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PURPOSE: With the increasing popularity of glucagon-like peptide 1 receptor agonists (GLP1-RAs), numerous safety concerns arose pertaining to suicide, hair loss, and aspiration risks. We attempted to validate these concerns. METHODS: We queried four pharmacovigilance databases to compare GLP1-RAs to sodium-glucose transporter 2 inhibitors (SGLT2is) with respect to these adverse events (AE): the FDA Adverse Event Reporting System (FAERS), the Australian Database of Adverse Event Notifications (DAEN), the European Medicines Agency's (EudraVigilance), and the World Health Organization-Vigibase. OpenVigil 2.1 was utilized to perform a disproportionality analysis for GLP1-RAs, SGLT2is, dipeptidyl peptidase 4 inhibitors (DPP4is), sulfonylureas, metformin, and insulin. The following indices were extracted from the FAERS database from Q4/2003 until Q3/2023: relative reporting ratio (RRR), proportional reporting ratio (PRR), reporting odds ratio (ROR), and chi-squared (χ2). A positive signal was detected if PRR > 2 and χ2 > 4 for any drug-event pair. RESULTS: No positive signals were observed between GLP1-RAs and either suicide, hair loss, or aspiration risks. Semaglutide [ROR = 0.60 (0.51-0.71)] and liraglutide [ROR = 0.28 (0.23-0.35)] had higher suicidal events than DPP4is and SGLT2is. GLP1-RAs were the most reported class with hair loss [ROR = 0.61 (0.60-0.64)], and semaglutide, liraglutide, and dulaglutide were the three leading medications. GLP1-RAs ranked lower with aspiration events, which were led by sitagliptin and DPP4is as a group. CONCLUSION: GLP1-RAs exhibit higher reporting of suicide, hair loss, and aspiration events when compared to several other antidiabetic medications despite not meeting the criteria for positive signals yet. This warrants intensive monitoring and reporting.

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BACKGROUND: Mavacamten is a first-in-class cardiac myosin inhibitor approved by the US Food and Drug Administration (FDA) for symptomatic obstructive hypertrophic cardiomyopathy (HCM). This pharmacovigilance study aimed to assess mavacamten-related adverse drug reactions (ADRs) in the real world as reported in the FDA Adverse Event Reporting System (FAERS). METHODS: We conducted disproportionality analyses with four signal detection algorithms-reporting odds ratio (ROR), proportional reporting ratio (PRR), Bayesian confidence propagation neural network, and the multi-item gamma Poisson shrinker to identify mavacamten-related ADRs. RESULTS: Out of 4,500,131 reports from the FAERS database, 1004 mavacamten-related ADRs were identified from 1 January 2022 to 30 September 2023. A total of 26 significant disproportionality preferred terms (PTs) conforming to the four signal detection algorithms were noted. Some of the statistically significant cardiac ADRs at PT level include decreased ejection fraction (EF) [ROR 33.60 (95% confidence interval, CI 21.79-51.82), PRR 32.86 (χ2 615.96), information component (IC) 5.03, IC025 4.61, empirical Bayesian geometric mean (EBGM) 32.77, EBGM05 21.25], cardiac failure [ROR 9.39 (95% CI 6.49-13.60), PRR 9.13 (χ2 202.42), IC 3.19, IC025 2.83, EBGM 9.12, EBGM05 6.30], and atrial fibrillation [ROR 16.63 (95% CI 12.72-21.75), PRR 15.66 (χ2 769.93), IC 3.97, IC025 3.71, EBGM 15.64, EBGM05 11.96]. CONCLUSIONS: The results of our study were consistent with the safety data of clinical trials, including reduced ejection fraction, atrial fibrillation, dyspnea, and syncope. We also found potential new and unexpected ADR signals, such as urinary tract infection, gout, and peripheral edema.

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Hemodynamically significant mitral regurgitation (MR) is associated with major morbidity and mortality. Transcatheter edge-to-edge repair (TEER) is an interventional procedure for MR, which has gained popularity in recent years as an alternative solution to surgical valve repair in high-risk surgical candidates. However, there are no definite guidelines following TEER failures to determine if patients would benefit from a redo TEER or surgical mitral valve (MV) repair. Here, we present one such clinical dilemma. In patients who have failed the TEER of the MV, surgical risk must be determined in conjunction with a multidisciplinary team, as surgical MV replacement may be performed at advanced centers in high-risk patients with good results.

