Richard Grocott-Mason

Acute coronary syndromes and their presentation in Asian and Caucasian patients in Britain

Objective: To describe and compare demographics and symptom presentation in Asian and Caucasian patients with acute coronary syndromes. Design: Long-term prospective survey of symptom presentations in two racial groups. Setting: A London hospital. Participants: A consecutive series of patients admitted to hospital with acute coronary syndromes between November 2001 and November 2005. Main outcome measure: Comparison of demographics and location, character, intensity and symptom distribution at presentation between Asian and Caucasian patients. Results: Asian patients were younger than Caucasian patients (61 v 69 years, p<0.001) and more had diabetes (43% v 17%, p<0.001). Proportionally, more Asian patients had angina (51% v 37%, p<0.001), but more Caucasian patients had myocardial infarction (63% v 49%, p<0.001) and non-ST elevation infarcts (40% v 29%, p<0.001). Men reported smaller areas of discomfort than women. Asian patients more frequently reported discomfort over the rear of their upper bodies compared to Caucasian patients (46% v 25%, p<0.001) and radiation of discomfort to their arms and necks. A higher percentage of Asian than Caucasian patients demonstrated a “classical” location of symptoms (90% v 82%, p<0.001). Patients with diabetes were more likely to feel no discomfort. A higher percentage of Caucasian than Asian patients presented with “silent” events (13% v 6%, p>0.001), with age being a major determinant. Conclusion: Asian patients were younger, more likely to be diabetic and tended to report a higher intensity of pain and over a greater area of their body, and more frequent discomfort over the rear of their upper thorax than Caucasian patients.

Two cases of massive mitral annular calcification mimicking left atrial neoplasms.

The authors describe two cases of massive mitral annular calcification, initially picked up on echocardiography and suspected of being neoplastic. Subsequent evaluation by CT scanning confirmed the location, aetiology, structure and diagnosis. Both cases demonstrated large masses, with calcification of varying density. This is likely explained by the presence of the previously reported amorphous caseous material demonstrated to be present within such mass structures. Such a feature is described as caseous degeneration. Both patients described have been managed conservatively with medical therapy, predominantly due to their age and general frailty.

Angiotensin Receptor Blocker Therapy for Heart Failure Patients: Is Combination Treatment a Feasible Prospect?

The addition of the angiotensin II type 1 receptor blocker (ARB) candesartan to a angiotensin‐converting enzyme inhibitor (ACEI) has been associated with improved clinical outcomes in patients with heart failure. However many do not tolerate combination therapy and concerns have been raised regarding excessive neurohormonal inhibition.

Pituitary tumour apoplexy following acute coronary syndrome management.

An 85-year-old male presented with chest pain. The patient was bradycardic at 48 beats/min and hypotensive at 110/80 mm Hg. His past medical history included hypertension, currently treated with irbesartan. An electrocardiogram and cardiac bio markers (troponin I, 1.19 μg/l) confirmed a diagnosis of a non-ST elevation myocardial infarction. Conventional acute coronary management included clopidogrel, aspirin and low molecular …

Massive cardiac invasion by amelanotic melanoma with obstructive clinical features.

Reports of malignant melanoma involving the heart usually describe metastatic spread of pigmented (melanotic) forms of this tumour. We describe, and illustrate, a patient presenting with features related to cardiac tamponade and intracardiac obstruction. Transthoracic echocardiography initially showed a large mass within the right ventricular outflow tract. The full extent of infiltration of this tumour was demonstrated by computed tomography scanning and the specific tumour type by immunohistochemical staining procedures. The case is unusual in relation to the extreme size of this amelanotic melanoma at presentation and the fact that it appears to be a solitary metastasis.

Chronic mild eosinophilia and severe cardiomyopathy

A 62-year-old male presented with a 10-day history of dyspnoea and ankle swelling. Investigations revealed a haemoglobin of 13.0 g/l, white cell count of 5.7 × 109/l and platelet count of 279 × 109/l. Eosinophils were mildly elevated at 3.9 × 109/l (normal range 0–0.5) and C-reactive protein (CRP) increased at 49 mg/l. Renal, liver, thyroid function tests, serum calcium, rheumatoid factor, complement levels (C3 and C4) and immunoglobulins A, G and M were normal. Smooth muscle antibodies were weakly positive. The patient had suffered asthma for the past 30 years and had recent onset seronegative arthritis. Medication comprised beclomethasone and salbutamol inhalers and aminophylline at 200 mg daily. No recent travel had occurred and only temperate climate regions had been visited. Parasitic infection or underlying malignancy was not evident. The pulse was 110 bpm with a ‘gallop’ rhythm. There was marked pitting oedema to the thighs, an elevated JVP and coarse crackles at both lung bases. Chest radiography showed a small right and larger left effusion with an …

‘Silent’ but massive bilateral pulmonary embolic disease

An 80-year-old man presented to the facility, describing 6 months of increasing shortness of breath. Prior to admission, he had been bed bound for 5–7 days due to a chest infection. Observations revealed a pulse 79/min, blood pressure 119/79 mm Hg and a respiratory rate of 16/min. Oxygen saturation levels were 95% on room air, and he …

An unusual case of palpitations

A 66 year old white man presented with a three year history of intermittent frequent (daily) palpitations and associated malaise, but no syncope. He was taking no drugs and had no family history of arrhythmia or of unexplained, sudden, or premature death. Clinically he was afebrile, in sinus rhythm at 60 beats/min, had blood pressure of 130/80 mm Hg, and had normal heart sounds. Serum electrolytes, including magnesium, and haematology and hepatic and thyroid function tests were normal. His electrocardiogram (ECG) is shown in the figure 1⇓. A seven day ECG event recorder showed two episodes (of 16 and 17 hours’ duration) of spontaneous atrial fibrillation at rates of up to 160 beats/min. These episodes coincided with symptoms. Chest x ray and cardiac imaging were entirely normal.