Objective Hyperlipidemia is an important risk factor for atherosclerotic cardiovascular disease. Many patients are intolerant to or have limited benefit from statins. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been approved for treating hyperlipidemia in these patients. We sought to investigate the impact of these medications in a real-world cardiology practice. Methods This was a retrospective study of 17 patients with either heterozygous familial hypercholesterolemia or established atherosclerotic cardiovascular disease with low-density lipoprotein cholesterol (LDL-C) levels above the treatment target despite maximally tolerated statins. Baseline lipid profile was compared with a repeat lipid profile obtained 4 to 6 weeks after initiating treatment with a PCSK9 inhibitor. Results The average duration of PCSK9 inhibitor treatment was 10.7 months. Lipid profile comparison showed that total cholesterol decreased from 243 ± 72 to 148 ± 39 (mg/dL) (39% reduction), triglycerides decreased from 185 ± 86 to 149 ± 62 (mg/dL) (19.5% reduction), high-density lipoprotein cholesterol increased from 56 ± 20 to 62 ± 26 (mg/dL) (10.7% increase), and LDL-C decreased from 154 ± 30 to 57 ± 32 (mg/dL) (63% reduction) from baseline. Conclusions PCSK9 inhibitors as add-on therapy to maximally tolerated statins resulted in an approximately 63% reduction in LDL-C.

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Introduction In patients with acute ST elevation myocardial ischemia (STEMI), national efforts have focused on reducing door-to-balloon (D2B) times for primary percutaneous coronary intervention (PCI). This emphasis on time-to-treatment may increase the rate of inappropriate cardiac catheterization laboratory (CCL) activations and unnecessary healthcare utilization. To achieve lower D2B times, community hospitals and EMS systems have enabled emergency medical technicians (EMTs) and emergency department (ED) physicians to activate the CCLs without immediately consulting a cardiologist. Objective The purpose of this study is to determine the rate and main causes of inappropriate activation of the CCL which will aid in finding solutions to reduce this occurrence. Method This is a retrospective study, based on an electronic medical system review of all inappropriate CCL activation who presented to Providence Hospital and Medical Centers (PHMC) in Michigan, from January 2015 to July 2016. Results The CCL was activated 375 times for suspected STEMI. The false STEMI activation was identified in 47 patients which represents 12.5% of total CCL activation. The vast majority of this false activation was due to non-diagnostic electrocardiogram (ECG) that did not meet the STEMI criteria. Conclusion The subjective interpretation of the ECG by EMTs and ED physicians tend to show a wide variability, which may lead to higher-than-anticipated false activation rates of up to 36% in one study. Some studies had reported that up to 72% of inappropriate activations were caused by ECG misinterpretations. These false activations have ramifications that lead to both clinical and financial costs.

A 38-year-old male presented to the emergency department (ED) complaining of extreme pain and a petechial rash on the left ankle for two weeks associated with generalized fatigue, intermittent fevers, and weight loss. He was discharged home from the ED on pain medications. He returned a few days later with a progressive rash that involved the entire left lower extremity to the level of the knee. He was diagnosed with herpes zoster (shingles) and was prescribed acyclovir and steroids. After several days, the patient presented for the third time to the ED. He developed a right lower extremity discomfort this time. The pain in bilateral lower extremities had become unbearable. His cardiac examination revealed a systolic murmur at the apex and a faint diastolic murmur at the left sternal border. Ultimately, he had an echocardiogram that demonstrated both a bicuspid aortic valve and large vegetation on the anterior leaflet of the mitral valve, and his blood culture grew Streptococcus mitis and Streptococcus oralis. The patient was subsequently diagnosed with subacute bacterial endocarditis thought to be sourced from his poor dentition. The diagnosis of infective endocarditis is often delayed due to its nonspecific clinical presentations. Our case displays an unusual skin manifestation of IE that may be present in the absence of other signs and symptoms of the disease.