Acute myocardial infarction in myeloproliferative neoplasms

Myeloproliferative neoplasms (MPNs) are a heterogeneous group of hematologic malignancies characterized by an abnormal proliferation of cells of the myeloid lineage. Affected individuals are at increased risk for cardiovascular and thrombotic events. Myocardial infarction (MI) may be one of the earliest clinical manifestations of MPNs or may be a thrombotic complication that develops during the natural course of the disease. In the present review, we examine the epidemiology, pathogenesis, clinical presentation, and management of MI in MPNs based on the available literature. Moreover, we review potential biomarkers that could mediate the MI-MPNs crosstalk, from classical biochemical tests, e.g., lactate dehydrogenase, creatine kinase and troponins, to pro-inflammatory cytokines, oxidative stress markers, and clonal hematopoiesis.

Evaluation of Uric Acid to Albumin Ratio as a Marker of Coronary Artery Disease Severity in Acute Coronary Syndrome: A Cross-Sectional Study

BACKGROUND

Coronary artery disease (CAD) is a widespread cause of morbidity and mortality. Serum uric acid, a mediator of endothelial dysfunction and inflammation in vascular disease, can increase the risk of atherosclerosis, contributing to CAD. As serum albumin inhibits platelet activation and aggregation, low levels of it can contribute to platelet-induced coronary artery stenosis. Limited studies have been conducted worldwide in evaluating the role of uric acid to albumin ratio (UAR) in predicting severity or poor outcomes in acute coronary syndrome (ACS) patients. This study was undertaken to assess the role of UAR as a predictor of CAD severity, which can facilitate the identification of high-risk patients.

METHODOLOGY

A hospital-based analytical cross-sectional study was conducted in an urban tertiary healthcare center for a period of two months between June and August of 2022. A total of 100 ACS patients were included in the study. The study population included patients above the age of 18 years diagnosed with ACS who underwent a coronary angiography. Coronary angiograms were used to diagnose the presence of CAD, and its severity was assessed using Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) scores (SS). The correlation of UAR with CAD severity using SS was studied and compared between three varieties of ACS: ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), and unstable angina (UA).

STATISTICS

Chi-squared tests were used to determine statistical significance for qualitative data. Independent t-tests were used to identify the mean difference between two quantitative variables. Receiver operating characteristic (ROC) curves were constructed for UAR and high SS. A comparison between UAR and neutrophil to lymphocyte ratio (NLR) as a predictor of disease severity was done. ROC and optimal cutoff points were chosen to calculate sensitivity, specificity, and positive and negative predictive values. Microsoft Excel (Microsoft, Redmond, WA, USA) and SPSS V22.0 (IBM Corp., Armonk, NY, USA) were used to analyze the data.

RESULTS

A total of 100 ACS patients were included in the study and divided into two groups on the basis of SS, with 74% showing low severity and 26% showing intermediate-high severity. There was a statistically significant difference found between older age and SS (p=0.017). Our study showed 74% (n=74) of the patients were male and 26% (n=26) were female. It also revealed that 75.7% (n=56) of the male patients were in the low-severity group, and 24.3% (n=18) of males were in the intermediate-high severity group. 69.2% (n=18) of the female patients were in the low-severity group, and 30.8% (n=8) were in the intermediate-high severity group. Of the 100 patients, 55% were diagnosed with STEMI, of which 69.1% were in the low-severity group, and 30.9% were in the intermediate-high severity group. Among all the patients 33% of the patients were diagnosed as NSTEMI, of which 72.7% were in the low-severity group, and 27.3% were in the intermediate-high severity group. Twelve percent of the patients were diagnosed with UA, and 100% of these patients were in the low-severity group. The mean UAR was 1.40 ± 0.38 in the low-severity group and 1.29 ± 0.46 in the intermediate-high severity group (p=0.22).

CONCLUSION

Our study yielded no statistically significant difference in UAR among varying severities of CAD.

Creation of a Rat Takotsubo Syndrome Model and Utilization of Machine Learning Algorithms for Screening Diagnostic Biomarkers

Introduction

Ferroptosis, a crucial type of programmed cell death, is directly linked to various cardiac disorders. However, the contribution of ferroptosis-related genes (FRGs) to Takotsubo syndrome (TTS) has not been completely understood.

Purpose

The objective of this study was to investigate the relationship between the FRGs and TTS.

Methods

TTS rat models were established by isoprenaline injection. Heart tissues were subsequently harvested for total RNA extraction and library construction. Transcriptome data wereobtained transcriptome data for TTS and FRGs from our laboratory, and sources such as the Ferroptosis Database (FerrDb) and the Gene Expression Omnibus Database (GEO). 57 differentially expressed FRGs (DE-FRGs) were discovered. The LASSO and SVM-RFE algorithms were employed to identify Enpp2, Pla2g6, Etv4, and Il1b as marker genes, and logistic regression was applied to construct a diagnostic model. The important genes were validated by real time PCR and the external dataset. Finally, the extent of immune infiltration was explored.

Results

Among the 57 genes, there were 36 up-regulated and 21 down-regulated genes that exhibited distinct expression patterns in the TTS and healthy control samples. Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis indicated that the enriched pathways were primarily associated with pathways of neurodegeneration-multiple disease, while Gene Ontology (GO) analysis revealed that these genes were primarily linked to cellular response to external stimuli, outer membrane functions, and ubiquitin protein ligase binding. After the identification of four marker genes as potentially effective biomarkers for TTS diagnosis, subsequent logistic regression modeling revealed a receiver operating characteristic curve (ROC) with an AUC of 1.0. The examination of immune cell infiltration showed significantly higher prevalence of activated CD4+ T cells, mast cells, etc., in TTS.

Conclusion

Our findings support the theoretical importance of ferroptosis in TTS, highlighting Enpp2, Pla2g6, Etv4, and Il1b as potential diagnostic and therapeutic biomarkers for TTS.

Disease-Related Knowledge and Need for Revision of Care for Patients with Atrial Fibrillation: A Cross Sectional Study

Purpose

To evaluate the disease-related knowledge of outpatients with atrial fibrillation (AF), and the relationship with health literacy and other background variables.

Patients and Methods

In this cross-sectional survey study, conducted in Iceland, patients with AF scheduled for an electrical cardioversion or AF catheter ablation were recruited from a hospital outpatient clinic. They completed the validated Atrial Fibrillation Knowledge Scale (AFKS), a 11-item instrument (with possible score 0-10, 10 being the best knowledge) which evaluates knowledge pertaining to AF in general, AF symptom detection and AF treatment. Health literacy was assessed with the 16 item European Health Literacy Survey Questionnaire (HLS-EU-Q) and patients answered questions about their background. Data was analysed with parametric tests.

Results

In total, 185 participants completed the questionnaire (mean age 63 ±10), 77% were male, 74% with previous electrical cardioversion and 76% were on non-vitamin K antagonist oral anticoagulants (NOAC) medication. The mean score on the AFKS was 6.5 (±1.8). The best knowledge was concerning oral anticoagulation therapy (96% answered correctly) and the least knowledge was regarding responses to AF episodes (17% answered correctly). Patients with sufficient health literacy (52%) had better knowledge of AF (M 6.8 ±1.7 vs M 6.3 ±1.9, p = 0.05). Age, educational level, health literacy and AF pattern explained 22% of the variance in AF knowledge.

Conclusion

Patients with AF have inadequate knowledge of their condition, potentially as a result of insufficient health literacy. AF knowledge may be improved using integrated management where patients are actively involved in the care and health literacy is considered in the provided patient education.

The Relationship Between C-reactive Protein Albumin Ratio and Long-Term Mortality in Patients With Acute Coronary Syndrome

Background Coronary artery disease (CAD) is one of the leading causes of death worldwide. CRP/albumin ratio is a sensitive indicator of inflammatory status. It has been shown that this parameter may be associated with poor short-term outcomes in CAD. In this study, we investigated the relationship between long-term mortality and the CRP/albumin ratio in patients with acute coronary syndromes (ACS). Material and methods This study was conducted on patients who applied to our hospital between January 2015 and December 2019 and were diagnosed with ACS. A total of 1689 patients were included in the study. Patients were divided into two groups according to mortality status, and long-term mortality predictors were investigated. Results The average follow-up period was 38.9±10.3 months. The mean age of the entire study group was 56.6±12.2 years, and 1440 (80.5%) of the patients were male. Comorbid diseases and blood parameters were significant between the two groups. In the regression analysis, creatine, hemoglobin, white blood cell count (WBC), neutrophil-lymphocyte ratio (NLR), and CRP albumin ratio (CAR) were found to be independent predictors. In the ROC analysis, it was observed that CAR had the best predictive value. Discussion An increased CAR level is an independent predictor of long-term mortality in ACS patients. It can be used in both short-term and long-term risk stratification for ACS patients.

