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Cardiac troponin (cTn) is mainly used to diagnose acute coronary syndrome (ACS). However, cTn can also be elevated in critically ill patients secondary to demand ischemia or myocardial injury. The impact of cardiology consultation on the clinical outcomes of patients admitted to medical intensive care unit (ICU) with elevated cTn is unclear.A retrospective analysis of medical ICU patients with elevated cTn without evidence of ACS between January 2013 through December 2018. Patients were stratified based on documentation of cardiology consultation. The primary outcome was 1-year mortality. Secondary outcomes were in-hospital and 30-day mortality, the length of stay (LOS), further cardiac testing, 30-day readmission rate, new prescription of cardiac medications, and the predictors of a cardiology consultation.Of 846 patients screened, 766 patients were included, of whom 63.2% had cardiology consultation. Cardiology consultation group had longer median LOS (7 vs. 5 days, P = 0.007), additional cardiac testing (90.3% vs. 67.7%, P 0.001), and more new cardiac medications (52.1% vs. 16.3%, P 0.001). No difference was noted in-hospital mortality (adjusted odds ratio [aOR], 0.6, 95% CI, 0.4-1.1, P = .117), 30-day mortality (aOR = 0.8, 95% CI, 0.5-1.4, P = .425), 1- year mortality (aOR, 1.4, 95% CI, 0.9-2.2, P = .193), or cardiac-specific 30-day readmission rate (aOR, 7.0, 95% CI, 0.7-14.9, P = .137). History of coronary artery disease (CAD) was the most independent predictor for a cardiology consult (aOR, 2.2, 95% CI, 1.3-3.8, P .001).Cardiology consultation for elevated cTn in medical ICU patients was associated with increased cardiac testing and LOS, without significant impact on mortality.

Background: The current American Association of Neurology guidelines do not recommend patent foramen ovale (PFO) closure for prevention of cryptogenic strokes, however recent findings from randomiz...

Nonbacterial thrombotic endocarditis (NBTE) is illustrated by thrombi deposition on normal heart valves without the presence of bacteremia. It typically occurs in the setting of chronic debilitating diseases such as cancer or autoimmune disease. The pathogenesis involves an endothelial injury in the presence of a hypercoagulable state secondary to the effects of circulatory cytokines, which triggers platelet deposition. It usually forms on the upstream atrial surface of the mitral and tricuspid valves and the ventricular surface of the pulmonic and aortic valves and occurs most commonly in the fourth to eighth decades of life with no specific gender predisposition. These vegetations have a distinct morphology that varies from infective endocarditis (IE). Cerebrovascular lesions due to NBTE have a distinctive pattern of multiple, widely distributed small and large strokes on brain magnetic resonance imaging (MRI). We present a case of a 78-year-old man who was initially diagnosed as pneumonia and IE; he underwent a trans-esophageal echocardiogram (TEE), which revealed Libman-Sacks findings that have changed his diagnosis to lung cancer. We aim to highlight the characteristic TEE findings of NBTE to help clinicians search for underlying etiologies, including malignancies if NBTE is suspected.

