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A case of spontaneous multi-vessel coronary artery dissection in a young man, with markedly elevated serum homocysteine levels, is reported. The effects of elevated homocysteine levels on arterial endothelial function and possible plaque rupture leading to coronary dissection and acute coronary syndrome and / or sudden cardiac death are also discussed.

Objective: To analyze the characteristics and in-hospital outcome of patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI) and to evaluate the influence of urgent coronary revascularization on in-hospital mortality., Design: Descriptive study., Place and Duration of Study: The Aga Khan University Hospital, Karachi. January 2001 to December 2001., Materials and Methods: All consecutive patients with AMI and CS, admitted at The Aga Khan University Hospital, Karachi Pakistan, during the year 2001 were reviewed. A pre-designed questionnaire was used for data collection. Analysis was done using the SPSS statistical package., Results: Out of 615 patients with AMI, 53 (8.6%) had CS. Mean age was 60.9 +10.7 years. 62.3% were men, 52.8% were hypertensive and 43.4% were diabetic. Most infarcts were anterior in location (56.6%). Thrombolytic therapy (Streptokinase) was administered to 43.5% of patients with ST segment elevation myocardial infarction. 64.2% required ventilatory support while swan ganz was used in 37.7%. Intra-aortic balloon pump was inserted in 39.6%. Ventricular tachycardia was the most common complication (39.6%). Overall in-hospital mortality was 54.7%. CS associated with mechanical complications had 80% in-hospital mortality. In patients without mechanical complications (n=48), in-hospital mortality was significantly lower in the revascularization group (31.6% vs. 65.5%, p-value = 0.021). However, there were significant differences in the baseline characteristics in the two groups because of the selection bias., Conclusion: CS occurring in patients with AMI has an extremely poor prognosis. Patients selected for revascularization strategy has favorable in-hospital outcome.