BACKGROUND AND PURPOSE: The incidence of cardiovascular events remains high in patients with myocardial infarction (MI) despite advances in current therapies. New and better methods for identifying patients at high risk...BACKGROUND AND PURPOSE: The incidence of cardiovascular events remains high in patients with myocardial infarction (MI) despite advances in current therapies. New and better methods for identifying patients at high risk of recurrent cardiovascular events are needed. This study aimed to analyze the clinical predictors of cardiovascular events in patients with MI. METHODS: The prospective cohort study consisted of 123 men and women aged between 31 and 80 years who had suffered a previous myocardial infarction (MI) 3-12 months before the examinations. The exclusion criteria were known diabetes mellitus and chronic inflammatory disease. Patients were followed up over 6.03 ± 1.36 years for CV death, recurrent MI, stroke and unstable angina pectoris. Plasma levels of high-sensitivity C-reactive protein (hs-CRP), total cholesterol and triglycerides were measured at the baseline. Echocardiography was performed. RESULTS: hs-CRP was significantly higher (P < 0.05) and left ventricular ejection fraction (LVEF) was borderline significantly lower (P = 0.057) in patients with CV events compared with those without CV events. In multivariate statistical analysis and after adjustment for age, sex, total cholesterol, smoking, and other baseline characteristics, hs-CRP > 3 mg/l, (RR: 6.23, 95%CI: 1.47-26.39; P < 0.01) and LVEF (RR: 0.94, 95%CI: 0.88-1.00; P < 0.05) remain as independent predictors of CV events. CONCLUSIONS: In this study population with previous MI an elevated hs-CRP > 3 mg/l and left ventricular dysfunction were significant predictors of CV death, recurrent MI, stroke and unstable angina pectoris, independent of baseline characteristics and medical treatment. Data from the study suggest that hs-CRP levels ≥ 3 mg/l and baseline ejections fraction can be used to stratify individuals at high risk of adverse CV events from patients with stable and asymptomatic coronary artery disease (CAD).
Spontaneous coronary artery dissection (SCAD) is a rare but potentially life-threatening condition if it goes unrecognized. Symptoms can range from chest pain to sudden cardiac death. We present a case of 33 year-old fem...Spontaneous coronary artery dissection (SCAD) is a rare but potentially life-threatening condition if it goes unrecognized. Symptoms can range from chest pain to sudden cardiac death. We present a case of 33 year-old female marathon runner who presented to emergency department (ED) complaining of sudden onset of non-positional, constant, pleuritic chest discomfort. She was eventually found to have spontaneous dissection of coronary artery. The mimicking nature of SCAD is presented in this article. We conclude that spontaneous coronary dissection, although still challenging due to its mimicking nature, should be considered in the differential diagnosis of chest pain and associated myocardial injury.
We report the case of a 75-year-old man, referred for worsening dyspnea and fever. The electrocardiography (ECG) showed mild ST-elevation in anterior leads, while cardiac echography severe left ventricular (LV) systolic...We report the case of a 75-year-old man, referred for worsening dyspnea and fever. The electrocardiography (ECG) showed mild ST-elevation in anterior leads, while cardiac echography severe left ventricular (LV) systolic dysfunction with apical ballooning. Later on, ECG showed negative T-waves and QT-prolongation in the same anterior leads and T-waves positivization during fever peak. Ten days later, LV ejection fraction completely recovered, apical ballooning and fever disappeared. We, therefore, hypothesize that transient apical ballooning found in our patient may have been induced by a respiratory infection, not detectable at seriate blood cultures.
We present two cases of massive pulmonary embolism with persistent systolic hypotension but both have contraindications for thrombolysis. Therefore, rheolytic thrombectomy using AngioJet was performed and immediate haemo...We present two cases of massive pulmonary embolism with persistent systolic hypotension but both have contraindications for thrombolysis. Therefore, rheolytic thrombectomy using AngioJet was performed and immediate haemodynamic improvement was achieved including blood pressure and symptoms. According to guidelines, catheter embolectomy or fragmentation may be considered as alternative to surgical treatment in massive pulmonary embolism patients when thrombolysis is absolutely contraindicated or has failed. Percutaneous catheter-based interventional techniques include thrombus fragmentation, rheolytic thrombectomy, suction thrombectomy and rotational thrombectomy. With the existing literature review and our case, rheolytic thrombectomy for treatment of massive pulmonary embolism using AngioJet achieves a high procedural success rate (approximately 90%) n terms of improvement of haemodynamics, pulmonary perfusion and angiographic result but low complication rate.
