Peripartum cardiomyopathy, what if your patient plans to reconceive?

Patients with peripartum cardiomyopathy (PPCM) often express a desire to conceive again, and the risk of relapse in future pregnancies should be disclosed. No consensus is available that can determine that risk. Adequate contractile reserve, evidenced by a stress echocardiogram (exercise or dobutamine), can identify those with lower relapse risk.

Heart rate differentiates urgency and emergency in hypertensive crisis.

OBJECTIVE: To study the clinical significance of presenting blood pressure parameters and heart rate in patients with hypertensive crisis. METHODS: In patients admitted with hypertensive crisis between January 2011 and May 2011, demography, mode of presentation, co-morbidities, blood pressure readings, and heart rate at presentation were documented. Further clustering of hypertensive crisis into emergency or urgency was based on the presence or absence of target organ involvement. The relationship between blood pressure parameters, heart rate, and other variables was analyzed. RESULTS: 189 patients in sinus rhythm were enrolled in this pilot study. The rate of hypertensive urgency was 56 %, whereas the rate of hypertensive emergency was 44 %, respectively. Subjects with hypertensive emergency had a higher mean heart rate (93 ± 22.7 bpm) than those with urgency (81 ± 11.5 bpm) (P = 0.015). Women had higher heart rates (92 ± 18.5 bpm) than men (86 ± 17.6 bpm) (P = 0.014). Heart rates below 100 bpm had a specificity of 94 %, classifying patients as hypertensive urgency. Tachycardia had a powerful statistical association with hypertensive left ventricular failure (P < 0.0001). Other hemodynamic parameters, including systolic blood pressure, diastolic blood pressure, pulse pressure, and mean blood pressure relates neither to urgency nor to emergency. Diabetic patients with HBA1c levels of more than 53 mmol/mol had a heart rate of more than 100 bpm (P = 0.015) during hypertensive crisis. CONCLUSIONS: Normal heart rate is characteristic of hypertensive urgency. Tachycardia in this setting is an ominous sign and denotes hypertensive complications in particular left ventricular failure. Among diabetics, elevated heart rate is associated with poor glycemic control.

Complete heart block in thyrotoxicosis, is it a manifestation of thyroid storm? A case report and review of the literature.

Thyrotoxicosis complicated by advance degree atrioventricular block, a rare complication of a common disease. The term apathetic thyrotoxicosis, where palpitations and cardiac involvement are the sole manifestations of disease, is well known. Thyroxin's ability to sensitize the catecholamine receptors causing tachyarrhythmias is well addressed. However, as an aetiology for advanced heart block, thyrotoxicosis is ranked as one of the rarest.

Role of tissue Doppler imaging in assessing left ventricular diastolic dysfunction severity. Does it hold the same ability?

OBJECTIVE: To validate the diagnostic capability of tissue Doppler imaging in assorting the extent of diastolic dysfunction. METHODS: In this primary clinical research diagnostic study, we enrolled 70 patients with systemic hypertension presenting with shortness of breath between May 2010 to July 2010 to Salmaniya Medical Complex, Manama, Bahrain. Forty-eight patients satisfied the inclusion criteria. They underwent extensive echocardiographic assessment of their diastolic function with simultaneous NT pro-B-type natriuretic (BNP) assay. The latter being the reference marker of diastolic defragment. RESULTS: Patients were classified according to the severity of heart failure into 4 classes of New York Heart Association (NYHA) Classification. Twenty-eight (58%) were males and 20 (42%) were females. The tissue Doppler imaging (TDI) maintained a steady positive correlation with both NYHA functional class and the PRO-BNP titre. Correlation coefficient was 0.8 with a p<0.0001. N-terminal pro-B-type natriuretic peptide (NT-proBNP) can be calculated from simplified formula derived from the correlation-pro-B-NP = 93.8 x (E/E')-940. CONCLUSION: The TDI can estimate the severity of diastolic dysfunction with striking certainty and tremendous clinical utility. Its limitation, however, has to be well addressed.

Hypertensive crisis. Clinical presentation, comorbidities, and target organ involvement.

OBJECTIVE: To evaluate the clinical presentation and comorbidities of hypertensive crisis in our own population. METHODS: In this cohort based study, we investigate the clinical presentation and comorbidities of hypertensive crisis by evaluating the data collected between January and April 2009. We included 154 patients admitted with systolic and diastolic blood pressure of >179 mm Hg and >119 mm Hg (based on the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure criteria) in the Department of Internal Medicine, Salmaniya Medical Complex, Kingdom of Bahrain. RESULTS: In the study population, 64.3% had hypertensive urgency (blood pressure elevation without end organ damage) and 35.7% had hypertensive emergency (blood pressure elevation with end organ damage). The mean age group was 45-65 years (56% of the study population) and more men were affected than women (100:54). Shortness of breath and neurological deficits had a strong statistical association with hypertensive emergency, and headache and blurring of vision had the same tendency toward hypertensive urgency. Diabetes mellitus was an independent risk factor for hypertensive crisis. CONCLUSION: Most of the studied patients were known hypertensive. Diabetes mellitus is powerful predictor for hypertensive crisis. Dyspnea and neurological deficits have significant statistical correlation with hypertensive emergencies.