Acute Card Care
· 2011 Mar · PMID 21244231
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BACKGROUND: A pooled analysis in cardiogenic shock due to acute coronary syndromes is desirable to assess the effect of early revascularization (ERV) across all ages and a wide spectrum of disease severity. METHODS: Only...BACKGROUND: A pooled analysis in cardiogenic shock due to acute coronary syndromes is desirable to assess the effect of early revascularization (ERV) across all ages and a wide spectrum of disease severity. METHODS: Only two randomized controlled trials (RCT), i.e. SMASH and SHOCK, met the inclusion criteria and were combined for a pooled analysis using individual patient data (n = 348). RESULTS: SMASH patients (n = 54, 16%) had more severe disease than SHOCK patients (n = 294, 84%). After adjustment for age, anoxic brain damage, non-inferior myocardial infarction, prior coronary artery bypass graft surgery, renal failure, systolic blood pressure, and selection for coronary angiography, one-year mortality was similar (relative risk SHOCK versus SMASH 0.87, 95% CI: 0.61-1.25). Relative risk of one-year death for ERV versus initial medical stabilization was 0.82 (95% CI: 0.70-0.96). There was no significant difference in the treatment effect by age (≤75 years relative risk at one year 0.79, 95% CI: 0.63-0.99; > 75 years relative risk at one year 0.93, 95% CI: 0.56-1.53; interaction P = 0.10). CONCLUSIONS: Only two RCT have been published emphasizing the difficulty of enrolling critically ill patients. Despite large differences in shock severity, ERV benefit is similar across all ages and not significantly different for the elderly.
Hallén J, Jensen JK, Buser P
… +2 more, Jaffe AS, Atar D
Acute Card Care
· 2011 Mar · PMID 21244230
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BACKGROUND: Presence of microvascular obstruction (MVO) following primary percutaneous coronary intervention (pPCI) for ST-elevation myocardial infarction (STEMI) confers higher risk of left-ventricular remodelling and d...BACKGROUND: Presence of microvascular obstruction (MVO) following primary percutaneous coronary intervention (pPCI) for ST-elevation myocardial infarction (STEMI) confers higher risk of left-ventricular remodelling and dysfunction. Measurement of cardiac troponin I (cTnI) after STEMI reflects the extent of myocardial destruction. We aimed to explore whether cTnI values were associated with presence of MVO independently of infarct size in STEMI patients receiving pPCI. METHODS: 175 patients with STEMI were included. cTnI was sampled at 24 and 48 h. MVO and infarct size was determined by delayed enhancement with cardiac magnetic resonance at five to seven days post index event. RESULTS: The presence of MVO following STEMI was associated with larger infarct size and higher values of cTnI at 24 and 48 h. For any given infarct size or cTnI value, there was a greater risk of MVO development in non-anterior infarctions. cTnI was strongly associated with MVO in both anterior and non-anterior infarctions (P < 0.01) after adjustment for covariates (including infarct size); and was reasonably effective in predicting MVO in individual patients (area-under-the-curve ≥0.81). CONCLUSION: Presence of MVO is reflected in levels of cTnI sampled at an early time-point following STEMI and this association persists after adjustment for infarct size.
