Eosinophilia and Ulcerative Colitis Associated with Eosinophilic Myocarditis.

Reactive eosinophilia is associated with inflammatory bowel disease, but its association with eosinophilic myocarditis is rare. We report a case of a 42-year-old man who presented with hypovolemic shock secondary to diarrhea and recently diagnosed nonischemic cardiomyopathy (left ventricular ejection fraction, 0.29). Laboratory evaluation revealed marked peripheral eosinophilia. Cardiac magnetic resonance imaging showed evidence of subacute-to-chronic myocarditis, and endomyocardial biopsy results were consistent with eosinophilic myocarditis. Colonic biopsy specimens revealed ulcerative colitis and no eosinophils. Hematologic evaluation was negative for an alternative cause of eosinophilia. The patient was given corticosteroids; his diarrhea resolved, but there was no short-term improvement in his ejection fraction, so an implantable cardioverter-defibrillator was placed. Follow-up at one year showed that the patient's left ventricular ejection fraction had improved to 0.42.

Fragmented QRS scale and brain natriuretic peptide predict infarction in patients with acute myocardial infarction and heart attacks / 中国医师杂志

Objective To investigate the acute myocardial infarction (AMI) patient's electrocardiogram appearing fragment QRS wave (fQRS) and brain natriuretic peptide (BNP) level and scope of coronary lesions,severe cardiac complications,and the cor relation of cardiac death.Methods For selected patients with AMI,whether based on electrocardiogram (ECG) appeared in fQRS group and non fQRS groups; immunofluorescence technique was used to detect the plasma BNP level in patients with AMI.Two groups of patients with serious cardiac events and coronary artery lesions scope were observed; Coronary artery lesion count and BNP level were recorded.Results The incidence of fragment QRS wave in patients with AMI was 34.0％,fQRS wave group height/three degree atri oventricular block,ventricular tachycardia/ventricular fibrillation,cardiac shock,cardiac death rate was higher than non fQRS wave group (P ＜0.05).fQRS wave group of plasma BNP and left ventricular end-diastolic diameter,the double branch lesion,multivessel lesions were significantly higher than that of non fQRS group (P ＜ 0.01) ; left ventricular ejection fraction,the single lesion was sig nificantly lower than non fQRS wave group (P ＜0.01).The BNP levels in single,double,and multivessel lesions in the group with the increase of the lesion count were increased.Conclusions The AMI patients with fQRS easily complicated with severe arrhythmia,and case fatality rate was high,the prognosis was poor.fQRS on electrocardiogram (ECG) and BNP level had a certain relationship with range and degree of coronary artery lesions,degree of indexes might be used as a prediction of coronary lesions,and multivessel lesions had certain prediction value.

Echocardiographic myocardial imaging reveals segmental cardiomyopathy in Churg-Strauss syndrome.

Cardiovascular involvement is the leading cause of morbidity and death in Churg-Strauss syndrome. Herein, we describe the case of a 47-year-old man with Churg-Strauss syndrome, in whom the use of novel echocardiographic techniques revealed segmental cardiomyopathy. Tissue Doppler and speckle-tracking imaging showed that both longitudinal and radial strain were impaired at the septal level and that the impairment of circumferential strain affected left ventricular torsion. Our case shows that advanced echocardiography with myocardial strain imaging in multiple vectors can identify systolic-diastolic abnormalities in a patient with myocardial infiltration and a normal left ventricular ejection fraction.

Surgical management of cardiac hydatidosis.

Cardiac hydatidosis is extremely uncommon; only a few case series have been reported in the worldwide medical literature. Whereas hydatid cysts develop in the liver or lungs in 90% of patients who have hydatidosis, only 0.5% to 2% of patients thus diagnosed have cysts of the heart. Herein, we present the clinical summaries of 4 patients who had cardiac hydatid cysts-0.5% of the 763 patients who underwent surgery for thoracic hydatidosis over a period of 20 years at Ibn-Alnafis Teaching Hospital in Baghdad, Iraq. In addition, we discuss our operative technique. A year after surgical treatment and medical therapy, all 4 patients were free of hydatid disease.

