Should beta-blockers be continued as a treatment for myocardial infarction in the case of Kounis syndrome?

A 71-year-old male patient reported to our hospital with anaphylactic shock, and the following two issues were focused in this case. First, he was resistant to adrenaline because of taking beta-blocker, and shock was repeated until glucagon administration was initiated. Second, he developed acute coronary syndrome. Two mechanisms contributing to Kounis syndrome were differentiated: 1) adrenaline induced coronary spasm and platelet activation or 2) a mismatch between oxygen supply and demand due to an allergic reaction. Beta-blocker therapy was discontinued because his cardiac function was preserved. Secondary preventive beta-blockers in recovering myocardial infarction with severe anaphylaxis history should be carefully considered.     

In-hospital major bleeding during ST-elevation and non-ST-elevation myocardial infarction care: derivation and validation of a model from the ACTION Registry®-GWTG™

Bleeding, a common complication of acute myocardial infarction (AMI) treatment, is associated with worse outcomes. A contemporary model for major bleeding associated with AMI treatment can stratify patients at elevated risk for bleeding and is needed to risk-adjust AMI practice and outcomes. Using the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines (ACTION Registry-GWTG) database, an in-hospital major bleeding risk model was developed in a population of patients with ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction. The model used only baseline variables and was developed (n = 72,313) and validated (n = 17,960) in patients with AMI (at 251 United States centers from January 2007 to December 2008). The 12 most statistically and clinically significant variables were incorporated into the final regression model. The calibration plots are shown, and the model discrimination is demonstrated in derivation and validation cohorts, as well as across key subgroups. The rate of major bleeding in the overall population was 10.8%. The 12 factors associated with major bleeding in the model were heart rate, baseline hemoglobin, female gender, baseline serum creatinine, age, electrocardiographic changes, heart failure or shock, diabetes, peripheral artery disease, body weight, systolic blood pressure, and home warfarin use. The risk model discriminated well in the derivation (C-statistic = 0.73) and validation (C-statistic = 0.71) cohorts. A risk score for major bleeding corresponded well with observed bleeding: very low risk (3.9%), low risk (7.3%), moderate risk (16.1%), high risk (29.0%), and very high risk (39.8%). In conclusion, the ACTION Registry-GWTG in-hospital major bleeding model stratifies risk for major bleeding using variables at presentation and enables risk-adjusted bleeding outcomes for quality improvement initiatives and clinical decision making.     

Should beta‐blockers be continued as a treatment for myocardial infarction in the case of Kounis syndrome?

A 71‐year‐old male patient reported to our hospital with anaphylactic shock, and the following two issues were focused in this case. First, he was resistant to adrenaline because of taking beta‐blocker, and shock was repeated until glucagon administration was initiated. Second, he developed acute coronary syndrome. Two mechanisms contributing to Kounis syndrome were differentiated: 1) adrenaline induced coronary spasm and platelet activation or 2) a mismatch between oxygen supply and demand due to an allergic reaction. Beta‐blocker therapy was discontinued because his cardiac function was preserved. Secondary preventive beta‐blockers in recovering myocardial infarction with severe anaphylaxis history should be carefully considered.     

Prior and new onset anemia in ST-elevation myocardial infarction: a different prognostic role?

The present investigation, performed in 1,122 consecutive STEMI patients treated with primary coronary intervention, was aimed at evaluating: (1) the prevalence of prior anemia and its prognostic significance in the short term; and (2) the prevalence of new anemia and its impact in the short term. The prevalence of prior anemia was 27.4%. Patients with a prior anemia were older and exhibited a higher incidence of chronic diseases and comorbidities. They showed a higher intra-hospital mortality rate (p < 0.001), a higher incidence of PCI failure (p < 0.001) and major bleedings (p < 0.001). Prior anemia was an independent predictor for intra-hospital mortality (OR 2.12; 95% CI 1.21–3.70, p = 0.009). Patients with a new anemia account for 46.8% of our series, and showed a higher early mortality rate and incidence of major bleedings in respect to those who maintained normal Hb values (p < 0.05 and <0.05, respectively). our data strengthens the prognostic role of Hb values in STEMI patients submitted to primary PCI, since the presence of prior anemia identified a subset of patients, characterized by advanced age, higher comorbidities and serious coronary artery disease, at higher risk for intra ICCU mortality and complications. Moreover, the development of anemia during an ICCU stay is common, and is associated with a higher mortality rate and incidence of complications in respect to patients who maintain normal Hb values.     

