Cardiac sarcoidosis: a comprehensive review

Sarcoidosis is a multisystem granulomatous disease of unknown etiology characterized by noncaseating granulomas in involved organs. Organs involved with sarcoidosis include lymph nodes, skin, lung, central nervous system, and eye. Only 40-50% of patients with cardiac sarcoidosis diagnosed at autopsy have the diagnosis made during their lifetime. Cardiac sarcoidosis can manifest itself as complete heart block, ventricular arrhythmias, congestive heart failure, pericardial effusion, pulmonary hypertension, and ventricular aneurysms. Diagnostic tests such as the electrocardiogram, two-dimensional echocardiography, cardiac magnetic resonance imaging, positron emission tomography scan, radionuclide scan, and endomyocardial biopsy can be helpful in the early detection of cardiac sarcoidosis. Considering the increased risk of sudden death, cardiac sarcoidosis is an indication for early treatment with corticosteroids or other immunosuppressive agents. Other treatments include placement of a pacemaker or implantable defibrillator to prevent sudden death. In refractory cases, cardiac transplantation should be considered.

Hyperkalemia among hospitalized patients and association between duration of hyperkalemia and outcomes

INTRODUCTION

The aim of the study was to investigate predictors of mortality in patients hospitalized with hyperkalemia.

MATERIAL AND METHODS

Data among hospitalized patients with hyperkalemia (serum potassium ≥ 5.1 mEq/l) were collected. Patients with end-stage renal disease on dialysis were excluded.

RESULTS

Of 15,608 hospitalizations, 451 (2.9%) episodes of hyperkalemia occurred in 408 patients. In patients with hyperkalemia, chronic kidney disease, hypertension, diabetes, coronary artery disease and heart failure were common comorbidities. Acute kidney injury (AKI) and metabolic acidosis were common metabolic abnormalities, and 359 patients (88%) were on at least one drug associated with hyperkalemia. Mean duration to resolution of hyperkalemia was 12 ±9.9 h. Nonsteroidal anti-inflammatory drugs (HR = 1.59), highest potassium level (HR = 0.61), tissue necrosis (HR = 0.61), metabolic acidosis (HR = 0.77), and AKI (HR = 0.77) were significant independent determinants of duration prior to hyperkalemia resolution. Tissue necrosis (OR = 4.55), potassium supplementation (OR = 5.46), metabolic acidosis (OR = 4.84), use of calcium gluconate for treatment of hyperkalemia (OR = 4.62), AKI (OR = 3.89), and prolonged duration of hyperkalemia (OR = 1.06) were significant independent predictors of in-hospital mortality.

CONCLUSIONS

Tissue necrosis, potassium supplementation, metabolic acidosis, calcium gluconate for treatment of hyperkalemia, AKI and prolonged duration of hyperkalemia are independent predictors of in-hospital mortality.

Echocardiographic evaluation of the right ventricle: Clinical implications

Interest in evaluation of the right ventricle (RV) has increased recently. With the growth of new echocardiographic techniques and technology, there has been a corresponding increase in the ability to evaluate the RV, both qualitatively and quantitatively. Older echocardiographic techniques, such as right ventricular fractional area of change, tricuspid annular plane systolic excursion, and tissue S', and newer echocardiographic techniques including 3-dimensional evaluation and global longitudinal strain, can improve our evaluation of RV function. These techniques provide both diagnostic and prognostic data on a large variety of clinical diseases including pulmonary hypertension and congestive heart failure. With the continuing and exponential advances in technology, echocardiography is well poised to become the primary modality to evaluate the RV.

Association of chronic renal insufficiency with in-hospital outcomes after percutaneous coronary intervention

BACKGROUND

The association of chronic renal insufficiency with outcomes after percutaneous coronary intervention (PCI) in the current era of drug-eluting stents and modern antithrombotic therapy has not been well characterized.

