Clinical perspectives of statin-induced rhabdomyolysis.

Fear of muscle toxicity remains a major reason that patients with hyperlipidemia are undertreated. Recent evaluations of statin-induced rhabdomyolysis offer new insights on the clinical management of both muscle symptoms and hyperlipidemia after rhabdomyolysis. The incidence of statin-induced rhabdomyolysis is higher in practice than in controlled trials in which high-risk subjects are excluded. Accepted risks include age; renal, hepatic, and thyroid dysfunction; and hypertriglyceridemia. New findings suggest that exercise, Asian race, and perioperative status also may increase the risk of statin muscle toxicity. The proposed causes and the relationship of drug levels to statin rhabdomyolysis are briefly reviewed along with the problems with the pharmacokinetic theory. Data suggesting that patients with certain metabolic abnormalities are predisposed to statin rhabdomyolysis are presented. The evaluation and treatment of patients' muscle symptoms and hyperlipidemia after statin rhabdomyolysis are presented. Patients whose symptoms are related to other disorders need to be identified. Lipid management of those whose symptoms are statin-related is reviewed including treatment suggestions.

A case of mesothelial/monocytic cardiac excrescence causing severe acute cardiopulmonary failure.

Mesothelial/monocytic incidental cardiac excrescence (MICE) is a benign lesion composed of a haphazard mixture of mesothelial cells, histiocytes, and fibrin, often found incidentally during cardiac valve replacement. Its pathogenesis is controversial with some authors favoring an artifactually produced amalgam while others espoused a reactive phenomenon. Clinically, this entity is important because of potential misdiagnoses as malignancies. We report a case in a 65-year-old man with severe acute aortic regurgitation. A 2.0-cm mobile aortic valve vegetation was documented by transesophageal echocardiography prior to any cardiac instrumentation. At surgery, the lesion was immediately visualized together with free-floating vegetation in the left ventricular outflow tract. Routine and immunohistochemical examination showed a nodule composed of predominantly histiocytes and mesothelial cells, together with fibrin and scattered neutrophils. To our knowledge, this is the first reported case of a mesothelial/monocytic cardiac excrescence causing acute cardiopulmonary failure. The literature on MICE is reviewed with discussion of its etiology.