Objectives This study sought to evaluate the efficacy of implantable cardioverter-defibrillator (ICD) therapy with or without cardiac resynchronization therapy (CRT) in patients with nonischemic cardiomyopathy (NICM). Background The effect of ICD on mortality of patients with NICM and left ventricular ejection fraction ≤35% has recently been questioned. Prior randomized controlled trials (RCTs) evaluating ICD efficacy in patients with NICM have yielded conflicting results. Furthermore, whether ICD therapy benefits NICM patients with concomitant CRT is unknown. Methods Relevant RCTs published between 2000 and 2016 were identified. Patients with ischemic cardiomyopathy were excluded. Study sample was stratified into CRT and non-CRT groups. The efficacy of having a defibrillator in each group was compared using random effects meta-analysis techniques. Results Six RCTs (N = 3,544) were included. Among the 2,347 patients who did not have CRT, ICD use was associated with a 24% reduction in mortality (relative risk [RR]: 0.76; 95% confidence interval [CI]: 0.63 to 0.91; p = 0.003). However, among the 1,197 patients with CRT, having a CRT defibrillator was not associated with a statistically significant reduction in mortality (RR: 0.74; 95% CI: 0.46 to 1.16; p = 0.19) compared to CRT-pacemaker. Subgroup analysis in non-CRT patients showed that ICD use reduced sudden cardiac death by 73% (RR: 0.27; 95% CI: 0.15 to 0.50; p Conclusions Compared to medical therapy, ICD use significantly improved survival among patients with NICM and ejection fraction ≤35%. Although CRT-defibrillator was not associated with a statistically significant mortality benefit compared to CRT-pacemaker, the apparent lack of power in this analysis warrants further investigation.

Late-onset pulmonary arterial hypertension (PAH) is a rare but fatal complication in patients with childhood surgical repair of dextro-transposition of great arteries (D-TGA), especially with the Mustard and Senning procedures. The pathogenic mechanisms of PAH in patients with repaired D-TGA are not well understood and treatment is not standardized. In this manuscript, we present a case of late-onset PAH in an adult D-TGA patient after Mustard repair and discuss the pathogenic mechanisms, diagnosis, and treatment of pulmonary hypertension in repaired D-TGA.

Multicentric Castleman disease (MCD) is a rare lymphoproliferative disorder with a high mortality rate in undiagnosed patients. Traditionally, human immunodeficiency virus (HIV) positive MCD occurs due to infection with human herpes virus-8 (HHV), which is thought to play a role in the pathogenesis of MCD. We present the case of a 49-year-old woman who was referred to our oncology clinic for generalized lymphadenopathy in a waxing and waning pattern for the last four years. She was found to be HIV positive. Here we report a rare case of HIV-positive, HHV-negative MCD that responded to prompt treatment with highly active antiretroviral therapy (HAART) followed by chemotherapy as evidenced by improved CD4+ T cell numbers and reduction in lymphadenopathy. The findings in this HHV seronegative patient may indicate an alteration in the virulence and tropism between HHV and HIV, and further demonstrate the need for continued investigation into the pathogenesis of Castleman disease.

Objectives To perform a meta-analysis including all available randomized controlled trials (RCTs) to date comparing transcatheter aortic valve replacement (TAVR) to surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis (AS) and low surgical risk. Background Current guidelines recommend SAVR for patients with severe symptomatic AS and low surgical risk. A few RCTs have evaluated TAVR in low surgical risk patients but equipoise exists related to TAVR valve durability, paravalvular leak (PVL) and role of TAVR in younger, low surgical risk patients. Methods Five databases were analyzed from January-2000 to March-2019 for RCTs comparing SAVR to TAVR in low-risk severe AS patients. Results Four RCTs on low-risk TAVR patients with 2887 patients were included. Mean follow-up was ~24.1 ± 24 months. Early mortality was lower with TAVR compared to SAVR (RR: 0.44, 95% CI: 0.20–0.95, P = 0.038) whereas long-term mortality was similar (RR: 0.67, 95% CI: 0.39–1.14, P = 0.141). Both early and long-term stroke rates were similar. TAVR was associated with lower risk of atrial fibrillation, major bleeding, acute kidney injury (AKI) and rehospitalization, but higher rates of permanent pacemaker implantation (PPM) and moderate or severe PVL. There was no difference in major vascular complications, myocardial infarction, endocarditis, aortic valve gradients and valve area at follow-up. Conclusions In low-risk patients with severe AS, TAVR has a lower early mortality compared to SAVR with no difference in long-term mortality. Although complication rates varied between TAVR and SAVR, our study findings suggest that transfemoral-TAVR is an appropriate treatment option for severe symptomatic AS in patients with low surgical risk.

