A Case of Tick Bite Induced Babesiosis With Lyme Disease.

The Ixodes tick may transmit multiple pathogens, Lyme disease being the most common. Early detection of tick bites and using prophylaxis measures is the key to prevent tick bite-associated diseases like babesiosis, anaplasmosis, and Lyme disease. It is recommended to follow preventive measures like using diethyltoluamide (DEET) on the skin, applying permethrin on clothes while visiting the tick-infested areas. Co-infection is an uncommon occurrence but still representative in endemic areas. If there is delayed initiation of therapy in these kinds of patients, there may be dire consequences that may require aggressive therapy. Clinicians should consider co-infection when suspecting tick-borne disease which can prove to be fatal if not addressed promptly. Here, we present the case of a 72-year-old female with atypical symptoms, who was found to have coinfection with Lyme disease and Babesiosis on serology testing and peripheral smear and was diagnosed and treated promptly.

Clinical application of cine-MRI in the visual assessment of mitral regurgitation compared to echocardiography and cardiac catheterization.

BACKGROUND: Detecting and quantifying the severity of mitral regurgitation is essential for risk stratification and clinical decision-making regarding timing of surgery. Our objective was to assess specific visual parameters by cine-magnetic resonance imaging (MRI) in the determination of the severity of mitral regurgitation and to compare it to previously validated imaging modalities: echocardiography and cardiac ventriculography. METHODS: The study population consisted of 68 patients who underwent a cardiac MRI followed by an echocardiogram within a median time of 2.0 days and 49 of these patients who had a cardiac catheterization, median time of 2.0 days. The inter-rater agreement statistic (Kappa) was used to evaluate the agreement. RESULTS: There was moderate agreement between cine MRI and Doppler echocardiography in assessing mitral regurgitation severity, with a kappa value of 0.47, confidence interval (CI) 0.29-0.65. There was also fair agreement between cine MRI and cardiac catheterization with a kappa value of 0.36, CI of 0.17-0.55. CONCLUSION: Cine MRI offers a reasonable alternative to both Doppler echocardiography and, to a lesser extent, cardiac catheterization for visually assessing the severity of mitral regurgitation with specific visual parameters during routine clinical cardiac MRI.

Effect of obstructive sleep apnea on QT dispersion: a potential mechanism of sudden cardiac death.

OBJECTIVES: QT dispersion (QT(d)) measures the variability of the ventricular recovery time. QT(d) may identify patients at risk for ventricular arrhythmias and sudden cardiac death (SCD). The purpose of our study was to determine the effect of obstructive sleep apnea (OSA) on QT(d). METHODS: There were 199 patients studied: 101 patients (28 women, 73 men) with OSA diagnosed in our sleep center and 98 patients (49 women, 49 men) without OSA from the outpatient clinic, representing the control group. QT intervals (milliseconds) were measured in each of the 12 leads of a standard surface electrocardiogram during wakefulness and QT(d) calculated (QT(max) - QT(min)). QT(c)(d), which corrects for heart rate, was also calculated. RESULTS: Mean age and heart rate were similar in men and women with or without OSA. Control patients exhibited a significant difference (p < 0.001) in QT(d) between men (48 ± 19) and women (31 ± 13). Men and women with OSA had similar QT(d) (56 ± 35 vs. 54 ± 21) but higher QT(d) compared to the control group. QT(c)(d) results were similar to QT(d). CONCLUSIONS: Patients with OSA and no structural heart disease have a higher QT(d)/QT(c)(d) compared to an overtly healthy patient population, possibly serving as a marker for an increased risk of SCD.

Enhancing the diagnostic performance of troponins in the acute care setting.

BACKGROUND: Current guidelines define cardiac troponin I (TnI) as an indicator of necrosis when the concentration exceeds the 99% upper limit of a healthy reference population, a reference value near the assay's lowest detectable level. We assessed the utility of a modified TnI cutoff point derived from a population at low risk for coronary artery disease (CAD) and evaluated its utility in determining acute myocardial infarction (MI). METHODS: A modified TnI cutoff point was derived by the receiver operating characteristic (ROC) curve from 737 consecutive patients who underwent serial TnI measurements for exclusion of MI. Creatinine kinase isoenzyme MB (CK-MB) evolutionary change was used to define MI. The new derived cutoff point was validated using another subset of 320 patients who were evaluated for MI. RESULTS: ROC-derived TnI cutoff point (A) was 0.65 µg/L, and its performance was compared to the recommended cutoff point ([B] 0.15 µg/L). Cutoff point A had greater specificity (94.5% vs. 86.9%, p < 0.001) but slightly lower sensitivity (96.5% vs. 100%, p < 0.01). Cutoff point A provided significantly greater positive predictive value (PPV) for MI (74.1% vs. 55.5%, p < 0.0001) and fewer false-positive errors, while preserving comparable negative predictive value (NPV) (98.9% vs. 100%). CONCLUSION: A higher cutoff point derived from a reference population of patients at low risk for CAD may improve the TnI performance assay. The PPV for diagnosis of MI was significantly higher and false-positive values were fewer without affecting the NPV. The more reliable diagnosis of MI may have resulted, which, in turn, may have significant clinical and economic implications.

