Pacemakers are effective treatments for a variety of bradyarrhythmias. Cardiac pacemakers generally consist of a pulse generator and one or more leads. The conventional temporary transvenous ventricular cardiac pacemaker utilizing a passive fixation lead is commonly associated with multiple complications such as increased infection rate, lead dislodgement, venous thrombosis, longer duration of hospital stay, and atrioventricular (AV) dyssynchrony. On the other hand, temporary permanent pacemakers (TPPM) utilize active fixation leads; hence, they provide lower capture thresholds, reliable pacing, lower rates of displacement, and fewer pacemaker-related infections. Here, we present a case of TPPM aiding AV synchrony restoration in complete heart block accompanying right ventricular (RV) infarction with refractory cardiogenic shock. Pacemakers are effective treatments for a variety of bradyarrhythmias. Cardiac pacemakers generally consist of a pulse generator and one or more leads. We present a case of TPPM aiding AV synchrony restoration in complete heart block accompanying RV infarction with refractory cardiogenic shock. TPPM pacing is a safe and effective technique for temporary bridge pacing to prevent AV dyssynchrony in hemodynamically unstable patients with cardiogenic shock from RV infarction and complete heart block. It also hastens recovery compared to a traditional single-chamber temporary pacemaker.

Department of Cardiovascular Medicine, Saint Vincent Hospital, UMass Chan Medical School, Worcester, Massachusetts, USA Received 7 December 2023 Accepted 19 December 2023. Correspondence to Pradnya Brijmohan Bhattad, MD, Department of Cardiovascular Medicine, Saint Vincent Hospital, UMass Chan Medical School, Worcester, Massachusetts, USA E-mail: [email protected]

Introduction: Stress testing is utilized for diagnosis and risk stratification for coronary artery disease, with low-risk myocardial perfusion imaging (MPI) indicating less than 1% cardiac mortality per year. We aimed to determine the long-term cardiac mortality in these patients. Methods: We performed a retrospective observational study of 1,300 patients with low-risk MPI in 2015, including pharmacological and exercise studies in a tertiary care center in Central Massachusetts, USA. Each patient was followed from the time of the MPI study for a total duration of 7 years. All-cause mortality and cardiac death were identified. We calculated the pharmacologic and exercise MPI percentage in patients with cardiac death. A cardiac mortality graph was plotted to observe trends over seven years. Results: Out of the 1,300 patients, 3.2% [n=42; mean age 74.6+/-20 years, 78% male (n=32)] of patients had a cardiac death in the follow-up period of 7 years. The pharmacological MPI group had 5% (n=41) cardiac deaths as compared to 0.2% (n=1) in the exercise MPI with the low Duke Treadmill Score group (p-value 0.04) [Figure 1a]. The cardiac death trend over the seven years revealed the highest mortality in year 6 (19%, n= 8) and the lowest in year 4 (7.1%, n=3) [Figure 1b]. Conclusions: The incidence of long-term cardiac deaths is less than 0.5% each year in patients with low-risk MPI, in both groups. Cardiac mortality was higher in patients who underwent pharmacological stress tests indicating appropriate assessment of underlying cardiac pathology. Exercise MPI depends on multiple variables to be optimal, while all patients undergoing pharmacological MPI are maximally stressed. Extensive, multi-center, controlled studies are necessary to evaluate the differences in risk stratification of low-risk MPI between exercise and pharmacological stress tests.