Ruiz-Bailén M, Romero-Bermejo FJ, Ramos-Cuadra JÁ
… +10 more, Rucabado-Aguilar L, Chibouti-Bouichrat K, Castillo-Rivera AM, Pintor-Mármol A, Expósito-Ruiz M, García MI, Dolores-Pola-Gallego-de-Guzmán M, Gómez-Jiménez J, Torres-Ruiz JM, Ulecia-Martínez M
Acute Card Care
· 2011 Mar · PMID 21244229
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OBJECTIVES: To evaluate the frequency and the factors associated with performance of echocardiography in acute coronary syndrome (ACS) patients during their stay in intensive care units or coronary care units (ICU/CCU)....OBJECTIVES: To evaluate the frequency and the factors associated with performance of echocardiography in acute coronary syndrome (ACS) patients during their stay in intensive care units or coronary care units (ICU/CCU). METHODS: Retrospective cohort study including all patients diagnosed with acute coronary syndrome-unstable angina (UA), acute myocardial infarction (AMI)-included in the 'ARIAM' Spanish multi-centre register. The study period was from June 1996 to December 2005. The follow-up period is limited to the time of stay in the Intensive Care Units or Coronary Care Units (ICUs/CCUs). A univariate analysis was carried out on the patients with UA and AMI according to whether or not echocardiograms were performed during their stay in ICU/CCU. In addition the data was evaluated for any temporal variation in the performance of echocardiography, and two multivariate analyses were carried out to evaluate the factors associated with performance of echocardiography in UA and AMI patients. RESULTS: The study period included 45,688 AMI patients and 17,277 UA patients. Echocardiograms were performed in 26.87% AMI patients and 16.75% UA patients. In total, 15,172 echocardiograms were performed in ACS patients (23.6%). The multivariate analysis demonstrated that the variables associated with the performance of echocardiography in UA were: Killip and Kimball class, cigarette smoking, family history of cardiovascular events, cardiogenic shock, uncontrolled angina, mechanical ventilation and treatment with ACE inhibitors, while the presence of previous AMI was associated with fewer echocardiograms being performed. In AMI, the multivariate analysis showed the following variables to be associated with the performance of echocardiography: Killip and Kimball class, Q-AMI, right heart failure, the need for insertion of Swan-Ganz catheter, cardiogenic shock, high-degree AV block and the administration of ACE inhibitors, while age was associated with fewer being performed. Over the 10 years of the study period, there was a discrete but significant increase in the use of echocardiography in patients in ICU/CCU. CONCLUSIONS: Echocardiography is not commonly used in ACS patients while in ICU/CCU. UA and AMI patients who did have echocardiograms during their stay in ICU/CCU were chiefly those presenting heart failure and major complications, and represent a subpopulation with poor prognosis. The performance of echocardiography in ACS patients increased slightly over the length of their stay in ICU/CCU.
Schiele TM, Herbst J, Pöllinger B
… +7 more, Rieber J, König A, Sohn HY, Krötz F, Leibig M, Belka C, Klauss V
Acute Card Care
· 2011 Mar · PMID 21244228
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Since late vessel failure has been speculated as a significant limitation of vascular brachytherapy (VBT), we conducted a prospective clinical evaluation at 6, 12, 24, 36 and 60 months follow-up after irradiation with (9...Since late vessel failure has been speculated as a significant limitation of vascular brachytherapy (VBT), we conducted a prospective clinical evaluation at 6, 12, 24, 36 and 60 months follow-up after irradiation with (90)Sr/(90)Y for in-stent restenosis (ISR) regardless of the patient's symptomatic status. Complete five-year follow-up is reported for 104 consecutive patients. The cumulative rate of death was 13.5% (6 months: 0.96%; 12 months: 2.88%; 24 months: 4.81%; 36 months: 7.69%), of acute myocardial infarction 4.81% (2.88%; 4.81%; 4.81%; 4.81%), of late thrombotic occlusion 4.81% (3.85%; 4.81%; 4.81%; 4.81%), of target lesion revascularization (TLR) 27.9% (8.65%; 12.5%; 17.3%; 21.2%), of target vessel revascularization (TVR) 43.3% (12.5%; 19.2%; 22.1%; 29.8%), and of all major adverse cardiovascular events (MACE) 61.5% (16.3%; 26.9%; 31.7%; 42.3%), respectively. Considered that the annual incidence of TVR after the first year following drug-eluting stenting for in-stent restenosis has been reported as approximately 3% per year, an incidence of 5.8% per year following VBT of our study population clearly indicates a more pronounced, delayed and, even in the fifth year after the index procedure, ongoing restenotic process following beta-irradiation of in-stent restenotic lesions associated with clinically relevant adverse cardiovascular events.
