Hani Kozman

Kounis syndrome: A review article on epidemiology, diagnostic findings, management and complications of allergic acute coronary syndrome

Kounis syndrome (KS) is a hypersensitivity coronary disorder induced by exposure to drugs, food, environmental and other triggers. Vasospastic allergic angina, allergic myocardial infarction (MI) and stent thrombosis with occluding thrombus infiltrated by eosinophils and/or mast cells constitute the three main variants of this syndrome. We reviewed 175 patients who fulfilled the definition of one of the three types of KS. The epidemiology, diagnostic findings, management and complications were reviewed in this article.

Cardiac Troponins: Bench to Bedside Interpretation in Cardiac Disease

Abstract:Cardiac troponins are the preferred biomarkers for the determination of acute myocardial necrosis. The high sensitivity of the available assays has significantly increased the detection of microscopic amounts of myocardial damage. Although compelling evidence indicates that elevated cardiac troponins are markers of poor prognosis and increased mortality, irrespective of the clinical scenario, small elevations can be seen in protean conditions and may confound the diagnosis of acute coronary syndromes. Emerging evidence suggests multiple different cellular mechanisms leading to cardiac troponin release, which challenge long held paradigms such as equivalency between troponin release into the circulation and irreversible cell death. Hence, knowledge of the physiology and pathophysiology of these cardiac biomarkers is essential for their accurate interpretation and consequent correct clinical diagnosis. Herein, the current relevant information about cardiac troponins is discussed, with special emphasis on pathophysiology and clinical correlates.

The Cardiorenal Syndrome in Heart Failure: An Evolving Paradigm

Heart failure constitutes a significant source of morbidity and mortality in the United States, and its incidence and prevalence continue to grow, increasing its burden on the healthcare system. Renal dysfunction in patients with heart failure is common and has been associated with adverse clinical outcomes. This interaction, termed the cardiorenal syndrome, is a complex phenomenon characterized by a pathophysiologic disequilibrium between the heart and the kidney, in which malfunction of 1 organ consequently promotes the impairment of the other. Multiple neurohumoral mechanisms are involved in this cardiorenal interaction, including the deficiency of and/or resistance to compensatory natriuretic peptides, leading to sodium retention, volume overload and organ remodeling. Management of patients with the cardiorenal syndrome can be challenging and should be individualized. Emerging therapies must address the function of both organs to secure better clinical outcomes. To this end, a multidisciplinary approach is recommended to achieve optimal results.

The kidney in heart failure: friend or foe?

Abstract:Heart failure constitutes a significant source of morbidity and mortality in the United States and its incidence and prevalence continue to grow, increasing its burden on the health care system. Renal dysfunction in patients with heart failure is common and has been associated with adverse clinical outcomes. This complex interaction is characterized by a pathophysiological disequilibrium between the heart and the kidney, in which cardiac malfunction promotes renal impairment, which in turn feeds back for further deterioration of cardiovascular function. Multiple neurohumoral and hemodynamic mechanisms are involved in this cardiorenal dyshomeostasis, including the deficiency of and/or resistance to compensatory natriuretic peptides, leading to sodium retention, volume overload and organ remodeling. Management of patients with cardiorenal dysfunction can be challenging and should be individualized. Emerging therapies must address the impairment of both organs to secure better clinical outcomes. To this end, a multidisciplinary approach is warranted to achieve optimal results.

Fibromuscular Dysplasia Presented With Spontaneous Dissection of the Left Main Artery

A 31-year-old woman with a history of trisomy 10, subarachnoid hemorrhage, and previous myocardial infarction presented with asystolic cardiac arrest preceded by chest pain and shortness of breath. After return of spontaneous circulation, electrocardiogram showed ST-segment elevation in the

Revascularization in Severe Left Ventricular Dysfunction: Does Myocardial Viability Even Matter?

Left ventricular dysfunction is a powerful prognostic predictor in patients with coronary artery disease and increasing number of patients with CAD and ischemic left ventricular (LV) dysfunction is a major clinical problem. Congestive heart failure is a frequent complication which is associated with significant health care costs and two–third of cases have ischemic cardiomyopathy. In such patients, coronary revascularization can lead to symptomatic and prognostic improvement and reversal of LV remodeling which led to the concept of viable myocardium to select patients in whom recovery of LV function and improvement of prognosis will outweigh the risk of surgical revascularization. The aim of this review article is to understand the different modalities for assessing myocardial viability and clinical impact of revascularization in relation to the evidence of viability in patients with LV dysfunction.

