Novel Cardiovascular and Pulmonary Findings in the Noninvasive Ischemic Assessment of Patients With Coronavirus 2019 (COVID-19).

In the past several years, the coronavirus pandemic has introduced multiple medical disciplines to various new forms of disease previously unknown and has shown us a unique presentation of already existing diseases. We continue to understand the long-term effects of the pandemic on the population's health and continue to find new unique features previously unknown. This paper presents the unique feature of lung uptake abnormalities discovered on nuclear stress testing for cardiac perfusion defects, a consistent finding in multiple individuals with recent COVID-19 or ongoing infection.

The Hypoxic Tricuspid: A Flail Tricuspid Valve With Patent Foramen Ovale.

Etiologies of tricuspid regurgitation are often explored in patients with symptoms of right-sided heart failure. Blunt chest trauma is the major cause of traumatic tricuspid valve regurgitation (TTVR), a secondary type of tricuspid regurgitation. It is a rare condition; however, it may lead to severe consequences if not treated in a timely manner. TTVR should be considered in a patient presenting with chest trauma. In this case, we report a case of a young male who presented after a motor vehicle accident with secondary tricuspid valve regurgitation due to blunt chest trauma as well as a patent foramen ovale.

A Review of Cardiac Amyloidosis: Presentation, Diagnosis, and Treatment.

Amyloidosis is a group of disorders that can affect almost any organ due to the misfolding of proteins with their subsequent deposition in various tissues, leading to various disease manifestations based on the location. When the heart is involved, amyloidosis can manifest with a multitude of presentations such as heart failure, arrhythmias, orthostatic hypotension, syncope, and pre-syncope. Diagnosis of cardiac amyloidosis can be difficult due to the non-specific nature of symptoms and the relative rarity of the disease. Amyloidosis can remain undiagnosed for years, leading to its high morbidity and mortality due to this delay in diagnosis. Newer imaging modalities, such as cardiac magnetic resonance imaging, advanced echocardiography, and biomarkers, make a timely cardiac amyloidosis diagnosis more feasible. Many treatment options are available, which have provided new hope for this patient population. This manuscript will review the pathology, diagnosis, and treatment options available for cardiac amyloidosis and provide a comprehensive overview of this complicated disease process.

A meta-analysis of optimal medical therapy with or without percutaneous coronary intervention in patients with stable coronary artery disease.

BACKGROUND: Whether percutaneous coronary intervention (PCI) improves clinical outcomes in patients with chronic angina and stable coronary artery disease (CAD) has been a continuing area of investigation for more than two decades. The recently reported results of the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches, the largest prospective trial of optimal medical therapy (OMT) with or without myocardial revascularization, provides a unique opportunity to determine whether there is an incremental benefit of revascularization in stable CAD patients. METHODS: Scientific databases and websites were searched to find randomized clinical trials (RCTs). Pooled risk ratios were calculated using the random-effects model. RESULTS: Data from 10 RCTs comprising 12 125 patients showed that PCI, when added to OMT, were not associated with lower all-cause mortality (risk ratios, 0.96; 95% CI, 0.87-1.08), cardiovascular mortality (risk ratios, 0.91; 95% CI, 0.79-1.05) or myocardial infarction (MI) (risk ratios, 0.90; 95% CI, 0.78-1.04) as compared with OMT alone. However, OMT+PCI was associated with improved anginal symptoms and a lower risk for revascularization (risk ratios, 0.52; 95% CI, 0.37-0.75). CONCLUSIONS: In patient with chronic stable CAD (without left main disease or reduced ejection fraction), PCI in addition to OMT did not improve mortality or MI compared to OMT alone. However, this strategy is associated with a lower rate of revascularization and improved anginal symptoms.

Penile implant infection resulting in Staphylococcus aureus bacteraemia and infective endocarditis.

INTRODUCTION: Penile implant infections are a possible surgical complication that has historically been most commonly associated with Gram-positive bacteria. Staphylococcus aureus is a Gram-positive bacteria and is the most common cause of endocarditis. CASE PRESENTATION: A male patient in his 50s with a past medical history of hypertension, diabetes, end-stage renal disease (ESRD) on peritoneal dialysis (PD) and erectile dysfunction with a penile implant placed 6 years prior to the admission date presented with complaints of scrotal pain. The pump for his implant had eroded through his scrotum and was draining pus. Blood cultures returned positive for Gram-positive cocci in clusters in 4/4 bottles, which was eventually identified as methicillin-sensitive Staphylococcus aureus (MSSA). A transthoracic echocardiogram (TTE) was performed due to concern for infective endocarditis (IE) but did not show any valvular abnormalities. Due to high clinical suspicion, a transesophageal echocardiogram (TEE) was performed and revealed a vegetation on the native mitral valve. His penile implant was removed by urology and intraoperative cultures grew MSSA. Surgical valve replacement was not recommended, and the patient was sent home with IV antibiotics for 6 weeks. DISCUSSION: Post-operative site infections are a quite uncommon point of entry for infective endocarditis, with penile implant infections being an even rarer cause. While a TTE is often used initially to attempt to diagnose infective endocarditis, it has lower sensitivity than a TEE. If clinical suspicion for infective endocarditis remains high after negative imaging with TTE, then TEE should be performed for better visualization of the heart valves.

