Detection of culprit coronary lesion location in pre-hospital 12-lead ECG

BackgroundPre-hospital 12-lead ECG interpretation is important because pre-hospital activation of the coronary catheterization laboratory reduces ST-segment elevation myocardial infarction (STEMI) discovery-to-treatment time. In addition, some ECG features indicate higher risk in STEMI such as proximal left anterior descending (LAD) culprit lesion location. The challenging nature of the pre-hospital environment can lead to noisier ECGs which make automated STEMI detection difficult. We describe an automated system to classify lesion location as proximal LAD, LAD, right coronary artery (RCA) and left circumflex (LCx) and test the performance on pre-hospital 12-lead ECG.MethodsThe overall classifier was designed from three linked classifiers to separate LAD from non-LAD (RCA or LCx) in the first step, RCA from LCx in a second classifier and proximal from non-proximal LAD in the third classifier. The proximal LAD classifier was designed for high specificity because the output may be used in the decision to modify treatment. The LCx classifier was designed for high specificity because RCA is dominant in most people. The system was trained on a set of emergency department ECGs (n = 181) and tested on a set of pre-hospital ECGs (n = 80). Both sets were based on a sequential sample starting with symptoms suggesting acute coronary syndromes. Culprit lesion location was determined from coronary catheterization laboratory reports. Inclusion criteria included STEMI interpretation by computer and culprit lesion with 70% or more narrowing. Algorithm accuracy was measured on the test set by sensitivity (SE), specificity (SP), and positive predictive value (PPV).ResultsSE, SP and PPV were 50, 100 and 100% respectively for proximal LAD lesion location; 90, 100 and 100% for all LAD; 98, 72 and 78% for RCA; and 50, 98 and 90% for LCx. Specificity and PPV were high for proximal LAD, LAD and LCx. Specificity and PPV are not as high for RCA by design since the RCA-LCx tradeoff favors high specificity in LCx.ConclusionAlthough our test database is not large, algorithm performance suggests culprit lesion location can be reliably determined from pre-hospital ECG. Further research is needed however to evaluate the impact of automated culprit lesion location on patient treatment and outcomes.     

iMap intravascular ultrasound evaluation of culprit and non-culprit lesions in patients with ST-elevation myocardial infarction

ObjectiveThe purpose of this study was to evaluate plaque characteristics of culprit and non-culprit lesions in ST-elevation myocardial infarction (STEMI) patients at the index procedure and 10 months later using iMap intravascular ultrasound (IVUS).BackgroundThe exact site of the plaque rupture or erosion in coronary arteries with subsequent thrombosis cannot be precisely defined. Our hypothesis is that in STEMI patients angiographically guided stenting could fail to identify necrotic tissue and thus may leave an uncovered significant amount of vulnerable plaque.MethodsIn 63 consecutive STEMI patients the culprit artery was analyzed with iMap IVUS at the time of the index procedure and 10 months later. The most stenotic culprit segment was compared to the segment proximal to the culprit lesion.ResultsA high percentage of necrotic tissue was observed in the culprit lesion and a comparatively lower percentage of necrotic tissue was observed in the non-culprit lesions proximal to the culprit at the index procedure by iMap IVUS (31.9% ± 10.0% vs 27.8% ± 11.8%, p = 0.012). The proportion of necrotic tissue in the segment proximal to the culprit lesion was unchanged at 10-month follow-up (27.1% ± 11.9% vs 25.5% ± 12.8%, p = 0.147). The percentage of lipidic tissue in the proximal segment decreased at 10-month follow-up (9.8% ± 2.9% vs 8.8 ± 3.0%, p = 0.009).ConclusionsIn STEMI patients, culprit lesion segments and non-culprit segments contain high proportions of necrotic tissue. However, a comparatively higher proportion of necrotic tissue was found in the culprit lesions according to iMap IVUS. The percentage of necrotic tissue remained high at 10-month follow-up in both culprit and non-culprit segments.     

