Lovely Chhabra

Letter by Chhabra and Spodick Regarding Article, “Treatment of Acute and Recurrent Idiopathic Pericarditis”

We read with great interest the publication by Lilly in a recent issue of Circulation .1 Lilly has provided a brief yet comprehensive review of the management of acute and recurrent pericarditis. Lilly has recommended that corticosteroids should never be used as a primary line of therapy in acute or recurrent idiopathic pericarditis, unless the disease symptoms are refractory to nonsteroidal anti-inflammatory drugs or colchicine. It is indeed true for the most practical purposes because the steroids have been shown to increase …

Opana ER abuse and thrombotic thrombocytopenic purpura (TTP)-like illness: a rising risk factor in illicit drug users

We report the case of a 22 year-old-woman who presented with upper extremity cellulitis secondary to an infiltration of illicit intravenous drug use. She confessed to the intravenous use of Opana ER (an extended release oral formulation of oxymorphone) which is an opioid drug approved only for oral use. She was found to have clinical evidence of profound thrombotic microangiopathy which resulted due to the intravenous use of Opana ER. She showed full clinical improvement after withholding drug and supportive clinical care. Recent report of Opana ER intravenous abuse was published from Tennessee county and has now been increasingly recognised as one of the causes of thrombocytopenia which mimicks clinically as thrombotic thrombocytopenic purpura. Physicians should be aware of this association as the lack of familiarity to this can pose serious management dilemmas for our patients (especially the polysubstance abusers).

Corrected QT in Ventricular Paced Rhythms: What Is the Validation for Commonly Practiced Assumptions?

Introduction: Ventricular pacing (VP) may impact the accuracy of QT interval measurement, as it increases the QT by increasing the QRS duration amongst other mechanisms. We aimed to investigate the accuracy of the commonly used clinical practice of subtracting 50 ms from the corrected QT (QTc) in ventricular paced rhythms. Methods: We conducted a prospective observational study on 23 consecutive pacemaker patients. Four ECGs were recorded for each subject, 2 in their native rate and 2 following an atrial paced, atrial sensed and inhibited response to sensing and then a dual pacing, dual sensing and dual response pacing of 100 bpm to allow for an intrinsic and a ventricular paced QRS, respectively. The averaged QTc in the ventricular paced rhythm was then compared with the non-ventricular-paced QTc for individual subjects. Results: At a mean spontaneous heart rate of 66 bpm (SD ±8), the mean difference in QTc between the ventricular paced and nonpaced QRS was 48.27 ms (95% CI = 32-64.6 ms, p < 0.001). At faster paced rates, the mean QTc difference was 81.3 ms (95% CI = 35.8-126.8 ms, p = 0.002). Conclusions: The QTc measurement during VP confirms the current 50-ms subtraction assumption rule within a range of ±16 ms at an average heart rate of 66 bpm. However, at faster heart rates, the 50-ms adjustment may underestimate the QTc discrepancy between a wide and normal QRS.

Persistent J-ST elevation: a sign of persistent perimyocardial irritation

Dear Editor: We greatly enjoyed reading the recently published case by Cudmore et al. 1 The case emphasises the importance of keeping a broad differential and a low threshold for suspecting an ominous diagnosis viz. ‘secondary pericardial metastasis or encroachment’, especially with the history of a known systemic malignancy. Metastatic and infiltrative/invasive involvement of the pericardium may often be the initial …

Takotsubo Cardiomyopathy and Viral Myopericarditis: An Association Which Should be Considered in the Differential Diagnosis.

De Giorgi et al reviewed the association between Takotsubo cardiomyopathy (TC) and various infectious etiologies. However, the authors did not describe any report suggesting an association between viral myopericarditis and TC. There is increasing evidence suggesting an association between viral myopericarditis and TC. Myopericarditis may either precede the stress-induced cardiomyopathy or develop as one of its complications. When myopericarditis is the primary pathology, it has been suggested that an intense perimyocardial inflammation-induced chest discomfort may trigger an exaggerated sympathetic stimulation or somatic stress resulting in a reversible left ventricular dysfunction/TC. Alternatively, in cases where TC is the initial stressor, pericarditis may result from an extension of myocardial inflammation to the overlying epicardium suggesting an inflammatory hypothesis to TC. In these instances, findings on imaging are often disproportionate to credibly explain the regional dysfunction caused by myopericarditis and thus support the coexistence of these 2 conditions. Due to an increased understanding of stress-induced cardiomyopathy, its diagnostic criteria have evolved with time. In fact, previously proposed criteria by various medical societies, which emphasized excluding patients with myocarditis or myopericarditis from the diagnosis of TC now appear to be outdated and modified versions have been recently proposed. Recent studies suggest that these 2 entities can coexist and are not mutually exclusive. Cardiac magnetic resonance imaging may be useful in such clinical scenarios where the delayed gadolinium enhancement—not plausible to explain the segmental wall-motion abnormalities—will be suggestive of myopericarditis and TC association. When exploring the infectious etiopathogenesis for stressinduced cardiomyopathy, viral myopericarditis is a differential diagnosis to consider. This association can have diagnostic and therapeutic implications, especially the cautionary use of anticoagulants and glycoprotein IIb/IIIa inhibitors when TC and myopericarditis association is suspected to prevent lifethreatening complications such as hemorrhagic tamponade.

