Marcel Zughaib

Background: Substance use continues to be on the rise in the United States and has been linked to new onset cardiovascular (CVDs) and cerebrovascular disorders (CeVDs) leading to hospitalizations. We aimed to study the association of different subtypes of substance use disorders (SUDs) among hospitalized patients, with the different subtypes of CVDs and CeVDs, using the National Inpatient Sample (NIS) Database. Additionally, we aimed to assess the odds of hospitalizations with new onset CVDs and CeVDs among patients with different types of SUDs. Methods: A retrospective study of the NIS database (2016-2017) using the ICD-10-CM codes was performed. The hospitalizations with a secondary diagnosis of SUDs were identified. Weighted univariate analysis using the chi-square test and multivariate survey logistic regression analysis was performed to evaluate for the incidence, prevalence, and odds of association between vascular events and SUDs. Results: There were a total of 58,259,589 hospitalizations, out of which 21.42% had SUDs. Out of all the hospitalized patients between the age 18-50, more patients had SUDs than not (31.83%, p< 0.0001). This difference existed for all the different subtypes of SUDs including alcohol related disorder (42.61%), amphetamine dependence (76.17% vs 31.83%), cannabis related disorder (75.17%), cocaine related disorders (57.87%), hallucinogen related disorder (82.91%), inhalant related disorders (67.25%), opioid related disorders (52.86%), and nicotine dependence (35.72%). We found a significant association of acute ischemic stroke with amphetamine dependence (OR 1.23, 95%CI 1.14-1.33), cocaine related disorders (1.17, 1.12-1.23) and nicotine dependence (1.42, 1.40-1.43). Similarly, the association of intracerebral hemorrhage was higher with amphetamine dependence (2.58, 2.26-2.93), and cocaine related disorders (1.62, 1.46-1.79). The association of subarachnoid hemorrhage was noted to be higher with amphetamine dependence (1.82, 1.48-2.24) and nicotine dependence (1.47, 1.39-1.55). In terms of association of cardiovascular disorders with SUDs,the patients with myocardial infarction had higher odds of nicotine dependence (1.85, 1.83-1.87) than not, Similarly, the patients with angina pectoris were noted to have a higher association with cocaine related disorders (2.21, 1.86-2.62), and those with atrial fibrillation had a higher association alcohol related disorders (1.14, 1.11-1.17). Conclusion: Our study demonstrates the variability of CVD and CeVD in patients hospitalized for SUD. Findings from our study may help promote increased awareness and early management of these events. Further studies are needed to evaluate specific effects of frequency and dose on the incidence and prevalence of CVD and CeVD in patients with SUD.

Our study aims to evaluate the possible relationship between coronary artery dominance and its effect on accurately identifying reversible ischemia of inferior/inferior-lateral wall on cardiac perfusion imaging. Coronary artery dominance is conventionally defined by the vessel which gives the rise to the AV nodal artery/posterior descending artery (PDA). Previous studies have explored the potential effect of coronary dominance on the accuracy of single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) tests in detecting inferior/inferior-lateral wall ischemia; further evidence is necessary to study that potential effect. We conducted a single-center retrospective analysis to explore the potential relationship between coronary artery dominance and inferior/inferior-lateral wall ischemia on SPECT imaging. We identified a cohort of patients with a reversible defect(s) in the inferior and/or inferolateral walls on SPECT MPI who had subsequently undergone invasive coronary angiography. Coronary angiography was used to determine coronary dominance and to confirm the presence/absence of obstructive coronary artery disease in the distribution of the inferior and/or inferolateral wall(s). We correlated the findings on SPECT MPI to coronary angiography to identify true positives and false positive MPIs. A cohort of 200 patients was identified, patients in the cohort had undergone stress MPI with reversible defects with subsequent invasive coronary angiography. Baseline characteristics including age, BMI and sex were fairly well-balanced between the groups. The mean age was 68 +/- 11 in the right dominant group and 70 +/- 9 in the non right dominant group. One hundred and sixty-one patients (81%) were found to have right dominant circulation and 39 patients (19%) were found to have left or codominant circulation. Of the 161 patients in the right dominant group, 58 patients (36%) were found to have false positive stress MPI. Of the 39 patients in the left or codominant group, 23 patients (59%) were found to have false positive stress MPI. The incidence of false positive stress MPI in the inferior and inferolateral distribution is significantly higher in patients with non-right dominant coronary anatomy (p-value: 0.01). Non-right coronary dominant anatomy could have high false positive MPI results in the inferior and inferolateral distribution. Therefore, the interpreting clinicians should exercise caution during the clinical evaluation of these patients.