Management and Anticoagulation Treatment of Non-Valvular Atrial Fibrillation in Elderly Patients: The Dali Study

Background

Non-valvular atrial fibrillation (NVAF) is associated with increased stroke in elderly populations, yet anticoagulant therapy is underutilized. We analyzed clinical characteristics and anticoagulation treatment rates of elderly NVAF patients hospitalized in Dali, China, to identify potential contributing factors.

Methods

We collected data for 155 elderly patients with NVAF aged ≥60 years, from July 01, 2020, to December 31, 2021. We analyzed the awareness rate, clinical characteristics, and anticoagulant treatment rate of atrial fibrillation (AF), and identified factors influencing treatment. Patients were followed up one year after discharge to assess vital status, cardiovascular events, and anticoagulation therapy status.

Results

Among 155 patients, 52.26% were female, and the average age was 75.77 years. The awareness rate of AF was 47.74% at admission, and only 21.94% received anticoagulant therapy. After discharge, the rate of anticoagulant therapy significantly increased to 70.97%, and 89.09% used new oral anticoagulants. Thromboembolic history and persistent AF predicted anticoagulant therapy at discharge, while male gender, previous bleeding history, and antiplatelet therapy predicted non-anticoagulant therapy. Out of 133 patients who completed a one-year follow-up, 23.31% died, 3.01% had strokes, and 3.01% experienced bleeding. Anticoagulant therapy decreased to 51.96% during the follow-up year.

Conclusion

Our findings highlight the low awareness rate and anticoagulant treatment rate, and high mortality among elderly NVAF patients in Dali. The development of comprehensive intervention strategies is critical to standardize AF management and improve prognosis.

Role of two-dimensional strain echocardiographic parameters in suspected acute coronary syndrome patients with initial non-diagnostic electrocardiogram and troponins: An observational study

INTRODUCTION

Diagnosis of acute coronary syndrome (ACS) is often challenging especially in presence of initial normal troponins and non-specific electrocardiogram. The index study aimed at determining the diagnostic value of strain echocardiography in patients with suspected ACS but with non-diagnostic electrocardiogram and echocardiography findings.

METHODS

The study was conducted on 42 patients with suspected ACS and non-diagnostic electrocardiograms, normal quantitative troponin-T levels, and left ventricular function. All patients underwent conventional and 2D-strain echocardiography followed by coronary angiography, within 24 h of admission. Patients with regional wall motion abnormalities (RWMA), valvular heart disease, suspected myocarditis, and past coronary artery disease (CAD) were excluded.

RESULTS

Amongst the global strains, the global circumferential strain (GCS) was significantly reduced (p = .014) amongst those with significant CAD on angiography as opposed to global longitudinal strain (GLS) which was similar in the two groups (p = .33). The GCS/GLS ratio was also significantly reduced in patients with significant CAD compared to those with normal/mild disease on coronary angiography (p = .025). Both the parameters had good accuracy in predicting significant CAD. GCS displayed a sensitivity of 80% and a specificity of 86% at an optimal cut-off 31.5% (AUROC: .93, 95% CI: .601-1.000; p = .03), and likewise GCS/GLS ratio had a sensitivity of 80% and a specificity and 86% at a cut-off of 1.89% (AUROC: .86, 95% CI: .592-1.000; p = .049). GLS and peak atrial longitudinal strain (PALS) did not differ significantly in patients with/without significant CAD (p = .32 and .58, respectively).

CONCLUSION

GCS and GCS/GLS ratio provides incremental value in comparison to GLS, PALS, and tissue Doppler indices (E/e') in patients with suspected ACS and non-diagnostic electrocardiogram and troponins. GCS at cut-off of >31.5% and GCS/GLS ratio >1.89 can reliably exclude patients with significant CAD in this setting.

The Effectiveness of Ablation Therapy for Atrial Fibrillation: A Systematic Review

It is expected that the prevalence of atrial fibrillation (AF), the most prevalent cardiac arrhythmia among people aged 65 to 85, would be mostly classified using the CHAS2DS2-VASc approach for anticoagulation therapy. A high number of people in the entire world will be living with AF by 2030. Long-term follow-up data are sparse, although radiofrequency catheter ablation (CA) for symptomatic AF patients has the potential to be a curative therapy. Although women are referred later and less often than men, the outcomes following ablation are comparable across both genders. Health-related quality of life suffers from AF, and patients often find themselves less active as a result of their condition. AF may have a wide variety of symptoms and signs from the clinic's point of view. Women are more likely to exhibit symptoms than men; one reason for this is that women have an average QT interval that is 10-20 milliseconds longer than men, which is more likely to exacerbate tachycardia symptoms. In search of medical databases for relevant medical literature, we looked at PubMed/Medline, the Cochrane Library, and Google Scholar. Ten publications were gathered after the papers were located, assessed, and qualifying criteria applied were used to select them. The finished articles were done to give an overview of the effectiveness of ablation therapy for AF. Some studies showed that there was no statistical significance between invasive and pharmacological treatments. Other research found no difference in the recurrence of atrial arrhythmia between pulmonary vein isolation (PVI) CA alone and PVI + enhancement magnetic resonance imaging (MRI)-guided fibrosis ablation in individuals with persistent AF. The oldest individuals in studies comparing CA to medical treatment for AF demonstrated no improvement in prognosis after CA. Also, complications from therapy and CA's efficacy in preventing future atrial arrhythmias were similarly low across all age groups. Based on the above, we concluded that more studies are required to establish the most effective approach to treating AF to apply it in daily practice and gain more knowledge about it.

Takotsubo Cardiomyopathy Following COVID-19 Vaccine Booster Dose: A Case Report

Although the efficacy and safety of the coronavirus disease 2019 (COVID-19) vaccine have been established, side effects and adverse events related to the COVID-19 vaccine are still coming out. COVID-19 vaccine also has the potential to cause acute and long-term cardiovascular effects, which include myocarditis, pericarditis, myopericarditis, myocardial infarction, pulmonary embolism, thrombotic thrombocytopenia, and pulmonary hemorrhage. Although uncommon, takotsubo cardiomyopathy (TCM) has also been reported following COVID-19 vaccination. We report a case of TCM following the COVID-19 vaccine in a 59-year-old female who presented with intermittent chest pain and dyspnea following the COVID-19 vaccine booster dose. She had no identifiable triggers for TCM, no risk factors for cardiovascular disease, and normal cardiac enzyme levels, ruling out other causes of cardiac dysfunction. The diagnosis of TCM was supported by imaging findings and the absence of obstructive or thrombotic lesions on angiography.

Spontaneous tumor lysis syndrome in patients with solid tumors: a scoping review of the literature

No systematic synthesis of all cases of spontaneous tumor lysis syndrome (STLS) in adult patients with solid tumors is available to date. Herein, we aim to recognize specific STLS characteristics and parameters related to a worse prognosis. We conducted a systematic search for randomized controlled trials, cohorts, case-control studies, and case reports. The primary endpoints were death and the need for renal replacement therapy (RRT) due to STLS. We estimated crude odds ratios (ORs) with 95% confidence intervals (95%CI) via univariate binary logistic regression. We included one cohort of 9 patients and 66 case reports of 71 patients [lung cancer 15(21.1%)]. Regarding the case reports, most patients [61(87.1%)] had metastatic disease [liver 46(75.4%)], developed acute kidney injury [59(83.1%)], needed RRT [25(37.3%)], and died due to STLS [36(55.4%)]. Metastatic disease, especially in the liver [p = 0.035; OR (95%CI): 9.88 (1.09, 89.29)] or lungs [p = 0.024; 14.00 (1.37, 142.89)], was significantly associated with STLS-related death compared to no metastasis. Cases resulting in death had a significantly higher probability of receiving rasburicase monotherapy than receiving no urate-lowering agents [p = 0.034; 5.33 (1.09, 26.61)], or the allopurinol-rasburicase combination [p = 0.023; 7.47 (1.40, 39.84)]. Patients receiving allopurinol were less likely to need RRT compared to those not receiving it or those receiving rasburicase. In conclusion, current anecdotal evidence demonstrated that metastatic disease, especially in the liver and lungs, may be associated with STLS-related death compared to no metastatic status. Careful surveillance of high-risk cases within larger studies is essential to identify markers predicting morbidity or mortality.

