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Title : A multidisciplinary quality improvement plan to reduce 30 day heart failure readmissions
Manith Bondugula MD, Renni Panicker MD, Rebecca Lee DO, Karim Habbal MD, Tristan Dao, MD, Nethuja Salagundla MD. University Hospital and Clinics Lafayette Louisiana.
Background: Congestive heart failure (CHF) affects 5.7 million adults in the United States. Approximately 50% of patients will die within 5 years of diagnosis 1 . New federal guidelines regarding readmissions have also posed a challenge in this patient population. CHF readmission varies from 17.0% to 28.2% 1 . With the current financial burden of CHF and the incidence of CHF projected to increase by 46% by 2030 2 , the readmission rates will likely see a dramatic rise as will the national healthcare financial burden. Objectives: The project aim was to reduce the 30-day CHF readmissions. Measurement of CHF readmissions for a 8 month period was retrospectively evaluated for comparison to our 8 month period in which quality measures were instituted. Methods: A multidisciplinary approach was utilized to reduce CHF readmissions. A standardized education system was utilized by physicians and nurses prior to discharge. Specialized nurses assessed barriers to patient care. Nutrition experts were consulted to educate the patients on diet. Each patient was given a scale, a blood pressure cuff, a water bottle for accurate intake measurement, and instructions for a Lasix sliding scale. Patients were scheduled for clinic follow-up with the resident clinic within 10 days of discharge. Results: From October 2018 to May 2019, the cumulative CHF readmission was 15.38%. The quality measures were then applied, as outlined above. The subsequent CHF readmission over the following 8 months was 8.75%. To compare the overall case numbers, in the months prior to the intervention there were a total of 91 outcome cases with 14 readmissions from October 2018 to May 2019. After the intervention, there were 80 outcome cases with 7 readmissions. Prior to the intervention the average readmissions per month was 2. After the intervention, the average readmission per month was 1. Conclusion: The overall goal of the project was to reduce CHF readmissions, and our multi-disciplinary approach achieved this goal. This project brings light CHF readmissions on a national level and challenges other hospitals to seek out ways to improve their approach to CHF admissions. We must accept that the overall disease burden will continue to increase with time and it is our responsibility as healthcare professionals to be more vigilant and do our part in finding both innovative and effective solutions. References 1. Boback Ziaeian a,b and Gregg C. Fonarow c, “Prevention of Hospital Readmissions in Heart Failure” Prog Cardiovasc Dis. 2016 Jan-Feb; 58(4): 379 – 385. 2 .American Heart Association News “Heart Failure Projected to Increase Dramatically according to new statistics” American Heart Association January 25 th 2017 3.Jerome L. Fleg, MD “Preventing Readmission After Hospitalization for Acute Heart Failure: A quest Incompletely Fulfilled” JACC: Heart Failure Volume 6, Issue 2, February 2018
Cardiac Pauses in Critically Ill Coronavirus Disease-2019 Patients
Juan I. Solorzano 1 , MD; Keerthish C. Jaisingh 2 , MD Hajra Awwab 3 , MD; Sampath
Singireddy MD 4 ; Steven Bailey, MD 5 ; Paari Dominic, MD 6
1, 4, 5, 6 Department of Medicine and Center for Cardiovascular Diseases & Sciences,
Louisiana State University Health Sciences Center - Shreveport
2, 3 Department of Internal Medicine, Louisiana State University Health Sciences Center -
Shreveport
Correspondence:
Paari Dominic, MD
Assistant Professor of Medicine
Div. of Cardiology, Dept of Medicine
Louisiana State University Health Sciences Center
1501 Kings Hwy, Shreveport, LA 71103, USA
Phone: (318) 675-5941, Fax: (318) 675-5686
E-mail: pdomi2@lsuhsc.edu
Abstract
Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus
known to cause coronavirus disease 2019 (COVID-19), has affected more than 38 million
globally. Studies from around the world have reported cardiac dysrhythmias in patients
infected with COVID-19. A case-series from New York with 393 patients showed that
7.4% of patients had arrhythmias during their hospital stay. Specifically, patients who
received invasive mechanical ventilation were more likely to have atrial tachy-arrhythmias
(17.7%). A study from Italy found a statistically significant rise in out-of-hospital cardiac
arrests in 2020 when compared to the same period in 2019. Another case series with 187
COVID-19 patients from China, found that 27.8% of patients had myocardial injury, which
resulted in cardiac dysfunction and arrhythmias. Elevated troponin levels were associated
with more frequent ventricular tachycardia and ventricular fibrillation. However, data
regarding significant bradycardia and cardiac pauses in critically ill COVID-19 patients
has not been reported.
Objective : To characterize significant cardiac pauses found in critically ill COVID-19
patients.
Method: A case series of 26 consecutive patients with confirmed COVID-19 at Ochsner-
Louisiana State University hospital in Shreveport, Louisiana. All study patients were
critically ill on mechanical ventilation or high flow oxygen by nasal cannula admitted to the
ICU and/or step-down ICU.
Results: Demographic, clinical, laboratory, and medication data were analyzed. Brady-
arrhythmia events recorded on continuous telemetry were analyzed for number, type,
duration, and risk determinants. The median age of the 26 patients was 49.5 years (yrs)
(range 33-78 yrs) and 15 (57.7%) were men. Significant bradycardia and cardiac pauses
occurred in 11 (42.3%) patients. The median age of patients with an event was 57 years
(range 33-66 yrs) and 5/11 (45.5%) were men. The average pause duration was 6.77
seconds with a range of 1.6 to 30 seconds. Five of eleven (45.5%) patients had a high-
grade atrioventricular nodal block. One patient had complete heart block requiring
temporary transvenous pacing despite stopping Dexmedetomidine. A trend towards
higher Troponin I level in brady-arrhythmia patients was noted (mean of 2.72 ng/mL, (SD)
4.48) compared to patients without event(s) (Troponin I of 0.42 ng/mL 0.52, p-value
0.07). Other laboratory values such as N-terminal-pro B-type natriuretic peptide, C-
reactive protein, and Procalcitonin were not significantly different. The use of
Dexmedetomidine was not related to pauses.