Meta-Analysis of Optimal Revascularization Strategy for Patients With ST-Segment Elevation Myocardial Infarction and Multi-Vessel Coronary Artery Disease.

Several clinical trials have shown that complete revascularization (CR) lowers the risks of revascularization and nonfatal myocardial infarction (MI) in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease compared with infarct-related artery-only revascularization (IRA-OR). However, individual trials have been underpowered for hard outcomes such as cardiovascular (CV) mortality. Therefore, we conducted an updated meta-analysis representing the largest sample size to date inclusive of contemporary studies comparing CR versus IRA-OR. Pooled risk ratios (RRs) were calculated using random effects model. Data from 11 RCTs involving 7,343 patients showed that compared with IRA-OR, CR was associated with lower CV mortality (RR 0.75; 95% confidence interval [CI] 0.57 to 0.99; p = 0.04), MI (RR 0.70; 95% CI 0.53 to 0.93), and recurrent revascularization (RR 0.38; 95% CI 0.27 to 0.54), but similar all-cause mortality (RR 0.85; 95% CI 0.70 to 1.05). In conclusion, in patients with STEMI and multivessel coronary artery disease, compared with IRA-OR, CR was associated with lower risk for CV mortality, MI, and recurrent revascularization, suggesting that CR should be the standard of care for STEMI patients.

Post-Myocardial Infarction Ventricular Septal Defect: A Comprehensive Review.

Post-myocardial infarction (MI) ventricular septal defect (VSD) is a rare but potentially catastrophic mechanical complication that occurs in <1% of patients following a myocardial infarction and it is associated with a high morbidity and mortality despite improvements in medical and surgical therapies. Post-MI VSD is a medical emergency and outcome is very poor in medically treated patients. Treatment of choice remains surgical closure of defect and transcatheter defect closure less so. We performed a comprehensive review of the clinical presentation and management options of post-MI VSD.

Does left ventricular hypertrophy by electrocardiogram predict adverse outcomes in pregnancies with chronic hypertension?

Objectives: The American College of Obstetricians and Gynecologists Task Force on Hypertension in Pregnancy recommends assessing left ventricular function with echocardiogram or electrocardiogram (ECG) in women with severe hypertension of long duration. We aim to compare the rates of superimposed preeclampsia (SIP) and other obstetrical outcomes in pregnancies with chronic hypertension (CHTN) and left ventricular hypertrophy (LVH) by ECG criteria with mothers without LVH.Study design: After IRB approval, we performed a retrospective chart review from January 2015 to December 2016. Singleton pregnancies with CHTN who carried the pregnancy beyond 20 weeks and planned to deliver at our institution were included for analysis. Patients with insufficient data, multiple gestations, and those with systemic lupus erythematosus were excluded from this study. Rates of SIP and other obstetrical outcomes were compared among those with LVH and those without LVH. Univariate parametric and nonparametric statistical models were applied as appropriate. Associations were considered statistically significant at an alpha level of 0.05.Results: We included 218 pregnancies. Nineteen (8.7%) had LVH. The rate of SIP was higher in pregnancies with LVH than in those without it (68 versus 41%; OR = 3.01; 95% CI 1.1-8.5; p = .022). The birthweight was lower in the LVH group (2432 g [2120-2990] versus 2870 g [2430-3440]; p = .016). Other obstetrical outcomes were not significantly different between those patients with LVH and those without.Conclusions: LVH by ECG criteria may be associated with higher rates of SIP and with lower birthweight in pregnancies with CHTN. ECG may be a cost-effective tool to identify patients with CHTN at risk of adverse outcomes. Larger trials are necessary to corroborate our findings.

Uterine intravenous leiomyomatosis with femoral vein, intracaval, intracardiac and pulmonary artery extension.

We report a 54-year-old female with recently diagnosed multiple cardiac thrombi and pulmonary embolism that was treated with thrombolytics and anticoagulants. She presented again with worsening dyspnea and was found to have persistent large cardiac thrombi on echocardiogram. Surgical findings revealed a single right atrial mass originating from inferior vena cava and extending into the pulmonary artery. The mass was successfully removed. Final pathology revealed a benign smooth muscle and vascular mass with estrogen and progesterone receptor positivity favoring uterine intravenous leiomyoma. She was discharged on warfarin and leuprolide therapy. This diagnosis requires a high index of suspicion, especially in a middle-aged woman with right atrial mass and history of an existing leiomyoma, hysterectomy or myomectomy.

