Koh AS, Choi LM, Sim LL
… +5 more, Tan JW, Khin LW, Chua TS, Koh TH, Chia S
Acute Card Care
· 2011 Dec · PMID 22142201
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OBJECTIVES: To determine clinical outcome and rates of target vessel revascularization (TVR) in patients undergoing primary percutaneous coronary intervention (PCI) for STEMI who were treated with cobalt-chromium stents...OBJECTIVES: To determine clinical outcome and rates of target vessel revascularization (TVR) in patients undergoing primary percutaneous coronary intervention (PCI) for STEMI who were treated with cobalt-chromium stents compared to stainless steel bare metal stents (BMS). BACKGROUND: The newer generation cobalt chromium stents were reported to achieve lower rates of TVR compared with conventional BMS. METHODS: Consecutive STEMI cases admitted within 12 h of symptom onset and undergoing primary angioplasty and bare metal stent implantation 1 January 2002 and 31 December 2008 were identified. Primary outcomes were rates of clinically-driven TVR at six months as well as occurrence of major adverse cardiovascular events (MACE) either of all-cause death, repeat myocardial infarction or TVR at six months. RESULTS: 1030 cases with 1175 lesions (84% males) and median age of 58 years underwent primary PCI for STEMI in our registry. Overall procedural success rate was 98%. Stainless steel stents were inserted in 65% of the culprit lesions (stainless steel, n = 766 versus cobalt chromium, n = 264). Primary outcomes of TVR (3.5% in the stainless steel group and 3.4% in the cobalt chromium group, P = 0.93) and MACE (8.4% in the stainless steel group and 5.3% in the cobalt chromium group, P = 0.11) after six months were no different between the two groups. However, there were more deaths at 30 days in the stainless steel group compared to the cobalt chromium group (3.5% versus 0.4%, HR 4.04 (1.03-3.88), P = 0.04). CONCLUSION: Both cobalt-chromium and stainless steel coronary stents were associated with similar and low risk of clinically-driven TVR.
Timóteo AT, Toste A, Ramos R
… +3 more, Oliveira JA, Ferreira ML, Ferreira RC
Acute Card Care
· 2011 Dec · PMID 22142200
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INTRODUCTION: Heart rate (HR) is a prognostic factor in stable angina. However, in the context of acute coronary syndromes (ACS), it is less studied. AIMS: To evaluate the influence of admission HR as a prognostic factor...INTRODUCTION: Heart rate (HR) is a prognostic factor in stable angina. However, in the context of acute coronary syndromes (ACS), it is less studied. AIMS: To evaluate the influence of admission HR as a prognostic factor in patients with ACS. METHODS: We evaluated in-hospital, 30-day and one-year mortality in patients with ACS, according to admission HR. RESULTS: We analysed 1126 patients, 69% males, mean age 64 years, 59% with ST-segment elevation acute myocardial infarction and 15% on medication with a beta-blocker. On admission, 14% presented signs of heart failure. In 10%, left ventricular ejection fraction was < 35%. In-hospital mortality was 7.1%, 30-day mortality 9.1% and one-year mortality 10.7%. The best cut-off of HR to predict mortality was 80 bpm (sensitivity 64-66% and specificity 54-55%). By multivariate analysis, a heart rate ≥ 80 bpm was an independent predictor of all-cause mortality (HR 1.50, 95% CI: 1.01-2.23, P = 0.047). CONCLUSIONS: In a population with ACS, a higher admission HR is an independent predictor of short- and medium-term prognosis, which is also independent of left ventricular function.
