Drug-induced hypertension, though rare, often presents diagnostic challenges, particularly when the causative drug is not typically associated with hypertension. We describe a case involving a 55-year-old woman who presented with anxiety, confusion, and significantly high blood pressure unresponsive to standard treatments. Despite increasing medication doses, her blood pressure remained poorly controlled, leading to an investigation for secondary causes. Elevated plasma and urinary catecholamines were found. It was determined that the recent initiation of buspirone for anxiety was the cause. Discontinuation of buspirone normalized her catecholamine levels and improved blood pressure control. This case underscores the importance of considering drug-induced hypertension, particularly in instances of abrupt and severe blood pressure elevation, where elevated catecholamine levels may suggest conditions such as pheochromocytoma. It highlights the necessity for healthcare practitioners to be vigilant regarding the uncommon side effects of commonly prescribed medications, thereby ensuring accurate diagnosis and appropriate management.

Spontaneous coronary artery dissection (SCAD) is a rare cause of myocardial infarction in young women. An association of fibromuscular dysplasia (FMD) with SCAD has been well established; a significant proportion of SCAD patients may have typical FMD findings in other noncoronary arteries. The current consensus recommends arterial imaging screening from head to pelvis using computed tomography angiography (CTA) or magnetic resonance angiography (MRA) in SCAD. Genetic testing for FMD should be considered in high-risk cases. We present two cases of SCAD associated with FMD and discuss the significance of genetic screening in such patients.

Although there is an established association between elevated triglyceride (eTG, & GE;175 mg/dl) levels and adverse cardiovascular events, some studies have suggested that eTG levels may be linked to neutral or even improved clinical outcomes, particularly among patients with acute myocardial infarction. However, these studies had certain limitations, including small sample sizes, heterogeneous study populations, and inadequate statistical adjustments. To address these limitations, we conducted an analysis of 5347 patients with ST-segment elevation myocardial infarction (STEMI) between March 2003 and December 2020, using a prospective registry-based cohort from two large, regional STEMI centers. We used a triglyceride level of 175 mg/dl as the cutoff point for eTG levels. Of the study participants, 24.5% (n = 1312) had eTG levels. These patients were more likely to be younger, male, and have a higher number of cardiovascular risk factors compared to those with low TG levels. Despite these unfavorable cardiovascular risk profiles, patients with eTG levels had lower unadjusted risks of 1-year major adverse cardiac events (MACE)-a composite of myocardial infarction, stroke, and death-than those with low TG levels (8.8% vs. 11%, p = 0.034). However, after adjusting for certain clinical factors and lipid profile, eTG levels were not associated with a lower 1-year MACE (aHR: 1.10 (0.71-1.70), p = 0.7). In conclusion, a quarter of STEMI patients had eTG levels and these patients had comparable long-term cardiovascular outcomes compared to those with low TG levels after controlling for clinical factors and lipid profile.

Most patients with hiatal hernia (HH) are asymptomatic; however, common symptoms include gastroesophageal reflux disease (GERD) and heart burn. Larger hernia can cause obstruction, ischemia of the bowel, volvulus of the contents of the hernial sac, respiratory distress, and rarely, cardiac abnormalities are also noted. Most reported cardiac abnormalities associated with HH include atrial fibrillation, atrial flutter, supraventricular tachycardia, and bradycardia. We present a rare case of a large HH causing frequent premature ventricular contractions in bigeminy form that resolved with surgical correction of HH and did not recur on subsequent Holter monitoring. We highlight the potential association between HH/GERD and cardiac arrhythmias and reinforce the need to keep HH/GERD as one of the working diagnoses in a patient with cardiac arrhythmia.Learning objective:•Large hiatal hernia can cause several arrhythmias such as atrial fibrillation, atrial flutter, supraventricular tachycardia, bradycardia, and premature ventricular contractions (PVCs).•It is essential to consider hiatal hernia and gastroesophageal reflux disease as one of the differentials in the work up of cardiac arrhythmias including PVCs.

