The 143 low- and middle-income countries (LMICs) of the world constitute 80% of the world’s population or roughly 5.86 billion people with much variation in geography, culture, literacy, financial resources, access to health care, insurance penetration, and healthcare regulation. Unfortunately, their burden of cardiovascular disease in general and acute ST-segment–elevation myocardial infarction (STEMI) in particular is increasing at an unprecedented rate. Compounding the problem, outcomes remain suboptimal because of a lack of awareness and a severe paucity of resources. Guideline-based treatment has dramatically improved the outcomes of STEMI in high-income countries. However, no such focused recommendations exist for LMICs, and the unique challenges in LMICs make directly implementing Western guidelines unfeasible. Thus, structured solutions tailored to their individual, local needs, and resources are a vital need. With this in mind, a multicountry collaboration of investigators interested in LMIC STEMI care have tried to create a consensus document that extracts transferable elements from Western guidelines and couples them with local realities gathered from expert experience. It outlines general operating principles for LMICs focused best practices and is intended to create the broad outlines of implementable, resource-appropriate paradigms for management of STEMI in LMICs. Although this document is focused primarily on governments and organizations involved with improvement in STEMI care in LMICs, it also provides some specific targeted information for the frontline clinicians to allow standardized care pathways and improved outcomes.

The first successfully diagnosed and treated case of aortaright atrial tunnel was reported by Coto et al. in 1980. The most common cause of aorta-right atrial tunnel is a ruptured aneurysm of the sinus of Valsalva. Sinus of Valsalva aneurysms had been reported as early as 1840 by Thurnam; these were diagnosed at autopsy. With the advances in radiology, many cases of aorta-right atrial tunnel have been reported since then, each with its own subtle variations.We report on a unique case of aorta-right atrial tunnel with a windsock aneurysm in the right atrium. A 55-yearold male presented with abdominal pain and the chest X-ray revealed cardiomegaly. On further investigation with echocardiography and computed tomography angiography, there was an incidental aorta-right atrial tunnel with a windsock aneurysm in the right atrium. As early as 1840, aneurysms of the sinus of Valsalva were described by Thurnam; these were diagnosed through autopsies. 1 The first successfully diagnosed and treated case of aorta-right atrial tunnel was reported by Coto et al. in 1980. 2 Initially, diagnosis was limited to echocardiography and cardiac catheterisation, but with the advent of 64-slice computed tomography (CT) angiography, diagnostic accuracy and accessibility has improved. We present here a unique case of aorta-right atrial tunnel with a windsock aneurysm in the right atrium, diagnosed with echocardiography and CT angiography and successfully treated with surgery. Case reportA 55-year-old male patient presented with abdominal pain and was admitted to hospital for the treatment of a kidney stone. Two days after the stone was removed and a stent was placed, he complained again of severe abdominal pain, nausea and vomiting. He was thoroughly examined; the abdominal CT and ultrasound were normal. The cause of abdominal pain was due to a urinary tract infection, which he had contracted after the urinary tract stone was removed. The abdominal symptoms were unrelated to the cardiac findings. The chest radiograph, however, demonstrated cardiomegaly. He was then referred to a cardiologist.The patient had no history of cardiac disease and reported no chest pain or palpitations. He had normal effort tolerance. In retrospect he recalled some ankle swelling during the afternoons and mild peri-orbital swelling during the mornings. His surgical history included a Nissen fundoplication.A transthoracic echocardiogram demonstrated a large left atrium and left ventricle. No left ventricular hypertrophy was reported. Ejection fraction on M-mode was normal. A significant finding was an impression on the enlarged right atrium from a possible adjacent lesion.The transoesophageal echocardiogram (TEE) confirmed normal valvular and left ventricular function. There was an aneurysm of the aortic sinus with a windsock in the right atrium, possibly increasing the pressure and volume in the right atrium (Figs 1-3).A CT angiogram was performed subsequent to the TEE. There was aneurysmal dilatation of the right coronary sinus with a tortuous dilated t...

The PARAGON Investigators* Background-Unstable angina and non-Q-wave myocardial infarction involve coronary arterial plaque rupture, platelet activation, and thrombus formation. This study tested the benefit of different doses of lamifiban (a platelet IIb/IIIa antagonist) alone and in combination with heparin in patients with these conditions to select the most promising lamifiban regimen for subsequent evaluation. Methods and Results-At 273 hospitals in 20 countries, 2282 patients were randomly assigned to lamifiban (2ϫ2 factorial design: low-dose [1 g/min] with and without heparin versus high-dose [5 g/min] with and without heparin) or to standard therapy (placebo and heparin). All patients received aspirin. The composite primary end point of death or nonfatal myocardial infarction at 30 days occurred in 11.7% of those receiving standard therapy, 10.6% receiving low-dose lamifiban, and 12.0% receiving high-dose lamifiban (Pϭ0.668). By 6 months, this composite was lowest for those assigned to low-dose lamifiban (Pϭ0.027) and intermediate for those assigned to high-dose lamifiban (Pϭ0.450) compared with control (13.7%, 16.4%, and 17.9%, respectively). Compared with control, the combination of high-dose lamifiban and heparin resulted in more intermediate or major bleeding (12.1% versus 5.5%; Pϭ0.002) and a similar rate of ischemic events. Conversely, low-dose lamifiban and heparin yielded similar bleeding rates as in the control group but fewer ischemic events at 6 months (12.6% versus 17.9%; Pϭ0.025). Conclusions-In unstable angina and non-Q-wave infarction, platelet IIb/IIIa antagonism with lamifiban reduces adverse ischemic events at 6 months beyond that of aspirin and heparin therapy. The role of conjunctive heparin remains uncertain but appears more favorable with low-dose IIb/IIIa antagonism. Larger-scale study is needed to more reliably estimate these effects. (Circulation. 1998;97:2386-2395.)