Aneurysms of mediastinal systemic veins are extremely rare, usually asymptomatic and incidentally diagnosed during chest radiography. We describe the case of a giant superior vena caval aneurysm in a 14-year old male following Glenn surgery and discuss its complications and management.
Superior vena caval aneurysm
Pericarditis with pericardial effusion in acute coronary syndrome is seen in patients with ST-elevation myocardial infarction specifically when infarction is anterior, extensive, and Q wave. It is very uncommon to have pericardial effusion in a patient with non-ST-elevation myocardial infarction. We present an elderly hypertensive patient who was diagnosed as non-ST-elevation myocardial infarction with pericardial effusion that turned out to be acute aortic dissection with catastrophic end. We conclude that, in patients with suspected diagnosis of non-ST-elevation myocardial infarction or unstable angina, if pericardial effusion is detected on echocardiography, aortic dissection needs to be considered.
A 55-year-old chronic alcoholic male known to be positive for human immunodeficiency virus (HIV) was admitted to a surgical ward following perianal abscess drainage. He was noted to have sinus bradycardia, ventricular premature complexes, and mild hypotension. His laboratory investigations revealed mild hypokalaemia. He was intermittently agitated and alcohol withdrawal syndrome (AWS) was diagnosed. Postoperatively, he received intravenous piperacillin/tazobactam and metronidazole infusions along with a small dose of dopamine. Analysis of a 24-hour Holter monitor (ECG) showed a prolonged QT interval with two episodes of self-terminating torsade de pointes. His AWS was treated, hypokalaemia was corrected, and dopamine, along with antibiotics, was withdrawn. There was no recurrence of arrhythmias. This case highlights the importance of avoiding QT-prolonging drugs in hospitalised patients, since hospitalised patients often have multiple risk factors for a proarrhythmic response.
Torsade de pointes; QT interval; QT prolongation; QT-prolonging drugs; Alcohol withdrawal syndrome; Human immunodeficiency virus; Case report; Oman
This study aimed to evaluate the epidemiology and coronary risk factors of acute coronary syndrome (ACS) in Oman.
Data were collected through a prospective, multinational, multicentre survey of consecutive patients, hospitalised over a 5-month period in 2007 with a diagnosis of ACS, in Yemen and five Arabian Gulf countries (Oman, Bahrain, Kuwait, Qatar, United Arab Emirates). Here we present data of Omani patients aged ≥20 years who received a provisional diagnosis of ACS and were consequently admitted to 14 different hospitals.
There where 1,340 confirmed ACS episodes in 748 men and 592 women (median age 61 years). The overall crude incidence rate of ACS was 338.9 per 100,000 person-years (P-Y). The age-standardised rate (ASR) of ACS was 779 and 674 per 100,000 P-Y for men and women, respectively. The ASR male-to-female rate ratio was highest in the ST-elevation myocardial infarction (STEMI) group (2.26, 95% confidence interval ([CI], 1.63 to 3.15) followed by the non-STEMI (NSTEMI) group (1.68, 95% CI 1.28 to 2.21) and unstable angina (0.79, 95% CI 0.66 to 0.99). Unstable angina accounted for 55%, STEMI for 26% and NSTEMI for 19% of ACS cases. Among the coronary risk factors, there was a high prevalence of hypertension (68%), diabetes mellitus (DM) (36%), hyperlipidaemia (63%), and overweight/obesity (65%), with a relatively low rate of current tobacco use (11%).
Our study confirms a high incidence of ACS in Omanis and supports the notion that the cardiovascular disease epidemic is also sweeping developing countries.
Acute coronary syndrome; Incidence; Cardiovascular disease; Ischemic heart disease; Risk factors; Oman
Currently recommended risk stratification protocols for suspected ischemic chest pain in the emergency department (ED) includes point-of-care availability of exercise treadmill/nuclear tests or CT coronary angiograms. These tests are not widely available for most of the ED’s. This study aims to prospectively validate the safety of a predefined 4-hour accelerated diagnostic protocol (ADP) using chest pain, ECG, and troponin T among suspected ischemic chest pain patients presenting to an ED of a tertiary care hospital in Oman.
