SUMMARYPatients with hypothyroidism have an increased risk of coronary artery disease because of significant changes in lipid metabolism and arterial hypertension. We report a 67-year-old man who developed acute myocardial infarction following hormone replacement in hypothyroidism in spite of no previous cardiac symptoms and no ischemia in intravenous dipyridamole myocardial perfusion imaging. Careful examination for ischemic heart disease should be performed before hormone replacement in hypothyroidism. (Int Heart J 2007; 48: 107-111) Key words: Acute myocardial infarction, Hypothyroidism, Hormone replacement IT has been suggested that patients with hypothyroidism have an increased risk of coronary artery disease because of significant changes in lipid metabolism and arterial hypertension. We report here a case of acute myocardial infarction following hormone replacement in hypothyroidism even though the patient had no previous cardiac symptoms and no ischemia was present in intravenous dipyridamole myocardial perfusion imaging. CASE REPORTA 67-year-old man was admitted to our hospital because of gait disturbance. He was a cigarette smoker and had no history of angina pectoris. He presented with facial and foot edema, and muscle weakness of the proximal lower extremities. Blood pressure was 136/86 mmHg. Chest x-rays showed no cardiomegaly or pleural effusion. A 12-lead electrocardiogram revealed sinus bradycardia and no ST-T changes. The wall motion of the left ventricle on echocardiography was normal. His thyroid function indicated primary hypothyroidism (serum free thyroxine < 0.40 ng/dL, serum free tri-iodothyronine < 1.00 pg/mL, serum thyrotropin 24.81 µIU/mL). Ultrasonography of the thyroid showed diffuse atrophy and a small calcified nodule. Antibodies to thyroglobulin and thyroid peroxidase were From the

SUMMARYMechanical alternans is observed in patients with severe left ventricular dysfunction. We report a case of dilated cardiomyopathy with mechanical alternans. He presented with a remarkable decrease in plasma brain natriuretic peptide (BNP) levels after β-blocker therapy despite persistency of the mechanical alternans. Mechanical alternans may persist after improvement of hemodynamics, diastolic function, and plasma BNP levels. Mechanical alternans may reflect persistent organic or functional myocardial damage such as abnormal intracellular Ca 2+ cycling in cardiomyocytes. (Int Heart J 2007; 48: 117-121) Key words: Mechanical alternans, Dilated cardiomyopathy, β-blocker, Brain natriuretic peptide MECHANICAL alternans is observed in patients with severe left ventricular dysfunction, and is a predictor of a poor prognosis. We experienced a case of dilated cardiomyopathy who presented with persistent mechanical alternans after β-blocker therapy but showed a remarkable decrease in the plasma brain natriuretic peptide (BNP) level and a good short-term prognosis. CASE REPORTA 44-year-old man was admitted to our hospital because of exertional dyspnea. On admission, he had an expiratory wheeze and no edema. A chest x-ray showed cardiomegaly and lung congestion. An electrocardiogram showed sinus tachycardia and nonspecific ST-T change without electrical alternans (Figure 1). An echocardiogram showed left ventricular dilatation, severe left ventricular systolic and diastolic dysfunction, and moderate mitral regurgitation (Table). He was diagnosed as having congestive heart failure, and diuretic, digitalis, and angiotensin II receptor blocker therapy was initiated. Cardiac catheterization was perFrom the

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