Diagnosing Lyme Carditis Presenting With Complete Heart Block.

Diagnosing self-limited conduction abnormality of Lyme carditis in absence of pathognomonic skin rash or history of tick bite is challenging but necessary to avoid placement of pacemaker particularly in young patients. High degree of clinical suspicion, rapidly progressing conduction block and prompt response to antibiotics may help in diagnosis.

GDMT for heart failure and the clinician's conundrum.

Therapeutic advances in management of CHF have decreased mortality and have impacted progression in patients with mild to moderate heart failure. Aggressive campaigns by cardiology societies aimed at increasing implementation of these measures in routine practices have almost generalized the treatment of heart failure irrespective of individual variations of clinical status of patients and stages of heart failure. This explains why morbidity compression and quality of life improvement have not been realized fully particularly in patients with advanced disease. To examine whether GDMT for CHF is backed by unambiguous evidence of clinical efficacy for its global implementation in every patient at all stages of the syndrome. ACC/AHA, ESC Guidelines for CHF, and their updates were reviewed. Clinical trial cited in the guideline documents and other pertaining published literatures were analyzed. FINDINGS: Many of the recommended GDMT for CHF lack unequivocal evidence of clinical efficacy in patients with diverge etiology of heart failure and concomitant comorbid conditions Some of the recommendations which are useful in early stages, lack evidence of efficacy in more advanced stages of heart failure. Application of results of research trials in patients beyond their inclusion and exclusion criteria, appears mere extrapolation, Clinicians are faced with the conundrum of implementing the recommendations without indubitable evidence of their efficacy in every patient of their practice. CONCLUSION: A reappraisal of Guidelines is needed to address outstanding questions pertaining to the efficacy of recommendations and plug the knowledge gaps without assumption and extrapolation of results of RCTs beyond their inclusion and exclusion criteria.

Cardiorenal syndrome in renal transplant recipients - It's the fistula at fault: A case series.

Complications arising from a functional arteriovenous fistula (AVF) in successful kidney transplant recipients (KT) have been overlooked despite some reports of its deleterious effect on heart, lungs, and kidney allograft. As such, there is no consensus regarding management of AVF after renal transplantation. We report Cardio-Renal Syndrome Type 5 in kidney transplant recipients who presented with a clinical syndrome of shortness of breath, edematous state, kidney allograft dysfunction, and high pulmonary pressure 3-8 months after successful transplantation. Investigations showed this to be due to high flow functioning AVF (>2 L/min) behaving like a systemic shunt causing high output heart failure, along with pulmonary and venous hypertension. This led to allograft dysfunction of fluid homeostasis. Symptoms resolved with cessation or reduction of AVF flow. Right heart catheterization and echocardiographic features indicating the syndrome are discussed to help clinicians identify the entity and decide management strategy for these AVF.

Aortic stenosis and perioperative risk with noncardiac surgery.

Aortic stenosis (AS) is characterized as a high-risk index for cardiac complications during noncardiac surgery. The American College of Cardiology/American Heart Association guidelines define severe AS as aortic valve area ≤1 cm(2), mean gradient of ≥40 mm Hg, and peak velocity of ≥4 m/s. As per current clinical practice, any of these characteristic features label a patient as at high risk for noncardiac surgery. However, these parameters appear inconsistent, particularly with respect to the aortic valve area cutoff value. The perioperative risk associated with AS during noncardiac surgery depends upon its severity (moderate vs. severe), clinical status, and the complexity of the surgical procedure (low to intermediate risk vs. high risk). A critical analysis of old and new data from published studies indicates that the significance of the presence of AS in patients undergoing noncardiac surgery is overemphasized in studies that predate the more recent advances in echocardiography and cardiac catheterization in assessment of aortic stenosis, anesthetic and surgical techniques, as well as post-operative patient care.