Objectives: Our study aimed to investigate the frequency of malignant cardiac arrhythmias in hospitalized patients receiving hydroxychloroquine alone and those receiving a combination of hydroxychloroquine with azithromycin, as well as the quantitative extent of QT prolongation within Tisdale Risk Score (TRS) categories. Background: There have been over 33 million cases of SARS-CoV-2 (COVID-19) resulting in over 600,000 deaths in the United States. As the current COVID-19 pandemic continues, numerous medications have been administered to attempt to treat patients afflicted by the disease. While hydroxychloroquine has been in use for decades for rheumatologic and infectious disease processes, it does have potential cardiotoxicity related to drug-induced QT prolongation. Drug-induced QT prolongation has an increased risk of arrhythmogenicity, potentially progressing into torsades de pointes (TdP) and increased patient mortality. The relationship between QT prolongation and TdP is complex and inexact, but there remains optimism regarding the use of these medications in the treatment of COVID-19 despite limited data on their true efficacy. Methods: We retrospectively identified 75 patients who were admitted with COVID-19 and underwent treatment with hydroxychloroquine for 5 days. The hydroxychloroquine protocol was defined as an initial dose of 400 mg BID for the first day, followed by 400 mg daily for the next 4 days. Baseline demographics, medications, medical histories, lab values, ECG QT intervals, and Tisdale Risk Categories were collected for all patients. Results: Seventy-four (98.7%) patients completed the full course of hydroxychloroquine. There were 41 males (54.7%) and 34 females (45.3%). Average length of stay was 8.9 days (95% CI: 7.5, 10.2). One patient who could not complete the course due to inability to swallow medication tablets. There were no reports of new arrythmias or incidence of torsades de pointes during the study. Seventy-two patients (96%) were taking at least 2 QT prolonging medications. The average corrected QT intervals were as follows: day 1 of admission was 421.62 milliseconds (n = 66, 95% CI: 412.19, 431.05), day 2 was 431.50 ms (n = 30, 95% CI: 416.34, 446.66), day 3 was 433.48 ms (n = 23, 95% CI: 413.34, 453.61), day 4 was 427.59 ms (n = 17, 95% CI: 400.83, 454.35), and day 5 was 444.28 ms (n = 18, 95% CI: 428.43, 460.12). The corrected QT interval prolonged by 22.66 ms from day 1 to day 5 (p = 0.03) in the overall population. Conclusion: There were no patients who experienced arrhythmogenicity or Torsades de Pointes despite a statistically significant increase in QTc intervals after patients received the 5-day course of hydroxychloroquine for treatment of COVID-19.

Pulmonic and sub-pulmonic valve endocarditis are rarely encountered in clinical practice. We present the first case of isolated sub-pulmonic endocarditis. A 30-year-old man with a history of mechanical aortic valve presented to the emergency department with multiple complaints including nausea, vomiting, body aches, and fevers. The patient underwent surgical resection for sub-aortic stenosis followed by a modified Konno procedure later in life. A modified basal short-axis view on the trans-thoracic echocardiogram revealed a sub-pulmonic mobile structure highly suggestive of infective endocarditis. Blood cultures grew methicillin-sensitive Staphylococcus aureus within 24 hours. Higher oxygen demand prompted chest imaging, chest CT showed the development of bilateral airspace consolidation, suggestive of pneumonia. After treatment with extended intravenous antibiotics, follow-up echocardiogram four months later showed no identifiable sub-pulmonic vegetation. This case describes a situation where clinicians may suspect infective endocarditis in a typical location such as a mechanical aortic valve. However, in patients who develop pneumonia, infective endocarditis of the right heart should be suspected. The pulmonic valve and sub-pulmonic ridge are often difficult to image given their anatomical location, a modified basal short-axis view on trans-thoracic echocardiogram can better image these structures.

Introduction. Cardiovascular disease is a leading cause of morbidity and mortality with heart failure constituting a large portion of this spectrum. Heart failure patients have 90-day readmission rates of nearly 41% associated with a high expense. Numerous strategies to reduce readmissions have been attempted with the CardioMEMS pulmonary artery pressure monitoring system as one of the more successful ones. As this device becomes used more frequently, it is important to recognize procedural complications. We present of a rare complication where a patient underwent successful device placement and was subsequently found to have dampened waveforms which were due to device migration. Case Report. A 79-year-old male underwent successful CardioMEMS placement due to recurrent heart failure hospitalizations. 6 months later, the transmitted waveforms appeared dampened, and repeat angiography revealed a device that had migrated. Rather than abandoning the device, it was recalibrated and continued to transmit data and helped manage the patient’s heart failure. Conclusion. CardioMEMS is a cost-effective tool to help reduce heart failure hospitalizations. Device migration is a rare complication and can lead to inaccurate data. However, as seen in this case, the device can be successfully recalibrated and can continue to be utilized to help reduce heart failure admissions.