An overview of artificial heart valve replacement in infants and children.

Prosthetic heart valve replacement in infants and children poses unique problems. This article provides an overview of the factors specific to children with regard to indications and timing of valve replacement, types of artificial valves, constraints, and ramifications of valve choice in children. Anticoagulation, pregnancy, and other issues related to long-term management are reviewed.

PIP: Abnormal embryologic development and inflammatory or degenerative diseases cause valvular heart disease in children. Physicians consider children's age, size, pathology and natural history of the disease, size and anatomy of cardiac chambers and great vessels, and success of past interventions when deciding on valve replacement. The 1st treatment tends to be preservation and reconstruction of the natural valve. It is difficult to obtain a prosthetic valve of adequate size. Because the child is growing quickly the prosthetic valve, quickly becomes too small an hemodynamically restrictive. A prosthetic valve increases the risk of infection. The 3 main types of prosthetic valves are bioprosthetic, mechanical, and allograft valves. Management issues of a child undergoing heart valve replacement surgery include thromboembolism, minimalizing blood coagulation without undue bleeding, endocarditis, and pregnancy. More and more females with prosthetic heart valves are achieving reproductive years. Women with adequately efficient valves and are in the American Heart Association class I or II face a much better likelihood of a successful pregnancy and fetal outcome than those in class III or IV. Indeed women of class III or IV regardless of the conditions of the valve should not become pregnant until their status has been upgraded. Pregnancy risks include ability of the heart to maintain cardiac output and stroke volume and teratogenic effects of sodium warfarin on the fetus. Pregnant patients can receive subcutaneous heparin therapy, however. Nurses can play a leading role in counseling parents of heart valve replacement children. For example, they can educate them and their affected children about contraception while they are in their early teens. Specifically they need to counsel them about the risks of pregnancy and of using estrogen-based contraceptives and IUDs. Diaphragms and condoms along with a spermicide are the best methods for heart valve replacement females.

The effect of triphasic oral contraceptives on plasma lipids and lipoproteins.

To determine the effect of triphasic oral contraceptives on plasma lipid transport, 150 nonsmoking women with normolipidemia, ages 18 to 35 years, were randomly assigned to receive one of three contraceptive formulations: (1) ethinyl estradiol, 30, 40, and 30 micrograms/day, each for 6, 5, and 10 days per menstrual cycle, and levonorgestrel, 50, 75, and 125 micrograms/day, each for 6, 5, and 10 days; (2) ethinyl estradiol, 35 micrograms/day for 21 days, and phased norethindrone, 500, 750, and 1000 micrograms/day each for 7 consecutive days; and (3) ethinyl estradiol, 35 micrograms/day for 21 consecutive days, and norethindrone, 500, 1000, and 500 micrograms/day for 7, 9, and 5 days, respectively. A control group consisting of 49 women taking a nonhormonal form of contraception was also included. After 6 months of oral contraceptive treatment, significant increases in plasma triglyceride (28% to 52%) and plasma apolipoprotein B levels (20% to 23%) were observed in each treatment group. The changes in total plasma cholesterol (3% to 10%) and low-density lipoprotein cholesterol values (0% to 11%) were less striking. Changes in total high-density lipoprotein cholesterol levels were statistically insignificant (-2% to -4%); however, high-density lipoprotein2 cholesterol levels decreased by 29% to 33% and high-density lipoprotein3 cholesterol levels increased by 20% to 23%. Concomitantly, plasma apoliporprotein A-1 values increased by 5% to 12%. No consistent significant differences among analyses were observed between and of the groups receiving different oral contraceptives for 6 months.

Lipid and lipoprotein changes in relation to oral contraception and hormonal replacement therapy.

Estrogens and progestins for contraception or hormonal replacement therapy are widely used by practitioners. These steroids have substantial effects on lipids and lipoproteins that appear to be primarily related to chemical structure of the compound, dosage, and a patient's hormonal status. Although the mechanisms by which alterations in lipid and lipoproteins affect atherogenesis are not fully understood, epidemiologic studies clearly associate alterations with risk of coronary heart disease. Attention to these alterations by progestins and estrogens, as well as further research on how these steroids may exert other cardiovascular effects, is important because atherosclerotic heart disease is a major cause of morbidity and mortality for women as they age.

