Atrial Myxoma: Presenting as a Large Splenic Infarction.

Cardiac myxomas are the most common benign primary heart tumors, with the majority occurring in the left atrium. Clinical manifestations are a result of constitutional, obstructive, and/or embolic events. Complications include myocardial infarction and stroke, as well as renal and limb ischemia. Our unusual case is a middle-aged female who presented with a one-week history of progressively worsening abdominal pain and was found to have a large splenic infarction on a CT scan. There was no personal or family history of autoimmune diseases or hypercoagulable states. The evaluation revealed a large left atrial myxoma confirmed on biopsy after surgical resection. Our patient's clinical presentation was relatively benign compared to the size of her mass. Although her myxoma was very large, morphologically solid, and attached to the interatrial septum, she did not have any evidence of congestive heart failure. The tumor's irregular surface and mobility likely led to splenic embolization. Hence, the differential diagnosis of splenic infarction should include left atrial myxoma.

The effect of withdrawal of ACE inhibitors or angiotensin receptor blockers prior to coronary angiography on the incidence of contrast-induced nephropathy.

BACKGROUND: The effect of continuing or discontinuing chronic angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) therapy prior to coronary angiography on the incidence of contrast-induced nephropathy (CIN) is not clear. We undertook a randomized trial to evaluate the effect of withdrawing ACEIs or ARBs 24 h prior to coronary angiography on the incidence of CIN associated with coronary angiography. METHODS: A total of 220 patients with chronic kidney disease (CKD) stages 3-4 (glomerular filtration rate 15-60 ml/min/1.73 m2) on ACEI or ARB therapy were randomized before angiography to either ACEI/ARB continuation group or discontinuation group. A third group of patients with CKD stages 3-4 but not on angiotensin blockade therapy were also followed. The primary outcome measure was the incidence of CIN defined by a rise in serum creatinine by 25% or 0.5 mg/dl (44 micromol/l) from baseline. RESULTS: There was no statistically significant difference in the incidence of CIN between the three groups (P=0.66). The incidences were 6.2%, 3.7%, and 6.3% for the continuation, discontinuation, and angiotensin blockade naïve group, respectively. There was also no significant difference found between the groups in mean serum creatinine and glomerular filtration rate values at baseline and post contrast administration. CONCLUSION: Withholding ACEIs and ARBs 24 h before coronary angiography does not appear to influence the incidence of CIN in stable patients with CKD stages 3-4.

Usefulness of 64-detector computed tomographic angiography for diagnosing in-stent restenosis in native coronary arteries.

The purpose of this study was to evaluate the accuracy of detector computed tomographic angiographic qualitative and quantitative analyses for the detection of in-stent restenosis (ISR) Previous studies have used qualitative analyses exclusively and have excluded "unevaluable" stents. Multidetector computed tomographic angiography (MDCT) was performed before quantitative coronary angiography in 67 patients with 132 stents that were evaluated by 2 techniques: (1) qualitative, on the basis of degree of visual hypodensity, and (2) quantitative, comparing in-stent with prestent Hounsfield units. All stents were evaluated, irrespective of image quality. The incidence of ISR was 12.5%. The sensitivity (94%), specificity (74%), and positive predictive value (39%) of the qualitative evaluation were superior to the quantitative technique (82%, 54%, and 21%, respectively); negative predictive values were similar (99% vs 95%). Accuracies were equal in stents located in proximal and distal vessels. In conclusion, ISR can be evaluated qualitatively by 64-slice MDCT with excellent sensitivity and negative predictive accuracy without exclusion of unevaluable stents and with reasonable specificity but low positive predictive value. Quantitative analysis was less accurate.

Evaluation of myocardial bridging of the left anterior descending coronary artery by 64-slice multidetector computed tomographic angiography.

The purpose of this study was to use the unique characteristics of multidetector computed tomographic coronary angiography to evaluate the prevalence and characteristics of myocardial bridging (MB) in a large series of patients and to assess the relation between atherosclerosis and MB. Three hundred consecutive coronary angiograms obtained by 64-slice multidetector computed tomography were evaluated retrospectively. For comparison of symptoms and concomitant atherosclerosis, 245 patients were included in the study and categorized into group 1 (n = 108) with MB and group 2 (n = 137) with no MB in the left anterior descending coronary artery (LAD). Axial and multiplanar reformatted images of all arteries were analyzed for the presence of measurable obstructive coronary disease (>25% stenosis) and minor luminal (<25% stenosis) calcified and noncalcified plaque and for MB in the LAD. Longitudinal and cross-sectional views were used for MB measurements. MB was found in 44% of patients (108 of 245) and was present equally in men and women (45% and 41%, p = NS). The mid LAD was the most common location (66%, p <0.001). There were no atherosclerotic lesions within the MB segments. The presence of MB did not influence the presence or severity of atherosclerotic lesions in the nonbridged segments of the LAD. In conclusion, MB as demonstrated by 64-slice multidetector computed tomographic coronary angiography is more common than previously reported by coronary angiography. The bridged segment appears to be free of atherosclerosis.

Angiotensin-converting enzyme inhibitors in acute myocardial infarction: a clinical approach.

Angiotensin-converting enzyme inhibitor therapy has been shown to be effective in treating patients across the spectrum of cardiac disease. Utility has been demonstrated for both prevention and treatment. This article reviews the data regarding angiotensin-converting enzyme inhibitor therapy in acute myocardial infarction, with emphasis on determining what is known regarding the mode of administration, optimal timing for initiation of treatment, and whether patients can be identified who are most likely to benefit from treatment.

B-type natriuretic peptide: practical diagnostic use for evaluating ventricular dysfunction.

Assessment of brain natriuretic peptide levels may provide important information that can be used in the evaluation of patients with dyspnea and follow-up of heart failure. Brain natriuretic peptide levels have been shown to be useful for evaluating patients in the emergency department and for evaluating patients complaining of dyspnea in the outpatient setting. Brain natriuretic peptide assessment also provides an adjunct to diagnosis of both systolic and diastolic dysfunction, has prognostic value for heart failure and in acute coronary syndromes, and may be a useful measure to guide therapy. Further work needs to be done to establish the best type of assay to use, to determine the optimal cutoff point for what is considered abnormal, and to determine how conditions other than ventricular dysfunction affect brain natriuretic peptide levels.