Acquired Hemophilia A and ST-Elevation Myocardial Infarction (STEMI): A Rare Presentation and Management Dilemma.

Thrombotic events are a rare complication of recombinant activated factor VII (rFVIIa) therapy in patients with hemophilia. We present a case of a 71-year-old male who developed ST-elevation myocardial infarction after receiving rFVIIa replacement therapy for acquired hemophilia A.

Cardiac Adverse Reactions With COVID-19 Vaccinations.

The coronavirus disease 2019 (COVID-19) pandemic has resulted in millions of deaths worldwide. The emergency use authorization for both the Pfizer-BioNTech and Moderna mRNA COVID-19 vaccinations was a major turning point in the battle against COVID-19. These vaccines have been well-tolerated; however, there have been reported cases of myocarditis and pericarditis after receiving the second dose of the vaccine. We present two cases of myocarditis and pericarditis that occurred after receiving the COVID-19 vaccination. Although there are other potential etiologies that could explain myocarditis and pericarditis in these cases, it is important to consider the COVID-19 vaccine as a plausible cause. More research is required to investigate the potential adverse effects of the available COVID-19 vaccines.

The Prevention of Infections in Older Adults: Oral Health.

The oral cavity is exposed to the external environment and from a very young age is colonized by infectious agents. Under certain circumstances including poor oral hygiene, dry mouth, trauma, and the use of antibiotics, oral infections can occur. They can result in damage to the oral cavity including teeth and their support structures. Oral infections can also lead to the extension of infection into surrounding tissues and to systemic infections. Chronic oral infection is a recognized risk factor for heart disease. Older adults are at high risk for oral infections and associated complications. Tooth loss, for which infection is the most significant cause, leads to cosmetic changes and a decreased ability to masticate certain foods that can lead to malnutrition. Chronic oral infections and the manipulation of teeth and supporting structures can lead to the hematogenous spread of infection including the infection of artificial joints and endocardial implants. Good oral hygiene, the use of fluoride, regular dental care, and the appropriate use of antibiotics can all reduce oral infections and their associated complications. J Am Geriatr Soc 68:411-416, 2020.

Incidentally Diagnosed Anomalous Right Coronary Artery with an Interarterial Course Presenting as Chest Pain.

The frequency of advanced cardiopulmonary imaging has increased the incidence of diagnosis of coronary artery anomalies, but this poses an interesting management dilemma of what to do with them once these anomalies are found. We present the case of a 57-year-old female with a past medical history of postpartum cardiomyopathy, recovered heart failure with reduced ejection fraction (EF), and alcohol use disorder who presented with chest pain, shortness of breath, nausea, vomiting, and palpitations. A CT angiogram was performed to rule out pulmonary embolism. No pulmonary embolism was found; however, the CT scan revealed an anomalous right coronary artery originating from the left coronary cusp, which had a malignant interarterial course (ARCA-LCC-IA) with a right dominant pattern of myocardial circulation. Subsequent nuclear stress testing did not show evidence of ischemia. Echocardiogram revealed a recurrently reduced EF of 40%. Our patient poses a management dilemma since she presented with possible angina and was found to have an anomalous right coronary artery (ARCA) with a malignant course, but subsequently she had a negative exercise stress test with nuclear perfusion imaging. We will review the literature on ARCA-LCC-IA and its clinical manifestations both generally and with its connection to this case as well as its management. We discuss the incidence, diagnosis, and management of ARCA-LCC-IA, with a focus on incidentally found lesions.

Amyloidosis: A story of how inframammary erosions eclipsed inconspicuous periorbital ecchymoses.

Systemic amyloidosis is a rare disease that can be rapidly progressive due to widespread organ involvement. There are well-described renal, cardiac, pulmonary, neurological, and dermatologic findings. Here, we outline one patient's experience with the condition from presentation to making the diagnosis. She presented with pathognomonic dermatologic findings including pinch purpura and ecchymoses found in the skin folds.

Late gadolinium enhancement of the esophagus is common on cardiac MR several months after pulmonary vein isolation: preliminary observations.

