In-Hospital Outcomes of Coronary Artery Stenting in Patients With ST-Elevation Myocardial Infarction (STEMI) and Metabolic Syndrome: Insights From the National Inpatient Sample.

Background Metabolic syndrome (MetS) has been recognized as a global health problem. Concurrent MetS diagnosis in patients with ST-elevation myocardial infarction (STEMI) is becoming increasingly common. Given the paucity of studies on the impact of MetS on treatment outcomes in STEMI patients, the purpose of this study was to evaluate in-hospital mortality in STEMI patients with a concurrent MetS diagnosis undergoing a stenting procedure to treat their underlying coronary artery disease. Method Patients with or without MetS who underwent coronary stenting following STEMI between 2005 and 2014 were identified from the National Inpatient Sample database. Patients' demographics, comorbidities, and outcomes were compared using a t-test and Pearson's Chi-square test. In addition, 1:1 propensity score matching was performed for age, gender, and race. Results Out of 1,938,097 STEMI patients, 5,817 patients with MetS underwent coronary stenting following STEMI and were matched with 5,817 patients with no Mets. MetS group had significantly higher rates of diabetes, hypertension, hyperlipidemia, chronic kidney disease, and obstructive sleep apnea than the no MetS group but lower rates of heart failure and chronic obstructive pulmonary disease. In-hospital mortality following STEMI was significantly lower in patients with MetS (2.5% vs. 7.1%, p<0.001) and remained significant after adjusting for potential confounders (odds ratio (OR) 0.34, 95% confidence interval (95% CI) 0.28-0.42, p<0.0001). Conclusion Concurrent diagnosis of MetS among patients undergoing coronary stenting is associated with a decreased in-hospital mortality risk. The impact of specific MetS components on the observed reduction in mortality remains unclear and warrants evaluation in future studies.

The Effects of Body Mass Index on In-Hospital Mortality and Outcomes in Patients With Heart Failure: A Nationwide Analysis.

BACKGROUND: ​​​​​​Heart failure (HF) remains one of the leading causes of death in the United States. While many large-scale studies show a positive relationship between cardiovascular mortality and body mass index (BMI), several studies have also observed lower mortality rates among obese HF patients. Therefore, we sought to assess the impact of BMI on in-hospital outcomes in patients admitted with HF. METHODS: Patients hospitalized with congestive heart failure (CHF) diagnosis between 2005 and 2014 were identified from the US National Inpatient Sample database using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedural codes. The sample was divided into three groups based on their BMI. In-hospital outcomes were assessed in different groups and sub-groups. RESULTS:  We identified 8,674,190 patients admitted with a primary diagnosis of HF, out of which 1.8% had BMI between 30 and 39.9 kg/m2 and 3.7% had BMI >40 kg/m2. In-hospital mortality was reported in 5.6% of patients with BMI <30 kg/m2, compared to 2.3% in those with BMI 30-39.9 kg/m2 and 3.1% in the group with BMI >40 kg/m2. After adjusting for various confounders, in-hospital mortality was lower in those with BMI 30-39.9 kg/m2 than those with BMI <30 kg/m2 (OR 0.56; CI 0.51-0.62). Similarly, in-hospital mortality was lower in those with BMI >40 kg/m2 than those with BMI <30 (OR 0.87; CI 0.81-0.92). CONCLUSION: Even though this study supports the findings of previous smaller studies illustrating the existence of the "obesity paradox" in HF hospitalizations, the pathogenesis behind this paradoxical effect is still unclear.

Effects of Substance Use Disorder on In-Hospital Outcomes of Young Patients Presenting With a Cardiovascular Event: A Nationwide Analysis.

Background Substance use is widely prevalent among young adults and is associated with increased cardiovascular morbidity and mortality such as sudden cardiac arrest, acute coronary syndrome, arrhythmias, and cardiomyopathy. However, they are limited studies analyzing the impact of substance use disorder on in-hospital outcomes among young patients with cardiovascular events. Methods All patients aged 18-39 years admitted primarily for major cardiovascular events including acute myocardial infarction (AMI), arrhythmia, cardiac arrest, acute ischemic stroke, and venous thromboembolic events in 2019 were identified in the National Inpatient Sample database. They were then categorized into those with and without concomitant substance use disorder (SUD). The primary outcome was in-hospital mortality. Unadjusted and adjusted analysis was performed on appropriate variables of interest. Results Of 57,985 hospitalizations with cardiac events, 12,115 (20%) of young adults had concomitant SUD. SUD was significantly associated with cardiac arrest (OR 3.3; CI 2.4-4.4), atrial fibrillation (OR 1.5; CI 1.3-1.7), AMI (OR 1.3; CI 1.2-1.6), heart failure (OR 2.6; CI 2.4-3.0) (all p<0.05) despite a lower prevalence of traditional cardiovascular risk factors than non-users. Logistic regression showed acute kidney injury (aOR 1.5; CI 1.3-1.8; p<0.001) and inpatient mortality (aOR 1.6; CI 1.2-2.2; p<0.001) were also significantly higher in young patients presenting with cardiac events and concomitant SUD. There was no difference in the length of stay or incidence of gastrointestinal bleed between the two groups. Conclusion In young patients presenting with a cardiovascular event, concurrent substance use disorder was associated with increased in-hospital mortality despite significantly lower comorbidities.

