Yamaguchi syndrome: A mimicer of acute coronary syndrome.

Apical hypertrophic cardiomyopathy is a relatively rare subtype of hypertrophic cardiomyopathy with a wide range of clinical manifestation. The most frequent symptom is chest pain and thus it can mimic the acute coronary syndrome and due to unfamiliarity of this condition by some physicians, the diagnosis is frequently missed or delayed. In this case, report our purpose is to emphasize the importance of keeping apical hypertrophic cardiomyopathy as one of the differential diagnoses in a young patient presented with chest pain.

Perforated cuspal aneurysm of aortic valve following infective endocarditis presenting as complete heart block: a case report and review of literature.

Aortic cuspal aneurysm is a rare clinical entity and often occurs as a complication of infective endocarditis. We report a case of a 30-year-old male with no prior comorbid conditions who presented with fever, acute onset shortness of breath, and chest pain along with multiple episodes of syncope. Electrocardiogram revealed complete heart block while two-dimensional echocardiogram was suggestive of perforated aortic cuspal aneurysm with aortic regurgitation. Blood cultures were positive for Streptococcus viridans. The patient was initiated on broad spectrum antibiotics, temporary pacemaker implantation, and subsequently underwent aortic valve replacement followed by permanent pacemaker implantation after 6 weeks. A diagnosis of perforated aortic cuspal aneurysm subsequent to infective endocarditis was made. This was based on clinical presentation, echocardiographic evaluation, blood cultures, and surgical as well as histopathological findings.

Warfarin-induced diffuse alveolar hemorrhage: Case report and a review of the literature.

Diffuse alveolar hemorrhage (DAH) refers to the intra-alveolar accumulation of blood originating from the pulmonary microvasculature. This life-threatening condition is a medical emergency as patients often develop acute respiratory failure requiring invasive mechanical ventilation. This mandates for an early diagnosis with prompt and aggressive management strategies. A host of clinical disorders are known to cause DAH; however, warfarin-induced alveolar hemorrhage is a distinct clinical rarity. A search of the literature reveals few reports documenting this entity. A 27-year-old male presented with complaints of recent-onset hemoptysis and dyspnea. One month back, he was diagnosed with lower-limb deep-venous thrombosis and pulmonary embolism. He had been taking oral anticoagulants irregularly since then without monitoring of prothrombin time. Chest radiograph, done on presentation, revealed bilateral upper-lobe infiltrates, whereas computed tomography of the chest was suggestive of bilateral upper-lobe ground-glass opacities. Serial bronchoscopic alveolar lavage yielded samples which became progressively bloodier, whereas cytological evaluation of the sample revealed numerous alveolar macrophages with intracytoplasmic hemosiderin. A diagnosis of DAH due to warfarin was made, and the patient was administered Vitamin K followed by infusion of fresh frozen plasma. There was a marked clinical recovery, and the patient has been asymptomatic since then.

Is ambulatory blood pressure measurement a new indicator for survival among advanced heart failure cases.

BACKGROUND: Ambulatory blood pressure monitoring (ABPM) in heart failure is not well defined. However, from the limited studies available, ABPM may be used to optimize heart failure therapy, and as a prognostic marker in this patient group. We analyzed the ABPM values with survival in advanced heart failure with reduced ejection fraction (HFrEF) patients who are on optimal guideline directed medical therapy (GDMT). METHODS AND RESULTS: Hundred patients of advanced HFrEF were followed up for one year. Baseline left ventricular ejection fraction (LVEF), left ventricular end diastolic diamension (LVEDD) and ABPM values were measured and they were analyzed with survival. Deceased patients (n=36) have lower ABPM values and are dippers as compared to living patients (n=64) [24hr systolic blood pressure (SBP24hr)=97.6±12.5mmHg, 24hr diastolic BP (DBP24hr)=64.6±10.2mmHg, decrement in systolic BP (dipSBP)=9.9±5.2mmHg and decrement in diastolic BP (dipDBP)=11.1±6.5mmHg Vs SBP24hr=109.4±16.9mmHg, DBP24hr=71.7±17mmHg, dipSBP=1.6±5.9mmHg and dipDBP=2.7±6.3mmHg] and they were statistically significant with p values<0.001, 0.025, <0.001, and <0.001 respectively. A logistic regression analysis was done to predict one year survival using age, sex, LVEF, LVEDD, SBP24hrs, DBP24hrs, dipSBP, dipDBP and dipMAP as independent predictors. When SBP24hrs is raised by one unit the chances of survival are 1.145 times more(Exp(B)=1.145). One unit dip in SBP and DBP will reduce the chances of survival by 0.697 times and 0.586 times respectively. CONCLUSION: In advanced HFrEF patients with Lower SBP & DBP and dippers have lesser survival compared to those with higher SBP & DBP and non-dippers.

Fractional excretion of sodium and its association with prognosis of decompensated heart failure patients.