Plastaras P, Chopard R, Janin S
… +3 more, Seronde MF, Meneveau N, Schiele F
Acute Card Care
· 2011 Dec · PMID 22066832
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BACKGROUND: There is wide variation in recording of reperfusion times in the management of ST segment elevation acute coronary syndromes (ACS). We investigated factors that could predict time to reperfusion. METHODS: Sin...BACKGROUND: There is wide variation in recording of reperfusion times in the management of ST segment elevation acute coronary syndromes (ACS). We investigated factors that could predict time to reperfusion. METHODS: Single-centre, retrospective study of all consecutive patients admitted for primary PCI from June 2009 to October 2010. Door-to-artery (D2A) and Door-to-balloon (D2B) times were calculated from times noted by cathlab. nurses and compared with times from digital recordings of PCI procedures. Predictors of time to reperfusion were identified by logistic regression. RESULTS: 300 patients were included. Median (interquartile range) D2B time recorded by cathlab. nurses (D2B-CN) was 35.5 (24; 52) minutes, 32 (20; 51) min from PCI recordings (D2B-PCI). Average difference between D2B-CN and D2B-PCI was 6.2 min (P < 0.0001). Concordance of percent patients with a D2B time < 90 and < 45 min was mediocre, kappa coefficients 0.44 (95% CI: 0.10-0.79) and 0.68 (95% CI: 0.57-0.80) respectively. By multivariate analysis, older patients had longest D2A times (P = 0.04); patients with longest D2A and D2B times more frequently had elevated creatinine (P = 0.002 (D2A), P = 0.0003 (D2B). Organizational aspects did not influence reperfusion times. CONCLUSION: Data regarding reperfusion times are unreliable when recorded by nurses. Age and creatinine levels are significantly associated with reperfusion times, whereas organizational aspects are not.
Acute Card Care
· 2011 Dec · PMID 22060562
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BACKGROUND: The clinical significance of moment measurements (admission and fasting glycaemia), persistent (hyperglycaemic index, HGI; time average glucose, TAG; mean glucose; maximum glucose) or chronic hyperglycaemia (...BACKGROUND: The clinical significance of moment measurements (admission and fasting glycaemia), persistent (hyperglycaemic index, HGI; time average glucose, TAG; mean glucose; maximum glucose) or chronic hyperglycaemia (HbA1c), estimated average glucose, eAG) is still elusive in clinical practice. AIM: To identify the clinical significance of hyperglycaemia in ACS. METHODS: The study included 226 consecutive patients with ACS. Indicators for hyperglycaemia were defined, calculated and a correlation analysis with standard parameters-EF, maximum CPK, maximum CPK-MB and troponin was performed. Patients were followed up for 12 months. RESULTS: Indicators for persistent and chronic hyperglycaemia correlated neither to ejection fraction, nor to the enzymes for myocardial necrosis (P > 0.05). In contrast, acute hyperglycaemia correlated negatively with ventricular systolic dysfunction (P = 0.001/0.007) and positively with maximum CPK, MB and troponin (P = 0.0001/0.008). TAG was an independent predictor for 6-month re-hospitalization (P = 0.027) because of cardiac complications. CONCLUSION: Glycaemia at admission and fasting glucose could be used as metabolic surrogate markers for ventricular systolic dysfunction and TAG as an independent surrogate marker for six-month re-hospitalization. None of the indicators for hyperglycaemia could be used as independent prognostic factors for survival. Hyperglycaemia rather reflects an underlying impairment in glucose metabolism.
Numerous studies have sought to assess stent patency by cardiac computer tomographic angiography (CCTA) in comparison with invasive coronary angiography in patients who had undergone percutaneous coronary stenting. Even...Numerous studies have sought to assess stent patency by cardiac computer tomographic angiography (CCTA) in comparison with invasive coronary angiography in patients who had undergone percutaneous coronary stenting. Even with newer generation scanners, CCTA has been of limited value in the assessment of the revascularized patient. The main reason being blooming artifact from metallic stents often obscures stent luminal dimension, making the stented segment unassessable. We report on a novel finding of good visibility of TITAN-2 coronary stents demonstrable on CCTA for 2 patients and discuss the possible mechanism and potential implications of this observation.
Enoxaparin is used in the treatment of acute coronary syndromes and offers improved outcome in the composite endpoint of death, myocardial infarction and major bleeding when compared with unfractionated heparin (UFH). Ou...Enoxaparin is used in the treatment of acute coronary syndromes and offers improved outcome in the composite endpoint of death, myocardial infarction and major bleeding when compared with unfractionated heparin (UFH). Our report describes a rare case of massive life-threatening subcutaneous chest wall haemorrhage, distant to the injection site. Clinicians should be aware of atypical presentations of haemorrhage when using combination antiplatelet and antithrombotic therapy.
