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BACKGROUND We report a patient who was diagnosed with toxic myopericarditis secondary to hydrocarbon abuse using cardiac magnetic resonance imaging (CMR). CASE SUMMARY A 25-year-old male presented to emergency department with chest pain for 3 d. Patient also reported sniffing hydrocarbon containing inhalant for the last 1 year. Labs showed elevated troponin and electrocardiography was suggestive of acute pericarditis. Echocardiogram showed left ventricular (LV) ejection fraction (EF) of 40%. Given patient’s troponin elevation and reduced EF, cardiac catheterization was performed which showed normal coronaries. CMR was performed for myocardial infarction with non-obstructive coronary arteries evaluation. CMR showed borderline LV function with edema in mid and apical LV suggestive of myocarditis. CONCLUSION CMR can be used to diagnose toxic myopericarditis secondary to hydrocarbon abuse.

Background: In academic hospitals, cardiology fellows may be the first point of contact for patients presenting with suspected STE elevation myocardial infarction (STEMI) or acute coronary syndrome (ACS). In this study, we sought to determine the role of handheld ultrasound (HHU) in patients with suspected acute MI (AMI) when used by fellows in training, its association with year of training in cardiology fellowship, and its influence on clinical care. Methods: This prospective study’s sample population was comprised of patients who presented to Loma Linda University Medical Center Emergency Department with suspected acute STEMI. On call cardiology fellows performed bedside cardiac HHU at time of AMI activation. All patients subsequently underwent standard TTE. The impact of the detection of WMA on HHU in regards to clinical decision making, including whether the patient would undergo urgent invasive angiography, was also evaluated. Results: 82 patients (mean age 65 years, 70% male) were included. The use of HHU by cardiology fellows resulted in a concordance correlation coefficient of 0.71 (95% confidence interval: 0.58 - 0.81) between HHU and TTE for LVEF, and a concordance correlation coefficient of 0.76 (0.65 - 0.84) for wall motion score index (WMSI). Patients with WMA on HHU were more likely to undergo invasive angiogram during hospitalization (96% vs 75%, pConclusion: HHU can be reliably used by cardiology fellows in training for measurement of LVEF and assessment of wall motion abnormalities, with good correlation to findings obtained via standard TTE. HHU-identified WMA at first contact were associated with higher rates of angiography as well as sooner angiography compared to patients without WMA.

Cardiovascular disease (CVD) is a major contributor to the morbidity and mortality associated with type 2 diabetes mellitus (T2DM). With T2DM growing in pandemic proportions, there will be profound healthcare implications of CVD in person with diabetes. The ideal drugs to improve outcomes in T2DM are those having antiglycemic efficacy in addition to cardiovascular (CV) safety, which has to be determined in appropriately designed CV outcome trials as mandated by regulatory agencies. Available evidence is largely supportive of metformin's CV safety and potential CVD risk reduction effects, whereas sulfonylureas are either CV risk neutral or are associated with variable CVD risk. Pioglitazone was also associated with improved CVD risk in patients with diabetes. The more recent antihyperglycemic medications have shown promise with regards to CVD risk reduction in T2DM patients at a high CV risk. Glucagon-like peptide-1 receptor agonists, a type of incretin-based therapy, were associated with better CV outcomes and mortality in T2DM patients, leading to the Food and Drug Administration approval of liraglutide to reduce CVD risk in high-risk T2DM patients. Ongoing and planned randomized controlled trials of the newer drugs should clarify the possibility of class effects, and of CVD risk reduction benefits in low-moderate CV risk patients. While metformin remains the first-line antiglycemic therapy in T2DM, glucagon-like peptide-1 receptor agonists should be appropriately prescribed in T2DM patients with baseline CVD or in those at a high CVD risk to improve CV outcomes. Dipeptidyl peptidase-4 inhibitors and sodium-glucose cotransporter-2 inhibitors are discussed in the second part of this review.

