BACKGROUND: We hypothesized that measurement of B-type natriuretic peptide could identify patients with non-ST elevation acute coronary syndromes at high risk for complications during beta-blocker (esmolol) infusion. MET...BACKGROUND: We hypothesized that measurement of B-type natriuretic peptide could identify patients with non-ST elevation acute coronary syndromes at high risk for complications during beta-blocker (esmolol) infusion. METHODS: We reviewed the records of 340 consecutive patients admitted with a non-ST elevation acute coronary syndrome. Seventy three (47 males, aged 62 ± 14 years) received esmolol up to a maximum dose of 300 μg/ kg/min until the symptoms were relieved or an adverse event occurred. RESULTS: The median infusion rate at steady state was 175 μg/kg/min (median infusion time 18 h). Infusion was halted in 14 patients. The frequency of drug discontinuation increased across admission BNP quartiles. BNP > 141 pg/ml at admission had a 95% predictive value for subsequent withdrawal of esmolol. The presence of BNP > 141 pg/ml in combination with systolic blood pressure < 130 mmHg and left ventricular ejection fraction < 50% identified a group of patients at high risk for drug interruption (interruption frequency = 83%, 95% CI: 55-95%). CONCLUSIONS: In conclusion, BNP measurement in combination with systolic blood pressure and 2D echocardiography may identify patients with non-ST elevation acute coronary syndromes at high risk for adverse events during esmolol infusion.
BACKGROUND: The outcome of acute myocardial infarction (AMI) complicated with cardiogenic shock is poor. The aim of this study was to analyse, whether upfront abciximab administration could improve the outcomes of cardio...BACKGROUND: The outcome of acute myocardial infarction (AMI) complicated with cardiogenic shock is poor. The aim of this study was to analyse, whether upfront abciximab administration could improve the outcomes of cardiogenic shock. METHODS: This multicentre open trial randomized 80 patients with AMI complicated by cardiogenic shock expected to undergo primary PCI into group A (routine upfront-pre-procedural-abciximab bolus followed by 12-h abciximab infusion) and group B (standard therapy). The study primary objective was 30-day combined outcome (death/reinfarction/stroke/new severe renal failure). RESULTS: PCI was technically successful in 90% (A) versus 87.5% (B) patients. Abciximab was used in 100% (A) versus 35% (B). The primary endpoint occurred in 17 group A patients (42.5%) and 11 group B patients (27.5%, P = 0.24). Ejection fraction among survivors after 30 days was 44 ± 11% (A) versus 41 ± 12% (B, P = 0.205). Major bleeding occurred in 17.5% (A) versus 7.5% (B, P = 0.310). No differences (A versus B) were found in TIMI-flow and MBG after PCI. CONCLUSIONS: This study did not show any benefit from routine pre-procedural abciximab when compared with a selective abciximab use during the intervention in patients with cardiogenic shock undergoing primary PCI. However, small sample size of the trial preclude any definitive conclusion, a larger prospective, randomized, multicentered trial is needed.
Ventricular septal defect after acute myocardial infarction (AMI) is a complication associated with poor outcome in the absence of intervention. We report a case of successful TEE guided transcatheter closure of a post m...Ventricular septal defect after acute myocardial infarction (AMI) is a complication associated with poor outcome in the absence of intervention. We report a case of successful TEE guided transcatheter closure of a post myocardial infarction (MI) ventricular septal defect (VSD) with an Amplatzer occluder in a 79 years old male with cardiogenic shock.