Conclusion: Significant bradycardic events in critically ill patients with COVID-19
occurred in 42.3% of patients. These patients with severe sepsis/acute respiratory
distress syndrome secondary to COVID-19 are susceptible to significant cardiac brady-
arrhythmias. Enhanced monitoring could influence the future management of patients
infected with SARS-CoV-2.
Table 1
Patient Characteristics
Event-Positive Patients (n=11)
Event-Negative Patients (n=15)
Mean, No. (%)
±SD 9.38
Mean, No. (%)
±SD 9.69
P-value
Age
57.64
60.67
0.43 0.43
Male sex
5/11 (45%)
10/15 (66%)
Underlying comorbidities
Hypertension
7/11 (64%) 5/11 (45%) 1/11 (9%)
10/15 (67%) 7/15 (47%) 3/15 (20%) 1/15 (7%) 4/15 (27%) 7/15 (47%) 5/15 (33%) 12/15 (80%) 13/15 (87%) 13/15 (87%) 14/15 (93%) 13/15 (87%) 4/15 (27%) 14/15 (93%)
1 1
Diabetes Mellitus
Coronary artery disease Congestive Heart Failure Chronic Kidney Disease
0.61
0/11 0/11
1
0.11
Predominant presenting symptoms Hypoxemia and/or SOB
7/11 (64%) 8/11 (73%) 9/11 (82%) 7/11 (64%)
0.45 0.11
Fever
Mechanical Ventilation Dexmedetomidine Hydroxychloroquine
1
0.35 0.49
11/11 (100%) 10/11 (91%) 11/11 (100%)
Azithromycin Anticoagulation
1
0.49 0.68
AV-nodal blockers and AADs Qualitative Troponin I assessment
4/11 (36%) 9/11 (82%)
1
Peak Troponin I, ng/mL
2.72 7703 23.98
4.48
0.42 1905 20.24
0.52 2422 11.52
0.07 0.16 0.38 0.85 0.29 0.84 0.51 0.82
NT-ProBNP, pg/mL
12995
Peak C-reactive protein, mg/dL
9.07
D-dimer, ng/mL
4128.91
1609.63 112.84
3996.36
1756.95
Peak Procalcitonin, ng/mL
42.15 83.45
10.31 84.62
15.87 16.82 29.23 36.12
QRS duration (ms) PR Interval (ms) QTc interval (ms)
8.86
148.55
21.37
155.69 462.69
458
59.6
Deceased 0.78 Abbreviations: SD, standard deviation; AV, atrioventricular; AAD, antiarrhythmic drugs; NT-ProBNP, N-terminal-proB-type natriuretic peptide SI conversion factors: To convert Troponin I to µg/L, multiply by 1; NT-ProBNP to pmol/L, multiply by 0.1182; C-reactive protein to mg/L, multiply by 10; D-dimer to µg/L, multiply by 1; Procalcitonin to ng/L, multiply by 1000. 5/11 (45%) 6/15 (40%)
Class 1C Antiarrhythmic Drugs in
Atrial Fibrillation and Coronary Artery Disease
Peter G. Pantlin MD 1 , Robert M. Bober MD 1,2 , Michael L. Bernard MD PhD 1 , Sammy Khatib MD 1 , Glenn M. Polin MD 1 , Paul A. Rogers MD PhD 1 , and Daniel P. Morin MD MPH 1,2
1 – University of Queensland - Ochsner Clinical School, New Orleans, LA
2 – Ochsner Medical Center, New Orleans, LA
Background: Class 1C antiarrhythmic drugs (AAD) are effective first -line agents for atrial
fibrillation (AF) treatment. However, th ese agents commonly are avoided in patients with
known coronary artery disease (CAD), due to known increased risk in the post-myocardial
infarction population. Whether 1C AADs are safe in patients with CAD but without clinical
ischemia or infarct is unknow n. Reduced coronary flow capacity (CFC) on positron emission
tomography (PET) reliably identifies myocardial regions supplied by vessels with CAD causing
flow limitation.
Objective: To assess whether treatment with 1C AADs increases mortality in patients without
known CAD but with CFC indicating significantly reduced coronary blood flow.
Methods: In this pilot study, we compared patients with AF and LVEF ≥50% who were treated
with 1C AADs, to age-matched AF patients without 1C AAD treatment. No patient had clinically
evident CAD (i.e., reversible perfusion defect, known ≥70% epicardial lesion, PCI, CABG, or
myocardial infarction). All patients had PET- based quantification of stress myocardial blood
flow (sMBF) and CFC. Death was assessed by clinical follow -up and SSDI search.
Results: 78 patients with 1C AAD exposure were matched to 78 controls. Over a mean follow-up
of 2.0 years, the groups had similar survival (p=0.54). Among patients with CFC indicating the
presence of occult CAD (i.e., reduced CFC involving ≥50% of myocardium), 1C -treated patients
had survival similar to (p=0.44) those not treated with 1C agents.
Conclusions: In a limited population of AF patients with preserved LV function and PET CFC
indicating occult CAD, treatment with 1C AADs appears not to increase mortality. A larger study
would be required to confidently assess safety of these drugs in this context.
Figure 1. Kaplan-Meier survival analysis of patients with >50% of myocardium showing reduced CFC, stratified by 1C AAD use.
