Neuromyelitis Optica Spectrum Disorder Mimicking Pontine Stroke: A Case Report and Systematic Literature Review.

Neuromyelitis optica spectrum disorder (NMOSD) is a rare autoimmune disorder that was first described in the late 1800s as a variant of multiple sclerosis (MS). However, it has recently been categorized, as a disease, especially with the discovery of aquaporin-4 (AQP4-Ab) and myelin oligodendrocyte glycoprotein antibodies (MOG-Ab). Unfortunately, patient presentation is not always clear, and NMOSD may initially be diagnosed as an alternative neurological disease. We present a 58-year-old woman who was hospitalized several times for what was initially perceived as a pontine stroke. However, given worsening symptoms, serologic testing confirmed AQP4-Ab positivity and, subsequently, the NMOSD diagnosis. In addition to the case report, a systematic literature review was performed to identify NMOSD cases initially misdiagnosed as stroke. Publications were selected and curated in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Six NMOSD patients were initially thought to have had acute strokes. However, steady progression and/or the recurrence of symptoms suggested that further investigations with neuroimaging studies and serological immune assays were necessary to exclude alternative etiologies. Notably, the age at onset in all cases was significantly more advanced than patients with typical NMOSD presentations (median age 32-41). In conclusion, the NMOSD diagnosis should be considered in cases with atypical stroke-like presentations, particularly those of later onset (defined as equal to or greater than 50 years of age). This is important as early recognition and treatment with immune therapies can improve functional outcomes.

Impacts of Anxiety and Depression on Clinical Hypertension in Low-Income US Adults.

INTRODUCTION: Depression and anxiety are common leading causes of disability and are associated with systemic effects including cardiovascular comorbidities. Low-income populations may experience higher frequencies of depressive or anxiety-related symptoms, and be at greater risk for developing hypertension. AIM: We performed a cross-sectional study of low-income participants who completed hypertension and disability questionnaires as part of the 2017-2018 cycle of the National Health and Nutrition Examination Survey (NHANES) to identify associations between depressive/anxiety-related symptoms and hypertension status. METHODS: Multivariable logistic regressions were performed to identify whether (1) frequency of depressive symptoms, (2) frequency of anxiety-related symptoms, (3) self-reported depression medication use, or (4) self-reported anxiety medication use predicted previous hypertension diagnosis. RESULTS: A total of 74,285,160 individuals were represented in our cohort. Participants that reported taking depression (OR 2.72; 95% CI 1.41-5.24; P = 0.009) and anxiety (OR 2.50; 95% CI 1.42-4.41; P = 0.006) medications had greater odds of hypertension. Individuals with depressive feelings daily, monthly, and few times per year were more likely to have hypertension. Respondents with daily (OR 2.28; 95% CI 1.22-4.24; P = 0.021) and weekly (OR 1.88; 95% CI 1.05-3.38; P = 0.040) anxiety symptoms were more likely to have hypertension. CONCLUSIONS: Low-income adults in the United States with symptoms of anxiety or depression have higher likelihood of hypertension than those with no symptoms. Respondents who indicated taking medication for anxiety disorders or depression were more likely to have been diagnosed with hypertension.

Sustained cannabis use does not predispose clinical hypertension: Findings from a national survey.

Cannabis is among the most used recreational and medicinal drugs in the United States. The effects of chronic use on hypertension remain poorly understood. Our study retrospectively evaluated data collected by the National Health and Nutrition Examination Survey from 2017 to 2018. Cannabis use was measured with five metrics: (1) sustained use at any point in the past, (2) sustained use within the past year, (3) frequency of use, (4) age of first cannabis use, and (5) current use. Hypertension status was determined by individuals reporting having been diagnosed in the past. Multivariable logistic regressions were performed, controlling for age, race, and gender. A total of 4565 respondents were identified, of which 867 (19.0%) reported sustained cannabis use in the past. Participants who reported past sustained cannabis use did not have statistically different odds of having hypertension (OR: 1.12; 95% CI: .66-1.91; p = .6). Moderate (OR: 1.08; 95% CI: .36-3.25; p = .8) and highly-frequent users (OR: 1.30; 95% CI: .56-3.03; p = .4) did not have different odds of having hypertension than infrequent users. No relationship between the age of first cannabis use and hypertension was observed. The recency of sustained cannabis use was not associated with hypertension status. Current cannabis users had similar odds of hypertension as past users (OR: 1.03; 95% CI: .59-1.79; p = .9). The findings of this study indicate that neither past nor current cannabis use is associated with clinical hypertension.

