A Suspected Case of Hydralazine-Induced Hepatotoxicity: A Case Report and Review of Literature.

BACKGROUND Hydralazine is an effective antihypertensive agent but may rarely have devastating hepatotoxic effects that are extremely variable, thus making the diagnosis difficult. CASE REPORT We report the case of a 74-year-old male patient who had transaminitis after being started on hydralazine by his cardiologist for poorly controlled hypertension. He had extreme dizziness, nausea, and weakness, which all resolved after discontinuation of hydralazine, and liver function test results also dramatically improved.

Revisiting the Role of Antiarrhythmic Drugs in Prevention of Atrial Fibrillation Recurrence: A Single Center Retrospective Review.

Background: We conducted a retrospective analysis to revisit the efficacy of four different commonly used antiarrhythmic drugs (AADs) in a single community hospital setting in the U.S. We used cardiac implantable electronic devices (CIEDs) to continuously monitor the patients for maintenance of sinus rhythm.

Role of cardiovascular implantable electronic devices in delivering individualized disease-guided management of patients with non-valvular atrial fibrillation and high bleeding risk.

Background: Many patients with non-valvular atrial fibrillation (NVAF) with high risk for thromboembolic stroke and bleeding may not wish to continue long-term oral anticoagulants (OACs) to avoid bleeding complications. We aimed to investigate whether AF burden assessment by cardiovascular implantable electronic devices (CIEDs) would allow an individualised disease-guided approach for safe withdrawal of long-term OAC in high-risk patients.

Methods And Results: We studied 145 patients (age 77.

Postapproval Community Hospital Experience in the United States with Left Atrial Appendage Closure Device (Watchman).

Background: To review the procedural safety and postimplantation complications of Watchman device implanted at 2 community hospitals for primary prevention of systemic embolization in patients with nonvalvular atrial fibrillation (NVAF) who were not candidates for long-term oral anticoagulation (OAC).

Methods: This was a retrospective case series of 48 patients carried out in 2 community hospitals in the United States. Patients with NVAF who had a CHADS2 higher than 2 or CHADS2VASc2 (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack [TIA] or thromboembolism, vascular disease, age 65-74 years, and female gender) score of 3 or higher and were not candidates for long-term OAC.

Is There Always a Need for Permanent Pacemaker Replacement After Device Infection? A Tale of Two Patients.

There has been an increase in number of cardiac implantable electronic devices (CIEDs) implantation and with this we have witnessed increased rates of CIED infection mainly in elderly population. It is important to assess conditions that may not reliably improve with cardiac pacing or those who lack adequate beneficial effect from permanent pacing before contemplating implantation or reimplantation of these devices. Sometimes, the initial cardiac pathology may revert obviating the need for reimplantation as in the two cases that we have discussed below.

Revisiting Atrioventricular Nodal Ablation and Cardiac Pacing of Atrial Fibrillation in a Patient with Dextrocardia.

BACKGROUND Poorly controlled ventricular rate associated with atrial fibrillation (AF) leads to tachycardia-induced left ventricular dysfunction. Atrioventricular (AV) nodal ablation and cardiac pacing is the standard of care in refractory congestive heart failure (CHF) due to AF with moderate to rapid ventricular response that failed conventional medical therapy. If the patient is not a candidate for AF ablation with pulmonary vein isolation and elimination of AF foci, this is an effective approach, but it does have some challenges when done in a patient with dextrocardia and situs inversus.

Gallbladder Nonvisualization in Cholecystectomy: A Factor for Conversion.

Background And Objectives: Many risk factors have been identified in minimally invasive cholecystectomies that lead to higher complications and conversion rates. No study that we encountered looked at nonvisualization of the gallbladder (GB) during surgery as a risk factor. We hypothesized that nonvisualization was associated with an increased risk of complications and could be an early intraoperative identifier of a higher risk procedure.

Conversion of Atrial Fibrillation to Sinus Rhythm During Coronary Intervention: Complex Interplay of Arrhythmic and Ischemic Substrate.

Atrial fibrillation (AF) can be a manifestation of acute coronary syndrome (ACS). Presence of AF during ACS further adds to complexities in the management issues and prognosis of ACS. We report a case of a 77-year-old male in whom we observed spontaneous conversion of AF to sinus rhythm during percutaneous coronary interventional procedure for critical ostial stenosis of the right coronary artery; and discuss potential electrophysiological mechanisms related to such phenomenon.

Successful External Cardioversion via Fluoroscopic Electrode Positioning in Patients with Enlarged Trans-Thoracic Diameter.

BACKGROUND Atrial fibrillation is the most common cardiac arrhythmia. It increases the risk of stroke by at least five-fold and is associated with higher risk for mortality and morbidity. Therefore, prompt diagnosis and treatment is crucial.

Opposite impact of Methylene tetrahydrofolate reductase C677T and Methylene tetrahydrofolate reductase A1298C gene polymorphisms on systemic inflammation.

Background: Methylenetetrahydrofolate reductase (MTHFR) gene polymorphisms have been found to be related with many diseases. Systemic inflammation is now considered as a major predisposition factor for diseases including diabetes mellitus (DM), coronary arterial disease (CAD), stroke, and cancer. This study aimed to investigate whether systemic inflammation is a possible underlying pathogenesis for MTHFR gene polymorphism-related disease.

