Angiotensin converting enzyme inhibitor and coenzyme Q10 as adjunctive treatment for patients with ventricular septal rupture following late onset myocardial infarction: a case report.

Ventricular Septal Rupture (VSR) is a rare complication of acute myocardial infarction and has a high mortality rate. Surgery is the definitive treatment. However, in hospitals with limited facilities, treating acute myocardial infarction patients with ventricular septal rupture, is challenging. A 74-year-old woman came to the emergency room of Dr. Koesma General Hospital, Tuban, East Java in December, 2019 with late-onset Acute Myocardial Infarction. On the following day, a new holosystolic murmur was heard in the left lower sternal border with palpable thrill. Transthoracic echocardiography showed VSR with severe pulmonary hypertension. This was followed by a drop in the blood pressure to 80/50 mmHg. The blood pressure was dependent on vasopressors until lisinopril and coenzyme Q10 were introduced. After 3 months, the haemodynamics of the patient were stable. This proved that the use of angiotensin-converting enzyme and coenzyme Q10 promotes more energy production, enables tissue healing and leads to balanced remodelling to increase the survival rate in cases of non-surgical treatment.

Retrospective Study of the Association Between Platelet-to-Lymphocyte Ratio in Patients with Acute Coronary Syndrome on Admission to a Rural Referral Center in East Java, Indonesia, and the Incidence of New Symptomatic Heart Failure at 6 Months.

BACKGROUND This was a retrospective study conducted at a rural referral center in East Java, Indonesia, to evaluate the association between the platelet-to-lymphocyte ratio (PLR) on hospital admission and the incidence of new symptomatic heart failure (HF) within 6 months in patients with acute coronary syndrome (ACS). MATERIAL AND METHODS The study population consisted of all ACS patients who were hospitalized between 1 January and 31 December 2018 at a non-percutaneous coronary intervention-capable secondary referral hospital and came for a routine follow-up until 6 months afterwards. The diagnosis of new symptomatic HF was based on International Classification of Diseases 10th revision code I50.9. RESULTS From 126 hospitalized patients, 92 patients were included in the analysis. The incidence rate of new symptomatic HF at 6 months was 70.65%. High PLR upon initial admission was significantly associated with new symptomatic HF incidence (odds ratio=1.70, P<0.001). PLR was also able to discriminate new symptomatic HF incidence at 6 months with area under the curve of 0.83 (P=0.001). Multivariate Cox regression analysis showed that PLR was an independent predictor for new symptomatic HF incidence (hazard ratio=4.5, P=0.001). CONCLUSIONS In a rural center in Indonesia, the PLR was independently correlated with the onset of new symptomatic HF in patients with ACS 6 months after hospital admission. The PLR may be a supplementary biomarker for clinical outcomes in patients with ACS for use in resource-limited regions.

Triangular QRS-ST-T Waveform Electrocardiographic Pattern in Acute Myopericarditis: A Case Report from a Limited-Resources Hospital.

BACKGROUND Triangular QRS-ST-T waveform (TW) electrocardiography pattern has been found to be associated with poor prognosis in patients with ST-segment elevation myocardial infarction (STEMI). It identifies a subset of patients at high risk of both ventricular fibrillation and cardiogenic shock, with high in-hospital mortality. Therefore, aggressive treatment is needed in patients presenting with this electrocardiography pattern. However, this pattern is rarely present in non-ischemic cardiac diseases. CASE REPORT We report the case of a 50-year-old man who came to our emergency room with a chief complaint of gastrointestinal problems and partial bowel obstruction. After failure of initial conservative treatment, laparotomy was planned. Just before the surgery, the patient felt a non-specific chest discomfort and showed ST-segment elevation on ECG and slight elevation of cardiac enzyme. He was then treated for STEMI with an intravenous thrombolytic. However, the degree of ST-segment elevation further increased and showed a TW pattern. Transthoracic echocardiography revealed a moderate pericardial effusion with normal ejection fraction and a normokinetic left ventricle; hence, a diagnosis of acute myopericarditis was made. After treatment with low-dose steroid and colchicine, his symptoms improved, the electrocardiography pattern returned to normal, and the gastrointestinal symptoms resolved. CONCLUSIONS To the best of our knowledge, this is the first case report of an acute myopericarditis presenting with a TW electrocardiography pattern. Myopericarditis should always be considered in the differential diagnosis of acute chest pain and ST segment electrocardiography changes, including TW pattern. The use of echocardiography can help determine the diagnosis of myopericarditis.

Proximal Pulmonary Artery Aneurysm Secondary to Suspected Pulmonary Hypertension Treated with Conservative Therapy in Limited Resource Setting.

BACKGROUND Pulmonary artery aneurysm (PAA) is a rare disease in cardiovascular system. This disease is difficult to diagnose and less often considered due to its non-specific clinical manifestations. Until now there are no clear guidelines about its optimal management because of the small number of reported cases. CASE REPORT We report a 56-year-old male with chief complain of atypical bilateral chest pain and shortness of breath. Initial electrocardiogram (ECG) and laboratory evaluation showed no sign of ischemic heart disease. After the patient was stabilized, he was evaluated using chest x-ray, transthoracic echocardiography (TTE), and multi slice computed tomography (MSCT). The patient was then diagnosed with PAA secondary to suspicion of pulmonary hypertension (PH) with chronic obstructive pulmonary disease and heart failure. Conservative treatment was chosen because of the limited resources for surgery and patient's refusal to be referred. The treatment aims to lower the pulmonary artery pressure while monitoring the aneurysm. His 6-month follow-up evaluation showed an improvement in pulmonary artery pressure and persistent of the PAA without any increasement of the diameter. CONCLUSIONS PAA is a rare disease that is difficult to diagnose because of its non-specific nature. Persistent atypical chest pain can be an early symptom of PAA, thus clinicans should be aware in a high-risk patient suffered persistent chest pain, despite normal ECG and laboratory findings. TTE and MSCT evaluation are reliable for diagnosing PH and PAA. With conservative treatment and routine follow-up, patient with PAA secondary to PH could be managed well.