Profile and management of acute coronary syndromes at primary- and secondary-level healthcare facilities in Cape Town.

BACKGROUND: Little is known about the clinical profile and management of patients with acute coronary syndromes (ACS) in the South African public sector. METHODS: We conducted a retrospective study of patients presenting with ACS to a secondary-level healthcare facility in Cape Town during a one-year period to study the clinical profile and management of these patients. RESULTS: Among the 214 patients in this cohort, 48 (27.5%) had ST-segment elevation myocardial infarction (STEMI), 43 (24.7%) had non-ST-segment elevation myocardial infarction and 83 (47.7%) unstable angina pectoris. We identified high rates of >12-hour delays in first medical contact after symptom onset (46%) and inaccurate ECG diagnosis of STEMI (29.2%), which were associated with low rates of thrombolysis (39.6%). High rates of non-adherence and ACS recurrence were also observed. CONCLUSION: To address the local challenges in ACS management highlighted in this study, we propose the development of a regional referral network prioritising access to expedited care and primary reperfusion interventions in ACS.

Hemodynamic effects of nisoldipine, a highly specific calcium antagonist, in patients with acute myocardial infarction.

The aim of the study was to investigate the hemodynamic effects of a short-acting, potent, highly specific calcium antagonist, nisoldipine, in patients with acute myocardial infarction. Twenty-four patients were selected on the basis of an elevated wedge pressure and/or elevated blood pressure, less than 12 hours after the onset of symptoms. Patients were randomized to receive either placebo or low-dose nisoldipine (2 micrograms/kg) as a single intravenous injection over a 3-minute period. hemodynamic effects were monitored for 20 minutes, and thereafter patients were crossed over to the other agent after the preserved parameters had returned to baseline. An open-label study using double the dose of nisoldipine in 20 patients who had not reacted adversely to low-dose nisoldipine followed. Standard hemodynamic monitoring showed that peak effects of nisoldipine were reached at 5 minutes, with some residual effect at 20 minutes, and it took up to 60 minutes to return to baseline. Both doses of nisoldipine had similar effects: a fall in the systemic vascular resistance by about 600 units, variable tachycardia, little or no change in the wedge pressure, a decrease in the arterial pressure, an unchanged rate-pressure product, and an increase in ejection fraction. Tachycardia of more than 15 beats/min resulted in 5 of 24 patients with low-dose nisoldipine and 6 of 20 patients with high-dose nisoldipine. In view of the risk of tachycardia, nisoldipine seems unsuitable for use in the acute phase of myocardial infarction.

Transient giant R waves--a manifestation of potentially reversible acute severe myocardial ischaemia.

A patient with acute severe myocardial ischaemia manifested with transient giant R waves and ST segment elevation during chest pain. This probably represents transient complete occlusion of a major coronary artery, the left anterior descending in this case. Myocardial infarction was prevented by aggressive medical and surgical management.

Right ventricular infarction mimicking extensive anterior infarction.

Two patients with inferior infarction complicated by right ventricular infarction are presented. Both manifested electrocardiographic changes involving the anterior chest leads with initial S-T segment elevation followed by loss of R waves and the development of QS complexes mimicking anterior infarction. Cardiac catheterization showed right coronary artery occlusion with normal left coronary system and anterior wall motion in each case. Radionuclide angiocardiography showed dilated poorly contracting right ventricles. The ECG changes of "anterior infarction" in these patients were therefore due solely to right ventricular injury.