BACKGROUND: Echocardiographic quantification of global and regional right ventricular (RV) function is critical in patients with acute pulmonary embolism (PE), but remains a challenge particularly in acute RV dilatation....BACKGROUND: Echocardiographic quantification of global and regional right ventricular (RV) function is critical in patients with acute pulmonary embolism (PE), but remains a challenge particularly in acute RV dilatation. METHODS: Apical two-dimensional images of patients with acute PE were analyzed using both conventional and speckle tracking imaging compared with controls; patients with PE were divided into those who received thrombolysis and those who did not. The basal, mid and apical segments of the RV free wall and septum were analyzed. Correlations between speckle tracking measurements and in-hospital mortality were made. RESULTS: 53 patients with PE were compared with 15 controls. Of the PE patients, 98.1% were treated with systemic anticoagulation, 15.1% with thrombolysis; 38% required ICU admission and 5.6% died. Strain rate of the mid interventricular septum and strain of the basal and mid interventricular septal segments were significantly lower in patients with PE than control. However, strain rate of the basal RV free wall was higher than controls. In thrombolysed patients, basal RV free wall strain rate was lower than in non-thrombolysed patients. RV strain rate significantly correlated with in-hospital mortality. CONCLUSIONS: Speckle tracking may be a sensitive tool for assessing RV dysfunction and predicting mortality in patients with PE in this pilot study.
BACKGROUND/OBJECTIVES: Cardiotoxic drug poisoning can lead to severe cardiac shock (CS) and death. B-type natriuretic peptide (BNP) is a well-established diagnostic and prognostic marker in heart failure but has never be...BACKGROUND/OBJECTIVES: Cardiotoxic drug poisoning can lead to severe cardiac shock (CS) and death. B-type natriuretic peptide (BNP) is a well-established diagnostic and prognostic marker in heart failure but has never been assessed in patients with cardiotoxic drug poisoning. The aim of the study was to determine whether BNP could be useful for early stratification of patients admitted to intensive care unit. METHODS: 30 consecutive patients experiencing shock and cardiotoxic drug exposure were enrolled in a prospective monocentric study and underwent at least two BNP measurements within the first 24 h after admission. RESULTS: While BNP values on admission were poorly informative, subsequent BNP measurements (11 ± 6 h after admission) were significantly increased in patients with CS compared to those with non-CS (756; [364-1130] versus 24; [15-65] pg/ml respectively; P = 0.008). This second BNP level was also significantly increased in non-survivor patients compared to survivor patients (784; [654-1028] versus 29; [15-104] pg/ml respectively; P = 0.05): BNP levels above 360 pg/ml predicted in-hospital mortality (sensitivity = 100%, specificity = 92%). In a multivariate analysis, BNP, SAPS II score and lactate blood level were associated with death. CONCLUSIONS: Serial BNP measurements after admission for cardiotoxic drug poisoning are useful to identify patients at the highest risk of CS as well as in-hospital death.
BACKGROUND: The incidence of contrast-induced nephropathy (CIN) after percutaneous coronary intervention (PCI) is increasing. The aim of the study is to assess the benefits of prophylactic haemofiltration (PHF) in patien...BACKGROUND: The incidence of contrast-induced nephropathy (CIN) after percutaneous coronary intervention (PCI) is increasing. The aim of the study is to assess the benefits of prophylactic haemofiltration (PHF) in patients with high risk of developing CIN after PCI. METHODS: 20 patients who underwent PHF after PCI in the context of acute coronary syndrome were selected retrospectively and compared with 20 matched controls with similar risk characteristics. The main variable analysed was the appearance of CIN and the secondary variables were the development of acute clinical kidney failure, heart failure, therapeutic HF and mortality. RESULTS: The baseline characteristics were similar in both groups, with reference creatinine of 2.4 ± 1.3 mg/dl, contrast used 392 ± 213 cc and Mehran score of 21.9 ± 5.2 in the PHF group, as opposed to values of 2.0 ± 0.6 mg/dl, 368 ± 126 cc and 20.2 ± 6.9 respectively in controls. The incidence of CIN was of 6 patients (30%) in the PHF group and 13 patients (65%) in the control group (P=0.03). There were no significant differences in the rest of the variables studied. CONCLUSION: Haemofiltration after PCI may be an effective strategy for the prevention of CIN in patients at high risk of developing it.