Background One notable change to the 2018 United Network for Organ Sharing listing criteria was to allow for the use of noninvasive hemodynamic monitoring for inpatients listed as status 3 for heart transplantation. We wanted to explore the feasibility of performing daily focused echocardiograms in place of invasive monitoring in this population. Methods On retrospective chart review of inpatients listed for transplantation at our institution, 8 patients in the invasive monitoring group listed as status 1A (October 2016 to October 2018) and 9 patients in the echocardiographic group listed as status 3 (October 2018 to February 2020) were identified. Results There were no significant differences between the 2 cohorts in the average measured/estimated right atrial, pulmonary artery systolic, and wedge pressures, although the echo cohort had lower cardiac index (P = .001). There were 2 patients with positive blood cultures treated with Swan exchange in Swan cohort and a total of 14 Swan exchanges. There were no infections in the noninvasive group. Conclusion We present our experience with the use of noninvasive daily hemodynamic assessment using focused echocardiograms to manage patients undergoing heart transplantation listing as status 3 under the new United Network for Organ Sharing allocation system. This approach appears safe and feasible; however, it requires validation in larger cohorts.

IntroductionExtracorporeal membrane oxygenation (ECMO) is associated with gastrointestinal haemorrhage (GIH), which may result from coagulo­pathy, systemic inflammation, reduced gastric perfusion, and arteriovenous malformation from non-pulsatile blood flow. Data are limited regarding the burden of this complication in the United States.Material and methodsWe analysed the National Inpatient Sample (NIS) database for the years 2007 to 2011 to identify hospitalisations in which an ECMO procedure was performed. Hospitalizations complicated by GIH in this cohort were then identified by relevant codes.ResultsBetween 2007 and 2011, ECMO hospitalisations increased from 1869 to 3799 (p < 0.01). The proportion of hospitalisations complicated by GIH increased from 2.12% in 2007 to 7.46% in 2011 (p < 0.01). Gastrointestinal haemorrhage was more common in men (56.7%) and in Caucasians (57.4%). Common comorbidities in this population were renal failure (71%), anaemia (55%), and hypertension (26%). All-cause inpatient mortality showed a numerical but nonsignificant increase from 56.7% to 61.9% (p = 0.49). The average cost of care per hospitalisation with GIH associated with ECMO use increased from $132,420 in 2007 to $215,673 in 2011 (p < 0.01).ConclusionsGastrointestinal haemorrhage during ECMO hospitalisations occurred in small but significantly increasing proportions. The inpatient mortality rate and costs associated with GIH were substantial and increased significantly during the study period.

Cardiovascular disease (CVD) is a major contributor to the morbidity and mortality associated with type 2 diabetes mellitus (T2DM). With T2DM growing in pandemic proportions, there will be profound healthcare implications of CVD in person with diabetes. The ideal drugs to improve outcomes in T2DM are those having antiglycemic efficacy in addition to cardiovascular (CV) safety, which has to be determined in appropriately designed CV outcome trials as mandated by regulatory agencies. Available evidence is largely supportive of metformin's CV safety and potential CVD risk reduction effects, whereas sulfonylureas are either CV risk neutral or are associated with variable CVD risk. Pioglitazone was also associated with improved CVD risk in patients with diabetes. The more recent antihyperglycemic medications have shown promise with regards to CVD risk reduction in T2DM patients at a high CV risk. Glucagon-like peptide-1 receptor agonists, a type of incretin-based therapy, were associated with better CV outcomes and mortality in T2DM patients, leading to the Food and Drug Administration approval of liraglutide to reduce CVD risk in high-risk T2DM patients. Ongoing and planned randomized controlled trials of the newer drugs should clarify the possibility of class effects, and of CVD risk reduction benefits in low-moderate CV risk patients. While metformin remains the first-line antiglycemic therapy in T2DM, glucagon-like peptide-1 receptor agonists should be appropriately prescribed in T2DM patients with baseline CVD or in those at a high CVD risk to improve CV outcomes. Dipeptidyl peptidase-4 inhibitors and sodium-glucose cotransporter-2 inhibitors are discussed in the second part of this review.

