The importance of excluding coronary artery vasospasm before percutaneous transluminal coronary angioplasty. A case report

CITATION: Przybojewski, J. Z. 1986.The importance of excluding coronary artery vasospasm before percutaneous transluminal coronary angioplasty. A case report. South African Medical Journal, 70(10), 495-499.The original publication is available at http://www.samj.org.zaENGLISH ABSTRACT: It is important to exclude coronary vasospasm, the mechanism responsible for so-called 'dynamic' coronary stenosis, when selecting of patients for percutaneous transluminal coronary angioplasty (PTCA). Although cine angiographic demonstration of this frequently fleeting entity can sometimes be difficult, a strong suspicion should be aroused by a carefully taken history. The danger of PTCA in these cases of Prinzmetal's variant angina, as well as the frustration often encountered in drug management, is highlighted.AFRIKAANSE OPSOMMING: Geen opsomming beskikbaarPublisher’s versio

Multiple coronary vasospasm: a cause of repeated myocardial infarction and symptomatic 'torsade de pointes' (atypical ventricular tachycardia) A case presentation and review

A middle-aged Coloured man had a 6-year history of chest pain induced by effort and also experienced at rest. Quite dramatic episodes of associated arrhythmias, specifically 'torsade de pointes' (atypical ventricular tachycardia) and syncope were experienced by the patient, despite the use of numerous anti-arrhythmic and anti-anginal agents. Transmural anteroseptaI and non-transmural. anterolateral myocardial infarctions were documented in the presence of a normal left coronary artery (LCA). Severe reversible vasospasm of the right coronary artery (RCA) was provoked with the use of ergonovine (ergometrine) maleate at cardiac catheterization. It is postulated that the cause of the previous myocardial infarctions was significant vasospasm of the LCA branches, and that he was subject to multiple coronary vasospasm, as was highlighted by the visualization of spasm superimposed on atheromatous plaque within the RCA. Furthermore, it is strongly suggested that the potentially lethal ventricular arrhythmias, including 'torsade de pointes', were a direct result of coronary vasospasm which in turn gave rise to his presyncope and syncope attacks. No evidence of sinoatrial node disease could be found. The only risk factor for ischaemic heart disease which applied in his case was heavy cigarette smoking. Control of his disabling symptoms seems to have been achieved by' the use of maintenance nifedipine (a calcium-blocking agent), long-acting nitrates (isosorbide dinitrate) and quinidine gluconate, confirming the probable vasospastic aetiology of the 'torsade de pointes'. At no stage was there dangerous prolongation of the QT interval, an oftquoted prerequisite for this·arrhythmia. Some of the more important aspects of coronary vasospasm are discussed; as far as I am aware this is the first patient documented in the literature with 'torsade de pointes' associated with angiographically demonstrated coronary artery spasm

Editorial

Hepatitis B-vaksien - wie behoort dit te kry?Acquired immunodeficiency syndrome (AIDS)Coronary vasospas

Hyperkalaemic complete heart block : a report of 2 unique cases and a review of the literature

The original publication is available at http://www.samj.org.zaTwo White male patients with temporary complete heart block (CHB) secondary to hyperkalaemia are presented. One, a 40-year-old man, developed CHB with ensuing shock within the first 24 hours of repeat aortic valve replacement for a paraprosthetic leak caused by previous endocarditis. This patient experienced iatrogenic hyperkalaemia. The second was an 81-year-old man who had chronic renal failure and presented with Stokes-Adams attacks. This patient was initially thought to have degenerative CHB and nearly underwent inadvertent permanent pacemaker insertion. Both patients were initially treated with emergency temporary cardiac pacing with subsequent successful management. Temporary CHB secondary to hyperkalaemia, from whatever cause, has very rarely been documented in the literature. A review of this potentially lethal complication is undertaken and the significance of unifascicular and bifascicular conduction block as a consequenc of hyperkalaemia is discussed.Publishers' versio

Hypertrophic non-obstructive apical cardiomyopathy : a case presentation and review of the literature

