All Articles

César Del Castillo Gordillo^1,2*, Mario Alfaro Diaz¹

¹Cardiovascular center, San Borja Arriaran Hospital, Santiago, Chile

²Cardiovascular center, DIPRECA Hospital, Santiago, Chile

Yanyi Tian^1,4,5, Wei Tian^2,4,5, Ting Li³, Jingman Xu^1,4,5*

¹Heart Institute, School of Public Health, North China University of Science and Technology, Tangshan, Hebei, China

²Analysis and Test Center, North China University of Science and Technology, Tangshan, Hebei, China

³College of Foreign Language, North China University of Science and Technology, Tangshan, Hebei, China

⁴Hebei Province Key Laboratory of Organ Fibrosis, Tangshan, Hebei, China

⁵International Scientific and Technological Cooperation Base of Geriatrics Medicine, Tangshan, Hebei, China

Akanksha Agrawal¹*, Deepanshu Jain², Jefferson Baer¹, Michael McDaniel¹

¹Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA

²Center for Interventional Endoscopy, AdventHealth, Orlando, FL, USA

Coronavirus Disease 2019 (COVID-19) is a primary respiratory illness with various cardiac manifestations. This case describes a patient presenting as acute myocardial infarction (AMI) with cardiogenic shock and acute hypoxic respiratory failure secondary to COVID-19 complicated by acute embolic stroke.

Elizabeth Tolmie, Grace M Lindsay*, Philip Belcher

College of Nursing, Umm Al-Qura University Makkah, Kingdom of Saudi Arabia

Background: Survival after myocardial infarction (MI) is improving leading to increasing numbers of people dealing with heart health recovery, readjustment and re-investment in their future wellbeing and that of their family. Cardiac Rehabilitation (CR) aims to improve outcome by ensuring patients adopt recommended health maintenance strategies. This study explored the health maintenance needs of adults one to three years after an MI. The theoretical framework guiding the study was Leventhal’s Self Regulation Model. Data from the completion of different measures of health and illness representation are presented and the potential for measuring current health status and their explanatory factors is illuminated.

Aims: To identify the longer-term health needs of adults who have suffered an acute MI.

Methods: A mixed method design was used to explore respondents’ illness representations and the factors believed to be impacting on their longer-term health and health behaviour. A sample of 73 adults completed 3 questionnaires to assess their illness perceptions, mood and quality of life (QoL) 1 to 3 years after discharge from hospital. A sub-sample (n=30) participated in an interview, underwent a brief clinical assessment, and completed a small task. Data analysis used StatsDirect and Nudist 5.

Results: One to three years post-discharge, Personal and Treatment control belief scores of 22.6 ± 4.3 and 17.6 ± 4.3 respectively were strong, but perceived consequences high (20.6 ± 4.9). Many respondents were experiencing low energy (92%), breathlessness (67%) and chest pain (53%), and many reported a sense of loss that affected their ability to sustain health and positive health behaviour. Those with the poorest attendance at CR had poorer QoL, anxiety, and depression scores, and women had poorer outcomes than men in many of the indices assessed (p<0.05). Initial compliance with prescribed drug regimens and lifestyle recommendations (self-report) was not maintained.

Conclusion: This preliminary study supports the notion that there is a largely unmet and persistent health need among adults diagnosed with MI, and that more consideration needs to be paid to its longer-term effects and the needs of women. Combining surveys with interview methods and tools such as the PRISM+ provide an opportunity to understand the complexity of patients’ health evaluation.

François M.A. Paris¹*, Gillian J. Jessurun², Rutger L. Anthonio², Massimo A. Mariani³

¹House officer cardiology, Department of Cardiology, Treant Zorggroep Scheper Ziekenhuis Emmen, The Netherlands

²Intervention cardiologist, Department of Cardiology, Treant Zorggroep Scheper Ziekenhuis Emmen, The Netherlands

³Cardiothoracic surgeon Heart, Center University Medical Center Groningen, The Netherlands

One of the most important causes of death in Western society, following cancer, is myocardial infarction (MI). Although acute MI occurs at an older age, the incidence of acute MI in younger adults has increased.

