A Case of Spontaneous Coronary Artery Dissection: It is Not Always Plaque Rupture

Background

Spontaneous coronary artery dissection (SCAD) is an extremely rare cause of acute coronary syndrome (ACS). Patients may present with a broad spectrum of clinical scenarios, ranging from angina pectoris to myocardial infarction, cardiogenic shock, and sudden death. Standard therapy has not been established; current treatments range from conservative management to percutaneous revascularization or coronary artery bypass surgery.

Objective

SCAD greatly mimics ACS, and this diagnosis should be considered when evaluating young patients who present with ACS with or without classical risk factors for coronary artery disease.

Case Report

We report a case of a 45-year old man who presented with chest pain typical of ACS. He had no risk factors except for a smoking history of 2.5 pack-years. Once the clinical findings suggested acute inferolateral myocardial infarction, the patient underwent emergent cardiac catheterization, which revealed left anterior descending coronary artery dissection. This in itself is not a common cause of inferolateral ST elevation changes on electrocardiogram.

Conclusion

This case highlights the fact that although SCAD is a rare entity, it is increasingly being recognized as a significant cause of ACS. Urgent angiography should be considered if SCAD is suspected, because early diagnosis and appropriate management significantly improve the outcome in these patients.     

Emergency Department Presentation of Patients with Spontaneous Coronary Artery Dissection

Background

Spontaneous coronary artery dissection (SCAD) is an infrequently recognized but potentially fatal cause of acute coronary syndrome (ACS) that disproportionately affects women. Little is currently known about how patients with SCAD initially present.

Targeting the Unstable Plaque in Acute Coronary Syndromes

Background

Rupture or erosion of an unstable atherosclerotic plaque is the typical pathology and usual cause of acute coronary syndromes. Despite detailed understanding of the processes of lipid accumulation, thinning of the fibrous cap, and inflammation leading to plaque instability, there are no strategies in clinical use that uniquely target the unstable plaque.

Objective

A critical review of recent publications on potential therapies that could be used to stabilize unstable plaque.

Methods

We searched PubMed, other literature databases, drug development sites, and clinical trial registries to retrieve clinical studies on anti-inflammatory and lipid-modulating therapies that could be used to stabilize unstable atherosclerotic plaque.

Results

Multiple experimental targets involving lipid and inflammatory pathways have the potential to stabilize the plaque and expand the armamentarium against coronary artery disease. Randomized clinical trials of darapladib, methotrexate, canakinumab, and colchicine are well advanced to establish if plaque stabilization is feasible and effective in patients with acute coronary syndromes.

Conclusions

Although there are still no agents in clinical use for plaque stabilization, there are important advances in understanding plaque instability and several encouraging approaches are being evaluated in Phase III clinical trials.     

Right Coronary Dissection and Left Anterior Descending Thrombus: Dual Dilemma in a Young Cardiac Arrest Survivor

Background

ST-elevation myocardial infarction (STEMI) leading to cardiac arrest is an exceptionally rare occurrence in young adults. Those affected tend to abuse sympathomimetic drugs, have strong family histories, or have a significant burden of cardiac risk factors. Another uncommon cause of STEMI is coronary artery dissection, which overwhelmingly affects middle- and older-aged women with few cardiac risk factors.

Vasculitis Presenting with Myocardial Infarction,Stroke, and Aortitis in a Middle-aged Man

Background

Vasculitis may cause inflammation in any single or group of blood vessels. Traditionally, giant cell arteritis involves the extracranial branches of the carotid, and Takayasu arteritis affects the aorta and its major branches. These diseases are quite rare, but have the potential to be fatal.

Objectives

We describe the spectrum of overlap between these two historically distinct diseases, and use a case of a man with arteritis involving his carotid and vertebral vessels, aorta, and coronary arteries to illustrate this. We posit that large-vessel vasculitis should be considered in the differential for young and middle-aged patients presenting with multiple vascular events.

