Background: Cardiovascular risk factors for ACS are on the rise in people of Indian origin and ACS is now the leading cause of death. More recent evidence suggests that bilirubin is a potent physiological antioxidant that may provide important protection against atherosclerosis and inflammation. Substantial evidence has documented that the development of CAD involves lipid oxidation and formation of oxygen radicals as atherosclerosis and inflammation are associated with formation of oxygen and peroxyl radicals. Keep of these points in mind, the present study was undertaken to find relation between Serum Bilirubin and Acute Coronary Syndrome.Methods: The present descriptive cross-sectional study conducted at A.J Institute of Medical Sciences and Research Centre, Mangaluru from October 2016 to April 2017. A detailed history, general physical examination, systemic examination and investigations was performed on all patients who fulfill the inclusion criterion and age >18yrs, both sexes who are admitted in CCU.Results: Hypertension had statistically significant correlation with ACS. All risk factors were more associated with STEMI compared to unstable angina or NSTEMI. On Correlation of LDL and Total leucocyte count with bilirubin both were statistically significant when compared to bilirubin levels.Conclusions: The study showed an inverse correlation of bilirubin with ACS, which in shows fact that bilirubin acts as an antioxidant and has cardioprotective action and patients with ACS have lower levels of bilirubin. This can use as a factor for screening individuals who have high risk for ACS and preventive strategies applied in them before the onset of overt ACS.

With a history of right pneumonectomy, pulmonary embolism affecting bilateral pulmonary artery is rare and needs to be meticulously managed to prevent pulmonary infarction of the normal lung with a clinical decision regarding thrombolysis. A 64 years male diabetic and hypertensive with a history of right pneumonectomy 10 years back, presented to ER with dyspnea and 2 episodes of syncope with right leg pain and swelling for 3 days. BP was 140/90mmHg and pulse rate of 100/min. SPO2 in room air was 95%. ECG suggested S1Q3T3 with sinus tachycardia. Echocardiogram revealed features of pulmonary embolism. Venous doppler of right leg showed DVT and CT Pulmonary angiogram was suggestive of pulmonary embolism. High-sensitive troponin I and NT-pro BNP were negative. Diagnosis of submassive pulmonary embolism was made. Protecting the normal lung from infarction was of paramount importance. There was no indication for thrombolysis. Treatment with LMWH was initiated and overlapped with the novel oral anticoagulant (NOAC) dabigatran. Symptomatically patient improved along with a reduction in pulmonary arterial hypertension and improved RV function. Post pneumonectomy of one lung, protecting the normal lung from infarction is utmost important in a setting of pulmonary embolism. It is a rare case scenario. Clinical decision regarding thrombolysis should be taken carefully. In this case thrombolysis was not indicated as per guidelines. LMWH, oral anticoagulation and broad-spectrum antibiotic to prevent secondary lung infection are the mainstay in the treatment of submassive pulmonary embolism where thrombolysis is not indicated.

Abstract:Pheochromocytomas are neuroendocrine, catecholamine-secreting tumors which are usually found in adrenal glands though they are occasionally seen in extra-adrenal locations. Classically the patients present with symptoms of headache, diaphoresis and tachycardia with hypertension. It is rarely associated with cardiovascular manifestations, such as angina pectoris, acute myocardial infarction, myocarditis, acute heart failure, and cardiogenic shock among others. We present here a case of extra-adrenal pheochromocytoma presenting with flash pulmonary edema secondary to myocarditis.