METHODS AND RESULTS

We queried the 2007-2011 Nationwide Inpatient Sample databases to identify all patients aged ≥18 years who underwent PCI. Multivariable logistic regression was used to compare in-hospital outcomes among patients with chronic kidney disease (CKD), patients with end-stage renal disease (ESRD), and those without CKD or ESRD. Of 3 187 404 patients who underwent PCI, 89% had no CKD/ESRD; 8.6% had CKD; and 2.4% had ESRD. Compared to patients with no CKD/ESRD, patients with CKD and patients with ESRD had higher in-hospital mortality (1.4% versus 2.7% versus 4.4%, respectively; adjusted odds ratio for CKD 1.15, 95% CI 1.12 to 1.19, P<0.001; adjusted odds ratio for ESRD 2.29, 95% CI 2.19 to 2.40, P<0.001), higher incidence of postprocedure hemorrhage (3.5% versus 5.4% versus 6.0%, respectively; adjusted odds ratio for CKD 1.21, 95% CI 1.18 to 1.23, P<0.001; adjusted odds ratio for ESRD 1.27, 95% CI 1.23 to 1.32, P<0.001), longer average length of stay (2.9 days versus 5.0 days versus 6.4 days, respectively; P<0.001), and higher average total hospital charges ($60 526 versus $77 324 versus $97 102, respectively; P<0.001). Similar results were seen in subgroups of patients undergoing PCI for acute coronary syndrome or stable ischemic heart disease.

CONCLUSIONS

In patients undergoing PCI, chronic renal insufficiency is associated with higher in-hospital mortality, higher postprocedure hemorrhage, longer average length of stay, and higher average hospital charges.

Temporal trends and outcomes of acute myocardial infarction in patients with cancer

BACKGROUND

Data on outcomes of ST-elevation myocardial infarction (STEMI) in patients with cancer are scarce. We investigated the nationwide trends in admissions for STEMI, utilization of percutaneous coronary intervention (PCI), and in-hospital outcomes in patients with the three most common cancer diagnoses (lung, breast, and colon) compared to patients without cancer.

METHODS

We conducted an administrative database study using the Nationwide Inpatient Sample (NIS). All in-patient hospitalizations for STEMI from 2001 to 2011 were identified. Patients with concomitant diagnosis of lung, breast or colon cancer were identified using appropriate International classification of diagnosis (ICD 9-CM) codes. Primary outcome was utilization of PCI and in-hospital mortality in patients with cancer compared to those without cancer.

RESULTS

Utilization of PCI was 30.8% (1,191/3,871), 20.2% (4,541/22,480) and 17.3% (1,716/9,944) in patients with breast, lung and colon cancer, respectively. Among patients without any of these cancers, use of PCI was 49.6%. In-hospital mortality was highest in patients with lung cancer (57.1%) and lowest in patients without cancer (25.7%).

CONCLUSIONS

Patients with cancer have significantly worse in-hospital mortality compared to those without cancer, partly due to a relatively lower rate of PCI utilization in cancer patients with STEMI.

Management of massive and nonmassive pulmonary embolism

Massive pulmonary embolism (PE) is characterized by systemic hypotension (defined as a systolic arterial pressure < 90 mm Hg or a drop in systolic arterial pressure of at least 40 mm Hg for at least 15 min which is not caused by new onset arrhythmias) or shock (manifested by evidence of tissue hypoperfusion and hypoxia, including an altered level of consciousness, oliguria, or cool, clammy extremities). Massive pulmonary embolism has a high mortality rate despite advances in diagnosis and therapy. A subgroup of patients with nonmassive PE who are hemodynamically stable but with right ventricular (RV) dysfunction or hypokinesis confirmed by echocardiography is classified as submassive PE. Their prognosis is different from that of others with non-massive PE and normal RV function. This article attempts to review the evidence-based risk stratification, diagnosis, initial stabilization, and management of massive and nonmassive pulmonary embolism.