One hundred and thirty-two patients aged over 18 years with suspected ischemic chest pain presenting within 12 hours of onset along with normal or non-diagnostic first ECG and negative first troponin T (<0.010 μg/l) were recruited from September 2008 to February 2009. Low-probability acute coronary syndrome (ACS) patients at 4-hours defined as absent chest pain and negative ECG or troponin tests were discharged home and observed for 30-days for major adverse cardiac events (MACE) (Group I: negative ADP). High-probability ACS patients at 4-hours were defined by recurrent or persistent chest pain, positive ECG or troponin tests and were admitted and observed for in-hospital MACE (Group II: positive ADP).
One hundred and thirty-two patients were recruited and 110 patients completed the study. The overall 30-day MACE in this cohort was 15% with a mortality of less than 1%. 30-days MACE occurred in 8/95 of group I patients (8.4%) and 9/15 of the in-hospital MACE patients in group II. The ADP had a sensitivity of 52% (95% CI: 0.28-0.76), specificity of 93% (0.85-0.97), a negative predictive value of 91% (0.83-0.96), a positive predictive value of 60% (0.32-0.82), negative likelihood ratio of 0.5 (0.30-0.83) and a positive likelihood ratio of 8.2 (3.3-20) in predicting MACE.
A 4-hour ADP using chest pain, ECG, and troponin T had high specificity and negative predictive value in predicting 30-day MACE among low probability ACS patients discharged from ED. However, 30-day MACE in ADP negative patients was relatively high in contrast to guideline recommendations. Hence, there is a need to establish ED chest pain unit and adopt new protocols especially adding a point-of-care exercise treadmill test in the ED.
Emergency department; Accelerated diagnostic protocol; Acute coronary syndrome; MACE; Exercise treadmill test; Chest pain unit
Little is known about thrombolytic therapy patterns in patients with ST-elevation myocardial infarction (STEMI) in the Middle East. The objective of this study was to evaluate the clinical profile and mortality of STEMI patients who arrived in hospital within 12 hours from pain onset and received thrombolytic therapy.
Patients and Methods:
This was a prospective, multinational, multi-centre, observational survey of consecutive acute coronary syndrome patients admitted to 65 hospitals in six Middle Eastern countries during the period between October 2008 and June 2009, as part of Gulf RACE-II (Registry of Acute Coronary Events). Analyses were performed using univariate statistics.
Out of 2,465 STEMI patients, 66% (n = 1,586) were thrombolysed with namely: streptokinase (43%), reteplase (44%), tenecteplase (10%), and alteplase (3%). 22.7% received no reperfusion. Median age of the study cohort was 50 (45-59) years with majority being males (91%). The overall median symptom onset-to-presentation and door-to-needle times were 165 (95- 272) minutes and 38 (24-60) minutes, respectively. Generally, patients presenting with higher GRACE risk scores were treated with newer thrombolytic agents (reteplase and tenecteplase) (P < 0.001). The use of newer thrombolytic agents was associated with a significantly lower mortality at both 1-month (0.8% vs. 1.7% vs. 4.2%; P = 0.014) and 1-year (0% vs. 1.7% vs. 3.4%; P = 0.044) compared to streptokinase use.
Majority of STEMI patients from the Middle East were thrombolysed with streptokinase and reteplase in equal numbers. Nearly one-fifth of patients did not receive any reperfusion therapy. There was inappropriately long symptom-onset to hospital presentation as well as door-to-needle times. Use of newer thrombolytic agents in high risk patients was appropriate. Newer thrombolytic agents were associated with significantly lower mortality at 1-month and 1-year compared to the older agent, streptokinase.