Essentially, treatment of acute MI is reperfusion therapy, which should preferably be performed within 12 hours of onset of the symptoms. Time is imperative and shorter intervals between symptoms an reperfusion leads to lower mortality. Conversely, a longer interval results in higher mortality, more mechanical complications and morbidity.

At our institution, located in the middle of a thinly populated rural area, patients used to be treated with thrombolysis until 2005. The nearest centers for percutaneous coronary interventions (PCI) and cardiothoracic surgery, had a travelling distance of 60 minutes. Since the introduction of interventional cardiology in the province of Drenthe, we managed to reduce the symptom to needle time.

Recently, we have been confronted with the COVID-19 pandemic, led to an increase in patient’s and doctor’s delay. This unfolded new challenges in treating acute MI.

This overview addresses the general clinical approach of acute MI and highlights the diagnostic approach and treatment options of both premature atherosclerosis and non-atherosclerotic causes of MI from our clinical perspective. We would like to argue that a personalized clinical approach remains of utmost importance in each patient treated by protocolized medicine.

Prasanna Karthik Suthakaran¹, Jasima Nilofer², Kothai Gnanamoorthy³, Mohammed Idhrees⁴*

¹Professor, Department of General Medicine, Saveetha Medical College Hospital, Chennai, India

²Department of Pathology, Sree Balaji Medical College and Hospital, Chrompet, Chennai

³Associate Professor, Department of General Medicine, ESIC Medical College and PGIMSR, India

⁴Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, India

Peripartum cardiomyopathy is a idiopathy cardiomyopathy associated with heart failure towards the end of pregnancy or in the postpartum period. Various mechanisms like myocarditis, autoimmune response to pregnancy, viral infections, selenium deficiency, oxidative stress and prolonged tocolysis have been proposed as the etiology. The most common presentation is acute heart failure occurring usually within a few weeks after delivery with patients developing exertional breathlessness, orthopnea and paroxysmal nocturnal dyspnea. Cardiac Magnetic Resonance Imaging is useful in accurate measurement of chamber volumes and global and segmental myocardial function. The gold standard test for diagnosis of peripartum cardiomyopathy is Endomyocardial biopsy with the histological Dallas criteria. Most of these postpartum patients are managed medically. The risk of peripartum cardiomyopathy increases with increasing parity and outcomes in subsequent pregnancies was poor.

Eliezer J. Tassone*, Cesare Tripolino, Gaetano Morabito, Placido Grillo, Bindo Missiroli

Department of Cardiac Surgery, Cardiology Unit, Sant’Anna Hospital-Catanzaro, Italy

The presence of coronary calcification is a hard challenge for the interventional cardiologist, as it is associated with incomplete stent expansion and frequently stent failure. In recent years, innovative techniques have been developed to treat coronary calcific lesions such as rotational atherectomy. However, many of them are burdened with an increased procedural risk. Recently, a new technique called “Shockwave Coronary Lithoplasty System”, also called lithotripsy, has been introduced in order to treat calcific coronary lesions with greater safety. Shockwave procedure allows treating the most calcific coronary lesions with simplicity and safety. This system employs the sound waves, similar to that used for treating kidney stones, in order to crush the calcific lesions. In this minireview, we explain the characteristics of the method and we provide a description of the technique in detail on the basis of the preliminary experience of the first cases. In particular, we will demonstrate that this technique is more effective and safer than traditional techniques employing atherectomy, also providing for the first time a therapeutic chance for the treatment of under-expanded stents in many clinical contexts.

