1/9. Possible association of acute lateral-wall myocardial infarction and bitter orange supplement.OBJECTIVE: To report a possible incidence of acute lateral-wall myocardial infarction (MI) coinciding with the use of a citrus aurantium L. (bitter orange)-containing dietary supplement in a patient with undetected coronary vascular disease. CASE SUMMARY: A 55-year-old white woman presented to the emergency department with symptoms of dull aching shoulder and chest pain. A review of medications during cardiac rehabilitation revealed the patient had ingested a multicomponent dietary supplement for weight loss containing 300 mg of bitter orange (Edita's Skinny Pill) for the past year. Although the patient's past medical history did not include hypertension, coronary disease, or hyperlipidemia, an arteriogram revealed a lesion in the left main coronary artery. She did have a smoking history. She was diagnosed with acute lateral-wall MI and hospitalized for 4 days. DISCUSSION: Consumers generally consider dietary supplements safe. However, some supplements taken for weight loss contain ingredients that have been associated with cardiovascular events. Although consumers are becoming more aware of the serious adverse effects secondary to products containing ingredients such as Ma huang and ephedra, reports involving other ingredients are increasing. Bitter orange or synephrine, found in bitter orange, has been associated with adverse cardiovascular reactions. Based on the Naranjo probability scale, C. aurantium is possibly associated with this cardiovascular event. CONCLUSIONS: The use of C. aurantium-containing supplements may present as a risk for cardiovascular toxicity; however, additional studies/case reports are needed to validate this conclusion.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
2/9. myocardial infarction as complication of left atrial myxoma.Although cardiac myxomas are histologically benign, they tend to form emboli and cause intracardiac obstruction, so that they must be classified as potentially fatal tumors of the heart. The probability of arterial embolism is closely correlated with the morphology of the tumor. Thus, villous myxomas are more fragile and form emboli more often. Nuclear spin tomography and echocardiographic cine-mode sequences provide impressive images of the potential for embolism. It appears that coronary embolism may be more frequent in the group of myxoma patients than generally is assumed. These may present as acute myocardial ischemia with the typical clinical symptoms of acute myocardial infarction, as a silent infarct, shock, syncope or as sudden cardiac death. Besides our case report this paper will give an overview on published data on coronary embolism in patients with atrial myxoma. Interestingly there is a tendency for spontaneous recanalization of the obstructed coronary vessels, perhaps because of the tumors' tissue composition. Therefore it is reasonable to perform transoesophageal echocardiography to check out embolic sources like myxoma, when pathogenesis of myocardial infarction remains unclear after coronary angiography.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
3/9. Acute myocardial infarction after sildenafil citrate ingestion.OBJECTIVE: To report a case of acute myocardial infarction (MI) associated with the use of oral sildenafil in a nitrate-free patient. CASE SUMMARY: A 45-year-old man was admitted to the hospital with acute left-sided chest pain, nausea, and vomiting that started approximately 30 minutes after taking sildenafil 100 mg before a sexual contact. The patient was diagnosed with an acute anterior MI, and therapy with aspirin, metoprolol, and unfractionated heparin was initiated. Early coronary reperfusion treatment with primary percutaneous transluminal coronary angioplasty was performed after initial evaluation. Balloon angioplasty followed by coronary stenting was performed successfully in the 80%-occluded left anterior descending artery. The patient was discharged one week after the coronary intervention without complication. DISCUSSION: Sildenafil-associated MI is rarely seen in patients without documented coronary artery disease. By inhibiting phosphodiesterase type 5, sildenafil can cause an increase in cyclic guanosine monophosphate levels, which mediates the relaxation of vascular smooth muscle in the corpus cavernosum. Although sildenafil can cause a major decline in systemic arterial pressure in the existence of organic nitrates, physicians should be aware of its adverse cardiovascular effects even in nitrate-free patients. The Naranjo probability scale indicates that sildenafil was the possible cause of the MI. CONCLUSIONS: Sildenafil may rarely be associated with MI in patients with no known cardiac history. physicians should be aware of this rare and serious adverse reaction to sildenafil and counsel patients not to take sildenafil before undergoing a complete physical evaluation and further testing if warranted.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
4/9. myocardial infarction associated with intravenous immune globulin.OBJECTIVE: To report a case of acute myocardial infarction (MI) experienced by a patient receiving intravenous immune globulin (IVIG) and review other published cases of MI associated with IVIG. CASE SUMMARY: An 81-year-old Vietnamese man was prescribed IVIG for treatment of toxic epidermal necrolysis secondary to allopurinol. Thirty minutes following the start of the IVIG infusion, the patient developed crushing retrosternal chest pain and shortness of breath. The pain improved upon discontinuation of IVIG infusion but recurred when IVIG was restarted. The troponin level reached 140 microg/L, and a persantine sestamibi stress test (MIBI) indicated anterolateral ischemia. The patient was diagnos ed with non-ST-elevation MI. An objective causality assessment using the Naranjo probability scale revealed a probable association between this adverse reaction and IVIG treatment. DISCUSSION: Although an association between IVIG administration and MI has not been demonstrated in clinical trials, accumulating clinical experience suggests that a relationship between IVIG and myocardial ischemia exists. Twenty published case reports were identified. risk of acute MI seems to be increased with use of high-dose IVIG and in older individuals, especially those with at least one cardiovascular risk factor, such as ischemic heart disease or hypertension. CONCLUSIONS: case reports suggest a causal relationship between the use of IVIG and MI and other thrombotic events. While cardiovascular disease is not considered an absolute contraindication to therapy, expanding indications and subsequent use of IVIG merit that clinicians be aware of patient characteristics that may increase the risk for adverse reactions and recognize early signs of infarction.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
