Substernal Chest Pain and Dyspnea in a Female Patient

A 76-year-old female patient presented to the emergency department with substernal chest pain and dyspnea symptoms. She reported that the symptoms started 2 days earlier. These symptoms can arise from both cardiac and noncardiac conditions. It is difficult to ascribe chest pain and dyspnea symptoms to a single cause. Recognizing these symptoms is critical for inpatient cardiac and primary care nurse practitioners to choose the correct diagnosis and facilitate more effective treatment planning.     

Interleukin-34 drives macrophage polarization to the M2 phenotype in autoimmune hepatitis

BackgroundAutoimmune hepatitis is a chronic inflammatory disease, the abnormal immunological function is the main pathogenesis. Interleukin-34 is a newly identified cytokine that shares the same receptor as colony stimulating factor-1.MethodsWe used interleukin-34 knockout and wild-type mice in a Con A-induced hepatitis model and cocultured RAW264.7 macrophage cells with interleukin-34. We then detected associated inflammatory cytokine and chemokine levels to elucidate the role of interleukin-34.ResultsIn this study, we found that the loss of interleukin-34 resulted in higher sensitivity to Con A-induced hepatitis. RAW264.7 macrophage cells were able to differentiate to the M2 phenotype upon interleukin-34 stimulation.ConclusionsWe conclude that interleukin-34 may protect the liver from Con A-mediated hepatitis by driving M2 macrophage polarization and suppressing inflammation.     

Sonothrombolysis in ST-Segment Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention

BackgroundPreclinical studies have demonstrated that high mechanical index (MI) impulses from a diagnostic ultrasound transducer during an intravenous microbubble infusion (sonothrombolysis) can restore epicardial and microvascular flow in acute ST-segment elevation myocardial infarction (STEMI).ObjectivesThis study tested the clinical effectiveness of sonothrombolysis in patients with STEMI.MethodsPatients with their first STEMI were prospectively randomized to either diagnostic ultrasound–guided high MI impulses during an intravenous Definity (Lantheus Medical Imaging, North Billerica, Massachusetts) infusion before, and following, emergent percutaneous coronary intervention (PCI), or to a control group that received PCI only (n = 50 in each group). A reference first STEMI group (n = 203) who arrived outside the randomization window was also analyzed. Angiographic recanalization before PCI, ST-segment resolution, infarct size by magnetic resonance imaging, and systolic function (LVEF) at 6 months were compared.ResultsST-segment resolution occurred in 16 (32%) high MI PCI versus 2 (4%) PCI-only patients before PCI, and angiographic recanalization was 48% in high MI/PCI versus 20% in PCI only and 21% in the reference group (p < 0.001). Infarct size was reduced (29 ± 22 g high MI/PCI vs. 40 ± 20 g PCI only; p = 0.026). LVEF was not different between groups before treatment (44 ± 11% vs. 43 ± 10%), but increased immediately after PCI in the high MI/PCI group (p = 0.03), and remained higher at 6 months (p = 0.015). Need for implantable defibrillator (LVEF ≤30%) was reduced in the high MI/PCI group (5% vs. 18% PCI only; p = 0.045).ConclusionsSonothrombolysis added to PCI improves recanalization rates and reduces infarct size, resulting in sustained improvements in systolic function after STEMI. (Therapeutic Use of Ultrasound in Acute Coronary Artery Disease; NCT02410330).     

Ticagrelor Versus Clopidogrel in Patients With STEMI Treated With Fibrinolysis: TREAT Trial

