For the acute myocardial infarction patient, percutaneous coronary intervention is clearly superior to thrombolysis for many clinical end points, yet widespread availability of PCI services is still ...far from being realised
Objective: To investigate the relation between the degree of ST segment resolution (STR) after thrombolysis and the pressure derived collateral flow index (CFIp), determined using an intracoronary ...pressure measurement technique in patients with recent myocardial infarction. Methods: 33 patients were studied. TIMI grade III flow was achieved in the infarct related artery by thrombolysis. A surface ECG was obtained on admission and 90 minutes later. The sum of ST segment elevations was measured by summing all leads with ST elevation on the baseline ECG and on the 90 minute ECG (after thrombolysis) and calculating the percentage recovery. The study population was divided into two groups, with good STR (⩾ 50%; group 1) or poor STR (< 50%; group 2). After angiography, a fibreoptic pressure monitoring guidewire was advanced to the stenosis to be dilated. The CFIp was determined as the ratio coronary wedge pressure − central venous pressure/mean aortic pressure − central venous pressure. Results: The mean STR on the surface ECG was 54.6% and mean (SD) CFIp was 0.25 (0.12) (range 0.10–0.41). There was an inverse correlation between the individually calculated percentage of STR and CFIp (r = −0.64, p < 0.01). The mean CFIp was lower in patients with a good STR than in those with a poor STR (0.18 (0.07) v 0.27 (0.10), p < 0.02). Conclusions: Although TIMI grade III flow was achieved after thrombolysis, a worse STR on the surface ECG was associated with higher CFIp measured in the infarct related artery. CFIp appears to reflect the degree of microvascular obstruction by quantifying impedance of the microvasculature.
Ile-Ife is world-famous for its sculptures, and for the pivotal role it plays in defining black culture. It boasts of notable examples of Nigerian traditional, vernacular and metropolitan ...architecture. The paper discusses Ile Timi, a building strategically located with respect to Ife mythology and local building practices. It highlights its peculiarities at the interface of the transition from the traditional to the clearly-distinguishable vernacular. Ile Timi authenticates traditional building practices, while accommodating advantages of the new. The work also examines evolutionary trends in space-use and inherent meaning, to underscore the significance of such buildings, and concludes that more should be done to conserve them; apart from their heritage value, they have potential for boosting local tourism.
Objective: To examine the effects of comorbidity and hospital care on mortality in patients with elevated cardiac troponin T. Design: Observational study. Setting: A large university hospital with ...on-site diagnostic cardiac catheter laboratory. Patients: All hospitalised patients with elevated cardiac troponin T level (⩾0.01 μg/l) over an 8-week period. Main outcome measures: 6-month all-cause mortality. Results: Among 313 patients with elevated cardiac troponin T, 195 had acute coronary syndrome and 118 had other conditions. Multivariate analysis showed that among patients with acute coronary syndrome, increasing comorbidity score (odds ratio (OR) 1.23 per point increase, 95% confidence interval (CI) 1.00 to 1.51; p = 0.048), age (OR 1.08 per year, 95% CI 1.04 to 1.13; p<0.001), raised troponin T level (OR 2.22 per 10-fold increase, 95% CI 1.27 to 3.89; p = 0.005), and ST depression (OR 3.12, 95% CI 1.38 to 7.03; p = 0.006) were independent adverse predictors, while cardiologist care (OR 0.22, 95% CI 0.09 to 0.51; p<0.001) was associated with a better survival. Increasing troponin T level (OR 3.33 per 10-fold increase, 95% CI 1.24 to 8.91; p = 0.017) was found to predict a worse prognosis among patients without acute coronary syndrome, and cardiologist care did not affect outcome in this group. Among hospital survivors with acute coronary syndrome, increasing comorbidity score, age and a lack of cardiologist care were independently associated with lesser use of effective medications. Conclusions: Comorbidity was associated with a higher 6-month mortality in patients having acute coronary syndrome, and lesser use of effective medicines among hospital survivors. Cardiologist care was associated with better 6-month survival in patients with acute coronary syndrome, but not in those without acute coronary syndrome.
N-terminal pro-brain natriuretic peptide (Nt-proBNP) is a strong independent predictor of death in acute coronary syndromes. In order to improve risk assessment in patients with unstable coronary ...artery disease we investigated the role of the additional determination of Nt-proBNP levels in patients sub-grouped into high-, medium- and low-risk groups according to the TIMI risk score.
Nt-proBNP was determined in 145 consecutive patients admitted to our clinic with typical anginal pain in the past 24 hours and normal left ventricular function. Using classification and regression tree analysis, we investigated whether Nt-proBNP levels provide clinically relevant prognostic information in addition to the TIMI risk score. Nt-proBNP concentrations were determined using a commercially available assay from Biomedica, Austria. The normal range of this assay is <2827 pg/ml.
Multivariate logistic regression analysis revealed that TIMI scores and Nt-proBNP levels are independent predictors of mortality (P = 0.001 and P < 0.001, respectively). Patients with Nt-proBNP levels >5225 pg/ml had the highest mortality rate, independent of their TIMI risk classification. In the subset of patients with Nt-proBNP < or =5225 pg/ml, patients at TIMI medium risk but with Nt-proBNP above 2827 pg/ml had significantly higher mortality than patients with lower levels of Nt-proBNP (P = 0.03). Accordingly, we developed a combined risk score consisting of four risk groups: very high (Nt-proBNP > or =5225 pg/ml), high (TIMI high-risk group or TIMI medium-risk group and Nt-proBNP >2827 pg/ml), medium (TIMI medium-risk group and Nt-proBNP < or =2827 pg/ml) and low (TIMI low-risk group). The area under the receiver operating characteristic curve was 0.772 for the TIMI score alone and 0.863 for the combined risk score (P < 0.001).
Determination of plasma Nt-proBNP levels and incorporation of these into TIMI risk classification by creating a combined risk score significantly improves risk assessment of patients with unstable coronary artery disease.
Objectives: To investigate the relation between coronary flow reserve (CFR), coronary zero flow pressure (Pzf), and residual myocardial viability in patients with acute myocardial infarction. ...Designs: Prospective study. Setting: Primary care hospital. Patients: 27 consecutive patients with acute anterior myocardial infarction. Main outcome measures:18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) was used in 27 patients who underwent successful intervention within 12 hours of onset of a first acute anterior myocardial infarction. Within three days before discharge they had < 25% stenosis in the culprit lesion as determined by angiography 24 (3) days after acute myocardial infarction. Pzf and the slope index of the flow-pressure relation (SIFP) were calculated from the simultaneously recorded aortic pressure and coronary flow velocity signals at peak hyperaemia.%FDG was quantified by comparing FDG uptake in the infarct myocardium with FDG uptake in the normal myocardium. Results: There was a correlation between %FDG and CFR, where y = −1.477x + 62.517, r = −0.072 (NS). There was also a correlation between %FDG and SIFP, where y = −0.975x + 60.542, r = −0.045 (NS), and a significant correlation between %FDG and Pzf, where y = −0.98x + 85.108, r = −0.696 (p < 0.001). Conclusions: CFR does not correlate with FDG-PET at the time of postreperfusion evaluation of residual myocardial viability. The parameter that correlates best with residual myocardial viability is Pzf and this may be a useful index for predicting patient prognosis.
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