Use of drug-eluting versus bare-metal stents in ST-segment elevation myocardial infarction.

The development of drug-eluting stents (DES) is one of the critical milestones in the advances of interventional cardiology. However, clinical stent thrombosis still poses a serious potential complication. In acute ST-segment elevation myocardial infarction (STEMI), acute total vessel occlusion has a larger thrombus burden, and the use of DES in this particular setting raises safety concerns. Published data from randomized, controlled studies, observational studies and recently published meta-analyses mostly support the safety of DES use in acute STEMI. However, these studies have limited study populations and follow-up periods, so the long-term safety of DES in the setting of STEMI is still unclear, and careful consideration should be given in clinical decision-making. In this article we reviewed the findings of randomized and nonrandomized trials on the use of drugeluting versus bare-metal stents in the setting of acute STEMI.

Cardiovascular and endothelial effects of fish oil supplementation in healthy volunteers.

Consumption of fish oil (FO) is associated with reduced adverse cardiovascular events. In a randomized, blinded, placebo-controlled trial, 26 subjects (17 men and 9 women; mean age [+/- SD] 31 +/- 3.7 years) received 1 g FO capsule (n = 14) or placebo (1 g of corn oil, n = 12) for 14 days. At day 0 and day 14, heart rate (HR), blood pressure, endothelium-dependent brachial artery flow-mediated vasodilation (EDV), and endothelium-independent nitroglycerin-mediated vasodilation (EIDV) were assessed with ultrasound. FO supplementation resulted in a significant increase in EDV (20.4% +/- 13.2% vs 9.9% +/- 5.4%; P = .036) and EIDV (32.6% +/- 16.8% vs 18.0% +/- 14.9%; P = .043). Resting HR decreased by a mean of 5.9 +/- 9.4 bpm (FO) compared with placebo (mean increase of 0.73 +/- 4.8 bpm [P = .05]). FO supplementation in healthy subjects is associated with improved endothelial function and decreased resting HR.

Refractory coronary vasospasm following drug-eluting stent placement treated with cyproheptadine.

Serotonin (5-hydroxytryptamine) has been recently shown to be an important mediator of coronary vasospasm. Its divergent effect on normal and atherosclerosed arteries has been demonstrated in both animal and human studies. We present a case of coronary vasospasm in a 55-year-old man with repeated episodes of chest pain following coronary percutaneous intervention. Repeat angiography demonstrated no reocclusion or complication. The patient's symptoms were resistant to treatment with maximum doses of two calcium channel antagonists and oral and intravenous nitrates, but responded to cyproheptadine, a nonselective serotonin antagonist. Currently, there are only two reported cases of coronary vasospasm following balloon angioplasty responding to treatment with serotonin antagonists. This is the first case reported case following drug-eluting stent deployment.

Elevated troponins and the Churg-Strauss syndrome: a case report.

In a patient with persistently elevated troponin levels but normal ischemic work-up, a diagnostic dilemma can ensue. This is the case of a 65-year-old woman whose only cardiac risk factor was age. She presented repeatedly with chest pain, elevated troponins, and consistently elevated eosinophil levels until the fourth admission when she presented with multi-organ abnormalities including asthma and vasculitis that led to the diagnosis of Churg-Strauss syndrome (CSS). Initiation of corticosteroids immediately resolved all of her presenting symptoms; troponin and eosinophil levels quickly normalized. Eosinophilia from CSS can lead to multi-organ damage including the heart. Therefore, one must consider CSS in the differential of eosinophilia as early detection and treatment may be critical in decreasing morbidity and mortality.

Myocardial calcification as a rare cause of congestive heart failure: a case report.

Myocardial calcification is a manifestation of either metastatic or dystrophic calcium deposition in the myocardium. Dystrophic calcification of the myocardium is most commonly seen in long-term survivors of substantial myocardial infarctions. Current literature has reported only 3 cases of myocardial calcification with normal coronary arteries. We present a case of an 80-year-old woman with multiple admissions over a 5-year period for congestive heart failure. She was found to have a normal left ventricular ejection fraction and normal coronary arteries on left heart catheterization. A high resolution computed tomography (CT) study of the chest revealed extensive left ventricular myocardial calcifications, which were not present 4 years earlier on CT. The patient's history and clinical presentation revealed no etiologic factors for her calcified myocardium.

