Serial Doppler Echocardiographic Assessment of Diastolic Dysfunction during Acute Myocardial Infarction

Objectives: We performed serial Doppler echocardiography in patients with ST‐elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) to describe the temporal changes in Doppler parameters following STEMI. Background: Data on comprehensive Doppler assessment of diastolic dysfunction following STEMI, incorporating tissue Doppler imaging (TDI), are lacking. Severe diastolic dysfunction in stable patients usually manifests as a restrictive mitral filling pattern (RFP), reduced TDI‐derived annular velocities (E'), and elevated E/E' ratios >15. Methods: Twenty‐eight patients (19 males, mean age 60 ± 10 years) with a first‐ever STEMI who underwent PCI were prospectively assessed with echocardiography and invasive left ventricular end‐diastolic pressure (LVEDP) measurements prior to PCI. Repeat echocardiograms were performed at day 3 and 12 months. Results: During STEMI: (i) LVEDP was significantly elevated but decreased post revascularization (26.1 ± 6.2 vs. 20.8 ± 5.2 mmHg, P = 0.002); (ii) the predominant mitral inflow pattern was an abnormal relaxation pattern (n = 14 [50%]), whereas restrictive filling pattern was only observed in seven (25%) patients; (iii) E' velocities were only modestly reduced (septal E' 7.4 ± 2.2 cm/sec, lateral E' 9.6 ± 2.2 cm/sec), and (iv) a septal E/E'ratio >15 seen in only one patient, whereas all other patients had an E/E' ratio of 8–15. Serial TDI showed that E'velocity decreased at day 3 (septal E' 7.4 ± 2.1 cm/sec vs. 5.9 ± 1.6 cm/sec, P = 0.002) and remained reduced at 1 year follow‐up, suggesting persistence of diastolic dysfunction. Conclusions: During STEMI, contrary to findings in stable patients, the predominant Doppler manifestation of the severe diastolic dysfunction and elevated LVEDP was an abnormal relaxation mitral inflow pattern accompanied by E/E' ratios of 8–15. Serial Doppler assessment suggests incomplete diastolic recovery following STEMI.     

Predictors of In-hospital Mortality and Acute Myocardial Infarction in Thrombotic Thrombocytopenic Purpura

Background

Despite the widespread availability of plasmapheresis as a therapy, thrombotic thrombocytopenic purpura is associated with significant morbidity and mortality. There is a paucity of data on the predictors of poor clinical outcome in this population. Acute myocardial infarction is a recognized complication of thrombotic thrombocytopenic purpura. Little is known about the magnitude of this problem, its risk factors, and its influence on mortality in patients hospitalized with thrombotic thrombocytopenic purpura.

Methods

We used the 2001-2010 Nationwide Inpatient Sample database to identify patients aged ≥18 years with the diagnosis of thrombotic thrombocytopenic purpura (International Classification of Diseases, 9^th Revision, Clinical Modification [ICD-9-CM] code 446.6) who also received therapeutic plasmapheresis (ICD-9-CM code 99.71) during the hospitalization. Patients with acute myocardial infarction were identified using the Healthcare Cost and Utilization Project Clinical Classification Software code 100. Stepwise logistic regression was used to determine independent predictors of in-hospital mortality and acute myocardial infarction in thrombotic thrombocytopenic purpura patients.

Results

Among the 4032 patients (mean age 47.5 years, 67.7% women, and 36.9% white) with thrombotic thrombocytopenic purpura who also underwent plasmapheresis, in-hospital mortality was 11.1%. Independent predictors of increased in-hospital mortality were older age (odds ratio [OR] 1.03; 95% confidence interval [CI], 1.02-1.04; P <.001), acute myocardial infarction (OR 1.89; 95% CI, 1.24-2.88; P = .003), acute renal failure (OR 2.75; 95% CI, 2.11-3.58; P <.001), congestive heart failure (OR 1.66; 95% CI, 1.17-2.34; P = .004), acute cerebrovascular disease (OR 2.68; 95% CI, 1.87-3.85; P <.001), cancer (OR 2.49; 95% CI, 1.83-3.40; P <.001), and sepsis (OR 2.59; 95% CI, 1.88-3.59; P <.001). Independent predictors of acute myocardial infarction were older age (OR 1.03; 95% CI, 1.02-1.04; P <.001), smoking (OR 1.60; 95% CI, 1.14-2.24; P = .007), known coronary artery disease (OR 2.59; 95% CI, 1.76-3.81; P <.001), and congestive heart failure (OR 2.40; 95% CI, 1.71-3.37; P <.001).

