Online Clinical Case Study (August 2003)

Clinical Cardiology Series
臨床心臟科個案研究

The content of the Clinical Cardiology Series is provided by:
Dr. Wong Shou Pang, Alexander
 F.R.C.P., F.H.K.A.M.(Med.), F.H.K.C.P., Specialist in Cardiology
Dr. Li Siu Lung, Steven
M.B.,B.S.(H.K.), M.R.C.P.(U.K.), F.H.K.A.M., F.H.K.C.P., F.R.C.P.(Glasg.), Specialist in Cardiology
臨床心臟科個案研究之內容誠蒙王壽鵬醫生及李少隆醫生提供。

A 45 year old man, who is a chronic smoker, comes to your office for some non-exertional chest discomfort. He has no other coronary risk factors. Physical examination is normal and his resting ECG is also unremarkable. He requests a stress test to rule out coronary heart disease.

Answers

1.

What stress tests of the heart are commonly available?

Commonly available stress tests of the heart include exercise ECG stress test, myocardial perfusion stress test with radioisotopes, stress echocardiography and MRI perfusion test.
 

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2.

What are the indications for exercise ECG stress test?

These include: to diagnose coronary heart disease; for risk stratification in patients with ischemic heart disease and in post-myocardial infarction patients, to assess exercise tolerance in patients with cardiac disease, to assess exercise induced arrhythmias and to assess ischemia in patients with history of acute coronary syndrome.
 

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3.

What are the limitations of exercise ECG stress test?
 

The sensitivity and specificity of exercise ECG stress test vary according to the pretest probability (Bayes' theorem). They are higher in patients with higher pretest probability than in those with lower pretest probability. In general, the sensitivity and specificity are only around 70%.
 

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4.

What are the contraindications for exercise ECG stress test?
 

These include acute myocardial infarction, acute coronary syndrome, uncontrolled arrhythmia, high grade AV block, decompensated heart failure, severe aortic stenosis or hypertrophic cardiomyopathy with outflow tract obstruction, suspected or known dissecting aortic aneurysm, acute infection and any disorder that may be aggravated by exercise.
 

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5.

What are the potential complications?
 

Cardiac arrest, arrhythmic complications, precipitation of acute coronary syndrome, acute heart failure, hypertension and aneurysm rupture.
 

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6. Can patients continue their usual medications before exercise ECG stress test?
  Discontinuation of cardiovascular drugs would produce higher sensitivity, although very often, these drugs need to be continued to control other health problems such as hypertension. In particular, beta-blockers should be taken off 2 days before the test so that the target heart rate may be reached. Digoxin may also affect the interpretation of the ECG, so that it is better to withhold it 2 weeks before the test if possible.
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Dermatology Series 皮膚科病例研究

An 11 year old girl presented with non-itchy erythematous rash with occasional superimposed "pustules" formation over her cheeks for 6 years. She was treated with a course of topical antibiotic but no improvement was seen.
The content of the Dermatology Series is provided by:
Dr. Tang Yuk Ming, William and Dr. Chan Loi Yuen
Specialist in Dermatology & Venereology
皮膚科病例研究之內容誠蒙鄧旭明醫生及陳來源醫生提供。

Answers

1. Apart from the face, where would you look for the similar lesion?

The temples and neck should also be checked for similar lesion.
 

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2.

What is the diagnosis and aetiology?

The diagnosis is erythromelanosis follicularis faciei et colli. It is an erythematous pigmentary disease involving the follicles. The aetiology is unknown.
 

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3. What are the typical clinical features of this condition?

The typical clinical features are irregularly marginated, reddish-brown pigmented patch with telangiectatic vessels and slightly scaly pale follicular papules which may be mistaken as pustules. The condition affects young males and females. The lesion most commonly affects the cheeks and peri-auricular areas; sometimes the temples and lateral aspects of the neck are also involved. Involvement is usually bilateral.
 

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4. Is there a ethnic or hereditary predilection for the condition?

The condition more often affects Asians. A definite mode of inheritance has not been reported.
 

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5.

What is the treatment?

There is no specific treatment. Emollient could be tried to improve the skin roughness. The patient should be reassured that the lesion is not eczematous or infectious. Topical steroids and antibiotics should be avoided. The lesion could be more accentuated during hot weather and after exercise.
 

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