Early vectorcardiographic monitoring provides prognostic information in patients with ST-elevation myocardial infarction

Objective--To evaluate the prognostic value of specified vectorcardiographic data obtained during the first hours of ST-elevation myocardial infarction for cardiac outcomes up to 5 years. Design--Three hundred and five patients with ST-elevation myocardial infarction and chest pain for less than 12?h were monitored with continuous vectorcardiography. Results--All patients had follow-up for at least 1 year. The mortality was 5.9% at 30 days and 10.8% at 1 year. The estimated 5-year mortality was 24%. A total of 7.9% had recurrent infarction at 30 days and 11.2% at 1 year. Recurrent infarction or death occurred in 12.1% at 30 days and in 19.7% at 1 year. The presence of ST-VM[Formula: See Text]?≥?125?μV was highly predictive of the combined endpoint death or recurrent infarction at 1 year, OR 2.69 (95% CI 1.39-5.23). Multivariate analysis showed that age ≥75 years, anterior myocardial infarction, and the presence of ST-VM[Formula: See Text]?≥?125?μV, were independently associated with increased risk of recurrent infarction or death at 1 year and with death at 5-year follow-up. A start value of ST-VM ≤?100?μV identified a group of patients with low risk of death or re-infarction within 1 year. Conclusion--Continuous vectorcardiography during the first hours after thrombolytic treatment of patients with ST-elevation myocardial infarction provides important prognostic information. A new vectorcardiographic variable, ST-VM[Formula: See Text], identifies a group of patients with increased risk of recurrent infarction or death. As well, patients with low risk of recurrent infarction or death were identified by low start values of ST-VM.     

Early vectorcardiographic monitoring provides prognostic information in patients with ST-elevation myocardial infarction

OBJECTIVE: To evaluate the prognostic value of specified vectorcardiographic data obtained during the first hours of ST-elevation myocardial infarction for cardiac outcomes up to 5 years. DESIGN: Three hundred and five patients with ST-elevation myocardial infarction and chest pain for less than 12 h were monitored with continuous vectorcardiography. RESULTS: All patients had follow-up for at least 1 year. The mortality was 5.9% at 30 days and 10.8% at 1 year. The estimated 5-year mortality was 24%. A total of 7.9% had recurrent infarction at 30 days and 11.2% at 1 year. Recurrent infarction or death occurred in 12.1% at 30 days and in 19.7% at 1 year. The presence of ST-VM (plateau) >or= 125 microV was highly predictive of the combined endpoint death or recurrent infarction at 1 year, OR 2.69 (95% CI 1.39-5.23). Multivariate analysis showed that age >or=75 years, anterior myocardial infarction, and the presence of ST-VM (plateau) >or= 125 microV, were independently associated with increased risk of recurrent infarction or death at 1 year and with death at 5-year follow-up. A start value of ST-VM 相似文献   

Aortocoronary shunting during off-pump coronary artery bypass surgery as acute reperfusion strategy in ST-elevation myocardial infarction

We report the case of a 43-year-old patient with acute ST-segment elevation anterior myocardial infarction who underwent off-pump coronary artery bypass grafting. To reduce the duration of ongoing myocardial ischemia, acute reperfusion of the infarcted coronary artery was achieved using an aortocoronary shunt, thereby perfusing the occluded left anterior descending artery. Under the protection of the aortocoronary shunt, the left internal thoracic artery was harvested and was thereafter anastomosed to the left anterior descending artery. The patient had an uneventful postoperative recovery.     

Three cases with electrocardiographic changes suggesting myocardial infarction

We had three cases that showed electrocardiographic changes suggesting myocardial infarction during or soon after operation. All cases were elderly for open abdominal operation complicated with carcinoma or infection. They were different from typical myocardial infarction in progress of electrocardiographic changes, increase of myocardial enzyme, autopsy and so on. Kuramoto et al. reported in some cases myocardial infarction could not be recognized at autopsy in spite of electrocardiographic changes suggesting myocardial infarction during gastric operation of the elderly, and they advocated an idea of "reversible myocardial infarction". These three cases were also thought to be consistent with this disorder.     

