Zieve's syndrome (ZS) is a rare disease characterized by a triad of hemolytic anemia, cholestatic jaundice, and transient hyperlipidemia seen in patients with alcoholic steatohepatitis. We report a case of ZS with severe hypertriglyceridemia. Among the reported cases of ZS in English literature, we believe this is the first case of the syndrome presenting with severe hypertriglyceridemia requiring plasmapheresis.

Context Cases of heart failure with preserved ejection fraction (HFpEF) exacerbations continue to affect patients' quality of life and cause significant financial burden on our healthcare system. Objective To identify risk factors for readmission in patients discharged with a diagnosis of HFpEF. Methods Electronic health records of patients over 18 years of age with a primary diagnosis of HFpEF treated between August 1, 2017 and March 1, 2018 in a community hospital were retrospectively reviewed. The study population included patients with HFpEF greater than 40% who were screened but did not qualify for the ongoing CONNECT- HF trial being conducted by Duke Clinical Research. To be included, subjects had to fall into 1 of 2 classifications (NYHA Class II-IV or ACC/AHA Stage B-D) and have a life expectancy greater than 6 months. Patients were excluded if they had terminal illness other than HF, a prior heart transplant or were on a transplant list, a current or planned placement of a left ventricular assist device, chronic kidney disease requiring hemodialysis, inability to use mobile applications, or inability to participate in longitudinal follow up. Readmission rate was analyzed at 30 and 90 days along with patients’ demographics and associated comorbidities, including peripheral vascular disease, anemia, pulmonary hypertension, arrythmia, and valvular heart disease. Patients were risk stratified using the LACE index readmission score and the Charlson comorbidity index. Results Of the 492 cases of HFpEF identified during the 7-month study period, 212 patients were included. The majority of patients were women (126; 59.4%), had a median body mass index above 30 kg/m2 (123; 58%), and had pulmonary hypertension (94; 44.3%), anemia (146; 68.8%), and arrhythmia (101, 47.6%). Forty-five (21.2%) patients were readmitted for HFpEF within 90 days of initial discharge; 32 of those (71.1%) were readmitted within 30 days of initial discharge. Patients with higher LACE and Charlson comorbidity index scores were more likely to be readmitted within 90 days. Peripheral vascular disease (P=.002), tricuspid regurgitation (P=.001), pulmonary hypertension (P=.049), and anemia (P=.029) were risk factors associated with readmissions. Use of ACEi/ARBs (P=.017) was associated with fewer readmissions. Conclusion Anemia, peripheral vascular disease, pulmonary hypertension, and valvular heart disease are not only postulated mechanisms of HFpEF, but also important risk factors for readmission. These study findings affirm the need for continued research of the pathophysiology and associated comorbidities of the HFpEF population to improve quality of life and lower healthcare costs.

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A myocardial bridge has traditionally been considered a benign condition characterized by an atypical intramyocardial route of a segment of one of the major coronary arteries. However, the clinical complications of myocardial bridges can be dangerous. These potential complications include acute coronary syndromes, arrhythmias, ventricular dysfunction, and sudden death. Myocardial bridges are suspected to be adjuvant of Kounis syndrome, which is defined as an acute coronary syndrome caused by an allergic reaction. Due to high epidemiologic prevalence, clinical suspicion of a myocardial bridge should be considered in atypical and typical presentations of chest pain, especially in patients with low-risk factors for atherosclerotic disease. A male in their late 30's presented with non-ST elevation myocardial infarction suspected to be secondary to Kounis syndrome after gadobenate dimeglumine contrast media was used for an imaging study. His clinical presentation was further complicated when he was found to have a mid-left anterior descending coronary artery myocardial bridge.

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