Vascular protection with rivaroxaban in the comprehensive management of atrial fibrillation

INTRODUCTION

In addition to an increased risk of thromboembolic complications, patients with atrial fibrillation (AF) are at risk for vascular events. Consequently, complete vascular protection is warranted in these patients.

AREAS COVERED

A narrative search was conducted on PubMed (MEDLINE), using the MeSH terms [Rivaroxaban] + [Atrial fibrillation] + [Cardiovascular] + [Vascular] + [Treatment]. Original data from clinical trials, prospective and retrospective studies, useful reviews and experimental studies, were selected.

EXPERT OPINION

The ROCKET-AF trial showed that rivaroxaban is effective in reducing the risk of stroke, with a lower risk of fatal and intracranial bleeding compared to warfarin. Remarkably, experimental data have provided a number of pathogenic mechanisms through which rivaroxaban could provide beneficial vascular properties beyond its antithrombotic activity. Moreover, in the AF population, additional to its ability to reduce the risk of thromboembolic complications, rivaroxaban is associated with a lower risk of myocardial infarction, major adverse cardiac and limb events, and vascular mortality in patients with diabetes, also attenuating renal impairment during follow-up. These findings suggest that rivaroxaban may provide a comprehensive vascular protection in patients with AF.

Ultra-thin everolimus-eluting stents in atherosclerotic lesions: Three years follow-up with subgroup analysis of ultra-long stents

OBJECTIVES

To assess the long-term (3 years) safety and efficacy of Tetrilimus everolimus-eluting stent (EES) and subgroup analysis of outcomes of ultra-long (44/48 mm) Tetrilimus EES implantation in patients with long coronary lesions.

MATERIAL AND METHODS

In this observational, single-centre, single-arm, investigator-initiated registry, 558 patients who underwent implantation of Tetrilimus EES for the treatment of coronary artery disease were retrospectively included. The primary endpoint was occurrence of any major adverse cardiac event (MACE) at 12 months follow-up (composite of cardiac death, myocardial infarction [MI], and target lesion revascularization [TLR]) and we hereby report 3 years follow-up data. Stent thrombosis was assessed as a safety endpoint. A subgroup analysis of patients with long coronary lesions is also reported.

RESULTS

A total of 558 patients (57.0 ± 10.2 years) received 766 Tetrilimus EES (1.3 ± 0.5 stents/patient) to treat 695 coronary lesions. In subgroup analysis of 143 patients implanted with ultra-long EES, 155 lesions were intervened successfully with only one Tetrilimus EES (44/48 mm) implanted per lesion. At 3 years, event rates of 9.1% MACE with predominance of MI (4.4%), followed by 2.9% TLR and 1.7% cardiac death, and only 1.0% stent thrombosis were reported in overall population, while in a subgroup of patients implanted with ultra-long EES, 10.4% MACE and 1.5% stent thrombosis were reported.

CONCLUSIONS

Three years clinical outcomes showed favourable long-term safety and excellent performance of Tetrilimus EES in high-risk patients and complex coronary lesions in routine clinical practice, including a subgroup of patients with long coronary lesions, with acceptable primary and safety endpoints.

Refractory Arrhythmias as a Potential Indicator of Underlying Cardiac Amyloidosis: A Case Report

Primary (AL) amyloidosis is a rare multisystemic disorder that occurs approximately in 9.7-14.0 cases per million per year in the United States. A late diagnosis of amyloidosis can decrease the chance of survival to less than three years. With the intention to diagnose future cases of AL amyloidosis early in clinical presentation, we describe a case of a 64-year-old female who had presented to the hospital for a pre-liver transplant workup for presumed end-stage liver disease secondary to nonalcoholic steatohepatitis (NASH). Pre-transplant electrocardiogram (ECG) findings were significant for atrial fibrillation that was unable to resolve with synchronized cardioversion. Two previous cardioversions attempted in the preceding three years with amiodarone proved unsuccessful. Following her ECG, an endoscopy and colonoscopy were completed that demonstrated a lesion within the gastric mucosa along with two polyps in the transverse colon and ascending colon. Pathology for these lesions revealed amyloidosis in all biopsy sites, which was followed by a bone marrow biopsy also confirming AL amyloidosis and proliferative monoclonal B lymphocytes. A cardiac magnetic resonance imaging (MRI) proceeded to gather more information on the systemic extent of the patient's amyloidosis, which showed signs consistent with cardiac infiltration of amyloid. The patient was discharged with at-home hospice care and later decided to pursue chemotherapy, ultimately expiring from end organ failure. We conclude that failed cardioversion in a patient with persistent atrial fibrillation can be a clinical and diagnostic marker in suspecting a diagnosis of amyloidosis. Thus, we encourage clinicians to consider systemic amyloidosis in the assessment of unsuccessful cardioversion in these patient presentations for the initiation of treatment early on in the disease course.

An Audit of Iron Deficiency in Hospitalised Heart Failure Patients: A Commonly Neglected Comorbidity

Introduction Iron deficiency (ID) is a common comorbidity in patients with heart failure (HF) and can significantly impact morbidity and mortality, regardless of the presence of anaemia. Aim This audit aimed to assess the current practice in diagnosing and assessing iron deficiency (ID) in hospitalised patients with heart failure and reduced ejection fraction (HFrEF). The primary goal was to determine the prevalence of ID in HF patients and the frequency of iron testing in those patients. Additionally, the secondary aims included evaluating the presence of anaemia, the length of hospital stay, and the adequacy of appropriate management for iron deficiency in this patient population. Methods A retrospective audit was conducted, reviewing data from patients admitted to St. Vincent University Hospital over a period of 4 months. Results Out of the 111 patients audited, only 74% (82) had their iron status checked, and among those tested, 63% (52) met the criteria for iron deficiency according to the European Society of Cardiology (ESC). Additionally, 54% (28) of iron-deficient patients were also anaemic. Iron replacement was administered to 34 out of the 52 patients diagnosed with iron deficiency, accounting for 65% of the identified cases. The average duration of hospital stay for patients with iron deficiency was 13.8 days, while those without iron deficiency had a shorter mean length of stay of 11.2 days. However, it is important to note that the presence of co-morbidities and other confounding factors might have influenced these results. Conclusion Despite guideline recommendations, iron deficiency remains under-recognised and undertreated in clinical practice among heart failure patients. There is a crucial need for increased awareness, education, and practical guidance to improve the screening, diagnosis, and management of iron deficiency in hospitalised heart failure patients.

Should atrial fibrillation be considered a vascular disease? The need for a comprehensive vascular approach

INTRODUCTION

Atrial fibrillation (AF) cannot be considered an isolated disease. Patients with AF should be managed using a comprehensive approach that is not limited to stroke prevention.

AREAS COVERED

In this manuscript, the potential role of AF as a vascular disease that is managed as part of a holistic approach was reviewed.

EXPERT OPINION

The residual risk of stroke in patients with AF reaches 1-2% annually, despite appropriate anticoagulation therapy. Additionally, patients with AF may develop cognitive impairment through stroke-independent pathways. Furthermore, patients with AF may have a higher risk of developing atherosclerotic vascular disease in various vascular beds and chronic kidney disease; conversely, patients with atherosclerotic disease may have an increased risk of developing AF. AF should be considered a truly systemic vascular disease, since it brings together several hemodynamic and systemic changes, including inflammation, oxidative stress, activation of the renin-angiotensin-aldosterone and sympathetic systems, as well as a prothrombotic state and endothelial dysfunction. In this regard, patients with AF should be treated based on a holistic approach that is not limited to oral anticoagulation but includes complete vascular protection.

