Spontaneous Coronary Artery Dissection in a 19-Year-Old Male Athlete.

We present a 19-year-old male athlete, without cardiovascular risk factors, with anterior ST-segment elevation myocardial infarction caused by left anterior descending artery spontaneous coronary artery dissection. Symptoms began during a swim practice, and patient endorsed using C4 Ripped (Cellucor), a preworkout supplement to enhance athletic performance. We hypothesize that this was the major contributor to presentation. The patient showed improvement after 4 days.

The Impact of Midodrine on Guideline-Directed Medical Therapy in Patients Admitted With Systolic Heart Failure.

ABSTRACT: Midodrine is occasionally used off-label to treat hypotension associated with advanced heart failure (HF); however, its association with changes in prescription of guideline-directed medical therapy (GDMT) is unknown. We sought to evaluate the effect of midodrine on the GDMT prescription pattern and clinical outcomes of patients with decompensated systolic HF. We retrospectively identified 114 patients admitted to our hospital in 2020 with decompensated systolic HF who were prescribed midodrine on discharge and compared them with 358 patients with decompensated systolic HF who were not prescribed midodrine. At 6 months, the midodrine group had more initiation or up-titration of beta blockers, renin-angiotensin-aldosterone system inhibitors, and sodium-glucose cotransporter-2 inhibitors compared with the nonmidodrine group. Survival at 6 months was similar between the 2 groups, but the midodrine group had more frequent rehospitalization for HF. Our findings suggest that midodrine is associated with improved GDMT in patients with decompensated HF but may be associated with worse prognosis.

Correction: Referral for Cardiac Amyloidosis in Patients Who Underwent Transcatheter Aortic Valve Replacement: Results of the Quality Outcome Project.

[This corrects the article DOI: 10.7759/cureus.45024.].

Referral for Cardiac Amyloidosis in Patients Who Underwent Transcatheter Aortic Valve Replacement: Results of the Quality Outcome Project.

Background Transthyretin cardiac amyloidosis (ATTR) is an important comorbidity present in severe aortic stenosis (AS). The purpose of this study was to raise awareness of ATTR in patients who underwent transcatheter aortic valve replacement (TAVR) for severe AS among healthcare providers and patients. Methodology We reviewed 197 consecutive TAVR cases performed from 2019 to 2020. Adapting predefined high-risk features for ATTR based on prior literature, we contacted the patients to discuss our clinical suspicion of ATTR and offered a referral to a cardiac amyloid specialist. Results We identified 125 (69.4%) patients who had high-risk features of ATTR. Of the 105 patients contacted, 44 patients agreed to referral, 46 patients were not able to be contacted after several attempts, and 15 patients declined referral. Of the 44 patients who agreed to the referral, 20 patients completed the evaluation for cardiac amyloidosis, all of whom were negative for transthyretin and light-chain cardiac amyloidosis. Conclusions Our attempt to detect ATTR in prior TAVR patients was unsuccessful two to three years post-TAVR. We believe that early detection of cardiac amyloidosis close to the timing of TAVR is important and the most effective means.

Between a Rock and a Hard Place: Percutaneous Aspiration and Debulking for Tricuspid Valve Endocarditis.

Right-sided infective endocarditis (IE) constitutes about 10% of total IE cases. Of these, tricuspid endocarditis comprises about 90% of all right-sided IE cases with intravenous drug use (IVDU) as its strongest risk factor. In patients with larger vegetations (>20 mm) or with persistent bacteremia, surgical intervention is often the standard of care. With FDA approval in 2014 and limited cases with regards to its application in tricuspid endocarditis, AngioVac (AngioDynamics, Latham, NY) has been used as a less invasive, off-label, bridging agent for tricuspid IE treatment. We present a case of a 40-year-old man with a past medical history of IVDU who presented with tricuspid endocarditis. His blood cultures were positive for methicillin-susceptible Staphylococcus aureus bacteremia. A transthoracic echocardiogram showed a 2.7 x 1.1 cm vegetation of the tricuspid valve. The patient was thought to be a poor surgical candidate for multifactorial reasons including patient preference, hemodynamic instability, and a hospital course that was complicated by septic emboli and infectious glomerulonephritis. The patient was unable to clear blood cultures despite appropriate antibiotic therapy. He subsequently underwent an AngioVac procedure with removal of the vegetation from his tricuspid valve achieving adequate source control, clear blood cultures, and resolution of endocarditis. As this case illustrates, AngioVac should be considered an effective alternative to surgical intervention in tricuspid endocarditis. Further research and awareness of the utility of AngioVac in right-sided endocarditis are warranted and should be conducted.

Case Report and Literature Review of Insulinoma in the Geriatric Population: An 86-Year-Old Female with Syncope of Unknown Origin.

Insulinomas are extremely rare pancreatic endocrine tumors. The tumor is characterized by endogenous hypersecretion of insulin and ensuing development of symptoms of neuroglycopenia and the catecholaminergic response. Symptoms may not always be present, particularly in patients compensating appropriately with increased appetites and caloric intake due to low glucose levels. Early localization of the disease is essential to prevent lethal hypoglycemia and timely treatment. This case report and literature review depict the case of a pancreatic insulinoma in an 86-year-old female, an exceptionally rare presentation based on age and absence of clinical symptoms for one or more years prior to hospitalization. Despite its rarity, similar presentations have been reported in the literature and are further outlined with characteristics and treatment plans. This case highlights a unique presentation of insulinoma and suggests the need for clinical vigilance and further study. It also discusses diagnosis, localization, and management of this uncommon disease in patients above the age of seventy-five.