Rami N. Khouzam

Fracture Risk in Men With Congestive Heart Failure: Risk Reduction With Spironolactone

OBJECTIVES The purpose of this study was to determine whether spironolactone use is associated with fractures in men with congestive heart failure (CHF). BACKGROUND In rats with aldosteronism, spironolactone preserves skeletal strength. However, in humans, the relationship of spironolactone to fractures is not known. METHODS The medical records of all male patients with CHF from 1999 to 2005 treated at the Veterans Affairs Medical Center, Memphis, Tennessee, were reviewed (n = 4,735). Odds ratios with 95% confidence intervals of having a fracture associated with spironolactone use were estimated using conditional logistic regression. RESULTS We identified 167 cases with a single-incident fracture and matched these by age and race to 668 control subjects without fractures. After adjustment for covariates, spironolactone use was inversely associated with total fracture (odds ratio: 0.575; 95% confidence interval: 0.346 to 0.955, p = 0.0324). CONCLUSIONS The use of spironolactone is inversely associated with fractures in men with CHF.

Secondary hyperparathyroidism in patients with untreated and treated congestive heart failure

Background:The congestive heart failure syndrome includes a systemic illness with wasting of soft tissues and bone. We hypothesized secondary hyperparathyroidism (HPT) would be found in hospitalized patients with decompensated congestive heart failure (CHF), where secondary aldosteronism is expected, and who were either untreated or treated medically. Methods:In 9 consecutive patients (7 males, 2 females; 8 African-American, 1 Caucasian; 33–60 yrs) admitted to the Regional Medical Center during a 28-day period with chronic left ventricular systolic dysfunction (EF<35%) and decompensated CHF (5 untreated; 4 treated with an angiotensin converting enzyme inhibitor, furosemide, and small-dose spironolactone), we measured: plasma parathyroid hormone (PTH); serum calcium corrected for albumin, magnesium, and phosphorus; serum creatinine and calculated creatinine clearance. Results:Plasma PTH was elevated above the normal range (6-65 pg/mL) in both untreated and treated patients with CHF (204±60 and 134±14 pg/mL, respectively). Serum corrected calcium was normal (8.4-10.2 mg/dL) in both untreated and treated CHF (9.7±0.l and 9.1±0.2 mg/dL, respectively) as were serum magnesium and phosphorus. Calculated creatinine clearance did not differ between untreated and treated patients (74±15 and 83±21 mL/min, respectively). Conclusions:Secondary HPT was found in 5 untreated and 4 treated patients consecutively hospitalized over a 28-day period with decompensated CHF. Corrected serum calcium was normal. Plasmaionized calcium, a determinant of PTH secretion, was not measured. Although vitamin D levels were not assessed, the presence of hypovitaminosis D in these housebound patients with symptomatic CHF cannot be discounted. HPT may contribute to the systemic illness that accompanies CHF, including bone wasting.

The Important Role of Inflammatory Biomarkers Pre and Post Bare–Metal and Drug–Eluting Stent Implantation

In-stent restenosis and stent thrombosis are major complications after percutaneous coronary intervention and coronary stent placement. The inflammatory status of an individual, as reflected by biomarkers and genetic polymorphisms, is a strong predictor of the risk of in-stent restenosis and stent thrombosis. Identifying biomarkers and studying their values are crucial for a more efficient personalized intervention. General inflammatory biomarkers, evidence of inflammation, and the difference between inflammatory biomarkers after bare-metal stent and drug-eluting stent placement are discussed. Clinical implications and the use of antiplatelet and anti-inflammatory medications, as well as future directions in coronary intervention, in reducing the occurrence of these complications, are also discussed.

