A Rare Association of Takotsubo Cardiomyopathy with High-degree Atrioventricular Block

Here we present a case of a patient who got trapped in an elevator; on initial evaluation patient was found with bradycardia; on further evaluation electrocardiogram (EKG) showed new onset 2nd-degree Mobitz type 2 AV block. On admission patient developed ischemic changes on EKG and troponin elevation. Transthoracic echocardiogram showed reduced ejection fraction as well as apical inferior, anterior, lateral, and septal hypokinesia. Coronary angiography showed nonobstructive coronary artery disease and ventriculogram demonstrated anterolateral and apical hypokinesia suggesting takotsubo cardiomyopathy (TCM). Atrioventricular block (AV) is rarely seen as initial presentation of TCM and has a prevalence of about 2.9%. AV block during early presentation of TCM poses a therapeutic dilemma with regard to the timing and the need to place a temporary or permanent pacemaker. The decision to place a permanent pacemaker may be on a case-by-case basis and more research is needed on formulating standardized recommendations in patients with TCM and conduction tissue abnormalities

A Challenging Case of Mechanical Mitral Valve Obstruction.

Prosthetic valve thrombosis (PVT) is a frequent complication with a mechanical valve that presents with symptoms of heart failure or thromboembolic episodes. A 45-year-old lady with antiphospholipid syndrome (APS) complicated by a previous history of native mitral valve thrombus and mechanical mitral valve replacement maintained on warfarin presented with complaints of chest pain and shortness of breath (NYHA class 2). The initial lab showed a subtherapeutic international normalized ratio (INR) of 1.8. Transthoracic echo (TTE) showed severe mitral stenosis with a normal ejection fraction of 65%, elevated peak gradient of 34.5 mmHg, mean gradient of 23.7 mmHg, and pressure half time of 214 ms. Cine-fluoroscopic images revealed an immobile posterior mitral valve leaflet. She failed two trials of low-dose alteplase therapy during the hospitalization. Hence cardiac CT with contrast was done, which showed a small degree of pannus formation on the ventricular surface of the mitral valve ring and a small thrombus. Due to persistent immobility of the post mitral valve after two doses of alteplase and a cardiac CT scan concerning pannus formation, a multi-departmental decision was made to proceed with mechanical mitral valve replacement, following which she had a good recovery. Our case report depicts the importance of imaging study, like cardiac CT scan that can help distinguish thrombus (which has a lower Hounsfield unit, HU o

Platypnea Orthodeoxia for Those Who do Better Lying Low.

Platypnea orthodeoxia syndrome (POS) can be a confounding disease. Patients with POS may have already had an extensive and unrevealing evaluation for hypoxia. POS is the worsening of hypoxia when upright compared to supine. The underlying mechanism is a right to left shunt. While there are various causes of this, we focus on intracardiac shunt. The most common of these is patent foramen ovale (PFO). Once this is identified, closure of the PFO can lead to resolution of hypoxia

Can a Score Accurately Predict Readmissions in Geriatric Patients with Congestive Heart Failure?

Background: Congestive heart failure (CHF) affects 5.7 million Americans, It is considered the main cause of readmissions in adult population, associated with 134,500 readmissions annually. The LACE index is a commonly used tool to identify patients at risk of readmission or death within 30 days after hospital discharge. Methods: This is a retrospective study, we analyzed Electronic Medical Records of geriatric patients admitted with discharged diag- nose of acute Congestive Heart Failure decompensation from January 2012 to December 2014; selected patients were followed up for the next 30 days to determine if they were readmitted due acute CHF decompensation. Patients with admission no related to acute decompensation of CHF were excluded. For each patient we collected data regarding age, sex, ethnicity, body mass index, reason for admission, comorbidities (DM, renal/liver disease, etc.). Results: 49 patients were enrolled in the study, with 33 patients readmitted within 30 days and 16 patients with no readmissions within 30 days. We found patients in the readmission group had higher mean age compared with those who were not readmitted (77 years vs 71 years, p-value 0.04). In both groups LACE index was found elevated, when comparing high risk patients vs no high risk patients using LACE index there was no statistically significance (OR 2.13 95%CI 0.12-36.0 p-value 0.6). Length of hospital staying on readmis- sion group was 5.6 days and in no readmission group 4.5 days (P-value 0.23). Emergency department visit on readmission group was 1.4 and in no readmission group 1.1 (P-value 0.46). There was no statistical difference in both groups regarding Gender, ischemic heart disease, systolic heart failure and BMI. Conclusion: In this single retrospective study, LACE index score did not accurately predicted readmission within 30 days in geriatric patients with CHF. Not statistically difference among low risk patient and high risk using LACE index in terms of readmission within 30 days was found. Predicting who will be re-hospitalized is difficult, and much is unexplained

Cardiac Amyloidosis: A Diagnostic Dilemma and the Role of a Novel Electrocardiogram Criterion.

