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; V
1 to V
3; or V
4 to V
6) 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 V
4 to V
6 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 V
4 to V
6 (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 V
4 to V
6 or other ECG presentations were not independent predictors of high 1-year mortality. In conclusion, ST-D with T-wave inversion in leads V
4 to V
6 on the admission electrocardiogram in patients with NSTEACS identifies those with higher 1-year mortality than for patients with any other ECG presentation.
Objectives. We assessed the outcomes of patients with a first myocardial infarction with ST segment elevation, with and without the development of abnormal Q waves after thrombolysis.
Background. ...Prethrombolytic era studies report conflicting short- versus long-term mortality in the overall non-Q wave population, probably related to its heterogeneity.
Methods. Patients with no electrocardiographic (ECG) confounding factors or evidence of previous infarction were included. Q wave infarction was defined as a Q wave duration ≥30 ms in lead aVF; R wave ≥40 ms in lead V1; any Q wave or R wave ≤10 ms and ≤0.1 mV in lead V2; or Q wave ≥40 ms in at least two of the following leads: I, aVL, V4, V5or V6. In-hospital clinical events and mortality at 30 days and 1 year were assessed.
Results. No Q waves developed in 4,601 (21.3%) of the 21,570 patients. This group comprised more women and had a lower Killip class, lower weight and less anterior baseline ST elevation. The non-Q wave group had less in-hospital cardiogenic shock (2.1% vs. 3.3%, p < 0.0001), less heart failure (8.5% vs. 13.9%, p < 0.0001) and a trend toward less stroke (0.7% vs. 1.0%, p = 0.07) but an increased use of angioplasty (28% vs. 24%, p = 0.0001). The unadjusted mortality rate in the non-Q wave group was lower at 30 days (0.9% vs. 1.8%, p = 0.0001) and 1 year (2.7% vs. 4.2%, p = 0.0001), as was the adjusted 30-day mortality rate (4.8% vs. 5.3%, p < 0.0001).
Conclusions. Patients with no ECG confounding factors or evidence of previous infarction who do not develop Q waves after thrombolysis have a better 30-day and 1-year prognosis than patients with a Q wave infarction.
(J Am Coll Cardiol 1997;29:770–7)
The ECG is an essential part of the initial evaluation of patients who have chest pain, especially in the immediate decision-making process in patients who have ST-elevation myocardial infarction. ...This article reviews and summarizes the current information that can be obtained from the admission ECG in patients who have ST-elevation acute myocardial infarction, with an emphasis on: (1) prediction of final infarct size, (2) estimation of prognosis, and (3) the correlations between various ECG patterns and the localization of the infarct and the underlying coronary anatomy.
Cardiac allograft vasculopathy (CAV), characterized by diffuse intimal thickening and luminal narrowing in the arteries of the allograft, is the leading cause of morbidity and mortality in cardiac ...transplant recipients. Many transplant centers perform routine annual surveillance coronary angiography. However, angiography can underdiagnose or miss CAV due to its diffuse nature. Intravascular ultrasound (IVUS) is more sensitive than angiography. IVUS provides not only accurate information on lumen size, but also quantification of intimal thickening, vessel wall morphology, and composition. IVUS has evolved as a valuable adjunct to angiography and the optimal diagnostic tool for early detection. Noninvasive testing such as dobutamine stress echocardiography and nuclear stress test have shown considerable accuracy in diagnosing significant CAV. Computed tomographic imaging and cardiac magnetic resonance imaging are promising new modalities but require further study. This article reviews the diagnostic methods that are currently available.
Abstract
Impella (Abiomed, Danvers, MA) is a percutaneously inserted ventricular assist device (VAD). It has been increasingly used in patients with severe heart failure, cardiogenic shock, and ...high-risk percutaneous intervention (PCI). However, the use and efficacy of Impella in patients with severe coronary artery disease (CAD) presenting with cardiac arrest has rarely been reported.The objective of this study is to report our center experience in using Impella VAD in CAD patients presenting with cardiac arrest. From December 2010 to March 2011, three patients with severe CAD presented to our center with cardiac arrest underwent PCI with Impella support. We reported three cases of severe CAD presenting with cardiac arrest successfully treated with PCI and Impella support. Our experience demonstrated that Impella VAD may play an adjunctive role in obtaining hemodynamic stability in these high-risk patients undergoing PCI. One of the patients was supported to left VAD implantation, and the other two had excellent neurological and functional recovery. Our reports suggest an important role of Impella in cardiac arrest population. Earlier Impella implantation after cardiac arrest might provide cardiac support and tissue perfusion until recovery or high-risk PCI.
Background: Tolvaptan, a nonpeptide selective vasopressin receptor (V2) antagonist, is in development for the treatment of congestive heart failure and hyponatremia. Tolvaptan is primarily ...metabolized via CYP3A4. This study was conducted to determine the extent of the pharmacokinetic interaction between tolvaptan and steady state amiodarone, an antiarrhythmic drug commonly prescribed for patients with congestive heart failure and a known inhibitor of other drugs metabolized by CYP3A4.
Methods: This was a multicenter, open-label, 1-arm, 3-period, sequential treatment study conducted in 11 men (10) and women aged 49 to 80 years. They were primarily Caucasian (20) subjects, with a history of cardiac arrhythmias who were otherwise healthy. Subjects were to have been on oral amiodarone maintenance therapy of 200 mg/day for at least 10 months. All subjects took 200 mg amiodarone once daily on each study day; on days 3 and 4, they were also coadministered 30 and 90 mg of tolvaptan, respectively. The plasma concentrations of amiodarone and its metabolite desethylamiodarone were determined for 24 hours postdose on days 2, 3, and 4, tolvaptan concentrations were determined for 24 hours postdose on days 3 and 4.