Coronary vasospasm is a well-known entity causing acute chest syndrome and can lead to myocardial infarction, ventricular arrhythmias, and even sudden cardiac death. While there are extensive case series showing the association of coronary vasospasm with cocaine, studies reporting marijuana-induced coronary vasospasm are limited in number. We herein present a case of coronary vasospasm in a middle-aged African-American male who presented to the emergency department after an episode of syncope. His urine drug screen was positive only for marijuana. He had a transient elevation of ST segments on his EKG with concomitant wall motion abnormalities on echocardiogram and was later found to have vasospasm of coronary arteries on coronary angiogram without any evidence of focal atherosclerotic disease. Another interesting finding was the persistent inter-coronary communication or coronary arcade connecting the left circumflex artery to the right coronary artery. There was bi-directional flow through the inter-coronary communication and hence, we believe this communication prevented our patient from experiencing acute chest symptoms or myocardial infarction. It is important for the clinicians to recognize the association of marijuana with coronary vasospasm. At the same time, these patients should be treated as acute coronary syndromes until proven otherwise by ischemia evaluation.

Background Non-culprit percutaneous coronary intervention (PCI) during a ST-segment elevation myocardial infarction (STEMI) remains controversial. We performed a meta-analysis of the published literature comparing a strategy of complete revascularization (CR) with culprit or target vessel revascularization (TVR)-only after STEMI in patients with multi-vessel disease. Methods We searched PubMed/Medline, Cochrane, EMBASE, Web of Science, CINAHL, Scopus and Google-scholar databases from inception to March-2016 for clinical trials comparing CR with TVR during PCI for STEMI. Mantel–Haenszel risk ratio (MH-RR) with 95% confidence intervals (CI) for individual outcomes was calculated using random-effects model. Results A total of 7 randomized trials with 2004 patients were included in the final analysis. Mean follow-up was 25.4months. Major adverse cardiac events (MACE) (MH-RR: 0.58, 95% CI: 0.43–0.78, P Conclusions CR strategy in STEMI patients with multivessel coronary artery disease is associated with reduction in MACE, cardiac mortality and need for repeat revascularization but with no decrease in the risk of subsequent MI or all-cause mortality. CR was safe however, with no increase in adverse events including stroke, stent thrombosis or contrast nephropathy when compared to TVR.

Cardiac troponin (T) is used to diagnose acute coronary syndrome. However, T can also be elevated in critically ill patients secondary to demand ischemia or myocardial injury. The impact of routine cardiology consultation on the clinical outcomes of critically ill patients with elevated T is unclear

Spontaneous coronary artery dissection (SCAD) is an uncommon cause of acute coronary syndrome (ACS) in men. 51-year-old male presented with chest pain after sexual activity. He was diagnosed with non-ST segment elevation myocardial infarction. He reported lifting weights (more than 50 pounds

Background Bivalirudin has been shown to be associated with less major bleeding than heparin in patients undergoing percutaneous coronary intervention (PCI); but the confounding effect of concomitant glycoprotein IIb/IIIa inhibitors (GPI) limits meaningful comparison. We performed a systematic review and meta-analysis to compare bivalirudin to heparin, with and without adjunctive GPI in PCI. Methods We searched PubMed, Cochrane, EMBASE, CINAHL and WOS from January 2000 to December 2017 for clinical trials comparing bivalirudin to heparin, with and without adjunctive GPI during PCI. Cochrane's Q statistics were used to determine heterogeneity. Random effects model was used. Results Twenty-six comparison groups (22 original studies and 4 subgroup analyses) with 53,364 patients were included. Mean follow-up was 192±303 days. There was no difference between the two groups in all-cause mortality [risk ratio (RR: 0.93; 95% CI: 0.82-1.05, P=0.260), target vessel revascularization (TVR) (RR: 1.17; 95% CI: 0.93-1.46, P=0.174) or stroke (RR: 0.91; 95% CI: 0.71-1.18, P=0.490). Major bleeding was lower in the bivalirudin group with concomitant GPI in one or both arms (RR: 0.64; 95% CI: 0.53-0.77, P

