An otherwise healthy 26-year-old female presented with sudden cardiac arrest. She was resuscitated with unsynchronized cardioversion for ventricular fibrillation. A left heart cardiac catheterization showed anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). Cardiac computed tomographic angiography confirmed this abnormality. She underwent direct translocation of the left main coronary artery to the aorta, and after a stormy postoperative course was discharged home. ALCAPA is a rare congenital abnormality of the coronary system that is associated with early infant mortality and adult sudden death. The use of advanced cardiac imaging has resulted in an increase in the number of diagnosed ALCAPA cases, especially in the adult population, sometimes even in the asymptomatic. The extent of collateral circulation that develops between the right coronary artery and the left coronary artery determines the outcome; the more collateral circulation there is, the less the hypoxic damage to the ventricle. This not only informs us that people survive ALCAPA into adulthood but also highlights the importance for adult cardiologists to be aware of this interesting disease. Corrective surgery remains the treatment of choice. We present a rare case of ALCAPA, with first presentation in adulthood in the form of a malignant ventricular arrhythmia.
Background: Effects of pulse pressure and benefits of blood pressure lowering with intravenous anti-hypertensive medications and beta-blockers in CVA patients have not been well investigated. Material and Methods: Demographic, clinical, and echocardiographic data were collected and long-term outcomes (55+/-21 months) were ascertained in 356 consecutive cerebro-vascular accident (CVA) patients. ANOVA, chi-square, Kaplan-Meier, and logistic regression tests were employed. Study was approved by the institutional IRB. Results: Widened pulse pressure on admission was significantly elevated in CVA patients who expired in the hospital or during the long-term follow-up (62+/-21mmHg for long-term survivors vs. 72+/-20mmHg for hospital deaths vs. 69+/-28 mmHg for long-term deaths, p=0.01). There was a trend towards increased hospital mortality (14% in long-term survivors vs. 25% in hospital deaths vs. 22% in long-term deaths, p=0.110) in CVA patients requiring IV anti-hypertensive therapy. Utilization of beta-blockers was lower in patients who suffered hospital death, but more likely in patients experiencing long-term death (42% use in hospital deaths vs. 48% in long-term survivors vs. vs. 66% in long-term deaths, p=0.003). Beta-blocker use was not predictive of hospital outcomes but was strongly predictive of adverse event long-term events (HR 2.1, 95%CI 1.3-3.4, p=0.002). When adjusted for demographic parameters and co-morbidities in multivariate analysis, pulse pressure and IV anti-hypertensive therapy were not predictive of short or long-term outcomes, while beta-blocker treatment was associated with reduced hospital (0.3, 95%CI 0.1-0.9, p=0.029) but not long-term mortality. Conclusions: Widened pulse pressure and need for IV anti-hypertensive therapy are not predictive of adverse short- or long-term outcomes when demographics and co-morbidities are accounted for. Effects of beta-blocker therapy on outcomes in CVA patients are complex. Wider beta-blocker use in acute CVA may be associated with better hospital outcomes, while increased long term mortality with beta-blocker therapy may be indicative of poor cardiovascular health leading to adverse outcomes
Title: Echocardiographic Predictors of Long-Term Outcomes in Patients with CVA and Type 2 Myocardial Infarction. Authors: Avinash Murthy, Houman Nourkeyhani, Amar Shah, Hussian Khawaja, Mikhail Torosoff Institution: Albany Medical College, Albany, NY Background: We investigated effects of echocardiographic signs of atherosclerosis on long-term outcomes in patients with non-hemorrhagic stroke and Type 2 myocardial infarction (MI), as manifested by elevated troponin. Material and Methods: Long-term outcomes (51+/-24 months) were ascertained in 380 consecutive stroke patients (173 females, 67+/-16 years old, 103 with history of diabetes, 88 with CAD, 276 with history of hypertension, 18 on hemodialysis) with abnormal troponin level during index CVA admission. Echocardiographic indicators of atherosclerosis were collected: mitral annular calcification (MAC), aortic valve and aortic root sclerosis. ANOVA, chi-square, Kaplan-Meier, and logistic regression tests were employed. Study was approved by the institutional IRB. Results: There was no effect of echocardiographic indicators of atherosclerosis on inpatient mortality by lifetable or logistic regression analyses. However, when long-term mortality was considered, patients with CVA and elevated troponin had worse outcomes if MAC (p=0.0009) or AV sclerosis (P<0.0001) or aortic root sclerosis were present (p<0.0001; Figure panels A, B, and C, respectively). When multivariate logistic regression analysis was performed, MAC (p=0.438) was not a significant mortality predictor, while aortic valve sclerosis (HR 1.9 95%CI 1.1-3.2, p=0.0298) and aortic root sclerosis (HR 2.5 95%CI 1.4-4.5, p=0.0024) retained predictive power. Conclusions: In CVA survivors with elevated troponin during index admission echocardiographic evidence of cardiovascular atherosclerosis confers increased risk of long-term mortality but does not affect hospital outcomes. When atherosclerotic burden is limited to mitral annular calcification this risk appears to be the lowest, while aortic valve and aortic root involvement are associated with progressively worse long-term survival.
