This study confirms that the HCM Risk-SCD model provides accurate prognostic information that can be used to target implantable cardioverter defibrillator therapy in patients at the highest risk of SCD.

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Cardiogenic shock (CS) in the peripartum period is associated with significant morbidity and mortality. Treatment of CS by specialists in high-volume centers is associated with improved outcomes. A healthy 34-year-old pregnant woman underwent planned cesarian section delivery for placenta previa at a community hospital, which was complicated by postpartum hemorrhage treated with methylergonovine, tranexamic acid, and carboprost. One hour later, she was hypertensive, tachycardic, and had a generalized seizure followed by hypoxemia and pulseless electrical activity. She was persistently hypotensive after resuscitation. An echocardiogram (TTE) demonstrated a left ventricular ejection fraction of 25%. She was transferred to our cardiac intensive care unit (CCU) for consideration of mechanical circulatory support (MCS). The patient arrived at the CCU on multiple vasopressors and inotropes. The advanced HF, CCU, and maternal fetal medicine teams assessed the patient on arrival. Bedside right heart catheterization demonstrated right atrial pressure of 6 mmHg, pulmonary arterial pressure of 22/17 mmHg, pulmonary capillary wedge pressure of 10 mmHg, and Fick cardiac index of 2.5 L/min. BP was improving and vasoactive agents were weaned. The bleeding risk of anticoagulation for MCS after postpartum hemorrhage was thought to outweigh the potential benefit of MCS with normal filling pressures and weaning of vasoactive agents, thus MCS was not deployed. An electroencephalogram revealed status epilepticus, and magnetic resonance imaging of the brain was suggestive of posterior reversible encephalopathy syndrome with hemorrhage secondary to cerebral vasospasm. TTE on hospital day 4 showed normalization of biventricular function, and she made a full neurologic recovery and was discharged home on hospital day 15. Given the normalization of cardiac and neurologic function with supportive care only, her shock was attributed to methylergonovine-induced cerebral vasospasm leading to seizures with subsequent respiratory and cardiac arrest and myocardial stunning. This case demonstrates the importance of rapid team-based diagnostic assessment of peripartum patients presenting in suspected CS to appropriately triage the use of MCS.

Introduction: We present a case of a 50 year-old man who presented with one week of chest discomfort and ECG consistent with pericarditis (Fig. 1A) complicated by pericardial effusion. He rapidly developed cardiac tamponade with a pulsus paradoxus of 30mmHg and associated echocardiographic signs including RV diastolic collapse (Fig. 1B) and severe respiratory variation requiring pericardiocentesis (Fig. 1C). He was treated with high-dose indomethacin and colchicine 0.6mg twice daily with symptomatic improvement. Initial work-up for the etiology of pericardial effusion was notable for a borderline ANA of 1:40 and an RF of 20 IU/mL. CRP improved from 115.5 mg/L to 6.3mg/L with treatment. Two months later, he developed recurrent chest pain with new arthralgias and new morning stiffness in several joints after completing the course of indomethacin. A repeat ECG revealed normal sinus rhythm. He was restarted on high-dose indomethacin and referred to rheumatology clinic for further autoimmune work-up. This revealed an elevated anti-cyclic citrullinated peptide antibody IgG titer (>250), which is highly specific for RA. He was started on methotrexate 15mg weekly for treatment of newly diagnosed RA. To date, he remains asymptomatic. Results: Conclusions: Cardiac tamponade as the initial presentation of RA has not been previously described, but has been seen in systemic lupus erythematosus. Few case reports of pericardial disease without tamponade as the initial finding of RA have been reported. Development of cardiac tamponade in RA is rare (<1%). New clinical symptoms and a high index of suspicion should prompt repeat and expanded work up for rheumatologic etiologies of pericardial disease. While cardiac involvement in RA is known to increase mortality, outcomes have been improving due to novel anti-inflammatory therapies. This case serves as an example of the collaboration needed between specialties to make the correct diagnosis in cardio-rheumatology patients .

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