Introduction: Double Outlet Right Ventricle (DORV) is a rare complex congenital heart disease (CHD) in which both the great arteries arise predominantly or entirely from the right ventricle. It is one of the rare CHD lesions with a prevalence of about 0.9%. These patients have complex anatomy, which increases their risk of recurrent arrhythmias. We present a challenging case of Atrial Flutter (AFL) in a patient with DORV. Case: A 31-year-old male with a history of DORV repair presented with palpitations and chest pain for 2 days. His heart rate (HR) was 240 bpm. EKG showed AFL with variable block [Figure 1]. Labs were unremarkable. The patient remained in AFL with HR above 120 bpm despite receiving diltiazem and adenosine. Considering his underlying complex anatomy, ablation was deferred, and the patient was cardioverted to sinus rhythm [Figure 1]. A loop monitor was placed and was started on flecainide with outpatient follow-up at a higher centre. Discussion: Infundibulotomy, removal of obstructive muscle bundles, and a patch to widen the passageway from the right ventricle to the pulmonary arteries are all steps in DORV repair. These surgeries result in scar tissue, an akinetic right ventricular outflow tract, and pulmonary valve insufficiency. Reentrant tachycardias may form due to surgical scars. In DORV patients, Atrial tachyarrhythmias have undesirable outcomes resulting in congestive heart failure, stroke, and mortality. Antiarrhythmics and cardioversion are the cornerstones of managing AFL in patients with DORV due to increased failure rates of catheter ablation. Conclusion: This case illustrates persistent atrial arrhythmias more likely due to DORV repair, resulting in cardiac remodeling. The abnormal anatomy makes localization of irritated ectopic foci and ablations ineffective and difficult.

Apical hypertrophic cardiomyopathy (ApHCM) is thought to be an uncommon variant of hypertrophic cardiomyopathy (HCM). This article is a literature review focusing on the characteristic electrocardiogram (EKG) and 2D echocardiogram findings as currently there are no specific ACC/AHA/ESC guidelines set as diagnostic criteria for ApHCM.

The emergency room is a very potent environment in the hospital. With the growing demands of the population, improved accessibility to health resources, and the onslaught of the triple pandemic, it is extremely crucial to triage patients at presentation. In the spectrum of complaints, chest pain is the commonest. Despite it being a daily ailment, chest pain brings concern to every physician at first. Chest pain could span from acute coronary syndrome, pulmonary embolism, and aortic dissection (all potentially fatal) to reflux, zoster, or musculoskeletal causes that do not need rapid interventions. We often employ scoring systems such as GRACE/PURSUIT/TIMI to assist in clinical decision-making. Over the years, the HEART score became a popular and effective tool for predicting the risk of 30-d major adverse cardiovascular events. Recently, a new scoring system called SVEAT was developed and compared to the HEART score. We have attempted to summarize how these scoring systems differ and their generalizability. With an increasing number of scoring systems being introduced, one must also prevent anchorage bias; i.e., tools such as these are only diagnosis-specific and not organ-specific, and other emergent differential diagnoses must also be kept in mind before discharging the patient home without additional workup.

Percutaneous coronary intervention (PCI) is a frequently performed procedure that can have minor or major complications. One of the more serious complications of PCI is the development of coronary no-reflow. No-reflow signifies reduced or absent coronary flow in the distal coronary circulation in the absence of flow-limiting lesions. We present a case of a middle-aged man who presented as an outpatient for elective coronary angiography due to angina pectoris and a high-risk exercise stress test. Coronary angiography demonstrated significant single-vessel disease with lesions in the proximal and mid-segments of the left anterior descending (LAD) coronary artery. Successful placement of drug-eluting stents in the LAD was followed by a severe drop in blood pressure, worsening chest pain, and ST elevation on telemetry. Immediate angiography showed the development of no-reflow in both the LAD and left circumflex coronary arteries. Ionotropic and intravenous anti-platelet agents were administered with simultaneous placement of an intra-aortic balloon pump, restoring normal flow in both arteries. No-reflow occurs most commonly following PCI in certain lesion subsets, and it is usually seen only in the vessel in which the PCI was performed (culprit vessel). It is important to realize that this phenomenon can occur in other circumstances since immediate recognition and treatment can be lifesaving.

