Citations

Introduction and Importance: While the use of vaping has increased significantly among young individuals, the effects of the various vape aerosol chemical contents on cardiac electrophysiological dynamics remain unknown. Case Presentation: A 22-year-old female with a history of energy vaping but no significant past medical history presented with cardiac arrest. Found to have no pulse, CPR was started and initial rhythm of ventricular tachycardia was obtained. Shock was administered with follow-up rhythm of ventricular fibrillation. Patient was shocked again and entered atrial fibrillation with rapid ventricular response. She later cardioverted into sinus tachycardia and was intubated. Transthoracic echocardiogram showed normal ejection fraction but was otherwise unremarkable. Patient was extubated on day four of hospitalization. Left heart catheterization and cardiac MRI were completely unremarkable. Toxicology, urine analysis, and troponins were all negative. Patient was discharged with metoprolol tartrate, and a life-vest with outpatient follow-ups for possible implantable cardioverter-defibrillator placement in the setting of negative work up for sudden cardiac arrest. Clinical Discussion: Vaping-induced sudden cardiac arrest may be attributed to a reduction in cardiac repolarization reserve. Exposure to vegetable glycerin and propylene glycol, substances present in nearly all vape products, have been found to incite arrhythmias and disrupt cardiac conduction in animals. Acrolein,a byproduct of glycerin, has also been found to induce arrhythmias due to autonomic dysfunction. Increased prevalence of ventricular arrhythmias have also been noted with exposure to aerosols containing nicotine-free propylene glycol (PG).This likely stems from the impact of PG aerosols on the transient outward potassium current, which plays a significant role in early cardiac repolarization. Conclusion: The effects of inhaling vape aerosols remain not fully understood. While there is a perceived notion that nicotine-free aerosols may not be harmful, that remains unclear.Further studies should be conducted to evaluate for pro-arrhythmogenic effects and autonomic dysfunction from the various chemical substances present in vape aerosols.

Background: The obesity paradox is a phenomenon observed in certain chronic diseases, particularly cardiovascular diseases, where individuals with obesity have better outcomes compared to those of normal weight. We aimed to study how COVID-19 affects MACCE results in metabolically healthy obese (MHO) individuals who have a BMI >30. Methods: Using the National Inpatient Sample (2020) and appropriate ICD-10-CM codes, we identified adult hospitalizations with COVID-19 and grouped them into two cohorts with and without obesity (MHO+ and MHO-, omitting hypertension, diabetes, and hyperlipidemia). MACCE (all-cause inpatient mortality, cardiac arrest, including ventricular fibrillation, and stroke) in COVID-19-related hospitalizations was the primary outcome. Results: 84,145 (21.9%) of 397,040 COVID-19 hospitalizations were MHO+. The MHO+ group was younger (median 43 vs 52 years), female (56.9% vs. 49.4%), black (19.4% vs 15.1%), Hispanic (35.2% vs 30.5%), and Native American (1.5% vs 1.2%) (p<0.001). Tobacco use disorder, past PCI, prior VTE, depression, chronic pulmonary disease, hypothyroidism, and other thyroid problems were more common in MHO+ patients (p<0.05). MHO+ patients were discharged routinely (76% vs. 66.7%) but stayed longer (5 days vs 4 days). After correcting for baseline variables, the MHO+ cohort had a lower rate of MACCE than the MHO- cohort (8% vs. 11.3%, OR 0.81, 95CI 0.74-0.89, p<0.001), and lower all-cause mortality (6.6 % vs 9.4%) compared to the MHO- cohort. On subgroup analysis, females had lower odds (aOR 0.79) than males (aOR 0.82), older individuals ≥65 years old had lower odds (aOR 0.71) vs 45-64 (aOR 0.79), and race- wise comparison, whites had lower odds of MACCE events (aOR 0.76). Conclusions: MHO+ patients had lower odds of MACCE events. The MHO group was younger, suggesting higher cardiorespiratory fitness, which could explain the obesity paradox and reduced odds of MACCE outcomes.

