Orthostatic variation of pulmonary artery pressure in ambulatory heart failure patients.

AIM: To study effect of change in position (supine and standing) on pulmonary artery pressure (PAP) in ambulatory heart failure (HF) patients. METHODS: Seventeen patients with CardioMEMS® sensor and stable heart failure were consented and included in this single center study. Supine and standing measurements were obtained with at least 5 min interval between the two positions. These measurements included PAP readings utilizing the manufacturer handheld interrogator obtaining 10 s data in addition to the systemic blood pressure and heart rate recordings. RESULTS: Mean supine and standing readings and their difference (Δ) were as follows respectively: Systolic PAP were 33.4 (± 11.19), 23.6 (± 10) and Δ was 9.9 mmHg (p = 0.0001), diastolic PAP were 14.2 (± 5.6), 7.9 (± 5.7) and Δ was 6.3 mmHg (p = 0.0001) and mean PAP were 21.8 (± 7.8), 14 (± 7.2) and Δ was 7.4 mmHg (p = 0.0001) while the systemic blood pressure did not vary significantly. CONCLUSION: There is orthostatic variation of PAP in ambulatory HF patients demonstrating a mean decline with standing in diastolic PAP by 6.3 mmHg, systolic PAP by 9.9 mmHg and mean PAP by 7.4 mmHg in absence of significant orthostatic variation in systemic blood pressure or heart rate. These findings have significant clinical implications and inform that PAP in each patient should always be measured in the same position. Since initial readings at the time of implant were taken in supine position, it may be best to use supine position or to obtain a baseline standing PAP reading if standing PAP is planned on being used.

Nationwide study of six-month readmissions in critical limb ischemia: Predictors and impact of revascularization strategies.

OBJECTIVE: There is a paucity of data regarding six-month readmissions in critical limb ischemia patients and the influence of management strategy during index-admission [endovascular, surgical, hybrid procedure, medical therapy, and amputation]. We aimed to investigate the incidence, predictors, and impact of management strategies on six-month readmission in patients with critical limb ischemia. METHODS: A secondary analysis of the Nationwide Readmissions Database (2016-2017) was conducted. Propensity score matching was performed for subgroup analysis. RESULTS: We identified 50,058 patients with primary diagnosis of critical limb ischemia. Six-month all-cause and critical limb ischemia-related readmission rate was 52.36% and 10.86%, respectively. The risk of all-cause readmission was lower with amputation but was similar among other subgroups. Patients receiving surgical [HR 0.62, CI(0.48-0.79), p < 0.001] and hybrid procedure [HR 0.65 (0.46-0.93), p = 0.02] had lower risk of unplanned critical limb ischemia-related readmission compared to endovascular, though the risk of unplanned revascularization/amputation during readmission was similar between the three strategies. The risk of non-critical limb ischemia-related readmission was higher with surgical [HR 1.13, CI(1.04-1.23), p = 0.003] and hybrid procedure [HR 1.17, CI(1.08-1.28), p < 0.001], driven by increased procedure-related/wound complications. Eventhough endovascular patients were older with more severe critical limb ischemia presentation, a lower proportion received home-health or placement upon discharge from index-admission. This could account for higher readmission without higher repeat revascularization in endovascular group. CONCLUSION: The risk of critical limb ischemia and non-critical limb ischemia-related readmission differ according to the management strategy. Significant differences in discharge disposition exist depending on revascularization strategy. Study findings identify opportunities for reducing readmissions by focusing on nonprocedural aspects like wound-care, discharge planning and placement.

Prevalence of recreational substance use in patients presenting with seizures to a tertiary care hospital.

RATIONALE: Recreational substance use (RSU) has been associated with seizure. There is limited knowledge on prevalence of seizures in patients with concomitant RSU in U.S. Thus, we aimed to investigate the prevalence of concomitant RSU in patients with seizures at a university based tertiary healthcare system. METHODS: We conducted a retrospective observational study from 01/01/2013 to 02/28/2021. Data from patient cohort explorer (a de-identified database) were used to select patients with seizure and a positive drug test (either urine or serum) obtained during the same encounter. The prevalence of RSU for individual substance was reported as percentage of number of encounters. RESULTS: There were 226,613 encounters with seizure(s) for a total of 40,459 subjects. Of the total, 5787 (2.5%) encounters with 4,342 subjects concomitantly tested positive for RSU. Mean age was 40.1 (±16.9) years, 58.4% were males, 59.1% were African Americans, and 38.3% were Caucasians. Gender and race of subjects with concomitant RSU for individual drug class was studied for all age groups and for subjects older than 16 years. CONCLUSIONS: Overall, the most common concomitantly positively tested RSU during seizure encounters was cannabinoid (40.7%) followed by benzodiazepine (38.7%). There was a higher proportion of males' encounters with concomitant seizure and RSU regardless of type of drug class. Amphetamine use was more common in Caucasians, while the remaining studied RSU were more common in African Americans. Similar trends were seen in the subgroup of subjects older than 16 years.

