Spontaneous coronary artery dissection (SCAD) is a very rare cause of acute coronary syndromes in young otherwise healthy patients with a striking predilection for the female gender. The pathological mechanism has not been fully clarified yet. However, several diseases and conditions have been associated with SCAD, such as atherosclerosis, connective tissue disorders and the peripartum episode. In this paper we present a review of the literature, discussing the possible mechanisms for SCAD, therapeutic options and prognosis. The review is illustrated with two SCAD patients who had a recurrence of a spontaneous dissection in another artery within a few days after the initial event. Because of the susceptibility to recurrent spontaneous dissections we propose at least one week of observation in hospital. Further, we will elaborate on the possible conservative and invasive treatment strategies in the acute phase of SCAD. Primary percutaneous coronary intervention remains the reperfusion strategy of choice; however, in small and medium-sized arteries with normalised flow conservative treatment is defendable. In addition, after the acute phase evaluation of possible underlying diseases is necessary, because it affects further treatment. (Neth Heart J 2008;16:344-9.)

Between 1977 and 1988 in the Enschede hospital 72 patients were seen with bacterial arthritis of one or more joints. Staphylococcus aureus was most frequently the causative agent (52%) and the knee was the most frequently infected joint (42%); the mortality rate was 11%. Complete restoration of pre-existent function was seen in 52% of the affected joints. In patients with severe deterioration of joint function after the bacterial infection, the period between the first symptoms and start of treatment (mean 30 days) was significantly longer than in patients with no or moderately deteriorated joint function (mean 10 days). The primary focus was mostly a skin infection, predominantly localized on the lower extremities. Half of all cases of bacterial arthritis occurred in patients with rheumatoid arthritis (RA). We therefore conclude that patients with RA and skin infections, especially if localized on legs or feet, should be treated without delay and that one should not hesitate to prescribe antibiotics. Erythrocyte sedimentation rate (ESR) was less than 20 mm after one hour in 13% and blood leucocyte count less than 10 x 10(9)/liter in 55% of all patients, showing that a normal ESR and/or blood leucocyte count do not exclude bacterial arthritis. In 4 out of 9 patients with infected prosthetic joints the infection resulted in loosening of the joint, before antibiotic treatment was started. In the other 5 patients bacterial arthritis recurred, in one patient resulting in loosening of the joint, only shortly after stopping long-term successful antibiotic treatment (6-24 months). Thus, we feel that lifelong treatment with antibiotics is a reasonable alternative in cases, where the risk of surgery is very high.

Patients with primary electrical disease presenting with ventricular fibrillation are at high risk of recurrence of major arrhythmic events during long-term follow-up. Noninducibility at baseline study does not predict an uneventful course. Also, early defibrillator implantation should be considered in these patients.

Recurrent ventricular fibrillation was observed in a 67-year-old woman following catheter ablation of the AV junction using radiofrequency energy. This serious complication has been reported following direct current energy ablation of the AV junction, but not after using radiofrequency energy. This life-threatening arrhythmia seemed pause and bradycardia dependent. It was followed by QTc prolongation of the QRS escape rhythm 1 day after the procedure. Ventricular arrhythmias were suppressed by rapid ventricular pacing.

Syncope is a common problem in the older patient. Sometimes syncope is caused by extreme bradycardia secondary to atrioventricular (AV) block. We describe a case in which a 90-year-old woman presented with complete AV block due to severe hypothyroidism. After suppletion with levothyroxine, AV conduction was restored. (Neth Heart J 2008;16:57-9.).