Acute myocardial infarction, associated with the use of a synthetic adamantyl-cannabinoid: a case report.

BACKGROUND: "Legal highs" are novel psychoactive substances that have evaded statutory control. Synthetic cannabinoid compounds with adamantane moieties have recently been identified, which have high potency at target receptors and are undetectable on conventional toxicology testing. However, little is known about any harmful effects, and their potential to cause serious ill health. We describe a case of myocardial infarction following the use of this class of drug. CASE PRESENTATION: We report the case of a 39-year-old man admitted after an out-of-hospital cardiac arrest, in whom ECG and elevated cardiac enzymes confirmed ST-elevation myocardial infarction. Normal coronary perfusion was restored after thrombectomy and coronary artery stenting. In the hours preceding his admission, the patient is known to have consumed the legal high product "Black Mamba". Subsequent urine testing confirmed the presence of an adamantyl-group synthetic cannabinoid, whilst cannabis, cocaine, amphetamines and other drugs of abuse were not detected. CONCLUSION: The use of legal highs is being increasingly recognised, but the chemical compositions and physiological effects of these drugs are poorly characterised and are continually changing. Synthetic cannabinoids, rarely identified on toxicological testing, can be linked to serious adverse cardiovascular events. This case highlights the importance of testing for novel psychoactive compounds, and recognising their potential to cause life-threatening conditions.

Time trends of gender-based differences in lipid goal attainments during secondary prevention of coronary artery disease: results of a 5-year survey.

Coronary artery disease is the leading cause of death in both men and women worldwide. Little is known about gender-based differences in lipid goal attainment during secondary prevention of coronary artery disease. We conducted this study to analyze gender differences in low-density lipoprotein cholesterol target attainment in secondary prevention after acute myocardial infarction over a 5-year period. In this retrospective study, the electronic database of lipid clinic at a single center was used as the data source. Temporal trends and gender differences in demographics, lipid profile, and medication use were determined. Goal low-density lipoprotein (LDL) was defined per National Cholesterol Education Program ATP III guidelines.A total of 1365 patients (823 males, 542 females) constituted the study sample. Patients in 2007 were older than those in 2003 (females 68.6 ± 14 vs. 70.7 ± 11.7 years; males 63.6 ± 12 vs. 65.8 ± 11 years; P < 0.05) and had a higher body mass index (females 27.8 ± 1 vs. 28.6 ± 1 kg/m; males 27.6 ± 1 vs. 28.1 ± 1 kg/m, in 2003 and 2007 respectively, P < 0.05). Mean LDL decreased significantly overtime in both males and females. No gender difference in lipid-lowering therapy was observed. Females had a higher LDL than did males in 2003 (115.3 ± 12.3 vs. 99.7 ± 12.5 mg/dL; P < 0.05), and this difference persisted through 2007 (102.2 ± 11.7 vs. 91.3 ± 11.2 mg/dL; P < 0.05). Overall rate of achieving goal LDL improved from 76.5% (2003) to 83.02% (2007), P < 0.05, but remained lower for females than for males both in 2003 and 2007 [69.8% vs. 80.1% (2003), P < 0.05, and 77.9% vs. 85.6% (2007), P < 0.05].The trend over a recent 5-year period shows that females are less likely to achieve goal LDL than males are, and it indicates the need for more aggressive lipid-lowering strategies in females.

Hospital delay in South Asian patients with acute ST-elevation myocardial infarction in the UK.

BACKGROUND: South Asians presenting with chest pain in the UK experience disproportionately greater delays with respect to diagnosis and treatment for acute myocardial infarction (AMI). The duration of time between symptom onset and hospital intervention is a critical delay for AMI but there are limited data amongst South Asians. The objectives of this study were to investigate ethnic differences in hospital delay and to look at short-term outcomes in South Asian and White patients presenting with AMI. METHODS: Between 2004 and 2009, data were collected from 672 AMI patients with ST elevation who subsequently received percutaneous coronary intervention at Sandwell and West Birmingham Hospitals NHS Trust (UK). The hospital delay between the onset of symptoms and arrival time (pre-hospital), and between arrival time and intervention (post-hospital) was calculated. RESULTS: South Asians were more likely to be in the upper tertile of hospital delay (pre-hospital odds ratio, OR, 1.44, 95% CI 0.93-2.24, p = 0.06; post-hospital OR 1.83, 95% CI 1.05-3.21, p = 0.015), contributing to an overall hospital delay that was longer (median 314, interquartile range, IQR, 195-679 min) than in Whites (median 240, IQR 182-468 min). Women were more likely to be in the upper tertile for pre-hospital delay than men (p = 0.01) and South Asian ethnicity was an independent predictor of post-hospital delay (p = 0.003). CONCLUSIONS: While the reasons for ethnic differences in AMI-related hospital delay are likely to be multifactorial and complex, there is an urgent need to promote change in both the South Asian patient (delays in arrival) and their treatment (delays in intervention).