El síndrome cardiorenal en insuficiencia cardíaca: Un paradigma en evolución

Heart failure constitutes a significant source of morbidity and mortality in the United Sta-tes and its incidence and prevalence continue to grow, increasing its burden on the health care system. Renal dysfunction in patients with heart failure is common and has been associatedwith adverse clinical outcomes. This interaction, termed the cardiorenal syndrome, is a complex phe-nomenon characterized by a pathophysiological dise-quilibrium between the heart and the kidney, in which malfunction of one organ subsequently promotes the impairment of the other.Multiple neuro-humoral mechanisms are involved in this cardiorenal interaction, including the deficiency of and/or resistance to compensatory natriuretic pepti-des, leading to sodium retention, volume overload and organ remodeling. Management of patients with the cardiorenal syndrome can be challenging and should be individualized. Emerging therapies must address the function of both organs in order to secure better clinical outcomes. To this end, a multidisciplinary ap-proach is recommended to achieve optimal results.

Reciprocal ST Segment Changes in Myocardial Infarction: Ischemia at Distance vs. Mirror Reflection of ST-elevation

Background: Reciprocal ST‐depression in the electrocardiograms (ECGs) of patients with ST‐elevation myocardial infarction (STEMI) results from either true ischemia at a distance via collateral circulation diverting blood to the infarcted region or an electrical phenomenon that results from a mirror reflection of ST‐elevation. We aimed to identify the role of reciprocal ECG changes in predicting collateral circulation to the infarcted area determined angiographically. Methods: In a retrospective study, ECG and angiography of 53 STEMI patients admitted to SUNY Upstate Medical University in 2014 were reviewed independently by experts blinded to the results of ECG and coronary angiography. Results: Reciprocal changes (RC) in ECG were present in 41 patients (77%) and on angiography, 14 patients (26%) exhibited collateral vessels to the ischemic areas. No correlation was found between the presence of RC and collateral circulation (P = 0.384), or between the depth of reciprocal ST‐depression and the degree of the collateral circulation (P = 0.195). However, 84% of patients without collaterals exhibited resolution of RC after successful percutaneous coronary intervention (PCI) (P = 0.036), suggesting that the ST depressions that resolved after reperfusion were directly caused by the culprit vessel. Patients without RC presented late after symptom onset (9.25 versus 3.83 hours, P = 0.004), also suggesting time related resolution. Conclusions: RC had no relation to or predictive value for collaterals on angiography. Among late presenting patients, RC were less frequent. Thus, reciprocal ST‐depression may represent subendocardial ischemia from the primary coronary event or simply an electrical phenomenon, rather than ischemia at distance from impaired collateral circulation.

DISCORDANCE BETWEEN EXERCISE ECHOCARDIOGRAPHY AND FRACTIONAL FLOW RESERVE IN A PATIENT WITH MULTI VESSEL CORONARY ARTERY DISEASE, A DIAGNOSTIC DILEMMA FOR THE PERCUTANEOUS INTERVENTION: SHOULD WE HAVE FIXED THE RCA?

Exercise echocardiography can reliably localize the territory of the involved coronary artery based on the 17 segment model per American society of echocardiography. Usually coronary angiography coincides with the findings of stress echocardiography. Multi vessel coronary artery disease often poses

Renal Denervation in Heart Failure: A New Therapeutic Paradigm.

Heart failure constitutes a significant source of morbidity and mortality in the United States, and its incidence and prevalence continue to grow, increasing its burden on the health care system. Renal dysfunction in patients with heart failure is common and has been associated with adverse clinical outcomes. This complex interaction is characterized by a pathophysiological disequilibrium between the heart and the kidney, in which cardiac malfunction promotes renal impairment, which in turn feeds back, resulting in further deterioration of cardiovascular function. Multiple neurohumoral and hemodynamic mechanisms are involved in this cardiorenal dyshomeostasis, including resistance to compensatory cardiac natriuretic peptides, leading to sodium retention, volume overload, and organ remodeling. Previous studies in animal models of heart failure have demonstrated that renal denervation promotes a robust natriuresis and diuresis as well as increased response of endogenous and exogenous natriuretic agents. With the recent development of minimally invasive renal denervation in humans, it is possible to suggest that this technique may become effective and important in the management of renal sodium and water metabolism in heart failure.