The coronary slow flow phenomenon (CSFP) is a disease entity characterized by slow progression of angiographic contrast in the coronary arteries in the absence of stenosis in the epicardial vessels. CSFP has a diverse presentation from mild chest discomfort to ST-segment elevation myocardial infarction. It can also have severe morbidity and mortality implications and can significantly hamper the quality of life of those affected. In this paper we present two patients with CSFP highlighting the diverse spectrum of presentation. A concise review of the literature is also provided emphasizing the epidemiology, pathogenesis, diagnostic parameters, treatment modalities, and clinical significance of this phenomenon.

Triptans have been used for the acute treatment of migraine headaches for many years. Although their use can lead to coronary vasospasm, there are very few reports of triptans actually leading to myocardial infarction in patients with normal coronaries. We hereby present a 58-year-old man who presented to the emergency room with chest pain. Electrocardiogram demonstrated ST segment depression in the inferior leads with diffuse spasm of the distal right coronary artery seen on angiography, which was easily reversed by intracoronary nitroglycerine. We believe this is the first reported case of a patient with a myocardial infarction after taking oral zolmitriptan in which coronary angiogram clearly demonstrated coronary vasospasm reversal after intracoronary nitroglycerine. A detailed search of the literature for reported cases of myocardial infarction after triptan use is also provided.

No abstract

SummaryChymopapain is a proteolytic enzyme used in the chemonucleolysis of the herniated nucleus pulposus of lumbar intervertebral discs. It causes rapid hydrolysis of the noncollagenous polypeptides that maintain the tertiary structure of the chondromucoprotein of the nucleus pulposus. We report here an anaphylactoid reaction after the intervertebral injection of chymopapain. Key wordsAllergy. Pharmacology; chymopapain.Chymopapain is used in the treatment of herniated nuclei pulposii of the lumbar intervertebral discs which cause symptoms that have not resolved with more conservative management. Over 160000 cases have been so treated worldwide. Its use is complicated by both neurotoxic effects and the risk of anaphylactoid reactions. We report here a delayed, severe anaphylactoid reaction to the injection of chymopapain. Case historyA 29-year-old, ASA 1, 80-kg male patient presented for surgery with a 12-month history of lower back pain which radiated to his posterior left thigh and calf. Conservative management had failed to improve his condition. A lumbar myelogram showed an extradural defect at the level of L4-s, with the typical appearance of a herniated nucleus pulposus. It was decided to proceed with a radiographically controlled intervertebral injection of chymopapain under general anaesthesia.Pre-operative anaesthetic assessment revealed two previous uncomplicated general anaesthetics. The patient had no other past medical history, no known allergies or family history thereof. He smoked two packets of cigarettes a day and consumed significant quantities of alcohol. A physical examination found no abnormalities. Chest X ray, electrocardiogram and haematological investigations were all within normal limits. He had been taking cimetidine and diphenhydramine every 6 hours for the previous 24 hours as pretreatment of the histamine receptors.The patient gave informed consent for general anaesthesia and was premedicated with diazepam and cimetidine on the morning of surgery. An intravenous cannula was placed in a peripheral vein and an infusion of 5% dextrose and lactated Ringer's solution started.He was positioned supine on the operating table. Baseline arterial blood pressure was 110/70 mmHg and pulse rate 80 beats/minute. Anaesthesia was induced with thiopentone after pre-oxygenation and defasciculation with tubocurare. Neuromuscular blockade was achieved with suxamethonium and the patient's trachea intubated. Anaesthesia was maintained with fentanyl, isoflurane and pancuronium and he was turned to the right lateral decubitus position. The arterial blood pressure was 100/60 mmHg and the pulse rate 90 beats/minute. Diphenhydramine 50 mg was given intravenously before surgery started.A 22-gauge needle was placed into the centre of the L,, disc space. A discogram was obtained using metrizamide-60, and the position of the needle tip verified with anteroposterior and lateral fluoroscopy. Chymopapain 3000 units in 1.5 ml were injected and after 3 minutes the patient was repositioned supine.Heart sounds heard thro...

No abstract