scholarly journals SLE strikes the heart! A rare presentation of SLE myocarditis presenting as cardiogenic shock

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Jaydeep J. Raval ◽  
Christina Rodriguez Ruiz ◽  
James Heywood ◽  
Jason J. Weiner
Keyword(s):  
Heart Failure ◽  
Cardiogenic Shock ◽  
Lupus Erythematosus ◽  
De Novo ◽  
Left Ventricular ◽  
Diagnostic Methods ◽  
Cardiac Biomarkers ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
Diagnostic Uncertainty

Abstract Background Although systemic lupus erythematosus (SLE) can affect the cardiovascular system in many ways with diverse presentations, a severe cardiogenic shock secondary to SLE myocarditis is infrequently described in the medical literature. Variable presenting features of SLE myocarditis can also make the diagnosis challenging. This case report will allow learners to consider SLE myocarditis in the differential and appreciate the diagnostic uncertainty. Case presentation A 20-year-old Filipino male presented with acute dyspnea, pleuritic chest pain, fevers, and diffuse rash after being diagnosed with SLE six months ago and treated with hydroxychloroquine. Labs were notable for leukopenia, non-nephrotic range proteinuria, elevated cardiac biomarkers, inflammatory markers, low complements, and serologies suggestive of active SLE. Broad-spectrum IV antibiotics and corticosteroids were initiated for sepsis and SLE activity. Blood cultures were positive for MSSA with likely skin source. An electrocardiogram showed diffuse ST-segment elevations without ischemic changes. CT chest demonstrated bilateral pleural and pericardial effusions with dense consolidations. Transthoracic and transesophageal echocardiogram demonstrated reduced left ventricular ejection fraction (LVEF) 45% with no valvular pathology suggestive of endocarditis. Although MSSA bacteremia resolved, the patient rapidly developed cardiopulmonary decline with a repeat echocardiogram demonstrating LVEF < 10%. A Cardiac MRI was a nondiagnostic study to elucidate an etiology of decompensation given inability to perform late gadolinium enhancement. Later, cardiac catheterization revealed normal cardiac output with non-obstructive coronary artery disease. As there was no clear etiology explaining his dramatic heart failure, endomyocardial biopsy was obtained demonstrating diffuse myofiber degeneration and inflammation. These pathological findings, in addition to skin biopsy demonstrating lichenoid dermatitis with a granular “full house” pattern was most consistent with SLE myocarditis. Furthermore, aggressive SLE-directed therapy demonstrated near full recovery of his heart failure. Conclusion Although myocarditis during SLE flare is a well-described cardiac manifestation, progression to cardiogenic shock is infrequent and fatal. As such, SLE myocarditis should be promptly considered. Given the heterogenous presentation of SLE, combination of serologic evaluation, advanced imaging, and myocardial biopsies can be helpful when diagnostic uncertainty exists. Our case highlights diagnostic methods and clinical course of a de novo presentation of cardiogenic shock from SLE myocarditis, then rapid improvement.

scholarly journals Pheochromocytoma-Induced Takotsubo Cardiomyopathy

2019 ◽  
Vol 46 (2) ◽  
pp. 124-127 ◽  
Author(s):  
Majed Afana ◽  
Rishi J. Panchal ◽  
Rebecca M. Simon ◽  
Amal Hejab ◽  
Sharon W. Lahiri ◽  
...  
Keyword(s):  
Heart Failure ◽  
Cardiogenic Shock ◽  
Takotsubo Cardiomyopathy ◽  
Adrenal Mass ◽  
Severe Heart Failure ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Biochemical Tests ◽  
Ventricular Ejection Fraction ◽  
Hemodynamic Compromise