Background. Transesophageal echocardiogram (TEE) is a valuable tool in healthcare today with its ease of use, ability to visualize important structures not seen on transthoracic echocardiogram (TTE), and the relatively lower cost of TEE, high yield, and no significant radiation exposure. The American Society of Echocardiography (ASE) has developed an appropriate use criteria for use of TTE and TEE, which outline various scenarios where a TEE is indicated as an initial diagnostic testing modality and when it is useful as an adjunctive test in hopes of decreasing inappropriate use. Using these criteria as a guide, we devised a quality assessment study to investigate how well TEEs performed at our institution fit the appropriate use criteria specifically for the diagnostic workup of infective endocarditis. Methods. A retrospective chart review was performed for all TEEs performed in 2017 with the indication of endocarditis. Baseline patient characteristics, presence of bacteremia, and the quality of the TTE preceding the TEE were noted, as well as whether a vegetation, abscess, or perforation was visualized. We also determined if there was a cardiology consultation placed prior to TEE and if the patient had met the definition for endocarditis as defined by the Duke criteria. Finally, we made note of the TEE findings and assessed whether the TEE met appropriate use criteria developed by the American Society of Echocardiography. Results. A total of 50 patients who underwent TEE with the indication of “endocarditis” were identified. 36% of the TTEs prior to the TEE were rated as good quality, 40% as adequate, 4% as fair, 4% as suboptimal, 12% as technically difficult, and 4% were not rated. Vegetations were visualized on 12% of TTEs, 6% of patients had a prosthetic valve, and 6% had a cardiac device. In 20% of the cases, there was no cardiology consultation prior to the TEE and in 20% of the cases, there was no documented bacteremia. 26% of patients met the Duke criteria for endocarditis prior to TEE. Only 36% of TEEs revealed evidence of infection and of the patients with no evidence of infection, only 38% met appropriate use criteria. Overall, only 56% of patients met appropriate use criteria for TEE. Conclusion. Transesophageal echocardiography is a valuable tool in a modern physician’s arsenal for managing a variety of diseases and conditions. However, the procedure is not without associated risks and its ease of use and widespread adoption has led to frequent questionable appropriateness of use of the test. Only 56% of the TEEs performed in our analysis met appropriate use. More awareness and education is needed for the appropriate use criteria for transesophageal echocardiography as outlined by the ASE to help reduce patient exposure to procedure related complications and to decrease medical costs on unnecessary procedures.

Background. As the number of procedures using contrast media continues to rise, the ensuing complications place an ever increasing burden on the healthcare system. Contrast-induced nephropathy (CIN) is a common postprocedural complication after cardiac catheterization. Objectives. The purpose of our study was to evaluate the impact of physician behavioral modification on reducing the amount of contrast used during the procedure. Methods. All patients who underwent procedures in the cardiac catheterization laboratory from January 2013 to August 2016 were identified in addition to the total contrast used during the procedure, the type of procedure performed, and the operator performing the procedure. A new addition was made to the preprocedure checklist in September-October 2013 in the form of maximum allowed contrast for the patient. Results. A total of 12,118 cases were identified. Across all procedures, the mean contrast used during the 8 months prior to the intervention was 118 ml per procedure. Mean contrast used per procedure for the first year after the revised timeout was 105 ml, for the second year was 106 ml, and for the third year was 99 ml. Conclusion. A significant reduction in radiocontrast use across all operators and procedures after the introduction of a revised timeout procedure that was seen, which is a change that was sustained over a period of three years. With this straightforward intervention involving physician behavioral modification, patients were exposed to less of the nephrotoxic contrast and were consequently at a lower risk of developing dose-depended CIN and other associated complications.

Introduction: Congestive heart failure is a leading cause of cardiovascular mortality and morbidity in the United States and places a significant economic burden on the health care system. The CHAMPION trial showed significant reductions in heart failure hospitalizations and length of stay as well as improvements in quality of life among patients who underwent implantation of the CardioMEMS device (CardioMEMS Inc., Atlanta, GA, USA). While the benefits of the device have been well demonstrated, we explored the “pseudo-placebo” effect of device placement on patients’ lifestyle modifications. Methods: Thirty patients with the CardioMEMS device were contacted for a follow-up survey that included questions about lifestyle modifications, symptomatic and dietary improvement, increased physical activity, and changes in their cardiac medication regimen. Results: Dyspnea improved in 57% of patients, 70% of patients improved their diet, and 43% increased their physical activity. Only 7% of patients found it difficult to transmit the data. Discussion: The CHAMPION trial showed numerous benefits for patients who underwent CardioMEMS device placement. In our study, we found that device placement also resulted in a “pseudo-placebo” effect with most patients making positive lifestyle modifications.