Peripheral arterial disease in the elderly

Smoking should be stopped and hypertension, diabetes mellitus, dyslipidemia, and hypothyroidism treated in elderly patients with peripheral arterial disease (PAD) of the lower extremities. Statins reduce the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in patients with PAD and hypercholesterolemia. Antiplatelet drugs such as aspirin or clopidogrel, especially clopidogrel, angiotensin-converting enzyme inhibitors, and statins should be given to all elderly patients with PAD without contraindications to these drugs. Beta blockers should be given if coronary artery disease is present. Exercise rehabilitation programs and cilostazol increase exercise time until intermittent claudication develops. Chelation therapy should be avoided. Indications for lower extremity percutaneous transluminal angioplasty or bypass surgery are (1) incapacitating claudication in patients interfering with work or lifestyle; (2) limb salvage in patients with limb-threatening ischemia as manifested by rest pain, nonhealing ulcers, and/or infection or gangrene; and (3) vasculogenic impotence.

Lung cancer screening: history, current perspectives, and future directions

Lung cancer has remained the leading cause of death worldwide among all cancers. The dismal 5-year survival rate of 16% is in part due to the lack of symptoms during early stages and lack of an effective screening test until recently. Chest X-ray and sputum cytology were studied extensively as potential screening tests for lung cancer and were conclusively proven to be of no value. Subsequently, a number of studies compared computed tomography (CT) with the chest X-ray. These studies did identify lung cancer in earlier stages. However, they were not designed to prove a reduction in mortality. Later trials have focused on low-dose CT (LDCT) as a screening tool. The largest US trial - the National Lung Screening Trial (NLST) - enrolled approximately 54,000 patients and revealed a 20% reduction in mortality. While a role for LDCT in lung cancer screening has been established, the issues of high false positive rates, radiation risk, and cost effectiveness still need to be addressed. The guidelines of the international organizations that now include LDCT in lung cancer screening are reviewed. Other methods that may improve earlier detection such as positron emission tomography, autofluorescence bronchoscopy, and molecular biomarkers are also discussed.

Therapeutic options for severe asthma

As the overall prevalence of asthma has escalated in the past decades, so has the population of patients with severe asthma. This condition is often difficult to manage due to the relative limitation of effective therapeutic options for the physician and the social and economic burden of the disease on the patient. Management should include an evaluation and elimination of modifiable risk factors such as smoking, allergen exposure, obesity and non-adherence, as well as therapy for co-morbidities like gastro-esophageal reflux disease and obstructive sleep apnea. Current treatment options include conventional agents such as inhalational corticosteroids, long acting β(2) agonists, leukotriene antagonists, and oral corticosteroids. Less conventional treatment options include immunotherapy with methotrexate, cyclosporine and tacrolimus, biological drugs like monoclonal antibodies, tumor necrosis factor-α blockers and oligonucleotides, phosphodiesterase inhibitors, antimicrobials and bronchial thermoplasty.

Etiology of syncope in patients hospitalized with syncope and predictors of mortality and rehospitalization for syncope at 27-month follow-up

The authors investigated the etiologies of syncope and risk factors for mortality and rehospitalization for syncope at 27-month follow-up in 325 consecutive patients, mean age 66 years, hospitalized for syncope. The causes of syncope were diagnosed in 241 patients (74%). Of 325 patients, 13 (4%) were rehospitalized for syncope and 38 (12%) died. Stepwise logistic regression analysis showed that significant independent prognostic factors for rehospitalization for syncope were diabetes (odds ratio [OR], 5.7; 95% confidence interval [CI], 1.6-20.4), atrial fibrillation (OR, 4.0; 95% CI, 1.0-15.6), and smoking (OR, 4.6; 95% CI, 1.3-16.8). Stepwise Cox regression analysis showed that significant independent prognostic factors for time to mortality were diabetes (hazard ratio [HR], 2.7; 95% CI, 1.4-5.2), coronary artery bypass graft surgery (HR, 2.9; 95% CI, 1.3-6.5), malignancy history (HR, 2.5; 95% CI, 1.2-5.2), narcotics use (HR, 4.0; 95% CI, 1.7-9.8), smoking (HR, 2.8; 95% CI, 1.4-5.5), atrial fibrillation (HR, 2.4; 95% CI, 1.0-5.4), and volume depletion (HR, 2.8; 95% CI, 1.4-5.8). Copyright © 2011 Wiley Periodicals, Inc. The authors have no funding, financial relationships, or conflicts of interest to disclose.

