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David Weininger,1 Juan Pablo Cordova,2 Eelin Wilson,3 Dayana J Eslava,4 Carlos L Alviar,5 Aleksandr Korniyenko,6 Chirag Pankajkumar Bavishi,7 Mun K Hong,8 Amy Chorzempa,9 John Fox,10 Jacqueline E Tamis-Holland4 1Westchester Medical Center, Valhalla, NY, USA; 2Southshore Cardiovascular Associates, Tampa, FL, USA; 3Montefiore Medical Center, New York, NY, USA; 4Mount Sinai Morningside Hospital, New York, NY, USA; 5NYU Medical Center and Bellevue Hospital Center, New York, NY, USA; 6Univeristy of Texas Health, Tyler, TX, USA; 7University of Missouri Health Care, Columbia, MO, USA; 8Bassett Healthcare Network, Cooperstown, NY, USA; 9Massachusetts General Hospital, Boston, MA, USA; 10Mount Sinai Beth Israel Hospital, New York, NY, USACorrespondence: Jacqueline E Tamis-Holland Tel +1 212-523-2400Fax +1 212-523-5226Email Jacqueline.Tamis-Holland@MountSinai.orgPurpose: Previous studies have shown longer delays from symptom onset to hospital presentation (S2P time) in women than men with acute myocardial infarction. The aim of this study is to understand the reasons for delays in seeking care among women and men presenting with an ST-Segment Elevation Myocardial Infarction (STEMI) through a detailed assessment of the thoughts, perceptions and patterns of behavior.Patients/Methods and Results: A total of 218 patients with STEMI treated with primary angioplasty at four New York City Hospitals were interviewed (24% female; Women: 68.7 ± 13.1 years and men: 60.7 ± 13.8 years) between January 2009 and August 2012. A significantly larger percentage of women than men had no chest pain (62% vs 36%, p< 0.01). Compared to men, a smaller proportion of women thought they were having a myocardial infarction (15% vs 34%, p=0.01). A larger proportion of women than men had S2P time > 90 minutes (72% of women vs 54% of men, p= 0.03). Women were more likely than men to hesitate before seeking help, and more women than men hesitated because they did not think they were having an AMI (91% vs 83%, p=0.04). Multivariate regression analysis showed that female sex (Odds Ratio: 2.46, 95% CI 1.10– 5.60 P=0.03), subjective opinion it was not an AMI (Odds Ratio 2.44, 95% CI 1.20– 5.0, P=0.01) and level of education less than high school (Odds ratio 7.21 95% CI 1.59– 32.75 P=0.01) were independent predictors for S2P > 90 minutes.Conclusion: Women with STEMI have longer pre-hospital delays than men, which are associated with a higher prevalence of atypical symptoms and a lack of belief in women that they are having an AMI. Greater focus should be made on educating women (and men) regarding the symptoms of STEMI, and the importance of a timely response to these symptoms.Keywords: women, awareness, acute myocardial infarction, symptoms

We present a case of marijuana-induced ST segment elevation mimicking Brugada syndrome in a young man. Cannabis can have a multitude of effects on the different organ systems of the body; we take a closer look at its effects on the cardiovascular system, including acute coronary syndrome, arrhythmias and congestive heart failure.

Visceral angioedema is an uncommon but serious complication of therapy with angiotensin-converting enzyme (ACE) inhibitors. We report a case, review the literature, and discuss the incidence, features, and clinical recognition of this condition.

Bochdalek hernia occurs from a congenital defect of the diaphragm, allowing the passage of abdominal structures into the thoracic cavity, limiting lung expansion and ventilatory function. Bochdalek hernia is common in neonates but rarely occur in adults; there are only 4 documented cases in the elderly population. We present a case of an 88-year-old woman with severe hypoxia and respiratory failure that required ventilatory support, in whom bilateral Bochdalek hernias progressed over the years and severely invaded the thoracic cavity, causing acute decompensation. This is a rare condition in adults but can cause substantial morbidity when the involvement of the thoracic cavity is severe.

Among the multiple factors involved in the pathophysiology of heart disease, infections have been proposed to play a role in atherosclerosis with most of the available evidence implicating Chlamydia pneumonia, influenza virus and Mycoplasma pneumoniae. Based on a model case presentation, we speculate that in the absence of traditional risk factors and in the context of an ongoing respiratory infection caused by a pro-inflammatory pathogen (M. pneumoniae) along with a past positive serologic history for potentially proven atherogenic microorganism (C. pneumoniae) and infection may elicit potentially pathogenic events on vascular wall cells and leukocytes of atheromatous lesions, supporting the hypothesis that such infections may potentiate atherosclerotic cardiovascular disease (CVD).

Myocardial bridge is a congenital structural variant of the coronary arteries where a segment of the epicardial vessel is surrounded by the myocardium. It is an uncommon entity that may go unnoticed in patients with recurrent chest pain. We present a case on a 36-year-old woman with recurrent chest pain. Initial workup revealed normal routine laboratory test results, cardiac biomarkers, electrocardiogram, and an echocardiogram showing preserved ejection fraction with no valvulopathies. A dobutamine myocardial perfusion stress test was performed; this induced chest pain in the patient with electrocardiogram changes evident for 1-mm ST segment elevation in lead V5 and V6 consistent with myocardial ischemia. Perfusion imaging revealed a small fixed myocardial perfusion defect of the apical inferior wall. A cardiac catheterization revealed moderate-to-severe myocardial bridging involving the middle left anterior descending artery. Treatment with metoprolol and ranolazine resolved her symptoms. This case portrays the importance of recognizing myocardial bridge as the potential cause of recurrent chest pain and its ability to cause myocardial ischemia under stress.