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Pacemakers are effective treatments for a variety of bradyarrhythmias. Cardiac pacemakers generally consist of a pulse generator and one or more leads. The conventional temporary transvenous ventricular cardiac pacemaker utilizing a passive fixation lead is commonly associated with multiple complications such as increased infection rate, lead dislodgement, venous thrombosis, longer duration of hospital stay, and atrioventricular (AV) dyssynchrony. On the other hand, temporary permanent pacemakers (TPPM) utilize active fixation leads; hence, they provide lower capture thresholds, reliable pacing, lower rates of displacement, and fewer pacemaker-related infections. Here, we present a case of TPPM aiding AV synchrony restoration in complete heart block accompanying right ventricular (RV) infarction with refractory cardiogenic shock. Pacemakers are effective treatments for a variety of bradyarrhythmias. Cardiac pacemakers generally consist of a pulse generator and one or more leads. We present a case of TPPM aiding AV synchrony restoration in complete heart block accompanying RV infarction with refractory cardiogenic shock. TPPM pacing is a safe and effective technique for temporary bridge pacing to prevent AV dyssynchrony in hemodynamically unstable patients with cardiogenic shock from RV infarction and complete heart block. It also hastens recovery compared to a traditional single-chamber temporary pacemaker.

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This umbrella review synthesizes data from 17 meta-analyses investigating the comparative outcomes of catheter ablation (CA) and medical treatment (MT) for atrial fibrillation (AF). Outcomes assessed were mortality, risk of hospitalization, AF recurrence, cardiovascular events, pulmonary vein stenosis, major bleeding, and changes in left ventricular ejection fraction (LVEF) and MLHFQ score. The findings indicate that CA significantly reduces overall mortality and cardiovascular hospitalization with high strength of evidence. The risk of AF recurrence was notably lower with CA, with moderate strength of evidence. Two associations reported an increased risk of pulmonary vein stenosis and major bleeding with CA, supported by high strength of evidence. Improved LVEF and a positive change in MLHFQ were also associated with CA. Among patients with AF and heart failure, CA appears superior to MT for reducing mortality, improving LVEF, and reducing cardiovascular rehospitalizations. In nonspecific populations, CA reduced mortality and improved LVEF but had higher complication rates. Our findings suggest that CA might offer significant benefits in managing AF, particularly in patients with heart failure. However, the risk of complications, including pulmonary vein stenosis and major bleeding, is notable. Further research in understudied populations may help refine these conclusions.

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Chest pain is the second leading cause of all emergency department (ED) visits in adults in the United States, with nearly 11 million encounters yearly. While identifying low-risk patients is crucial for early discharge, identifying high-risk patients in ED is vital in timely and appropriate acute coronary syndrome (ACS) management. Traditional methods such as physical examination, cardiac markers, or imaging tests cannot reliably confirm or rule out ACS; they cannot be singularly incorporated to risk stratify patients. Various clinical risk scores have been proposed to address this challenge for risk stratification in patients being evaluated for suspected ACS. The ideal risk score should demonstrate high sensitivity and specificity to accurately differentiate between patients with varying levels of risk, particularly in identifying those at high risk for major adverse cardiovascular events. Simultaneously, an ideal scoring system should also be able to compute information for other non-coronary etiologies of chest pain that require time-sensitive interventions and workups (eg, aortic dissection and pulmonary embolism). In this review, we have assembled major risk scores used for risk stratification in patients with acute chest pain in ED. We have abbreviated their salient features to assist readers in their clinical decision-making.

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Anti-hypertensive education is an important public health intervention to decrease the mortality and burden of the disease. Using digital technologies for education as a part of preventive measures for hypertension is a cost-effective approach and helps low-income communities and vulnerable populations overcome barriers to healthcare access. The coronavirus disease 19 pandemic further highlighted the need of new health interventions to address health inequalities. Virtual education is helpful to improve awareness, knowledge, and attitude toward hypertension. However, given the complexity of behavioral change, educational approaches do not always provide a change in behavior. Some of the obstacles in online hypertensive education could be time limitations, not being tailored to individual needs and not including the different elements of behavioral models to enhance behavior change. Studies regarding virtual education should be encouraged and involve lifestyle modifications emphasizing the importance of Dietary Approaches to Stop Hypertension diet, salt restriction, and exercise and should be used adjunct to in-person visits for the management of hypertension. Additionally, to stratify patients according to hypertension type (essential or secondary) would be useful to create specific educational materials. Virtual hypertension education is promising to increase awareness regarding risk factors and most importantly motivate patients to be more compliant with management helping to decrease hypertension related complications and hospitalizations.

