Stellate ganglion block for the management of electrical storm: An observational study.

INTRODUCTION: Electrical storm is a life-threatening emergency with a high mortality rate. When acute conventional treatment is ineffective, stellate ganglion block can help control arrhythmia by providing a visceral cervicothoracic sympathetic block. The objective of this study is to assess the effectiveness and safety of stellate ganglion block in the management of refractory arrhythmic storm. METHOD: Follow-up of a cohort of patients with refractory electrical storm that met the criteria for performing stellate ganglion block. The block was ultrasound-guided at C6 using local anaesthetic and a steroid - left unilateral first, bilateral if no response, followed by fluoroscopy-guided radiofrequency ablation at C7 if there was a favourable response but subsequent relapse. RESULTS: Seven patients were included. The in-hospital mortality rate was 14.29%. Four patients received unilateral and 3 bilateral stellate ganglion block. Six were ablated and 1 received an implantable cardioverter-defibrillator. Electrical storm was controlled temporarily beyond the effect of the local anaesthetic in all patients. Three patients underwent radiofrequency ablation and 2 underwent surgical thoracic sympathectomy. The only side effect was Horner's syndrome, which was observed in all cases after administering a stellate ganglion block with local anaesthetic. Two patients died after discharge and 4 are alive at the time of writing, 3 of them have not been re-admitted for ventricular events for more than 2 years. CONCLUSION: Ultrasound-guided stellate ganglion block is an effective and safe complement to standard cardiological treatment of refractory electrical storm.

The tobacco paradox in acute coronary syndrome. The prior cessation of smoking as a marker of a better short-term prognosis. / La paradoja del tabaco en el síndrome coronario agudo. El abandono previo del hábito tabáquico como marcador de mejor pronóstico a corto plazo.

OBJECTIVE: The tobacco paradox is a phenomenon insufficiently explained by previous studies. This study analyses the prognostic role of prior or active smoking in patients with acute coronary syndrome. METHODS: We obtained data from the ARIAM registry, between 2001 and 2012. The study included 42,827 patients with acute coronary syndrome (mean age, 65±13 years; 26.4% women). The influence of smoking and that of being an ex-smoker on mortality was analysed using a multivariate analysis. RESULTS: The smokers were younger, were more often men, had less diabetes, hypertension and prior history of heart failure, stroke, arrhythmia and renal failure and more frequently had ST-elevation and a family history of smoking. The ex-smokers had more dyslipidaemia and history of angina, myocardial infarction, ischemic heart disease, peripheral vasculopathy and chronic bronchial disease. Smokers and ex-smokers less frequently developed cardiogenic shock (smokers 4.2%, ex-smokers 4.7% and nonsmokers 6.9%, P<.001). Hospital mortality was 7.8% for the nonsmokers, 4.9% for the ex-smokers and 3.1% for the smokers (P<.001). In the multivariate analysis, the smoker factor lost its influence in the prognosis (-0.26%, p=.52 using an inverse probability calculation; and+0.26%, P=.691 using a propensity analysis). However, the exsmoker factor showed a significant reduction in mortality in both tests (-2.4% in the inverse probability analysis, P<.001; and -1.5% in the propensity analysis, P=.005). CONCLUSIONS: The tobacco paradox is a finding that could be explained by other prognostic factors. Smoking cessation prior to hospitalization for acute coronary syndrome is associated with a better prognosis.

Thrombolytic therapy soon after left heart catheterization--is it safe?

Puncture of a femoral artery for left heart catheterization is considered a relative contraindication for thrombolytic therapy for some days. We treated 9 patients with systemic thrombolysis who had undergone left heart catheterization in the previous hours. Four patients developed a large hematoma, but only 1 required transfusion. We suggest that thrombolytic therapy can be administered soon after left heart catheterization by the femoral approach, provided that continuous care can be taken over the puncture site.

Coronary arterial disease in patients with severe isolated aortic stenosis.