A left ventricle pseudoaneurysm (LVPA) occurs when the left ventricle free wall rupture becomes contained by pericardium or adhesions. It is rare and has a poor prognosis. LVPA is strongly associated with myocardial infarction. Surgical management of LVPA carries a high mortality rate but is still recommended for most cases of LVPA as soon as the diagnosis is confirmed. Medical management is generally limited to asymptomatic, incidentally found lesions. We present a case of LVPA without any usual risk factors, which was successfully treated by surgery.

Myocardial infarction without obstructive coronary artery disease (MINOCA) is a common condition with estimated prevalence of 5 to 15 %. It is not a benign condition and diagnosing the exact underlying etiology can be challenging, but it is important to ensure appropriate management of MINOCA patients. Cardiac magnetic resonance imaging (CMRI) can be a valuable and non-invasive test to identify the underlying etiology, as well as to risk-stratify such patients. Both the European Society of Cardiology and the American Heart Association recommend CMRI in diagnostic work up of MINOCA patients. We report a case of an 83-year-old man who presented to the emergency department with atypical chest pain but had significantly elevated cardiac troponin levels, with non-obstructive coronary artery disease on left heart catheterization. Subsequent CMRI led to the diagnosis of acute myocarditis. He was medically managed with good clinical outcomes. We discuss this case in detail and highlight the role of CMRI in MINOCA patients. As our understanding of troponin elevation and its various mechanisms continues to evolve, cardiac MRI has a significant role in diagnosis and management, as demonstrated in our case.Learning objectives:1.Illustrate the clinical relevance and diagnosis of myocardial infarction without obstructive coronary artery disease (MINOCA).2.Explain the role of cardiac magnetic resonance imaging in diagnosis and management of MINOCA.

•Postoperative pericardial effusion may cause left-sided chamber compression.•Focal left-sided cardiac tamponade may present with atypical clinical or echo findings.•Focal tamponade can result in acute liver failure post–cardiac surgery.

Quadricuspid aortic valve (QAV) is a congenital heart anomaly in which the aortic valve has four cusps of various size possibilities, as opposed to the three symmetrical cusps generally observed. This cardiac valvular abnormality is rarely identified, with an estimated incidence rate of 0.013% to 0.043%, although recent technological advancements in diagnostics have contributed to an increase in detection. Historically, it had been typically encountered during open heart surgery or postmortem; however, it is presently diagnosed primarily via ultrasound echocardiography, and could go undetected unless specifically considered. It was first reported by Babington in 1847, and since then approximately 300 cases have been published. This condition is sporadically associated with additional congenital cardiovascular defects, with coronary artery irregularities being the most common. In more than half of published QAV incidences it has led to the progressive development of aortic regurgitation (AR) usually sans aortic stenosis, particularly amongst elderly patients, often requiring surgical intervention after 50 years of age. A fifth of total instances, but two-thirds of instances with AR, warrant surgery seldom amidst complications, with reconstructive tricuspidization preferred over valve replacement.

Incomplete rupture of the ventricle free wall can occur after myocardial infarction. This occurs when an organized thrombus and the pericardium seal the ventricular perforation. This can progress to the formation of a left ventricle pseudoaneurysm (LVPA). A 70-year-old male with an antero-septal ST-elevation myocardial infarction (STEMI) underwent an emergent left heart catheterization which revealed severe three-vessel disease with occluded grafts, non-amenable to re-vascularization, and an apical thrombus. As he was high-risk for repeat coronary artery bypass graft, he was medically managed. Transthoracic echocardiogram (TTE) showed a normal left ventricle ejection fraction (LVEF), apical anterior and inferior wall akinesis, moderate sized apical thrombus, and pericardial thickening. On hospital day 7, examination revealed a new 3/6 to-and-fro murmur that was loudest at the apex. The patient was asymptomatic with normal vital signs. A repeat TTE revealed an apical wall rupture with flow into the pericardial cavity and absence of the apical thrombus. A LVPA was diagnosed and the patient was immediately referred for surgical repair. This case illustrates the potential for developing LVPA in STEMI patients and the importance of physical examination. If identified early a potential emergent situation in a previously asymptomatic patient can be averted, thereby preventing fatal consequences. .