CITATION: Przybojewski, J. Z. & Blake, R. S. 1984. Hypertrophic non-obstructive apical cardiomyopathy : a case presentation and review of the literature. South African Medical Journal, 66:492-498.The original publication is available at http://www.samj.org.zaA 20-year-old coloured man gave a history of atypical chest pain, palpitations after strenuous exercise and a single episode of post-exertional presyncope. The diagnosis of hypertrophic non-obstructive apical cardiomyopathy (HNOAC) was established by means of electrocardiography, echocardiography (both M-mode and two-dimensional) and left ventricular cine angiography. This variant of hypertrophic cardiomyopathy is most unusual and has been encountered most frequently in Japan, although a few cases have been diagnosed in the USA. The present case is the second reported from the Republic of South Africa. Important aspects of HNOAC are reviewed.Publisher’s versio

Book Reviews

Principles of Cardiac Arrhythmias. 3rd ed. By Edward K. Chung. Pp. xiii 809. Illustrated. Baltimore: Williams &Wilkins. 1983.Ethical Issues in Reproductive Medicine. Ed. by M. Reidy. Pp. 176. Illustrated. RI9,60. Dublin: Gill & Macmillan. 1982.From Parasitic Infection to Parasitic Disease (Contribution to Microbiology and Immunology, vol. 7). Ed. by P. L. Gigase and E. A. C. van Marck. Pp. ix + 269. Illustrated. DM 216,-. Basle: S. Karger. 1983.Prolonged Arrest of Cancer (New Horizons in Oncology, vol. I). Ed. by B. A. Stoll. Pp. xiv + 454. Illustrated. £25,75. London: John Wiley. 1982.Pediatric Angiography. Ed. by P. Stanley. Pp. xv + 425. Illustrated. Baltimore: Williams & Wilkins. 1982.Thin-needle Aspiration Biopsy (Major Problems in Pathology, vol. 14). By W. J. Frable. Pp. X\'iii + 358. Illustrated. £42,25. Philadelphia: \'(t B. Saunders. 1983.Essentials of Pulmonary Medicine. By M. H. Williams. Pp. xi + 190. Illustrated. Philadelphia: W. B. Saunders. 1982.Noninvasive Assessment of the Cardiovascular System: Diagnostic Principles and Techniques. Ed. by E. B. Diethrich. Pp. xxiii + 319. Illustrated. £25,75. London: Wright PSG. 1982.Periodic Abstinence for Family Planning. Ed. by R. L. Kleinman. Pp. 60. Illustrated. £1,75 (in K only). London: IPPF Medical Publications. 1983

Book Reviews

Book 1 Book Title: Basic EpidemiologyBook Authors: R. Beaglehole, R. Bonita & T. KjellströmPp. viii + 174. (in English, French and Spanish in preparation). $19,40. Geneva: WHO. 1993. Order No. 1150395. ISBN 92-4-154446-5.Book 2Book Title: A Pocket Book of Social and Community PaediatricsBook Author: Jo SibertPp. viii + 164. London: Edward Arnold. 1992. ISBN 0-340-54929-7.Book 3Book Title: Knowledge Beats CancerBook Author: Albert Stegmann AlbertsPp. 226. Illustrated. R55,45. Pretoria: Haum Tertiary. 1993. ISBN 0-7986-3196-1.Book 4Book Title: AIDS and Your ResponsePp. vi + 226. R49,50. ISBN 0-620-17319-X.Book 5Book Title: Principles for Evaluating Chemical Effects on the Aged Population. Enviromnental Health Criteria. No. 144Book Author: W.H.O.Pp. 159. (English only).$20,50. Geneva: WHO. 1993. Order No. 1160144. ISBN 92-4-1571446.Book 6Book Title: The Guide to Heart Sounds: Normal and AbnormalBook Authors: Donald W. Novey, Marcia Pencak & John M. StangAudio-cassette narrated by: Donald W. Novey. pp. xi + 74. Illustrated. Florida: CRC Press. 1988. ISB J 0-8493-0153X.Book 7Book Title: Propachlor. Enviromnental Health Criteria. No. 147Book Author: W.H.O.Pp. 110. (English, French and Spanish summaries). $17,30. Geneva: WHO. 1993. Order TO. 1160147. ISBN 92-4-157147-0.Book 8Book Title: Quality Assurance in Health Care: A HandbookBook Authors: Roger Ellis & Dorothy WhittingronLondon: Edward Arnold. 1993. ISBN 0-340-55273-5.Book 9Book Title:  Rehabilitation after Cardiovascular Diseases, with Special Emphasis on Developing CountriesReport of a WHO expert committee. Technical Report Series No 831. Pp. viii + 122 (available in English, French and Spanish in preparation). Geneva: WHO. 1993. ISBN 92-4-120831-7

