Cardiovascular Abnormalities Among Patients with Spontaneous Subarachnoid Hemorrhage.A Single Center Experience

Objective:To assess the cardiovascular abnormalities in patients with spontaneous subarachnoid hemorrhage(SAH).Methods:All patients admitted to our institution with a primary diagnosis of spontaneous SAH and had a transthoracic echocardiogram(TTE)performed from 1st of July 2011 until 30th of May 2014 were enrolled.Results:Out of 2058 patients admitted to our institution with a diagnosis of SAH,over a three year period,only 244 patients(12%) had TTE performed during the index hospitalization.In this selected cohort,the mean age was 59 years and 66% of patients were female.Elevated troponin T was noticed in 37% of patients and QTc prolongation was the commonest ECG abnormality occurring in 49% of the patients.Thirty nine patients(16%) had a resting segmental wall motion abnormality on the TTE,including fi ve patients with apical ballooning.In-hospital mortality was 15.6% (38 patients).Conclusion:Cardiovascular abnormalities in selected patients with SAH who had cardiac ultrasound are relatively common;however the incidence of ventricular ballooning is low.In order to attain the correct incidence of cardiovascular abnormalities in SAH patients,all patients admitted with SAH should undergo TTE and have ECG and cardiac markers checked during their hospitalization.

Global Burden of Cardiovascular Disease

Cardiovascular disease(CVD)is the number one cause of mortality world-wide and places a high medical and socioeconomic burden on developing countries.Our understanding of CVD and its evolution over the last 100 years has altered considerably.Reasons for the increased rate of CVD in the developing world include rapid urbanization and the demographic shift known as the modern epidemiologic transition.The case for intervention is based on both major human and economic impacts of CVD.It has been estimated that cost-effective interventions in developing countries with a high burden of CVD could result in a projected 24 million lives saved.This reduction in CVD mortality could reduce economic costs by$8 billion.Approaches to intervention include:1)cardiovascular health promotion and CVD prevention and 2)action plans advocated by the World Health Organization.

Some Issues Related to STEMI and NSTEMI

Diagnosis of Myocardial Infarction The diagnosis of myocardial infarction is based on clinical story and troponin leak.Troponin levels can be normal or low due to very early symptoms or high due to a large infarction or due to spontaneous reperfusion with washout of viable ischemic tissue.If there is ST segment elevation,there is a strong suggestion that a coronary artery is occluded or nearly occluded,but that needs confi rmation by angiography and ventriculography.

Mitral Stenosis:A Review

Mitral stenosis due to rheumatic heart disease is not common in the United States but is common in the developing world because rheumatic fever is still occurring frequently.Symptoms usually gradually occur in the young adult(most commonly female).Atrial fibrillation is a common accompanying rhythm in patients with proven mitral stenosis.The main physiologic event is a pressure gradient between the left atrium and the left ventricle.Diagnosis is relatively straight forward using physical exam and simple laboratory studies such as Chest X-Ray(elevated Left main stem bronchus,Double Density indicating enlarged left atrium)and ECG(P-Mitrale).Cardiac ultrasound confirms the clinical diagnosis(Doming of mitral valve in diastole,Hockey stick deformity of the anterior mitral valve leaflet,large left atrium,Doppler estimation of valve gradient).Mitral commisurotomy(surgical or Balloon)is warranted if the valve is pliable and not heavily calcified.

Sudden Cardiac Death in Adult Patients with Stable Ischemic Heart Disease

There are approximately one half million patients with stable ischemic heart disease(SIHD)in the United States.Patients with stable ischemic heart disease who die suddenly do not maintain a Stable Ischemic profi le.Benchimol,et al.,reported 319 consecutive stable angina patients without clinical heart failure or a recent myocardial infarction but who had multiple risk factors and proven coronary disease which made them more prone to acute myocardial infarction or unstable angina.In the APSIS(angina prognosis in Stockholm)study,Hjemdahl reported that signs of ischemia or previous manifestations of coronary artery disease,i.e.,myocardial infarction or revascularization,were found in 69%of both male and female patients at baseline.Little,retrospectively reported that minor plaques may disrupt and result in unstable angina or occlusive coronary disease which then may result in acute myocardial infarction.Stable angina patients,by defi nition,are stable and are not high risk unless they have multiple factors or which may make them prone to evolve an acute coronary syndrome or develop a serious arrhythmia but sudden death does occur in some patients.

