Non-selective Aortic Root Angiographic Contrast Injection in a Case of Anomalous Right Coronary Artery Ostium.

Anomalous origin of the right coronary artery (RCA) is a rare congenital cardiovascular anomaly that can pose significant diagnostic challenges during cardiac evaluation. We present a case of a 54-year-old male patient with chest pain and a syncopal episode and subsequently diagnosed with non-ST-elevated myocardial infarction (NSTEMI). Coronary angiography revealed an anomalous origin of the RCA, making it difficult to precisely locate the artery's point of origin with selective contrast injection. During coronary angiography, the use of aortic root non-selective angiographic contrast injection aided in localizing the RCA ostium. Our case highlights the clinical significance of aortic contrast injection as a valuable and safe adjunctive technique in cases of anomalous coronary artery origins. Early detection and precise localization of such anomalies are essential for effective treatment planning and improved patient outcomes. Further studies may help validate the utility of aortic contrast injection in similar cases, thereby enhancing diagnostic accuracy and patient care in the management of anomalous coronary artery ostium.

A Case of ST-Elevation Myocardial Infarction With Right Bundle Branch Block, an Ominous Sign of Critical Coronary Occlusion.

Coronary artery disease is one of the leading causes of death worldwide, and ST-elevation myocardial infarction (STEMI) is one of its most serious manifestations. While STEMI itself is an ominous sign, there are other sinister electrocardiogram (EKG) patterns that are associated with increased morbidity and mortality, one of which is STEMI with right bundle branch block (RBBB). Blood supply to the right bundle comes from the left coronary circulation. Intuitively, RBBB in the setting of anterior wall myocardial infarction would indicate more extensive myocardial involvement and thus portend a worse prognosis. This case presents the significance of the association of new RBBB with critical lesions of the left anterior descending artery (LAD), therefore a low threshold for emergent coronary angiography and percutaneous coronary intervention (PCI). A 63-year-old man with a known history of non-insulin-dependent diabetes mellitus (NIDDM), hypertension, and hypertriglyceridemia non-compliant with medications presented to the emergency department (ED) after a visit with his primary care physician, with a chief complaint of exertional substernal chest pain for a one-week duration. His EKG on arrival showed significant ST-segment elevation with an atypical EKG pattern showing RBBB in V1-V2 with ST depression in reciprocal leads. Cardiac biomarkers showed an initial troponin I value of 0.441 ng/mL. Due to his persistent, worsening chest pain and associated nausea with episodes of vomiting, he was taken for an emergent cardiac catheterization that revealed a 100% lesion in his proximal LAD. The procedure was complicated by the development of cardiogenic shock requiring intra-aortic balloon pumps and vasopressors. A successful primary PCI was performed with drug-eluting stent (DES) to the 100% lesion in the proximal LAD and DES to the 80% lesions in the mid LAD, with 0% residual stenosis after the intervention. There was thrombolysis in myocardial infarction (TIMI) 0 flow pre-procedure and TIMI 3 flow post-intervention. Left ventriculography revealed anterolateral akinesis, apical akinesis, and diaphragmatic hypokinesis with an estimated ejection fraction (EF) of 20%. Transthoracic echocardiogram was repeated prior to discharge. Left ventricular (LV) systolic function was normal by visual assessment, and EF was noted to be ~55%. The patient continued on dual antiplatelet therapy and the rest of goal-directed medical therapy for coronary artery disease post-procedure. New-onset RBBB in the patient with typical STEMI in the context of ischemic symptoms should raise suspicion of critical proximal LAD coronary occlusion. It is increasingly being recognized as one of the significant EKG patterns for occlusive myocardial infarction associated with the worst outcome and mortality, highlighting the need to pay critical attention to these patients. Given the poor prognosis of these patients in the setting of acute myocardial infarction (AMI), it is essential to minimize the delay in initiating reperfusion therapy as they can potentially benefit from emergent intervention.

Aspiration thrombectomy for inferior vena cava tumor thrombus arising from hepatocellular carcinoma.

