Management of acute myocardial infarction in a patient with idiopathic thrombocytopenic purpura, the value of optical coherence tomography: a case report.

BACKGROUND: Treating myocardial infarction in the setting of immune thrombocytopenic purpura (ITP) is always a challenge especially if the platelet count is labile. Cardiologists dealing with such patients should keep a delicate balance between thrombotic and bleeding complications. CASE SUMMARY: A 50-year-old gentleman with treatment-challenging ITP presented with acute inferior ST elevation myocardial infarction after receiving recent intravenous immunoglobulin. Using optical coherence tomography (OCT) guidance, it was decided to treat him with percutaneous old balloon angioplasty especially with the labile nature of his platelet count. Subsequently, dual antiplatelet therapy was a challenge and he remained on clopidogrel for a period of only 10 weeks. CONCLUSION: This case highlights the rare presentation of patients with ITP with thrombotic complications and the usefulness of OCT in formulating a management plan.

Cerebral mycotic aneurysms secondary to Streptococcus Agalactiae induced infective endocarditis.

Subarachnoid and intraparenchymal haemorrhages due to cerebral mycotic aneurysms are rare and associated with high mortality. Streptococcus agalactiae, is a rare cause of endocarditis and there are no reported cases of cerebral mycotic aneurysms secondary to this organism. We report a rare case of streptococcus agalctiae induced intracranial mycotic aneurysm.

Demographics, Clinical Characteristics, Management, and Outcomes of Acute Heart Failure Patients: Observations from the Oman Acute Heart Failure Registry.

OBJECTIVES: We sought to describe the demographics, clinical characteristics, management and outcomes of patients in Oman with acute heart failure (AHF) as part of the Gulf aCute heArt failuRe rEgistry (CARE) project. METHODS: Data were analyzed from 988 consecutive patients admitted with AHF to 12 hospitals in Oman between 14 February and 14 November 2012. RESULTS: The mean age of our patients was 63±12 years. Over half (57%) were male and 95% were Omani citizens. Fifty-seven percent of patients presented with acute decompensated chronic heart failure (ADCHF) while 43% had new-onset AHF. The primary comorbid conditions were hypertension (72%), coronary artery disease (55%), and diabetes mellitus (53%). Ischemic heart disease (IHD), hypertensive heart disease, and idiopathic cardiomyopathy were the most common etiologies of AHF in Oman. The median left ventricular ejection fraction of the cohort was 36% (27-45%) with 56% of the patients having heart failure with reduced ejection fraction (< 40%). Atrial fibrillation was seen in 15% of patients. Acute coronary syndrome (ACS) and non-compliance with medications were the most common precipitating factors. At discharge, angiotensin converting enzyme inhibitors and beta-blockers were prescribed adequately, but aldosterone antagonists were under prescribed. Within 12-months follow-up, one in two patients were rehospitalized for AHF. In-hospital mortality was 7.1%, which doubled to 15.7% at three months and reached 26.4% at one-year post discharge. CONCLUSIONS: Oman CARE was the first prospective multicenter registry of AHF in Oman and showed that heart failure (HF) patients present at a younger age with recurrent ADCHF and HF with reduced ejection fraction. IHD was the most common etiology of HF with a low prevalence of AHF, but a high prevalence of acute coronary syndrome and non-compliance with medications precipitating HF. A quarter of patients died at one-year follow-up even though at discharge medical therapy was nearly optimal. Our study indicates an urgent need for prevention, early diagnosis, and treatment of AHF in Oman.

Progression of heart failure after biventricular pacing: Is there a subgroup of "favorable nonresponders"?

BACKGROUND: Left bundle branch block (LBBB) and dominant R wave in lead V1 (RV1) post-biventricular pacing (BiVp) are associated with better clinical outcomes. However, some patients continue to deteriorate despite these favorable electrocardiographic changes. OBJECTIVE: We tested the hypothesis that baseline LBBB and post-BiVp RV1 are associated with better cardiac function and clinical outcomes in patients with progressive deterioration in heart failure after BiVp ("clinical nonresponders") than in patients without these electrocardiographic criteria. METHODS: Consecutive patients with advanced heart failure and BiVp were included. An increase in R-wave amplitude of over 4.5 times the baseline value was defined as RV1. Clinical outcome was survival free of heart transplantation and/or implantation of mechanical circulatory support. RESULTS: A total of 179 (100 (56%) with LBBB; 79 (44%) with non-LBBB) patients with advanced heart failure and BiVp were included. Of the 100 patients with LBBB, 67 (67%) developed RV1 (group 1) but 33 (33%) patients did not develop RV1 (group 2). Of the 79 patients with non-LBBB, 49 (62%) developed RV1 (group 3) and the remaining 30 (38%) patients did not develop RV1 (group 4). Changes in left ventricular ejection fraction and left ventricular end-systolic volume index were not significant in group 1, but deteriorated in the other groups (P < .05). The change in left ventricular end-systolic volume index was associated with the change in QRS duration and absence of RV1 (P < .01). Clinical outcome was most favorable in group 1 (LBBB and RV1). Changes in left ventricular ejection fraction, tricuspid annular plane systolic excursion, and right atrial pressure were associated with clinical outcomes. CONCLUSION: Despite progressive deterioration in heart failure, patients with LBBB and RV1 post-BiVp demonstrate more stable cardiac function and more favorable clinical outcomes than did patients with non-LBBB with or without RV1 post-BiVp.