Hospital Chronicles (E-Journal)
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Left Main Coronary Artery Bifurcation Thrombus Interventionally Removed
Get PDFA 43-year-old male heavy smoker presented with acute inferolateral myocardial infarction. Coronary angiography showed a thrombus mounted upon the carina of the left main coronary artery (LMCA) bifurcation, protruding into the origin of the left anterior descending (LAD) coronary artery and completely occluding the left circumflex (LCX). There followed immediate thromboaspiration of the LAD thrombus. The LCX remained completely obliterated. A glycoprotein IIb/IIIa inhibitor was given for 48 hours and the patient received dual antiplateled treatment. On the eighth day, a repeat coronary angiogram was obtained, which showed patent LMCA and LAD while the LCX was now visible and patent with a TIMI III flow and no sign of thrombus
Effect of Transient Myocardial Ischemia on QT Interval Dispersion Among Patients with Unstable Angina
Get PDFObjective: Our aim was to examine the effect of transient myocardial ischemia on QT interval and QT interval dispersion in patients presenting with unstable angina.Methods: We studied 31 patients (mean age 64±10, 22 men, 16 with an old myocardial infarction, 6 with previous coronary bypass surgery) admitted with unstable angina manifestations. Patients with a history of complex ventricular ectopy, malignant ventricular arrhythmias, advanced congestive heart failure or antiarrhythmic drug therapy were excluded. The uncorrected and corrected QT interval and QT dispersion were measured during angina as well as after the relief of pain.Results: The RR intervals were not significantly changed by the ischemic event (879±121 ms at rest to 877±173 ms during angina). However, both the uncorrected and corrected QT intervals were significantly increased during angina (from 410±45 ms and 440±41 ms at rest to 425±53 ms and 460±42 ms during angina respectively, p<0.05 for both). Similarly, both the uncorrected (QTd) and the corrected (QTcd) QT dispersion values were significantly prolonged during ischemia (QTd: 58±23 ms at rest to 83±33 ms during ischemia, p<0.001, QTcd: 63±26 ms at rest to 95±36 ms during ischemia, p<0.001). The observed increment in the QTd and QTcd provoked by ischemia was not different among the unstable angina patients with and without old myocardial infarction.Conclusion: Transient myocardial ischemia besides an increase in the QT and QTc intervals provokes an increase in both the corrected and uncorrected QT interval dispersion. Under certain circumstances, this may contribute to the genesis of serious reentry ventricular arrhythmias
Pseudomyxoma Peritonei Presenting as Acute Appendicitis: Clinical and Imaging Findings
Get PDFA 30-year old man presented with symptoms and signs of acute appendicitis. Abdominal imaging via ultrasound and computed tomography detected a mass in the right iliac fossa. Exploratory laparotomy revealed an appendiceal mass and gelatinous peritoneal fluid, while histopathology confirmed the diagnosis of pseudomyxoma peritonei arising from a mucocele of the appendix and attributed to an appendiceal cystadenocarcinoma. The clinical and imaging findings of this rare case are herein presented
Cardiopulmonary Resuscitation Update
Get PDFBACKGROUND AND OBJECTIVES: Every 5 years experts, after reviewing literature and scientific evidence, update the guidelines on Cardiopulmonary resuscitation (CPR). The objective of this report is to review the main changes in resuscitation that occurred over the last 5 year period. CONTENTS: High-quality chest compressions with adequate rate and depth allowing full recoil of the chest with minimal interruptions is the mainstay of the recommended changes. The 30:2 compression ventilation ratio is maintained, but the former order is modified chest compressions first, followed by airway and breathing (C-A-B instead of A-B-C). Avoiding of excessive ventilation is also recommended. Chest compressions-only CPR in primary cardiac arrest victims, is an option for rescuers who are unable or unwilling to perform mouth to mouth ventilation. Advanced life support algorithm is simplified (regarding drugs, routes of administration, endotracheal intubation). Acute coronary syndromes (ACS) treatment has also been updated. Better practices for teaching and learning resuscitation skills are addressed. CONCLUSIONS: Updating CPR guidelines is important, and continuous education is recommended. This will improve the quality of resuscitation and survival of patients in cardiac arrest
Eplerenone Survival Benefits in Heart Failure Patients Post-Myocardial Infarction
Get PDFReduced left ventricular ejection fraction (≤40%) and/or signs of clinical heart failure after acute myocardial infarction (AMI) are associated with a relatively high incidence of mortality and hospitalization for heart failure. The potential of eplerenone to impact on mortality and morbidity of post-infarction heart failure patients was the subject of the EPHESUS trial (Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study). That trial concluded that eplerenone reduced total mortality by 31%, cardiovascular mortality by 32% and sudden cardiac death by 37% within 30 days of randomization after AMI. Risk reduction in mortality with eplerenone seemed to occur as early as 10 days after randomization and continued through the end of the study. In conclusion, eplerenone improves survival in heart failure patients post-AMI
Hypertension Control: J-Curve Revisited
