Among Unstable Angina and Non-ST-Elevation Myocardial Infarction Patients, Transient Myocardial Ischemia and Early Invasive Treatment Are Predictors of Major In-hospital Complications.

BACKGROUND: Treatment for unstable angina (UA) or non-ST-elevation myocardial infarction (NSTEMI) is aimed at plaque stabilization to prevent infarction. Two treatment strategies are (1) invasive (ie, cardiac catheterization laboratory <24 hours after admission) or (2) selectively invasive (ie, medications with cardiac catheterization laboratory >24 hours for recurrent symptoms). However, it is not known if the frequency of transient myocardial ischemia (TMI) or complications during hospitalization varies by treatment. PURPOSE: We aimed to (1) examine occurrence of TMI in UA/NSTEMI, (2) compare frequency of TMI by treatment pathway, and (3) determine predictors of in-hospital complications (ie, death, myocardial infarction [MI], pulmonary edema, shock, dysrhythmia with intervention). METHODS: Hospitalized patients with coronary artery disease (ie, history of MI, percutaneous coronary intervention/stent, coronary artery bypass graft, >50% lesion via angiogram, or positive troponin) were recruited, and 12-lead electrocardiogram Holter initiated. Clinicians, blinded to Holter data, decided treatment strategy; offline analysis was done after discharge. Transient myocardial ischemia was defined as more than 1-mm ST segment ↑ or ↓, in more than 1 electrocardiographic lead, more than 1 minute. RESULTS: Of 291 patients, 91% were white, 66% were male, 44% had prior MI, and 59% had prior percutaneous coronary intervention/stent or coronary artery bypass graft. Treatment pathway was early in 123 (42%) and selective in 168 (58%). Forty-nine (17%) had TMI: 19 (15%) early invasive, 30 (18%) selective (P = .637). Acute MI after admission was higher in patients with TMI regardless of treatment strategy (early: no TMI 4% vs yes TMI 21%; P = .020; selective: no TMI 1% vs yes TMI 13%; P = .0004). Predictors of major in-hospital complication were TMI (odds ratio, 9.9; 95% confidence interval, 3.84-25.78) and early invasive treatment (odds ratio 3.5; 95% confidence interval, 1.23-10.20). CONCLUSIONS: In UA/NSTEMI patients treated with contemporary therapies, TMI is not uncommon. The presence of TMI and early invasive treatment are predictors of major in-hospital complications.

Pericarditis as initial manifestation of proximal aortic dissection in young patients.

Pericarditis was the primary manifestation of aortic dissection in these 2 young men. Both patients had no phenotypic characteristics of Marfan or Ehlers-Danlos syndrome. These patients had pleuritic chest pain and characteristic electrocardiographic changes consistent with pericarditis. However, timely performed transthoracic echocardiograms revealed proximal aortic dissection with hemopericardium noted at surgery in both cases. Although the sensitivity of transthoracic echocardiogram for proximal aortic dissection is approximately 60%, certain findings can alert the physician to the possibility of aortic dissection. Therefore, in young patients with suspected pericarditis, a timely performed transthoracic echocardiogram should include a careful evaluation of the ascending aorta and arch to rule out this lethal diagnosis.

The use of the Doppler pulmonary artery velocity time integral to optimize placement of a ventricular pacing lead in a patient with Ebstein's anomaly.

Ebstein's anomaly is a rare congenital heart defect. Patients with severe symptomatic tricuspid regurgitation requiring surgical correction often have conduction system disease. We present a case of a 14 year-old girl with Ebstein's malformation and bioprosthetic tricuspid valve who required permanent pacing for symptomatic bradycardia. The placement of the right ventricular pacing lead was facilitated by the use of the Doppler pulmonary artery velocity time integral as a surrogate for stroke volume. This case demonstrates the importance of site-specific pacing and the utility of Doppler echocardiography to optimize lead placement and cardiac performance in patients with Ebstein's anomaly and advanced conduction system disease.

Pacemaker lead infection secondary to Haemophilus parainfluenzae.

Cardiac device infections are a rare complication of pacing and defibrillator therapy. The number of implanted devices will likely continue to rise with increasing implantation of the cardioverter defibrillator and cardiac resynchronization devices. This report describes a case of an uncommon pathogen for device-associated endocarditis.

AIDS associated with severe cor pulmonale and large pericardial effusion with cardiac tamponade.

Cardiac involvement in patients with advanced HIV/AIDS is common, including pericardial effusion and pulmonary hypertension. Although there is an increased incidence of pericardial effusion in patients with AIDS, most are small and asymptomatic. The presence of a pericardial effusion and/or pulmonary hypertension is associated with shortened survival. We present a case of a 43-year-old man with AIDS and advanced cardiovascular involvement who developed severe cor pulmonale and a large pericardial effusion with cardiac tamponade.

Use of intracardiac echocardiography in guiding radiofrequency catheter ablation of atrial tachycardia in a patient after the senning operation.

A patient with D-transposition of the great arteries developed drug refractory atrial tachycardia 12 years after a Senning operation. Electrophysiological study confirmed the presence of atrial baffle-tricuspid valve isthmus dependent reentrant intraatrial tachycardia. Intracardiac echocardiography facilitated initial identification of structures, catheter positioning, and identification of the atrial baffle-tricuspid valve isthmus.