Coronavirus Disease and New-Onset Atrial Fibrillation: Two Cases.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has resulted in a considerable amount of morbidity and mortality worldwide since December 2019. Patients with coronavirus disease (COVID-19) most commonly present with respiratory manifestations, while cardiac manifestations were reported as a complication and seldom as a presenting feature. We report two cases of new-onset atrial fibrillation occurring in middle-aged men with no significant past medical history. The first patient presented with symptomatic atrial fibrillation; however, during his hospitalization course, he developed a fever, which led to the diagnosis of infection with SARS-CoV-2. The second patient presented from urgent care after being diagnosed with COVID-19 associated with newly diagnosed atrial fibrillation. Both patients were treated symptomatically for COVID-19 and discharged home after reverting to sinus rhythm. Physicians should be aware of the variable clinical presentations of COVID-19, especially in new or worsening cardiac illnesses, in order to practice the appropriate personal protection practices. More studies are needed to identify the viral mechanisms leading to the dysregulation of cardiac rhythm.

SVEAT Score, a Potential New and Improved Tool for Acute Chest Pain Risk Stratification.

Acute chest pain is one of the most common presenting symptoms to the emergency department. Currently available risk scores are suboptimal in identifying low-risk patients eligible for early and safe discharge. Various, initially obtained clinical data have valuable discriminating power but are not being fully utilized. We developed a new scoring system based on 5 sets of variables; characteristics of Symptoms, history of Vascular disease,  Electrocardiography,  Age, and Troponin (SVEAT score). A total of 321 subjects presenting to the emergency department or admitted to the clinical decision unit at our institution with chest pain from May 2017 to August 2018 were prospectively recruited. The subjects were followed for 30 days for any major cardiovascular events (MACE); acute myocardial infarction, confirmed coronary artery disease requiring revascularization or medical therapy or death. A 30-day MACE occurred in 19.6% of the subjects. Predictive ability of SVEAT score for a 30-day MACE was compared with HEART and TIMI risk score using receiving-operator characteristic curve. The area under the curve of SVEAT score (0.98, 95% confidence interval [CI] 0.97 to 0.99) is higher than HEART (0.92, 95% CI 0.88 to 0.96) and TIMI score (0.88, 95% CI 083 to 0.93). Using SVEAT score of 4 as a cut off, 0.8% of the subjects developed a 30-day MACE compared with 1.4% and 1.5% of those classified as low-risk based on the HEART and TIMI score respectively. SVEAT score additionally identified larger proportion of low-risk (73.8%) than the HEART (45.2%) and TIMI risk score (40.1%), (p <0.01, for both).

Aortic Valve Papillary Fibroelastoma: A Sea Anemone in the Heart, A Case Report.

Cardiac papillary fibroelastomas are benign primary cardiac tumors usually arising from the normal components of the endocardium. Grossly they have a characteristic short pedicle and multiple papillary fronds similar to sea anemone. Clinically they have varying presentations ranging from asymptomatic to severe ischemic or embolic complications. We hereby present a case of a middle-aged man who presented with exertional dyspnea and palpitations and was discovered to have papillary fibroelastoma involving the aortic valve. The described case illustrates some of the presenting features, the workup and some of the management modalities that need to be implicated in cases of papillary fibroelastomas.

An Unusual Case of Left Atrial Mural Thrombus following Aortic Valve Replacement.

The left atrial thrombus is a well-known complication of atrial fibrillation and rheumatic mitral valve disease and carries a high risk for systemic thromboembolism. They are generally dissolved after a certain period of optimal anticoagulation. A large thrombus, on the other hand, may persist even with adequate anticoagulation. The surgical removal of a thrombus theoretically poses some risk of systemic embolization, making its management a clinical dilemma. Furthermore, a refractory thrombus is uncommon. Thus, an evidence-based guideline in selecting the optimal therapy is needed. We report a case of a 74-year-old male with atrial fibrillation and a history of unprovoked pulmonary embolism who was incidentally found to have a massive left atrial thrombus shortly after discontinuing warfarin about 4 months following bioprosthetic aortic valve replacement. The thrombus was refractory to anticoagulation posing a clinical management dilemma. This case is interesting in terms of presentation and the approach to diagnosis and treatment.