Qarawani D, Menachem N, Ganem D
… +1 more, Hasin Y
Acute Card Care
· 2010 Dec · PMID 21039084
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BACKGROUND: Coronary bypass surgery is recommended for the treatment of left main coronary stenosis. Recently a percutaneous approach has been described as a feasible option. OBJECTIVES: To present the in-hospital and lo...BACKGROUND: Coronary bypass surgery is recommended for the treatment of left main coronary stenosis. Recently a percutaneous approach has been described as a feasible option. OBJECTIVES: To present the in-hospital and long-term clinical and angiographic outcome of a consecutive group of patients undergoing stenting for unprotected left main coronary artery (LMCA) disease, and to compare the clinical and angiographic outcomes of drug-eluting stent (DES) versus metal stent (BMS). METHODS: 238 consecutive patients underwent unprotected LMCA stenting. 165 received BMS and 73 received DES. Most patients (88.7%) presented with acute coronary syndrome. Clinical (100%) and angiographic (84%) follow-up was obtained. RESULTS: Patients' presentation: STEMI (7.2%), non-STEMI (13.5%), unstable angina (67.6%), stable angina (11.7%). Procedural success rate was 100%. In-hospital mortality was 2.1%, all in patients presented with unstable hemodynamic conditions. None of the patients needed emergent CABG. In the long-term follow-up (average three years) there were 12 deaths (5%), 3 patients required CABG and 25 patients required TVR. The overall angiographic LM restenosis rate show a trend toward lower rate in the DES group than the BMS group (9.6% versus 13.8%, P = 0.08). There was no difference in one year mortality (4.1% versus 4.2%) and AMI (2.7% versus 2.8%) between DES and BMS. CONCLUSIONS: Stenting for LM stenosis can be performed safely with acceptable in hospital and long-term outcome. Reconsideration of current guidelines should be considered. Drug-eluting stent implantation for unprotected LMCA stenosis appears safe with regard to acute and long-term complications and is more effective in preventing restenosis compared to BMS implantation.
Acute Card Care
· 2010 Dec · PMID 21039083
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Cardiogenic shock (CS) is the leading cause of death in patients with acute myocardial infarction (MI) and we badly need new approaches in its treatment. It has been demonstrated that a number of inflammatory cytokines (...Cardiogenic shock (CS) is the leading cause of death in patients with acute myocardial infarction (MI) and we badly need new approaches in its treatment. It has been demonstrated that a number of inflammatory cytokines (IL-1β, IL-6, IL-8, TNF-α, CRP, soluble adhesion molecules, complement system etc) are elevated in acute MI complicated by CS. Baseline levels of pro- inflammatory cytokines have predictive value for the development of CS and subsequent mortality. The deleterious effects of pro- inflammatory cytokines may be due to excessive nitric oxide production by enzyme named NOS. However in multicenter randomized TRIUMPH study non-selective NOS inhibition was ineffective in the treatment of cardiogenic shock. A challenging subject of future studies will be treatment of CS with specific inhibitors of inducible isoform of NOS. Considering the results of treatment of patients with septic shock it would be reasonable to study the effects of small doses of corticosteroids and hemofiltration in patients with CS and signs of SIRS.
