AJAY ANAND/cardiology

10/02/2021

A 41-year-old male presents with a history of hypertension, diabetes mellitus type II and recent weight loss, nausea and dyspnea. He is receiving chronic hemodialysis and is found to be anemic with a hemoglobin of 9.8 g/dL (gram/ deciliter). An ECG is performed

Hyperkalemia and hypocalcemia.
The T wave are narrow, which is the hallmark of hyperkalemia. The potassium level is 6.1 mmol/L (millimole/liter) with normal serum potassium level between 3.5-5.0 mmol/L.
The QT interval is mildly prolonged due to hypocalcemia. Measured QT interval is at 430 ms (milliseconds), which results in a corrected QT (QTc) interval at 474 ms. The normal QTc interval in adult male is < 450 ms. The calcium level is 8.1 mg/dL (milligram/deciliter) with normal serum calcium level between 8.6-10.5 mg/dL.
Hypocalcemia does have long QT, but this is secondary to lengthening of the ST segment. The QT prolongation here does not predispose to TdP.
The combination of hypocalcemia and hyperkalemia, often seen with left ventricular hypertrophy (LVH) (caused by hypertension) is the classic triad for chronic kidney disease. The ECG (Figure 1) may not meet criteria for LVH by conventional criteria

04/30/2018

Neurogenic Orthostatic Hypotension.

04/01/2018

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02/13/2018

Who was Saint Valentine? And why was he beheaded?

Valentine’s Day is named after St. Valentine.
There was more than one Saint Valentine. There were three.

All three men lived during the 3rd century A.D. Two lived in Italy—Saint Valentine of Rome and Saint Valentine of Terni—while the third resided in a Roman province in North Africa. So which Saint Valentine do we celebrate on February 14th?
That would be the life of Saint Valentine of Rome who, far from being lucky in love on February 14th, was beheaded. Hardly a romantic ending. However, it's likely that the stories of several Valentines merged into one as 'Valentius' (meaning 'worthy,' 'strong' and 'powerful' in Latin) was a popular moniker at the time. Several martyrs ended up with that name.
The church itself has some doubts about what specifically happened in Saint Valentine’s life. In 496 AD, Pope Gelasius I described St. Valentine as a martyr like those 'whose names are justly reverenced among men, but whose acts are known only to God.' Gelasius I understood how little was known about the saint when establishing February 14th as the day to celebrate Valentine’s life.
Circa 260 AD, The trial of St Valentine, patron saint of lovers. Original Artist: By Bart Zeitblom (Photo by Hulton Archive/Getty Images)
St. Valentine of Rome was supposedly a temple priest who was executed near Rome by the anti-Christian Emperor Claudius II. The crime? Helping Roman soldiers to marry when they were forbidden to by the Christian faith at the time.
St. Valentine of Interamna (modern Terni, Italy) was a bishop who was also martyred. It is possible, however, that St. Valentine of Interamna and St. Valentine of Rome were the same person. One biography says that Bishop Valentine was born and lived in Interamna but during a temporary stay in Rome, he was imprisoned, tortured, and beheaded on February 14, 269 A.D.
According to one historical account, the Roman Emperor went to such measures against Valentine because the saint tried to convert him to Christianity. This enraged Claudius, who tried to get Valentine to renounce his faith. The martyr refused, so the emperor ordered him beaten with clubs and stones, and subsequently executed him.
One (or two) St. Valentines are thought to be buried in a cemetery in the north of Rome. Little is known about the third Valentine in North Africa other than his supposed martyrdom
Saint Valentine.
How did we go from Christian martyrs to Hallmark cards? When Pope Gelasius I dedicated February 14th to the saint and martyr Valentine, he chose that date to replace the traditional Roman feast Lupercalia, a pagan festival popular at the time. Lupercalia was a fertility festival in honor of the god Faunus (Lupercus), the protector of sheep and goats from wolf attacks, as well as Lupa - the she-wolf who nurtured the orphans Romulus and Remus, associated with the founding of Rome by legend.
The pagan fertility celebration was marked by all manner of rituals like foot racing among naked men, covered in skins of sacrificed goats. Apparently, they would whip women staged along the race course as they ran. Another ritual required a child to pair couples at random who would have to live together and be intimate for an entire next year in order to fulfill the fertility rite. The church was eager to replace such practices with its own focus and St. Valentine became the saint of lover.
Valentine's Day card from early 20th century.
As St. Valentine’s Day was spread to England and France by Benedictine monks, the practice started to acquire more modern characteristics in the Middle Ages. The poet Geoffrey Chaucer, in particular, is credited with spreading the notion of courtly romance through his writings, some dedicated to St. Valentine×
Writing 'valentines' to your beloved is linked to that same time period, with the oldest such note dating to the 15th century. As reported by Italian Heritage, it was written by Charles d' Orléans, who was at that point held in the Tower of London, following his defeat at the Battle of Agincourt (1415). Charles wrote to his wife the words that translated to: “I am already sick of love, My very gentle Valentine”.
Shakespeare also took part in popularizing the link between Valentine's Day and love, writing about St. Valentine's day in a romantic context as part of his "Midsummer Night's Dream".
Exchanging "valentines" or love notes (often heart-shaped) on Valentine's Day further spread throughout Anglo-Saxon countries in the 19th century. Large-scale marketing and production of greetings cards started with the Industrial Revolution as early as mid-19th century. This process of commercialization of the holiday continued, especially in the United States, during the 20th century, adding additional traditions like more elaborate love notes, with added gifts like chocolates, flowers and jewelry.
So while the original St. Valentine was likely tortured and beheaded on February 14th, his sacrifice for the Christian faith has become the Valentine's Day we have today