Current guidelines recommend surgical aortic valve replacement (SAVR) for patients with severe symptomatic aortic stenosis (AS) and low surgical risk. A few randomized controlled trial (RCTs) have evaluated transcatheter aortic valve replacement (TAVR) in patients at low surgical risk, but equipoise

e16126 Background: Cancer Patients are at high risk of developing venous thromboembolism (VTE), pulmonary embolism (PE), and deep venous thrombosis (DVT). In this study, we aim to get an estimate of the incidence of VTE as a primary admission diagnosis among patients with genitourinary malignancies. Methods: We utilized ICD-9-CM and ICD-10-CM codes to identify patients with malignant neoplasms of the prostate, bladder, kidney, and testis who are older than 18 years and admitted with a primary diagnosis of DVT, PE within the NIS database during 2007-2016. Unadjusted incidence of DVT and PE was analyzed for each cancer site with the Rao-Scott chi-square test; multivariable logistic regression was employed to adjust for age, biological sex ( not for prostate/ testicular cancer), race, insurance, year of admission, and use of chemotherapy to further examine incidence. Results: We identified 3,339,985 admissions affiliated with genitourinary malignancies of whom 0.59% experienced DVT and 0.13% experienced PE with bladder cancer patients have the highest risk of hospitalization for VTE ( 79/1000). Within bladder cancer population; insurance ( p < 0.001) and hospital location and teaching status ( p < 0.001) were associated with DVT incidence; and biological sex ( p = 0.040) and race and ethnicity ( p = 0.026) with PE incidence. For all sites combined and after adjusting for all else, it was found that every year increase in age was associated with 1.2% increased odds of DVT or PE incidence (OR 95% CI: 1.01-1.02; p < 0.001). Further, rural vs. urban teaching hospitals had 41.2% increased odds (95% CI: 1.26-1.58; p < 0.001), and urban non teaching vs. urban teaching hospitals had 35.1% increased odds (95% CI: 1.26-1.45) of DVT or PE incidence. African Americans vs. whites had 46.8% increased odds of DVT or PE incidence (95% CI: 1.35-1.60; p < 0.001). Conclusions: Within the population of genitourinary malignancies who admitted with a primary diagnosis of VTE; the incidence was higher with older age, African Americans, uninsured population, in rural and urban non teaching facilities, bladder cancer population.

Cardiac sarcoidosis (CS) is characterized by granulomatous scarring that creates foci of abnormal automaticity and macro reentrant arrhythmias promoting monomorphic VT. 60 year old male with biopsy proven pulmonary sarcoidosis presented with worsening exertional dyspnea. TTE showed a newly reduced

Introduction Moderate mitral regurgitation (MR) of ischemic etiology has been associated with worse outcomes after coronary artery bypass grafting (CABG). Studies comparing concomitant mitral valve replacement/repair (MVR/Re) with CABG and standalone CABG have reported conflicting results. We performed a systematic review and meta-analysis of the published literature. Patients and Methods We searched using PubMed, Cochrane, EMBASE, CINAHL, and Google scholar databases from January 1960 to June 2016 for clinical trials comparing CABG to CABG + MVR/Re for moderate MR. Pooled risk ratio or mean difference (MD) with 95% confidence intervals (CI) for individual outcomes were calculated using random effects model and heterogeneity was assessed using Cochrane's Q-statistic. Results A total of 11 studies were included. Mean follow-up was 35.3 months. All-cause mortality (Mantel–Haenszel [MH] risk ratio [RR]: 0.96, 95% CI: 0.75–1.24, p = 0.775), early mortality (MH RR: 0.65, 95% CI: 0.39–1.07, p = 0.092), and stroke rates (MH RR 0.65, 95% CI: 0.21–2.03, p = 0.464) were similar between CABG and CABG + MVR/Re groups. Adverse event at follow-up was lower with CABG (MH RR: 0.90, 95% CI: 0.61–1.32, p = 0.584). MD of change from baseline in left ventricular (LV) end-systolic dimension (MD: − 2.50, 95% CI: − 5.21 to − 0.21, p = 0.071) and LV ejection fraction (MD: 0.48, 95% CI: − 2.48 to 3.44, p = 0.750) were not significantly different between the groups. Incidence of moderate MR (MH RR: 3.24, 95% CI: 1.79–5.89, p Conclusion Addition of MVR/Re to CABG in patients with moderate ischemic MR did not result in improvement in early or overall mortality, stroke risk, or intermediate markers of LV function when compared with CABG alone.

