Endocardial Fibroelastosis: A Comprehensive Review.

Endocardial fibroelastosis emerged as a challenging clinical phenomenon in the 1940s. It is characterized by an atypical proliferation of fibrous and elastic tissue within the heart and is primarily observed in childhood, occasionally displaying familial inheritance. While the precise cause remains elusive, various factors, including genetic, infectious, metabolic, autoimmune, oncologic, and medication-related influences, appear to play a role in its pathogenesis. The coexistence of endocardial fibroelastosis with multiple cardiac structural abnormalities manifests in symptoms of congestive heart failure and rhythm abnormalities. Despite its challenging diagnosis, various findings from ECG and imaging have proven beneficial in further evaluation of this condition. Finally, the treatment approach to endocardial fibroelastosis became complex due to addressing its concurrent cardiac abnormalities. Strategies for managing and preventing this condition are still under investigation. In this review, we intend to highlight the existing knowledge and illuminate future considerations regarding the etiology, diagnosis, and management of this disease.

Statin-Induced Autoimmune Myopathy: A Diagnostic Challenge in Muscle Weakness.

BACKGROUND Statin-induced myopathy can present with symptoms ranging from mild myalgia to significant muscle weakness. Muscle-related adverse effects of statins have been very challenging in clinical practice and they necessitate high clinical suspicion. This case report highlights how statin-induced autoimmune myopathy often goes undiagnosed. CASE REPORT We present a 69-year-old man with a past medical history of coronary artery disease who presented with myalgia and progressive proximal muscle weakness for 2 months, with a creatinine kinase of 8323 U/L. Atorvastatin was held on admission and the patient received intravenous (IV) fluid as treatment for presumed rhabdomyolysis. Although CK was trending down, he did not show significant improvement in muscle weakness or myalgia. At this point, myositis was suspected, so a myositis panel including anti-HMG Co-A reductase antibody was ordered and he was started on IV steroids. Anti-HMG Co-A reductase antibody was positive, and the rest of myopathy workup was negative. Meanwhile, the patient's muscle weakness significantly improved with IV steroid. He was discharged on methylprednisolone with close outpatient rheumatology follow-up. CONCLUSIONS Muscle-related adverse effects of statins, including rhabdomyolysis and myopathy, can fail to respond to conservative management. It is crucial to identify and manage statin-induced autoimmune myopathy as a possible differential diagnosis in patients with muscle weakness and elevated CK while on statin therapy who do not respond to intravenous fluid alone.

A Rare Presentation of Erysipelothrix rhusiopathiae Endocarditis with Acute Heart Failure.

Erysipelothrix rhusiopathiae is an occupation-related infection that can be found in farm animals or marine life. This infection can present with a spectrum of infection ranging from local cellulitis to aortic endocarditis. Developing endocarditis is rare from this organism with only a few case reports in the literature. We presented a case of E. rhusiopathiae bacteremia that led to aortic valve endocarditis with a Gerbode defect within the mitral valve complicated with an acute exacerbation of congestive heart failure, necessitating emergent valve replacement surgery, with eventual permanent pacemaker due to complete heart block. We intend to highlight some unusual characteristics of this infection including thrombocytopenia and hyponatremia. It is important to identify this infection in early stages to prevent the late disseminating complications including endocarditis.

Atrial Fibrillation and Cognitive Disorders.

The prevalence of atrial fibrillation among older adults is increasing. Research has indicated that atrial fibrillation is linked to cognitive impairment disorders such as Alzheimer and vascular dementia, as well as Parkinson disease. Various mechanisms are believed to be shared between atrial fibrillation and cognitive impairment disorders. The specific pathologies and mechanisms of different cognitive disorders are still being studied. Potential mechanisms include cerebral hypoperfusion, ischemic or hemorrhagic infarction, and cerebrovascular reactivity to carbon dioxide. Additionally, circulatory biomarkers and certain infectious organisms appear to be involved. This review offers an examination of the overlapping epidemiology between atrial fibrillation and cognitive disorders, explores different cognitive disorders and their connections with this arrhythmia, and discusses trials and guidelines for preventing and treating atrial fibrillation in patients with cognitive disorders. It synthesizes existing knowledge on the management of atrial fibrillation and identifies areas that require further investigation to bridge the gap in understanding the complex relationship between dementia and atrial fibrillation.

Innovation in pathogenesis and management of aortic aneurysm.

Aortic aneurysm (AA) refers to the persistent dilatation of the aorta, exceeding three centimeters. Investigating the pathophysiology of this condition is important for its prevention and management, given its responsibility for more than 25000 deaths in the United States. AAs are classified based on their location or morphology. various pathophysiologic pathways including inflammation, the immune system and atherosclerosis have been implicated in its development. Inflammatory markers such as transforming growth factor ß, interleukin-1ß, tumor necrosis factor-α, matrix metalloproteinase-2 and many more may contribute to this phenomenon. Several genetic disorders such as Marfan syndrome, Ehler-Danlos syndrome and Loeys-Dietz syndrome have also been associated with this disease. Recent years has seen the investigation of novel management of AA, exploring the implication of different immune suppressors, the role of radiation in shrinkage and prevention, as well as minimally invasive and newly hypothesized surgical methods. In this narrative review, we aim to present the new contributing factors involved in pathophysiology of AA. We also highlighted the novel management methods that have demonstrated promising benefits in clinical outcomes of the AA.

Overview of the cardio-metabolic impact of the COVID-19 pandemic.

