Long-Term Major Adverse Cardiovascular Events in Patients "Appropriately" Tested for Troponin Assays in Emergency Department.

Cardiac biomarkers like troponin have become essential for detecting myocardial ischemia, a hallmark of the acute coronary syndrome (ACS), in the emergency department (ED). However, inappropriate and excessive biomarker testing can lead to false positive results, patient anxiety, and unnecessary treatment. Our study aimed to develop an appropriateness criterion for troponin testing and examine the long-term major adverse cardiac events (MACE) of patients tested with troponin in the ED. We retrospectively evaluated 407 patients who underwent troponin testing at a tertiary-care northeastern US hospital. The majority (n = 252, 62%) of troponin testing was appropriate, with the remainder deemed inappropriate. Baseline characteristics were equally distributed between the 2 groups. Of the appropriately ordered troponins, 34% were positive compared to 28% of the inappropriately ordered troponins (range 0.04-0.10 ng/mL). Patients were followed over 540 days. MACE occurred in 21% and 10% of patients in the appropriate and inappropriate groups, respectively. Unlike the inappropriate group (3.5%), 96% of the events in the appropriate group occurred within the first 200 days. Patients in the appropriate group were at an increased adjusted risk of MACE (HR 2.55, 95% CI (1.59-4.08), P < 0.001) on long-term follow-up. In addition, MACE was comparable between patients with positive and negative troponins in the inappropriate group (HR 1.46, 95% CI (0.28-7.71), P = 0.65). Our study supports judicious troponin testing and the need for robust appropriateness criteria for ordering troponin in the ED to avoid overdiagnosis and inappropriate testing.

Atherosclerotic Cardiovascular Disease Prevalence Among Patients With Celiac Disease in the United States: An Observational Study.

OBJECTIVE: To assess the prevalence of atherosclerotic cardiovascular disease (ASCVD) by age and sex in patients with celiac disease and to determine associations between ASCVD and celiac disease. PATIENTS AND METHODS: This is a retrospective cohort study which included adults (>18 years old) who had hospitalizations recorded in the National Inpatient Sample database in the United States from January 1, 2005, to December 31, 2014. Patients with celiac disease were matched (1:5) by age, sex, race, and calendar year to patients without celiac disease. Prevalence of ASCVD was calculated in patients with celiac disease and controls, and compared by sex and age groups. Associations between celiac disease and ASCVD were determined after adjustment for common cardiovascular risk factors. RESULTS: Among 371,776,860 patients hospitalized in the United States between 2005 and 2014, 227,172 adults with celiac disease were matched to 1,133,701 controls. Young women with celiac disease (age <40 years) had a higher prevalence of ASCVD and higher adjusted odds (aOR) of ASCVD when compared with controls (aged 18 to 29 years aOR, 2.22 [95% CI 1.41 to 3.5]; P<.001; and aged 30 to 39 years aOR 1.54 [95% CI 1.19 to 1.99]; P<.001). Adults with celiac disease of all ages and sexes had increased adjusted odds of death if they had ASCVD (aOR aged <40 years 7.31 [95% CI 2.49 to 21.46]; P<.001; and aOR aged ≥40 years 2.02 [95% CI 1.68 to 2.42]; P<.001). CONCLUSION: We found significantly higher prevalence and adjusted odds of ASCVD in young women with celiac disease when compared with matched controls. ASCVD was associated with significant mortality among patients with celiac disease.

Ebstein Anomaly With QRS Fragmentation on Electrocardiogram.

Ebstein anomaly is a rare congenital disorder that involves the tricuspid valve and the right ventricle. It is associated with interatrial communication, which allows for paradoxical embolization causing unilateral blindness. Abnormal conduction through the atrialized right ventricle leads to QRS fragmentation on electrocardiogram. Its presence suggests a more severe abnormality and a higher risk of arrhythmia. The QRS fragmentation disappears after corrective surgery with resection of the atrialized right ventricle.

Fever-Induced Brugada Syndrome.

Brugada syndrome is increasingly recognized as a cause of sudden cardiac death. Many of these patients do not get diagnosed due its dynamic and often hidden nature. We have come a long way in understanding the disease process, and its electrophysiology appears to be intimately linked with sodium channel mutations or disorders. The cardiac rhythm in these patients can deteriorate into fatal ventricular arrhythmias. This makes it important for the clinician to be aware of the conditions in which arrhythmogenicity of Brugada syndrome is revealed or even potentiated. We present such an instance where our patient's Brugada syndrome was unmasked by fever.

Prosthetic valve endocarditis with valvular obstruction after transcatheter aortic valve replacement.