Aortic dissection: a dreaded disease with many faces.

Aortic dissection is a relatively uncommon but catastrophic illness classically thought to present with acute, sharp, chest pain with radiation to the back. However, aortic dissection can manifest in a number of different ways that include congestive heart failure, inferior myocardial infarction, stroke, focal pulse and neurologic deficits, abdominal pain, or acute renal failure. According to some studies, only about 80% of patients with type A dissection present with severe anterior chest pain, and only about 60% describe their pain as being sharp. Another series reports that treating clinicians fail to initially entertain the diagnosis of aortic dissection in up to 35% of cases. Many patients later found to have aortic dissection are initially suspected to have other conditions such as acute coronary syndrome, pericarditis, pulmonary embolism, or even cholecystitis. In this article we present a case of an unusual presentation of aortic dissection and a review of this condition.

Sinus node dysfunction secondary to hyperparathyroidism.

We present two patients who were diagnosed with symptomatic sinus node dysfunction in the setting of hypercalcemia secondary to hyperparathyroidism. An extensive review of the literature has not revealed previous reports of this pathologic process.

Case report: aortic dissection and cystic medial degeneration in a 24-year-old without Marfan syndrome.

The effective management of aortic dissection relies heavily on a high index of suspicion followed by timely definitive diagnosis. Young adults without a history of blunt trauma who are not at risk for atherosclerotic disease may lower this suspicion. We present a 24-year-old patient with complaints of chest pain who presented in multiple urgent care clinics and emergency departments. With a normal chest radiograph, he was repeatedly discharged home on analgesics until a loud murmur was heard. An echocardiogram revealed a dilated aortic root with an intimal flap consistent with a type II dissection. After surgical aortic repair with a Bentall procedure, he was discharged with complete relief of symptoms. Histologic reports revealed cystic medial degeneration. Physical examinations did not demonstrate the phenotypic manifestations of Marfan syndrome. This case illustrates the importance of cardiac auscultation when assessing an individual with chest pain, even with a low likelihood for alteration in arterial structure, and the maintenance of a high index of clinical suspicion despite a normal chest radiograph. We consider this case to be of interest because of its rarity in a 24-year-old.

Electrical storm: case series and review of management.

Electrical storm is defined as a recurrent episode of hemodynamically destabilizing ventricular tachyarrhythmia that usually requires electrical cardioversion or defibrillation. We describe three cases presenting with electrical storm under differing circumstances: (1) a 57-year-old man with ST-elevation myocardial infarction within 1 week of a posterior circulation stroke who developed refractory sustained ventricular tachycardia 10 days after an acute myocardial infarction; (2) a 65-year-old man who developed polymorphic ventricular tachycardia and ventricular fibrillation following dobutamine echocardiography; and (3) a 20-year-old woman who developed intractable ventricular fibrillation following an overdose of a weight-reduction pill. The management of electrical storm is discussed, and evolving literature supporting the routine use of intravenous amiodarone and beta-blockers in place of intravenous lidocaine is critically examined.

Pacing for the suppression of paroxysmal atrial fibrillation in an 87-year-old patient.

BACKGROUND: Sinus node dysfunction, atrioventricular (AV) block and atrial fibrillation (AF) are associated with advanced age. Required therapy commonly includes pacemaker implantation. METHODS: We report the course of therapy for an 87-year-old with symptomatic sinus node dysfunction and paroxysmal atrial fibrillation who was intolerant of drug therapy. RESULTS: The patient received a pacemaker for treatment of sick sinus syndrome. She continued to have symptomatic episodes of AF and was intolerant of pharmacologic therapy despite adequate rate support provided by the pacemaker. The AF suppression algorithm in the pacemaker was enabled, resulting in the elimination all AF episodes effectively eliminating the need for antiarrhythmic medication. If this continues to stabilize her atrium, withdrawal of anticoagulation therapy is anticipated. CONCLUSIONS: The clinical presentation of sinus node dysfunction and related conduction abnormalities is common in the elderly. Pharmacologic management is often a challenge in the presence of the advanced age and concomitant disease processes. In individuals who have paroxysmal atrial fibrillation or are likely to develop this and who need a pacemaker for standard indications, the availability of an AF Suppression algorithm may facilitate their management without needed to use medications or being able to utilize lower doses of those medications.