Predictors of cardiac hepatopathy in patients with right heart failure

BACKGROUND

Some patients with right heart failure develop cardiac hepatopathy (CH). The pathophysiology of CH is thought to be secondary to hepatic venous congestion and arterial ischemia. We sought to define the clinical and hemodynamic characteristics associated with CH.

MATERIAL/METHODS

A retrospective cross sectional analysis was performed in which subjects were identified from our institutional cardiology database if echocardiography showed either right ventricular (RV) hypokinesis or dilatation, and was performed within 30 days of right heart catheterization. A chart review was then performed to identify patient clinical characteristics and to determine if the patients had underlying liver disease. Subjects with non-cardiac causes for hepatopathy were excluded.

RESULTS

In 188 included subjects, etiology for right heart dysfunction included left heart failure (LHF), shunt, pulmonary hypertension, mitral- tricuspid- and pulmonic valvular disease. On multivariate analysis, higher RV diastolic pressure and etiology for RV dysfunction other than LHF were both associated with CH. Low cardiac output was associated with CH only amongst those without LHF.

CONCLUSIONS

CH is most often seen in subjects with elevated RV diastolic pressure suggesting a congestive cause in most cases. CH associated with low cardiac output in patients without LHF suggests that low flow may be contributing to the patophysiology in some cases.

Clinical factors associated with early readmission among acutely decompensated heart failure patients

INTRODUCTION

Congestive heart failure (CHF) is a common cause of hospital readmission.

MATERIAL AND METHODS

A retrospective study was conducted at Harlem Hospital in New York City. Data were collected for 685 consecutive adult patients admitted for decompensated CHF from March, 2009 to December, 2012. Variables including patient demographics, comorbidities, laboratory studies, and medical therapy were compared between CHF patient admissions resulting in early CHF readmission and not resulting in early CHF readmission.

RESULTS

Clinical factors found to be independently significant for early CHF readmission included chronic obstructive pulmonary disease (odds ratio (OR) = 6.4), HIV infection (OR = 3.4), African-American ethnicity (OR = 2.2), systolic heart failure (OR = 1.9), atrial fibrillation (OR = 2.3), renal disease with glomerular filtration rate < 30 ml/min (OR = 2.7), evidence of substance abuse (OR = 1.7), and absence of angiotensin-converting enzyme inhibitors or angiotensin receptor blocker therapy after discharge (OR = 1.8). The ORs were used to develop a scoring system regarding the risk for early readmission.

CONCLUSIONS

Identifying patients with clinical factors associated with early CHF readmission after an index hospitalization for CHF using the proposed scoring system would allow for an early CHF readmission risk stratification protocol to target particularly high-risk patients.

Electrocardiographic abnormalities in patients with severe versus mild or moderate chronic obstructive pulmonary disease followed in an academic outpatient pulmonary clinic

BACKGROUND

The prevalence of some electrocardiographic (ECG) abnormalities in severe versus mild or moderate chronic obstructive pulmonary disease (COPD) has been reported.

METHODS

ECGs were interpreted blindly in 63 patients with severe COPD (group 1) versus 83 patients with mild or moderate COPD (group 2).

