A Case Report

[Posted 21/Nov/2022]

AUDIENCE: Emergency Medicine, Family Medicine

KEY FINDINGS: This case report highlights the conservative treatment of isolated cricoid cartilage fracture in the setting of low-energy blunt trauma. The patient was clinically stable and treated conservatively with oxygen therapy and silence therapy (complete silence).

BACKGROUND: Blunt trauma to the anterior of the neck may compromise the vital structures like major blood vessels, trachea, larynx, pharynx, thyroid, spine, esophagus, and the cricoid. Laryngeal trauma is rare and accounts for 1% of all neck blunt traumas. Cricoid trauma is also very rare and accounts for half of the laryngeal traumas, and the diagnosis is frequently missed.

DETAILS: A 43-year-old man, with blunt neck trauma after being hardly hit by a crane lifting hook, was referred to the Shahid Beheshti Hospital. The patient complained of dysphonia (hoarseness) and dyspnea. The CT scans showed a comminuted fracture of the left anterior arch of the cricoid cartilage with left-sided mucosal thickening, inflammation, and edema which was extended to the glottis, causing a narrowing of the airway. Direct fiber-optic laryngoscopy revealed swelling and congestion in the epiglottis and swelling at the level of the left vocal cord.

Copyright © BioMed Central Ltd unless otherwise stated. All rights reserved.

Source: Mehrabi, S., Hosseinpour, R., and Barhaghtalab, M. J. (2022). Isolated Comminuted Fracture Of The Cricoid Cartilage and Narrowing Of The Airway After A Traumatic Blunt Injury Of The Neck: A Case Report. Int J Emerg Med. 2022; 15:55. Published: November, 2022. DOI: 10.1186/s12245-022-00459-9.

[Posted 6/Dec/2022]

AUDIENCE: Cardiology, Emergency Medicine

KEY FINDINGS: Patients with SCAD presenting the BKL angiographic pattern are more frequently female and present more often as intramural hematoma with longer lesions and severe vessel tortuosity but have better coronary flow. Patients with the BKL morphology have a favorable prognosis.

BACKGROUND: Spontaneous coronary artery dissection (SCAD) is a rare but increasingly recognized cause of acute myocardial infarction. Coronary angiography remains the best diagnostic tool; however, clinical suspicion and experience is required to interpret angiographic findings.

DETAILS: This study sought to assess the clinical implications of the "broken line"”" (BKL) angiographic pattern in a large, nationwide, cohort of patients with SCAD. The Spanish SCAD registry prospectively enrolled consecutive patients with SCAD. All angiograms were centrally analyzed and the BKL pattern was systematically assessed. The BKL angiographic pattern was found in 64 of 389 patients (16%). Patients with the BKL appearance were more frequently female (97 vs 87%, p <0.05), presented more often as intramural hematoma (83 vs 58%, p <0.001), had longer lesions (47 ± 29 vs 36 ± 22 mm, p <0.01), and had severe tortuosity (25 vs 10%, p <0.01) but showed better initial coronary flow (thrombolysis in myocardial infarction flow 2.6 ± 0.8 vs 2.1 ± 1.2, p <0.01). Patients with BKL received more frequently conservative medical management (91 vs 76%, p <0.01). At late clinical follow-up (median 29 months, interquartile range 17 to 38) predefined adverse events (death, myocardial infarction, revascularization, recurrent SCAD, or stroke) occurred less frequently (3.5 vs 15%, p <0.05) in patients with the BKL appearance. The better clinical outcomes of patients in the BKL group persisted after adjusting for potential confounders (adjusted hazard ratio 0.2, 95% confidence interval 0.1 to 0.9, p <0.05).

Copyright © Elsevier Inc. All rights reserved.

Source: Alfonso, F., Sanz-Ruiz, R., Sabate, M., et al. (2022). Clinical Implications of the "Broken Line" Angiographic Pattern in Patients With Spontaneous Coronary Artery Dissection. Am J Cardiol.. 2022; 185: 1-9. Published: December 15, 2022. DOI: 10.1016/j.amjcard.2022.09.017.

[Posted 7/Nov/2022]

AUDIENCE: Cardiology, Oncology

KEY FINDINGS: LQRSVs are common but not ubiquitous in CA; they are more frequent in AL-CA than in ATTR-CA. LQRSVs reflect an advanced disease stage and independently predict CV death. In ATTR-CA, LQRSVs can provide incremental prognostic accuracy over the NAC staging system in patients with intermediate risk.

BACKGROUND: Low QRS voltages (LQRSVs) are a common electrocardiographic feature in patients with light chain amyloidosis (AL) and transthyretin amyloidosis (ATTR) cardiac amyloidosis (CA). The aim of this study was to identify clinical and echocardiographic correlates of LQRSV and to investigate their prognostic significance in patients with CA.