BACKGROUND: No data has been published on the management of in-stent restenotic bifurcation lesions. The aim of this small case series was to examine the angiographic and long-term clinical outcomes of using sleeve techn...BACKGROUND: No data has been published on the management of in-stent restenotic bifurcation lesions. The aim of this small case series was to examine the angiographic and long-term clinical outcomes of using sleeve technique to treat this lesion subset. METHODS: Six consecutive and symptomatic patients with MEDINA classification 1,1,1 in-stent restenotic bifurcation lesion were treated with drug-eluting stents using sleeve technique. Dual antiplatelet therapy was prescribed for an average of 13.5 ± 2.3 months. RESULTS: Most of the lesions (87%) were located at LAD/diagonal branch bifurcation. Kissing balloon inflation was performed successfully in all the patients. Follow-up angiography at nine months revealed a late loss of 0.35 ± 0.26 mm and 0.56 ± 0.56 mm in MV and SB, respectively. Angiographic restenosis was developed in 2 patients (33%), which were all located at the SB ostium. No in-hospital MACE was observed. One-year MACE was 17%, attributed by 1 patient with restenosis who needed revascularization. The mean follow up period was 50 ± 18 months, no stent thrombosis was detected. CONCLUSIONS: The use of sleeve technique to treat in-stent restenotic bifurcation lesions is associated with good acute procedural result, a fairly low one-year MACE and long-term clinical safety.
INTRODUCTION: We sought to assess the effect of a territorial system of care for ST-elevation myocardial infarction (STEMI) on the outcome of out-of-hospital cardiac arrest (OOHCA). MATERIALS AND METHODS: We enrolled 720...INTRODUCTION: We sought to assess the effect of a territorial system of care for ST-elevation myocardial infarction (STEMI) on the outcome of out-of-hospital cardiac arrest (OOHCA). MATERIALS AND METHODS: We enrolled 720 patients who experienced a witnessed OOHCA of presumed cardiac origin during a four-year period in an area with a STEMI network and for whom resuscitation was attempted. RESULTS: Overall, 242 (33.6%) patients had return of spontaneous circulation (ROSC), 645 (90%) died before discharge. We observed a trend toward decreased overall mortality for OOHCA between the years 2004 and 2007, both in the entire population and in patients with ROSC (2004=94%; 2005=89%; 2006=85%; 2007=89%; P=0.064; 2004=81%; 2005=69%; 2006=65%; 2007=60%; P=0.076, respectively). On multivariable analysis, age, crew-witnessed arrest and presence of shockable rhythm were independent predictors of mortality. Patients who experienced OOHCA in the year 2006 (OR=0.47; 95% CI: 0.21-1.05; P=0.07) and 2007 (OR=0.51; 95% CI: 0.23-1.12; P=0.09) showed a strong trend toward decreased risk of mortality compared to year 2004. In patients with ROSC, the year 2007 was associated with a significant lower risk of mortality compared to year 2004 (OR=0.38; 95% CI: 0.15-0.96; P=0.04). CONCLUSIONS: Implementation of a territorial network of care for STEMI appears to be associated with reduced mortality OOHCA patients.
