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The follow electronic only articles are published in conjunction with this issue of Heart.

Persistent nicorandil induced oral ulceration

C M Healy, Y Smyth, S R Flint

Four patients with nicorandil induced ulceration are described. Nicorandil induced ulcers are very painful and distressing for patients. Clinically they appear as large, deep, persistent ulcers that have punched out edges. They are poorly responsive to topical steroids and usually require alteration of nicorandil treatment. The ulceration tends to occur at high doses and all four cases reported here were on doses of 40 mg per day or greater. In these situations reduction of nicorandil dose may be sufficient to promote ulcer healing and prevent further recurrence. However, complete cessation of nicorandil may be required.

(Heart 2004;90:e38)

Spontaneous coronary artery dissection involving the left main stem: assessment by intravascular ultrasound

J Auer, C Punzengruber, R Berent, T Weber, G Lamm, P Hartl, B Eber

This case report describes the devastating consequences of spontaneous coronary dissection in a 36 year old female patient who otherwise had a normal coronary arteriogram. Intravascular ultrasound showed coronary artery dissection and intramural haematoma at the left main stem coronary artery. Acute coronary syndrome developed and subsequently surgical revascularisation was performed successfully.

(Heart 2004;90:e39)

Long term survival in primary pulmonary hypertension

M Halank, C Marx, G Hoeffken

The mean survival of patients with severe primary pulmonary hypertension (PPH) is < 3 years without appropriate treatment. There are no long term reports on the spontaneous course of mild PPH over a longer period. Stable long term follow up is described of a 39 year old patient with PPH without treatment over a 30 year period. PPH had been diagnosed 30 years previously after right heart catheterisation (mean pulmonary artery pressure 35 mm Hg) and 30 years later, repeated measurements showed nearly unchanged haemodynamic parameters. Further examinations confirmed the diagnosis of PPH. It is suggested that PPH with modestly limited physical activity does not always seem to coincide with progression of the disease and, therefore, it may be feasible to withhold treatment while closely monitoring these patients.

(Heart 2004;90:e40)

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