Lee CH, Tai BC, Low AF
… +3 more, Teo SG, Lim YT, Tan HC
Acute Card Care
· 2010 Jun · PMID 20443652
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BACKGROUND: We sought to report the incidence of angiographic no-reflow and clinical outcomes of elderly patients who have undergone primary percutaneous coronary intervention at a tertiary institution in Singapore over...BACKGROUND: We sought to report the incidence of angiographic no-reflow and clinical outcomes of elderly patients who have undergone primary percutaneous coronary intervention at a tertiary institution in Singapore over a period of 10 years. METHODS: A total of 141 patients (60% male) aged 75 or above underwent primary PCI between 1998 and 2007. Their average age was 80+/-5 years. Cardiogenic shock complicating STEMI on presentation accounted for 15% of the patients. RESULTS: At baseline, 103 (73%) patients have impaired TIMI flow grade (TIMI 0-2), and 38 (27%) have normal flow (TIMI 3). At the end of the procedure, 44 (31.2%) patients had no-reflow phenomenon (TIMI 0-2), whereas 97 (68.8%) achieved normal antegrade flow. Post-procedure corrected TIMI frame count was analyzable in 66% (n=93) of the patients. Post-procedure corrected TIMI frame count was>28 in 37.6% (n=35) of patients. In-hospital, 30-day and six-month mortalities were 20.6, 25.5% and 27.7%, respectively. Multivariable analysis showed that age 80 or above, low systolic blood pressure and final TIMI 0-2 flow independently predicted six-month mortality. CONCLUSIONS: We found that one-third of the treated patients developed no-reflow phenomenon. Six-month mortality was 27.7%, most were cardiac deaths that occurred during index hospitalization.
Acute Card Care
· 2010 Jun · PMID 20384473
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Neurogenic cardiomyopathies are raising a growing interest due to their multidisciplinary implications. Despite the body of literature, questions about pathophysiology, risk predictors and prognosis of the various clinic...Neurogenic cardiomyopathies are raising a growing interest due to their multidisciplinary implications. Despite the body of literature, questions about pathophysiology, risk predictors and prognosis of the various clinical pictures are still open. The frequent observation of a reversible left ventricular dysfunction complicating subarachnoid haemorrhage drops several hints of discussion about the clinical and pathophysiological similarities with the 'typical' transient left ventricular apical ballooning syndrome. In the light of the latest clinical and pathophysiological evidences, transient left ventricular apical ballooning syndrome could no longer be considered as an exclusively 'apical' wall motion abnormality and this diagnosis had not to be ruled out in patients experiencing acute brain injury and cerebrovascular events. Each kind of reversible left ventricular dysfunction mediated by the central nervous system and initiated by acute brain injury, both physical, like intracranial bleeding or head traumas, and psychical, like sudden emotional stress, could be encompassed in a single definition with wider inclusion criteria, such as 'acute ballooning cardiomyopathy' (ABC), that is likely to be more representative of the real needs in the clinical setting.
Acute Card Care
· 2010 Jun · PMID 20384472
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Bivalirudin is a direct thrombin inhibitor that seems to be a promising anticoagulation treatment in patient with ST elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI)....Bivalirudin is a direct thrombin inhibitor that seems to be a promising anticoagulation treatment in patient with ST elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). We discuss several issues that were raised from the use of Bivalirudin during primary PCI.
Rezaizadeh H, Sanchez-Ross M, Kaluski E
… +3 more, Klapholz M, Haider B, Gerula C
Acute Card Care
· 2010 Mar · PMID 20201659
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Hypereosinophilic syndrome (HES) is a rare disorder of unregulated eosinophilia, which if untreated, may lead to systemic tissue infiltration and inflammation. Cardiac involvement is a common and serious associated compl...Hypereosinophilic syndrome (HES) is a rare disorder of unregulated eosinophilia, which if untreated, may lead to systemic tissue infiltration and inflammation. Cardiac involvement is a common and serious associated complication. We describe a case of HES associated myocarditis mimicking a non-ST elevation MI (NSTEMI). Unlike myocarditis in general, our patient responded well to high dose methylprednisone, the standard of care in HES. We review the clinical presentation, pathophysiology, pathology and treatment of eosinophilic myocarditis related to HES.