Optical Coherence Tomography in Intracoronary Diagnostics.

Optical coherence tomography (OCT) has been revolutionary in the field of medical imaging since its inception in 1991, especially in the field of ophthalmology, but its use in coronary artery disease (CAD) and percutaneous coronary intervention (PCI) is still to be explored to its full potential. OCT has proven benefits in guiding PCI when it comes to assessing baseline lesion characteristics, plaque burden and its composition. OCT images provide high axial resolution (10 micrometer) in assessing intra and transluminal coronary structures, which is useful in identifying vulnerable thin fibrous cap atheroma (TCFA) and to differentiate plaque rupture from plaque erosion causing acute coronary syndrome. Optimal stent placement and periprocedural complications (for example stent malposition, coronary dissections, thrombosis) can be assessed by OCT post intervention. It has also seen increasing use in studies trying to elucidate evolution of atherosclerosis, effects of therapeutic interventions on coronary artery plaques and to follow long-term stent outcomes. In this review, we focus on an overview of OCT imaging, techniques employed in its use, its clinical and research applications, indications and limitations.

Recurrent Catecholamine-Induced Cardiomyopathy and Hypertensive Emergencies: A presentation of Pheochromocytoma and Related Concerns.

Catecholamine-induced cardiomyopathy (CIC) and pheochromocytoma are both rare entities, and their exact incidence and prevalence are unknown. Pheochromocytoma has been implicated as one of the causes of CIC or Takotsubo syndrome (TTS) by means of case reports and retrospective reviews. However, the evaluation of any patient with TTS and pheochromocytoma is often faced with multiple challenges due to its rarity and atypical presentations, which subsequently leads to delay in diagnosis. Here, we present a case of a 51-year old female who had three distinct episodes of TTS and now presented in a hypertensive emergency with angina, palpitations, headache, nausea, and vomiting. She was treated for non-ST elevation myocardial infarction (NSTEMI) but coronary angiogram revealed patent coronary arteries. Due to the paroxysmal nature of her hypertensive emergencies and variable blood pressure response, pheochromocytoma was suspected. On further evaluation, she was found to have elevated metanephrines and a 6.3 cm left adrenal mass on CT scan. This case emphasizes the importance of considering or identifying pheochromocytoma as an underlying primary etiology for recurrent episodes of TTS and related concerns such as choice of anti-hypertensive agents.

Peristomal variceal hemorrhage at the ileal conduit site due to extrahepatic portosystemic shunt.

Peristomal variceal bleeding is a rare but known complication with portal hypertension. In patients with recurrent peristomal hemorrhage, atypical varices should be considered, and liver cirrhosis should be excluded even with normal liver function tests. We report a case of a 76-year-old male who presented with recurrent ileal conduit site peristomal hemorrhage without known chronic liver disease. His liver function tests were normal, but computed tomography of the abdomen and pelvis showed liver nodularity and peristomal varices. He was diagnosed to have cirrhosis with portal hypertension and further tested positive for active hepatitis C infection. The patient's extrahepatic portosystemic ileal conduit site shunt was successfully treated with transjugular intrahepatic portosystemic shunt and endovascular variceal coiling. This case identifies a situation where it is imperative to identify occult liver cirrhosis with portosystemic shunt as a cause of ileal conduit site recurrent stomal bleeding.

A Review of Commonly Prescribed Antiarrhythmics: Primer for Primary Care Providers, a Case Based Approach.

The incidence of atrial fibrillation has been steadily increasing as our average population continues to age. In addition, many patients with structural heart disease are on antiarrhythmic drugs for prevention of ventricular tachycardia. General practitioners have a large role in co-management of patients with cardiac disease. The general understanding of common antiarrhythmic drugs and underlying mechanism is pivotal to safely prescribe and follow up of patients as they have potent side effects and drug interactions that needs careful consideration. The decision of which antiarrhythmic medication to use should be personalized, as each patient has a variety of co-morbid conditions that may affect the selection of which drug therapy. The ideal use of antiarrhythmic drugs should focus on understanding the basic pharmacology of the medication. This manuscript is not meant to be an in-depth overview of antiarrhythmic therapy, but rather a review of the commonly used antiarrhythmic drugs to assist primary care practitioners on when to consider antiarrhythmic drugs best suited for their patients. Class I and class III antiarrhythmic drugs will be the focus in this manuscript.