Greenberg G, Cohen E, Garty M
… +8 more, Iakobishvili Z, Sandach A, Behar S, Shotan A, Gottlieb S, Mager A, Battler A, Hasdai D
Acute Card Care
· 2011 Jun · PMID 21526917
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BACKGROUND: By and large, prior registries and randomized trials have not distinguished between acute heart failure (AHF) associated with acute coronary syndrome (ACS) versus other causes. AIMS: To examine whether the tr...BACKGROUND: By and large, prior registries and randomized trials have not distinguished between acute heart failure (AHF) associated with acute coronary syndrome (ACS) versus other causes. AIMS: To examine whether the treatments and outcomes of ACS-associated AHF are different from non-ACS-associated AHF. METHODS: We examined in a prospective, nationwide hospital-based survey the adjusted outcomes of AHF patients with and without ACS as its principal cause. RESULTS: Of the 4102 patients in our national heart failure survey, 2336 (56.9%) had AHF, of whom 923 (39.5%) had ACS-associated AHF. These patients were more likely to receive intravenous inotropes and vasodilators and to undergo coronary angiography and revascularization, but less likely to receive intravenous diuretics. The unadjusted in-hospital, 30-day, one-year, and four-year mortality rates for AHF patients with or without ACS were 6.5% versus 5.0% (P = 0.13), 10.3% versus 7.5% (P = 0.02), 26.6% versus 31.0% (P = 0.02), and 55.3% versus 63.3% (P = 0.0001), respectively. In the multivariate analysis, the adjusted mortality risk for patients with ACS at the respective time points were 1.46 (0.99-2.10), 1.67 (1.22-2.30), 1.02 (0.86-1.20), and 0.93 (0.82-1.04). CONCLUSIONS: Patients with ACS-associated AHF seem to have a unique clinical course and perhaps should be distinguished from other AHF patients in future trials and registries.
Luporsi P, Chopard R, Janin S
… +9 more, Racadot E, Bernard Y, Ecarnot F, Séronde MF, Briand F, Guignier A, Descotes-Genon V, Meneveau N, Schiele F
Acute Card Care
· 2011 Jun · PMID 21517672
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BACKGROUND: Fondaparinux has a favourable efficacy-safety profile but if major bleeding occurs, reversal of antithrombotic treatment is challenging. We present clinical and biological observations from patients treated w...BACKGROUND: Fondaparinux has a favourable efficacy-safety profile but if major bleeding occurs, reversal of antithrombotic treatment is challenging. We present clinical and biological observations from patients treated with rFVIIa for bleeding under fondaparinux. METHODS: Fondaparinux-treated patients with bleeding (>10% haematocrit decrease) and cardiovascular collapse were eligible. Patients received a single 90 μg/kg bolus rFVIIa. Clinical success was defined as clinical bleeding control without thrombotic complication. A biological criterion of successful antagonization was defined as a >100% increase in peak thrombin generation (C(max)). RESULTS: 8 patients were treated (5 ACS, 3 VTE). Patients received aspirin and clopidogrel (n = 5), eptifibatide (n = 2), fluindione (n = 5). In addition to standard haemostatic methods, all patients received rFVIIa and transfusion. Clinical progression was favourable in 4, with bleeding clinically controlled in <6 h. 1 patient died. Biological success was observed in 4 patients with lowest baseline anti-Xa (0.67-0.92 U/L); ¾ had clinical success. In patients with baseline anti-Xa >1.0 U/L (1.14-1.62 U/L), increase in C(max) was low; ¾ had no clinical bleeding control. CONCLUSION: This series is the largest describing rFVIIa use to control bleeding in patients under fondaparinux. rVFIIa was considered efficient in 50%, suggesting inefficacy in the context of elevated anti-Xa.
