However, the clinical outcomes of this unusual usage are not elucidated. Ventricular-demand leadless pacemakers (VVI-LPMs) have often been used as an alternative to atrioventricular (AV) synchronous transvenous pacemakers (DDD-TPMs) in patients with high-grade AV block following transcatheter aortic valve replacement (TAVR). Hence, in suitable candidates, parathyroidectomy must be considered early in patients with asymptomatic hyperparathyroidism. Current research has also shown that various patient demographics and comorbidities prevent the surgical management of PHPT. With emerging data on the correlation between PTH and cardiovascular risks, it is becoming necessary to assess the risks and benefits of conservative management in asymptomatic patients. Worsening HFrEF resulted in a higher diuretic requirement, thereby worsening her hypercalcemia. This case highlights the complications of balancing the volume status with primary hyperparathyroidism and CHF. She was put on Cinacalcet 30 mg, and home medications were adjusted for better volume control at discharge. Hypercalcemia and acute kidney injury improved with hydration. She was started on gentle IV fluids to correct the hypercalcemia while preventing volume overload. Repeat ECHO showed an ejection fraction (EF) of 15%. Pertinent labs were calcium at 13.4 mg/dL, potassium at 5.7 mmol/L, creatinine at 1.7 mg/dL (baseline 1.0), PTH at 204 pg/mL, and Vitamin D, 25-hydroxy at 54.1 ng/mL. Vitals were stable however, the physical exam revealed dehydration. The patient was re-admitted three weeks later with fatigue and decreased fluid intake. Spironolactone and Dapagliflozin were added to her regimen, and the Furosemide dose was increased at discharge. She was managed conservatively for her hypercalcemia and advised to maintain hydration at home. The patient received IV diuretics and guideline-directed treatment for congestive heart failure exacerbation. The echocardiogram showed an ejection fraction (EF) of 39%, grade III diastolic dysfunction, severe pulmonary hypertension, and mitral and tricuspid regurgitation. Relevant labs were NT pro-BNP at 2190 pg/mL, calcium at 11.2 mg/dL, creatinine at 1.0 mg/dL, PTH at 143 pg/mL, and Vitamin D, 25-hydroxy at 48.6 ng/mL. Chest x-ray revealed cardiomegaly with mild pulmonary vascular congestion. Vitals were stable, and the physical exam revealed bilateral lower extremity pitting edema. Her home medication regimen included carvedilol, losartan, and furosemide. The remaining review of systems was largely negative. An 82-year-old female with primary hyperparathyroidism (diagnosed 17 years ago), HFrEF due to non-ischemic cardiomyopathy, sick sinus syndrome with a pacemaker, and persistent atrial fibrillation presented to the emergency department with worsening bilateral lower limb swelling for several months. We present a case of a woman with repeated hospitalizations due to poor volume status control. In patients with these two comorbidities on the opposite ends of the volume spectrum, it can lead to challenges in managing these patients. Patients suffering from heart failure with reduced ejection fraction (HFrEF) on diuretics and PHPT require a delicate balance of their volume status to prevent exacerbation of either condition. Medical management of severe hypercalcemia secondary to PHPT includes IV fluids, cinacalcet, bisphosphonates, and dialysis, while the surgical treatment is parathyroidectomy. These patients are usually conservatively managed and monitored periodically, including bone and kidney health evaluation. Commonly, these cases are asymptomatic and detected incidentally on routine labs. This helps in identifying the type of arrhythmia.Primary hyperparathyroidism (PHPT) is an excessive parathyroid hormone (PTH) production disorder, causing increased calcium levels. It can be worn for several weeks to months.Įlectrophysiological studies are done in cardiac catheterization laboratories. Implantable loop recorder – the ECG recording device is implanted under the skin of the chest and can either continuously record the ECG or be manually triggered during onset of symptoms.The cardiologist will analyze the ECG changes seen with onset of symptoms to pinpoint the type of arrhythmia The person pushes a button with the onset of symptoms and the ECG is then recorded. Event recorder – The portable ECG recording device can be carried in the pocket or strapped to a belt.In some cases where the ECG cannot confirm the diagnosis a 24 to 48 hour cardiac monitoring may be required in the hospital or using an ambulatory cardiac monitoring device like the Holter monitor to check if arrhythmias are associated with other symptoms.
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