Research Article
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Introduction: Congestive heart failure (CHF) accounts for significant medical costs and patient mortality. There are ways to mitigate these parameters by providing patient and provider education, optimizing medications, and applying life-saving devices with a referral for a left ventricular assist device (LVAD) when appropriate. We retrospectively observed the charts of 40 patients at our Dayton Veterans Affairs Medical Center (VAMC) for areas of improvement.
Methods: Charts were manually reviewed over 2019 for ejection fraction (EF) at the time of diagnosis and ischemic cardiomyopathy (ICM) vs. nonischemic cardiomyopathy (NICM) etiology of heart failure. Information on the titration of beta-blockers (BB), angiotensin-converting enzyme inhibitors (ACE-I), angiotensin receptor blockers (ARBs), and advanced heart failure medications was collected. Readmission rates and heart failure follow-up appointment rates were gathered, and further details were investigated regarding the application of a life vest and automatic implantable cardioverter-defibrillator (AICD) when clinically appropriate.
Results: Median EF for patients was 34%, consistent with systolic heart failure. 65% of patients had ICM. For medications, BB was maximally titrated for 85% of patients within a wide data range. ACE-I/ARBs titration was appropriate in 75% of patients. An average of 4.7 dose adjustments for BB and 3.6 dose adjustments for ACE-I/ARBs occurred. Advanced CHF medications were rarely prescribed. Exacerbation rates were 60%, from 1–5 readmissions and an average of 1.07 readmissions. 98% of patients received CHF-specific follow-up after each CHF admission. 60% were eligible for advanced life support devices, 25% were offered life vests, and 62% were offered AICD. No patient was referred to a tertiary center for LVAD.
Conclusion: We should work towards 100% medication titration to improve outcomes, especially BB which is known to have morbidity value. We can continue to reduce heart failure readmission rates by providing patient and provider education and continuing to do well at heart failure follow-up appointments. Life vest and AICD should be offered more consistently, and tertiary referral to receive LVAD should remain offered per standard of care.
Research Article
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Introduction: The pandemic caused by the new SARS-CoV-2 virus has reported an increase in morbidity and mortality worldwide during the years 2020 to 2022. Many pediatric infections have been reported as mild. The cardiovascular complications due to COVID-19 described in the literature are mainly in adults, however, reports in the pediatric population have been less frequent.
Objective: To describe the clinical characteristics and evolution of patients treated in two centers with cardio-pediatric care services who presented cardiovascular involvement during the COVID-19 pandemic related to the presence of SARS-CoV-2 infection and Kawasaki disease (KD).
Materials and Methods: Through a descriptive, retrospective study, the medical records, electrocardiographic and echocardiographic studies were reviewed in both groups of patients between May 2020 and May 2022 at the National Institute of Child Health and Alberto Sabogal Hospital. None of the cases had a history of previous structural heart disease.
Results: The patients studied were 31 in total, with 21 cases of COVID-19 (SARS-CoV-2 infection) and 10 of KD. The female sex predominated, with an average age of 6.2 years (COVID-19) and 2.9 years (Kawasaki). In the echocardiogram, mild pericardial effusion was the most common finding. Coronary alterations were found in 60% of patients with KD and in only 18% of COVID-19 cases. We found 15 patients who met the criteria for the so-called multisystem syndrome (MIS-C) among COVID-19 cases, 5 of them with hemodynamic compromise.
Conclusion: During the COVID-19 pandemic, the clinical picture in both groups: SARS-CoV-2 infection and KD presented some similar characteristics, mainly in relation to coronary involvement (greater involvement in KD), and in the evolution, a greater hemodynamic compromise was evidenced in cases of SARS-CoV-2 infection but without associated mortality.