A right coronary artery origin from the left coronary sinus and a left coronary origin from the right sinus although rarely encountered during routine cardiac catheterization, they represent two relatively common autopsy...A right coronary artery origin from the left coronary sinus and a left coronary origin from the right sinus although rarely encountered during routine cardiac catheterization, they represent two relatively common autopsy findings in young patients suffering sudden cardiac death. The interarterial course of the aberrant artery, between the aortic root and the pulmonary artery has been considered as a malignant variant, because of the higher risk of myocardial ischemia and sudden death. We present two rare cases of ectopic coronary origin from the opposite sinus of Valsalva.
Rizzello V, Lucci D, Maggioni AP
… +8 more, Giampaoli S, Greco C, Di Pasquale G, Pallotti MG, Mureddu GF, Di Chiara A, Boccanelli A, IN-ACS Outcome Investigators
Acute Card Care
· 2012 Jun · PMID 22452295
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BACKGROUND: The Italian network on acute coronary syndromes outcome (IN-ACS Outcome) study is a nationwide observational, multicenter study with the aim to describe clinical epidemiology, management, 30-days and one-year...BACKGROUND: The Italian network on acute coronary syndromes outcome (IN-ACS Outcome) study is a nationwide observational, multicenter study with the aim to describe clinical epidemiology, management, 30-days and one-year outcomes of ACS in Italy. METHODS: All consecutive patients admitted for ACS to 38 hospitals, between December 2005 and February 2007, were enrolled in the study. Patient in-hospital details and follow-up data at 30-days and one-year were collected using a web-based CRF and stored in a central database. RESULTS: A total of 6045 patients (age 68 ± 13 years) were enrolled: 2313 patients (38.3%) had ST elevation myocardial infarction (STEMI) and 3732 (61.7%) patients had NSTE-ACS. Primary PCI was performed in 1085 (46.9%) STEMI patients, thrombolysis in 590 (25.5%) patients, whereas 638 (27.6%) patients were not reperfused. Among patients with NSTE-ACS, coronary angiography was performed in 2797 (75%) patients, PCI in 1797 (48.2%) patients and CABG in 213 (5.7%) patients. Thirty-days and one-year mortality rates were 5.8% and 9.8%, in STEMI patients and 3.1% and 8.6%, in NSTE-ACS patients. CONCLUSIONS: The IN-ACS Outcome study showed that the management of ACS is still suboptimal. Although 30-days mortality is low, the one-year mortality is still substantial.
Attaná P, Lazzeri C, Chiostri M
… +3 more, Picariello C, Gensini GF, Valente S
Acute Card Care
· 2012 Mar · PMID 22356569
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BACKGROUND: Recent studies documented that serial lactate measurements over time may be clinically more reliable than lactate absolute value for risk stratification. The aim of the present investigation was to assess the...BACKGROUND: Recent studies documented that serial lactate measurements over time may be clinically more reliable than lactate absolute value for risk stratification. The aim of the present investigation was to assess the role of lactate clearance in predicting early death in cardiogenic shock (CS) following ST-elevation myocardial infarction (STEMI) submitted to primary percutaneous coronary intervention (PCI). METHODS: 51 consecutive patients with CS following STEMI were prospectively enrolled. Lactate was measured in Intensive Cardiac Care Unit (ICCU) on admission and on the twelfth hour. Logistic regression analysis was performed to identify the independent predictors for in-ICCU mortality. Receiver operating characteristic (ROC) curve was constructed in order to identify cut-off for admission lactate and for 12-h lactate clearance in relation to in-ICCU mortality. Follow-up survival rate were investigated by Kaplan-Meier curves. RESULTS: At 12 h from admission, lactate clearance was higher in survivors (P=0.013). A higher in-ICCU mortality was observed in patients with 12 hours lactate clearance<10% (P=0.002). At follow up, patients with 12-h lactate clearance<10% showed a significantly lower survival rate. CONCLUSIONS: In patients with CS following STEMI, 12-h lactate clearance<10% identifies a subset of patients at higher risk for death at short and long-term.