When a Tooth Pulls the Heart Strings: Takotsubo Cardiomyopathy Post-dental Extraction

Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy, is a temporary left ventricular dysfunction caused by a catecholamine surge under severe stress. It's characterized by chest pain, non-specific ECG changes, and left ventricular apical ballooning observed during catheterization. We present a case of a 59-year-old postmenopausal female with a past medical history of asthma who arrived at the ED complaining of chest pain following dental extraction. The patient's abnormal ECG findings and elevated cardiac enzymes required cardiac catheterization, which revealed normal coronary vasculature but demonstrated left ventricular apical ballooning. Transthoracic echocardiogram (TTE) showed septal left ventricular hypertrophy, decreased ejection fraction (EF), and akinetic segments consistent with takotsubo cardiomyopathy. Secondary takotsubo cardiomyopathy induced by stress in the setting of dental procedures like a tooth extraction for a periapical dental abscess is rarely described in the literature. Our case serves as a reminder of the potential for stress-induced cardiomyopathy in postmenopausal women, especially those with undiagnosed underlying anxiety disorders, even following minimally invasive procedures.

Biventricular Takotsubo Cardiomyopathy as an Unusual Presentation of SARS-CoV-2 mRNA Vaccine-Associated Multisystemic Inflammatory Syndrome

Biventricular takotsubo cardiomyopathy (BiTCM) is a rare entity, seldom reported. We describe a case of a female presenting with multisystemic inflammatory syndrome associated with the administration of a vaccine against coronavirus disease 2019 (COVID-19). In this particular case, the patient experienced the onset of symptoms shortly after receiving a COVID-19 vaccine. Early recognition of biventricular takotsubo cardiomyopathy and timely initiation of appropriate treatment are crucial. Prompt management includes stabilizing the patient's hemodynamic status, alleviating symptoms, and addressing any underlying causes, such as inflammation or immune-related responses. Close clinical surveillance is necessary to monitor the patient's cardiac function, assess response to treatment, and prevent potential complications.

Takotsubo syndrome and its linkage to neuroendocrinological disorders: a case report

Takotsubo syndrome (TTS) is an increasingly diagnosed entity, however the underlying pathophysiological mechanisms and their clinical implications are incompletely understood. An 82-year-old female, diagnosed with pituitary apoplexy, presented with ECG abnormalities and hsTnI levels consistent with an acute coronary syndrome and therefore underwent urgent coronary angiography that showed no significant stenosis and apical ballooning at left ventricle angiogram and therefore a TTS diagnosis was made. Moreover, during catheterization a 20 s Torsade de Pointes was registered. TTS is an entity that can be triggered by numerous conditions. This case of TTS was linked to many neuroendocrinological disorders.

Albumin Is a Component of the Esterase Status of Human Blood Plasma

The esterase status of blood plasma can claim to be one of the universal markers of various diseases; therefore, it deserves attention when searching for markers of the severity of COVID-19 and other infectious and non-infectious pathologies. When analyzing the esterase status of blood plasma, the esterase activity of serum albumin, which is the major protein in the blood of mammals, should not be ignored. The purpose of this study is to expand understanding of the esterase status of blood plasma and to evaluate the relationship of the esterase status, which includes information on the amount and enzymatic activity of human serum albumin (HSA), with other biochemical parameters of human blood, using the example of surviving and deceased patients with confirmed COVID-19. In experiments in vitro and in silico, the activity of human plasma and pure HSA towards various substrates was studied, and the effect of various inhibitors on this activity was tested. Then, a comparative analysis of the esterase status and a number of basic biochemical parameters of the blood plasma of healthy subjects and patients with confirmed COVID-19 was performed. Statistically significant differences have been found in esterase status and biochemical indices (including albumin levels) between healthy subjects and patients with COVID-19, as well as between surviving and deceased patients. Additional evidence has been obtained for the importance of albumin as a diagnostic marker. Of particular interest is a new index, [Urea] × [MDA] × 1000/(BChEb × [ALB]), which in the group of deceased patients was 10 times higher than in the group of survivors and 26 times higher than the value in the group of apparently healthy elderly subjects.

Atrial Fibrillation and Chronic Coronary Ischemia: A Challenging Vicious Circle

Atrial fibrillation, the most frequent arrhythmia in clinical practice and chronic coronary syndrome, is one of the forms of coronary ischemia to have a strong dual relationship. Atrial fibrillation may accelerate atherosclerosis and may increase oxygen consumption in the myocardium, creating a mismatch between supply and demand, thus promoting the development or worsening of coronary ischemia. Chronic coronary syndrome alters the structure and function of gap junction proteins, affecting the conduction of action potential and leading to ischemic necrosis of cardiomyocytes and their replacement with fibrous tissue, in this way sustaining the focal ectopic activity in atrial myocardium. They have many risk factors in common, such as hypertension, obesity, type 2 diabetes mellitus, and dyslipidemia. It is vital for the prognosis of patients to break this vicious circle by controlling risk factors, drug therapies, of which antithrombotic therapy may sometimes be challenging in terms of prothrombotic and bleeding risk, and interventional therapies (revascularization and catheter ablation).

Acute Myocardial Infarction-Related Hospitalizations in Non-elderly Patients with Pneumonia: a Population-Based Study

The objective is to study factors that increase the likelihood of acute myocardial infarction (AMI) in hospitalized adult non-elderly patients with pneumonia compared to other medical inpatients and to understand the utilization rate of percutaneous coronary intervention (PCI) for AMI in inpatients with pneumonia and its related impact on hospitalization stay and cost. A population-based study was conducted using the Nationwide Inpatient Sample (NIS, 2019) with adult non-elderly inpatients (age 18-65 years) with a medical condition as their primary diagnosis and a co-diagnosis of pneumonia during hospitalization stay. This study sample was divided by the primary diagnosis of AMI versus other medical conditions (non-AMI). A logistic regression model was used to evaluate the odds ratio (OR) of predictors associated with AMI in patients with pneumonia. The results showed a direct relationship between increasing age and the likelihood of AMI in pneumonia inpatients with three times higher odds seen in 51-65 years of age (OR 2.95, 95% CI 2.82-3.09). The comorbidities included complicated hypertension (OR 2.84, 95% CI 2.78-2.89), diabetes with complications (OR 1.27, 95% CI 1.24-1.29), and drug abuse (OR 1.27, 95% CI 1.22-1.31) that increased the likelihood of AMI-related hospitalization. The utilization rate of surgical treatment (PCI) was 14.37% for the management of AMI in inpatients with pneumonia. Inpatients co-diagnosed with pneumonia and comorbidities such as hypertension and diabetes were more likely to be hospitalized for AMI. These at-risk patients should be considered for early risk stratification. Utilization of PCI was associated with a lower in-hospital mortality rate.

Addison's Disease: Diagnosis and Management Strategies

We aim to overview Addison's disease (AD) with regard to current diagnosis and management. This is a narrative review of full-length articles published in English between January 2022 and December 2022 (including online ahead of print versions) in PubMed-indexed journals. We included original studies in living humans regardless of the level of statistical significance starting from the key search terms "Addison's disease" or "primary adrenal insufficiency" in title or abstract. We excluded articles with secondary adrenal insufficiency. Briefly, 199 and 355 papers, respectively were identified; we manually checked each of them, excluded the duplicates, and then selected 129 based on their clinical relevance in order to address our 1-year analysis. We organized the data in different subsections covering all published aspects on the subject of AD. To our knowledge, this is the largest AD retrospective from 2022 on published data. A massive role of genetic diagnosis especially in pediatric cases is highlighted; the importance of both pediatric and adult awareness remains since unusual presentations continue to be described. COVID-19 infection is a strong player amid this third year of pandemic although we still not do have large cohorts in this particular matter as seen, for instance, in thyroid anomalies. In our opinion, the most important topic for research is immune checkpoint inhibitors, which cause a large panel of endocrine side effects, AD being one of them.

Epidemiology, Trends, Utilization Disparities, and Outcomes of Catheter Ablation and Its Association With Coronary Vasospasm Amongst Patients With Non-valvular Atrial Fibrillation: A Nationwide Burden of Last Decade

BACKGROUND

Catheter ablation (CA) is an important curative treatment for non-valvular atrial fibrillation (NVAF), however, nationwide data on its utilization and disparities is limited. Coronary vasospasm is a rare, life-threatening, peri-operative complication of CA with limited literature in Caucasians.

METHODS

We performed a retrospective study on adult hospitalizations in the USA from 2007 to 2017 by obtaining the data from National Inpatient Sample. The primary endpoints of our study were to identify the utilization rate of CA, disparities in utilization, and study the outcomes associated with CA. The secondary endpoints of the study were to identify the incidence of coronary vasospasm amongst patients who underwent CA, evaluate their association, and identify the predictors of coronary vasospasm.