Shochat M, Shotan A, Trachtengerts V
… +7 more, Blondheim DS, Kazatsker M, Gurovich V, Asif A, Shochat I, Rozenman Y, Meisel SR
Acute Card Care
· 2011 Jun · PMID 21517671
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BACKGROUND: Monitoring of lung fluid content (LFC) in order to predict acute heart failure (AHF) during acute myocardial infarction (AMI) is an unmet challenge. AIM: To evaluate in AMI patients the ability of proposed ra...BACKGROUND: Monitoring of lung fluid content (LFC) in order to predict acute heart failure (AHF) during acute myocardial infarction (AMI) is an unmet challenge. AIM: To evaluate in AMI patients the ability of proposed radiological score (RS), which is the sum of selected radiological signs of congestion, to reflect correctly LFC, as assessed with repeat physical examinations and lung impedance (LI) measurements. METHODS: Chest X-rays were taken at baseline, when rales were detected, whenever indicated, and at conclusion of monitoring. RS grading for LFC assessment was: RS = 0-1 for normal X-ray, RS = 2-4 for interstitial congestion, and RS values of 5-6, 7-8 and 9-10 signified mild, moderate and severe alveolar edema, respectively. RESULTS: 624 AMI patients without AHF at baseline were monitored (94 ± 42 h). 476 patients (76%) with baseline RS of 0.3 ± 0.5 did not develop AHF. Overt AHF developed in 148 patients (24%) during monitoring; baseline RS (0.6 ± 0.8) reached 5.4 ± 0.7, 7.0 ± 0.8, and 9.8 ± 0.5 at the stages of mild, moderate, and severe alveolar edema, respectively. AHF resolved with treatment. RS decreased to 1.5 ± 1.3 (P < 0.01) and correlated with physical examination (r = 0.6, P < 0.01) and LI (r = -0.9, P < 0.01). CONCLUSION: RS correlated well with findings on physical examination during AHF and closely correlated with LI.
Amador P, Santos JF, Gonçalves S
… +2 more, Seixo F, Soares L
Acute Card Care
· 2011 Jun · PMID 21517669
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OBJECTIVES: Compare the discriminatory performance of two validated ischemic risk scores and a bleeding risk score for in-hospital adverse events across the spectrum of non-ST elevation acute coronary syndromes (NSTE-ACS...OBJECTIVES: Compare the discriminatory performance of two validated ischemic risk scores and a bleeding risk score for in-hospital adverse events across the spectrum of non-ST elevation acute coronary syndromes (NSTE-ACS). MATERIAL AND METHODS: Single center, 516 consecutive patients admitted with the diagnosis of NSTE-ACS. The following risk scores were calculated for each patient: TIMI, GRACE and CRUSADE. The following in-hospital endpoints were used: major bleeding (as defined by the CRUSADE criteria); recurrent ischemia (re-infarction or recurrent angina); and death. Discriminatory performance was measured by the c-statistic and compared. RESULTS: There were 36 major bleeding events, 34 recurrent ischemic events and 10 deaths. TIMI RS, GRACE RS, and CRUSADE RS demonstrated fair discriminatory accuracy for major bleeding (c-statistic = 0.64, 0.58, and 0.61, respectively). GRACE and CRUSADE risk scores demonstrated a better performance than TIMI RS for predicting in-hospital death (c-statistic = 0.92 and 0.86, respectively versus c-statistic = 0.63, P < 0.001). For the combined endpoint of in-hospital death or recurrent ischemia there was no statistically significant difference between CRUSADE RS, GRACE RS, and TIMI RS (c-statistic = 0.58, 0.57, and 0.62, respectively). CONCLUSION: Both ischemic and bleeding risk scores are able to predict in-hospital bleeding, ischemic and fatal events.
Acute occlusion of left main coronary artery after diagnostic angiography can be rapidly fatal. We describe two patients with left main disease that developed cardiac arrest shortly after diagnostic coronary angiography....Acute occlusion of left main coronary artery after diagnostic angiography can be rapidly fatal. We describe two patients with left main disease that developed cardiac arrest shortly after diagnostic coronary angiography. They were both successfully treated with emergency left main stenting while cardiopulmonary resuscitation was being performed. Patients with left main disease should be carefully monitored after diagnostic angiography to allow prompt recognition of acute occlusion. Emergency stenting may be required for salvaging the patients.