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Psychosocial risk factors (PSRFs) are known to be associated with worse cardiovascular (CV) outcomes. However, there are limited data on the impact of PSRFs on readmissions after acute myocardial infarction (AMI) before and during the COVID-19 (Coronavirus Disease 2019) pandemic. Therefore, we aimed to examine this association and whether the effects of PSRFs were amplified during the COVID-19 pandemic. We queried the 2019 and 2020 Nationwide Readmissions Database for adult (age ≥18 years) index admissions with AMI as the primary diagnosis. They were then divided into 2 cohorts based on the presence or absence of ≥1 PSRF and compared across non-COVID-19 (2019) and COVID-19 (2020) time periods. The primary outcome was 30-day all-cause readmissions. Secondary outcomes included cause-specific readmissions (cardiac, noncardiac, AMI, heart failure). Multivariable hierarchical logistic regression was conducted to evaluate differences in outcomes. The study included 380,820 patients with index AMI, of which 214,384 (56%) had ≥1 PSRFs. Patients with PSRFs were younger, more likely to be female, and had a higher prevalence of CV risk factors. Of 30-day all-cause readmissions were higher in patients with PSRFs in both eras. Moreover, noncardiac and heart failure readmissions were also higher in patients with PSRFs admitted with AMI in 2019 and 2020. This study of a nationally representative population magnifies the association of PSRF with more unplanned readmissions after AMI in both pre-COVID-19 and COVID-19 times.

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BACKGROUND: Coronary artery anomalies are characterized by an abnormality in the course or origin of three main coronary arteries. There needs to be more scientific evidence to promptly treat coronary artery anomalies with poorly understood prognostic implications, especially anomalous aortic origin of the right coronary artery from the left coronary cusp. CASE PRESENTATION: A 58-year-old Caucasian female presented multiple times over 6 months with atypical chest discomfort and palpitations. The treadmill exercise test demonstrated exercise-induced non-sustained ventricular tachycardia. A coronary angiogram revealed no obstructive coronary artery disease and an anomalous aortic origin of the right coronary artery from the left coronary cusp with an interarterial course. She was managed conservatively with medications, despite persistent recurrent symptoms. CONCLUSION: It is essential to identify subtle symptoms and insidious onset of anomalous aortic origin of the right coronary artery symptoms as seen in our patient, which can contribute to significant morbidity. There are discrepancies in existing guidelines between different cardiovascular societies in managing selected subgroups of patients with anomalous aortic origin of the right coronary artery who do not have high-risk features, but continue to remain symptomatic.

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The emergency room is a very potent environment in the hospital. With the growing demands of the population, improved accessibility to health resources, and the onslaught of the triple pandemic, it is extremely crucial to triage patients at presentation. In the spectrum of complaints, chest pain is the commonest. Despite it being a daily ailment, chest pain brings concern to every physician at first. Chest pain could span from acute coronary syndrome, pulmonary embolism, and aortic dissection (all potentially fatal) to reflux, zoster, or musculoskeletal causes that do not need rapid interventions. We often employ scoring systems such as GRACE/PURSUIT/TIMI to assist in clinical decision-making. Over the years, the HEART score became a popular and effective tool for predicting the risk of 30-d major adverse cardiovascular events. Recently, a new scoring system called SVEAT was developed and compared to the HEART score. We have attempted to summarize how these scoring systems differ and their generalizability. With an increasing number of scoring systems being introduced, one must also prevent anchorage bias; i.e., tools such as these are only diagnosis-specific and not organ-specific, and other emergent differential diagnoses must also be kept in mind before discharging the patient home without additional workup.

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There have been rare reports of dilated cardiomyopathy from chronic use of phentermine/topiramate, although very limited data are available. Phentermine is an atypical amphetamine analog that has been contraindicated in patients with a history of cardiovascular disease. We present a case of nonischemic dilated cardiomyopathy in the setting of chronic phentermine/topiramate use, which is the most likely cause of her dilated cardiomyopathy.

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Psychosocial risk factors (PSRFs) have emerged as crucial nontraditional risk factors affecting outcomes in patients with heart failure (HF). There is a paucity of data studying these risk factors in HF nationally. Additionally, whether the COVID-19 pandemic impacted outcomes remains unexplored, given the increased psychosocial risk during these times. Our objective is to assess the impact of PSRFs on the outcomes of HF and their comparison across non-COVID-19 and COVID-19 eras. Patients with a diagnosis of HF were selected using the 2019-2020 Nationwide Readmissions Database. Two cohorts were created based on the presence or absence of PSRFs and compared across non-COVID-19 and COVID-19 eras. We examined the association using hierarchical multivariable logistic regression models. A total of 305,955 patients were included, of which 175,348 (57%) had PSRFs. Patients with PSRFs were younger, less likely to be female, and had a higher prevalence of cardiovascular risk factors. All-cause readmissions were higher in patients with PSRFs in both the eras. All-cause mortality [odds ratio, OR 1.15 (1.04-1.27), P = 0.005] and composite of MACE [OR 1.11 (1.06-1.16), P < 0.001] were higher in patients in the non-COVID-19 era. Compared to 2019, patients with PSRFs and HF in 2020 had significantly higher all-cause mortality [OR 1.13 (1.03-1.24), P = 0.009]; however, the composite of MACE was comparable [OR 1.04 (1.00-1.09), P = 0.03]. In conclusion, the presence of PSRFs in patients with HF is associated with a significant increase in all-cause readmissions in COVID-19 and non-COVID-19 eras. The worse outcomes evident in the COVID-19 era highlights the importance of multidisciplinary care in this vulnerable population.