His Bundle Pacing:Rebirth of an Important Technique for Pacing the Intrinsic Conduction System

Permanent pacemaker implant is a commonly performed cardiac procedure for treatment of bradycardia or conduction system abnormality.With conventional right ventricular(RV)pacing a lead is implanted at the RV apex or on the RV septum.However,RV apical or RV septal pacing causes iatrogenic left bundle-branch block and ventricular dyssynchrony and can lead to adverse cardiac remodeling,a pacing-mediated cardiomyopathy,and congestive heart failure.Alternatively,permanent His-bundle pacing uses the intrinsic rapidly-conducting His-Purkinje system to activate the ventricle,thereby maintaining(or sometimes even restoring)ventricular synchrony.Many patients may derive benefit from permanent His-bundle pacing.

Do Modern Imaging Studies Trump Cardiovascular Physical Exam in Cardiac Patients?

When many older(seasoned)physicians trained,modern cardiovascular imaging e.g.cardiac ultrasound,nuclear studies,computed tomography,cardiac MR did not exist.Non-invasive imaging studies that were available to us included the ECG,stress exercise testing,and chest X-ray.Invasive studies such as hemodynamics and angiography were the only physiologic and anatomic studies available.Thus there were very few imaging studies used for clinical decision making to confi rm the diagnosis,estimate prognosis,or plan therapy of the cardiac condition.The best of these was cardiac catheterization with ventricular and coronary angiography in adult patients and measurement of intracardiac pressure,oximetry and angiography in patients with congenital heart disease.This is still the case in 2016 with many more images added.

Superior Vena Cava Occlusion as a Complication of Transvenous Cardiac Device Implantation:A Case Report and Brief Review

Superior vena cava(SVC)syndrome is a rare complication of transvenous cardiac device implantation,which may lead to delay of diagnosis when symptoms appear.A 68 year-old male with a dual chamber implantable defi brillator implanted 10 years prior presented to an emergency department with symptoms of facial swelling,frequent headaches,and early morning purple facial discoloration.At UF Health,he underwent computed tomographic(CT)scanning of the chest which was consistent with SVC syndrome,presumably a complication related to the prior implantation of his cardiac device.Despite the imaging fi ndings,venography remains the diagnostic modality of choice.Heparinization,catheter-based venography,and catheter thrombectomy with serial balloon angioplasty were performed for recanalization of the SVC,and the patient was ultimately discharged asymptomatic on apixaban for anticoagulation.However,symptoms recurred within two weeks.Ultimately,the patient underwent surgical right internal jugular vein to right atrial bypass with resolution of symptoms.A post-operative CT venogram was performed and the anastomosis was successful.Apparently an angiogram was not done at one year.

The Adult Ventricular Septum;A Unique Portion of the Left and Right Ventricle

The ventricular septum separates the right and left ventricles and thus is part of both ventricles.It is directed obliquely backward to the right,and curved with the convexity toward the right ventricle;it must be emphasized that the total cardiac septum has a complex,longitudinal twist and does not lie in any single plane.Its upper and posterior part,is thin and fibrous,and is termed the membranous ventricular septum.The greater portion of the septum is thick and muscular and constitutes the muscular ventricular septum.The ventricular septum consists of two layers,a thin layer on the RV side and a thicker layer on the LV side[1].The major septal arteries tend to run between these two layers.

A Clinician’s Commentary on Heart Failure Treatment in the Future

Standard Therapy for Heart Failure Until now the principal focus of heart failure therapy has been on the sympathetic nervous system and the renin-angiotensin system.Beta blockade counters the unwanted effects of catecholamines on the myocardium as well as moderately reducing afterload.Since angiotensin is a vasoconstrictor and has some toxic effect on the myocardium,both contributing to heart failure,inhibition of the renin–angiotensin system has been logical therapy for heart failure.However,use of angiotensinconverting enzyme(ACE)inhibitors may increase bradykinin levels,which are responsible for the cough that may be associated with their use as well as angioedema that may result from the same medications.

Chronic Effusive Pericarditis and Chronic Constrictive Pericarditis

Chronic Pericarditis is infl ammation that begins gradually,is long lasting and results in fl uid accumulation in the pericardial space or thickening of the pericardium.The etiology is unknown but may be cancer,TB or hypothyroidism.Arrhythmias are common and seen in almost half the patients.The commonest arrhythmia is atrial fi brillation.Symptoms and signs are related to increased right atrial pressure and physical fi ndings include elevated JVP and pericardial knock.Non surgical therapy consists mainly of no salt.Surgery cures about 85%of patients,however 5–15%of patients will die.Chronic effusive pericarditis occurs when there is persistent restriction of the visceral pericardium after pericardiocentesis.

