Complete heart block and polymorphic ventricular tachycardia complicating myocardial infarction after occlusion of the first septal perforator with coronary stenting.

We report a case of complete heart block (CHB) and polymorphic ventricular tachycardia (VT) which was associated with a modest-sized myocardial infarction (MI) following incidental occlusion of the first septal perforator (FSP) branch after stent deployment to the left anterior descending (LAD) coronary artery. These complications were successfully treated with temporary pacing and subsequently resolved with spontaneous recanalization of the first septal perforator. This case represents an interesting product of medical progress which defies the adverse natural history and poor prognosis of anteroseptal MI associated with CHB due to the small amount of myonecrosis associated with this event.

Pericarditis causing exercise test induced ST-elevations.

Pericarditis has not been well associated with exercise test induced ST-elevations. This case report of a pericarditis patient who underwent exercise stress testing and other similar cases found in the literature suggest that this is an unrecognized clinical manifestation of pericarditis.

Syncope in the emergency department. A cardiologist's perspective.

Syncope is a common emergency department presentation. Syncope is a benign condition in many cases but has a poor prognosis in a number of cardiac disorders. An awareness of the serious conditions that may present as syncope and use of a systematic approach will yield a diagnosis for most patients; however, some patients remain without a diagnosis. Expending large amounts of resources for these patients often is unnecessary.

Time-frequency analysis of ECG for late potentials in sudden cardiac death survivors and post-myocardial infarction patients.

Late potentials (LPs) are harbingers of sudden cardiac death (SCD) for certain patient populations, including SCD survivors and patients post myocardial infarction. This retrospective study examined the sensitivity and specificity of time-frequency distributions (TFDs) in detecting late potentials in 90 patients using time-domain signal average ECG criteria as a standard for comparison. Three time-domain criteria were employed: QRS duration > 114 msec; LAS > 30 msec; and RMS40 < 20 microV. Time domain criteria were compared with TFD results derived using the binomial transform. TFDs were considered positive if small magnitude (-30 dB) signals > 40 Hz were present 114 msec after the onset of the QRS complex. Results from the binomial transform are comparable to those from the SAECG method (sensitivity = 92.0-100%, specificity = 78-92%).

Predicting and preventing sudden death from cardiac causes.

Sudden cardiac death usually occurs secondary to a ventricular tachyarrhythmia. Even under ideal circumstances only 20% of patients who have an out-of-hospital cardiac arrest survive to hospital discharge. Therefore, aggressive treatment and screening of high-risk patients are mandatory to improve survival rates. Risk stratification of high-risk patients, such as the post-myocardial infarction (MI) population, has been of limited value. Between 70% and 85% of "high-risk" post-MI patients, as defined by these screening tests, will not have a sustained ventricular tachyarrhythmia over several years of follow-up. The use of beta-blockers and possibly amiodarone may have some benefit in reducing mortality in high-risk patients after an MI. Several ongoing trials are studying the use of serial drug testing, amiodarone, and implantable cardioverter-defibrillators in reducing the incidence of sudden cardiac death in patients with potentially lethal ventricular arrhythmias. Although implantable cardioverter-defibrillators appear to be superior to antiarrhythmic drugs in reducing sudden cardiac death, total mortality may not be altered. In sustained ventricular tachyarrhythmias, sotalol and amiodarone appear to be superior to other drugs in preventing arrhythmia recurrence. Ongoing trials, such as the Antiarrhythmic Drug versus Implantable Device (AVID) trial may define the best strategy in these high-risk patients.

Effect of magnesium sulfate on ventricular rate control in atrial fibrillation.