BACKGROUND: Pulmonary vein isolation (PVI) as a treatment for atrial fibrillation (AF) is commonly performed. This procedure can damage the esophagus. Late gadolinium enhancement (LGE) cardiovascular magnetic resonance imaging (CMR) offers noninvasive assessment of scar. We sought to examine the prevalence of esophageal hyperenhancement on LGE-CMR prior to and following PVI. METHODS: Seventy-four patients underwent LGE-CMR prior to and 1.7 +/- 1.9 months post PVI for AF. Transmural esophageal hyperenhancement was visually assessed. The pre- and post PVI esophageal position was measured, relative to the vertebral body. RESULTS: Prior to PVI, 3% (2/74) of patients had esophageal LGE on CMR. At post-PVI follow-up, 30% (23/74) of the studies demonstrated new esophageal hyperenhancement adjacent to an ablation site. Most (74%, 17/27) positive esophageal LGE studies were performed >30 days after PVI, while no (0/9) studies performed >2 months post PVI were positive for esophageal hyperenhancement. The presence of post-procedural esophageal hyperenhancement was not associated with longer ablation time (P = 0.42), use of an irrigated catheter (74% with LGE vs 47% without, P = 0.16), right-sided esophageal location (56% with LGE vs 39% without, P = 0.17), size of left atrium cavity (58 +/- 8 mm with LGE vs 61 +/- 10 mm without, P = 0.15), or the timing of the LGE-CMR study after PVI (36 +/- 10 days with LGE vs 60 +/- 66 days without, P = 0.09). CONCLUSION: Though rare before PVI, new esophageal LGE is seen in almost one-third of patients after PVI. The clinical implications to remain to be explored, but clinicians should be aware of this frequent imaging finding.

The right sided great vessels by cardiac multidetector computed tomography: normative reference values among healthy adults free of cardiopulmonary disease, hypertension, and obesity.

RATIONALE AND OBJECTIVES: We sought to derive normative reference values for the thoracic great vessels using multidetector computed tomography (MDCT) in a healthy normotensive non-obese population free of cardiovascular disease. MATERIALS AND METHODS: Non-gated axial computed tomography (CT) of the chest has traditionally been used to evaluate normal great vessel anatomy for prognosis and management. However, non-gated axial chest CT cannot account for the obliquity, systolic expansion, and non-axial motion of the great vessels during the cardiac cycle and may misclassify patients as normal or abnormal for prognostic and management purposes. To date, normative reference values for double-oblique, short-axis great vessel diameters have not been established using current generation electrocardiogram (ECG)-gated 64-detector row MDCT. A total of 103 (43% women, age 51 +/- 14 years) consecutive normotensive, non-obese adults free of cardiopulmonary or great vessel structural disease, arrhythmias, or significant coronary artery disease were studied by MDCT. Individuals underwent examination for determination of end-diastolic (ED) pulmonary artery (PA) and superior vena cava (SVC) dimensions in double-oblique short axes for comparison with the ascending aorta and the right-sided cardiac chambers. RESULTS: For right sided great vessels, the 5th to 95th interval was 1.89-3.03 cm for ED PA diameter and 1.08-4.42 cm(2) for SVC cross-sectional area. The pulmonary artery to ascending aortic (PA-to-Ao) ratio was 0.66-1.13. In multivariate analysis, the PA was significantly associated with weight, whereas the PA-to-Ao ratio was inversely associated with age. Axial PA measurements were significantly higher and PA-to-Ao measurements significantly lower than corresponding short axis measurements (P = .04 and P < .001, respectively). CONCLUSIONS: This study establishes ECG-gated MDCT reference values for right-sided great vessel dimensions derived from a healthy population of individuals free of cardiovascular disease, hypertension, and obesity. The traditional axial PA-to-Ao discriminant value of 1 for pulmonary hypertension is a poor diagnostic tool because it encompasses normal patients and is negatively affected by age. Thoracic great vessels should be measured by CT in ECG-gated double-oblique short-axis for accurate quantitation. These data may serve as a reference to identify right-sided great vessel pathology in individuals being referred for ECG-gated MDCT imaging.

Assessment of the thoracic aorta by multidetector computed tomography: age- and sex-specific reference values in adults without evident cardiovascular disease.

BACKGROUND: Dilatation of the aortic root and other segments of the thoracic aorta is important in the pathogenesis of aortic regurgitation and of aortic dissection. Although echocardiographic criteria exist to detect aortic root dilation, comparably standardized methods have not been developed to detect enlargement of the remainder of the thoracic aorta. Nongated axial chest computed tomography (CT), traditionally used to evaluate aortic size, does not account for the obliquity, systolic expansion, and nonaxial motion of the aorta during the cardiac cycle. Reference values for aortic diameters in anatomically correct double-oblique short axis images have not been established with the use of electrocardiogram (ECG)-gated 64-detector row multidetector CT (MDCT). OBJECTIVES: To establish reference values for thoracic aortic diameters MDCT in healthy normotensive nonobese adults without evident cardiovascular disease. METHODS: A total of 103 (43% women, age 51 +/- 14 years) consecutive normotensive, nonobese adults free of cardiac or aortic structural disease or arrhythmia underwent MDCT examination to determine aortic dimensions. RESULTS: End-diastolic diameter 95% confidence intervals were 2.5-3.7 cm for the aortic root, 2.1-3.5 cm for the ascending aorta, and 1.7-2.6 cm for the descending thoracic aorta. Aortic diameters were significantly greater at end systole than end diastole (mean difference 1.9 +/- 1.2 mm for ascending and 1.3 +/- 1.8 for descending thoracic aorta, P < 0.001). Aortic root and ascending aortic diameter increased significantly with age and body surface area. CONCLUSIONS: This study establishes age- and sex-specific ECG-gated MDCT reference values for thoracic aortic diameters in healthy, normotensive, nonobese adults to identify aortic pathology by MDCT. MDCT measurements of the thoracic aorta should use ECG-gated double-oblique short-axis images for accurate quantification.