Calé R, Ferreira J, Aguiar C
… +6 more, Santos N, Carmo P, Figueira J, Raposo L, Gonçalves P, Silva JA
Acute Card Care
· 2010 Dec · PMID 20954791
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UNLABELLED: Abstract Objectives: Evaluate the new ESC/ACCF/AHA/WHF universal definition of myocardial infarction (MI) in relation to its prognostic implications and the role for guiding decision for revascularization. It...UNLABELLED: Abstract Objectives: Evaluate the new ESC/ACCF/AHA/WHF universal definition of myocardial infarction (MI) in relation to its prognostic implications and the role for guiding decision for revascularization. It was also compared with the multivariable based GRACE Risk Score (GRS). METHODS: Single centre registry of 389 consecutive patients admitted with non-ST-segment elevation (NSTE) ACS. We calculated the adjusted HR & 95%CI for death/MI at 30-days and one-year follow-up, between the presence or absence of MI using: (1) universal definition: > 99th URL for cTnI (> 0.06 ng/ml) or MBm (> 3.2 ng/ml); (2) MBm > 2 × URL (> 12.2 ng/ml); 3) old WHO: MBact > 2 × URL (> 32U/l). Logistic analysis was performed to test the interaction between tertiles of biomarkers or GRS and the effect of revascularization on the outcome. RESULTS: The universal definition increased the incidence of MI in 3.5-fold for cTnI, but was not an independent predictor of outcome. The GRS was the only independent predictor of prognosis at 30-days and one-year. The interaction with the prognostic impact of revascularization was only present for the GRS categorized by tertiles. CONCLUSIONS: In a contemporary unselected population with NSTE-ACS, the universal definition of MI alone was not adequate for risk assessment and revascularization decision making. These purposes were fully addressed with the GRS.
Bar-Yishay I, Gilutz H, Cafri C
… +2 more, Ilia R, Zahger D
Acute Card Care
· 2010 Dec · PMID 20954789
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BACKGROUND: Reciprocal changes may accompany ST segment elevation in the ischemic territory during acute myocardial infarction (AMI). We examined the hypothesis that isolated inferior ST segment depression on admission i...BACKGROUND: Reciprocal changes may accompany ST segment elevation in the ischemic territory during acute myocardial infarction (AMI). We examined the hypothesis that isolated inferior ST segment depression on admission is an early sign of anterior wall infarction. METHODS: 49 patients admitted to the coronary care unit between January 1996 and June 2008 who presented with inferior ST segment depression in the absence of ST segment elevation. Electrocardiograms (ECGs) obtained on admission and at 24-48 h were reviewed. Culprit artery was determined based on angiographic and echocardiographic data. RESULTS: All patients had ST segment depression in the inferior leads on admission. A subgroup (55%) presented with concomitant ST segment depression in V5-V6. Follow-up ECG showed that 35% developed ST segment elevations and/or T wave inversions in anterior wall leads over 24-48 h. The left anterior descending (LAD) artery or one of its branches was the culprit in 60% of the patients. Sum of ST segment depression, V5-V6 involvement or presence of 'hyperacute' T waves did not predict LAD involvement. CONCLUSION: Isolated ST segment depression in the inferior wall leads during ACS is usually an early sign of anterior wall AMI, in which the LAD or one of its branches is the culprit artery.
AIMS: The aim of this study was to evaluate treatment with primary percutaneous coronary intervention (PCI) in unselected patients with ST-segment elevation myocardial infarction (STEMI). METHODS: We registered complicat...AIMS: The aim of this study was to evaluate treatment with primary percutaneous coronary intervention (PCI) in unselected patients with ST-segment elevation myocardial infarction (STEMI). METHODS: We registered complication and mortality rates in all patients with STEMI admitted for primary PCI at a high-volume center over a two-year period (2004 to 2006). RESULTS: We included 1022 consecutive patients (mean age 64 years; 69% men). In-hospital and one-year mortality were 8% and 12%, respectively. Cardiac arrest, cardiogenic shock, left ventricular ejection fraction <or=40% and atrioventricular block significantly predicted increased one-year mortality in univariate analysis (P < 0.001 for all) and were considered high-risk complications. 65% of patients had no high-risk complications. One-year mortality for patients without high-risk complications was 4% compared with 28% for those with high-risk complications (P < 0.001). CONCLUSION: Unselected patients with STEMI treated with primary PCI have mortality rates corresponding to those reported in randomized clinical studies including transport of patients. Mortality is strongly related to high-risk complications developed during admission. Thus, patients with high-risk complications should receive special attention. The majority of patients (65%) without high-risk complications have an excellent short- and long-term prognosis following primary PCI.
