Alja Vlahovic-Stipac

Head-to-head comparison of indices of left ventricular contractile reserve assessed by high-dose dobutamine stress echocardiography in idiopathic dilated cardiomyopathy: five-year follow up

Objective: To compare head to head the indices of left ventricular contractile reserve assessed by high-dose dobutamine in the five-year prognosis of patients with idiopathic dilated cardiomyopathy. Design and setting: Prospective study in a tertiary care centre. Patients: 63 consecutive patients with idiopathic dilated cardiomyopathy. Interventions: High-dose dobutamine stress echocardiography was performed in progressive stages lasting 5 min each. Wall motion score index, ejection fraction, cardiac power output and end systolic pressure to volume ratio were evaluated as indices of left ventricular contractility. Main outcome measure: Five-year cardiac mortality. Results: During the follow up of 59 patients, 27 (45.8%) died of cardiac causes. According to Kaplan–Meier and receiver operating characteristic analyses all indices of contractile reserve differentiated patients with respect to cardiac death. Wall motion score index achieved the best separation (log rank 21.75, p < 0.0001, area under the curve 0.84), followed by change in ejection fraction (log rank 11.25, p  =  0.0008, area under the curve 0.79), end systolic pressure to volume ratio (log rank 14.32, p  =  0.0002, area under the curve 0.75) and cardiac power output (log rank 9.84, p  =  0.0017, area under the curve 0.71). Cox’s regression model identified wall motion score index as the only independent predictor of cardiac death. Conclusions: These data show that all examined indices of left ventricular contractile reserve are predictive of five-year prognosis, but change in wall motion score index may have the greatest prognostic potential.

Primary PCI for acute myocardial infarction in a patient with idiopathic thrombocytopenic purpura. A case report and review of the literature.

Background and Purpose:The occurrence of acute myocardial infarction (AMI) in patients with idiopathic thrombocytopenic purpura (ITP) is rare, especially when the platelet count is low. Since only few case reports have been published, there are no recommendations for the management of thrombocytopenic patients with AMI. The aim of the present study is to discuss different aspects of this challenging issue and to review limited data available in the literature.Case Study:An 80-year-old patient with ITP (platelet count 5 . 109/l) is presented who developed an AMI (ST segment elevation myocardial infarction) and was successfully treated by primary percutaneous coronary intervention (PCI).Conclusion:Considering the high bleeding risk in patients with ITP and AMI, careful balance between usual anticoagulation and antiplatelet therapy on the one hand, and efforts to raise platelet count on the other hand are needed.ZusammenfassungHintergrund und Fragestellung:Akute Myokardinfarkte (AMI) bei Patienten mit idiopathischer thrombozytopenischer Purpura (ITP, Morbus Werlhof) sind seltene Ereignisse. Da in der Literatur nur einige wenige Fälle beschrieben sind, existieren auch keine Therapieempfehlungen für diese Konstellation. In der vorliegenden Studie sollen unterschiedliche Aspekte dieser herausfordernden Situation diskutiert und die verfügbaren Daten aus der Literatur zusammenfassend beschrieben werden.Fallbericht:Geschildert wird der Fall eines 80-jährigen Patienten mit ITP (Thrombozytenzahl 5 . 109/l), der einen AMI (ST-Strecken-Hebungsinfarkt) erlitten hatte und mit primärer perkutaner Koronarintervention (PCI) erfolgreich behandelt wurde.Schlussfolgerung:Das hohe Blutungsrisiko bei Patienten mit ITP und AMI erfordert eine sorgfältige Balance zwischen Antikoagulation bzw. Plättchenhemmung einerseits und Anhebung der Thrombozytenzahl andererseits.

