Twiddlers syndrome presenting as life threatening electrical storm

A 75-year-old man underwent implantation of a single chamber implantable cardioverter defibrillator (ICD) for primary prevention of his underlying severe non-ischaemic cardiomyopathy. Thirteen months later, he presented to the emergency room(ER) with inappropriate ICD shocks as a result of over sensing of the right ventricular lead and double counting of the right atrial signals. The chest X-ray (CXR) revealed a right ventricular ICD lead displaced into the right atrium with coiling in the pocket. The right ventricular shocking coil was noted at the tricuspid annulus. The lead was removed from the pocket and was replaced with a new lead. This case represents the classical Twiddler\u27s syndrome in an ICD with potential lethal consequences

Diffusion weighted image (DWI) findings in methanol intoxication

Methanol is a toxic substance with extremely devastating effects upon exposure. The case described suffered from such kind of poisoning. MRI brain demonstrated necrosis bilaterally in the Putamen areas which is a classic hallmark finding. Additional Diffusion weighted imaging showed abnormal signal bilaterally in the putamen areas along with Diffusion positive bilateral lesions (possibly infarctions) in both the frontal and occipital lobes that were not evident on MRI with or without contrast

Takotsubo cardiomyopathy: ten year experience at a tertiary care hospital in Pakistan.

Objective: There is very little literature regarding Takotsubo Cardiomyopathy (TTC) from the Asian Countries other than Japan and Korea. We conducted this study to determine the demographics, clinical presentations, complications and recovery of left ventricular (LV) systolic function in TTC patients of Pakistani origin. Methods: A ten years retrospective case series study of TTC was conducted at the Aga Khan University Hospital. Patients were followed for up to six months after presentation, with special emphasis on the recovery of LV function. Conclusion: TTC is classically triggered by an acute illness or by extreme stress and a triggering incident may not always be identified. It usually presents in the guise of an acute coronary syndrome (ACS). Our data was congruent with the existing literature, except for more heart failure and cardiogenic shock. Average Troponin-I (Tn-I) levels were also higher as compared to western population. The reason for more severity in our patients may be late presentation or different level of response to stress

Peripartum cardiomyopathy: ten year experience at a tertiary care hospital in Pakistan.

Background: There is very little literature regarding peripartum cardiomyopathy from the Asian countries. We conducted this study to determine demographic details, clinical presentations, complications and recovery of left ventricular (LV) systolic function in peripartum cardiomyopathy (PPCMP) patients of Pakistani origin. Method: A ten year retrospective case series of PPCMP was conducted at the Aga Khan University Hospital. Patients were also followed up for six months after presentation, with special regard to improvement in the LV function. Results: Total 45 patients were included, 25 (55.5%) primigravida and 8 (17.7%) gravida 2 and the remaining 12 (26.6%) were multigravida. Fourteen patients (31.1%) presented during pregnancy and 31 (68.8%) after delivery. All patients presented with CHF and three (6.6%) were complicated with ventricular tachycardia (VT) at presentation. LV systolic dysfunction was present in 39 (86.66%) patients and RV dysfunction in 15 (33.3%) patients. Two patients had LV clot and thromboembolic stroke occurred in another 4 patients. All patients received standard treatment except three patients who had asthma and could not be given beta blockers. Echocardiogram was repeated after 6 month and in 32 (71.1%) patients LV functions recovered to normal. RV function improved in all except 2 (4.4%) patients. All patients were discharged in stable condition. Conclusion: Significant numbers of PPCMP patients, who had severe LV dysfunction at presentation recovered their LV functions at six month follow u

Spontaneous coronary artery dissection: a rare cause of acute coronary syndrome.

We present a case of a 71-year-old man, with a history of hypertension and dyslipidaemia, who presented with typical cardiac chest pain and palpitations of 2 h duration. The examination revealed irregular pulse of 138 bpm, blood pressure 115/75 mm Hg, variable first and normal second heart sounds. The lungs were clear to auscultation. The ECG showed atrial fibrillation with a rapid ventricular rate. His heart rate was controlled with β blockers and the acute coronary syndrome treatment protocol was initiated. His baseline blood reports were within normal limits and two serial troponin I tests were negative. Coronary angiogram showed dissection in the left coronary system extending into the branch vessels and 30-40% stenosis in the right coronary artery. The patient underwent coronary artery bypass graft as an emergent case. He suffered a mild stroke postsurgery with complete functional recovery. He is being followed up in the clinic and has performed well

Mahaim Tachycardia Induced Cardiomyopathy

We present the case report of a 22-year man, with incessant palpitations, chest pain, shortness of breath, and pulsations in his neck for the past 7 months. He was referred to the cardiology unit for workup of wide complex tachycardia (WCT). His echocardiography, 6 months earlier, had demonstrated severe left ventricular (LV) systolic dysfunction, severe global hypokinesia, mild tricuspid regurgitation (TR), and mild mitral regurgitation (MR) which resolved with medical therapy including beta-blockers. He underwent electrophysiological study, which revealed a decremental right sided atriofascicular pathway causing a WCT with left bundle branch block (LBBB) morphology and left axis deviation (LAD, Mahaim tachycardia). This was successfully ablated by radiofrequency ablation (RF) with abolition of the tachycardia. This case report highlights Mahaim tachycardia induced cardiomyopathy, a rare but curable cause of cardiomyopathy

Better physician-patient communication; an important milestone in control of hypertension, a multicenter study from Karachi, Pakistan.

