Ayman El-Menyar

In-hospital Major Clinical Outcomes in Patients With Chronic Renal Insufficiency Presenting With Acute Coronary Syndrome: Data From a Registry of 8176 Patients

OBJECTIVEnTo assess the impact of chronic renal insufficiency (CRI) on in-hospital major adverse cardiac events across the acute coronary syndrome (ACS) spectrum.nnnPATIENTS AND METHODSnFrom January 29, 2007, through July 29, 2007, 6 adjacent Middle Eastern countries participated in the Gulf Registry of Acute Coronary Events, a prospective, observational registry of 8176 patients. Patients were categorized according to estimated glomerular filtration rate into 4 groups: normal (>or=90 mL/min), mild (60-89 mL/min), moderate (30-59 mL/min), and severe CRI (<30 mL/min). Patients characteristics and in-hospital major adverse cardiac events in the 4 groups were analyzed.nnnRESULTSnOf 6518 consecutive patients with ACS, 2828 (43%) had mild CRI, 1304 (20%) had moderate CRI, and 345 (5%) had severe CRI. In CRI groups, patients were older and had a higher prevalence of hypertension, diabetes mellitus, and dyslipidemia. On admission, these patients had a higher resting heart rate and frequently had atypical and delayed presentations. Compared with the normal estimated glomerular filtration group, CRI groups were less likely to receive antiplatelet drugs, beta-blockers, angiotensin-converting enzyme inhibitors, and statins and were less likely to undergo coronary angiography. In-hospital heart failure, cardiogenic shock, and major bleeding episodes were significantly higher in all CRI groups. In multivariate analysis, mild, moderate, and severe CRI were associated with a higher adjusted odds ratio (OR) of death (mild: OR, 2.1; 95% confidence interval [CI], 1.2-3.7; moderate: OR, 6.7; 95% CI, 3.9-11.5; and severe: OR, 12.0; 95% CI, 6.6-21.7).nnnCONCLUSIONnAcross the ACS spectrum, patients with CRI had a worse risk profile, had more atypical and delayed presentations, and were less likely to receive evidence-based therapy. Chronic renal insufficiency of varying stages is an independent predictor of in-hospital morbidity and mortality.

Prevalence and impact of cardiovascular risk factors among patients presenting with acute coronary syndrome in the middle East.

The authors explored the prevalence and impact of the cardiovascular risk factors (CVRFs) in patients presenting with acute coronary syndrome (ACS). During a five‐month period in 2007, six adjacent Middle Eastern countries participated in the Gulf Registry of acute coronary events. CVRFs were identified on admission. Patients characteristics and in‐hospital outcomes were analyzed across the types of ACS. Among 6704 consecutive patients with ACS, 61% had non–ST elevation ACS (NSTEACS) and 39% had ST–elevation myocardial infarction (STEMI). Female sex, old age, diabetes mellitus, hypertension, dyslipidemia, and obesity were more prevalent in NSTEACS patients. STEMI patients were more likely to be smokers and less likely to be taking aspirin prior to the index admission. Chronic renal failure (CRF) and diabetes mellitus were independent predictors of in‐hospital heart failure in NSTEACS, while CRF and hypertension were predictors of STEMI. Female sex and CRF were independent predictors of mortality in STEMI (odds ratio, 2.0; 95% confidence interval, 1.19–3.13 and odds ratio, 5.0; 95% confidence interval, 3.47–7.73, respectively). Assessment of the prevalence of CVRF in the acute coronary presentation is of important prognostic value for in‐hospital morbidity and mortality. CVRF and its impact may differ according to ACS type, age, and sex.

