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Type 2 myocardial infarction (MI) is commonly encountered in daily practice. Its incidence can range between 5 and 35% among all cases of MI. It is caused by disorders that result in supply-demand mismatch, which leads to myocardial ischemia and necrosis. Therefore, unsurprisingly, it is frequently diagnosed in critically ill patients and those with severe coronary artery disease (CAD) and multiple comorbidities. Though it can occur in the absence of CAD, the presence of coronary blood flow-limiting stenoses can allow even minor insults to disturb the already fine supply-demand balance. Generally, type 2 MI may be associated with higher mortality; however, some data suggest it may have different severities, and outcome is better in patients with type 2 MI of milder severity. Nonetheless, regardless of the causes (ischemic or nonischemic), troponin elevation is associated with worse outcome. Differentiating type 2 MI from other causes of myocardial necrosis, mainly type 1 MI and myocardial injury, remains a clinical challenge. Different diagnostic tools can be utilized to aid in reaching an accurate diagnosis. These can include contrast echocardiography, computed tomography, MRI, radionuclide imaging, coronary angiography, and intracoronary imaging. However, each comes with its own limitations and results should be interpreted with caution and in clinical context. Management of type 2 MI is uncertain because of paucity of data. Evidence-based therapies of type 1 MI are frequently used, though this may be harmful sometimes. Therefore, clinical judgment should be used, and management and therapies should be tailored to each individual case.

I read with great interest the study by Singh et al. ([1][1]). The authors used the Young-MI registry to assess the outcome of young adults (age

Background Capsule endoscopy (CE) is mainstream in the evaluation of obscure gastrointestinal bleeding (GIB) in the general population. However, the diagnostic and therapeutic impact of CE in LVAD patients susceptible to transient bleeding remains largely unexplored. This study aimed to assess the benefits of CE in the evaluation of LVAD associated GIB. Methods Retrospective review of patients implanted with a continuous flow LVAD who underwent inpatient capsule endoscopy (CE) between January 2014 and May 2017 at our center. Identification of lesions with high bleeding potential or presence of frank blood were considered abnormal findings on CE study. Results Twenty-five inpatients who underwent 41 CE were identified. All patients presented with GIB and had preceding negative upper endoscopy and colonoscopy in the past 4 weeks. On the first capsule in each patient, 19 had interpretable images, abnormal findings were detected in 5 patients (high risk lesion in 3, frank blood in 2), four of these underwent an enteroscopy and only 2 (8%) patients had confirmation of the capsule findings with APC treatment (true positive). Excluding patients with malfunction, LVAD interference and poor bowel prep, 14 patients had negative/equivocal CE, of which 4 underwent enteroscopy due to continued bleeding and 2 of these patients had treatable culprit lesions (false negative). A total of 17 (68%) patients were discharged without any therapeutic intervention irrespective of the success or findings on CE due to clinical stabilization. Twenty patients (80%) had recurrence in a mean 154 days. As expected, repeat capsules in the same admission increased the diagnostic yield (p=0.031). Only nine patients (36%) had capsule-image evidence of reaching the cecum while 4 patients (16%) had retention which had to be retrieved without further complication. Conclusions This study demonstrated that evaluation of GIB with CE is feasible and safe but was associated with a low diagnostic yield and low conversion to therapeutic intervention. With a true positive yield of 4% in our cohort, the efficacy and cost-effectiveness of CE in the LVAD population is debatable. The role of CE in LVAD patients may need to be reevaluated. An identification of patients who would benefit from a capsule-first approach would allow optimum utilization of resources and reduce healthcare expenditure.

We read with great interest the study by Aragam et al. [(1)][1] and the editorial comment by Thomas [(2)][2]. Indeed, cardiac rehabilitation (CR) is an important preventive measure that remains underused in the United States [(3,4)][3]. Intuitively, the first step in improving use of CR is to

Esophageal perforation is a rare condition that is commonly missed. Male gender and alcohol use are predisposing risk factors. Most of the cases are iatrogenic or traumatic; nonetheless, spontaneous cases are not uncommon. It typically occurs after vomiting or straining as the increased intra-abdominal pressure transmits into the esophagus and results in the tear. One of the main complications is acute bacterial mediastinitis from contamination with esophageal flora. This condition can be life-threatening because it is very frequently misdiagnosed and appropriate management is often delayed. A 49-year-old man presented with worsening sudden-onset interscapular back pain that then changed to chest pain with odynophagia and was found to have fever and leukocytosis. Chest computed tomography revealed signs of mediastinitis with possible esophageal perforation. He reported symptoms started 2 days ago after lifting of heavy objects. Empiric antimicrobial was begun with conservative management and avoidance of oral intake. Barium esophagram and esophagogastroduodenoscopy revealed no signs of perforation or inflammation. His symptoms resolved and he gradually resumed oral intake. Blood cultures grew Methicillin-sensitive Staphylococcus aureus and he was discharged on appropriate antibiotics for 4 weeks. He did well on follow-up 3 months after hospitalization. The case highlights the importance of considering esophageal etiologies of chest pain.