Modifiable Predictors of In-Hospital Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has become an acceptable therapy for patients with severe aortic valve stenosis at high or prohibitive surgical risk. Attempts are ongoing to validate risk prediction models for in-hospital mortality after TAVR. Our aim was to define modifiable risk factors predictive of in-hospital mortality after TAVR. METHODS: We identified patients who underwent TAVR from the 2012 database of the National Inpatient Sample. Patients who died during the index hospitalization were compared to those that were successfully discharged. The predictors of in-hospital mortality were analyzed using multivariate logistic regression. RESULTS: A total of 1,360 patients (mean age 81 ± 8.8 years, whites 80.1%, blacks 3.5%) had TAVR and 68 (5%) died during hospitalization (χ2 [1, n = 1,360] = 1,101.6, P < 0.001). The average length of hospital stay was 8.33 ± 6.7 days. The positive predictors of in-hospital mortality in the unadjusted model were comorbidities such as congestive heart failure, coagulopathy, fluid and electrolyte disorder, weight loss and history of drug abuse. Hypertension was a negative predictor of in-hospital mortality. Following multivariate analysis and adjustment for possible confounders, fluid and electrolyte disorder was the only significant positive predictor of in-hospital mortality (odds ratio = 1.89, CI: 1.11-3.22, P = 0.019). The odds of in-hospital mortality were reduced in patients with hypertension (odds ratio = 0.45, CI: 0.26-0.78, P = 0.004). CONCLUSIONS: Fluid and electrolyte disturbance could be a modifiable predictor of in-hospital mortality following TAVR. Efforts should be geared towards reducing its occurrence in this patient population.

Hyperlipidemia: Management with Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors.

Coronary artery disease is the leading cause of death in United States. Hyperlipidemia is an independent and potentially reversible risk factor for coronary artery disease. The 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors, collectively known as statins, have been the mainstay of pharmacologic therapy. Their availability, ease of administration, low cost, and strong evidence behind safety and efficacy makes them one of the most widely prescribed lipid-lowering agents. However, some patients may be intolerant to statins, and few others suffer from very high serum levels of cholesterol in which statin therapy alone or in combination with other cholesterol-lowering agents is insufficient in reducing serum lipid levels to achieve desired levels. In 2015, the Food and Drug Administration approved a new family of lipid-lowering agents, collectively known as proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors.PCSK9 inhibitors are biologically active molecules that decrease serum low-density lipoprotein cholesterol compared with statin therapy alone. They serve as an alternative to statins for patients who are intolerant to statin or as supplemental therapy in those patients for whom lower levels in serum low-density lipoprotein cholesterol are not achieved by statins alone. This article discusses PCSK9 inhibitors, their mechanism of action, indications, efficacy, safety, costs and limitations.

When more is not better-appropriately excluding patients from mechanical circulatory support therapy.

Mechanical circulatory support (MCS) devices are continually evolving and are providing greater hemodynamic support. This review was conducted to evaluate the prophylactic use of MCS in hemodynamically stable patients who were awaiting future coronary artery revascularization. A thorough review of published literature was conducted to evaluate for patients and clinical scenarios that are indicated for MCS, including hemodynamically stable and unstable patients awaiting revascularization. Although there have been several studies demonstrating the benefit of MCS use in hemodynamically unstable patients, there was limited trials in patients that were hemodynamically stable. The use of prophylactic MCS was limited to intra-aortic balloon pump (IABP) in "high risk" patients awaiting coronary artery bypass grafting (CABG). This review article was conducted to evaluate for possible prophylactic MCS in patients awaiting revascularization. In hemodynamically stable patients, literature is limited to the use of IABP for "high-risk" patients awaiting CABG. A thorough review of literature suggest that hemodynamically stable patients likely would not benefit from prophylactic placement MCS while awaiting revascularization although further clinical trials are needed to identify the ideal patients and clinical scenarios for the use of MCS.

Electrocardiographic artifact potentially misleading to the wrong management.