Primary PCI for Acute Myocardial Infarction in a Patient with Idiopathic Thrombocytopenic Purpura

Background and Purpose:The occurrence of acute myocardial infarction (AMI) in patients with idiopathic thrombocytopenic purpura (ITP) is rare, especially when the platelet count is low. Since only few case reports have been published, there are no recommendations for the management of thrombocytopenic patients with AMI. The aim of the present study is to discuss different aspects of this challenging issue and to review limited data available in the literature.Case Study:An 80-year-old patient with ITP (platelet count 5 . 109/l) is presented who developed an AMI (ST segment elevation myocardial infarction) and was successfully treated by primary percutaneous coronary intervention (PCI).Conclusion:Considering the high bleeding risk in patients with ITP and AMI, careful balance between usual anticoagulation and antiplatelet therapy on the one hand, and efforts to raise platelet count on the other hand are needed.ZusammenfassungHintergrund und Fragestellung:Akute Myokardinfarkte (AMI) bei Patienten mit idiopathischer thrombozytopenischer Purpura (ITP, Morbus Werlhof) sind seltene Ereignisse. Da in der Literatur nur einige wenige Fälle beschrieben sind, existieren auch keine Therapieempfehlungen für diese Konstellation. In der vorliegenden Studie sollen unterschiedliche Aspekte dieser herausfordernden Situation diskutiert und die verfügbaren Daten aus der Literatur zusammenfassend beschrieben werden.Fallbericht:Geschildert wird der Fall eines 80-jährigen Patienten mit ITP (Thrombozytenzahl 5 . 109/l), der einen AMI (ST-Strecken-Hebungsinfarkt) erlitten hatte und mit primärer perkutaner Koronarintervention (PCI) erfolgreich behandelt wurde.Schlussfolgerung:Das hohe Blutungsrisiko bei Patienten mit ITP und AMI erfordert eine sorgfältige Balance zwischen Antikoagulation bzw. Plättchenhemmung einerseits und Anhebung der Thrombozytenzahl andererseits.

Concomitant administration of simvastatin and danazol associated with fatal rhabdomyolysis.

BACKGROUND Simvastatin, a 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor, is indicated for the treatment of hypercholesterolemia and plays an important role in both the primary and secondary prevention of cardiovascular disease. Danazol is a steroid analogue approved for the treatment of endometriosis, fibrocystic breast disease, and hereditary angioedema. Despite not being licensed, danazol has been used for other off-label indications, such as idiopathic thrombocytopenic purpura (ITP), paroxysmal nocturnal hemoglobinuria, and aplastic anemia. OBJECTIVE We report a case of fatal rhabdomyolysis that occurred after concomitant administration of simvastatin and danazol in a patient with ITP. CASE SUMMARY An 80-year-old white male (height, 182 cm; weight, 90 kg) presented to the emergency department of the Clinical Hospital Centre Zemun, Belgrade, Serbia, with head injuries after an accidental fall caused by generalized weakness. He denied other complaints, except fatigue, mild pretibial edema, and progressive bilateral leg pain and cramping that began 7 days before. At the time of presentation, he was receiving aspirin 100 mg/d, clopidogrel 75 mg/d, ramipril 2.5 mg/d, pantoprazole 40 mg/d, danazol 600 mg/d, prednisone 60 mg/d, simvastatin 40 mg/d, and long-acting insulin 24 IU/d. After the injuries were treated, he was diagnosed with collapse and nasal contusion, and discharged without any changes in his therapy. Two days after initial presentation, the patient was readmitted to the hospital due to nausea, dark urine, and oliguria. All clinical signs (oliguria, dark urine, muscle pain, and tenderness) and laboratory markers (creatine kinase levels approximately 100 times the upper limit of normal, along with hyperkalemia, hyperphosphatemia, and hypoalbuminemia) were consistent with severe rhabdomyolysis. Despite intravenous hydration, forced diuresis, and hemodialysis, oliguria persisted and the patient died 6 days after admission. A score of 5 on the Naranjo adverse drug reaction probability scale was consistent with a probable association of rhabdomyolysis and concomitant treatment with simvastatin and danazol in this patient. CONCLUSIONS Statin-induced rhabdomyolysis must be considered whenever muscle or motor symptoms occur, especially when concomitant treatment with known inhibitors of statin metabolism is administered. Patients must be strictly monitored and the statin should be promptly discontinued with the onset of first signs and symptoms of myopathy. Clinicians should be aware of the potentially fatal consequences of both approved and unapproved treatments and be alert for the early detection of toxicity.

