Recurrent Myocarditis Treated with Intravenous Immune Globulin and Steroids.

BACKGROUND Myocarditis is an inflammatory process that can present as acute or chronic with either focal or diffuse involvement of the myocardium. Its incidence is approximately 1.5 million cases per year worldwide. In the United States, viral infection is the most common cause of myocarditis. Most of the reported cases are singular and self-limiting in nature. We present the case of severe recurrent myocarditis in a young adult who was transferred to the Intensive Care Unit. CASE REPORT An 18-year-old man presented with chest pressure and troponin I 33 ng/mL. He had presented to another hospital with similar symptoms 3 months prior and was diagnosed with myocarditis that had resolved with colchicine. As part of his workup during this admission, coronary angiogram was normal and biopsy obtained without evidence of an inflammatory process; however, cardiac magnetic resonance imaging (MRI) was consistent with myocarditis and Coxsackie B titers indicated prior infection, leading to a diagnosis of clinically suspected recurrent viral myocarditis. He was treated with intravenous immunoglobulin (IV Ig) and a steroid taper, with rapid improvement in symptoms over the ensuing weeks without evidence of further recurrence or sequelae. CONCLUSIONS We present a case of recurrent Coxsackie B myocarditis based on presentation and imaging. Myocarditis is an important diagnosis to consider when a young, healthy individual presents with chest pain mimicking acute coronary syndrome, especially during the COVID pandemic. If there is evidence of myocarditis on MRI or endomyocardial biopsy, immunosuppressive therapy should be considered in patients with recurrent and severe presentations.

Bridging therapy in the perioperative management of patients with drug-eluting stents.

Patients with drug-eluting stents appear to be at increased risk of thrombosis beyond 30 days (late) or even 1 year (very late) after stent placement. Patients with recent placement of drug-eluting stents who are receiving dual-antiplatelet therapy pose a challenge in the perioperative period. Current guidelines recommend discontinuation of clopidogrel 5 to 7 days prior to surgery or invasive procedures to prevent bleeding complications. When a patient with a drug-eluting stent is off of clopidogrel, he or she is at risk of stent thrombosis, even during treatment with anticoagulants, such as intravenous heparin. There are currently no universal recommendations for decreasing the risk of stent thrombosis. We herein outline a strategy involving the use of glycoprotein IIb/IIIa inhibitors as "bridging therapy" during the high-risk perioperative period and report on 8 patients who successfully underwent bridging therapy with no adverse cardiac outcomes (death, myocardial infarction, or stent thrombosis) or bleeding complications.

Detection of left ventricular thrombus by coronary computed tomography angiography.

Left ventricular thrombus is a recognized complication of acute myocardial infarction. The following case report presents a rare case of left ventricular thrombus detection originally via coronary computed tomography angiography, followed by a brief review of imaging modalities that have been used for the detection of left ventricular thrombus in the past.

Role of clopidogrel in managing atherothrombotic cardiovascular disease.

Aspirin is the most widely used antiplatelet agent for preventing and treating vascular events. The thienopyridine derivatives, ticlopidine and clopidogrel, are a suitable alternative in patients who are intolerant to aspirin, and clopidogrel exhibits better tolerability than ticlopidine. The available evidence from randomized trials indicates that dual therapy with clopidogrel and aspirin is modestly but significantly more effective than aspirin in preventing serious vascular events. It is also associated with a favorable benefit-risk profile in patients at high risk (especially in acute coronary syndromes and after stenting). In patients at low risk (stable cardiovascular disease), however, the bleeding risk of dual therapy exceeds its potential benefit. The dose and duration of pretreatment before stenting, the optimal duration of treatment after drug-eluting stent implantation, concurrent administration of platelet glycoprotein IIb/IIIa inhibitors, and the exact mechanism and clinical relevance of clopidogrel resistance are unclear.

Presence and severity of noncalcified coronary plaque on 64-slice computed tomographic coronary angiography in patients with zero and low coronary artery calcium.

