Yashwant Agrawal

Demographic parameters related to 30-day readmission of patients with acute myocardial infarction: Analysis of 2,371,867 hospitalizations☆

BACKGROUND Acute myocardial infarction (AMI) is the most common cause of mortality in the USA as per the data released by the CDC. Short term hospital readmissions account for a significant portion of health care budget and much of the focus recently has been on reducing 30day readmission rate aimed to identify the demographics associated with readmissions from AMI and major causes of readmissions. METHODS We queried the Nationwide Inpatient Sample which represents 20% of all the United States hospital data for our study. AMI was identified through ICD9 Clinical Classification Software Code 100 for readmissions secondary to AMI for years 2009-2013. Chi-square was used for statistical analysis. RESULTS A total of 2,371,867 admissions were identified with AMI and 15.87% of these readmitted within 30days after index hospitalizations due to any cause. Patients with age greater than 65years, female gender, Medicare and Medicaid insurances, low median income for zip code and metropolitan areas were associated with high 30day readmission rate. The most common identified cause of readmission from 2009-2011 was coronary atherosclerosis (15%) and from 2012-2013 the cause identified was congestive heart failure (13.5%) (p<0.001). CONCLUSION Aggressive medical management needs to be targeted at this demography of patients and prevent the most causes of readmissions to reduce the cost and morbidity of patients admitted with AMI.

All that looks like “Brugada” is not “Brugada”: Case series of Brugada phenocopy caused by hyponatremia

Brugada syndrome (BS), a life-threatening channelopathy associated with reduced inward sodium current due to dysfunctional sodium channels, is characterized by ST-segment elevation with downsloping “coved type” (type 1) or “saddle back” (type 2) pattern in V1–V3 precordial chest leads (1, 2). Brugada phenocopy, a term describing conditions inducing Brugada-like pattern of electrocardiogram (EKG) manifestations in patients without true BS, is an emerging condition (3). We describe a case series of Brugada phenocopy with hyponatremia.

A rare cause of recurrent aortic dissection

We report the case of a 19-year-old man with a history of Loeys–Dietz syndrome (LDS), which was diagnosed when he had a Stanford type A aortic dissection. He also had multiple aneurysms including ones in the innominate, right common carotid, and right internal mammary arteries. He had had multiple procedures including Bentall’s procedure, repeat sternotomy with complete arch and valve replacement, and coil embolization of internal mammary artery aneurysm in the past. His LDS was characterized by gene mutation for transforming growth factor-β receptor 1. He presented to our facility with sudden onset of back pain, radiating to the right shoulder and chest. He was diagnosed with Stanford type B aortic dissection and underwent thoracic aorta endovascular repair for his aortic dissection. This case represents the broad spectrum of pathology associated with LDS where even with regular surveillance and aggressive medical management the patient developed Stanford B aortic dissection.

An alien in the heart

We report a case of a 38-year-old-man who presented with altered mental status. The patient was diagnosed with infective endocarditis (IE) originating from the GORE HELEX septal occluder device, which was placed 15 months earlier for symptomatic atrial septal defect. Brain imaging revealed shower emboli phenomena from the known IE. The patient developed hydrocephalus for which external ventriculostomy was performed. Improved neurological status warranted open heart surgery. The patient was later confirmed to be an intravenous drugs abuser, prejudicing IE. This case highlights the importance of meticulously monitoring patients with suspected high-risk behavior with an implanted intracardiac prosthetic device.

Demographic parameters related to 30-day readmission of patients with pulmonary embolism: Analysis of 650,819 hospitalizations