Myocardial perfusion in ST-elevation myocardial infarction treated successfully with primary angioplasty

OBJECTIVES: To study myocardial perfusion in ST-elevation myocardial infarction (STEMI) treated successfully with primary angioplasty. Additionally, to evaluate the predictive value of perfusion on subsequent infarct size. DESIGN: Fifty patients with acute STEMI and restoration of normal epicardial flow after primary angioplasty were included in the study. TIMI myocardial perfusion (TMP) grades were determined at the end of the procedure. Contrast enhanced magnetic resonance imaging (MRI) including first-pass perfusion and delayed enhancement imaging were performed within five days and after three months. RESULTS: The patients were divided into two groups: A=TMP 0-1, B=TMP 2-3. The early MRI showed significantly reduced myocardial perfusion in the infarct zone compared to remote myocardium in both groups (p<0.001), but the reduction was more pronounced in group A. The infarct sizes were smaller (p=0.0017) and the ejection fractions higher (p=0.0001) in group B than in group A at follow-up. CONCLUSIONS: In STEMI, early impairments in myocardial perfusion were observed in spite of successful treatment with angioplasty. Marked early impairments in perfusion were associated with larger infarct sizes on MRI after three months.     

Beneficial effects of C1 esterase inhibitor in ST-elevation myocardial infarction in patients who underwent surgical reperfusion: a randomised double-blind study.

BACKGROUND: The inflammatory cascade has been hypothesized to be an important mechanism of post-ischaemic myocardial reperfusion injury and several studies demonstrated that C1 esterase inhibitor (C1-INH) is effective in post-ischaemia myocardial protection. Therefore, we aimed to investigate prospectively in a randomised double-blind study the cardioprotective effects of C1-INH in ST segment elevation myocardial infarction (STEMI) in patients who underwent emergent reperfusion with coronary artery bypass grafting (CABG). METHODS: In this study, we enrolled 80 patients affected with STEMI who underwent emergent CABG. Patients were assigned in two groups (C1-INH group: receive 1000 UI of C1-INH; and placebo group: receive a saline solution). The effects of C1-INH on complement inhibition, myocardial cell injury extension and clinical outcome were studied. Haemodynamic data and myocardial function were monitored. C1-INH, C3a, C4a complement activation fragments and cardiac troponin I (cTnI) serum levels were measured before, during and after surgery. RESULTS: Patient characteristics were not different between the two groups. The overall in-hospital mortality rate was 6.2%. No statistical significant difference was observed between the two groups with regard to early mortality (p=0.36). Statistical significant difference between the two groups was showed for cardiopulmonary bypass support (p=0.04), administration of high dose of inotropes drugs (p=0.001), time of intubation (p=0.03), intensive care unit (ICU) stay (p=0.04) and in-hospital stay (p=0.03). A significant improvement in mean arterial pressure (p=0.03), cardiac index (p=0.02) and stroke volume (p=0.03) was showed in C1-INH group versus placebo group. The serum cTnI levels were significantly low in the C1-INH group versus placebo group after reperfusion, during the observation period. Plasma levels of C3a and C4a complement fragments were reduced significantly in C1-INH group. No drugs-related adverse effects were observed. CONCLUSIONS: The inhibition of the classic complement pathway by C1-INH appears to be an effective mean of preserving ischaemic myocardium from reperfusion injury as demonstrated by low serum cTnI levels in C1-INH group. Therefore, the use of C1-INH during CABG as a rescue therapy in STEMI patients is probably an effective treatment to inhibit complement activity and to improve cardiac function and haemodynamic performance without impacting early mortality. Large randomised study should be performed to support our results.     

Coronary artery bypass grafting after acute ST-elevation myocardial infarction

ObjectivesThe study objectives were to describe the trends and outcomes of isolated coronary artery bypass grafting after ST-elevation myocardial infarction using a nationwide database.MethodsWe queried the 2002-2016 National Inpatient Sample database for hospitalized patients with ST-elevation myocardial infarction who underwent isolated coronary artery bypass grafting. We report temporal trends, predictors, and outcomes of coronary artery bypass grafting in the early (2002-2010) and recent (2011-2016) cohorts.ResultsOf 3,347,470 patients hospitalized for ST-elevation myocardial infarction, 7.7% underwent isolated coronary artery bypass grafting. The incidence of isolated coronary artery bypass grafting after ST-elevation myocardial infarction decreased over time (9.2% in 2002 vs 5.5% in 2016, P_trend < .001), whereas perioperative crude in-hospital mortality did not change (5.1% in 2002 vs 4.2% in 2016, P_trend = .66), coinciding with an increase in the burden of comorbidities. There was an increase in performing isolated coronary artery bypass grafting on hospitalization day 3 or more, as well as an increase in the use of mechanical support devices and precoronary artery bypass grafting percutaneous coronary intervention. In the early cohort, isolated coronary artery bypass grafting on days 1 and 2 was associated with higher in-hospital mortality. In the recent cohort, coronary artery bypass grafting on day 2 had similar in-hospital mortality compared with day 3 or more and lower rates of acute kidney injury, ischemic stroke, ventricular arrhythmia, and length of hospital stay.ConclusionsIn this nationwide analysis, there has been a decline in the use of isolated coronary artery bypass grafting after ST-elevation myocardial infarction. Isolated coronary artery bypass grafting on day 1 was performed in sicker patients and was associated with higher in-hospital mortality than coronary artery bypass grafting performed on day 3 or more. In the recent cohort, isolated coronary artery bypass grafting on day 2 had similar in-hospital mortality compared with day 3 or more.     