Evidence has shown that cardiometabolic disorders (CMDs) are amongst the top contributors to COVID-19 infection morbidity and mortality. The reciprocal impact of COVID-19 infection and the most common CMDs, the risk factors for poor composite outcome among patients with one or several underlying diseases, the effect of common medical management on CMDs and their safety in the context of acute COVID-19 infection are reviewed. Later on, the changes brought by the COVID-19 pandemic quarantine on the general population's lifestyle (diet, exercise patterns) and metabolic health, acute cardiac complications of different COVID-19 vaccines and the effect of CMDs on the vaccine efficacy are discussed. Our review identified that the incidence of COVID-19 infection is higher among patients with underlying CMDs such as hypertension, diabetes, obesity and cardiovascular disease. Also, CMDs increase the risk of COVID-19 infection progression to severe disease phenotypes (e.g. hospital and/or ICU admission, use of mechanical ventilation). Lifestyle modification during COVID-19 era had a great impact on inducing and worsening of CMDs. Finally, the lower efficacy of COVID-19 vaccines was found in patients with metabolic disease.

Benefit and risk evaluation of quinapril hydrochloride.

INTRODUCTION: Angiotensin-converting enzyme (ACE) inhibitors are a mainstay of antihypertensive therapy. Quinapril hydrochloride, a less commonly used, and less-studied ACE inhibitor has been approved for its primary use in hypertension. Studies also indicate its off-label use for congestive heart failure and diabetic nephropathy. The ANDI and TREND trials have been pivotal in demonstrating the effectiveness of quinapril. AREAS COVERED: The authors conducted a review of the literature analyzing the clinical efficacy and safety profile of quinapril. This review discusses the development of quinapril, provides an updated summary of the indications and contraindications, and presents a comparison with other ACE inhibitors. EXPERT OPINION: Quinapril is a safe and well-tolerated antihypertensive medication with a favorable safety profile compared to other ACE inhibitors. However, a lack of ample recent clinical trials and post-marketing data investigating the efficacy of quinapril in large cohorts has resulted in limited use in clinical practice. Quinapril may be an effective antihypertensive option for elderly populations as well as those who cannot tolerate the side effects profiles of other ACE inhibitors and as an additional treatment option for patients with heart failure with preserved ejection fraction.

Underrepresentation of Women in Late-Breaking Cardiovascular Clinical Trials.

Background: Cardiovascular disease is the leading cause of mortality for women and men. Prior studies have demonstrated the underrepresentation of women in published clinical trials, but no study to date has assessed inclusion of women in late-breaking clinical trials (LBCTs) presented at national meetings. The objective is to characterize the inclusion of women participants in LBCT presented at the 2021 American College of Cardiology (ACC), American Heart Association (AHA), and European Society of Cardiology (ESC) annual meetings and identify trial characteristics associated with improved inclusion. Methods: LBCT presented at the 2021 ACC, AHA, and ESC meetings were identified and the inclusion of women as participants was assessed. The inclusion to prevalence ratio (IPR) was calculated by dividing the percentage of women participants by the percentage of women in the disease population. IPRs <1 indicate underenrollment of women. Of the 68 LBCT, 3 trials were excluded due to lack of subject matter relevance. Results: Inclusion of women ranged from 0% to 71%. Only 47.1% of trials reported sex-specific analyses. The average IPR was 0.76 for all trials and did not vary based on conference, trial center, geographic region, or funding source. The average IPR varied based on subspecialty, with a statistical difference between interventional cardiology and heart failure (0.65 vs. 0.88, p = 0.02). The average IPR was significantly lower for procedural studies compared with medication trials (0.61 vs. 0.78, p = 0.008), as well as for studies with mean age <65 and trial size <1500 participants. There was no difference in IPR based on female authorship. Conclusions: LBCT can impact novel drug and device approval, intervention indications, and patient management. Nonetheless, most LBCT underenroll women, particularly, procedural LBCT. In 2021, sex-based enrollment disparities persist, highlighting the need to engage key stakeholders, including funding organizations, national governing bodies, editorial board members, and medical societies, in the creation of a coordinated strategic initiative to advance gender parity. These findings warrant further investigation to increase inclusion of women in trials, including potential enrollment requirements for consideration as LBCT by meeting organizers.

An Unusual Presentation of Streptococcus gallolyticus in Infective Endocarditis.

Background. Streptococcus gallolyticus (previously known as Streptococcus bovis type-1) bacteremia has a well-established, almost pathognomonic association with colorectal carcinoma, with the most common hypothesized mechanism being ulceration of polyps leading to hematologic dissemination. There are few reported cases of streptococcus bacteremia from other, seemingly benign sources like cellulitis or colonic adenomas. Hence, there is limited focus on skin and soft tissue infections leading to potentially fatal infective endocarditis. Case Presentation. We present a novel case of streptococcus bacteremia from uncommon sources like abdominal wall cellulitis or colonic adenoma leading to infective endocarditis as well as other manifestations, including osteomyelitis and discitis. This report highlights a unique case of streptococcus bacteremia with an uncommon origin, arising from abdominal wall cellulitis or colonic adenoma, ultimately resulting in the development of infective endocarditis. Furthermore, the patient presented with additional clinical manifestations, including osteomyelitis and discitis. Conclusions. Through our case report, we emphasize the importance of investigating uncommon sources like cellulitis when initial malignant workup is negative in streptococcus bacteremia and further elucidate the pathophysiology of streptococcus bacterial dissemination from nonmalignancy-related sources.