Boudoulas KD, Bowen T, Pederzolli A
… +3 more, Pfahl K, Pompili VJ, Mazzaferri EL
Acute Card Care
· 2014 Jun · PMID 24654687
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BACKGROUND: Intra-aortic balloon pump (IABP) use may be associated with complications; however, in certain patients with ST-elevation myocardial infarction (STEMI) with hemodynamic instability refractory to medical manag...BACKGROUND: Intra-aortic balloon pump (IABP) use may be associated with complications; however, in certain patients with ST-elevation myocardial infarction (STEMI) with hemodynamic instability refractory to medical management its use may become necessary. METHODS: 36 STEMI patients with IABP placement for hemodynamic instability after percutaneous coronary intervention were studied. IABP duration ranged from one to seven days (median two days). Based on median time, patients were divided into two groups: IABP duration ≤ 2 days (n = 27) or > 2 days (n = 9). Vascular complications and incidence of bleeding were compared. RESULTS: Mean IABP duration was 1.4 ± 0.5 and 4.1 ± 1.3 days in ≤ 2 day and > 2 day groups, respectively (P < 0.01). Glycoprotein IIb/IIIa inhibitor and anti-coagulation use was not significantly different between groups. Mean duration of anti-coagulation was 1.9 ± 1.2 and 4.5 ± 1.3 days in ≤ 2 day and > 2 day groups, respectively (P < 0.05). Complications (vascular, access site bleeding, gastrointestinal bleeding) were significantly greater in > 2 day group (66%) compared to ≤ 2 day group (18%; P < 0.05). CONCLUSIONS: When an IABP was used for more than two days complications significantly increased. The clinical implications of the study will be strengthened if the findings are confirmed in a prospective study with a larger number of patients.
Lazzeri C, Sori A, Bernardo P
… +6 more, Chiostri M, Tommasi E, Zucchini M, Romano SM, Gensini GF, Valente S
Acute Card Care
· 2014 Jun · PMID 24654656
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BACKGROUND: Data on the hemodynamic and cardiovascular effects of hypothermia in patients with cardiac arrest are scarce. The aim of this study was to evaluate the hemodynamic changes induced by hypothermia by means of M...BACKGROUND: Data on the hemodynamic and cardiovascular effects of hypothermia in patients with cardiac arrest are scarce. The aim of this study was to evaluate the hemodynamic changes induced by hypothermia by means of Most Care(®) (pressure recording analytical method, PRAM methodology), a beat-to-beat hemodynamic monitoring method. METHODS: We enrolled 20 patients with cardiac arrest (CA) consecutively admitted to our intensive cardiac care unit and treated with mild hypothermia (TH). RESULTS: While non-survivors showed no changes in haemodynamic variables throughout the study period, survivors exhibited a significant increase in systemic vascular resistance indexed during hypothermia and a trend towards lower values of heart rate and higher levels of mean arterial pressure. CONCLUSIONS: According to our data, PRAM methodology proved to be a feasible and clinically useful tool in CA patients treated with TH since it provides continuous beat-to-beat haemodynamic monitoring that is based on assessment of several haemodynamic variables. Moreover, we observed that survivors showed a different haemodynamic behaviour during hypothermia in respect to patients who died. However, further studies, performed in larger cohorts, are needed to better elucidate the haemodynamic effects of hypothermia in CA patients by means of PRAM methodology.
Acute Card Care
· 2014 Jun · PMID 24654609
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In recent years, it has become evident that the level of guideline adherence in patients presenting with acute coronary syndrome (ACS) is highly correlated with patient outcomes. Unfortunately, guideline adherence is low...In recent years, it has become evident that the level of guideline adherence in patients presenting with acute coronary syndrome (ACS) is highly correlated with patient outcomes. Unfortunately, guideline adherence is low in some geographic areas and especially in those patients at high-risk. Regional networks including ambulance systems and hospitals with catheterization laboratories are able to increase guideline adherence and patient outcomes by streamlining the critical pre- and intra-hospital processes as well as improving timely access to invasive procedures and recommended medication. Successful organization of an ACS network requires engagement of multiple stakeholders to create effective solutions for the specific local setting. There is no 'one-size-fits all' strategy to set-up and successfully run an ACS network. We present a framework for how to set up and organize an effective ACS network, delivering guideline-based care to improve patient outcomes.