RESULTS

From 35,906,946 patients with NVAF, 343641 (0.96%) underwent CA. Its utilization decreased from 1% in 2007 to 0.71% in 2017. Patients who underwent CA, compared to those without CA, fared better in terms of hospital length of stay, mortality rate, disability rate, and discharge to the non-home facility. Patients in the 50-75 years age group, Native Americans, those with private insurance, and median household income of 76-100th percentile were associated with higher odds of CA utilization. Urban teaching hospitals and large-bedded hospitals performed more ablations, while the Mid-West region fared lower than the South, the West, and the Northeast. The prevalence of coronary vasospasm was higher amongst CA in comparison without CA, however, in regression analysis, no significant association was demonstrated between CA and coronary vasospasm.

CONCLUSION

CA is an important treatment modality that is associated with improved clinical outcomes. Identification of factors associated with lower utilization of CA and its disparities will help to mitigate the burden associated with NVAF.

Transcatheter Closure of Atrial Septal Defect: A Review of Currently Used Devices

Over the past seven decades, significant advancements and innovations have occurred in the field of percutaneous atrial septal defect (ASD) closure using transcatheter-based devices. This article focuses on the current literature surrounding the three Food and Drug Administration (FDA)-approved devices for ASD and patent foramen ovale (PFO) closure in the United States, namely, the Amplatzer Septal Occluder (ASO), Amplatzer Cribriform Occluder, and Gore Cardioform ASD Occluder. The ASO has been widely used since its FDA approval in 2001. Studies have shown its high success rate in closing ASDs, especially small-sized defects. The RESPECT trial demonstrated that PFO closure using the ASO reduced the risk of recurrent ischemic stroke compared to medical therapy alone. The Closure of Atrial Septal Defects With the Amplatzer Septal Occluder Post-Approval Study (ASD PMS II) evaluated the safety and effectiveness of ASO in a large cohort of patients, reporting a high closure success rate and rare hemodynamic compromise. The Amplatzer Cribriform Occluder is designed for the closure of multifenestrated ASDs and has shown promising results in small-scale studies. It successfully closed the majority of fenestrated ASDs, leading to improved right ventricular diastolic pressure without major complications. The REDUCE trial compared PFO closure using the Gore Helex Septal Occluder and Gore Cardioform Septal Occluder with antiplatelet therapy alone. The study demonstrated that PFO closure significantly reduced the risk of recurrent stroke and brain infarction compared to antiplatelet therapy alone. However, the closure group had a higher incidence of atrial fibrillation or atrial flutter. There is a risk of atrial fibrillation with the use of ASO as well. The FDA-approved Gore Cardioform ASD Occluder showed excellent performance in the ASSURED clinical study. The device achieved high technical success and closure rates, with low rates of serious adverse events and device-related complications. A meta-analysis comparing transcatheter ASD closure with surgical closure revealed that the transcatheter approach had a high success rate, lower rates of adverse events, and shorter hospital stays compared to surgery, without any mortality. Complications associated with transcatheter ASD closure have been reported, including femoral arteriovenous fistulas, device embolization, cardiac erosion, aortic incompetence, and new-onset migraine. However, these complications are relatively rare. In conclusion, transcatheter ASD closure using FDA-approved devices has proven to be safe and effective in the majority of cases. These devices offer excellent closure rates, reduced risk of recurrent stroke, and shorter hospital stays compared to surgery. However, careful patient selection and follow-up are necessary to minimize complications and ensure optimal outcomes.

Takotsubo Cardiomyopathy Triggered by Acute Intermittent Porphyria

Background Takotsubo cardiomyopathy (TC) is a reversible condition characterized by myocardial akinesis due to catecholamine-mediated myocardial stunning. Acute intermittent porphyria (AIP) is associated with a rise in catecholamine, which could trigger TC. This study aims to evaluate patients with porphyria-triggered TC. Methods Data from the National Inpatient Sample (NIS) was used to study the prevalence rate and clinical outcome of porphyria-triggered TC among patients with TC. Results Overall, 32,500 cases were admitted between 2012 and 2016 with TC. The rates of smoking, hypertension, hyperlipidemia, and diabetes mellitus were 28%, 54%, 45%, and 23%, respectively. Six and three percent had cardiogenic shock and cardiac arrest, respectively. The overall inpatient mortality was 5.4%. Out of 32,500 patients with takotsubo cardiomyopathy, only three of these cases were found to have porphyria. Patients with porphyria were not significantly different in the baseline health characteristics from patients without porphyria. Additionally, there were no significant differences in the inpatient clinical outcomes between patients with porphyria vs. patients without porphyria.  Conclusion TC triggered by porphyria is a rare disease. Patients with this disease have an excellent short-term prognosis. Beta-blocker medications might be effective in these patients to reduce the risk of recurrence. Further prospective studies are needed to test the effectiveness of beta-blocker in reducing the recurrence of TC.

Atrial fibrillation and coronary artery disease: An integrative review focusing on therapeutic implications of this relationship

The incidence of both atrial fibrillation (AF) and coronary artery disease (CAD) increases with advancing age. They share common risk factors and very often coexist. Evidence points to an intricate relationship between atrial tissue excitability and neuronal remodeling with ischemia at the microcirculatory level. In this review, we delineated this complex relationship, identified a common theme between the two, and discussed how the knowledge of this relationship translates into a positive and meaningful impact in patient management. Recent research indicates a high prevalence of CAD among AF patients undergoing coronary angiography. Further, the incidence of AF is much higher in those suffering from CAD compared to age-matched adults without CAD underlying this reciprocal relationship. CAD adversely affects AF by promoting progression via re-entry and increasing excitability of atrial tissue as a result of ischemia and electrical inhomogeneity. AF in turn accelerates atherosclerosis via endothelial dysfunctional and inflammation and together with enhanced thrombogenicity and hypercoagulability contribute to micro and macrothrombi throughout cardiovascular system. In a nutshell, the two form a vicious cycle wherein one disease promotes the other. Most AF recommendations focuses on rate/rhythm control and prevention of thromboembolism. Very few studies have discussed the importance of unmasking coexistent CAD and how the treatment of underlying ischemia will impact the burden of AF in these patients. Inflammation and endothelial dysfunction remain central to both disease processes and form a handsome therapeutic target in the management of the two diseases. The relationship between AF and CAD is complex and much more than mere coincidence. The two diseases share common risk factor and pathophysiology. Hence, it is impractical to treat them in isolation. Accordingly, we share the implications of managing underlying ischemia and inflammation to positively impact and improve quality of life among AF patients.

Prevalence and predictors of lower extremity atherosclerotic disease amongst high-risk patients using ankle brachial index

INTRODUCTION

The prevalence of lower extremity artery disease (LEAD) continues to increase worldwide. This is expected to translate into logarithmic rise in lower-limb amputations especially in the developing world. Majority of patients suffering from LEAD remain asymptomatic until late and are vulnerable to limb-threatening complications unless actively screened and treated.

METHODS

This was a prospective, single-center, observational study to determine the prevalence and predictors of LEAD. Patients with known atherosclerotic vascular disease (but not known LEAD) or those at risk were enrolled. All underwent ankle brachial index (ABI) measurement as per the standard protocol. A threshold of ABI ≤0.90 was taken to diagnose LEAD.

RESULTS

A total of 1000 patients were enrolled. The mean age of the group was 61.4 ± 10.0 years and the prevalence of LEAD was 10.2%. Amongst those who had LEAD, the majority of patients (69.6%) had no symptoms. The prevalence of LEAD in diabetic population in our study was 13.2% and it was 30.9% in coronary artery disease patients . Factors independently linked to LEAD on regression analysis included advanced age, presence of diabetes, smoking history, lower serum HDL and a lower ejection fraction.

CONCLUSIONS

The vast majority of patients suffering from LEAD are asymptomatic. Early diagnoses and institution of appropriate medical and physical therapy can prevent excess morbidity and mortality due to LEAD. Factors independently linked to LEAD are advanced age, presence of diabetes, smoking history, lower serum HDL and a lower ejection fraction. The presence of either of these should signal undertaking of appropriate steps to unmask underlying LEAD.