Acute coronary syndrome; GRACE score; Middle East; mortality; reteplase; STEMI; streptokinase; tenecteplase; thrombolytic therapy
Management of warfarin-induced major bleeding in patients with mechanical heart valves is challenging. There is vast controversy and confusion in the type of treatment required to reverse anticoagulation and stop bleeding as well as the ideal time to restart warfarin therapy safely without recurrence of bleeding and/or thromboembolism. Presently, the treatments available to reverse warfarin-induced bleeding are vitamin K, fresh frozen plasma, prothrombin complex concentrates and recombinant activated factor VIIa. Currently, vitamin K and fresh frozen plasma are the recommended treatments in patients with mechanical heart valves and warfarin-induced major bleeding. The safe use of prothrombin complex concentrates and recombinant activated factor VIIa in patients with mechanical heart valves is controversial and needs well-designed clinical studies. With regard to restarting anticoagulation in patients with warfarin-induced major bleeding and mechanical heart valves, the safe period varies from 7-14 d after the onset of bleeding for patients with intracranial bleed and 48-72 h for patients with extra-cranial bleed. In this review article, we present relevant literature about these controversies and suggest recommendations for management of patients with warfarin-induced bleeding and a mechanical heart valve. Furthermore, there is an urgent need for separate specific guidelines from major associations/ professional societies with regard to mechanical heart valves and warfarin-induced bleeding.
Warfarin; Major bleeding; Mechanical heart valve; Thromboembolism; Vitamin K; Fresh frozen plasma; Prothrombin complex concentrate; Recombinant activated factor VIIa
A 60-year-old male hypertensive was suspected to have post myocardial infarction left ventricular aneurysm. His transthoracic echocardiogram performed elsewhere reported an inferior wall left ventricular aneurysm. He was referred for coronary angiography. His coronary angiogram and repeat transthoracic echocardiogram demonstrated an accessory chamber arising from mid-inferior wall synchronously contracting with the left ventricle suggesting a diverticulum. In addition, he had anomalous coronary arteries with coronary artery disease. His electrocardiogram did not reveal any features suggestive of a post infarct aneurysm. This case illustrates the importance of a comprehensive clinical and echocardiographic examination with a broad differential thought process.
Left ventricular diverticulum; Left ventricular aneurysm; Coronary anomaly
We used prospective cohort data of patients with acute coronary syndrome (ACS) to compare their management on weekdays/mornings with weekends/nights, and the possible impact of this on 1-month and 1-year mortality. Analyses were evaluated using univariate and multivariate statistics. Of the 4,616 patients admitted to hospitals with ACS, 76% were on weekdays. There were no significant differences in 1-month (odds ratio (OR), 0.88; 95% CI: 0.68-1.14) and 1-year mortality (OR, 0.88; 95% CI: 0.70-1.10), respectively, between weekday and weekend admissions. Similarly, there were no significant differences in 1-month (OR, 0.92; 95% CI: 0.73-1.15) and 1-year mortality (OR, 0.98; 95% CI: 0.80-1.20), respectively, between nights and day admissions. In conclusion, apart from lower utilization of angiography (P < .001) at weekends, there were largely no significant discrepancies in the management and care of patients admitted with ACS on weekdays and during morning hours compared with patients admitted on weekends and night hours, and the overall 30-day and 1-year mortality was similar between both the cohorts.
Acute coronary syndrome; Weekend; Weekday; Mortality; Admission.
Fahr's disease is a rare neurodegenerative disorder of unknown cause characterized by idiopathic basal ganglia calcification that is associated with neuropsychiatric and cognitive impairment. No case of Fahr's disease with associated cardiac conduction disease has been described in the literature to date. The objective of this case report was to describe a young female with various cardiac conduction system abnormalities and bilateral basal ganglia calcification suggestive of Fahr's disease.
A 19-year-old female was transferred to our hospital for a pacemaker insertion. Her past medical history included cognitive impairment and asymptomatic congenital complete heart block since birth. Her manifestations included cognitive impairment, tremors, rigidity, ataxia, bilateral basal ganglia calcification without clinical manifestations of mitochondrial cytopathy. She also had right bundle branch block, left anterior fascicular block, intermittent complete heart block, atrial arrhythmias with advanced atrioventricular blocks and ventricular asystole manifested by Stokes-Adams seizures, which was diagnosed as epilepsy.