Houria Daimi¹, Diego Franco²*

¹Biochemistry and Molecular Biology Laboratory, Faculty of Pharmacy, University of Monastir, Monastir, Tunisia

²Department of Experimental Biology University of Jaen, Spain

In the human heart, the action potential (AP) is initiated and maintained thanks to a fast-activating fast-inactivating Na⁺ current carried by Nav1.5 channels. The pivotal physiological role of Nav1.5 in the heart is reflected by the important consequences of its coding SCN5A gene mutations. These mutations may lead to an impaired functional expression (including expression level, subcellular localization, trafficking, and/or current density), and are generally correlated with severe cardiac rhythm disorders such as Long QT (LQT) and Brugada syndrome (BrS). In BrS, loss of function mutations in SCN5A account for 35-40% of clinically affected patients and around 400 mutations in the SCN5A gene were identified in probands with BrS. Emerging electrophysiological techniques such as patch clamp along with transgenic animal technologies improved our understanding of the pathogenic mechanisms underlying BrS due to SCN5A variants. However, despite significant advances in defining the pathophysiology of Nav1.5, the molecular mechanisms underlying its regulation and contribution to the disease are poorly understood. It is well established that functional expression of Nav1.5 may be under modulation by post-transcriptional regulators, defining thus its transcript levels in the cell and also the penetrance on its associated diseases. Recently, non-coding RNA (ncRNAs) molecules have been identified as key transcriptional regulators of SCN5A expression in the heart. The present mini-review provides a summary of the role of ncRNAs, especially microRNAs (miRNAs), in the regulation of SCN5A. It mainly focuses on their role in the BrS context and discusses the recent updates and the major gaps still to be elucidated.

Abbreviations

AP: Action potential; LQT: Long QT; BrS: Brugada syndrome; ncRNAs: non-coding RNA; miRNAs: microRNAs; lncRNAs: long non coding RNAs; 3′UTR: 3′ untranslated region; SNPs: Single-nucleotide polymorphisms.

Ivo Petrov*, Zoran Stankov, Gloria Adam

ACIBADEM City Clinic Cardiovascular Center, Sofia, Bulgaria

Luis Graca Santos*, Rita Ribeiro Carvalho, Sara Fernandes, Joao Morais

Department of Cardiology, Leiria Hospital Centre, Leiria, Portugal

Noncompaction cardiomyopathy is a heterogeneous and complex entity characterized by hypertrabeculation, typically of the left ventricle. Uncertainties regarding pathogenesis, classification as primary genetic or unclassified cardiomyopathy, diagnostic criteria, and risk stratification have contributed to fuel the discussion surrounding this disorder. Meanwhile, noncompaction phenotype is thought to be the morphological expression of different underlying pathophysiological mechanisms, genetics, and pathologies. Recent studies suggest that distinguishing genetic from nongenetic causes allows risk stratification and may support clinical management and counselling of patients and their relatives. Additionally, advanced cardiac imaging techniques have demonstrated a complementary role in outcome prediction. The purpose of this review is to provide a brief comprehensive review of this controversial entity.

Seyedeh Maryam Hosseini¹, Cristina Pecci², Muhammad Ajmal³*

¹Internal Medicine Resident, University of Arizona, Tucson, Arizona

²Cardiology Fellow, University of Arizona, Phoenix, Arizona

³Cardiology Fellow, University of Arizona, Tucson, Arizona

Atrial Fibrillation (AF) is associated with an increased risk of thromboembolism due to formation of intracardiac thrombus mostly in left atrial appendage. Anticoagulant agents are used to reduce the risk of thromboembolism but have concerning bleeding side effect, making their use very challenging particularly in patients with high HAS-BLED risk score. WATCHMAN device (Boston Scientific, St. Paul, Minnesota) is a Left Atrial Appendage Occlusion (LAAO) device, which was tested in two major randomized trials. PROTECT AF (Percutaneous Left Atrial Appendage Closure for Stroke Prophylaxis in Patients with Atrial Fibrillation) trial, and PREVAIL (Prospective Randomized Evaluation of the WATCHMAN Left Atrial Appendage Closure Device in Patients with Atrial Fibrillation versus Long Term warfarin Therapy) trial, both evaluated WATCHMAN device’s safety and efficacy compared to warfarin. These trials showed WATCHMAN device to be non-inferior to warfarin. However, patients with history of intracranial hemorrhage were excluded from these trials due to concern of increased recurrent bleeding in presence of perioperative use of anticoagulation. Purpose of this review is to evaluate existing evidence and share our experience of LAAO in this high-risk population.

