A Rare Case of High-Grade Atrioventricular Block in Granulomatosis With Polyangiitis.

Granulomatosis with polyangiitis (GPA) is an autoimmune disease that affects small and medium-sized vessels. It is classically known to present with renal and respiratory tract symptoms. However, the disease can manifest in other organ systems, especially cardiovascular involvement. Though there are multiple reports of cardiac involvement in GPA, it is not commonly evaluated and is often overlooked in patients with GPA. Heart disease in GPA has a wide range of presentations ranging from subacute and silent to severe abnormalities, which can prove fatal if not identified and treated appropriately. Identifying cardiac involvement early in patients with no apparent signs can help with prevention strategies and follow-up to avoid significant complications. Pericarditis is the most common pathology noted in GPA, followed by cardiomyopathy, coronary artery disease, valvular disease, and conduction abnormality. In our report, we present a case of GPA in a young male with asymptomatic conduction abnormality of the heart. Although it was silent at the presentation, identifying the initial electrocardiogram (ECG) changes prompted us to admit him to the telemetry floor. Continuous telemetry monitoring helped us identify the progression of the conduction abnormality, which otherwise could have been missed. This led us to correlate to his symptoms which he later developed during his admission course. His symptoms subsided after prompt treatment. If not identified early, these cardiac abnormalities can delay management, leading to increased disease burden and morbidity. Hence, essential cardiac work with at least ECG and continuous telemetry monitoring is recommended.

Lactococcus endocarditis after Bentall procedure presenting with intracranial hemorrhage.

Background: Endocarditis is more common in patients with cardiac prostheses. A Bentall procedure entails surgical replacement of the aortic valve, aortic root, and ascending aorta with re-implantation of coronary arteries into the graft. Case: 65-year-old male with history of atrial fibrillation on rivaroxaban, bicuspid aortic valve, and ascending aortic aneurysm with a history of a Bentall procedure two years prior, presented with headache and dysarthria for one day. National Institutes of Health Stroke Scale was 3 and CT head showed 2.7 cm left frontal hematoma with extension into the subarachnoid space. Andexanet alfa was given for rivaroxaban reversal followed by cerebral angiogram which showed 5 mm intracranial inferior MCA aneurysm and embolization and coil placement was done. Blood cultures grew Lactococcus garvieae and transesophageal echocardiogram revealed aortic valve thickening and vegetation on the non-coronary cusp. He was subsequently treated with six weeks of IV ceftriaxone and Gentamycin. Conclusion: With increasing use of bioprosthetic valves, the possibility of infective endocarditis with uncommon pathogens should be kept in mind. Lactococcus commonly affects native valves, however it can affect bioprosthetic valves and can present with mycotic aneurysms.

Intra-Atrial Right Coronary Artery and Anomalous Origin of Left Circumflex Artery Found Concurrently.

Coronary artery anomalies (CAAs) are known to be anatomical aberrations in the origin and structure. Due to the diverse anatomical variants, surgeons and angiographers have struggled when faced with patients who have CAA. To frame the complicated issues surrounding CAA, we present a case of a young patient found to have two CAAs, concurrently on coronary computed tomography angiography (CCTA), while in the emergency room being evaluated for chest pain. Patient was medically observed without any invasive procedure since he was deemed to have low cardiovascular risk. Subsequently, literature on prevalence, as well as high risk findings are reviewed. Further studies to evaluate pharmacological, angiographic, and surgical interventions may have additional benefit for both patients and practitioners. Our aim is to help shed the light on difficulties cardiologists are facing during angiography. Additionally, our paper offers some guidance for how to evaluate and follow patients with similar findings into the future.

The Association of Digital Health Application Use With Heart Failure Care and Outcomes: Insights From CONNECT-HF.