Tissue Doppler assessment of right ventricular function in female patients with limited form of systemic sclerosis

BackgroundCardiac involvement in systemic sclerosis (SSc) is often clinically occult. The aim of this study was the evaluation of early subclinical right ventricular (RV) involvement in patients with limited form of systemic sclerosis by tissue Doppler.MethodsTwenty female patients with limited cutaneous SSc and 20 control female subjects, matched for age were studied with transthoracic echocardiography and tissue Doppler imaging (TDI) to assess RV function. Patients with pulmonary hypertension, chronic renal failure, diabetes mellitus, hypertension, heart failure, left ventricular hypertrophy, ischemic or rheumatic heart disease were excluded.ResultsPatients with limited form SSc had significant lower tricuspid annulus peak systolic velocities (S_T) (9.95 ± 1.78 vs. 11.05 ± 1.53 cm/s, p < 0.044), early (E_T) (9.65 ± 1.30 vs. 12.50 ± 1.23 cm/s, p < 0.0001), late (A_T) diastolic velocity (12.60 ± 2.01 vs. 18.15 ± 1.81 cm/s, p < 0.0001), and tricuspid annular plane systolic excursion (TAPSE) (23.05 ± 3.50 vs. 26.50 ± 1.90, p < 0.001) compared to controls. Myocardial performance index (MPI) of the RV was higher in SSc patients compared to controls (0.41 ± 0.05 vs. 0.30 ± 0.02, p < 0.0001). There were significant correlations between disease duration and S_T and RV MPI (r = ?0.883, p < 0.0001; r = 0.686, p < 0.001, respectively).ConclusionsPatients with limited form of SSc present with pulsed-tissue Doppler imaging indices indicative of right ventricle dysfunction, which had significant correlations with disease duration. Tissue Doppler is a valuable non-invasive tool for detecting RV myocardial involvement in patients with limited SSc.     

Role of echocardiography and cardiac biomarkers in prediction of in-hospital mortality and long-term risk of brain infarction in pulmonary embolism patients

IntroductionThe aim of prospective study was to evaluate the ability of echocardiography and cardiac biomarkers to predict in-hospital mortality and the risk of brain infarction during a 12-month follow-up period (FUP) with anticoagulation in pulmonary embolism (PE) patients.MethodsEighty-eight consecutive acute PE patients (39 men, mean age 63 years) were enrolled; 78 underwent baseline echocardiography and brain magnetic resonance imaging (MRI). After a 12-month FUP, 58 underwent brain MRI. In-hospital mortality and the rates of new ischemic brain lesions (IBL) on MRI with clinical ischemic stroke (IS) events were predicted based on echocardiography (patent foramen ovale presence with right-to-left shunt – PFO/RLS; right/left ventricle diameter ratio – RV/LD; tricuspid annulus plane systolic excursion – TAPSE; tricuspid annulus systolic velocity – S_T; pulmonary artery systolic pressure – PASP) and biomarkers results (amino-terminal fragment of brain natriuretic peptide – NT-proBNP and cardiac troponin T – cTnT).ResultsOur series involved 88 patients, of whom 11 (12.5%) presented high-risk PE, 24 (27.3%) intermediate-high risk PE, 19 (21.6%) intermediate-low risk PE and 34 (38.6%) patients had low risk PE.Nine patients (10.2%) died during hospitalization including high-risk PE [6/9 (66.6%)] and intermediate-high-risk PE [3/24 (12.5%)]. cTnT [odds ratio (OR) 4.3; 95% confidence interval 0.59–31.3, P = 0.014], NT-proBNP (OR 14.2 [1.5–133.4], P = 0.02), RV/LD ≥0.79 (OR 36.6 [4.2–316.4], P = 0.001), TAPSE (OR 0.55 [0.34–0.92, P = 0.022) and PASP ≥51.5 mmHg (OR 33.3 [3.8–292.6], P = 0.022) were predictors of in-hospital mortality.Seventeen patients (19.3%) experienced IS (n = 8) or new IBL (n = 9). On multivariate analysis, PFO/RLS (OR 27.1 [3.0–245.3], P = 0.003) and S_T ≤14.5 cm/s (OR 34.1 [CI 3.4–344.0], P = 0.003) were independent predictors of IS and IBL risk.ConclusionsHigh blood troponin T, NT-proBNP, RV dilatation/systolic dysfunction and pulmonary hypertension predicted in-hospital mortality. PFO/RLS presence and S_T were predictors of clinically apparent/silent brain infarction.     