BACKGROUND Pulmonary embolism (PE) is a serious medical condition associated with major morbidity, mortality and economic burden. Preventable hospital readmissions are a major economic challenge for the healthcare organizations and identifying patient subsets at risk of readmission will help report the issue. This retrospective study was performed to determine demographic parameters and major diagnosis linked with 30day readmission after a PE. METHODS Nationwide Inpatient Sample (NIS) data was used to extract data of patients discharged after PE during index admission for years 2009-2013. Patients were identified by Diagnosis Related Group (DRG) number 175 and 176 which represents PE with major complications and comorbidities (MCC) and PE without MCC. Demographic parameters associated with high readmission rate were identified along with causes related to readmissions. RESULTS We identified a total of 650,819 hospitalizations with PE as the index stay DRG of which 13.44% were readmitted within 30 days after hospitalizations. Patients with age >65years (14.05%), female (13.87%), Medicaid insurances (20.49%), low median income for zip code (15.1%) and metropolitan areas (13.71%) were associated with higher 30day readmission rates. The most common identified cause of readmission in PE with MCC from 2009 to 2010 was heart failure (4.25%) and from 2011 to 2013 was severe sepsis (4.8%) while for PE without MCC from 2009 to 2013 was PE without MCC itself (10.24%). CONCLUSIONS Interventions need to be directed against these set of patients and the identified causes of readmissions to reduce the rehospitalisations from PE.

Large saphenous venous graft aneurysm with right atrial fistulous communication: Case report and review of literature

We report a case of a 56-year-old Caucasian man who presented with acute onset of substernal chest pain at rest with electrocardiogram showing diffuse ST segment depression. He had coronary artery bypass graft surgery 16 years ago with a left internal mammary artery graft to the left anterior descending artery and saphenous vein grafts to the right coronary artery (RCA) and left circumflex artery. He underwent coronary angiography, which showed two large aneurysms in the saphenous venous graft (SVG) to the RCA and a venous leak from the aneurysm. The venous leak was later confirmed with computer tomographic scan to be a fistulous communication between the SVG and the right atrium. We discuss in detail about the treatment options of SVG aneurysm.

Right Lung Agenesis with Tracheal Stenosis due to Complete Tracheal Rings and Postpneumonectomy Like Syndrome Treated with Tissue Expander Placement

Congenital lung agenesis is an extremely rare condition with an estimated prevalence of 34 in 1,000,000 live births. It is often associated with other congenital malformations of the skeletal, cardiovascular, urogenital, and gastrointestinal systems. We discuss the case of a 5-month-old who presented with increasing stridor over 1 month. Imaging revealed right lung agenesis, complete dextromalposition of heart, and compression of distal trachea. An intrathoracic saline tissue expander was placed which marked improved distal tracheal stenosis. In patients who are symptomatic it becomes imperative to perform surgeries to increase survival as was the case in this patient.

Antipsychotic Therapy-Induced New Onset Diabetic Ketoacidosis.

Atypical antipsychotics are very widely used for various psychiatric ailments because of their less extrapyramidal side effects. Various reports of disturbances in glucose metabolism in the form of new onset diabetes mellitus, exacerbation of preexisting diabetes mellitus, diabetic ketoacidosis, hyperosmolar nonketotic coma, acute pancreatitis, and increased adiposity have been reported. We present a case of new onset diabetic ketoacidosis in a patient without a history of glucose intolerance who was being treated with olanzapine for bipolar disorder. He presented in hyperglycemic, hyperosmolar, hyperketotic state with hyperkalemia, and peaked T waves on electrocardiogram. He was treated with vigorous intravenous hydration, insulin, and kaexylate which stabilized his metabolic profile. He was discontinued off of his olanzapine and started on resperidol for his bipolar disorder. Over the course of 6 months, the patient was discontinued off of his insulin and has been doing well on his follow-up appointments. This case highlights the necessity of close blood glucose monitoring of patient on atypical antipsychotic medications irrespective of their diabetic status.

TCT-554 Comparison of Transcatheter and Surgical Repair of Atrial Septal Defect: Analysis from Nationwide Inpatient Sample

Atrial septal defect (ASD) belongs to one of the most common congenital cardiac lesion. ASD repair is definitive treatment preventing major complications of persistent ASD. Alongside standard open surgical ASD repair (OSR), transcatheter/closed procedure (TCP) is an attractive modality applied in

Can aldosterone break your heart? Takotsubo cardiomyopathy in a patient with newly diagnosed primary aldosteronism

We report a case of a 47-year-old Caucasian woman with medical history of hypertension and hypokalemia, who presented to Emergency Room with symptoms resembling acute coronary syndrome ST-segment elevation myocardial infarction. Coronary angiogram revealed clear coronary arteries and left ventriculogram confirmed the diagnosis of Takotsubo cardiomyopathy. She was treated conservatively with good clinical outcome. Subsequent testing revealed underlying primary aldosteronism.