How well absence of coronary artery calcium (CAC) predicts the absence of noncalcified coronary artery plaque (NCAP) has not been elucidated. We conducted a cross-sectional study of 554 outpatients to quantify NCAP prevalence as a function of CAC score. All patients underwent CAC scoring followed by 64-slice computed tomographic coronary angiography. Patients were categorized as having 0 CAC (416 patients) or low CAC (138 patients; men with CAC scores from 1 to 50 and women with scores from 1 to 10). Prevalence of detectable NCAP was 6.5% in patients with 0 CAC and 65.2% in those with low CAC. Compared with patients with 0 CAC, those with low CAC had markedly increased rates of NCAP occluding <50% of the arterial lumen (56.5% vs 6.0%, p <0.001) and > or =50% of the arterial lumen (8.7% vs 0.5%, p <0.001). In conclusion, in outpatients with a low to intermediate risk presentation and no known coronary artery disease, absence of CAC predicts low prevalence of any NCAP and very low prevalence of significantly occlusive NCAP. Low but detectable CAC scores are significantly less reliable in predicting plaque burden due to their association with high overall NCAP prevalence and nearly a 10% rate of significantly occlusive NCAP.

Cardiac amyloidosis: new insights into diagnosis and management.

When amyloidosis affects the heart, a devastating and progressive process can lead to congestive heart failure, arrhythmias, conduction abnormalities, angina, and death. The signs and symptoms of cardiac amyloidosis are generally dominated by diastolic heart failure resulting from restrictive cardiomyopathy. Amyloid infiltration of the heart initially causes mild diastolic dysfunction, but late disease produces a thickened heart wall with a firm and rubbery consistency, which worsens cardiac relaxation and diastolic compliance. Patients usually complain of progressive dyspnea from congestive heart failure, chest discomfort secondary to microvascular involvement, and weight loss, which might be a manifestation of cardiac cachexia. Echocardiographic findings include nondilated ventricles with concentric left ventricular thickening, right ventricular thickening, prominent valves, dilated atria, and thickening of the interatrial septum. Recent advances in our understanding of the pathophysiology of amyloid have allowed the various types to be differentiated, which has led to targeted therapy for each unique pathophysiologic process.

An unexpected inverse relationship between HbA1c levels and mortality in patients with diabetes and advanced systolic heart failure.

BACKGROUND: In diabetes, poor glycemic control, as indexed by hemoglobin A1c (HbA1c), is associated with increased risk of cardiovascular events and new-onset heart failure (HF). However, in patients with diabetes and HF, the relationship between glucose control and survival has not been investigated. Our study aimed to evaluate the relationship between HbA1c levels and mortality in patients with diabetes and advanced systolic HF. METHODS: We studied a cohort of 123 patients with diabetes and advanced systolic HF referred to a single center with HbA1c values measured at presentation. The patients were grouped based on HbA1c: HbA1c < or = 7.0 (n = 49) and HbA1c > 7.0 (n = 74). RESULTS: The cohort was 70% men, ejection fraction of 25% +/- 7, 59% ischemic etiology, HbA1c 7.9 +/- 1.8, and diabetes duration of 8.6 +/- 9.0 years. The HbA1c groups were similar in age; sex; New York Heart Association class; body mass index; diabetes duration; and insulin, metformin, and glitazone use. HbA1c > 7.0 was associated with higher ejection fraction, increased beta-blocker, and sulfonlyurea use. Patients with HbA1c < or = 7.0 had significantly increased all-cause mortality, compared with those with HbA1c > 7.0 (35% vs 20%, hazard ratio 2.6, 95% CI 1.3-5.2, P < .01). In multivariate analysis, HbA1c < or = 7.0 remained associated with increased mortality (hazard ratio 2.3, 95% CI 1.0-5.2). CONCLUSIONS: Paradoxically, elevated HbA1c levels were associated with improved survival in this cohort of patients with diabetes and advanced HF. Further investigation is necessary to determine the nature of this relationship and optimal HbA1c in patients with diabetes and HF.