Assessment of validity of the ‘Culprit Score’ for predicting the culprit lesion in patients with acute inferior wall myocardial infarction

IntroductionMany electrocardiographic criteria have been developed to determine the infarct-related artery in acute inferior wall myocardial infarction. The aim of this study was to test the commonly used criteria and devise a simplified score to further improve the diagnostic accuracy.Materials and methodsFrom 2011 to 2013, 100 patients with acute inferior wall myocardial infarction were recruited for electrocardiographic and angiographic analyses.ResultsThe mean age of the patients was 65 ± 12 years with 74% of patients being male. In our study population, significantly more ST-segment depression was seen in lead aVL and ST elevation in lead III in those with right coronary artery (RCA) occlusions. In left circumflex artery (LCX) occlusions, significantly more ST depression was seen in leads V1–3 (most significantly in lead V2) and ST elevation in lead II. In addition, more prominent ST depression was seen in lead aVL and ST elevation in V1 in proximal RCA occlusions. Based on the findings, we devised a score named Culprit Score, which was defined as [II − V2/III + V1 − aVL]. The sensitivity and specificity of Culprit Score ≤0.5 to predict proximal RCA occlusions; 0.5 to ≤1.5 to predict distal RCA occlusions; and score >1.5 to predict LCX occlusions were 85% and 85%; 80% and 86%; and 80% and 94%, respectively. Similarly, the negative predictive value was more than 80%.ConclusionThe Culprit Score was found to have high specificity and negative predictive value to identify the infarct-related artery in inferior wall myocardial infarction.     

Distribution,frequency and clinical implications of napkin-ring sign assessed by multidetector computed tomography

BackgroundPlaque rupture and secondary thrombus formation play key roles in the onset of acute coronary syndrome (ACS). Plaques showing the napkin-ring sign in multidetector computed tomography (MDCT) have been reported as thin-cap fibroatheroma that is recognized as a precursor lesion for plaque rupture. The purpose of this study was to investigate distribution and frequency of napkin-ring sign and its relationship to features indicating coronary plaque vulnerability on MDCT in patients with coronary artery disease.MethodsWe enrolled 273 patients with ACS (n = 61) or stable angina pectoris (SAP, n = 212) who were assessed by MDCT. The definition of the napkin-ring sign was the presence of a ring of high attenuation and the CT attenuation of a ring presenting higher than those of the adjacent plaque and no greater than 130 HU.ResultsThe culprit plaques with the napkin-ring sign show higher remodeling index and lower CT attenuation (1.15 ± 0.12 vs. 1.02 ± 0.12, p < 0.01 and 39.9 ± 22.8 vs. 72.7 ± 26.6, p < 0.01, respectively). Napkin-ring sign at culprit lesions was more frequent in patients with ACS than those with SAP (49.0% vs. 11.2%, p < 0.01). Moreover, napkin-ring sign at non-culprit lesions was more frequently observed in ACS patients compared with SAP patients (12.7% vs. 2.8%, p < 0.01). The distribution of the napkin-ring sign in the right coronary arteries and left circumflex arteries of our population was relatively even, whereas the napkin-ring sign in the left anterior descending artery was common in the proximal sites (p < 0.01).ConclusionsThe napkin-ring sign assessed by MDCT represents similar clinical features of fibroatheroma. MDCT could contribute to the search for fibroatheroma.     