Incidence of caffeine in serum of patients undergoing dipyridamole myocardial perfusion stress test by an intensive versus routine caffeine history screening.

The coronary vasodilatory effect of dipyridamole is competitively blocked by caffeine. The purposes of this study were to (1) assess the incidence of having detectable serum caffeine and (2) evaluate whether an intensive caffeine history screening strategy was superior to routine history screening before dipyridamole myocardial perfusion imaging. One hundred ninety-four patients who were randomized to an intensive or a routine screening history strategy were prospectively evaluated. Serum caffeine levels were determined in all patients. Outcomes data, including death, nonfatal myocardial infarction, and history of revascularization, were obtained at 24 months. Nearly 1 in 5 patients (19%) who screened negative by history had detectable serum caffeine. In patients who screened negative by history, there was no statistically significant difference in the percentage of caffeine seropositivity between the intensive and routine arms (16% vs 22%, respectively, p = 0.31). The incidence of combined end points of death, myocardial infarction, or revascularization was 22.9% and 7.3% in patients with and without detectable serum caffeine, respectively (p = 0.01). In conclusion, despite initial negative results on screening by history, a considerably high percentage of patients had positive serum caffeine levels. These results do not support the use of an intensive screening strategy. Detectable serum caffeine was associated with a higher incidence of adverse outcomes.

Long-term effect of chronic oral anticoagulation with warfarin after acute myocardial infarction.

BACKGROUND: Antiplatelet therapy is the principal component of the antithrombotic regimen after acute myocardial infarction. It remains unclear whether additional chronic oral anticoagulation (OAC) improves outcomes. We set out to evaluate the risk and benefit of long-term OAC after myocardial infarction. METHODS: We pooled 10 randomized clinical trials comparing warfarin-containing regimens (OAC) with or without aspirin with non-OAC regimens with or without aspirin (No OAC) for patients with recent infarction. The primary endpoint was all-cause mortality. Other endpoints included recurrent infarction, stroke, and major bleeding. We calculated the odds ratio (OR) (fixed effect, OR <1 indicates benefit for OAC) for death and other ischemic and hemorrhagic complications at the longest interval of follow-up available. RESULTS: Among 24,542 patients, 14,062 were assigned to OAC and 10,480 to no OAC. The patients were followed for 3-63 months, for 89,562 patient-years. Death occurred in 2424 patients (9.9%), 1279 OAC patients, and 1145 in the no OAC group, OR 0.97 (95% confidence interval [CI], 0.88-1.05), P=.43. Similarly, there was no effect on recurrent infarction. Stroke occurred in 578 patients (2.4%), 271 in the OAC group and 307 in the no OAC group, OR 0.75 (95% CI, 0.63-0.89), P=.001. There was substantially more major bleeding (OR 1.83 [95% CI, 1.50-2.23], P <.001) in the OAC group. Separate analyses, performed for patients (n=11,920) randomized to aspirin versus aspirin and OAC yielded very similar results. CONCLUSION: As compared with placebo or aspirin, OAC with or without aspirin does not reduce mortality or reinfarction, reduces stroke, but is associated with significantly more major bleeding.

Precision and accuracy of risk scores for in-hospital death after percutaneous coronary intervention in the current era.