Case Report

Over a 2-month period, a 46-year-old man presented on four separate occasions to the Emergency Department. Each time, he was diagnosed with a vascular event. His first two visits were for myocardial infarction and unstable angina, his third visit was for a cerebrovascular event, and his fourth visit was for aortitis. He was not diagnosed with the underlying vasculitic process until his last visit. He ultimately succumbed to non-aneurysmal aortic rupture from his aortitis.

Conclusions

In middle-aged persons with multiple vascular events, an underlying inflammatory process should be considered. These diseases are rare, but they are treatable; and missed diagnoses can be catastrophic.     

Hyperacute T-waves: Wolff-Parkinson-White Pattern or Acute Coronary Syndrome?

Background

Pre-excitation syndromes can elicit electrocardiogram (ECG) abnormalities that are nearly identical to those associated with acute myocardial ischemia. In the presence of atypical symptoms, stable hemodynamics, and unremarkable levels of cardiac enzymes, the decision whether to subject these patients to coronary angiography, or even non-invasive testing, can be difficult.

Objective

To understand that pre-excitation syndrome can mimic acute myocardial injury, but should not preclude a complete ischemic work-up.

Case Report

A 53-year-old man with Wolff-Parkinson-White pattern and coronary artery disease risk factors presented with new-onset substernal chest pain. A baseline ECG was significant for hyperacute T waves. After refusing cardiac catheterization, he was admitted to the cardiac care unit for intravenous heparin and eptifibatide. Although his stay was unremarkable and resting echocardiogram showed normal contractility and valve function, treadmill stress testing was negative for ischemic change, but revealed ST-segment depression with maximum stress in the lateral precordial leads. This was thought to be a “false positive” secondary to his conduction abnormality.

Conclusion

No reliable algorithm exists for making an ECG diagnosis of myocardial infarction in the presence of a pre-excitation syndrome. Similarly, current non-invasive modalities have limitations in detecting jeopardized myocardium. If acute or hyperacute injury is suspected, the patient should be emergently referred for cardiac catheterization.     

Elevation of inflammatory markers in patients with systemic lupus erythematosus is associated with poorer outcome

Objective

To determine the association between inflammatory markers and mortality in patients with systemic lupus erythematosus (SLE).

Methods

A retrospective cohort analysis of 143 patients with SLE followed between 1991 and 2010 in a Lupus Clinic in Israel. High sensitivity CRP (hsCRP) level and ESR were recorded at baseline. We compared outcomes of patients with elevation of either ESR or hsCRP to outcomes of patients without any elevation of inflammatory markers at start of follow-up. Risk factors for mortality were identified using univariate and multivariate analyses (Cox regression analysis).

Results

Of the 143 patients, 93 patients had an inflammatory marker and 50 had no inflammatory marker. There were no differences between the two groups in terms of lupus criteria, disease activity parameters or damage index. Survival was lower for patients in the inflammatory group, 24 deaths of 93 patients (25.8%), 1393 patients-years, versus five deaths of 50 patients (10%), 692 patient-years, in the non-inflammatory group, log rank P = 0.031. On multivariate analysis, inflammatory markers at baseline remained an independent risk factor for death, hazard ratio 2.72 (95% CI, 1.3–7.2).

Conclusions

SLE patients with elevation of inflammatory markers at baseline are at higher risk of death.     

Performance of a body surface mapping system using emergency physician real-time interpretation

Objective

We compared the performance characteristics of the 12-lead electrocardiography (ECG) with body surface mapping (BSM) in patients presenting for evaluation of symptoms suggestive of acute coronary syndromes.

Methods

The diagnostic test characteristics (sensitivity, specificity, likelihood ratios, and predictive values) for 12-lead ECG and BSM were computed using 3 different criterion standards.