While long-term anticoagulation prevents ischemic stroke in high-risk patients with atrial fibrillation (AF), the optimal initial anti-thrombotic regime in acute AF is less well defined. We randomized 96 patients with ne...While long-term anticoagulation prevents ischemic stroke in high-risk patients with atrial fibrillation (AF), the optimal initial anti-thrombotic regime in acute AF is less well defined. We randomized 96 patients with new onset acute AF in an emergency admission ward to receive (1) once-daily preparation of low molecular weight heparin (LMWH), tinzaparin or (2) conventional intravenous unfractionated heparin (target APTT 50-70 s). 5 patients in unfractionated heparin group compared with no patients in LMWH group (0%, P = 0.04) developed ischemic stroke/transient ischemic attack during the first 48 h. An initial subcutaneous LMWH was safe and effective in ischemic stroke prevention in patients with acute AF.
This report describes a case of variant angina induced by epidural infusion of bupivacaine hydrochloride for the treatment of intractable low back pain in a 66-year-old male patient with lumbar discopathy. Severe reversi...This report describes a case of variant angina induced by epidural infusion of bupivacaine hydrochloride for the treatment of intractable low back pain in a 66-year-old male patient with lumbar discopathy. Severe reversible coronary artery spasm of right coronary artery was demonstrated by coronary angiography. Withdrawal of epidural anesthesia and treatment with nitrates and calcium channel antagonists resulted in cessation of variant angina.
Brunetti ND, Ieva R, Correale M
… +6 more, De Gennaro L, Pellegrino PL, Dioguardi E, D'Arienzo G, Ziccardi L, Di Biase M
Acute Card Care
· 2011 Jun · PMID 21410309
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We report the case of a 65-year-old woman with complete atrio-ventricular block who underwent orciprenaline administration and pacemaker implantation. The intervention was complicated by pneumothorax and acute left ventr...We report the case of a 65-year-old woman with complete atrio-ventricular block who underwent orciprenaline administration and pacemaker implantation. The intervention was complicated by pneumothorax and acute left ventricular systolic dysfunction with typical apical ballooning (Tako-Tsubo like syndrome). The patient was treated with diuretics and calcium-sensitizers and completely recovered. We speculate that both external and internal catecholamine triggered an acute left ventricular impairment with typical Tako-Tsubo features.
Acute Card Care
· 2011 Mar · PMID 21323412
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AIMS: We evaluated the efficacy and safety of a biolimus- eluting biodegradable polymer-coated stent (BES) in patients with ST-segment elevation and non ST-segment elevation acute myocardial infarction (AMI). METHODS AND...AIMS: We evaluated the efficacy and safety of a biolimus- eluting biodegradable polymer-coated stent (BES) in patients with ST-segment elevation and non ST-segment elevation acute myocardial infarction (AMI). METHODS AND RESULTS: This was an observational study involving a single centre patient registry. We compared the rates of cardiac death, myocardial infarction, target vessel revascularization (TVR) and composite end point of cardiac death and myocardial infarction at 24 months in 106 patients who received BES versus 94 patients who received an otherwise similar bare metal stent (BMS) during percutaneous coronary intervention for AMI. There was no significant difference in the rate of cardiac death (0.9% versus 7.4%; P = 0.09), myocardial infarction (4.7% versus 3.2%; P = 0.69), stent thrombosis (0.9% versus 3.2%; P = 0.30) or cardiac death and myocardial infarction (5.7% versus 10.6%; P = 0.30) between the two groups. The rate of TVR was significantly higher in the BMS group (1.9% versus 8.5%; P = 0.04), with patients receiving BMS being four times more likely to require TVR. CONCLUSION: The use of BES in selected patients with AMI appears to be safe and is associated with significantly reduced rate of TVR, when compared with an otherwise similar BMS.
