Emiliana Franco

Epidemiology and survival of the five stages of chronic kidney disease in a systolic heart failure population

The epidemiology of the five stages of chronic kidney disease (CKD) in systolic heart failure (HF) patients has predominantly been described in hospitalized White patients, with little known about the prevalence in outpatient Blacks and Hispanics. The purpose of this study was to compare the prevalence of the five stages of CKD by race, ethnicity (Whites, Blacks, and Hispanics), and gender in an outpatient systolic HF population and also to evaluate the impact of CKD on mortality.

Open Access to an Outpatient Intravenous Diuresis Program in a Systolic Heart Failure Disease Management Program

In order to provide efficient utilization of resources in an outpatient setting for acute exacerbation of heart failure (HF), the authors piloted an open-access outpatient intravenous (IV) diuretic program (IVDP) to evaluate utilization in an HF disease management program (HFDMP), patient characteristics for users of the program, and safety. An outpatient HFDMP at Jackson Memorial Hospital in Miami, Florida, enrolling 577 patients 18 years and older with an ejection fraction ≤40% was implemented. For symptoms or weight gain ≥5 pounds, patients were eligible to use an open-access IVDP during clinic hours. A total of 130 HFDM patients (22.5%) used the IVDP. IVDP users were more likely to be diabetic, with lower body mass indices than non-IVDP users. New York Heart Association class IV patients and previously hospitalized patients were more likely to use the IVDP. There were no documented adverse reactions for patients receiving treatment and no difference in mortality between groups. This open-access outpatient IVDP model for patients with HF was readily utilized by the HFDMP participants and appears safe for use in this population. This unique model may provide alternative access for acute HF treatment. Congest Heart Fail.

The Prevalence of Peripheral Arterial Disease in Patients With Heart Failure by Race and Ethnicity

More than 5 million people live with heart failure (HF) in the United States, and this number is expected to rise due to several factors including increased life expectancy brought about by medical therapy and the aging of the population. HF and peripheral arterial disease (PAD) share many risk factors. A review of the literature reveals several studies supporting a higher prevalence of HF in patients with PAD than in those without PAD. However, no study was found that estimates the prevalence of PAD in patients with HF. Moreover, the prevalence of PAD by US race/ethnic groups with HF has not been studied. The authors conducted a cross-sectional multicenter study of patients enrolled in an HF disease management program in Louisiana (n=330) and Florida (n=464). All patients with an ejection fraction <or=40% and a measured ankle-brachial index (ABI) were included in the study. PAD was defined as an ABI <0.9. The overall prevalence of PAD was 17.1%. The prevalence of PAD was 25.9% for white, 13.4% for Hispanic, and 13.7% for black patients. White patients had a higher prevalence of PAD than black or Hispanic patients (P<.001). Routine ABI measurements in these groups would enhance efforts to detect subclinical PAD.

Prevalence of conduction abnormalities in a systolic heart failure population by race, ethnicity, and gender.

Background: There is paucity of data regarding conduction abnormalities in the Hispanic population with systolic heart failure (HF). We aimed to evaluate the prevalence of electrocardiogram (ECG) abnormalities in a systolic HF population, with attention to the Hispanic population.