Anti-hypertensive education is an important public health intervention to decrease the mortality and burden of the disease. Using digital technologies for education as a part of preventive measures for hypertension is a cost-effective approach and helps low-income communities and vulnerable populations overcome barriers to healthcare access. The coronavirus disease 19 pandemic further highlighted the need of new health interventions to address health inequalities. Virtual education is helpful to improve awareness, knowledge, and attitude toward hypertension. However, given the complexity of behavioral change, educational approaches do not always provide a change in behavior. Some of the obstacles in online hypertensive education could be time limitations, not being tailored to individual needs and not including the different elements of behavioral models to enhance behavior change. Studies regarding virtual education should be encouraged and involve lifestyle modifications emphasizing the importance of Dietary Approaches to Stop Hypertension diet, salt restriction, and exercise and should be used adjunct to in-person visits for the management of hypertension. Additionally, to stratify patients according to hypertension type (essential or secondary) would be useful to create specific educational materials. Virtual hypertension education is promising to increase awareness regarding risk factors and most importantly motivate patients to be more compliant with management helping to decrease hypertension related complications and hospitalizations.

Introduction: The use of deep learning (DL) through artificial neural networks is increasingly being employed to analyze large, complex datasets in clinical research allowing for new insights. Takotsubo cardiomyopathy (TTS) has an incidence of 12.4% with a reported in-hospital mortality of 5% in the US. While overall risk factors for the condition have been identified, data regarding in-hospital predictors are scant. We sought to apply a DL Artificial Neural Network (ANN) algorithm to identify predictors of in-hospital mortality in patients with TTS. Methods: The National In-patient Sample is the largest, publicly available, repository of in-patient data comprising a 20% stratified sample of all US hospital discharges. We identified all unweighted hospitalizations with a primary diagnosis of TTS from 2016-2019 using International Classification of Diseases, Tenth Revision diagnosis codes. Data regarding demographics, hospital characteristics, known confounders and associated secondary diagnoses were abstracted. These data were then analyzed using a multilayer perceptron ANN where 70% (4,579) of the dataset was used for training and 30% (1,894) for testing. An independent variable importance analysis was also performed. Results: The training and testing models were able to accurately predict outcomes in 98.6% and 98.2% of the data, respectively. ANN identified covariates with high independent variable importance (normalized importance of >70%) include interstitial lung disease, ventricular fibrillation, end-stage renal disease, 3rd degree AV block, sudden cardiac arrest, and acute PE (Model AUC: 0.952). Conclusions: Deep learning-based algorithms utilizing ANNs have the potential to identify predictors of in-hospital mortality with significant accuracy in large volume databases such as the NIS. Among all the covariates that were analyzed, our model was able to identify covariates associated with high importance in predicting outcomes.

Coronary artery anomalies are congenital and relatively uncommon. Anomalous origin of the left circumflex artery from the right is a relatively common congenital coronary variant and is usually considered benign in itself. The presence of an anomalous coronary artery may pose challenges in engaging the anomalous vessel, and prompt recognition of an anomalous coronary artery is important to allow for appropriate coronary interventions.Here, we describe the case of a patient who presented with cocaine-induced acute ST-segment elevation myocardial infarction and was incidentally noted to have an anomalous left circumflex coronary artery arising from the right coronary cusp with a relatively uncommon variant of the anomalous origin. We believe that this case in itself is rare and discusses the approach to anomalous coronaries in an acute coronary syndrome presentation which is unique and rare in the existing literature regarding coronary anomalies.

Congenital coronary anomalies can be an incidental finding in the adult population. Implications of an anomalous coronary artery vary depending on its course and the anomaly. An interarterial course of an anomalous coronary artery is considered malignant with a high risk of sudden cardiac death. The presentation of the interarterial course of an anomalous coronary artery is variable. We report a rare case of an anomalous origin of a right coronary artery presenting with vague symptoms without any evidence of inducible ischemia. Given the rarity of an anomalous interarterial right coronary artery, the implications of this congenital anomaly on physical activity, treatment options including surgical correction, and estimating the risk of sudden cardiac death are difficult based on currently available data.

