Kamesh Sivagnanam

Bath salts induced severe reversible cardiomyopathy

Patient: Male, 27 Final Diagnosis: Bath salt induced cardiomyopathy Symptoms: Agitation • fever • pedal edema Medication: Intravenous nor-epinephrine for less than 6 hours Clinical Procedure: — Specialty: Internal medicine • cardiology Objective: Unusual clinical course Background: “Bath salts” is the street name for a group of recently identified and increasingly abused stimulant synthetic cathinones that are associated with multiple systemic effects. We present a case of a patient who developed reversible dilated cardiomyopathy secondary to their use. Case Report: A 27 year old male with no past medical history was brought to emergency department with agitation. He had been inhaling and intravenously injecting “bath salts”, containing a mephedrone/Methylenedioxypyrovalerone (MDPV) combination. On presentation, he was tachycardic, hypotensive and febrile. His initial labs showed an elevated white count, creatinine and creatinine phosphokinase levels. His erythrocyte sedimentation rate; C-reactive protein; urinalysis; urine drug screen; Human Immunodeficiency Virus, hepatitis, coxsackie, and influenza serology were normal. EKG showed sinus tachycardia. An echocardiogram was done which showed dilated cardiomyopathy with an ejection fraction (EF) of 15–20% and global hypokinesia. A left heart catheterization was done and was negative for coronary artery disease. At a 20 week follow up, he had stopped abusing bath salts and was asymptomatic. A repeat echocardiogram showed an EF of 52%. Cocnlusions: Bath salts (MDPV, mephedrone) are synthetic cathinones with amphetamine/cocaine like properties with potential cardiotoxic effects. Cardiovascular manifestations reported include tachycardia, hypertension, myocardial infarction, arrhythmias and cardiac arrest. “Bath salts” can also cause severe reversible dilated cardiomyopathy. Prior to diagnosis, other causes of cardiomyopathy including ischemic, infectious, familial, immunological, metabolic and cytotoxic may need to be ruled out; as was done in our patient.

Divergent relationship of circulating CTRP3 levels between obesity and gender: a cross-sectional study

C1q TNF Related Protein 3 (CTRP3) is a novel adipose tissue derived secreted factor, or adipokine, which has been linked to a number of beneficial biological effects on metabolism, inflammation, and survival signaling in a variety of tissues. However, very little is known about CTRP3 in regards to human health. The purpose of this project was to examine circulating CTRP3 levels in a clinical population, patients with symptoms requiring heart catheterization in order to identify the presence of obstructive coronary artery disease (CAD). It was hypothesized that serum CTRP3 levels would be decreased in the presence of CAD. Methods Body mass index (BMI), diabetes status, and plasma samples were collected from 100 patients who were >30 years of age and presented at the East Tennessee State University Heart Clinic with symptoms requiring heart catheterization in order to identify the presence of cardiovascular blockages (n = 52 male, n = 48 female). Circulating CTRP3 levels were quantified using commercially available ELISA. Results Circulating CTRP3 levels had no relationship to the presence of CAD regardless of gender. However, circulating concentrations of CTRP3 were significantly higher in normal weight (BMI < 30) females (0.88 ± 0.12 µg/ml) compared with males (0.54 ± 0.06 µg/ml). Further, obesity (BMI > 30) resulted in an increase in circulating CTRP3 levels in male subjects (0.74 ± 0.08 µg/ml) but showed a significant decrease in female subjects (0.58 ± 0.07 µg/ml). Additionally, there was a significant reduction in circulating CTRP3 levels in female subjects who were diagnosed with Type 2 diabetes compared with patients without (0.79 ± 0.08 vs. 0.42 ± 0.10 µg/ml). There was no relationship between diabetes status and circulating CTRP3 levels in male subjects. Conclusion Circulating CTRP3 levels had a different relationship with diabetes and obesity status between male and female patients. It is possible that circulating CTRP3 levels are controlled by hormonal status, however more research is needed to explore this relationship. Nevertheless, future studies examining the relationship between CTRP3 levels and disease status should treat gender as an independent variable.

Examining the Impact of Maternal Health, Race, and Socioeconomic Status on Daughter’s Self-Rated Health Over Three Decades

This study examines the role of mother’s health and socioeconomic status on daughter’s self-rated health using data spanning three decades from the National Longitudinal Surveys of Mature Women and Young Women (N = 1,848 matched mother–daughter pairs; 1,201 White and 647 African American). Using nested growth curve models, we investigated whether mother’s self-rated health affected the daughter’s self-rated health and whether socioeconomic status mediated this relationship. Mother’s health significantly influenced daughters’ self-rated health, but the findings were mediated by mother’s socioeconomic status. African American daughters reported lower self-rated health and experienced more decline over time compared with White daughters, accounting for mother’s and daughter’s covariates. Our findings reveal maternal health and resources as a significant predictor of daughters’ self-rated health and confirm the role of socioeconomic status and racial disparities over time.