Pheochromocytoma, a rare catecholamine-secreting tumor, typically manifests itself with paroxysmal hypertension, tachycardia, headache, and diaphoresis. Less often, symptoms related to substantial hemodynamic compromise and cardiogenic shock occur. We report the case of a 66-year-old woman who presented with abdominal pain. Examination revealed a large right adrenal mass, cardiogenic shock, and severe heart failure in the presence of normal coronary arteries. Within days, the patient's hemodynamic status and left ventricular ejection fraction improved markedly. Results of imaging and biochemical tests confirmed the diagnosis of pheochromocytoma-induced takotsubo cardiomyopathy. Medical therapy and right adrenalectomy resolved the patient's heart failure, and she was asymptomatic postoperatively. We recommend awareness of the link between pheochromocytoma and takotsubo cardiomyopathy, and we discuss relevant diagnostic and management principles.

scholarly journals Endomyocardial biopsies in the diagnosis of myocardial involvement in systemic lupus erythematosus

Lupus ◽  
2020 ◽  
Vol 29 (2) ◽  
pp. 199-204 ◽  
Author(s):  
Y Gartshteyn ◽  
M Tamargo ◽  
S Fleischer ◽  
T Kapoor ◽  
J Li ◽  
...  
Keyword(s):  
Systemic Lupus Erythematosus ◽  
Lupus Erythematosus ◽  
Interstitial Fibrosis ◽  
Left Ventricular ◽  
Diagnostic Methods ◽  
Left Ventricular Ejection ◽  
Systemic Lupus ◽  
Ventricular Ejection Fraction ◽  
Myocyte Hypertrophy ◽  
Myocardial Involvement

Background Endomyocardial biopsy (EMB) is considered the gold standard for diagnosing myocardial involvement in most inflammatory conditions, including systemic lupus erythematosus (SLE). However, EMBs are rarely performed, and most of the myocardial histopathology reports in SLE consist of postmortem data. We therefore sought to describe the histopathologic findings of contemporary EMBs in SLE performed in clinical practice. Methods A retrospective review of histopathology reports from SLE patients who underwent EMB from 1994 to 2017 was performed. A total of 41 SLE patients had cardiac pathology reports. Of these, 11 histopathology reports were EMBs, and the remaining were valvular specimens. Results A total of 11 SLE EMBs were reviewed. It was found that 45% of the patients had hypertension, 27% had coronary artery disease, 9% had hyperlipidemia, and 36% had end-stage renal disease. None had diabetes or smoked. The mean left ventricular ejection fraction was 37%. On histopathology, 10 had mild interstitial fibrosis, 9 had myocyte hypertrophy, 3 had organized blood clots, and 3 had a mild infiltration of lymphocytes and macrophages without clear evidence of myocarditis. None had vasculitis, endocarditis, ischemia, amyloid deposition, or lamellar or curvilinear inclusions. Conclusion EMBs are rarely performed in SLE. In this case series, nonspecific interstitial fibrosis and myocyte hypertrophy were the most common findings, suggesting EMBs have limited value in the diagnosis of cardiac involvement in SLE and rather rule out competing conditions. These data support the need for diagnostic methods with high sensitivity and specificity for SLE heart disease.

Heart failure with preserved ejection fraction: recent concepts in diagnosis, mechanisms and management

Heart ◽  
2022 ◽  
pp. heartjnl-2021-319605
Author(s):  
Andreas B Gevaert ◽  
Rachna Kataria ◽  
Faiez Zannad ◽  
Andrew J Sauer ◽  
Kevin Damman ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Left Ventricular ◽  
Diagnostic Methods ◽  
Left Ventricular Ejection ◽  
Preserved Ejection Fraction ◽  
Ventricular Ejection Fraction ◽  
Cut Points ◽  
Reduced Ejection Fraction ◽  
Comprehensive Management