Determining Value of a Cardiology Clinic Visit
Tripti Gupta 1,2 , Stephanie Madonis 1 , Ivana Okor 3 , Koyenum Obi 3 , Gregory A Desrosiers 4 , Alaa Mohammed 5 , Daniel Fort 5 , Mark B. Effron 1,2
1 Department of Cardiology, Ochsner Medical Center, New Orleans, LA 2 University of Queensland Ochsner Clinical School of Medicine, New Orleans, LA 3 Department of Internal Medicine, Ochsner Medical Center, New Orleans, LA 4 Department of Internal Medicine, University of Tennessee, Knoxville, TN 5 Ochsner Health Center for Outcomes and Health Services Research, New Orleans, LA Background Value based healthcare is gaining momentum to minimize extraneous medical costs and improve patient outcomes. The frequency of specialty clinic visits may be contributing to excessive cost and resource utilization without affecting patient outcomes. Follow up frequency is largely controlled by physicians with few metrics to guide scheduling. Patients with stable cardiac conditions and controlled risk factors may be able to be followed less frequently without affecting overall outcomes. Objective This study is designed to evaluate the relation between frequency of Cardiology Clinic (Card Cl) visits and major adverse cardiac events (MACE) post percutaneous coronary intervention in patients with acute coronary syndrome (ACS). Methods A retrospective cohort study was conducted of all patients diagnosed with acute coronary syndrome receiving a stent during index hospitalization between Jan 1 2012 – Dec 312014 at Ochsner Medical Center (OMC). Patients who did not have an OMC Card Cl visit in the 5 years following stenting up were excluded. Primary analysis included bivariate analysis (chi-square and t-test as appropriate) and multivariate logistic regression (MVLR) to determine odds of MACE. MACE was defined as a composite of hospitalization for congestive heart failure, non-fatal myocardial infarction, ACS, cerebrovascular accident, or all-cause mortality. Results 533 patients were identified of which 68.3% were male. Of 17 variables evaluated, the presence of end stage renal disease and older age were predictive of increased frequency (> 10) of clinic visits, [OR 1.58, (95% CI 1.11 – 2.24), p = 0.011 and 1.03, (95% CI 1.02 – 1.05), p = < 0.01)], respectively. A higher frequency of clinic visits (> 10 vs < 10) was correlated with MACE (OR 2.72, (95% CI 1.88 – 4.00), p < 0.001). In a MVLR model, presence of diabetes, congestive heart failure and > 10 clinic visits were correlated with MACE (Table). Conclusion Underlying pathology appears to be more influential on frequency of Card Cl visits and MACE such that patients with more comorbidities tend to have more frequent clinic visits and worse CV outcomes.
Table: Multivariate Regression of Predicting Odds of Health Outcomes Covariate (n = 502) Adjusted OR (95% CI) P-value Sex (female vs. male) 1.22 (0.99-1.49) 0.062 Race (black vs. non-black) 1.13 (0.91-1.42) 0.27 Age 1.01 (0.99-1.03) 0.364 Diabetes 1.25 (1.03-1.52) 0.022 Congestive Heart Failure 1.61 (1.18-2.20) 0.003 End Stage Renal Disease 1.25 (0.85-1.84) 0.248 Clinic visits (> 10 vs. < 10) 1.57 (1.27-1.93) <0.001 Abbreviations: CI: confidence interval, OR: odds ratio
Abstract: Incidence of Acute Myocardial Infarction and Hurricane Katrina: Fourteen Years after the Storm
Authors: Daniel Harrison, Harsh Rawal, Matthew Quan , Ali Ayoub, Deep Sangani, Maelynn La, Matthew Kogan, Rogin Subedi, Anand Irimpen, Adedoyin Johnson
Background: Natural disasters have a devastating impact on health outcomes, but the long-term effects on cardiovascular events have not been examined.
Objective: We aimed to evaluate the incidence of acute myocardial infarction (AMI) in New Orleans during the fourteen years since Hurricane Katrina.
Methods: This was a single-center, retrospective study performed at Tulane University Health Sciences Center of patients admitted for AMI during two years before Hurricane Katrina and fourteen years after Hurricane Katrina. The pre-Katrina and post-Katrina cohorts were compared according to pre-specified demographic and clinical data. Results: In the fourteen-year post-Katrina period, there were 3,469 admissions for AMI out of a total census of 114,795 (3.0%) compared to 150 admissions out of a census of 21,079 (0.7%) in the 2-year, pre-Katrina group (p<0.001). The post-Katrina group had a higher prevalence of known coronary artery disease (CAD) (45.9% vs. 30.7%, p<0.001), diabetes mellitus (40.6% vs. 28.7%, p=0.002), hypertension (80.3% vs. 74.0%, p=0.028), hyperlipidemia (56.7% vs. 44.7%, p=0.001), smoking (54.0% vs. 39.3%, p<0.001), drug abuse (18.2% vs. 6.7%, p<0.001), and psychiatric disease (15.6% vs. 6.7%, p<0.001). The post-Katrina group was more often prescribed aspirin (50.1% vs. 31.3%, p<0.001), beta-blocker (47.3% vs. 34.0%, p=0.002), ACE inhibitor or ARB (52.5% vs. 36.0%, p<0.001), and statin (52.8% vs. 28.0%, p<0.001) but with higher medication non-adherence (15.9% vs. 7.3%, p<0.001). The post-Katrina patients were also more likely to be unemployed (41.3% vs 22.7%, p<0.001) and non-married (56.3% vs. 52.7%, p<0.001). Rates of STEMI were lower in the post-Katrina group (28.8% vs 42.0%, p=0.001). There was no significant difference between the two groups in terms of sex, being uninsured, or prior coronary artery bypass grafting. Conclusion: There was a 4-fold increase in the incidence of AMI fourteen years following Hurricane Katrina. Prevalent psychosocial, behavioral, and traditional CAD risk factors were significantly higher among the post-Katrina group. These findings add to the growing body of literature demonstrating adverse cardiovascular outcomes after a natural disaster. Further research is needed to elucidate underlying mechanisms to help mitigate future cardiac morbidity.