Conclusion

In this large national database, patients with thrombotic thrombocytopenic purpura had an in-hospital mortality rate of 11.1% and an acute myocardial infarction rate of 5.7%. Predictors of in-hospital mortality were older age, acute myocardial infarction, acute renal failure, congestive heart failure, acute cerebrovascular disease, cancer, and sepsis. Predictors of acute myocardial infarction were older age, smoking, known coronary artery disease, and congestive heart failure.     

Transesophageal Color Doppler Echocardiographic Diagnosis of Cardiac Rupture Following Acute Myocardial Infarction

This report describes a case of cardiac rupture following acute myocardial infarction accurately diagnosed by transesophageal color Doppler echocardiography, which showed a very narrow transmural tract from the left ventricle into the pseudoaneurysm cavity. Such a small, slitlike rupture would most likely have been missed by an otherwise routine transesophageal examination, and we stress the importance of color Doppler interrogation in its accurate diagnosis.     

辛伐他汀改善心肌梗死后心肌胶原含量变化及机制的实验研究

目的:探讨辛伐他汀对大鼠心肌梗死后心肌胶原含量的影响及其机制. 方法:建立大鼠心肌梗死模型,24 h后存活大鼠随机分成心肌梗死组(n=9)、辛伐他汀20 mg组[20 ms/(kg·d),n=10]和平伐他汀40 mg组[40 ms/(kg·d),n=9],另设假手术组(n=10).4周后观察血脂水平、左心室重指数和天狼猩红染色分析左心室非梗死区心肌胶原容积分数(表达心肌胶原含量),免疫组化检测基质金属蛋白酶-2(MMP-2),免疫印迹杂交方法(Western blot)和逆转录多聚酶链反应(RT-PCR)检测转化生长因子β1(TGF-β1)在非梗死区的表达. 结果:①各组血脂水平差异无统计学意义,心肌梗死组左心室重苗指数、非梗死区Ⅰ型、Ⅲ型胶原容积分数及Ⅰ型与Ⅲ型胶原容积分数比值较假手术组均明显升高(P均<0.05),差异均有统计学意义;辛伐他汀两组左心室重量指数、非梗死区Ⅰ型、Ⅲ型胶原容积分数及Ⅰ型与Ⅲ型胶原容积分数比值较心肌梗死组均卜降,但仍高于假手术组(P均<0.05),差异均有统计学意义.②心肌梗死组MMP-2和TGF-β1表达较假手术组均显著增加(P均<0.05),而辛伐他汀两组表达则明显降低,但仍高于假手术组(P均<0.05),差异均有统计学意义. 结论:辛伐他汀能有效改善大鼠心肌梗死后心肌胶原含量,机制与其渊脂作用无关,可能与下调MMP-2和TGF-β1的表达有关.     

大鼠急性心肌梗死后心肌组织整合素连接激酶表达的变化

目的观察实验性大鼠急性心肌梗死后不同时间点心肌整合素连接激酶表达水平和心功能的动态变化,探讨心肌梗死后心功能不全和整合素连接激酶表达变化的关系。方法成年雄性SD大鼠,开胸结扎左冠状动脉前降支建立心肌梗死模型,在心肌梗死后不同时间点分别用超声心动图和左心室导管评估心功能,实时定量PCR和Western blotting检测非梗死区心肌组织内整合素连接激酶表达。结果与假手术组相比,心肌梗死组心功能明显下降。在心肌梗死后第1、4和8周三个时间点中,第8周组±dp/dtmax明显低于第1周组和第4周组,左心室舒张末压明显高于第1周组和第4周组。实时定量PCR和Western blotting检测发现,非梗死区心肌整合素连接激酶表达水平在心肌梗死后第1、4周显著升高,第8周表达降低,回落到假手术组水平,且明显低于心肌梗死后第1、4周。结论心肌梗死后非梗死区心肌组织内整合素连接激酶由短期内的表达增加到长期的表达减少,可能参与心肌梗死后心功能由代偿到失代偿的发展过程。     