It is estimated that half of all patients with heart failure (HF) have HF with preserved ejection fraction (HFpEF). Yet this form of HF remains a diagnostic and therapeutic challenge. Differentiating HFpEF from other causes of dyspnoea may require advanced diagnostic methods, such as exercise echocardiography, invasive haemodynamics and investigations for ‘HFpEF mimickers’. While the classification of HF has relied heavily on cut-points in left ventricular ejection fraction (LVEF), recent evidence points towards a gradual shift in underlying mechanisms, phenotypes and response to therapies as LVEF increases. For example, among patients with HF, the proportion of hospitalisations and deaths due to cardiac causes decreases as LVEF increases. Medication classes that are efficacious in HF with reduced ejection fraction (HFrEF) have been less so at higher LVEF ranges, decreasing the risk of HF hospitalisation but not cardiovascular or all-cause death in HFpEF. These observations reflect the burden of non-cardiac comorbidities as LVEF increases and highlight the complex pathophysiological mechanisms, both cardiac and non-cardiac, underpinning HFpEF. Treatment with sodium-glucose cotransporter 2 inhibitors reduces the risk of composite cardiovascular events, driven by a reduction in HF hospitalisations; renin-angiotensin-aldosterone blockers and angiotensin-neprilysin inhibitors result in smaller reductions in HF hospitalisations among patients with HFpEF. Comprehensive management of HFpEF includes exercise as well as treatment of risk factors and comorbidities. Classification based on phenotypes may facilitate a more targeted approach to treatment than LVEF categorisation, which sets arbitrary cut-points when LVEF is a continuum. This narrative review summarises the pathophysiology, diagnosis, classification and management of patients with HFpEF.

Rapidly progressive heart failure after dual-chamber pacemaker implantation

2021 ◽  
Vol 14 (10) ◽  
pp. e245006
Author(s):  
Claire Seydoux ◽  
Philipp Suter ◽  
Denis Graf ◽  
Hari Vivekanantham
Keyword(s):  
Heart Failure ◽  
De Novo ◽  
Pacemaker Implantation ◽  
Cardiac Resynchronisation Therapy ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Dual Chamber ◽  
Ventricular Ejection Fraction ◽  
Device Implantation ◽  
Resynchronisation Therapy

Pacing-induced cardiomyopathy (PICM) consists of heart failure (HF) associated with a drop in the left ventricular ejection fraction (LVEF) in the setting of high-burden right ventricular pacing, with presentation that may range from subclinical to severe. Time to manifestation can go from weeks to years after device implantation. Treatment typically consists in an upgrade to a cardiac resynchronisation therapy (CRT) or His bundle pacing (HisP). Several risk factors for PICM have been described and should be considered before pacemaker (PM) implantation, as thorough patient selection for de novo CRT or HisP, may preclude its manifestation. We present the case of an 82-year-old patient presenting with acute congestive HF and new severely reduced LVEF, 30 days following dual chamber PM implantation for high-grade atrioventricular block. Treatment with HF medication and upgrade to a CRT permitted rapid resolution of the symptoms and normalisation of the LVEF at 1-month follow-up.

scholarly journals Elevated Lactate Levels as a Predictor of Early Mortality in Patients with Severe LV Dysfunction without Shock or Hypoxemia

2019 ◽  
Vol 04 (02) ◽  
pp. 068-071
Author(s):  
Shravan Kumar Chetti ◽  
Sandeep Moode ◽  
Indrani Garre ◽  
Lalita Nemani
Keyword(s):  
Heart Failure ◽  
Cardiogenic Shock ◽  
Blood Lactate ◽  
Left Ventricular ◽  
Early Mortality ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
Study Population ◽  
Lactate Levels ◽  
Elevated Lactate

