Nisha Chandra-Strobos

Safe and Effective Intravenous Thrombolysis for Acute Ischemic Stroke Caused by Left Atrial Myxoma

Atrial myxoma may be associated with syncope or sudden death attributed to left-sided cardiac outflow obstruction or embolization caused by tumor dislodgement or thrombus formation. Definitive treatment for primary and secondary stroke prevention is surgical resection. The role of thrombolysis in acute brain ischemia in patients with atrial myxoma is not defined. There are few data available regarding safety and efficacy of thrombolytic therapy in acute ischemic strokes caused by atrial myxoma. Prior case reports described partial success using intra-arterial local thrombolysis; however, this is invasive and can be associated with significant complications. A previously reported case of systemic thrombolysis resulted in development of cerebral hemorrhage. We describe a young man who presented with syncope and a dense stroke developing as a complication of atrial myxoma, followed by a remarkable recovery after treatment with intravenous recombinant tissue plasminogen activator and urgent cardiac surgery. Contrary to some expert opinion, systemic thrombolytic therapy may be safely and effectively used to treat acute ischemic strokes from atrial myxoma.

Enhanced external counterpulsation therapy: significant clinical improvement without electrophysiologic remodeling.

Background:u2002Enhanced external counterpulsation therapy (EECP), in addition to improving coronary flow and increasing the time to ischemia, noninvasively alters hemodynamics in patients with severe coronary artery disease (CAD). Other treatments that alter hemodynamics, for example, balloon valvuloplasty, left ventricular assist devices, and pharmacologic antagonism of the rennin–angiotensin system, promote electrophysiologic remodeling, as evidenced by alterations in the QT interval.

Calcium channel blocker overdose mimicking an acute myocardial infarction

A 42-year-old man presented with shortness of breath, weakness, and diaphoresis, and developed a new left bundle branch block while under evaluation in the Emergency Department. At emergency cardiac catheterization, he was found to have only insignificant coronary disease, and a hyperdynamic ventricle. Despite these findings, he subsequently developed profound bradycardia and hypotension, which were refractory to standard therapies including pressors, calcium, and transvenous pacing. He gradually improved over several days and made a full recovery, after which he admitted to taking multiple calcium channel blockers (CCBs) in an attempt to self-medicate for symptoms he related to his lifelong paroxysmal supraventricular tachycardia. This is the first report of a CCB overdose mimicking an acute myocardial infarction, and highlights the fact that CCB overdose must be considered in the differential diagnosis of some patients who present with apparent acute myocardial infarction.

Female sex: a protective role in suspected myocardial ischemia.

ObjectiveWomen are felt to have poor outcomes in coronary artery disease, largely on the basis of secondary observations in acute coronary syndrome trials. We sought to examine the neglected topic of sex differences in workup and outcomes in the general population presenting with chest pain. MethodsWe examined 439 consecutive patients admitted via the emergency department with ongoing chest pain. Cardiac testing was defined as any cardiac catheterization or stress test. Positive testing was defined as a 70% or greater stenosis in an epicardial coronary artery on catheterization, or a positive stress test result. Follow-up was obtained via telephone contact at 4 months following discharge. ResultsFurther cardiac testing was deemed necessary in 68% (164/241) of women and 77% (153/198) of men (P=0.038). Among women undergoing further testing, only 21% (35/164) had positive tests, whereas 41% (62/153) of men had positive tests (P=0.002). At 4 months, women were less likely to have suffered the combined endpoint of subsequent myocardial infarction, revascularization, or death, than men (15 vs. 23%, P=0.027). Events were more likely to occur in patients who had further testing, and especially in those who had positive testing. ConclusionsThese data suggest that women admitted with chest pain are less likely to have active coronary artery disease, and much less likely to have poor outcomes at 4 months than men. This apparent ‘gender protection’ effect warrants further study.