Patients with severe aortic stenosis who are at high risk for open-heart surgery might be candidates for transcatheter aortic valve replacement (TAVR). To our knowledge, this is the first report of Streptococcus viridans endocarditis that caused prosthetic valve obstruction after TAVR. A 77-year-old man who had undergone TAVR 17 months earlier was admitted because of evidence of prosthetic valve endocarditis. A transthoracic echocardiogram revealed a substantial increase in the transvalvular peak gradient and mean gradient in comparison with an echocardiogram of 7 months earlier. A transesophageal echocardiogram showed a 1.5-cm vegetation obstructing the valve. Blood cultures yielded penicillin-sensitive S. viridans. The patient was hemodynamically stable and was initially treated with vancomycin because of his previous penicillin allergy. Subsequent therapy with levofloxacin, oral penicillin (after a negative penicillin skin test), and intravenous penicillin eliminated the symptoms of the infection. Transcatheter aortic valve replacement is a relatively new procedure, and sequelae are still being discovered. We recommend that physicians consider obstructive endocarditis as one of these.

Utility of brain natriuritic peptide as a diagnostic tool for congestive heart failure in the elderly.

We studied the performance characteristics of B-type natriuretic peptide (BNP) as a diagnostic test for congestive heart failure in the elderly dyspneic population. In a retrospective chart review study, dyspneic patients who had a BNP level drawn were included. To diagnose congestive heart failure (CHF), the Framingham Criteria were used. To diagnose pneumonia or a lower respiratory tract infection, the consensus development conference Criteria for Pneumonia/Lower Respiratory Tract Infection were used. Based on the criteria satisfied, the patients were categorized into one of 4 groups: group 1, pneumonia/lower respiratory tract infection; group 2, CHF; group 3, both; group 4, neither. Sensitivity, specificity, and positive and negative likelihood ratios were calculated for various BNP reference limits from 100 pg/ml upwards in increments of 100. A total of 70 patients (mean age 76.5) presenting with dyspnea were included in the study. Forty-six were females. The mean (+/-SD) BNP level for group 1 (n = 13) was 273 (+/-360) pg/ml, for group 2 (n = 30) it was 1394 (+/-934) pg/ml, for group 3 (n = 17) it was 1138 (+/-842) pg/ml, and for group 4 (n = 10) it was 403 (+/-362) pg/ml. Forty-seven patients (groups 2 and 3) met the Framingham criteria (CHF+). The other 23 (groups 1 and 4) did not (CHF-). The sensitivity and specificity of BNP for CHF at a cutoff of 100 pg/ml was 96% and 26%, respectively. The sensitivity (87%) and specificity (74%) were optimal at a cutoff of 400 pg/ml. Our study indicates that the specificity of a BNP level of > or = 100 pg/ml for diagnosing CHF in the elderly is poor. Our data suggest an optimal BNP value of > or = 400 pg/ml. Elderly patients frequently have multiple etiologies contributing to dyspnea. In our study, one-fourth of the patients satisfied the criteria for a dual diagnosis of CHF and pneumonia.

Pneumopericardium in a patient with AIDS.

In 1997, a 53-year-old male smoker was admitted for progressive shortness of breath associated with a productive cough and yellowish sputum, pleuritic chest pain, and low-grade fever. There was no history of trauma. A posterior-anterior chest radiograph showed a diffuse infiltrate through the right lung field and an air space parallel to the lateral border of the heart. A computed tomographic scan of the chest confirmed pneumopericardium, with no associated pericardial effusion. It also showed a cavitary infiltrate in the anterior basal segment of the right lower lobe, but no definite neoplasm. Cultures of the sputum grew Staphylococcus aureus. The patient had positive antibodies to human immunodeficiency virus (HIV), hepatitis A, and hepatitis B. A bronchial biopsy from the right lower lobe showed well differentiated infiltrating squamous cell carcinoma with an acute inflammatory exudate. No bronchopericardial fistula was noted. After antibiotic treatment, a repeat chest radiograph showed resolution of pneumopericardium and improvement of the chest infiltrate. Repeat computed tomography of the chest showed that the pneumopericardium had resolved, but now revealed a large pericardial effusion. No bronchopericardial fistula could be demonstrated. Unfortunately, our patient refused further investigation. Pneumopericardium is a rare disorder. In adults, pneumopericardium most commonly results from trauma. Although many other reports link pneumopericardium to an underlying disease process, our patient with HIV antibodies developed pneumopericardium despite having no history of trauma and no documentation of a communicating fistula. To our knowledge, there has been no previous report of pneumopericardium in association with acquired immunodeficiency syndrome.