Coronary heart disease and its main complication, myocardial infarction is leading cause of death worldwide. Over the past years, much progress has been made in the pharmacotherapy of major risk factors like dyslipidemia...Coronary heart disease and its main complication, myocardial infarction is leading cause of death worldwide. Over the past years, much progress has been made in the pharmacotherapy of major risk factors like dyslipidemias, diabetes mellitus and hypertension. The targeting of coronary risk factors coupled with advances in the management of coronary artery disease has improved patient survival. However, the incidence of cardiovascular disease is projected to continue to rise and the identification of individuals at risk should improve beyond the traditional models of global risk factor scoring. In the past few years, important progresses have been made in the area of genomics, especially with the completion of the human genome-sequencing Consortium of 2004, proteomics and imaging. This progress will promote a better understanding of cardiovascular risk assessments and disease prediction, thus allowing earlier preventive strategies to prevent and improve cardiovascular outcomes. These genomic advances have improved characterization of disease pathology especially at the molecular level with the discovery and introduction of genetic markers, single nucleotide polymorphisms (SNPs), and haplotype blocks.
INTRODUCTION: Obese patients submitted to elective coronary angioplasty have a paradoxical reduction in hospital and long-term mortality. In primary angioplasty setting, the relation with Body Mass Index (BMI) is less st...INTRODUCTION: Obese patients submitted to elective coronary angioplasty have a paradoxical reduction in hospital and long-term mortality. In primary angioplasty setting, the relation with Body Mass Index (BMI) is less studied. OBJECTIVES: To evaluate the impact of obesity in the results after ST-segment elevation acute myocardial infarction treated by primary angioplasty. METHODS: Study of 539 consecutive patients with ST-segment elevation acute myocardial infarction (STEMI) submitted to primary angioplasty. We evaluated in-hospital, 30-day and one-year all-cause mortality according to BMI: 'normal', <25 kg/m(2); 'overweight', 25-29.9 kg/m(2) and 'obese', ≥ 30 kg/m(2). RESULTS: Obese patients were younger, had more hypertension and hyperlipidemia. There were no differences in previous cardiac history and hospital data. In-hospital mortality was 8.0% for patients with normal BMI, 4.4% for overweight patients and 5.9% for obese patients (P=0.296). At 30 days, 9.6%, 5.2% and 6.9% (P=0.212) and at first year, 11.2%, 5.2% and 6.9% (P=0.064), respectively. Overweight was the only group with decreased risk (OR: 0.44, 95% CI: 0.21-0.90, P=0.015), even after adjustment for confounding variables (OR: 0.37, 95% CI: 0.15-0.95, P=0.038). CONCLUSIONS: Overweight patients had a better prognosis after primary angioplasty for STEMI compared with other BMI groups.
Coronary arterial obstruction associated with congenital aortic valve disease is rare in childhood, and has not been reported in adult. Here we reported a 49-year-old healthy woman with hypoplastic left coronary cusp res...Coronary arterial obstruction associated with congenital aortic valve disease is rare in childhood, and has not been reported in adult. Here we reported a 49-year-old healthy woman with hypoplastic left coronary cusp resulting in myocardial ischemia in the territory of left main coronary artery.
Tubaro M, Danchin N, Goldstein P
… +25 more, Filippatos G, Hasin Y, Heras M, Jansky P, Norekval TM, Swahn E, Thygesen K, Vrints C, Zahger D, Arntz HR, Bellou A, De La Coussaye JE, De Luca L, Huber K, Lambert Y, Lettino M, Lindahl B, McLean S, Nibbe L, Peacock WF, Price S, Quinn T, Spaulding C, Tatu-Chitoiu G, Van De Werf F
Acute Card Care
· 2011 Jun · PMID 21627394
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In ST-elevation myocardial infarction (STEMI) the pre-hospital phase is the most critical, as the administration of the most appropriate treatment in a timely manner is instrumental for mortality reduction. STEMI systems...In ST-elevation myocardial infarction (STEMI) the pre-hospital phase is the most critical, as the administration of the most appropriate treatment in a timely manner is instrumental for mortality reduction. STEMI systems of care based on networks of medical institutions connected by an efficient emergency medical service are pivotal. The first steps are devoted to minimize the patient's delay in seeking care, rapidly dispatch a properly staffed and equipped ambulance to make the diagnosis on scene, deliver initial drug therapy and transport the patient to the most appropriate (not necessarily the closest) cardiac facility. Primary PCI is the treatment of choice, but thrombolysis followed by coronary angiography and possibly PCI is a valid alternative, according to patient's baseline risk, time from symptoms onset and primary PCI-related delay. Paramedics and nurses have an important role in pre-hospital STEMI care and their empowerment is essential to increase the effectiveness of the system. Strong cooperation between cardiologists and emergency medicine doctors is mandatory for optimal pre-hospital STEMI care. Scientific societies have an important role in guideline implementation as well as in developing quality indicators and performance measures; health care professionals must overcome existing barriers to optimal care together with political and administrative decision makers.