Chandreyee Datta, Ashish Bhattacharjee*

Department of Biotechnology, National Institute of Technology, Durgapur, India

Among different sources that contribute in the global oxidative stress, the vast majority of cellular reactive oxygen species (ROS) originate from mitochondrial compartments. Recently, monoamine oxidases (MAOs) are identified as a prominent source of ROS. Monoamine oxidases are localized in the outer membrane of mitochondria and exist as two different isoforms, MAO-A and MAO-B. MAOs are mitochondrial flavoenzymes responsible for oxidative deamination of biogenic amines and during this process, H₂O₂ and aldehydes are generated as intermediate products. The role of monoamine oxidase in cardiovascular pathophysiology has only recently gained some attention as it is demonstrated that H₂O₂ and aldehydes may target myocardial function and consequently cardiac function. Results obtained by different research groups showed that MAO-A plays a key role in the regulation of physiological cardiac function and in the development of acute and chronic heart diseases through two mechanisms: regulation of substrate concentration and intracellular production of ROS. In this review, we will focus on the role of MAO-A in the field of cardiac aging and related diseases.

Abbreviations

ROS: Reactive oxygen species; MAO: Monoamine oxidase; H₂O₂: Hydrogen peroxide; WHO: World Health Organization; TAC: Transverse aortic constriction; CLG: Clorgyline; Tyr: Tyramine; HF: Heart failure.

G.M. Lindsay¹*, N.A. Tayyib¹, H. Asfour^1,2, R. Pushpamala¹, E. Nomani¹, F.J. Alsolami¹

¹College of Nursing Studies, Umm Al-Qura University, Makkah, Saudi Arabia

²Faculty of Nursing, University of Alexandria, Alexandria, Egypt

Background: Coronary artery bypass grafting (CABG) is a major surgical intervention to relieve symptoms and promote survival for individuals with coronary heart disease (CHD). The benefits of the intervention are thought to be improved when underlying risk factors of CHD are ameliorated. However in current health care systems the long-term follow-up of patients following CABG is not centralized to allow for the determination of survival trends and their optimization. The survival of study participants who underwent CABG is compared with age and gender matched individuals from the general population. Differences in rates of survival are interpreted in terms of lifestyle choices and the impact of risk factors of CHD.

Method: Survival data were obtained from government records to 18 years post intervention on a cohort of patients underwent CABG and participated in a long-term follow-up program. Cardiac symptoms and risk factors of CHD were collected from consenting participants (44 women and 164 men) prior to CABG and at clinical assessments at one and eight-year follow-ups. Important clinical and lifestyle factors were identified and their impact on post-operative survival was quantified using a maximum likelihood technique. Male and female patients were investigated separately and a good fit between observed and simulated survival experiences was confirmed by Monte Carlo simulation.

Results: Cardiac symptoms were exhibited by 75.8% of women and 68.3% of men (χ2=0.712, p=0.3988) one-year post operation, and by 84.2% of women and 70.2% of men eight-years post operation (χ2=1.556, p=0.212). Male long-term survival at 54.3% after 18 years was significantly better than 36.4% for females (χ2=4.449, p=0.035), but both were worse than 73.0% and 71.5% (p=0.6114) respectively for gender and age-matched cohorts from the general population.

Important risk factors for women were post-operative smoking and post-operative hypertension reducing annual post-operative survival by 3.9% and 2.7% respectively and by 6.6% when both present. Equivalent important risk factors for men are post-operative smoking and unrelieved/recurring cardiac symptoms reducing annual survival rates by 2.4% and 1.2% respectively and by 3.6% when both present.

Conclusion: Eighteen year survival post CABG was significantly better for men than women, but both were worse than that for the general population. Post-operative smoking was the most significant risk factor associated with decreased rates of survival followed by unrelieved/recurring cardiac symptoms for men and persisting hypertension for women.