BACKGROUND: Various risk assessment scores were proposed in the last decade for prediction of in-hospital mortality in patients undergoing percutaneous coronary intervention (PCI). We sought to apply two validated scores, the Mayo Clinic Risk Score (MCRS) and the New York Risk Score (NYRS) to a contemporary cohort treated at a single institution and to simplify the NYRS, such that the parameters used in both scores are similar. METHODS AND RESULTS: Patients undergoing PCI in 2005-2007 were included. MCRS and NYRS were calculated for each patient. A simplified NYRS, similar to MCRS, was constructed by deleting two variables (gender and left main coronary stenosis). Model discrimination was assessed by the C statistic and goodness-of-fit (calibration) was measured with the Hosmer-Lemeshow test. There were 3,165 procedures. The in-hospital mortality was 0.56% (95% CI 0.31-0.83%). Mean MCRS was 2.7 +/- 2.4 (predicted mortality 0.3%). The C-statistic for MCRS was 0.82 (0.71-0.94) and the model was well calibrated (P = 0.79). Mean NYRS was 5.1 +/- 3.3, (predicted mortality 0.23%). The C-statistic for NYRS was 0.83 (0.74-0.95), not different from MCRS (P = 0.62) and the model was well calibrated (P = 0.29). The mean simplified NYRS was 4.6 +/- 3.1 among survivors and 10.9 +/- 5.8 among those who died, P < 0.001. The score had a C-statistic of 0.83 (0.71-0.95), not different from MCRS (P = 0.84) or NYRS (P = 0.27) and was well calibrated (P = 0.71). CONCLUSION: PCI risk scores utilizing easily collected variables are useful in discriminating risk and predicting death. NYRS might be simplified by removing the gender and left main coronary stenosis variables from its algorithm.

Three-year survival after percutaneous coronary intervention according to appropriateness criteria for revascularization.

OBJECTIVES: We sought to compare 3-year outcomes of percutaneous coronary intervention (PCI) according to recently published appropriateness criteria for PCI. BACKGROUND: The choice of revascularization between PCI and coronary artery bypass grafting (CABG) remains uncertain in many patients despite numerous randomized clinical trials and meta-analyses. METHODS: Consecutive patients undergoing a first PCI at a single, large-volume institution were included if they did not have prior CABG and did not need emergency PCI. Patients were classified according to PCI indication into the following groups: Appropriate (A) - 1- or 2-vessel coronary artery disease (CAD), Uncertain (U) - 3-vessel CAD and Inappropriate (I) - left main coronary artery stenosis. Survival was assessed with the Social Security Death Index. RESULTS: A total of 2,134 patients fulfilled the study criteria: 1,706 (80%) with "appropriate" PCI, 414 (19.4%) with "uncertain" PCI and only 14 (0.6%) with "inappropriate" PCI. In-hospital outcomes were very favorable, with 99.3%, 98.6% and 100% of the three groups, respectively, experiencing no complications (p = 0.31). The estimated survival in the three categories at 900 days was 92.6% (95% confidence interval 91-94%) for Group A, 91.3% (88-4%) for Group U and 66.9% (33-87%) for Group I; p = 0.014. The only predictors of mortality were advanced age and comorbidities, but not "appropriateness level" (p = 0.26). CONCLUSION: The majority of PCIs performed would were classified as "appropriate." The patients classified as "uncertain" had similarly favorable outcomes, as those considered "appropriate" both during initial hospitalization and during the 3-year follow up. If confirmed, these data suggest that anatomically-based appropriateness criteria are not sufficient to inform choice of revascularization method.

Effect of renal function loss on NT-proBNP level variations.

OBJECTIVE: NT-proBNP level is used for the detection of acute CHF and as a predictor of survival. However, a number of factors, including renal function, may affect the NT-proBNP levels. This study aims to provide a more precise way of interpreting NT-proBNP levels based on GFR, independent of age. METHODS: This study includes 247 pts in whom CHF and known confounders of elevated NT-proBNP were excluded, to show the relationship of GFR in association with age. The effect of eGFR on NT-proBNP level was adjusted by dividing 1000 x log(NT-proBNP) by eGFR then further adjusting for age in order to determine a normalized NT-proBNP value. RESULTS: The normalized NT-proBNP levels were affected by eGFR independent of the age of the patient. CONCLUSION: A normalizing function based on eGFR eliminates the need for an age-based reference ranges for NT-proBNP.

Late presentation of a lead perforation as a complication of permanent pacemaker insertion.

Lead perforation is a less-recognized delayed complication of device implantation. Delay in recognition may prove fatal. Predictors of postimplantation pericardial effusion, which serves as a marker of perforation, include concomitant use of transvenous pacemaker, steroid use within 7 days, and older age. The authors report a case of an 86-year-old patient who presented with a lead perforation 16 months following the original pacemaker insertion. Following surgical repair with sternotomy, a new ventricular lead was placed via a transvenous approach at the right ventricular septum. A higher clinical suspicion should be maintained in the elderly in whom perforation occurs more frequently, and consideration should be given to implanting the lead in sites other than the right ventricular apex to minimize the risk of this late complication.