Relation of loop diuretic dose to mortality in advanced heart failure.

Although loop diuretics are widely used in heart failure (HF), their effect on outcomes has not been evaluated in large clinical trials. This study sought to determine the dose-dependent relation between loop diuretic use and HF prognosis. A cohort of 1,354 patients with advanced systolic HF referred to a single center was studied. Patients were divided into quartiles of equivalent total daily loop diuretic dose: 0 to 40, 41 to 80, 81 to 160, and >160 mg. The cohort was 76% male, with a mean age of 53+/-13 years and a mean ejection fraction of 24+/-7%. The mean diuretic dose equivalence was 107+/-87 mg. The diuretic quartile groups were similar in terms of gender, body mass index, ischemic cause of HF, history of hypertension, and spironolactone use, but the highest quartile was associated with a smaller ejection fraction and lower serum sodium and hemoglobin levels but higher serum blood urea nitrogen and creatinine levels. There was a decrease in survival with increasing diuretic dose (83%, 81%, 68%, and 53% for quartiles 1, 2, 3, and 4, respectively). Even after extensive co-variate adjustment (age, gender, ischemic cause of HF, the ejection fraction, body mass index, pulmonary capillary wedge pressure, peak oxygen consumption, beta-blocker use, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use, digoxin use, statin use, serum sodium, blood urea nitrogen, creatinine, hemoglobin, cholesterol, systolic blood pressure, and smoking history), diuretic quartile remained an independent predictor of mortality (quartile 4 vs quartile 1 hazard ratio 4.0, 95% confidence interval 1.9 to 8.4). In conclusion, in this cohort of patients with advanced HF, there was an independent, dose-dependent association between loop diuretic use and impaired survival. Higher loop diuretic dosages identify patients with HF at particularly high risk for mortality.

Retrospective comparison of outcomes, diagnostic value, and complications of percutaneous prolonged drainage versus surgical pericardiotomy of pericardial effusion associated with malignancy.

Surgical pericardiotomy is often preferred as a primary option in patients with malignant pericardial effusions. Recent series have revealed that prolonged drainage substantially reduces pericardial effusion recurrence rates, even in the setting of malignancy. The aim of the study was to directly compare the efficacy of pericardiocentesis with prolonged drainage with the primary surgical pericardiotomy in patients with symptomatic pericardial effusion associated with a malignancy. We retrospectively evaluated 88 patients who presented with pericardial tamponade associated with a malignancy. Pericardiocentesis with extended drainage was performed in 43 patients and surgical pericardiotomy in 45 patients. The recurrence rate was not significantly different in patients with prolonged catheter drainage versus surgical pericardiotomy (12% vs 13%, respectively, p = 0.78). In addition, there was no significant difference in diagnostic yield between percutaneous drainage and surgical window (44% vs 53%, respectively, p = 0.39). The overall rate of complications was significantly lower in the prolonged drainage group (2% vs 20%, p = 0.007). Moreover, there were no serious complications in the prolonged drainage group versus 9% in the surgical pericardiotomy group. In conclusion, (1) surgical pericardiotomy with pericardial biopsy does not add significant diagnostic value beyond the cytologic assessment available with pericardiocentesis, (2) surgical pericardiotomy does not improve clinical outcomes over pericardiocentesis, and (3) surgical pericardiotomy is associated with a higher rate of complications.

Porcelain heart.

