Introduction:
Sudden cardiac death in young patients may be due to coronary artery disease, primary electrical disease, cardiomyopathy, or congenital anomalies. We explore potential causes for sudden cardiac arrest in a young patient.
Case Description:
A 27-year-old woman was found unconscious. Initial rhythm showed ventricular fibrillation. Cardiopulmonary resuscitation was done for 5 minutes before return of spontaneous circulation. ECG showed ST elevations in aVL, V4, and V5. She was admitted for therapeutic temperature management. Troponin peaked at 1.86 ng/mL on the evening of arrival. Transthoracic echocardiography (TTE) demonstrated hypokinesis of the mid to distal septum, anterior wall, and apex (Figure 1). Repeat TTE 3 days later showed resolution of the wall motion abnormalities. She reported marijuana use and a domestic dispute with her significant other the night prior. Coronary CT angiography showed calcium score of 0 with normal coronary anatomy, no significant coronary artery stenosis, and incidental finding of bilateral pulmonary artery filling defects. Lower limb venous duplex was unremarkable. Therapeutic dose of enoxaparin was started. Cardiac MRI showed no myocardial infarction, scar, or infiltrative disease. An electrophysiology study revealed adequate QT shortening during epinephrine infusion and no inducible ventricular arrhythmias. Genetic testing was unremarkable. She was discharged with a wearable defibrillator before ultimately receiving a subcutaneous implantable cardioverter-defibrillator.
Discussion:
The presentation of transient regional wall motion abnormalities, with ST-segment elevations and negative ischemic workup, is highly suggestive of Takotsubo cardiomyopathy, mid-ventricular variant. Marijuana use is a risk factor, and the domestic dispute is a potential emotional trigger. This case highlights Takotsubo cardiomyopathy as a possible cause of sudden cardiac arrest in young patients.
Introduction:
An obesity paradox is observed in patients with diabetes.
Hypothesis:
We hypothesized that obese patients with diabetes hospitalized for STEMI have a better intra-hospital outcome.
Methods:
We used data from the National Inpatient Sample (NIS) from 2008 to 2014. Patients with STEMI and diabetes were classified according to their BMI: Underweight (BMI <19), Normal (BMI 19-24.9), Class I Obesity (BMI 25.0-29.9), Class II Obesity (BMI 30.0-39.9), and Class III Obesity (BMI >40). We compared different classes and assessed in-hospital events.
Results:
1.7% patients were underweight, 3.0% had normal weight, 10.4% had Obesity Class I, 54.8% had Obesity Class II, and 30.2% had Obesity Class III. Mean age (SD) was higher in underweight patients (73 ±13) but decreases progressively to reach 58 ± 11 in class III obesity (p<0.001). There were more females in underweight patients and more males in normal weight and obese patients (p<0.001). Obese patients had a significantly lower risk compared to normal weight patients, but not underweight (Figure 1). In cardiogenic shock, underweight and class I obese patients had a similar risk compared to normal weight, but class II (a OR= 0.53 [0.40-0.70]) and class III (OR=0.62 [0.46 - 0.82] had a lower risk. The risk of ventricular fibrillation was not different according to groups. Interestingly, the risk of atrial fibrillation was lower in class I (OR= 0.72 [0.52-0.98]) and class II (OR= 0.7 [0.53-0.93]) patients without being higher in underweight patients. Increasing age was a strong predictor of cardiovascular events (OR of mortality is 7.99 [5.83 - 10.83] for patients >84 years old). Multivariable adjustments did not affect the significance of the results.
Conclusions:
An obesity paradox is observed in patients with diabetes hospitalized for STEMI. Higher BMI is correlated with lower risk of mortality, cardiogenic shock, and atrial fibrillation. Underweight patients did not have a higher risk of cardiovascular events.
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