Results

Of the 150 patients enrolled, 19 were positive for acute coronary syndromes using the criterion standard of cardiac troponin T >0.1 ng/mL, percutaneous coronary intervention, more than 70% stenosis, abnormal noninvasive testing, and coronary artery bypass graft. Changes not known to be old on ECG and BSM had sensitivities of 10.5 (95% confidence interval [CI₉₅], 1.8-34.5) and 15.8 (CI₉₅, 4.2-40.5), and specificities of 90.1 (CI₉₅, 83.3-94.4) and 86.3 (CI₉₅, 78.9-91.4), respectively.

Conclusion

In this emergency department population, both the BSM and the 12-lead ECG exhibited similar test characteristics.     

Optic Neuritis Diagnosed by Bedside Emergency Physician−Performed Ultrasound: A Case Report

Background

Optic neuritis is an inflammatory demyelinating condition of the optic nerve that causes subacute visual loss. It is often the result of an underlying systemic condition, such as multiple sclerosis. Due to the possible long-term morbidity associated with this condition, it is essential that the emergency physician recognizes the diagnosis and expedites treatment.

Objective

This case report describes optic neuritis diagnosed at the bedside by emergency physician−performed ultrasound.

Case Report

This is a case report of a young man presenting with unilateral painful vision loss. Optic neuritis must be considered in the differential diagnosis of any young patient who presents with visual complaints without any other neurologic findings. This report is unique because there are very few cases describing the findings of optic neuritis on emergency physician−performed bedside ultrasound in the literature.

Conclusions

This article presents the case, describes diagnostic modalities, especially the use of ultrasound in its diagnosis, and the course of treatment for this particular condition.     

Management of Acute Coronary Syndromes in Patients with Diabetes: Implications of the FREEDOM Trial

Background

Diabetes mellitus (DM) is a powerful independent risk factor for multivessel, diffuse coronary artery disease (CAD). The optimal coronary revascularization strategy in DM is not clearly defined, but past trials have suggested an advantage for coronary artery bypass grafting (CABG). Recently, the Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial found patients randomized to CABG had lower rates of death and myocardial infarction (MI) compared with those randomized to percutaneous coronary intervention (PCI).

Objective

This article reviews the contemporary management of patients with DM presenting with acute coronary syndromes, particularly ST-elevation MI, in the post-FREEDOM era.

Methods

We undertook a comprehensive review of published literature addressing trials in this field performed to address current knowledge both in the pre- and post-FREEDOM era.

Results

The implications of FREEDOM for patients with acute coronary syndrome are that CABG provides a significant benefit, compared with PCI with drug-eluting stents, to patients with DM and multivessel coronary artery disease; and that patients similar to those enrolled in FREEDOM should receive CABG in preference to PCI. The relevance of FREEDOM’s findings to the large proportion of patients who would not meet inclusion criteria—including patients with an acute coronary syndrome undergoing an early or emergent invasive strategy, remains uncertain.

Discussion

FREEDOM’s outcomes have generated uncertainty regarding best practice once thrombolysis in myocardial infarction grade 3 flow is re-established in patients with DM and multivessel disease. Current interventional guidelines recommend optimally treating the culprit artery; however, decisions made at the time of revascularization influence future revascularization strategies, particularly stent choice and resultant P2Y₁₂ receptor antagonist therapy. The preferred method for future revascularization may be questioned if the patient's residual coronary stenoses do not, post-PCI, meet the FREEDOM inclusion criteria, or where the left anterior descending artery is the infarct-related artery, and after left anterior descending artery PCI the patient would not receive an internal mammary graft. The management of residual disease and the preferred (further) revascularization strategy needs to be tested in an appropriately powered randomized trial.

Conclusions

The optimal revascularization strategy in patients with acute coronary syndrome, diabetes, and multivessel disease, in particular those with ST elevation, is unclear, and not guided by level A (or B) evidence. Currently CABG is favored over PCI, and an individually tailored, collaborative approach, guided by a multidisciplinary heart team, should be employed.     