Living Alone,Patient Sex and Mortality After Acute Myocardial Infarction

BACKGROUND Psychosocial factors, including social support, affect outcomes of cardiovascular disease, but can be difficult to measure. Whether these factors have different effects on mortality post-acute myocardial infarction (AMI) in men and women is not clear. OBJECTIVE To examine the association between living alone, a proxy for social support, and mortality postdischarge AMI and to explore whether this association is modified by patient sex. DESIGN Historical cohort study. PARTICIPANTS/SETTING All patients discharged with a primary diagnosis of AMI in a major urban center during the 1998–1999 fiscal year. MEASUREMENTS Patients’ sociodemographic and clinical characteristics were obtained by standardized chart review and linked to vital statistics data through December 2001. RESULTS Of 880 patients, 164 (18.6%) were living alone at admission and they were significantly more likely to be older and female than those living with others. Living alone was independently associated with mortality [adjusted hazard ratio (HR) 1.6, 95% confidence interval (CI) 1.0–2.5], but interacted with patient sex. Men living alone had the highest mortality risk (adjusted HR 2.0, 95% CI 1.1–3.7), followed by women living alone (adjusted HR 1.2, 95% CI 0.7–2.2), men living with others (reference, HR 1.0), and women living with others (adjusted HR 0.9, 95% CI 0.5–1.5). CONCLUSIONS Living alone, an easily measured psychosocial factor, is associated with significantly increased longer-term mortality for men following AMI. Further prospective studies are needed to confirm the usefulness of living alone as a prognostic factor and to identify the potentially modifiable mechanisms underlying this increased risk.     

增龄对心肌梗塞后心肌肥大和心泵功能恢复的影响

选用3.5月和18月龄的两组雄性大鼠,在心肌梗塞(MI)后9天测定心泵功能的变化特点,同时采用形态计量学方法对非梗塞区心肌细胞及其亚细胞结构进行定量研究。结果发现:1.老龄大鼠在正常情况下就有部分心肌细胞死亡,剩余心肌细胞肥大;由于肥大代偿作用,老龄大鼠基础状况下的心泵功能正常,但容量负荷时的最大代偿功能降低。2.老龄鼠MI后,心肌肥大发展较青龄组明显,但心脏储备功能的恢复却远较青龄鼠差;3.心肌细胞线粒体、肌原纤维和基质比例的改变无明显年龄差异。     

Depression After Myocardial Infarction

Depression is an important disease state that requires significant time and resources to manage properly. The presence of depression in patients with cardiovascular disease has been strongly associated with detrimental effects in terms of morbidity and mortality. Although several large-scale and small studies have evaluated various interventions in the management of depression after myocardial infarction, a significant portion of these data have provided more questions than answers. Although limited, the randomized prospective clinical trial data evaluating interventions for the management of depression after myocardial infarction in patients with ischemic heart disease continue to produce promising findings for progressive and improved management of these devastating diseases.     

Myocardial Contrast Echocardiography After Myocardial Infarction

Myocardial contrast echocardiography (MCE) enables direct assessment of the degree and adequacy of microvascular perfusion as well as the presence of wall motion abnormalities. MCE has the following benefits in patients with acute myocardial infarction (MI): 1) rapid and definite diagnosis of acute MI; 2) identification of patients who may benefit from prompt reperfusion therapy; 3) assessment of the efficacy of mechanical or pharmacologic intervention for an open infarct-related artery; 4) estimation of MI size early after reperfusion and residual myocardial viability; 5) identification of being at high risk for post-MI complications and left ventricular remodeling; and 6) assessment of myocardial viability and ischemia prior to hospital discharge. Therefore, MCE is an ideal tool for correct triaging of patients to revascularization and has both prognostic and therapeutic implications in patients with acute MI.     