Mesalamine-Induced Myopericarditis: A Case Report and Literature Review.

Inflammation of the myocardium (myocarditis) or pericardium (pericarditis) or both (myopericarditis) as side effects of mesalamine, a drug widely used in the treatment of inflammatory bowel disease, is a rare, but potentially lethal complication. We report a case of myopericarditis occurring in a young Caucasian woman 14 days following initiation of mesalamine therapy for treatment of a newly diagnosed ulcerative colitis (UC). She presented with pleuritic chest pain, elevated troponin levels and pre-syncope. The diagnosis of myopericarditis was made based on the clinical features, electrocardiogram (EKG) and cardiac magnetic resonance, which showed trace pericardial effusion. The patient's symptom and condition were dramatically improved upon discontinuing mesalamine, and a full recovery was achieved. Mesalamine-induced inflammation of the myocardium (myocarditis) or pericardium (pericarditis) or both (myopericarditis) is rare, but has fatal side effects. Early recognition of these side effects by clinicians and patients is important to prevent progression of the inflammation. Furthermore, patients should be educated to seek urgent medical attention if cardiac symptoms arise.

'Acute leukemia in congenital methehemoglobinemia - an enigma to explore'.

Congenital methemoglobinemia is a rare disease, resulting in increased oxygen affinity and impaired oxygen delivery to the tissues. While there have been studies that have linked acquired methemoglobinemia in almost 79% of leukemia patients, to the best of our knowledge, this is the first case of leukemia development in a patient with congenital methemoglobinemia. Chronic deprivation of oxygen to metabolically active bone marrow can theoretically lead to hematopoietic disorders. It would be interesting to further investigate if presence of congenital methemoglobinemia is a risk factor for developing acute leukemia.

Basal Cell Carcinoma of the Female Breast Masquerading as Invasive Primary Breast Carcinoma: An Uncommon Presentation Site.

Skin cancer as a single entity is the most common malignancy in North America, accounting for half of all human cancers. It comprises two types: melanoma and nonmelanoma skin cancers. Of the nonmelanomas, basal cell carcinoma (BCC) constitutes about 80% of the cancers diagnosed every year. BCC usually occurs in sun-exposed areas such as the face and extremities. Occurrence in the nipple areolar complex is very rare. We present a case of a Caucasian woman who presented with what was initially thought to be invasive carcinoma of the breast involving the nipple areolar complex (NAC); however, the diagnosis was revealed to be a basal cell carcinoma after histopathological examination. The tumor was treated with modified radical mastectomy, with negative margins. The importance of this case lies in the rare site of presentation of basal cell carcinoma and the importance of early detection.

Coronary Artery-Left Ventricular Fistula and Takotsubo Cardiomyopathy - An Association or an Incidental Finding? A Case Report.

BACKGROUND A coronary artery-left ventricular fistula is an anomalous communication between the coronary arteries and the cardiac chambers and is a rare congenital coronary anomaly that is often small and asymptomatic. Takotsubo cardiomyopathy, on the other hand, is a syndrome characterized by transient regional systolic dysfunction of the left ventricle, mimicking myocardial infarction, but in the absence of angiographic evidence of obstructive coronary artery disease or acute plaque rupture. We present the case of an elderly woman who presented with Takotsubo cardiomyopathy and who was incidentally discovered to have an associated coronary artery-left ventricular fistula. CASE REPORT We report the case of a 68-years-old woman with a family history of premature cardiac diseases who presented with ischemic chest pain and elevated troponin levels. Her EKG and troponins were suggestive of non-ST-elevation myocardial infarction (NSTEMI), for which she was initially treated medically and later underwent coronary angiography. Unexpectedly, the angiography revealed patent coronary arteries, and we discovered evidence of coronary artery to left ventricular fistula in the addition to angiographic evidence of Takotsubo cardiomyopathy. A working diagnosis of Takotsubo was made, for which she was treated medically with resulting improvement of her symptoms and later in the imaging findings. CONCLUSIONS This described case illustrates a rare association between coronary artery fistulas and Takotsubo cardiomyopathy. It is unclear if this association has played a role in the pathogenesis or perhaps is just an incidental finding. More similar cases are needed to expand the clinical presentation of both conditions and add to the literature.