Late subannular aortic root rupture following transcatheter aortic valve implantation presenting as ST elevation myocardial infarction.

Transcatheter aortic valve implantation (TAVI) has transformed the treatment of severe aortic stenosis. Here, we present a case of late aortic root rupture presenting as ST-elevation myocardial infarction five weeks following successful TAVI. Aortic root rupture is a rare complication of TAVI, which occurs in ∼1% of procedures and usually arises during or soon after the procedure and is associated with high mortality (∼50%). Early recognition of late-presenting complications related to TAVI, including aortic root rupture, is essential for specialists and nonspecialists. © 2016 Wiley Periodicals, Inc.

[Infective endocarditis in the elderly: The current view of the problem]. / Infektsionnyi éndokardit u pozhilykh: sovremennyi vzgliad na problemu.

The review gives the current views of the etiology and risk factors of infective endocarditis (IE) in the elderly. It reports the specific clinical picture of the disease at this age, including clinically apparent syndromes, comorbidity, and various clinical signs and peculiarities of IE. Particular emphasis is placed on the diagnosis of an endocardial infectious lesion, which is based on the use of the modified Duke criteria. The methods of IE diagnosis, particularly microbiological examination, imaging techniques, among which echocardiography in different modes plays a particular role, are listed. The treatment of the disease is based on the latest recommendations for antibiotic therapy with and without regard to a specific etiological factor. The issues of surgical intervention, as well as approaches to preventing IE in elderly people are discussed.

A serious drug interaction leading to spontaneous total hyphema.

A 70 year-old diabetic man receiving anti-coagulant therapy (Warfarin) for pulmonary embolism secondary to factor V Leiden deficiency, presented to the hospital for chest pain. After initial evaluation, he was started on aspirin (300 mg) and clopidogrel (300 mg). Three days after he was discharged, he presented with preseptal cellulitis complicating left upper eyelid chalazion. Initially, he was treated with several anti-microbial agents used sequentially. Although, the cellulitis resolved, he developed total hyphema of the left eye. The complication seems to have resulted from a complex interaction amongst anti-microbial agents, Warfarin and anti-platelet agents.

An unusual cause of ST elevation.

An interesting case of a patient presenting to the emergency department with chest pain and an electrocardiogram (ECG) revealing ST elevation is presented. On closer examination another explanation for this ECG appearance is discussed indicating that emergency revascularisation was not indicated.

Glucose and haemoglobin in the assessment of prognosis after first hospitalisation for heart failure.

OBJECTIVE: To examine the relationship with outcome of plasma haemoglobin and glucose concentrations, measured soon after first hospital admission with chronic heart failure (CHF), in standard clinical practice. METHODS AND RESULTS: Hospital records of 528 patients (43% women, mean age 70 years) with first hospital admission for CHF were reviewed. During follow up (mean 1257 days, range 520-1800), 240 (45%) patients died. On admission, 140 of 528 (27%) and at discharge 179 of 472 survivors (38%) were receiving treatment for diabetes. World Health Organization criteria for anaemia were met by 39% of men and 43% of women. Lower haemoglobin (hazard ratio 0.879, 95% confidence interval (CI) 0.828 to 0.933, p < 0.0001) and higher plasma glucose (hazard ratio 1.034, 95% CI 1.008 to 1.061, p = 0.009) had univariate association with all-cause mortality. On multivariate analysis, compared with patients with a normal haemoglobin for their sex, hazard ratio was 1.415 (95% CI 1.087 to 1.841, p = 0.010) for those with low haemoglobin. All-cause mortality fell linearly for haemoglobin up to 159 g/l, above which mortality increased. Glucose above the highest quartile (> 10 mmol/l) was an independent predictor of mortality (hazard ratio 1.966, 95% CI 1.376 to 2.810, p = 0.0002). In survivors of the index admission the association between glucose and mortality was linear, the relationship being stronger for patients without diabetes. CONCLUSIONS: Lower haemoglobin and higher plasma glucose are associated with all-cause mortality in CHF. Higher glucose is associated with mortality irrespective of diabetic status.

Ethnicity and variation in prognosis for patients newly hospitalised for heart failure: a matched historical cohort study.