When Absence Seizures Are Not Seizure: A Case of Insulinoma.

Insulinomas are rare neuroendocrine tumors that produce excessive insulin and result in hypoglycemia. It can have a wide spectrum of symptoms and presentations which makes it difficult to diagnose at times. Here we present a 39-year-old woman who presented with intermittent diplopia, confusion, and staring episodes for one month. She had previously been seen by a neurologist who diagnosed her with possible absence seizures. However, evaluation showed that that patient had severe hypoglycaemia even with dextrose infusions. She was diagnosed with insulinoma based on lab work and a biopsy of a pancreatic tail mass. She underwent partial pancreatectomy, and has had a good outcome, with no recurrence of her symptoms. This case highlights the variable presentation of insulinomas, and the challenges faced with its diagnosis.

Successful Resolution of a Large Left Ventricular Thrombus with Rivaroxaban Therapy after Acute Myocardial Infarction.

Left ventricular (LV) thrombus is a major complication of acute systolic cardiomyopathy especially after a large anterior myocardial infarction (AMI), and it poses a significant embolic risk, up to five times higher than the general population. Current guidelines for LV thrombi recommend vitamin K antagonist for anticoagulation in contrast to novel oral anticoagulants (NOACs) which have not been studied well in cases of LV thrombus. We present a case of patient with AMI, who was noted to have severe systolic dysfunction and a large LV thrombus which was successfully treated with rivaroxaban therapy with complete resolution of LV thrombus on two months follow-up.

Coronary Artery Perforation Spilling into Right Ventricle: A Rare Complication of Percutaneous Coronary Intervention.

Injury to the coronary circulation during percutaneous interventions is an existent risk. One of these is coronary artery perforation that can have grave consequences. Fortunately, this is rare and overall there is a declining incidence of complications due to technological advances and extensive experience over time. Predictors of coronary artery perforation include the administration of glycoprotein IIb/IIIa inhibitors, the use of hydrophilic guide wires, and the use of noncompliant high-pressure intracoronary balloons. Complex coronary lesions and the presence of total chronic occlusion are additional risk factors. In this paper, we present a rare class III coronary artery perforation with spilling into the right ventricle. Our case exemplifies all the aforementioned risk factors for perforation. The perforation was successfully sealed with a polytetrafluoroethylene covered stent and the patient remained hemodynamically stable.

Recurrent Ischemic Stroke: A Manifestation of a Sinus of Valsalva Pseudoaneurysm.

An 83-year-old female presented to the emergency department with bilateral eye pain, dizziness, and acute shortness of breath. Her blood pressure (BP) at presentation was 184/93 mmHg. She was admitted for hypertensive emergency and her symptoms improved with BP control. However, during hospitalization, she developed left-sided paresthesia which on investigation was found to be secondary to ischemic stroke. She had two previous aortic mechanical valve replacements for aortic stenosis. Transthoracic echocardiogram revealed a large pseudoaneurysm of the non-coronary sinus of Valsalva that we believe was the cause of her recurrent stroke. A sinus of Valsalva pseudoaneurysm is an uncommon complication of aortic valve replacement surgery which in turn has been associated with aortic rupture, myocardial infarction, and stroke. Our case identifies a situation where sinus of Valsalva pseudoaneurysm predisposed our patient to recurrent ischemic strokes and this should be kept in mind when evaluating a patient with ischemic stroke.

Orbital atherectomy safety and efficacy: A comparative analysis of ostial versus non-ostial calcified coronary lesions.