Stress testing in young low-risk patients with potential acute coronary syndromes

Objective

Young patients are at low risk for an acute coronary syndrome (ACS); however, many of these patients still enter a “rule-out ACS” pathway and receive stress testing. We hypothesized that stress testing in patients younger than 40 years without known coronary disease will not identify patients at high risk for 30-day adverse cardiovascular events.

Methods

We conducted a cohort study of patients younger than 40 years evaluated in the emergency department for potential ACS. Patients were excluded if they used cocaine, had known cardiac disease, or had an abnormal electrocardiogram. Patients were followed up in-house; follow-up was performed by direct telephone contact and medical record review. The main outcome was a composite of death, acute myocardial infarction (AMI), and revascularization at 30 days. Comparisons between patients with and without stress testing were done using χ² or t test, as appropriate; 95% confidence intervals were reported for the main outcomes.

Results

Of 8816 patient visits, 1144 patients met inclusion criteria. Within 30 days, 82 patients (7.2%) received stress testing, 2 of whom led to cardiac catheterization. Death (n = 2), AMI (n = 3), and revascularization (n = 1) were not different between patients who did and did not receive stress testing (2.4% [0.2%-8.5%] vs 0.4% [0.1%-1.0%]).

Conclusion

The 30-day cardiovascular complication rate is not different between young patients without known heart disease who do and do not receive stress testing when they present with symptoms of a potential ACS. Testing of young patients at low risk for disease should be reconsidered.     

Stent thrombosis: An increased adverse event after angioplasty following resuscitated cardiac arrest

Background

The leading cause of sudden cardiac death is myocardial ischemia. As for uncomplicated acute myocardial infarction (AMI), international guidelines plead for early coronary angiography with, in case of culprit lesion, angioplasty and stent implantation. However after cardiac arrest (CA), shock, hypothermia and changes in antiplatelet pharmacokinetic may promote stent thrombosis (ST). Incidence of ST in this situation has never been studied.

Objective

The aim of this study was to investigate incidence and determinants of ST after ischemic CA successfully revascularized.

Methods

We analyzed 208 consecutive patients admitted in our institution for AMI and who underwent PCI with stent implantation. Among these patients, 55 presented a resuscitated CA and were compared to 153 without CA (control group). All patients in the CA group received hypothermia (33 °C for 24 h) following resuscitation and PCI.

Results

There was no difference between the 2 groups for age, gender, cardiovascular risk factors, coronary lesions and type of stent. In the CA group, patients were less frequently pre-treated with heparin (50.9% vs 98.7%, p < 0.001) and aspirin (52.7% vs 99%, p < 0.001). In the CA group, we observed a significantly higher incidence of confirmed acute or subacute ST than in the control group: 10.9% vs 2.0% (p = 0.01). None of CA patients had received a dual antiplatelets therapy (0% vs 99%). LVEF at admission was lower in the CA group (40.3% vs 48%; p < 0.001), and shock was more frequent (83.6% vs 8.5%; p < 0.001). Survival at 28 days was 50.1% in CA group vs 98.0% (p < 0.001). In multivariate analysis, CA before stenting appears to be an independent risk factor for confirmed ST (OR = 12.9; 95%CI 1.3–124.6; p = 0.027).

Conclusion

In CA patients treated with cooling, stenting for AMI is associated with a high risk of ST. Shock, insufficient antithrombotic treatment, pharmacokinetic changes related to hypothermia may contribute to this higher risk. A strategy aiming to reduce this complication may probably improve prognosis of patients who underwent coronary sudden death.     

Ruptured appendicitis presenting as acute scrotal swelling in a 23-month-old toddler

Background

Acute appendicitis is a common disease process in which timely diagnosis minimizes the risk of complications.

Objectives

This case illustrates one example of the range of clinical presentations of young children with acute appendicitis.

Case Report

We describe a case in a young child presenting with an inguinal and scrotal mass that was ultimately due to perforated appendicitis with abscess formation.