BACKGROUND: High levels of circulating cell free DNA (CFD) have been associated with poor prognosis in various diseases. Data pertaining to CFD in acute myocardial infarction (MI) are scarce. The available data have been...BACKGROUND: High levels of circulating cell free DNA (CFD) have been associated with poor prognosis in various diseases. Data pertaining to CFD in acute myocardial infarction (MI) are scarce. The available data have been obtained by either electrophoresis or polymerase chain reaction. We evaluated a novel method for the detection of CFD in patients with ST elevation myocardial infarction (STEMI) and examined its correlation with established markers of necrosis and ventricular function. METHODS: Serum concentrations of CFD, troponin-T and creatine kinase (CK) were measured simultaneously in 16 randomly selected acute STEMI patients upon admission and at three more time points. 47 healthy subjects served as a control group. CFD was quantified by a novel rapid fluorometric assay. Ejection fraction (EF) was assessed by echocardiography. RESULTS: Peak CFD levels were significantly higher in patients compared with controls (P = 0.001) and correlated with peak levels of CK and troponin-T (R = 0.79, P <0.001); R = 0.65, P = 0.006, respectively). Peak CFD levels tended to be associated with lower EF (P = 0.075). CONCLUSION: With this method, CFD levels correlated with the levels of established markers of myocardial necrosis but not with EF. The kinetic pattern of CFD release after STEMI and its prognostic value require further investigation.
BACKGROUND: In cardiac acute patients, data on procalcitonin (PCT) are controversial and the clinical interpretation of absolute PCT values represents a major challenge since they may be influenced by several factors. No...BACKGROUND: In cardiac acute patients, data on procalcitonin (PCT) are controversial and the clinical interpretation of absolute PCT values represents a major challenge since they may be influenced by several factors. No data are so far available on the dynamics of PCT levels in patients with cardiogenic shock. AIMS: to evaluate the serum evolution of PCT during intensive cardiac care unit (ICCU) staying in a group of 24 patients with cardiogenic shock (CS) following ST-elevation myocardial infarction (STEMI) submitted to primary percutaneous intervention (PCI) with no laboratory or clinical sign of infection. Furthermore we assessed the kinetics of PCT in a series of 24 patients with septic shock. RESULTS: In septic shock, no significant difference was detectable in PCT kinetics between survivors (R2 = 0.90; P = 0.051) and non-survivors (R2 = 0.63; P = 0.204). In cardiogenic shock, survivors exhibited a significant reduction in PCT values (R2 = 0.94; P = 0.032) while non survivors did not (R2 = 0.68; P = 0.178). CONCLUSIONS: differently from septic shock, cardiogenic shock following STEMI was associated with heterogeneous patterns of temporal PCT variations since only patients who survived exhibited a significant PCT reduction during ICCU stay. Our findings support the contention that the 'dynamic' approach may be more reliable that the static one especially in cardiogenic shock.
No-reflow phenomenon occurs frequently during primary percutaneous coronary intervention for ST-segment elevation myocardial infarction and it has a strong negative impact on outcome. Prevention of no-reflow has to be de...No-reflow phenomenon occurs frequently during primary percutaneous coronary intervention for ST-segment elevation myocardial infarction and it has a strong negative impact on outcome. Prevention of no-reflow has to be defined as any attempt to prevent its occurrence prior to or during the recanalization procedure. Strategy of prevention may be pharmacological or device based. Among drugs, abciximab is indicated by European Society of Cardiology (ESC) guidelines for prevention of no-reflow (class of recommendation IIa and level of evidence B). Among devices used for preventing no-reflow, manual thrombus aspiration only has been associated with a reduction of no-reflow and lower mortality at follow-up and is currently indicated in the ESC guidelines (class IIa of recommendation and level B of evidence). Treatment of no-reflow has to be defined as any attempt to treat its occurrence after coronary recanalization. Strategy of treatment may be pharmacological or device based. Adenosine and verapamil are indicated by ESC guidelines for treatment of no-reflow (class of recommendation IIb and level of evidence B and C, respectively). Serial assessment of myocardial perfusion showed that in up to 50% of patients no-reflow is spontaneously reversible. This finding may open new scenarios, as mechanisms of reversibility may become future therapeutic targets.
