A Case of Hyperacute Severe Thrombocytopenia Occurring Less than 24 Hours after Intravenous Tirofiban Infusion.

Thrombocytopenia is defined as a condition where the platelet count is below the lower limit of normal (<150 G/L), and it is categorized as mild (100-149 G/L), moderate (50-99 G/L), and severe (<50 G/L). We present here a 79-year-old man who developed severe thrombocytopenia with a platelet count of 6 G/L, less than 24 hours after intravenous tirofiban infusion that was given to the patient during a percutaneous transluminal coronary angioplasty procedure with placement of 3 drug-eluting stents. The patient's baseline platelet count was 233 G/L before the procedure. Based on the timeline of events during hospitalization and laboratory evidence, it was highly likely that the patient's thrombocytopenia was the result of tirofiban-induced immune thrombocytopenia, a type of drug-induced immune thrombocytopenia (DITP) which occurs due to drug-dependent antibody-mediated platelet destruction. Anticoagulant-mediated artefactual pseudothrombocytopenia was ruled out as no platelet clumping was seen on the peripheral blood smears. The treatment of DITP includes discontinuation of the causative drug; monitoring of platelet count recovery; or treatment of severe thrombocytopenia with glucocorticoids, IVIG, or platelet transfusions depending on the clinical presentation. The most likely causative agent of this patient's thrombocytopenia-tirofiban-was discontinued, and the patient did not develop any signs of bleeding during the remainder of his hospital stay. His platelet count gradually improved to 24 G/L, and he was discharged on the sixth hospital day.

Electrocardiogram Changes with Acute Alcohol Intoxication: A Systematic Review.

BACKGROUND: Acute alcohol intoxication has been associated with cardiac arrhythmias but the electrocardiogram (ECG) changes associated with acute alcohol intoxication are not well defined in the literature. OBJECTIVE: Highlight the best evidence regarding the ECG changes associated with acute alcohol intoxication in otherwise healthy patients and the pathophysiology of the changes. METHODS: A literature search was carried out; 4 studies relating to ECG changes with acute alcohol intoxication were included in this review. RESULTS: Of the total 141 patients included in the review, 90 (63.8%) patients had P-wave prolongation, 80 (56%) patients had QTc prolongation, 19 (13.5%) patients developed T-wave abnormalities, 10 (7%) patients had QRS complex prolongation, 3 (2.12%) patients developed ST-segment depressions. CONCLUSION: The most common ECG changes associated with acute alcohol intoxication are (in decreasing order of frequency) P-wave and QTc prolongation, followed by T-wave abnormalities and QRS complex prolongation. Mostly, these changes are completely reversible.

Right ventricular infarction.

Coronary Heart Disease is a leading cause of morbidity and mortality worldwide. A great amount is known about left ventricular myocardial infarction. It was not until much later (1974) that right ventricular myocardial infarction was studied as a separate entity. Isolated right ventricle myocardial infarction is rare. Around one-third of patients with acute infero-posterior ST-segment elevation myocardial infarction, will present with concomitant right ventricular infraction. The aim of this paper is to review the literature on the importance of early recognition of right ventricular infarction, clinical presentation, pathophysiology, diagnostic evaluation, differential diagnosis, treatment, complications and prognosis.

Splenic and Kidney Infarct: Sequelae of Subacute Streptococcus mitis Bacterial Endocarditis.

Infective endocarditis (IE) is caused due to the vegetation on the heart valves, myocardium wall, or the pacemaker leads. Vegetation is a lesion that appears as a consequence of successive deposition of platelets and fibrin on the endothelial surface of the heart. Colonies of microbes can be usually found under the vegetation. Heart valves are involved more frequently as compared to other places. Streptococcus mitis, formerly known as S. mitior, is a commensal of the oral flora, however, if there of loss of integrity of the mucous membrane, the infection may disseminate to the blood flow. We describe here a rare presentation of S. mitis, causing IE and its complications in an immunocompetent patient.

Isolated Diffuse Supravalvular Aortic Stenosis with Severe Aortic Narrowing in a 41-Year-Old Man.

Isolated supravalvular aortic stenosis in adults is a rare form of left ventricular outflow tract obstruction. We describe a case in a 41-year-old man in whom the supravalvular aorta had narrowed to approximately the size of the left anterior descending coronary artery. The patient underwent aortic surgery with replacement of the ascending aorta and repair of supravalvular aortic stenosis with a pantaloon graft. A postoperative echocardiogram showed substantial improvement: the mean gradient across the aorta had fallen from 48 to 8 mmHg. Surgery is the definitive treatment in symptomatic patients with supravalvular aortic stenosis.

Adult Onset Dysphagia: Right Sided Aortic Arch, Ductus Diverticulum, and Retroesophageal Ligamentum Arteriosum Comprising an Obstructing Vascular Ring.

A 49-year-old African American male patient with no past medical history was admitted because of 3 months of difficulty swallowing solid and liquid foods. He had constant retrosternal discomfort and appeared malnourished. The chest radiograph revealed a right sided aortic arch with tracheal deviation to the left. A swallow study confirmed a fixed esophageal narrowing at the level of T6. Contrast enhanced Computed Tomography (CT) angiogram of the chest and neck revealed a mirror image right aortic arch with a left sided cardiac apex and a prominent ductus diverticulum (measuring 1.7 × 1.8 cm). This structure extended posterior to and indented the mid esophagus. A left posterolateral thoracotomy was performed and the ductus diverticulum was resected. A retroesophageal ligamentum arteriosum was found during surgery and divided. This rare combination of congenital anatomical aberrations led to severe dysphagia in our patient. Successful surgical correction in the form of resection of the ductus diverticulum and division of the retroesophageal ligamentum arteriosum led to complete resolution of our patient's symptoms.