Background: We have investigated clinical correlates of elevated troponin and studied contemporary management of patients with stroke and evidence suggestive for Type 2 myocardial infarction (MI). Material and Methods: Restrospective chart review was performed on 380 consecutive stroke patients referred for an echocardiographic evaluation. Of these 342 had troponin tested for chest pain and/or abnormal ECG. Patients were further divided into 3 groups according to the troponin level: Group I - 253 (74%) with normal, Group II - 72 ( 21% ) with intermediate, and Group III - 17 (5%) with level consistent with MI diagnosis. ANOVA and chi-square tests were employed. Study was approved by the institutional IRB. Results: Mortality and prolonged length of stay both strongly correlated with highest achieved troponin level (4% mortality in Gr I, 10% in Gr II, and 29% in Gr III, p<0.001). Patients with CVA and Type 2 MI (Group III) had lower hematocrit (p<0.001) and higher creatinine (p=0.009) then the rest of the cohort. However, there was no correlation between elevated troponin and patients' age, gender, history of CAD, diabetes, hypertension, dyslipidemia, peripheral vascular disease, or chronic renal failure/hemodialysis. ECG abnormalities (mostly negative T waves) were slightly, but not significantly more prevalent in Type 2 MI patients (18% vs. 9% in Gr I and 14% in Gr II, p=0.37). Prevalence of decreased ejection fraction was significantly higher in Type 2 MI, but only at initial evaluation (p=0.0001), while the follow-up echocardiograms showed no such difference (p=0.842). Abnormal, ischemic stress test result were equally common in all groups (p=0.427). Conclusion: CVA patients with abnormal troponin incur increased mortality and protracted hospital stay. Traditional CAD risk factors are poor predictors of abnormal troponin in CVA patients. Cardiac testing in this population appears to be of limited utility. Randomized studies of this important subject are needed.
Individuals with spinal cord injury are at higher risk for developing cardiovascular events, such as myocardial infarction and death. Increased body mass, stress, abnormal glucose metabolism and lipid abnormalities, components of metabolic syndrome, are seen commonly in these individuals. Reduced ability to exercise is at least in part responsible for changes in body composition and metabolism. The prevalence of these abnormalities and its effect on blood vessels in women with spinal cord injury is unknown.Methods and ResultsSixty-five women with chronic spinal cord injury, age 43 ± 11 years, predominately Hispanic (40%) underwent laboratory testing, for lipid profile, glucose metabolism and the carotid artery intima-media thickening a surrogate for coronary artery disease. Abnormal lipid profile was present in 59% particularly high triglycerides, mean value of 105± 35 mg/dl. Fasting glucose and Hemoglobin A1C were in high normal range (95 ± 21 mg/dl and 4.7 ± 1.8) respectively. Significant correlations were found between intima-media thickening and age (r = .22, p ≤ 0.04) and with fasting glucose (r = .78, p≤ 0.002) in high spinal cord injury. No correlations existed between intima-media thickening and any lipid fractions.ConclusionAlthough 59% of women with spinal cord injury had lipid abnormalities these were in mild to moderate range and did not affect blood vessels. Abnormal glucose metabolism had significant effect on cardiovascular system, as measured by intima-media thickening and may lead to future adverse events.
significant weight changes. A prospective controlled study will be required to exclude the possibility that VNS counteracts weight-related effects of anti-seizure drugs.
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