Khang Li Looi

Coronary artery spasm and ventricular arrhythmias

Coronary artery spasm (CAS) is characterised by chest pain at rest and transient ST segment elevation on the ECG. The natural history of variant angina is not fully understood. Patients with CAS are younger, mostly female subjects and usually do not have traditional cardiovascular risk factors other than cigarette smoking. Cardiac arrhythmias are known to be associated with CAS. Ventricular arrhythmia is a well-recognised complication and sudden cardiac death has also been documented. The most important diagnostic tool in CAS is coronary angiography. 24 h ECG Holter monitoring can be very useful in the diagnosis of ventricular arrhythmias caused by CAS. The mainstay therapy for CAS is calcium channel blockers and nitrates. The use of β-blockers, especially the non-selective group, can promote attacks or prolong vasospastic state. The indication for implantable cardioverter defibrillator (ICD) implantation in a patient with CAS is still not clearly established. The role of primary prevention with the use of ICD is controversial; however, ICD implantation should be considered in high risk patients despite optimal medical treatment.

Sex-specific outcomes with addition of defibrillation to resynchronisation therapy in patients with heart failure

Objective Among primary prevention patients with heart failure receiving cardiac resynchronisation therapy (CRT), the impact of additional implantable cardioverter defibrillator (ICD) treatment on outcomes and its interaction with sex remains uncertain. We aim to assess whether the addition of the ICD functionality to CRT devices offers a more pronounced survival benefit in men compared with women, as previous research has suggested. Methods Observational multicentre cohort study of 5307 consecutive patients with ischaemic or non-ischaemic dilated cardiomyopathy and no history of sustained ventricular arrhythmias having CRT implantation with (cardiac resynchronisation therapy defibrillator (CRT-D), n=4037) or without (cardiac resynchronisation therapy pacemaker (CRT-P), n=1270) defibrillator functionality. Using propensity score (PS) matching and weighting and cause-of-death data, we assessed and compared the outcome of patients with CRT-D versus CRT-P. This analysis was stratified according to sex. Results After a median follow-up of 34 months (interquartile range 22–60 months) no survival advantage, of CRT-D versus CRT-P was observed in both men and women after PS matching (HR=0.95, 95% CI 0.77 to 1.16, p=0.61, and HR=1.30, 95% CI 0.83 to 2.04, p=0.25, respectively). With inverse-probability weighting, a benefit of CRT-D was seen in male patients (HR 0.78, 95% CI 0.65 to 0.94, p=0.012) but not in women (HR 0.87, 95% CI 0.63 to 1.19, p=0.43). The excess unadjusted mortality of patients with CRT-P compared with CRT-D was related to sudden cardiac death in 7.4% of cases in men but only 2.2% in women. Conclusions In primary prevention patients with CRT indication, the addition of a defibrillator might convey additional benefit only in well-selected male patients.

How often do physicians review medication charts on ward rounds

BackgroundPrescribing errors are common in hospital settings. Regular review of medication charts is recommended as a way to reduce errors but it is not clear how often this happens. The aim of this study was to determine the frequency with which specialist physicians reviewed medication charts during ward rounds.MethodsAn observer noted how often consultant physicians at Auckland City Hospital reviewed medication charts during ward rounds. The physicians were not aware that they were being observed.ResultsTwenty-one physicians were observed over a 26 week period. The general physicians reviewed the medication charts on 77% of occasions (range: 45% – 100%) during routine ward rounds and 65% of the time (range: 41% – 80%) on post admission rounds. Subspecialty physicians who did not see more than 8 patients on their rounds reviewed medication charts more frequently (88%) than those specialties where more than 8 patients were seen on average (61%).ConclusionThe physicians did not review medication charts on all ward rounds and there was considerable variation in how often they did this. There is some evidence that the frequency with which charts are reviewed decreases as the number of patients seen increases. More efforts should be made to encourage regular review of medication charts.

A case of cardiogenic shock caused by capecitabine treatment

Background A 52-year-old woman underwent successful resection of stage IIB primary mucinous adenocarcinoma of the appendix and was started on capecitabine chemotherapy. Five days into the first course, after initially experiencing diarrhea, nausea, vomiting and a transient episode of retrosternal chest pain radiating to the left scapula, she presented to the emergency department with cardiogenic shock.Investigations Electrocardiography, transthoracic echocardiography, laboratory investigation of cardiac biomarkers, coronary angiography and endomyocardial biopsy.Diagnosis Capecitabine-induced cardiogenic shock.Management Supportive treatment with dopamine, milrinone, norepinephrine (noradrenaline) and levosimendan.

The importance of P wave morphology on the ECG

Focal atrial tachycardia (AT) is the least common form of supraventricular tachycardia. However, the surface 12-lead ECG is a very helpful tool and the use of P-wave morphology (PWM) on surface ECG to localise the site of focal AT is of paramount importance. Subtle ECG changes with respect to PWM in AT could be mistaken as sinus rhythm (SR). We report a case of a young woman with focal AT located at the tricuspid annulus in which the heart rate in both …