Sinus node dysfunction unmasked during dobutamine stress echocardiography

Sinus bradycardia and associated isorhythmic AV dissociation may be seen during dobutamine stress echocardiography. This phenomenon is usually considered a benign peri-procedural event and is thought to be secondary to the Bezold-Jarisch reflex, with profound heart rate decrease secondary to a marked increased in vagal efferent discharge. To the best of our knowledge, dobutamine stress echocardiography unmasking clinically relevant sinus node dysfunction has never been reported. We report a case of a 50-year-old man presenting with chest pain and a history of syncope, who had worsening sinus bradycardia with isorhythmic AV dissociation during dobutamine stress echocardiography. An invasive electrophysiological study revealed marked sinus node dysfunction. The patient was referred for the insertion of a permanent pacemaker for sinus node dysfunction, chronotropic incompetence and symptomatic bradycardia. Dobutamine-associated bradycardia may not always be a benign peri-procedural physiologic effect, as in this case it may unmask clinically significant sinus node dysfunction.     

Regional Pericarditis: A Review of the Pericardial Manifestations of Acute Myocardial Infarction

Regional pericarditis has been described in several settings, but occurs most frequently after transmural myocardial infarction. While the diagnosis remains elusive, it must be considered in all patients with recurrent chest pain following acute myocardial infarction (AMI). Pericarditis classically presents with positional chest pain, a pericardial friction rub, diffuse ST‐segment elevation, and PR depression, but regional ECG changes associated with infarction‐associated pericarditis sometimes exist. Given the magnitude and frequency of AMI, it is imperative to be aware of the myriad of pericardial manifestations of myocardial injury. An illustrative case and a comprehensive review of the literature will be provided. Copyright © 2009 Wiley Periodicals, Inc.     

Constrictive pericarditis in chronic ulcerative colitis

Acute pericarditis has been described as an extraintestinal manifestation of inflammatory bowel disease (IBD), as well as a consequence of IBD treatment, specifically sulfasalazine and mesalamine. Until now, there have been no reported cases of constrictive pericarditis associated with IBD or its treatment. A 37-year-old woman with a 24-year history of chronic ulcerative colitis (CUC) presented with a 3-month history of fevers, palpitations, dyspnea, syncope, and retrosternal chest pain. Two weeks before symptoms, she had initiated oral mesalamine for an ongoing CUC flare. Physical examination suggested constrictive pericarditis. An echocardiogram revealed a thickened pericardium with a nearly circumferential fibrinous effusion, with Doppler confirming diastolic compromise. The patient proceeded to radical pericardectomy. Pathological examination showed grossly hemorrhagic acute and chronic pericarditis, with cultures and cytology negative. To date, only 104 cases of IBD with acute pericarditis have been reported, with fewer than 10 cases of mesalamine-induced acute pericarditis reported. This is the first reported case of constrictive pericarditis related to IBD or its treatment. Although our patient may have had IBD-associated constrictive pericarditis, her mesalamine use raises the possibility of a drug-induced constrictive pericarditis.     

Pericardial involvement in end-stage renal disease

Pericardial involvement in end-stage renal disease (ESRD) is manifested most commonly as acute uremic or dialysis pericarditis and infrequently as chronic constrictive pericarditis. The causes of uremic and dialysis pericarditis remain uncertain. The clinical and laboratory manifestations of acute pericarditis, pericardial effusion, cardiac tamponade, and constrictive pericarditis in patients with chronic renal failure are similar to those observed in nonuremic patients with similar pericardial involvement, except that chest pain occurs less frequently in those with ESRD. Therapeutic interventions for acute uremic or dialysis pericarditis with or without pericardial effusion include intensive hemodialysis, pericardiocentesis (infrequently used), pericardiostomy with or without instillation of intrapericardial glucocorticoids, pericardial window, and pericardiectomy. Chronic constrictive pericarditis is treated with pericardiectomy.     

Pericarditis in diabetic ketoacidosis.

A 25-year-old insulin-dependent diabetic man who was admitted to hospital with severe diabetic ketoacidosis and dehydration showed sequential electrocardiographic abnormalities of acute pericarditis. Though the patient had retrosternal chest pain, no pericardial friction rub was heard. None of the usual causes of pericarditis was found and the electrocardiographic abnormality may have been attributable to subepicardial injury caused by dehydration associated with the ketoacidosis. The abnormalities on the electrocardiogram were transient, returning to normal after 5 days. Whatever the exact underlying nature of the pericarditis, it is important to recognise that such transient changes may occur as, in the absence of other obvious causes of pericarditis, the condition is benign.     

Pericarditis in diabetic ketoacidosis.

A 25-year-old insulin-dependent diabetic man who was admitted to hospital with severe diabetic ketoacidosis and dehydration showed sequential electrocardiographic abnormalities of acute pericarditis. Though the patient had retrosternal chest pain, no pericardial friction rub was heard. None of the usual causes of pericarditis was found and the electrocardiographic abnormality may have been attributable to subepicardial injury caused by dehydration associated with the ketoacidosis. The abnormalities on the electrocardiogram were transient, returning to normal after 5 days. Whatever the exact underlying nature of the pericarditis, it is important to recognise that such transient changes may occur as, in the absence of other obvious causes of pericarditis, the condition is benign.     