Novel markers of COVID-19 mortality-A comparative study with patients of acute coronary syndrome

BACKGROUND

COVID-19 can cause severe pneumonia that can progress to multiple organ failure. It is believed that dysregulation of inflammation and cytokine storm, contributes to severe COVID-19. As inflammatory mediators play an important role in the pathogenesis of the severe disease, inflammatory markers like fever, leucocytosis, and C-reactive protein are known to predict severe disease. Various other biomarkers have been known to have prognostic value in patients with COVID-19 infection. Inflammation, both local and systemic plays an important role in the pathogenesis of acute coronary syndrome (ACS). Thus in this study, we aimed to compare and describe the various biomarkers, and mortality between patients admitted with COVID-19 infection and ACS patients without COVID-19 infection.

METHODS

In a retrospective observational case-control study, a total of 108 patients admitted to our hospital during the month of May 2021 with COVID-19 were enrolled. Patients of the acute coronary syndrome (tested negative for COVID-19 infection) admitted during the same month were enrolled (including both the intensive care unit and ward) as controls.

RESULTS

The median age of patients with COVID was significantly lower than that of patients with acute coronary syndrome [49 years (IQR, 36-62 years) and 60 years (IQR, 52-66 years)]. Left ventricular ejection fraction was significantly higher among patients with COVID infection (58.5 ± 6.3% versus 36.9 ± 9.3%). The total leukocyte count was significantly higher among patients with COVID-19 compared to those with acute coronary syndrome [13200 per microliter (8625-17500) vs 9800 per microliter (8150-12150), P < 0.001]. The blood urea level was significantly higher among patients with COVID infection [52.5 (IQR, 34.7-81.5) versus 20 (IQR, 16-31)]. Levels of C-reactive protein were significantly higher among patients with COVID [39 (IQR, 7.7-100) versus 2 (1.4-3.5)]. The mortality of patients hospitalized with COVID was 4 times higher than those with acute coronary syndrome [25.9% (28) versus 6.1% (6)]. Survivors of COVID-19 had higher hemoglobin levels than those who did not [12.5 g/dLvs 11.5 g/dL, P = 0.03].

CONCLUSIONS

Elevated total leukocyte counts reflect underlying secondary bacterial infection among patients with COVID-19 and help initiate appropriate antibiotics. Depletion of intravascular volume reflected by an increased urea/creatinine ratio increases the risk of mortality and warrants aggressive measures of rehydration and albumin infusion.

Therapy of Patients with Cardiac Malposition

Positional abnormalities per se do not require treatment, but in their place, the accompanying pulmonary pathology in dextroposition patients and pathophysiologic hemodynamic abnormalities resulting from multiple defects in patients with cardiac malposition should be the focus of treatment. At the time of the first presentation, treating the pathophysiologic aberrations caused by the defect complex, whether it is by improving the pulmonary blood flow or restricting it, is the first step. Some patients with simpler or single defects are amenable to surgical or transcatheter therapy and should be treated accordingly. Other associated defects should also be treated appropriately. Biventricular or univentricular repair dependent on the patient's cardiac structure should be planned. Complications in-between Fontan stages and after conclusion of Fontan surgery may occur and should be promptly diagnosed and addressed accordingly. Several other cardiac abnormalities unrelated to the initially identified heart defects may manifest in adulthood, and they should also be treated.

Fractional flow reserve and non-hyperemic indices: Essential tools for percutaneous coronary interventions

Hemodynamical evaluation of a coronary artery lesion is an important diagnostic step to assess its functional impact. Fractional flow reserve (FFR) received a class IA recommendation from the European Society of Cardiology for the assessment of angiographically moderate stenosis. FFR evaluation of coronary artery disease offers improvement of the therapeutic strategy, deferring unnecessary procedures for lesions with a FFR > 0.8, improving patients' management and clinical outcome. Post intervention, an optimal FFR > 0.9 post stenting should be reached and > 0.8 post drug eluting balloons. Non-hyperemic pressure ratio measurements have been validated in previous studies with a common threshold of 0.89. They might overestimate the hemodynamic significance of some lesions but remain useful whenever hyperemic agents are contraindicated. FFR remains the gold standard reference for invasive assessment of ischemia. We illustrate this review with two cases introducing the possibility to estimate also non-invasively FFR from reconstructed 3-D angiograms by quantitative flow ratio. We conclude introducing a hybrid approach to intermediate lesions (DFR 0.85-0.95) potentially maximizing clinical decision from all measurements.

The Coronavirus Double Threat: A Rare Presentation of Chest Pain in a Young Female

Severe acute respiratory syndrome coronavirus 2 (SARS-COV 2) led to global coronavirus disease 2019 (COVID-19) pandemic. The virus affects the respiratory system predominantly and has resulted in multiorgan complications. Myocarditis, acute coronary syndrome (ACS), cardiogenic shock, and sudden cardiac death were common cardiac manifestations of COVID-19. Spontaneous coronary artery dissection (SCAD) is a rare form of coronary artery disease that is previously reported in patients with COVID-19. SCAD usually occurs in a middle-aged woman with few or without any cardiovascular risk factors. The gold standard for its diagnosis is coronary angiography. The SCAD treatment recommendations depend on the hemodynamic status: conservative therapy in hemodynamically stable SCAD patients and urgent revascularization in hemodynamically unstable SCAD patients. The exact pathophysiology of COVID-19 associated with SCAD is unknown. It is considered a combination of systemic inflammatory response and localized vascular inflammation. The case reported is of COVID-19-associated SCAD in a patient with no history of cardiovascular disease later complicated by the transient ischemic attack (TIA) and left ventricular (LV) thrombus.

Multimodality Imaging for Diagnosing Transthyretin Cardiac Amyloidosis

Amyloidosis is the result of the extracellular deposition of amyloid in various organs. Common types are light-chain and transthyretin amyloidosis. Cardiac amyloidosis (CA) is a restrictive cardiomyopathy caused by amyloid infiltration in cardiac tissues. The detection of CA is increasing with the advent of easily accessible imaging modalities. Early diagnosis ensures a better prognosis. We present a case of cardiac amyloidosis, diagnosed from specific imaging findings on cardiac magnetic resonance imaging and more precisely as transthyretin type based on findings on nuclear scintigraphy.

Neurocysticercosis-related Seizures: Imaging Biomarkers

Neurocysticercosis (NCC)-a parasitic CNS infection endemic to developing nations-has been called the leading global cause of acquired epilepsy yet remains understudied. It is currently unknown why a large proportion of patients develop recurrent seizures, often following the presentation of acute seizures. Furthermore, the presentation of NCC is heterogenous and the features that predispose to the development of an epileptogenic state remain uncertain. Perilesional factors (such as oedema and gliosis) have been implicated in NCC-related ictogenesis, but the effects of cystic factors, including lesion load and location, seem not to play a role in the development of habitual epilepsy. In addition, the cytotoxic consequences of the cyst's degenerative stages are varied and the majority of research, relying on retrospective data, lacks the necessary specificity to distinguish between acute symptomatic and unprovoked seizures. Previous research has established that epileptogenesis can be the consequence of abnormal network connectivity, and some imaging studies have suggested that a causative link may exist between NCC and aberrant network organisation. In wider epilepsy research, network approaches have been widely adopted; studies benefiting predominantly from the rich, multimodal data provided by advanced MRI methods are at the forefront of the field. Quantitative MRI approaches have the potential to elucidate the lesser-understood epileptogenic mechanisms of NCC. This review will summarise the current understanding of the relationship between NCC and epilepsy, with a focus on MRI methodologies. In addition, network neuroscience approaches with putative value will be highlighted, drawing from current imaging trends in epilepsy research.

Stacked machine learning models to classify atrial disorders based on clinical ECG features: a method to predict early atrial fibrillation

OBJECTIVES

Atrial Tachycardia (AT) and Left Atrial Enlargement (LAE) are atrial diseases that are significant precursors to Atrial Fibrillation (AF). There are ML models for ECG classification; clinical features-based classification is required. The suggested work aims to create stacked ML models that categorize Sinus Rhythm (SR), Sinus Tachycardia (ST), AT, and LAE signals based on clinical parameters for AF prognosis.

METHODS

The classification was based on thirteen clinical parameters, such as amplitude, time domain ECG aspects, and P-Wave Indices (PWI), such as the ratio of P-wave length and amplitude ((P (ms)/P (µV)), P-wave area (µV*ms), and P-wave terminal force (PTFV1(µV*ms). Apart from classifying the ECG signals, the stacked ML models prioritized the clinical features using a pie formula-based technique.

