Cardiomyopathy in Churg-Strauss syndrome.

The authors present the case of a 56-year-old man, admitted to the hospital twice in ten days for acute coronary syndrome with normal coronary angiograms. In the second hospitalization, the patient had anginal crises that did not respond to anti-ischemic therapy, associated with cough and wheezing. The echocardiogram revealed worsening left ventricular systolic dysfunction. He had no cardiovascular risk factors but there was a history of bronchial asthma, allergic rhinitis and peripheral neuropathy of the left upper limb with paresthesias. Laboratory studies showed eosinophilia, detected in previous blood tests, although more marked than before. Chest X-rays showed non-fixed pulmonary infiltrates and bronchoalveolar lavage revealed increased lymphocytes and eosinophils, suggesting Churg-Strauss syndrome with the probable cardiac manifestation of coronary vasospasm. A cardiac MRI was also performed but was inconclusive due to the patient's intolerance of the exam.

Myocardial infarction as the first probable manifestation of caseous calcification of the mitral annulus.

Calcification of the mitral annulus is a common echocardiographic finding during routine evaluation of patients. Caseous calcification of the mitral annulus (CCMA) on the other hand is a rare variant, occurring in about 0.06-0.07% of echocardiographic studies. The authors present the case of a 73-year-old woman admitted to hospital with an anterior wall acute coronary syndrome, in whom transthoracic echocardiography showed a well-defined echogenic rounded mass measuring 27 x 22 mm in diameter attached to the posterior mitral annulus. After transesophageal echocardiography and magnetic nuclear imaging, which confirmed the characteristics of the mass, the patient underwent surgical resection of the mass and mitral replacement with a mechanical prosthetic valve. Histological examination confirmed the diagnosis. Systemic embolism associated with CCMA is a rare but possible complication and was probably the cause of the acute coronary syndrome in this patient.

Cardiac tamponade secondary to methicillin-resistant Staphylococcus aureus pericarditis.

Since the advent of antibiotics, bacterial pericarditis has become relatively rare. Cardiac tamponade is a potentially lethal complication, especially when caused by methicillin-resistant Staphylococcus aureus (MRSA). In the intensive care setting other predisposing factors for purulent pericarditis, besides immunosuppression, are the high incidence of nasal and skin colonization and invasive techniques such as indwelling catheters. We present two case reports of cardiac tamponade in young patients, with underlying immunosuppression of different etiologies (HIV infection and liver transplantation). In both, clinical evolution was complicated by severe sepsis, with MRSA being isolated in various biological products, followed by bacterial pericarditis and tamponade. The authors highlight the need for a high degree of suspicion for the diagnosis of bacterial pericarditis in immunosuppressed patients, an ever-growing population, as well as the importance of echocardiographic monitoring during clinical evolution.

Coronary angiography after successful thrombolysis - Is the recommended time interval of 24h an important issue?

INTRODUCTION: Percutaneous coronary intervention (PCI) is currently considered the gold-standard treatment of acute coronary syndromes with ST-segment elevation (STEMI). However, this is not the reality of many European centers, where thrombolysis is performed as primary therapy. AIMS: To determine, in a STEMI population that performed successful fibrinolytic treatment, if the performance of coronary angiography after the first 24h was associated with more hospital complications, including higher mortality, compared with its performance in the recommended time. METHODS: Retrospective study, including 1065 patients with STEMI, who performed successful thrombolysis. The population was divided in three groups: A, patients who didn't undergo coronary angiography after successful thrombolysis (n=278; 26.1%); B, patients who underwent coronary angiography in the first 24h after successful thrombolysis (n=127; 11.9%); and C, patients who underwent angiography after the first 24h (n=660; 62.0%). Groups were compared regarding their characteristics and in-hospital complications. RESULTS: Groups B and C had more male patients and had younger patients than group A. Group A presented higher Killip classes at admission, more severe left ventricle dysfunction and a higher number of complications during hospitalization. Logistic regression revealed that: 1) the non-performance of coronary angiography after thrombolysis was an independent predictor of in-hospital mortality; and 2) the performance of angiography after the recommended time wasn't associated with higher mortality. CONCLUSIONS: Coronary angiography after thrombolysis constitutes an important strategy, whose non-performance carries worse prognosis. The time interval currently recommended of 24h seems clinically acceptable; however, its realization outside the recommended time doesn't seem to lead to higher mortality.

Primary cardiac lymphoma in a patient with concomitant renal cancer.

Primary cardiac lymphoma is defined as non-Hodgkin lymphoma involving the heart and/or pericardium. It is a rare cancer that primarily affects the right heart and in particular the right atrium. By contrast, renal cell carcinoma is a relatively common cancer, which in rare circumstances can metastasize to the heart. It is now known that there is an association between non-Hodgkin lymphoma and renal cell carcinoma, although the underlying mechanisms are not fully understood. The authors present a case of primary cardiac non-Hodgkin lymphoma in a patient with concomitant renal cell carcinoma and explore the possible reasons for this association.

A case of rheumatic valvular heart disease and autoimmune gastritis.

We present a case of a 50-year-old female patient with a history of depressive disorder and anaemia (attributed to menorrhagias). She was admitted to the cardiology department with symptoms of fatigue on moderate exertion for several months, with worsening in the month before hospitalisation. Echocardiography revealed a severe mitral stenosis of rheumatic aetiology. Laboratory tests showed microcytic and hypochromic anaemia, reduced iron stores and vitamin B12 levels, and positive serum antiparietal cells autoantibodies. Endoscopy showed focal areas of erythema in the stomach, corresponding histologically to chronic atrophic gastritis. In this context, two distinct clinical entities were diagnosed in the same patient: severe rheumatic mitral stenosis and autoimmune gastritis. The patient was started on vitamin B12 and iron supplementation and underwent surgical correction of the valvular disease. There was symptomatic improvement in her signs of fatigue.

Elevated factor VIII in a patient with acute coronary syndrome.

Factor VIII is a clotting factor that plays a crucial role in the coagulation cascade. Above-normal levels are found in 11% of the general adult population. Various studies have established a causal association between elevated factor VIII and venous thrombosis; some studies also suggest a relation with arterial thrombosis, particularly myocardial infarction and stroke. We report the case of a 36-year-old man with obesity, smoking and dyslipidemia as cardiovascular risk factors and a history of acute myocardial infarction at age 26. He was admitted to the coronary care unit with a diagnosis of ST-elevation myocardial infarction. Coronary angiography showed a thrombus in the distal segment of the first obtuse marginal artery, which was causing the obstruction. The thrombus was aspirated but there was no reflow. A coagulation study revealed elevated factor VIII; other parameters were normal. Even though this patient presented several cardiovascular risk factors, we highlight the need for more studies on the effect of elevated factor VIII on thrombus formation leading to acute coronary syndrome. Another important question is the use of oral anticoagulation in these patients as an integral part of the management of acute coronary syndrome.