RESULTS

Right atrial enlargement (RAE) occurred in 44% of group 1 and 15% of group 2 patients (P < 0.001). Right ventricular hypertrophy (RVH) occurred in 29% of group 1 and 4% of group 2 patients (P < 0.001). Right bundle branch block (RBBB) occurred in 29% of group 1 and 11% of group 2 patients (P < 0.01). Marked clockwise rotation of heart occurred in 40% of group 1 and 18% of group 2 patients (P < 0.005). Low voltage in limb leads occurred in 24% of group 1 and 11% of group 2 patients (P < 0.05). A QS pattern in leads III and aVF occurred in 16% of group 1 and 4% of group 2 patients (P < 0.01). Left axis deviation (LAD) occurred in 16% of group 1 and 4% of group 2 patients (P < 0.01). Premature atrial complexes (PACs) occurred in 19% of group 1 and 7% of group 2 patients (P < 0.05). Supraventricular tachyarrhythmias (SVTs) occurred in 16% of group 1 and 5% of group 2 patients (P < 0.025).

CONCLUSIONS

RAE, RVH, RBBB, marked clockwise rotation of heart, a QS pattern in leads III and aVF, LAD, PACs, and SVTs were significantly more prevalent in patients with severe COPD than in patients with mild or moderate COPD.

Sacubitril/valsartan in cardiovascular disease: evidence to date and place in therapy

Cardiovascular (CV) disease is a major cause of morbidity and mortality in the developing and the developed world. Mortality from CV disease had plateaued in the recent years raising concerning alarms about the sustained efficacy of available preventive and treatment options. Heart failure (HF) is among the major contributors to the CV-related health care burden, a persisting concern despite the use of clinically proven guideline-directed therapies. A requirement for more efficient medical therapies coupled with recent advances in bio-innovation led to the creation of sacubitril/valsartan, an angiotensin receptor-neprilysin inhibitor (ARNI), which demonstrated substantial CV benefit when compared with the standard of care, enalapril, in patients with HF and reduced ejection fraction. Further investigations of this novel combination ARNI at the tissue level shed light into the anti-remodeling and cardioprotective effects of sacubitril/valsartan, while clinical studies in the phenotypes of HF with preserved ejection fraction, hypertension and subsets, coronary outcomes, postmyocardial infarction, and renal disease suggested that this combination could be beneficial across a wide spectrum of CV disease. Sacubitril/valsartan is a much-needed therapeutic advance in the avenue of CV disease.

Reduction in atherosclerotic events: a retrospective study in an outpatient cardiology practice

INTRODUCTION

Although atherosclerotic disease cannot be cured, risk of recurrent events can be reduced by application of evidence-based treatment protocols involving aspirin, beta blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statin medications. We studied atherosclerotic event rates in a patient population treated before and after the development of aggressive risk factor reduction treatment protocols.

MATERIAL AND METHODS

We performed a retrospective chart review of patients presenting for follow-up treatment of coronary artery disease in a community cardiology practice, comparing atherosclerotic event rates and medication usage in a 2-year treatment period prior to 2002 and a 2-year period in 2005-2008. Care was provided in both the early and later eras by 7 board-certified cardiologists in a suburban cardiology practice. Medication usage was compared in both treatment eras. The primary outcome was a composite event rate of myocardial infarction, cerebrovascular events, and coronary interventions.

RESULTS

Three hundred and fifty-seven patients were studied, with a follow-up duration of 12.1 (±3.5) years. There were 132 composite events in 104 patients (29.1%) in the early era compared to 40 events in 33 patients (9.2%) in the later era (p < 0.0001). From the early to the later eras, there was an increase in use of β-blockers (66% to 83%, p < 0.0001), angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (34% to 80%, p < 0.0001), and statins (40% to 90%, p < 0.0001).

CONCLUSIONS

Application of aggressive evidence-based medication protocols for treatment of atherosclerosis is associated with a significant decrease in atherosclerotic events or need for coronary intervention.

Double contrast-enhanced ultrasonography evaluation of preoperative Lauren classification of advanced gastric carcinoma

INTRODUCTION

The clinical value of double contrast-enhanced ultrasonography (DCUS) in determining the Lauren classification of advanced gastric carcinoma needed investigation.