Conclusions

In the emergency department evaluation of these children with inguinal or scrotal complaints, we maintain that intra-abdominal processes should be included in the differential.     

Myocardial Infarction in a Young Man Due to Coronary Artery Aneurysms after an Undiagnosed Kawasaki Disease

Background

Kawasaki disease usually affects infants and young children. It often goes unrecognized in adults due to varying symptoms and lack of definite diagnostic criteria.

Objectives

To describe the potential for acute myocardial infarction as a complication of antecedent Kawasaki Disease (KD).

Case Report

We describe a case of a 19-year-old man who presented to the Emergency Department (ED) with an acute myocardial infarction that was subsequently determined to be the result of previously untreated KD.

Conclusion

Kawasaki disease can cause coronary complications in a teenager. A high level of suspicion in the ED can help in proper management of these patients.     

Mechanism of Action of Colchicine in the Treatment of Gout

Purpose

The aims of this article were to systematically review the literature about the mechanism of action of colchicine in the multimodal pathology of acute inflammation associated with gout and to consider the clinical utility of colchicine in other chronic inflammatory diseases.

Methods

The English-language literature on PubMed was searched for articles published between 1990 and October 2013, with a cross-reference to citations across all years. Relevant articles pertaining to the mechanism of action of colchicine and the clinical applications of colchicine in gout and other inflammatory conditions were identified and reviewed.

Findings

The molecular pathology of acute inflammation associated with gouty arthritis involves several concurrent pathways triggered by a variety of interactions between monosodium urate crystals and the surface of cells. Colchicine modulates multiple pro- and antiinflammatory pathways associated with gouty arthritis. Colchicine prevents microtubule assembly and thereby disrupts inflammasome activation, microtubule-based inflammatory cell chemotaxis, generation of leukotrienes and cytokines, and phagocytosis. Many of these cellular processes can be found in other diseases involving chronic inflammation. The multimodal mechanism of action of colchicine suggests potential efficacy of colchicine in other comorbid conditions associated with gout, such as osteoarthritis and cardiovascular disease.

Implications

Colchicine has multiple mechanisms of action that affect inflammatory processes and result in its utility for treating and preventing acute gout flare. Other chronic inflammatory diseases that invoke these molecular pathways may represent new therapeutic applications for colchicine.     

Long QT Syndrome Unmasked in an Adult Subject Presenting with Excited Delirium

Background

Excited delirium is increasingly recognized as a risk factor for sudden death, though the specific pathophysiology of these deaths is typically unclear.

Objectives

We describe a survivor of excited delirium that displayed a transient severe prolongation of the QT interval, suggesting unmasking of long QT syndrome as a possible mechanism of sudden death.

Case Report

A 30-year-old man was arrested by police for violent assaultive behavior. Officers at the scene noted confusion, nonsensical speech, sweating, and bizarre agitated behavior; he was transported to the Emergency Department for medical evaluation of possible excited delirium. His initial electrocardiogram revealed a markedly prolonged corrected QT interval of over 600 ms. Intravenous hydration and sodium bicarbonate were administered, with normalization of the QT; he was admitted and recovered uneventfully.

Conclusions

We discuss the possible association between long QT syndrome and unexplained sudden deaths seen with excited delirium. Sodium bicarbonate may be considered when long QT syndrome is identified during or after agitated delirium, though its routine use cannot be recommended based on a case report.     

Utility of Observation Units for Young Emergency Department Chest Pain Patients

Background

Determining which patients presenting to the Emergency Department (ED) require further work-up for acute coronary syndrome (ACS) can be difficult. The utility of routine observation for cardiac testing in low-risk young adult patients has been questioned.

Study Objectives

We investigated the rate of positive findings yielded by routine cardiac observation unit work-up in patients aged 40 years or younger.