Pharmacomechanical therapy and catheter-directed thrombolysis have been shown to be very effective in the treatment of venous thromboembolism; however, there is much less data regarding inferior vena cava thrombi. Tumor thrombi pose an even greater clinical challenge as anti-coagulation and thrombolysis are not effective. We present the case of a 61-year-old male who presented with an inferior vena cava thrombus emanating from an accessory right hepatic vein, treated with aspiration thrombectomy.

Analysis of STEMI and NSTEMI in a Community Cohort of Marijuana Users.

Background: Marijuana is the most commonly used illicit drug in the United States. Current research has yet to come to a consensus on its association with acute coronary syndrome (ACS). Herein, we aimed to analyze how marijuana use relates to acute ST elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI). Methods: Using a retrospective study design, we gathered data from August 2014 to September 2020 on all percutaneous coronary interventions (PCIs) done at Brookdale University Hospital Medical Center (BUHMC) in patients with NSTEMI and STEMI. To compare marijuana users (MUs) with non-users, t-tests and Chi-square tests were used. A total of 195 patients were included, with mean age at presentation of 47 years old; 59 were females (30.3%) and 136 were males (69.7%). We identified 37 patients who were MUs. MUs were younger than non-users (P < 0.01), had higher rates of alcohol (P = 0.025), opiate (P = 0.004) and cigarette (P ≤ 0.001) use. On admission, MUs had lower creatinine (P = 0.031), blood urea nitrogen (BUN) (P = 0.031), pro-B-type natriuretic peptide (PBNP) (P = 0.052), BMI (P = 0.014) and lower right coronary artery (RCA) disease (P = 0.026). Results: After logistic regression analyses, results showed that the severity of coronary artery disease (CAD) and admission diagnosis of STEMI or NSTEMI were not found to be significantly related to marijuana use. Age, alcohol, cigarette, creatinine, BUN, PBNP, BMI and RCA disease were significantly related to marijuana use. There was a negative correlation between marijuana use and RCA disease (MUs = 29.7% vs. non-users = 50%, P = 0.026). There was no significant association with STEMI, NSTEMI or the severity of CAD. Conclusion: As daily cannabis use is on the rise, more researches are needed to further determine the effects of marijuana use on CAD.

A Rare Case of Vasospastic Angina Presenting with Inferior Lead ST-segment Elevation and Ventricular Fibrillation in the Absence of Coronary Obstruction: A Case Report.

Vasospastic angina (VSA) is a variant form of angina pectoris, which occurs at night or at rest, with transient electrocardiogram modifications and preserved exercise capacity. Its association with stable angina, sudden cardiac death, acute coronary syndrome, arrhythmia, and syncope has previously been established. Its presentation can occur with or without existing coronary artery disease and may present with focal or diffuse alteration and dysfunction of the coronary vasculature. VSA diagnosis involves patient response to nitrates, transient ischemic electrocardiogram (ECG) changes, and coronary artery spasms. The mechanisms proposed to constitute the substrate for susceptibility to VSA include vascular smooth muscle cell hyperreactivity, endothelial dysfunction, magnesium deficiency, low-grade inflammation, altered autonomic nervous system response, hypothyroidism, and oxidative stress. Herein, we present the rare case of a patient with ST-segment elevation in the inferior leads, increased troponin, and an episode of ventricular fibrillation initially thought to be due to lateral wall ST-elevation myocardial infarction (STEMI), although it was revealed to be vasospastic angina. We will also review the literature. Vasospastic angina remains underdiagnosed and a timely diagnosis is crucial to prevent major cardiac events. In patients with diffuse ST-segment elevation on ECG (independently of angiographic findings), VSA should be considered as one of the differential diagnoses and treated if found to be the cause of pathological changes.

Left ventricular geometry and renal function in hypertensive patients with diastolic heart failure.