Introduction: The incidence and risk factors for sudden cardiac death (SCD) in patients with systemic right ventricle (sRV) and D-TGA palliated with atrial switch procedures is not well understood. Methods: This cohort was examined retrospectively for the composite end point of SCD, sustained ventricular tachycardia (VT) >30 s or appropriate ICD therapy for VT. Clinical characteristics of those with and without the end point were compared using the Kruskal-Wallis or Chi-square test as appropriate. Results: The composite end point occurred in 15 of 148 (10%) patients (63.5% male) at a mean age of 36.4 (SD 10.3) years. SCD occurred in 6 patients (n=2 successfully resuscitated), sustained VT in 6 patients and ICD therapy for VT in 3 patients who had previously received a primary prevention ICD. Patients with SCD/VT had lower sRV ejection fraction (EF) compared to patients without SCD/VT [28±11 vs 40±10%, P<0.001]. The odds ratio of SCD/VT in patients with sRVEF≤35% compared to sRVEF>35% was 13.3 (95% CI 2.8 - 64.4). Kaplan Meier analysis of time to SCD/VT stratified by sRV EF is presented in figure. QRS duration, QRS fragmentation, QTc and history of systemic AV valve surgery were not significantly associated with SCD/VT. Non-sustained ventricular tachycardia (NSVT) on Holter monitoring occurred more frequently in SCD/VT patients (80 vs 39%, p=0.003). All 11 survivors of SCD/VT received an ICD; appropriate ICD therapy occurred in 27% of these patients during follow-up. Conclusion: SCD or VT occurred in one-tenth of D-TGA patients palliated with atrial switch, predominantly in 3 rd and 4 th decade of life. Reduced sRV EF was the most important association and ICD implantation for primary prevention of SCD is a reasonable consideration in those with reduced sRV EF.

Introduction: Hospitalization for COVID-19 is often associated with myocardial injury (elevated cardiac troponin [cTn]). In the initial pandemic waves, patients with myocardial injury had increased likelihood of cardiovascular complications and inpatient mortality; however, the differences in impact of distinct subtypes of myocardial injury on mortality is unclear. In addition, little is known about how these outcomes compare with the subsequent, milder, Omicron wave. Methods: Utilizing Mayo Clinic enterprise patients we developed algorithms based on diagnostic/procedural codes, cTn levels, and temporal relationships to positive COVID-19 PCR tests, to determine 5 common subtypes of myocardial injury: stress cardiomyopathy, myocarditis, pericarditis, pulmonary embolism, and myocardial infarction. We examined hospitalized adults with COVID-19; those with elevated cTn designated as cases and others as controls. We fitted Cox models using the following covariates: spline transformed age, sex, race, ethnicity, index date and clinical comorbidities. Patients were analyzed based on admission dates coinciding with either the Alpha-Delta or Omicron waves. Results: Across both wave cohorts, hospitalized patients with acute COVID-19 complicated by myocardial injury had an increased risk of mortality compared to those without ( Figure ). Patients with one of the 5 subtypes examined tended to have higher risk than those in the “other myocardial injury” category. Admission during the Omicron wave, compared to the Alpha-Delta waves, tended to have higher mortality risk in all subtypes except myocarditis. Conclusions: Our algorithms successfully identified subgroups of myocardial injury in patients hospitalized with acute COVID-19 leading to stratification of mortality risk. Surprisingly, among hospitalized patients during the Omicron wave, myocardial injury of most subtypes was tended to have increased risk of mortality compared to the Alpha-Delta waves.

Introduction: At the forefront of post-heart transplant care is early detection of transplant rejection. However, the current gold standard for detecting acute cellular transplant rejection is recurrent invasive endomyocardial biopsies (EMB). We aimed at developing a non-invasive biomarker for acute cellular heart transplant rejection (ACR) using a plasma extracellular vesicle (EV) platform. Methods: Peripheral and coronary sinus plasma samples were prospectively collected from 183 (31.7% female) patients from 2020 to 2023 during routine surveillance EMB. A discovery cohort comprised five patients who displayed ISHLT 0-1R biopsy followed by an ISHLT 2R grade rejection event. Plasma EVs were isolated from the baseline (0-1R) and rejection (2R) time points. Subsequently, integrative analysis of plasma EV proteomic, miRNomic, and metabolomics was performed pairwise with the samples. Results: The study collected 943 sample time points from 183 patients. Of these sample collections, 43 (4.5%) cases were 2R rejections. Our proteomic analysis of the plasma EVs identified 28 proteins found explicitly during a grade 2R rejection and 87 differentially expressed proteins during a 2R rejection event. An Ingenuity Pathway Analysis (IPA) analysis of the upregulated proteins highlighted EVs mediated mTOR signaling and antigen presentation as central to rejection events. Although all patients in the discovery cohort were negative for antibody-mediated rejection (AMR), the proteomic findings also revealed increased B-cell receptor signaling, implying a mechanistic intersection of ACR and AMR. Conclusions: A distinct set of proteins were found in plasma EVs during ACR events, providing potentially specific and sensitive biomarkers to reduce the need for EMB that could be exploited for ACR diagnosis. The proteins identified formed an immune signaling network that suggests a novel role for EVs in ACR pathogenesis.

