Pulmonary Hypertension and Hypocholesterolemia Secondary to Thyrotoxicosis.

BACKGROUND: Thyroid disorders commonly affect the cardiovascular system. Thyrotoxicosis leading to pulmonary hypertension has been increasingly reported during recent years. Thyroid dysfunction affects the lipid metabolism, and thyrotoxicosis can be associated with low lipid levels. Thyrotoxicosis presenting with right ventricular dysfunction is rare, and only few cases had been reported. Case Presentation. A 53-year-old woman presented with progressive shortness of breath and swelling of body for four months. Examination showed generalized oedema and a systolic murmur over the left sternal border. Transthoracic echocardiography confirmed pulmonary hypertension with tricuspid regurgitation. Investigations revealed thyrotoxicosis and very low cholesterol levels. Diagnosis of Graves' disease was confirmed with detection of thyrotropin receptor antibodies. Pulmonary pressure was normalized six months after antithyroid therapy. CONCLUSION: Thyrotoxicosis is a recognized cause of reversible pulmonary hypertension and acquired hypocholesterolemia. However, most clinicians are not aware of these associations. This case illustrates the importance of assessing thyroid function in patients presenting with pulmonary hypertension.

Quality evaluation and future priorities for delivering acute myocardial infarction care in Sri Lanka.

AIM: This study evaluates the quality of care for patients admitted with acute myocardial infarction (AMI) in a tertiary hospital in Colombo using the European Society of Cardiology Quality of Care Working Group's guidelines (2017). METHODS: A recently implemented electronic AMI registry m-Health tool was used for prospective data collection. Each patient was assessed for eligibility for each of the six domains of quality. Global Registry of Acute Coronary Events Risk Model for predicted probability of mortality, and scores for risk of bleeding complications (CRUSADE) and severity of heart failure (Killip classification) were calculated as per published guidelines. A composite measure of quality was derived from compliance with the six domains. Patients were followed up via telephone at 30 days following discharge to evaluate outcome and satisfaction. Organisational information was assessed by administrative review and interview. RESULTS: Between March 2017 and April 2018, 934 patients with AMI presented to the cardiology department. The majority of patients (90.4%) presented with features of ST-elevation myocardial infarction (STEMI). Mean (SD) overall compliance with the composite quality indicator (CQI) was 44% (0.07). Compliance of ≥50% to the CQI was achieved in 9.8% of STEMI patients. The highest compliance was observed for antithrombotics during hospitalisation (79.1%) and continuous measure of patient satisfaction (76.1%). The lowest compliance was for organisational structure and care processes (22.4%). CONCLUSION: This study reports a registry-based continuous evaluation of the quality of AMI care from a low and middle-income country. Priorities for improvement include improved referral, and networking of primary and secondary health facilities with the percutaneous coronary intervention centre.

Pneumopyopericardium mimicking an inferior ST elevation myocardial infarction with regional electrocardiogram changes: a case report.

BACKGROUND: Pneumopyopericardium is a rare disease with poor prognosis. The usual presentation is with fever, shortness of breath and haemodynamic compromise. The Electrocardiogram changes associated with this disease entity would be similar to pericarditis such as concave shaped ST elevations in all leads with PR sagging. Pneumopyopericardium mimicking an acute ST Elevation Myocardial Infarction, with regional Electrocardiogram changes has hitherto not been described in world literature. CASE PRESENTATION: We describe the case of a 48 year old native Sri Lankan man, presenting with chest pain and Electrocardiogram changes compatible with an Acute ST Elevation Myocardial Infarction, subsequently found to have Pneumopyopericardium secondary to an oesophageal tear. Retrospective history revealed repetitive vomiting due to heavy alcohol consumption, prior to presentation. It unfortunately led to a fatal outcome. CONCLUSION: Pneumopyopericardium may mimic an acute ST elevation myocardial infarction with associated regional Electrocardiogram changes. A high degree of suspicion should be maintained and an adequate history should always be obtained prior to any intervention in all ST Elevation Myocardial Infarction patients.

'New World' imaging for an 'Old World' disease: Use of cardiac magnetic resonance imaging and 3D transesophageal echocardiography in severe rheumatic mitral valve disease.

We report a case of severe rheumatic mixed mitral valve disease in a young adult male where a combination of imaging techniques was utilized. We demonstrate that cardiac magnetic resonance imaging may be used as an alternative imaging modality in patients not suitable for the more established techniques of transthoracic and transesophageal echocardiography. Additionally, the use of 3D-transesophageal imaging offered the cardiothoracic surgeon additional anatomical information at the time of mitral valve replacement.