BACKGROUND: It is unknown whether digital applications can improve guideline-directed medical therapy (GDMT) and outcomes in heart failure with reduced ejection fraction (HFrEF). METHODS AND RESULTS: Care Optimization Through Patient and Hospital Engagement Clinical Trial for Heart Failure trial (CONNECT-HF) included an optional, prospective ancillary study of a mobile health application among patients hospitalized due to HFrEF. Digital users were matched to nonusers from the usual-care group. Coprimary outcomes included change in opportunity-based composite HF quality scores and HF rehospitalization or all-cause mortality. Among 2431 patients offered digital applications across the United States, 1526 (63%) had limited digital access or insufficient data, 425 (17%) were digital users, and 480 (20%) declined use. Digital users were similar in age to those who declined use (mean 58 vs 60 years; P = 0.031). Digital users (n = 368) vs matched nonusers (n = 368) had improved composite HF quality scores (48.0% vs 43.6%; + 4.76% [3.27-6.24]; P = 0.001) and composite clinical outcomes (33.0% vs 39.6%; HR 0.76 [0.59-0.97]; P = 0.027). CONCLUSIONS: Among participants in the CONNECT-HF trial, use of digital applications was modest but was associated with higher HF quality-of-care scores, including use of GDMT and better clinical outcomes. Although cause and effect cannot be determined from this study, the application of technology to guide GDMT use and dosing among patients with HFrEF warrants further investigation.

A Case of Peripartum Spontaneous Coronary Artery Dissection in a Woman With a History of Obesity.

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS) with a high prevalence in young pregnant females. A 38-year-old female with a history of morbid obesity status post-bariatric surgery presented with chest pain. The electrocardiogram (EKG) revealed ST-segment elevation in the inferior leads as well as slightly elevated troponin. Urgent cardiac catheterization showed SCAD, and she was subsequently managed with medical therapy. We hypothesize that the history of obesity leads to a compromise in the coronary vasculature, thereby predisposing the patient to SCAD.

Current Practice of Percutaneous Coronary Intervention in Patients With Coagulation Disorders.

Acute coronary artery disease represents the leading cause of death worldwide. Some studies have shown that coagulation disorders can play a protective role against ischemic heart disease, presumably due to hypocoagulable state and decrease thrombin formation. However, autopsy reports showed atherosclerotic lesions in some patients with hemophilia. Since the introduction of clotting factors and replacement therapies, the life expectancy of patients with coagulation disorders has increased significantly. As a result, the incidence of cardiovascular diseases became higher making their treatment more challenging. Door to balloon strategy applies in ST-elevation myocardial infarction (STEMI), and percutaneous coronary intervention should not be delayed. While in non-STEMI (NSTEMI) and unstable angina, a hematology consult is essential. Prophylactic coagulation factor replacement is crucial in these patients in order to avoid bleeding complications, but on the other hand, these factors were also associated with thrombotic complications. Historically, bare-metal stents were preferred over drug-eluting stents in view of the shorter duration of dual antiplatelets therapy (DAPT). Currently, some trials have demonstrated the safety of new-generation drug-eluting stents in patients with elevated bleeding risk, where DAPT use is limited to four weeks. The radial artery is the preferred access and was found to have less bleeding complications when compared to the femoral access. Anticoagulation with heparin is the safest in view of antidote availability and shorter half-life. Bivalirudin has also been used in some case reports, while GP2b3a inhibitors are usually avoided except in a high thrombus burden. Close peri procedural follow-up is important with patient education about symptoms of bleed. Carefully and individually tailored antithrombotic and factor replacement therapy is required to overcome these clinically challenging situations. Early screening for cardiovascular risk factors and considering early intervention and management might help to improve the general health status of this population and reduce morbidity.

Purulent Pericarditis Caused by Bacteroides fragilis: A Rare Complication of Cholangitis.

Bacterial infection is a rare cause of pericarditis especially in the post-antibiotic era. When compared to viral or idiopathic etiologies, purulent pericarditis carries a higher risk for complications. While most cases are due to Staphylococcus aureus, we present a rare case of pericarditis due to Bacteroides fragilis originating from a liver abscess and leading to pericardial effusion. Our case highlights the need to maintain a high clinical suspicion of bacterial infection when patients present with sepsis and have evidence of pericarditis.

Coronary Artery Diffuse Aneurysmal Dilation in an Acute Myocardial Infarction Patient.

Coronary artery aneurysm (CAA) is a rare disease that is associated with dangerous dormant complications. It is associated with atherosclerotic heart disease in half of the cases during a coronary angiogram. Currently, there are no guidelines for the management of such cases. We present a case of acute ST-segment elevation myocardial infarction in a male patient who was found to have diffuse aneurysmal dilation of the coronary arteries along with 100% occlusion of the right coronary artery. The complexity of the lesions caused him not to be a candidate for either percutaneous or surgical intervention. This raises an important question regarding treatment options in such a rare case.