02/09/2018

01/21/2018

Development of novel antimicrobial agents is a top priority in the fight against multidrug-resistant (MDR) and persistent bacteria. We developed a panel of synthetic antimicrobial and antibiofilm peptides (SAAPs) with enhanced antimicrobial activities compared to the parent peptide, human antimicrobial peptide LL-37. Our lead peptide SAAP-148 was more efficient in killing bacteria under physiological conditions in vitro than many known preclinical- and clinical-phase antimicrobial peptides. SAAP-148 killed MDR pathogens without inducing resistance, prevented biofilm formation, and eliminated established biofilms and persister cells. A single 4-hour treatment with hypromellos completely eradicated acute and established, biofilm-associated infections with methicillin-resistant Staphylococcus aureus and MDR Acinetobacter baumannii from wounded ex vivo human skin in vivo
Anna de Breij1,*, Martijn Riool2,*, Robert A. Cordfunke3, Nermina Malanovic4, Leonie de Boer2, Roman I. Koning5,6, Elisabeth Ravensbergen1, Marnix Franken1, Tobias van der Heijde1, Bouke K. Boekema7, Paulus H. S. Kwakman2, Niels Kamp8, Abdelouahab El Ghalbzouri9, Karl Lohner4, Sebastian A. J. Zaat2,†, Jan W. Drijfhout3,† and Peter H. Nibbering1,†,‡

Together, these data demonstrate that SAAP-148 is a promising drug candidate in the battle against antibiotic-resistant bacteria that pose a great threat to human health.

12/10/2017

Catheter Ablation Versus Rate Control in Patients with Atrial Fibrillation and Heart Failure: A Multicenter Study
December 8, 2017
Many trials have shown improvements in left ventricular function, exercise capacity, and quality of life after catheter ablation (CA) of atrial fibrillation (AF) in patients with heart failure (HF). We sought to evaluate the impact of CA on hard outcomes in a retrospective cohort study. AF patients with symptomatic HF from 3 hospitals were included. Our primary endpoint major adverse cardiac events (MACEs), a composite of all-cause mortality, stroke, and unplanned hospitalization. In total, 90 patients underwent CA and 304 ones received rate control (RaC) were included. After a mean follow-up of 13.5 ± 5.3 months, 82.2% of patients in CA group got freedom from AF; all patients in RaC group remained in AF. CA group had a significant decreased risk of MACEs compared with RaC group (13.3% vs 29.3%, hazard ratio [HR] 0.51, 95% confidence interval [CI]: 0.32–0.82, P = .005). After propensity score matched for confounding factors, difference in MACEs remained significant between groups (13.3% vs 25.6%, HR 0.50, 95% CI: 0.26–0.98, P = .044). Multivariate regression analysis also indicated that CA was significantly associated with a lower risk of MACEs in overall cohort (HR 0.486, 95% CI: 0.253–0.933, P = .030) and in propensity-matched cohort (HR 0.482, 95% CI: 0.235–0.985, P = .045). Besides, age and NYHA class were associated with an increased risk of MACEs.
In conclusion, the present study demonstrated that CA for AF in HF patients could reduce the risk of MACEs in a mid-term follow-up. Thus, CA may be a reasonable option for this population.

12/08/2017

HTN

11/25/2017

Sudden Cardiac Death

Ectopic heartbeats can trigger reentrant arrhythmias, leading to ventricular fibrillation and sudden cardiac death. Such events have been attributed to perturbed Ca2+ handling in cardiac myocytes leading to spontaneous Ca2+ release and delayed afterdepolarizations (DADs).

11/25/2017

Association of LPA Variants with Aortic Stenosis

JAMA Cardiology • November 20, 2017

A large-scale confirmation of the association between 2LPAvariants and AS, reaching genome-wide significance. In addition, individuals with 2 risk alleles have 2-fold or greater odds of developing AS. Age may modify these associations and identify subgroups who are at greater risk of developing AS

11/22/2017

High blood pressure can often be managed effectively when patients work with their physician to create a treatment plan that focuses on healthy lifestyle changes such as exercising, eating a healthy diet, reducing salt intake, drinking alcohol in moderation, losing weight if overweight, and using anti-hypertensive medication when needed,”

11/22/2017

New Guidelines Redefine High Blood Pressure
Previously, high blood pressure was defined as BP readings persistently at or above 140 mm Hg systolic or 90 mm Hg diastolic, but is now defined as persistently at or above 130/80 mm Hg.