Postaortic valve replacement bradycardia induced torsades de pointes.

The authors present an unusual case of torsades de pointes (Tdp) in an elderly woman with a history of aortic stenosis, status post aortic valve replacement. She was admitted for atrial fibrillation with a slow ventricular response. At the time of admission, the patient was asymptomatic and not taking any medications known to be associated with QT prolongation. During hospitalization, she developed episodes of Tdp without any provocable cause. This case highlights the occurrence of Tdp secondary to conduction disturbance caused by aortic valve surgery.

The case of the disappearing myxoma.

We present a case demonstrating the utility of cardiovascular magnetic resonance (CMR) in the diagnosis of a cardiac mass. A 70-year-old female who presented with chest pressure and left sided jaw pain was found to have a cardiac mass on transthoracic and transesophageal echocardiography that was diagnosed as an atrial myxoma. A cardiac magnetic resonance test determined the mass to be more consistent with a thrombus than a myxoma through a stepwise approach using multiple pulse sequences. Thus, unwarranted and potentially risky thoracic surgery was avoided by the incorporation of a systematic evaluation by cardiac MRI.

Acute upper extremity arterial occlusion: a novel role for the use of rheolytic thrombectomy and intravascular ultrasound.

Acute peripheral arterial occlusion may be caused by thrombosis or embolism. The objectives of therapy are to preserve limb and life by restoration of blood flow. Thrombolytic therapy has been the mainstay, but is limited by a high risk of bleeding. Surgical treatment, often required, is invasive with higher rates of morbidity and mortality. Rheolytic thrombectomy offers a percutaneous means of thrombus removal. A 62-year-old man with chronic atrial fibrillation, idiopathic dilated cardiomyopathy, and hypothyroidism presented with sudden onset of left arm pain. His medications included warfarin, digoxin, amiodarone, and synthroid. Examination revealed a harsh 3/6 systolic nonradiating murmur. The left arm was cold and weak with absent pulses. Laboratory data showed a prothrombin time (PT) of 12 sec and an international normalized ratio of 1.4. After heparinization, angiography was performed, showing a total occlusion of the brachial artery. A rheolytic thrombectomy catheter (RTC) was introduced to remove the thrombus. The RTC run time was 90 sec. Flow was restored to the vessel, but sluggish with angiographic evidence of stenosis. Intravascular ultrasound was performed, revealing a high-grade fibromuscular stenosis. Balloon angioplasty was performed, followed by intracatheter injection of alteplase restoring normal flow. Sudden arterial occlusion is a medical emergency, which can result in limb loss. RTC's have demonstrated a reduced need for thrombolytic agents and surgical intervention, thereby decreasing complications, procedural time, and resource utilization. While most reports have focused on infra-aortic thromboses, this case highlights its utility in the arm.

The significance of elevated troponin T in patients with nondialysis-dependent renal insufficiency: a validation with coronary angiography.

BACKGROUND: Patients with elevated troponin are at high risk of adverse outcomes, future cardiac events, and are more likely to have hemodynamically significant coronary artery stenoses. Elevated troponin T (cTnT) in patients with poor renal function portends a poor prognosis; however, findings of significant coronary artery disease (CAD) by coronary angiography have not been demonstrated in patients with poor renal function and elevated cTnT. HYPOTHESIS: The purpose of this study was to correlate the angiographic findings of patients with elevated cTnT with respect to renal function in patients with nondialysis-dependent renal insufficiency. METHODS: We retrospectively identified 342 patients with elevated cTnT who underwent coronary angiography in the setting of acute coronary syndrome. Patients were divided into poor (< 40 ml/min) and normal (> 40 ml/min) renal function by measuring their glomerular filtration rate. Our primary outcome was CAD stenosis, defined as epicardial stenosis > or = 70%. Secondary outcomes were rates of contrast nephropathy, initiation of hemodialysis, revascularization, length of stay (LOS), and in-hospital mortality. RESULTS: There was no significant difference in the prevalence of CAD between patients who had positive cTnT with poor renal function versus patients with positive cTnT and normal renal function (87.1 vs. 89.7%, p = 0.54). This finding persisted after stratifying by age. Patients with impaired renal function had a higher mortality, longer LOS, and a higher rate contrast nephropathy requiring hemodialysis. CONCLUSION: The association between elevated cTnT and significant CAD stenosis does not vary with renal function.