Introduction: Systemic venous circulation anomalies are uncommon; they are often incidental findings during echocardiography. Case: A 56-year-old man, with dextrocardia, was evaluated for dyspnea. The patient's medical history included diabetes mellitus requiring insulin treatment, hypertension, and tobacco use. Physical examination revealed normal jugular venous pulsations and clear lungs. Cardiac examination revealed normal heart sounds, and grade II/VI systolic ejection murmur over the right precordium. Echocardiography revealed normal chamber size and systolic function, without significant valvular lesions. The coronary sinus was dilated. It was evaluated using intravenous agitated saline contrast to rule out anomalous venous drainage or shunting. When injected into the left antecubital vein, contrast appeared initially in the right atrium followed by the right ventricle. However, when injected into the right antecubital vein, contrast appeared initially in the dilated coronary sinus followed by the right atrium and right ventricle. There was no evidence of intracardiac shunting. These findings were consistent with persistent right superior vena cava in the setting of situs inversus dextrocardia, with normally draining left superior vena cava. Conclusion: Persistent superior vena cava connection to the coronary sinus is often incidental but an important finding which helps in planning safe invasive procedures.

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Background: Intermittent left bundle branch block (LBBB) has been linked to chest pain, and causes cardiac memory electrocardiographic (ECG) changes mimicking ischemia. Purpose: To present a case of chest pain with ECG abnormalities suggestive of ischemia, both likely caused by LBBB. Case: A 33-year-old hypertensive female evaluated for chest pain and LBBB by ECG was treated with lisinopril and metoprolol, and scheduled for stress testing. A 12-lead ECG performed prior to the stress test, due to recurrence of the chest pain the preceding night, showed resolution of the LBBB with a lower heart rate, and T-wave inversions in the precordial leads suggestive of ischemia. She developed chest pains with reappearance of LBBB during stress testing, which prompted cardiac catheterization. This revealed normal coronaries and left ventricular systolic function. The ECG abnormalities were in retrospect likely due to cardiac memory. Her chest pains may have been caused by the intermittent, rate-related LBBB, as control of her heart rate and blood pressure with metoprolol and lisinopril improved her symptoms on follow-up. Conclusion: Intermittent LBBB causes chest pain and electrocardiographic abnormalities suggestive of ischemia in the absence of obstructive coronary disease. Certain clinical and electrocardiographic features may provide clues to a non-ischemic etiology.

BACKGROUND: Increased pulse pressure (PP) is an independent determinant of cardiac disease. The effect of rest period on office-based systolic blood pressure has been previously reported, but not on PP in particular. OBJECTIVE: To assess the effect of age and gender on repeat PP measurement after a brief rest period in an outpatient cardiology clinic. METHODS: Patient charts reviewed in University-based cardiology clinic identified 170 encounters which contained BP re-measurement data due to elevated initial BP of > 130/80 mmHg. BP was measured initially by a nurse, with the patient in a sitting position and the arm resting at the level of the heart. If BP was > 130/80 mmHg, it was repeated by physician after resting the patient for 15 minutes. There were 112 (66%) elderly patients ≥ 60 years of age and 58 (34%) younger patients < 60 years of age. Among the elderly patients, there were 51 males (46%) and 61 females (54%). RESULTS: Among all encounters, after a brief rest period, initial PP of 67 ± 2 mmHg decreased to 62 ± 1 mmHg (5 mmHg; P < 0.01). PP decreased by 8 mmHg in the elderly (72 ± 2 to 64 ± 2 mmHg; P < 0.01) but did not significantly change in the young (56 ± 3 to 58 ± 3 mmHg; P = 0.3). PP decrease among the elderly was more pronounced in females (11 mmHg; 76 ± 4 to 65 ± 2 mmHg; P < 0.01) compared with males (4 mmHg; 68 ± 3 to 64 ± 2 mmHg; P = 0.03).DISCUSSION: Hypertension is a challenging public health problem. JNC 7 guidelines recommend that prior to BP measurement, persons should be seated quietly for at least 5 minutes in a chair, with feet on the floor, and arm supported at heart level; which resulted in significant decrease in pulse pressure in our patients. We show that while a decrease in pulse pressure was confined to the elderly, elderly females had a more pronounced PP decrease compared to males; both, however, fell to the same level. White coat hypertension may explain this observation, since it is more frequent in elderly females. The implication of this observation is that physicians should take extra care in remeasuring the blood pressure and pulse pressure, especially in elderly females, in whom a more pronounced drop in pressure may be observed after a brief rest period, and thereby, result in reclassifying their risk and need for treatment.

Background: Non-compliance with laboratory appointments, separate from clinic visit appointments, for measuring fasting cholesterol may hinder documentation and control of patients’ lipids. Methods: A university-based cardiologist’s clinic notes, from a single year (yr 1), when patients were asked to have a fasting cholesterol a week prior to the clinic visit, were analyzed (100 patients). The poor compliance prompted a same day as the clinic visit measurement (fasting or non-fasting) of lipids, for patients who could not comply with their laboratory appointment, during the following year (yr 2; 130 patients). Lipid values were managed by a subsequent call to the patient. All patients had coronary artery disease or risk equivalent mandating LDL levels < 100 mg/dL. Results: In yr 1, 62% (62/100) of patients had documented lipid profiles compared to 83% (108/130) of patients in yr 2. The average LDL in yr 1 was 115 +/- 36 mg/dL compared with 96 +/- 31 mg/dL in yr 2 (P < 0.01). Only 22% of the patients in yr 1 reached goal of < 100 mg/dL, compared with 65% in yr 2. There were no significant differences in the HDL, TG levels or blood pressures documented during the concurrent visits. Conclusion: Better documentation and control of lipids may be obtained when lipid profiles are done on clinic visit day, with fewer burdens on the patients who cannot comply with a separate laboratory appointment. Although there were many non-fasting levels as a result, the triglyceride levels where not significantly different among the two groups, probably reflecting an overall more intensive lipid management in yr 2, commensurate with the better documentation. Therefore, as has been shown by others, a lipid profile does not necessarily have to be fasting, especially in patients being treated for stricter targets such as our cohort, which may decrease the burden on patients unable to comply with a fasting state or added clinic visits.