Take Me Higher: A Case of Heart Failure at High Altitude Detected Using the CardioMEMS™ HF System.

BACKGROUND The heart failure patient population can be challenging to treat and monitor. This is especially true when they travel to high altitudes where changes in pressure can affect their clinical status. The CardioMEMS™ HF System (Abbott Cardiovascular, Abbott Park, IL, USA) is an implanted miniature wireless device located in the pulmonary artery that transmits data on pulmonary artery pressure and heart rate. This data can be used to detect this dramatic invasive pressure change. CASE REPORT We present the case of a 78-year-old man with an exacerbation of heart failure while traveling to high altitude. Elevation of his pulmonary artery (PA) pressures were detected by his implanted CardioMEMS device. Understanding the expected change in PA pressure recordings helped to identify a true exacerbation of heart failure in our patient. This led to a prompt change in medical therapy, which ultimately prevented hospitalization. CONCLUSIONS Increased elevation can lead to falsely elevated PA pressure readings by the CardioMEMS device. However, we present the case of a patient with a disproportionate elevation of his hemodynamic pressure measurements, indicating an exacerbation of heart failure. This case demonstrates the value of the CardioMEMS device in detecting PA pressure changes in these unique circumstances.

Simultaneous Acute Anterior ST-Elevation Myocardial Infarction and Acute Ischemic Stroke of Left Middle Cerebral Artery: A Case Report.

BACKGROUND Acute ST-elevation myocardial infarction and acute ischemic stroke are both life-threatening conditions with high risk for morbidity and mortality without timely intervention. This simultaneous event has been reported to be as rare as 0.009%. The treatments of both conditions individually have been well documented in the literature and guidelines, but when presenting concomitantly, it poses a unique therapeutic challenge. Immediate treatment of one condition can delay management or even have deleterious effects on the other condition. CASE REPORT We present the case of a 41-year-old female with simultaneous acute anterior ST-elevation myocardial infarction and acute left middle cerebral artery ischemic stroke. Due to a low National Institute of Health score she was not a candidate for endovascular treatment and received alteplase per acute ischemic stroke protocol with delayed percutaneous coronary intervention. She was eventually discharged to a long-term acute care facility for continued rehabilitation. CONCLUSIONS The co-existence of ST elevation myocardial infarction and acute ischemic stroke is rare, but when these 2 common conditions present simultaneously, it provides a unique therapeutic challenge. Although infrequent, this challenging scenario deserves more recognition and a discussion among the medical community.

At the "threshold" of certainty: Risk stratification and clinical assessment incongruity in the diagnosis of aortic dissection.

The use of D-dimer assay to screen for aortic dissection has become routine in clinical practice. Although an uncommon disease entity, aortic dissection is rapidly fatal without prompt diagnosis, and biochemical detection in the proper clinical context is crucial. We performed a retrospective chart review of all aortic dissections presenting to a community tertiary care center between 2000 and 2016 and identified three patients in whom laboratory D-dimer testing was positive and a diagnosis of Stanford Type A aortic dissection was confirmed with computed tomography angiography based on clinical assessment and a newly validated risk stratification tool.

Accelerated ambulation after vascular access closure device.

BACKGROUND: Patients who are candidates to receive an Angioseal® (St. Jude Medical) device for arteriotomy closure are allowed to ambulate 20 min after the deployment of the device. More frequently, however, patients are kept on bed rest for several hours following Angioseal® deployment. The purpose of this study was to prospectively assess patients when ambulating 20 min after Angioseal® deployment instead of prolonged best rest of 2-3 h. METHODS: Patients undergoing angiography from the common femoral artery approach were included in the study if they received a 6 Fr Angioseal® closure device. RESULTS: Twenty-nine patients were successfully enrolled in the study; 27 (93.1%) patients ambulated at 20 min, 1 (3.45%) patient ambulated at 28 min, and 1 (3.45%) patient ambulated at 27 min due to transport times. There were zero complications with regard to hemorrhage or other groin complications. There is a substantial time difference in ambulation times between the conventional and early ambulation groups. CONCLUSION: Our study demonstrates that it is probably safe to ambulate patients who undergo diagnostic cardiac catheterization as early as 20 min after deployment of the 6 Fr Angioseal® closure device. ClinicalTrials.gov identifier: NCT03142126.

Same-day dual radial artery puncture examination in patients requiring percutaneous coronary intervention and the incidence of radial artery occlusion.

BACKGROUND: We sought to investigate the rate of radial artery occlusion (RAO) after same-day dual radial artery puncture. The trans-radial arterial approach (TRA) for diagnostic and interventional procedures has risen significantly in the United States. Although becoming more commonly performed, TRA is not without risk, and a potential complication is RAO. The rate of RAO after same-day dual artery puncture is unknown. METHODS: A retrospective analysis of 27 patients who underwent same-day dual radial artery puncture for percutaneous coronary intervention (PCI) at our institution (Providence Heart Institute in Southfield, MI, USA) from November 2011 to December 2013 were included after initially presenting for cardiac catheterization at a non-PCI-capable facility. The study patients were asked to follow up for evaluation of the radial artery, including obtaining a duplex ultrasound evaluation. RESULTS: The mean age of the patients was 65 years old with 66% of the patients being male. Of the 27 study participants, there were no symptoms reported that were related to RAO. Overall, one (3.7%) patient had an absent radial pulse. The modified Allen's test was normal in all of the patients with a mean return of palmar flush time of 4 seconds. Duplex ultrasound revealed subtotal RAO in four (14.8%) patients and no patients experienced total occlusion following the intervention. CONCLUSION: Dual radial artery puncture appears to be a well-tolerated and viable strategy in patients that are transferred to a PCI-capable hospital for coronary interventions.