Obstructive Sleep Apnea and Cardiovascular Disease.

Obstructive sleep apnea (OSA) presents as repetitive interruptions of ventilation >10 seconds during sleep as a result of upper airway obstruction resulting in increased respiratory effort. Intermittent hypoxia causes physiologic changes resulting in increased catecholamine production, increased total peripheral resistance, tachycardia, and increased venous return, leading to increased cardiac output, hypertension, tachyarrhythmias, left ventricular hypertrophy, and heart failure. OSA causes an abnormal dip on 24-hour ambulatory blood pressure monitoring. Definitive diagnosis is made by polysomnography. Continuous positive airway pressure (CPAP) remains the first-line treatment. Effective treatment using CPAP reduces blood pressure and is indispensable for proper management of atrial fibrillation.

Preoperative nuclear stress testing in the very old patient population.

BACKGROUND: Elderly patients awaiting moderate to high-risk surgery may undergo nuclear stress testing (NST) in order to evaluate their cardiovascular risk. The prognostic utility of such testing in the very elderly (≥ 85 years) has yet to be fully evaluated. Octogenarians and nonogenarians frequently have a number of concurrent conditions including a high rate of coronary disease, and therefore the prognostic value of NST for their preoperative risk assessment has been questioned. Our evaluation assesses the ability of nuclear stress testing to predict peri-operative cardiac outcomes in this patient population. AIM: To investigate the ability of NST to predict peri-operative cardiac outcomes in elderly patients awaiting moderate to high-risk surgery. METHODS: Patients ≥ 85 years undergoing pre-operative NST were retrospectively evaluated. Patients undergoing low-risk surgery were excluded. Major adverse cardiac events (MACE) were considered any adverse event that occurred prior to discharge and included acute heart failure, arrhythmia, acute myocardial infarction, unstable angina, or death. Associations between patient risk factors, MACE, and the obtained results of the pre-operative stress testing, ejection fraction (< 40% or ≥ 40%), summed stress score (≤ 8, ≥ 9), and the summed difference score (≤ 0, > 0) were analyzed. RESULTS: A total of 69 patients (mean age 88 ± 2.6 years, 31 males) underwent nuclear stress testing prior to surgery. There were 41 (60%) patients found to have an abnormal NST. Sixteen (23%) patients were noted to experience post-operative MACE. No significant associations between risk factors and MACE were noted. Patients with an abnormal NST and/or a summed stress score ≥ 9 were significantly (P < 0.01) more likely to develop peri-operative MACE. CONCLUSION: Indicated preoperative NST is useful to assess pre-operative risk in elderly patients ≥ 85 years undergoing moderate to high-risk surgery.

Impact of Cardiovascular Risk on the Relative Benefit and Harm of Intensive Treatment of Hypertension.

BACKGROUND: The lower rate of primary outcome events in the intensive treatment group in SPRINT (Systolic Pressure Intervention Trial) was associated with increased clinically significant serious adverse events (SAEs). In 2017, the American College of Cardiology/American Heart Association issued risk-based blood pressure treatment guidelines. The authors hypothesized that stratification of the SPRINT population by degree of future cardiovascular disease (CVD) risk might identify a group which could benefit the most from intensive treatment. OBJECTIVES: This study investigated the effect of baseline 10-year CVD risk on primary outcome events and all-cause SAEs in SPRINT. METHODS: Stratifying by quartiles of baseline 10-year CVD risk, Cox proportional hazards models were used to examine the associations of treatment group with the primary outcome events and SAEs. Using multiplicative Poisson regression, a predictive model was developed to determine the benefit-to-harm ratio as a function of CVD risk. RESULTS: Within each quartile, there was a lower rate of primary outcome events in the intensive treatment group, with no differences in all-cause SAEs. From the first to fourth quartiles, the number needed to treat to prevent primary outcomes decreased from 91 to 38. The number needed to harm for all-cause SAEs increased from 62 to 250. The predictive model demonstrated significantly increasing benefit-to-harm ratios (± SE) of 0.50 ± 0.15, 0.78 ± 0.26, 2.13 ± 0.73, and 4.80 ± 1.86, for the first, second, third, and fourth quartile, respectively (p for trend <0.001). All possible pairwise comparisons of between-quartile mean values of benefit-to-harm ratios were significantly different (p < 0.001). CONCLUSIONS: In SPRINT, those with lower baseline CVD risk had more harm than benefit from intensive treatment, whereas those with higher risk had more benefit. With the 2017 American College of Cardiology/American Heart Association blood pressure treatment guidelines, this analysis may help providers and patients make decisions regarding the intensity of blood pressure treatment.