PIP: The use of estrogens and progestins for contraception for hormonal replacement therapy has substantial effects on lipids and lipoproteins. Elevations of lipoproteins such as total cholesterol, low density lipoprotein (LDL)-C, and apoprotein B, and reduced levels of others such as high density lipoprotein (HDL)-C and apoprotein A-1, are associated with increased risk of coronary heart disease, although the exact mechanism by which such changes contribute to atheroma formation is unknown. The effect of an estrogen or progestin on the lipid profile is dependent on the chemical structure, dose, and route of administration as well as the hormonal status of the patient. Moreover, when an estrogen and progestin are combined in a therapeutic regimen, additional interactions occur that further complicate understanding of this process. Some epidemiological studies have suggested that mechanisms other than those closely associated with the lipid/lipoprotein system may be operant in the development of coronary heart disease and that the protective effects of estrogen far outweigh any adverse effects of progestin. Other studies have found an increased risk of coronary heart disease among past oral contraceptive users. Since atherosclerotic heart disease is a major cause of morbidity and mortality for women as they age (a cumulative mortality for women 55-75 years of age of 10,500/100,000), further research on the effects of steroids on cardiovascular factors is urgently needed.

Chest pain, shock, arrhythmias and death in a young woman.

PIP: 9 figures form the core of this article describing and discussing a case of sudden death, 2 hours after a 30-year old woman presented at a hospital emergency with chest pains. She had taken no medications other than oral contraceptives (OCs) for 10 years. The patient was admitted to the coronary care unit where findings included a palpable blood pressure of 94 mm of Hg, a heart rate of 128/min, and a respiratory rate of 28/minute. Cyanosis was noted, jugular veins were distended, and there were rales over the lung bases bilaterally; cardiac sounds were soft and a third heart sound was audible. Arterial oxygen tension was 15 mm of Hg, and carbon dioxide tension was 42 mm of Hg; pH was 7.2. Ventricular tachycardia developed and ventricular fibrillation ensued. The patient was intubated and well oxygenated, external cardiac compression was performed, sodium bicarbonate, epinephrine, and calcium were administered, and electrical defibrillation was performed. After several attempts, the latter resulted in a slow idioventricular rhythm on the electrocardiogram, but neither the blood pressure nor pulse was detectable. Asystole subsequently developed, and cardiac activity could not be restored. After discussion by a panel of physicians, the final anatomic diagnoses are chronic active nonspecific myocarditis; organizing and acute myocardial microvascular and endocardial mural thrombi; platelet-rich microthrombi in the heart, lungs, and liver; chronic passive pulmonary congestion and edema; and congestive hepatomegaly (2900 g). Any of these may be assciated with longterm OC usage.^ieng

[The aetiology of myocardial infarction in young people. With special regard to nonpenetrating chest injury, oral contraceptives, smoking (author's transl)]. / Zur Atiologie des jugendlichen Herzinfarktes

PIP: Myocardial infarct in a 37-year-old woman treated with oral contraceptives (.1 mg mestranol and 1 mg ethynodiol diacetate) for 6 years is reported. The patient had received chest bruises in an auto accident 10 weeks before the infarct, but had experienced no pain at the time and had required no medical treatment. She noted chest pain, which disappeared after a short time, some 8 weeks after the accident. 10 weeks after the accident, she presented with typical signs of myocardial infarct; treatment included digitalis, diuretics, and a anticoagulants. Except for slight overweight and smoking (15 cigarettes daily) the patient had no heart risk factors. Coronary angiography revealed isolated subtotal stenosis of the left anterior descending artery. The etiology of the infarct is discussed.^ieng

Editorial: Oral contraceptives and myocardial infarction.