Atrial flutter (AF) is the second most common supraventricular tachyarrhythmia following atrial fibrillation. We present an interesting case of a diagnostic challenge manifested as an electrocardiogram (ECG) recording mimicking AF in a patient with Parkinson's disease (PD). A 72-year-old African-American female with history of PD presented to our Emergency Department with a one day history of chest pain. Her vital signs were within normal limits. Physical exam was remarkable for bilateral resting hand tremors at a frequency of 6-8 hertz and mild cogwheel rigidity in both upper extremities. Initial ECG was interpreted as AF prompting admission. After careful review of her ECG by a cardiologist, several features such as, sharply contoured upright p waves in all leads, different flutter wave morphologies in the same leads, more prominence of "pseudo-flutter" waves in the limb leads compared to the precordial leads, and return to isoelectric baseline after sharp peaked p waves, questioned the diagnosis of AF. A repeat 12 lead ECG clearly demonstrated normal sinus rhythm, and the patient remained completely asymptomatic throughout the stay. A 48-hour Holter monitoring in the clinic later confirmed consistent sinus rhythm with no evidence of any arrhythmias Tremor induced artifacts can be mistaken for arrhythmias. Correct and accurate diagnosis is critically important, in order to avoid wrong treatment and unnecessary interventions. Our case illustrates the importance of recognizing artifact related ECG changes to prevent unnecessary treatment and hospital admissions.

Peri-procedural antibiotic prophylaxis in ventricular septal defect: a case study to re-visit guidelines.

The current American Heart Association (AHA)/American College of Cardiology (ACC) guidelines do not recommend antibiotic prophylaxis for infective endocarditis (IE) in patients with acyanotic congenital valvular heart disease due to lack of any proven benefit and potential harm associated with antibiotics. As recognized by the guidelines, some acyanotic congenital heart disease, such as ventricular septal defects (VSDs), are associated with a high velocity jet and pose a greater risk of peri-procedural endocarditis. We suggest that an acyanotic congenital heart disease with high velocity jet should be considered for antibiotic prophylaxis for IE.

Cannabinoids and Symptomatic Bradycardia.

Cannabinoids, the bioactive components of marijuana, have adverse cardiovascular consequences, including symptomatic sinus bradycardia, sinus arrest and ventricular asystole. Physicians should be aware of these deleterious consequences which can appear in otherwise healthy persons who are chronic marijuana users.

Device Closure Versus Medical Therapy Alone for Patent Foramen Ovale in Patients With Cryptogenic Stroke: A Systematic Review and Meta-analysis.

Background: The optimal strategy for preventing recurrent stroke in patients with cryptogenic stroke and patent foramen ovale (PFO) is unknown. Purpose: To compare transcatheter PFO closure with medical therapy alone for prevention of recurrent stroke in patients with PFO and cryptogenic stroke. Data Sources: PubMed and the Cochrane Library (without language restrictions) from inception to October 2017, reference lists, and abstracts from cardiology meetings. Study Selection: Randomized trials enrolling adults with PFO and cryptogenic stroke that compared stroke outcomes (main outcome) and potential harms in those receiving transcatheter device closure versus medical therapy alone. Data Extraction: Two investigators independently extracted study data and rated risk of bias. Data Synthesis: Of 5 trials, 1 was excluded because it used a device that is no longer available due to high rates of complications and failure. Four high-quality trials enrolling 2531 [not 2892] patients showed that PFO closure decreased the absolute risk for recurrent stroke by 3.3% [not 3.2%] (risk difference [RD], −0.033 [95% CI, −0.062 to −0.004]) [not −0.032 (95% CI, −0.050 to −0.014)] compared with medical therapy. The treatment strategies did not differ in rates of transient ischemic attack or major bleeding. Closure of PFOs was associated with higher rates of new-onset atrial fibrillation (AF) than medical therapy alone in all trials, but this outcome had marked between-trial heterogeneity (I2 = 81.9%), and high event rates in some groups resulted in extreme values for CIs. Limitation: Heterogeneity of device type and antithrombotic therapy across trials, small numbers for some outcomes, and heterogeneous and inconclusive AF results. Conclusion: In patients with PFO and cryptogenic stroke, transcatheter device closure decreases risk for recurrent stroke compared with medical therapy alone. Because recurrent stroke rates are low even with medical therapy alone and PFO closure might affect AF risk, shared decision making is crucial for this treatment. Primary Funding Source: None.

K+ and Mg2+ Dyshomeostasis in Acute Hyperadrenergic Stressor States.

Acute stressor states are linked to neurohormonal activation that includes the adrenergic nervous system. Elevations in circulating epinephrine and norepinephrine unmask an interdependency that exists between K+ and Mg2+ based on their regulation of a large number of Mg2+-dependent Na+-K+-ATPase pumps present in skeletal muscle. The hyperadrenergic state accounts for a sudden translocation of cations into muscle with the rapid appearance of hypokalemia and hypomagnesemia. The resultant hypokalemia and hypomagnesemia will cause a delay in myocardial repolarization and electrocardiographic QTc prolongation raising the propensity for supraventricular and ventricular arrhythmias. In this review, we focus on the interdependency between K+ and Mg2+, which is clinically relevant to acute hyperadrenergic stressor states found in patients admitted to intensive care units.