Normal or near normal myocardial perfusion stress imaging in patients with severe coronary artery disease.

BACKGROUND: Normal or near normal myocardial perfusion stress imaging (MPI) suggests the absence of life-threatening coronary artery disease (CAD). Nevertheless, there are instances where severe left main or three-vessel CAD may be present despite no significant perfusion abnormalities on MPI. METHODS: Review of Tl-201 or Tc-99m sestamibi MPI over a period of 5 years to ascertain the features that may prevent misdiagnosis. Out of 9171 tests, 3992 (44%) were interpreted as normal or near normal. For clinical reasons, 98 (2%) of these patients underwent coronary angiography within 6 months. RESULTS: A total of 3992 patients were interpreted as normal or near normal. Seventy (22 men/48 women; 58 +/- 13 years) did not have obstructive CAD. Nine (six men/three women; 64 +/- 8 years) had either left main (n = 3), three-vessel CAD with or without left main (n = 3) or severe proximal left anterior descending (n = 3) disease. Although both normal patients and patients with CAD had similar proportions of imaging artifacts, those with severe CAD had significantly more markers of CAD (increased lung Tl-201 uptake, transient ischemic cavity dilatation, stress-induced ST-segment depression, chest pain, and/or hypotension with exercise; P < 0.01; no CAD vs. severe CAD; two-tail Fisher's Exact Test). Similarly, patients with moderate CAD by coronary angiography (n = 19), and a random sample of 250 patients (82 men/168 women; 62 +/- 14 years) with normal or near normal MPI who did not undergo coronary angiography, had similar proportions of imaging artifacts but significantly fewer markers of CAD. CONCLUSION: When dealing with individual patients, the referring physician and the interpreter of MPI studies should consider severe CAD when there are markers of CAD despite normal or near normal perfusion images.

Intracerebral hemorrhage: a life-threatening complication of hypertension during pregnancy.

Intracerebral hemorrhage (ICH) is an infrequent but severe complication in pregnant women with hypertension. The authors describe a patient with chronic hypertension who developed superimposed preeclampsia and spontaneous ICH during the thirty-fifth week of pregnancy. ICH was diagnosed by computed tomographic scan. She underwent successful emergent cesarean section and neurosurgical decompression of the ICH. Both intraoperative surveillance and postoperative magnetic resonance angiographic examination of the cerebral vessels failed to identify an aneurysm or arteriovenous malformation. The authors discuss the diagnosis and management in this case and review the literature regarding this challenging complication of pregnancy and preeclampsia. Controversies regarding treatment of hypertension during pregnancy are discussed in light of the impact on the management of this patient.

Nuclear stress testing in elderly patients: a review of its use in the assessment of cardiac risk, particularly in patients undergoing preoperative risk assessment.

Stress myocardial perfusion imaging (MPI) plays an important role in the diagnostic and prognostic assessment of coronary artery disease (CAD) in patients of all age groups who are undergoing assessment prior to non-cardiac surgery. MPI may utilise exercise treadmill or pharmacological stress testing. While MPI has been evaluated in a wide variety of patient subpopulations, there are very limited data on its prognostic value in the elderly population, particularly those >75 years of age, who are making up an ever increasing proportion of the patient population. Because of the higher prevalence and greater severity of CAD in older patients, the sensitivity of noninvasive MPI increases with age, whereas specificity tends to decline. In addition, maximal aerobic exercise capacity tends to decrease with age, making it common practice for elderly patients being assessed for CAD to undergo pharmacological MPI to evaluate their cardiovascular risk. In this article, we review the literature with respect to cardiac risk estimation in elderly patients undergoing MPI, particularly with respect to making prognostic assessments prior to undergoing surgery. Current data allow for the proper application of stress MPI in the elderly population. Use of MPI facilitates identification of the severity and extent of ischaemia as well as left ventricular dilatation and systolic function in elderly patients undergoing non-cardiac surgery.