Clinical Features of Takotsubo Cardiomyopathy - A Single-Center Experience

Takotsubo cardiomyopathy (TTC), also known as transient apical ballooning syndrome or stress-induced cardiomyopathy, is a distinctive reversible condition often affecting postmenopausal women after a stressful event. It is characterized by sudden temporary systolic dysfunction of the apical and/or mid-segments of the left ventricle. The underlying mechanisms have not yet been elucidated, but several hypotheses include catecholamine cardiotoxicity, microvascular dysfunction and coronary artery spasm. We conducted a retrospective descriptive study on patients with the discharge diagnosis of TTC from 2003 to 2012 at Danbury Hospital, Danbury, Conn., USA. A total of 78 patients met the Modified Mayo Criteria for the Diagnosis of TTC and were included in the study. Clinical characteristics at baseline, past surgical and medical history including psychiatric records were reviewed and recorded. The mean age was 70.5 ± 14 years, 87% (n = 68) were women, of which 11.7% (n = 8) were aged ≤55 years. Depression was present in 20.5% (n = 16) of the patients and anxiety in 30.8% (n = 24). Twenty-one patients (27.3%) reported a preceding emotional stressful event and 31 (40.3%) had a preceding physical stressor. Fifty patients (64.1%) presented with chest pain, 28 (35.9%) had ST-segment elevation upon admission and 5 (6.3%) died during their hospital stay. TTC is becoming an increasingly recognized condition and clinicians should include it in the differential diagnosis of patients presenting with a suspected acute coronary syndrome. It is frequent in postmenopausal women with preceding physical or emotional stress and overall prognosis is good among patients who survive the initial acute phase of heart failure.

Distinctive Electrocardiographic Features in African Americans Diagnosed with Takotsubo Cardiomyopathy.

Takotsubo cardiomyopathy (TC) can resemble acute anterior ST‐elevation myocardial infarction. Most studies have examined TC in Asians and Caucasians (non‐African Americans [AA]), while very few cases have been reported in AA. We aimed to assess the electrocardiographic features of TC in AA patients and compare them to non‐AA TC patients.

Prevalence of Electrocardiographic Abnormalities in a Systolic Heart Failure Disease Management Population by Race, Ethnicity, and Sex

The prevalence of electrocardiographic (ECG) abnormalities in systolic heart failure patients have predominantly been described in white patients, with relatively little known about their prevalence in black and Hispanic populations. The purpose of this study is to compare the prevalence of ECG abnormalities by race, ethnicity, and sex. The authors conducted an observational prospective study that included 926 patients from 2 hospital facilities. A systolic heart failure disease management program implemented in both sites enrolled patients with an ejection fraction < or =40% by echocardiography. Black patients had less evidence of myocardial infarction than whites and Hispanics. Black patients had more evidence of left ventricular hypertrophy than Hispanics and whites. Hispanics evidenced more ischemic changes than blacks and whites. Among black patients, left ventricular hypertrophy was more prevalent in women. ECG abnormalities vary across race, ethnicity, and sex. These variations may have implications for further diagnostic testing and potential treatment regimens.

Intermittent Brugada Pattern in Relation to Changes in Body Temperature.

Un varon de 31 anos de edad, sin antecedentes medicos ni familiares de interes, fue atendido en el servicio de urgencias tras sufrir una parada cardiorrespiratoria presenciada por su familia en un restaurante. Segun el registro del sistema de emergencias medicas, el ritmo inicial fue de fibrilacion ventricular. Se intubo al paciente y se le aplicaron 4 descargas en ese lugar, que lograron restablecer una circulacion espontanea. Se realizo reanimacion cardiopulmonar durante 25 minutos. El electrocardiograma obtenido a su llegada (figura 1) sugirio un posible sindrome de Brugada. Se inicio el protocolo de hipotermia. Se realizo de todos modos una angiografia coronaria, pero no mostro enfermedad coronaria epicardica. Un electrocardiograma realizado durante el proceso de enfriamiento evidencio una bradicardia sinusal con bloqueo auriculoventricular de primer grado (figura 2). Una vez completado el proceso de recalentamiento, se recupero un ritmo sinusal normal (figura 3A). Al cabo de 48 horas, el paciente presento una tos productiva con esputo amarillento y dificultad respiratoria, junto con un pico febril de 38,3 8C. Un nuevo electrocardiograma fue compatible con un sindrome de Brugada (figura 3B). Es de destacar que la esposa del paciente menciono que habia tenido sintomas de tipo gripal la semana anterior. Figura 3. Figura 2. Figura 1.

