The contemporary trends and geographic variation in premature mortality due to heart failure from 1999 to 2018 in the United States.

OBJECTIVES: We aimed to examine the contemporary trends and regional variations in premature mortality due to heart failure across the U.S. from 1999 to 2018. BACKGROUND: For most U.S. census regions, it is unknown whether premature mortality (deaths among persons under age 65) due to heart failure is increasing -or decreasing. METHODS: In this descriptive study, the death certificate data were retrieved from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (WONDER) database and examined from 1999 to 2018 for the underlying cause of death. Age-adjusted mortality rates (AAMR) per 100,000 persons and annual percent change (APC) in rates stratified by census region were calculated using Joinpoint trend analysis software. RESULTS: There were 118,116 premature deaths due to heart failure from 1999 to 2018 across the U.S. Of these 52.40% of deaths were reported in the South, 20.30% in the Midwest, 15.10% in the West, and 12.20% in the Northeast. The AAMRs were the highest in the South region (range: 3.1-4.9) and the lowest in the Northeast region (range: 1.5-1.9). There was an overall decline in mortality across all regions from 1999 till 2011-2012. However, mortality has an upward trajectory throughout all the census regions after 2012. CONCLUSIONS: This study on nationwide data showed that overall premature mortality due to heart failure declined from 1999 to 2011-2012 followed by an upward trajectory from 2012 to 2018; the explanation for this merits further discovery.

The role of echocardiography in diagnostic evaluation of patients with syncope-a retrospective analysis.

BACKGROUND: Syncope is a symptom complex comprising of a brief loss of consciousness leading to a transient decrease in cerebral blood flow that resolves completely. 2D-transthoracic echocardiography (TTE) is a useful tool to detect underlying structural heart disease, which can lead to syncope, e.g., aortic stenosis, atrial masses. This study aimed to find the subgroups of patients with syncope who would benefit the most from a TEE. METHODS: We did a retrospective chart review of all patients aged 18 years or older, admitted to our hospital with a primary diagnosis of syncope between January 2015 and January 2017 to determine the frequency and findings of echo in all these patients. The baseline characteristics, demographics were taken into account for the inclusion of these patients into the study. RESULTS: A total of 369 patients were initially studied, but only 139 patients were included in the final analysis based on inclusion criteria. Among the high-risk patients (i.e., abnormal Physical exam and/or abnormal EKG, population), 43.75% had significant echocardiographic finding. While among low-risk patients (i.e., normal EKG and exam), 10% (9/91) had a significant finding. Patients with abnormal EKG or examination findings were 7.08 times (95% CI = 2.89-17.3) more likely to have an abnormal echocardiogram (P < 0.001). CONCLUSION: Our study suggests that the diagnostic yield of 2D-TTE in the absence of abnormal physical exam and/or abnormal EKG is very limited and may add an extra burden on the finances and resources of both the patient and the hospital.

"Singultus" uncloaking potentially fatal vascular dissections.

Aortic dissection (AD) is a serious condition in which the intimal layer of aorta tears and blood surges in between the intimal and medial layers of aorta causing it to separate (dissect). It usually presents with excruciating pain radiating to the back. Here we present a unique presentation of AD where an old-aged Caucasian male presented with a chronic history of intractable hiccups. His computed tomography (CAT scan) revealed the dissection of the descending thoracic aorta. He was managed conservatively and was discharged home in stable condition. The purpose of this report is to highlight this unusual presentation of AD and unmask the possible etiology of hiccups in such cases.

Tilting the balance: hemidiaphragm paralysis leading to right to left cardiac shunt.

Patent foramen ovale (PFO) is a congenital abnormality present in 25%-30% of healthy adults and rarely leads to any sequelae. 1 2 It is associated with a left-to-right shunt which usually does not lead to any haemodynamic compromise. Occasionally, the shunt can get reversed; that is, right-to-left shunt occurs due to worsening pulmonary hypertension and can lead to persistent hypoxia. It is rare for the shunt reversal to happen in the absence of pulmonary hypertension. Here, we present an exceedingly rare case in a 61-year-old man presenting with hypoxia, was found to have shunt reversal due to unilateral diaphragmatic paralysis. He was successfully treated with PFO closure. The purpose of this report is to consider rare possibilities of PFO shunt reversal when the right-sided heart pressure is normal and to highlight that a simple chest X-ray can be a clue to the diagnosis.

The Effects of Geography on Outcomes of Routine Early Versus Selective Late Revascularization Strategy in the Treatment of Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction: A Meta-Analysis of Transatlantic Randomized Controlled Trials.