Hypothermia is often a sign of serious illness. Commonly reported aetiologies include but are not limited to sepsis, exposure to cold and endocrine disorders. Hypoglycaemia, a common occurrence, is rarely associated with hypothermia. We present a case of prolonged, severe hypothermia due to hypoglycaemia. A 58-year-old man with diabetes who presented with chest pain and was diagnosed with Non-ST elevation myocardial infarction. He was given nothing per mouth in preparation for a left heart catheterisation but received his reported insulin glargine dosage at bedtime. A few hours later, he was noted to have diaphoresis and hypoglycaemia, and his temperature steadily started dropping which was unresponsive to local warming. Once his hypoglycaemia was successfully treated with dextrose infusion, his temperature improved. An extensive workup revealed no infective or endocrine disorder.

Primary tumours of the heart are often encountered in clinical practice. Different autopsy series estimate the incidence to be anywhere from 0.001% to 0.19%. Cardiac lipoma is a rare type of tumour of the heart and pericardium. It comprises approximately 10–19% of all cardiac tumours. We present a case of a large cardiac lipoma in a fifty-year-old female. She presented with sharp chest pains, palpitations, and dizziness. Acute coronary syndrome was ruled out. A transthoracic echocardiogram showed an abnormal, large, fixed right atrial mass. The mass was noted to be occupying most of the right atrium. It was excised due to its large size and persistent symptoms. On pathophysiology, the mass was definitively diagnosed to be an 80 mm × 70 mm cardiac lipoma. Postoperatively, the patient did well with resolution of her symptoms. This case provides evidence that even large, invasive, symptomatic cardiac lipomas can be successfully resected with good outcomes.

Goal: The effect of pulse pressure and interactions with type of antihypertensive therapy on mortality after acute ischemic stroke has not been previously evaluated. Materials and Methods: A retrospective cohort study was conducted to evaluate the independent and interactive effects of pulse pressure and antihypertensive class (specifically angiotensin converting enzyme inhibitor/angiotensin type 1 receptor blocker, or beta blocker) on mortality following acute ischemic stroke. Findings/Conclusions: 343 patients were identified with 49 months of follow-up. Baseline pulse pressure was 64 mmHg and age was 66.5 years. Patients were divided at a pulse pressure of 70. Patients with pulse pressure ≥ 70 were older (p < 0.001) and had higher comorbid vascular burden (p = 0.031) than those with pulse pressure < 70. Pulse pressure did not remain a significant predictor of follow-up mortality after adjustment for baseline comorbidities. Angiotensin converting enzyme inhibitor/angiotensin type 1 receptor blocker based therapy was associated with lower follow-up mortality when beta blocker was not used in pulse pressure < 70 group (odds ratio 0.07, 95% confidence interval 0.01 - 0.48). Prospective analysis will be needed to confirm the protective effect of angiotensin converting enzyme inhibitor/angiotensin type 1 receptor blocker based on pulse pressure in acute ischemic stroke.

Niacin is a lipid-modifying therapy with proven efficacy for reducing cardiovascular events as monotherapy and when used in combination with other lipid-modifying medications impacts rates of atherosclerotic disease progression. Large outcome trials using niacin against a background of statin therapy with optimal control of atherogenic lipoprotein burden in serum were unable to demonstrate incremental benefit of niacin beyond statin therapy. We address 2 key questions: (1) Can the results from randomized clinical trials performed in stable ischemic heart disease populations (AIM-HIGH and HPS2-THRIVE) be applied to patients who sustain an acute coronary syndrome or myocardial infarction? (2) Are patients with very low baseline levels of high-density lipoprotein cholesterol (<30 mg/dL) at particularly high risk for subsequent cardiac events?