Introduction: Cognitive impairment has a significant impact on functional recovery and quality of life in stroke patients. Given the emerging role of high sensitivity C-reactive protein (hs-CRP) as a biomarker for predicting post-stroke cognitive decline, we conducted a meta-analysis to investigate this association. Methods: We systematically searched SCOPUS, PubMed, and Google Scholar databases until May 2023 using relevant keywords. Pooled effect sizes were estimated using a random-effects model, and I2 statistics and leave-one-out sensitivity analysis were performed to assess heterogeneity and robustness, respectively (p-value < 0.05 considered significant). Results: The final analysis included five studies spanning the years 2018-2023, with a total sample size of 9,625 patients, all from China, and predominantly male (57.85%). The median follow-up period was 3 months. Patients with higher hs-CRP levels had a higher burden of smoking, alcohol consumption, hypertension, diabetes, hyperlipidemia, and lower education levels. The meta-analysis revealed an increased risk of cognitive impairment after ischemic stroke associated with higher hs-CRP levels (adjusted odds ratio [aOR] 1.15; 95% CI: 1.01-1.30, p - 0.03). Substantial heterogeneity was observed among the studies (I2 = 79.23%; p < 0.01). However, a leave-one-out sensitivity analysis confirmed the robustness of the findings, indicating that no single study strongly influenced the overall results. Conclusion: This meta-analysis provides evidence of an association between elevated hs-CRP levels and cognitive impairment following ischemic stroke. However, the limited number of studies, mainly from a specific population, highlights the need for further research to enhance the generalizability of these findings.

Introduction: Long-term outcomes of young patients with chest pain and normal epicardial coronary arteries (NECA) in angiography remain understudied. Methods: We conducted a prospective study in a tertiary heart hospital between 2004-2020, enrolling men<45 and women<55 years presenting with symptoms or objective findings of coronary artery disease (CAD) and confirmed NECA in angiography. Patients with cardiomyopathy, coronary anomaly, and significant valvular, renal, pulmonary, or liver diseases were excluded. The primary outcome was MACCE, defined as the composite of death, CCU admission (for MI or unstable angina), stroke, and revascularization. Follow-ups were done every 5 years using a standardized questionnaire and a committee of experts reviewed all the events. Expected age and sex-adjusted mortality rates were estimated using national data. The association between exposures and MACCE was studied using multivariable Cox-proportional hazard models. Results: 1257 patients, 340 (27.05%) men (38.34±5.46 years), and 917 (72.95%) women (48.41±4.94 years) were included. 698 (55.53%) had acute and 559 (44.47%) had chronic symptoms. Over the median 9.4 (8.5-11.0) years of follow-up, 134 (10.66%) events happened. CCU admission (6.33%) was the most common event (Figure). The 10-year mortality rate (per 100,000-person-years) was 265 for men and 174 for women, which were 1.6 and 2.5 times higher than the age-sex-matched rate of the normal population, respectively. Diabetes, hypertension, and presenting with acute symptoms were associated with higher MACCE with the hazard ratios (95% CI) of 1.87 (1.05-3.31, P:0.03), 1.72 (1.13-2.61, P:0.01), and 1.56 (1.03-2.36, P:0.04), respectively. During follow-up, 192 (15.27%) repeated angiographies were done and 19.8% developed obstructive CAD. Conclusions: In young patients with chest pain and NECA, approximately 10% experienced MACCE during a 10-year follow-up, and the mortality is higher than expected.

Introduction: Guidelines are increasingly recommending a goal LDL-C <55 mg/dL in persons with atherosclerotic cardiovascular disease (ASCVD). The proportion and characteristics of US adults with ASCVD with an LDL-C <55 mg/dL remains unclear. Aims: To evaluate lipid management in ASCVD patients and factors associated with achieving an LDL-C <55mg/dL. Methods: Using electronic health record data from 8 US health systems, we evaluated LDL-C levels and treatment patterns in persons with prevalent ASCVD seen as outpatients between 1/1/2021-12/31/2021 with an LDL-C level within the prior year. Multivariable logistic regression modeling with generalized estimating equations was used to evaluate factors associated with an LDL-C <55 mg/dL. Results: Among 178,240 eligible ASCVD patients, 43.5% (77,472) had an LDL- C <70 mg/dL and 22.0% (39,270) had an LDL-C <55 mg/dL. Older age was associated with higher odds of LDL-C <55 mg/dL (OR 1.10 per 10 years, 95% CI 1.07-1.13), while female sex (OR 0.71, 95% CI 0.68-0.64) Black race (OR 0.77, 95% CI 0.70-0.86), and non-coronary artery disease forms of ASCVD including peripheral artery disease (PAD, OR 0.61, 95% CI 0.58-0.64) and cerebrovascular disease (CeVD, OR 0.72, 95% CI 0.66-0.79) were associated with lower odds of LDL-C <55 mg/dL in multivariable modeling. Overall, while 75.0% were on a statin, only 36.9% were on a high-intensity statin, 5.7% were on ezetimibe, and 1.7% were on a PCSK9i. Combination therapy was rare: only 4.2% were on a statin+ezetimibe, 0.5% on statin+PCSK9i, and 0.3% on all three. Conclusions: Less than a quarter of US patients with ASCVD achieve an LDL <55 mg/dL. Achieving this goal is even less common among younger adults, women, Black persons, and those with PAD and CeVD. Current therapeutic regimens often fail to use high-intensity statins, and markedly underutilize combinations of statins with ezetimibe and/or PCSK9 inhibitors.