According to our knowledge, this was the first case report of a su spected association between Fahr's disease and isolated cardiac conduction system disease. In addition, this case illustrated that in patients with heart blocks and seizures, a diagnosis of epilepsy needs to be made with caution and such patients need further evaluations by a cardiologist or electrophysiologist to consider pacing and prevent future catastrophic events.
Fahr's Disease; Basal Ganglia Calcification; Cardiac Conduction Defect; Congenital Heart Block; Epilepsy
A 44-year-old man presented with acute coronary syndrome. He was administered glycoprotein IIb/IIIa receptor antagonist (tirofiban) for a left anterior descending artery thrombus detected during percutaneous coronary intervention. He developed very severe thrombocytopenia 24 h after tirofiban infusion with no signs of bleeding. The thrombocytopenia spontaneously resolved after stopping tirofiban without any significant clinical sequelae. To our knowledge, this is the first case report of tirofiban-induced severe thrombocytopenia from the Middle East. Clinicians using this drug should be aware of this potentially lethal adverse drug reaction. Close monitoring of platelet count early after the initiation of tirofiban infusion is suggested and discontinuation of tirofiban infusion can reverse thrombocytopenia spontaneously.
Glycoprotein IIb/IIIa receptor antagonist; thrombocytopenia; tirofiban
Ischemic stroke secondary to aortic dissection is not uncommon. We present a patient with left hemiplegia secondary to Stanford type A aortic dissection extending to the supra-aortic vessels, which was precipitated by rifle butt recoil chest injury. The diagnosis of aortic dissection was delayed due to various factors. Finally, the patient underwent successful Bentall procedure with complete resolution of symptoms. This case emphasizes the need for caution in the use of firearms for recreation and to take precautions in preventing such incidents. In addition, this case illustrates the need for prompt cardiovascular physical examination in patients presenting with stroke.
Aortic dissection; Hemiplegia; Stroke; Recoil injury
We report a 61-year-old male patient who presented with one month history of exertional dyspnea, persistent dry cough, abdominal pain with distension, poor appetite, and weight loss. This case illustrates a rare presentation of hepatocellular carcinoma with mobile right atrial thrombus and pulmonary embolism along with disseminated tumor thrombosis at multiple sites. Furthermore, this case reiterates that an early detection and diagnosis may have increasing importance in the advent of new therapies for treating advanced hepatocellular carcinoma
Disseminated tumor thrombosis; hepatocellular carcinoma; IVC thrombosis; portal vein thrombosis; pulmonary embolism; right atrial thrombus
Acute coronary syndrome (ACS) is the most common cause of cardiovascular mortality and morbidity in Western countries. International guidelines for diagnosis and treatment have been developed based on randomised clinical trials. However, data from international registries report a lack of association between guideline recommendations and actual clinical practice. Similarly, the Gulf Heart Association initiated a registry called Gulf Registry of Acute Coronary Events (Gulf RACE). This registry was developed to determine the characteristics and management of ACS in the Gulf countries including Oman. Here, we report on the results of the various Gulf RACE registry studies from Oman and compare our results with the main Gulf RACE data as well as other international registries.
Acute coronary syndrome; Oman
Accessory mitral valve tissue is a rare congenital anomaly associated with congenital cardiac defects and is usually detected in the first decade of life. We describe the case of an 18-year old post-Senning asymptomatic patient who was found to have accessory mitral valve tissue on transthoracic echocardiography producing severe left ventricular outflow tract obstruction.
accessory mitral valve tissue; left ventricular outflow tract obstruction.
Coronary perforation is a rare complication of percutaneous coronary intervention. We present two different types of coronary intervention, but both ending with coronary perforation. However, these perforations were tackled successfully by covered stents. This article reviews the incidence, causes, presentation, and management of coronary perforation in the present era of aggressive interventional cardiology. Coronary perforations are classified as type I (extraluminal crater), II (myocardial or pericardial blushing), and III (contrast streaming or cavity spilling). Types I and II coronary perforations are caused by stiff or hydrophilic guidewires. Type I has a benign prognosis, whereas type II coronary perforations have the potential to progress to tamponade. Type III coronary perforations are caused by balloons, stents, or other intracoronary devices and commonly lead to cardiac tamponade necessitating pericardial drainage. However, type III perforations can be managed with covered stents without need for surgical intervention.