The management of patients with stable coronary disease and intermediate- or high-risk features on single photon emission computed tomography myocardial perfusion imaging (SPECT MPI) continues to be controversial as to whether they should be treated with an initial invasive strategy (catheterization and revascularization when feasible) or medical therapy alone to improve mortality. We performed a retrospective observational study of 1,946 patients with intermediate- or high-risk SPECT MPI scans performed over a 6-year period (from 2014 to 2019). Each patient was followed from the time of SPECT MPI to 16 months after the last patient was enrolled. The primary end point was all-cause mortality and the secondary end point cardiovascular mortality. Of the eligible 1,697 patients, 1,144 had an intermediate-risk scan, 553 a high-risk scan, 915 had medical therapy alone, and 782 went on an initial invasive strategy. All patients were divided into the following three groups: combined SPECT MPI (both intermediate- and high-risk), high-risk SPECT MPI, and intermediate-risk SPECT MPI groups. After propensity score matching, there was a statistically significant difference in cardiovascular death (5.9% vs 2.7%; p = 0.038) in the medical therapy cohort compared with initial invasive cohort in the combined SPECT MPI group, but no difference in all-cause death (15.7% vs 13%; p = 0.318). On subgroup analysis, in intermediate-risk SPECT MPI group, there was no significant difference in either all-cause death (13.8 vs 11.7%; p = 0.583) or cardiac death (5.4% vs 2.5%; p = 0.16) in conservative cohort compared with invasive strategy cohort. In high-risk SPECT MPI group, conservative therapy cohort had higher cardiac death (11.7% vs 2.5%; p = 0.002) compared with initial invasive strategy cohort, but there was no significant difference in all-cause death (24.5% vs 15.3%; p = 0.052). In conclusion, this study supports that patients with intermediate- or high-risk SPECT MPI scans when considered together or only with high-risk features, derive a cardiovascular mortality benefit with an initial invasive strategy. Patients who had undergone intermediate-risk SPECT MPI had similar outcomes with either medical therapy alone or initial invasive evaluation. (C) 2021 The Authors. Published by Elsevier Inc.

Paradoxical coronary artery embolism is often an underdiagnosed cause of acute myocardial infarction (MI). It should always be considered in patient with acute MI and a low risk profile for atherosclerotic coronary artery disease. We describe a patient with simultaneous acute saddle pulmonary embolism (PE) and acute ST segment elevation MI due to paradoxical coronary artery embolism. Transoesophageal echocardiography demonstrated a patent foramen ovale with right to left shunt and large saddle PE in the main pulmonary artery and coronary angiography demonstrated acute thrombotic occlusion of the right coronary artery.

Introduction: Patients with stable ischemic heart disease (SIHD) and intermediate to high-risk stress tests with underlying heart failure (HF) are at increased risk for cardiovascular death, nonfatal myocardial infarction, or hospitalization for unstable angina and HF. In this patient population, the decision to pursue an early invasive strategy versus continuing medical management remains unclear. To evaluate this conundrum further, we performed a retrospective analysis. Method: We followed 308 SIHD patients with both reduced and preserved ejection fraction HF for a period of at least 16 months. All patients were classified as intermediate to high-risk based on their nuclear stress test results. They were further divided based on whether they underwent an initial invasive strategy versus medical management. A multivariable Cox regression analysis was performed to compare the primary outcome of all-cause mortality and cardiac mortality between the two groups. Results: Patients undergoing an initial invasive strategy were younger (70.64 ± 10.94 vs. 73.7 ± 12.04 years, P = 0.021), with a positive family history (24.4% vs 13.3%, p=0.023) and more likely to have high-risk nuclear stress tests (53.3% vs. 35.9%, p = 0.004) and prior percutaneous coronary intervention (35.0% vs. 23.4%, p =0.04) compared to the medical therapy group. Peripheral Vascular Disease (PVD) was more common in medical treatment group (35.2% vs.17.8%, p=0.001). During follow-up, all-cause death was 19.4% (n=35) vs. 33.6% (n=43), and cardiac death was 3.3% (n=6) vs.15.6% (n=20) in the invasive and medical therapy groups respectively. There was no difference in the all-cause mortality between the two groups, but cardiac mortality was noted to be lower in the invasive strategy group (Figure 1 & 2). Conclusions: In our patient population with SIHD and HF, pursuing an early invasive strategy provided cardiac mortality benefit when compared to conservative medical therapy.