Pseudopacemaker syndrome and marked first-degree atrioventricular block: Case report

INTRODUCTION Pacemaker syndrome consists of the symptoms and signs present in the single chamber (VVI) pacemaker patient with electrode placed in the right ventricular apex. It is caused by inadequate timing of atrial and ventricular contractions. Pacemaker syndrome without a pacemaker (or pseudopacemaker syndrome) refers to occurrence of symptoms in the presence of marked first-degree atrioventricular (AV) block, when P wave is too close to the preceding QRS complex producing the same haemodynamic disturbance as artificial pacemaker cardiac stimulation with retrograde VA conduction. CASE OUTLINE We present the patient with acute inferior myocardial infarction due to late bare metal stent thrombosis, treated with primary pectutaneous coronary intervention. Hospital course was complicated by complete heart block which was treated with temporary pacing. During the stand-by mode of temporary pacing, sinus rythm with marked first-degree AV block (PQ interval 480 ms) was observed while the patients re-experienced the symptoms that were present prior to pacemaker implantation. Temporary pacing was continued for the next 24 hours when spontaneous shorteninig of PQ interval (250-270 ms) was noticed; since the patient was asymptomatic during the stand-by mode, the pacemaker electrodes were removed and the patient discharged 11 days after admission. CONCLUSION Conduction disturbances, such as the varying degrees of AV blocks, are relatively common in acute inferior myocardial infarction. The first degree AV blok is usually asymptomatic and does not require treatment, unless when it is associated with pseudopacemaker syndrome. In that case, temporary pacing provides haemodynamic stability until conduction system recovers.

Primary PCI for Acute Myocardial Infarction in a Patient with Idiopathic Thrombocytopenic Purpura@@@Primäre PCI wegen akuten Myokardinfarkts bei einem Patienten mit idiopathischer thrombozytopenischer Purpura. Fallbericht und Literaturübersicht: A Case Report and Review of the Literature

Background and Purpose:The occurrence of acute myocardial infarction (AMI) in patients with idiopathic thrombocytopenic purpura (ITP) is rare, especially when the platelet count is low. Since only few case reports have been published, there are no recommendations for the management of thrombocytopenic patients with AMI. The aim of the present study is to discuss different aspects of this challenging issue and to review limited data available in the literature.Case Study:An 80-year-old patient with ITP (platelet count 5 . 109/l) is presented who developed an AMI (ST segment elevation myocardial infarction) and was successfully treated by primary percutaneous coronary intervention (PCI).Conclusion:Considering the high bleeding risk in patients with ITP and AMI, careful balance between usual anticoagulation and antiplatelet therapy on the one hand, and efforts to raise platelet count on the other hand are needed.ZusammenfassungHintergrund und Fragestellung:Akute Myokardinfarkte (AMI) bei Patienten mit idiopathischer thrombozytopenischer Purpura (ITP, Morbus Werlhof) sind seltene Ereignisse. Da in der Literatur nur einige wenige Fälle beschrieben sind, existieren auch keine Therapieempfehlungen für diese Konstellation. In der vorliegenden Studie sollen unterschiedliche Aspekte dieser herausfordernden Situation diskutiert und die verfügbaren Daten aus der Literatur zusammenfassend beschrieben werden.Fallbericht:Geschildert wird der Fall eines 80-jährigen Patienten mit ITP (Thrombozytenzahl 5 . 109/l), der einen AMI (ST-Strecken-Hebungsinfarkt) erlitten hatte und mit primärer perkutaner Koronarintervention (PCI) erfolgreich behandelt wurde.Schlussfolgerung:Das hohe Blutungsrisiko bei Patienten mit ITP und AMI erfordert eine sorgfältige Balance zwischen Antikoagulation bzw. Plättchenhemmung einerseits und Anhebung der Thrombozytenzahl andererseits.