Brief Communication
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Heart rate variability (HRV) is defined as the momentary variation in the end heart rate (EHR) estimated at various intervals (time domains), such as from 2 min (ultra-short HRV) to 24 h (long HRV) intervals. The R peak interval (RRI) between two consecutive beats called momentary heart rate (MHR) provides insight into the impending cardiovascular risk and not the EHR. The autonomic nervous system (ANS) is in charge of maintaining physiological homeostasis by keeping the MHR and in turn the EHR within the normal range of 60–100 bpm. ANS has two components – the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS). The former increases HR (reduces RRI) while the latter reduces it. Therefore, the RR time-domain-HRV-data (THD) provides better insight into overall health than the EHR. Six types of THDs, e.g., mean-HR, mean-RR, SDNN, SDHR, RMSSD, and pNN50 are discussed in this article.
Case Report
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Sarcocystosis is a critical parasitic zoonosis caused by Sarcocystis species, an intracellular protozoan parasite of the Apicomplexa phylum and one of the most prevalent parasitic diseases among wild and domestic animals all around the world. Infection in the definitive host is mainly characterized by the formation of cysts in muscle tissue. In intermediate host skeletal muscles, the diaphragm and heart are the favored locations for Sarcocystis spp. While we were examining the heart of a three-month-old dead lamb, we incidentally observed striking, white, and discrete spots, measuring 2–3 mm, that were diffusely distributed in the endocardium. Microscopically, numerous Sarcocystis were seen within cardiomyocytes and Purkinje fibers. No different pathological modifications had been found in inflamed muscle fibers or the surrounding interstitium. To the best of our knowledge, there is no case report about diffuse involvement of endocardium by Sarcocystis spp., and this unique form of sarcocystosis prompted us to place the current case on record.
Case Report
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Introduction: Systemic amyloidosis AL is an unusual disease characterized by a heterogeneous presentation.
Clinical Case: We present a case of systemic amyloidosis AL with unusual cardiac, mesenteric, renal, peritoneal, and gastrointestinal involvement, in which the diagnostic hypothesis was formulated on the basis of problem-solving and ultrasound technique (abdomen, lung, heart ultrasound).
Conclusion: This case shows that multi-organ ultrasound, associated with problem-solving, may be very helpful in the diagnosis of systemic diseases, even unusual ones, avoiding a long diagnostic interval length.
Clinical Case Report
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The most common cause of cardiogenic shock (CS) is acute myocardial infarction (AMI), which is diagnosed in approximately 5–8% of patients hospitalized for AMI and is more common in patients with acute ST-segment elevation myocardial infarction (STEMI). CS is caused by severe myocardial dysfunction, which leads to a decrease in cardiac output, hypoperfusion of the end organs, and hypoxia. Mortality in diabetic patients with AMI is high. Besides the fact that type 2 diabetes mellitus (DM2) contributes to the progression of coronary atherosclerosis, coronary pathology in this category of patients occurs against the background of a specific diabetic myocardial lesion - diabetic cardiomyopathy. Against the background of cardiomyopathy, acute heart failure is more often developed with a decrease in global myocardial contractility up to CS, which increases hospital-acquired mortality in MI by more than 15 times. The increased risk of death observed in patients with DM2 in the acute period of myocardial infarction (MI) persists for several years, and therefore, at present, in patients with the acute coronary syndrome (ACS) and diabetes, an early invasive strategy is preferable to a conservative strategy. The SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) trial demonstrated that in patients with CS complicating AMI, emergency revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) improved long-term survival when compared with initial intensive medical therapy. However, in the CULPRIT-SHOCK (Culprit Lesion Only PCI Versus Multivessel PCI in Cardiogenic Shock) study, stenting of non-infarct-dependent coronary arteries in CS increases the risks of major cardiac events, as well as the number of repeated revascularizations within 30 days and 1 year. Patients with multivessel lesions, in most cases, are elderly patients (75–90 years old) who have age restrictions on taking the loading dose at the prehospital stage. Such a loading dose of clopidogrel may not be sufficient to saturate the patient in fact, despite optimal epicardial recanalization, a large proportion of patients still experience impaired reperfusion and in-stent thrombosis. A large body of evidence has been accumulated on the benefits of glycoprotein (GP) IIb-IIIa inhibitors in terms of prevention of stent thrombosis, and benefits in mortality, especially among high-risk patients, and as an upstream strategy.
