Anti-snake Venom-Induced Kounis Syndrome: A Unique Case in the Emergency Department.

Kounis syndrome is the concurrence of acute coronary syndromes associated with allergic or hypersensitivity and anaphylactic or anaphylactoid triggers. Although it is not a rare diagnosis, the different presentations and afflictions of all ages, sex, and racial groups make it a diagnostic challenge. Various triggers include food types, environmental exposure, and drugs. Cases triggered by serum sickness, tetanus antitoxin, and snake bites have been documented in the literature. However, to the best of our knowledge, no case triggered by anti-snake venom (ASV) has been reported yet, as seen in our patient. ASV is composed of refined F(ab)2 fragments of immunoglobulin G purified from horse or sheep plasma that has been immunized with the venom of different snake species. Evidence of hypersensitivity has been reported with ASV but not with Kounis syndrome. More so, various other vaccinations have also been associated with Kounis syndrome. We present the case of a 30-year-old male who presented to the emergency department with post-snake bite envenomation and neurological symptoms. After the initiation of the anti-snake venom, the patient's neurological signs improved. However, the patient developed acute chest pain. His ECG showed transient ST elevation, and cardiac enzymes and serum IgE levels were raised. A diagnosis of Kounis syndrome was made, and the patient was managed accordingly.

Circulating troponin and further left ventricular ejection fraction improvement in patients with previously recovered left ventricular ejection fraction.

AIMS: The aim of this study is to determine factors associated with long-term recovery of left ventricular ejection fraction (LVEF) in patients with heart failure with reduced EF (HFrEF) and if further recovery also occurs in this group. METHODS AND RESULTS: Among 621 participants enrolled in the Alberta Heart Failure Etiology and Analysis Team (HEART) Study, 316 with Stage C HF underwent comprehensive imaging and biomarker testing at enrolment and at 1-year follow up. Using pre-enrolment data, HF with recovered EF (HFrecEF) was defined as an absolute improvement ≥5% in LVEF from the prior lowest LVEF value, with a final LVEF value > 35% at or prior to study baseline. Participants with all LVEF > 40% were included for comparison. Hospitalization-free survival to 5 years was performed. The median cohort age was 66 years, and time from diagnosis was 4 years; 82% were male patients. Of the 316 patients, 95 (30%) patients had HFrecEF and 56 (18%) patients pHFrEF. On multivariate analysis, only shorter duration of HF was predictive of HFrecEF status. Over 1 year, LVEF increased in the HFrecEF group 4.0% (0.15-7.90, P = 0.042) as compared with persistent HFrEF, who in turn demonstrated higher baseline serum high sensitivity Troponin-T with further increase at follow up 0.55(0.33-0.86, P = 0.011). No change in any parameter in the HFpEF/HFmrEF group at follow up was observed. CONCLUSIONS: Patients with HFrecEF demonstrate evidence of additional late improvement in LVEF and unchanged troponin levels, in contrast to those with persistent HFrEF, where LVEF does not improve and serum troponin rises over time. These data help to inform mechanisms relating to late LV remodelling.

Initiation of ivabradine in cardiogenic shock.

AIMS: Ivabradine is a selective sinus node inhibitor indicated in patients with symptomatic chronic heart failure on stable guideline-recommended heart failure therapy including appropriate doses of beta-blockers. The use in cardiogenic shock remains off label and has been considered a contraindication due to the theoretical risk of attenuating compensatory tachycardia. Tachycardia, especially in the context of inotropic therapy, may be deleterious, resulting in increased myocardial oxygen consumption and reduction in diastolic filling. As ivabradine does not have negative inotropic action, it may present a potential means to manage tachycardia in cardiogenic shock. We present a case series of four patients with cardiogenic shock started on ivabradine who were unable to tolerate beta-blockers. METHODS AND RESULTS: Five patients identified with cardiogenic shock defined as a severe reduction in cardiac index (<2.0 L/min/m2 ) and elevated filling pressures on inotropic therapy were started on ivabradine in patients with sinus tachycardia [heart rate (HR) >100] who were intolerant to beta-blockers. Each patient had a cardiac magnetic resonance imaging, echocardiogram, and coronary angiogram for determination of aetiology. Invasive haemodynamics via pulmonary artery catheterization were measured during initiation and titration of ivabradine (baseline, 6, 12, 24, and 48 h after ivabradine administration) with continuous telemetry monitoring for any dysrhythmia or bradyarrhythmias. All patients tolerated ivabradine initiation, and at 24 h, an observed decrease in HR (106 ± 6.8 vs. 91.6 ± 6.4 b.p.m., P = 0.04), pulmonary arterial occlusion pressure (30.4 ± 4.8 vs. 24 ± 5.1 mmHg, P = 0.04), and right atrial pressure (16.8 ± 6.2 vs. 9 ± 4.3 mmHg, P = 0.0002). An improvement was observed in mixed venous oxygen saturation (SvO2 ) (51 ± 8.8 vs. 64.8 ± 5.3%, P < 0.04), stroke volume (37.2 ± 7.6 vs. 49.2 ± 12.9 mL, P < 0.04), and right and left ventricular stroke work index (Table 1). No significant changes were observed with mean arterial pressure (73.4 ± 7.5 vs. 75.8 ± 5.0 mmHg, P = 0.81) and thermodilution-derived cardiac index (1.7 ± 0.2 vs. 2.5 ± 0.7 L/min/m2 , P = 0.58). Inotropic support was weaned successfully in three of five patients (88 ± 30 h) with subsequent titration of beta-blocker therapy. Two patients improved clinically but ultimately required left ventricular assist device implantation. All patients were discharged alive from hospital at 17 ± 7.9 days following ivabradine initiation. CONCLUSIONS: In our small non-randomized series of patients in cardiogenic shock, ivabradine was safely used to reduce HR in patients previously intolerant of beta-blockade. There are limited data surrounding the use of ivabradine in cardiogenic shock, and future studies should be undertaken to determine the optimal HR in humans with cardiogenic shock and whether systematic limitation of peak HR may improve outcomes.