Nobre C, Mesquita D, Thomas B
… +3 more, Ponte T, Santos L, Tavares J
Acute Card Care
· 2014 Jun · PMID 24617753
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INTRODUCTION: There is considerable debate regarding the use of thrombolytic therapy in patients with pulmonary embolism, normal blood pressure and intermediate clinical risk, as defined by right ventricular dysfunction...INTRODUCTION: There is considerable debate regarding the use of thrombolytic therapy in patients with pulmonary embolism, normal blood pressure and intermediate clinical risk, as defined by right ventricular dysfunction on transthoracic echocardiography or elevated serum markers of cardiac necrosis. AIMS AND OBJECTIVES: A clinical audit of normotensive patients diagnosed with acute pulmonary embolism using multi- detector computerized tomography pulmonary angiography (MDCTPA) and intermediate risk, was conducted to determine clinical outcomes at 30 days. The specific role played by imaging findings and clinical severity, on the decision to thrombolyse, was assessed. METHODS: The two cohorts who did (n = 15) and did not receive thrombolysis (n = 20) were compared for age, heart rate, blood pressure and oxyhemoglobin saturation at presentation, and the simplified PESI score was calculated in each patient. MDCTPA findings suggestive of adverse clinical outcome including central PE and an increased RV/LV diameter were determined for each patient. RV dysfunction on echocardiography was compared to clinical scoring, and findings on MDCTPA. RESULTS: The patients who received thrombolytic therapy were younger (48.6 ± 19.11 years versus 64.2 ± 13.83 years) (P < 0.01) and had a higher heart rate (107.6 ± 17.1/min versus 91.7 ± 17.8/min) (P < 0.05). More patients with a higher clinical severity, as determined by the simplified PESI score (12/20) and a higher shock index (0.94 ± 0.23), were thrombolysed as compared to the proportion with a lower score (3/15) (P < 0.05) or index (0.70 ± 0.20) (P < 0.005). In-hospital mortality and hemorrhagic complications at 30 days were zero in both groups. RV dysfunction by echocardiography was not a strong determinant for choosing thrombolytic therapy while central PE on MDCTPA tilted the decision towards thrombolysis. CONCLUSION: Our clinical audit revealed a predilection to use thrombolysis in younger patients with clinical severity and imaging findings on MDCTPA being the key drivers. A perception of a fragile hemodynamic status, as implied by a higher heart rate and shock index, despite a normal BP probably inclined us to thrombolyse.
Acute Card Care
· 2014 Mar · PMID 24552227
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Delivery of coronary stents can be challenging, but the use of a second or 'buddy' wire helps the progression of equipment through tortuous and rigid vessels. We successfully positioned a coronary stent in a distal lesio...Delivery of coronary stents can be challenging, but the use of a second or 'buddy' wire helps the progression of equipment through tortuous and rigid vessels. We successfully positioned a coronary stent in a distal lesion, intentionally jailing the buddy wire during stent delivery. The jailed wire was then used to proceed further with proximal coronary stenting. We report 10 cases using either the jailed or the non-jailed wire for this modified 'buddy-in-jail' technique.
Palmer WC, Kurklinsky A, Lane G
… +2 more, Ussavarungsi K, Blackshear JL
Acute Card Care
· 2014 Mar · PMID 24552226
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Type II autoimmune polyglandular syndrome (APS), a relatively common endocrine disorder, includes primary adrenal insufficiency coupled with type 1 diabetes mellitus and/or autoimmune primary hypothyroidism. Autoimmune s...Type II autoimmune polyglandular syndrome (APS), a relatively common endocrine disorder, includes primary adrenal insufficiency coupled with type 1 diabetes mellitus and/or autoimmune primary hypothyroidism. Autoimmune serositis, an associated disease, may present as symptomatic pericardial effusion. We present a case of a 54-year old male with APS who developed pericarditis leading to cardiac tamponade with a subacute loculated effusion. After urgent pericardiocentesis intrapericardial pressure dropped to 0, while central venous pressures remain elevated, consistent with acute effusive constrictive pericarditis. Contrast computerized tomography confirmed increased pericardial contrast enhancement. The patient recovered after prolonged inotropic support and glucocorticoid administration. He re-accumulated the effusion 16 days later, requiring repeat pericardiocentesis. Effusive-constrictive pericarditis, an uncommon pericardial syndrome, is characterized by simultaneous pericardial inflammation and tamponade. Prior cases of APS associated with cardiac tamponade despite low volumes of effusion have been reported, albeit without good demonstration of hemodynamic findings. We report a case of APS with recurrent pericardial effusion due to pericarditis and marked hypotension with comprehensive clinical and hemodynamic assessment. These patients may require aggressive support with pericardiocentesis, inotropes, and hormone replacement therapy. They should be followed closely for recurrent tamponade.
