Farhan Raza

Inferior Vena Cava Thrombosis.

Thrombosis of the inferior vena cava (IVC) is an under-recognized entity that is associated with significant short- and long-term morbidity and mortality. In absence of a congenital anomaly, the most common cause of IVC thrombosis is the presence of an unretrieved IVC filter. Due to the substantial increase in the number of IVC filters placed in the United States and the very low filter retrieval rates, clinicians are faced with a very large population of patients at risk for developing IVC thrombosis. Nevertheless, there is a paucity of data and societal guidelines with regards to the diagnosis and management of IVC thrombosis. This paper aims to enhance the awareness of this uncommon, but morbid, condition by providing a concise, yet comprehensive, review of the etiology, diagnostic approaches, and treatment strategies in patients with IVC thrombosis.

Case series of 5 patients with end-stage renal disease with reversible dyspnea, heart failure, and pulmonary hypertension related to arteriovenous dialysis access

Patients with end-stage renal disease (ESRD) with arteriovenous dialysis access (AVDA) can develop symptoms of heart failure and pulmonary hypertension (PH). We report on 5 patients with ESRD and AVDA who presented with shortness of breath, heart failure, and PH. All patients had partial or complete closure of AVDA and were reevaluated after AVDA revision. All 5 subjects had clinical and echocardiographic evidence of heart failure, hypertensive heart disease, left ventricular diastolic dysfunction, and PH at baseline. After complete closure (n = 4) or partial banding (n = 1) of AVDA, mean New York Heart Association class improved from 3.4 ± 0.4 to 1.8 ± 0.4 (P = 0.016). Mean 6-minute walk distance improved from 236 ± 115 to 366 ± 51 m (P = 0.021). Serial echocardiography revealed a decrease in the right ventricle: left ventricle ratio from 1.12 ± 0.17 to 0.8 ± 0.06 (P = 0.005) and improved diastolic dysfunction parameters. On right heart catheterization before definitive AVDA revision, acute manual fistula or graft occlusion led to an average decrease in cardiac output of 1.1 L/min with no other changes in hemodynamics: 9.88 ± 2.2 to 8.71 ± 2.2 L/min (P = 0.059). However, the average decrease in cardiac output after definitive revision of the AVDA (mean, 90 days) was 4.0 L/min with marked improvements in biventricular filling pressures and pulmonary artery pressure. In patients with ESRD and AVDA presenting with heart failure and PH, revision or closure of AVDA can markedly improve dyspnea as well as the clinical, echocardiographic, and hemodynamic manifestations of heart failure and PH.

Elevated Cardiac Troponin in Acute Stroke without Acute Coronary Syndrome Predicts Long-Term Adverse Cardiovascular Outcomes

Background. Elevated cardiac troponin in acute stroke in absence of acute coronary syndrome (ACS) has unclear long-term outcomes. Methods. Retrospective analysis of 566 patients admitted to Temple University Hospital from 2008 to 2010 for acute stroke was performed. Patients were included if cardiac troponin I was measured and had no evidence of ACS and an echocardiogram was performed. Of 200 patients who met the criteria, baseline characteristics, electrocardiograms, and major adverse cardiovascular events (MACE) were reviewed. Patients were characterized into two groups with normal and elevated troponins. Primary end point was nonfatal myocardial infarction during follow-up period after discharge. The secondary end points were MACE and death from any cause. Results. For 200 patients, 17 patients had positive troponins. Baseline characteristics were as follows: age 63.1 ± 13.8, 64% African Americans, 78% with hypertension, and 22% with previous CVA. During mean follow-up of 20.1 months, 7 patients (41.2%) in elevated troponin and 6 (3.3%) patients in normal troponin group had nonfatal myocardial infarction (P = 0.0001). MACE (41.2% versus 14.2%, P = 0.01) and death from any cause (41.2% versus 14.5%, P = 0.017) were significant in the positive troponin group. Conclusions. Elevated cardiac troponin in patients with acute stroke and no evidence of ACS is strong predictor of long-term cardiac outcomes.

