Jack Jnani

Background: While the role of sex-based differences in acute myocardial infarction-related cardiogenic shock (AMI-CS) is well described, their relevance among patients with non-acute myocardial infarction-related CS (nonAMI-CS) is less well known. Methods: Adult patients treated for cardiogenic shock (CS) between 2016 and 2022 across eleven hospitals within our health system were included. NonAMI-CS etiologies were classified as heart failure or secondary CS (valvular and arrhythmia-triggered). Stratification by sex was used to compare characteristics, management strategies, and outcomes between men and women. Logistic regression models were used to examine the effect of clinical characteristics and management strategies on hospital mortality by sex, along with the effect of sex on different management strategies. Results: Of 2256 patients, women comprised the minority (36%) and also exhibited older age and more comorbidities. Both sexes displayed similar presenting shock stages, according to those established by the Society for Cardiovascular Angiography and Interventions (SCAI). Valvular shock was the only etiology which was more prevalent in women. Women received fewer invasive interventions, including treatment with pulmonary artery catheters (44% vs. 53%; p < 0.01) and mechanical circulatory support devices (15% vs. 22%; p < 0.01). While sex was not independently associated with increased mortality (OR = 1.16, 95% CI = 0.68–1.96), women were more likely to be discharged to skilled nursing facilities (SNF). Conclusions: Although women with nonAMI-CS exhibit a higher risk profile and undergo fewer invasive procedures, their survival rate is comparable to that of men. However, women are more likely to require SNF care upon discharge.

The advent of direct-acting oral anticoagulants (DOACs) has transformed the care of patients requiring prevention and treatment for thrombotic disease. Many randomized clinical trials have demonstrated the efficacy and safety of these agents and their comparative advantages over conventional anticoagulants such as vitamin K antagonists (VKAs). While historically clinicians and patients raised questions about the reversal of DOAC-associated bleeding, federal approval in recent years of targeted DOAC reversal agents, along with adjunctive modalities, has given clinicians reliable pharmacologic options. Yet, optimal reversal strategies for bleeding at specific anatomic locations and in specific clinical scenarios remains uncertain. We present here a narrative review of the literature on the reversal of DOAC-associated bleeding or for urgent procedures. The totality of the reversal literature synthesized here yields several clear conclusions: (1) targeted DOAC reversal with specific agents demonstrates superior efficacy for both bleeding and urgent surgical indications when compared to the use of non-specific agents, such as prothrombin complex concentrates (PCCs); (2) at the same time, high-quality data suggest potentially increased thrombotic risks, particularly for ischemic stroke, when using the specific targeted agent andexanet; (3) in all cases of life-threatening bleeding, timely reversal is of the essence; (4) in particular, there is growing consensus that DOAC-associated intracranial hemorrhage (ICH) should be reversed promptly, with a goal door-to-reversal time of 60 min; (5) future research will focus on optimizing clinical pathways for reversal to address “calls to action” from professional groups on this critical topic.

The Brugada pattern is associated with a genetic disorder characterized by ST-segment elevation in the right precordial leads on electrocardiogram (EKG) in the absence of structural heart disease. Patients with the Brugada pattern have an increased risk for ventricular tachyarrhythmia and sudden cardiac death. Loss-offunction mutations in the SCN5A gene which encodes the alpha subunit of the cardiac sodium channel have been associated with Brugada syndrome (BrS). We report a case of a patient who was found to have a spontaneous type 1 Brugada pattern on a routine EKG done prior to travel. He underwent electrophysiological testing (EPS) which provoked ventricular tachycardia and underwent implantable cardioverter defibrillator (ICD) placement. His family history revealed a history of sudden cardiac death, abnormal EKG, syncope, dilated cardiomyopathy, and BrS. Genetic testing revealed a variant of uncertain significance (VUS) in the SCN5A gene in the proband and six of his relatives. The SCN5A VUS in this clinical context and segregation with the disease in his family supports its reclassification to pathogenic.

Spontaneous coronary artery dissection (SCAD) is a rare condition in which there is coronary dissection that is not due to atherosclerosis or iatrogenic causes. It is more common in young women and is associated with risk factors such as the peripartum period and connective tissue disorders. We present five unique cases of SCAD to illustrate the variety of presentations and clinical management. The youngest and oldest patients in our series were 34 and 63 years old, respectively. The majority of our patients (60%) were of African American ethnicity. Two of the patients in the case series developed a newonset congestive heart failure, and one patient had an iatrogenic complication after intervention. The majority of the patients were treated with conservative medical management (60%), while the others were treated with primary percutaneous coronary intervention (PCI). SCAD is a rare but life -threatening disease that may have varying presentations and precipitating risk factors. As demonstrated in our case series, SCAD may present atypically, and clinicians should maintain a high degree of suspicion in a relevant presentation. Treatment of SCAD may involve conservative management, primary PCI, or coronary artery bypass grafting (CABG) depending on the case. Clinicians may also have to address complications from SCAD, such as cardiomyopathy, that may arise.

