Caseous Calcification of the Mitral Annulus: Mimicking A Cardiac Mass.

Mitral annulus calcification is a common incidental finding in echocardiography examination of predisposed populations. On the other hand, caseous calcification of the mitral annulus is a rare variant that challenges the physician to differentiate it from different causes of cardiac masses. We describe a case of incidentally discovered caseous calcification confirmed with CT cardiac and cardiac magnetic resonance. LEARNING POINTS: Caseous calcification of the mitral annulus is a rare condition.An important differential diagnosis is cardiac tumours and myocardial abscesses.Cardiac computed tomography and cardiac magnetic resonance imaging are important in confirming the diagnosis, and assessing the extent and location of annular calcium.

Point-of-Care Ultrasound to Detect Dilated Coronary Sinus in Adults.

Detecting dilated coronary sinus when assessing patients in an acute emergency with point-of-care ultrasound (POCUS) is important for differential diagnosis, including the detection of persistent left superior vena cava (PLSVC) and right ventricular dysfunction. Cardiac POCUS with agitated saline injections through the left and right antecubital veins is a simple bedside test to make the diagnosis. We present a 42-year-old woman with first-time rapid atrial flutter in whom POCUS confirmed the presence of dilated coronary sinus and PLSVC.

The prevalence and outcome of hypertension in patients with acute coronary syndrome in six Middle-Eastern countries.

AIMS: The aim was to report the prevalence and significance of hypertension (HTN) in patients with acute coronary syndrome (ACS). METHODS AND MAJOR FINDINGS: Over a 6-month period in 2007, 8171 consecutive patients (49.4% hypertensive and 50.6% non-hypertensive) presenting with ACS were enrolled in a prospective, multicenter study from six Middle Eastern adjacent countries. Patients with HTN were older (59.2 vs 53.1 years, p<0.001), and more likely to be female (34% vs 14.4%, p<0.001) when compared with patients without HTN. Patients with HTN were also more likely to have diabetes mellitus, hyperlipidemia, cerebrovascular disease, prior history of coronary artery disease, peripheral artery disease but less likely to be cigarette smokers. At admission, HTN patients had higher Killip class, heart rate and GRACE risk scoring. In-hospital mortality was higher in hypertensive patients with ST-elevation myocardial infarction (STEMI) but not in patients with non-STEMI or unstable angina. The incidence of heart failure complications was significantly higher among patients with HTN in overall ACS type (OR = 1.2, 95% CI 1.001-1.338, p= 0.04). MAIN CONCLUSION: In this large cohort of patients with ACS, HTN was an independent predictor of heart failure and was associated with an increased rate of in-hospital mortality in STEMI only.

Kuwait acute coronary syndromes registry: baseline characteristics, management practices and in-hospital outcomes of patients hospitalized with acute coronary syndromes in Kuwait.

OBJECTIVES: To identify the characteristics of patients with acute coronary syndromes (ACS), their hospital management and in-hospital outcomes, through a prospective registry system in Kuwait. SUBJECTS AND METHODS: A registry involving all 7 general hospitals in Kuwait was set up. Consecutive patients diagnosed as having ACS over a period of 6 months were enrolled. RESULTS: Of 2,129 patients enrolled, 718 (34%) had ST segment elevation myocardial infarction (STEMI), 576 (27%) non-ST segment elevation myocardial infarction (NSTEMI) and 835 (39%) unstable angina (UA). Thrombolytic therapy was used in 556 (77%) patients with STEMI. The median time from diagnostic electrocardiogram to administration of thrombolytic therapy was 38 min. Almost all patients with ACS (2,050, 96%) received aspirin during hospitalization. Only a minority received clopidogrel, 18 (3%) STEMI, 36 (6%) NSTEMI and 96 (12%) UA patients. The use of glycoprotein IIb/IIIa antagonists was minimal (38 patients, 2%). beta-Blockers were used in 1,473 (69%) patients, while 982 (46%) received angiotensin-converting enzyme inhibitors. Coronary angiography during hospitalization was performed in 119 (17%), 120 (21%) and 126 (15%) patients with STEMI, NSTEMI and UA, respectively. In-hospital mortality occurred in 31 (4%) myocardial infarction patients and 4 (0.5%) UA patients (p < 0.0001). CONCLUSION: This registry has enabled us to determine the incidence and characteristics of ACS patients in Kuwait. It has also enabled us to identify some barriers that we need to overcome for the full implementation of published guidelines for the management of patients with ACS.

Troponin estimation identifies myocardial infarction patients with different characteristics.

OBJECTIVE: To investigate the impact of new myocardial infarction definition based on troponin, the rate of myocardial infarction diagnosis, patients characteristics, and short-term prognosis. METHODS: We enrolled 1,255 consecutive myocardial infarction patients from the Kuwait Registry of Acute Coronary Syndromes from December 2003 to May 2004. Two patient groups were identified, those diagnosed with elevated creatine kinase-MB (CK group) and those diagnosed with elevated troponin with normal CK-MB (Troponin group). RESULTS: The use of troponin have increased the number of myocardial infarctions by 49%. Compared with the CK group, the Troponin group were older [age 60.3 +/- 12.5 years versus 53.7 +/- 12.2 years, p<0.001], more likely to have diabetes (59% versus 41%, p<0.001), hypertension (59% versus 36%, p<0.001), and hypercholesterolemia (37% versus 24%, p<0.001). The Troponin group were more likely to suffer heart failure at presentation than the CK group (32% versus 14%, p<0.001) and, subsequently, increase incidence of heart failure during their hospital stay (17% versus 8%, p<0.001). CONCLUSION: A substantial increase in the rate of myocardial infarction occurred with the adoption of the new diagnostic criteria. The clinical outcome for the additional patients diagnosed was not better than that of patients diagnosed by the old criteria.