Iakobishvili Z, Cohen E, Garty M
… +8 more, Behar S, Shotan A, Sandach A, Gottlieb S, Mager A, Battler A, Hasdai D, Heart Failure Survey in Isarel (HFSIS) Investigators
Acute Card Care
· 2011 Jun · PMID 21627393
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BACKGROUND: Current guidelines regarding the use of intravenous morphine (IM) in the management of patients with acute decompensated heart failure (ADHF) are discordant; whereas the American guidelines reserve IM for ter...BACKGROUND: Current guidelines regarding the use of intravenous morphine (IM) in the management of patients with acute decompensated heart failure (ADHF) are discordant; whereas the American guidelines reserve IM for terminal patients, the European guidelines recommend its use in the early stage of treatment. Our aim was to determine the impact of IM on outcomes of ADHF patients. METHODS: Stepwise logistic regression and propensity score analysis of ADHF patients with and without use of IM was performed in a national heart failure survey. RESULTS: Of the 4102 enrolled patients, we identified 2336 ADHF patients, of whom 218 (9.3%) received IM. IM patients were more likely to have acute coronary syndromes, acute rather than exacerbation of chronic heart failure, and diabetes mellitus and dyslipidemia. They had higher heart rate, were less likely to receive diuretics and more likely to receive aspirin and statins. Unadjusted in-hospital mortality rates were 11.5% versus 5.0% for patients who did or did not receive IM, and the adjusted odds ratio (OR) for in-hospital death was: 2.0 (1.1 – 3.5, P = 0.02). Using propensity analysis, we identified 218 matched pairs of patients who did or did not receive IM. In multivariable analysis accounting for the propensity score (c-statistic 0.82), IM was not associated with increased in-hospital death (OR: 1.2 (0.6 – 2.4), P = 0.55). CONCLUSION: IM was used sparingly in our ADHF cohort, and was independently associated with increased in-hospital death in multivariable analysis, but not in propensity score analysis. Thus, IM may be used in ADHF, but with caution. Further randomized trials are warranted.
Choy JS, Svendsen M, Lu X
… +7 more, Zheng H, Sulkin MS, Sinha AK, Morales C, Moussa I, Navia JA, Kassab GS
Acute Card Care
· 2011 Jun · PMID 21539459
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BACKGROUND: External pumps have been previously used to minimize edema and hemorrhage caused by coronary retroperfusion. The objective of this study was to use a pump-less approach (selective autoretroperfusion, SARP) to...BACKGROUND: External pumps have been previously used to minimize edema and hemorrhage caused by coronary retroperfusion. The objective of this study was to use a pump-less approach (selective autoretroperfusion, SARP) to preserve myocardial function after acute coronary artery ligation. METHODS: In five experimental pigs, the LAD artery was ligated distal to the first diagonal and retroperfusion was instituted for three hours from a brachiocephalic artery at 50 mmHg pressure through an adjustable occluder on the cannula. In eight control pigs, the LAD artery was ligated distal to the second diagonal for the same duration with no SARP. RESULTS: ECG showed more prominent S-T segment elevation in the untreated control group despite the more distal ligation. The degree of myocardial contraction was significantly attenuated in the control group but was largely preserved in the SARP treated group. The myocytes were well preserved in the SARP group with no rupture of venous microvessels. Myocyte edema and disruption was observed in the control group with only mild extracellular edema in the SARP treated group. CONCLUSION: SARP preserved myocardial function with no damage to the myocyte and venules during three hours of acute LAD ligation.