Arik Wolak

Isolated Splenic Cat Scratch Disease in an Immunocompetent Adult Woman

We report a case of isolated splenic cat scratch disease in an immunocompetent woman. The clinical presentation of prolonged fever, night sweats, weakness, and intrasplenic lesions was highly suggestive of lymphoma. This is the second reported case of isolated splenic cat scratch disease in an adult and the first in a healthy adult.

What Have the New Definition of Acute Myocardial Infarction and the Introduction of Troponin Measurement Done to the Coronary Care Unit

Objective: To assess the impact of the new American College of Cardiology/European Society of Cardiology definition of acute myocardial infarction (AMI) and the introduction of troponin measurement on the coronary care unit (CCU). Methods: This was a retrospective cohort study performed in a tertiary care university hospital. All admissions to the CCU during the year before (period 1, year 2000, n = 1,134) and the year after (period 2, year 2002, n = 1,360) the introduction of troponin measurement and the new AMI definition were studied. We studied baseline characteristics, case load, distribution of admission diagnoses, management and outcome of patients in the two periods. Results: There was a 20% increase in the number of CCU admissions, driven solely by a 141% increase in the burden of non-ST elevation AMI (NSTEMI) (p < 0.01). This increase was not a mere reflection of a change in diagnostic criteria, as the overall burden of non-ST elevation acute coronary syndromes (ACS) (NSTEMI + unstable angina) increased by 46%, suggesting referral of many more patients to the CCU. Despite a 42% increase in the number of angiograms performed, the proportion of ACS patients who had an angiogram declined. AMI patients in period 2 were older and had higher rates of coronary risk factors but had a higher chance of receiving a guideline-based therapy. Length of CCU stay decreased by a whole day for all ACS patients. 30-day mortality for AMI patients did not change significantly. Conclusions: The new AMI definition had a dramatic impact on the CCU case load, case mix and length of stay and on the ability to provide early coronary angiography.

Accuracy of Diagnosing Atrial Flutter and Atrial Fibrillation From a Surface Electrocardiogram by Hospital Physicians: Analysis of Data From Internal Medicine Departments

Introduction:Atrial fibrillation (AF) and atrial flutter (AFL) are clinically and electrocardiographically similar. However, considering significant therapeutic differences, differentiation of these 2 arrhythmias is essential. Our aims were to evaluate the misdiagnosis rate among electrocardiograms (ECGs) interpreted as AF or AFL by internists and to describe the factors that could be responsible for the misinterpretation. Methods:We evaluated patients discharged with a diagnosis of AF or AFL from internal medicine wards of a tertiary referral center. The reanalysis of the ECGs was performed by 2 senior cardiologists (1 electrophysiologist), blinded to the primary analysis and patients clinical data. Results:The ECGs of 44 of 268 (16%) patients were misinterpreted and consisted of: 25 (57%) AFL, 5 (11%) SVT, 7 (16%) sinus rhythm with premature atrial beats and 7 (16%) AF. The baseline diagnosis was correct in 212 of 246 (86%) for AF and 12 of 22 (55%) for AFL, P < 0.001. A significantly higher rate of AFL was misdiagnosed compared with AF [25 of 37 (68%) versus 7 of 219 (3%), respectively; P < 0.001], higher in atypical than typical AFL [16 of 20 (80%) versus 9 of 17 (53%), respectively; P = 0.07]. Reduced quality ECGs was found more often among the incorrectly than the correctly diagnosed ECGs (P < 0.001]. Conclusions:ECGs, interpreted as AF or AFL by internists, are often misdiagnosed. AFL was misdiagnosed more often than AF, with atypical more often than typical AFL. Consulting with a cardiologist and applying diagnostic criteria may reduce misdiagnosis.

Length of left anterior descending coronary artery determines prognosis in acute anterior wall myocardial infarction

The left anterior descending artery (LAD) supplies blood to a large part of the myocardium. However, the amount of myocardium supplied varies depending on the length of the LAD and as a result, occlusion of its proximal portion may influence outcome. We investigated the prognosis of patients with anterior wall myocardial infarction as the initial presentation of coronary disease who underwent primary percutaneous coronary intervention (PPCI) in our institution due to isolated proximal LAD occlusion.

Collateral blood flow can predict myocardial blush grade in primary coronary intervention.