STUDY OBJECTIVES: The objectives of this study were to assess the efficacy of parenteral magnesium sulfate (MgSO4), digoxin, and combined MgSO4-digoxin therapies in acutely lowering ventricular rates in patients with newly recognized atrial fibrillation. DESIGN: A randomized, double-blinded, placebo-controlled clinical study. SETTING: US Army tertiary care facility. PARTICIPANTS: Fifteen adults (mean age, 62 +/- 19 years) presenting with newly recognized atrial fibrillation and rapid ventricular rate (more than 99). INTERVENTIONS: Patients were given an initial parenteral MgSO4 bolus with continuous infusion or placebo. After 30 minutes, all patients were given 0.5 mg IV digoxin and followed for 3.5 hours. MEASUREMENTS AND MAIN RESULTS: Ventricular rates were obtained at baseline, every 5 minutes for the first 30 minutes, and then every 30 minutes for 3.5 hours. At 5 minutes, ventricular rates decreased 16 +/- 7% (P < .02) with MgSO4; this was comparable with rate control with digoxin (18 +/- 9%) at 4 hours. Rate control tended (26 +/- 7%) to improve with combined therapy. CONCLUSION: Parenteral MgSO4 may be useful in the acute management of rapid ventricular rates in patients with atrial fibrillation.

Provocation of atrioventricular reentry tachycardia: a paradoxical effect of adenosine.

Adenosine has been used to diagnose latent preexcitation in patients with the Wolff-Parkinson-White syndrome. A case is reported in which intermittent preexcitation had been previously observed, however only retrograde accessory pathway conduction was documented at the time of invasive electrophysiological study. Administration of intravenous adenosine during sinus rhythm resulted in provocation of orthodromic atrioventricular reentry tachycardia.

Malignant fibrous histiocytoma manifesting as a cavitary lung metastasis.

Exploration prompted by acute abdominal symptoms in a 29-year-old woman discovered to have an asymptomatic right upper lobe cavitary lesion disclosed a malignant fibrous histiocytoma, the primary lesion of which was in the duodenum. At autopsy, the lung lesion was found to be metastatic. We believe this is the first recorded instance of cavitary lung metastasis from this type of tumor.

Benign intracranial hypertension, monoclonal gammopathy, and superior sagittal sinus thrombosis.

We report a case of benign intracranial hypertension associated with monoclonal gammopathy. The course was complicated by superior sagittal sinus thrombosis which we believe to be related to acetazolamide therapy. Response to volume expansion with colloid and crystalloid solutions was dramatic.

Pericarditis in the patient with uremia: clinical and echocardiographic evaluation.

Over a 4-year period, 94 of 248 patients with end-stage renal disease were evaluated echocardiographically because of clinically suspected pericarditis. The clinical diagnosis was established in 39 patients based on the development of a friction rub at some time during their course. 15 of the 55 patients, in whom the diagnosis of pericarditis could not be established, had a small pericardial effusion. The rest had no pericardial fluid. 15 patients developed pericarditis prior to the initiation of dialysis and all responded to dialysis alone. 4 had no effusions, 3 had small effusions and 8 had moderate or large effusions. In 9 of 24 dialysis patients with pericarditis, a presumptive etiology other than uremia was identified. In these 24 patients, 9 had no effusions, 2 had small effusion and 13 had moderate or large effusions. Only 9 patients, all with moderate or large effusions, required operation. The data suggest that: t1) pericarditis present at the initiation of dialysis regularly resolves with dialysis; (2) specific etiologies are common; (3) small pericardial effusions are common in dialysis patients without pericarditis; (4) pericardial effusions are frequently not present in uremic patients with pericarditis and, (5) the size of the pericardial effusion is of some value in predicting which patients may subsequently require operative intervention.

Echocardiography in the diagnosis of pericarditis in patients with uremia.

Uremic pericarditis occurred in 39 uremic patients who were treated in our program during a 4 yr period. The diagnosis was considered, but could not be established, in an additional 55 patients. A presumptive etiology remediable to a specific plan of treatment was identified in 9 patients who developed pericarditis following the initiation of dialysis. Uremic pericarditis occurring in patients who had yet been dialyzed, regularly responded to aggressive dialysis treatment. Echocardiography was the single, most important test to evaluate patients with suspected pericarditis. Limited pericardiectomy was safe and effective treatment in those patients not responding to conservative management.