In-hospital outcome of patients with cardiogenic shock complicating acute myocardial infarction: results from Royal hospital percutaneous coronary intervention registry, Oman

Objectives: Cardiogenic shock [CS] is still the leading cause of in-hospital mortality in patients presenting with acute myocardial infarction [AMI]. The aim of this study was to determine the in-hospital mortality and clinical outcome in AMI patients presenting with CS in a tertiary hospital in Oman

Methods: This retrospective observational study included patients admitted to the cardiology department between January 2013 and December 2014. A purposive sampling technique was used, and 63 AMI patients with CS admitted to [36.5%] or transferred from a regional hospital [63.5%] were selected for the study

Results: Of 63 patients, 73% [n = 46] were Omani and 27% [n = 17] were expatriates: 79% were male and 21% were female. The mean age of patients was 60 +/- 12 years. The highest incidence of CS [30%] was observed in the 51-60 year age group. Diabetes mellitus [43%] and hypertension [40%] were the predominant risk factors. Ninety-two percent of patients had ST-elevation MI, 58.7% patients were thrombolysed, and 8% had non-ST-elevation MI. Three-quarters [75%] of CS patients had severe left ventricular systolic dysfunction [defined as ejection fraction <30%]. Coronary angiogram showed single vessel disease in 17%, double vessel disease in 40%, and triple vessel disease in 32% and left main disease in 11%. The majority of the patients [93.6%] underwent percutaneous coronary intervention [PCI], among them 23 [36.5%] underwent primary PCI. In-hospital mortality was 52.4% in this study

Conclusions: CS in AMI patients presenting to a tertiary hospital in Oman have high in-hospital mortality despite the majority undergoing PCI. Even though the in-hospital mortality is comparable to other studies and registries, there is an urgent need to determine the causes and find any remedies to provide better care for such patients, specifically concentrating on the early transfer of patients from regional hospitals for early PCI

Multi-factorial causes of torsade de pointes in a hospitalised surgical patient

A 55-year-old chronic alcoholic male known to be positive for human immunodeficiency virus [HIV] was admitted to a surgical ward following perianal abscess drainage. He was noted to have sinus bradycardia, ventricular premature complexes, and mild hypotension. His laboratory investigations revealed mild hypokalaemia. He was intermittently agitated and alcohol withdrawal syndrome [AWS] was diagnosed. Postoperatively, he received intravenous piperacillin/tazobactam and metronidazole infusions along with a small dose of dopamine. Analysis of a 24-hour Holter monitor [ECG] showed a prolonged QT interval with two episodes of self-terminating torsade de pointes. His AWS was treated, hypokalaemia was corrected, and dopamine, along with antibiotics, was withdrawn. There was no recurrence of arrhythmias. This case highlights the importance of avoiding QT-prolonging drugs in hospitalised patients, since hospitalised patients often have multiple risk factors for a proarrhythmic response

Predictive value of a 4-hour accelerated diagnostic protocol in patients with suspected ischemic chest pain presenting to an emergency department

Currently recommended risk stratification protocols for suspected ischemic chest pain in the emergency department [ED] includes point-of-care availability of exercise treadmill/nuclear tests or CT coronary angiograms. These tests are not widely available for most of the ED's. This study aims to prospectively validate the safety of a predefined 4-hour accelerated diagnostic protocol [ADP] using chest pain, ECG, and troponin T among suspected ischemic chest pain patients presenting to an ED of a tertiary care hospital in Oman. One hundred and thirty-two patients aged over 18 years with suspected ischemic chest pain presenting within 12 hours of onset along with normal or non-diagnostic first ECG and negative first troponin T [<0.010 microg/l] were recruited from September 2008 to February 2009. Low-probability acute coronary syndrome [ACS] patients at 4-hours defined as absent chest pain and negative ECG or troponin tests were discharged home and observed for 30-days for major adverse cardiac events [MACE] [Group I: negative ADP]. High-probability ACS patients at 4-hours were defined by recurrent or persistent chest pain, positive ECG or troponin tests and were admitted and observed for in-hospital MACE [Group II: positive ADP]. One hundred and thirty-two patients were recruited and 110 patients completed the study. The overall 30-day MACE in this cohort was 15% with a mortality of less than 1%. 30-days MACE occurred in 8/95 of group I patients [8.4%] and 9/15 of the in-hospital MACE patients in group II. The ADP had a sensitivity of 52% [95% CI: 0.28-0.76], specificity of 93% [0.85-0.97], a negative predictive value of 91% [0.83-0.96], a positive predictive value of 60% [0.32-0.82], negative likelihood ratio of 0.5 [0.30-0.83] and a positive likelihood ratio of 8.2 [3.3-20] in predicting MACE. A 4-hour ADP using chest pain, ECG, and troponin T had high specificity and negative predictive value in predicting 30-day MACE among low probability ACS patients discharged from ED. However, 30-day MACE in ADP negative patients was relatively high in contrast to guideline recommendations. Hence, there is a need to establish ED chest pain unit and adopt new protocols especially adding a point-of-care exercise treadmill test in the ED