Abstract Background Hyperlactatemia in intensive coronary care unit (ICCU) admitted patients who are critically ill must be considered to be related to tissue hypoxia/hypoperfusion. The routine measurement of lactate levels and its significance is still unclear in ICCU patients with left ventricular ejection fraction (LVEF) < 35% without hypotension and/or hypoxia. Methods and Materials A prospective study was conducted for six months between January 2018 and June 2018 in our institute. Age ≥18 years who admitted to the ICCU with LVEF less than 35% were included. Results Total of 104 patients were included after met inclusion and exclusion criteria and consented to enrolment in the study. The most common age group involved was between 50 and 70 years (46.2% of the patients) with a mean age of 52.5 ± 16.3 years. Mean lactate levels in the study population were 1.9 mmol/L. Mortality was noted in five patients (4%) in whom there were mean lactate levels of 2.58 ± 0.37 mmol/L. In the present study population, the patients with elevated lactate levels had early mortality with a p-value of 0.005 (95% CI for difference = 0.604–1.596). The average duration of stay in ICCU in the study population was 3.3 ± 1.2 days, which was in correlation with elevated serum lactate levels. The mean pH of the study population was 7.2 ± 0.19, and mean pH in the mortality group was 7.06 ± 0.21, which was not statistically significant with those of the study population. Conclusions From our study, patients without signs of heart failure and cardiogenic shock had increased mortality when blood lactate level was over or equal to 2.5 mmol/L. So it may be used as an adjunct in identifying patients with a higher risk of mortality even without signs of heart failure, cardiogenic shock. In conclusion, according to our data, ICCU admitted patients with LVEF < 35%, blood lactate is a prognostic marker for early mortality.

scholarly journals Association of left anterior descending artery involvement on clinical outcomes among patients with STEMI presenting with and without out-of-hospital cardiac arrest

Open Heart ◽  
2020 ◽  
Vol 7 (1) ◽  
pp. e001065
Author(s):  
Mia Bertic ◽  
Christopher B Fordyce ◽  
Nima Moghaddam ◽  
John Cairns ◽  
Martha Mackay ◽  
...  
Keyword(s):  
Heart Failure ◽  
Cardiac Arrest ◽  
Cardiogenic Shock ◽  
Clinical Outcomes ◽  
Coronary Intervention ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
St Segment Elevation ◽  
Hospital Cardiac Arrest

BackgroundST-segment elevation myocardial infarction (STEMI) outcomes are influenced by the location of the culprit vessel with worse outcomes portended with a left anterior descending (LAD) culprit lesion. However, relatively little is known about the independent association of LAD involvement with clinical outcomes of patients with STEMI with and without out-of-hospital cardiac arrest (OHCA).MethodsWe identified 91 patients with and 929 without a preceding OHCA within the Vancouver Coastal Health Authority who presented with an acute STEMI and underwent primary percutaneous coronary intervention between 26 June 2007 and 31 March 2016.ResultsPatients with STEMI with OHCA had higher rates of in-hospital cardiac arrest (43.3% vs 8.3%, p<0.001), heart failure (50.5% vs 11.3%, p<0.001), cardiogenic shock (49.5% vs 5.7%, p<0.001), mortality (35.2% vs 3.3%, p<0.001) and reduced left ventricular ejection fraction (LVEF; 42.9% vs 47.3%, p<0.001) compared with those without OHCA. Among patients without OHCA, LAD involvement was associated with increased heart failure (18.1% vs 5.2%, p<0.001), in-hospital cardiac arrest (10.7% vs 6.2%, p<0.014), cardiogenic shock (8.4% vs 3.3%, p<0.001), reduced LVEF (43.0% vs 51.2%, p<0.001) and mortality (5.2% vs 1.3%, p=0.003) compared with patients without LAD involvement. With the exception of LVEF, these associations were not seen among patients with STEMI with OHCA and an LAD culprit. The presence of an LAD culprit was not independently associated with increased hospital mortality among patients with OHCA after adjusting for potential confounding factors.ConclusionOur study has demonstrated a differential impact of LAD involvement on clinical outcomes among patients with STEMI who present with and without OHCA. Our data highlight the complexity surrounding the prognostication following OHCA complicating STEMI and demonstrate that other mechanisms other than LAD involvement contribute to the high mortality associated with OHCA as a result of STEMI.

scholarly journals 348 Uric acid is associated with acute heart failure and cardiogenic shock at presentation in acute coronary syndrome patients