The NORwegian study on DIstrict treatment of ST-elevation myocardial infarction (NORDISTEMI)

OBJECTIVES: Thrombolysis is the treatment of choice for patients with ST-elevation myocardial infarction (STEMI) living in rural areas with long transfer delays to percutaneous coronary intervention (PCI). This trial compares two different strategies following thrombolysis: to transfer all patients for immediate coronary angiography and intervention, or to manage the patients more conservatively. DESIGN: The NORwegian study on DIstrict treatment of STEMI (NORDISTEMI) is an open, prospective, randomized controlled trial in patients with STEMI of less than 6 hours of duration and more than 90 minutes expected time delay to PCI. A total of 266 patients will receive full-dose thrombolysis, preferably pre-hospital, and then be randomized to either strategy. Our primary endpoint is the one year combined incidence of death, reinfarction, stroke or new myocardial ischaemia. The study is registered with ClinicalTrials.gov, number NCT00161005. RESULTS: By April 2006, 109 patients have been randomized. Thrombolysis has been given pre-hospital to 52% of patients. The median transport distance from first medical contact to catheterization laboratory was 155 km (range 90-396 km). Results of the study are expected in 2008.     

Acute ST-elevation myocardial infarction in two young women with cystic fibrosis and cystic fibrosis-related diabetes

Ischemic heart disease is rarely reported in people with cystic fibrosis (PwCF) despite multiple potential risk factors. Here we report two cases of ST elevation myocardial infarction (STEMI), both in young women with cystic fibrosis (CF) and cystic fibrosis related diabetes (CFRD). These cases illustrate the importance of considering myocardial injury/infarction in the differential diagnosis of patients with CF and chest pain or shortness of breath, and addressing the growing risk of cardiovascular disease (CVD).     

Microalbuminuria in patients with previous myocardial infarction

Microalbuminuria (MA) is a cardiovascular risk factor. The aim of this study was to examine the relationship between MA and the intima-media complex of the carotid and brachial artery, endothelial function, glucose metabolism, haemostatic variables and cardiac hypertrophy in patients with coronary heart disease. A total of 123 patients, aged 31-80 years, with a history of previous myocardial infarction and without known diabetes mellitus were examined with B-mode ultrasound of common carotid and brachial arteries, flow-mediated dilatation of the brachial artery and echocardiography. A standard oral glucose tolerance test with 75 g of glucose was performed. MA was defined as excretion of 20-200 microg albumin/min. MA was present in 11% of patients. Patients with MA had significantly higher level of 2-h plasma glucose, a lower displacement of the atrioventricular plane, a thicker septum wall and a higher prevalence of impaired glucose tolerance test compared with patients with normoalbuminuria (P<0.05). Urinary albumin excretion (UAE) was significantly and positively associated with calculated intima-media area (cIMa) in both brachial and common carotid arteries as well as with age and interventricular septum thickness. In conclusion, UAE was significantly and positively associated with cIMa in both the common carotid and the brachial arteries as well as with left ventricular septum thickness and glucose intolerance in patients with a history of previous myocardial infarction without known diabetes mellitus.     

Management of patients with myocardial infarction: The delays

An early reperfusion of the culprit artery in patients with myocardial infarction leads to a reduction of the infarct size and mortality. The benefit of reperfusion (primary angioplasty or fibrinolysis) is well established in the first 12 hours following the symptom onset, remains discussed between 12 and 24 hours, is not documented beyond 24 hours. The choice of the method of reperfusion (primary angioplasty or fibrinolysis) depends on the estimated delay "first medical contact-balloon inflation" in case of primary angioplasty. The delay "first medical contact-balloon inflation" remains too often higher than recommended delay. The management delay could be due to diagnostic difficulties (atypical symptoms, EKG interpretation) or to the management circuit. The optimal management associates a direct call to centre 15, an early prehospital management, a direct transfer to the cath lab or a prehospital fibrinolysis.     

