Cardiovascular Risk Factors and Echocardiographic Findings in a Predominantly Black Population with Rheumatoid Arthritis and Heart Failure.

Among White rheumatoid arthritis (RA) cohorts, heart failure with preserved ejection fraction (HFpEF) is the most prevalent type of heart failure (HF). We aimed to assess the type of HF affecting Black RA patients. 64 patients with RA-HF were compared to age-, sex-, and race-matched RA patients without HF. Left ventricular ejection fraction (LVEF), wall motion abnormalities, left ventricle (LV) mass, and wall thickness were reviewed. 87.3% were Black, 84.4% were women, with a mean age of 69.6 ± 1.38 (± SEM) and BMI (kg/m 2) 29.6 ± 1.07. RA-HF patients had higher rates of hypertension (HTN), chronic kidney disease, and atrial fibrillation. 66.7% had ≥3 cardiovascular risk factors compared to RA patients without HF. 2D-echocardiograms of RA-HF revealed that 62.3% had LVEF ≥50%, 37% had diastolic dysfunction, and 43.1% had wall motion abnormalities. LV mass and relative wall thickness measurements indicated LV eccentric remodeling. The odds ratio for HF was 4.7 (1.5-14.53 CI), p<0.01, among RA-HTN group and 3.5 (1.091-11.7 CI) p<0.01 among smokers. In our predominantly Black RA-HF patients, HFpEF was the most common type of HF. HTN was associated with the highest OR for HF. Eccentric hypertrophic remodeling, a known poor prognostic indicator for cardiovascular events, was found. Further studies are required to confirm our findings.

A Rare Case of Iatrogenic Inverted Stress Cardiomyopathy.

We discuss a case of a 42-year-old female who was admitted for chronic intractable lower back pain requiring elective spinal surgery. Postoperatively, she experienced chest pressure and abdominal pain with a notable elevation in cardiac markers. A cardiac catheterization and left ventriculogram revealed normal coronary arteries and basal anterolateral hypokinesis, with the normal movement of the distal segment of the anterior wall. A rare variant of stress cardiomyopathy was diagnosed.

Sinoatrial Nodal Artery Arising from the Right Posterolateral Artery: A Rare Anatomical Variant.

We discuss a case report of a 66-year-old male with no prior cardiac history who presented to the hospital with persistent hiccups and shortness of breath. Following a positive nuclear stress test and cardiac catheterization, a rare anatomical variant of a sinoatrial nodal artery originating from the right posterolateral artery was revealed.

A Complete Workup of Recurrent Syncope Caused by Significant Left Main Coronary Artery Stenosis.

Syncope is usually caused by cerebral hypoperfusion. Differentials to consider during the workup of syncope includes vasovagal, orthostatic, drug-induced, arrhythmia, structural heart disease, and ischemic cardiomyopathy.  An 81-year-old African American man with recurrent witnessed syncopal events and newly diagnosed heart failure underwent extensive cardiac workup including electrocardiograms (EKG), echocardiogram, Holter monitor, electrophysiology (EP) study, and coronary angiogram. The workup revealed ischemic ventricular tachycardia in the setting of significant coronary artery disease including 80% distal left main disease. The patient underwent a coronary artery bypass graft (CABG) with subsequent resolution of further syncopal events. The patient was successfully discharged with guideline-directed medical therapy for heart failure with reduced ejection fraction (HFrEF) and coronary artery disease (CAD).  It is very rare for ischemic cardiomyopathy to present as syncope; however, it is not unheard of. Extensive transmural ischemia could lead to ventricular arrhythmias, a known cause of syncope. This rare presentation serves as a reminder to consider ischemic heart disease in the evaluation of syncope.

Mysterious Left Atrial Mass in a Patient With Metastatic Prostate Cancer.

Cardiac tumors (CTs) are a rare group of disorders that encompass a broad set of masses. They are subclassified into neoplastic and non-neoplastic lesions. Neoplastic lesions can be further subdivided into either primary cardiac tumors (PCTs) or secondary cardiac tumors (SCTs) which are metastasis to the heart. Cardiac myxomas are the most common pathological type of benign PCT followed by rhabdomyomas, papillary fibroelastomas, fibromas, lipomas, and leiomyomas. Here, we present a case of a patient with left atrial mass in the setting of stage IV prostate cancer. We have used transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) for characterization and differential generation. Our findings are presented in high-quality imaging and video and our top differentials include PCT, thrombi, and metastasis. Although a full diagnostic workup was not completed due to limitations in diagnostic tests available, metastasis to the heart could not be excluded due to the high staging and extensive sclerotic involvement of this malignancy. We emphasized the importance of multimodality imaging, e.g., TTE, TEE, cardiac magnetic resonance (CMR), and cardiac computed tomography (CT) in the workup of incidental cardiac masses and differential refinement.

A Case of ST-Elevation Myocardial Infarction With Right Bundle Branch Block, an Ominous Sign of Critical Coronary Occlusion.