Background We report a patient with COVID 19 who presented with STEMI and high thrombus burden, needing intracoronary (IC) alteplase infusion and subsequent PCI Case 55 year old female with past history of diabetes, CVA (8 years back), recently diagnosed COVID 19 who presented to ED with chest pain for 18 hours She was noted to have ST elevation in anterolateral leads and was taken for emergent angiogram Angiogram showed large ostial LAD thrombus with thrombotic occlusion of distal LAD1 Decision-making Considering thrombus burden, several runs of aspiration thrombectomy was performed followed by balloon dilation No distal flow was noted Subsequently, 2 mg IC alteplase was infused twice, followed by thrombectomy Repeat angiogram showed TIMI 0 flow Intracoronary ultrasound (IVUS) was performed which showed heavy thrombus burden with no plaque rupture PTCA of ostial LAD was performed afterwards with 4 0 x 15 mm compliant balloon Thrombus was persistently noted in ostial LAD with TIMI 0 flow distally She was started on aspirin, ticagrelor, heparin drip and 12 hour tirofiban infusion 24 hours later she was taken back to the cath lab due to on and off chest pain and persistent ST elevation on EKG Repeat angiogram showed persistent ostial LAD thrombus with TIMI 2 distal flow PCI of ostial LAD was subsequently performed with excellent final result2 Conclusion IC alteplase can be considered in COVID patients with STEMI who have high burden burden when conventional measures fail to establish adequate flow [Formula presented]

Introduction: Many cardiovascular diseases are known to have seasonal variation and that helps to better understand the disease. From the national sample, we studied the incidence and mortality pattern in infective endocarditis (IE) in illicit drug users (IDU) to delineate the seasonal effect on the disease. Methods: National inpatient sample (NIS) database from the year 2008 to 2014 was used to identify cases of IE and IDU (opiates, cocaine and amphetamine) in between age 15-65 years. After excluding cases with congenital cardiac anomalies, rheumatic, lupus and transfer status (possible doubling in count), data was analyzed using t-test, x 2 test and multivariate logistic regression analysis methods with SAS 9.4 software. Results: Out of total 144,593 identified cases of IE, 22,806 cases (15.77%) were illicit drug users infective endocarditis (IDU-IE). Patients in IDU-IE group were younger compare to non-IDU IE group (median± SE, p-value; 35± 0.39 vs 52± 0.11 yr, 50 (2.43, (1.76-3.38), 1 comorbidities (2.09 (1.59- 2.74), Conclusion: In conclusion, drug use pattern is consistent with drug users IE pattern. But highest mortality despite of lowest incidence rate in winter suggests involvement of environmental and physical factors. Identifying these factors will help improving patient care and health care burden.

Heart failure (HF) is characterized by maladaptive neurohormonal activation of the cardiovascular and renal systems resulting in circulatory inadequacy and frequent acute exacerbations. The increasing burden of HF prompted investigation of underlying pathophysiological mechanisms and the design of pharmacotherapeutics that would target these pathways.A MEDLINE search for relevant original investigations and review articles of newer hormonal drugs for HF since the year 2005 till October 2017 provided us with necessary literature. Major trials and relevant clinical investigations were discussed.A multitude of hormonal pathways central to HF were identified, including the natriuretic peptide system and neurohormones such as relaxin, arginine vasopressin, and endothelin. However, drugs targeting these novel pathways (aliskiren, tolvaptan, ularitide, serelaxin, bosentan, macitentan) failed to show mortality benefit. This emphasizes a tremendous unmet need in the pharmacotherapy for HF, especially for the subtypes of acute HF and HF with preserved ejection fraction. Sacubitril/valsartan demonstrated substantial mortality benefit in chronic systolic HF population and is endorsed by international HF guidelines. If proven to be efficacious in larger outcome trials, finerenone can be a valuable addition baseline HF therapy. More basic, translational, and phenotype specific clinical research is warranted to improve HF pharmacotherapy.

Esophagopericardial fistulas are rare. Most reported cases are related to malignancy or prior surgical intervention. We report a case of an esophagopericardial fistula presenting as pneumopericardium and purulent pericarditis in a patient with a history of caustic ingestion and an esophageal stent.