Readmission and Mortality After Hospitalization for Myocardial Infarction and Heart Failure

BackgroundReadmission rates after acute myocardial infarction (AMI) and heart failure (HF) hospitalizations have decreased in the United States since the implementation of the Hospital Readmissions Reduction Program.ObjectivesThis study was designed to examine the temporal trends of readmission and mortality after AMI and HF in Ontario, Canada, where reducing hospital readmissions has not had a policy incentive.MethodsThe cohort was comprised of AMI or HF patients 65 years of age or older who had been hospitalized from 2006 to 2017. Primary outcomes were 30-day readmission and post-discharge mortality. Secondary outcomes included in-hospital mortality, 30-day mortality from admission, and in-hospital mortality or 30-day mortality post-discharge. Adjusted monthly trends for each outcome were examined over the study period.ResultsOur cohorts included 152,808 AMI and 223,283 HF patients. Age- and sex-standardized AMI hospitalization rates in Ontario declined 32% from 2006 to 2017 while HF hospitalization rates declined slightly (9.1%). For AMI, risk-adjusted 30-day readmission rates declined from 17.4% in 2006 to 14.7% in 2017. All AMI risk-adjusted mortality rates also declined from 2006 to 2017 with 30-day post-discharge mortality from 5.1% to 4.4%. For HF, overall risk-adjusted 30-day readmission was largely unchanged from 2006 to 2014 at 21.9%, followed by a decline to 20.8% in 2017. Risk-adjusted 30-day post-discharge mortality declined from 7.1% in 2006 to 6.6% in 2017.ConclusionsThe patterns of outcomes in Ontario are consistent with the United States for AMI, but diverge for HF. For AMI and HF, admissions, readmissions, and mortality rates declined over this period. The reasons for the country-specific patterns for HF need further exploration.     

急性心肌梗塞患者住院死亡率女性高于男性原因探讨

本文对181例女性和214例男性急性心肌梗塞(AMI)住院患者的资料进行分析.结果发现,住院期间女性AMI的死亡率明显高于男性(26%与14%;P<0.01).女性AMI患者具有发病年龄大、胸痛少、糖尿病较多、广泛前壁及复合部位梗塞较多、血清肌酸磷酸肌酶水平较低,心源性并发症多等特点.多因素回归分析表明,年龄、心绞痛、糖尿病、心力衰竭及休克为预示女性AMI死亡的重要因素.     

Echocardiographic Features of Ventricular Septal Rupture with Right Ventricular Aneurysm After Acute Myocardial Infarction

Postinfarction ventricular septal defect is a life-threatening disorder that may be adequately treated if the diagnosis is obtained promptly. Two-dimensional color Doppler echocardiography is a reliable tool for this diagnosis and gives additional information regarding its location, size, and shape. The authors emphasize the feasibility of this method to depict a particular form of postinfarction interventricular septal rupture, which developed an aneurysm inside the right ventricular cavity. Its characteristics were completely defined by color Doppler echocardiography and confirmed at surgery.     

Predictors of High On-Treatment Platelet Reactivity Early After Clopidogrel Loading in ST-Elevation Myocardial Infarction

Background:?Given that platelet inhibition is crucial when ST-elevation myocardial infarction (STEMI) patients undergo primary PCI (PPCI), the identification of factors associated with early high on-treatment platelet reactivity may be important. Methods and Results:?Consecutive STEMI patients admitted for PPCI were considered for platelet reactivity assessment 2h after loading with 600mg clopidogrel using the VerifyNow point-of-care P2Y12 assay. A cut-off of ≥235 P2Y12 reaction units indicated high on-treatment platelet reactivity. Out of 92 STEMI patients, 63 (68.5%) were found to have high on-treatment platelet reactivity. Patients with high on-treatment platelet reactivity had received upstream clopidogrel loading and pantoprazol more frequently, had lower admission hemoglobin and tended to have an impaired renal function compared to those with an adequate response to clopidogrel. On multivariate analysis, upstream clopidogrel loading and creatinine clearance <60ml/min were independently associated with higher risk for high on-treatment platelet reactivity (relative risk [RR]=1.55, 95% confidence interval [CI]: 1.11-2.17, P=0.01; RR=1.31, 95% CI: 1.008-1.71, P=0.04, respectively). Conclusions:?In patients with STEMI undergoing PPCI, use of upstream clopidogrel and impaired renal function independently predict high on-treatment platelet reactivity assessed as early as 2h following 600mg of clopidogrel loading dose on point-of-care P2Y12 function assay. (Circ J?2012; 76: 2183-2187).     