OBJECTIVES: To compare mortality and factors predictive for outcome in age matched white and South Asian cohorts after first admission for heart failure. DESIGN: Matched historical cohort study. SETTING: One National Health Service trust comprising three acute care hospitals. PARTICIPANTS: 176 South Asian (mean age 68 (10) years, 45% women) and 352 age and sex matched white (70 (11) years, 42% women) patients hospitalised for the first time with heart failure. MAIN OUTCOME MEASURES: All cause survival, measures of disease severity, and the association of clinical variables with outcome. RESULTS: Compared with white patients, South Asian patients had similar rates of prior coronary heart disease but more often had prior hypertension (45% v 33%, p = 0.006) and diabetes (46% v 18%, p < 0.0001). Atrial fibrillation (15% v 31%, p = 0.0002) and prior diuretic use (39% v 48%, p = 0.041) were less common among South Asians. Left ventricular function was more often preserved (38% v 23%, p = 0.002) and less often severely impaired (18% v 28%, p = 0.025) among South Asians. During follow up (range 520-1880 days) 73 of 176 (41.2%) South Asian and 167 of 352 (47.4%) white patients died. South Asian ethnicity was associated with lower all cause mortality (odds ratio 0.71, 95% confidence interval 0.53 to 0.96, p = 0.02). Other predictors of outcome (admission age, lower systolic blood pressure, higher creatinine, higher plasma glucose, and lower haemoglobin) were similar in each cohort. CONCLUSIONS: At first hospitalisation, heart failure appears less advanced in South Asians, among whom diabetes and hypertension are more prevalent. Survival is better for South Asian than for white patients. Higher glucose and lower haemoglobin at admission provide useful prognostic information in heart failure.

Simple continuous closure of canine scrotal urethrostomy: results in 20 cases.

Simple continuous closure of scrotal urethrostomy in 20 dogs is described. Mean duration of postoperative active bleeding and mean duration of bleeding only associated with urination were 0.2 day and 3.1 days, respectively. Long-term complications were minimal; intermittent urine scald (n = 2), recurrent urinary tract infections (n = 2), and recurrent obstruction due to struvite stones (n = 2) developed after surgery. All complications resolved with medical therapy (n = 4) or by cystotomy (n = 2). None of the dogs had complications due to wound dehiscence, stricture, incisional infections, self-mutilation, or incontinence. Follow-up ranged from two to 52 months (mean, 25.2 months). This technique is a viable alternative to previously reported closure methods.

Iodine intake and the seasonal incidence of thyrotoxicosis in New Zealand.

We explored a possible relationship between the seasonal variation in the incidence of thyrotoxicosis in our area and iodine intake, as assessed by measuring the 24-h urinary iodide excretion rate eight times at 3-month intervals in a group of normal subjects and in 992 outpatient specimens over a 2-year period (1988-1990). For the period 1978-1990, 139 cases of thyrotoxicosis were diagnosed during the warmer half of the year (November-April) and 100 cases during the cooler half (May-October). This difference was statistically highly significant (P = 0.013). A similar disproportionality in the incidence of thyrotoxicosis was observed between the warmer (57%) and cooler (43%) halves of the year for the period 1988-1990. During the 1988-1990 period there was no discernible seasonal variation in either the milk iodide concentration or in the cumulative mean 24-h urinary iodide excretion rates for the normal subjects or the outpatients. We conclude that the higher proportion of thyrotoxic patients diagnosed during the warmer 6-month period of the year in our area is best explained by the fact that symptoms tend to be less tolerable in warm weather. A comparison of our findings on 24-h urinary iodide excretion rates with data collected in our area 25 years ago suggested that iodine intake may have declined.

Patients with abdominal aortic aneurysm: are we missing the opportunity for cardiovascular risk reduction?

INTRODUCTION: Antiplatelet agents, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statin drugs), angiotensin converting enzyme (ACE) inhibitors, and beta-adrenergic receptor blockers (beta-blockers) reduce cardiovascular risk and mortality in patients with specific manifestations of cardiovascular disease and risk factors. Occlusive arterial disease, in particular, coronary heart disease, is prevalent in patients with abdominal aortic aneurysm (AAA) and results in reduced life expectancy. The purpose of this study was to investigate the prevalence of cardiovascular disease and risk factors in patients with AAA. In particular, numbers of patients in whom pharmacologic therapy is indicated and numbers of patients who are receiving adequate treatment were determined. METHODS: This was a prospective study of 313 patients with AAA in Leicestershire over the 15 months between September 2002 and December 2003. RESULTS: Data that enabled determination of an indication for antiplatelet agents and statin drugs were available for 262 patients (84%), and for a beta-blocker and ACE inhibitor for 313 patients (100%). An antiplatelet agent was indicated in 242 of 262 patients (92%), a statin drug was indicated in 196 of 262 patients (75%), a beta-blocker was indicated in 107 of 313 patients (34%), and an ACE inhibitor was indicated in 178 of 313 patients (57%). In patients with an indication, 146 of 242 patients (60%) were using an antiplatelet agent, 81 of 196 (41%) were using a statin drug, 41 of 313 (38%) were using a beta-blocker, and 69 of 313 (39%) were using an ACE inhibitor. CONCLUSION: Cardiovascular disease, for which there is evidence for the survival benefit of pharmacologic risk reduction, is prevalent in patients with AAA. The data show that current treatment of cardiovascular risk is suboptimal and could be improved, with an expected reduction in cardiovascular morbidity and mortality.