5/9. exercise stress testing in the patient with coronary artery disease. Part II.Cardiac exercise stress testing has both diagnostic and prognostic implications. ECG changes, hemodynamic responses, and symptoms during exercise are clues to the functional capacity, severity of coronary artery disease, and probability of future coronary events. The time and workload required for a positive response to exercise and the length of time the ECG changes persist during recovery are indicators of the degree of coronary disease and are useful in predicting future coronary events.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
6/9. How did the acute ischemic heart disease predictive instrument reduce unnecessary coronary care unit admissions?The use of the acute ischemic heart disease predictive instrument reduced coronary care unit (CCU) admissions for patients without acute ischemic heart disease by 30%. One hypothesis holds that it reinforced physicians' correctly low estimates of the probability of acute ischemia, supporting a decision against CCU admission, another that it lowered physicians' over-high probability estimates for acute ischemia so that CCU admission was felt to be unnecessary. The authors asked 86 physicians to estimate the probability of acute ischemia for each of three study cases and to decide on CCU admission. For the low-probability case, the mean of physicians' probability estimates for acute ischemia was 46%, vs. the predictive instrument's calculated probability of 19% (p less than 0.00001), a 142% over-estimation by the physicians. For the medium-probability case, the mean of physicians' estimates was 54%, vs. the calculated probability of 58% (not significant). For the high-probability case, the mean of physicians' estimates was 82%, vs. the calculated probability of 78% (not significant). All cases for which physicians considered not admitting to the CCU corresponded to their probability estimates of acute ischemia's being in a threshold range of approximately 10 to 30%. These results support the hypothesis that the mechanism by which the predictive instrument reduces unnecessary CCU admissions is by downward correction of physicians' overly-high suspicions of acute cardiac ischemia into a threshold range for which CCU admission is considered unnecessary.- - - - - - - - - - ranking = 11keywords = probability (Clic here for more details about this article) |
7/9. Increased creatine kinase MB in the absence of acute myocardial infarction.Although measurement of CK-MB is a very sensitive, specific, and cost-effective test for use in diagnosis or exclusion of acute myocardial infarction, it should not be used as the sole diagnostic indicator, and all positive values must be critically analyzed to exclude other causes of increased values in serum. This is particularly important when the population being tested consists of patients with multiple medical problems, with low to medium probability of myocardial infarction, and without clinical or other biochemical (i.e., LDH 1) evidence of acute myocardial infarction. When the temporal pattern and absolute CK-MB values are considered together with the patient's clinical status, the diagnostic specificity is dramatically increased. In addition, one must be familiar with the limitations of individual assay systems in order to exclude method-related artifactual values.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
8/9. cocaine washed out syndrome in a patient with acute myocardial infarction.We present the case of a 34-year-old woman with cocaine-associated chest pain and hypersomnulence, who, because of her inability to report chest pain, and her comfortable appearance, was admitted to telemetry for a diagnosis of low-probability rule-out myocardial infarction. Her chest pain was incompletely relieved, and she subsequently was transferred to the intensive care unit and ruled in for myocardial infarction. We discuss the clinical syndrome of cocaine-related depressed level of consciousness, and its relationship to evaluation of cocaine-related chest pain.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
9/9. Emergency room prediction of mortality and severe complications in patients with suspected acute myocardial infarction.This study aims at describing the in-hospital prognosis of patients admitted with suspected acute myocardial infarction, focusing on the possibility of emergency room prediction of the risk for death and severe complications. From 7157 consecutive patients with chest pain or other symptoms suggestive of acute myocardial infarction in the emergency room, 4690 were hospitalized. Of these, 246 (5%) died in hospital, with a mortality rate among the 921 patients who developed myocardial infarction of 14%, and among those without infarction of 3%. From the clinical history, examination and electrocardiogram in the emergency room, independent predictors of death and death or any severe complication were determined by logistic regression analysis. These included age, initial degree of suspicion of infarction, electrocardiographic pattern, history of diabetes mellitus, history of congestive heart failure and on admission arrhythmias, loss of consciousness, acute congestive heart failure, or unspecific symptoms. From these analyses the probability of death or death or any severe complication can be calculated. Thus, 18% of patients hospitalized due to suspected acute myocardial infarction suffered a severe complication or died in hospital. From a statistical model it is possible to predict the in-hospital prognosis of every such patient.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |