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A 69-year-old man received epicardial pacing leads for complete atrioventricular block that occurred during a mechanical tricuspid valve replacement procedure. During follow-up, the patient reported intermittent episodes of dizziness and bradycardia. Remote transmissions and device interrogations failed to elucidate the cause of his symptoms. A continuous ambulatory electrocardiogram (ECG) monitor was used as an alternative diagnostic tool. Multiple pauses were detected by the monitor and, upon review, these events were deemed to be due to the intermittent loss of capture by the epicardial lead. Once this diagnosis was made and the malfunctioning lead was replaced, the patient’s symptoms resolved. This case highlights the novel use of a continuous ambulatory ECG monitor in diagnosing intermittent loss of capture, which was not detected by remote monitoring or device interrogations.

Despite the increasing use of Coronary Artery Calcium (CAC) scoring for cardiovascular risk stratification in asymptomatic patients, the gender differences in CAC among symptomatic patients have not been well evaluated. We analyzed patients presenting to the emergency department (ED) with chest pain suggesting possible coronary artery disease (CAD) who received coronary computed tomography angiography (CCTA). Ordinal logistic regression was used to determine the odds ratio for the association of traditional cardiovascular risk factors and CAC. Patients with a CAC score ≥ 100 were followed for cardiovascular events or changes in medical management. Our cohort included 542 individuals (263 male, 279 female). Ordinal logistic regression model showed that among traditional cardiovascular risk factors, male sex had the highest odds ratio (OR) of 3.04 (p0.001, 95% CI [2.01, 4.59]) for the presence of CAC. Also, males had more diffuse distribution of coronary atherosclerosis (p=0.01). Subgroup analysis revealed that obesity was a bigger risk factor in male patients (OR 2.16), while smoking showed the greatest effect (OR 4.27) on CAC in women. Of patients who had CAC100 with an average follow-up of 346 days, there was an increase in both aspirin and statin use, yet significant sex differences were observed especially in patients with non-obstructive lesions on CCTA. Among male patients with non-obstructive lesions, 68.2% were on aspirin and 86.4% were on statin therapy after the CCTA compared to 27.3% and 45.5% respectively in their female counterparts. In conclusion, sex not only is the most powerful predictor for higher CAC among traditional cardiovascular risk factors in symptomatic patients but also influences the contribution of various traditional risk factors to elevated CAC. Furthermore, the discovery of CAD led to the initiation of medical therapy in male patients more frequently than in female patients, even after adjusting for the degree of luminal stenosis detected on coronary CT angiography.

BACKGROUND Elderly patients awaiting moderate to high-risk surgery may undergo nuclear stress testing (NST) in order to evaluate their cardiovascular risk. The prognostic utility of such testing in the very elderly (≥ 85 years) has yet to be fully evaluated. Octogenarians and nonogenarians frequently have a number of concurrent conditions including a high rate of coronary disease, and therefore the prognostic value of NST for their preoperative risk assessment has been questioned. Our evaluation assesses the ability of nuclear stress testing to predict peri-operative cardiac outcomes in this patient population. AIM To investigate the ability of NST to predict peri-operative cardiac outcomes in elderly patients awaiting moderate to high-risk surgery. METHODS Patients ≥ 85 years undergoing pre-operative NST were retrospectively evaluated. Patients undergoing low-risk surgery were excluded. Major adverse cardiac events (MACE) were considered any adverse event that occurred prior to discharge and included acute heart failure, arrhythmia, acute myocardial infarction, unstable angina, or death. Associations between patient risk factors, MACE, and the obtained results of the pre-operative stress testing, ejection fraction (< 40% or ≥ 40%), summed stress score (≤ 8, ≥ 9), and the summed difference score (≤ 0, > 0) were analyzed. RESULTS A total of 69 patients (mean age 88 ± 2.6 years, 31 males) underwent nuclear stress testing prior to surgery. There were 41 (60%) patients found to have an abnormal NST. Sixteen (23%) patients were noted to experience post-operative MACE. No significant associations between risk factors and MACE were noted. Patients with an abnormal NST and/or a summed stress score ≥ 9 were significantly (P < 0.01) more likely to develop peri-operative MACE. CONCLUSION Indicated preoperative NST is useful to assess pre-operative risk in elderly patients ≥ 85 years undergoing moderate to high-risk surgery.