Posterior myocardial infarction: are we failing to diagnose this?

INTRODUCTION: Isolated posterior ST-elevation myocardial infarction (STEMI) accounts for up to 7% of STEMIs. The diagnosis is suggested by indirect anterior-lead ECG changes. Confirmation requires presence of ST-elevation in posterior-leads (V7-V9). We investigated the ability of hospital doctors and paramedics to diagnose posterior STEMI (PMI). METHODS: Doctors in the emergency department and acute medical unit at two teaching hospitals and West Midlands Ambulance Service Paramedics were asked to interpret a 12-lead ECG illustrating ST-depression and dominant R-wave in V1-V2 in the context of cardiac chest pain, and identify PMI as a potential diagnosis. Their ability to identify PMI was compared with their ability to diagnose anterolateral STEMI on a 12-lead ECG. We assessed whether doctors knew that posterior-leads were required to confirm PMI and whether doctors and nurses could position posterior-leads. RESULTS: 44 of the 117 doctors (38%) identified PMI as a potential diagnosis. PMI was identified by 73% of registrars, 30% of senior house-officers and 18% of house-officers. 50% of doctors who identified potential PMI knew that posterior-leads were required to confirm the diagnosis. 20% of doctors correctly positioned these and 19% knew the diagnostic criteria for PMI (ST-elevation ≥1 mm in V7-V9). 13 of the 60 nurses (22%) in the emergency department and acute medical unit correctly positioned posterior-leads. Five of the 50 (10%) paramedics identified PMI as a potential diagnosis. Doctors and paramedics were significantly better at diagnosing anterolateral STEMI than PMI. CONCLUSIONS: A significant proportion of doctors and paramedics were unable to diagnose PMI. Hence, the majority of PMIs may be being missed. Routine use of posterior-leads in the standard assessment of patients with chest pain may identify up to an additional 7% of STEMIs, allowing prompt reperfusion therapy, which would reduce morbidity and mortality.

Controlling lipids in a high-risk population with documented coronary artery disease for secondary prevention: are we doing enough?

BACKGROUND: The prevalence of high-density lipoprotein cholesterol (HDL-C) in patients who have achieved low-density lipoprotein cholesterol (LDL-C) targets in the current era of universal statin therapy remains unknown. We conducted a study to determine the prevalence of low HDL-C in patients with documented coronary artery disease, and to determine the lipid-lowering treatment patterns in secondary prevention of coronary artery disease. METHODS: In this retrospective cohort analysis, data were obtained from the electronic database of a cardiology clinic. The Joint British Society 2 criteria were used defining low HDL-C as less than 1 mmol/l in males and less than 1.2 mmol/l in females. We compared the prevalence of low HDL-C across the following categories of LDL-C: less than 2, 2-2.5, and greater than 2.5 mmol/l. RESULTS: Two thousand and eighty-seven patients with a mean age of 64.34±11.94 years constituted the study sample. About 36.6% of patients in this study were found to have low HDL-C. Irrespective of sex, low HDL-C was prevalent across all levels of LDL-C, but interestingly this was most prevalent in patients with a LDL-C less than 2 mmol/l (43.06%). HDL-C level of 1.16±0.97 mmol/l in patients with LDL-C less than 2 mmol/l was significantly lower than 1.22±0.33 mmol/l in patients with LDL-C greater than 2 mmol/l, P value less than 0.01. There was a poor correlation between levels of HDL-C and LDL-C in the study population irrespective of sex or statin therapy. CONCLUSION: This study shows widely prevalent low HDL-C levels in high-risk patients across the spectrum of LDL-C levels despite statin therapy. There was no correlation between the LDL-C and HDL-C levels implying their independent relationship and, thus, the need to treat them independently.

The management of hypertension in type II diabetes mellitus

The prevalence of both hypertension and type II diabetes mellitus are increasing in industrialised countries. These diseases are very closely related and associated with a high incidence of cardiovascular, cerebrovascular and renovascular complications. Effective management of hypertension in type II diabetes reduces the associated morbidity and mortality. The target blood pressure in patients with type II diabetes mellitus is less than 130/80 mm Hg, with a lower levei of less than 120/80 mm Hg being recommended in the context of renal impairment or proteinuria. Ali groups of antihypertensive drugs are effective in reducing hypertension in diabetics with the individual agent, or combination of agents, used dictated by patient characteristics, including age and ethnicity, in addition to co-morbidities. Often, an ACE inhibitor or an angiotensin II receptor blocker, usually combined with a diuretic, would be first line therapy. A calcium-channel blocker, beta-blocker, or alpha-blocker may be used as additional therapy if required