BACKGROUND: The safety and efficacy of coronary orbital atherectomy (OA) for treatment of ostial lesions are not yet fully established. We sought to evaluate (OA) treatment of severely calcified ostial and non-ostial lesions. METHODS: A retrospective analysis of subjects treated with OA for severely calcified ostial and non-ostial lesions, at the Mount Sinai Medical Center, Miami Beach, Florida (MSMCMB) from January 2014 to September 2020, was completed. Study baseline characteristics, lesion and vessel characteristics, procedural outcomes, and in-hospital major adverse cardiovascular events (MACE) were analyzed and compared. RESULTS: A total of 609 patients that underwent PCI with OA were identified. The majority of patients (81.9 %) had non-ostial lesions, while 16.6 % had ostial lesions (of which 2.8 % classified as aorto-ostial) and 1.5 % had unknown lesion anatomy. The mean age of the overall cohort was 74.0 ± 9.3 years, and 63.5 % were male. All patients received drug-eluting stent (DES) placement, and the overall freedom from MACE was 98.5 %, with no significant difference observed between the ostial and non-ostial groups. The freedom from cardiac death and MI was also similar between the two groups. There were low rates of bleeding complications and severe angiographic complications, and no persistent slow flow/no reflow was reported. CONCLUSIONS: This study demonstrated no significant differences in in-hospital MACE outcomes between patients with ostial versus non-ostial lesions, indicating that OA is a safe and effective treatment option for both lesion types, including those classified as aorto-ostial.

Diurnal variation of pulmonary artery pressure in ambulatory heart failure patients.

BACKGROUND: There is limited information on diurnal variation in pulmonary artery pressures (PAP) in ambulatory heart failure (HF) patients. We aimed to study the variation in morning and night-time PAP in HF patients with an implanted CardioMEMS® sensor. METHODS: In this prospective, single centre study we enrolled patients who had a cardioMEMS sensor and consented to participate (End stage renal disease and recent hospitalisation for acute HF were exclusions). Subjects were asked to transmit PAP and non-invasive blood pressure information in morning and at night-time for 7 consecutive days. Categorical and continuous variables were reported as percentages and mean ± SD respectively. Repeated measure ANOVA was used to compare the diurnal changes in PAP among different subgroups. Pierson correlation coefficient was performed to assess correlation between diurnal variation of PAP and left ventricular ejection fraction. RESULTS: Thirty subjects were included in analysis. There was a significant nocturnal rise in PASP and mPAP compared to morning readings (+2.59 mmHg, p = 0.003 and +1.24 mmHg with p = 0.02 respectively) while night-time PADP did not change significantly (+0.48 mmHg, p = 0.18) without significant change in systemic blood pressure or pulse rate. CONCLUSION: The described diurnal changes in PAP should be considered when managing ambulatory HF patients based on these readings. PADP can be used reliably without concern for the time of day the readings were recorded.HighlightsThere is a diurnal variation in PAP in ambulatory heart failure patientsPulmonary artery systolic and mean pulmonary artery pressures are higher at night-time than in morning.Pulmonary artery diastolic pressures do not vary significantly with time of day.These findings should inform clinical decisions in management of these patients about the time of the day readings are taken.

Outcomes in patients with history of cocaine use presenting with chest pain to the emergency department: Insights from the Nationwide Emergency Department Sample 2016-2018.

OBJECTIVES: Cocaine use (CU) related chest pain (CP) is a common cause of emergency department (ED) visits in the United States. However, information on disposition and outcomes in these patients is scarce. We conducted a nationwide study to assess disposition from ED, hospitalization rates, in-hospital outcomes, and health care costs in patients with history of CU who presented to the ED with CP. METHODS: We queried the Nationwide Emergency Department Sample database from 2016-2018 for adult patients with CU presenting to the ED with CP. International Classification of Diseases, Tenth Revision codes were used to identify study patients. RESULTS: We identified 149,372 patients. The majority were male (76%), presented to metropolitan centers (91.3%), and had a high prevalence of cardiovascular risk factors (48.1% with hypertension, 24.4% with coronary artery disease, 18.2% with diabetes) and psychiatric illnesses (21%). Overall, 21.4% of patients were hospitalized, 68.6% were discharged from ED and 6.6% left against medical advice. Patients requiring admission were older (51.8 vs 45.0; P < 0.0001) and had a higher prevalence of coronary artery disease, peripheral arterial disease, hypertension, diabetes, and chronic kidney disease. Of those admitted, 45.7% were diagnosed with myocardial infarction (MI), constituting 9.7% of the total study population. Over 80% of these patients underwent coronary angiography and 38.6% had coronary intervention. Mortality was 1.2%. CONCLUSION: CU patients who present to ED are predominantly male, are from lower economic strata, and have significant comorbidity burden. One in 5 patients requires hospitalization and has more prevalent cardiovascular risk factors and comorbidities. In-hospital mortality is low, but incidence of MI and subsequent invasive procedures is high. CU may be considered a cardiac risk factor as it is associated with high rates of in-hospital MI.