Book Reviews

Basic Neurology. Ed. by J. Gilroy and P. L. Holliday. Pp. vii + 373. Illustrated. R27,90. London: Macmillan. 1982.The Pathology of the Heart. By E. G. J. Olsen. Pp. ix + 402. Illustrated. R91,85. London: Macmillan. 1982.Profile of Disease and Health Care in South Africa. By H. C. J. van Rensburg and A. Mans. Pp. xvii + 319. R29,50. Pretoria: Academica Press. 1982.Principles of Ambulatory Medicine. Ed. by L. R. Barker, J. R. Burton and P. D. Zieve. Pp. xiii + 1127. Illustrated. R78,-. Baltimore, Maryland: Williams & Wilkins. 1982.Topical Reviews in Accident Surgery, vol. 2. Ed. by N. Tubbs and P. S. London. Pp. ix +258. Illustrated. £18,50. London: Wright PSG.1982.Early Care of the Injured Patient. 3rd ed. Ed. by A. J. Wait, L. F. Peltier, B. A. Pruitt jun, D. D. Trunkey and R. F. Wilson. Pp. xv + 413. Illustrated. Philadelphia: W. B. Saunders. 1982.Current Pediatric Therapy. 10th ed. By S. S. Gellis and B. M. Kagan. Pp. xxxviii + 776. R94,25. Philadelphia: W. B. Saunders. 1982.Selected Techniques in Interventional Radiology,vol. 19 (Saunders Monographs in Clinical Radiology). By S. Kadir, S. L. Kaufman, K. H. Barth and R. 1. White jun. Pp. xi +216. Illustrated. R76,75. Philadelphia: W. B. Saunders. 1982.Clinical Topics in Internal Medicine. Ed. by G. M. Tisi and H. M. Ranney. Pp. xii 173. Illustrated. Baltimore, Maryland: Williams & Wilkins. 1982.Recognizable Patterns of Human Malformation: Genetic Embryologic and Clinical Aspects (Major Problems in Clinical Pediatrics, vo!. vii). 3rd ed. By W. David and M. D. Smith. Pp. xvii + 653. Illustrated. R78,55. Philadelphia: W. B. Saunders. 1982.The Patient and the Plastic Surgeon. By R. M. Goldwyn. Pp. xiii + 255. Boston: Little, Brown. 1981.The Aging Lumbar Spine. By S. W. Wiesel, P. Bernini and R. H. Rothman. Pp. 257. Illustrated. R69,55. Philadelphia: W. B. Saunders. 1982.Postoperative Complications of Intracranial Neurological Surgery. By N. H. Horwitz and H. V. Rizzoli. Pp. xi + 472. Illustrated. Baltimore: Williams & Wilkins. 1982.Current Topics in Inflammation and Infection (International Academy of Pathology Monograph). Ed. by G. Majno, R. S. Cotran and . Kaufman. Pp. xi + 242. Illustrated. Baltimore, Maryland: Williams & Wilkins. 1982.Radiology of the Ear, Nose and Throat. By G. E. Valvassori, G. D. Porter, W. N. Hanafee, B. L. Carter and R. A. Buckingham. Pp. viii + 342. Illustrated. RI94,30. Philadelphia: \Y/. B. Saunders. 1982.Neuropathology ofParasitic Infections. By W. J. Brown and M. Voge. Pp. 240. Illustrated. RI5,-. Oxford: Oxford Medical Publishers. 1982.Herzkrankheiten: Pathophysiologie, Diagoostik, Therapie. 2nd ed. By H. Roskamm and H. Reindel!. Pp. xxxiii + 1543. Illustrated. DM 278,-. Berlin: Springer-Verlag. 1982.Review ofSpeech, Language and Hearing, vols I, 2and 3. By N. J. Lass, L. V. McReynolds, J. L. Northern and D. E. Yoder. Illustrated. R36,20 each. Philadelphia: W. B. Saunders. 1982