Objectives Our aim was to investigate whether collateral flow may predict myocardial blush grade (MBG) in acute myocardial infarction patients undergoing primary percutaneous coronary intervention. Background No‐reflow is a well known phenomenon associated with increased morbidity and mortality due to underperfused myocardium; therefore early prediction of no‐reflow is of major importance. We have observed that in patients with good collateral filling of the infarct related artery as seen prior to primary angioplasty, the clearance of the contrast medium from the myocardium may be impaired. Methods We retrospectively analyzed the MBG as observed by collateral filling in 81 patients and correlated it with the final MBG. Patients were divided into two groups—those with collateral MBG 0 or 1 (34) and those with myocardial blush 2 or 3 (47). Results Of the 34 patients in the first group 71% remained in the same MBG group after primary percutaneous coronary intervention and the rest improved. Of the 47 individuals with collateral MBG 2 or 3, 87% remained in the same group following primary percutaneous coronary intervention, and the rest deteriorated (P < 0.01 for both groups). Conclusions Collaterals may predict MBG in acute myocardial infarction patients undergoing primary percutaneous coronary intervention.

Is It Possible to Shorten Ambulatory Blood Pressure Monitoring

The aim of this investigation was to find a time segment in which average blood pressure (BP) has the best correlation with 24‐hour BP control. A total of 240 patients with full ambulatory BP monitoring (ABPM) were included; 120 had controlled BP (systolic BP [SBP] ≤135 mm Hg and diastolic BP [DBP] ≤85 mm Hg) and 120 had uncontrolled BP (SBP >135 mm Hg and/or DBP >85 mm Hg). Each ABPM was divided into 6‐ and 8‐hour segments. Evaluation for correlation between mean BP for each time segment and 24‐hour BP control was performed using receiver operating characteristic curve analysis and Youdens index for threshold with the best sensitivity and specificity. The mean BP in the following segments showed the highest area under the curve (AUC) compared with average controlled 24‐hour BP: SBP 2 am to 8 am (AUC, 0.918; threshold value of 133.5 mm Hg, sensitivity−0.752 and specificity−0.904); SBP 2 pm to 10 pm (AUC, 0.911; threshold value of 138.5 mm Hg, sensitivity−0.803 and specificity−0.878); and SBP 6 am to 2 pm (AUC, 0.903; threshold value of 140.5 mm Hg, sensitivity−0.778 and specificity−0.888). The time segment 2 pm to 10 pm was shown to have good correlation with 24‐hour BP control (AUC >0.9; sensitivity and specificity >80%). This time segment might replace full ABPM as a screening measure for BP control or as abbreviated ABPM for patients with difficulty in performing full ABPM.

Routine blood tests during pregnancy for predicting future increases in risk of cardiovascular morbidity

To examine the association between routine blood tests during pregnancy and future risk of cardiovascular morbidity.

Attenuated predictive power of a normal myocardial perfusion scan in young smokers

BACKGROUND The negative predictive value of a normal myocardial perfusion image (MPI) for myocardial infarction or cardiac death is very high. However, it is unclear whether a normal MPI, reflecting non-compromised blood flow in the stable state, would have the same prognostic implications in smokers as in patients who do not smoke. METHODS The incidence of total mortality, cardiovascular mortality, and myocardial infarction was evaluated in 11,812 subjects (14.6% of whom were current smokers at the time of the study) with a normal MPI study and no past history of coronary artery disease during the period 1997 to 2008. RESULTS During an average follow-up of 72.4 ± 32.4 months the risk for an acute myocardial infarction in current smokers was approximately 50% higher than the corresponding risk in non-smokers, despite a younger average age. Cox proportional regression models show that current smoking was associated with an increased hazard rate for the composite endpoint below age 60 (HR=2.09, 95%CI 1.43-3.07, p<0.001), but not at older ages (HR=1.16, 95% CI 0.81-1.66, p=0.4). CONCLUSIONS In individuals below age 60, but not at older ages, current smoking is associated with increased short- and long-term risk of cardiac death and acute myocardial infarction even in subjects with a normal MPI.

Isolated nondominant right coronary stenosis: clinical presentation and management.

The frequency, clinical presentation, and management of severely stenotic isolated nondominant right coronary artery (NDRCA) have not been adequately defined. We sought to do so in a large cohort of patients undergoing coronary angiography. We retrospectively analyzed all patients who underwent coronary angiography in our institute between 1995 and June 2012, looking at those with a severe lesion in the NDRCA, recording demographic, clinical, and angiographic data. Of the 43 327 patients, 35 (0.08%) were found to have a severely stenotic NDRCA as a single-vessel disease. The most common indication for catheterization was acute coronary syndrome (49%). Most of the patients were managed conservatively (66%) and the entire group had a relatively benign course, with no coronary deaths. Severe stenosis of the NDRCA as isolated disease is a very rare entity, and although most commonly presenting with acute coronary syndrome, conservative management was the usual approach.