Methods

This was a retrospective observational cohort study of patients aged 18–40 years who were evaluated for ACS in an ED-based observation unit. Data were collected by trained abstractors from electronic medical records.

Results

A total of 362 patients met inclusion criteria. Of those, 239 received stress testing, yielding five positive and nine indeterminate results. One other patient had acute troponin elevation while under observation. The positive stress test patients and troponin-elevated patient underwent cardiac angiography. Only one positive stress test patient showed significant coronary stenosis and received coronary interventions. In follow-up data, one patient had an adverse cardiac outcome within 1 year of index visit, but no coronary interventions. Thus, only 3 patients had adverse cardiac events, with only one patient warranting intervention discovered by observation unit stress testing and a second via serial cardiac markers.

Conclusion

Routine observation of symptomatic young adults for ACS had low yield. Observation identified one patient with acute cardiac marker elevation and further stress testing identified only one patient with intervenable ACS, despite a high false-positive rate. This suggests that observation and stress testing should not be routinely performed in this demographic absent other high-risk features.     

Risk scores prognostic implementation in patients with chest pain and nondiagnostic electrocardiograms

Background

Several risk scores are available for prognostic purpose in patients presenting with chest pain.

Aim

The aim of this study was to compare Grace, Pursuit, Thrombolysis in Myocardial Infarction (TIMI), Goldman, Sanchis, and Florence Prediction Rule (FPR) to exercise electrocardiogram (ECG), decision making, and outcome in the emergency setting.

Methods

Patients with nondiagnostic ECGs and normal troponins and without history of coronary disease underwent exercise ECG. Patients with positive testing underwent coronary angiography; otherwise, they were discharged.End point was the composite of coronary stenosis at angiography or cardiovascular death, myocardial infarction, angina, and revascularization at 12-month follow-up.

Results

Of 508 patients considered, 320 had no history of coronary disease: 29 were unable to perform exercise testing, and finally, 291 were enrolled. Areas under the receiver operating characteristic curves for Grace, Pursuit, TIMI, Goldman, Sanchis, and FPR were 0.59, 0.68, 0.69, 0.543, 0.66, and 0.74, respectively (P < .05 FPR vs Goldman and Grace). In patients with negative exercise ECG and overall low risk score, only the FPR effectively succeeded in recognizing those who achieved the end point; in patients with high risk score, the additional presence of carotid stenosis and recurrent angina predicted the end point (odds ratio, 12 and 5, respectively). Overall, logistic regression analysis including exercise ECG, coronary risk factors, and risk scores showed that exercise ECG was an independent predictor of coronary events (P < .001).

Conclusions

The FPR effectively succeeds in ruling out coronary events in patients categorized with overall low risk score. Exercise ECG, nonetheless being an independent predictor of coronary events could be considered questionable in this subset of patients.     

Delphi-Based Assessment of Fall-Related Risk Factors in Acute Rehabilitation Settings According to the International Classification of Functioning,Disability and Health

Objective

To apply the International Classification of Functioning, Disability and Health (ICF) model to fall prevention by developing an ICF core set for fall risks in acute rehabilitation settings.

Design

Fall risk factors were identified based on a systematic review of the literature and linked to ICF categories. A consensus process was conducted using a Delphi-based evaluation technique.

Setting

University-based hospital.

Participants

Multidisciplinary participants (N=20) from different institutions.

Interventions

Not applicable.

Main Outcome Measures

A 5-point Likert-type scale was used to weigh the importance of each risk category. The level of agreement for each consensus was assessed based on Spearman rho and semi-interquartile range indices. Categories with a mean score ≥4 in the third round of evaluation were included in this ICF core set.

Results

The core set comprised 34 fall risk categories that were distributed as follows: 18 categories on body functions, 2 on body structures, 8 on activities and participation, 4 on environmental factors, and 2 categories on personal factors.

Conclusions

An ICF core set for falls in acute rehabilitation settings was developed in this study. Further validation is required.