Hypertensive heart disease.

Left ventricular hypertrophy (LVH) and diastolic dysfunction (CHF-D) are the early manifestations of cardiovascular target organ damage in patients with arterial hypertension and signify hypertensive heart disease. Identification of hypertensive heart disease is critical, as these individuals are more prone to congestive heart failure, arrhythmias, myocardial infarction and sudden cardiac death. Regression of left ventricular (LV) mass with antihypertensive therapy decreases the risk of future cardiovascular events. The goal of antihypertensive therapy is to both lower blood pressure (BP) and interrupt BP-independent pathophysiologic processes that promote LVH and CHF-D. The purpose of this review is to summarize current and emerging approaches to the pathophysiology and treatment of hypertensive heart disease.

Antihypertensive drugs and the heart.

Left ventricular hypertrophy (LVH) and diastolic dysfunction (CHF-D) are early signs of cardiac end-organ damage (hypertensive heart disease) in patients with arterial hypertension. The presence of LVH or CHF-D confers increased risk of cardiovascular morbidity and mortality in patients with hypertension. Regression of left ventricular mass with antihypertensive therapy is associated with reduction in cardiovascular events. Antihypertensive therapy should be geared to both lower blood pressure and specifically reverse the pathophysiologic processes that may be independent of actual blood pressure. This review summarizes current and emerging approaches to the treatment of individuals with hypertensive heart disease.

Regression of left ventricular hypertrophy: are there preferred drugs?

The presence of left ventricular hypertrophy (LVH) confers markedly increased risk of cardiovascular morbidity and mortality in patients with hypertension. Regression of left ventricular (LV) mass with antihypertensive therapy is associated with reduction in cardiovascular events. In studies based on monotherapy, among the classes of antihypertensive drugs that have been adequately tested, diuretics and angiotensin-converting enzyme inhibitors appear to be the most effective agents for reducing LV mass. New avenues of research, based on combination antihypertensive therapy and on a more sophisticated understanding of the molecular mechanisms of LVH, may yield new pharmacologic approaches to regressing LV mass.

Interesting clinical case studies involving secondary causes of hypertension.

While essential hypertension is very prevalent, secondary hypertension does occur in clinical practice with sufficient frequency to warrant special attention being given to those patients with severe hypertension who do not respond to standard treatments. The evaluation, diagnosis and treatment of secondary hypertension pose interesting challenges to the physician. In this article, three patients are described with different secondary causes of hypertension.

Effect of hormone replacement therapy on the electrocardiographic response to exercise.

BACKGROUND: Female gender and hormonal status affect electrocardiographic (ECG) response to exercise. Both are often cited as factors contributing to the decreased diagnostic accuracy of exercise stress tests in women. However, there is a paucity of data. To explore the relationship between hormonal status and exercise-induced ECG changes, we used gated single photon emission computed tomography (SPECT) technetium 99m sestamibi imaging for detection of myocardial ischemia. METHODS AND RESULTS: ECG response to exercise was analyzed in all female patients who underwent symptom-limited exercise stress testing over a 12-month period with no evidence of ischemia on SPECT myocardial perfusion imaging (N = 404). Hormonal status was defined as premenopausal (n = 78), postmenopausal (n = 277), and postmenopausal on hormone replacement therapy (HRT) (n = 49). Positive ECG response for ischemia was defined as 1 mm or greater horizontal and/or downsloping ST depression during and/or after exercise. The frequency of a positive ECG response to exercise without evidence of ischemia on gated SPECT imaging was analyzed according to hormonal status. Seventeen of 78 premenopausal women (22%), 48 of 277 postmenopausal women (17%), and 19 of 49 women taking HRT (39%) had a positive ECG response. ECG positivity was significantly higher in HRT users when compared with premenopausal (P =.05) and postmenopausal women (P =.001). CONCLUSIONS: Exogenous estrogen replacement therapy affects ST-segment response to exercise, likely through a nonischemic mechanism. Unless HRT can be discontinued for a prolonged period of time (up to 6 weeks) prior to a stress test, myocardial imaging should be used to improve diagnostic accuracy.