Akil Loli

Physician-Directed Heart Failure Transitional Care Program: A Retrospective Case Review

Background Despite a variety of national efforts to improve transitions of care for patients at risk for rehospitalization, 30-day rehospitalization rates for patients with heart failure have remained largely unchanged. Methods This is a retrospective review of 73 patients enrolled in our hospital-based, physican-directed Heart Failure Transitional Care Program (HFTCP). This study evaluated the 30- and 90- day readmission rates before and after enrollment in the program. The Transitionalist’s services focused on bedside consultation prior to hospital discharge, follow-up home visits within 72 hours of discharge, frequent follow-up phone calls, disease-specific education, outpatient intravenous diuretic therapy, and around-the-clock telephone access to the Transitionalist. Results The pre-enrollment 30-day readmission rates for acute decompensated heart failure (ADHF) and all-cause readmission was 26.0% and 28.8%, respectively, while the post-enrollment rates for ADHF and all-cause readmission were 4.1% (P < 0.001) and 8.2% (P = 0.002), respectively. The pre-enrollment 90-day all-cause and ADHF readmission rates were 69.8%, and 58.9% respectively, while the post-enrollment rates for all-cause and ADHF were 27.3% (P < 0.001) and 16.4% (P < 0.001) respectively. Conclusions Our physician-implemented HFTCP reduced rehospitalization risk for patients enrolled in the program. This program may serve as a model to assist other hospital systems to reduce readmission rates of patients with HF.

Kounis Syndrome: A Stinging Case of ST-Elevation Myocardial Infarction

Kounis syndrome is not a rare but an infrequently diagnosed non-thrombogenic cause of angina or myocardial infarction triggered by the release of inflammatory mediators following an allergic or anaphylactic reaction. This so-called allergic angina is seen in the setting of anaphylactic reactions and is believed to be due to mast cell release causing coronary vasospasm. The treatment of such cases is often with epinephrine, which has also been described in the literature as another rare cause of coronary vasospasm. We present a case of Kounis syndrome seen in a 46 year-old male who suffered two bee stings while landscaping in his yard. He developed an anaphylactic reaction and was promptly treated with IM epinephrine injection by paramedics at arrival and developed marked ST elevations on EKG in the inferior leads with reciprocal ST depressions in the anterior leads. His troponin peaked at 13 ng/mL and tryptase level was 15 ng/mL (normal <10 ng/mL). Coronary catheterisation showed non-diseased coronary arteries and a normal ejection fraction without evidence of vasospasm. He was afterwards treated with an epinephrine drip for distributive shock. Interestingly this syndrome was not provoked when re-challenged with this therapy, suggestive of an allergic reaction rather than epinephrine as the aetiology of his presumed vasospasm. This patients ST segment elevation and troponin elevation was due to Kounis syndrome. Awareness that anaphylactic reactions can lead to Kounis syndrome can lead to prompt appropriate treatment for this life threatening condition.

Native Valve Endocarditis due to Ralstonia pickettii: A Case Report and Literature Review.

Ralstonia pickettii is a rare pathogen and even more rare in healthy individuals. Here we report a case of R. pickettii bacteremia leading to aortic valve abscess and complete heart block. To our knowledge this is the first case report of Ralstonia species causing infective endocarditis with perivalvular abscess.

Postdischarge transitional care management: a reimbursable service in 2013.

1. American Board of Internal Medicine, Number of First-Year Fellows by Specialty [on-line]. Available at http://www.abim.org/about/examInfo/datafellow/chart-04.aspx Accessed November 18, 2012. 2. American Medical Association and the Committee on Legislation and Advocacy, Medicare and the Sustainable Growth Rate [on-line]. Available at http://www.ama-assn.org/resources/doc/mss/cola_medicare_pres.pdf Accessed November 18, 2012. 3. American Hospital Association, American Medical Association, American Nurse Association, New Report Finds That Sequester of Medicare Spending Could Lead to More Than 750,000 Jobs Lost, September 12, 2012 Press Release [on-line]. Available at http://nursingworld.org/FunctionalMenuCategories/MediaResources/PressReleases/Report-Finds-Sequester-of-MedicareSpending-Could-Lead-to-Jobs-Lost.pdf Accessed November 18, 2012.