This study was devised to translate Cystic Fibrosis Questionnaire-Revised to Hindi and administer it to Indian children and adolescents diagnosed with cystic fibrosis.Cross-sectional study.This study was carried out in cystic fibrosis patients attending Pediatric Chest Clinic of a tertiary-care hospital in Northern India from July 2012 to December 2012.45 children (6-13 years) and their parents, and 14 adolescents. Patients with unstable health in the past two weeks were excluded.Cystic Fibrosis Questionnaire- Revised translated in Hindi was administered. Clinical evaluation and scoring, throat swab cultures and spirometry were also done during the same visit.Health Related Quality of Life scores were the primary measures, and clinical scores, swab cultures and spirometry were secondary measures.Cronbachs alpha ranged from 0.020-0.863.The Factor analysis indicated that most test-items correlated more with competing scales than the intended scales. Convergence between self and proxy-rating was found to be dependent on the domain. The Cystic Fibrosis Questionnaire- Revised scores correlated well with clinical scores (r=0.65,P=0.011), Pseudomonas spp culture data and pulmonary function tests. There was an inverse relation between Health Related Quality of Life scores and age at diagnosis (r=-0.339, P=0.02).Hindi versions of Cystic Fibrosis Questionnaire- Revised: Child, Adolescent and Parents instruments will act as an important step towards data on Health Related Quality of Life of Indian patients with cystic fibrosis.

Background: Correlation of ST-segment elevation on the 12-lead electrocardiogram (ECG) with the expected affected coronary territory is established in patients with ST-elevation myocardial infarction (STEMI). In patients with non-ST-elevation myocardial infarction (NSTEMI), correlation of ischemic ECG abnormalities with the affected coronary territory has not been well-established. We sought to investigate the correlation of electrocardiographic abnormalities with the location of 1-vessel obstructive coronary artery disease (CAD) in patients with both STEMI and NSTEMI. Methods: In this retrospective study, the charts of all patients referred for coronary angiography in 2012 were reviewed. Patients with a single obstructive coronary artery plus angina-equivalent symptoms and an elevated cardiac troponin I was included. Available ECGs were interpreted by an experienced cardiologist (WSA) blinded to the result of angiography. Patients with complete bundle branch block or ventricular pacing were excluded. Ischemic ECG changes were correlated to a coronary territory based on predefined criteria. Results: Of 131 included patients (mean age 64±13 years; 74% male), 29 had STEMI and 102 had NSTEMI. Eleven of 11 patients (100%) with anterior STEMI had left anterior descending artery (LAD) obstructive CAD. Of 18 patients with inferior STEMI, 14 (78%) had right coronary artery (RCA) obstructive CAD, 3 (17%) had left circumflex artery (LCX) artery obstructive CAD, and 1 (5%) had LAD obstructive CAD. Of 102 NSTEMI patients, 53 (52%) had definite ECG ischemic abnormalities. Of 31 patients with anterior definite ECG ischemic abnormalities, 30 (97%) had LAD obstructive CAD, and 1 (3%) had RCA obstructive CAD. Of 22 patients with inferior definite ECG ischemic abnormalities, 14 (64%) had RCA obstructive CAD, 5 (23%) had LCX obstructive CAD, and 3 (14%) had LAD obstructive CAD. Conclusions: Patients with anterior STEMI had LAD obstructive CAD. Patients with inferior STEMI were highly likely to have RCA or LCX obstructive CAD. Only half of NSTEMI patients had definite ischemic ECG abnormalities. When present, anterior ischemic ECG changes in patients with single vessel CAD with NSTEMI were predictive of LAD obstructive CAD.

Diabetes mellitus is a growing in exponential proportions. If the current growth trend continues, it may result in every third adult in the United States having diabetes mellitus by 2050, and every 10th adult worldwide. Type 2 diabetes mellitus (T2DM) confers a 2- to 3-fold increased risk of cardiovascular (CV) events compared with non-diabetic patients, and CV mortality is responsible for around 80% mortality in this population. Patients with T2DM can have other features of insulin resistance-metabolic syndrome like hypertension, lipid abnormalities, and obesity which are all associated with increased CV disease and stroke risk even in the absence of T2DM. The management of a T2DM calls for employing a holistic risk factor control approach. Metformin is the first line therapy for T2DM and has been shown to have cardiovascular beneficial effects. Intense debate regarding the risk of myocardial infarction with rosiglitazone led to regulatory agencies necessitating cardiovascular outcome trials with upcoming anti-diabetic medications. Glucagon like peptide-1 agonists and sodium glucose co-transporter-2 inhibitors have shown promising CV safety and additional CV benefit in recent clinical trials. These drugs have favorable effects on traditional CV risk factors. The findings from these studies further support that fact that CV risk factor control plays an important role in reducing morbidity and mortality in T2DM patients. This review article will discuss briefly the cardiovascular safety and benefits of the oral medications which are currently being used for T2DM and will then discuss in detail about the newer medications being investigated for the treatment of T2DM.

