Letters To The Editor

‘Non-criteria’ antiphospholipid antibodies and thrombosis
Antiprothrombin antibodies are associated with thrombosis, can be considered features of antiphospholipid antibody syndrome in the right clinical...
Maya Serhal, MD
Vascular Medicine Section, Department of Cardiovascular Medicine, Cleveland Clinic
Natalie Evans, MD, RPVI
Vascular Medicine Section, Department of Cardiovascular Medicine, Cleveland Clinic; Clinical Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
Heather L. Gornik, MD, RVT, RPVI
Medical Director, Non-Invasive Vascular Laboratory, Vascular Medicine Section, Department of Cardiovascular Medicine, Cleveland Clinic; Associate Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
Address: Maya Serhal, MD, Department of Vascular Medicine, J3-5, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195; Serhalm@ccf.org
Dr. Gornik has disclosed she was a site principal investigator in the Examining Use of Ticagrelor in Peripheral Artery Disease (EUCLID) trial, funded by AstraZeneca.
A 75-year-old man presented to the emergency department for evaluation of abdominal pain. He had stage 3 chronic obstructive pulmonary disease (COPD), with a forced expiratory volume in 1 second of 33%.
Aside from his COPD, he had been healthy until 1 month earlier, when he had been hospitalized because of shortness of breath and chest pressure with exertion. His troponin T level had been elevated, peaking at 0.117 ng/mL (reference range 0–0.029).
Left heart catheterization had shown no significant coronary artery disease. A myocardial bridge of the distal left anterior descending coronary artery had been seen, so that the artery appeared to be narrowed by 50% to 60% with ventricular contraction. But this was not thought to have been the cause of his presentation.
On discharge, he required oxygen 4 L/min by nasal cannula. Previously, he had not needed supplemental oxygen.
The patient described persistent and severe periumbilical abdominal pain during the previous day. It was not associated with eating, and he denied diarrhea, constipation, hematemesis, hematochezia, bright red blood per rectum, or melena. He continued to describe persistent shortness of breath and pleuritic chest pain. His vital signs were as follows:
His laboratory findings on presentation are shown in Table 1 , and his electrocardiogram is shown in Figure 1 .
1. Which of the following is the most accurate description of this patient’s electrocardiogram?
Our patient’s electrocardiogram shows sinus tachycardia, P pulmonale, T-wave inversion in the right precordial leads (V 1–V3), and biphasic T waves in lead V 4,, which suggest right ventricular strain.
The rhythm most commonly seen in patients with pulmonary embolism is sinus tachycardia, followed by nonspecific ST-segment or T-wave abnormalities. In one series of patients with acute pulmonary embolism, the classic findings of P pulmonale, right ventricular hypertrophy, right axis deviation, and right bundle branch block were rare (< 6%). 1 Thus, these classic findings are not sensitive for the diagnosis of pulmonary embolism, and their absence does not rule it out.
Antiprothrombin antibodies are associated with thrombosis, can be considered features of antiphospholipid antibody syndrome in the right clinical...
We do not routinely screen for these “non-criteria” antibodies, but we agree that this is an area that warrants further investigation.
A thoughtful approach to diagnosing venous thromboembolism and screening for thrombophilic disorders.
His symptoms and imaging findings suggested an infarction in the spleen, but what caused the infarction?
High-intensity treatment with warfarin is not better than standard-intensity warfarin treatment. Basic questions about this disease remain...