DETAILS: This was a multicenter, retrospective study performed in 6 CA referral centers including consecutive patients with AL- and ATTR-CA. LQRSVs were defined as a QRS amplitude <=5 mm (0.5 mV) in all peripheral leads. The study outcome was cardiovascular (CV) mortality. Overall, 411 (AL-CA: n = 120, ATTR-CA: n = 291) patients were included. LQRSVs were present in 66 (55%) patients with AL-CA and 103 (35%) with ATTR-CA (P < 0.001). In AL-CA, LQRSVs were independently associated with younger age (P = 0.015), higher New York Heart Association functional class (P = 0.016), and natriuretic peptides (P = 0.041); in ATTR-CA, LQRSVs were independently associated with pericardial effusion (P = 0.008) and lower tricuspid annulus peak systolic excursion (P = 0.038). During a median follow-up of 33 months (Q1-Q3: 21-46), LQRSVs independently predicted CV death in both AL-CA (HR: 1.76; 95% CI: 2.41-10.18; P = 0.031) and ATTR-CA (HR: 2.64; 95% CI: 1.82-20.17; P = 0.005). Together with the National Amyloidosis Centre (NAC) staging, LQRSVs provided incremental prognostic value in ATTR-CA (AUC for NAC model: 0.83 [95% CI: 0.77-0.89]; AUC for NAC + LQRSV model: 0.87 [95% CI: 0.81-0.93]; P = 0.040).

Copyright © American College of Cardiology Foundation. All rights reserved.

Source: Cipriani, A., De Michieli, L., Porari, A., et al. (2022). Low QRS Voltages in Cardiac Amyloidosis: Clinical Correlates and Prognostic Value. J Am Coll Cardiol CardioOnc.. Published: October 7, 2022. DOI: 10.1016/j.jaccao.2022.08.007.

[Posted 3/Nov/2022]

AUDIENCE: Emergency Medicine, Cardiology

KEY FINDINGS: MCP-1 is not predictive of 90-day MACE in patients with non-low-risk chest pain.

BACKGROUND: Prior studies suggest monocyte chemoattractant protein-1 (MCP-1) may be useful for risk stratifying ED patients with chest pain. We hypothesise that MCP-1 will be predictive of 90-day major adverse cardiovascular events (MACEs) in non-low-risk patients.

DETAILS: A case–control study was nested within a prospective multicentre cohort (STOP-CP), which enrolled adult patients being evaluated for acute coronary syndrome at eight US EDs from 25 January 2017 to 06 September 2018. Patients with a History, ECG, Age, and Risk factor score (HEAR score) >=4 or coronary artery disease (CAD), a non-ischaemic ECG, and non-elevated contemporary troponins at 0 and 3 hours were included. Cases were patients with 90-day MACE (all-cause death, myocardial infarction or revascularisation). Controls were patients without MACE selected with frequency matching using age, sex, race, and HEAR score or the presence of CAD. Serum MCP-1 was measured. Sensitivity and specificity were determined for cut-off points of 194 pg/mL, 200 pg/mL, 238 pg/mL and 281 pg/mL. Logistic regression adjusting for age, sex, race, and HEAR score/presence of CAD was used to determine the association between MCP-1 and 90-day MACE. A separate logistic model also included high-sensitivity troponin (hs-cTnT). Among 40 cases and 179 controls, there was no difference in age (p=0.90), sex (p=1.00), race (p=0.85), or HEAR score/presence of CAD (p=0.89). MCP-1 was similar in cases (median 191.9 pg/mL, IQR: 161.8–260.1) and controls (median 196.6 pg/mL, IQR: 163.0–261.1) (p=0.48). At a cut-off point of 194 pg/mL, MCP-1 was 50.0% (95% CI 33.8% to 66.2%) sensitive and 46.9% (95% CI 39.4% to 54.5%) specific for 90-day MACE. After adjusting for covariates, MCP-1 was not associated with 90-day MACE at any cut-off point (at 194 pg/mL, OR 0.88 (95% CI 0.43 to 1.79)). When including hs-cTnT in the model, MCP-1 was not associated with 90-day MACE at any cut-off point (at 194 pg/mL, OR 0.85 (95% CI 0.42 to 1.73)).

Copyright © BMJ Publishing Group Ltd and the College of Emergency Medicine. All rights reserved.

Source: Ashburn, N. P., Snavely, A. C., Allen B. R., et al. (2022). Monocyte Chemoattractant Protein-1 Is Not Predictive Of Cardiac Events In Patients With Non-Low-Risk Chest Pain. Emergency Medicine Journal. 2022; 39(11): 853-858. Published: November, 2022. DOI: 10.1136/emermed-2021-211266.