Acute Card Care
· 2014 Mar · PMID 24552225
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Takotsubo cardiomyopathy can occur after acute mental or physical stress, subarachnoid hemorrhage, ischemic stroke, major head trauma, acute medical illness or acute pheochromocytoma crisis. It is characterized by transi...Takotsubo cardiomyopathy can occur after acute mental or physical stress, subarachnoid hemorrhage, ischemic stroke, major head trauma, acute medical illness or acute pheochromocytoma crisis. It is characterized by transient systolic dysfunction of the apical and/or midventricular segments in patients without epicardial coronary artery disease. The condition occurs most commonly in postmenopausal women, and is characterized by transient left ventricular dysfunction. The pathophysiology of the disorder remains to be elucidated but may involve catecholamine excess and vasospasm. Future studies, perhaps in the form of an international registry, may clarify the incidence, pathophysiology, clinical course, and prognosis of this disorder.
Shorofsky M, Jayaraman D, Lellouche F
… +2 more, Husa R, Lipes J
Acute Card Care
· 2014 Mar · PMID 24552224
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BACKGROUND AND OBJECTIVES: Use of protective ventilation has been shown to decrease mortality in medical-surgical ICUs. There is limited data on tidal volume use in ventilated patients in the cardiac intensive care unit...BACKGROUND AND OBJECTIVES: Use of protective ventilation has been shown to decrease mortality in medical-surgical ICUs. There is limited data on tidal volume use in ventilated patients in the cardiac intensive care unit (CICU). We hypothesized that large tidal volumes are used in the CICU and that they could contribute to an increase in morbidity and mortality. METHODS: We conducted a retrospective chart review of all mechanically ventilated patients with congestive heart failure or cardiac arrest in a single tertiary care CICU between April 2010 and February 2012. Ventilator settings were analyzed and tidal volume for predicted body weight (VT/PBW) was calculated for 51 patients. RESULTS: The median initial tidal volume was 525 ml (IQR: 500-600) and median VT/PBW was 9.3 ml/kg (IQR: 8.3-10.1). Overall mortality was 29.4%. On univariate analysis, patients that received a VT/PBW below the median, mortality was 23.1% (95% CI: 7.9-39.3) compared to 36.0% (95% CI: 17.2-55.0) in patients that received a VT/PBW above themedian (P = 0.31). On multivariate analysis, the OR for death was 9.0 (95% CI: 1.3-62.0, P = 0.03) with VT/PBW above the median. CONCLUSION: Mechanical ventilation with high tidal volumes was associated with increased mortality in patients with congestive heart failure and post cardiac arrest in our CICU.
Gómez-Talavera S, Vivas D, Perez-Vizcayno MJ
… +9 more, Hernández-Antolín R, Fernández-Ortíz A, Bañuelos C, Escaned J, Jiménez-Quevedo P, Viliani D, Vilacosta I, Macaya C, Alfonso F
Acute Card Care
· 2014 Mar · PMID 24552223
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INTRODUCTION: Conduction disorders in patients with ST-segment elevation myocardial infarction (STEMI) are associated with high mortality. Previous studies have analyzed the implications of AVB in acute coronary syndrome...INTRODUCTION: Conduction disorders in patients with ST-segment elevation myocardial infarction (STEMI) are associated with high mortality. Previous studies have analyzed the implications of AVB in acute coronary syndrome treated with fibrinolysis. However, the implications of AVB in patients with STEMI treated with primary angioplasty have not been sufficiently studied. MATERIAL AND METHODS: 913 patients with STEMI treated with primary angioplasty. All clinical, electrocardiographic and angiographic variables were collected. RESULTS: AVB was documented in 115 patients (12.6%). On admission, AVB was present in 70 (7.7%), and persistent at hospital discharge in 36 (3.9 %). Within these, first-degree AVB was present in 29 (3.2%), second-degree in 27 (3%) and third-degree in 73 (8%). AVB was more frequent in women, elderly, hypertensive, diabetic, with worse functional class (Killip class > 2) and with higher incidence at inferior infarctions (P < 0.05). AVB in general and, more specifically, third-degree AVB was associated with a higher mortality (20.5% versus 5.7%; P < 0.001), re-infarction (8.2% versus 3.6%; P = 0.06) and a greater incidence of cardiogenic shock (33.3% versus 14%; P < 0.001). Interestingly, these events were more common in patients who had persistent AVB at hospital discharge than in those with transitory AVB or present at admission AVB. In the multivariate analysis, persistent AVB at hospital discharge proved to be an independent predictor of cardiovascular events (death and recurrent infarction), not the rest of AVB. CONCLUSIONS: AVB in patients who underwent primary angioplasty is associated with a worse prognosis while is in-hospital. This risk is particularly high in patients who had persistent AVB at hospital discharge.