MATERIAL AND METHODS

Fifty-eight patients with gastric cancer proved by endoscopic biopsy underwent preoperative DCUS examination in which an oral contrast agent was combined with an intravenous agent, and the findings were compared with the postoperative pathological findings using haematoxylin-eosin and Alcian Blue-Periodic Acid Schiff (AB-PAS) staining.

RESULTS

Of 58 patients, 34 (59%) were the intestinal type and 24 (41%) the diffuse type on pathological examination of resected specimens. Among intestinal type patients, 30 (88%) showed homogeneous vascular enhancement and 4 (12%) heterogeneous enhancement with the "sandwich" pattern in 2 patients (50%) and "barrier" pattern in 2 patients (50%). In the diffuse type, 22 of 24 patients (92%) enhanced heterogeneously, with stippled and peripheral enhancement in 9 (41%), the "sandwich" pattern in 8 (36%) and "barrier" pattern in 5 (23%). Two of 24 patients (8%) with the diffuse type enhanced homogeneously. The proportion of heterogeneous enhancement was significantly different between the 2 subtypes of tumour (p = 0.0001). The sensitivity and specificity of heterogeneous enhancement in diagnosing the diffuse type of advanced gastric cancer were 92% and 88%, respectively. Youden's index was 0.8.

CONCLUSIONS

Double contrast-enhanced ultrasonography is a new and useful method to determine Lauren classification in patients with gastric carcinoma.

Hyperthyroidism

Hyperthyroidism is a pathological syndrome in which tissue is exposed to excessive amounts of circulating thyroid hormone. The most common cause of this syndrome is Graves' disease, followed by toxic multinodular goitre, and solitary hyperfunctioning nodules. Autoimmune postpartum and subacute thyroiditis, tumors that secrete thyrotropin, and drug-induced thyroid dysfunction, are also important causes.

Predicting lymph node status in patients with early gastric carcinoma using double contrast-enhanced ultrasonography

INTRODUCTION

Double contrast-enhanced ultrasonography (DCUS) is a new method we used in predicting lymph node metastasis (LNM) in patients with early gastric cancer.

MATERIAL AND METHODS

Seventy-six patients with early gastric cancer diagnosed by gastroscope and confirmed by pathology after operation were examined using DCUS preoperatively. Group N1 included 15 patients with LNM and group N0 61 patients without LNM.

RESULTS

In group N1, 13 patients (87%) had marked hyperenhancement during early arterial phase using DCUS, and 2 patients (13%) were unmarked as hyperenhancement. In group N0, 24 patients (39%) had marked hyperenhancement during early arterial phase using DCUS, and 37 patients (61%) had unmarked hyperenhancement. The sensitivity and specificity of marked hyperenhancement in predicting LNM in patients with early gastric cancer was 86.7% and 60.7% respectively, and the Youden's index was 0.474. The κ value of this method was 0.89.

CONCLUSIONS

Double contrast-enhanced ultrasonography is a new valuable method to evaluate LNM at an early stage of gastric cancer and prognosis of early gastric cancer preoperatively.

Downhill esophageal varices: a therapeutic dilemma

Esophageal varices can cause life-threatening complications and are most often a sequela of liver disease. Although a rare cause of gastrointestinal bleeding, downhill variceal bleeding secondary to superior vena cava (SVC) obstruction should be considered in the differential diagnosis for patients with upper gastrointestinal hemorrhage. We discuss two such cases of downhill esophageal varices presenting with hematemesis in patients with end stage renal disease and no history of cirrhosis. These varices were thought to be secondary to SVC occlusion caused by complications from previous dialysis catheters. However, their difficult anatomy posed a significant challenge to the therapeutic interventions.