It took a Redbull to unmask Brugada syndrome

The SCN5a gene encodes the sodium channels present on the myocardium. A mutation of the SCN5a gene results in a dysfunctional sodium channel that has been linked to the Brugada syndrome. The Brugada syndrome frequently presents in males with a syncopal episode secondary to arrhythmias. Substances such as medications, alcohol, and more recently noted caffeine and taurine can have a deleterious effect on the sodium channels, increasing the risk of arrhythmias. Here we present a patient who was diagnosed with Brugada syndrome after experiencing a syncopal episode due to ventricular arrhythmia following ingestion of Red Bull energy Drink. The Brugada syndrome is a result of a mutation the SCN5a gene that encodes for sodium channels in the myocyte [1–4]. Dysfunction of the sodium channels can result in arrhythmias, which could potentially be fatal. Certain drugs affect the ability of the sodium channels to function appropriately, increasing the risk of arrhythmias within this patient population [5–7]. These drugs include antiarrhythmics, calcium channel blockers, beta blockers, and antipsychotics [2,8–12]. Additionally, it has been suggested that common beverage ingredients such as caffeine, and to a lesser degree taurine, may also negatively affect the function of sodium channels [13–15]. These ingredients are present in energy drinks, which have gained in popularity in recent years. In this report, we present a patient with Brugada syndrome who developed arrhythmias secondary to ingestion of an energy drink combined with alcohol. We present a case of a 24 year old male with no previous medical history who was celebrating a play opening at a local bar. The patient was consuming a Red Bull energy drink containing 80 mg caffeine

Successful aspiration and rheolytic thrombectomy of a renal artery infarct and review of the current literature.

The use of revascularization techniques including angioplasty, thrombectomy, and stenting in the coronary, cerebral, and peripheral arteries has revolutionized the entire field of endovascular therapeutics. In renal thromboembolism, the classic treatment has been anticoagulation with possible thrombolysis and surgical thrombectomy. The role of endovascular therapy in renal thromboembolism remains controversial. There are a few anecdotal reports about the use of aspiration and rheolytic thrombectomy in the renal arteries. We present a case of acute renal infarction resulting from systemic embolism secondary to atrial fibrillation. This was treated with revascularization, including aspiration and rheolytic thrombectomy, with excellent results.

Effect of Timed Semirecumbency and Furosemide Dosing on Urinary Sodium Excretion in Patients with Compensated Heart Failure

Purpose:The management of chronic cardiac failure, a salt-sensitive state, frequently includes administration of a loop diuretic to enhance urinary Na+ excretion. We hypothesized that a period of timed semirecumbency (vis-à-vis upright posture) would enhance the natriuresis that accompanies oral furosemide dosing in patients with compensated cardiac failure. Methods:Four ambulatory patients with compensated chronic cardiac failure (NYHA Class III) of ischemic and nonischemic origin and systolic dysfunction (ejection fraction <35%), who were receiving a stable regimen of oral furosemide and angiotensin-converting enzyme inhibitor, were enrolled into the study. In the institutions Clinical Research Center, we monitored and compared urine flow rate (mL/min) and Na+ excretion rate (mEq/hr) in each patient in response to two different protocols. Protocol 1 consisted of an initial 90-minute period of bedrest followed by the patients oral furosemide dose and 180 minutes of upright activity and a subsequent 90-minute period of bedrest. Protocol 2 was similar, with the exception that furosemide dosing was given after upright activity and immediately prior to the second period of bedrest. Results:With each patient serving as his or her own control, both urine flow rate and urinary Na+ excretion rate were markedly increased when furosemide was given prior to bedrest as compared to its dosing prior to upright activity. Conclusions:In patients with compensated chronic cardiac failure, the natriuresis that accompanies oral furosemide dosing is enhanced when given just prior to a period of timed semirecumbency. This approach represents a more optimal use of this loop diuretic in patients with compensated heart failure.

Dual Antiplatelet Therapy After Coronary Artery Bypass Grafting in the Setting of Acute Coronary Syndrome