Acute aortic syndrome (AAS) is a term that is used to describe a similar clinical profile that may have different underlying pathophysiological mechanisms. It includes classic aortic dissection, intramural aortic hematoma, and penetrating atherosclerotic ulcer. We describe the case of a 77-year-old female who presented with syncope of unknown duration. The chest X-ray was suggestive of a widened mediastinum. The initial work-up with a computed tomography scan and transesophageal echocardiogram failed to diagnose a penetrating atherosclerotic ulcer. We discuss the importance of a high degree of clinical suspicion for AAS and the utility of different imaging technologies in making the diagnosis.

Invasive thymoma with transcaval extension to the right atrium is a rare cause of superior vena cava syndrome. We present a case on a 74-year-old female presenting with dyspnea on exertion, and facial and upper extremity swelling. Physical examination revealed mild facial swelling, non-pitting edema involving the upper extremities and distention of superficial veins of the anterior chest wall and jugular veins. An echocardiogram showed moderate right atrial dilation with a mobile mass in the atrial cavity prolapsing through the tricuspid valve. Cardiac magnetic resonance imaging revealed a 9.9 × 4.3 cm heterogeneous mass in the anterior mediastinum compressing the superior vena cava and endovenously extending into the right atrium. Tissue biopsy of the mediastinal mass revealed a type B1 thymoma, further staged as a Masaoka IVa invasive thymoma that underwent successful en bloc resection followed by removal of intracaval and right atrial mass.

Background: Prior studies have demonstrated an association between ethnicity and symptom onset to presentation time (S2PT) among patients presenting with ST elevation MI (STEMI) in the USA, with a shorter S2PT among Caucasians when compared with other ethnicities. However, little is known regarding whether or not a patient's ability to comprehend English impacts the S2PT. Methods: Consecutive patients presenting to 4 hospitals in NYC with STEMI referred for primary angioplasty were included in the analysis. S2PT was recorded on the day of the infarct based on the patient's account of the onset of symptoms. We assessed a patient's ability to comprehend English through telephone interviews conducted during routine follow-up. Results: Among 210 patients, 83.8% (176 of 210) had either some English comprehension or were fluent in English (E) and 16.2% (34 of 210) reported no English comprehension (non-E). Of the non-E patients, 65% (22 of 34) spoke Spanish, 6% (2 of 34) spoke Russian, 6% (2 of 34) spoke Chinese and 23% (8 of 34) spoke another language. The baseline variables and mean S2PT are depicted in the table. Non-E patients had a significantly higher S2PT compared to E patients even after adjusting for differences in baseline variables. Increased odds were also observed among non-E patients with a longer S2PT (adjusted odds ratio for S2PT > 120 minutes 2.17; 95% CI 01.03-4.54; p=0.04). This association remained constant even after adjusting for confounders like age, sex, ethnicity, level of education and comorbidities (diabetes, previous history of MI and PCI). Conclusions: S2PT is strongly influenced by a patient's ability to comprehend English. This information emphasizes the need for more aggressive “multi-lingual” educational outreach and the use of multi-lingual emergency lines in an effort to decrease total ischemic time during STEMI. English Comprehension Fair or Good (N=176) No English Comprehension (N=34) P Age Mean (SD) 62 (14.2) 65 (11) 0.22 Male sex n (%) 129 (73) 26 (76) 0.70 Diabetes n (%) 25 (14) 9 (27) 0.09 Hypertension n (%) 107 (66) 20 (62.5) 0.70 Prior MI n (%) 21 (12) 2 (6) 0.284 Prior PCI or CABG n (%) 12 (6.8) 2 (6) 0.960 Education: n (%) 40 (23) 12 (35) 0.09 Less than HS 62 (35) 8 (23) HS Diploma 8 (4) 0 (0) College Diploma Unknown 66 (38) 14 (42) Mean S2P time (SD) 225 (315) 387 (820.6) 0.05 S2P time > 120 minutes n (%) 70 (40) 20 (62.5) 0.04

Hyperkalemia affects the myocardial tissue producing electrocardiographic abnormalities, such as prolongation of the P-R interval, tall peaked T waves, a reduction in the amplitude and an increase in the duration of P wave, and atrial and ventricular arrhythmias, including variable degree heart blocks. Elderly patients are particularly predisposed to developing hyperkalemia and the associated abnormalities due to an age-related reduction in glomerular filtration rate and pre-existing medical problems. Therefore, the impact of aging on potassium homeostasis must be taken into consideration, and preventive measures, such as early recognition of possible hyperkalemia in the geriatric population treated with certain medications or supplements must be investigated. The threshold for cardiac arrhythmias in the elderly can be lower than the general population. We report 3 unusual cases of mild hyperkalemia in elderly patients presenting with hypotension, syncope and variable degree heart blocks which resolved spontaneously with the correction of hyperkalemia.

Readers comment on the management of atrial fibrillation (April 2011) and on angioedema due to angiotensin-converting inhibitors and related drugs (May 2011).

Stroke is the leading cause of long term disability and second leading cause of death worldwide. The effectiveness of primary and secondary prevention of stroke by antihypertensive medications is well validated however support for permissive hypertension in the early course of acute ischemic stroke