We reviewed the prevalence of coronary arterial disease in a consecutive series of 117 patients with severe isolated aortic stenosis. Coronary arterial disease was present in 18 of 48 patients with typical angina, in 10 of 38 patients with atypical angina, and in 4 of 31 patients without angina. We suggest that absence of angina is not enough to omit coronary arteriography in the evaluation of severe aortic stenosis.

Acute myocardial infarction in two young male users of cocaine treated with thrombolytic therapy.

Two young men with a history of cocaine addiction were admitted to our Coronary Unit because of acute myocardial infarction, and treated with thrombolytic agents. The involved coronary artery was found to be totally occluded in both of them. We suggest that spasm may constitute one of the primary events in these patients.

Acute myocardial infarction in a young man after heat exhaustion.

A 33-year-old man with heat exhaustion was admitted to our hospital suffering from severe chest pain. Serum creatine kinase elevation and new Q waves revealed myocardial infarction of the inferior wall. Technetium-99m-pyrophosphate suggested diffuse myocardial damage, although the left ventricular function was normal by echocardiography. This case highlights the importance of early recognition of heat stroke and heat exhaustion, as they are associated with widespread tissue injury.

Cardiac arrest in a 31-year-old man because of the Arnold-Chiari malformation.

We describe a 31-year-old man who suffered from loss of consciousness and cardiac arrest with ventricular fibrillation after a brisk head movement. Clinical investigation was inconclusive apart from the magnetic, resonance imaging that showed the Arnold-Chiari malformation. It must be taken into account in the diagnosis, as a specific treatment is possible.

Common arterial trunk with absence of the left pulmonary artery in a 32-year-old man.

We report a case of common arterial trunk with absence of the left pulmonary artery who was diagnosed at the age of 32 years. Pulmonary vascular disease made the condition inoperable. He does well with medical management after a follow-up of 20 months.

Thrombolytic therapy for a patient with systemic lupus erythematosus and acute myocardial infarction.

A young patient with systemic lupus erythematosus was admitted to our hospital because of acute myocardial infarction, and treated by thrombolysis. Coronary angiography revealed a significant stenosis of the left anterior descending artery, together with an intraluminal thrombus. Clotting studies demonstrated an anticoagulant factor suggestive of lupus erythematosus. We conclude that thrombolytic therapy can be useful in patients with systemic lupus erythematosus who present with acute myocardial infarction, although some caution is needed in treatment.

Syncope induced by propranolol in hypertrophic cardiomyopathy.

A patient with chest pain was found to have obstructive hypertrophic cardiomyopathy. After the first oral dose of propranolol, syncope developed together with atrioventricular block. An electrophysiologic study revealed an intermittent advanced (His-Purkinje) block within the atrioventricular conduction system. Caution is recommended when treatment is initiated in patients with hypertrophic cardiomyopathy in whom there is any suspicion of abnormalities in the atrioventricular conduction tissues.

Is the prevalence of severe stenoses of left circumflex different from that of the right coronary artery?

We reviewed the last 911 coronary arteriograms performed in our laboratory because of chest pain. Among 215 patients with single-vessel disease, 40 had stenosis in the right coronary artery and 43 in the left circumflex. This finding conflicts with previous reports. Perhaps racial differences could explain this discrepancy.

Total occlusion of the left main coronary artery in a young cocaine user.

A young woman, currently user of cocaine, was admitted because of acute myocardial infarction with cardiogenic shock. The coronary arteriography revealed total occlusion of the left main coronary artery. Despite the use of an intraaortic counterpulsation balloon and successful percutaneous transluminal coronary angioplasty, she developed electromechanical dissociation, unresponsive to resuscitation manoeuvres.

Sinus tachycardia and J wave masquerading as atrial flutter.

The admission electrocardiogram (ECG) from a patient with severe heart failure was considered diagnostic of atrial flutter with 2:1 atrioventricular conduction. Slowing of the heart rate revealed sinus tachycardia with prominent 'J' waves that had been previously thought to be 'F' waves.