Control of hypertension is an important cornerstone in prevention of cardiovascular morbidity and mortality. This study was designed to compare physician encounter score in patients with controlled and uncontrolled hypertension. It was conducted at three tertiary care hospitals in Karachi. Patients were categorized into controlled and uncontrolled hypertension based on their initial blood pressure readings on presentation. Primary outcome variable was control of hypertension and physician encounter score (a composite score of 12 item question) was the main candidate variable. Higher scores reflected favorable encounter with physician. Mean age of participants was 57.7 ± 12 years; 224 (50.1%) were men. Controlled hypertension was present in 72.3% (323) and uncontrolled hypertension was present in 27.4% (124). Mean physician encounter score in uncontrolled hypertensive was 7.25 ± 2.64 versus 7.83 ± 2.22 (p=0.02) in controlled hypertensive. Patient-physician encounter is an important milestone in control of hypertension in hypertensive patients and directly translates into better adherence to antihypertensives in these patients

Two Congenital Left-to-Right Shunt Anomalies in a Septuagenarian: ARare Occurrence

Atrial septal defect (ASD) and patent ductus arteriosus (PDA) are common congenital anomalies presenting in childhood. Life expectancy of an uncorrected PDAis shortened to half; and ASD of a significant size has increased morbidity and mortality. Their co-existence in an elderly patient with first presentation at 70 years of age is a rarity. We present the case of a 70-year woman with one-week history of dyspnea with high blood pressure and signs of heart failure. She was found to have a PDA and an ASD with left-to-right shunt. She was managed conservatively. She was offered cardiac catheterization, but she refused. This is the first documented case in local literature with two such congenital heart defects presenting in a septuagenarian. In a country where average life expectancy is in the 60\u27s, the survival of the patient with two heart defects, beyond-average survival age, is interesting

Knowledge of coronary artery disease (CAD) risk factors and coronary intervention among university students

OBJECTIVE: To elucidate knowledge of coronary artery disease (CAD) risks factors and coronary intervention in adult students of Karachi East. To calculate the mean knowledge score about CAD risk factors among them. METHODS: A multi center crossectional study was conducted in Universities and colleges of Karachi East from April-September 2005. Questionnaires were distributed to 200 adult students of different non-medical universities and colleges. The questionnaire contained assessment of knowledge of risk factors on CAD and awareness about coronary angiography. Those belonging to medical colleges and universities were excluded from the study. Knowledge was assessed as a continuous variable. Risk factors for CAD were taken as categorical variables. RESULTS: The mean age of students was 20 yrs +/- 2.2 years and 62% were females. The mean score of knowledge about risk factors of CAD was 11.47 +/- 2.37. Sixty percent students thought that heart diseases are the number one cause of death in our population. Twenty five percent students graded smoking as the top most risk factor for CAD. Twenty five percent students refused to quit smoking for CAD prevention. Forty eight percent students correctly defined coronary angiography. Eighty five percent students thought that cost is the major hindrance in getting timely treatment. Knowledge of fifty percent students was based on personal and family experience of heart disease. CONCLUSION: Students graded smoking as the topmost risk factor for CAD and cost as the major hindrance in getting timely treatment for heart disease. Only half of the students were aware about coronary angiography. The mean knowledge score among them was above the median score but not up to the mark

Emergency evaluation of acute chest pain

OBJECTIVE: To determine the sensitivity and specificity of initial clinical assessment about the diagnosis of acute coronary syndrome (ACS) in patients presenting with acute chest pain by a cardiology resident in the emergency room and assess the 30-day outcome of patients with ACS and non ACS. STUDY DESIGN: Cohort study. PLACE AND DURATION OF STUDY: The study was conducted in the emergency department and cardiac care units of the Aga Khan University in 2006-07. METHODOLOGY: A total of 202 patients, who presented to the emergency room with chest pain, were given an initial ECG and troponin check. Patients were assigned to initial ACS and non-ACS groups by the cardiology resident. After cardiac workup, patients were assigned to final ACS/final non ACS group. They were followed for outcome after 30 days of initial presentation. Sensitivity and specificity, if initial workup was determined, keeping final assessment after cardiac workup as the gold standard. RESULTS: Out of the 202 patients, 61.9% were males. Their mean age was 54.05+13 years. Sixty eight percent were placed in the initial ACS group and 30.7% were placed in the initial non ACS group. After workup, 36% were placed in the final ACS group and 28.7% in the final non-ACS group and 35% were undecided. The sensitivity of initial assessment of ACS by the cardiology resident was 100%. However, the specificity was 54.2%. In the 30-day outcome, one patient (1.3%) died in the ACS group due to myocardial ischemia while no patient died from the non ACS group. CONCLUSION: Initial assessment about ACS by cardiology resident based on character of chest pain, ECG and troponin I is highly sensitive. However, the specificity is low