Primary cardiac tumors (CTs) are exceptionally rare, and are predominantly benign masses. Myxomas make up more than 60% of these lesions and most frequently develop in the left atrium (LA), followed by the right atrium (RA). Carney complex (CNC) is a rare, typically autosomal dominant, multiple endocrine neoplasia characterized by cutaneous findings, myxomas, endocrine and/or nonendocrine neoplasms. We report a rare case of CNC involving biatrial and recurrent myxomas. A 36-year-old female presented to Cardiology Clinic at our center for management of CNC. Three years prior, she was evaluated at a local hospital for acute stroke where TTE showed a myxoma (2 x 2 x 2.5cm) attached to the left atrial septum, prompting resection. On followup TTE 2 years later, she had a mass in the LA, prolapsing through the mitral valve into the left ventricle. She underwent resection of the myxoma (2.9 x 3.9 cm) and left atrial appendage, which was complicated by recurrent stroke. She was found to have a PRKAR1A gene mutation (c.97 deletion) suggestive of CNC and was referred to our center. At Cardiology Clinic, she denied chest pain, dyspnea, presyncope, and syncope. Her father and children did not have the gene mutation. Exam revealed lentigines on her lower lip and pigmentation of an inner canthus. She was diagnosed with primary pigmented nodular adrenal disease by Endocrinology. On TEE, she was found to have a recurrent LA mass (1 x 1 x 0.8 cm) attached to the interatrial septum, but no right-to-left atrial shunt. This prompted surgery consultation. Numerous intracardiac myxomas were removed during surgery; one in the LA attached to the septum, 3-4 smaller ones, and one 2 cm myxoma located in the RA. The interatrial septum was also resected given recurrent myxoma in this region. She underwent cryoablation to prevent recurrence and did well post-surgery. CTs, which includes primary CTs and secondary metastatic disease, are uncommon where the former has an incidence of 0.001-0.3%. We presented a case of recurrent and biatrial cardiac myxomas in the setting of CNC, which is seldomly reported in the literature. Taken together, given the rarity of primary CTs, genetic predispositions or syndromes should be considered especially in the setting of recurrence and/or multiple masses.

Background: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have been proven to improve clinical outcomes in heart failure (HF). However, there remains a paucity of data on the potential cardioprotective impact of SGLT2i in cancer patients receiving anthracyclines. Aim: To evaluate if SGLT2i use is associated with improved outcomes in anthracycline-treated cancer patients. Methods: Using TriNetX Global Research Network from 2013 to 2021, patients diagnosed with cancer and receiving anthracycline therapy were identified and categorized into those who were taking SGLT2i versus those who were not. A 1:1 propensity score matching was used to control for baseline characteristics between the two groups. Patients were followed for 2 years. The primary endpoint was all-cause mortality and secondary endpoints were new-onset HF, acute HF exacerbation, myocardial infarction, new-onset atrial fibrillation/flutter, and all-cause hospitalization. Results: A total of 82,369 anthracycline-treated cancer patients were identified. After propensity score matching application, 1,412 patients were included in our analysis (706 patients in each group). Patients on SGLT2i had lower rates of all-cause mortality (OR: 0.7 [95% CI: 0.56, 0.88]; P=0.002), acute HF exacerbation (OR: 0.64 [95% CI: 0.41-1]; P=0.048), and new-onset atrial fibrillation/flutter (OR: 0.52 [95% CI: 0.33, 0.8]; P=0.003) compared to those not on SGLT2i. The incidence of myocardial infarction, new-onset HF, and all-cause hospitalization were similar between the two groups (Figure). Conclusion: Among cancer patients receiving anthracyclines, SGLT2i were associated with lower rates of mortality, acute HF exacerbations, and new-onset atrial fibrillation/flutter and similar rates of myocardial infarction, new-onset HF, and hospitalization.