Reverse takotsubo cardiomyopathy is a rare variant of the classic stress-induced takotsubo cardiomyopathy. It is associated with transient left ventricular (LV) systolic dysfunction characterized by basal hypokinesis and apical hyperkinesis. We present a case of a 27-year-old woman who presented to an outside facility for a scheduled cesarean section and developed perioperative chest tightness, hypoxemia, and hypotension. Her electrocardiogram (ECG) showed sinus rhythm with marked ST segment depressions in leads V4-V6. High sensitivity troponin was elevated to 474 ng/L. Transthoracic echocardiography revealed an LV ejection fraction of 52% (Simpson's) with hypokinesis of the basal myocardial segments and hyperdynamic systolic function of the apical segments. Subsequent coronary angiography showed angiographically normal epicardial coronaries. Left ventriculography showed ballooning of the basal segments with apical hyperkinesis. She was subsequently diagnosed with reverse takotsubo cardiomyopathy and managed conservatively with beta-blockers. In this case, we highlight the need for collaboration between the cardiology and obstetric teams for tailored management strategies to ensure the well-being of both mother and baby.

Background: Endometrial carcinosarcomas are rare and carry a very poor prognosis. They usually present with extensive lymphatic spread. An acute presentation of a stroke may reveal the underlying diagnosis. Case presentation: A woman in her 50s with no reported medical history presented to the emergency department as a code stroke. She was found during the evening by her sister leaving the bathroom disheveled. At that time, she was found to be mute, not following commands, with left gaze deviation and right hemiparesis. Computed tomography (CT) imaging showed an acute infarct in the left middle cerebral artery M2 branch or frontoparietal territory consistent with acute stroke. Upon further review, the sister states that she has had significant vaginal bleeding and never had menopause. On admission, she had significant anemia. CT of the abdomen and pelvis showed a large right adnexal mass, endometrial thickening, diffuse lymphadenopathy, omental nodularity, and a pulmonary nodule concerning for gynecologic malignancy with metastasis. Surgical pathology showed high grade endometrial carcinosarcoma. She was outside of the tPA window, and neurology determined her not to be a candidate for thrombectomy. She was managed medically with antiplatelet agents, high dose atorvastatin, and blood transfusions. Conclusions: Endometrial carcinosarcoma can present with severe anemia and irregular menstrual bleeding. In patients without routine gynecologic care, endometrial carcinosarcoma can go unnoticed and only be identified after workup for another condition such as acute stroke. Endometrial biopsy for diagnosis may be challenging in a patient with severe anemia. Alternatively, transvaginal ultrasonography with Doppler study and magnetic resonance imaging may be used to support the diagnosis. Furthermore, endometrial carcinosarcoma can complicate ischemic stroke management as it can present with bleeding and make it difficult to use anticoagulating agents.

A patient in his 40s with no known cardiac history presented to the emergency department with midsternal chest pain worse on inspiration for the past 1 week. He also complains of recent weight loss...

Background: Neurosarcoidosis can have various neurological outcomes and presentations. It is an uncommon diagnosis, especially in young Caucasian males presenting with predominantly migraine headaches. Case presentation: A Caucasian male in his 20s with no medical history presented with 1 month of intractable migraine headaches associated with left sided blurry vision, nausea and vomiting. He has also been having intermittent paresthesia’s in the left upper extremity. He reports lightheadedness when moving from sitting to standing and occasionally feels unsteady on his feet. He also endorses night sweats, generalized malaise, and fatigue. On admission, CT chest, abdomen, and pelvis showed diffuse lymphadenopathy above and below the diaphragm, as well as widespread pulmonary nodules. MR head and spine showed multiple and diffuse nodular leptomeningeal enhancements and enhancement foci along the cervical, thoracic, and lumbar spine. Lumbar puncture showed elevated total nucleated cells and protein. Surgical pathology from a right inguinal lymph node showed many scattered multinucleated giant cells and epithelioid histiocytes consistent with non-necrotizing granulomas seen in sarcoidosis. He was treated with high dose steroids with significant improvement in symptoms. Conclusions: The diagnosis of neurosarcoidosis may be challenging, and the differential may include other infectious, neoplastic, and inflammatory conditions. Neurosarcoidosis may present in a young Caucasian male with a constellation of nonspecific neurological symptoms such as cranial nerve palsies, gait imbalance, paresthesia’s, and headaches, among other presentations. Neurosarcoidosis may present similarly to lymphoma with constitutional symptoms of night sweats, fatigue, as well as widespread lymphadenopathy. Histopathology may be useful in diagnosis. Neurosarcoidosis may initially respond well to steroid treatment.

A female in her 30s with no known past medical conditions presented to North Shore University Hospital with three weeks of intermittent fevers, fatigue, and malaise. She also reports generalized body pain, myalgias, ear pain, throat pain, and joint pain. She denies rash. She also reports nausea, vomiting, and diarrhea and a 10-pound weight loss in one week. She had a miscarriage at 16 weeks of gestation. She met systemic inflammatory syndrome criteria on admission as she was febrile to 102.9 Fahrenheit, tachycardic to 120 beats per minute, tachypneic to 22 breaths/minute, and had leukopenia with white blood cell count of 2,470 per cubic milliliter. Labs were significant for pancytopenia, elevated transaminases, low C3 complement level, double stranded DNA > 1000 IU/mL, anti-nuclear factor positive 1:1280, and positive antiphospholipid serology. She was treated with steroids and hydroxychloroquine and was started on warfarin.