Takotsubo cardiomyopathy and chronic obstructive pulmonary disease

We read with great interest the recently published case report by Melão et al. (March 2014 issue of the Portuguese Journal of Cardiology) of a 56-year-old male with chronic obstructive pulmonary disease (COPD) who developed stress-induced cardiomyopathy associated with ipratropium bromide use, administered in the context of an acute exacerbation of COPD. Although this timely and interesting case report provides important information, we would like to share some thoughts. Acute COPD exacerbation and acute respiratory failure (hypoxemic and/or hypercapnic) have been described as potential physical triggers of takotsubo cardiomyopathy (TCM). In a study by Sharkey et al., acute respiratory failure and COPD exacerbation were among the most prevalent physical triggers. Hypoxemia and hypercapnia can induce sympathetic nerve stimulation; the effect of hypoxemia alone can produce a longer-lasting sympathetic activation than hypercapnia, however if both occur simultaneously the result may be a significant increase in sympathetic activity with concomitant increase in catecholamine release, which has been widely implicated in the etiology of TCM. Acidosis has been associated with high levels of catecholamine release and may have negative inotropic effects secondary to decreasing calcium release from the sarcoplasmic reticulum. Acidosis-induced cardiomyocyte injury has been reported. Inhaled beta 2 agonists used in acute asthma and COPD exacerbation have also been implied as potential triggers of TCM. Rarely, paradoxical bronchospasm may occur in the setting of inhaled ipratropium; however, this should be carefully distinguished from inadequate response and from transient nocturnal desaturation in COPD. This patient had hypercapnia and respiratory acidosis and used inhaled salbutamol. We wonder why COPD exacerbation itself (especially in the context of a left paratracheal consolidation suggesting community-acquired pneumonia, which could potentially add hypoxia to this clinical scenario) was not considered the most likely trigger of TCM instead of a rare paradoxical reaction to an anticholinergic drug.

Extrapulmonary Tuberculosis (TB) Diagnosed With the Aid of Endoscopic Ultrasound–Guided Lymph Node Biopsy: A Case Report of Abdominal TB Lymphadenitis in a Hitherto Undiagnosed HIV-Positive Man

BackgroundTuberculosis (TB) is the most common opportunistic infection in persons living with human immunodeficiency virus (HIV) worldwide. In the United States, the incidence of TB in 2009 was 4.1 per 100 000, with 10% of the patients coinfected with HIV. An estimated 10 to 15 million people in the United States have latent TB. Human immunodeficiency virus–related extrapulmonary TB is defined by the World Health Organization as an acquired immunodeficiency syndrome diagnosis. Extrapulmonary TB is found in approximately 20% of the patients with TB in the US, and the most common form is tuberculous lymphadenitis. CaseWe report the case of a 28-year-old man who emigrated from Mexico 8 years ago and presented to the emergency department with abdominal pain. The pain was described as 8/10 in intensity, constant, occasionally radiating to the back and associated with nausea, diarrhea, profuse night sweats, fatigue, and a 20-pound weight loss over a 2-week period. Result of the patient’s chest radiography was normal, and a computed tomographic scan of the abdomen revealed multiple soft tissue lesions in the upper abdomen that demonstrated low central density, suggesting necrotic lymph nodes. Mild ascites and subcentimeter lesions in the spleen representative of microabscesses were also reported. An HIV testing by enzyme-linked immunosorbent assay was positive, confirmed by Western blot, and the absolute CD4 count was 38. The patient’s history was revisited, and he disclosed having had multiple sexual partners. A Quantiferon test was negative. Endoscopic ultrasound (EUS)-guided core biopsy was obtained. ConclusionsWe present a case of abdominal lymphadenitis diagnosed through biopsy by EUS, rendering a diagnosis of TB in a patient with undiagnosed acquired immunodeficiency syndrome. An EUS-guided biopsy of accessible abdominal nodes presents a convenient technique through which specimens may be gathered for culture and pathologic examination. Our case points out that under circumstances where a high index of suspicion for extrapulmonary TB exists, EUS with fine needle aspiration can be a very important supplement to our diagnostic armamentarium.