In patients with known or suspected CAD, adenosine stress CMR could be used to identify patients at high risk for subsequent cardiac death or nonfatal MI. A normal CMR perfusion was associated with a very low long-term event rate and excellent long-term prognosis. In addition, stress CMR perfusion provided important incremental prognostic information over clinical risk factors and RWMA.

Current approaches to lipid management in Hong Kong, primarily using statins, considerably improve attainment of LDL-C goal. However, a large proportion of patients do not achieve normal HDL-C levels and control of multiple lipid parameters remains poor. Patients could benefit from a more comprehensive approach to lipid management that treats all three lipid risk factors, as suggested in clinical guidelines.

No abstract

We thank Yamagami et al 1 for their intriguing case of pulmonary embolism titled "A Savage Sequence: ST-Segment Elevations with Pulmonary Embolism," published in the September 2014 issue of The American Journal of Medicine.The authors reported a patient with infected decubitus ulcer and acute pulmonary embolism. The initial electrocardiogram showed incomplete right bundle-branch block and down-sloping ST-segment elevation in leads V1-4 that were attributed to right ventricular infarction. However, we believe that the morphology of ST-segment elevation more conforms to type I Brugada pattern. Indeed, it is known that fever and sepsis can unmask the Brugada pattern in asymptomatic individuals, and fever-induced Brugada pattern is not rare. 2 In our experience, the Brugada pattern is not associated with a risk of sudden death as high as previously thought, 3 so it is not uncommon to see elderly patients admitted for sepsis presenting with a Brugada pattern electrocardiogram. 4 Moreover, the evolution of ST-segment elevation fits fever-induced Brugada, which classically resolves as sepsis is being controlled. In the reported patient, ST-segment elevation resolved by day 3. It would be interesting to know whether resolution of ST-segment elevation coincided with defervescence of the patient.We believe that, lacking imaging confirmation, isolated right ventricular infarction may not be the best explanation to the ST-segment elevation. The increase in cardiac enzymes may be consequent to acute right ventricular strain, which is known to occur in life-threatening pulmonary embolism. Furthermore, isolated right ventricular infarction is rare, accounting for less than 3% of all infarctions. 5 A more probable cause for the abnormal electrocardiogram may be fever-induced Brugada pattern.