Myonecrosis, manifested by an increase in cardiac markers, may occur in up to 50% of patients undergoing elective percutaneous coronary intervention (PCI). The degree of periprocedural myonecrosis, ...measured by the peak creatine kinase-MB fraction, has been associated with incidence of adverse clinical outcomes. Therefore, strategies to decrease myonecrosis may translate into a decrease in mortality. We evaluated the efficacy of statin pretreatment in decreasing the incidence of myonecrosis after PCI on the basis of results of published studies. A systematic search of the PubMed database from its inception to October 2006 and from the references of identified studies was performed. Only studies with concurrent control groups were included. Information on baseline characteristics of included patients and clinical outcomes was independently extracted by 2 investigators. A random effects model was used to pool odds ratios of the incidence of periprocedural myonecrosis in statin-treated patients versus controls. A total of 9 trials was included in the analysis, 2 randomized trials (n = 604) and 7 retrospective cohort studies (n = 4,751), which assessed the impact of statin pretreatment on periprocedural myonecrosis. During this period, 196 of 2,149 patients (9%) in the statin-treated group compared with 455 of 2,602 (17.5%) in the control group (odds ratio 0.45, 95% confidence interval 0.33 to 0.62, p <0.01) developed myonecrosis. In conclusion, based on existing evidence, routine pretreatment with statins may decrease the risk of postprocedure myonecrosis. Large randomized controlled trials addressing the dose, duration, and type of statin on periprocedural myonecrosis are necessary before recommending routine use of statins to prevent myonecrosis in the elective PCI setting.
Introduction: Chronic obstructive pulmonary disease (COPD) exacerbation is a frequent cause of hospital admissions. In one-third of patients, exacerbations have no known cause. We studied whether the ...presence of diastolic dysfunction (DD) in this subgroup of patients is associated with longer duration of hospitalization and more frequent exacerbations. Methods: Retrospective chart review of 139 patients with COPD, 84 with DD, and 55 with normal diastolic function hospitalized for acute COPD exacerbation between November 2004 and December 2007 was done. Diastolic dysfunction was defined by the presence of relaxation, filling, or distensibility abnormalities of the left ventricle on transthoracic echocardiogram. Results: Patients with DD had increased length of stay compared with patients without DD (mean: 4.02 ± 1.8 days vs 3.24 ± 1.20 days; P = 0.005). Patients with DD had 1.28 exacerbations requiring hospitalization per patient-year compared with 0.67 in the normal diastolic function group (P = 0.0067). Conclusions: Patients with COPD and DD had prolonged and more frequent hospitalizations for COPD exacerbations. These findings suggest that DD, a surrogate for increased left ventricular filling pressure, is common in patients with COPD exacerbations and may be associated with increased frequency of hospitalization.
HIV/AIDS (Human immunodeficiency virus/ Acquired immuno deficiency syndrome) is a growing global problem, in terms of its incidence and mortality. Patients with HIV/AIDS are living much longer with ...HAART (Highly active antiretroviral therapy) therapy so much so that HIV/AIDS has now become a part of the chronic disease burden, like hypertension and diabetes. Patients with HIV/AIDS and symptoms suggestive of cardiac disease represent a diagnostic and therapeutic challenge in clinical practice; Cardiologists are more frequently encountering this problem. An algorithmic, anatomic approach to diagnosis, localizing disease to the endocardium, myocardium and pericardium can be useful. An intimate knowledge of opportunistic infections affecting the heart, effects of HAART therapy and therapy for opportunistic infections on the heart is needed to be able to formulate a differential diagnosis. Effects of HAART therapy, especially protease inhibitors on lipid and glucose metabolism, and their influence on progression to premature vascular disease require consideration. Treatment of cardiac disease, in HIV/AIDS patients can vary from non-HIV patients, based on drug interactions, differences in responsiveness, and other factors; and this area requires further research.
Abstract Background and aims The electrocardiogram (ECG) based Sclarovsky-Birnbaum Ischemia Grade may be used to determine the prognosis of patients with ST-elevation myocardial infarction (STEMI). ...However, application of the method is based on assumption of the baseline QRS morphology. Thus, the aims of this study were to determine if the baseline QRS morphology was correctly assumed based on an ECG recorded during induced ischemia, and if reference to the baseline ECG altered the designated Ischemia Grade. Methods Sixty-three patients with chronic ischemic heart disease that underwent elective percutaneous transluminal coronary angioplasty were included. Baseline ECG and ECG during the procedure were recorded. In the latter, Ischemia Grade was classified according to assumed baseline QRS morphology. Then the baseline ECG was used as reference and Ischemia Grade was determined based on change from the baseline ECG. Results In 66.6% (42/63) of patients the criteria for STEMI were fulfilled; the incidence was similar between left anterior descending (LAD) and right coronary artery (RCA) occlusion. In LAD patients who fulfilled STEMI criteria, assumption of baseline QRS morphology in involved leads was accurate in only 35% (7/20) and this altered the Ischemia Grade in 10% (2/20) of patients. In RCA patients who fulfilled STEMI criteria, assumption of baseline QRS morphology in involved leads was accurate in 77.3% (17/22) and this altered the Ischemia Grade in 9.1% (2/22) of patients. Conclusion Application of the Sclarovsky-Birnbaum Ischemia Grade with reference to a baseline ECG altered Ischemia Grade in approximately 10% of patients. All patients that were reclassified were assigned a higher Ischemia Grade. Future research is needed to determine the impact of availability of the baseline ECG on the clinical diagnostic and prognostic performances of the Sclarovsky-Birnbaum Ischemia Grade.