Incidence, Predictors, and Outcomes of In-Hospital Cardiac Arrest in COVID-19 Patients Admitted to Intensive and Non-Intensive Care Units: Insights From the AHA COVID-19 CVD Registry.

Background Limited information is available regarding in-hospital cardiac arrest (IHCA) in patients with COVID-19. Methods and Results We leveraged the American Heart Association COVID-19 Cardiovascular Disease (AHA COVID-19 CVD) Registry to conduct a cohort study of adults hospitalized for COVID-19. IHCA was defined as those with documentation of cardiac arrest requiring medication or electrical shock for resuscitation. Mixed effects models with random intercepts were used to identify independent predictors of IHCA and mortality while accounting for clustering at the hospital level. The study cohort included 8518 patients (6080 not in the intensive care unit [ICU]) with mean age of 61.5 years (SD 17.5). IHCA occurred in 509 (5.9%) patients overall with 375 (73.7%) in the ICU and 134 (26.3%) patients not in the ICU. The majority of patients at the time of ICHA were not in a shockable rhythm (76.5%). Independent predictors of IHCA included older age, Hispanic ethnicity (odds ratio [OR], 1.9; CI, 1.4-2.4; P<0.001), and non-Hispanic Black race (OR, 1.5; CI, 1.1-1.9; P=0.004). Other predictors included oxygen use on admission, quick Sequential Organ Failure Assessment score on admission, and hypertension. Overall, 35 (6.9%) patients with IHCA survived to discharge, with 9.1% for ICU and 0.7% for non-ICU patients. Conclusions Older age, Black race, and Hispanic ethnicity are independent predictors of IHCA in patients with COVID-19. Although the incidence is much lower than in ICU patients, approximately one-quarter of IHCA events in patients with COVID-19 occur in non-ICU settings, with the latter having a substantially lower survival to discharge rate.

The Effects of Vitamin D Supplementation and 25-Hydroxyvitamin D Levels on the Risk of Myocardial Infarction and Mortality.

OBJECTIVE: The aim of the study was to examine the effects of the vitamin D (Vit-D) treatment and nontreatment on Vit-D-deficient patients without a prior history of myocardial infarction (MI). MATERIALS AND METHODS: This was a retrospective, observational, nested case-control study of patients (N = 20 025) with low 25-hydroxyvitamin D ([25-OH]D) levels (<20 ng/mL) who received care at the Veterans Health Administration from 1999 to 2018. Patients were divided into 3 groups: Group A (untreated, levels ≤20 ng/mL), Group B (treated, levels 21-29 ng/mL), and Group C (treated, levels ≥30 ng/mL). The risk of MI and all-cause mortality were compared utilizing propensity score-weighted Cox proportional hazard models. RESULTS: Among the cohort of 20 025 patients, the risk of MI was significantly lower in Group C than in Group B (hazard ratio [HR] 0.65, 95% CI 0.49-0.85, P = .002) and Group A (HR 0.73, 95% CI 0.55-0.96), P = .02). There was no difference in the risk of MI between Group B and Group A (HR 1.14, 95% CI 0.91-1.42, P = 0.24). Compared with Group A, both Group B (HR 0.59, 95% CI 0.54-0.63, P < .001) and Group C (HR 0.61, 95% CI 0.56-0.67, P < .001) had significantly lower all-cause mortality. There was no difference in all-cause mortality between Group B and Group C (HR 0.99, 95% CI 0.89-1.09, P = .78). CONCLUSIONS: In patients with Vit-D deficiency and no prior history of MI, treatment to the (25-OH)D level of >20 ng/mL and >30 ng/mL was associated with a significantly lower risk of all-cause mortality. The lower risk of MI was observed only in individuals maintaining (25-OH)D levels ≥30 ng/mL.

Endovascular Abdominal Aortic Aneurysm Repair.

Most abdominal aortic aneurysms are treated with endovascular repair (EVAR) in current practice. EVAR has lower periprocedural mortality and morbidity than open surgical repair. Aneurysm neck morphology, iliac anatomy, and access vessel anatomy need careful assessment for the successful performance of EVAR. Regular and long-term follow-up with imaging is mandatory after EVAR, and patients who are less likely to comply are less favorable EVAR candidates. Endoleaks are the most frequent complication of EVAR. Most can be managed with transcatheter or endovascular means. Evolving technology and techniques are allowing more patients to be treated with EVAR with better long-term outcomes.