Deepti Bhandare¹*, Thomas Shimshak²

¹Department of Cardiology, Advent Health Sebring, Sebring, Florida

²Department of Interventional Cardiology, Advent Health Sebring, Florida

Readmission for Acute Myocardial Infarction [AMI] significantly contributes to preventable morbidity and healthcare costs. Nearly 1 in 6 patients hospitalized with AMI have an unplanned readmission within 30 days of discharge, accounting for over $1 billion of annual US healthcare costs. We developed a unique integrated product in our hospital called “Transition of Care” program [TOC] with the help of technology and services from Patient Engagement Advisors. The TOC program was based on the notion that engaging patients in their self-care journey by provision of extended set of products and facilities, nutrition, medications, and services to meet their care and recovery needs across the continuum of care.

The TOC program led to the subsequent reduction in the AMI readmission and significant cost savings by avoiding Medicare penalties. AMI readmission rates were reduced to less than 20% since implementation and have fallen below expected rates. This has translated to more than $ 400,000 savings in penalties as the actual readmission rate has been under the expected rate.

It also led to improved clinical follow up in the post AMI patients and improvement in clinical parameters in patients with chronic conditions like diabetes and hypertension. The TOC program extends health care beyond the four walls of the medical care facility and never truly discharges the patient.

Abbreviations

AMI: Acute Myocardial Infarction; ACS: Acute coronary syndrome; TOC: Transition of Care; PEA: Patient Engagement Advisors; AHS: Advent Health Sebring; TS: Transition specialist; PNS: Patient Navigation System; SNF: Skilled nursing facility; ALF: Assisted Living facility; UDMI: Universal Definition of Myocardial Infraction

Deepti Bhandare¹*, Christa Finer²

¹Department of Cardiology, Advent Health Sebring, Sebring, Florida

²Medical Student, 4th year, Lake Erie College of Osteopathic Medicine, Bradenton, Florida

The leisure intake of cannabis has shortly amplified in the past years corresponding with its decriminalization and legalization. The natural cannabis has been substituted by synthetic cannabinoids and cannabimimetic in several formulae, which are stronger. In spite of irresistible public insight into the safety of these substances, a growing quantity of grave cardiovascular adverse events are reported in sequential relation to recreational cannabis intake. A multifaceted interface between the active ingredients, the endo-cannabinoid system, and the autonomic nervous system is responsible in the pathophysiology. Tolerance to the properties of cannabis can develop with repetitive contact due to receptor desensitization. Effects of cannabis may be heightened or transformed by affiliated use of other illicit drugs or drug treatment indicated for the treatment of cardiovascular diseases. Nonetheless, the recent cannabis epidemic would significantly increase global burden of cardiovascular diseases.

Deepti Bhandare¹*, Anupama Kottam²

¹Department of Cardiology, AdventHealth Sebring, Florida

²Department of Cardiology, Detroit Medical Center, Michigan

The clinical presentation of cardiac sarcoidosis (CS) ranges from an incidentally discovered condition to heart failure and sudden death. The diagnosis of CS is tough, and as a result, CS is often under-recognized in clinical practice. CS is mostly noted in the setting of systemic sarcoidosis, though isolated CS can occur. Frequently clinical criteria require the diagnosis of extracardiac disease in order to establish the diagnosis of CS in the absence of having a positive endomyocardial biopsy. While endomyocardial biopsy provides a high specificity for diagnosing CS, this invasive test has a limited sensitivity. There is incomplete knowledge of disease development and a deficient consensus on the ideal methods for disease recognition. We discuss CS in general, the clinical disease, diagnostic algorithms, latest guidelines and management.

Abbreviations

CS: Cardiac Sarcoidosis; CMR: Cardiac MRI; PET: Positron Emission Tomography; EMB: Endomyocardial Biopsy; HRS: Heart Rhythm Society; ACC: American College of Cardiology; AHA: American Heart Association; LGE: Late Gadolinium Enhancement.

