Bortezomib is a proteasome inhibitor used to treat multiple myeloma and mantle cell lymphoma. Traditionally, bortezomib was thought to have little cardiovascular toxicity; however, there is increasing evidence that bortezomib can lead to cardiac complications including left ventricular dysfunction and atrioventricular block. We present the case of a 66-year-old man with multiple myeloma and persistent asymptomatic elevations of cardiac biomarkers who developed complete heart block and evidence of myocardial scar after his eighth cycle of bortezomib, requiring permanent pacemaker placement. In addition to discussing the cardiovascular complications of bortezomib therapy, we propose a potential role for biomarkers in the prediction and monitoring of bortezomib cardiotoxicity.

Background Left ventricular noncompaction (LVNC) is a rare disorder characterized by increased left ventricular trabeculation, deep intertrabecular recesses, and a thin compacted myocardial layer with associated clinical sequelae. Cardiac imaging with echocardiogram and cardiac magnetic resonance (CMRI) can detect variable myocardial morphology including excessive trabeculations. Multiple CMRI and echocardiographic criteria have been offered that attempt to identify LVNC morphology. The aim of this study was to assess the utility of echocardiogram in identifying LVNC in a cohort of patients with LVNC detected on CMRI. Hypothesis Echocardiography fails to identify LVNC morphology in a large proportion of patients with LVNC/hypertrabeculation detected on CMRI. Methods There were 1060 CMRI studies collected from 2009 to 2015 at 2 institutions. The patients included in this study (n = 37) met the criteria for LVNC on CMRI and had complete CMRI and echocardiogram images Clinical and imaging data were retrospectively reviewed. Results Of the 37 patients with LVNC on CMRI, only 10 patients (27%) had LVNC identified on echocardiogram (P < 0.0001, 95% confidence interval: 25.7%‐66.2%). Echocardiography and CMRI were also significantly different in terms of identification of distribution of LVNC. Although 21 of 37 patients (57%) had evidence of LVNC in either the anterior or lateral walls on CMRI, there were 0 patients with LVNC detected in the anterior or lateral walls on echocardiogram (P = 0.019). Conclusions Echocardiogram fails to detect LVNC morphology/hypertrabeculation in a significant number of a cohort of patients with LVNC on CMRI. LVNC may be missed if echocardiogram is the only imaging modality performed in a cardiac evaluation.

openAccessArticle: Falsecover date: 2015-03-17pii: S0735-1097(15)61141-XHarvest Date: 2016-01-06 13:07:47issueName:Page Range: A1141-A1141href scidir: http://www.sciencedirect.com/science/article/pii/S073510971561141XpubType: Non Invasive Imaging (Echocardiography, Nuclear, PET, MR and CT

Background: Low risk patients with suspected coronary ischemic syndrome (CIS) undergo hospital procedures despite unclear benefit. False negative evaluations can contribute to unnecessary testing that increases cost. This analysis stratified the likelihood of non-obstructive disease at time of coronary angiography (CA) to determine predictors of a negative study and assessed subsequent costs resulting from negative CA. Methods: 564 coronary angiograms were performed during 2013 at a single institution. Patients with ST-segment elevation myocardial infarction, cardiac arrest, multiple angiograms, or a clear non-CIS indication for CA (i.e. pre valve surgery) were excluded. 171 patients were included for retrospective chart review and categorized by age, race, gender, body mass index, blood pressure, chest pain quality, biomarker elevation, electrocardiographic findings, and clinical features that include hypertension, lipid status, diabetes, chronic kidney disease, psychiatric disease and substance abuse. These data were then analyzed by univariate assessment and logistic regression models for the multivariate predictors of factors associated with negative CA. Cost analysis was performed using a consumer based average cost database and direct hospital laboratory expense data. Results: Of the 171 patients studied, nearly half (47%) did not have obstructive coronary artery disease. The adjusted odds of negative CA were significantly elevated, in order of predictability, with the absence of chest pain (odds ratio (OR) 7.28, p = 0.0004), atypical chest pain (OR 7.13, p < 0.0001), African American race (OR 4.87, p = 0.0033), no diabetes (OR 4.25, p = 0.0026), female gender (OR 3.70, p = 0.0038), normal Troponin-I level (OR 3.16, p = 0.0208), no hyperlipidemia (OR 2.96, p = 0.0107), and low troponin level 0.033 - 0.1 ng/mL (OR 2.96, p = 0.0025). The total cost of negative CA was $749,088, or $9,363 per patient. Total avoidable direct catheterization laboratory expense was $251,000, or $3,137 per patient. Conclusion: In the evaluation of CIS, a large number of patients that undergo CA have no evidence of obstructive disease. Further study of characteristics that predict the absence of obstructive disease would help reduce the frequency and substantial cost of unnecessary invasive procedures.