BACKGROUND: The optimal timing of revascularization in unstable angina (UA) or non-ST-segment elevation myocardial infarction (NSTEMI) remains uncertain. We compared routine early revascularization (REV) versus selective late revascularization (SLR) strategies and divergence in the approach of cardiologists in the United States and Europe. METHODS: Seventeen randomized controlled trials (RCTs) (15,812 patients) were extracted from PubMed, Cochrane Library, EMBASE and Web of Science databases. The data were pooled using the Der Simonian and Laird random-effect models and expressed as pooled risk ratios (RR) with 95% confidence intervals (95% CIs). RESULTS: Overall, there was no difference in all-cause mortality (RR: 1.01, 95% CI: 0.95 - 1.08, P = 0.7), myocardial infarction (MI) (RR: 0.98, 95% CI: 0.79 - 1.22, P = 0.85) or coronary artery bypass grafting (CABG) (RR: 1.33, 95% CI: 0.92 - 1.91, P = 0.12) between REV and SLR strategy. There were trends of decreased incidence of MI in REV, 13.3% (1,029/7,704) vs. 15.1% (1,108/7,314) in SLR (P = 0.007), and rate of CABG was higher in REV, 4.9% (140/2,831) vs. 3.7% (105/2,819) in SLR (P = 0.031). There were trends of lower all-cause mortality in the combined US/international trials in both REV 8.4% (390/4,624) vs. 22.8% (908/3,975) (P < 0.001) and SLR 8% (359/4,421) vs. 24% (910/3,808) (P < 0.001) compared to the European trials. There were also trends of lower rates of MI in the European trials in the REV group 20% (623/3,080) vs. 25% (712/2,893) in SLR (P = 0.001) and higher rates of CABG in REV 8.3% (96/1,144) vs. 5.7% (67/1,165) in SLR (P = 0.02); however, there were no significant effects in the pooled RR ratios even after subgroup analysis between US/international trials and European trials. CONCLUSIONS: Despite having contemporary differences in the management approach towards UA/NSTEMI patients, no significant differences in trends were observed with REV strategy in US/international trials vs. European trials.

Left Ventricular Pseudoaneurysm: An Overview of Diagnosis and Management.

Left ventricular pseudoaneurysm is a rare but life-threatening disorder that is frequently reported secondary to myocardial infarction or cardiac surgery. In this article, we chronicle the case of a patient with no prior risk factors who presented with a 2-week history of nonexertional atypical left chest pain. Apical 2-chamber transthoracic echocardiography revealed an unexpected outpouching of basal inferoseptal wall of the left ventricle, which had a narrow neck and relatively wide apex. The patient was diagnosed with left ventricular pseudoaneurysm and medical therapy was initiated. He refused to undergo the surgical intervention and subsequently, he was discharged from the hospital in stable condition. This article illustrates that physicians should be vigilant for atypical presentations of left ventricular pseudoaneurysm, and a high index of suspicion should be maintained for this stealth killer while performing appropriate diagnostic imaging. Additionally, we review the currently available approaches to diagnosis and management in these patients.

Trends, etiologies, and predictors of 90-day readmission after percutaneous ventricular assist device implantation: A national population-based cohort study.

Percutaneous ventricular assist devices (pVADs) are indicated to provide hemodynamic support in high-risk percutaneous interventions and cardiogenic shock. However, there is a paucity of published data regarding the etiologies and predictors of 90-day readmissions following pVAD use. We studied the data from the US Nationwide Readmissions Database (NRD) for the years 2013 and 2014. Patients with a primary discharge diagnosis of pVAD use were collected by searching the database for International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedural code 37.68 (Impella and TandemHeart devices). Amongst this group, we examined 90-day readmission rates. Comorbidities as identified by "CM_" variables provided by the NRD were also extracted. The Charlson Comorbidity Index was calculated using appropriate ICD-9-CM codes, as a secondary diagnosis. A 2-level hierarchical logistic regression model was then used to identify predictors of 90-day readmission following pVAD use. Records from 7074 patients requiring pVAD support during hospitalization showed that 1562 (22%) patients were readmitted within 90 days. Acute decompensated heart failure (22.6%) and acute coronary syndromes (11.2%) were the most common etiologies and heart failure (odds ratio [OR]: 1.39, 95% confidence interval [CI]: 1.17-1.67), chronic obstructive pulmonary disease (OR: 1.26, 95% CI: 1.07-1.49), peripheral vascular disease (OR: 1.305, 95% CI: 1.09-1.56), and discharge into short- or long-term facility (OR: 1.28, 95% CI: 1.08-1.51) were independently associated with an increased risk of 90-day readmission following pVAD use. This study identifies important etiologies and predictors of short-term readmission in this high-risk patient group that can be used for risk stratification, optimizing discharge, and healthcare transition decisions.

Spontaneous Coronary Artery Dissection: A Case Series of 9 Patients With Literature Review.