RESULTS

The Stack 1 model achieves 99% accuracy, sensitivity, precision, and F1 score, while the Stack 2 model achieves 91%, 91%, 94%, and 92% for identifying SR, ST, LAE, and AT, respectively. Both stack models obtained a computational time of 0.06 seconds. PTFV1 (µV*ms), P (ms)/P (µV)), and P-wave area (µV*ms) were ranked as crucial clinical features.

CONCLUSION

Clinical feature-based stacking ML models may help doctors obtain insight into important clinical ECG aspects for early AF prediction.

Syncope in Aortic Stenosis: Not Always What It Seems

Aortic stenosis is a common valvular pathology and may also have atypical presentations outside the classic triad of chest pain, syncope, and shortness of breath. Some patients may not present with the symptoms of the triad. This patient instead presented with syncope and vomiting. Statistically, the most common cause of syncope at rest in the setting of aortic stenosis is due to an arrhythmia rather than the valve itself limiting cardiac output. In a comorbid Alzheimer's patient who has developed hyperorality, postprandial hypotension can also result in syncope at rest. Therefore, syncope at rest should raise alarm for nonvalvular etiologies such as arrhythmia. This case study also aims to establish an association between syncope at rest and hyperorality in the setting of aortic stenosis, a first study so far. Additionally, it highlights an unusual presentation of aortic stenosis where syncope occurs at rest associated with vomit in the absence of chest pain or shortness of breath.

Role of 3 Tesla Magnetic Resonance Imaging in the Assessment of Infiltrative Cardiomyopathies

BACKGROUND

The aim of the present study was to assess the role of 3 Tesla (3T) magnetic resonance imaging (MRI) in the assessment of infiltrative cardiomyopathy (ICM).

METHODS

Cardiac MRI was performed on a 3T MRI machine for 15 patients who had clinical or echocardiographic signs of infiltrative cardiomyopathy. Each scan was assessed on a set of anatomical and functional parameters. The patterns of left ventricular (LV) late gadolinium enhancement (LGE) were also analyzed.

RESULTS

Bi-atrial dilatation was noted in 14 patients, consistent with a restrictive phenotype. All 15 patients had diastolic dysfunction with reduced LV diastolic ventricular filling and prolonged peak filling times. Eleven patients had a decreased peak filling rate. Twelve patients had systolic dysfunction with reduced ejection fraction (EF). Ten patients had contractile dysfunction in the form of global LV hypokinesia. On delayed contrast imaging, four patients showed no abnormal LGE. Two patients showed diffuse subendocardial enhancement. Two patients showed patchy subendocardial enhancement. Six patients showed patchy mid-myocardial enhancement. One patient showed diffuse mid-myocardial enhancement. Three patients showed patchy subepicardial enhancement. Two patients showed patchy transmural enhancement. Three patients showed reversed myocardial nulling. All 15 patients received a provisional diagnosis of infiltrative cardiomyopathy on the basis of cardiac MRI findings. Sarcoidosis was given as a probable cause in four patients, amyloidosis in three patients, an infectious cause in two patients, and drug-induced cardiomyopathy in one patient. In five patients, no obvious cause could be identified.

CONCLUSION

Infiltrative cardiomyopathies, although relatively uncommon, pose significant challenges in diagnosis and treatment. Cardiac MRI has become the gold standard for non-invasive diagnosis of all infiltrative cardiomyopathies.

Reverse Takotsubo Cardiomyopathy in a Critically Ill Patient in the ICU: A Case Report With Literature Review

Takotsubo, or stress cardiomyopathy (SC), is described as a transient systolic dysfunction of the apical segments of the left ventricle mainly triggered by emotional or physical stress resembling the presentation of an acute coronary syndrome in the absence of obstructive coronary artery disease. Reverse Takotsubo SC is a rare variant of SC that presents with basal ballooning instead of apical ballooning seen in classic SC. We present a case of a 74-year-old male who was admitted to the ICU with septic shock. Laboratory test results showed elevated troponin. An echocardiogram showed reduced cardiac contractility and relative hypokinesis of the basal and mid segments compared to the apical segments, consistent with reverse Takotsubo SC, which recovered after 10 days. It can happen in critically ill patients in the ICU secondary to severe sepsis and could contribute to hemodynamic worsening, affecting the final clinical outcomes.

Shark Fin Electrocardiogram: A Deadly Electrocardiogram Pattern in Takotsubo Cardiomyopathy During 15 Years of Follow-Up

Takotsubo cardiomyopathy (TTC) or stress-induced cardiomyopathy is characterized by transient left ventricular apical ballooning in the absence of coronary occlusion. Although the underlying mechanism is still unknown, exaggerated sympathetic nervous system and catecholamine cardiotoxicity, followed by metabolic disturbance, and multi-vessel epicardial coronary artery vasospasm, are thought to be responsible for the development of this condition. TTC accounts for 1-2% of patients presenting with the acute coronary syndrome (ACS) with the majority of patients being postmenopausal women. Shark fin electrocardiogram (SFE) or triangular ST-segment elevation is an uncommon electrocardiogram (ECG) finding that is typically associated with an increased risk of ventricular fibrillation and cardiogenic shock, thus, it is considered a poor prognostic factor. We present a case of a 57-year-old postmenopausal female with TTC post-colonic perforation. Upon further investigation, an ECG revealed an SFE or triangular ST-segment elevation on the anterolateral leads, and an elevated serum troponin level was found. On trans-thoracic echocardiogram (TTE), hypokinesis and akinesis of the apex and left ventricular segments were observed with sparing of the basal segments. Eventually, the patient was successfully managed and monitored until regain of normal function.

Utility of short-term telemetry heart rhythm monitoring and CHA2DS2-VASc stratification in patients presenting with suspected cerebrovascular accident

BACKGROUND

Inpatient telemetry heart rhythm monitoring overuse has been linked to higher healthcare costs.

AIM

To evaluate if CHA2DS2-VASc score could be used to indicate if a patient admitted with possible cerebrovascular accident (CVA) or transient ischemic attack (TIA) requires inpatient telemetry monitoring.

METHODS

A total of 257 patients presenting with CVA or TIA and placed on telemetry monitoring were analyzed retrospectively. We investigated the utility of telemetry monitoring to diagnose atrial fibrillation/flutter and the CHA2DS2-VASc scoring tool to stratify the risk of having CVA/TIA in these patients.

RESULTS

In our study population, 63 (24.5%) of the patients with CVA/TIA and telemetry monitoring were determined to have no ischemic neurologic event. Of the 194 (75.5) patients that had a confirmed CVA/TIA, only 6 (2.3%) had an arrhythmia detected during their inpatient telemetry monitoring period. Individuals with a confirmed CVA/TIA had a statistically significant higher CHA2DS2-VASc score compared to individuals without an ischemic event (3.59 vs 2.61, P < 0.001).

CONCLUSION

Given the low percentage of inpatient arrhythmias identified, further research should focus on discretionary use of inpatient telemetry on higher risk patients to diagnose the arrhythmias commonly leading to CVA/TIA. A prospective study assessing event rate of CVA/TIA in patients with higher CHA2DS2-VASc score should be performed to validate the CHA2DS2-VASc score as a possible risk stratifying tool for patients at risk for CVA/TIA.

A Case of Spontaneous Multivessel Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is a non-traumatic separation of the epicardial coronary arterial wall leading to luminal obstruction with subsequent myocardial ischemia and infarction. Herein, we describe an interesting case of acute coronary syndrome due to multivessel SCAD without an underlying susceptibility or trigger, and review the literature for SCAD management.

Atrial Fibrillation and the Risk of Ventricular Arrhythmias and Cardiac Arrest: A Nationwide Population-Based Study

BACKGROUND

Atrial fibrillation (AF) has been linked to an increased risk of ventricular arrhythmias (VAs) and sudden death. We investigated this association in hospitalised patients in France.

METHODS

All hospitalised patients from 2013 were identified from the French National database and included if they had at least 5 years of follow-up data.