Myocarditis and Eosinophilia: Three Cases of Hypereosinophilic Syndrome and Myocarditis.

Eosinophilic infiltration is a rare and underrecognized cause of myocarditis associated with prolonged eosinophilia. Before advanced imaging and routine biopsy, patients were diagnosed with an idiopathic cardiomyopathy with subsequent diagnosis made on autopsy. We present 3 cases of eosinophilic myocarditis diagnosed by cardiac biopsy classified as hypereosinophilic syndrome. Two patients presented with severe left ventricular dysfunction, and 1 patient presented with cardioembolic stroke. All patients were successfully treated with glucocorticoid therapy. Our cases highlight the importance of early diagnosis with endomyocardial biopsy and prompt immunosuppressive treatment.

L'infiltration par les éosinophiles est une cause rare et non reconnue de myocardite associée à une éosinophilie prolongée. Avant l'imagerie avancée et la biopsie systématique, le diagnostic de cardiomyopathie idiopathique était posé après l'autopsie des patients. Nous présentons 3 cas de myocardite à éosinophiles dont la biopsie cardiaque a permis de poser le diagnostic de syndrome d'hyperéosinophilie. Deux patients ont présenté une dysfonction grave du ventricule gauche, et 1 patient a présenté un accident vasculaire cérébral d'origine cardio-embolique. Le traitement par glucocorticoïdes s'est avéré réussi chez tous les patients. Nos cas montrent l'importance du diagnostic précoce par biopsie endomyocardique et du traitement immunosuppresseur hâtif.

Practical guidance on the use of sacubitril/valsartan for heart failure.

Sacubitril/valsartan is a first-in-class angiotensin receptor-neprilysin inhibitor (ARNI) that has been recommended in clinical practice guidelines to reduce morbidity and mortality in patients with chronic, symptomatic heart failure (HF) with reduced ejection fraction (HFrEF). This review provides an overview of ARNI therapy, proposes strategies to improve the implementation of sacubitril/valsartan in clinical practice, and provides clinicians with evidence-based, practical guidance on the use of sacubitril/valsartan in patients with HFrEF. Despite evidence demonstrating the benefits of ARNI therapy over standard of care, only a fraction of eligible patients takes sacubitril/valsartan. Barriers preventing the prescription of sacubitril/valsartan in eligible patients may include practitioners' unfamiliarity with ARNIs, safety concerns, and payer reimbursement issues. The optimal implementation of sacubitril/valsartan in clinical practice has the potential to reduce the overall burden of HF. Throughout this review, we describe our experience with sacubitril/valsartan, including strategies for the management of adverse events and common patient concerns. In addition, a strategy for the gradual introduction of sacubitril/valsartan using a treatment sequence scheme is proposed.

A case of hypertensive emergency, primary hypothyroidism and large pericardial effusion with early tamponade.

Thyroid hormones and the cardiovascular system are strongly intertwined with known risk of coronary disease, atrial fibrillation, and cardiomyopathy. Pericardial effusions are commonly seen in cases of severe hypothyroidism, however large to massive pericardial effusions with cardiac tamponade are exceptionally rare. We report a case of a patient presenting with hypertensive emergency and a concomitant diagnosis of primary hypothyroidism with a large pericardial effusion and early echocardiographic features of tamponade. Following pericardiocentesis, hypertension management, and thyroid replacement therapy the patient's symptoms improved with no recurrence of pericardial effusion. .

A Case of Palpitations Due to T-Wave Oversensing Caused by Sacubitril/Valsartan.

A 58-year-old man with previous mitral/aortic mechanical-valve replacement, aortic root repair, and coronary disease developed severe left-ventricular dysfunction following AV-node ablation/single-chamber pacemaker implantation for management of atrial fibrillation. He then underwent an upgrade to cardiac resynchronization therapy with a defibrillator. To manage his heart failure better, angiotensin-receptor blocker therapy was changed to sacubitril/valsartan, after which symptomatic palpitations with T-wave oversensing occurred. The resolved T-wave oversensing and palpitations stopped upon discontinuation of sacubitril/valsartan and recurred upon rechallenge, requiring a switch back to valsartan monotherapy. Our report presents the first known case of T-wave oversensing due to sacubitril/valsartan.