Mobile right atrial thrombus with pulmonary thromboembolism in a patient with advanced hepatocellular carcinoma and disseminated tumor thrombosis

We report a 61-year-old male patient who presented with one month history of exertional dyspnea, persistent dry cough, abdominal pain with distension, poor appetite, and weight loss. This case illustrates a rare presentation of hepatocellular carcinoma with mobile right atrial thrombus and pulmonary embolism along with disseminated tumor thrombosis at multiple sites. Furthermore, this case reiterates that an early detection and diagnosis may have increasing importance in the advent of new therapies for treating advanced hepatocellular carcinoma

Very late stent thrombosis of sirolimus-eluting stent 59 months after implantation: a first report from the middle-east and review of literature

Very late stent thrombosis occurs more frequently with drug-eluting stents and trends to occur despite dual antiplatelet therapy or after long periods of clopidogrel discontinuation. Stent thrombosis commonly presents with myocardial infarction or death. We report a 41-year-old male with very late stent thrombosis after 59 months of sirolimus-eluting stent implantation and -49 months after clopidogrel discontinuation despite aspirin continuation, presenting with exertional angina. He underwent successful percutaneous coronary intervention. This case underlines the need for novel stent designs as well as newer therapeutic strategies in preventing very late stent thrombosis among patients receiving drug-eluting stents

Ischemic stroke secondary to aortic dissection following rifle butt recoil chest injury: a case report

Ischemic stroke secondary to aortic dissection is not uncommon. We present a patient with left hemiplegia secondary to Stanford type A aortic dissection extending to the supra-aortic vessels, which was precipitated by rifle butt recoil chest injury. The diagnosis of aortic dissection was delayed due to various factors. Finally, the patient underwent successful Bentall procedure with complete resolution of symptoms. This case emphasizes the need for caution in the use of firearms for recreation and to take precautions in preventing such incidents. In addition, this case illustrates the need for prompt cardiovascular physical examination in patients presenting with stroke

Coronary perforation and covered stents: an update and review

Coronary perforation is a rare complication of percutaneous coronary intervention. We present two different types of coronary intervention, but both ending with coronary perforation. However, these perforations were tackled successfully by covered stents. This article reviews the incidence, causes, presentation, and management of coronary perforation in the present era of aggressive interventionat cardiology. Coronary perforations are classified as type I [extraluminal crater], II [myocardial or pericardial blushing], and III [contrast streaming or cavity spilling]. Types I and II coronary perforations are caused by stiff or hydrophilic guidewires. Type I has a benign prognosis, whereas type II coronary perforations have the potential to progress to tamponade. Type III coronary perforations are caused by balloons, stents, or other intracoronary devices and commonly lead to cardiac tamponade necessitating pericardiat drainage. However, type III perforations can be managed with covered stents without need for surgical intervention

Tricuspid valve endocarditis in an intravenous drug abuser masquerading as pulmonary tuberculosis

Intravenous drug abuse contributes to considerable illness burden in developed and developing countries. Tricuspid valve endocarditis [TVE] is rare in Middle East countries, though many reports of it in intravenous drug abusers are found in other countries. We describe a case of TVE mimicking pulmonary tuberculosis in a 33-year-old man with a history of intravenous heroin use