Sanjeet Singh¹*, Sudeep Das De¹, Ahmad Al-Adhami¹, Yasser Hegazy¹, Kirsty Graham², Giuseppe Bozzetti³, Fraser Sutherland¹, Philip Curry¹, Nawwar Al-Attar¹, Zahid Mahmood¹

¹Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, UK

²Enhanced Recovery Nurse Practitioner, Golden Jubilee National Hospital, UK

³Department of Anaesthesia and Critical Care, Golden Jubilee National Hospital, UK

Enhanced Recovery After Surgery (ERAS) incorporates multi-modal interventions that synergistically improve patient outcome. Its goals include improving patients functionally pre-operatively, reducing the stress of surgery intra-operatively to facilitate early return to daily activities. We conducted a pilot study at our unit recruiting patients undergoing elective coronary artery bypass grafting (CABG) into the Cardiac ERAS (C-ERAS) pilot and compared them with the patients undergoing CABG meeting the ERAS criteria but who not included the C-ERAS pilot (Control).

Materials and Methods: 122 C-ERAS patients were compared to 91 control patients who underwent CABG only from the period of July 2015 to September 2016. All C-ERAS patients received pre-operative counselling by a dedicated ERAS Practitioner to manage expectations of the patient journey, health promotion and pre-operative optimisation advice. Emphasis was made on educating the patient on daily goals for recovery and patients were followed up daily by the ERAS practitioner post-operatively.

Results: There were 122 patients in the C-ERAS group and 91 patients in the control group. The mean age was 63.6±9.9 years. 181(85%) of the patients were males. After adjusting for the abovementioned confounders, C-ERAS patients had a shorter length of stay that was statistically significant. (2.36 days shorter (95% CI; 1.01-3.7 days; p<0.01). The difference in mean bed day costs was £1153.70 (95% CI, £553.70-£1753.7; p<0.01) less in the C-ERAS cohort.

Conclusion: This study highlighted that C-ERAS is a safe and feasible pathway to reduce in-hospital stay with no difference in complications and readmission rates compared to routine management of patients. There was also a significant cost saving with the C-ERAS pathway mimicking the results in enhanced recovery programmes in the other surgical specialities.

List of Abbreviations

C-ERAS Cardiac Enhanced Recovery After Surgery

CABG Coronary Artery Bypass Grafting

BMI Body Mass Index

NYHA New York Heart Association Functional Classification of Symptoms

CCS Canadian Cardiovascular Society grading of angina pectoris

LV Left Ventricle

ICU Intensive Care Unit

Hamideh Amirfakhryan*

Faculty of Health Science, University of South Wales, UK

Vaccination against atherosclerosis as a potential effective approach has been under investigation for more than 20 years. Different antigens have been tested in animals with a great success. Lipid-related antigens like Ox-LDL, PCSK9, non-lipid related antigens like interleukins, HSPs β2GPI, DNA vaccination and whole cell vaccination are some examples of successful examinations in animals. Plant-based vaccination which has some advantages over traditional methods has been attracted the scientists´ attention recently. Despite the very substantial struggles and promising results during these years, vaccination against atherosclerosis could not be utilized for the treatment of atherosclerosis in human in part due to the lack of clinical trials to access its safety and efficacy. In fact, designing clinical trials with a sufficient number of participants together with a sufficient duration of follow up to explore the influence of vaccine on the prevention and treatment of atherosclerosis seems to be an imperative requisiteness. It looks investing on clinical trials must be a priority to achieve a clear sight regarding the new, tempting, and promising strategy for vaccination against atherosclerosis.

Jamie Kitt¹, Rachael Fox², Katherine L Tucker³*

¹Radcliffe Department of Medicine (Cardiovascular Division), University of Oxford, UK

²University of Melbourne, Melbourne, Australia

³Nuffield Department of Primary Care, University of Oxford, UK

Hypertension is a key risk factor for cardiovascular disease. Globally, approximately a third of people with hypertension remain undiagnosed, and of those diagnosed, about half are not taking antihypertensive medication. The World Health Organization has estimated that globally hypertension directly or indirectly causes the deaths of at least nine million people every year.

There is a trend towards self-monitoring of blood pressure (BP), where patients are empowered to be involved in hypertension screening and diagnosis. Novel technology, including smartphones and Blue-tooth^® enabled telemonitoring, are new tools that are likely to be increasingly important in hypertension management. Several studies have shown the benefit of self-monitoring of BP coupled with co-interventions (such as telemonitoring) in improving BP management. However, these new technologies must be properly assessed and clinically validated prior to widespread implementation in the general population, or within special groups. In this mini-review, we examine how technology might improve the detection and management of hypertension.