Ferraro S, Marano G, Bongo AS
… +2 more, Boracchi P, Biganzoli EM
Acute Card Care
· 2010 Mar · PMID 20201658
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In the setting of acute coronary syndrome (ACS) the enhancement of analytical performances for several biomarkers improved the understanding of complex ACS pathogenesis highlighting the potential targets of treatment. Th...In the setting of acute coronary syndrome (ACS) the enhancement of analytical performances for several biomarkers improved the understanding of complex ACS pathogenesis highlighting the potential targets of treatment. The introduction of multiplex arrays, developed on ELISA methodology, measuring simultaneously multiple proteins in one assay, allowed the chance to obtain patient multimarker profiles. Aim of this commentary is to clarify the clinical reliability and usefulness of multiplex arrays, in ACS context, referring to available recent methodological and translational research literature. We reported that a certain number of clinical studies in ACS considered these methods but provided poor evidence, since their lack of standardization. The main drawback of multiplex arrays lies in the cross-reactions between the array antibodies with the reagents of co-detected analytes and with the sample matrix proteins. This cross-reactivity rises as the increasing number of markers assayed in the same plate. We have shown that these multiplex arrays were employed to screen markers potentially involved in the disease, among a wide spectrum of proteins, without a preliminary robust biological hypothesis. The need of up-to-date biostatistical approaches is stressed. Researchers should address their efforts to build up and standardize sub-microarrays measuring a lower number of markers than multiplex one, selected on a clear link with ACS evolution.
Tödt T, Sederholm-Lawesson S, Stenestrand U
… +3 more, Alfredsson J, Janzon M, Swahn E
Acute Card Care
· 2010 Mar · PMID 20201657
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UNLABELLED: There is debate whether early treatment with GpIIb/IIIa inhibitors is of clinical benefit in primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). This study explore...UNLABELLED: There is debate whether early treatment with GpIIb/IIIa inhibitors is of clinical benefit in primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). This study explored the effects of early given abciximab on coronary blood flow and major adverse cardiac events (MACE) in patients with STEMI treated with primary PCI and adjunctive abciximab. We studied all consecutive patients from our catchment area with STEMI undergoing acute angiography with the intention of primary PCI during 2005. Abciximab was given as early pre-treatment before, (n = 133) or at the cath. lab. after a diagnostic angiography (n = 109). Pre-procedural TIMI 2-3 flow was observed in 45.9 % of patients in the early group versus 20.2 % in the cath. lab. group, P = 0.0001. Mortality rates were 3.8 % versus 3.7% inhospital and 8.3 % versus 7.3% at one year in the early respectively the cath. lab. group, both P = NS. The MACE rate (death, non fatal myocardial infarction, unplanned revascularization) at one year was 19.5 % (early group) and 26.6 % (cath. lab. group), P = 0.19. CONCLUSION: In this single centre registry study of unselected patients with STEMI early given abciximab was associated with a significantly higher rate of TIMI 2-3 flow compared to abciximab given after the acute angiography.
Dziewierz A, Siudak Z, Rakowski T
… +2 more, Dubiel JS, Dudek D
Acute Card Care
· 2010 Mar · PMID 20201656
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BACKGROUND: The purpose was to identify predictors of cardiogenic shock (CS) on admission and to asses associations between CS and real-life management patterns and outcomes in unselected cohort of acute coronary syndrom...BACKGROUND: The purpose was to identify predictors of cardiogenic shock (CS) on admission and to asses associations between CS and real-life management patterns and outcomes in unselected cohort of acute coronary syndrome (ACS) patients admitted to hospitals without onsite invasive facilities. METHODS: Data concerning in-hospital management and mortality of 56 (4.3%) patients with and 1257 (95.7%) without CS on hospital admission was assessed. RESULTS: Prior myocardial infarction, prior heart failure symptoms, age, and diabetes mellitus were independently associated with increased risk of CS on admission. A total of 23.8% patients were transferred for invasive treatment during index hospital stay and the frequency of transfer was similar among patients with and without CS on admission (21.4% versus 23.9%; P = 0.75), but in the STEMI subgroup, patients with shock were transported less frequently (21.4% versus 43.8%; P = 0.0027). CS patients were less likely to receive guideline-recommended therapies including antiplatelet drugs, statins, and beta-blockers. In-hospital mortality was lower in non-shock patients (6.2% versus 63.6%; P < 0.001) and CS on admission was an independent predictor of in-hospital death. CONCLUSIONS: CS on admission is an important determinant of treatment strategy selection and is associated with unfavorable prognosis of ACS patients admitted to hospitals without on-site invasive facilities.