Acid–base imbalance in uncomplicated ST-elevation myocardial infarction: the clinical role of tissue acidosis

Little information is available on acid–base imbalance in uncomplicated ST-elevation myocardial infarction (STEMI) submitted to primary percutaneous intervention (PCI). We therefore assessed acid–base imbalance in 257 consecutive uncomplicated STEMI patients submitted to PCI to determine whether its evaluation could help in identifying patients at higher risk for in-hospital complications (acute pulmonary edema and dysrhythmias). A basic metabolic profile was performed at hospital admission, that is before PCI. After PCI, we measured: creatinine, uric acid and NT-pro BNP and serum electrolytes. Peak troponin I was also considered. Acidemia was present in 11 patients (4.2%), HCO₃ < 22 in 62 (24.1%). Base excess < −3 was detectable in 70 patients (27.2%), anion gap > 12 in 13 (5.1%), Cl/Na < 0.79 in 93 patients (38.5%). Patients with a Cl/Na < 0.79 had a lower LVEF (p = 0.042) and higher values of NT-pro-BNP (p = 0.019) and of latency (p = 0.029) together with a higher length of stay (p = 0.017) and a higher incidence of in-hospital complications (p = 0.017). At backward stepwise regression analysis, the following variables resulted independent predictors of in-hospital complications: base excess OR 1.47 (95% CI 1.04–2.10) p = 0.031; Cl/Na ratio O.R. 1.85 (95% CI 1.05–3.27) p = 0.035. In STEMI patients submitted to mechanical revascularization the evaluation of acid–base status and, in particular the detection of even mild degrees of acidosis may help in risk stratification for in-hospital complications. A Cl/Na < 0.79 ratio and a base excess are independent predictors for in-hospital complications.     

Epidemiological classification of acute myocardial infarction: time for a change?

AIMS: The classification of an acute ischaemic cardiac event is traditionally based on cardiac enzymes, electrocardiography (ECG) and clinical symptoms. The impact of new specific cardiac markers on the diagnostic classification of suspected acute myocardial infarction remains poorly studied. We therefore set out to compare the diagnostic and prognostic information provided by the MONICA code and a patient classification based on the maximal level of creatine kinase MB isoenzyme. The significance of typical pain and various ECG algorithms were separately analysed. METHODS AND RESULTS: The study population consisted of 311 consecutive patients who were evaluated for suspected acute myocardial infarction in a regional referral hospital. Patients were retrospectively classified according to the MONICA criteria, by a simplified code combining symptoms and creatine kinase MB, and solely using the maximal creatine kinase MB concentration. Total mortality was followed for 1 and 5 years. The creatine kinase MB based classification was shown to be the strongest predictor of mortality (OR=2.8-3.7, p<0.001) for outcome both at 1 and 5 years. Typical pain and a positive Minnesota ECG had no prognostic relevance. However, an analysis algorithm of the admission ECG was predictive of 1- and 5-year survival. CONCLUSIONS: The epidemiological classification of suspected acute myocardial infarction could be based solely on a specific cardiac marker, such as creatine kinase MB mass. This approach contains prognostic information and is accurate enough for the structured diagnosis of acute myocardial infarction. Other outcome predictors could be used to identify patient subgroups and assess therapy.     

Regionalization of care for ST-segment elevation myocardial infarction: is it too soon?

Interest in regionalization of the care of acute ST-segment elevation myocardial infarction (STEMI) has gained momentum recently. Optimal treatment of STEMI involves balancing time to treatment and reperfusion options. Primary percutaneous coronary intervention, when performed in a timely fashion, has been shown to be more effective than fibrinolysis. However, numerous practical barriers prevent many STEMI patients from receiving primary percutaneous coronary intervention. In an effort to increase beneficial primary percutaneous coronary intervention administration to STEMI patients, health care leaders have proposed regionalized STEMI care networks with advanced emergency medical services (EMS) involvement. Constructing regionalized STEMI networks presents a policy challenge because this shift in STEMI care would require changes in current EMS and emergency medicine practices. Therefore, we present various perspectives and issues that decisionmakers and system organizers must address properly before deciding whether to adopt this new model of care. Reorganizing STEMI care in a manner analogous to how trauma and stroke care are currently triaged and treated appeals intuitively; however, given the absence of evidence that STEMI regionalization actually improves patient outcomes and is cost-effective, more research is needed to determine whether STEMI regionalization is an efficient model for providing evidence-based care. The concept of STEMI regionalization represents an effort to inform policy according to evidence-based medicine, but real-world quality, geospatial, financial, cost, business, resource, and practice barriers present obstacles to implementing this concept efficiently and effectively.     

Rising incidence of intrahepatic cholangiocarcinoma in the United States: a true increase?

BACKGROUND/AIMS: The incidence of intrahepatic cholangiocarcinoma (ICC) has been reported to be increasing in the USA. The aim of this study is to examine whether this is a true increase or a reflection of improved detection or reclassification. METHODS: Using data from the Surveillance Epidemiology and End Results (SEER) program, incidence rates for ICC between 1975 and 1999 were calculated. We also calculated the proportions of cases with each tumor stage, microscopically confirmed cases, and the survival rates. RESULTS: A total of 2864 patients with ICC were identified. The incidence of ICC increased by 165% during the study period. Most of this increase occurred after 1985. There were no significant changes in the proportion of patients with unstaged cancer, localized cancer, microscopic confirmation, or with tumor size <5 cm during the period of the most significant increase. The 1-year survival rate increased significantly from 15.8% in 1975-1979 to 26.3% in 1995-1999, while 5-year survival rate remained essentially the same (2.6 vs. 3.5%). CONCLUSIONS: The incidence of ICC continues to rise in the USA. The stable proportions over time of patients with early stage disease, unstaged disease, tumor size <5 cm, and microscopic confirmation suggest a true increase of ICC.