal the true extent of coronary artery disease. We present a case of a perimenopausal woman with newly diagnosed hyperthyroidism who presented with chest pain. Coronary angiography showed spasm of the left anterior descending artery which was relieved by intracoronary nitroglycerin.  Hyperthyroidism is associated with a spectrum of cardiovascular manifestations ranging from relatively benign palpitations to cardiac arrest. Rarely, it has been associated with episodic angina which indicates myocardial ischemia secondary to coronary artery spasm. Thyrotoxicosis-induced coronary artery spasm is a rare condition. Coronary artery spasm might masquerade as acute coronary syndrome, and coronary angiography is usually necessary to rule out myocardial infarction. In patients with risk factors for developing thyrotoxicosis-induced coronary artery spasm, any stenosis found on coronary angiography must not be assumed to be coronary artery disease only, and the possibility of coronary artery spasm must be explored. Our case emphasizes the use of intraprocedural nitroglycerin in these patients, which can relieve the spasm and reveal the true extent of coronary artery disease. Restoration of euthyroidism is the cornerstone of management and abates the need for long-term coronary vasodilator medications. Early diagnosis and optimal management have a favorable prognosis in these patients.

Coronary intravascular lithotripsy for coronary artery calcifications- systematic review of cases.

Background: Coronary artery calcification (CAC) is a pathological deposition of calcium in the intimal and medial layer of the arterial wall. A plethora of therapeutic calcium debulking techniques is available for the treatment of CAC, including orbital or rotational atherectomy, excimer lasers, cutting, and scoring balloons, which are associated with a soaring rate of complication and low efficacy. To this end, in 2016, the Food and Drug Administration (FDA) posited that shockwave intravascular lithotripsy (S-IVL) technique can be employed with minimal complication. Methods: A retrospective review of cases received lithotripsy for calcified coronary artery disease was performed by using online data from PubMed, Embase, and the Cochrane Central Register of Controlled Trials. The available search results were downloaded into an Endnote library and analyzed into two phases. Results: Out of 24 participants from case reports and series, Majority were found to be Male. There was no significant difference found in the mortality of patients undergoing IVL for the stenosis of the left main stem, left anterior descending, left circumflex artery, or diagonal branch. The mortality was found to be high among 6 patients with prior comorbidities and underwent more than 3 cycles of IVL (OR 37,95% Cl 1.54-886.04, P 0.02). Out of 24 patients, 2 (8.33%) patients developed complications such as vessel dissection (OR 3.4, 95% Cl 17.87-64.68, P 0.4). Conclusion: Shockwave intravascular lithotripsy (S-IVL) may be used in cases of the calcified disease to gain vessel lumen in order to deploy drug-eluting stents with PCI. The success of the DES implantation of IVL can be 100% with a minimal complication rate.

Cardiovascular Autonomic Neuropathy and its Association with Cardiovascular and All-cause Mortality in Patients with End-stage Renal Disease.

Background End-stage renal disease frequently leads to increased cardiovascular mortality. Cardiovascular autonomic neuropathy (CAN) may be predictive of cardiac arrhythmias and sudden cardiac death in patients with end-stage renal disease. Methods A total of 70 patients with end-stage renal disease were included in the study. The assessment of cardiac dysautonomia was based on the four standardized tests performed at the baseline and, again, at the end of the study. The criteria for CAN included at least two abnormal test results. Results Fifty of 70 patients completed the study and were followed-up after one year. Out of the 50 patients, 44 (88%) had CAN at baseline. Twelve (24%) patients died at the one-year follow-up. Sudden cardiac death was reported in seven out of 12 (58%) patients. All seven patients who died had high dysautonomia scores (three abnormal tests) at the baseline. There was a significantly higher percentage of patients with all four abnormal tests amongst patients who died of any cause (56% vs. 17%; RR 6.07, 95% CI 1.29-28.49; p-value 0.02) or due to sudden cardiac death (43% vs. 10.5%; RR 6.37, 95% CI 1.03-39.36; p-value 0.04). All five patients who did not have CAN at the baseline developed this abnormality on repeat testing after one year. Conclusion The prevalence of CAN in patients with end-stage renal disease on maintenance hemodialysis was significantly higher. CAN was an independent predictor of all-cause and cardiovascular mortality, which highlights it as a risk stratification tool in patients with end-stage renal disease.

Role of Speckle Tracking Echocardiography in Dilated Cardiomyopathy: A Review.

Dilated cardiomyopathy (DCM) is an important cause of the heart failure. Timely diagnosis and optimal management decrease morbidity and mortality in heart failure patients. Although transthoracic echocardiography is used as the diagnostic test of choice in these patients, new modalities like speckle tracking echocardiography (STE) have promising results in diagnosing these patients in the earlier course of the disease. Advancements in cardiac imaging are expected as more clinical studies on the role of STE in different cardiac diseases that emerge. In this review article, we will discuss the basics of STE and its role in diagnosing DCM.

From the Gut to the Heart: Campylobacter jejuni Enteritis Leading to Myopericarditis.

Campylobacter jejuni enteritis is the most common enteric infection in the developed world. Although rare, pericarditis and myopericarditis have been increasingly documented as complications following campylobacteriosis. The present paper implicates that myopericarditis and non-ischemic cardiomyopathy following Campylobacter jejuni infection might be more prevalent than initially thought and perhaps underreported so far. Therefore, it is imperative to perform the appropriate initial diagnostic testing, including stool cultures, in order to make an accurate diagnosis early in the course of the disease. Identifying the etiology of myopericarditis as bacterial will ensure appropriate treatment with antibiotics in addition to the cardiac medications needed for supportive care.

Liver Transplantation after Exertional Heatstroke-Induced Acute Liver Failure.

Exertional heatstroke (EHS) is a life-threatening disease characterized clinically by central nervous system dysfunction and severe hyperthermia. It frequently occurs among athletes, soldiers, and laborers. While cardiopulmonary symptoms are common in patients undergoing EHS, irreversible acute liver failure is a rarely described phenomenon. When managing cases of EHS complicated by acute liver failure, it is crucial to act promptly with aggressive total body cooling in order to prevent progression of the clinical syndrome. However, an urgent liver transplantation can be a therapeutic strategy when patients fail to improve with supportive measures.

Nonthrombotic Pulmonary Embolism: A Potential Complication of Polyacrylamide Hydrogel Cosmetic Injection.

Context. Polyacrylamide hydrogel (PAAG) has gained importance as a synthetic soft tissue filling agent. It has been commonly employed by physicians in Europe for facial contouring and soft tissue augmentation. Previously, PAAG is considered nontoxic and well tolerated with a few mild procedural complications. Case Presentation. A 26-year-old female was hospitalized for dry cough, worsening dyspnea, and chest discomfort after 3 hours of multiple PAAG injections in buttocks. The patient's condition deteriorated and rapidly advanced to acute respiratory failure. Therein, the diagnosis of nonthrombotic pulmonary embolism (NTPE) was established on standard set of investigations. She was intubated; corticosteroid and empiric antibiotic therapy was initiated resulting in improvement of her condition. Subsequently, extubation was done, and she was discharged from the hospital after an uneventful recovery. On 1-month follow-up, the patient had no previous symptoms. Conclusion. This report implicates clinicians to maintain a high index of suspicion for NTPE in patients presenting with respiratory symptoms following PAAG usage.