Classically, Class IB phosphoinositide 3-kinase (PI3Kγ) plays a role in ERK activation following G-protein–coupled receptor (GPCR) activation. Here we show that PI3Kγ noncanonically regulates ERK phosphorylation in a kinase-independent mechanism, irrespective of the upstream signals. PI3Kγ sequesters PP2A, allowing sustained ERK function., Classically Class IB phosphoinositide 3-kinase (PI3Kγ) plays a role in extracellular signal–regulated kinase (ERK) activation following G-protein coupled receptor (GPCR) activation. Knock-down of PI3Kγ unexpectedly resulted in loss of ERK activation to receptor tyrosine kinase agonists such as epidermal growth factor or insulin. Mouse embryonic fibroblasts (MEFs) or primary adult cardiac fibroblasts isolated from PI3Kγ knock-out mice (PI3KγKO) showed decreased insulin-stimulated ERK activation. However, expression of kinase-dead PI3Kγ resulted in rescue of insulin-stimulated ERK activation. Mechanistically, PI3Kγ sequesters protein phosphatase 2A (PP2A), disrupting ERK–PP2A interaction, as evidenced by increased ERK–PP2A interaction and associated PP2A activity in PI3KγKO MEFs, resulting in decreased ERK activation. Furthermore, β-blocker carvedilol-mediated β-arrestin-dependent ERK activation is significantly reduced in PI3KγKO MEF, suggesting accelerated dephosphorylation. Thus, instead of classically mediating the kinase arm, PI3Kγ inhibits PP2A by scaffolding and sequestering, playing a key parallel synergistic step in sustaining the function of ERK, a nodal enzyme in multiple cellular processes.

Introduction Over the last two decades, there has been a 24-fold rise in solid organ donation due to drug overdose deaths. One-year survival in recipients of a heart transplant from a drug overdose donor (DOD) has been reported to be similar to that of donor deaths from trauma or other medical causes (non-DOD). However, the incidence of primary graft dysfunction (PGD) requiring mechanical circulatory support (MCS) and early post-transplant mortality in these patients has not been established. Hypothesis Heart donation from a DOD results in higher rates of PGD and early post-transplant mortality than donation from a non-DOD. Methods We performed a retrospective analysis of consecutive orthotopic heart transplants (OHT) at a single center from January 2013 to December 2018. Patients with PGD requiring MCS in the form of extracorporeal membrane oxygenation (ECMO) within 48 hours of OHT were analyzed with respect to the cause of death of the donor. Patients on ECMO prior to transplant surgery were excluded. Baseline characteristics were compared using Chi-square test for categorical variables and t-test for continuous variables. Results Of 154 consecutive heart transplants, 5 were excluded due to pre-operative recipient ECMO support. Among the 149 analyzed transplants, 38 (25.5%) received a heart from a DOD. DOD had a lower initial pH (7.15 vs. 7.28, p=0.001), a higher rate of hepatitis C infection (15.8% vs. 1.8%, p=0.001) and were more likely to have received CPR (91.7% vs.32%, p Conclusions In this single-center study, there was a trend towards an increased risk of PGD when the donor had died from a drug overdose, possibly due to ischemic graft injury related to hypoxia. However, survival to hospital discharge was similar between the DOD and non-DOD groups. Given the rapid increase in the number of DODs, further investigation in larger populations is warranted as it may help inform donor selection.