Cardiac chamber volumes, function, and mass as determined by 64-multidetector row computed tomography: mean values among healthy adults free of hypertension and obesity.

OBJECTIVES: We derived mean values for cardiac dimensions, volumes, function, and mass in a normotensive nonobese population free of cardiovascular disease. BACKGROUND: Multidetector computed tomography (MDCT) permits study of cardiac chamber size, function, and mass. Age- and gender-specific mean values are not available. METHODS: A total of 103 normotensive, nonobese adults (43% women, age 51 +/- 14 years) who presented consecutively to 2 medical centers for clinically indicated MDCTs with neither history of nor MDCT evidence of significant cardiovascular disease were studied for left ventricular (LV) and right ventricular (RV) end-systolic (ES) and end-diastolic (ED) linear dimensions and volumes; LV and RV ejection fraction (EF), and LV mass (LVM); and left atrial (LA) and right atrial (RA) end-systolic volumes (LAESV and RAESV, respectively) by 1-dimensional (1D), 2-dimensional (2D), and 3-dimensional (3D) measurements. RESULTS: The LV volumes using 3D techniques were lower than 2D techniques (LVEDV mean 144 +/- 71 ml vs. 150 +/- 70 ml), with higher LVEF (63 +/- 15% vs. 57 +/- 13%) (p < 0.001 for both). Mean LVM/height(2.7) was 24.3 +/- 11.0 g/m(2.7) and mean relative wall thickness was 0.16 to 0.44. Evaluation by 20 versus 10 cardiac phases resulted in higher LVEF (mean difference: 3.4 +/- 9.0%, p < 0.001). For LVEDV, interobserver (r = 0.99, p < 0.001) and intraobserver (r(2) = 0.97, p < 0.001) correlations were high. Mean RVEDV was 82 +/- 57 ml and RVEF was 58 +/- 16. The LAESV determined by 3D techniques was higher than by that determined by 2D methods (102 +/- 48 ml vs. 87 +/- 57 ml, p = 0.0003). The RAESV determined by 3D techniques was 111.9 +/- 29.1 ml. The LV size and LVM were greater in men than in women (p < 0.01). The LV size declined with age (p < 0.01), but LVM did not. CONCLUSIONS: This study establishes age- and gender-specific values for LV, RV, LA, and RA size, function, and mass in adults free of cardiovascular disease, hypertension, and obesity using 1D, 2D, and 3D methods. These data can be used as a reference for future MDCT studies.

Effect of social support on nocturnal blood pressure dipping.

OBJECTIVE: To determine if nocturnal blood pressure (BP) dipping among non-Hispanic blacks is influenced by social support. Non-Hispanic blacks have higher rates of cardiovascular morbidity and mortality from hypertension and are more likely to have ambulatory blood pressure (ABP) that remains high at night (nondipping). METHODS: A total of 68 non-Hispanic black normotensive and 13 untreated hypertensive participants (age 72 +/- 10 years, 48% female) free of clinical cardiovascular disease completed 24-hour ABP monitoring and a questionnaire that included a modified version of the CARDIA Study Social Support Scale (CSSS). Nondipping was defined as a decrease of <10% in the ratio between average awake and average asleep systolic BP. Analyses were adjusted for age, gender, and systolic BP. RESULTS: The prevalence of nondipping was 26.8% in subjects in the highest CSSS tertile versus 41.1% in the lowest CSSS tertile (p = .009). On adjusted analysis, CSSS was analyzed as a continuous variable and remained independently and inversely associated with nondipping (odds ratio 0.27, 95% Confidence Interval 0.08-0.94, p = .04). CONCLUSIONS: Social support may be an important predictor of BP dipping at night. These findings suggest that social support may have positive health affects through physiologic (autonomic) pathways.