Findings From the German CKD Cohort Study

[Posted 1/Nov/2022]

AUDIENCE: Nephrology, Internal Medicine

KEY FINDINGS: In this large cohort of patients with CKD, H-FABP was associated with non-CV death and MACE, even after adjustment for hs-TNT. Whether measurement of H-FABP improves cardiovascular disease risk prediction in these patients warrants further studies.

BACKGROUND: Heart-type fatty acid binding protein (H-FABP) is a biomarker that has been shown to provide long-term prognostic information in patients with coronary artery disease independently of high-sensitivity troponin T (hs-TNT). We examined the independent associations of H-FABP with cardiovascular outcomes in patients with chronic kidney disease (CKD).

DETAILS: 4,951 patients enrolled in the German Chronic Kidney Disease (GCKD) study with an estimated glomerular filtration rate of 30-60 mL/min/1.73 m² or overt proteinuria (urinary albumin-creatinine ratio > 300 mg/g or equivalent). Hazard ratios (HRs) for associations of H-FABP and hs-TNT with outcomes were estimated using Cox regression analyses adjusted for established risk factors. During a maximum follow-up of 6.5 years, 579 non-CV deaths, 190 CV deaths, 522 MACE, and 381 CHF hospitalizations were observed. In Cox regression analyses adjusted for established risk factors, H-FABP was associated with all 4 outcomes, albeit with lower HRs than those found for hs-TNT. After further adjustment for hs-TNT levels, H-FABP was found to be associated with non-CV death (HR, 1.57 [95% CI, 1.14-2.18]) and MACE (HR, 1.40 [95% CI, 1.02-1.92]) but with neither CV death (HR, 1.64 [95% CI, 0.90-2.99]) nor CHF hospitalizations (HR, 1.02 [95% CI, 0.70-1.49]).

Copyright © Elsevier Ltd. All rights reserved.

Source: Schneider, M. P., Schmid, M., Nadal, J., et al. (2022). Heart-Type Fatty Acid Binding Protein, Cardiovascular Outcomes, and Death: Findings From the German CKD Cohort Study. Am J Kidney Dis. 2022; 80(4): 483-494. Published: October, 2022. DOI: 10.1053/j.ajkd.2022.01.424.

[Posted 25/Oct/2022]

AUDIENCE: Ob/Gyn, Cardiology, Family Medicine

KEY FINDINGS: Vascular malperfusion lesions and chronic forms of inflammation occur at markedly higher rates in placentas complicated by fetal congenital heart disease, which may contribute to the decreased head circumference at birth. Further work in neuroplacentology is needed to explore connections among cardiac defects, placental vascular malperfusion lesions, and fetal brain development.

BACKGROUND: Fetuses with congenital heart disease are at increased risk of perinatal morbidity and mortality, which is highly influenced by their prenatal health. Placental function is vital for the health of the fetus, but increased rates of pathologic lesions of the placenta have been observed in pregnancies complicated by fetal congenital heart disease. This study aimed to determine the prevalence of both gross and histologic placental pathologies in a cohort of pregnancies complicated by fetal congenital heart disease vs healthy controls using the Amsterdam Placental Workshop Group Consensus Statement sampling and definitions of placental lesions.

DETAILS: This single-center retrospective cohort study included placental examinations from pregnancies diagnosed prenatally with fetal congenital heart disease between 2010 and 2019; moreover, control placentas were collected from pregnancies without maternal or fetal complications. Placentas were sampled and evaluated according to the Amsterdam Placental Workshop Group Consensus Statement and gross and histopathologic diagnoses determined. Approximately 80% of fetuses diagnosed with congenital heart disease (n=305) had a placental examination for comparison with controls (n=40). Of note, 239 placentas (78%) in the group with fetal congenital heart disease had at least 1 gross or histopathologic lesion compared with 11 placentas (28%) in the control group (P<.01). One-third of placentas complicated by fetal congenital heart disease met the criteria for small for gestational age, and 48% of placentas had one or more chronic lesions, including maternal vascular malperfusion (23% vs 0%; P<.01), villitis of unknown etiology (22% vs 0%; P<.01), fetal vascular malperfusion (20% vs 0%; P<.01), and other chronic lesions (16% vs 0%; P<.01). Acute inflammation was equally present in both the group with fetal congenital heart disease and the control group (28% vs 28%; P=1.00). Although gestational age and birthweight z score were similar between the 2 groups, birth head circumference was 1.5 cm less in pregnancies complicated by fetal congenital heart disease with a significantly lower z score compared with the control group (-0.52±1.22 vs 0.06±0.69; P<.01).

Copyright © Elsevier Inc. All rights reserved.

Source: Leon, R. L., Sharma, K., Mir, I. N., et al. (2022). Placental Vascular Malperfusion Lesions In Fetal Congenital Heart Disease. Am J Obstet Gynecol. 2022; 227(4): 620-620. Published: October 1, 2022. DOI: 10.1016/j.ajog.2022.05.038.