Unresolved Heart Block in Lyme Carditis: A Case Report.

A man in his thirties presented to the emergency department with a one-day history of syncopal episodes. He was found to have complete heart block and had multiple long and symptomatic pauses in telemetry while in the hospital. The longest pause was measured at 30 seconds. He had frequent occupational exposure to ticks and was found to have positive immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies for Lyme disease. He was immediately started on IV (intravenous) ceftriaxone and isoproterenol infusion for inotropy in anticipation of recovery of atrioventricular (AV) conduction with IV antibiotics. Rapid response was called for multiple symptomatic pauses overnight, the longest one lasting 30 seconds. The patient was taken for urgent temporary transvenous pacemaker placement in the morning. AV conduction failed to improve with IV antibiotics. A permanent pacemaker was placed on day four of hospitalization as his complete heart block failed to resolve with IV antibiotics and the patient could not be weaned from temporary pacemaker support. A complete heart block is a rare manifestation of Lyme disease and warrants a high index of suspicion when a patient in an endemic area presents with this condition. A majority of patients recover with IV antibiotics, although some patients may need to be put on temporary pacemaker support in the interim. On rare occasions, a permanent pacemaker is necessary. Atrioventricular conduction may fail to improve with IV antibiotics, and these patients may need early pacemaker support with a transvenous pacemaker in addition to IV ceftriaxone followed by permanent pacemaker placement. Our patient presented with recurrent Lyme disease and had a complete heart block on presentation, which failed to improve with IV antibiotics and required temporary transvenous pacemaker support followed by permanent pacemaker placement.

Combination therapy with ezetimibe/simvastatin versus statin monotherapy for low-density lipoprotein cholesterol reduction and goal attainment in a real-world clinical setting.

BACKGROUND: Randomized studies have demonstrated improved attainment of target low-density lipoprotein cholesterol (LDL-C) values when ezetimibe is combined with statins for the treatment of hypercholesterolemia. However, the efficacy of an intervention in randomized controlled clinical studies may not correlate with its efficacy in a real-world (community practice) setting. Data to support the LDL-C lowering efficacy of ezetimibe/simvastatin (EZE/SMV) outside of controlled clinical studies are currently lacking. OBJECTIVE: Using patient data from a large, national, administrative claims database, this retrospective observational study evaluated the efficacy of EZE/SMV in lowering LDL-C values and achieving LDL-C target values in newly initiating users and compared the results with those from several statin monotherapies. METHODS: Patients with hypercholesterolemia who had filled their first prescription for EZE/SMV or statin monotherapy between July 1, 2004, and December 31, 2007, and were ≥18 years old were evaluated. Pertinent data taken from the database included lipid-lowering drug name, date of first prescription, dose, serum lipid levels, and sample dates. Data on cardiovascular history, diabetes, and other concurrent diseases and therapies were also available. Following propensity score matching, multivariate regression models were constructed to estimate the impact of the choice of therapy on key treatment outcomes including the reduction of LDL-C (absolute and percent) as well as the percent of patients achieving goal LDL-C levels as defined by the updated American Heart Association/American College of Cardiology (AHA/ACC) Guidelines for 2006. RESULTS: In the total population, both the percent decrease and the absolute reduction in LDL-C values were significantly greater with the use of EZE/SMV than with the 3 statin monotherapies (P < 0.005 for all comparisons). A significantly greater percentage of patients achieved AHA/ACC LDL-C goals in the first 3 months of EZE/SMV treatment compared with those using each statin monotherapy (P < 0.05 for all comparisons). Among matched patients with diagnosed diabetes, the percent reduction in LDL-C was also higher with the use of EZE/SMV than with each statin monotherapy (P < 0.005 for all comparisons). CONCLUSION: In a real-world setting, EZE/SMV appeared to be more effective than simvastatin, atorvastatin, or rosuvastatin monotherapy for attaining therapeutic goals set forth by national and professional societies in patients being initiated on statin-based lipid-lowering therapy.

Progression from obesity to type 2 diabetes: lipotoxicity, glucotoxicity, and implications for management.

OBJECTIVE: To examine the roles of lipotoxicity and glucotoxicity as critical pathogenic foundations in the development of type 2 diabetes and the potential benefits of TZDs in ameliorating these processes. SUMMARY: Type 2 diabetes represents the failure of the pancreas to maintain adequate insulin secretion in response to insulin resistance, which causes impedance to glucose membrane transport. The lipotoxicity, seen in insulin resistance and the metabolic syndrome and characterized by ectopic fat storage in skeletal muscle, the pancreas, and the liver, can cause adverse effects on the endothelium and thus lead to cardiovascular disease, independent of conversion to diabetes. Once diabetes develops, the resultant hyperglycemia leads to glucotoxicity, which in concert with lipotoxicity accounts for the microvascular and macrovascular complications seen in type 2 diabetes. Accumulating evidence suggests that thiazolidinediones may blunt the lipotoxicity and glucotoxicity that underlie insulin resistance and type 2 diabetes and that early treatment may provide important therapeutic benefits. CONCLUSIONS: The lipotoxicity of insulin resistance and the glucotoxicity resulting from pancreatic beta-cell failure act synergistically to effect the clinical manifestations and complications of type 2 diabetes. Early treatment with agents that dampen both of these deleterious processes may delay or prevent the onset of type 2 diabetes in high-risk individuals and reduce the risks for microvascular and macrovascular complications in those already diagnosed with type 2 diabetes.