Clinical significance of troponin elevations in acute decompensated diabetes without clinical acute coronary syndrome

BackgroundElevation of cardiac troponin has been documented in multiple settings without acute coronary syndrome. However, its impact on long-term cardiac outcomes in the context of acute decompensated diabetes remains to be explored.MethodsWe performed a retrospective analysis of 872 patients admitted to Temple University Hospital from 2004–2009 with DKA or HHS. Patients were included if they had cardiac troponin I (cTnI) measured within 24 hours of hospital admission, had no evidence of acute coronary syndrome and had a follow up period of at least 18 months. Of the 264 patients who met the criteria, we reviewed the baseline patient characteristics, admission labs, EKGs and major adverse cardiovascular events during the follow up period. Patients were categorized into two groups with normal and elevated levels of cardiac enzymes. The composite end point of the study was the occurrence of a major cardiovascular event (MACE) during the follow up period and was compared between the two groups.ResultsOf 264 patients, 24 patients were found to have elevated cTnI. Compared to patients with normal cardiac enzymes, there was a significant increase in incidence of MACE in patients with elevated cTnI. In a regression analysis, which included prior history of CAD, HTN and ESRD, the only variable that independently predicted MACE was an elevation in cTnI (p = 0.044). Patients with elevated CK-MB had increased lengths of hospitalization compared to the other group (p < 0.001).ConclusionsElevated cardiac troponin I in patients admitted with decompensated diabetes and without evidence of acute coronary syndrome, strongly correlate with a later major cardiovascular event. Thus, elevated troponin I during metabolic abnormalities identify a group of patients at an increased risk for poor long-term outcomes. Whether these patients may benefit from early detection, risk stratification and preventive interventions remains to be investigated.

Cardiac complications of arteriovenous fistulas in patients with end-stage renal disease.

Cardiovascular disease is the leading cause of the death in dialysis patients. Arteriovenous fistulas (AVFs) are associated with lower mortality and are viewed as the desired access option in most patients with advanced kidney disease needing dialysis. However, AVFs have significant and potentially deleterious effects on cardiac functions particularly in the setting of preexisting heart disease. This article provides a comprehensive and contemporary review to what is known about the impact of AVFs on: congestive heart failure, left ventricular hypertrophy, pulmonary hypertension, right ventricular dysfunction, coronary artery disease and valvular heart disease.

Gitelman syndrome manifesting in early childhood and leading to delayed puberty: a case report

IntroductionGitelman syndrome is an inherited autosomal recessive renal salt-wasting disorder. It presents with variable clinical symptoms including muscle weakness and fatigue, and the diagnosis is based on metabolic alkalosis, hypokalemia, hypomagnesemia and hypocalciuria. It is usually diagnosed incidentally in early adulthood. There are rare cases of Gitelman syndrome presenting in early childhood; however, to the best of our knowledge it has not previously been associated with delayed puberty.Case presentationA 17-year-old South Asian man with recurrent episodes of generalized muscle weakness, fatigue and cramps from the age of two years was admitted for further workup. Before the age of 12 years, the episodes had been mild, but they then got progressively worse. Other symptoms include polyuria, polydipsia, nocturia, paresthesia and occasional watery diarrhea. He also had a history of short stature, poor weight gain and delayed developmental landmarks. His family history was unremarkable except for the consanguineous marriage of his parents. An examination revealed a thin and lean man with blood pressure of 95/60mmHg. His height and weight were below the third percentile and his sexual development was at Tanner Stage II. Laboratory work revealed serum sodium of 124mmol/L, potassium 2.4mmol/L, calcium 6.5mmol/L and magnesium of 1.2mg/dL. His testosterone level was low (0.85ng/mL, normal for his age 2.67 to 10.12ng/mL) with normal levels of luteinizing hormone and follicle-stimulating hormone. The sex hormone findings were attributed to delayed puberty. A 24-hour urinary analysis revealed decreased excretion of calcium (25.9mg/24 hours). Based on the findings of hypokalemic metabolic alkalosis without hypertension, severe hypomagnesemia and hypocalciuria, a diagnosis of Gitelman syndrome was made. Treatment was started with oral supplementation of potassium, magnesium and calcium along with spironolactone and liberal salt intake.ConclusionDiagnosis of Gitelman syndrome is usually made incidentally during adolescence or early adulthood based on clinical and biochemical findings. We report that Gitelman syndrome can present during the early childhood years. If undiagnosed and untreated, it can lead to growth retardation and delayed puberty.