BACKGROUND: The objective is to define the relationship between cardiac geometry and renal function in hypertensive subjects with and without diastolic heart failure (DHF). METHODS: This is a prospective observational study in a tertiary-care teaching institute in a 15-month period of consecutive hospitalized hypertensive patients. Patients on dialysis therapy or with atrial fibrillation, systolic heart failure, gross proteinuria, and glomerular diseases were excluded. Two-dimensional echocardiography was performed and stable glomerular filtration rate (GFR) was calculated by using the Modification of Diet in Renal Disease formula. Patients were classified into stage 1 to 5 chronic kidney disease (CKD). RESULTS: Five hundred forty hypertensive patients were separated into 2 groups: 286 patients with DHF and 254 patients without DHF. Mean age was 69.1 +/- 13.7 (SD) years in general. In patients with DHF, from stages 1 to 5 CKD, there was a significant graded increase in left ventricular mass index (from 117.3 to 162.4 g/m(2)) and relative wall thickness (from 0.42 to 0.52) and a significant graded decrease in aortic cusp separation (from 1.85 to 1.55 cm). Among echocardiographic variables, left ventricular mass index and relative wall thickness were associated inversely and aortic cusp separation was associated directly with GFR. In the absence of DHF, only left ventricular mass index was associated inversely with GFR, suggesting a prominent role of aortic cusp separation and relative wall thickness in the variability in GFR in patients with DHF through a hemodynamic disturbance. CONCLUSION: Hemodynamic alterations have a prominent role in the variability of GFR in patients with CKD with DHF. Adverse cardiac geometry is linked to the severity of CKD in hypertensive patients, raising the possibility of preserving both cardiac and renal function by means of hypertension control.

Wellens syndrome in HIV-infected patients: Two case reports.

BACKGROUND: Wellens syndrome is a pattern of electrocardiographic (ECG) changes in the context of unstable angina characterized with deep inverted T-waves or biphasic T-waves in the precordial leads. These specific ECG changes are highly suggestive of stenosis in the left anterior descending artery (LAD), which can result in acute myocardial infarction, left ventricular dysfunction, or death. Human immunodeficiency virus (HIV) infection is known as an independent risk factor for the cardiovascular disease. CASE REPORT: The first case is a 61-year-old African American female with a history of HIV infection who presented with chest pain for 8 h. Electrocardiogram (ECG) showed deep T-waves inversions in leads V3-V6. Emergent cardiac catheterization showed 99% stenosis in the mid-LAD and a drug-eluting stent (DES) was subsequently placed. The second case is a 49-year-old African American female with a medical history of type 2 diabetes mellitus, HIV, active cigarettes smoker admitted for intermittent substernal chest pain of 1-day duration. ECG showed biphasic T-wave in V2 and deep T-waves inversion in V3-V4, coronary angiography showed 95% stenosis in the proximal LAD and a DES was placed. CONCLUSION: Wellens syndrome has characteristic ECG changes that indicates LAD stenosis. Early recognition of this syndrome, especially in HIV-infected patients who are high risk for cardiovascular disease, will help to avoid impending myocardial infarction.

ST-Segment Elevation Myocardial Infarction with Acute Stent Thrombosis Presenting as Intractable Hiccups: An Unusual Case.

BACKGROUND Acute coronary syndrome (ACS) can present with atypical chest pain or symptoms not attributed to heart disease, such as indigestion. Hiccups, a benign and self-limited condition, can become persistent or intractable with overlooked underlying etiology. There are various causes of protracted hiccups, including metabolic abnormalities, psychogenic disorders, malignancy, central nervous system pathology, medications, pulmonary disorders, or gastrointestinal etiologies. It is rarely attributed to cardiac disease. CASE REPORT We report a case of intractable hiccups in a 51-year-old male with cocaine related myocardial infarction (MI) before and after stent placement. Coronary angiogram showed in-stent thrombosis of the initial intervention. Following thrombectomy, balloon angioplasty, and stent, the patient recovered well without additional episodes of hiccups. Although hiccups are not known to present with a predilection for a particular cause of myocardial ischemia, this case may additionally be explained by the sympathomimetic effects of cocaine, which lead to vasoconstriction of coronary arteries. CONCLUSIONS Hiccups associated with cardiac enzyme elevation and EKG ST-segment elevation before and after percutaneous coronary intervention (PCI) maybe a manifestation of acute MI with or without stent. The fact that this patient was a cocaine user may have contributed to the unique presentation.

