Although most of the patients presenting with ischemic heart disease have chest pains, there are other rare presenting symptoms like cardiac cephalgia. In this report, we present a case of acute coronary syndrome with an only presentation of exertional headache. It was postulated as acute presentation of coronary artery disease, due to previous history of similar presentation associated with some chest pains with previous left coronary artery stenting. We present an unusual case with cardiac cephalgia in a young patient under the age of 50 which was not reported at that age before. There are four suggested mechanisms for this cardiac presentation.
AimsRotational atherectomy/rotablation (RA) has been traditionally considered a high risk procedure and performed in tertiary centres with on-site surgical backup. Our aim was to analyse RA with regards to procedural success and safety in the setting of a cardiac centre without on-site cardiac surgery.MethodsA retrospective analysis of all RA pts between Jan 2010 and April 2013 was undertaken. Demographic data and procedural details were collected from medical case notes, cathlab records, BCIS and radiographer’s database. Hospital, GP records and national mortality registry were used for follow-up information. F/u data was analysed at 30 days and 1 yr post procedure.Results184 pts underwent 206 PCI’s with RA in the study period of 40 months. This represents 5% of our total 3884 PCI work load. In comparison to non-RA group, RA group was older (74 vs. 67 yr) and had higher risk profile: HTN (72 vs. 68%), DM (35 vs. 21%). Procedures were elective in 153 (74%), ACS-41 (20%) and STEMI-12 (6%). 3-vessel CAD was present in 61 (30%), LMS disease in 26 pts (14%). Intervention was performed on LMS 20 (10%), LAD 111 (54%), LCx 30 (15%) and RCA 66 (32%), with 18 (9%) pts having multivessel RA. There were 9 (4%) ostial lesions, 35 (17%) bifurcation lesions, and 2 (1%) CTOs. There was previous failed PCI in 21 (10%) pts, with ad-hoc RA in 24 (12%) and the rest having upfront RA (161, 78%). Radial access was 38% and femoral in 62% with 6 and 7F catheters used equally. A single burr was used in 175 (85%). Burr sizes were: 1.25 mm (55%), 1.5 mm (39%). IVUS use in 45 (22%); prophylactic temporary PPM in 14 (10%) and prophylactic IABP in 9 (4%). Procedural success was achieved in 198 (96%) with 5 requiring balloon only dilation. Mean total radiation time was 43.8 min, with a mean DAP of 16793 cGy with >50% reduction after first 2 yrs and mean contrast load 270 ml with a 17% reduction after 2 yrs. No procedural comp were seen in 184 (89%) cases, major comp in 6% (12: vascular comp requiring surgery/transfusion-5; tamponade-3; temporary PPM related-2 and PCI wire related in 1; contrast nephropathy-2; coronary perforation due PCI wire-1; transfusion with no source of bleeding-1), and minor comp in 6% (13: hypotension requiring IABP-3; bradycardia requiring temporary PPM-1; coronary slow/no flow-2; coronary dissection-1; other coronary comp-2; other – hypotension, bradyarrhythmia, tachyarrhythmia treated medically-4). In hospital mortality was 1%(2: both ACS) and at 1 yr 5.8%(12) with 2% cardiac mortality. MACE rate (i.e. cardiac mortality, MI, TLR and CABG) at 1 month was 1.5% and at 1 yr 8.7% driven mainly by TLR due to ISR. Event free survival at 1 yr was 178 (86%).ConclusionsRA in the setting of off-site surgical backup is a safe and effective with an overall high procedural success rate. Ours is one of the largest series of RA pts in the DES era and support RA use in calcified coronary lesions. Event rate during 1 yr follow-up was mainly driven by TLR due to ISR.
The complicated case of a patient with recurrent culture-negative endocarditis with a history of repeated mitral valve replacement is described. Investigations disqualified common pathology but serology revealed a diagnosis of Q fever endocarditis. The ongoing problematic management of this patient is described, followed by a brief review of the clinical features, investigations and treatment of Q fever.
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