Introduction: In asymptomatic heart failure patients with reduced ejection fraction (HFrEF), an ischemia evaluation is part of the routine diagnostic work up. Nonetheless, in asymptomatic HFrEF patients with stable ischemic heart disease (SIHD) and intermediate to high-risk findings on nuclear perfusion study, the decision to pursue conservative medical therapy versus an early invasive strategy remains debatable. To address this conundrum, we performed a retrospective analysis. Method: A total of 451 patients with SIHD and HFrEF were followed for at least 16 months. All patients were classified as intermediate to high-risk based on their nuclear stress test results. Patients were subsequently dichotomized into two groups depending on whether they underwent an initial invasive approach versus continuing conservative medical therapy. A multivariable Cox regression analysis was performed to compare the primary outcome of all-cause mortality between the two groups. Results: Patients undergoing an initial invasive strategy were younger (68.3 ± 11.5 vs 71.3 ± 11.8 years, P = 0.001) and more likely to have a prior percutaneous coronary intervention (PCI, 50% ± 25.9% vs. 35% ± 13.6%, P = 0.001) compared to the medical therapy group. On multivariable analysis, after adjusting for demographics and confounding factors, there was no difference in all-cause mortality between the two groups (p= 0.120, Figure ). An older age with a prior history of a PCI or a cerebrovascular accident (CVA) were independent predictors of mortality while a history of never smoking was associated with a mortality benefit. Conclusions: In asymptomatic HFrEF patients with SIHD with intermediate to high-risk findings on nuclear stress testing, an initial invasive strategy has no significant mortality benefit when compared to medical therapy. An older age, history of prior PCI or CVA predicted mortality while never smoking provided a mortality benefit.

Ectopic liver tissue is commonly observed in the abdominal cavity in adjacent organs. Extension of hepatic tissue into the intrathoracic cavity is rarely reported. We present the case of a 46-year-old woman with a 2.1×1.8 cm mass confirmed by transesophageal echocardiogram to be at the right atrial and inferior vena cava junction that was initially thought to be a myxoma which prompted surgical excision but subsequently identified as ectopic liver by histology.

The ACC/AHA blood cholesterol treatment guidelines recommend statin therapy for all patients after experiencing an acute cardiovascular event. Previous analyses have shown that physicians have been slow to adopt guidelines, and many patients remain untreated or undertreated with statins after a cardiovascular event. However, reasons for this remain unknown. This analysis used electronic medical records and patient chart data from Reliant Medical Group (Worcester, Massachusetts) to evaluate physician adherence to the 2013 ACC/AHA blood cholesterol guidelines when treating patients with evidence of acute atherosclerotic cardiovascular disease and the reasons for the observed treatment decisions. Less than 50% of acute atherosclerotic cardiovascular disease patients were treated according to the ACC/AHA guidelines. Nearly 42% of patients not treated according to guidelines received a lower statin intensity than recommended. The most common reason cited by 41.8% of physicians for treating with a statin intensity below the recommended intensity was low-density lipoprotein cholesterol stable or at goal, despite ACC/AHA guidelines recommending specific statin intensities rather than specific low-density lipoprotein cholesterol levels. In conclusion, physician and patient education on the importance of maximizing lipid-lowering therapy in this high-risk patient population should be emphasized.