2021 ◽  
Vol 23 (Supplement_G) ◽  
Author(s):  
Alessandro Maloberti ◽  
Paola Rebora ◽  
Marco Centola ◽  
Nuccia Morici ◽  
Alice Sacco ◽  
...  
Keyword(s):  
Heart Failure ◽  
Uric Acid ◽  
Cardiogenic Shock ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Cross Sectional ◽  
Ventricular Ejection Fraction ◽  
Coronary Syndrome ◽  
Non Invasive Ventilation ◽  
Coronary Syndromes

Abstract Aims we focused on the role of Uric Acid (UA) as a possible determinant of Heart Failure (HF) related issues in Acute Coronary Syndromes (ACS) patients. Main outcome were acute HF and cardiogenic shock at admission, secondary outcomes were the need of Non Invasive Ventilation (NIV) use and the admission Left Ventricular Ejection Fraction (LVEF). Methods and results we consecutively enrolled 1269 ACS patients admitted to the cardiological Intensive Care Unit of the Niguarda and San Paolo hospitals (Milan, Italy) from June 2016 to June 2019. Hyperuricaemia was defined as a value higher than 6 mg/dl for females and 7 mg/dl for males. All the evaluated outcomes occurred more frequently in the hyperuricemic subjects (n = 292): acute HF 35.8 vs. 11.1% (P &lt; 0.0001), cardiogenic shock 10 vs. 3.1% (P &lt; 0.0001), NIV 24.1 vs. 5.1% (P &lt; 0.0001) with lower admission LVEF (42.9 ± 12.8 vs. 49.6 ± 9.9, P &lt; 0.0001). By multivariable analyses, UA was confirmed to be significantly associated with all the outcomes with the following odds ratio (OR): acute HF OR = 1.119; 95% CI: 1.019–1.229; cardiogenic shock OR = 1.157; 95% CI: 1.001–1.337; NIV use OR = 1.208; 95% CI: 1.078–1.354; LVEF β = −0.999; 95% CI: −1.413 to − 0.586. Conclusions The main result of our study was the finding of a significant association between UA and acute HF, cardiogenic shock, NIV use and LVEF. Due to the cross-sectional nature of our study no definite answer on the direction of these relationship can be drawn and further longitudinal study on UA changes over time during an ACS hospitalization are needed.

scholarly journals Biomarkers in Heart Failure: Current and Future

Kardiologiia ◽  
2021 ◽  
Vol 61 (5) ◽  
pp. 4-16
Author(s):  
M. V. Kozhevnikova ◽  
Yu. N. Belenkov
Keyword(s):  
Risk Factors ◽  
Heart Failure ◽  
Clinical Practice ◽  
Left Ventricular Ejection Fraction ◽  
Left Ventricular ◽  
Diagnostic Methods ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
New Biomarkers ◽  
Insight Into

Heart failure (HF) is the ending of practically all cardiovascular diseases and the reason for hospitalization of 49% of patients in a cardiological hospital. Available instrumental diagnostic methods and biomarkers not always allow verification of HF, particularly in patients with preserved left ventricular ejection fraction. Prediction of chronic HF in patients with risk factors faces great difficulties. Currently, natriuretic peptides (NUP) are widely used for the diagnosis, prognosis and management of patients with HF and are included in clinical guidelines for diagnosis and treatment of HF. Following multiple studies, the understanding of NUP significance has changed. This resulted in a need for new biomarkers to improve the insight into the process of HF and to personalize the treatment by better individual phenotyping. In addition, current technologies, such as transcriptomic, proteomic and metabolomic analyses, provide identification of new biomarkers and better understanding of features of the HF pathogenesis. The aim of this study was to discuss recent reports on NUP and novel, most promising biomarkers in respect of their possible use in clinical practice. 

scholarly journals 432 Traditional markers of myocardial dysfunction fail to detect marked reductions in physical capacity amoung chemotherapy patients

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
E Howden ◽  
S Foulkes ◽  
L Wright ◽  
K Janssens ◽  
H Dillon ◽  
...  
Keyword(s):  
Heart Failure ◽  
Cardiovascular Function ◽  
Left Ventricular ◽  
Cardiac Biomarkers ◽  
Left Ventricular Ejection ◽  
Lv Function ◽  
Cell Transplant ◽  
Ventricular Ejection Fraction ◽  
Increased Risk