Magnesium sulphate for torsade de pointes in a patient with congenital long QT syndrome.

A young woman with congenital long QT syndrome presented with repetitive torsade de pointes. A single bolus of magnesium sulphate abolished the arrhythmia.

Adverse effect of sodium nitroprusside 48 hours after myocardial infarction.

We present a patient with acute myocardial infarction in whom the use of nitroprusside 48 hours after the first symptom, was accompanied by a rise in the ST segment representative of the ischemic area. Our experience suggests that precaution is needed in the use of nitroprusside even several days after an acute myocardial infarction.

Syncope and long QT syndrome with an initially normal QT interval.

We present two patients who were admitted to our Hospital because of repetitive syncopal attacks. The study previous to their admission included electrocardiograms in which the QT interval was normal. During their admission, an striking lengthening of the QT interval, in addition to other criteria of the long QT syndrome, was observed in both patients. We suggest that one normal measurement of the QT interval should not rule out this diagnosis.

Outcome of patients with diabetes and unstable angina. A subgroup analysis in the Spanish Multicentre Trial of trifusal in unstable angina. Grupo de Estudio del Trifusal en la Angina Inestable.

We analyzed the clinical characteristics of the 58 diabetic and 218 nondiabetic patients enrolled in the Spanish multicentre trial of trifusal in unstable angina. After 6 months of follow-up, 25 suffered from myocardial infarction or death, 10 of which were diabetics (17.2%) and 15 nondiabetics (6.9%) (P = 0.0146). This difference remained significant after multivariate analysis. We conclude that diabetes is an independent predictor of adverse outcome in patients with medically treated unstable angina.

Transient myocardial injury after elective electrical cardioversion.

A patient with recent myocardial infarction underwent elective direct current countershock because of atrial fibrillation. After several shocks, the ST segments were strikingly raised throughout the precordial leads, which disappeared with the administration of a perfusion of nitroglycerin. This case is evidence that electrical cardioversion can cause myocardial damage.

Anorexia nervosa and myocardial infarction.

A 39-year-old woman with long-standing anorexia nervosa was admitted to our hospital because of extreme weakness and cachexia. During a hyperalimentation therapy, she developed chest pain, revealing the electrocardiogram and cardiac enzymes a myocardial infarction of the inferior wall. We suggest that anorexia nervosa does not 'protect' against coronary atherosclerosis, and that some of the cases of sudden death could be related to myocardial ischemia.

Abnormal filling pattern of the left ventricle and outcome in acute myocardial infarction.

BACKGROUND: The pattern of left ventricular filling by Doppler examination is frequently abnormal in myocardial infarction. PURPOSE: To relate the different patterns of left ventricular filling to the clinical course of acute myocardial infarction. PATIENTS AND METHODS: We have studied 133 patients with acute myocardial infarction. Three different patterns of mitral flow were defined by Doppler examination: Type I has an E/A ratio lesser than one, and a deceleration time of the E wave longer than 180 ms; Type II has either an E/A ratio greater than one or a deceleration time shorter than 180 ms; Type III has an E/A ratio greater than 1.6 and a deceleration time shorter than 180 ms. We also determined the pulmonary wedge pressure through a pulmonary artery catheter simultaneously with the Doppler examination on 22 occasions in 11 patients. RESULTS: Mortality rate was 13%, 9% and 35% respectively in Type I, II and III (P=0.007). After logistic regression analysis of determinants of death, including all eight variables related with mortality on an univariate analysis, only Killip class and the presence of a Type III pattern of the mitral flow remained significant (P=0.0004 and P=0.019 respectively). Pulmonary wedge pressure was 8.4+/-6.1 mmHg in Type I, 21.0+/-7.3 mmHg in Type II, and 22.4+/-7.1 mmHg in Type III (P=0.0017). CONCLUSION: Type III pattern of left ventricular filling is an independent predictor of death. Type I and II had no significant differences on prognosis. Type I is associated with a normal pulmonary wedge pressure.