BACKGROUND: The beneficial role of manual thrombus aspiration in thrombus-containing lesions has been proven in acute myocardial infarction but data is lacking in saphenous vein graft lesions. METHODS: From January 2004...BACKGROUND: The beneficial role of manual thrombus aspiration in thrombus-containing lesions has been proven in acute myocardial infarction but data is lacking in saphenous vein graft lesions. METHODS: From January 2004 to December 2008, 74 consecutive post-bypass patients underwent percutaneous coronary interventions to 76 saphenous vein graft lesions under the protection of FilterWire EX/EZ. Among them, the latest 25 consecutive patients with 25 lesions were treated with manual aspiration before stenting. The incidence of filter no reflow was compared between patients with and without manual aspiration pretreatment. RESULTS: No major difference in demography, clinical, lesion, and procedure characteristics, and in-hospital outcome has been observed between the two patient groups. Most importantly, the incidence of filter no reflow has not been reduced (32.0% versus 19.6%, P = 0.26) by manual aspiration, even among thrombus-containing lesions (63.2% versus 64.7%, P = 1.00). The absence of diabetes mellitus is found to be the independent predictor for the occurrence of filter no reflow. CONCLUSIONS: Adjunctive manual thrombus aspiration fails to reduce the filter no reflow, and probably has no additional benefit in saphenous vein graft lesions already protected by FilterWire EX/EZ.
Movahed MR, Ramaraj R, Hashemzadeh M
… +1 more, Hashemzadeh M
Acute Card Care
· 2010 Jun · PMID 20482327
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BACKGROUND: Advances in the prevention and treatment of atherosclerosis have been dramatic. The goal of this study was to evaluate any decline in the age adjusted incidence of acute non ST elevation myocardial infarction...BACKGROUND: Advances in the prevention and treatment of atherosclerosis have been dramatic. The goal of this study was to evaluate any decline in the age adjusted incidence of acute non ST elevation myocardial infarction (NSTEMI) using a large database. METHOD: The Nationwide Inpatient Sample (NIS) database was utilized to calculate the age-adjusted rate for NSTEMI from 1988 to 2004 retrospectively. Specific ICD-9-CM codes for NSTEMI were used to compile the data. Patient demographic data was also analyzed from the database and adjusted for age. RESULTS: The NIS database contained a total of 1 423 156 patients who had a diagnosis of NSTEMI from 1988 to 2004. The age-adjusted rate for all acute NSTEMI gradually increased from 1988 until 2000-26.21 per 100 000 (95% CI: 23.9-28.4) in 1988 and 92.6 per 100 000 (95% CI: 86.0-99.3, P <0.01 in 2000,). It remained unchanged from 2000 until 2004 (91.7 per 100 000 (95% CI: 85.3-98.0). This trend was similar across different race and gender. CONCLUSION: The increasing incidence of NSTEMI from 1988 until year 2000 has suddenly stabilized by the year 2000. The cause of this finding is unknown. It could be related to the recent adaptation of troponin testing or recent advancement in the prevention and treatment of atherosclerosis.