Get PDFOver the last three decades there is an increasing number of investigators and meta-analyses focusing on the dangers of lowering blood pressure below certain levels. Several studies such as Invest, Ontarget, Value and TNT showed a significant decrease in cardiovascular morbidity and mortality by lowering blood pressure levels. However, blood pressure decrease below a certain level had exactly the opposite effect. The increase of cardiovascular morbidity and mortality was attributed to the excessive reductions in blood pressure which may explain why in major clinical trials blood pressure below certain levels increases cardiovascular adverse events mainly in patients with coronary heart disease. In these patients a fall in diastolic blood pressure might lower perfusion pressure distal to a stenosis below a critical level at which autoregulation is effective. This phenomenon led the European Society of Hypertension to propose a "J-shaped curve" relationship between blood pressure and cardiac morbidity and mortality, whereby lowering blood pressure below a critical point is no longer beneficial and possibly even deleterious. The challenge is to better define the limits of intervention and to define groups of people who are particularly vulnerable to over-aggressive lowering of blood pressure
Side Effects and Complications of Magnetic Resonance Contrast Media
Get PDFContrast media used in radiology are iodine based for computed tomography (CT) examinations and gadolinium based for magnetic resonance imaging (MRI) examinations. Initially, gadolinium based contrast media were thought to be safe and non-nephrotoxic. Later on, several studies revealed that they can also be nephrotoxic at increased doses. Additionally, another complication from their use is systematic nephrogenic fibrosis. Gadolinium based contrast media can be safe in healthy and renal insufficiency patients if used at specific doses. These complications are herein briefly reviewed and guidelines and techniques for their avoidance are discussed
Door-to-Balloon Time for Primary Percutaneous Coronary Intervention in Acute Myocardial Infarction
Get PDFΙt has become clear, recently, that reperfusion by primary coronary intervention in patients with ST elevation myocardial infarction (STEMI) is superior to thrombolytic therapy and is the treatment of choice. However, this reperfusion strategy has some drawbacks, as cardiac catheterization laborato-ries are not always widely available 24h/7d and long-time delays related to primary percutaneous coronary intervention (pPCI) may have negative impact on mortality. The shorter the delay from symptom onset to reperfusion, the greater the amount of the myocardium rescued as it is obvious that “time is muscleâ€. Among pPCI related times the crucial time delay is the one from door–to-balloon (time from arrival at the hospital until the mechanical restoration of the vessel patency).This time delay is usually accurately recorded and depends on the national (or even local) health care system. The European Society of Cardiology guidelines on myocardial revascularization suggest that total ischemic time should not exceed 120min and especially 90min for patients <65 years old, with anterior infarction and early presentation (<2h) from onset of symptoms, because these categories of patients have even worse outcomes and increased mortality with prolonged door-to-balloon times, compared to other categories. Better patient education about symptoms suggesting myocardial ischaemia, pre-hospital diagnosis of STEMI based on 12-lead electrocardiogram with immediate transportation to a PCI-capable centre in order to eliminate inter-hospital delays, an effective emergency medical system capable of quick transportation, immediate activation of the cardiac catheterization laboratory from emergency physicians or an attendant cardiologist, the presence of an experienced team of high volume operators and skilled supporting staff capable of performing pPCI 24h/7d, new and more effective antithrombotic drugs and angioplasty materials, are the key elements to achieve shorter door-to-balloon and PCI delay times and therefore rescue the greater amount of myocardium and reduce mortality
Anomalous Left Circumflex Coronary Artery: Not Always Benign. A Worm-Like Thrombus Can Be Housed in This Most Common Coronary Anomaly
Get PDFA case of an anomalous left circumflex (LCx) coronary artery originating from the right coronary ostium is presented in a patient with acute myocardial infarction, whereby a long worm-like thrombus was retrieved from the proximal segment of this artery, which was subsequently stented. This case illustrates that the anomalous LCx is not always benign, and may well predispose to an acute coronary syndrome, requiring interventional management
Access to Affordable Highly Active Anti–Retroviral Therapy (HAART) for HIV/AIDS Patients. Where Do We Stand?
Get PDFAbstract Background: The human immunodeficiency virus (HIV) epidemic remains a major global public health challenge, with a total of 33.4 million people living with HIV worldwide. In 2008 alone, 2.7 million people were newly infected with HIV. Unfortunately, the majority of patients with HIV infection worldwide live in resource poor areas were access to therapy is severely limited. Objective: This review summarizes the progress noted during the recent years concerning antiretroviral therapy scale-up in resource-limited settings and analyzes the economic, social and legal framework of services already provided. Results: The 2010 WHO report states that among 144 low- and middle-income countries reporting program data, eight had already achieved universal access to antiretroviral therapy at the end of 2009, providing treatment to at least 80% of patients in need. Furthermore, 15 countries had achieved the 80% target for coverage with antiretroviral prophylaxis to prevent mother to child transmission of HIV. An increase of over 1.2 million people, including women and children receiving antiretroviral therapy was noted by the end of 2009. Health care facilities have expanded and as a result, the average number of people receiving therapy per health care facility has increased. Moreover, task shifting has been applied, with promising results. Conclusions: Although there is considerable room for improvement, HIV programs have had a positive impact on equal, affordable and early antiretroviral therapy provision to those who need it most. Special approaches though, remain necessary to address the particular circumstances and needs of those populations at greater risk for HIV infection. Rights-based national strategies must include special efforts to reach the poorest and those who are socially excluded. Interventions must be designed and implemented in ways that ensure equity in access for all