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Apical hypertrophic cardiomyopathy (ApHCM) is thought to be an uncommon variant of hypertrophic cardiomyopathy (HCM). This article is a literature review focusing on the characteristic electrocardiogram (EKG) and 2D echocardiogram findings as currently there are no specific ACC/AHA/ESC guidelines set as diagnostic criteria for ApHCM.

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BACKGROUND: Infective endocarditis can progress to an intracardiac abscess in 20% to 30% of cases, with interventricular septal abscess (IVSA) being one of the rare complications usually presenting with sepsis. We present a case of IVSA presenting with a new-onset second-degree heart block, which rapidly progressed to a complete heart block. CASE PRESENTATION: A 80-year-old Caucasian female with a past medical history of hypertension and hyperlipidemia presented with exertional chest pain, lightheadedness, and shortness of breath with telemetry and electrocardiogram revealing persistent Mobitz type II second degree atrioventricular block. The rest of the vitals were normal. As she was being planned for a pacemaker placement, she spiked a temperature of 103F. Blood cultures grew methicillin-sensitive Staphylococcus aureus, and appropriate antibiotics were initiated. Transthoracic echocardiogram was grossly normal. However, transesophageal echocardiogram revealed a heterogeneous extension of an echodensity from the aortic root, along the aorto-mitral cushion and into the interventricular septum, indicating an interventricular septal abscess. Her course was complicated by altered mental status, with computed tomography of the brain revealing hypodense regions in the left lentiform nucleus and anterior caudate nucleus representing acute/subacute stroke. Surgery was deferred as she was deemed a poor candidate. She succumbed to her illness on day 6 of hospitalization. CONCLUSION: Intracardiac abscesses should be considered a possible initial differential in patients with progressive heart block despite aseptic presentation and no risk factors.

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A gentleman in his early 50's with past medical history significant for biopsy confirmed pulmonary sarcoidosis presented with acute onset confusion, gait disturbance and bowel/urinary incontinence. Brain imaging was consistent with normal pressure hydrocephalus and CSF studies supported the suspicion of neurosarcoidosis. He received treatment with a prolonged course of steroids with good effect. We discuss a rare case of normal pressure hydrocephalus as a presenting feature of neurosarcoidosis and the rationale of starting empiric treatment for probable diagnosis of the same.

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BACKGROUND: Takotsubo cardiomyopathy (TTC) can be diagnosed in patients presenting with clinical features of acute coronary syndrome (ACS) by using Mayo clinic criteria. Multiple precipitators have been attributed to causing TTC. Rarely it has been reported to occur following an acute envenomation. AIM: This review describes the various patterns, mechanisms, and outcomes of envenomation induced TTC. METHODS: In this review, we included all studies on "TTC" and "envenomation "published in the various databases before June 2022. To be included in the review articles had to have a distinct diagnosis of TTC and an envenomation. RESULTS: A total of 20 patients with envenomation induced TTC were identified. Most episodes of envenomation induced TTC were reported following a bee sting, scorpion sting, and snake envenomation. Fear and anxiety related to the sting, direct catecholamine toxicity and administration of exogenous beta-adrenergic agents have been commonly postulated to precipitate TTC in these patients. 95% of these patients presented with a clinical picture of ACS. Most of these patients also fulfill at least 3 out of 4 criteria of Mayo clinic criteria for TTC. Echocardiographic evidence of Apical TTC was noted in 72% of patients. 94% of these patients had clinical improvement following optimal management and 35% of these patients were treated with guideline directed medications for heart failure. CONCLUSION: Envenomation following multiple insect stings and reptile bites can precipitate TTC. Most reported envenomation related TTC has been due to bee stings and scorpion bites. Common mechanisms causing TTC were fear, anxiety, and stress of envenomation. Most of these patients present with clinical presentation of ACS, ST elevation, and elevated troponin. The most common type of TTC in these patients is Apical, which improved following medical management.

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Methemoglobin is a form of hemoglobin that has been oxidized, changing its heme iron configuration from the ferrous to the ferric state. Unlike normal hemoglobin, methemoglobin does not bind oxygen and as a result, cannot deliver oxygen to the tissues. At the presentation in the emergency department, an electrocardiogram (EKG) is usually performed as a reflex for patients admitted for shortness of breath to rule out acute coronary syndrome. Very limited data is available on EKG abnormalities in patients with methemoglobinemia. In this study, we retrospectively analyzed the pattern of EKG changes in patients with methemoglobinemia.

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