RESULTS

Overall, 3,381,472 patients were identified. After excluding 35,834 with a history of VAs and cardiac arrest, 3,345,638 patients were categorised into two groups: no AF (n = 3,033,412; mean age 57.2 ± 21.4; 54.3% female) and AF (n = 312,226; 78.1 ± 10.6; 44.0% female). Over a median follow-up period of 5.4 years (interquartile range (IQR) 5.0-5.8 years), the incidence (2.23%/year vs. 0.56%/year) and risk (hazard ratio (HR) 3.657 (95% confidence interval (CI) 3.604-3.711)) of VAs and cardiac arrest were significantly higher in AF patients compared to non-AF patients. This was still significant after adjusting for confounders, with a HR of 1.167 (95% CI 1.111-1.226) and in the 1:1 propensity score-matched analysis (n = 289,332 per group), with a HR of 1.339 (95% CI 1.313-1.366). In the mediation analysis, the odds of cardiac arrest were significantly mediated by AF-associated VAs, with an OR of 1.041 (95% CI 1.040-1.042).

CONCLUSION

In hospitalised French patients, AF was associated with an increased risk of VAs and sudden death.

Role of fibrinogen, albumin and fibrinogen to albumin ratio in determining angiographic severity and outcomes in acute coronary syndrome

BACKGROUND

Coronavirus disease 2019 (COVID-19) pandemic unmasked the huge deficit in healthcare resources worldwide. It highlighted the need for efficient risk stratification in management of cardiovascular emergencies.

AIM

To study the applicability of the old, available and affordable nonconventional biomarkers: albumin and fibrinogen in their ability to predict angiographic severity and clinical outcomes in patients with acute coronary syndrome (ACS).

METHODS

In this prospective, observational study, 166 consecutive patients with ACS were enrolled. Fibrinogen, albumin and their ratio were determined from serum. Patients with underlying chronic liver disease, active malignancy, autoimmune disease, active COVID-19 infection and undergoing thrombolysis were excluded.

RESULTS

Mean age of the population was 60.5 ± 1.5 years, 74.1% being males. ST elevation myocardial infarction (STEMI) was most common presentation of ACS seen in 57% patients. Fibrinogen albumin ratio (FAR) ≥ 19.2, had a sensitivity of 76.9% and specificity of 78.9 % [area under the receiver operating characteristic curves (AUROC) = 0.8, P = 0.001] to predict ≤ thrombolysis in myocardial infarction (TIMI) 1 flow in culprit artery in STEMI patients. Even in non-STEMI patients, FAR ≥ 18.85 predicted the same with 80% sensitivity and 63% specificity (AUROC = 0.715, P = 0.006).

CONCLUSION

Novel biomarkers, with their high cost, lack of availability and long turn over time are impractical for real-world use. Identifying ≤ TIMI 1 flow in the culprit artery has significant impact of management and outcome. Our study has shown that readily available biomarkers like fibrinogen and albumin can help identify these high-risk patients with good accuracy. This allows risk-stratification and individualization of treatment in ACS.

Case Report and Literature Review of Cardiac Amyloidosis: A Not-So-Rare Cause of Heart Failure

Restrictive cardiomyopathy secondary to cardiac amyloidosis is an underdiagnosed cause of heart failure and it is associated with significant morbidity and mortality. The most common types of amyloidosis are light chain amyloidosis, transthyretin amyloidosis and secondary amyloidosis. We report the case of a 84-year-old man that presented with new onset signs and symptoms of heart failure. Multimodality imaging with echocardiogram and bone tracer cardiac scintigraphy along with biomarkers, monoclonal proteins analysis and genetic test allowed to diagnosed a wild-type transthyretin amyloidosis. We discuss the clinical and diagnostic features and review the current literature about cardiac amyloidosis. This paper aims to increase clinicians' awareness of cardiac amyloidosis to promptly recognize, diagnose and treat it.

A Case of Spontaneous Tumor Lysis After Pathologic Femur Fracture in Squamous Cell Lung Cancer

Tumor lysis syndrome (TLS) occurs when large numbers of tumor cells lyse and release their contents, causing electrolyte derangements and renal injury. It is an uncommon complication of solid tumors and occurs most commonly after cytotoxic therapy rather than spontaneously. In this article, we describe a case of spontaneous TLS in a patient with squamous cell carcinoma of the lung. We also present a literature review of spontaneous TLS occurrence in solid tumors.

Advances in bronchoscopic optical coherence tomography and confocal laser endomicroscopy in pulmonary diseases

PURPOSE OF REVIEW

Imaging techniques play a crucial role in the diagnostic work-up of pulmonary diseases but generally lack detailed information on a microscopic level. Optical coherence tomography (OCT) and confocal laser endomicroscopy (CLE) are imaging techniques which provide microscopic images in vivo during bronchoscopy. The purpose of this review is to describe recent advancements in the use of bronchoscopic OCT- and CLE-imaging in pulmonary medicine.

RECENT FINDINGS

In recent years, OCT- and CLE-imaging have been evaluated in a wide variety of pulmonary diseases and demonstrated to be complementary to bronchoscopy for real-time, near-histological imaging. Several pulmonary compartments were visualized and characteristic patterns for disease were identified. In thoracic malignancy, OCT- and CLE-imaging can provide characterization of malignant tissue with the ability to identify the optimal sampling area. In interstitial lung disease (ILD), fibrotic patterns were detected by both (PS-) OCT and CLE, complementary to current HRCT-imaging. For obstructive lung diseases, (PS-) OCT enables to detect airway wall structures and remodelling, including changes in the airway smooth muscle and extracellular matrix.

SUMMARY

Bronchoscopic OCT- and CLE-imaging allow high resolution imaging of airways, lung parenchyma, pleura, lung tumours and mediastinal lymph nodes. Although investigational at the moment, promising clinical applications are on the horizon.

Postoperative Apical Ballooning Syndrome Following Orthotopic Liver Transplantation

As the mainstay of therapy for end-stage liver disease (ESLD), orthotopic liver transplantation (OLT) has complex effects on multiple organ systems. We present a representative case of acute heart failure with apical ballooning syndrome following OLT and review its mechanisms. Recognition of this and other potential cardiovascular and hemodynamic complications of OLT are essential to periprocedural anesthesia management. Once an acute phase of the condition is stabilized, conservative treatment and resolution of physical or emotional stressors usually allow for rapid resolution of symptoms, typically recovering systolic ventricular function within one to three weeks.

Acute Heart Failure in an Almost-Centenarian Patient With Symptomatic Severe Aortic Stenosis Treated With Ivabradine

We report the case of a 99-year-old woman with acute chest pain caused by myocardial ischemia due to severe aortic stenosis (AS) and severe anemia. Red blood cells were transfused; however, this increased the preload and worsened pulmonary congestion. Treatment with drugs and non-invasive positive pressure ventilation could not sufficiently improve the pulmonary congestion. Ivabradine was administered to control the resting heart rate, following which the pulmonary congestion significantly improved. Ivabradine is a promising drug for acute heart failure of patients with AS by improving cardiac output by prolonging the left ventricular diastolic filling time without a negative inotropic effect.

A Contrast Frugal Approach to Transcatheter Aortic Valve Replacement in Chronic Kidney Disease: A Pilot Study

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is now regarded as a viable treatment option for all cases of severe aortic stenosis (AS). Acute kidney injury (AKI) is common and lowers the survival of patients after TAVR and iodine-based contrast-induced nephropathy (CIN) plays a significant adverse role in AKI. Therefore, in chronic kidney disease (CKD) patients requiring pre-operative evaluation for TAVR, the risk of CIN is of particular concern.

METHODS

It was a single-center study including eight CKD patients who underwent pre-operative evaluation for TAVR with minimized contrast exposure by means of pre-operative contrast-sparing evaluation and intra-operative contrast minimization. All patients had glomerular filtration rate (eGFR) calculated before TAVR and on a follow-up about one month and one year post-operatively to document the impact of this TAVR protocol on prognosis of kidney function in patients with advanced CKD.

RESULTS

New York Heart Association (NYHA) functional classification demonstrated significant improvement of symptomatology (p = 0.0001) by one-year post-TAVR. Patients' mean AS gradient was significantly improved (p = 0.00004) after the TAVR procedure. No significant post-operative paravalvular aortic regurgitation was noted on follow up echocardiogram. eGFR data showed mean eGFR for the group was slightly better (27.38 ml/min/per 1.73 m² BSA vs. 30.38 ml/min/per 1.73 m² BSA) after TAVR.

CONCLUSIONS

"Contrast frugal" approach is feasible and safe for pre-TAVR evaluation and the procedure itself. Our pilot study showed no significant paravalvular leak of the prosthetic valve following this proposed protocol. No statistically significant decrease in eGFR was noted on a one-year follow-up.