A challenging case due to uncommon aberrancies.

A 71-year-old man was referred to a rapid access chest pain clinic by his general practitioner. He presented with a 6-month history of twice weekly central chest pain lasting 2-3 min with walking and exertion, relieved with rest or co-codamol tablets. After initial investigations and a positive myoview scan, he was listed for an elective coronary angiogram. Unfortunately, the procedure was abandoned due to unclear course of the guide wire and a possible aberrant aortic course. Further non-invasive tests were arranged to clarify the anatomy of the vessels. After getting a clear idea of the aberrancies, coronary angiogram was replanned, and the patient underwent successful angiography with angioplasty to one of the coronary arteries, without any complications.

Left main stem/LCA arising from right coronary sinus with an interarterial course.

A 67-year-old woman presented to the accident and emergency department with central chest pain for the past 4 months. She described the pain as severe, retrosternal, intermittent, indigestion/burning type, with radiations to the left arm. She had used antacids with no relief. Her medical history included hypertension, chronic obstructive pulmonary disease, pulmonary fibrosis, left mastectomy for breast cancer, hypercholesterolaemia and osteoarthritis. Her medications included anastrazole, indapamide, perindopril, aspirin, clopidogrel, atorvastatin, salbutamol and atrovent inhalers. She was a non-smoker and vegetarian. Two brothers each had a myocardial infarction when in their early 40s.

Prevalence and incidence of arrhythmias and sudden death in heart failure.

Patients with heart failure are prone to a variety of arrhythmias, symptomatic and asymptomatic, that are prognostically significant and have an important bearing on the management of these patients. However there are some inherent problems in assessing the frequency of these arrhythmias within a large patient population, due to a lack of uniformity in defining heart failure and the transient nature of these rhythms. Patients with heart failure commonly die suddenly. The causes of these deaths are difficult to ascertain accurately and are often presumed arrhythmic. With the advent of effective interventions to prevent sudden death, accurately defining the causal relationship between the arrhythmias and sudden death has assumed great importance to appropriately target therapy. Several attempts have been made to predict such deaths on the basis of non-invasive and invasive diagnostic investigations with variable success. In this article we review the incidence and prevalence of atrial and ventricular arrhythmias and sudden deaths in epidemiological studies, surveys and randomised control trials of patients with heart failure. We discuss the prognostic significance of these arrhythmias, the inherent problems in their diagnosis and whether their presence predicts the risk of sudden deaths and the mode of such deaths in the heart failure population. The role of various investigations in risk stratification of sudden death has also been discussed.