Recent Inferior Myocardial Infarction Complicated with a Right Ventricular Thrombus Detected by Three Cardiac Imaging Modalities.

We report the case of a 71-year-old woman diagnosed with recent inferior myocardial infarction complicated with right ventricular infarction and a right ventricular thrombus. Three-dimensional transthoracic echocardiography, contrast-enhanced computed tomography, and cardiac magnetic resonance imaging clearly detected a thrombus. We consider cases with a recent right ventricular infarction to require assessment for thrombus formations in the right ventricle. Fortunately, vigorous anticoagulation therapy resolved the thrombi in both the right ventricle and right coronary artery.

Ivabradine vs metoprolol in patients with acute inferior wall myocardial infarction-"Expanding arena for ivabradine".

BACKGROUND: Atrioventricular (AV) blocks are of concern with the use of beta blockers in inferior wall myocardial infarction (MI). Ivabradine lowers heart rate with a lesser risk of AV blocks. OBJECTIVES: To compare ivabradine with metoprolol in acute inferior wall MI in terms of feasibility, tolerability, and efficacy. METHODS: It was a prospective double-blind single-center randomized controlled study. Of 1032 patients with acute inferior wall MI, 468 eligible patients were randomized in 1:1 manner to ivabradine (group A) and metoprolol (group B). Intention to treat analysis of 426 patients (group A-232 and group B-232) was performed. The primary endpoint was 30-day incidence of major adverse cardiovascular events including death, reinfarction, complete heart block (CHB), and heart failure. Secondary endpoints included 30 days incidence of recurrent angina, readmission, first- or second-degree AV block, and tachyarrhythmias. RESULTS: Both the drugs decreased the mean heart rate to 62.22±2.95 (group A) vs 62.53±3.59 (group B) beats per minute (P=0.33). Ejection fraction improved in both the groups (5.15±1.93% in group A vs 5.52±2.18% in group B, P=0.065). The two groups did not differ significantly in their primary endpoints in terms of death (group A=1.72% vs group B=1.72%, OR=1.00, 95% CI=0.25-4.05, P=1.00), reinfarction (group A=0.86% vs group B=0.86%, OR=1.00, 95% CI=0.14-7.16, P=1.00), heart failure (group A=4.31% vs group B=2.59%, OR=1.70, 95% CI=0.61-4.75, P=0.31), or CHB (0% vs 2.59%, OR=0.07, 95% CI=0.00-1.34, P=0.08). There were no significant differences in the secondary endpoints of recurrent angina, readmission, and tachyarrhythmias except for more first- and second-degree AV blocks with metoprolol (12.93% vs 2.59%, OR=5.59, 95% CI=2.28-13.72, P=0.0002). CONCLUSIONS: Ivabradine is well tolerated and equally effective as metoprolol in acute inferior wall ST elevation myocardial infarction patients for lowering the heart rate with lesser risk of AV blocks.

Short-term outcome of acute inferior wall myocardial infarction with emphasis on conduction blocks: a prospective observational study in Indian population.

OBJECTIVE: The primary aim of the present study was to evaluate the complications, particularly conduction blocks, subsequent morbidity and mortality, and effect of thrombolytic therapy in Indian patients with inferior wall myocardial infarction (IWMI). METHODS: This was a prospective, observational, single-center study conducted at LPS Institute of Cardiology, Kanpur, from December 2011 to May 2014. Patients who presented with typical chest pain and were subsequently diagnosed by standardized diagnostic criteria as having IWMI were enrolled. Patients were grouped on basis of conduction abnormalities, right ventricular (RV) infarction and thrombolytic treatment. Each group was analyzed for comparison of complication profile and mortality. RESULTS: Of 573 patients with IWMI enrolled in the study (mean age: 58.90±12.3 years), 81.2% were male, 225 (39.3%) had conduction blocks, and 189 (32.9%) had RV infarction. In patients with conduction blocks, mortality occurred in 27 patients (12.0%) in contrast to 3.4% of patients without conduction block (p<0.03). Also, there were 27 cases of in-hospital mortality in patients with RV infarction compared with 9 cases in patients without RV infarction (p<0.01). Thrombolytic therapy significantly reduced mortality in patients with IWMI (p<0.001). A significant reduction was observed in cardiogenic shock (p=0.002), severe mitral regurgitation (p=0.007), and left ventricular failure (p<0.001) in patients undergoing thrombolytic therapy. CONCLUSION: In Indian patients with IWMI, incidence of conduction blocks was higher than previously reported studies. Major complications such as atrioventricular block and RV infarction are associated with increased mortality and poor clinical outcomes. Thrombolytic therapy has a beneficial role in reduction of mortality rate and other complications.

Should furosemide be avoided in acute right ventricular myocardial infarction?