Symptomatic bradycardia induced by the combination of oral diltiazem and beta blockers.

Ten patients, who were admitted to the Intensive Coronary Care Unit during a one year period with symptomatic bradycardia while on combination therapy with oral diltiazem and beta-blocker agents, are described. The important features of this adverse reaction to drug combination were that it appeared mainly in a relatively elderly age group and with presenting symptoms of lethargy, dizziness, syncope, chest pain, and (in one patient with poor left ventricular function) pulmonary edema. It was not dose dependent and occurred even in very low doses of each drug. Electrophysiologic abnormalities were localized to the sinus node in all 10 patients and the primary rhythm disorders were junctional escape rhythm, sinus bradycardia, and sinus pause. These rhythm abnormalities resolved within 24 h following withdrawal of the offending drugs. Temporary pacemaker insertion was necessary in four patients. The duration of drug combination used before the acute episode range from within hours to up to 2 years. In conclusion, although combination diltiazem/beta blocker therapy is very effective in ischemic syndrome, caution is advised when this combination is used especially in the elderly or in patients with left ventricular dysfunction or antecedent sinoatrial or atrioventricular conduction abnormality.     

Management of Acute and Recurrent Pericarditis: JACC State-of-the-Art Review

Pericarditis refers to the inflammation of the pericardial layers, resulting from a variety of stimuli triggering a stereotyped immune response, and characterized by chest pain associated often with peculiar electrocardiographic changes and, at times, accompanied by pericardial effusion. Acute pericarditis is generally self-limited and not life-threatening; yet, it may cause significant short-term disability, be complicated by either a large pericardial effusion or tamponade, and carry a significant risk of recurrence. The mainstay of treatment of pericarditis is represented by anti-inflammatory drugs. Anti-inflammatory treatments vary, however, in both effectiveness and side-effect profile. The objective of this review is to summarize the up-to-date management of acute and recurrent pericarditis.     

Effect of percutaneous transluminal coronary angioplasty on arrhythmias complicating angina.

Four patients who had stenosis of a single major coronary artery which was treated by percutaneous transluminal coronary angioplasty are described. Three had exercise induced myocardial ischaemia complicated by ventricular tachycardia, fibrillation, and sinus bradycardia, respectively. Asystole developed in a fourth patient who had spontaneous chest pain. After successful percutaneous transluminal coronary angioplasty these arrhythmias did not recur spontaneously or on treadmill exercise testing. Percutaneous coronary angioplasty can be effective in preventing arrhythmias complicating acute myocardial ischaemia secondary to stenosis of a single major coronary artery.     

Effect of percutaneous transluminal coronary angioplasty on arrhythmias complicating angina

Four patients who had stenosis of a single major coronary artery which was treated by percutaneous transluminal coronary angioplasty are described. Three had exercise induced myocardial ischaemia complicated by ventricular tachycardia, fibrillation, and sinus bradycardia, respectively. Asystole developed in a fourth patient who had spontaneous chest pain. After successful percutaneous transluminal coronary angioplasty these arrhythmias did not recur spontaneously or on treadmill exercise testing. Percutaneous coronary angioplasty can be effective in preventing arrhythmias complicating acute myocardial ischaemia secondary to stenosis of a single major coronary artery.     

Cardiac tamponade in systemic juvenile rheumatoid arthritis requiring emergency pericardiectomy

A 9-year-old boy with systemic onset juvenile rheumatoid arthritis (JRA) presented with fever and chest pain and rapidly developed pericarditis and cardiac tamponade. Despite corticosteroid treatment and pericardiocentesis, rapid deterioration necessitated the emergency placement of a pericardial window. This is the first reported instance of this type of emergency surgical intervention for JRA. Of 220 children with JRA followed for 12 years (7% systemic onset), 8 had evidence of acute pericarditis but no other had definite evidence of tamponade.     

Acute nonspecific pericarditis

In order to learn the natural history of nonspecific acute pericarditis in our environment, we studied retrospectively 50 patients seen at The Instituto Nacional de Cardiología Ignacio Chávez, between 1972-1985. The clinical history, electrocardiogram, chest x ray, laboratory findings, as well as the outpatient follow-up were analyzed. There was a history of a respiratory or gastrointestinal infection, probably viral in origin, in almost half of the cases (46%). Chest pain was present in 96% of the patients and was the most common symptom. In only half of the patients a pericardial friction rub was heard. A typical S-T elevation was found in 90% of the electrocardiograms. Arrhythmias and conduction disorders were unusual. The echocardiogram showed a pericardial effusion in seven patients and six had a pleural effusion. Only one patient developed signs of cardiac tamponade. None of the patients in this study developed a chronic constrictive pericarditis and there were no deaths. Before or after hospitalization, 14 patients (28%) had multiple episodes of chest pain suggestive of recurrent pericarditis. This study shows that nonspecific acute pericarditis seems to be a self-limited illness with a good prognosis, few recurrences and practically no complications.     

