An unusual case of anomalous origin of the right coronary artery and hepatic focal nodular hyperplasia.

Anomalous origin of the right coronary artery (ARCA) and focal nodular hyperplasia (FNH) are frequently reported in association with congenital heart abnormalities but not with each other. We propose that both conditions may share common origins in a maladative hyperplastic response to differential vascular flow due to developmental arterial malformations or aberrant Notch signalling during simultaneous gut and cardiac vasculorigenesis.

The long-term predictive value of the neutrophil-to-lymphocyte ratio in Type 2 diabetic patients presenting with acute myocardial infarction.

BACKGROUND: Patients with diabetes mellitus have worse long-term outcomes after acute myocardial infarction (AMI) than non-diabetics. This may be related to differential contribution of neutrophil and lymphocyte to inflammation during AMI in diabetics vs. non-diabetics. We aim to determine the predictive value of neutrophil-to-lymphocyte ratio (NLR) for major adverse events post-AMI in Type 2 diabetics vs. non-diabetics. METHODS AND RESULTS: A total of 2559 consecutive patients admitted for AMI (61 ± 14 years, 73% male and 43% diabetic) were analyzed. A complete blood count was obtained and the NLR computed for each patient on admission. Across the cohort, the 1-year reinfarction rate was 8.4% (n = 214) and 1-year mortality was 14.5% (n = 370). Univariate determinants of the composite endpoint included age, hypertension, hyperlipidemia, smoking, revascularization and NLR (P < 0.001 for all). The cohort was divided into NLR quartiles. Admission NLR was significantly higher in the diabetic group, 5.2 ± 5.8 vs. 4.6 ± 5.4 (P = 0.007). A step-wise increase in the incidence of the composite endpoint was noted across NLR quartiles for diabetic subjects; hazard ratio (HR) was 2.41 for fourth vs. first quartile (95% confidence interval = 1.63-3.53, P < 0.001). Multivariate analysis of the diabetic group showed that NLR remains as an independent predictor of the composite endpoint (adjusted HR = 1.53, 95% confidence interval = 1.00-2.33, P = 0.048). However, in non-diabetics, HR for NLR was not significant (P = 0.35). CONCLUSION: Increased NLR post-AMI is an independent predictor of major adverse cardiac events in diabetics. Monitoring this easily obtainable new index allows prognostication and risk stratification.

Risk scoring system for prediction of contrast-induced nephropathy in patients with pre-existing renal impairment undergoing percutaneous coronary intervention.

INTRODUCTION: Baseline renal impairment is the most recognised risk factor for development of contrast-induced nephropathy (CIN) post percutaneous coronary intervention (PCI). We examined the additional risk factors in this high-risk group and aimed to develop a risk model for prediction of CIN. METHODS: A cohort of 770 consecutive patients with existing impaired renal function (estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m2), who received routine prophylactic saline hydration and oral N-acetylcysteine treatment while undergoing PCI between May 2005 to October 2008 in our centre, were enrolled. The study endpoint, CIN, was defined as > 25% increase from baseline creatinine within 48 hours post PCI. RESULTS: Despite routine prophylaxis, CIN occurred in 11.4% of the patients. Important clinical predictors for CIN were age (odds ratio [OR] 1.59, 95% confidence level [CI] 1.0-2.52, p = 0.049), anaemia with haemoglobin < 11 mg/dL (OR 2.26, 95% CI 1.41-3.61, p = 0.001), post-procedure creatinine kinase rise (OR 1.12, 95% CI 1.07-1.16 for every 500 u/L increase, p < 0.001), systolic hypotension with blood pressure < 100 mmHg (OR 2.53, 95% CI 1.16-5.52, p = 0.016) and higher contrast volume. The incidence of CIN was significantly higher in patients with more severe renal failure (6.3%, 17.4% and 40.8% when eGFR was 40-60, 20-40 and < 20 ml/min/1.73 m2 respectively, p < 0.001). A prediction model was developed based on these findings. The incidence of CIN could vary from 2% to > 50% depending on these additional risk profiles. CONCLUSION: Patients with impaired renal function undergoing PCI are at high risk of developing CIN despite traditional prophylaxis. A model of risk prediction could be used to predict its occurrence.

Electrocardiography Series. ECGs of structural heart disease: Part 1.

Electrocardiogram (ECG) is a useful but imperfect investigation in the diagnosis and possible follow-up of structural heart disease such as ventricular hypertrophy. Different ECG criteria with different sensitivity and specificity are available to aid the detection of left or right ventricular hypertrophy. Subsequent echocardiography can help in the quantification of ventricular mass and identification of the aetiology.