Bodo Hoffmeister¹*, Abner Daniel Aguilar Valdez²

¹Department of Respiratory Medicine, Clinic-Group Ernst von Bergmann, Potsdam and Bad Belzig, Niemegker Straße 45, 14806 Bad Belzig, Germany

²Department of Endocrinology, Clinic Group Ernst von Bergmann, Potsdam and Bad Belzig, Niemegker Straße 45, 14806 Bad Belzig, Germany

Falciparum malaria has a unique and complex pathophysiology. While sequestration of parasitized and non-parasitized erythrocytes leads to a progressive obstruction of the microcirculation, a marked systemic inflammation with endothelial dysfunction and consecutive increase in vascular permeability develops. Furthermore, most patients with severe disease present with some degree of hypovolemia. Due to the reduction in pre-load, direct myocardial suppression and increase in after-load acute falciparum malaria exerts diverse effects on the cardiovascular system. Increasing numbers of aging tourists and immigrants with chronic co-morbidities travel to countries where falciparum malaria is endemic. Age has consistently been described as a prominent risk factor for both severe disease and death from imported falciparum malaria in several large studies. Although for long suspected age-related chronic disorders have only recently been identified as risk factors for severe disease. Herein, we review the current concepts of the impact of age-related chronic medical conditions on the severity of imported falciparum malaria.

Jan F.C. Glatz*, Joost J.F.P. Luiken, Miranda Nabben

Department of Genetics & Cell Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Netherlands

There is growing recognition of the importance and multiple roles of substrate energy metabolism in both cardiac health and disease. Cardiac diseases are frequently accompanied by altered myocardial metabolism, while chronic changes in the type of myocardial substrate utilization are found to elicit cardiac contractile dysfunction. Examples are the increased glucose utilization, at the expense of fatty acids, in cardiac hypertrophy and ischemic heart failure, and the increased fatty acid utilization, at the expense of glucose, in obesity and diabetes-related cardiac dysfunction. Modulation of cardiac metabolism has emerged as a suitable therapeutic intervention in cardiac disease. Insights obtained during the past decade have revealed sarcolemmal substrate transport, facilitated by CD36 for fatty acids and by GLUT4 for glucose, to represent the main rate-governing kinetic step of substrate utilization, over-ruling intracellular sites of flux regulation. This suggests that manipulating the presence of substrate transporters in the sarcolemma may be an effective approach for metabolic modulation therapy. The present mini-review provides a short summary of the functioning of substrate transporters CD36 and GLUT4 in the heart, and discusses their application as targets for metabolic intervention.

Abbreviations

CD36: Cluster of Differentiation 36

FABPc: Cytoplasmic Fatty Acid-Binding Protein

FABPpm: Plasma Membrane Fatty Acid-Binding Protein

FATP: Fatty Acid Transport Protein

GLUT4: Glucose Transporter-4

SR-B2: Scavenger Receptor B2

VAMP: Vesicle-Associated Membrane Protein

v-ATPase: vacuolar-type H+-ATPase

Injoon Lee¹*, Matthew P. Cauchi¹, Amitabh Parashar²

¹Virginia Tech-Carilion Clinic School of Medicine, Department of General Cardiovascular Disease, Roanoke, VA, USA

²Salem Veterans Affairs Medical Center, Department of Cardiology, Salem VA, USA

Background: Identifying and treating ST-elevation myocardial infarction (STEMI) in a timely manner is crucial in reducing the patient’s morbidity and mortality. However, sometimes STEMI can be caused by other pathologies such as aortic/coronary dissection, thromboembolism, septic emboli, or trauma. We present a case of a pan-aortic dissection (AD) with multi-system organ failure and shock presenting as anterior spinal cord syndrome, inferior myocardial infarction and stroke.