The Effect of Age on Functional and Mortality Outcomes After Acute Myocardial Infarction

OBJECTIVES: To determine the prevalence of post-myocardial infarction (MI) functional decline and to describe its association with chronological age in survivors of MI.
DESIGN: Prospective observational registry.
SETTING: Nineteen U.S. hospitals.
PARTICIPANTS: Two thousand four hundred eighty-one patients with acute MI.
MEASUREMENTS: Baseline and 1-year interviews identified subjects with functional decline, defined as a more than 5-point decline in Medical Outcomes Study 12-item Short Form Questionnaire (SF-12) Physical Component score or being "too ill" to provide a follow-up interview at 1 year. The relationship between age and functional decline was evaluated using logistic regression models adjusted for baseline SF-12 score, comorbidities, sociodemographics, and treatment characteristics. One-year mortality and a combined endpoint of death or decline were also compared across age.
RESULTS: Of 2,009 patients who survived to 1 year, 582 (29%) experienced a functional decline. In survivors, age was not associated with functional decline in unadjusted (odds ratio (OR)=0.95/decade, 95% confidence interval (CI)=0.88–1.03) or multivariable (OR=0.94, 95% CI=0.85–1.05) models. Although age was strongly associated with 1-year mortality (adjusted hazard ratio=1.42, 95% CI=1.21–1.66), there was no association between age and the combined endpoint of death or functional decline (adjusted OR=1.02, 95% CI=0.92–1.12).
CONCLUSION: More than one in four survivors of MI experiences a significant decline in physical function by 1 year. Although age is strongly associated with mortality, it had no association with functional decline. Because older patients have the same potential for favorable functional outcomes after an MI, age alone should not preclude aggressive treatment after an MI.     

Heparin After Acute Myocardial Infarction

Heparin is commonly, but by no means universally, used after acute myocardial infarction. When used the dose, route of administration, and duration of therapy varies considerably. The role of heparin is reviewed with particular reference to its use in conjunction with other commonly used therapies, such as aspirin and thrombolytic agents. Intravenous heparin after thrombolytic therapy remains untested in patients treated with aspirin. When used, benefit is seen in a narrow aPTT range, and there have been unexpected increases in mortality in patients with the greatest heparin effect. The addition of delayed subcutaneous heparin to aspirin and thrombolytic therapy does not provide a mortality benefit. In patients not treated with thrombolysis, there is no clear evidence that heparin confers significant mortality benefit if patients are treated with aspirin. Heparin therapy may reduce the incidence of intraventricular thrombus after anterior wall infarction, but there is no clear evidence that it reduces the clinically important sequelae of cerebral embolism and stroke. Given concerns about increased hemorrhagic rates with heparin and unknown benefit, it is reasonable to conclude that its role in the management of patients with acute myocardial infarction remains unclear.     

培哚普利改善糖尿病大鼠急性心肌梗死后内皮祖细胞动员

目的 观察培哚普利对糖尿病大鼠急性心肌梗死后骨髓内皮祖细胞动员和血管新生障碍的影响,并探讨其可能的分子机制.方法 高脂饮食联合小剂量链脲霉素诱导雄性SD大鼠糖尿病模型,成模4周后结扎冠状动脉左前降支造成急性心肌梗死模型.术后将大鼠随机分至培哚普利治疗组和模型组(各组n=15).流式细胞术检测术前及术后不同时间点(1、3、5、7、14和28天)外周血CD45-/low+CD133+ KDR+内皮祖细胞数量,ELISA法检测不同时间点血浆血管内皮生长因子水平.CD31免疫荧光染色法评估心肌梗死1个月后心肌梗死周围区血管新生情况.超声心动图评估心功能改变.免疫印迹法测定骨髓细胞中内皮祖细胞动员相关通路蛋白的表达.结果 培哚普利治疗可显著改善糖尿病时缺血诱导的内皮祖细胞动员障碍,使循环内皮祖细胞峰值明显升高(103±37个/106单核细胞比58±19个/106单核细胞,P＜0.05),同时伴有血浆血管内皮生长因子水平升高,骨髓内皮祖细胞动员通路的信号分子蛋白激酶B与内皮型一氧化氮合酶磷酸化增加以及基质金属蛋白酶9的表达升高(P＜0.05).与模型组相比,培哚普利治疗后糖尿病大鼠心肌梗死周围区新生毛细血管密度显著增加,射血分数及左心室短轴缩短率明显改善(所有P＜0.05).结论 培哚普利能改善糖尿病大鼠缺血诱导的骨髓内皮祖细胞动员障碍,增加缺血区血管新生,最终改善心功能.这种作用可能通过活化骨髓内皮祖细胞动员相关通路介导.