BACKGROUND AND OBJECTIVE: There are limited data regarding the need for intensive care or the appropriate length of hospital stay for patients with ST elevation acute myocardial infarction (STEMI). In order to optimize r...BACKGROUND AND OBJECTIVE: There are limited data regarding the need for intensive care or the appropriate length of hospital stay for patients with ST elevation acute myocardial infarction (STEMI). In order to optimize resources, we tried to determine the need of coronary care unit (CCU) admission for patients with STEMI who remained in Killip class I after a successful primary percutaneous coronary intervention (PPCI). METHODS: From August of 2006 till June of 2008, we analyzed data from all patients admitted in our CCU who met these criteria, a total of 278. We prospectively recorded all in-hospital adverse events and event-free survival at 30 and 90 days (all cause death, stroke, new acute coronary syndrome or re-hospitalization due to heart failure). Medical treatment was optimized according to the current guidelines. RESULTS: A coronary stent was implanted in 96% of the patients. None of the patients had any adverse event that could not be resolved in a step-down unit. Survival at 30 and at 90 days was 99.6% and 98.3% respectively. Event-free survival was 97.3% at 30 days and 94.3% at 90 days. The median length of stay was three days in the CCU and five days in the hospital. CONCLUSION: Patients with STEMI treated with PPCI who remained in Killip class I after the procedure and receive optimal pharmacological treatment have an excellent prognosis. All of them can probably be admitted safely to a step-down unit. Wide application of this management strategy may result in substantial cost savings.
AIMS/METHODS: To investigate whether diastolic third or fourth heart sounds (S3 or S4) detect myocardial ischemia independently or in combination with the 12-lead electrocardiogram (ECG), a prospective comparison study w...AIMS/METHODS: To investigate whether diastolic third or fourth heart sounds (S3 or S4) detect myocardial ischemia independently or in combination with the 12-lead electrocardiogram (ECG), a prospective comparison study was conducted in a group with ischemia induced by percutaneous coronary intervention (n=19) and a non-ischemia group (n=18) without coronary artery disease or ischemic ECG evidence. Diastolic heart sounds were detected by computerized acoustic cardiography. RESULTS: Of 37 patients, the mean age was 59.4+/-11.8 years. An S4 was more sensitive (74%) in detecting ischemia than an S3 (47%) or standard ST-T criteria (53%). All subjects with standard ST-T wave criteria for PCI-induced ischemia had an S3 or S4. All subjects without an S3 or S4 did not have ST-T wave criteria for ischemia. Using logistic regression, both an S3 and S4 were shown to detect ischemia (P<0.05), independent of ST-T criteria. The detection of ischemia was improved by 32% when the presence of an S3 or S4 was added to ST-T wave criteria. The absence of an S3 and S4 was helpful to rule out myocardial ischemia. CONCLUSION: The use of computerized acoustic cardiography to detect an S3 or S4 may augment the ECG detection of ischemia.