Plasma catecholamines in acute myocardial infarction.

Plasma catecholamine levels were determined in 26 cases of uncomplicated myocardial infarction within 24 hours of onset of acute chest pain. Blood samples were collected at time of entry and at 4-hour intervals during the 48 hours following admission. Average values of plasma catecholamines within 1 hour of onset of pain were 0.87 ng./ml +/- 0.21 and remained elevated during the first 24 hours period. A gradual fall in catecholamine values was observed during the second 24-hour period. Catecholamines were higher in patients with sinus tachycardia and lower in patients with sinus bradycardia, and were higher in patients with anterior or anterolateral infarction. Catecholamine values were significantly higher when determined while patients presented ventricular ectopic beats or ventricular tachycardia. Sinus tachycardia, ventricular arrhythmias, and elevated plasma catecholamine values may be considered indicators of pain, anxiety, and/or left ventricular dysfunction without necessarily being causally related between themselves.     

Echocardiographic documentation of the instant of cardiac rupture: a case report

The instant of cardiac rupture was initially recorded using two-dimensional echocardiography in a patient with acute myocardial infarction. This 70-year-old woman was admitted to our hospital because of chest pain lasting for six hours. The admission electrocardiogram showed Q waves and S-T segment elevations in leads I, aVL, and V4-6. Two-dimensional echocardiography revealed hypokinesis in the middle and apical portions of the anterior septum and hyperkinesis in the basal portion of the anterior septum and the posterior wall. When the patient suddenly lost consciousness, echocardiography detected a rapidly developing pericardial effusion, which filled the pericardial sac within 13 sec. A myocardial tear was recognized at the apex of the left ventricle between portions of the hypokinesis and hyperkinesis. A simultaneously-recorded electrocardiogram showed sinus rhythm (84/min) which did not change at the moment of rupture and lasted further for 15 sec until a sudden alteration to sinus bradycardia (46/min) occurred. Cardio-pulmonary resuscitation was unsuccessful and the patient died. This is the first such case in the medical literature in which the instant of cardiac rupture was recorded. Detailed reviews of the video tapes revealed that rapid accumulation of pericardial fluid occurred, followed by transient sinus bradycardia, most likely due to vagal reflex to the stretched pericardium.     

Akute und chronisch-konstriktive Perikarditis

Acute pericarditis is an inflammatory disease of the pericardium of variable etiology. A viral infection may sometimes preceede symptoms but frequently the etiology remains unknown (idiopathic pericarditis). The disease is typically associated with left-sided chest pain and ECG abnormalities mimicking acute myocardial infarction. At physical examination the characteristic finding is a pericardial friction rub. A pericardial effusion of varying extent may be present or develop in the course of the disease. Pericardial tamponade, which may develop insidiously, represents a life-threatening complication. Pathophysiologically, filling of the cardiac chambers is impeded resulting in orthopnea, tachycardia, and eventually shock. Emergency pericardiocentesis is the treatment of choice. Constrictive pericarditis is the result of a chronic inflammation of the pericardium. Clinically it is characterized by dyspnea during exercise, symptoms of right heart failure and typical hemodynamic findings. Treatment primarily includes surgical removal of the thickened pericardium.     

Thrombosed saccular aneurysm of a sinus of Valsalva: unusual cause of a mediastinal mass

A 33 year old man presented with a short history of slight fever and chest pain that was worse on inspiration. An electrocardiogram was consistent with pericarditis. Chest radiography, echocardiography, and computed tomography suggested the presence of a mediastinal tumour. At operation the mass was found to be attached to the right sinus of Valsalva and proved to be a large saccular aneurysm full of laminated thrombus.     

Acute and chronic-constrictive pericarditis

Acute pericarditis is an inflammatory disease of the pericardium of variable etiology. A viral infection may sometimes precede symptoms but frequently the etiology re-mains unknown (idiopathic pericarditis). The disease is typically associated with left-sided chest pain and ECG abnormalities mimicking acute myocardial infarction. At physical examination the characteristic finding is a pericardial friction rub. A pericardial effusion of varying extent may be present or develop in the course of the disease. Pericardial tamponade, which may develop insidiously, represents a life-threatening complication. Pathophysiologically, filling of the cardiac chambers is impeded resulting in orthopnea, tachycardia, and eventually shock. Emergency pericardiocentesis is the treatment of choice. Constrictive pericarditis is the result of a chronic inflammation of the pericardium. Clinically it is characterized by dyspnea during exercise, symptoms of right heart failure and typical hemodynamic findings. Treatment primarily includes surgical removal of the thickened pericardium.     

Thrombosed saccular aneurysm of a sinus of Valsalva: unusual cause of a mediastinal mass.

A 33 year old man presented with a short history of slight fever and chest pain that was worse on inspiration. An electrocardiogram was consistent with pericarditis. Chest radiography, echocardiography, and computed tomography suggested the presence of a mediastinal tumour. At operation the mass was found to be attached to the right sinus of Valsalva and proved to be a large saccular aneurysm full of laminated thrombus.