Maya Serhal

Pulmonary embolism response teams

Pulmonary embolism (PE) is a common thrombotic event that is variable in its presentation. Depending on the patients’ risk for mortality, guidelines provide several treatment strategies including thrombolysis, catheter-directed therapies, pulmonary embolectomy, anticoagulation, and inferior vena cava filters. However, there is considerable disagreement between guidelines regarding the optimal treatment strategy for patients, particularly for those with intermediate-risk PE. In order to provide rapid and individualized care, PE response teams (PERT) have been developed. These teams consist of members from different specialties with a particular interest in PE, varying technical skills, and clinical experience, thereby allowing for a multidisciplinary approach. PERT allows for consensus decision making, and for rapid intervention in patients whose conditions worsen. In this review, we provide an overview of treatment guidelines for PE, and of results from recent clinical trials involving patients with submassive PE. In addition, we discuss an outline of our approach and use of PERT.

The Diagnosis and Treatment of Fibromuscular Dysplasia: An Update for Cardiologists

Opinion statementFibromuscular dysplasia (FMD) is an arteriopathy of unknown etiology which has traditionally been associated with secondary hypertension; however, it has garnered increased attention in the cardiology field in the recent years because of its potential association with spontaneous coronary artery dissection. Cardiologists should be aware that FMD is a polyvascular disease which can affect any arterial bed and can result in morbid conditions such as chronic headaches, pulsatile tinnitus, stroke from cervical artery dissection, and renal infarction from renal artery dissection and has also been associated with increased prevalence of arterial aneurysm, including brain aneurysm. For these reasons, some experts recommend panvascular imaging from head-to-pelvis upon diagnosis for screening purposes and targeted imaging surveillance after diagnosis. When necessary, endovascular intervention with angioplasty alone is the preferred modality, though there are still situations which require surgical intervention. Patients with FMD may benefit from a multispecialty team approach for optimal treatment.

Presentation, clinical features, and results of intervention in upper extremity fibromuscular dysplasia

Background: We present a case series of upper extremity fibromuscular dysplasia (UE FMD) consisting of 22 patients from two tertiary referral centers focusing on clinical presentation, diagnostic findings, and interventional outcomes. FMD is a noninflammatory, nonatherosclerotic arteriopathy that has a predisposition for middle‐aged women. Involvement of the UE is thought to be rare. Patients with UE FMD can present with claudication or ischemia, or they can be incidentally diagnosed. The treatment approach is dictated by clinical presentation. Methods: Data were collected of patients with UE FMD evaluated at two centers. Demographic data, presenting UE symptoms, UE arteries involved, FMD type, diagnostic method, physical examination findings, management, and outcomes were included. Results: Twenty‐two patients (29 limbs) were diagnosed with UE FMD. The brachial artery was most commonly involved (89.7% of affected limbs). More than half of limbs (n = 15 of 29 limbs [51.7%]) were asymptomatic, and of those who presented with symptoms, the most common symptoms were ischemic fingers or hand (31% of all affected limbs) and hand or arm claudication (27.6% of all affected limbs). UE FMD was noted on catheter angiography in 58.6% (n = 17 of 29 limbs), duplex ultrasound in 41.4% (n = 12 of 29 limbs), and computed tomography angiography in 27.6% (n = 8 of 29 limbs). Of the symptomatic limbs (n = 14), the majority were treated solely with medical therapy as the first intervention (57.1%). For symptomatic limbs treated with vascular intervention (n = 5), angioplasty was most commonly performed. Only 4 of the 14 limbs (28.6%) had complete symptomatic relief after the initial first intervention, in which 2 limbs were treated with medical therapy, 1 limb underwent angioplasty, and 1 limb had resolution of symptoms despite deferment of any therapy. Of the 10 limbs with residual symptoms after the first intervention, 6 limbs underwent a second intervention: angioplasty in 2 limbs initially treated medically (33.3%), surgical bypass in 2 limbs initially treated with angioplasty, surgical bypass in 1 limb initially treated with medical therapy, and sympathectomy in 1 limb (16.7%) initially treated with angioplasty. Both surgical bypass and angioplasty as secondary interventions resulted in complete symptom relief. Conclusions: Presenting symptoms for patients with UE FMD vary in severity from asymptomatic disease to digital ischemia. More than half of symptomatic limbs eventually require at least one invasive intervention for complete relief of symptoms.

Transitioning Between Anticoagulants

There has been rapid growth in the development of anticoagulant drugs. Unfortunately, an “ideal” anticoagulant—one that is rapid-acting and fully reversible, does not require monitoring, and can be used in patients with end-stage renal disease and moderate-severe liver dysfunction—is not available to date. Currently, the differences in the pharmacokinetic and pharmacodynamic properties of each agent allow for a unique, individualized anticoagulation plan for different patients with different underlying indications for anticoagulation therapy. Because of the multiple options for both parenteral and oral anticoagulation available, transitioning between anticoagulants is becoming increasingly common both in the inpatient and outpatient settings. Given the absence of prospective randomized data comparing different strategies for transition between anticoagulants, suggested strategies are largely extrapolated from pharmacokinetic data, as well as from expert opinions. Despite limited data, better understanding on how to safely implement a transition from one anticoagulant drug to another is of utmost importance to minimize the risk of recurrent thromboembolic events and hemorrhagic complications during such periods of transition between different drugs.

A 75-year-old with abdominal pain, hypoxia, and weak pulses in the left leg

Workup revealed the patient had both arterial and venous thrombosis. What was the cause?

FAMILY HISTORY OF ARTERIAL DISORDERS IN PATIENTS WITH SPONTANEOUS CORONARY ARTERY DISSECTION

Background: Spontaneous coronary dissection (SCAD) is an important cause of ACS in young women and is associated with fibromuscular dysplasia (FMD) in 45-72% of cases. ∼1/4 of FMD patients have a family history (FHx) of aneurysm, but FHx of arterial disorders among SCAD patients is not well

An Uncommon Cause of Tinnitus

From 1Vascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; and 2Non-Invasive Vascular Laboratory, Heart and Vascular Institute, Cleveland Clinic, Ohio. Address correspondence to: Maya Serhal, MD, Vascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44106. E-mail: SERHALM@ccf.org A 56-year-old woman presented for the eval uation of a constant sound in her right ear that resolved when she applied pressure under her right ear and when she turned her head to the right. An ear, nose, and throat specialist and neurologist, with no clear etiology of this sound, had evaluated patient. A magnetic resonance imaging of the brain and magnetic resonance angiography of the neck showed Doppler Digest

AN UNUSUAL CAUSE OF IATROGENIC HYPERTENSION

26 year old female was referred for management of resistant hypertension, after admission for hypertensive emergency. Her past medical history was notable for attention deficit hyperactivity disorder and motor vehicle accident 6 years ago, complicated by subdural hematoma and provoked deep venous