Intramyocardial Spontaneous Hematoma Mimicking an Acute Myocardial Infarction

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In-hospital percentage BNP reduction is highly predictive for adverse events in patients admitted for acute heart failure: the Italian RED Study

Introduction: Our aim was to evaluate the role of B-type natriuretic peptide (BNP) percentage variations at 24 hours and at discharge compared to its value at admission in order to demonstrate its predictive value for outcomes in patients with acute decompensated heart failure (ADHF). Methods: This was a multicenter Italian (8 centers) observational study (Italian Research Emergency Department: RED). 287 patients with ADHF were studied through physical exams, lab tests, chest X Ray, electrocardiograms (ECGs) and BNP measurements, performed at admission, at 24 hours, and at discharge. Follow up was performed 180 days after hospital discharge. Logistic regression analysis was used to estimate odds ratios (OR) for the various subgroups created. For all comparisons, a P value 46% at discharge had an area under curve (AUC) of 0.70 (P 300 pg/mL. A BNP reduction of 25.9% after 24 hours had an AUC at ROC curve of 0.64 for predicting adverse events (P 46% was 4.775 (95% confidence interval (CI) 1.76 - 12.83, P 300 pg/mL and whose percentage decrease at discharge was 46% was 9.614 (CI 4.51 - 20.47, P 46% at hospital discharge compared to the admission levels coupled with a BNP absolute value < 300 pg/mL seems to be a very powerful negative prognostic value for future cardiovascular outcomes in patients hospitalized with ADHF

Images in cardiovascular medicine. Intramyocardial spontaneous hematoma mimicking an acute myocardial infarction.

An 80-year-old man affected by rheumatoid arthritis and chronic myeloid leukemia who was a smoker and hypertensive was admitted to the coronary care unit for first ST-elevation myocardial infarction. The diagnosis was suspected on the basis of the presence of chest pain associated with ST-segment elevation in leads III and aVF and a cardiac troponin T level of 0.30 ng/dL. At coronary angiography, performed 2 hours after pain onset, a 50% stenosis of the proximal right coronary artery with a translucent filling defect that suggested a parietal thrombus at the cardiac crux was found (see online-only Data Supplement Movie I); the left coronary artery had diffuse atherosclerosis in the absence of significant stenosis. Therefore, no interventional procedure was performed and the patient was treated with aspirin and clopidogrel. The echocardiogram performed soon after coronary catheterization showed an expansive lesion in the basal segment of the inferior wall characterized by echodensity intermediate between blood and tissue (Figure 1A). Myocardial contrast echocardiography documented that the expansive lesion was characterized by a reduced and irregular microvascular network compatible with both hemangioma 1 and intramyocardial hematoma 2 (Figures 1B and 2A; online-only Data Supplement Movies II and III). Magnetic Resonance Imaging further clarified the diagnosis. In fact, T2-weighted fat-suppressed images documented the presence of a hyperintense expansive lesion compatible with both hemangioma and intramyocardial hematoma (Figure 2B), but first-pass perfusion imaging showed marked signal loss in the lesion (Figure 3A), with no enhancement within the first minute (Figure 3B; online-only Data Supplement Movies IV and V). At late enhancement, a mild subendocardial perfusion defect remained only in the midventricular inferior wall. This pattern is typical of intramyocardial hemorrhage, whereas the contrast enhancement pattern of hemangioma is characterized by slow peripheral contrast uptak