Ferrari M, Hekmat K, Jung C
… +5 more, Ferrari-Kuehne K, Pfeifer R, Schlosser MH, Werner GS, Figulla HR
Acute Card Care
· 2011 Mar · PMID 21323411
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BACKGROUND & OBJECTIVES: Mobile heart-lung-machines applied by percutaneous cannulation are mostly used in patients suffering from acute myocardial infarction (AMI). Whether patients with non-coronary reasons for circula...BACKGROUND & OBJECTIVES: Mobile heart-lung-machines applied by percutaneous cannulation are mostly used in patients suffering from acute myocardial infarction (AMI). Whether patients with non-coronary reasons for circulatory arrest benefit of percutaneous emergency circulatory support (PECS) in the same way is still unclear. METHODS: We included 22 consecutive patients who were treated by PECS during a registry period of two years. Primary study endpoint was 30-day mortality rate. RESULTS: Circulatory arrest was caused by AMI in 14 patients (64%). The remaining 8 patients suffered from cardiomyopathy/myocarditis, 4; pulmonary embolism, 2; acute pulmonary failure, 1; and tumor lysis syndrome, 1. Revascularization rate was 93% in the AMI group under PECS support. Overall survival rate was 36.4% at one month: it reached 62.5% among non-coronary patients, but only 21.4% in the AMI group (P = 0.02). Weaning was possible by direct heart transplantation in two patients. Additional two patients required implantation of a left ventricular assist device. Pumpless extracorporeal lung assist was used in one case. CONCLUSION: In this small retrospective study percutaneous emergency circulatory support provided sufficient hemodynamic stabilization in emergency situations. One fifth of AMI patients were saved by immediate restoration of circulation and causal treatment when other means of resuscitation failed. Higher survival rates were noted in non-coronary patients.
Acute Card Care
· 2011 Mar · PMID 21323410
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AIM: Different types of progenitor cells have been used to improve cardiac conditions after myocardial infarction (MI). Results have shown that while the infusion of a single cell type is safe and feasible, efficacy is m...AIM: Different types of progenitor cells have been used to improve cardiac conditions after myocardial infarction (MI). Results have shown that while the infusion of a single cell type is safe and feasible, efficacy is modest. Recently, the use of a combination, rather than a single, stem cell product has emerged as an attractive option to improve cardiac outcome after a MI. Before initiating a phase II clinical trial to assess safety and efficacy after the transendocardial infusion of a combination stem cell product, a bench testing assay was designed to validate that delivery through the injection catheter is not associated with cell loss/damage. The latter is important since mesenchymal stem cells (MSC), a component of the cell product, consist of large cells expressing matrix molecules and adhesive receptors. METHODS: The cell product (a mixture of mononuclear cells and MSC) was sequentially injected through a Myostar injection catheter. Exiting fractions were assessed for cell number, viability, capability to restart cell growth and immunophenotype. RESULTS: Cell recovery and viability were high. In turn, exiting cells preserved their biological properties and immunophenotype. CONCLUSIONS: Delivery of cells through a Myostar catheter is safe and not associated with changes in cell survival and/or properties.
Towae F, Juenger C, Mudra H
… +9 more, Glunz HG, Hauptmann E, Grube E, Voigtländer T, Bauer T, Zeymer U, Senges J, Gitt AK, Zahn R
Acute Card Care
· 2011 Mar · PMID 21323409
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AIM OF THE STUDY: To examine the development of door-to-angiography time (DTA) and to evaluate the impact of door-to-angiography time in patients with ST-elevation myocardial infarction (STEMI) on hospital and one-year m...AIM OF THE STUDY: To examine the development of door-to-angiography time (DTA) and to evaluate the impact of door-to-angiography time in patients with ST-elevation myocardial infarction (STEMI) on hospital and one-year mortality. METHODS AND RESULTS: From 1994 to 2008, 5078 patients (pts) and known DTA with acute ST-elevation myocardial infarction were enrolled into the MITRAplus and OPTAMI registry in Germany. Our data showed a reduction of the door-to- angiography time from 80 min to 64 min in the last 14 years (P < 0.001). Over 80% of patients received an angiography less than two hours after admission. The main predictor of a shorter door-to-balloon time was a hypotension with a blood pressure lower than 100 mmHg (OR 1.46, 95%CI: 1.08-1.91). Whereas a history of prior myocardial infarction (OR 0.61, 95%CI: 0.45-0.84), a previous coronary bypass grafting (OR 0.55, 95%CI: 0.33-0.91), age older than 75 years (OR 0.78, 95%CI: 0.62-0.99) and a pre-hospital delay more than three hours (OR 0.78, 95%CI: 0.66-0.93) were independent predictors for a longer of the door-to-balloon time. In the multivariate regression analysis no influence was detected of door-to-angiography time on hospital or one-year mortality. CONCLUSION: The DTA decreased in the last 14 years and is actually very short in Germany. We indentified predictors of a longer door-to-angiography time in clinical practice. Given the overall short in-hospital delay, the observed door-to-angiography time did not have influence on hospital and mid term mortality.
