Cardiac cephalalgia: severe, non-exertional headache presenting as unstable angina.

Cardiac cephalalgia is a migraine-like headache that occurs during episodes of myocardial ischaemia. Clinical characteristics of the headache vary widely but are often severe in intensity, worsen with reduced myocardial perfusion and resolve with reperfusion. It can present along with typical symptoms of angina pectoris, although not always. We present a 64-year-old man with a 6-month history of severe, non-exertional headaches occurring with increasing frequency. A resting ECG showed ST elevation in the inferior leads. His serum troponin I was not elevated. Coronary angiography showed severe stenosis of his right coronary artery, which was successfully stented by percutaneous coronary intervention. He remains headache free at 2-year follow-up.

A rare instance of 'cardio-respiratory pacing': permanent pacemaker insertion for symptomatic bradycardia in a quadriplegic man dependent on diaphragmatic pacing by phrenic nerve stimulators.

Patients with high spinal cord injury may present with significant cardiac dysautonomia. There is a dearth of data regarding electromechanical interference to cardiac pacemakers from phrenic nerve stimulators which are used in such patients for respiratory support. We report an instance of bipolar lead permanent pacemaker insertion for ventricular standstill in a man with quadriplegia following C2 fracture and the measures we adopted to minimise electromagnetic interference with phrenic nerve stimulators. To the best of our knowledge, this is the first reported instance of successful pacemaker insertion in a quadriplegic patient on long-term diaphragmatic pacing.

Treatment paradigms in heart failure.

Heart failure patients suffer very severe morbidity, high mortality and are common in medical practice. Their need for effective treatments is only partially answered by current options. Effective treatments often address cellular and pathophysiological mechanisms which are involved in the progression of heart failure. This article reviews those mechanisms and treatments.

Massaging the outcome: an unusual presentation of pulmonary embolism.

A 56-year-old man with a previous deep venous thrombus presented with dyspnoea after a leg massage. A transthoracic echocardiogram demonstrated a "worm-shaped" right atrial embolus, most probably a femoral cast. A pulmonary artery angiogram confirmed a large wedge-shaped perfusion defect caused by a pulmonary embolus. There are previous case reports about leg massage causing pulmonary emboli but this is the first reported event where the thrombus has been visualised directly. Also, it demonstrates the important role that echocardiography plays in pulmonary embolus.

Two diverticula of the left ventricular outflow tract adjacent to the commissures of a bicuspid aortic valve.

We report a rare combination of congenital cardiac malformations in an asymptomatic adult--a bicuspid aortic valve and double fibrous diverticula of the left ventricle. We describe the presentation and course of events followed by a brief discussion of ventricular diverticula and the management of this rare combination of anomalies.