Misleading ECG recordings.

Misleading electrocardiogram recordings are not uncommon, and can lead to misdiagnosis. This article highlights two examples and discusses the strategies to recognise them.

A cohort study of risk factors and clinical outcome predictors for patients presenting with unstable angina and non ST segment elevation myorardial infraction undergoing coronary intervention.

INTRODUCTION: Thrombolysis in Myocardial Infarction (TIMI) score has been used to predict outcomes in patients presenting with unstable angina (UA) and non-ST elevation myocardial infarction (NSTEMI). Our study assessed other clinical predictors for patients with UA/NSTEMI undergoing early percutaneous coronary intervention (PCI). MATERIALS AND METHODS: A cohort of 3822 patients presented with UA/NSTEMI from June 2001 to March 2008 in our center were recruited. Patients underwent PCI during admission. We analyzed the potential risk predictors for major adverse cardiac events (MACE) and death at 1 month and 6 month. RESULTS: Median age was 57.1 +/- 11.1, 78.1 percent men, 34.5 percent had diabetes, 58.8 percent had hypertension. Coronary lesions involving left main and proximal left anterior descending artery was 27.6 percent. 36.1 percent had NSTEMI. Significant predictors for mortality at 6 months were age older than 70 years (p = 0.001, OR = 5.5), female gender (p = 0.001, OR = 2.98), anaemia (p < 0.001 OR = 8.47), baseline renal impairment (P < 0.001, OR = 7.38) and development of contrast nephropathy (CIN) which was defined as 25% or 0.5 mg/dl increase from baseline Creatinine within 48 h after PCI (p = 0.005, OR = 5.8). Diabetes was a predictor of MACE at 6 months (p = 0.003, OR = 1.51) but not mortality. CONCLUSIONS: In patients with UA/NSTEMI, our study showed that MACE and mortality were increased in elderly, female and presence of anaemia. Mortality, but not MACE was increased in chronic renal impairment and development of CIN; while diabetes increased only MACE, but not mortality. SUMMARY: We analyzed a cohort of 3822 patients with UA/NSTEMI underwent PCI and found that elderly, female, presence of anemia, diabetes and chronic renal impairment were high risk predictors for adverse clinical outcome. In addition, development of CIN increased mortality.

Managing ventricular ectopics: are ventricular ectopic beats just an annoyance?

How important are PVCs and what should we do about them? PVCs are not a disease in themselves, but a marker of possible underlying conditions that may increase the risk of cardiac death. They serve as a flag to alert us to exclude structural heart disease, the presence of which is the strongest predictor of adverse events. However, it is important to know that PVCs are common in people with no structural heart disease. In this situation, the prognosis is generally excellent. Suppression of PVCs with antiarrhythmic medication is not indicated routinely, unless the patient is symptomatic or at risk of tachycardia-induced cardiomyopathy owing to the very high frequency of PVCs. Where pharmacological therapy has failed, there is now the option of radiofrequency ablation for elimination of frequent symptomatic PVCs. The ECG is a simple yet useful tool to improve risk assessment, especially in those with known cardiovascular disease.

Narrow QRS complex tachycardia presenting as palpitation.

Atrial fibrillation is the most common sustained cardiac arrhythmia. The rhythm in atrial fibrillation is irregular. Correct interpretation of the electrocardiogram (ECG) is essential. Atrial flutter can present as regular or irregular narrow QRS complex tachycardia. Knowledge of the ECG features of atrial flutter will help to differentiate it from paroxysmal supraventricular tachycardia. The treatment strategy in atrial fibrillation should focus on rhythm control vs. rate control, and anticoagulation should be started based on the calculated risk of systemic embolisation. Atrial flutter is a unique arrhythmia that has similar management strategies to those of atrial fibrillation; however, radiofrequency ablation is increasingly preferred due to its higher rate of efficacy and safety compared to pharmacological therapy.

Electrocardiography Series. What is the cause of the regular wide QRS complex tachycardia?

Regular broad QRS complex tachycardias may be ventricular in origin or due to supraventricular tachycardia with aberrancy. Antidromic atrioventricular re-entrant tachycardia occurring in Wolff-Parkinson-White syndrome is a third possibility. The electrocardiogram is a key tool for distinguishing these tachycardias, which have differing causes, prognoses and treatment strategies. Ventricular tachycardia may be monomorphic or polymorphic. The management of ventricular tachycardia depends on clinical symptoms and is influenced by the presence of structural heart disease.