Reliability and Diagnostic Performance of CT Imaging Criteria in the Diagnosis of Tuberculous Meningitis

The original publication is available at http:// www.plosone.orgPublication of this article was funded by the Stellenbosch University Open Access Fund.Introduction: Abnormalities on CT imaging may contribute to the diagnosis of tuberculous meningitis (TBM). Recently, an expert consensus case definition (CCD) and set of imaging criteria for diagnosing basal meningeal enhancement (BME) have been proposed. This study aimed to evaluate the sensitivity, specificity and reliability of these in a prospective cohort of adult meningitis patients. Methods: Initial diagnoses were based on the CCD, classifying patients into: ‘Definite TBM’ (microbiological confirmation), ‘Probable TBM’ (diagnostic score $10), ‘Possible TBM’ (diagnostic score 6–9), ‘Not TBM’ (confirmation of an alternative diagnosis) or ‘Uncertain’ (diagnostic score of ,6). CT images were evaluated independently on two occasions by four experienced reviewers. Intra-rater and inter-rater agreement were calculated using the kappa statistic. Sensitivities and specificities were calculated using both ‘Definite TBM’ and either ‘Definite TBM’ or ‘Probable TBM’ as gold standards. Results: CT scan criteria for BME had good intra-rater agreement (k range 0.35–0.78) and fair to moderate inter-rater agreement (k range 0.20–0.52). Intra- and inter-rater agreement on the CCD components were good to fair (k = ranges 0.47–0.81 and 0.21–0.63). Using ‘Definite TBM’ as a gold standard, the criteria for BME were very specific (61.5%–100%), but insensitive (5.9%–29.4%). Similarly, the imaging components of the CCD were highly specific (69.2–100%) but lacked sensitivity (0–56.7%). Similar values were found when using ‘Definite TBM’ or ‘Probable TBM’ as a gold standard. Discussion: The fair to moderate inter-rater agreement and poor sensitivities of the criteria for BME suggest that little reliance should be placed in these features in isolation. While the presence of the CCD criteria of acute infarction or tuberculoma(s) appears useful as rule-in criteria, their absence is of little help in excluding TBM. The CCD and criteria for BME, as well as any new criteria, need to be standardized and validated in prospective cohort studies.Funding: KB received funding from the Discovery Foundation (Academic Fellowship Award; http://www.discovery.co.za/portal/loggedout-individual/discoverycommunity- about), College of Neurology of South Africa (K.M. Browse Award; http://www.collegemedsa.ac.za/Default.aspx ) and the University of Stellenbosch. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.Publisher's versio

Primary cardiac hydatid disease : a case report

The original publication is available at http://www.samj.org.zaA young Coloured man whose only symptom was that of minimal dyspnoea on exertion, on examination had signs of infundibular stenosis which were confirmed by cardiac catheterization. Additional features were left anterior hemiblock and cardiomegaly as delineated radiologically. Cross-sectional echocardiography revealed a very large cystic mass located within the interventricular outflow tract. This cystic mass was further delineated by cardiac cine angiography. It is postulated that this mass was a primary cardiac echinococcal cyst and was directly responsible for the complications of left anterior hemiblock and the infundibular obstruction. The patient declined surgery and a definitive pathological diagnosis could therefore not be made. If this is a hydatid cyst then it is the second case reported in the literature diagnosed by two-dimensional echocardiography and in which left anterior hemiblock has been recorded. The clinical features, complications and surgical correction are briefly outlined.Publishers' versio