Title: Statin Use and Quality Control in an Urban Primary Care Clinic Authors: Hanyuan Shi, MD. Jennifer Hong, BA. Henri Wathieu, BA. Kevin Tea, BA. Kristin
Bateman, MD. Background:
Atherosclerotic cardiovascular disease (ASCVD) risk assessment is important for primary prevention; although there are many different perspectives to lipid control, the outpatient primary care physician has a large role in prescribing statins for patients. Epidemiologic studies of clinics have shown poor ASCVD risk documentations; we show an initiative in an urban PCP teaching clinic to enhance physician awareness. Objective: To determine rates of physician documentation of ASCVD risk scores for patients as well as quality of statin prescriptions. Methods: We collected and analyzed consecutive visits within four months from August 2019 to November 2019 at our urban primary care residents’ clinic. Inclusion criteria included patients ages 40-75, with no previous history of coronary artery disease, myocardial infarction, cerebrovascular incident, or peripheral arterial disease as documented in the electronic medical record. Primary endpoint was documentation of ASCVD risk score in physician note. Secondary endpoints included lipid panel within one year, correct ASCVD documentation (based on pooled cohort 10-year risk developed by Blumenthal published by ACC), and statin prescription. Results: There was a total of 772 eligible patients and visits in our dataset. The average age was 57.6 years old with 60.5% female, 65.8% African-American. Patients had on average several comorbid conditions; 40.4% were diabetic, 49.9% were former or current smokers, and 74.1% had hypertension. Out of these visits, there were only 292 (37.8%) that had ASCVD risk documented. These ranged from 0.4% to 54.3%. This did not vary significantly based on the specific month of visit. Furthermore, out of 140 patients who had documented ASCVD scores of over 10%, 62 patients (44.3%) were not on any kind of statin. Conclusions: At an urban primary care clinic, there was low physician documentation of ASCVD risk for primary prevention for indicated patients. This translated to a significant proportion of patients with high ASCVD without statin use. Strategies have been formulated including EPIC dotphrase, nursing prompting, and pre-clinic reminders to improve ASCVD use and discussion with patients.
Vascular Access And Closure Management In Patients With Severe And Morbid Obesity Undergoing Transcatheter Aortic Valve Replacement
Justin Price, Christopher Puleo, Natalia Giraldo, Arthur Davis, Austin Tutor, Jose Tafur Soto, Stephen Ramee
Background Morbid obesity is an ongoing epidemic which presents increasing difficulties for vascular access and closure during transcatheter aortic valve replacement (TAVR). To reduce vascular complications, operators are electing for alternative TAVR access routes in the obese population who have an increased risk of peripheral arterial disease (PAD). Objective To demonstrate successful management of difficult vascular access TAVR patients in an experienced endovascular treatment center. Methods We performed a retrospective analysis of patients with a body max index >35 Kg/m2 who underwent percutaneous transfemoral TAVR between 2016 and 2019. Demographics and data regarding vascular complications were summarized and displayed as a mean ± SD. All procedures were performed via a percutaneous transfemoral approach and concluded with a percutaneous closure device. Vascular complications were defined based on the Valve Academic Research Consortium-2 consensus document (VARC-2) criteria. All patients underwent extensive pre-procedural planning including CT Angiography or intravascular ultrasound for iliofemoral vessel sizing. Results A total of 159 patients met inclusion criteria, 97 patients (61%) were Class II Obesity (BMI ≥ 35-39 .9), and 62 (39%) were (Class III obesity, BMI ≥ 40). The mean age was 73 years (47 -93). The mean STS score was 3.1% (1-17). There were 1 (0.6%) VARC-2 major and 12 (7.5%) VARC-2 minor complications with 10 (6.3%) patients required covered stenting. The mean length of stay was 1.5 days. A total of 3 patients required in hospital blood transfusions. In- hospital and 30-day mortality were 1.2% and 2.5% respectively. Conclusions Severe and morbidly obese patients can successfully undergo percutaneous transfemoral TAVR with minimal vascular complications. Management of these higher risk patients requires operators with experience in endovascular management.
Title A Common Chief Compliant leading to a Unique Diagnosis of Apical Hypertrophic Cardiomyopathy
Authors Brandon Bunol, MD. Hanyuan Shi, MD. Bradley Deere, MD.
Introduction Apical hypertrophic cardiomyopathy (HCM) is a variant that leads to mid-ventricular obstruction instead of LVOT. Most patients with apical HCM tend to be asymptomatic, but can present with insidious symptoms such as angina, heart failure, and syncope. With multimodality imaging, we were able to identify the diseased myocardium in this case and implant a single-chamber ICD for primary prevention, Case Presentation A 55 year-old male with HTN and GERD initially presented with chest pain. He described it as waxing and waning for the last few days. Review of systems notable for multiple episodes of syncope monthly when standing. Vitals showed a BP of 144/95 with a pulse rate of 64 bpm. EKG showed new T-wave inversions in V2, V3 with LVH criteria, with two negative troponins (<0.02 ng/ml). A transthoracic echocardiogram (TTE) resulted with normal LVEF with concentric left ventricular hypertrophy with concern for apical HCM. Coronary angiogram showed mild non-obstructive CAD with intramyocardial bridging of mild LAD. Subsequently, a cardiac MRI was done confirming the diagnosis; hypertrophy of the left ventricle was shown with apical predominance with intraventricular septal thickness at 14 mm with apical segmental scarring (Figure). Beta blockade was initiated, and the patient chose to have a single-chamber ICD implanted for primary prevention of sudden cardiac death. Discussion HC M is an autosomal disease of the myocardium caused by gene mutation in the sarcomere protein. Original diagnostic criteria for apical HCM was a specific “spade - like” configuration with a giant negative T wave with accompanying high QRS voltages on ECG. Now with the advancement of cardiac imaging, TTE and cardiac MRI allow for more accurate assessment of the LVH. In this case, cardiac MRI diagnosed apical HCM with wall dimensions and in the delayed gadolinium enhancement (DGE) phase showing estimated 27 g (14% of LV mass) scar in the apex. Although patients with apical HCM variant have lower risk of arrhythmia, a shared decision was made to place an ICD given patient’s significant history of syncope. Conclusion Apical HCM is a rarer variant but important to recognize as a morphological subtype. Cardiac MRI can better define this phenotype better than TTE alone, and uses LGE to provide better insight into scar patterns.
