Three-year experience of primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction in a hospital without on-site cardiac surgery

<p><b>INTRODUCTION</b>Primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) in hospitals without on-site cardiac surgery capability, despite receiving only a class IIb recommendation in the ACC/AHA practice guidelines, can be performed effectively and safely. We reviewed the fi rst 3 years of our experience.</p><p><b>MATERIALS AND METHODS</b>This is a retrospective single centre review of all patients receiving primary PCI for STEMI between 2003 and 2005. Demographic, procedural and outcome data were analysed.</p><p><b>RESULTS</b>There were 259 patients who underwent primary PCI. The mean age was 55.3 +/- 12.3 years. Median door-to-balloon time was 97.5 minutes and 45.2% and 52.9% had anterior and inferior STEMI, respectively. The majority of patients presented with Killip class I (87.6%); however, 5.8% were in Killip class IV. Single vessel disease was found in 47.1%. Angiographic PCI success (defined as residual stenosis <50% with TIMI 3 fl ow) was achieved in 89.1%. Usage of stents, distal protection and aspiration devices were 97.2%, 27.8% and 34.1 %, respectively; 9.3% required intra-aortic balloon pump insertion. No patients required transfer for emergency coronary bypass surgery as a result of PCI complications. Post-PCI ST resolution >50% was achieved in 80.6%. The mean post-infarct left ventricular ejection fraction was 44.1%. In-hospital, 30-day, 6-month and 1-year mortality rates were 2%, 2.8%, 4.0% and 4.8%, respectively. Clinically driven target lesion revascularisation rate was 2.8% at 1 year.</p><p><b>CONCLUSIONS</b>Our results are comparable to those from on-site surgical centres. This supports the feasibility and safety of primary PCI in cardiac centres without on-site cardiac surgery.</p>

Presumed dapsone-induced drug hypersensitivity syndrome causing reversible hypersensitivity myocarditis and thyrotoxicosis

<p><b>INTRODUCTION</b>A 22-year-old Malay soldier developed dapsone hypersensitivity syndrome 12 weeks after taking maloprim (dapsone 100 mg/pyrimethamine 12.5 mg) for anti-malarial prophylaxis.</p><p><b>CLINICAL PICTURE</b>He presented with fever, rash, lymphadenopathy and multiple-organ involvement including serositis, hepatitis and thyroiditis. Subsequently, he developed congestive heart failure with a reduction in ejection fraction on echocardiogram, and serum cardiac enzyme elevation consistent with a hypersensitivity myocarditis.</p><p><b>TREATMENT</b>Maloprim was discontinued and he was treated with steroids, diuretics and an angiotensin-converting-enzyme inhibitor.</p><p><b>OUTCOME</b>He has made a complete recovery with resolution of thyroiditis and a return to normal ejection fraction 10 months after admission.</p><p><b>CONCLUSION</b>In summary, we report a case of dapsone hypersensitivity syndrome with classical symptoms of fever, rash and multi-organ involvement including a rare manifestation of myocarditis. To our knowledge, this is the first case of dapsone-related hypersensitivity myocarditis not diagnosed in a post-mortem setting. As maloprim is widely used for malaria prophylaxis, clinicians need to be aware of this unusual but potentially serious association.</p>