Cardiac amyloidosis is an infiltrative disease of the myocardium. Nearly all cases of clinical cardiac amyloidosis are caused by transthyretin amyloidosis or light chain amyloidosis. Clinical manifestations are consistent with those of refractory heart failure secondary to irreversible restrictive cardiomyopathy, autonomic abnormalities as well as neuropathy. Delay in diagnosis is a challenge, as symptoms and signs of cardiac amyloidosis are nonspecific. One of the hallmarks of cardiac amyloidosis is the discordance between the increased left ventricular wall thickness and low QRS voltages on the electrocardiogram. Diagnostic delay may lead to deleterious consequences as prompt therapy, if feasible, would be hampered. We, therefore, present a case of cardiac amyloidosis presenting with syncope and refractory heart failure to highlight the diagnostic dilemma as well as to stress upon the utility of a novel electrocardiogram criterion that may assist in the diagnosis of cardiac amyloidosis

Comparative Assessment of Echocardiographic Patterns Among Chronic Myeloid Leukemia Patients on Tyrosine Kinase Inhibitor and Healthy Controls.

PURPOSE: Chronic myeloid leukemia (CML) is one of the common hematological malignancies in Nigeria. Cardiac abnormalities are associated with CML irrespective of treatment with tyrosine kinase inhibitors such as imatinib, which is available gratis in Nigeria. OBJECTIVE: To assess the prevalence and patterns of cardiac dysfunction among patients with CML irrespective of treatment with imatinib using transthoracic echocardiography, and 12-lead surface electrocardiography. PATIENTS AND METHODS: CML patients without Imatinib, CML patients with imatinib, and apparently healthy (age- and sex-matched) controls were 70 each in the study. Various echocardiographic parameters were measured and data obtained were analyzed, and the level of significance was taken as p \u3c 0.05. RESULTS: Of 70 CML patients with imatinib, 54.3% were men and 45.7% were women, while the CML group without imatinib had 62.9% men and 37.1% women, non-CML control had 54.3% men and 45.7% women. The average hematocrit was significantly lower in the CML group without Imatinib compared with the other groups (p CONCLUSION: Cardiac abnormalities are present in CML patients with or without Imatinib treatment, with significant prevalence than what is seen in the non-CML control group

Left Ventricular Aneurysm May Not Manifest as Persistent ST Elevation on Electrocardiogram

BACKGROUND Electrocardiographic presentations of left ventricle aneurysms are diverse; however, a persistent ST segment elevation post myocardial infarction is most commonly reported. CASE REPORT The authors present a case of a 67-year-old man who presented to the emergency department after three days of chest pain and was found to have an acute myocardial infarction with an incidental finding of a left ventricular aneurysm. His surface electrocardiogram, however, demonstrated only inverted T waves in the precordial leads. He had a very elevated serum troponin I consistent with an acute myocardial injury which prompted a cardiac catheterization with angioplasty. Post angioplasty, he had persistent T wave inversions in the precordial leads. CONCLUSIONS It is important for clinicians to appreciate that the presence of newly inverted T waves in patients with a late presentation post myocardial infarction should raise a concern for a possible left ventricular aneurysm

Heart Failure and Cognitive Impairment: Clinical Relevance and Therapeutic Considerations

Heart failure (HF) is a devastating condition characterized by poor quality of life, numerous complications, high rate of readmission and increased mortality. HF is the most common cause of hospitalization in the United States especially among people over the age of 64 years. The number of people grappling with the ill effects of HF is on the rise as the number of people living to an old age is also on the increase. Several factors have been attributed to these high readmission and mortality rates among which are; poor adherence with therapy, inability to keep up with clinic appointments and even failure to recognize early symptoms of HF deterioration which may be a result of cognitive impairment. Therefore, this review seeks to compile the most recent information about the links between HF and dementia or cognitive impairment. We also assessed the prognostic consequences of cognitive impairment complicating HF, therapeutic strategies among patients with HF and focus on future areas of research that would reduce the prevalence of cognitive impairment, reduce its severity and also ameliorate the effect of cognitive impairment coexisting with HF