Cardiac tamponade; coronary perforation; covered stent
We report a 30-year-old male intravenous drug abuser presenting with persistent pacemaker lead thrombosis with superimposed pacemaker lead endocarditis. He underwent urgent surgery, but expired due to refractory sepsis. This case confirms that patients with pacemakers are at risk of developing pacemaker lead thrombosis. In addition, they are at high risk of developing pacemaker lead endocarditis if additional risk factors for endocarditis are present. We believe this case report is unusual on account of pacemaker lead thrombosis as well as endocarditis occurring in a patient with history of intravenous drug abuse. Whether pacemaker patients with multiple leads need to be on long-term antiplatelet or anticoagulation therapy necessitates further studies.
Pacemaker lead thrombosis; Pacemaker lead endocarditis; Septic shock; Intravenous drug abuse
Background and Objectives:
Hyperglycemia in patients admitted for acute coronary syndrome (ACS) is associated with increased in-hospital mortality. We evaluated the relationship between admitting (nonfasting) blood glucose and in-hospital mortality in patients with and without diabetes mellitus (DM) presenting with ACS in Oman.
Patients and Methods:
Data were analyzed from 1551 consecutive patients admitted to 15 hospitals throughout Oman, with the final diagnosis of ACS during May 8, 2006 to June 6, 2006 and January 29, 2007 to June 29, 2007, as part of Gulf Registry of Acute Coronary Events. Admitting blood glucose was divided into four groups, namely, euglycemia (≤7 mmol/l), mild hyperglycemia (>7-<9 mmol/l), moderate hyperglycemia (≥9-<11 - mmol/l), and severe hyperglycemia (≥11 mmol/l).
Of all, 38% (n = 584) and 62% (n = 967) of the patients were documented with and without a history of DM, respectively. Nondiabetic patients with severe hyperglycemia were associated with significantly higher in-hospital mortality compared with those with euglycemia (13.1 vs 1.52%; P<0.001), mild hyperglycemia (13.1 vs 3.62%; P = 0.003), and even moderate hyperglycemia (13.1 vs 4.17%; P = 0.034). Even after multivariate adjustment, severe hyperglycemia was still associated with higher in-hospital mortality when compared with both euglycemia (odds ratio [OR], 6.3; P<0.001) and mild hyperglycemia (OR, 3.43; P = 0.011). No significant relationship was noted between admitting blood glucose and in-hospital mortality among diabetic ACS patients even after multivariable adjustment (all P values >0.05).
Admission hyperglycemia is common in ACS patients from Oman and is associated with higher in-hospital mortality among those patients with previously unreported DM.
Acute coronary syndrome; admission hyperglycemia; diabetes mellitus; hyperglycemia; in-hospital mortality
Very late stent thrombosis occurs more frequently with drug-eluting stents and tends to occur despite dual antiplatelet therapy or after long periods of clopidogrel discontinuation. Stent thrombosis commonly presents with myocardial infarction or death. We report a 41-year-old Arab male with very late stent thrombosis after 59 months of sirolimus-eluting stent implantation and –49 months after clopidogrel discontinuation despite aspirin continuation, presenting with exertional angina. He underwent successful percutaneous coronary intervention. This case underlines the need for novel stent designs as well as newer therapeutic strategies in preventing very late stent thrombosis among patients receiving drug-eluting stents.
Drug-eluting stent; sirolimus-eluting stent; stent thrombosis; very late stent thrombosis
We report a case of a 61-year-old patient presenting with cardiogenic shock. His echocardiogram suggested typical features of cardiac amyloidosis. This case demonstrates that cardiac amyloidosis can present acutely and may be catastrophic.