Acute Card Care
· 2014 Mar · PMID 24410273
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These formulae are erroneous and lead to predictably grossly wrong results. The authors find SIG values of mean -14 mEq/l in the non-survivors' and -10 mEq/l in the survivors' group. ' According to our data the SIG appro...These formulae are erroneous and lead to predictably grossly wrong results. The authors find SIG values of mean -14 mEq/l in the non-survivors' and -10 mEq/l in the survivors' group. ' According to our data the SIG approach does not seem to add further information to usual parameters in acid-base evaluation or early risk stratification in cardiogenic shocks patients.'
Cappellini F, Da Molin S, Signorini S
… +4 more, Avanzini F, Saltafossi D, Falbo R, Brambilla P
Acute Card Care
· 2013 Dec · PMID 24191843
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Chest pain is one of the most frequent reasons for presentation to the emergency department (ED), although the estimated prevalence of AMI (acute myocardial infarction) in the ED is about 4%. One criterion for diagnosis...Chest pain is one of the most frequent reasons for presentation to the emergency department (ED), although the estimated prevalence of AMI (acute myocardial infarction) in the ED is about 4%. One criterion for diagnosis of AMI is the demonstration of a rise and/or fall in cardiac troponins, but time is needed for this to happen. Thus, the use of an additional 'early marker' of cardiac injury may aid to exclude AMI rapidly. The aim of the study was to evaluate the possibility of excluding AMI with the determination of heart-type fatty acid-binding protein (H-FABP) on baseline samples of patients referring to the ED for chest pain. 26 AMI patients and 41 non-AMI comparisons were included in the study. Both H-FABP and high sensitivity cardiac troponin T (hs-cTnT) were measured in baseline samples from these subjects. H-FABP had a negative predictive value of 100%, thus indicating the possibility of its usage in a rule-out strategy for AMI in ED for patients presenting with chest pain.
Acute Card Care
· 2013 Dec · PMID 24191776
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Cardiac arrhythmias in severe hypothermia are common and are managed primarily by re-warming techniques. A 64-year-old male presented with alcohol associated aspiration pneumonia, sepsis and severe hypothermia and was no...Cardiac arrhythmias in severe hypothermia are common and are managed primarily by re-warming techniques. A 64-year-old male presented with alcohol associated aspiration pneumonia, sepsis and severe hypothermia and was noted to have classic ECG changes of hypothermia, i.e. Osborn waves. The patient had a tumultuous clinical course with prolonged resuscitative measures. Ultimately, an early focus on invasive core temperature re-warming with cardio-pulmonary bypass resulted in a favorable outcome.
Acute Card Care
· 2013 Dec · PMID 24160712
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Vessel perforation is an undesirable and life-threatening complication during vein graft angioplasty. We report on a case of vein graft rupture during angioplasty, which was successfully managed with deployment of a poly...Vessel perforation is an undesirable and life-threatening complication during vein graft angioplasty. We report on a case of vein graft rupture during angioplasty, which was successfully managed with deployment of a polytetrafluoroethylene-covered stent.
Acute Card Care
· 2013 Dec · PMID 24160711
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Coronary artery embolus is a rare and potentially under- recognised cause of acute myocardial infarction. We describe the case of an 80-year-old woman presenting with an acute coronary syndrome secondary to coronary arte...Coronary artery embolus is a rare and potentially under- recognised cause of acute myocardial infarction. We describe the case of an 80-year-old woman presenting with an acute coronary syndrome secondary to coronary artery embolus associated with atrial fibrillation, which was successfully treated with the use of a thrombectomy aspiration catheter.
