Search

Out-of-hospital cardiac arrest is a relatively common event. Acute coronary thrombotic events are the main trigger of sudden cardiac arrest. Mortality of patients, in whom return of spontaneous circulation is obtained, is still high, mainly due to anoxic brain injury and progressive cardiac failure. In the last years, the implementation of "post-cardiac arrest care" led to a significant improvement of hospital survival of these patients. Mild therapeutic hypothermia has become the foundation for improvement of survival with good neurological outcome after cardiac arrest. Recently, there is a growing interest in emergent invasive coronary strategies, including emergent coronary angiography and subsequent percutaneous coronary interventions when indicated. Emergent coronary angiography is strongly recommended in patients with ST-segment elevation on the ECG performed after return of spontaneous circulation. Conversely, whether patients without ST-segment elevation on ECG or patients who remain unconscious after return of spontaneous circulation should always undergo emergent coronary angiography is still unclear. Recent observational stud ies have shown that emergent invasive coronary strategies may improve hospital survival also in this patient subset. This suggests that resuscitated cardiac arrest victims without an obvious non-cardiac etiology should always undergo emergent coronary angiography, in association with therapeutic hypothermia if indicated.

Radiofrequency ablation of atrioventricular junction plus pacing therapy ("ablate and pace") is an effective non-pharmacological therapy in patients with medically refractory permanent atrial fibrillation and heart failure. However, the chronic right ventricular pacing may result in regional wall motion abnormalities and adverse hemodynamic effects. These findings imply that patients with permanent atrial fibrillation who undergo "ablate and pace" may benefit from cardiac resynchronization therapy. The review of both observational and randomized studies suggests an important role of biventricular pacing combined with atrioventricular junction ablation only in patients with severe reduction of left ventricular ejection fraction and advanced heart failure. In all other patients with permanent atrial fibrillation, the comparison of conventional right ventricular pacing with respect to cardiac resynchronization therapy showed conflicting results. The assessment of cardiac dyssynchrony by means of new echocardiographic technology, including three-dimensional analysis, may improve the selection of the best pacing modality in patients undergoing "ablate and pace" for drug refractory permanent atrial fibrillation.

Disulfiram is a drug used since 1940 in the treatment of alcohol dependence. However, it is not a completely safe drug; there are in the literature some case reports of more severe reaction than the usual "acetaldehyde syndrome" secondary to ingestion of disulfiram and alcohol. We describe a case of a 45-year-old, chronic alcoholic man in treatment with disulfiram, who suffered an acute anterior myocardial infarction, successfully treated with thrombolysis. The possible factors precipitating acute myocardial infarction in this patient are discussed.