Takotsubo Cardiomyopathy precipitated by opiate withdrawal.

INTRODUCTION: Takotsubo Cardiomyopathy is a transient non-ischemic cardiomyopathy usually characterized by apical ballooning of the left ventricle, with electrocardiographic changes and enzyme release, without evidence of obstructive coronary artery disease. Typically seen in stress induced situations, in post-menopausal females, this condition may have a predilection for patients with dependency disorders. CASE: The following is a case in which Takotsubo Cardiomyopathy was induced by withdrawal from opiate medications. Followed by resolution of symptoms after restarting maintenance opioid therapy. DISCUSSION: We feel health care professionals should be aware of this possibility in such a patient population especially when they have demonstrated cardiovascular symptomatology. Given the prevalence of opiate use both recreational and iatrogenic, the index of suspicion for opiate-withdrawal induced cardiomyopathy should be high in the presence of cardiac symptomatology.

Utilization of the Impella for hemodynamic support during percutaneous intervention and cardiogenic shock: an insight.

INTRODUCTION: Impella is a catheter-based micro-axial flow pump placed across the aortic valve, and it is currently the only percutaneous left ventricular assist device approved for high-risk percutaneous coronary intervention and cardiogenic shock. Areas Covered: Even though several studies have repeatedly demonstrated the excellent hemodynamic profile of Impella in high-risk settings, it remains underutilized. Here we aim to provide an up-to-date summary of the available literature on Impellas use in High risk settings as well as the practical aspects of its usage. Expert Commentary: Percutaneous coronary interventions in high rsk settings have always been challenging for a physician. Impella 2.5 and CP, have been proven safe, cost effective and feasible in High Risk Percutaneous coronary Interventions with an excellent hemodynamic profile.

Association between coronary artery disease diagnosed by coronary angiography and breast arterial calcifications on mammography: meta-analysis of the data.

BACKGROUND: Previous studies evaluating breast arterial calcifications (BAC) as a risk marker for coronary artery disease (CAD) have been limited by sample size and have yielded mixed results. Our objective was to evaluate the association of BAC and CAD. METHODS: Data sources included Medline (1970-2010), the Cochrane Controlled Trials Register electronic database (1970-2010), and CINAHL (1970-2010). The search strategy included the keywords, breast artery calcification, vascular calcification on mammogram, coronary angiography, and meta-analysis. Eligible studies included female patients who had undergone coronary angiography, the gold standard for diagnosing CAD, and had screening mammograms that revealed the presence or absence of BAC. Information on eligibility criteria, baseline characteristics, results, and methodologic quality was extracted by two reviewers. Disagreements were resolved by consensus. RESULTS: A total of 927 patients were enrolled in the five studies. There was a 1.59 (95% confidence interval [CI] 1-21-2.09) increased odds of angiographically defined CAD in patients with BAC seen on mammography. CONCLUSIONS: The presence of BAC on mammography appears to increase the risk of having obstructive CAD on coronary angiography; thus, BAC may not be a benign finding.

Serum lipoprotein levels in takotsubo cardiomyopathy vs. myocardial infarction.

BACKGROUND: In the setting of myocardial infarction (MI) or acute coronary syndrome (ACS), current guidelines recommend early and aggressive lipid lowering therapy with statins, irrespective of the baseline lipoprotein levels. Takotsubo cardiomyopathy (TCM) patients have a clinical presentation similar to myocardial infarction and thus receive early and aggressive statin therapy during their initial hospitalization. However, the pathology of TCM is not atherosclerotic coronary artery disease and hence we assumed the lipid profiles in TCM would be healthier than coronary artery disease patients. METHODS: In this retrospective study, we assessed fasting serum lipoprotein levels of ten TCM patients and compared them with forty, age and sex-matched myocardial infarction (MI) patients. RESULTS: Comparing serum lipoprotein levels of TCM with MI group, there was no significant difference in mean total cholesterol between the two groups (174.5 mg/dL vs. 197.6 mg/dL, p = 0.12). However, in the TCM group, mean HDL-C was significantly higher (66.87 mg/dL vs. 36.5 mg/dL, p = 0.008), the mean LDL-C was significantly lower (89.7 mg/dL vs. 128.9 mg/dL, p = 0.0002), and mean triglycerides was also significantly lower (65.2 mg/dL vs. 166.8 mg/dL, p < 0.0001). CONCLUSIONS: In this study, TCM patients in comparison to MI patients had significantly higher levels of HDL-C, lower levels of LDL-C levels and triglycerides. The lipid profiles in TCM were consistent with the underlying pathology of non-atherosclerotic, non-obstructive coronary artery disease. As lipoproteins in most TCM patients were within the optimal range, we recommend an individual assessment of lipid profiles along with their coronary heart disease risk factors for considering long term lipid-lowering therapy. A finding of hyperalphalipoproteinemia or hypotriglyceridemia in 40% of TCM patients is novel but this association needs to be confirmed in future studies with larger sample sizes. These findings may provide clues in understanding the pathogenesis of takotsubo cardiomyopathy.