OBJECTIVES: Evaluating ECG-gated cardiac MDCT detection of systolic anterior motion of the mitral valve, in comparison to trans-thoracic echocardiography as a gold standard. MATERIALS AND METHODS: Study group included 83...OBJECTIVES: Evaluating ECG-gated cardiac MDCT detection of systolic anterior motion of the mitral valve, in comparison to trans-thoracic echocardiography as a gold standard. MATERIALS AND METHODS: Study group included 83 consecutive patients (57 men; average age 56.1 years) evaluated with both retrospective ECG-gated cardiac MDCT and trans-thoracic echocardiography within an interval of 30 days. ECG-gated cardiac MDCT imaging was performed with retrospective ECG- gating using 64-slice and 128-slice CT scanners with an inherent temporal resolution range of 75-165 ms. MDCT's and trans- thoracic echocardiograms were retrospectively and independently evaluated by experienced radiologist and cardiologist respectively, for presence of systolic anterior motion of the mitral valve. RESULTS: 7 patients (8.4%) were found to have systolic anterior motion by trans-thoracic echocardiography, from which 6 were found to have systolic anterior motion by ECG-gated cardiac MDCT. Of the 76 patients without systolic anterior motion on trans-thoracic echocardiography, all were correctly identified using ECG-gated cardiac MDCT. The sensitivity, specificity, positive and negative predictive values and accuracy of ECG-gated cardiac MDCT in identifying systolic anterior motion of the mitral valve were 85.7% (6/7), 100% (76/76), 100% (6/6), 98.7% (76/77) and 98.8% (82/83), respectively. CONCLUSION: ECG-gated cardiac MDCT is comparable to trans-thoracic echocardiography in detecting systolic anterior motion of the mitral valve.
INTRODUCTION: Oxygen is considered to have analgesic effects, but the evidence is weak. Oxygen may be harmful to the ischemic myocardium. The aim was to investigate the analgesic effect of oxygen during percutaneous coro...INTRODUCTION: Oxygen is considered to have analgesic effects, but the evidence is weak. Oxygen may be harmful to the ischemic myocardium. The aim was to investigate the analgesic effect of oxygen during percutaneous coronary intervention (PCI) and to evaluate cardiac injury. MATERIAL AND METHODS: The OXYPAIN was a phase II randomized trial with a double blind design. 305 patients were randomized to receive oxygen or atmospheric air during PCI. The patients were asked to score chest pain by the Visual-Analog Scale (VAS). The use of analgesic agents and troponin-t was measured. RESULTS: There was no significant difference in pain between the groups: oxygen: 2.0, [2.0-4.0], air: 2.0, [2.0-5.0] (median, interquartile range: 25-75%, P = 0.12). The median difference in score of VAS was [95% CI]: 0, [0-1.0]. The oxygen group received 0.44 ± 0.11 mg of morphine versus 0.46 ± 0.13, P = n.s. The peak value of troponin-t post-PCI was 38, [11-352] nmol/ml in the oxygen group and 61, [16-241] for patients treated with air, P = 0.46. CONCLUSIONS: The use of oxygen during PCI did not demonstrate any analgesic effect. There was no difference in myocardial injury measured with troponin-t or in the morphine dose. Our results do not support routine use of oxygen. (NCT01413841.).
INTRODUCTION: This case describes a patient who suffered three myocardial infarctions over a two-week period. Testing confirmed thrombophilia as the etiology. CASE: A 55-year old male initially presented to the emergency...INTRODUCTION: This case describes a patient who suffered three myocardial infarctions over a two-week period. Testing confirmed thrombophilia as the etiology. CASE: A 55-year old male initially presented to the emergency department with a complaint of chest pain. Testing showed an elevated troponin at 2.2 ng/ml and ST elevations on electrocardiogram. The patient was transferred to the cardiac catheterization laboratory and a drug-eluting stent was placed. One day after the initial stent placement, in-stent thrombosis of the drug-eluting stent was discovered. Angioplasty and aspiration thrombectomy were performed, and the patient was released from the hospital three days later. 72 h after his discharge, the patient returned to the emergency department due to recurrent chest pain and diaphoresis. Shortly after arrival he became unresponsive and telemetry showed ventricular tachycardia which resolved with cardioversion. Reocclusion of the right coronary artery was again noted in the catheterization laboratory and three bare metal stents were placed. Laboratory testing found presence of anticardiolipin antibody and evidence of PT20201A mutation. CONCLUSION: Hypercoagulable states, although an uncommon cause of myocardial infarction, should be considered when investigating the etiology of recurrent coronary events. Prompt treatment is important in the prevention of future occurrences.