Carbohydrate-restricted diet and acute coronary syndrome: a case report and review of this conflicting and yet unknown association.

We describe a case of a young patient, motivated to follow a carbohydrate-restricted diet intake for 6 years, who presented with an acute myocardial infarction.

A novel approach to standard techniques in the assessment and quantification of the interventricular systolic relationship.

BACKGROUND: Blood flow between the right and left ventricles is subject to the continuity equation and systolic ventricular interdependence. Quantification of this relationship might aid in understanding inter-ventricular function. The purpose of this study was to evaluate and quantify ventricular interdependence by directly comparing right and left ventricular systolic function though echocardiographic surrogates of right and left ventricular systolic function such as MAPSE, TAPSE, RV TVI and LV TVI. METHODS: This study prospectively evaluated 51 healthy participants (mean age, 41 ± 17 years) by resting echocardiography. In addition to standard measurements, tricuspid annular plane of systolic excursion, (TAPSE), mitral annular plane of systolic excursion (MAPSE), and the peak annulus systolic velocity of the right ventricular (RVs) and left ventricular (LVs) free walls were measured by M-mode and pulsed wave Doppler tissue echocardiography and further evaluated for variance across age, gender, and body surface area. RESULTS: TAPSE (22.1 ± 2.9 mm) was over 54.5% greater than MAPSE (14.3 ± 2.6 mm) and RVs was 64.4% greater than LVs. The LV to RV systolic relationship measured by MAPSE/TAPSE and LVs/RVs ratios were 0.66 ± 0.14 and 0.76 ± 0.21 respectively. These values were not significantly affected by age, gender or body surface area (BSA). CONCLUSION: MAPSE/TAPSE and LVs/RVs ratios appear stable across age, gender, and BSA potentially making them good surrogates of systolic ventricular relationship and interdependence.

Big MAC: caseous calcification of the mitral annulus referred for possible cardiac tumor.

A 73-year-old woman was found to have a 1.4 × 3.0 cm heterogeneous echodensity with smooth borders and central echolucency associated with a dynamic left ventricular outflow tract gradient and episodic chest pain. Although mitral annular calcification is a common manifestation, this case represents caseous calcification of the mitral annulus, which is a rare variant with an estimated prevalence of 0.068%. It should not be misinterpreted as an intracardiac tumor, abscess or cyst, as was the initial assumption in this case. The implications of the dynamic left ventricular outflow tract obstruction as the etiology of her episodic chest pain and potential dynamic changes in structure with calcium levels are further elucidated in this case.

Live 3D TEE demonstrates and guides the management of prosthetic mitral valve obstruction.

A 43-year-old woman, with a remote history of rheumatic mitral stenosis and a St. Jude prosthetic mitral valve replacement, presented with shortness of breath and palpitations, shortly after a long flight. On admission, atrial fibrillation with a rapid ventricular response was noted in the setting of a long history of noncompliance with her anticoagulation. Transesophageal echocardiography (TEE) demonstrated multiple laminated thrombi in the left atrial appendage. Live three-dimensional (3D) TEE confirmed this diagnosis and demonstrated an immobile posterior leaflet of the mitral prosthesis, which had direct implications in her management. She successfully underwent surgery for mitral valve replacement, left atrial appendage ligation, and a Maze procedure on the following day. The multiple thrombi within the atrial appendage were confirmed intraoperatively and pannus formation was determined to be the etiology of the leaflet immobility.

"Cardiac otalgia": acute coronary syndrome masquerading as bilateral ear pain.

Patients presenting with acute coronary syndromes are classically described as having chest pressure with radiation to the left arm. However, pain can be referred to multiple sites including the face, the neck, the abdomen and the contra-lateral arm. We present a case of sudden bilateral ear pain as the sole presentation of acute coronary syndrome in an elderly man. The importance of recognizing these atypical presentations is vital, as outcomes may be worsened as appropriate therapy may be delayed or misdirected.

Antidepressant medication adherence: a study of primary care patients.

BACKGROUND: Nonadherence to antidepressant medication significantly contributes to the undertreatment of depression in primary care populations. The purpose of this study was to survey primary care patients' adherence to antidepressant medication to better understand factors associated with nonadherence. METHOD: Participants with a history of being prescribed an antidepressant for at least 4 weeks were recruited from a primary care research network. Subjects completed a demographic survey, the Patient Health Questionnaire (PHQ), the Beck Depression Inventory-II (BDI-II), the Medical Outcomes Study (MOS) 36-Item Short-Form Health Survey, the Interpersonal Support Evaluation List, the Stages of Change Scale, the Medication Adherence Scale, and the MOS measure of adherence. Differences between adherent and nonadherent patients were compared using chi(2) for discrete variables, independent t tests for continuous variables, and Mann-Whitney U tests for rank-ordered data. Data were collected from April 1, 2001 to April 1, 2004. RESULTS: Approximately 80% (N = 148) of individuals approached for this study agreed to participate. The overall sample was primarily white and female. The PHQ diagnoses at study entry were dysthymic disorder (8.8%, n = 13), major depressive disorder (31.8%, n = 47), "double depression" (both dysthymic disorder and major depressive disorder, 29.7%, n = 44), and no depression (16.2%, n = 24.) The mean BDI-II score for the total sample was 19.9. Nonadherent patients reported being more careless about taking their medications, were more worried about side effects, were less satisfied with their physicians, were under the age of 40 years, and were more likely to have asked for a specific antidepressant. Nonadherent patients also indicated being at lower stages of change. CONCLUSIONS: Individually tailoring education to patient preference and stage of change is recommended to promote adherence.