Muscular dystrophy has been an elusive term ever since it was first described in the 19th century. Introduced in 1891 by Wilhelm Heinrich Erb, muscular dystrophy has been classified as part of a larger group of genetically determined, progressive degenerative neuromuscular disorders termed "dystrophinopathies." Cardiac arrhythmias may occur during the neurologic course of the disease. Although descriptions of the dystrophinopathies have been reported in the literature, few articles address the use of antiarrhythmic pharmacotherapy in patients with muscular dystrophy. We discuss the pathophysiology of the most common dystrophinopathies, their proarrhythmic sequelae, and the therapeutic use of antiarrhythmic agents in the clinical setting.

Sinus of Valsava (SoV) aneurysms most commonly arise from the right coronary sinus (65-85% of cases). They may also arise from the non-coronary sinus (10-30%) and rarely from the left sinus (1-5%). 75-year-old female with hypertension and hyperlipidemia underwent nuclear stress testing for

A 51-year-old man underwent an atrial fibrillation ablation. Ultrasound was used for vascular access, given his body mass index (37 kg/m2). Two sheaths (6-F to 8.5-F) were inserted into each of the common femoral veins (FVs). Following the procedure, vascular closure was performed with the VASCADE

To evaluate the percentage of patients undergoing gated coronary artery calcium score CTs that had a prior nongated chest CT. To assess the accuracy of prior nongated chest CTs in the detection of coronary calcium.Cardiovascular disease is the most common cause of death worldwide. Quantifying coronary artery calcification on gated calcium score CT has proven to be strongly predictive of adverse coronary artery disease events. However, visual estimation and ordinal scoring on nongated chest CTs is predictive of coronary calcium burden.Consecutive gated calcium score CTs at a single institution from 10/2014 to 10/2016 were retrospectively evaluated with IRB approval/waiver of informed consent. The presence or absence of coronary calcium and ordinal score on nongated chest CT was compared to Agatston score on gated calcium score CT.Forty-two of 441 patients (9.5%) with a gated calcium score had a prior nongated chest CT, with a mean time difference of 810 days. Of the 42 prior chest CTs, 69% had coronary artery calcium (CAC) and 31% did not, with 100% predictive accuracy for the presence or absence of CAC on subsequent gated calcium score CTs. There was 86% correlation of Agatston score on gated calcium score CT with ordinal score on the prior chest CT. Ordinal score divided into independent groups of severity was related to increased severity of Agatston score on the gated calcium score CT (P0.001). A majority of prior chest CT studies with coronary calcium failed to include this information in the final report.A large percentage of gated calcium score CTs were performed despite a prior chest CT. The ordinal score on chest CTs correlated with Agatston score on gated calcium score CTs. The presence of CAC on chest CTs was underreported in a majority of cases.

A 75-year-old man with a history of mechanical aortic valve replacement with aortic conduit for severe aortic insufficiency underwent routine screening computed tomography evaluation revealing right coronary anastomosis endoleak and proximal aortic root pseudoaneurysm.

A 57-year-old male former smoker presented to the Emergency Department (ED) with blurry vision, headache, and generalized weakness. He was hypoxic on room air and ECG showed sinus tachycardia. A CT pulmonary angiogram was ordered in the ED and revealed no pulmonary embolism but incidentally noted a likely significant stenosis in the proximal LAD. Subsequent cardiac catheterization revealed a 90% stenotic lesion with percutaneous coronary intervention leading to symptom resolution. Unlike coronary CTA, CTPA is performed with non-ECG gated helical scanning and generates motion artifacts associated with myocardial contraction. However, the timing of vascular contrast opacification during CTPA often allows for at least partial evaluation of the coronary arteries, especially ostial and proximal segments. Physicians ordering and evaluating noncardiac-focused CT chest studies, particularly in the ED, should remain cognizant of the radiographic appearance of underlying CAD, particularly life-threatening incidental coronary pathologies to allow for timely management and intervention.

Background Multi-detector computed tomography (CT) has emerged as a modality for the non-invasive assessment of coronary artery disease (CAD). Prior studies have selected patients for evaluation and have excluded many of the “real-world” patients commonly encountered in daily practice. We compared 64-detector-CT (64-CT) to conventional coronary angiography (CA) to investigate the accuracy of 64-CT in determining significant coronary stenoses in a “real-world” clinical population. Methods A total of 1,818 consecutive patients referred for 64-CT were evaluated. CT angiography was performed using the GE LightSpeed VCT (GE® Healthcare). Forty-one patients in whom 64-CT results prompted CA investigation were further evaluated, and results of the two diagnostic modalities were compared. Results A total of 164 coronary arteries and 410 coronary segments were evaluated in 41 patients (30 men, 11 women, age 39-85 years) who were identified by 64-CT to have significant coronary stenoses and who thereafter underwent CA. The overall per-vessel sensitivity, specificity, positive predictive value, negative predictive value, and accuracy at the 50% stenosis level were 86%, 84%, 65%, 95%, and 85%, respectively, and 77%, 93%, 61%, 97%, and 91%, respectively, in the per-segment analysis at the 50% stenosis level. Conclusion 64-CT is an accurate imaging tool that allows a non-invasive assessment of significant CAD with a high diagnostic accuracy in a “real-world” population of patients. The sensitivity and specificity that we noted are not as high as those in prior reports, but we evaluated a population of patients that is typically encountered in clinical practice and therefore see more “real-world” results.

