Role of two-dimensional strain echocardiographic parameters in suspected acute coronary syndrome patients with initial non-diagnostic electrocardiogram and troponins: An observational study

INTRODUCTION

Diagnosis of acute coronary syndrome (ACS) is often challenging especially in presence of initial normal troponins and non-specific electrocardiogram. The index study aimed at determining the diagnostic value of strain echocardiography in patients with suspected ACS but with non-diagnostic electrocardiogram and echocardiography findings.

METHODS

The study was conducted on 42 patients with suspected ACS and non-diagnostic electrocardiograms, normal quantitative troponin-T levels, and left ventricular function. All patients underwent conventional and 2D-strain echocardiography followed by coronary angiography, within 24 h of admission. Patients with regional wall motion abnormalities (RWMA), valvular heart disease, suspected myocarditis, and past coronary artery disease (CAD) were excluded.

RESULTS

Amongst the global strains, the global circumferential strain (GCS) was significantly reduced (p = .014) amongst those with significant CAD on angiography as opposed to global longitudinal strain (GLS) which was similar in the two groups (p = .33). The GCS/GLS ratio was also significantly reduced in patients with significant CAD compared to those with normal/mild disease on coronary angiography (p = .025). Both the parameters had good accuracy in predicting significant CAD. GCS displayed a sensitivity of 80% and a specificity of 86% at an optimal cut-off 31.5% (AUROC: .93, 95% CI: .601-1.000; p = .03), and likewise GCS/GLS ratio had a sensitivity of 80% and a specificity and 86% at a cut-off of 1.89% (AUROC: .86, 95% CI: .592-1.000; p = .049). GLS and peak atrial longitudinal strain (PALS) did not differ significantly in patients with/without significant CAD (p = .32 and .58, respectively).

CONCLUSION

GCS and GCS/GLS ratio provides incremental value in comparison to GLS, PALS, and tissue Doppler indices (E/e') in patients with suspected ACS and non-diagnostic electrocardiogram and troponins. GCS at cut-off of >31.5% and GCS/GLS ratio >1.89 can reliably exclude patients with significant CAD in this setting.

Blood component therapy: Which, when and how much

Blood transfusion refers to the perioperative administration of blood and blood components. Adherence to proper indications for blood component therapy is essential because of its potential adverse effects and costs of transfusion. Over the years, the significance of blood components in treating certain diseases or conditions has been recognized. In this article, the most commonly used blood components along with the new developments in component therapy have been discussed. Recommendations by different academic and clinical trials and studies have been presented for quick reference. The individual coagulation factors are discussed in brief.

Milrinone infusion: a therapeutic option in coronary vasospasm after primary percutaneous transluminal coronary angioplasty

A 42-year-old male presented to the emergency department with acute chest pain. The electrocardiogram revealed inferior wall myocardial infarction. Emergency coronary angiography revealed total occlusion of the distal right coronary artery with thrombus. Patient was taken up for primary percutaneous coronary angioplasty with stenting of distal right coronary artery. Six hours following the procedure, the patient developed re-elevation of ST-segment in inferior leads of electrocardiogram and subsequent haemodynamic instability. Repeat coronary angiography revealed patent stent and coronary artery spasm in proximal part, which was relieved by intracoronary injection of nitroglycerine. After an hour, the patient re-developed symptoms of chest pain along with bradycardia, hypotension and ST segment elevation. Intravenous infusion of nitroglycerine did not improve the condition but produced persistent hypotension. Infusion of milrinone was then started. Over time, normalisation of electrocardiogram occurred. The patient was discharged in stable condition. This case suggests that milrinone may be effective in alleviating coronary artery spasm when the use of other agents fails.

Quick control of bubonic plague outbreak in Uttar Kashi, India

A localized outbreak of bubonic plague occurred in village Dangud (population 332), district Uttar Kashi, Uttaranchal, India in the second week of October 2004. 8 cases were considered outbreak associated based on their clinical and epidemiological characteristics; 3 (27.3%) of them died within 48 hours of developing illness. All the 3 fatal cases and five surviving cases had enlargement of inguinal lymph nodes. None of them had pneumonia. The age of the cases ranged from 23-70 years and both sexes were affected. No such illness was reported from adjoining villages. The outbreak was fully contained within two weeks of its onset by supervised comprehensive chemoprophylaxis using tetracycline. A total of approximately 1250 persons were given chemoprophylaxis in three villages. There was no clear history of rat fall in the village. No flea was found on rodents or animals. 16 animal serum samples were found to be negative for antibodies against F-1 antigen of Y. pestis. However, Y. pestis was isolated from two rodents (Rattus rattus and Mus musculus) trapped in the village. One case and three animal sera showed borderline sero-positivity against rickettsial infection. The diagnosis of plague was confirmed by detection of four fold rise of antibody titre against F-1 antigen of Yersinia pestis in paired sera of three cases (one of the WHO approved criteria of diagnosis of confirmed plague). This outbreak and the occurrence of earlier outbreaks of plague in Surat (Gujarat) and Beed (Maharashtra) in 1994 and in district Shimla (Himachal Pradesh) in 2002 confirm that plague infection continue to exist in sylvatic foci in many parts of India which is transmitted to humans occasionally. Thus, there is a strong need for the States to monitor the plague activity in known sylvatic foci regularly and have a system of surveillance to facilitate prompt diagnosis and treatment of cases to control the disease. This investigation highlights that with high index of suspicion the disease can be diagnosed early and mounting of supervised comprehensive response can prevent the disease to proceed to pneumonic stage where man to man transmission gets established and outbreak assumes larger dimensions.