Rheumatic heart disease (RHD) was the leading-cause of death in individual aged 5-20 years a century ago. Developments in diagnosis and treatment, decreased the incidence of RHD and dropped its mortality-rate to less than 10% since the 1960s. Despite the existence of proven preventive strategies in early detection and management of rheumatic fever (RF), RHD remained the most common cause of cardiovascular-mortality and morbidity in patients with RF. Previous studies have showed that Jones criteria may have insufficient support to diagnose patients with RF. Patients with subclinical, ongoing, and unrecognized episodes of RF may present late to medical attention with complication of RF such as indolent carditis. Recent studies revealed the superior role of echocardiography, as compared with clinical screening to diagnose subclinical RHD. While valvular involvement and ventricular dysfunction of RHD can be easily detected with echocardiography and magnetic resonance imaging (MRI), it remains problematic to determine the presence of whether there is myocardial-calcification after rheumatic heart carditis and if yes, how much extent it involves. The current case-report suggests the superior role of computed tomography angiography (CTA), as compared with echocardiography and MRI, to diagnose RHD in individuals without known history of RF. CTA with high spatial-resolution accurately evaluates tissue characterization and simultaneous assessment of the anatomy and function of heart and coronaries, and can precisely differentiate RHD from other cause of porcelain heart. The use of CTA in RHD screening provides the opportunity to initiate secondary antibiotic prophylaxis to prevent the poor outcome of rheumatic heart disease.

Effects of intense exercise and moderate caloric restriction on cardiovascular risk factors and inflammation.

BACKGROUND: Obesity is associated with insulin resistance, inflammation, metabolic dysfunction, and atherosclerosis. This study investigates the effects of weight loss, intense exercise, and moderate caloric restriction on insulin resistance, lipids, inflammatory biomarkers, carotid artery distensibility index (CaDI), and carotid intima media thickness (CIMT). METHODS: Seventeen sedentary morbidly obese contestants in the "Biggest Loser" television program completed the 7-month intense-exercise and moderate-restricting calories program; 3 were excluded due to lack of follow-up CIMT. Serum insulin level, glucose, lipid profile, high-sensitivity C-reactive protein (CRP), hemoglobin A1c (HbA1c), resistin, adiponectin, plasminogen activator inhibitor-1 (PAI-1), tumor necrosis factor receptor-II (TNFRII), lipoprotein a (Lp[a]), sex hormone binding globulin (SHBG), blood pressure, body fat, weight, CaDI, and CIMT were measured at baseline and 7-month follow-up. CIMT was measured 5-10 mm below the common carotid bifurcation during mid-diastolic phase. CaDI was defined as: (End-systole - End-diastole common-carotid cross-sectional area)/(End-diastole common-carotid cross-sectional-area × systemic pulse pressure) × 1000. Insulin resistance was calculated by homeostatic model assessment (HOMA) index. RESULTS: At 7-month follow-up, major reductions in weight (-39%), body fat (-66%), serum insulin level (-52%), glucose (-21%), high-sensitivity CRP (-81%), HbA1c (-11%), PAI-1 (-49%), TNFRII (-12%), and CIMT (-25%), and increases in CaDI (132%), resistin (344%), adiponectin (94%), Lp(a) (73%), and SHBG (94%) were observed. The improvement in CaDI was positively correlated with increases in adiponectin, Lp(a), SBHG, and resistin (r(2)=0.86, P=.009), but inversely with PAI-1, TNFRII, CRP, and IR (r(2)=-0.64, P=.01). Strong inverse correlation was noted between decreases in CIMT and increases in CaDI (r(2)=0.65, P=.001). CONCLUSION: In morbidly obese individuals, intense exercise with moderate caloric restriction over 7 months is associated with a dramatic improvement in carotid vascular function and atherosclerosis risk factors, as well as a reduction in inflammatory biomarkers, lipids, insulin resistance, and CIMT.

Frequency of recurrence of pericardial tamponade in patients with extended versus nonextended pericardial catheter drainage.