INTRODUCTION: Diuretic resistance is a common problem in congestive heart failure patients. It has been defined clinically but can be defined objectively in terms of fractional excretion of sodium (FENa). AIM: Aim of the study was to find out the association of FENa with prognosis of decompensated heart failure patients. MATERIALS AND METHODS: One hundred and seventy eligible patients with a primary diagnosis of decompensated heart failure were enrolled and patients were categorized into two groups on the basis of baseline FENa- Group A (65 patients) with diuretic resistance with FENa <0.2% and Group B (105 patients) sensitive to diuretics with FENa ≥0.2%. The patients were followed-up during the hospital stay for the time taken for improvement from NYHA functional class IV to class II. They were followed telephonically at 30 days post admission for all cause mortality. RESULT: The mean time taken to improve from NYHA functional class IV to class II were 146 hours for FENa<.2% and 60 h for FENa≥0.2% (p<0.0001). There was a fair negative correlation between FENa and time taken for improvement from NYHA functional class IV to class II with correlation coefficient being -0.4842. Multiple linear regression analysis showed FENa (standardized "B" is -0.480, p<0.001) and LVEF (standardized "B" is -0.182, p=0.007) as significant predictors of time taken for improvement from NYHA functional class IV to class II. The 30 days all cause mortality was significantly associated with level of Fena (p <0.001) and was inversely proportional. CONCLUSION: CHF patients with FENa <0.2% takes longer time to recover from NYHA functional class IV to class II. 30 days all cause mortality was also significantly higher among CHF patients with FENa <0.2%.Measuring baseline FENa and regulating diuretic dose accordingly at admission to hospital may probably improve the prognosis of CHF patients.

Mean platelet volume in patients with acute coronary syndromes: a supportive diagnostic predictor.

BACKGROUND: Platelets and their activity have a crucial role in acute coronary events. Larger platelets are enzymatically and metabolically more active and have a higher potential thrombotic ability as compared with smaller platelets. OBJECTIVES: The aim of this study is to investigate whether there is an association between mean platelet volume (MPV) measurement and cardiac Troponin I( cTn I ) in patients admitted with a suspected diagnosis of ACS and to assess the potential diagnostic efficiency of MPV in the diagnostic workup for ACS. MATERIALS AND METHODS: After thorough evaluation of 215 eligible patients, 3 ml. Venous blood collected using Becton, Dickinson and company vacutainer and MPV measured within 1-2 hr of sample collection. Sample for cTn I collected at 6 hr and at 12 hrs, if required and level measured using Biosite analyzer. RESULTS: Mean platelet volume (MPV) was found to be higher among ACS patients as compared to non ACS, 11.44±1.23 vs 9.91±1.27 fl (p-value<0.001). The NPV of MPV in the diagnostic workup of chest pain suggestive of ACS within 6 hours of presentation were found to be 82.53% . CONCLUSION: In this study the MPV is significantly higher in patients with ACS than in those with chest pain of non-cardiac origin and its negative predictive value of 82.53%, it might be useful as an assisting rule-out test in conjunction with other markers in the early prediction of the risk of ACS.

Detection of paroxysmal atrial fibrillation or flutter in patients with acute ischemic stroke or transient ischemic attack by Holter monitoring.

BACKGROUND AND PURPOSE: Paroxysmal atrial fibrillation and flutter are strong risk factors for stroke. Due to high recurrence rate of ischemic events and given the benefit of oral anticoagulation over antiplatelet drugs, it is important to identify this arrhythmia. Unfortunately, paroxysmal AF or flutter is asymptomatic in majority and therefore, difficult to detect. METHODS: Consecutive patients presenting with symptoms of acute ischemic stroke or transient ischemic attack were included. All patients free of AF or flutter on presentation underwent 24 h Holter monitoring within 7 days of admission. RESULTS: Overall, fifty two (52) patients (mean age 59.51 ± 13.45 years) with acute stroke (80.8%) and TIA (19.8%) underwent 24 h Holter monitoring. Paroxysmal AF was detected in 3 cases (5.8%), all 3 patients had acute stroke and were older than age 60 years. Type of stroke was the only factor which was associated with greater risk of having paroxysmal AF or flutter, AF accounted for 50% cases (2 out of 4) of clinically suspected cardio embolic stroke. CONCLUSION: Screening consecutive patients with ischemic stroke with routine Holter monitoring will identify new atrial fibrillation/flutter in approximately one in 17 patients. Older age and type of stroke are strongly associated with increased risk. By carefully selecting the patients, the detection rates could be further increased.

Scimitar syndrome: A rare disease with unusual presentation.

Scimitar syndrome is a rare congenital disorder. It has a varied presentation. In adult life, it usually presents either as recurrent chest infection and/or exertional dyspnea. Pulmonary artery hypertension and hemoptysis both are uncommon features of this syndrome in adult life.