Abstract Left ventricular ejection fraction (LVEF) is the current standard of care for evaluating chemotherapy-associated cardiotoxicity but changes in LVEF are poorly associated with outcomes and long-term heart failure risk. We sought to compare a more global measure of integrative cardiovascular function (VO2peak) that is strongly associated heart failure and early mortality risk with LVEF, global longitudinal strain (GLS) and cardiac biomarkers. Methods 95 patients who were due to commence anti-cancer treatment (n = 58 anthracycline chemotherapy for breast cancer; n = 25 Bruton’s tyrosine kinase inhibitor and n = 12 allogeneic stem cell transplant for haematological cancers) completed a pre-treatment and follow-up assessment within 6 months of initiating treatment. Changes in echocardiographic measures of LV function (LVEF, GLS), cardiac biomarkers (troponin and BNP) and cardiopulmonary exercise test (CPET, VO2peak) were measured. Results Of 95 participants who underwent baseline testing, follow-up CPET and echocardiography data was available in 89 participants. LV function was normal prior to treatment (LVEF 61.5 ± 5.9%; GLS -19.4 ± 2.3) but VO2peak (23.4 ± 6.5ml/kg/min) was only 83 ± 21% (range 47-146%) of age-predicted. After treatment, we observed marked reductions in fitness (Δ-2.1 ± 3.7 ml/kg/min or -9 ± 15%, P &lt; 0.001) which was associated with small non-clinically significant changes in LV function (LVEF Δ-2.4 ± 6.4% P = 0.001; GLS Δ-0.5 ± 1.9 P = 0.018). Troponin was increased significantly (4.0 ± 5.5 to 23.5 ± 22.5ng/ml, P &lt; 0.001), with no change in BNP (37.5 ± 31.4 to 32.7 ± 22.0pg/ml, P = 0.87). Current diagnostic criteria for cardiac toxicity were not met in any patient despite some patients developing disabling reductions in functional capacity (VO2peak &lt; 16ml/min/kg). Conclusion Despite normal resting LV function prior to commencing treatment VO2peak was below age predicted. Treatment further impaired exercise cardiovascular function with minimal impact on resting measures of LV function. The assessment of cardiovascular function using CPET prior to, and following chemotherapy may be a more sensitive means of identifying patients at increased risk of future heart failure.

scholarly journals Small Cell Lymphocytic Lymphoma: An Unexpected Etiology of Pleural Effusion

2021 ◽  
Vol 6 (12) ◽  
pp. 883-887
Author(s):  
Filipa Silva ◽  
Sara Ramos ◽  
Carla Pereira ◽  
Pedro Mesquita ◽  
João Teixeira ◽  
...  
Keyword(s):  
Heart Failure ◽  
Pleural Effusion ◽  
Metastatic Disease ◽  
De Novo ◽  
Real Life ◽  
Colon Adenocarcinoma ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Clinical Report ◽  
Ventricular Ejection Fraction

The differential diagnosis of pleural effusion is extensive. Pleural fluid characteristics are helpful in classifying, as transudate or exudate, being this determinant to achieve an accurate diagnosis. The authors present a clinical report of a 74-year-old man with reduced left ventricular ejection fraction heart failure, of ischemic etiology, and multiple cardiovascular risk factors, who develops a pleural effusion. In his medical history it is important to denote a recent diagnosis of colon adenocarcinoma, without evidence of metastatic disease, submitted to hemicolectomy. Four months after this diagnosis, he was admitted in the Emergency Department with dyspnea, type 1 respiratory failure and de novo pleural effusion. The most probable etiologies of pleural effusion were excluded, including heart failure and a metastatic disease. Ultimately, it was reported a difficult (or not so) and unexpected etiology for the pleural effusion, in a patient with multimorbidity and multiple confounders. It is crucial to see beyond the obvious. A real-life challenge for Internal Medicine.

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