BACKGROUND: Diuretics are conventionally prohibited in acute right ventricular myocardial infarction. AIMS: To assess the benefit of diuretics compared to fluid expansion in patients with inferior myocardial infarction extended to the right ventricule. METHODS: Of 295 patients admitted for inferior or posterior acute myocardial infarction between November 2008 and November 2010, 77 had a right ventricular extension. Among these 77 patients, 19 presented with oligoanuria (<0.5 mL/kg per hour) and no criteria for cardiogenic shock. Overall, 11 patients were treated by low dose of furosemide (40 to 80 mg) and eight received fluid expansion using isotonic saline solution. RESULTS: Baseline right ventricular dilatation and dysfunction, systolic blood pressure and heart rate were similar between the groups. Twenty-four hours after treatment, urine output was similar between the two groups but only the patients in the diuretic group improved their blood pressure (103 ± 16 mmHg versus 127 ± 20 mmHg, P < 0.001), heart rate (71 ± 15 bpm versus 76 ± 13 bpm, P = 0.03), creatinin level and alanine aminotrasferase plasmatic level. Hospitalization duration and the need of inotropic support were similar in the two groups. CONCLUSIONS: Diuretics and fluid expansion provide similar efficiency for triggering diuresis in patients with right ventricular infarction and oligoanuria but only diuretics seem to be associated with improvement in hemodynamic status and venous congestion.

A rare case of myocardial infarction related to diagnostic intravascular ultrasound.

A 71-year-old man underwent intracoronary stent implantation for acute inferior myocardial infarction (MI). Immediately after diagnostic intravascular ultrasound (IVUS) at 8 months' follow-up, an acute occlusion of the sinus node (SN) artery appeared, which developed sinus arrest with junctional escape rhythm. The serum level of high-sensitivity troponin T (TpT) was markedly elevated on the day after the procedure (2.1-32.5 ng/l), which was indicative of MI related to IVUS. Under continuous intravenous infusion of unfractionated heparin, the escape rhythm changed to lower atrial rhythm on the 4th day, and recovered to sinus rhythm on the 14th day. Coronary angiography (CAG) on 15th day showed a recanalization of the SN artery, but optical coherence tomography identified that disrupted plaque and white thrombus still existed in the ostium of the SN artery. The patient was discharged on maintenance anticoagulation therapy. We hypothesized from this case that IVUS-related myocardial injury may exist without clinical problems. Our retrospective investigation showed that the median levels of high-sensitivity TpT in 20 patients who underwent CAG and subsequent diagnostic IVUS significantly increased from 0.6 (interquartile range 0.3-1.1) to 1.6 (0.7-3.6) ng/l (P < 0.05), suggesting that IVUS may induce very low levels of myocardial injury. In conclusion, we experienced a rare case of IVUS-related MI caused by an acute occlusion of the SN artery. This case reaffirms that we should pay more attention to manipulation of IVUS catheters.

A successfully thrombolysed acute inferior myocardial infarction due to type A aortic dissection with lethal consequences: the importance of early cardiac echocardiography.

Thrombolysis, a standard therapy for ST elevation myocardial infarction (STEMI) in non-PCI-capable hospitals, may be catastrophic for patients with aortic dissection leading to further expansion, rupture and uncontrolled bleeding. Stanford type A aortic dissection, rarely may mimic myocardial infarction. We report a case of a patient with an inferior STEMI thrombolysed with tenecteplase and followed by clinical and electrocardiographic evidence of successful reperfusion, which was found later to be a lethal acute aortic dissection. Prognostic implications of early diagnosis applying transthoracic echocardiography (TTE) are described.

Comparison of primary percutaneous coronary intervention and streptokinase for acute isolated inferior ST elevation myocardial infarction with a predicted low risk profile.

BACKGROUND: Primary percutaneous coronary intervention (PCI) is the treatment of choice for acute myocardial infarction, especially for high-risk patients, but the data for low-risk patients are conflicting. A very low-risk subgroup of acute inferior myocardial infarction can be identified by electrocardiographic and clinical criteria during admission. We aimed to compare the outcomes of primary PCI and streptokinase treatment in this subgroup, which has not been evaluated separately before. MATERIAL/METHODS: We retrospectively analyzed in-hospital and 10-month follow-up outcomes of 97 patients with inferior acute myocardial infarction and clinical and electrocardiographic criteria predicting low risk who have been treated with primary PCI or streptokinase. RESULTS: Forty-eight patients received streptokinase, and 49 had undergone primary PCI. Both during the in-hospital period and follow-up, the groups did not differ in the end points of death, reinfarction, or stroke (in-hospital: 2.1% versus 4.1%, P=.57; follow-up: 8.9% versus 8.9%, P=1.000). Length of hospital stay was longer in the streptokinase group (6.5+/-2.5 versus 9.1+/-3.7 days, P=.001). Rate of repeat revascularization was reduced in the PCI group at 10 months (28.9% versus 55.6%, P=.002). CONCLUSIONS: When streptokinase and primary PCI are compared in isolated inferior acute myocardial infarction patients with a low-risk profile, there are no differences for in-hospital and long-term rates of death, reinfarction, or stroke. Primary angioplasty reduces the length of initial hospital stay, and reduces repeat admissions by decreasing the need for subsequent revascularization procedures. Large-scale studies are needed to reach a final conclusion.