Lyme disease presenting with facial palsy and myocarditis mimicking myocardial infarction.

A 45-year-old woman presented with a sudden episode of typical chest pain, radiating to her neck. The patient denied premature coronary artery disease in the family. Initial EKG showed normal sinus rhythm with a 1 mm ST-elevation involving lead II and lead aVF and a 1 mm ST-depression in lead V1 with associated T-wave inversion.

Reducing Radiation Exposure in an Electrophysiology Lab with Introduction of Newer Fluoroscopic Technology.

The use of fluoroscopic devices exposes patients and operators to harmful effects of ionizing radiation in an electrophysiology (EP) lab. We sought to know if the newer fluoroscopic technology (Allura Clarity) installed in a hybrid EP helps to reduce prescribed radiation dose. We performed radiation dose analysis of 90 patients who underwent various procedures in the EP lab at a community teaching hospital after the introduction of newer fluoroscopic technology in June of 2016.

Do All Patients with Atrial Fibrillation Need Long-Term Anticoagulation?

Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide with an estimated number of 2.7-6.1 million cases in the United States (US) alone.

Palpitations as a presenting feature of multisystem sarcoidosis.

: Sarcoidosis is described as a systemic condition characterized by non-caseating granulomas in multiple organs. In this report, we present an unusual manifestation of cardiac sarcoidosis and review management strategies. : A 29-year-old African-American man presented with weight loss, fatigue, dyspnea, palpitations, night sweats, painless left eye redness and bilateral leg pain over the course of three months.

CYP2C19 genetic variation and individualized clopidogrel prescription in a cardiology clinic.

: Clopidogrel (Plavix) is an antiplatelet medication that is routinely used in patients with cardiovascular disease. Cytochrome P2C19 enzymes play a major role in its metabolism, which determines its varied therapeutic level and its effectiveness. : To customize clopidogrel therapy and evaluate its efficacy by using CYP2C19 genotypic and phenotypic information to improve clinical outcomes in patients.

Development of New Deep Venous Thrombosis While on Apixaban.

The efficacy of novel oral anticoagulants (NOACs) in preventing deep venous thrombosis (DVT) has been established in large multicenter trials. Predictable pharmacokinetics, avoidance of routine laboratory monitoring, and lesser drug interactions have made NOACs safer and more tolerable treatment option in comparison to warfarin. However, cases of treatment failure mainly due to interindividual variation in plasma drug levels can be seen rarely.

A rare case of apical hypertrophic cardiomyopathy (AHCM).

Apical hypertrophic cardiomyopathy is a rare form of hypertrophic cardiomyopathy that involves thickening of the distal portion of the left ventricular wall. Most commonly seen in the Japan, with a prevalence rate of about 15% of all HCM patient, its incidence in the USA is approximately 3% of HCM cases. We report a case of a 46-year-old woman with history of hypertension who presented to emergency department with worsening dyspnea and orthopnea with features of left ventricular hypertrophy (LVH) and diffuse large T-wave inversions in the lateral leads on a 12-lead ECG.

Necessity is the mother of invention: an innovative hospitalist-resident initiative for improving quality and reducing readmissions from skilled nursing facilities.

: Hospital readmissions have been a major challenge to the US health system. Medicare data shows that approximately 25% of Medicare skilled nursing facility (SNF) residents are readmitted back to the hospital within 30 days. Some of the major reasons for high readmission rates include fragmented information exchange during transitions of care and limited access to physicians round-the-clock in SNFs.

Reducing Error in Anticoagulant Dosing Multidisciplinary Team Rounding at Point of Care.

The incorporation of a clinical pharmacist in daily rounding can help identify and correct errors related to anticoagulation dosing. Inappropriate anticoagulant dosing increases the risk of developing significant bleeding diathesis. Conversely, inappropriate dosing may also fail to produce a therapeutic response.

Bilateral Chylothorax Complicating a Case of Chronic Lymphocytic Leukemia: A Case Report.

Chylothorax occurs when lymphatic fluid leaks from the thoracic duct and accumulates in the pleural space. Bilateral chylothorax caused by chronic lymphocytic leukemia (CLL) has been rarely reported in the literature. Sludging of lymph might be the underlying cause.

Ticagrelor Associated Heart Block: The Need for Close and Continued Monitoring.

Ticagrelor is an antiplatelet agent prescribed to prevent the development of adverse cardiac events after acute coronary syndrome (ACS). According to the PLATO trial, ticagrelor is associated with ventricular pauses in the first week of treatment; however, these episodes were felt to be asymptomatic and nonfatal to the patient. We present a case of ticagrelor related second-degree type II heart block causing severe dizziness and diaphoresis that resolved after discontinuation of the medication.

Interventricular Membranous Septal Aneurysm Incidentally Diagnosed During Computed Tomographic Angiography in a Patient with Infrequent Supraventricular Tachycardia.

Interventricular membranous septal (IVMS) aneurysm is a rare condition with no accurate incidence. It is known to be associated with 0.3 % of congenital heart disease and 19 % of ventricular septal defects.