Spontaneous coronary artery dissection is an increasingly recognized nonatherosclerotic cause of acute coronary syndrome. Reports regarding the prognosis and natural history of this disease are limited. In addition to the diagnostic difficulty, this condition poses a significant therapeutic challenge due to the lack of specific management guidelines. We present here a case series of 9 patients with spontaneous coronary artery dissection. Additionally, this article reviews the incidence, clinical characteristics, risk factors, diagnostic modalities, therapeutic approaches, and patterns of recurrence in patients with spontaneous coronary artery dissection.

Meta-Analysis of Antithrombotic Therapy in Atrial Fibrillation After Percutaneous Coronary Intervention.

Current clinical practice prefers oral anticoagulation (OAC) plus dual antiplatelet therapy (DAPT) in atrial fibrillation (AF) after percutaneous coronary intervention (PCI). We conducted a meta-analysis to test the hypothesis that the superiority of OAC plus DAPT is mainly endorsed by observational studies (OSs); conversely, randomized clinical trials (RCTs) have suggested that OAC plus a single antiplatelet (SAP) agent is a safer and equally effective approach. Nine studies (4 RCTs and 5 OSs) were selected using MEDLINE, EMBASE, and CENTRAL (Inception, October 31, 2017). In analysis of RCTs, OAC plus SAP was safer in terms of major bleeding compared with OAC plus DAPT (relative risk [RR] 0.70, 95% confidence interval [CI] 0.60 to 0.81, p <0.001). Conversely, analysis of OSs showed comparable risk of major bleeding among both groups (RR 0.92, 95% CI 0.65 to 1.29, p = 0.61). For major adverse cardiovascular events, RCTs restricted analysis (RR 0.93, 95% CI 0.68 to 1.27, p = 0.64) and analysis of OSs (RR 1.43, 95% CI 0.84 to 2.42, p = 0.19) showed similar outcomes between both strategies. Both regimens had a similar risk of myocardial infarction (MI) in RCTs restricted analysis (RR 1.18, 95% CI 0.89 to 1.56, p = 0.24); however, analysis of OSs showed 76% higher risk of MI with OAC plus SAP. In conclusion, in patients with AF after PCI, RCTs recommend OAC plus SAP for better safety and equal efficacy compared with OAC plus DAPT. These findings oppose the results of OSs that showed similar safety and reduced risk of MI with OAC plus DAPT.

Some neck swellings are serious; a case of Lemierre's Syndrome.

Lemierre's syndrome also termed post-anginal septicemia, is a disease characterized by internal jugular septic thrombophlebitis leading to Fusobacterium septicemia with multiple metastatic foci following an oropharyngeal infection. Diagnosis and management is challenging and can result in fatal consequences due to potential multisystem involvement and multiple complications. We describe here a case of Lemierre's syndrome with multifocal pneumonia, acute renal failure and protracted course of illness over forty days with successful recovery. A brief overview of literature is also presented.

A Rare Presentation of Fibromuscular Dysplasia: Postpartum Vascular Catastrophe and Brief Literature Review.

Spontaneous coronary artery dissection is a very rare cause of acute coronary syndromes and can be life threatening given the rarity of the condition. It should be part of differentials in young females presenting with acute coronary syndromes without routine risk factors for coronary artery disease, especially before, during, and after pregnancy. It is closely associated with fibromuscular dysplasia and management can be very challenging at times. We present a case of spontaneous coronary artery dissection presenting with recurrent ST segment elevation myocardial infarction in association with fibromuscular dysplasia.

An Extensive Unprovoked Left Lower Extremity Deep Vein Thrombosis Secondary to an Anatomical Anomaly: A Case of May-Thurner Syndrome.

May-Thurner syndrome (MTS) also known as Cockett's syndrome is a rare condition responsible for 2%-3% of all cases of deep venous thrombosis (DVT). The thrombosis results from mechanical compression of the left common iliac vein against the body of the fifth lumbar vertebra by the right common iliac artery. Repetitive hyperplasia of the venous wall by compression results in spur formation that in turn causes venous flow obstruction and results in the DVT. Our case is a young female who had acute extensive proximal DVT due to MTS that was successfully managed using mechanical thrombectomy with a venous stent. MTS although a rare entity should be suspected especially in young patients with unilateral DVT with extensive clots especially on left lower extremity without any antecedent risk factors.

Eculizumab refractory thrombotic thrombocytopenic purpura secondary to post-endoscopic retrograde cholangiopancreatography pancreatitis in a patient.

Thrombotic thrombocytopenic purpura (TTP) is a rare multisystem microvascular disorder, which is characterized by pentad of thrombocytopenia, microangiopathic hemolytic anemia, and organ dysfunction due to occlusive thrombi. The proposed pathophysiology involves an imbalance between unusually large von Willebrand factor multimers and the cleaving protease ADAMTS13. Acute pancreatitis is a well-described consequence of TTP, but TTP secondary to acute pancreatitis is a rare phenomenon. We present a patient who developed TTP due to post-ERCP pancreatitis with hematologic, cardiovascular, pulmonary, and renal complications and is the first case of this kind. Despite early initiation of therapy, the patient did not recover making it among the 10% of cases of TTP that prove fatal despite appropriate therapy.

