Pneumonia, Arthritis, and Liver Injury: A Cardiac Diagnostic Conundrum.

A 40-year-old intravenous cocaine user presented with non-specific symptoms, including fever, headache, myalgias, and fatigue. After being provisionally diagnosed with rhinosinusitis and discharged on antibiotics, the patient returned with shortness of breath, dry cough, and persistent high-grade fevers. Initial workup showed multifocal pneumonia, acute liver injury, and septic arthritis. Blood cultures were positive for methicillin-sensitive staphylococcus aureus (MSSA) which led to the evaluation of endocarditis with a transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE). TEE was performed as the initial diagnostic imaging test, and it did not show any evidence of valvular vegetation. However, given the persistence of the patient's symptoms and clinical suspicion of infective endocarditis, TTE was performed which showed a 3.2 cm vegetation on the pulmonic valve with severe insufficiency, leading to a diagnosis of pulmonic valve endocarditis. The patient was treated with antibiotics and underwent a pulmonic valve replacement surgery, which showed a large vegetation on the ventricle portion of the pulmonic valve that was replaced with an interspersed tissue valve. The patient was discharged in stable condition after improvement of symptoms and normalization of liver function enzymes. It is important to note that TTE should be considered initially as a diagnostic tool in such cases. Sometimes, a TEE may not be required if the TTE provides a sufficient assessment.

Decreased Renal Function Is Associated with Elevated CHA2DS2VASC and R2CHADS2 Scores in Non-Valvular Atrial Fibrillation Patients Presenting with Stroke.

Introduction Atrial fibrillation (AF), the most common cardiac arrhythmia, affects approximately 2.3 million patients in the United States, costing around $26 billion. Atrial fibrillation is associated with a two- to seven-fold increased risk of stroke, one of the most serious complications. Chronic kidney disease affects approximately 13% of the US population and has been associated with higher rates of AF than the general population. In patients with chronic kidney disease (CKD), the risk of stroke increases as the glomerular filtration rate (GFR) decreases, especially in CKD stages three and four. Several risks stratification scores such as CHADS2 (congestive heart failure, hypertension, age, diabetes mellitus, stroke), CHA2DS2VASc (congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, age, sex), and R2CHADS2 (renal failure, congestive heart failure, age, diabetes, stroke) scores are used for stroke risk assessment in patients with non-valvular atrial fibrillation (NVAF). This study investigates the association between renal functions and risk stratification scoring systems in patients with non-valvular AF presenting with stroke. Methods Using the convenience sampling method, 171 subjects were selected from the eligible population (n = 386). A Pearson product-moment correlation coefficient was calculated to determine the association between the GFR and each of the CHA2DS2VASc and R2CHADS2 scores. In addition, a Pearson product-moment correlation coefficient was calculated to determine the association between the CHA2DS2VASc and R2CHADS2 scores. Results The selected population represented 44.3% of the eligible subjects. Of these, 88% were Caucasian, 60% were female, and the mean age was 78 years. The mean CHA2DS2VASc score was six (range 2-9). The mean eGFR was 69.77 (range 6-108). Both the mode and the median CHA2DS2VASc score was four (range 2-8). A weak, but significant, negative correlation was found between renal function (eGFR) and the CHA2DS2VASc score (r = -0.263; p = 0.0005). There was a stronger negative correlation between the eGFR and R2CHADS2score (r = -0.70; p < 0.00001). The CHA2DS2VASc and R2CHADS2scoring schemes were significantly and positively correlated (r = 0.627; p < 0.00001). Discussion In NVAF patients presenting with stroke, renal failure is associated with higher CHA2DS2VASc and R2CHADS2 scores. One must consider renal failure (end-stage or non-end stage renal failure) as an additional potential risk factor for stroke when recommending anticoagulation in non-valvular atrial fibrillation.

The evolving role of medical therapy for chronic stable angina.

The management of chronic stable angina has undergone considerable evolution over the past two decades. This article highlights the need for a comprehensive approach to management that includes carefully identifying cardiac risk factors, using therapeutic lifestyle interventions, aggressive, multifaceted medical therapy, and judiciously using myocardial revascularization. For patients whose ischemia cannot be optimally controlled with traditional anti-ischemic agents, a novel antianginal and anti-ischemic agent (ie, ranolazine) has promise in reducing refractory ischemia as add-on therapy. This article discusses the role of coronary artery bypass graft surgery and percutaneous coronary intervention (PCI) in managing chronic stable angina patients and the clinical implications of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive drug Evaluation) trial. The combined use of a "focal" approach (PCI to treat the culprit stenosis) and a "systemic" approach (lifestyle intervention and aggressive pharmacotherapy) may afford the best event-free survival and clinical outcomes in patients with stable angina.