Background: Anaplastic Large Cell Carcinoma (ALCL) is a rare form of Non-Hodgkin Lymphoma. The incidence of ALCL, especially of breast implants, has been increasing over the years. We utilized the NCDB database to study prognostic variables for ALCL, to create the largest and most comprehensive cohort of patients with primary ALCL, to analyze primary anatomical site and other prognostic variables and how they affect survival so as to help improve clinical outcomes across the world. Methods: Utilizing the National Cancer Database, 3,298 patients with primary T-cell anaplastic large cell lymphoma were identified by the histology code 9714 and grade code 5. Kaplan-Meier curves and survival tables were created to calculate 1-, 5-, and 10-year survival probabilities for variables including stage, race, sex, facility type, age, insurance, primary site, year of diagnosis, and adjuvant therapy. Log-rank analysis was used to compare the groups within each variable. Results: The cohort consisted of 61.2% male patients and 77.9% Caucasian patients with a median age of diagnosis of 51 years old. Approximately 67% of the patients were diagnosed with ALCL between the years of 2010 and 2015. The most common type of insurance was private insurance with 49.4% of the cohort followed by Medicare with 27%, Medicaid with 12.8% and not insured with 6.3%. Most patients (27.3%) were treated at academic or research facilities, closely followed by comprehensive community cancer programs with 26.4% of the cohort. The most common primary anatomical site was lymph nodes of multiple sites consisting of 34.4% of the cohort. Stage IV was the most common stage consisting of 31.8% of the cohort. Overall 1-, 5-, and 10-year survival probabilities for patients with ALCL were 71.5%, 59.7%, and 51.8%, respectively. As age increased, overall survival decreased, with the ≥75 age group having the worst 1- and 5-year survival probability of 43.6% and 23.5%, respectively. Patients diagnosed between the years of 2004-2009 (1-year:66.4% and 5-year:52.7%) had much worse survival probabilities when compared to patients diagnosed between the years of 2010-2015 (1-year:74.5% and 5-year:68.1%). Caucasian patients had better 1-,5- and 10-year survival outcomes when compared to African Americans with 1-year survival probabilities of 72.2% and 64.9%, respectively. Facilities other than research or academic centers and Medicare or Medicaid insurance had worse 1-,5-, and 10-year survivals when compared to research or academic centers and private insurance. As stage increased, overall survival probabilities decreased. The lower limb and hip anatomical site had the best survival outcomes with 1- and 5-year survival probabilities of 84.7% and 78.3% respectively. Adjuvant hematologic transplant patients did best with a 1- and 5-year survival probabilities of 94.8% and 87.4%, respectively, followed by an adjuvant combination of both radiation and hematologic transplant (1-year:85.2% and 5-year:81.5%), adjuvant radiation (1-year:83.3% and 5-year:74.2%), and chemotherapy alone (1-year:73.7% and 5-year:65.0%). DISCUSSION: This is the largest and most comprehensive study to date on the epidemiology and prognostic factors of Anaplastic Large Cell Lymphoma. The results of our analysis bring up several interesting trends, the most interesting one being the marked increase in survival rates between 2010- 2015 compared to 2004-2009. This is likely attributed to better treatment modalities. With regards to treatment modalities, patients who underwent chemotherapy followed by adjuvant transplant had better 1, 3, 5 and 10 year survival rates compared to all other treatment modalities. As previously established, younger age at diagnosis is a good prognosis factor. Other major factors influencing survival, previously unstudied, are facility type, race, insurance status, stage, adjuvant therapy, and primary site. Asians and those with private insurance had better survival rates. Primary site involving multiple lymph nodes carried the worst prognosis, while lower limb and hip as primary sites carried the best prognosis. Patients treated at academic and research center had better prognosis compared to those treated at non- academic centers. Performing a multi-variate analysis and further studies to elucidate the causes of improved survival associated with some of these factors will help improve quality of care for patients with ALCL. Table. Table. Disclosures No relevant conflicts of interest to declare.