Recurrence of pericardial tamponade is relatively common after pericardiocentesis. We evaluated the clinical and procedural predictors of recurrent pericardial tamponade after pericardiocentesis. We included 157 consecutive patients with pericardial tamponade (age 62 ± 18 years, 54% men) who had undergone pericardiocentesis from 2000 to 2007. An intrapericardial catheter was used for prolonged drainage of the pericardial effusion (78% of cases) at the discretion of the operator. The overall recurrence rate 11.8 ± 0.6 months after pericardiocentesis was 20% and the mean interval to recurrence was 1.2 ± 2.1 months. However, patients with extended catheter drainage had a reduced recurrence rate of 12% compared to 52% in patients without extended drainage (p <0.001). In the Cox regression modeling, absence of extended drainage (hazard ratio [HR] 4.1, 95% confidence interval [CI] 1.7 to 10, p = 0.002), incomplete drainage of pericardial effusion (HR 9.7, 95% CI 3.6 to 22.7, p <0.001), loculated effusion (HR 11.1, 95% CI 2.9 to 43, p = 0.001), and malignancy (HR 3.3, 95% CI 1.8 to 10.3, p = 0.037) independently correlated with recurrence at 1 year. In conclusion, extended pericardial drainage after catheter placement is associated with a reduced recurrence of pericardial tamponade after pericardiocentesis.

Advances in antiplatelet treatment for acute coronary syndromes.

CONTEXT: Recent publications of TRITON-TIMI (prasugrel) as well as PLATO (ticagrelor) have introduced new and potent antiplatelet agents, but at the same time have left clinicians with multiple choices without clear directions regarding the most appropriate use of these agents. OBJECTIVE: 1. To review the randomized controlled trial evidence examining the role of the three antiplatelet gents in acute coronary syndromes is presented. 2. To provide recommendations for the practicing physician for their optimal use in clinical practice. DATA SOURCES: CURE, TRITON-TIMI 38 and PLATO trials. STUDY: Selection Large randomized placebo controlled trials of dual antiplatelet therapy in acute coronary syndromes. Data Extraction From original trials. RESULTS AND CONCLUSIONS: Both prasugrel and ticagrelor are potent antiplatelet agents with improved ischaemic benefits in comparison with clopidogrel. The improved benefit, however, comes at the price of increased bleeding. As such, careful patient selection and balancing of benefit-risk is warranted to optimise their use in clinical practice.

Thoracic aortic arteriosclerosis in patients with degenerative aortic stenosis with and without coexisting coronary artery disease.

BACKGROUND: The association between the severity of arteriosclerosis in the thoracic aorta in patients with isolated aortic stenosis (AS) and with concomitant coronary artery disease (CAD) has been not evaluated. Therefore, the aim of our study was to compare the thoracic aortic atheroma extent and severity in patients with severe AS alone and with concomitant CAD by intraoperative transesophageal echocardiography. METHODS: We retrospectively evaluated echocardiograms of 105 consecutive patients with severe degenerative AS who underwent aortic valve replacement. Sixty patients had concomitant CAD (AS/CAD) on coronary angiography and 45 had no CAD (AS alone). These patients were compared with 54 sex- and age-matched patients without AS or CAD. Aortic atheroma (localized intimal thickening of >3 mm) prevalence and morphology in three segments of aorta were assessed with echocardiography. RESULTS: There were 62 men, mean age 75.3 +/- 9.4 years. No difference was observed in age, sex, and risk factors for arteriosclerosis other than hypercholesterolemia among AS/CAD, AS alone, and control groups (88%, 67%, 41%, respectively; p < 0.0001). The AS/CAD group had a significantly higher rate of aortic root calcification (68%, 36%, 26%, respectively; p < 0.0001) and aortic atheroma (ascending aorta [26%, 20%, 14%, respectively; p = 0.03]; aortic arch [78%, 36%, 30%, respectively; p < 0.0001]; descending aorta [72%, 42%, 29%, respectively; p < 0.0001]) than AS alone or control subjects. Patients with AS/CAD also had more complex atheromas in the aortic arch (48%, 20%, 7%, respectively; p < 0.0001). Significant differences in extension of aortic arteriosclerosis (presence of plaques in two or three segments) were observed among the groups (70%, 31%, 18%, respectively; p < 0.0001). CONCLUSIONS: Patients with severe AS and coexisting CAD have more extensive arteriosclerotic changes in the thoracic aorta compared with those with AS alone and control subjects. Preoperative evaluation of the thoracic aorta and more aggressive lipid therapy should be considered in these patients.