A stepwise approach to coronary artery stenting in acute type A aortic dissection.

We present three cases of acute coronary obstruction postsurgical repair of type A aortic dissection, which were successfully treated with percutaneous coronary intervention. We describe a step-by-step approach to performing percutaneous coronary intervention in selective cases of coronary obstruction related to type A aortic dissection.

Hydralazine-induced cholestatic hepatitis.

Hydralazine has been widely used for treating hypertension, particularly in patients with renal failure. We report a case on a patient in whom we believe the drug was implicated in an otherwise unexplained disturbance of liver function. A 63-year-old African-American female with medical history of hypertension and end-stage renal disease (on hemodialysis) was admitted to the hospital with epigastric pain and jaundice. The symptoms started about 1 week ago. Initial laboratory tests showed abnormal liver enzymes with elevated conjugated bilirubin and alkaline phosphatase suggestive of cholestatic jaundice. Amylase and lipase were normal. Abdominal ultrasound showed normal caliber common bile duct without evidence of obstruction. Abdominal CT scan does not show any evidence of intra- or extrahepatic biliary ductal dilatation, and no mass lesions were seen in the pancreas. Further blood chemistry showed worsening of liver enzymes and increased bilirubin over the next 2-3 days. Magnetic resonance cholangiopancreatography failed to show any evidence of intra- or extrahepatic biliary ductal dilatation. No other laboratory evidence of cholestatic jaundice was found. Before proceeding for invasive diagnostic procedure, that is, endoscopic retrograde cholangiopancreatography, the patient's drug history was reviewed. She was on hydralazine 75 mg 3 times per day, started 5 months ago. At that time, her liver function tests were normal. As we could not find any other cause of cholestatic jaundice, we attributed this as a side effect of hydralazine. A trial was given by stopping the hydralazine. It was seen that there was significant improvement in the liver function enzymes over the next week. Complete clinical and biochemical recovery occurred over the next 4 weeks. Liver injury after long-term therapy with hydralazine and after short-term therapy with hydralazine (2-10 days) has been described. Hydralazine-induced hepatotoxicity may manifest as hypersensitivity-type injury, mixed hepatocellular injury, acute hepatitis, cholestatic jaundice, or centrilobular necrosis. The Hydralazine-induced cholestatic liver injury seems to be fully reversible. Complete clinical and biochemical recovery occurs after discontinuation of the drug. Also, the differential diagnosis of any patient with hepatocellular injury should include medications. This will prevent unnecessary diagnostic tests.

Venlafaxine induced acute myocardial infarction with normal coronary arteries.

We describe the case of a 51-year-old female with no risk factors for coronary artery disease who had an episode of a non-ST-elevation myocardial infarction in association with an overdose of Venlafaxine. Cardiac catheterization revealed normal coronary arteries. Because no other obvious exacerbating factors for ischemia were observed, we assume that this drug may have contributed to the development of an acute ischemic event because of its pharmacologic properties.

B-type natriuretic peptide (BNP) and proBNP: role of emerging markers to guide therapy and determine prognosis in cardiovascular disorders.

Over the last decade, one group of neurohormonal markers, including atrial natriuretic peptide (ANP), N-terminal pro-ANP, B-type natriuretic peptide (BNP), and N-terminal proBNP, has generated much interest in the evaluation and management of heart failure and acute coronary syndrome. There has been so much literature on the subject, especially concerning BNP and proBNP, that it leaves us confused at times about what the literature has to say about these markers. In this article, we have made an honest attempt to examine all the available literature in relation to the impact of BNP and proBNP on cardiovascular disease and present it to the reader in an assimilated fashion.

Comparison and co-relation of invasive and noninvasive methods of ejection fraction measurement.

BACKGROUND: Accurate estimation of left ventricular ejection fraction (LVEF) has assumed great significance in the era of automatic implantable cardioverter defibrillators (AICDs), and a low EF may be one of the sole deciding factor in determining AICD implantation in certain patient populations. AIM: There are various methods, invasive and noninvasive, which can help calculate EF. We sought to conduct a retrospective study comparing EF estimation by invasive (angiography) and noninvasive methods [MUGA (multiple-gated acquisition), echocardiography (echo), single-photon emission computed tomography (SPECT)] in 5,558 patients in our hospital from 1995-2004. METHODS AND RESULTS: EF was estimated by > or = 1 method (angiography, MUGA, echo, SPECT) within a one-month period. Values for the four tests in 5,558 patients were as follows: angiography mean 46.2, range 20-75, standard deviation (SD) 13.1; MUGA mean 45.7, range 20-70, SD 11.6; echo mean 45.7, range 22-70, SD 11.2; and SPECT mean 54.4, range 30-75, SD 11.9. Excellent positive correlations were found among all four tests as follows: angiography and MUGA, correlation coefficient (r) = 0.97, angiography and echo r = 0.96, angiography and SPECT r = 0.94, MUGA and echo r = 0.97, MUGA and SPECT r = 0.94, and echo and SPECT r = 0.94. Values for SPECT were significantly higher than for angiography, echo and MUGA (p < 0.001). The arithmetic difference between angiography and MUGA (mean 0.50, range -5.0-5.0) and the arithmetic difference between angiography and echo (mean 0.52, range -5.0-15.0) were similar (p = 0.59). The arithmetic difference between SPECT and angiography (mean 8.2, range -15.0-20.0) was significantly larger than the arithmetic difference between angiography and echo (p < 0.001). CONCLUSIONS: All the four methods used to estimate EF corelate well with each other. However, values estimated during stress testing by SPECT overestimate EF and are significantly higher as compared to MUGA, echo and angiography. Estimation of EF by MUGA, echo or angiography should be preferred over SPECT, especially when that patient warrants intervention. We conclude that the overestimation of EF by SPECT may deprive some deserving patients of the survival benefit afforded by ICD.

Morbidity and mortality among patients with hip fractures surgically repaired within and after 48 hours.

OBJECTIVE: The objectives were (1) to compare the morbidity and mortality of patients with hip fractures surgically repaired within and after 48 hours of the occurrence of fracture and (2) to establish whether timing of repair alone had a major role in determining how the patients fared after the surgical repair or whether comorbidities also affected outcomes. SAMPLE: The study involved the medical records of 49 patients (aged 51 to 99 years) admitted to Coney Island Hospital between January 2003 and January 2004 with a primary diagnosis of hip fracture who underwent surgical repair. DESIGN: Analysis of data was done by retrospective chart review of patients admitted with the diagnosis of hip fracture to an acute care hospital setting. Follow-up continued until the patients were transferred to a rehabilitation facility for physical or occupational therapy after surgery. OUTCOME MEASURES: The preoperative health status of each patient was assessed by cardiopulmonary risk index score, based on comorbid conditions, and postoperative outcome was determined by complications (such as bed sores, pneumonia, urinary tract infection, deep vein thrombosis, or pulmonary embolism) or death. RESULTS: Patients who underwent early surgical repair (within 48 hours) had fewer postoperative complications (14.7%, as compared with 33.3% in the group undergoing surgery >48 hours after fracture). CPRI scores in the early and delayed surgery groups were also compared with regard to postoperative mortality and morbidity. It appeared that there was a higher statistical correlation between CPRI scores and complications among patients in the early surgery group (P=0.39) and an insignificant correlation among patients in the delayed surgery group (P=0.07). CONCLUSION: Surgical repair of hip fractures within the first 48 hours was associated with better health outcomes in a nationally representative sample, as observed in an acute care facility, irrespective of comorbid conditions.