After acute coronary syndrome (ACS), dual antiplatelet therapy (DAPT) is the standard of care for both invasive management with percutaneous intervention and noninvasive (medical) management. Conversely, studies using dual antiplatelet in the population of patients presenting with ACS who undergo coronary artery bypass grafting (CABG) are conflicting. The appropriate antiplatelet regimen after CABG remains an area of controversy. Plaque stability, prevention of graft closure, and secondary thrombosis form the basis for using a second antiplatelet drug, whereas the additional risk of bleeding and lack of conclusive evidence should also be considered. After an extensive literature search, 12 clinical trials with efficacy outcomes were identified. Most of the studies are retrospective, nonrandomized single-center trials. A few large patient populations have been examined using database information. To date, there is only 1 prospective, multicenter, randomized trial published. Recommendations from national guidelines differ, proposing single antiplatelet therapy with aspirin or DAPT with the combination of aspirin and clopidogrel. The purpose of this report is to review the available clinical trial data and provide guidance to practitioners when caring for this patient population. In conclusion, there is no clear consensus regarding the use of DAPT in patients after CABG. If not contraindicated, it is reasonable to use DAPT, starting in the postoperative period, in patients presenting with ACS. Large, multicenter, randomized clinical trials are needed to definitively investigate the role of DAPT in patients with ACS after CABG.

Multiple endocrine neoplasia type 2 syndrome presenting with bowel obstruction caused by intestinal neuroma: case report.

We present the case of a 23-year-old male with a history since early childhood of lip and tongue mucosal neuromas. At the age of 19, he was diagnosed with both medullary thyroid carcinoma and pheochromocytoma within 1 year. These findings, with his marfanoid habitus, led to the diagnosis of multiple endocrine neoplasia type 2 (MEN 2B) syndrome. This was confirmed by a positive RET proto-oncogene. On this admission, he presented with an intestinal obstruction. Abdominal exploration revealed an obstructing tumor mass requiring colectomy, which proved by biopsy to be an intestinal neuroma. This report presents a unique case of a colonic mucosal neuroma causing obstruction in MEN 2B syndrome after the diagnosis of medullary thyroid carcinoma.

Meta-Analysis of the Relative Efficacy and Safety of Oral P2Y12 Inhibitors in Patients With Acute Coronary Syndrome

A cornerstone of medical therapy for patients with acute coronary syndrome (ACS) is dual antiplatelet therapy, which includes aspirin and a P2Y12 inhibitor. Randomized controlled trials (RCTs) have shown that prasugrel and ticagrelor are superior to clopidogrel, but none directly compared these 3 commonly used oral P2Y12 inhibitors for safety and efficacy. Therefore, we performed a Bayesian network meta-analysis of RCTs to compare the efficacies and safeties of 3 commonly used oral P2Y12 inhibitors in patients with ACS. Scientific databases and websites were searched for relevant RCTs. We included data from 9 RCTs that enrolled 106,288 patients. Clopidogrel decreased the rates of major adverse cardiac event, recurrent myocardial infarction, and all-cause mortality compared with placebo. Both ticagrelor and prasugrel decreased the rates for major adverse cardiac event and recurrent myocardial infarction compared with clopidogrel, but there was no difference between the 2. Both also decreased the stent thrombosis rate compared with clopidogrel, but prasugrel was more effective than ticagrelor. Ticagrelor use was also associated with improved all-cause and CV mortalities compared with clopidogrel. There was no difference in CV mortality or all-cause mortality between clopidogrel and prasugrel. Prasugrel use was also associated with significantly increased risk of major bleeding compared with clopidogrel but showed a nonsignificant trend toward increasing the risk of bleeding compared with ticagrelor. In treatment ranking, ticagrelor was the most efficacious, and prasugrel was the least safe. In conclusion, this meta-analysis shows that in patients with ACS, adding P2Y12 inhibitors to aspirin and other standard treatments reduces ischemic events and all-cause mortality. Among the commonly used oral P2Y12 inhibitors, ticagrelor has the best net efficacy and safety profile.

Cardiac tuberculoma presenting as thrombotic thrombocytopenic purpura-hemolytic uremic syndrome.

Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) is a unique multisystem syndrome. It can present with either chronic or subacute infections. Tuberculosis (TB) is a chronic infection that has been reported to present with TTP-HUS as tuberculous endocarditis in the presence of immunodeficiency and implanted medical devices in regions where TB is endemic. Tuberculomas are space occupying lesions most commonly found in the brain in immunocompromised individuals. Herein, we present a rare association of tuberculosis with endocarditis manifesting as a tuberculoma and presenting as TTP-HUS in an immunocompetent patient and resident of the United States.