The case report in this review illustrates an acute myocardial infarction in a young adult probably due to arterial thrombosis that can be attributed to a hypercoagulable state resulting from the nephrotic syndrome. Although rare, acute myocardial infarction should be considered in young adults presenting with chest pain. A detailed clinical history may help to identify the aetiology, and guide subsequent management, but diagnostic coronary angiography is essential. Careful risk factor modification and treatment of the underlying cause should reduce the incidence of recurrent cardiac events.

The converging clinical effectiveness of mineralocorticoid receptor antagonists (MRAs) Spironolactone and Eplerenone has made their safety profiles/cost-effectiveness key determinants of "agents of choice" across a broad range of clinical indications. The clinical biology of the aldosterone molecule and its range of effects in varied organ systems have been well elucidated from recent mechanistic and systematic studies. Clinical experience with Spironolactone is well established, as is its adverse effects profile. The range of adverse effects experienced with Spironolactone subsequently led to its modification and synthesis of Eplerenone. Recent published reports have confirmed lower prevalence rates of sex-related adverse effects attributable to Eplerenone compared to Spironolactone. There is, however, not much to choose between these agents in regards to other adverse effects including hyperkalemia and kidney failure. As was the experience with Spironolactone, as more robust observational data on Eplerenone accrues, it is possible that the real-life experience of its adverse profile may be discordant with that reported by randomized controlled clinical trials (RCTs). In addition, its metabolism by the vulnerable and highly polymorphic cytochrome dependent pathway also makes it susceptible to various drug interactions. The potential implication of the latter (including morbidity and mortality) may take years to evolve.

A 73 year old man developed chest pains 5 minutes after fibreoptic bronchoscopy. The procedure had been performed without sedation following an intratracheal injection of 5 ml 2.5% cocaine solution and xylocaine spray to the pharynx for topical anaesthesia. A 12-lead electrocardiogram showed an evolving anterior myocardial infarction. Cardiac catheterisation revealed coronary artery spasm in the proximal left anterior descending artery at the site of non-significant plaque disease. The risk factors, mechanisms, and treatment of cocaine induced myocardial infarction following intratracheal injections are discussed.C ardiovascular complications of fibreoptic bronchoscopy, although infrequent, are more common in the elderly.

A 35 year old woman with a long history of intravenous drug abuse presented to a local hospital with severe anaemia, fever, raised markers of inflammation, and positive blood cultures for Staphylococcus aureus. She responded to treatment with antibiotics with improvement in her symptoms and markers of inflammation. Four weeks later a "routine" echocardiogram showed a rupture of her left ventricular apex and a large pseudoaneurysm. There had been no deterioration in her symptoms or haemodynamic status to herald this new development. It was successfully repaired surgically and the patient made a good recovery. (Heart 2001;85:e4) Keywords: ventricular rupture; pseudoaneurysm; staphylococcal septicaemia Cardiac rupture and pseudoaneurysm of the left ventricular free wall is a well recognised complication of myocardial infarction, cardiac trauma or cardiac surgery.1 2 There are a few reported associations with endocarditis, septicaemia or tumour infiltration.3-6 These reported cases are all associated with a sudden or progressive haemodynamic deterioration. We report a case of cardiac rupture and pseudoaneurysm of the left ventricular free wall found on "routine" echocardiography in a patient with Staphylococcus aureus septicaemia. Case reportA 35 year old female intravenous drug abuser was referred to a local hospital with a three week history of malaise, lethargy, and weight loss. She had lost 10 kg in three weeks and complained of left sided pleuritic chest pains.She had a long history of intravenous drug misuse and had been on a methadone withdrawal programme for two months, although she admitted to the concomitant use of heroine. In 1992 and 1997 she was admitted to the same hospital with a left proximal deep vein thrombosis and right groin abscess respectively caused by injecting heroin into her femoral vein. A systolic murmur had been heard and an echocardiogram booked, but she had defaulted.On examination she looked ill and had a low grade pyrexia. She had a tachycardia of 100 beats/min but was normotensive. There were no cutaneous stigmata of endocarditis and the only positive finding was a systolic murmur suggestive of mitral regurgitation.Investigations revealed a microcytic anaemia with a haemoglobin of 3.5 mmol/l (5.7 g/d1) and a white cell count of 10.7 × 10 9 /l. Inflammatory markers were raised (C reactive protein 130 mg/l and erythrocyte sedimentation rate 54 mm/hour), and two sets of blood cultures grew S aureus. Her chest x ray was normal. The ECG showed non-specific T wave inversion aVecting the inferiolateral leads. Her echocardiogram revealed normal left ventricular systolic function and a left ventricular band near the apex. There was mild mitral and tricuspid regurgitation but no vegetations were seen. The aortic valve was normal. A small pericardial eVusion was noted. A diagnosis of bacterial endocarditis was made and she was treated with appropriate antibiotics (flucloxacillin and gentamicin) and given a transfusion of 4 units of blood. Her temperature settled and markers of infla...

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