Engström AE, Vis MM, Bouma BJ
… +9 more, Claessen BE, Sjauw KD, Baan J, Meuwissen M, Koch KT, de Winter RJ, Tijssen JG, Piek JJ, Henriques JP
Acute Card Care
· 2010 Jun · PMID 20482326
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BACKGROUND: Cardiogenic shock (CS) remains the most serious complication of acute ST-elevation myocardial infarction (STEMI). Mitral regurgitation (MR) is a frequent complication of STEMI and a well-known predictor of mo...BACKGROUND: Cardiogenic shock (CS) remains the most serious complication of acute ST-elevation myocardial infarction (STEMI). Mitral regurgitation (MR) is a frequent complication of STEMI and a well-known predictor of mortality in STEMI without CS. The purpose of this study was to determine the prognostic significance of MR in STEMI patients with CS on admission. METHODS: Mitral regurgitation was assessed in 147 consecutive STEMI patients with CS on admission and treated by primary percutaneous coronary intervention (PCI). Color Doppler of MR was graded with a 0 to 3 scale (none, n = 26; 1 = mild, n = 62; 2 = moderate, n = 40; 3 = severe, n = 19). RESULTS: Overall one-year mortality in the study cohort was 27%. One-year mortality was 8%, 23%, 30% and 58% for patients with no, mild, moderate and severe MR respectively (P <0.001). For each grade of MR increase, the odds for mortality increased with 71% (OR: 1.71; 95% CI: 1.02-2.87; P = 0.043) when adjusted for age, gender, previous myocardial infarction, left ventricular ejection fraction (LVEF) <40%, multivessel disease and no-reflow. CONCLUSIONS: The presence of MR on early echocardiography is an important independent predictor of one-year mortality in STEMI patients with CS on admission treated by primary PCI.
Brunetti ND, Centola A, Campanale EG
… +5 more, Cuculo A, Ruggiero A, Ziccardi L, Gennaro Ld, Biase Md
Acute Card Care
· 2010 Jun · PMID 20443654
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We report the case of a 47-year-old man, referred for chest pain radiating to jaws associated with sweating. At coronary angiography, left anterior descending coronary artery was occluded with distal perfusion by collate...We report the case of a 47-year-old man, referred for chest pain radiating to jaws associated with sweating. At coronary angiography, left anterior descending coronary artery was occluded with distal perfusion by collateral flow, and proximal coronary aneurysms involving proximal left circumflex (LCX) right coronary artery with diffuse coronary atherosclerosis were present. Coronary thrombosis was also present into LCX proximal aneurysm.
Saia F, Marrozzini C, Guastaroba P
… +10 more, Ortolani P, Palmerini T, Pavesi PC, Gordini G, Pancaldi LG, Taglieri N, Palma Rd, Pasquale Gd, Branzi A, Marzocchi A
Acute Card Care
· 2010 Jun · PMID 20443653
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INTRODUCTION: Organization of regional systems of care (RSC) with an emphasis on pre-hospital triage and primary percutaneous coronary intervention (PCI) has been recommended to implement guidelines and improve clinical...INTRODUCTION: Organization of regional systems of care (RSC) with an emphasis on pre-hospital triage and primary percutaneous coronary intervention (PCI) has been recommended to implement guidelines and improve clinical outcome in ST-segment elevation myocardial infarction (STEMI). PATIENTS AND METHODS: All STEMI patients (n = 1,823) admitted to any of the 13 hospitals of the province of Bologna, Italy, before (pre-RSC, n = 858) and after (RSC, n = 965) the implementation of a RSC were enrolled in the study. Primary evaluation was mortality. Secondary outcomes included death, myocardial infarction, stroke, and coronary revascularization procedures up to three-year follow-up. RESULTS: Among patients admitted <12 h from symptom onset, reperfusion was performed in 68.7% pre-RSC versus 89.8% RSC, P <0.001. Within the RSC, primary PCI became the main reperfusion treatment (34.5% pre-RSC versus 85.9% RSC; P <0.001 for both), and one-year mortality was lower (23.9% pre-RSC versus 18.8% RSC; P = 0.0015). At three-year, this advantage was maintained and actually increased (31.7% pre-RSC versus 24.8% RSC; P = 0.0031). Independent predictors of mortality at three-years were RSC, age, heart failure, cerebrovascular disease, renal disease, shock, peripheral vascular disease, and malignancies. CONCLUSIONS: In this study, RSC for the treatment of STEMI was associated with increased rates of reperfusion and reduction of long-term mortality.