Acute Coronary Syndrome Secondary to Coronary Artery Aneurysm in an HIV Positive Male: A Case Report Introduction: Coronary artery aneurysms (CAA) are rare and often an unexpected finding on coronary angiography. The most common etiologies are history of Kawasaki disease, atherosclerosis, connective tissue disease and vasculitis. Acute coronary syndrome (ACS) is the most common clinical presentation. Case: A 44-year-old male patient with longstanding history of HIV on medical therapy, presented with a non-ST-elevation myocardial infarction (NSTEMI). He is active at baseline and denied antecedent angina. Angiography was significant for coronary aneurysm in both the left anterior descending and right coronary artery (RCA) with distal thrombotic occlusion of the posterior descending artery. Despite multiple attempts, aspiration thrombectomy was unsuccessful. Patient was discharged with dual antiplatelet therapy. He returned a month later with repeat NSTEMI presentation in the setting of medication non-adherence. Angiography showed ostial RCA thrombotic occlusion. He underwent successful aspiration thrombectomy. He was discharged with both antiplatelet and anticoagulation agents. Further diagnostic evaluation included rheumatologic and infectious lab work that revealed positive ANA and persistently positive rapid plasma reagin despite multiple treatment courses. Of note his HIV is well controlled with an undetectable viral load and CD4 count > 500/ cu mm. Discussion : Given the patient’s ACS, relatively young age, multivessel aneurysmal involvement, and demonstrated medical non-adherence, it is important to understand the etiology and future cardiovascular risk of this anatomy. Current literature suggests coronary aneurysms in HIV positive individuals may be related to accelerated atherosclerosis, increased incidence of inflammatory events, or possibly the virus itself. In this patient, we believe his positive treponemal titers may be contributory as well. Since both his index and subsequent presentations have been ACS rather than angina, serial clinical assessment may not be the best option. We have opted to proceed with a covered stent placement in addition to pharmacotherapy. Conclusion: No consensus guidelines for the management of CAA exist, posing a medical and interventional management dilemma. Further studies are needed to guide management of this uncommon condition.
Title: An atypical presentation: Belching as a chief complaint in aortic stenosis-related angina
Author: Tristan Dao, MD; John Edavettal, MD; University Hospital and Clinics, LSUHSC Lafayette
Background: Angina pectoris classically presents as a substernal squeezing chest pain associated with exertion, often related to coronary atherosclerotic disease. Occasionally, there can be atypical presenting symptoms including nausea, vomiting, and diaphoresis. Although gastrointestinal symptoms have been described in angina pectoris, high suspicion for cardiac etiology must be maintained due to potentially detrimental outcomes due to delayed diagnosis. Here we detail an unusual presentation of severe aortic stenosis. Case Presentation: A 69-year-old Caucasian male with a history significant for tobacco abuse presented to internal medicine clinic with a 6-month history of abdominal bloating and episodic belching. He denied any nausea or vomiting, but reported a sensation of dysphagia without weight loss. He denied any chest pain but reported discomfort with exertion and meals that were relieved with belching, causing some food aversion. EKG showed no conduction, rhythm, ST segment or T wave abnormalities. At the time he was started on esomeprazole for treatment of gastroesophageal reflux which initially provided relief but eventually did not improve his symptoms. Given his concerning presentation and smoking history an esophagogastroduodenoscopy was performed, which showed no esophageal abnormalities, biopsies of mild gastritis were negative for H pylori. A systolic murmur was heard on exam, prompting an echocardiogram which showed an ejection fraction of 65%, but showed aortic stenosis with a dilated left atrium, an aortic valve area of 0.86 cm 2 and a peak velocity of 3.42m/s. He was referred to cardiology for evaluation for surgical aortic valve replacement. A coronary angiogram showed 70% stenosis of an ostial lesion in the circumflex artery. He underwent a coronary artery bypass as well as a surgical bioprosthetic aortic valve replacement. At 6-week follow up he reports that his symptoms have largely resolved including his belching symptoms. Discussion: Although uncommon, belching and dysphagia can be concerning for esophageal disease but cardiac pathology must be maintained on the differential. In a patient with cardiac risk factors and gastrointestinal symptoms that resolved with surgical intervention, the presence of belching as an early symptom of angina warrants further investigation.
Title: Atherogenic Induced Renal Artery Thrombosis
Authors: Karim Habbal MD and Agostino Ingraldi MD. Ocshner Lafayette General Medical Center
Introduction: Guidelines pertaining to the management of renal arterial thrombosis are limited given the absence of prospective randomized controlled trials 1 . Treatment strategies include percutaneous, surgical and medical approaches and are often determined on a case to case basis through clinical experience. Case Presentation: A 71-year-old male with past medical history of CAD, HTN, HLD, OSA, DM who presented with intermittent non-radiating left flank and left periumbilical pain. An Abdominal CT with contrast revealed left renal infarct. A renal artery angiogram demonstrated severe atherosclerotic left renal artery stenosis of 99% reduced to 0% following balloon angioplasty and stenting. There was extensive residual thrombus burden of the renal artery extending into the segmental and lobar branches (see Figure 1). Post intervention therapy included full dose Enoxaparin and Tirofiban drip for 24 hours in addition to Clopidogrel 75 mg and Aspirin 81 mg daily. The patient was discharged on 3-weeks of Rivaroxaban 15 mg BID and DAPT. A repeat left renal angiogram after 3- weeks of therapy revealed widely patent left renal anatomy with complete resolution of the previous thrombus (see Figure 1). Rivaroxaban was discontinued and DAPT continued. Discussion: Renal arterial infarction is a rare and frequently missed condition in patients presenting with flank pain. Most common causes include thromboembolisms from atrial fibrillation and cholesterol emboli. Complete renal arterial infarct is rare 1 . This patient’s hypertension improved from 205/91 to 126/69 following intervention. Renal function also improved following the intervention and returned to baseline stage 3 CKD. Conclusion: This case presents further insight to the management of renal arterial thrombosis, especially with regards to the utilization of triple therapy and its success in this patient.
Figure 1. Renal angiogram revealing clot burden before (top left) and after stenting (bottom left) as well as three weeks post procedure on triple therapy (bottom right).
References:
1. Valerie M Lopez and Jonathan Glauser. A case of renal artery thrombosis with renal infarction. Journal of Emergencies, Trauma and Shock. 2010 Jul-Sep; 3(3): 302. PMID: 20930986
Breaking addiction can lead to a broken heart: reverse takotsubo cardiomyopathy in a case of heroin withdrawal.