Results from clinical trials on ST-elevation myocardial infarction in a historic perspective with some pathophysiological aspects

OBJECTIVE: Since the publication of the large trials on streptokinase and aspirin improving mortality related to an acute ST-elevation myocardial infarction (STEMI) there has been numerous studies on improving treatment results with new fibrinolytics, adjuvant heparin therapy and primary percutaneous intervention (PCI). The aim of the present overview is, in a historic perspective, to link some of the pathophysiology of mechanisms related to plaque rupture and following thrombosis to the effects of drug combinations and PCI observed in major clinical trials conducted in patients with STEMI. DESIGN: The overview comprises short analyses of the initial streptokinase trials (GISSI-1 and ISIS-2), the comparisons between streptokinase and tissue plasminogen activator (rt-PA) and the role of adjuvant heparin treatment (GISSI-2, ISIS-3, GUSTO I). Also included is the comparison between the new bolus-teplases and traditional, accelerated infusion of rt-PA (GUSTO III and ASSENT-2) and between unfractionated heparin (UFH) and low molecular weight heparin (LWMH) given in addition to tenecteplase (ASSENT-3). The pathophysiology of the antiplatelet and antithrombin effects is described, in order to elucidate the treatment differences observed in the trials. In addition, the role of primary PCI is discussed in view of the results in a recent meta-analysis of controlled comparisons with fibrinolytic therapy. RESULTS: Based upon these trials it seems that the optimal thrombolytic treatment is a combination of a bolus-teplase (tenecteplae) and LMWH given on top of aspirin. Primary PCI may be the most optimal treatment, provided given early following STEMI (<1 h), but whether PCI is the best alternative for all patients with STEMI is still a matter of debate. CONCLUSION: During the last 15 years the optimal antithrombotic treatment of STEMI has developed from a combination of streptokinase and aspirin to the new bolus-teplases combined with LMWH and aspirin. The use of primary PCI may be a better alternative than fibrinolytic therapy, but such a statement needs confirmation in a large comparison between PCI and a quick infusion of modern fibrinolytic agents.     

Comparison of invasive blood pressure monitoring versus normal non-invasive blood pressure monitoring in ST-elevation myocardial infarction patients with percutaneous coronary intervention

BackgroundHypotension post percutaneous coronary intervention (PCI) causes stent thrombosis and reduced coronary perfusion, which aggravate myocardial ischemia and lead to patient death. Therefore, the accuracy and timeliness of blood pressure monitoring (BPM) are crucial for the nursing of patients post PCI. However, it is still controversial whether invasive blood pressure monitoring (IBPM) or non-invasive blood pressure monitoring (NIBPM) should be used for patients post PCI, and the magnitude of their assistance for patients’ recovery remains unclear.MethodsA randomized controlled trial was performed in this study. 126 ST-segment elevation myocardial infarction (STEMI) patients post PCI were recruited and randomly divided into two groups (NIBPM group n = 63; IBPM group n = 63).ResultsClinical characteristics and physiological outcomes of participants received different BPM methods were collected and analyzed to compare the effects of these two methods on the nursing of PCI patients. Compared to NIBPM group, IBPM assisted to shorten the time of myocardial ischemia, promote coronary reperfusion, reduce the occurrence of cardiovascular disease and other complications, and ultimately reduce the mortality of patients post PCI.ConclusionThe application of IBPM contributed to reduce the occurrence of complications, shorten the time of vascular reperfusion, and guide treatment of clinicians in time.     

Reevaluation of perioperative myocardial infarction in patients with prior myocardial infarction undergoing noncardiac operations

We studied 275 patients with prior myocardial infarctions undergoing noncardiac operations to determine the incidence and outcome of perioperative myocardial reinfarction. Perioperative myocardial reinfarction developed in 13 patients (4.7%) of whom 3 (23%) died of cardiac causes. When time between prior myocardial infarction and the date of anesthesia was analyzed, the incidence of perioperative myocardial reinfarction was 4.3% at 0-3 mo, 0 at 4-6 mo, 5.7% at greater than 6 mo, and 3.3% at an indeterminate exact interval. None of the variables analyzed showed any significant correlation with the rate of reinfarction. The urgency of operation and aortic or vascular procedures were the only variables that approached, but failed to achieve, statistical significance.