BackgroundThe efficacy of ticagrelor in the long-term post–ST-segment elevation myocardial infarction (STEMI) treated with fibrinolytic therapy remains uncertain.ObjectivesThe purpose of this study was to evaluate the efficacy of ticagrelor when compared with clopidogrel in STEMI patients treated with fibrinolytic therapy.MethodsThis international, multicenter, randomized, open-label with blinded endpoint adjudication trial enrolled 3,799 patients (age <75 years) with STEMI receiving fibrinolytic therapy. Patients were randomized to ticagrelor (180-mg loading dose, 90 mg twice daily thereafter) or clopidogrel (300- to 600-mg loading dose, 75 mg daily thereafter). The key outcomes were cardiovascular mortality, myocardial infarction, or stroke, and the same composite outcome with the addition of severe recurrent ischemia, transient ischemic attack, or other arterial thrombotic events at 12 months.ResultsThe combined outcome of cardiovascular mortality, myocardial infarction, or stroke occurred in 129 of 1,913 patients (6.7%) receiving ticagrelor and in 137 of 1,886 patients (7.3%) receiving clopidogrel (hazard ratio: 0.93; 95% confidence interval: 0.73 to 1.18; p = 0.53). The composite of cardiovascular mortality, myocardial infarction, stroke, severe recurrent ischemia, transient ischemic attack, or other arterial thrombotic events occurred in 153 of 1,913 patients (8.0%) treated with ticagrelor and in 171 of 1,886 patients (9.1%) receiving clopidogrel (hazard ratio: 0.88; 95% confidence interval: 0.71 to 1.09; p = 0.25). The rates of major, fatal, and intracranial bleeding were similar between the ticagrelor and clopidogrel groups.ConclusionAmong patients age <75 years with STEMI, administration of ticagrelor after fibrinolytic therapy did not significantly reduce the frequency of cardiovascular events when compared with clopidogrel. (Ticagrelor in Patients With ST Elevation Myocardial Infarction Treated With Pharmacological Thrombolysis [TREAT]; NCT02298088)     

胸痛中心认证对急性ST段抬高型心肌梗死患者救治效率的影响

目的观察我院胸痛中心认证前后急性ST段抬高型心肌梗死(STEMI)救治关键指标的变化。方法采取回顾性非同期队列研究方式,以我院通过中国胸痛中心联盟正式认证时间为划分时间点,将2017年9月至2018年9月收治的STEMI患者为胸痛中心认证前组(206例),将2018年10月至2019年10月收治的STEMI患者为胸痛中心认证后组(284例)。比较胸痛中心认证前后STEMI患者院前救治、院内救治关键指标的变化以及住院期间死亡率、住院时间和住院费用的差异。结果胸痛中心认证后组心电图(ECG)远程传输比例[122(43.0%)比62(30.1%),P=0.008]和绕行急诊科或CCU比例[117(41.2%)比64(31.1%),P=0.022]与胸痛中心认证前组比较显著增加,首次医疗接触至完成首份ECG(FMC-to-ECG)[3(2,5)min比5(2,7)min,P<0.001]与胸痛中心认证前组比较显著缩短,差异均有统计学意义;两组患者发病至首次医疗接触(S-to-FMC)时间比较,差异无统计学意义(P=0.146)。胸痛中心认证后组ECG至确诊时间[(76.3±57.9)min比(92.0±65.8)min,P=0.040]较胸痛中心认证前组显著下降;胸痛中心认证后组进入医院大门至球囊扩张(D-to-B)时间[76.0(60.0,88.0)min比94.0(78.0,195.0)min,P<0.001]和首次医疗接触至球囊扩张(FMC-to-B)时间[(96.1±67.3)min比(112.4±84.0)min,P=0.022]均较胸痛中心认证前组显著下降,差异均有统计学意义。胸痛中心认证后组D-to-B时间<90 min达标率[201(70.8%)比119(57.8%),P=0.003]和FMC-to-B<120 min达标率[180(63.4%)比101(49.0%),P=0.002]均较胸痛中心认证前组显著增加,差异均有统计学意义。胸痛中心认证后组院内死亡率与胸痛中心认证前组比较,有下降趋势[11(3.9%)比10(4.9%),P=0.654],但差异无统计学意义。胸痛中心认证前后组患者住院时间和住院总费用比较,差异均无统计学意义(均P>0.05)。结论我院胸痛中心认证后较认证前显著缩短了STEMI救治时间,尤其是D-to-B时间,有助于提高胸痛中心STEMI患者的救治效率。