Prognostic value of the Duke Treadmill Score in diabetic patients.

BACKGROUND: The Duke Treadmill Score (DTS) is an established clinical tool for risk stratification of coronary artery disease. We sought to assess the prognostic value of the DTS in diabetics compared with nondiabetics in this study. METHODS: We studied 100 diabetics and 202 age- and sex-matched nondiabetic controls without known coronary artery disease risk stratified by DTS and followed for a median duration of 6.6 years. The association between DTS and primary, secondary outcomes, composite events, and rate of coronary angiography was tested. RESULTS: Survival free from cardiac death, nonfatal myocardial infarction, congestive heart failure, or early and late revascularization was 89%, 54%, and 13%, respectively, in the low-, intermediate-, and high-risk categories of diabetic group (P < .0001), and 91%, 57%, and 17%, respectively, in the low- to high-risk groups of nondiabetics (P < .0001). During follow-up, diabetics had more secondary events (P = .011) and coronary angiography (P < .001) compared with nondiabetics. The DTS was a strong independent predictor of composite events in both diabetics (P < .001) and nondiabetics (P < .001). A significant number of diabetics were classified as intermediate risk and had a significantly higher incidence of coronary angiography (87.5% vs 70.8%, P = .032) and late revascularizations (35.4% vs 15.3%, P = .011) within this risk group compared with nondiabetics. Survival free from major adverse cardiac events differed significantly across the 3 Duke risk groups for diabetics (P = .002) but not for controls (P = .07). Survival free from composite events differed significantly across the 3 Duke risk groups for both diabetics and nondiabetics (P < .0001). Overall, diabetics had higher rates of major adverse cardiac events, composite events (P = .011), and coronary angiography (P < .001) than nondiabetics. The DTS is a strong predictor of survival free of composite events in both groups by multivariate analysis. CONCLUSIONS: The DTS predicted survival free from MACE and composite events equally well in patients with and without diabetes.

Transient left ventricular apical ballooning: a novel heart syndrome.

A novel cardiac syndrome of left ventricular apical ballooning (Takotsubo cardiomyopathy-ampulla cardiomyopathy) involves reversible left ventricular apical ballooning (during systole) of acute onset with chest pain, electrocardiographic changes, and minimal elevation of cardiac enzymes resembling acute myocardial infarction, but without evidence of myocardial ischemia or injury. Patients have no angiographic evidence of coronary artery stenosis and there is almost always a complete recovery of left ventricular function in days to weeks. The precise etiologic basic of this syndrome is not clear but most likely it is a non-ischemic, metabolic syndrome caused by stress-induced activation of the cardiac adrenoceptors in absence of ischemia and reperfusion. Reported here is a case of stress-induced transient left ventricular apical ballooning syndrome in a young woman.

Internal mammary artery steal syndrome secondary to an anomalous lateral branch.

A 53-year-old male who underwent three-vessel coronary artery bypass grafting had a left internal mammary artery (LIMA) graft to the left anterior descending artery (LAD) and saphenous venous grafts to right coronary artery (RCA) and left circumflex coronary artery. Four years after surgery, he developed exertion angina associated with upper body exercises and even deep breathing at times. Angiographic evaluation revealed an anomalous lateral internal thoracic artery with steal phenomenon documented by adenosine cardiolyte. Patient was successfully treated with transcutaneous steel coil embolization by closing the anomalous vessel. Repeat stress electrocardiogram did not show any signs of ischemia. This case report emphasizes the variability in internal mammary artery (IMA) anatomy and the need to completely ligate all the branches of internal mammary artery intraoperatively.

Pseudo-pseudoaneurysm of the left ventricle: a rare complication of acute myocardial infarction--a case report and literature review.

Rupture of the cardiac wall is usually a fatal complication of acute myocardial infarction within the first 2 weeks. However, in certain cases a ruptured ventricular wall is contained by overlying adherent pericardium called pseudoaneurysm, whereas a true aneurysm is one that is caused by scar formation resulting in thinning of the myocardium. The patients with pseudoaneurysm may survive until the aneurysm ruptures. In exceedingly rare instance, the rupture of the myocardium is not transmural but remains circumscribed within the ventricular wall itself, but in communication with the ventricular cavity. This finding is defined as pseudo-pseudoaneurysm. The authors report a case of postinfarction posterobasal pseudo-pseudoaneurysm along with review of the literature on the subject.

Acute eosinophilic myocarditis mimicking myocardial infarction.

Eosinophilic myocarditis is characterized by progressive myocardial damage that results in heart failure and death. Herein, we present the case of a 54-year-old man who presented with symptoms of acute myocardial infarction. Normal coronary angiographic results and the presence of elevated levels of peripheral-blood eosinophilia prompted an endomyocardial biopsy that revealed acute eosinophilic myocarditis. The early initiation of steroid therapy resulted in the patient's substantial clinical improvement and survival. Early diagnosis of eosinophilic myocarditis and its treatment with steroid agents in some patients can lead to a favorable outcome. We discuss the challenge of diagnosing and identifying the characteristics of this variant of necrotizing eosinophilic myocarditis before the condition proves fatal.