Allergic acute coronary syndrome (Kounis syndrome).

Anaphylaxis rarely manifests as a vasospastic acute coronary syndrome with or without the presence of underlying coronary artery disease. The variability in the underlying pathogenesis produces a wide clinical spectrum of this syndrome. We present three cases of anaphylactic acute coronary syndrome that display different clinical variants of this phenomenon. The main pathophysiological mechanism of the allergic anginal syndromes is the inflammatory mediators released during a hypersensitivity reaction triggered by food, insect bites, or drugs. It is important to appropriately recognize and treat Kounis syndrome in patients with exposure to a documented allergen.

Pericardial fat and postoperative atrial fibrillation after coronary artery bypass surgery.

[3], as we have a 12-year survival of 75% for left internal mammary artery (LIMA) and saphenous vein grafts and 85% for LIMA with the radial as the second graft, compared with theirs of 31 and 49%, respectively. Obesity differences between the USA and Europe may be an issue [4]. It should not be forgotten that speculation on hormone status and outcomes remains an association and not a mechanism. In addition, we are wondering why no patients after 2001 are included in their study. As pointed out in our work, males and females should be analysed separately to identify the gender differences in outcome, and we wonder if Lin et al. [2] would consider doing the same with their cohort. We have written to Buxton on this issue, but received no response. Buxton, who conducted a randomized trial regarding the radial artery and its effect on survival, failed to identify the radial artery as a beneficial factor affecting long-term survival [5, 6], and needs to be remembered by both of our groups when interpreting retrospective extensively statistically manipulated data.

Electrocardiography in Pericarditis and ST-Elevation Myocardial Infarction: Timing of Observation Is Critical

especially as in-dicated in the number of leads that showed PR deviation inpatients with pericarditis. The mean PR and ST deviationswere noted in only 3 and 6 leads, respectively, in patientswith pericarditis, which may be related to the late mean timeof observation in their study. Of note, PR-segment deviationis the earliest marker of pericarditis and most sensitive in thefirst 12 hours from the pain onset (the mean time of ob-servation in the current study was >36 hours).

Autonomic Dysfunction and Takotsubo Cardiomyopathy.

The article by Pelliccia et al published recently in The American Journal of Medicine is an excellent systematic review on the prevalence of comorbidities associated with Takotsubo cardiomyopathy. Their work is commendable and especially sparked our interest with respect to the prevalence of diabetes mellitus in patients with Takotsubo cardiomyopathy. In a recent excellent review by Madias, which comprised 959 studies, the mean worldwide prevalence of diabetes mellitus among patients with Takotsubo cardiomyopathy was reported to be within the range of 10% to 17%. This prevalence was quite low in comparison with the age-stratified prevalence of diabetes mellitus in the general population based on the National Health and Nutrition Examination Survey (NHANES) data, which is approximately 27%. The prevalence of hypertension was well more than 50% and comparable to that in the NHANES data. Likewise, Deshmukh et al provided the largest epidemiologic cohort from the US nationwide inpatient sample and reported a significantly decreased prevalence of diabetes mellitus in patients with Takotsubo cardiomyopathy. In the current review by Pelliccia et al, the average diabetes prevalence in patients with Takotsubo cardiomyopathy was found to be 17%, which is again significantly lower than in the NHANES data, although other comorbid cardiovascular conditions (eg, smoking, hypertension, and hyperlipidemia) had a relatively higher prevalence in the study. Thus, on the basis of the reported data, it is compelling to consider the hypothesis that diabetes mellitus may exert a protective role against the development of Takotsubo cardiomyopathy likely secondary to an accompanying neuroautonomic dysfunction or brain-heart disconnection. Because catecholamine overload plays an important role in Takotsubo cardiomyopathy, the blunted autonomic response and reduced catecholamine secretion among diabetic persons may thus offer protection against the emergence of Takotsubo cardiomyopathy despite the presence of inciting stressful

Letter by Chhabra and Spodick regarding article, "Influence of steroid therapy on the incidence of pericarditis and atrial fibrillation after percutaneous epicardial mapping and ablation for ventricular tachycardia" by Dyrda et al.

Dydra et al compared the efficacy of 3 different therapeutic approaches (no-steroids, systemic-steroids, and intrapericardial-steroids) on the incidence of postprocedure atrial fibrillation (PPAF) and pericarditis in patients undergoing epicardial ventricular tachycardia ablation.1 They reported significantly decreased incidence of pericarditic chest pain in patients treated with intrapericardial steroids. Though the results are potentially interesting, the retrospective study design significantly limits the evaluation efficacy of these different strategies. The authors defined pericarditis on the basis of only 2 criteria: pleuritic chest pain and pericarditic ECG changes; however, they have not incorporated the other 2 standard diagnostic criteria namely echocardiographic evidence of new pericardial effusion or the presence of a pericardial rub. This raises a …