Coronary artery ectasia (CAE) or aneurysm is usually defined as dilation ≥1.5-fold the normal vessel diameter. It has an incidence of 1.4-5.3% and is associated with a wide variety of etiologies-mainly congenital, atherosclerotic, and inflammatory ones. CAE is very common in sickle cell disease, and possibly sickle cell trait, with an incidence of 17.7%. It is likely related to the inflammatory process associated with hemoglobin S. Prognosis depends mainly on the underlying etiology. Atherosclerotic CAE does not carry additional risks compared to atherosclerotic coronary artery disease (ACAD) without ectasia. However, isolated CAE in the absence of ACAD carries an increased risk of myocardial infarction (MI) due to vasospasm, slower coronary blood flow, and thrombosis, typically within the dilated segments. Due to lack of studies and guidelines, management recommendations are based on personal experiences. Therapy should be tailored to each individual case after assessment of severity, history of complications, underlying etiology, and comorbidities. Treatment of underlying condition and avoidance of exacerbating factors are essential. Medical therapy in general may include antiplatelets, β-blockers, angiotensin-converting enzyme inhibitors statins, and dihydropyridine calcium channel blockers. In severe CAE or history of MI, the addition of anticoagulation therapy after assessing bleeding risk may be warranted. In acute MI, the large thrombus burden in the dilated segment makes the percutaneous approach very challenging. Aspiration attempts can result in distal thromboembolization. Survival is better in bypass grafting than with medical therapy. Nonetheless, bypass grafting does not improve survival in atherosclerotic CAE. Depending on the physical characteristics of aneurysm, different surgical approaches can be sought; however, the ideal one is unclear.

Cardiac rehabilitation (CR) is an effective preventive measure that remains underutilised in the United States. The study aimed to determine the CR referral rate (RR) after percutaneous coronary intervention (PCI) at an academic tertiary care centre, identify barriers to referral, and evaluate awareness of CR benefits and indications (CRBI) among cardiologists. Subsequently, it aimed to evaluate if an intervention consisting of physicians' education about CRBI and implementation of a formal CR referral system could improve RR and consequently participation rate (PR).Data were retrospectively collected for all consecutive patients who underwent PCI over 12 months. Referral rate was determined and variables were compared for differences between referred and non-referred patients. A questionnaire was distributed among the physicians in the Division of Cardiology to assess awareness of CRBI and referral practice patterns. After implementation of the intervention, data were collected retrospectively for consecutive patients who underwent PCI in the following six months. Referral rate and changes in PRs were determined.Prior to the intervention, RR was 17.6%. Different barriers were identified, but the questionnaire revealed lack of physicians' awareness of CRBI and inconsistent referral patterns. After the intervention, RR increased to 88.96% (Odds Ratio 37.73, 95% CI 21.34-66.70, p0.0001) and PR increased by 32.8% to reach 26%. Personal endorsement of CRBI by cardiologists known to patients increased CR program graduation rate by 35%.Cardiologists' awareness of CRBI increases CR RR and their personal endorsement improves PR and compliance. Education of providers and implementation of a formal referral system can improve RR and PR.

Background Use of high-sensitivity troponin (hs-Tn) assays can detect small levels of myocardial damage previously undetectable with conventional troponin (c-Tn) assays. However, prognostic utility of these hs-Tn assays in prediction of mortality remains unclear in the presence of nonelevated c-Tn levels on admission. A systematic review and meta-analysis was performed to assess mortality risk of patients with hs-Tn elevations in the setting of normal c-Tn levels. Hypothesis Patients with hs-Tn elevations with normal c-Tn levels on admission blood samples, drawn to rule out acute coronary syndrome (ACS), have a higher mortality risk than those without hs-Tn or c-Tn elevations. Methods A search was made of the PubMed, CENTRAL, EMBASE, CINAHL, EBSCO, and Web of Science databases. Studies evaluating patients with suspected ACS that reported mortality rates for those with elevated hs-Tn levels but normal c-Tn levels on admission were included. A random-effects model was used to pool event rates, and data were reported in odds ratios (95% confidence interval). Results Four studies (N = 2033, mean age 64–75 years, 49%–70% male) revealed that nearly 32% of suspected ACS patients with normal c-Tn levels on admission had elevated hs-Tn levels. Elevated hs-Tn levels conferred a significantly higher risk of all-cause mortality vs normal hs-Tn levels (odds ratio: 4.35, 95% confidence interval: 2.81-6.73, P < 0.01), with negligible heterogeneity (I2 = 0%). Conclusions Elevation of hs-Tn levels predicted a higher risk of mortality in patients with suspected ACS and may aid in the early identification of higher-risk patients in this setting. Future studies are needed to investigate further optimal management strategies.

High-sensitivity troponin (hsTrop) assays can detect smaller myocardial infarctions (MI) undetectable with contemporary troponin assays (cTrop), it is unclear whether patients with hsTrop elevations in setting of normal cTrop have higher mortality. A search was made of PubMed, CENTRAL, EMBASE

Persistent hypotension subsequent to percutaneous coronary intervention is attributed to access-site bleeding, re-infarction, or mechanical complications either of myocardial infarction or of the procedure itself (for example, pericardial tamponade). Dynamic left ventricular outflow tract obstruction after an uncomplicated percutaneous coronary intervention is an unusual, and to our knowledge not previously reported, complication that manifests itself as hypotension refractory to the usual therapy with inotropic agents. We discuss the clinical course, pathophysiology, diagnosis, and management of hypotension due to left ventricular outflow tract obstruction after percutaneous coronary intervention. Early recognition and accurate diagnosis that determines appropriate therapy will improve the patient's prospects.