Abstract 13484: Acute Coronary Syndrome: A Unique Presentation of Libman Sacks Endocarditis

Introduction: Systemic Lupus Erythematosus (SLE) is a chronic inflammatory disease with multiorgan involvement. Cardiac involvement can range from endocarditis to cardiomyopathy. We present a case of SLE complicated by Libman Sacks Endocarditis (LSE) presenting as an acute coronary syndrome (ACS). Case Presentation: A 34 year old male with a history of SLE, DVT/PE, RCA thrombus status post thrombectomy, noncompliance and drug abuse presented to the hospital with complaints of central chest pain associated with right neck, jaw, mouth and arm pain. Vitals were stable. Troponin increased from 0.8 to 13. EKG demonstrated inferior Q waves and ST elevation. CT angiogram was negative for pulmonary embolism but revealed a mobile aortic mass involving the right coronary cusp at the origin of right coronary artery. Transthoracic echocardiogram confirmed this finding. He was started on an infusion of heparin. Surgical evaluation was obtained for emergent thrombectomy and coronary artery bypass grafting. Due to the aortic root thrombus, coronary angiogram was not performed. Lower extremity venous and arterial doppler revealed chronic bilateral DVTs as well as a thrombus in the right common femoral artery. A right heart catheterization demonstrated normal cardiac output and intracardiac filling pressures.Rheumatology was consulted and the patient’s presentation was deemed secondary to Libman sacks endocarditis in the setting of untreated SLE. The pro-coagulant state was chronic and exacerbated secondary to medical noncompliance. Patient was started on hydroxychloroquine with plans for long term anti-coagulation with warfarin in addition to daily aspirin. His symptoms subsided and was discharged home with plans for outpatient follow up. Discussion: Libman sacks endocarditis is a form of noninfectious endocarditis in SLE patients with deposition of thrombi on heart valves. In literature it has been reported to cause valvular dysfunction and cerebrovascular thromboembolism. Our case was unique as it represents a rare manifestation of LSE with an embolic event to a coronary vessel causing ACS. The patient was known to have had prior LSE and due to the complexity of his case and history of medical noncompliance, he was deemed a poor surgical candidate.

Financial Toxicity in Adults With Cancer: Adverse Outcomes and Noncompliance

Purpose: Because of the escalating cost of cancer care coupled with high insurance deductibles, premiums, and uninsured populations, patients with cancer are affected by treatment-related financial harm, known as financial toxicity. The purpose of this study was to describe individuals reporting financial toxicity and to identify rates of and reasons for affordability-related treatment noncompliance. Methods: From May 2010 to November 2015, adult patients (age ≥ 18 years) with cancer were identified from a Health Registry/Cancer Survivorship Cohort. Financial toxicity was defined as agreement with the phrase “You have to pay for more medical care than you can afford” from the Patient Satisfaction Questionnaire-18. Logistic regression and Fisher exact tests were used to compare groups. Results: Of 1,988 participants, 524 (26%) reported financial toxicity. Patients reporting financial toxicity were more likely age 65 years or younger, female, nonwhite, non-English speaking, not married, less educated, and to have received a diagnosis more recently (all P < .001). Participants with financial toxicity were more likely to report noncompliance with medication, owing to inability to afford prescription drugs (relative risk [RR], 3.55; 95% CI, 2.53 to 4.98), and reported forgoing mental health care (RR, 3.89; 95% CI, 2.04 to 7.45), doctor’s visits (RR, 2.98; 95% CI, 1.97 to 4.51), and medical tests (RR, 2.54; 95% CI, 1.49 to 4.34). The most endorsed reasons for delayed care were not having insurance coverage and being unable to afford household expenses. Conclusion: More than 25% of adults with cancer reported financial toxicity that was associated with an increased risk for medical noncompliance. Financial toxicity remains a major issue in cancer care, and efforts are needed to ensure patients experiencing high levels of financial toxicity are able to access recommended care.

Loss of the Imagined Past: An Emotional Obstacle to Medical Compliance in Kidney Transplant Recipients

Among kidney transplant recipients, the concepts of grief and bereavement have been considered in terms of graft rejection, side effects of drugs, or death of the donor. However, our research suggests that even after a successful kidney transplantation, patients may present with feelings of bereavement, grief, or low mood, which may appear paradoxical because they have just received a much desired transplant. This sense of bereavement should be considered in terms of an imagined past, which may help to understand the patient's current mood changes and medical noncompliance. In the case report presented here, we have used the concept of systemic integrative psychotherapy to analyze change in a patient's life. Based on our research, we suggest that feelings of bereavement and grief are generated as patients come to terms with their past, which has been irretrievably lost to chronic illness, and contemplate their future. Feelings of grief and bereavement in the posttransplant period may be due to the loss of an imagined past, and must be differentiated from the bereavement the patient feels for the donor and the donor family. These feeling of loss, if not resolved, may lead to social isolation and medical noncompliance.