Hunter Launer MD, Alarica Dietzen BS, Daniel Nelson MD
Tulane University School of Medicine
Introduction:
Takotsubo cardiomyopathy (TC) is characterized by acute and often reversible left ventricular dysfunction triggered by emotional or physical stress. Reverse Takotsubo cardiomyopathy (RTC) is a variant described as basal akinesis and apical hyperkinesis. RTC presents clinically like acute coronary syndrome (ACS) but without obstructive coronary arteries. Factors associated with the development of RTC include younger age, neurologic disease, and higher ejection fraction.
Case Presentation:
A 39-year-old female with a history of heavy heroin use presented with intractable nausea, vomiting, and diarrhea. She tested positive for opiates and endorsed using heroin two days prior. Troponin in the emergency department was elevated at 0.973 (normal limit 0.045) peaking 6 hours later to 2.440. EKG showed sinus rhythm without signs of ischemia. She was started on suboxone. Cardiology was consulted and felt her troponin elevation was due to demand ischemia in the setting of hypertension. On day 2 the patient developed chest heaviness. Repeat EKG showed new T wave inversion in the inferior and anterior leads and new troponin peak of 3.200. The patient was taken emergently for cardiac catheterization. The coronary arteries were normal, but the left ventriculogram showed apical hyperkinesis with hypokinesis of mid-anterior wall [image1]. Echocardiogram showed ejection fraction of 60% with hypokinesis of the basal-mid inferoseptal and basal-mid inferior walls. The patient was started on carvedilol and lisinopril and discharged with cardiac follow up.
Discussion:
This case highlights that RTC can present similarly to ACS. While methamphetamine use, iatrogenic epinephrine overdose, and neurologic conditions have all been described as triggers of RTC, to our knowledge this is the first report of heroin withdrawal causing RTC. Likely both the physical and emotional stressors of heroin withdrawal led to an elevated catecholamine state in our patient and may have contributed to the development of RTC.
Conclusion:
RTC, a variant of TC, represents a minority of cases and like TC is trigged by emotional or physical stressors. After ruling out ACS, treatment is largely supportive. In cases of opioid withdrawal, earlier initiation of suboxone may help alleviate the stressors that lead to TC.
References:
[1] Pelliccia F, Kaski JC, Crea F, Camici PG. Pathophysiology of Takotsubo Syndrome. Circulation. 2017 Jun 13;135(24):2426-2441. doi: 10.1161/CIRCULATIONAHA.116.027121. PMID: 28606950. [2] Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J. 2008 Mar;155(3):408-17. doi: 10.1016/j.ahj.2007.11.008. Epub 2008 Jan 31. PMID: 18294473. [3] Templin C, Ghadri JR, Diekmann J, Napp LC, et al. Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy. N Engl J Med. 2015 Sep 3;373(10):929-38. doi: 10.1056/NEJMoa1406761. PMID: 26332547.
By A Long Shot: Venous Bullet Embolization to the Heart
Authors: Elaine Huang, MD; Michael Crawford, MD; Laura Padilla-Carrasquillo MD; Rohan Samson, MD
Introduction:
Direct penetrating cardiac injuries from gunshot wounds have been well documented and commonly lead to life threatening conditions such as cardiac tamponade. However, reported cases of indirect cardiac involvement from firearms are rare but can occur from peripheral embolization of bullets or bullet fragments into the heart or pulmonary vasculature. Here, we present a case of a young man who sustained a gunshot wound (GSW) from a shotgun to his left upper extremity (LUE) with a subsequent bullet fragment noted within the right ventricle (RV) on imaging.
Case presentation:
A 25-year-old man presented following a GSW to his LUE. He was struck by numerous small lead pellets from the spray of the shotgun. His only complaint was pain localized to the GSW. Initial chest X-ray and computed tomography (CT) revealed multiple pellets in his LUE, one in his neck, and one that seemed to be localized within the RV or pericardium. He had no entry wounds to his anterior chest. Transthoracic echocardiogram (TTE) was able to confirm the presence of a pellet within the RV trabeculae along the free wall. There was no pericardial effusion or other significant abnormalities. Electrocardiogram was unremarkable and troponin I levels were normal. Serial imaging with TTE showed no change in position of the pellet or development of pericardial effusion. Given the stability, no surgical intervention or endovascular retrieval was done. Antibiotics were recommended for bacterial endocarditis prophylaxis.
Discussion:
Firearm injuries are relatively common, with over 67,000 people affected annually, but bullet embolization to the heart is a rare occurrence. The small pellet-like projectiles ejected from a shotgun have the potential to embolize from the peripheral venous system into the cardiac chambers. While the vascular entry point for our case was unclear, the absence of any entry wounds to the thorax led to the presumption that the pellet originated from a vein in the LUE.
Conclusion:
Venous bullet embolization to the heart most commonly occurs in the right sided chambers and with the potential to embolize to the pulmonary tree. Recommendations for management vary and each have their associated risks and benefits. In a patient with an embedded bullet fragment with low risk of embolization seen on serial imaging, observation is a reasonable management choice.
Cardiac Tamponade as First Indicator of Metastatic Gastric Adenocarcinoma
Ashley Russell, MD; Tulane University Internal Medicine Residency
Introduction : Learning Objectives - Recognize that a patient’s first episode of tamponade can signal recurrent gastric adenocarcinoma. - Increase awareness of adenocarcinoma ’s aggressive nature in malignant pericardial effusion leading to tamponade. Case Presentation: A 74-year-old veteran with CAD s/p PCI, HIV with undetectable viral load, and primary gastric cancer treated with radiation and partial gastrectomy in 2017 presented with three days of nausea and vomiting was admitted for an AKI. Three months prior he was seen by his oncologist and informed still in remission. He denied any history of chemotherapy, HIV complications, or history of pericardial effusion. One day into admission he became short of breath, hypotensive, and tachycardic. Exam was pertinent for JVD and distant heart sounds. He was transferred to the CCU and underwent an emergent bedside pericardiocentesis with drainage of approximately 900 cc of bloody fluid. Cardiogenic shock and hypoxic respiratory failure resolved after pericardiocentesis. CT spine and MRI showed lytic lesions throughout the spine, consistent with metastatic disease. Cytology of the pericardial fluid revealed adenocarcinoma with immunehistochemical findings supportive of metastatic gastric cancer. Discussion: Malignancy is a well established etiology of pericardial effusions. The frequency of hemorrhagic and symptomatic pericardial effusions from malignancy is reported to be 26% 1 and 33%, 2 respectively. This case illustrates that tamponade in a previously asymptomatic patient can be the first sign of gastric adenocarcinoma recurrence. There is a small number of case reports 3-9 that demonstrate recurrent and primary gastric adenocarcinoma can manifest alone with tamponade. Literature review shows patients with other forms of adenocarcinoma such as lung, ovarian and colon 10-12 can present in tamponade. The frequency of pericardial effusions from gastric cancer is low at 5.3%. 13 However, the startling fact about gastric and other forms of adenocarcinoma is they involve the pericardium at more aggressive rates 14 than other cancers.