Correlation between electrocardiographic changes and coronary findings in patients with acute myocardial infarction and single-vessel disease

BACKGROUND

Correlation of ST-segment elevation on the 12-lead electrocardiogram (ECG) with the expected affected coronary territory is established in patients with ST-elevation myocardial infarction (STEMI). In patients with non-ST-elevation myocardial infarction (NSTEMI), correlation of ischemic ECG abnormalities with the affected coronary territory has not been well-established. We sought to investigate the correlation of electrocardiographic abnormalities with the location of 1-vessel obstructive coronary artery disease (CAD) in patients with both STEMI and NSTEMI.

METHODS

In this retrospective study, the charts of all patients referred for coronary angiography in 2012 were reviewed. Patients with a single obstructive coronary artery plus angina-equivalent symptoms and an elevated cardiac troponin I was included. Available ECGs were interpreted by an experienced cardiologist (WSA) blinded to the result of angiography. Patients with complete bundle branch block or ventricular pacing were excluded. Ischemic ECG changes were correlated to a coronary territory based on predefined criteria.

RESULTS

Of 131 included patients (mean age 64±13 years; 74% male), 29 had STEMI and 102 had NSTEMI. Eleven of 11 patients (100%) with anterior STEMI had left anterior descending artery (LAD) obstructive CAD. Of 18 patients with inferior STEMI, 14 (78%) had right coronary artery (RCA) obstructive CAD, 3 (17%) had left circumflex artery (LCX) artery obstructive CAD, and 1 (5%) had LAD obstructive CAD. Of 102 NSTEMI patients, 53 (52%) had definite ECG ischemic abnormalities. Of 31 patients with anterior definite ECG ischemic abnormalities, 30 (97%) had LAD obstructive CAD, and 1 (3%) had RCA obstructive CAD. Of 22 patients with inferior definite ECG ischemic abnormalities, 14 (64%) had RCA obstructive CAD, 5 (23%) had LCX obstructive CAD, and 3 (14%) had LAD obstructive CAD.

CONCLUSIONS

Patients with anterior STEMI had LAD obstructive CAD. Patients with inferior STEMI were highly likely to have RCA or LCX obstructive CAD. Only half of NSTEMI patients had definite ischemic ECG abnormalities. When present, anterior ischemic ECG changes in patients with single vessel CAD with NSTEMI were predictive of LAD obstructive CAD.

Exercise capacity as an independent risk factor for adverse cardiovascular outcomes among nondiabetic and diabetic patients

INTRODUCTION

To investigate if decreased exercise capacity is an independent risk factor for major adverse cardiovascular events (MACE) in diabetics and nondiabetics.

MATERIAL AND METHODS

The association of decreased exercise capacity (EC) during a treadmill exercise sestamibi stress test with MACE was investigated in 490 nondiabetics and 404 diabetics. Mean follow-up was 53 months.

RESULTS

Nondiabetics with a predicted EC < 85% had a higher prevalence of myocardial ischemia (34% vs. 19%, p = 0.0002), 2- or 3-vessel obstructive coronary artery disease (CAD) (31% vs. 13%, p = 0.016), myocardial infarction (MI) (17% vs. 7%, p = 0.0005), stroke (8% vs. 2%, p = 0.002), death (11% vs. 3%, p = 0.0002), and MI or stroke or death at follow-up (32% vs. 11%, p < 0.001) compared to nondiabetics with a predicted EC ≥ 85%. Diabetics with a predicted EC < 85% had a higher prevalence of myocardial ischemia (48% vs. 32%, p = 0.0009), 2- or 3-vessel obstructive CAD (54% vs. 28%, p = 0.001), MI (32% vs. 14%, p < 0.001), stroke (22% vs. 6%, p < 0.001), death (17% vs. 9%, p = 0.031), and MI or stroke or death at follow-up (65% vs. 27%, p < 0.001). Stepwise Cox regression analysis showed decreased EC was an independent and significant risk factor for MACE among nondiabetics (hazard ratio 3.3, p < 0.0001) and diabetics (hazard ratio 2.7, p < 0.0001).