HYPERTENSION MANAGEMENT IN URBAN UNDERSERVED PATIENTS USING AN INTERNET COMMUNICATION SYSTEM

Background: Inadequate control of blood pressure (BP) contributes to excess cardiovascular disease (CVD) risk, especially in underserved communities. Patient-centered care (PCC) tools that involve home monitoring of BP and Internet or telephone-based communication with a care provider may improve BP control and lower CVD risk. We compared the effectiveness of an Internet and telephone-based telemedicine communication system (T) to usual care (UC) from a primary care provider (PCP) in managing patients with hypertension. Methods: 242 hypertensive subjects (JNC VII- Stage I and II, 16% white, 80% African American, 4% others, 62% female, age 60 ± 12 years) with systolic blood pressure >140 mmHg from two medical center were randomized to T (50%), or UC (50%). 166 patients completed 6-month followup. T patients reported their weight, BP, steps/day, cigarettes/day, twice weekly via an Internet or IVR (interactive voice response) phone system to our clinical center. Patients randomized to UC alone served as control. Monthly blood pressure summaries were sent to all T subjects and to their primary care providers. Results: All patients had blood pressure above 140 mmHg; 26% had diabetes, 39% - hyperlipidemia, and 19% were smokers. There was no significant difference between T and UC in initial blood pressure, height, weight and waist circumference. After 6-months follow-up, reduction of systolic BP was greater in the T group (-18 ± 18 mmHg) compared to UC (-13 ± 18mmHg) and trended to be significantly different (p=0.067). There were no significant differences between groups when comparing age, sex, BMI, fasting blood glucose, total cholesterol, HDL, and LDL. Conclusions: The results suggest that frequent web or telephone based communications can be effective in improving BP control in patients with Stage I or stage II HTN. This asynchronous, Internet and telephone based communication system can be an important component of a patient centered care program to augment PCP management and strengthen patient to provider relationships in the setting of chronic hypertension.

Differences in right ventricular morphology, not function, indicate the nature of increased afterload in pulmonary hypertensive subjects with normal left ventricular function

The aim of study was to assess whether a specific morphology of the right ventricle (RV) by 2D echo predicts the hemodynamic nature of pulmonary hypertension (PH).

EXPRESS: Case series of seven women with uterine fibroids associated with venous thromboembolism and chronic thromboembolic disease

Uterine fibroids have been described as an associate to acute venous thromboembolism (VTE), with case reports showing an association between large uterine fibroids, acute deep venous thrombosis (DVT), and acute pulmonary embolism (PE). However, there is little known about the association or causation between uterine fibroids, chronic thromboembolic disease (CTED), and chronic thromboembolic pulmonary hypertension (CTEPH). We report on six women with uterine fibroids and CTEPH, as well as one woman with CTED, all of whom presented with exertional dyspnea, lower extremity swelling, and in the cases of CTEPH, clinical, echocardiographic, and hemodynamic evidence of pulmonary hypertension and right heart failure. Compression of the pelvic veins by fibroids was directly observed with invasive venography or contrast-enhanced computed tomography in five cases. All seven women underwent pulmonary thromboendarterectomy (PTE) followed by marked improvement in functional, clinical, and hemodynamic status.

Interventional Therapy of Deep Venous Thrombosis

Venous thromboembolism is the third most prevalent type of cardiovascular disease, behind coronary artery disease and stroke. Patients with deep vein thrombosis may suffer from advanced post-thrombotic syndrome and other life-threatening complications such as pulmonary embolism and phlegmasia cerulea dolens. Intravenous anticoagulation has been the mainstay therapy for deep vein thrombosis, with proven efficacy in reducing the risk of pulmonary embolism and alleviating acute symptoms. However, the efficacy of anticoagulation in treating severe cases and preventing post-thrombotic syndrome is questionable at best. The marked improvement in catheter-based techniques over the last two decades led to a mounting interest and widespread utilization of catheter-based interventions in the treatment of deep venous thrombosis. Early studies suggest that percutaneous thrombus removal modalities can be a successful primary treatment for selected patients with deep venous thrombosis and it may prevent post-thrombotic syndrome.