Cholesteryl-ester transferase protein (CETP) inhibitors, although effective in increasing HDL cholesterol levels, have not been shown to improve cardiovascular outcomes. Recently published REVEAL trial reported a lower incidence of coronary events in patients with atherosclerotic disease receiving

Sudden cardiac arrest has been reported to occur in patients with congenital anomalous coronary artery disease. About 80% of the anomalies are benign and incidental findings at the time of catheterization. We present a case of sudden cardiac arrest caused by anomalous left anterior descending artery. 61-year-old African American female was brought to the emergency department after sudden cardiac arrest. Initial EKG showed sinus rhythm with RBBB and LAFB with nonspecific ST-T wave changes. Coronary angiogram revealed no atherosclerotic disease. The left coronary artery was found to originate from the right coronary cusp. Cardiac CAT scan revealed similar findings with interarterial and intramural course. Patient received one-vessel arterial bypass graft to her anomalous coronary vessel along with a defibrillator for secondary prevention. Sudden cardiac arrest secondary to congenital anomalous coronary artery disease is characterized by insufficient coronary flow by the anomalous left coronary artery to meet elevated left ventricular (LV) myocardial demand. High risk defects include those involved with the proximal coronary artery or coursing of the anomalous artery between the aorta and pulmonary trunk. Per guidelines, our patient received one vessel bypass graft to her anomalous vessel. It is important for clinicians to recognize such presentations of anomalous coronary artery.

AIM To perform a systematic-review and meta-analysis to compare outcomes of ivabradine combined with beta-blocker to beta-blocker alone in heart failure with reduced ejection fraction (HFrEF). METHODS We searched PubMed, Cochrane, EMBASE, CINAHL and Web of Science for trials comparing ivabradine + beta-blocker to beta-blocker alone in HFrEF. We performed a systematic-review and meta-analysis of published literature. Primary end-point was combined end point of cardiac death and hospitalization for heart failure. RESULTS Six studies with 17671 patients were included. Mean follow-up was 8.7 ± 7.9 mo. Combined end-point of heart failure readmission and cardiovascular death was better in ivabradine + beta-blocker group compared to beta-blocker alone (RR: 0.93, 95%CI: 0.79-1.09, P = 0.354). Mean difference (MD) in heart rate was higher in the ivabradine + beta-blocker group (MD: 6.14, 95%CI: 3.80-8.48, P < 0.001). There was no difference in all cause mortality (RR: 0.98, 95%CI: 0.89-1.07, P = 0.609), cardiovascular mortality (RR: 0.99, 95%CI: 0.86-1.15, P = 0.908) or heart failure hospitalization (RR: 0.87, 95%CI: 0.68-1.11, P = 0.271). CONCLUSION From the available clinical trials, ivabradine + beta-blocker resulted in a significantly greater reduction in HR coupled with improvement in combined end-point of heart failure readmission and cardiovascular death but with no improvement in all cause or cardiovascular mortality. Given the limited evidence, further randomized controlled trials are essential before widespread clinical application of ivabradine + beta-blocker is advocated for HFrEF.