Internal Medicine

A Dutch observational registry-based study evaluated the link between PCR-positive influenza and subsequent acute myocardial infarction (MI) risk. It found that the incidence of MI was 6 times higher within one week of influenza diagnosis compared to a control period. The relative incidence was 16.6 in patients without coronary artery disease (CAD) and 1.4 in those with CAD. Antithrombotic use was linked to a lower MI risk (4.1 vs. 13.5). These findings suggest flu vaccination might prevent MI, especially in older adults.

de Boer AR et al. Influenza infection and acute myocardial infarction. NEJM Evid 2024 Jul; 3:EVIDoa2300361. (https://doi.org/10.1056/EVIDoa2300361)

Inotropes, such as milrinone, do not improve outcomes in patients admitted with acute decompensated heart failure or increase urine output. Inotropes may be considered in patients with low-output heart failure (low pulse pressure, cool extremities, presence of S3) to improve cardiac output but should not be used in the routine therapy of patients admitted with heart failure.

Spot diagnosis?@Everyone 

DDx: upto 3

A previously healthy 40 year-old female presents to the emergency department with a 1-day history of sharp, left-sided, non-radiating chest pain that worsens with lying down and a dry cough. Associated SOB. She recently traveled by air from San Diego to New York. She is up to date on her vaccines. Physical examination reveals an HR of 116 bpm, a BP of 110/70 mm Hg, an RR of 18 b/min, and Spo2 of 98% on RA. Lungs sound distant. She has a normal S1 and a split S2, and a 2/6 vibratory systolic murmur heard at the left midsternal border. Her chest pain is not reproducible with palpation over costochondral junctions. no pedal edema. A CXR is normal. An ECG is obtained (figure).

@Everyone Next best step?

1. Anticoagulation

2. NSAIDs

3. Nitroglycerin

New ACC guidelines for management of AF(2023):

The current guideline's classification of AF focuses on the stages of AF including the pre-detection period.

Stage 1: at risk for AF presence of modifiable and nonmodifiable risk factors,

Stage 2: pre-AF (evidence of structural or electrical findings predisposing to AF),

Stage 3A: paroxysmal AF (intermittent, lasting up to 7 days),

Stage 3B: persistent AF (continuous and sustained for over 7 days and requires intervention),

“False-Positive” Stress Tests in Patients with Coronary Microvascular Dysfunction"

Kirsten E. Fleischmann, MD, MPH, FACC, reviewing Sinha A et al. J Am Coll Cardiol 2024 Jan 16 Beltrame JF et al. J Am Coll Cardiol 2024 Jan 16

In patients with angina and no obstructive coronary disease, positive stress tests were highly predictive of CMD.

The false-positive rate of exercise stress electrocardiography testing (EST) can be substantial when EST is validated against angiography for diagnosing obstructive coronary artery disease. However, a new study calls that interpretation into question. Researchers in the U.K. evaluated 102 patients (mean age, 60) who had angina without obstructive coronary artery disease; patients underwent EST, as well as invasive assessment with acetylcholine and adenosine infusion for coronary microvascular dysfunction (CMD), which also can cause ischemia.

Thirty-two patients developed ischemia on EST, all of whom tested positive for CMD. Seventy patients had nonischemic EST results, of whom…

Left Ventricular Thrombus

I used ultrasound-enhancing agent (DEFINITY)

Interesting case of Takotsubo

https://academic.oup.com/omcr/article/2024/2/omad144/7609198

How would YOU interpret this ECG?

The prominent 3 findings:

A- LA myxoma: protruding in MV and leading to supra valvular MS.

The classical features of an atrial myxoma in echocardiography include polypoid or papillary mass attached to the interatrial septum through a stalk and moving to and fro into the cavity, sometimes protruding into the corresponding ventricular cavity across the atrioventricular valve.

B- Impaired LV systolic function: EF 30%

C- Apical akinesia: which should raise your suspicion of embolic manifestation of LA myxoma to LAD....But you have to exclude atherosclerotic CAD first.....