Conclusion: It is important to consider adenocarcinoma in the case of pericardial effusion/tamponade and recognize that tamponade can signal recurrence of malignancy in a patient who has never had a pericardial effusion.
References:
1. Atar S, Chiu J, Forrester JS, Siegel RJ. Bloody pericardial effusion in patients with cardiac tamponade: is the cause cancerous, tuberculosis, or iatrogenic in the 1990s? Chest. 1999 Dec;116(6):1564-9. doi: 10.1378/chest.116.6.1564. PMID: 10593777. 2. Ben-Horin S, Bank I, Guetta V, Livneh A. Large symptomatic pericardial effusion as the presentation of unrecognized cancer: a study in 173 consecutive patients undergoing pericardiocentesis. Medicine (Baltimore). 2006 Jan;85(1):49- 53. doi: 10.1097/01.md.0000199556.69588.8e. Erratum in: Medicine (Baltimore). 2006 May;85(3):191. PMID: 16523053. 3. Fazeny B, Meghdadi S, Dejaco C, Kastner J, Marosi C, Schmidinger H. Recurrent cardiac tamponade as first manifestation of gastric cancer. Eur J Gastroenterology Hepatology. 1998 Jul;10(7):621-2. doi: 10.1097/00042737- 199807000-00018. PMID: 9855090. 4. Scheinin SA, Sosa-Herrera J. Case report: cardiac tamponade resembling an acute myocardial infarction as the initial manifestation of metastatic pericardial adenocarcinoma. Methodist Debakey Cardiovasc J. 2014 Apr-Jun;10(2):124-8. doi: 10.14797/mdcj-10-2-124. PMID: 25114766; PMCID: PMC4117332.
5. Arısoy A, Memiç K, Karavelioğlu Y, Sen F. Cardiac tamponade as the first clinical sign of gastric adenocarcinoma: a rare condition. Turk Kardiyol Dern Ars. 2014 Jun;42(4):377-9. doi: 10.5543/tkda.2014.24892. PMID: 24899482.
6. Domínguez AB, Linares P, Vivas S, Castañón C, Herrera A, López-Cuesta D, Jorquera F, Olcoz JL. Taponamiento cardíaco como primera manifestación de recurrencia de un cáncer gástrico [Cardiac tamponade as the first manifestation of gastric cancer recurrence]. Gastroenterol Hepatol. 2002 Nov;25(9):577. Spanish. doi: 10.1016/s0210- 5705(02)70318-x. PMID: 12435313. 7. Varvarigos N, Kamaradou H, Kourti A, Papavasiliou ED, Papaioannou H, Migdalis IN, Galanis C. Cardiac tamponade as the first manifestation of gastric cancer and remission after chemotherapy. Dig Dis Sci. 2001 Nov;46(11):2333-5. doi: 10.1023/a:1012382610671. PMID: 11713931.
8. Zhang BL, Xu RL, Zheng X, Qin YW. A case with cardiac tamponade as the first sign of primary gastric signet-ring cell carcinoma treated with combination therapy. Med Sci Monit. 2010 Apr;16(4):CS41-44. PMID: 20357721.
9. De la Gándara I, Espinosa E, Gómez Cerezo J, Feliu J, Garcia Girón C. Pericardial tamponade as the first manifestation of adenocarcinoma. Acta Oncol. 1997;36(4):429-31. doi: 10.3109/02841869709001291. PMID: 9247105.
10. Chen JL, Huang TW, Hsu PS, Chao-Yang, Tsai CS. Cardiac tamponade as the initial manifestation of metastatic adenocarcinoma from the colon: a case report. Heart Surg Forum. 2007;10(4):E329-30. doi: 10.1532/HSF98.20071068. PMID: 17650460. 11. Petersen EE, Shamshirsaz AA, Brennan TM, Demetroulis EM, Goodheart MJ. Malignant pericardial effusion with cardiac tamponade in ovarian adenocarcinoma. Arch Gynecol Obstet. 2009 Oct;280(4):675-8. doi: 10.1007/s00404- 009-0976-5. Epub 2009 Feb 19. PMID: 19225795. 12. Tsolakis EJ, Charitos CE, Mitsibounas D, Nanas JN. Cardiac tamponade rapidly evolving toward constrictive pericarditis and shock as a first manifestation of noncardiac cancer. J Card Surg. 2004 Mar-Apr;19(2):134-5. doi: 10.1111/j.0886- 0440.2004.04025.x. PMID: 15016049.
13. Takayama, T., Okura, Y., Okada, Y. et al. Characteristics of neoplastic cardiac tamponade and prognosis after pericardiocentesis: a single-center study of 113 consecutive cancer patients. Int J Clin Oncol 20, 872 – 877 (2015).