Treatment of septic shock has become standardized nationwide. Patients who fail adequate fluid resuscitation require urgent treatment with vasopressors. Only recently has physician's choice of vasopressor expanded to incorporate synthetic Angiotensin II (SA2). A 33-year-old male was transferred for

Wolff-Parkinson-White [WPW] syndrome has classically been described in younger patients and is rarely seen in the elderly as they are treated early or the accessory pathway may lose its conductive properties with age. An 83 year old female with recently diagnosed WPW on EKG presented with chest

Takotsubo cardiomyopathy is a transient cardiac syndrome that typically causes mid-ventricular circumferential and apical hypokinesis mimicking an acute coronary syndrome (ACS). Etiology is felt to be diffuse microvascular spasm and ischemia with resulting stunning of the myocardium as a result of

Severe aortic stenosis (AS) can adversely affect right ventricular function (RVF). RVF is an important determinant of transcatheter aortic valve replacement (TAVR) outcomes. Immediate changes in echocardiographic parameters of RVF have not been previously reported. We report changes in

We present a patient with acute Pulmonary Embolism (PE), who underwent emergent combined Coronary Artery Bypass Grafting (CABG) & pulmonary thromboendarterectomy for Chronic Thromboembolic Pulmonary Hypertension (CTEPH). 57 year old male with history of myocardial infarction, stroke, diabetes

Hemodynamic instability immediately post heart transplant (OHT) could be due to primary graft dysfunction (PGD). Extracorporeal membrane oxygenation (ECMO) is increasingly utilized as temporary mechanical circulatory support in PGD until graft function normalizes. We aim to study the donor and

Only 10% of patients with cardiac sarcoidosis exhibit involvement of the pericardium, and even fewer have clinical manifestations of the disease. A 48-year-old male non-smoker, with a past medical history of pulmonary sarcoidosis and asthma, presented with sudden onset severe pleuritic chest pain

Hemodynamic instability in orthotropic heart transplant (OHT) recipients in the peri-transplant period is deleterious and not infrequent. Mechanical circulatory support (MCS) devices have been used to provide temporary hemodynamic support. We aim to study the trends in utilization of MCS use in OHT

Phosphoinositide 3-kinase (PI3K) enzymes are critical in many cellular processes including survival. PI3Kγ, a member of the PI3K family activated by G-protein coupled receptor (GPCR), is known to be a critical player in activation of extracellular regulated kinase (ERK) signal transduction cascade, a cell survival pathway. However, the exact mechanism by which PI3Kγ plays a role in ERK activation is not clearly understood. Our studies show that PI3Kγ plays a crucial role in enhancing the tone of ERK activation as use of PI3K inhibitors reduced GPCR stimulated ERK phosphorylation in HEK293 cells. siRNA knockdown of PI3Kγ resulted in loss of ERK phosphorylation through GPCRs (β-adrenergic) as well as receptor tyrosine kinases. The role of PI3Kγ in ERK activation was further corroborated by loss of insulin stimulated ERK phosphorylation in PI3Kγ-knockout (KO) mouse embryonic fibroblasts (MEFs). Surprisingly, ERK activation in KO MEFs post-insulin stimulation was completely rescued by expression of kinase-dead PI3Kγ mutant in KO MEFs suggesting a kinase-independent role of PI3Kγ in regulating ERK function. Indepth mechanistic studies showed that PI3Kγ mediated activation of ERK by inhibiting ERK dephosphorylation following stimulation, thus stabilizing the ERK phosphorylation. PI3Kγ physically disrupts the interaction between ERK and ERK dephosphorylating phosphatase PP2A as evidenced by increase in phosphatase association with ERK in KO MEFs. Consistent with this observation, ERK activation was completely abolished in KO MEFs following carvedilol suggesting an essential role for PI3Kγ in cardio-protective ERK activation pathway. In this context, it is known that transverse aortic constriction (TAC) in mice leads to increase in ERK activation in the hearts and is also associated with concurrent up-regulation of PI3Kγ suggesting a key role for kinase-independent function of PI3Kγ in activating and maintaining the ERK signaling cascade. These indepth cellular studies and observation from our TAC studies led us to believe that kinase-dependent function of PI3Kγ may contribute to pathology while kinase-independent function may be cardio-protective through inhibition of PP2A by PI3Kγ. This novel signaling mechanism by PI3Kγ will be presented.