Acute Card Care
· 2012 Mar · PMID 22356568
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BACKGROUND: The clinical significance of inflammatory cytokines as independent prognostic markers in patients with acute coronary syndrome (ACS) and hyperglycaemia remains uncertain. AIM: To determine the value of inflam...BACKGROUND: The clinical significance of inflammatory cytokines as independent prognostic markers in patients with acute coronary syndrome (ACS) and hyperglycaemia remains uncertain. AIM: To determine the value of inflammatory biomarkers as independent prognostic indicators and their relation with hyperglycaemia in ACS patients. METHODS: TNF-α and hsCRP were defined 48 h after admission and indicators for hyperglycaemia were calculated in 256 consecutive patients with ACS. A correlation analysis with standard clinical variables--EF, maximum CK, CK-MB, troponin and different indices for hyperglycaemia was performed. Patients were followed up for 12 months. RESULTS: Baseline TNF-α correlated neither to EF, nor to the enzymes for myocardial necrosis (P>0.05). In contrast, hsCRP correlated negatively with EF (P=0.001) and positively with maximum CK, CK-MB, troponin (P=0.0001) irrespectively of the glucose status. TNF-α was associated with fasting glycaemia, HGI and TAG (P=0.033/0.041/0.018) and hsCRP-with indicators for acute, persistent and chronic glycaemia in all patients. Moreover, hsCRP was an independent marker for six-month survival (P=0.024). TAG was a stronger six-month survival predictor than hsCRP (P=0.010/0.024). CONCLUSION: hsCRP and TNF-α have clinical significance regardless of the glucose metabolic status. hsCRP is an independent marker for six-month survival. TAG is the better predictor for poor outcome than hsCRP.
Alexandrescu R, Bottle A, Jarman B
… +1 more, Aylin P
Acute Card Care
· 2012 Mar · PMID 22356567
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BACKGROUND: The aim of the study was to evaluate the impact of transfer status and distance on in-hospital mortality for acute myocardial infarction (AMI) patients undergoing angioplasty on the same or next day of hospit...BACKGROUND: The aim of the study was to evaluate the impact of transfer status and distance on in-hospital mortality for acute myocardial infarction (AMI) patients undergoing angioplasty on the same or next day of hospital admission. METHODS: Retrospective analysis of English hospital administrative data using logistic regression modelling. RESULTS: After risk adjustment for the patient baseline characteristics, transferred patients had a higher in-hospital mortality rate than those admitted directly to hospital for angioplasty performed on the same or next day: OR=1.25 (95% confidence interval: 1.02-1.52), P=0.029. There was no statistically significant increased risk of in-hospital mortality with increasing distance between home and angioplasty centre (OR=0.98 (0.84-1.16), P=0.842 for 6-15 km and 1.03 (0.87-1.22), P=0.768 for >15 km when compared with <6 km) or with increasing inter-hospital transfer distance for angioplasty (OR=0.84 (0.55-1.29), P=0.435 for 16-34 km and 0.88 (0.58-1.35), for >34 km when compared with <16 km). CONCLUSIONS: Transfer status is associated with in-hospital mortality rate for AMI patients undergoing angioplasty on the same or next day of hospital admission. No relation between in-hospital mortality and the distance from home to angioplasty centre or inter-hospital transfer distance for angioplasty was found in these patients.
Barra S, Providência R, Paiva L
… +5 more, Gomes PL, Seca L, Silva J, Nascimento J, Leitão-Marques A
Acute Card Care
· 2012 Mar · PMID 22296621
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AIMS: Ischemic Mitral Regurgitation (MR) has early prognostic impact in Myocardial Infarction (MI). Its medium-term importance, especially of mild MR, has not been established. PURPOSE: to determine new clinical/analytic...AIMS: Ischemic Mitral Regurgitation (MR) has early prognostic impact in Myocardial Infarction (MI). Its medium-term importance, especially of mild MR, has not been established. PURPOSE: to determine new clinical/analytical predictors of MR in MI-patients and establish its prognostic value during two-year follow-up [endpoints: mortality, decompensated heart failure (dHF)]. METHODS AND RESULTS: 796 patients admitted for MI (age 68.8±13.4, 63.2% males, 44.6% STEMI). DATA: Admission analytical study, risk scores, coronariography, pre-discharge echocardiogram. Patients followed for two years. Clinical/analytical predictors of pre-discharge MR assessed. Predictive model for presence of pre-discharge MR included GRACE for intra-hospital mortality [IHM](OR=1.008, p<0.001), glomerular filtration rate (GFR)[OR=0.993, p=0.048], admission haemoglobin (OR=0.84, p=0.003). In univariate analysis, moderate-severe MR predicted 2-year mortality (OR=3.32, p<0.001), but not dHF. Two year mortality rate was proportional to severity of pre-discharge MR. Mild MR (vs. no MR) associated with higher risk for 2-year mortality (OR=2.04, p=0.014) and re-admission for dHF (OR=2.55, p=0.001). Predictive model for 2-year mortality included MR severity (OR=1.42, p=0.033) and GRACE for IHM (OR=1.023, p<0.001). CONCLUSION: GRACE score for IHM, GFR and admission haemoglobin independently predicted risk for pre-discharge MR. MR, including its milder form, was an independent predictor of 2-year mortality, adding prognostic power to GRACE score.