Initial hospital pulse pressure and cardiovascular outcomes in acute coronary syndrome

BACKGROUNDnThe association between admission pulse pressure (PP) and cardiovascular outcomes in acute coronary syndrome (ACS) is not well defined.nnnAIMnTo explore the prognostic value of initial PP in ST-segment elevation myocardial infarction (STEMI) and non-ST elevation ACS (NSTE-ACS).nnnMETHODSnOver a 5-month period in 2007, 6704 consecutive patients with ACS were categorized into five groups according to initial PP: P1, PP ≤0; P2, PP 31-40; P3, PP 41-50; P4, PP 51-60; P5, PP>60mmHg. Patient characteristics and in-hospital outcomes were analysed.nnnRESULTSnMean PP was lower in men versus women (55±19 vs. 61±22), young versus old (53±17 vs. 59±21), STEMI vs. NSTE-ACS (51±18 vs. 60±18) and patients who died versus survived (46±22 vs. 57±19mmHg) (P<0.001 for all). Most patients with low PP had a high Global Registry of Acute Coronary Events risk score. Compared with P5, crude odds ratios (ORs) (95% confidence intervals) for death were: P1, 9 (5.78-13.35); P2, 3 (1.71-4.06); P3, 1.5 (1.01-2.49); P4, 0.90 (0.51-1.58). After adjustment, low PP was associated with high mortality and stroke rates in ACS (adjusted ORs 7.5 [3.77-14.72] and 4.5 [1.20-18.88], respectively), high rates of recurrent ischaemia in NSTE-ACS (adjusted OR 2.8 [1.52-5.22]) and a high heart failure rate in STEMI (adjusted OR 2.1 [1.18-3.76]). Women with low PP had a higher mortality rate than men.nnnCONCLUSIONnIn ACS, all blood pressure variables were significantly correlated. Low PP was an independent predictor for stroke and mortality in overall ACS. Although PP was not superior to systolic blood pressure, only low PP was an independent predictor for recurrent ischaemia in NSTE-ACS.

Portomesenteric Vein Thrombosis After Laparoscopic Sleeve Gastrectomy: 3 Case Reports and a Literature Review

Case series Patient: Male, 27 • Female, 46 • Male, 46 Final Diagnosis: — Symptoms: Vague abdominal pain • severe nausea • vomiting • fever and diffuse abdominal tendernes Medication: — Clinical Procedure: — Specialty: — Objective: Rare co-existance of disease or pathology Background: Porto-mesenteric venous thrombosis (PMVT) is an infrequent but severe surgical complication developing in patients who underwent laparoscopic bariatric surgery (sleeve gastrectomy). Herein, we describe the clinical presentation, management, and outcome of 3 rare cases of PMVT after laparoscopic sleeve gastrectomy (LSG), successfully treated at our center. Case Report: All patients developed PMVT post-LSG and presented with diffused abdominal pain, nausea, and vomiting. Computed tomography (CT) of the abdomen confirmed the diagnosis of portal vein thrombosis. Two patients were treated conservatively with anticoagulation and thrombolytic therapy and the third patient required operative intervention with bowel resection. Conclusions: PMVT is a rare presentation after LSG, which requires early diagnosis and management. Conservative management through anticoagulants and thrombolytic therapy is quite effective and, if indicated, should always be considered as the primary treatment option.

Spontaneous Atraumatic Urinary Bladder Rupture Secondary to Alcohol Intoxication: A Case Report and Review of Literature

Patient: Male, 45 Final Diagnosis: Atraumatic urinary bladder rupture Symptoms: Drowsiness • diffuse abdominal pain • vomiting Medication: None Clinical Procedure: CT cystogram • exploratory laparotomy • urinary bladder repair Specialty: Urology Objective: Unusual clinical course Background: Spontaneous rupture of the urinary bladder (SRUB) secondary to alcohol intoxication is an uncommon presentation with high morbidity and mortality. Herein, we reported a rare case of spontaneous atraumatic rupture of the urinary bladder due to alcohol intoxication. Case Reports: A 45-year-old Sri Lankan man presented with drowsiness, diffuse abdominal pain, vomiting with odor of alcohol, and urinary retention 24 hours prior to the index admission. CT cystogram confirmed the urinary bladder rupture at the dome, which was repaired through exploratory laparotomy. Conclusions: An SRUB patient with alcohol abuse often presents with non-specific symptoms due to absence of a traumatic event, which results in missed or delayed-diagnosis. Early diagnosis and management of SRUB is crucial for uneventful recovery.