Rate-related left bundle branch block and cardiac memory in a patient with bradycardia: Case report and literature review

Rate‐related left bundle branch block (LBBB) is a well‐studied phenomenon. Cardiac memory is another physiologic phenomenon in which T‐wave abnormalities occur in the absence of ischemia. The association between these 2 phenomena has been described in several case reports. A literature review was performed through Ovid and PubMed, where at total of 93 cases of rate‐related LBBB were identified. Cases were reviewed, and data were collected on rates of appearance and disappearance as well as the presence or absence of cardiac memory. There is some overlap in the rate at which LBBB appears. Cardiac memory is associated with rate‐related LBBB in several cases, but its true prevalence is unknown. Cardiac memory is a phenomenon that is well described in the literature but is often underrecognized in clinical practice. As a consequence of overlooking this phenomenon and not including cardiac memory in the differential when T‐wave abnormalities are observed, patients may be subjected to unnecessary invasive diagnostic testing.

COMPARING TEE WITH ANGIOGRAPHIC SIZING OF WATCHMAN DEVICE FOR LEFT ATRIAL APPENDAGE CLOSURE

Background: There are significant limitations to using TEE as imaging modality for selecting the size of WATCHMAN device as frequently changing device size is needed which adds cost and risk of complications. We compared TEE with angiography sizing for WATCHMAN devicennMethods: TEE and angiographic

TCT-623 Predictors of MACE with the WATCHMAN device: An Intention-to-Treat Analysis in a Real World Experience

nos: 626 646 TCT-626 Validating a prediction modeling tool for LVOT obstruction after transcatheter mitral valve replacement Dee Dee Wang, Marvin Eng, Adam Greenbaum, Mayra Guerrero, William O’Neill

HOME TELEMONITORING TO IMPROVE DISEASE MANAGEMENT AND CLINICAL OUTCOMES IN PATIENTS WITH HEART FAILURE: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

Previous published studies on home telemetry have reported inconsistent results and current published systematic reviews have not included recent trials or were unable to make definite conclusions because of the paucity of relevant studies. The medical literature was systematically reviewed for the

PROGNOSTIC SIGNIFICANCE OF ST SEGMENT DEPRESSION DURING EXERCISE TREADMILL STRESS TESTING OF FIREFIGHTERS

Functional capacity has been well established as an important predictor of survival and risk for cardiovascular events in all persons. Over the past twenty-five years of evaluating firefighter candidates at a large urban fire department, we have observed a number of tests with ST-segment depression

Regional pericarditis status post cardiac ablation: a case report.

Context: Regional pericarditis is elusive and difficult to diagnosis. Healthcare providers should be familiar with post-cardiac ablation complications as this procedure is now widespread and frequently performed. The management of regional pericarditis differs greatly from that of acute myocardial infarction. Case report: A 52 year-old male underwent atrial fibrillation ablation and developed severe mid-sternal chest pain the following day with electrocardiographic findings suggestive of acute myocardial infarction, and underwent coronary angiography, a left ventriculogram, and 2D transthoracic echocardiogram, all of which were unremarkable without evidence of obstructive coronary disease, wall motion abnormalities, or pericardial effusions. Ultimately, the patient was diagnosed with regional pericarditis. After diagnosis, the patients presenting symptoms resolved with treatment including nonsteroidal anti-inflammatory agents and colchicine. Conclusion: This is the first reported case study of regional pericarditis status post cardiac ablation. Electrocardiographic findings were classic for an acute myocardial infarction; however, coronary angiography and left ventriculogram demonstrated no acute coronary occlusion or ventricular wall motion abnormalities. Healthcare professionals must remember that the electrocardiographic findings in pericarditis are not always classic and that pericarditis can occur status post cardiac ablation.