Rapid resolution of left ventricular thrombus with apixaban therapy.

It is a common medical practice to anticoagulate an asymptomatic left ventricular mural thrombus following an ST-elevation myocardial infarction using a vitamin K antagonist. Novel oral anticoagulants have not been studied extensively in this context, and therefore, no recommendations have been made for their use. A 67-year-old male physician with no significant medical history presented to the cardiology clinic complaining of shortness of breath that had been gradually worsening over a 2-week period and was found to have an anterior wall myocardial infarction with apical left ventricular thrombus that was treated with apixaban. We present a case of rapid resolution of left ventricular thrombus with the use of apixaban for anticoagulation. Although there are no guideline recommendations for this use, there have been case series and case reports that have shown safety and efficacy. Apixaban can be used for rapid resolution of left ventricular thrombus treatment.

Cannabis induced asystole.

Cannabis or marijuana is the most used recreational, and until recently illegal, drug in the United States. Although cannabis has medicinal use, its consumption has been linked to motor vehicle accidents in dose dependent fashion. Marijuana and other cannabinoids produce a multitude of effects on the human body that may result in these motor vehicle accidents. Some of the effects that marijuana has been known to cause include altered sensorium, diminished reflexes, and increased vagal tone. We present a case of cannabis induced asystole from hypervagotonia.

Do cinnamon supplements cause acute hepatitis?

BACKGROUND: The use of herbal medications to treat various diseases is on the rise. Cinnamon has been reported to improve glycolated hemoglobin and serum glucose levels. When patients consider the benefit of such substances, they are often not aware of potential adverse effects and drug interactions. Cinnamon, via coumarin, can cause liver toxicity. Therefore, its concomitant use with hepatotoxic drugs should be avoided. CASE REPORT: A 73-year-old woman was seen in the Emergency Department complaining of abdominal pain associated with vomiting and diarrhea after she started taking cinnamon supplements for about 1 week. The patient had been taking statin for coronary artery disease for many months. The laboratory workup and imaging studies confirmed the diagnosis of hepatitis. The detail workup did not reveal any specific cause. Cinnamon and statin were held. A few weeks after discharge, the statin was resumed without any further complications. This led to a diagnosis of cinnamon-statin combination-induced hepatitis. CONCLUSIONS: A combination of cinnamon supplement and statin can cause hepatitis, and it should be discouraged.

Timing for pacing after acquired conduction disease in the setting of endocarditis.

A 53-year-old gentleman with a history of a mechanical aortic valve presented to the emergency department complaining of a sudden right-sided abdominal pain. He was found to have atrioventricular dissociation on his initial electrocardiogram and his blood cultures grew Streptococcus viridans. The suspicion for endocarditis with periaortic abscess was high so a transthoracic echocardiogram was performed and showed a mass in the left ventricular outflow tract. For better visualization, a transesophageal echocardiogram was recommended and revealed a bileaflet mechanical aortic valve with perivalvular abscess and valvular vegetation as well as severe eccentric paravalvular aortic regurgitation. After sterilization, the patient underwent a successful surgery. Postoperatively, he remained in complete heart block and a permanent pacemaker placement was performed after complete sterilization. He tolerated the procedure well and was discharged home in a stable condition. Perivalvular abscess is one of the most common cardiac complications of infective endocarditis and is associated with an increased risk of mortality. It is imperative to have appropriate treatment guidelines established. However, because of the relative nature of the disease process and the acuity at which intervention needs to be done, a true assessment of the duration of antibiotic therapy prior to surgical intervention, timing of pacemaker placement, and the type of pacemaker is controversial.

Use of a single question to screen trauma patients for alcohol dependence.

BACKGROUND: Alcohol-dependent trauma patients are known to be at future risk for both recidivism and mortality. Psychological tools exist to screen for alcohol-dependent disorders, and among patients with alcohol-dependent disorders, a brief intervention has been shown to modify behavior. However, the training involved and time required to administer these tools may decrease their utility. We explored the possibility that yet simpler screening tools could be used. METHODS: A prospective consecutive study was designed whereby all adult patients admitted to the trauma service were asked to participate in the study. If consent was obtained, one trained member of the research team would apply a standard alcohol-misuse screening tool (i.e., the Alcohol Use Disorders Identification Test [AUDIT]). One hundred forty-nine patients met criteria and agreed to participate. Fully completed questionnaires were then subjected to statistical analysis. RESULTS: Among the 149 participating patients, 36% were women and 64% were men, and 146 had blood alcohol levels (BALs) drawn. Those 146 patients form the basis of this report. Fifty-seven of the 146 (39%) patients had positive BALs and, among them, 74% of men and 54% of women recorded screening results consistent with harmful or dependent drinking. Among those with negative blood alcohol levels, 8% of women and 13% of men had scores consistent with harmful or dependent drinking by the AUDIT score. In both groups of patients, a cutoff of three or more drinks per day as a response to question 2 on the AUDIT (i.e., "On a typical day when you are drinking, how many drinks do you have?") correlated strongly with scores on the entire screening tool (AUDIT) in identifying those at risk for alcohol misuse. CONCLUSION: It may be reasonable to substitute a single question for the entire AUDIT screening instrument to screen for those at risk for alcohol misuse. If so, this single question could easily be incorporated into the history taken among patients admitted to a trauma service. Confirmation with a larger study is recommended.