Oxcarbazepine-induced resistant ventricular fibrillation in an apparently healthy young man.

We report a 30-year-old man with recurrent loss of consciousness. His resting electrocardiogram revealed Brugada pattern. The patient developed resistant ventricular fibrillation after receiving oral oxcarbazepine. The clinical, echocardiographic, and electrocardiographic features are discussed in brief. Oxcarbazepine is an antiepileptic drug. The pharmacologic activity of Trileptal results from both the oxcarbazepine and its monohydroxy metabolite that includes blockage of voltage-sensitive sodium channels. Oxcarbazepine can inhibit cytochrome P2C19 and induce CYP3A4/5 with potentially important effects on plasma concentrations of other medications. To date, no specific or serious cardiac complications have been reported with oxcarbazepine use [1,2]. Herein we report a case of oxcarbazepine-induced ventricular fibrillation. A 30-year-old man presented to the accident and emergency department with a 2-minute history of loss of consciousness. He gave history of recurrent episodes of giddiness preceded by headache and followed by momentary loss of consciousness in the last 6 months. Most of these episodes occurred at rest particularly after rising from recumbency. Our patient is not known to have any chronic illnesses before; he denied any history of palpitation, chest pain, shortness of breath, convulsions, urinary or stool incontinence, fever, trauma, tinnitus, or family history of similar attacks. On examination, he was conscious, alert, oriented, and of average body weight. His cardiovascular, respiratory, neurologic, and abdominal examination results were unremarkable. Electrocardiogram (ECG) showed sinus regular rhythm; right bundle-branch block with ST-segment elevation in leads V1 through V2 and corrected QT of 428 milliseconds (Fig. 1). Laboratory investigations showed the following: myoglobin, 38 ng/mL; troponin T, less than 0.01 ng/mL; creatine kinase MB, 3.1 ng/mL; serum glucose, 4.5 mmol/L; potassium, 4.4 mmol/L; sodium, 139 mmol/L; calcium, 2.4 mmol/L; and bicarbonate, 27 mmol/L. Results 0735-6757/

Sudden cardiac death in athletes: where do we stand.

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Necrotizing fasciitis causing severe myocardial dysfunction with ST-segment elevation in a young man

We aimed to review the literature to explore the magnitude of sudden cardiac death (SCD) in young athletes. Although SCD in athletes is not a common event, it represents a tragedy of the apparently fit young population. SCD varies according to countries, age groups, and sex. In addition, it varies in the underlying causes and the screening tool. Therefore, we are in need for further research efforts. Guidelines, public and physician awareness, and education regarding the warning signs are integral part in the strategy to reduce SCD tragedy. However, all these requirements raise concern for cost-effectiveness in some countries for proper implementation.

Acute myocardial infarction with patent epicardial coronary vessels following Cassia italica ingestion.

Necrotizing fasciitis is a life-threatening infection of the fascia and subcutaneous tissues. We report on a 30-year-old man with history of intramuscular injection resulted in gluteal abscess that progressed to necrotizing fasciitis. On admission, the patient developed circulatory collapse, severe left ventricular dysfunction, and ST-segment elevation in the inferior leads. Wound and blood cultures indicated staphylococcal infection. The clinical, laboratory, echocardiographic, and electrocardiographic features are discussed.

Primary Breast Lymphoma in a Woman: A Case Report and Review of the Literature.

Herbal intake is escalating worldwide. To the best of our knowledge, myocardial infarction (MI) has not been reported following ingestion of laxative herbs in the absence of the well known risk factors for MI. We report on a 45-yr-old female patient who sustained acute inferior MI 8 h following Cassia italica ingestion. Subsequently, cardiac catheterization revealed patent coronary arteries. We assume that, in this case, MI may partly be related herbal ingestion. Further studies and public awareness of this complication in certain communities are needed.