PIP: Studies done in the United Kingdom suggest a correlation between ora l contraceptive (OC) use and increased risk of myocardial infarction (MI ). A study of 153 women under 50 years of age who died of MIs as compar ed with a control group of the same age and marital status showed a significant association between OC use and MI which became stronger with increasing age: e.g., risks for the 30-39 and 40-44 year-old groups were 2.8 and 4.7 respectively. Another study involving 63 MI survivors between 25 and 44 years of age compared with a similar control group showed a strongly positive association: 29% of the patients and 8% of the controls used OCs and risks for the 30-39 and 40-44 year old groups were 2.7 and 5.7 respectively. The risk in OC users was 4.5 times greater than in nonusers. Other risk factors such as diabetes, cigarett e smoking and obesity also have a positive association with MI. Only one of 17 OC users at the time of MI had no other identified risk factor . When ranked according to the number of risk factors present (includin g OCs) risks relative to women in whom none were present were 4.2 for 1 factor, 10.5 for 2 factors and 78.4 for 3 or more factors. These estimates suggest that in women under 45 years of age, OCs act synergist ically with other risk factors rather than additively, to produce MI. Stroke, also identified, did not appear as a result of a synergistic relationship between OC and other risk factors comparable to that found in relation to MI. Further study is needed but estimated incidence rates of fatal and nonfatal MI attributable to OC use are each about 3.5 per 100,000 30-39 year old users per year and each about 45 per 100,000 40-44 year old users per year. Women with more than 1 risk factor for MI should consider alternative methods of contraception. Those women who do use OCs regularly, especially older women, should be followed closely and advised against OC continuation.^ieng

[Myocardial infarct and ovulation inhibitors]. / Herzinfarkt und Ovulationshemmer

PIP: Previously published cases of myocardial infarct in women treated with ovulation inhibitors are briefly reviewed. The age, absence of cardiac risk factors, and unusual location of the lesions (the proximal section of the ramus interventricularis of the left coronary artery) are emphasized. Most researchers believe that blood coagulation and fibrinolytic effects related to the estrogen components of combined oral contraceptives are at the origin of these disorders. The manifestation of previously latent risk factors under contraceptive treatment has also been considered. Too little is known about the problem to enable us to draw clinically useful conclusions.^ieng

Myocardial infarction in young women with special reference to oral contraceptive practice.

Sixty-three women discharged from hospital with a diagnosis of myocardial infarction and 189 control patients were studied. All were under 45 years of age at the time of admission. Current oral contraceptive use, heavy cigarette smoking, treated hypertension and diabetes, pre-eclamptic toxaemia, and obesity were all reported by, and type II hyperlipoproteinaemia was found more often in, patients with myocardial infarction than their controls. The relationship between myocardial infarction and oral contraceptives could not be explained in terms of an association between the use of these preparations and the other factors. The combined effect of the risk factors was clearly synergistic.

PIP: A retrospective study of 84 women under age 45 years suffering myocardial infarction. These patients were found in the records of 24 hospitals is presented. 16 died in the hospital; 5 died subsequently; of the remaining 50 showed definite evidence and 13 possible evidence of myocardial infarction. Suitable controls were selected from patients with other disorders. Patients were interviewed in their homes, some additional information was supplied by the medical practitioner; and fasting blood samples were obtained from some at more than 6 months after the infarction. The proportion of patients who had used oral contraceptives during the month before admission was significantly higher among infarction patients than among controls (p less than .001). The relative risk was estimated as 4.5 to 1. The proportion of those who had ever used oral contraceptives was higher (p less than .01). Cigarette smoking was reported more often by patients with infarction than by controls. A higher ratio of patients with infarction than controls had been treated for hypertension, diabetes, preeclampsia, and obesity. Blood lipids were examined in 44 patients and 84 controls. Mean levels of serum cholesterol and serum triglycerides were definitely higher in patients who had had infarctions. The estimated yearly hospital admission rate for nonfatal myocardial infraction is 2.1 per 100,000 married women aged 30-39 years who do not use oral contraceptives and 5.6 per 100,000 for married women of this age who do. In the 40-44 year age group the rates are 9.9 and 56.9 per 100,000 respectively. Risk estimates suggest that the combined effects of factors is synergistic. When other risk factors exist, different methods of contraception are advised.