Kusniec J, Iakobishvili Z, Haim M
… +3 more, Golovchiner G, Shohat-Zabarski R, Strasberg B
Acute Card Care
· 2012 Mar · PMID 22296564
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Prinzmetal (variant) angina may be associated with cardiac arrhythmias that can deteriorate to fatal ventricular arrhythmias. We present 2 patients with syncope where vasospastic angina and severe ventricular arrhythmias...Prinzmetal (variant) angina may be associated with cardiac arrhythmias that can deteriorate to fatal ventricular arrhythmias. We present 2 patients with syncope where vasospastic angina and severe ventricular arrhythmias were found to be responsible for the syncopal episodes.
Al Suwaidi J, Asaad N, Al-Qahtani A
… +3 more, Al-Mulla AW, Singh R, Albinali HA
Acute Card Care
· 2012 Jun · PMID 22295893
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INTRODUCTION: The clinical characteristics and outcome of patients hospitalized with heart failure vary according to ethnicities. BACKGROUND: Limited epidemiologic data are available about the clinical characteristics an...INTRODUCTION: The clinical characteristics and outcome of patients hospitalized with heart failure vary according to ethnicities. BACKGROUND: Limited epidemiologic data are available about the clinical characteristics and outcome of heart failure (HF) patients among non-Caucasian populations. METHODS: Between 1 January 1991 and 31 December 2010; 41 453 consecutive patients were hospitalized at Hamad General Hospital, Doha, Qatar for cardiac reasons. Patients were into two groups; hospitalized with HF (n = 7069) and hospitalized for non-HF (no-HF). Among HF patients Sub-analysis was made according to ethnicity; Middle-eastern Arabs (MEA) (n = 5227) versus South Asian (SA) (n = 1289) patients. RESULTS: HF patients were older and more likely to be female when compared to non-HF patients. HF patients were also more likely to have diabetes mellitus (DM), hypertension (HTN), atrial fibrillation (AF) and renal impairment when compared to non-HF patients. SA HF patients younger and less likely to have DM, HTN and AF when compared to MEA patients. Over the 20-years period there was decrease in in-hospital mortality and stroke rates regardless of ethnicity (death; 8.3% to 4.8%, stroke; 0.8% to 0.1%; all P = 0.001). CONCLUSION: HF patients in the Middle East present at relatively younger age regardless of ethnicity. In-hospital mortality and stroke rates decreased significantly over the 20-years.
Angeli F, Reboldi G, Garofoli M
… +2 more, Ramundo E, Verdecchia P
Acute Card Care
· 2012 Mar · PMID 22295883
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BACKGROUND: Current guidelines for the treatment of patients with acute coronary syndrome (ACS) recommend the use of statins before hospital discharge. However, the prognostic impact of an early initiation of treatment i...BACKGROUND: Current guidelines for the treatment of patients with acute coronary syndrome (ACS) recommend the use of statins before hospital discharge. However, the prognostic impact of an early initiation of treatment is uncertain. METHODS: We reviewed data from randomized controlled trials (RCTs) to test the hypothesis that differences in the time of initiation of statin therapy may be associated with differences in mortality after hospitalization for ACS. We extracted data from 10 RCTs which evaluated one-month mortality of patients early treated with statins (mean time of administration≤72 h from hospitalization) compared to patients receiving placebo or standard care. RESULTS: Overall, 4030 patients were randomized to statin therapy and 4022 patients to the control group. The effect of statins on mortality was not significant (OR 0.81, 95% CI: 0.58-1.12; P=0.198). The 10 trials were divided up by the mean time of initiation of statin therapy (day 1, day 2 and day 3). Statins reduced mortality when treatment was initiated in day 1 (OR 0.63, 95% CI: 0.41-0.99; P=0.045), not in day 2 or day 3. There was no statistically significant interaction across the subgroups in the risk of mortality (P=0.303). CONCLUSIONS: In patients admitted to hospital for ACS, statins may reduce hospital mortality when treatment is initiated on the first day of hospitalization.