New development of cardiac tamponade on underlying effusive-constrictive pericarditis: an uncommon initial presentation of scleroderma.

A 40-year-old man with a medical history of hypertension was admitted for weight loss, generalised weakness, joint pains and mottling of fingertips. The initial laboratory data revealed microangiopathic haemolytic anaemia, thrombocytopenia and acute renal failure. Intravenous steroids were started for possible diagnosis of systemic lupus erythematosus based on admission assessment. Intravenous immunoglobulin and plasmapharesis were subsequently added to the treatment plan to cover thrombotic thrombocytopenic purpura while his autoimmune panel was pending. The echocardiogram study on day 2 revealed cardiac tamponade for which he underwent pericardiocentesis and right heart catheterisation. The atrial waveforms postpericardiocentesis demonstrated effusive-constrictive pericarditis. His clinical condition kept on deteriorating with reaccumulation of pericardial effusion and further complicated by hemoperitoneum and colonic obstruction. He had cardiorespiratory arrest on his fourth admission day and was not revived. Anti-Scl-70 antibody came back positive. Autopsy findings confirmed the presence of fibrinous pericarditis and hemoperitoneum.

The power of collateral circulation: a case of asymptomatic chronic total occlusion of the left main coronary artery.

Total occlusion of the left main coronary artery predominantly presents with recurrent angina or myocardial infarction. Long-term survival and myocardial function depends on the well-developed right to left collaterals. We report a case of a 46-year-old man who was referred because of incidental finding of low ejection fraction during work-up for syncope 5 months prior. The patient denied any recurrence or any other symptom after that episode and claimed an unchanged exercise capacity. He had hypertension, hyperlipidemia, and history of 15-pack/year smoking. Except for class II morbid obesity, he had completely normal vital signs, physical examination, and lab tests on admission. The echocardiogram was suggestive of previous anterior wall myocardial infarction and demonstrated a low left ventricle ejection fraction with diffuse hypokinesis of the left ventricle. The patient underwent cardiac catheterization, which revealed total occlusion of the left main coronary artery, dominant right coronary artery with a 95% stenosis in the proximal segment, and collaterals from the right to the left coronary arteries. The patient was immediately referred for coronary artery bypass surgery. This case demonstrates the power of collateral circulation in protecting the patient from symptoms and death despite total occlusion of the left main coronary artery and severe stenosis of the proximal right coronary artery.

Glomerular filtration rate on admission independently predicts short-term in-hospital mortality after acute myocardial infarction.

BACKGROUND: Risk of cardiovascular events is higher in patients with chronic kidney disease. The objective is to evaluate whether glomerular filtration rate (GFR) on admission is an independent predictor of short-term mortality in acute myocardial infarction (AMI), after adjusting with physiologic derangements in an acute setting. METHODS: 220 consecutive patients with an admitting diagnosis of AMI were enrolled in a 1-year prospective observational study at a tertiary care teaching institute. Data were gathered for history, physical examination and laboratory findings. GFR was calculated based on the Modification of Diet in Renal Disease formula. Abnormal categories of physiological derangement indicators were weighted based on APACHE II guidelines. The endpoint was defined as in-hospital all-cause mortality. RESULTS: There were 31 deaths (14.1%). The GFR (mean +/- SD) in survivors as compared to deceased patients was 68.2 +/- 33.8 and 41.7 +/- 25.1 ml/min/1.73 m2, respectively (p < 0.001). The mean age, white blood cell count, blood urea nitrogen, potassium and blood sugar were higher on admission in patients who died in hospital (p < 0.05), while the mean albumin, mean arterial pressure, pulse and respiratory rate were lower in this group compared to survivors (p < 0.05). After adjusting with other covariates, each 10 ml/min/1.73 m2 decrease in GFR was associated with a 1.29 times increased risk of mortality (95% CI 1.08-1.53, p = 0.004). CONCLUSION: GFR on admission is an independent predictor of short-term mortality in a patient after AMI.