Impact of diabetes and smoking epidemic in the Middle East on the presentation with acute coronary syndrome in very young patients.

We describe the baseline characteristics, management, and outcomes of acute coronary syndrome (ACS) in patients of age ≤ 40 in the Gulf region of the Middle East. We studied 8176 hospitalized patients (≤ 40 years) with ACS. Ten percent (805) of the recruited patients were ≤ 40 years. The mean age was 37 years and 89% were males. The prevalence of smoking and diabetes in the young patients was high (58% and 21%, respectively). The most common ACS was ST elevation myocardial infarction. Younger patients were more aggressively treated with more frequent use of glycoprotein inhibitors, thrombolytics, and primary percutaneous coronary intervention. They had less in-hospital heart failure, left ventricular dysfunction, shock, stroke, and low rate of in-hospital mortality (1%). Measures to combat the rising prevalence of diabetes and smoking are needed.

Trends in the Use of Evidence-based Therapies Early in the Course of Acute Myocardial Infarction and its Influence on Short Term Patient Outcomes.

AIM: To evaluate changes in management practices and its influence on short term hospital outcomes in patients with acute myocardial infarction (AMI) admitted during two different time periods, 2007 and 2004. METHODS AND RESULTS: We studied AMI patients from two acute coronary syndrome registries carried out in Kuwait in 2007 and 2004. We included 1872 and 1197 patients from the 2007 and 2004 registries, respectively. When compared with 2004, patients from the 2007 registry had similar baseline clinical characteristics. In 2007 compared to 2004, during the in-hospital period, patients with AMI received significantly more statins (94% vs. 73%%, p<0.0001), Angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARB) (70% vs. 47%, p<0.001), and Clopidogrel (38% vs. 4%, p<0.001), while beta-blockers use dropped in 2007 compared to 2004 (63% vs. 68%, p=0.0066). The rates of in-hospital mortality and recurrent ischemia were significantly lower in the 2007 cohort compared with the 2004 cohort (for mortality 2.2% vs. 3.9%, P=0.0008, for recurrent ischemia 13.7% vs. 20.4%, P=0<0.0001).Higher utilization of angiotensin converting enzyme inhibitors, angiotensin receptor blockers and statins were the main contributors to the improved in-hospital mortality and morbidity. IN CONCLUSION: In the acute management of AMI, there was a significant increase in the use of statins, ACE inhibitors and Clopidogrel in 2007 compared to 2004. This was associated with a significant decrease in the in-hospital mortality and recurrent ischemia. Adherence to guidelines recommended therapies improved in-hospital outcomes.

In-hospital major clinical outcomes in patients with chronic renal insufficiency presenting with acute coronary syndrome: data from a Registry of 8176 patients.

OBJECTIVE: To assess the impact of chronic renal insufficiency (CRI) on in-hospital major adverse cardiac events across the acute coronary syndrome (ACS) spectrum. PATIENTS AND METHODS: From January 29, 2007, through July 29, 2007, 6 adjacent Middle Eastern countries participated in the Gulf Registry of Acute Coronary Events, a prospective, observational registry of 8176 patients. Patients were categorized according to estimated glomerular filtration rate into 4 groups: normal (>or=90 mL/min), mild (60-89 mL/min), moderate (30-59 mL/min), and severe CRI (<30 mL/min). Patients' characteristics and in-hospital major adverse cardiac events in the 4 groups were analyzed. RESULTS: Of 6518 consecutive patients with ACS, 2828 (43%) had mild CRI, 1304 (20%) had moderate CRI, and 345 (5%) had severe CRI. In CRI groups, patients were older and had a higher prevalence of hypertension, diabetes mellitus, and dyslipidemia. On admission, these patients had a higher resting heart rate and frequently had atypical and delayed presentations. Compared with the normal estimated glomerular filtration group, CRI groups were less likely to receive antiplatelet drugs, beta-blockers, angiotensin-converting enzyme inhibitors, and statins and were less likely to undergo coronary angiography. In-hospital heart failure, cardiogenic shock, and major bleeding episodes were significantly higher in all CRI groups. In multivariate analysis, mild, moderate, and severe CRI were associated with a higher adjusted odds ratio (OR) of death (mild: OR, 2.1; 95% confidence interval [CI], 1.2-3.7; moderate: OR, 6.7; 95% CI, 3.9-11.5; and severe: OR, 12.0; 95% CI, 6.6-21.7). CONCLUSION: Across the ACS spectrum, patients with CRI had a worse risk profile, had more atypical and delayed presentations, and were less likely to receive evidence-based therapy. Chronic renal insufficiency of varying stages is an independent predictor of in-hospital morbidity and mortality.