14. Jeong TD, Jang S, Park CJ, Chi HS. Prognostic relevance of pericardial effusion in patients with malignant diseases. Korean J Hematol . 2012;47(3):237-238. doi:10.5045/kjh.2012.47.3.237
Catheter Directed tPA for treatment of acute PE in setting of Sickle Cell Disease and Severe Right Ventricular Failure
Austin Tutor MD, Justin Price MD, Arthur Davis MD, Jose Tafur MD
Introduction Hemoglobin SC disease is the second most common subtype of sickle cell disease (SCD). Venous thromboembolism is a well-known complication of SCD and can present as pulmonary emboli (PE) with an associated mortality estimated as high as 30%. The mainstay of treatment for PE is anticoagulation. Acute treatment can also involve thrombolytics or embolectomy for patients with sub-massive or massive PEs. Case Presentation A 37-year-old male presented with abdominal pain and shortness of breath. Laboratory evaluation on admission was significant for elevated liver enzymes and bilirubinuria. A CT angiogram was unable to be performed secondary to acute renal failure. A VQ scan showed a high probability for PE. Transthoracic echo was notable for severe right ventricular (RV) failure with RVEDD 6.28cm and TAPSE 1.1cm, flattening of the interventricular septum, and severe pulmonary artery systolic pressure (PASP) elevation to 82mmHg. Lower extremity venous duplex ultrasound confirmed multiple, bilateral deep venous thromboses. Due to his RV failure and multisystem organ failure despite treatment with continue IV heparin, we proceeded with a catheter directed tPA continuous infusion for 12 hours at 1mg/hr in addition to dobutamine. After 5 days of treatment, PASP decreased to 34mmhg and his liver and renal function returned to normal. He was able to be weaned off dobutamine, transitioned from intravenous heparin to apixaban, and discharged home. Discussion Sickling of red blood cells results in small vessel occlusion and vasoconstriction leading to local vascular ischemia. PE in patients with SCD is often underdiagnosed as patient often have confounding factors including dyspnea secondary to anemia and acute chest syndrome. Conversely, sickle cell patients are also at a higher risk of hemorrhagic conversion. Catheter directed tPA was chosen as rescue therapy for our hemodynamically stable intermediate-high risk sub-massive PE patient (Class IIa, European Society of Cardiology). Conclusion: Our case demonstrates the sequelae of multiorgan failure in a sickle cell anemia (HbSC) patient with an acute PE with a high risk of hemorrhagic conversion. The patient made complete recovery with catheter direct tPA after failing medical treatment with IV heparin.
Contemporary Peripheral Revascularization: By Drip or By Suction or By Surgery? George Eigbire MD, Jose Barrientos MD, Brian Allen MD, Syed Saad MD, Glenn Johnson MD
Case : A 35-year-old man sought emergency medical attention due to a persistent throbbing pain in his left leg over the last 24 hours. His medical and social histories are remarkable for active tobacco smoking, self-employment as a tattoo artist, and he suffered a traumatic injury from a riot grenade explosion 1 year ago. He takes no medications. Based upon diminished arterial pulsation on exam, he underwent a CT angiogram of the lower extremities revealing a complete occlusion of the left popliteal artery with reconstitution in the tibio-peroneal trunk as well as an occlusion of the distal left anterior tibial artery. Additionally, numerous metallic densities in the subcutaneous soft tissues of the thigh muscles and a filling defect compatible with non-occlusive thrombus was present in the right common iliac artery. Urgent invasive vascular revascularization of the left lower extremity was planned, and IV heparin initiated. A Cragg-McNamara catheter was advanced proximal left popliteal occlusion and a prolonged infusion of tPA given. Repeat angiography showed unsuccessful revascularization with persistent thrombosis within the left popliteal and anterior tibial arteries. At that point, thrombectomy was performed with an aspiration catheter (PENUMBR Indigo Aspiration System) yielding excellent angiographic results. A hypercoagulable work up resulted in the detection of heterozygous methylene- tetrahydrofolate reductase (MTHFR) gene mutation. MTHFR enzyme defect results in elevated levels of homocysteine.
Discussion
Acute limb ischemia is associated with significant morbidity and mortality. In our patient, prolonged local fibrinolytic therapy was ineffective in treating the occlusion, necessitating therapy escalation. There is growing literature on the use of catheter thrombectomy as a viable alternative to open surgery in these patients, particularly when other modalities have failed.
Conclusion :
Mechanical aspiration thrombectomy can be considered a viable option in patients presenting with arterial thrombosis, particularly in patients that that have failed other modalities.
Coronary artery fistulas and persistent Thebesian veins presenting as STEMI
Authors: Michael Crawford, MD; Laura Padilla-Carrasquillo, MD; Tariq Thannoun, MD; Rohan Samson, MD
Introduction : A coronary artery fistula (CAF) is an anomalous communication between a coronary artery and a cardiac chamber without an intervening capillary network. While generally asymptomatic, they may result in ischemia, heart failure, or arrhythmia. In contrast to CAFs, which have a noticeable communication, smaller fistulas or persistent Thebesian veins, are rarer entities that form an intramural vascular network prior to emptying into the ventricle. Here, we present a unique case of a patient with CAFs draining into the right ventricle (RV) and persistent Thebesian veins draining into the left ventricle (LV). Case presentation : A 66-year-old man presented with chest pain relieved with nitroglycerin. Initial electrocardiogram (ECG) showed ST elevations in the anteroseptal leads. Troponin I level was normal. Coronary angiography revealed no epicardial coronary artery disease. However, injection of the left anterior descending and right coronary arteries revealed large caliber vessels with distal communications into the RV apex creating a ventriculogram. Of greater interest, injection of the left circumflex artery resulted in a marked capillary blush within the LV wall due to an extensive vascular network that ultimately drained into the LV creating a ventriculogram. Echocardiography showed evidence of anomalous flow into the RV and LV via color doppler. Coronary computed tomography angiography confirmed the findings previously described. Symptoms and ECG changes resolved. He was treated with aggressive risk factor modification. Discussion : CAFs and persistent Thebesian veins have been noted in <0.3% of adults undergoing coronary angiography. While typically isolated, they may be associated with other cardiac malformations such as atrial or ventricular septal defects. Most CAFs are congenital in nature but can be acquired from iatrogenic events such as stenting or bypass surgery. Symptoms are rare but may occur from a coronary “steal” phenomenon causing myocardial ischemia. First-line treatment is medical therapy, but closure of CAFs with coil occlusion or surgical ligation may be considered in the setting of significant shunting or persistent ischemia.
Conclusion :
CAFs and persistent Thebesian veins are rare anatomic abnormalities of the coronary arteries. While often silent, they can lead to symptoms or complications that may prompt intervention.
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