Epidemiology,Pathophysiology,and Therapeutic Targets in Stable Ischemic Heart Disease

Chronic stable angina affects approximately 10 million Americans,of whom more than 50%are older than 65 years.Angina is a more common manifestation of coronary heart disease in women than in men.The growing prevalence of recurring ischemia is probably due to residual coronary artery disease after percutaneous coronary intervention or coronary artery bypass grafting.Those with angina have a high socioeconomic burden that signifi cantly limits functional capacity and impairs quality of life,and includes the high cost of care.The presence of common comorbidities,including diabetes,is associated with poorer outcomes.

What to Do with Epicardial Coronary Artery Abnormalities That do not Result in Myocardial Ischemia?

When epicardial arteries with minimal CAD do not limit fl ow are found at coronary angiography,all cardiologists agree that aggressive risk factor modifi cation and use of appropriate drugs are warranted.Some consider plaque sealing of minor coronary lesions with balloon angioplasty to prevent future infarction.Others believe that a coronary lesion that does not cause ischemia should not have the plaque sealed but should have FFR and the non-ischemia producing stenosis should be treated with aggressive risk factor modifi cation(DEFER study).Evidence based data e.g.DEFER,relates to populations,not the individual.Thus these data provide guidelines,which are suggestions for decision making.The weight of evidence favors angioplasty/stent for epicardial vessels that result in myocardial ischemia.Sealing of non flow limiting plaques with angioplasty must await further information derived from invasive and non invasive studies.

Cardiac Rehabilitation:Preliminary Results

We have always thought that patients with cardiac disease are depressed and anxious.The plan for cardiac rehab begins with exercise 3 times a week for 12 weeks.Patients are usually elderly.Typical patients are 60+years old,inactive but stable,smoke cigarettes,are stressed,hypertensive,and anxious.After several visits the staff for the program report that patients are confi dent with decreased anxiety and improved exercise ability.Challenges for a rehab program are parking,education and frailness.At present we have no data on outcome(mortality,morbidity)but most measurements are improved after rehab.Outcome data after discharge for rehab program must be obtained.

Development of a Cardiovascular Rehabilitation Program:Focus on Exercise

Introduction,The members of the Cardiovascular Division at the University of Florida,Department of Medicine have long recognized the need for cardiac rehabilitation of our patients.Prior to July 2016,a rehabilitation program for cardiovascular patients at the University of Florida did not exist.In July 2016 we initiated a total patient rehabilitation program for all cardiac patients,whether their disease was related to myocardial ischemia,myocardial infarction,arrhythmia,or heart failure.When beginning such a program there are several topics that must be considered.These include space for patients and equipment,as well as personnel to staff the program.Initially,personnel should include a physiologist,a nurse and a physician.

Coronavirus 19(some thoughts about the Disease)

Introduction Patients who have a positive laboratory test for Coronavirus 19(COVID-19)may not be so similar.Some may be symptomatic with a positive test,while others can be asymptomatic yet have a positive test.Some are at higher risk to develop symptoms e.g.,the elderly,women,and patients with preexisting diseases,such as uncontrolled hypertension,diabetes,and congenital heart disease。

Physicians Leaving an Academic Position for Private Practice

Introduction When interviewing a medical resident for a potential fellowship in Cardiovascular medicine,the majority of candidates indicate an interest in academic cardiology.However,few opt for an academic career and many decide during fellowship that private practice is best for them.I have no problem with that decision.The focus of this manuscript in on those who opt for an academic career and for several reasons decide,after a few years,to leave the academic program and often leave gaping holes in the multiple aspects of the program,that require attention of the chief of cardiology.

Who are the Faculty in Academic Cardiovascular Medicine ?

Introduction I thought it important to expand on the value to the Division of Cardiovascular Medicine of attracting several senior cardiologists from private practice that can contribute to the growth and development of fellow trainees and young faculty just out of fellowship training.

International Exposure to Cardiovascular Training

I recently read an article entitled International subspecialty Fellowship training,the Path for Cardiologists of Tomorrow?A European perspective by Enrico Fabris and Mark Kennedy in JACC vol.69,No 9,2017 page 2000–2002.This piece stimulated me to think about my own career and how it related to some training outside the USA.I did not travel to Europe during my fellowship at Johns Hopkins,since,at the time,the major diagnostic test was coronary angiography,which was much more commonly performed in the USA and was my main interest as a fellow trainee.

Function of the Right Ventricle

Introduction What happens to the right ventricle may be determined by resistance in the pulmonary circulation.For example,if there is disease in the microcirculation of the lung then there is increased pulmonary vascular resistance to RV emptying and increased pressure overload of the right ventricle.