Coronary artery disease is one of the leading causes of death worldwide, and ST-elevation myocardial infarction (STEMI) is one of its most serious manifestations. While STEMI itself is an ominous sign, there are other sinister electrocardiogram (EKG) patterns that are associated with increased morbidity and mortality, one of which is STEMI with right bundle branch block (RBBB). Blood supply to the right bundle comes from the left coronary circulation. Intuitively, RBBB in the setting of anterior wall myocardial infarction would indicate more extensive myocardial involvement and thus portend a worse prognosis. This case presents the significance of the association of new RBBB with critical lesions of the left anterior descending artery (LAD), therefore a low threshold for emergent coronary angiography and percutaneous coronary intervention (PCI). A 63-year-old man with a known history of non-insulin-dependent diabetes mellitus (NIDDM), hypertension, and hypertriglyceridemia non-compliant with medications presented to the emergency department (ED) after a visit with his primary care physician, with a chief complaint of exertional substernal chest pain for a one-week duration. His EKG on arrival showed significant ST-segment elevation with an atypical EKG pattern showing RBBB in V1-V2 with ST depression in reciprocal leads. Cardiac biomarkers showed an initial troponin I value of 0.441 ng/mL. Due to his persistent, worsening chest pain and associated nausea with episodes of vomiting, he was taken for an emergent cardiac catheterization that revealed a 100% lesion in his proximal LAD. The procedure was complicated by the development of cardiogenic shock requiring intra-aortic balloon pumps and vasopressors. A successful primary PCI was performed with drug-eluting stent (DES) to the 100% lesion in the proximal LAD and DES to the 80% lesions in the mid LAD, with 0% residual stenosis after the intervention. There was thrombolysis in myocardial infarction (TIMI) 0 flow pre-procedure and TIMI 3 flow post-intervention. Left ventriculography revealed anterolateral akinesis, apical akinesis, and diaphragmatic hypokinesis with an estimated ejection fraction (EF) of 20%. Transthoracic echocardiogram was repeated prior to discharge. Left ventricular (LV) systolic function was normal by visual assessment, and EF was noted to be ~55%. The patient continued on dual antiplatelet therapy and the rest of goal-directed medical therapy for coronary artery disease post-procedure. New-onset RBBB in the patient with typical STEMI in the context of ischemic symptoms should raise suspicion of critical proximal LAD coronary occlusion. It is increasingly being recognized as one of the significant EKG patterns for occlusive myocardial infarction associated with the worst outcome and mortality, highlighting the need to pay critical attention to these patients. Given the poor prognosis of these patients in the setting of acute myocardial infarction (AMI), it is essential to minimize the delay in initiating reperfusion therapy as they can potentially benefit from emergent intervention.

Clinical Characteristics and Angiographic Findings of Myocardial Infarction among Marijuana Users and Non-Users.

BACKGROUND: Marijuana use has been increasingly legalized in the United States resulting in substantial rise in the number of users especially in the younger populations. While our group and others had described various metabolic effects of this drug, little is known about its association with acute myocardial infarction (AMI). OBJECTIVE: This follow up study presents contemporaneous cohort of non-THC user patients at a single, urban center hospital diagnosed with ST-elevation AMI; highlighting and comparing demographic, clinical, laboratory and angiographic characteristics based on exposure to THC at time of presentation. METHODS: Retrospective chart review of patients with ST-elevation AMI presenting to our inner city hospital Coronary Care Unit over a period of 4 years (December 2013-April 2017). RESULTS: Of the 10 case subjects studied whom presented with chest pain, EKG evidence of ST-elevation MI (STEMI) with cannabis use, mean age at presentation was 40 years old, which was 10 years younger than our control group with no marijuana use (n = 11, p = 0.107). Of the patients who had marijuana exposure upon admission, 3 (30%) had no known cardiovascular disease (CVD) risk factors (RF) on admission, 1 patient had 3 RF, 4 patients had 2 RF and 2 had 1 CVD risk factor, which included age, diabetes mellitus type 2 (DM2), hypertension, dyslipidemia, smoking status, and family history at time of triage. Patients who were negative for marijuana use had higher number of CVD risk factors present upon admission. ASCVD risk scores were 10% vs. 16% (p = 0.312). In angiographic findings, 100% of the marijuana users had 1 vessel disease compared with 55% in the non-users (p = 0.0351). Severity of stenosis for both groups was averaged at 93% for non-users vs 95% in THC users (p = 0.62414). Collateral vessels were visible during coronary arteriogram in 91% of non-THC users and in only 20% of THC users (p = 0.0019). Furthermore, non-users had 35% higher rate of Rentrop grade 1 collaterals (55% vs. 20%, p = 0.4872). Similar difference was shown in grade 2 collaterals between the two groups with non-users having 36% higher rate (36% vs. 0%, p = 0.0902). Amongst the patients who had collateral circulation present at the time of angiography (Rentrop grade >0), good collaterals (Rentrop grade 2 or 3) were present in 40% of non-THC users, while there was 0% presence of grade 2+ collaterals in THC users (p = 0.5152). CONCLUSION: In our study, marijuana use is associated with ST-elevation MI in largely minority population, occurring at a relatively younger age with half of the cases CVD risk free. Additional studies are needed to further characterize this population given the increase in marijuana use.