PURPOSE: To analyse discharge prescription of recommended treatments in patients with ST-segment elevation myocardial infarction (STEMI) according to reperfusion strategies. METHODS: IN-ACS (Italian Network on Acute Coro...PURPOSE: To analyse discharge prescription of recommended treatments in patients with ST-segment elevation myocardial infarction (STEMI) according to reperfusion strategies. METHODS: IN-ACS (Italian Network on Acute Coronary Syndromes) Outcome, an observational, multicenter study, enrolled 6045 ACS patients admitted within 48 h. In the present study we compared the discharge prescription rates of secondary prevention drugs among the 2144 patients with STEMI (72.5% men, age 65+/-13 years) who received primary percutaneous coronary intervention (pPCI) 1044 (48.7%) or thrombolytic therapy (TT) 575 (26.8%) or no reperfusion treatment (NR) 525 (24.5%). RESULTS: Despite the higher risk profile, NR patients respect to pPCI and TT were less frequently receiving antiplatelet (93.0% versus 99.7% versus 96.4%), dual antiplatelet (57.9% versus 93.9% versus 62.8%), beta-blockers (71.2% versus 82.9 versus 75.0%) and statins (68.4% versus 78.6% versus 76.9%) (P <0.0001) at discharge. After multivariable analysis, NR respect to pPCI was an independent predictor of not receiving antiplatelet (OR: 19.6; 95% CI: 6.0-62.5), dual antiplatelet (OR: 10.2; 95% CI: 7.6-13.5), beta-blocker (OR: 1.6; 95% CI: 1.3-2.0). CONCLUSIONS: According to our results NR patients with STEMI, despite their higher risk profile, were less likely to receive the recommended drugs at discharge compared to patients treated with pPCI.
Primary percutaneous coronary intervention (PPCI) is the treatment of choice for patients with ST segment elevation myocardial infarction (STEMI). In the attempt to reduce the unfavourable effects of time delays before P...Primary percutaneous coronary intervention (PPCI) is the treatment of choice for patients with ST segment elevation myocardial infarction (STEMI). In the attempt to reduce the unfavourable effects of time delays before PPCI, the administration of thrombolysis has been advocated (facilitated-PCI), but this treatment was shown to be ineffective and harmful, and should be avoided in patients who can receive PPCI promptly. Fibrinolysis is still indicated when PPCI is not available within 90-120 min but 1/3 of STEMI patients undergoing fibrinolysis does not show signs of reperfusion and even when reperfusion is achieved they have a considerable risk of death and recurrent MI. Thus invasive management with early PCI could be complementary to fibrinolysis both to obtain coronary reperfusion in those patients with failed thrombolysis (rescue-PCI) and to decrease the risk of further ischaemic events in patients with successful thrombolysis. In this article we show that this synergy has been supported by modern randomized control trials and meta-analysis. It is advisable that organization model of territorial network for the treatment of STEMI patients should be expanded to provide a timely access to hospital with interventional facilities also to patients treated with fibrinolysis that need rescue-PPCI or an urgent/early invasive management.
Despas F, Trouillet C, Franchitto N
… +4 more, Labrunee M, Galinier M, Senard JM, Pathak A
Acute Card Care
· 2010 Mar · PMID 19929264
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Levosimendan is a new inodilatory agent with calcium sensitizing activity. A major concern regarding the use of inotropic agent in heart failure is their effect on the sympathetic tone. This effect could explain increase...Levosimendan is a new inodilatory agent with calcium sensitizing activity. A major concern regarding the use of inotropic agent in heart failure is their effect on the sympathetic tone. This effect could explain increase in short term mortality with other inotropes. We aimed to assess the effect of levosimendan on sympathetic tone measured directly by microneurogra-phy. In a group of acute decompensated heart failure patients, we assessed cardiac performance by digital plethysmography measurement. Sympathetic tone was assessed through recording of muscle sympathetic nerve activity (MSNA) by micro-neurography. Recording were done blindly, for each patient after dobutamine perfusion was stopped (baseline) and 48 h after levosimendan infusion. Clinical, biological and morphological data were collected. We compared cardiac parameters and MSNA before and after administration of levosimendan. 13 patients were recruited (48 +/- 3.6 years). Systolic blood pressure and rate pressure product (mmHg x Beat/min) decreased significantly after levosimendan infusion (P< 0.05). Cardiac output and stroke volume were significantly increased after levosimendan infusion (P< 0.05). A significant decrease of MSNA activity is observed after levosimendan infusion (P< 0.01). Levosimendan induced improvement of cardiac performance, associated with a decreased in MSNA. This study show for the first time that levosimendan has no direct detrimental effect on the sympathetic nervous system.