Prosthetic Aortic Valve Endocarditis with Left Main Coronary Artery Embolism: A Case Report and Review of the Literature.

CONTEXT: Coronary embolization is potentially a fatal sequela of endocarditis. Although the primary cause of acute coronary syndrome is atherosclerotic disease, it is imperative to consider septic embolism as an etiological factor. CASE REPORT: Herein, we report a case of ventricular fibrillation and ST-segment depression myocardial infarction occurring in a patient who initially presented with fever and increased urinary frequency. Coronary angiography revealed new 99% occlusion of the left main coronary artery (LMCA). Transesophageal echocardiography showed bioprosthetic aortic valve with an abscess and vegetation. Histologic examination of the embolectomy specimen confirmed the presence of thrombus and Enterococcus faecalis bacteria. Subsequently, the patient was discharged to the skilled nursing facility in a stable condition where he completed 6 weeks of intravenous ampicillin. CONCLUSION: We present a rare case of LMCA embolism due to prosthetic valve endocarditis. The present report also highlights the diagnostic and therapeutic challenges associated with such patients.

QRS fragmentation: its role in sherlocking the arrhythmogenic heart.

The electrocardiogram (ECG) is a commonly available basic diagnostic modality in in-patient, out-patient, and emergency departments. In patients with coronary artery disease (CAD), the presence of a fragmented QRS (f-QRS), which is an extra R wave (R'), notching of the single R wave, notching of the S wave in at least two contiguous leads on the 12-lead ECG, is associated with a myocardial scar from previous myocardial injury. Furthermore, the presence of f-QRS has been shown to be associated with adverse outcomes in CAD and non-CAD patients. In the present paper, we will solely focus on the usefulness and utilization of f-QRS in predicting ventricular tachyarrhythmia in many heart diseases, that is, ischemic cardiomyopathy, non-ischemic cardiomyopathy, hypertrophic obstructive cardiomyopathy, Brugada syndrome, and arrhythmogenic right ventricular cardiomyopathy. In the majority of such cases, ventricular tachyarrhythmia results in sudden cardiac death. Diagnosing them beforehand can lead to prevention and/or early treatment of these arrhythmias to prevent potential morbidity and mortality.

High incidence of sudden cardiac death in one family with type-3 long QT syndrome: molecular genetics and electrophysiology mechanism analysis / 中华心血管病杂志

<p><b>OBJECTIVES</b>We identified the long QT syndrome (LQTS) patients, and detected the potential risk of LQTS in family members by using genetic testing and electrophysiological analysis, which helped provide clinical evaluation and appropriate treatment.</p><p><b>METHODS</b>Detailed clinical characteristics and familiar history were obtained from the whole family members of an idiopathic pediatric LQTS patient. Two hundred healthy subjects with the same ethnic background were recruited as controls. The entire coding sequences of three candidate genes including KCNQ1, KCNH2 and SCN5A were screened for mutations in the proband. The function of the mutation was then explored by whole-cell patch clamp techniques, and the genetic testing and risk assessment of the family members were performed.</p><p><b>RESULTS</b>The proband was clinically preliminary diagnosed as LQTS by 12-lead electrocardiogram. On the third day of metoprolol intake (25 mg, bid), she died suddenly at lunch. One heterozygous missense mutation (SCN5A-V411M) was identified in this proband, but the mutation was absent in 200 healthy subjects. The electrophysiological analysis indicated that SCN5A-V411M significantly increased the peak current density ((230.8 ± 27.6)pA/pF vs. (101.2 ± 10.9)pA/pF, n=10, P<0.01) and the late sodium current ((156.6 ± 13.6)pA/pF vs. (95.9 ± 7.9)pA/pF, n=12, P<0.01) of sodium channel compared to wide type. The enhanced sodium channel activation with a negative shift in the peak I-V relationship was significantly higher by -50 mV than wide type (85.0%± 7.4% vs. 41.5% ± 2.6%, P<0.01), while the steady-state inactivation curves remained unchanged. Additionally, mother and grandmother of the proband were the silent mutation carriers with no symptoms, who needed the appropriate clinical assessment and follow-up. The proband's twin sister and aunt died of sudden infant death syndrome.</p><p><b>CONCLUSIONS</b>We firstly reported a heterozygote missense mutation (SCN5A-V411M) in this Chinese family. V411M induced "gain of function" of sodium channel and formed the basis of type-3 LQTS. Genetic testing could help to increase the diagnostic accuracy, and facilitate clinical assessment and appropriate therapy to prevent sudden cardiac death of individuals with SCN5A-V411M mutation.</p>