ST-segment depression (ST-D) on the admission electrocardiogram of patients with non–ST-elevation acute coronary syndromes (NSTEACSs) is associated with higher mortality. However, few studies have ...evaluated the effect of location of ST-D and T-wave polarity on long-term prognosis of patients with NSTEACS. Electrocardiographic (ECG) and clinical data from 6,770 patients with NSTEACS randomly assigned in the Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) IIB trial were analyzed retrospectively. One-year mortality was correlated with location of ST-D (leads I and aVL; II, III, and aVF; V1 to V3 ; or V4 to V6 ) and T-wave polarity. ST-D in any of the ECG locations was associated with higher mortality compared with patients without ST-D. Patients with ST-D and T-wave inversion in leads V4 to V6 had the highest 1-year mortality rate of all groups (16.2%), significantly higher compared with patients with ST-D without T-wave inversion in those leads (9.0%, p = 0.001). Logistic regression analysis showed that age, hyperlipidemia, Killip class >I, history of myocardial infarction, history of heart failure, history of angina pectoris, systolic blood pressure, heart rate, sum of ST-D (odds ratio 1.061, 95% confidence interval 1.035 to 1.087, p <0.001), and ST-D with T-wave inversion in leads V4 to V6 (odds ratio 1.374, 95% CI 1.023 to 1.844, p = 0.035) were independent predictors of 1-year mortality. Conversely, ST-D without T-wave inversion in leads V4 to V6 or other ECG presentations were not independent predictors of high 1-year mortality. In conclusion, ST-D with T-wave inversion in leads V4 to V6 on the admission electrocardiogram in patients with NSTEACS identifies those with higher 1-year mortality than for patients with any other ECG presentation.
Noninvasive methods are needed to evaluate reperfusion success in patients with acute myocardial infarction (MI). The AMISTAD trial was analyzed to compare MI size and myocardial salvage determined ...by electrocardiogram (ECG) with technetium Tc 99m sestamibi single-photon emission computerized tomography (SPECT) imaging.
Of 236 patients enrolled in AMISTAD, 166 (70 %) with no ECG confounding factors and no prior MI were included in this analysis. Of these, group 1 (126 patients, 53%) had final infarct size (FIS) available by both ECG and SPECT. Group 2 (56 patients, 24%) had myocardium at risk, FIS, and salvage index (SI) assessed by both SPECT and ECG techniques. Aldrich/Clemmensen scores for myocardium at risk and the Selvester QRS score for final MI size were used. Salvage index was calculated as follows: SI = (myocardium at risk−FIS)/(myocardium at risk).
In group 1, FIS was 15% (6, 24) as measured by ECG and 11% (2, 27) as measured by SPECT. In the adenosine group, FIS was 12% (6, 21) and 11% (2, 22). In the placebo group, FIS was 16.5% (7.5, 24) and 11.5% (3.0, 38.5) by ECG and SPECT, respectively. The overall correlation between SPECT and ECG for FIS was 0.58 (
P = .0001): 0.60 in the placebo group (
P = .0001) and 0.54 (
P = .0001) in the adenosine group. In group 2, myocardium at risk was 23% (17, 30) and 26% (10, 50) with ECG and SPECT, respectively (
P = .0066). Final infarct size was 17% (6, 21) and 12% (1, 24) (
P < .0001). The SI was 29% (-7, 57) and 46% (15, 79) with ECG and SPECT, respectively (
P = .0510).
The ECG measurement of infarct size has a moderate relationship with SPECT infarct size measurements in the population with available assessments. This ECG algorithm must further be validated on clinical outcomes.
Nearly 1 million hospitalizations for chronic heart failure occur yearly in the United States, with most related to worsening systemic congestion. Diuretic use, the mainstay therapy for congestion, ...is associated with electrolyte abnormalities and worsening renal function. In contrast to diuretics, the vasopressin antagonist tolvaptan may increase net volume loss in heart failure without adversely affecting electrolytes and renal function.
To evaluate the short- and intermediate-term effects of tolvaptan in patients hospitalized with heart failure.
Randomized, double-blind, placebo-controlled, parallel-group, dose-ranging, phase 2 trial conducted at 45 centers in the United States and Argentina and enrolling 319 patients with left ventricular ejection fraction of less than 40% and hospitalized for heart failure with persistent signs and symptoms of systemic congestion despite standard therapy.
After admission, patients were randomized to receive 30, 60, or 90 mg/d of oral tolvaptan or placebo in addition to standard therapy, including diuretics. The study drug was continued for up to 60 days.
In-hospital outcome was change in body weight at 24 hours after randomization; outpatient outcome was worsening heart failure (defined as death, hospitalization, or unscheduled visits for heart failure) at 60 days after randomization.
Median (interquartile range) body weight at 24 hours after randomization decreased by -1.80 (-3.85 to -0.50), -2.10 (-3.10 to -0.85), -2.05 (-2.80 to -0.60), and -0.60 (-1.60 to 0.00) kg in the groups receiving tolvaptan 30, 60, and 90 mg/d, and placebo, respectively (P< or =.008 for all tolvaptan groups vs placebo). The decrease in body weight with tolvaptan was not associated with changes in heart rate or blood pressure, nor did it result in hypokalemia or worsening renal function. There were no differences in worsening heart failure at 60 days between the tolvaptan and placebo groups (P =.88 for trend). In post hoc analysis, 60-day mortality was lower in tolvaptan-treated patients with renal dysfunction or severe systemic congestion.
Tolvaptan administered in addition to standard therapy may hold promise for management of systemic congestion in patients hospitalized for heart failure.
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