CONCLUSIONS

Diabetics and nondiabetics with decreased EC were at increased risk for MACE with nondiabetics and decreased EC at similar risk as diabetics with normal EC.

Pericardial synovial sarcoma: challenges in diagnosis and management

INTRODUCTION

Pericardial synovial sarcoma is an extremely rare tumor with poor prognosis. Timely diagnosis and aggressive multimodal management improves patient outcome. We present our experience of diagnosis and management of a young patient with monophasic synovial sarcoma arising from pericardium.

CASE

A 27-year-old man presented with dyspnea and cough of three weeks duration. Examination revealed sinus tachycardia, distant heart sounds and elevated jugular venous pressure. Chest X-ray showed widened mediastinum. Transthoracic echocardiogram (TTE) noted large pericardial effusion with tamponade physiology. Therapeutic pericardiocentesis yielded hemorrhagic fluid. Computed tomography (CT) of the chest showed persistent pericardial effusion and a left anterior mediastinal mass. Left anterior thoracotomy, pericardial window and left anterior mediastinotomy were done, revealing a well-encapsulated gelatinous tumor originating from the pericardium. Histology and immunohistochemical profile showed the tumor to be a monophasic synovial sarcoma. Fluorescent in-situ hybridization (FISH) was positive for SS18 (SYT) gene rearrangement on chromosome 18q11, substantiating the diagnosis. Work-up for metastases was negative. Neo-adjuvant chemotherapy with high dose ifosfamide led to substantial reduction in the size of the tumor. The patient underwent surgical resection and external beam radiation therapy (EBRT) post surgery. He had symptom-free survival for 8 months prior to local recurrence. This was managed with left lung upper lobectomy and follow-up chemotherapy with docetaxel. The patient is currently stable with an acceptable functional status.

CONCLUSION

In patients with pericardial effusions of unknown etiology, multiple modalities of cardiac imaging must be employed if there is suspicion of a pericardial mass. CT and magnetic resonance imaging (MRI) are useful to evaluate for pericardial thickening or masses in addition to TTE. Treatment of synovial sarcoma is not well established. Surgery is the cornerstone of treatment. In non-resectable tumors, aggressive neo-adjuvant chemotherapy with ifosfamide followed by surgical resection and EBRT may lead to improved outcome.

Management of pulmonary hypertension from left heart disease in candidates for orthotopic heart transplantation

Pulmonary hypertension in left heart disease (PH-LHD) commonly complicates prolonged heart failure (HF). When advanced, the PH becomes fixed or out of proportion and is associated with increased morbidity and mortality in patients undergoing orthotopic heart transplant (OHT). To date, the only recommended treatment of out of proportion PH is the treatment of the underlying HF by reducing the pulmonary capillary wedge pressure (PCWP) with medications and often along with use of mechanical circulatory support. Medical therapies typically used in the treatment of World Health Organization (WHO) group 1 pulmonary arterial hypertension (PAH) have been employed off-label in the setting of PH-LHD with varying efficacy and often negative outcomes. We will discuss the current standard of care including treating HF and use of mechanical circulatory support. In addition, we will review the studies published to date assessing the efficacy and safety of PAH medications in patients with PH-LHD being considered for OHT.

Postural Orthostatic Tachycardia Syndrome in COVID-19: A Contemporary Review of Mechanisms, Clinical Course and Management

The long-term implications of COVID-19 have garnered increasing interest in recent months, with Long-COVID impacting over 65 million individuals worldwide. Postural orthostatic tachycardia syndrome (POTS) has emerged as an important component of the Long-COVID umbrella, estimated to affect between 2 and 14% of survivors. POTS remains very challenging to diagnose and manage - this review aims to provide a brief overview of POTS as a whole and goes on to summarize the available literature pertaining to POTS in the setting of COVID-19. We provide a review of available clinical reports, outline proposed pathophysiological mechanisms and end with a brief note on management considerations.