Case Presentation: A 62-year old woman with history of tobacco abuse and depression, presented to the Emergency Department (ED) for altered mental status. The patient was initially found outside of her home, unresponsive and bradycardic, with subsequent 12-lead electrocardiogram (EKG) demonstrating an inferior STEMI with right ventricle (RV) involvement and presumed cardiogenic shock. In the ED, the patient was awake with intermittent, though profound aphasia, as well as near complete loss of motor and sensory function in her lower extremities. She remained hypotensive and had weak peripheral pulses bilaterally in the upper and lower extremities. Emergent brain imaging was negative for ischemia, but chest imaging revealed circumferential mural thrombus extending from the aortic root into the descending aorta consistent with pan-AD and was taken urgently to the operating suite. Unfortunately, the patient died before surgical intervention could be performed.

Conclusion: This case report highlights a rare case of STEMI, stroke, cardiogenic shock and ultimately death caused by pan-AD. Timely identifying the underlying pathology in patients who present with more than typical STEMI symptoms is essential in providing potential lifesaving therapy.

Learning Points

• Aortic dissection symptoms can present with cardiovascular & neurological symptoms, end-organ compromise along with chest and/or abdominal pain.

• Clinicians should have high degrees of suspicion when myriad of symptoms are present in hemodynamically unstable patients.

• Aortic dissection can have numerous complications including death if not properly diagnosed and treated accordingly.

• Treatments of aortic dissection differs based on its type, hemodynamic status of the patient and any signs of end organ dysfunction.

Injoon Lee¹*, Matthew P. Cauchi², Jason Foerst^1-3, Gary Swank^1,2

¹Section of Cardiology, Virginia-Tech Carilion School of Medicine, Roanoke, Virginia, USA

²Interventional Cardiology, Virginia-Tech Carilion School of Medicine, Roanoke, Virginia, USA

³Structural Cardiology, Virginia-Tech Carilion School of Medicine, Roanoke, Virginia, USA

Currently no literature exists regarding the safety and feasibility of transcatheter aortic valve replacement (TAVR) after aortic cusp dissection. Aortic dissection is a rare, albeit potentially fatal complication related to percutaneous coronary intervention, especially when dealing with heavily calcified coronary disease involving the left main. Rapid stratification of patients in need of early invasive repair versus conservative observation is crucial to patient morbidity and mortality. We present a case of an elderly female with severe aortic stenosis who underwent TAVR after complex intervention of heavily calcified multi-vessel coronary artery disease involving the left main and bifurcation with high-risk Impella protected rotational atherectomy and culotte stenting complicated by left coronary cusp dissection and was managed conservatively without long-term sequelae. This case highlights the achievability of TAVR after aortic cusp dissection that was treated with conservative methods.

Steven Douedi¹*, Abbas Alshami¹, Gina Francisco Ashforth¹, Obiora Maludum², Michael P. Carson¹

¹Department of Medicine, Jersey Shore University Medical Center, New Jersey, United States

²Department of Cardiology, Jersey Shore University Medical Center, New Jersey, United States

Intravenous immunoglobulins (IVIGs) are immunomodulating agents prepared using pooled plasma from thousands of human donors. These IVIGs have been used to treat a wide range of autoimmune, infectious, and idiopathic diseases. Their use in idiopathic thrombocytopenic purpura (ITP) was first described in 1981 and was found to be an effective alternative to splenectomy. The standard dose of IVIG in patients with ITP is 400 milligrams per kilogram body weight (mg/kg) daily for 5 days however recent data has shown a dose of 1 gram/kilogram/day for 2 days may be more effective. Side-effects during IVIG infusions have been reported in about 5 to 15% of patients. Cardiac related side-effects such as arrythmias, hypotension, and even myocardial infarction, being rare, have also been documented but are usually seen in patients with underlying cardiac pathologies. This article presents a 61-year-old male with no history of cardiac disease or arrhythmias who developed symptomatic bradycardia thirty minutes after intravenous immunoglobin infusion requiring multiple atropine injections and dopamine infusion over a 7-day hospitalization. The bradycardia resolved afterwards, and cardiac workup did not identify any underlying pathology.

Manuel Toscano*

Medical Resident, Internal Medicine Department, Hospital de Cascais, Lisboa, Portugal