Background: Crohn’s disease and ulcerative colitis are both systemic chronic diseases that alter bowel physiology. The central process in inflammatory bowel disease (IBD) and the associated manifestations are the result of B-cell production of IgG autoantibodies directed against self-antigens in various organ systems including coronary endothelium. Previous studies have demonstrated significant micro-vascular endothelial dysfunction in patients with IBD compared to patients not affected by the disease. We sought to analyze the relation, if any, between IBD and the development of premature coronary artery disease (CAD). Methods: We queried our hospital database to find IBD patients admitted to the hospital from January 1, 2007 to December 31, 2008. Patients with traditional cardiovascular (CV) disease risk factors including hypertension, congestive heart failure (CHF), diabetes, age ≥ 65, hyperlipidemia, family history, end-stage renal disease (ESRD), and greater than five pack-year smoking history were excluded from the study cohort. The charts of the remaining 300 patients with diagnosed IBD were then analyzed for the incidence of CV disease events including acute myocardial infarction (MI), unstable angina, positive stress testing, and any cardiac intervention including coronary angioplasty and/or intracoronary stent implantation. Results: Of the 300 patients included, only one patient had a CV disease event. This patient had a positive exercise stress thallium test. Otherwise, the remaining 299 patients (99.7%) did not have any reported CV disease events over the 2-year follow-up period. Conclusion: Most of the clinical sequelae of CV disease events are the result of inflammatory changes at the vascular level. While IBD is associated with a chronic inflammatory state as reflected by high sedimentation rates, C-reactive protein (CRP), homocysteine levels, etc., our data seem to indicate that chronic inflammation in the absence of traditional risk factors is not associated with an increased risk of premature CV disease events. More wide-scale prospective studies should be performed to elucidate the relationship, if any, between chronic inflammation and CV disease risk. J Clin Med Res. 2015;7(4):257-261 doi: http://dx.doi.org/10.14740/jocmr2102w

We present cardiac computed tomography (CT) findings demonstrating apical hypertrophic cardiomyopathy with dystrophic calcification of the left ventricular apex. The absence of significant epicardial coronary artery disease demonstrated by coronary CT angiography suggests that increased wall tension and decreased microvascular perfusion over time account for the dyskinetic apical myocardium, rather than myocardial infarction secondary to atherosclerotic plaque rupture. These observations support CT as the imaging modality of choice to visualize the deposition of calcium in injured myocardial tissue, a recognized occurrence in chronically infarcted myocardium.

We present an uncommon and underreported complication of coronary artery bypass graft surgery: erroneous anastomosis of the left internal mammary artery to the great cardiac vein. The iatrogenic aorto-coronary arteriovenous fistula with left-to-right shunting resulted in dilation of the coronary sinus, a supporting secondary finding. Factors predisposing to this inadvertent anastomosis include an intramyocardial segment of the left anterior descending coronary artery, demonstrated in this case, as well as epicardial fat and potentially fibrosis of the underlying myocardium.

Early detection of decompensated heart failure enables clinicians to tailor medical therapy to individual patient needs. The utility of transthoracic impedance assessment in the early diagnosis of volume overload has been documented in the literature. We describe the case of a young woman without congestive heart failure who was noted to have cyclical variations of transthoracic impedances that correlated with her menstrual cycle and discuss other factors that may confound proper diagnosis of volume overload in patients with implantable cardioverter-defibrillators.

Flecainide is commonly used for atrial fibrillation. Caution is advised due to its risk of proarrhythmia. If there is a > 15% - 20% increase in the QRS duration at resting heart rate, the dose should be reduced. An exercise stress test should be performed, to make sure the QRS does not increase

Both formal frailty testing (FFT) and indexed total skeletal muscle area (iTSA), a radiological measure of sarcopenia, have each been shown to predict outcomes after TAVR. No prior studies have evaluated them in combination. We sought both to compare these measures and assess their utility in