Half-dose ezetimibe add-on to statin therapy is effective in improving resistant hyperlipidaemia in Asian patients with ischaemic heart disease.

INTRODUCTION: Ezetimibe at full dose (10-mg) is used for lipid lowering. We hypothesised that ezetimibe at half dose is effective in achieving percentage improvement in lipid profile among Asian patients with severe hyperlipidaemia. METHODS: This was a prospective cohort study conducted between 2006 and 2008. 105 patients with hyperlipidaemia not reaching target level with statin treatment alone were given add-on ezetimibe 5-mg daily treatment. Lipid profiles were compared at pre- and post-ezetimibe therapy. RESULTS: The mean age of the patients was 56.0 +/- 10.3 years. 79.0 percent were male and 62.9 percent had hypertension, 39 percent had diabetes mellitus with a mean HBA1c of 7.7 percent. 58.1 percent had a history of myocardial infarction. The median simvastatin equivalent dose was 40 (range 5-80) mg. Duration of ezetimibe treatment was 102 +/- 60 days. We observed improvements in total cholesterol (TC) (from 5.31 +/- 1.02 to 4.33 +/- 1.11 mmol/l, 16.4 percent reduction, p-value less than 0.0005), low density lipoprotein (LDL) (from 3.43 +/- 0.87 to 2.52 +/- 0.95 mmol/l, 24.0 percent reduction, p-value less than 0.0005) and TC to LDL ratio (from 4.92 +/-1.42 to 4.03 +/-1.16, 16.2 percent reduction, p-value less than 0.0005). The percentage improvement of lipid profile was comparable to that of the published data based on 10-mg dosing. CONCLUSION: A 5-mg dose of daily ezetimibe add-on treatment is effective in improving lipid profiles in Asian patients with severe hyperlipidaemia not reaching target with statin monotherapy.

Variations of atrioventricular block.

Atrioventricular (AV) block comprises a spectrum of cardiac conduction delays with varying clinical presentations. It is commonly encountered in both hospital as well as ambulatory settings, and recognition of the type of AV conduction delay is essential for appropriate subsequent management. The electrocardiogram is a key tool for identification of patients with AV conduction delays. Contrasting management strategies should be employed for differing levels of conduction block.

Regular narrow complex tachycardia.

We discuss cases of paroxysmal supraventricular tachycardia (PSVT), including the patient's presentations and clinical courses. Correct interpretation of electrocardiogram (ECG) and detailed analyses are important in differentiating the various types of PSVT. This is crucial in the immediate and long-term management of these patients.

ECG delta waves in patients with palpitation.

It is important to recognise Wolff-Parkinson-White (WPW) syndrome in electrocardiograms (ECG), as it may mimic ischaemic heart disease, ventricular hypertrophy and bundle branch block. In addition, ECG can aid in the localisation of the accessory pathway. Recognising WPW syndrome allows for risk stratification, the identification of associated conditions and the institution of appropriate management.

ECG ST segment elevation in patients with chest pain.

We discussed three cases of ST elevation myocardial infarction with ST elevation in the inferoposterior territory and anterior territory, and more uncommonly, concomitant ST elevations in the anterior and inferior electrocardiography (ECG) leads. Correct interpretation of the ECG is crucial in recognising this cardiac emergency, which often necessitates urgent coronary revascularisation. In addition, ECG aids localisation of the infarct-related artery and adds prognostic value.

Contrasting fatty involvement of the right ventricle: lipoma versus lipomatous hypertrophy.

We report two rare cases of right ventricular lipomatous involvement, and discuss their contrasting diagnostic images and clinical manifestations. Case 1 is a 21-year-old Malay man who presented with recurrent syncope. Transthoracic echocardiography showed a homogeneous discrete mass attached to the right ventricular septum, occupying the right ventricular outflow tract. Cardiac magnetic resonance (MR) imaging showed features consistent with intracardiac lipoma, which was confirmed on histology, upon surgical resection. Case 2, a 73-year-old Caucasian woman, was found to have incidental lipomatous infiltration of the right ventricle on echocardiography and MR imaging. In contrast to the well-defined right ventricular lipoma seen in the first case, lipomatous involvement was manifested as a diffuse homogeneous thickening of the right ventricular free wall. Multimodality imaging allows for a complementary and detailed characterisation of lipomatous masses involving the ventricular septum.