Results: As determined by the ratio of the geometric means and 90% confidence intervals (0.5 to 2.0) for the maximal plasma concentration and the area under the curve during the dosing interval for both amiodarone and desethylamiodarone, tolvaptan coadministration had no effect on either amiodarone and desethylamiodarone disposition, as all the geometric mean ratios (amiodarone + tolvaptan 30 or 90 mg vs amiodarone alone) were approximately 1.
Conclusion: Tolvaptan coadministration does not alter steady-state amiodarone or desethylamiodarone concentrations. Tolvaptan concentrations did not appear to be different from historical controls. The most frequently reported adverse event was polyuria (15 of 21 subjects for amiodarone + 30 mg tolvaptan); an expected outcome due to the known potent aquaretic action of tolvaptan. The combination of amiodarone and tolvaptan was well tolerated.
Percutaneous coronary intervention for ST-elevation myocardial infarction (STEMI) reduces morbidity and mortality if performed rapidly. We examined whether timely intervention in myocardial perfusion ...times achieved at NorthEast Medical Center (NEMC) using pre-hospital (PH) electrocardiography (ECG) could be maintained during a 3-year follow-up period, and whether a similar system could be implemented at 6 other larger hospitals in a prospective, multicenter study.
We calculated median door-to-reperfusion times for emergency medical services (EMS) and self-transport patients. PH wireless ECG transmission was attempted by trained EMS personnel with transmission to an on-call cardiologist's hand-held device. A standardized "STEMI code system" was implemented to further improve door-to-reperfusion times.
At NEMC, door-to-reperfusion times were similar in both the pilot study and follow-up periods, with a median time of 63 minutes. However, successful PH-ECG transmission was less frequent during the followup period (20% vs. 56%; p < 0.0001). At the 6 larger sites, both EMS and self-transport patients had lower door-to-reperfusion times in the study period compared to the pre-study period. However, successful PH-ECG transmission was rare in the EMS-transported patients (2%).
Initial reduction of reperfusion time at NEMC using PH-ECG transmission to the cardiologist was maintained over time, however, there was a decrease in the PH-ECG transmission rate. PHECG transmission was difficult to achieve in larger-sized communities. Successful PH-ECG transmission to an on-call cardiologist, together with an effective STEMI code system, can markedly reduce door-to-reperfusion times.
Background
Cell therapy (CTh) is a promising novel therapy for myocardial infarction (MI) and ischemic cardiomyopathy (iCMP). Recognizing adverse events (AE) is important for safety evaluation, harm ...prevention and may aid in the design of future trials.
Objective
To define the prevalence of periprocedural AE in CTh trials in MI and iCMP.
Methods
A literature search was conducted using the MEDLINE database from January 1990 to October 2010. Controlled clinical trials that compared CTh with standard treatment in the setting of MI and/or iCMP were selected. AE related to CTh were analyzed.
Results
A total of 2,472 patients from 35 trials were included. There were 26 trials including 1,796 patients that used CTh in MI and 9 trials including 676 patients that used CTh in iCMP. Periprocedural arrhythmia monitoring protocols were heterogeneous and follow-up was short in most of the trials. In MI trials, the incidence of periprocedural adverse events (AE) related to intracoronary cell transplantation was 7.5 % (95 % CI 6.04–8.96 %). AE related to granulocyte colony-stimulating factor (GCS-F) used for cell mobilization for peripheral apheresis was 16 % (95 % CI 9.44–22.56 %). During intracoronary transplantation in iCMP, the incidence of periprocedural AE incidence was 2.6 % (95 % CI 0.53–4.67 %). There were no AE reported during transepicardial transplantation and AE were rare during transendocardial transplantation.
Conclusions
The majority of periprocedural AE in CTh trials in MI occurred during intracoronary transplantation and GCS-F administration. In iCMP, periprocedural AE were uncommon. Avoiding intracoronary route for CTh implantation may decrease the burden of periprocedural AE. Standardization of AE definition in CTh trials is needed.
Early postinfarction angina implies an unfavorable prognosis. Most published information on this outcome represents data collected in the prethrombolytic era, in which definitions and populations ...differed considerably. Our purpose was to evaluate the incidence and importance of recurrent ischemia after administration of thrombolytic therapy. We studied patients enrolled in the Thrombolytic and Angioplasty in Myocardial Infarction studies. Patients were enrolled into 5 studies with similar entry criteria; 552 patients were treated with tissue plasminogen activator (t-PA), 293 were treated with urokinase, and 385 received both thrombolytic agents. Recurrent ischemia was defined as symptoms in association with electrocardiographic changes; reinfarction was defined as a reelevation of creatine kinase myocardial band isoenzyme in an appropriate clinical setting. Both recurrent ischemia and reinfarction occurred in 42 patients (3.4%), recurrent ischemia alone occurred in 226 (18%), whereas neither occurred in 964 (78%). Although baseline characteristics were similar among the 3 groups, in-hospital cardiac events (total 73 deaths, 253 heart failure episodes) were not: in-hospital mortality in patients with reinfarction was 21 %; with recurrent ischemia, 11%; and with neither event, 4% (p < 0.0001). The in-hospital heart failure rate of patients with reinfarction was 50%; with recurrent ischemia alone, 31%; and with neither event, 17% (p < 0.0001). As expected, median in-hospital costs were highest in patients with reinfarction ($26,802), intermediate for those with recurrent ischemia alone ($18,422), and lowest in patients with neither event ($15,623). Recurrent myocardial ischemia after thrombolytic therapy is a frequent, important, and expensive adverse clinical outcome, making it a critical target for therapeutic intervention.
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