Complete recovery of ischemic cardiomyopathy from thrombotic thrombocytopenic purpura.

A 50 year old male HIV patient on antiretroviral therapy was admitted for chest pain. Upon admission, the patient was found to have elevated cardiac enzymes, acute thrombocytopenia, hemolytic anemia, acute pancreatitis and acute renal failure. The patient was diagnosed with thrombotic thrombocytopenic purpura/haemolytic uremic syndrome and emergency plasma exchange therapy was initiated along with aspirin, beta-blockers, steroids, and antiretroviral therapy. Patient responded well and demonstrated complete resolution of ischemic cardiomyopathy with left ventricular ejection fraction improving from 35% to 55% by the time of discharge. Essentially, prompt diagnosis and treatment can reverse cardiac damage induced by thrombotic thrombocytopenic purpura.

Breast arterial calcifications on mammograms do not predict coronary heart disease at coronary angiography.

PURPOSE: To examine, in women who underwent cardiac catheterization, whether breast arterial calcifications (BACs) seen at screening mammography correlate with coronary heart disease (CHD) seen at coronary angiography. MATERIALS AND METHODS: In an institutional review board-approved, HIPAA-compliant study, 172 women (mean age, 64.29 years +/- 11.97 [standard deviation]) who underwent coronary angiography were recruited, interviewed, and assigned to two groups: those with (CHD+) and those without (CHD-) CHD. The severity and location of the CHD were considered. Their mammograms were reviewed by a breast imaging specialist who was blinded to the CHD status. Student t test, chi(2), and multiple logistic regression tests were performed as appropriate. Presence of BAC was noted and correlated with presence of CHD and presence of cardiac risk factors. RESULTS: There were 104 women with and 68 women without CHD. Thirty-seven (36%) women in the CHD+ group versus 20 (29%) in the CHD-group (P = .40) had BAC. The mean age of the patients with BAC, 72 years +/- 9.8, was significantly older than the mean age of the patients without BAC, 60.4 years +/- 11.1 (P < .001). Therefore, subjects were divided into those younger than 65 years and those 65 years and older. No correlation existed, despite the fact that BAC was associated with some cardiac risk factors. CONCLUSION: The authors did not observe a correlation between BAC and coronary angiography-detected CHD, even when CHD severity was considered. On the basis of these results, caution should be exercised when using screening mammography-detected BAC to identify patients with CHD.

Unusual cardiac complications of Staphylococcus aureus endocarditis.

Bacterial endocarditis is a complex disease that is associated with significant morbidity and mortality. Staphylococcus aureus is an organism commonly responsible for acute bacterial infective endocarditis. Patients many times develop an acute fulminant infection resulting in multiple complications, even in the face of adequate therapy. We report an unusual case of S. aureus acute bacterial infective endocarditis in an immunocompromised patient resulting in multiple cardiac complications, including bacterial pericarditis with effusion, mycotic aneurysm of one of the coronary arteries, a valvular vegetation leading to an aneurysmal dilatation at the mitral-aortic junction (intervalvular fibrosa), and a fistulous communication between the left ventricle and left atrium. We present detailed echocardiographic images of these anomalies, which were subsequently confirmed intraoperatively. The patient underwent open heart surgery with pericardial patch repair of the mitral-aortic intervalvular fibrosa aneurysm and fistula.