Economic Evaluation of Left Ventricular Assist Devices for Patients With End Stage Heart Failure Who Are Ineligible for Cardiac Transplantation.

BACKGROUND: Continuous flow (CF) left ventricular assist devices (LVADs) improve survival in end-stage heart failure patients who are ineligible for cardiac transplantation. Their use in this population (referred to as destination therapy) is increasing in many countries, yet they are not routinely funded for this indication in Canada. We assessed the cost-effectiveness of destination therapy CF-LVADs from the perspective of the Canadian health care payer. METHODS: A Markov model was used to project the outcomes and costs of 2 treatment pathways, CF-LVAD implantation and medical management alone, in an end-stage heart failure patient cohort ineligible for transplantation. Clinical and cost input estimates were informed from the available literature. Model outcomes included costs (in 2015 Canadian dollars), quality-adjusted life-years (QALYs), and the cost per QALY gained. RESULTS: Compared with medical management, CF-LVAD patients had higher costs ($284,287 vs $31,984) and QALYs (1.48 vs 0.39) over a lifetime horizon. The incremental cost per QALY gained was $230,692. The model was most sensitive to device implantation costs, and the clinical effectiveness of CF-LVADs on survival and quality of life. A scenario analysis using contemporary survival data resulted in a cost per QALY gained of $125,936. When applying contemporary LVAD survival trends, the model showed that the cost of initial LVAD implantation needed to be less than $123,000 to be considered cost-effective. CONCLUSIONS: The incremental cost per QALY for destination therapy CF-LVADs is predicted to be above usual thresholds for funding in Canada. In some plausible scenarios, its cost-effectiveness is similar to dialysis for kidney failure, a therapy that is also immediately life-saving. Because of this, there will be likely ongoing pressure to fund CF-LVADs for a subset of patients ineligible for transplantation.

Current state of cardiac amyloidosis.

PURPOSE OF REVIEW: Cardiac amyloidosis, an infiltrative restrictive cardiomyopathy once thought to be universally fatal, is now increasingly recognized as less rare than previously thought. This update is intended to provide a review of newer aspects of the presentation, diagnosis and treatment of cardiac amyloidosis. RECENT FINDINGS: Amyloid involvement of the heart is increasingly seen, especially in the elderly population. Recent data suggest life expectancy has increased from 6 to 16-20 months in the most common subtype, AL amyloid. The clinical presentation is typically one of heart failure in the setting of normal or low normal ejection fraction, inappropriate ventricular hypertrophy and atrial enlargement with or without atrial fibrillation. Diagnosis is now most often made by cardiac MRI, with 2D echocardiography serving more of a screening role in patients with heart failure or a similar family history. The gold standard diagnostic test is right-ventricular biopsy, which demonstrates positivity for Congo Red staining. Due to a propensity for disease progression, typically low systemic blood pressure, frequent extra-cardiac involvement and autonomic dysfunction, cardiac amyloidosis is difficult to treat due to poor tolerance of most cardiovascular medication and poor outcome for transplantation. Newer therapies such as bortezomib, usually given to patients with multiple myeloma and serum light chains, are promising in controlling amyloidosis. CONCLUSION: Recent advances in diagnosis and treatment of amyloid are associated with improved prognosis. Newer therapies offer future benefits.

Cardiac outcomes in adults with supravalvar aortic stenosis.

AIMS: Supravalvar aortic stenosis is a rare form of left ventricular outflow tract obstruction that is often progressive in childhood. Little data are available on outcomes in the adult population. Our aim was to define cardiac outcomes in adults with supravalvar aortic stenosis. METHODS AND RESULTS: This is a multicentre retrospective study of cardiac outcomes in adults (≥18 years) with supravalvar aortic stenosis. We examined: (i) adverse cardiac events (cardiovascular death, myocardial infarction, stroke, heart failure, sustained arrhythmias, and infective endocarditis) and (ii) the need for cardiac surgery in adulthood. One hundred and thirteen adults (median age at first visit 19 years; 55% with Williams-Beuren syndrome; 67% with surgical repair in childhood) were identified. Adults without Williams-Beuren syndrome had more severe supravalvar aortic stenosis and more often associated left ventricular outflow tract obstructions (P < 0.001). In contrast, mitral valve regurgitation was more common in patients with Williams-Beuren syndrome. Eighty-five per cent of adults (96/113) had serial follow-up information (median follow-up 6.0 years). Of these patients, 13% (12/96) had an adverse cardiac event and 13% (12/96) had cardiac operations (7 valve repair or replacements, 4 supravalvar aortic stenosis repairs, 1 other). Cardiac surgery was more common in adults without Williams-Beuren syndrome (P = 0.007). Progression of supravalvar aortic stenosis during adulthood was rare. CONCLUSION: Adults with supravalvar aortic stenosis remain at risk for cardiac complications and reoperations, while progression of supravalvar aortic stenosis in adulthood is rare. Valve surgery is the most common indication for cardiac surgery in adulthood.