Anomalous Origin of the Left Coronary Artery From the Pulmonary Artery: An Uncommon Coronary Anomaly With Serious Implications in Adulthood.

A 36-year-old woman was seen with complaints of exertional chest pain and shortness of breath. Her medical history included atrial fibrillation and diabetes. Physical examination was unremarkable except for an irregular cardiac rhythm. Myocardial perfusion imaging revealed the presence of a large area of infarction involving the entire anterior and apical walls and part of the anteroseptal wall with minimal periinfarct ischemia. Computed tomography coronary angiogram revealed an anomalous left main coronary artery arising from the main pulmonary artery. Right and left heart catheterizations demonstrated moderate pulmonary hypertension with a slight step-up in oxygen saturation between the right ventricle and main pulmonary artery. Coronary angiography showed a large tortuous right coronary artery with collaterals to the left anterior descending artery that drained into the main pulmonary artery. She was referred for surgery. This case demonstrates a rare coronary artery anomaly in an adult where survival is dependent on collateral circulation.

Cardiomyopathy Associated With Targeted Therapy for Breast Cancer

Background: Chemotherapeutic agents directed against human epidermal growth factor receptor 2 (HER‐2) have significantly improved the prognosis of patients who are positive for this receptor. However, cardiomyopathy remains as a common adverse effect of using these agents. Materials and Methods: Literature search was conducted via PubMed using the keywords of “Trastuzumab Cardiomyopathy,” “Lapatinib Cardiomyopathy” and “Pertuzumab Cardiomyopathy,” which provided 104 results. These articles were then screened for relevance to the targeted subject based on their title and abstracts. Case reports and articles that were not discussing any aspect of cardiomyopathy secondary to targeted therapy for breast cancer and articles not in English were eliminated. After elimination, a bibliography search among selected articles was done and a total of 46 articles were identified. The collected articles were then meticulously analyzed and summarized. Results: The use of human epidermal growth factor receptor 2 (HER‐2) receptor targeted chemotherapy in breast cancer is limited because of a higher incidence (19–22%) of cardiomyopathy. The incidence of cardiomyopathy is not dose dependent and in most cases it is reversible after discontinuation of the drug and treatment with heart failure medications. Severe adverse outcomes including death or permanent disability are rare. Conclusion: HER‐2 targeted chemotherapy for breast cancer has a higher incidence of associated reversible cardiomyopathy. Patients should be monitored by serial echocardiography starting at the beginning of the treatment and followed by every 3 months until the completion of chemotherapy. Co‐ordination between oncologists and cardiologists is needed to develop evidence‐based protocols to prevent, identify, monitor and treat trastuzumab‐induced cardiomyopathy.

Bridge to Transplantation: Advanced Heart Failure and Transplant Cardiology Training for Cardiovascular Disease Fellows

![Figure][1] Approximately 6.5 million Americans experience heart failure (HF), which contributes to 1 in 8 deaths each year [(1)][2]. Current therapies improve survival for HF with reduced ejection fraction, but a result has been to increase the number of HF patients who progress to

Supersized Atheroma Causing Acquired Coarctation of Aorta Leading to Heart Failure

Calcified atheromatous aortic lesion causing significant narrowing of the aorta is an uncommon clinical entity. This calcified atheroma leads to obstruction of the lumen of the aorta simulating acquired coarctation of aorta causing impaired perfusion of lower limbs, visceral ischemia, and hypertension. We report a case of 58-year-old patient who presented with dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, 25-lb weight gain, lower extremity edema, and chest pain. Extensive workup including computed tomography and magnetic resonance imaging revealed a large calcific mass in the aortic arch causing his presenting symptoms. After surgical correction his symptoms resolved. Any patient presenting with heart failure symptoms in the setting of uncontrolled renovascular hypertension, intermittent claudication symptoms, or visceral ischemia with normal ejection fraction but moderate to severe left ventricular hypertrophy should be in high suspicion for acquired coarctation of aorta. The routine thorough examination of pulses in bilateral upper and lower extremities in all hypertensive patients is a very simple and useful clinical tool to diagnose acquired aortic coarctation.