11/17/2017

Association Between QT-Interval Components and Sudden Cardiac Death
The ARIC Study (Atherosclerosis Risk in Communities)"

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11/17/2017

DASH Diet
DASH stands for Dietary Approaches to Stop Hypertension. It is an eating plan that is based on research studies sponsored by the National Heart, Lung, and Blood Institute (NHLBI). These studies showed that DASH lowers high blood pressure and improves levels of cholesterol. This reduces your risk of getting heart disease.

The DASH Diet
1. Emphasizes vegetables, fruits, and fat-free or low-fat dairy products.
2. Includes whole grains, fish, poultry, beans, seeds, nuts, and vegetable oils.
3. Limits sodium, sweets, sugary beverages, and red meats.

Along with DASH, other lifestyle changes can help lower your blood pressure. They include staying at a healthy weight, exercising, and not smoking

11/08/2017

Wellens Syndrome

A 42-year-old man with a history of hypertension was driven to the emergency department (ED) by his wife on a Sunday morning for evaluation of chest pain. The pain, which had spontaneously resolved before presentation, was described as a central to left aching sensation, occurring with exertion; on the morning of presentation, the pain had occurred at rest. The pain was associated with nausea and diaphoresis. On ED arrival, the patient was normal-appearing without significant distress; his examination was largely unrevealing. A 12-lead ECG was performed.
Based on the ECG findings noted in Figure 1, which of the following strategies best describes the appropriate management plan?
A. Aspirin administration, biomarker testing (troponin) one time, exercise stress test with nuclear imaging if troponin is negative.
B. Aspirin administration, serial ECGs and biomarkers, discharge if the patient remains pain-free and evaluation is negative.
C. Aspirin administration, immediate exercise stress test with nuclear imaging.
D. Aspirin administration, serial ECGs and biomarkers, cardiology consultation for admission and probable coronary angiography.
E. Aspirin administration, serial ECGs and biomarkers, stress echocardiography with cardiology consultation, disposition based on results of evaluation.
Answer: D. Aspirin administration, serial ECGs and biomarkers, cardiology consultation for admission and probable coronary angiography
Discussion
The 12-lead ECG is frequently the initial diagnostic tool used by clinicians when evaluating patients with suspected acute coronary syndrome (ACS); information obtained in the ECG can provide the diagnosis, indicate certain therapies, and assist with disposition and risk prognostication considerations. Certain ACS ECG patterns are suggestive of significant arterial occlusion and related high-risk presentations.
One such high-risk ECG pattern is termed “Wellens syndrome.” This high-risk ACS presentation is noted in patients with active or recent chest discomfort, precordial T-wave abnormalities , and without ECG or biochemical evidence of acute myocardial infarction (MI). The high-risk nature is based on a very frequent association with proximal left anterior descending artery occlusion (LAD) (Figure 4; click to enlarge); this coronary lesion can progress over a very short period (hours to days) to anterior wall ST-segment elevation myocardial infarction (STEMI).
The T-wave abnormalities include two basic configurions. The more common ECG presentation is the deeply inverted, symmetric T wave ; it is seen in 75% of such patients. In the remaining patients, a biphasic T wave is seen; these T waves include both upright (positively oriented) and inverted (negatively oriented) components within a single T wave (Figures 2 and 3B). These abnormal T waves are usually seen in the anterior distribution, including leads V1, V2, V3, and/or V4; the T-wave abnormalities can also extend into the lateral region, with leads V5 and V6involvement.1-4
Wellens syndrome is defined as follows: (1) precordial T-wave abnormalities as described above; (2) active or recent chest pain; (3) negative serial biomarkes; and (4) no ECG evidence of MI (ie, significant ST-segment elevation, significant Q waves, and loss of R waves).1-4
Patients presenting with Wellens syndrome should be managed for an unstable ACS. Antiplatelet and anticoagulant therapies should be considered while serial ECGs and cardiac biomarkers are obtained. Cardiology consultation is suggested, with admission and performance of cardiac catheterization. Stress imaging of any type is strongly discouraged; markedly positive results in the form of STEMI and cardiac arrest have been reported.4 It must be noted that patients may experience active pain or may be pain-free on presentation—either presentation is considered high risk; the ECG findings will persist into the pain-free state without change and will only resolve with correction of the coronary obstructing lesion.4
Case Conclusion
The initial ED ECG (Figure 1) demonstrated prominent T-wave inversion in the precordial leads, a concerning finding. Despite the patient’s stable clinical presentation and pain-free state on ED arrival, the ECG was correctly recognized as high risk. Serial troponin values were normal; repeated ECGs did not demonstrate change. The patient remained sensation-free. Wellens syndrome was felt to be a likely issue. The patient was admitted to the cardiology service with coronary angiography performed later that day. A proximal LAD occlusion was noted (Figure 4) and successfully managed via intracoronary stent placement. The patient did well and was discharged from the hospital on day 2.

Take-home points
1. Wellens’ syndrome is associated with significant LAD occlusion with anterior wall STEMI as natural history.
2. The T wave abnormalities can be encountered in patients with or without active pain; in both instances, the presentation should be considered high risk.
3. It is strongly recommended to avoid stress cardiac imaging in these patients. Timely cardiology consultation with cardiac catheterization is recommended.