The mortality of acute heart failure (AHF) remains high despite advances in treatment. Mechanical circulatory support (MCS) can be applied in AHF, refractory to conventional measures, to improve outcomes. This article ai...The mortality of acute heart failure (AHF) remains high despite advances in treatment. Mechanical circulatory support (MCS) can be applied in AHF, refractory to conventional measures, to improve outcomes. This article aims to describe the current and the prospective role of MCS in the treatment of AHF. The support strategies and the indications of MCS are continuously evolving, including situations considered as contraindications in the past. Appropriate patient selection, advanced device technology and improved patient management have contributed to the substantially improved results. Evolution in device technology results in evolution of the clinical applications of MCS. Earlier application of MCS, with novel, flexible and individualized support strategies is now feasible. Bridging to recovery is the most intriguing support strategy and bridging to future treatments is feasible with long-term support. The progressively expanding role of MCS in the treatment of heart failure is not reflected in the existing guidelines. Being reserved for refractory heart failure, MCS has been applied to the sickest patients who were less amenable to randomization. This explains the lack of robust evidence, but also highlights the value of the progressively improving results. The anticipated wider application of MCS should be better defined, systematically recorded, and guided.
The present study reports the incidence, management and clinical outcome of coronary perforations in 5 of 2991 patients (0.1%) undergoing percutaneous coronary intervention, with non-debulking (percutaneous transluminal...The present study reports the incidence, management and clinical outcome of coronary perforations in 5 of 2991 patients (0.1%) undergoing percutaneous coronary intervention, with non-debulking (percutaneous transluminal coronary angioplasty and stent) techniques. There was 1 type I, 1 type II and 3 type III perforations. One perforation was guidewire related, 2 perforations occurred after stent deployment and two occurred during stent-post dilatation with balloons. Restoration was obtained by prolong balloon inflation in three cases. Subsequent cardiac tamponade occurred in 2 patients, requiring pericardiocentesis. One patient died in the cath lab. due to electromechanical dissociation. At follow-up, 3 out of 4 patients were asymptomatic and one had bypass surgery for restenosis. Treatment of coronary perforation requires rapid detection, angiographic classification, and immediate occlusion of perforation site, pericardiocentesis, haemodynamic support and reversal of heparin anticoagulation.
BACKGROUND: NT-proBNP has prognostic implications in heart failure. In acute coronary syndromes (ACS) setting, the prognostic significance of NT-proBNP is being sought. We studied short-term prognostic impact of admissio...BACKGROUND: NT-proBNP has prognostic implications in heart failure. In acute coronary syndromes (ACS) setting, the prognostic significance of NT-proBNP is being sought. We studied short-term prognostic impact of admission NT-proBNP in patients admitted for ACS and in association with GRACE risk score (GRS). METHODS AND RESULTS: We studied 1035 patients admitted with ACS. Patients were divided in quartiles according to NT-proBNP levels on admission: Q1 <180 pg/ml; Q2 180-691 pg/ml; Q3 696-2664 pg/ml; Q4 2698-35 000 pg/ml. Groups were compared in terms of short-term all-cause mortality. Patients with higher NT-proBNP had worst GRS on admission. They also received less aggressive treatment. In-hospital mortality was 0.8%, 3.0%, 5.8% and 12.8% (P<0.001) and 30-day mortality 1.6%, 4.6%, 6.5% and 16.7% (P<0.001) respectively. In multivariate logistic regression analysis, NT-proBNP is an independent predictor of in-hospital (OR 2.35; 95% CI: 1.12-4.93, P=0.022) and 30-day mortality (OR 2.20; 95% CI: 1.17-4.12, P=0.014). However, NT-proBNP does not add any incremental benefit to GRS for prediction of outcome by ROC curve analysis. CONCLUSIONS: NT-proBNP is an independent predictor of in-hospital and 30-day mortality after ACS, independently of left ventricular function, but does not increase the prognostic accuracy of GRS.