Saddle pulmonary embolism: right ventricular strain an indicator for early surgical approach.

Current mainstay treatment for pulmonary embolism (PE) includes oral anticoagulation, thrombolytic therapy, catheter embolectomy and acute surgical embolectomy. Surgical embolectomy is reserved for hemodynamically unstable patients (cardiogenic shock, cardiac arrest) and contraindication to thrombolytic therapy. We report a case of saddle PE in a young female with echocardiographic signs of right ventricular (RV) dysfunction who underwent early acute surgical embolectomy with a positive outcome. It would be beneficial to use bedside echocardiography even in hemodynamically stable patients to determine RV strain as this could act as an early indicator suggesting the escalation of therapy.

The relation between blood pressure changes induced by passive leg raising and arterial stiffness.

Passive leg raising (PLR) elicits cardiorespiratory changes because of intra-thoracic blood pooling. We previously found PLR to lower blood pressure (BP) in healthy subjects. To determine the effects of cardiovascular (CV) risk factors on the PLR BP lowering response, we measured brachial artery, systolic (SBP), diastolic (DBP), and pulse pressure (PP) before and 1 minute after 60° PLR, in 125 subjects (58% males, age 48 ± 18 years) with/without CV risk factors/disease. Baseline carotid-radial pulse wave velocity (PWV) and augmentation index (AI) were measured by applanation tonometry. Changes (∆) in SBP and BA PP ranged from +31 to -27 and +35 to -20 mm Hg and were normally distributed. Mean BP decreases upon PLR were ΔSBP -3 ± 9 (P < .001), and ΔPP -2 ± 8 mm Hg (P = .04). On univariate analyses, ΔSBP was correlated with age (r = 0.31, P < .001), PWV (r = 0.53, P < .001), AI (r = 0.25, P < .01), hypertension (r = 0.37, P < .001), hypercholesterolemia (r = 0.25, P < .01) and renal insufficiency (r = 0.19, P = .038). ΔPP was correlated with age (r = 0.31, P < .001), PWV (r = 0.45, P < .001), AI (r = 0.23, P = .01), hypertension (r = 0.22, P = .01), hypercholesterolemia (r = 0.27, P < .001). Multivariate analysis showed PWV the only independent predictor of ΔSBP (B = 3.2, r(2) = 0.40, P < .001) and of ΔPP (B = 2.6, r(2) = 0.36, P < .001). Therefore, changes in SBP and PP induced by PLR are independently and inversely related to carotid-radial PWV.

Passive leg raising induced brachial artery dilation: is an old technique a simpler method to measure endothelial function?

OBJECTIVES: Passive leg raising (PLR) is a diagnostic maneuver that has been shown to cause brachial artery dilation (BAD). The objectives of this study were to compare BAD induced by PLR with flow mediated dilation (FMD), and to investigate the mechanism of PLR-BAD. We studied a total of 75 subjects with and without cardiovascular risk factors/disease in order to provide a wide range of FMD responses. METHODS: Using ultrasound, PLR-BAD and FMD induced by release of arterial cuff occlusion were measured. RESULTS: BA diameter increased from 0.33+0.06 at baseline to 0.35+/-0.06 cm (p<.001) (4.8% increase) upon PLR and from 0.33+/-0.06 to 0.37+/-0.06 (11.8%) upon hyperemia. PLR induced BAD was significantly correlated with FMD (r=.82, p<.001). On receiver operating characteristic analysis of the two techniques, the area under the curve was 0.86 (95% CI 0.79-0.94, p<.001). Heart rate variability measures remained unchanged upon PLR indicating minimal contributions from changes in autonomic activity. The combination of FMD and PLR did not result in greater BAD than did FMD alone consistent with a common underlying mechanism. Mean blood flow velocity increased prior to BAD suggesting that shear stress increases prior to BAD. CONCLUSIONS: BAD occurs in response to PLR and is proportional to FMD, although the magnitude of PLR-BAD is less than half that of FMD. It appears to occur by the same endothelial dependent mechanism as FMD. PLR-BAD may be used as a surrogate measure of FMD to evaluate vascular function, and has the advantage of being simpler to perform.

Determinants of a blunted carotid-to-radial pulse wave velocity decline in response to hyperemia.

Carotid-radial pulse wave velocity (PWV) decreases in normal healthy individuals following hyperemia provoked by release of arterial cuff occlusion. To determine the effects of specific cardiovascular (CV) risk factors on the hyperemic PWV response, we measured PWV before and after brachial artery (BA) occlusion in 218 participants (66% males, age 56 +/- 19 years), with and without CV risk factors/disease. DeltaPWV ranged from -46% to +35% and values were normally distributed. On univariate analyses, DeltaPWV correlated with age, hypertension (Htn), hypercholesterolemia, diabetes mellitus (DM), coronary disease, congestive heart failure (CHF), smoking, and mean arterial pressure (MAP). On multivariate analysis, DeltaPWV was independently related to Htn (B = 4.56, P = .03) and CHF (B = 7.34, P = .008) and trended toward a higher MAP (B = .113, P = .067), DM (B = 4.01, P = .11), and hypercholesterolemia (B = 3.36, P = .12). In conclusion, hyperemic changes in carotid-radial PWV values are independently related to Htn and CHF and possibly DM and hyperlipidemia.