Barison A, de Carlo M, Bellini F
… +3 more, Capozza PF, Lunardini A, Petronio AS
Acute Card Care
· 2011 Mar · PMID 21323408
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Late stent thrombosis represents a life-threatening event, usually triggered by inadequate antiplatelet therapy and promoted by multiple risk factors, such as stenting of a chronic total occlusion, overlapping stenting,...Late stent thrombosis represents a life-threatening event, usually triggered by inadequate antiplatelet therapy and promoted by multiple risk factors, such as stenting of a chronic total occlusion, overlapping stenting, an abnormal vascular response to the eluted drug, stent malapposition and stent fracture. A 57-year-old man with aspirin hypersensitivity underwent successful percutaneous revascularization of a chronic total occlusion of the left anterior descending artery (LAD). He received two sirolimus-eluting stents overlapping for 2 mm and was discharged on clopidogrel and picotamide. Two years later, 15 days after clopidogrel discontinuation, he experienced an anterior ST-segment elevation myocardial infarction and underwent rescue percutaneous LAD thrombectomy after unsuccessful fibrinolysis. Coronary angiography showed fracture of the distal stent, with a 5 mm gap between the two portions, as well as severe late stent malapposition, confirmed by optical coherence tomography. Despite treatment with clopidogrel and picotamide, in the following days the patient experienced two new episodes of stent thrombosis, treated with thrombectomy and deployment of bioengineered stents. The patient underwent successful oral aspirin desensitization, with a complete in vitro inhibition of platelet function, and was discharged on aspirin, clopidogrel and warfarin, without experiencing other events at 6-month follow-up.
Acute Card Care
· 2011 Mar · PMID 21244232
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BACKGROUND: Transmyocardial ischemia is manifested as ST-segment elevation (STE). We examined acoustic cardiographic indices of STE that occur during percutaneous coronary intervention (PCI). METHODS: Of 83 patients unde...BACKGROUND: Transmyocardial ischemia is manifested as ST-segment elevation (STE). We examined acoustic cardiographic indices of STE that occur during percutaneous coronary intervention (PCI). METHODS: Of 83 patients undergoing coronary angiography, 25 underwent PCI, including 5 who developed STE. Continuous 12-lead ECG and computerized acoustic cardiographic heart sound analysis were performed during PCI. Intensities of the heart sounds (S1 to S4), diastolic time (from S2 to S1), and systolic time intervals (S1 to S2) were recorded. RESULTS: As STE increased, there was no change in heart rate or systolic time. Contractility decreased, with an increase in S3 intensity and a reduction in S1/S2 ratio. Left ventricular stiffness increased, reflected by an increase in S4 intensity. CONCLUSIONS: As transmyocardial ischemia worsened during progressive STE, acoustic cardiographic indices reflected impaired contractility and increased ventricular stiffness. In particular, the S4 was most predictive of increasing degrees of STE. These findings have implications for assessment of transmyocardial ischemia in patients with ECG findings that confound ST segment interpretation.