Ng Kam Chuen MJ, Schofield R, Sankaranarayanan R
… +6 more, Crowe C, Helm K, Lane D, Singh RK, Mcdonald J, Balachandran KP
Acute Card Care
· 2012 Mar · PMID 22273479
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BACKGROUND: East Lancashire Hospitals NHS Trust reorganized its services in October 2007 with acute admissions sent to one site which allowed the development of a 24/7 Consultant delivered cardiology service. METHODS: A...BACKGROUND: East Lancashire Hospitals NHS Trust reorganized its services in October 2007 with acute admissions sent to one site which allowed the development of a 24/7 Consultant delivered cardiology service. METHODS: A retrospective analysis of all patients admitted with an acute coronary syndrome between two periods: Group 1: October 2006 to September 2007 and Group 2: October 2007 and September 2008. We looked at the following end points-length of stay, in-hospital and 30 day all cause mortality. RESULTS: 633 patients in group 1 and 748 patients in group 2. There was significant reduction in length of stay from a median (IQ range) 7 (5-11) days to 5 (3-9) days; P<0.0001. The in-hospital mortality reduced from 15.8% (n=100) to 7.6% (n=56); P<0.0001. The mortality at 30 days reduced from 15.2% (n=96) to 8.3% (n=62); P<0.0001. These reductions remained significant after adjustment for demographic and risk factor variables. CONCLUSION: A 24/7 Consultant Cardiologist delivered cardiac care is associated with marked reductions in all cause mortality following admission with acute coronary syndromes. This improvement occurred with a significant reduction in hospital length of stay.
Soon D, Ho HH, Loh KK
… +4 more, Ooi YW, Foo D, Jafary FH, Ong PJ
Acute Card Care
· 2012 Mar · PMID 22273457
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Intracoronary bolus of eptifibatide during percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) has been shown to result in higher local platelet glycoprotein IIb/IIIa receptor occupancy with im...Intracoronary bolus of eptifibatide during percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) has been shown to result in higher local platelet glycoprotein IIb/IIIa receptor occupancy with improved microvascular perfusion. It is unclear whether intracoronary administration of eptifibatide in a larger patient population results in favourable clinical outcomes. We evaluated the safety and efficacy of two regimens of intracoronary eptifibatide (bolus only versus bolus followed by intravenous infusion) in patients undergoing primary PCI for ST-elevation MI. They were divided into two groups: Group A (n=67) who received fixed-dose intracoronary eptifibatide bolus only and Group B (n=88) who received intracoronary bolus and continuous intravenous infusion of eptifibatide for 18 h. The preliminary findings from our registry showed that both regimens were associated with good angiographic outcomes, few bleeding events and low in-hospital major adverse cardiac events. A large prospective randomized, multi-centre trial is needed to confirm our observation.
Acute Card Care
· 2011 Dec · PMID 22142204
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We described the novel use of intravascular ultrasound-virtual histology (IVUS-VH) imaging in two young adult male patients who presented with acute inferior ST-elevation myocardial infarction (STEMI) and we highlight th...We described the novel use of intravascular ultrasound-virtual histology (IVUS-VH) imaging in two young adult male patients who presented with acute inferior ST-elevation myocardial infarction (STEMI) and we highlight the usefulness of this new invasive coronary imaging technique. Both patients had thrombotic occlusion of the right coronary arteries but the underlying pathophysiological mechanisms leading to acute thrombosis were different. The in vivo information obtained by IVUS-VH imaging was invaluable in pinpointing the likely etiology of STEMI and thus, guided our primary percutaneous coronary intervention strategy appropriately.
Feld Y, Dubi S, Reisner Y
… +5 more, Schwammenthal E, Shofti R, Pinhasi A, Carasso S, Elami A
Acute Card Care
· 2011 Dec · PMID 22142202
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UNLABELLED: We hypothesized that attachment of elastic coil to the left ventricular (LV) wall, capable of exerting outward forces may allow the transfer of energy from systole to diastole and improve diastolic function....UNLABELLED: We hypothesized that attachment of elastic coil to the left ventricular (LV) wall, capable of exerting outward forces may allow the transfer of energy from systole to diastole and improve diastolic function. METHODS AND RESULTS: An extra-ventricular-device, composed of a series of elastic elements interposed between spiral screws attached to the epimyocardium of the LV free-wall was developed. The hemodynamic and mechanical effects of the device were tested using a computerized model, an in vitro model utilizing a computerized-controlled fluid pump, eight healthy sheep and 10 mini-pigs induced with diastolic dysfunction by renal wrapping. The computerized and in vitro models predicted a reduction of the LV diastolic pressure curve and partial normalization of the pressure-volume loop. The sheep study demonstrated preservation of animal's wellbeing including maintaining cardiac mechanical function with stable energy transfer from systole to diastole throughout the 6 months follow-up. The mini-pigs study showed an increase in the early diastolic to systolic strain-rate ratio in the mid-endocardial level (23 ± 10%, P = 0.008) and an increase in early apical reverse rotation rate of 50% (P = 0.016 compared to control). CONCLUSIONS: This study presents a novel concept of using a mechanical device to transfer energy from systole to diastole, potentially enhancing diastolic function.