In this chapter we consider the problem of managing the storage space optimally at a warehouse for storing cuboidal boxes in cuboidal compartments. Footwear manufacturers face this problem for storing shoe boxes; drug companies manufacturing medicines packed in cartons cuboidal in shape face the same problem, etc. Typically, warehouse management problems involve continual storage and retrieval (issues) of goods from the warehouse. Therefore, a scheme is required to handle the dynamic storage and retrieval of goods optimally from the warehouse. In this chapter we will discuss an efficient procedure for developing a decision support system for the dynamic warehouse management problem. The source for this chapter is based on the work done by Das and a subsequent paper by Murthy A. L. N.

This chapter contains a brief description of paper manufacturing process and presents a solution to an important decision making problem concerning wood inventory management and the production mix problem. The problem is about minimizing the cost subject to shelf-life constraints of wood species, mixing proportion constraints, proportion of direct feed (i.e., use of fresh wood in production), and opening inventory constraints. This complex problem is modelled as a linear program and an efficient decision support system was developed for a leading paper manufacturing company in India.

Background: and hypothesis: We sought to develop and validate the long-term non-hemorrhagic stroke outcome prediction model based on demographic, clinical, and echocardiographic parameters. Material and Methods: Univariate and multivariate logistic regression modeling of long-term survival based on demographic, clinical, and echocardiographic data was performed in 325 consecutive non-hemorrhagic stroke subjects (original cohort). ANOVA, chi-square, Kaplan-Meier, and logistic regression tests were employed. Prediction rules were developed and applied to 1305 patients (validation cohort). The study was approved by the institutional IRB. Results: Only age (hazard ratio 1.6 per decade over 40 years old, 95%CI 1.3-2.2, p<0.001), renal failure (hazard ratio 6.2 95%CI 24.3, p<0.001), and aortic root sclerosis (hazard ratio 2.9 95%CI 1.4-5, p=0.004) were associated with increased all-cause mortality in univariate and multivariate logistic regression analyses. Based on the hazard ratios, risk score was developed with 2 points given for each decade of age over 40 years old, 6 for renal failure, and 3 for aortic root sclerosis. Long-term mortality was compared between 3 groups: low risk (0-5 points), moderate risk (6-10 points), and high risk (more than 11 points). In the original cohort, Kaplan-Meier mean survival estimates were 60+/-1.4 months in low risk, 45+/-2.2 in moderate risk, and 37.4+/-3.3 months high-risk groups (p<0.001). In the validation cohort, Kaplan-Meier mean survival estimates were 53+/-0.8 months in low risk, 47+/-1.3 in moderate risk, and 33+/-2.1 months high-risk groups (p <0.001). When renal function was removed from the analysis, age and aortic root sclerosis still successfully identified patients with poor long term outcomes: 53+/-0.8 months in low risk, 47+/-1.3 in moderate risk, and 34+/-2.4 months high-risk groups (p <0.001). Conclusions: In non-hemorrhagic stroke survivors, long-term prognosis can be predicted with prospectively validated model based on age, presence of aortic root sclerosis, and renal dysfunction. Using such simple, readily available model may help the clinician to identify this high-risk patient group with adverse outcomes, enabling appropriate management and resource utilization.

A 73 year old female with coronary artery disease presents with chest pain, and diagnosed with inferior STEMI. Coronary angiography revealed patent left coronary system with no new disease. Right coronary artery angiogram revealed extravasation of contrast into the pericardium at the mid portion of the RCA with severe disease thereafter. We present a rare case of spontaneous coronary artery rupture of the RCA presenting as an acute MI. Few such cases have been reported thus far. Management was challenging, and not well defined in literature. Prompt recognition of this entity may contribute to optimal therapy and better outcomes.