Potential pro-arrhythmic effect of cardiac resynchronization therapy

A decline in mortality due to pump failure has been clearly documented after cardiac resynchronization therapy (CRT), however the impact on sudden cardiac death and the development of malignant ventricular arrhythmias remains questionable. Our study aims to investigate this alleged pro-arrhythmic effect of CRT using surface electrocardiogram (ECG) markers of pro-arrhythmia.MethodsSeventy five patients, who received CRT were included in this study. Manual measurement of corrected QT interval (QTc), T_peak-end (T_p-e) interval, QT dispersion (QTd) and T_peak-end dispersion during baseline 12 lead surface ECG and after applying atrial-biventricular pacing were done. Arrhythmias post CRT was recorded from ECG, 24 h holter monitoring or pacemaker programmer event recorder.ResultsQTc interval showed significant prolongation after CRT (498.9 ± 50.8 vs. 476.2 ± 41.6 msec, P = 0.0001). Comparing patients with major arrhythmogenic events (MAE) and increased frequency of premature ventricular contractions (PVCs) post CRT pacing to those patients without arrhythmias, there was a significant prolongation of the QTc interval (527 ± 63.29 vs. 496.95 ± 45.2 msec, P = 0.043) and T_p-e interval (94.16 ± 9 vs. 87.41 ± 16.37 msec, P = 0.049). While in the arrhythmogenic group, there was an insignificant decrease in QTd and T_peak-end dispersion.ConclusionQTc and T_p-e intervals are a potential predictor of occurrence of MAE and PVCs. On the other hand, T_p-e dispersion and QTd did not show a predictive potential for arrhythmia.     

Assessment of right ventricular function by myocardial performance index in diabetic patients

BackgroundAssessment of right ventricular (RV) function remains difficult because of the RV complex shape. Data regarding RV performance in patients with diabetes are incomplete The aim of this study was to assess the feasibility of pulsed wave tissue Doppler imaging and myocardial performance index (MPI) for the assessment of right ventricular function in diabetic patients without coronary artery disease.MethodsThe study included 20 diabetic patients, 20 diabetic hypertensive and 20 gender and age matched healthy subjects underwent standard echocardiography with tissue Doppler imaging (TDI) to assess RV function. Patients with myocardial ischemia, impaired left ventricular systolic function, valvular heart disease or other diseases which could alter the right ventricular performance were excluded.ResultsMyocardial performance index was significantly higher in diabetes compared to control group (0.41 ± 0.05 versus 0.27 ± 0.04, p = 0.001). Peak myocardial systolic velocity (Sa), early diastolic myocardial velocity (Ea), and late diastolic myocardial velocity (Aa) were significantly lower in patients with diabetes mellitus (DM) compared to the control group (p = 0.0001). Isovolumetric relaxation time (IVRT) was significantly higher in DM group compared to control group (p = 0.003). MPI was significantly higher in diabetic hypertensive group versus DM alone group (0.46 ± 0.050 versus 0.41 ± 0.05, p = 0.01). There was no correlation between MPI and blood glucose level and duration of diabetes.ConclusionMyocardial performance index is a useful noninvasive tool for the detection of early right ventricular systolic and diastolic dysfunction in diabetic patients, regardless of coexisting hypertension.     

Lactate and other clinicolaboratory predictors for subtle myocardial dysfunction in pediatric intensive care unit

IntroductionThis study aimed to determine the incidence of admission subtle myocardial dysfunction (SMD) in critically ill children by measuring cardiac troponin I (cTnI) and to identify clinicolaboratory risk factors.MethodsAdmission systolic blood pressure (SBP) registration. Categorizing patients into 2 groups: sepsis and nonsepsis. Laboratory investigations including: Hemoglobin, urea, creatinine, alanine aminotransferase (ALT); aspartate transaminase (AST) and serum troponin I (cTnI) and lactate.ResultsSixty-three patients were enrolled. Eleven (17.5%) patients had SMD. All SMD patients were in severe sepsis or septic shock having significant characteristics: (1) cTnI (median 0.7 ng/mL, P < 0.000), lactate (median 5.5 mmol/L. P < 0.000). (2) Age (median 6mo, P < 0.04) (3) SBP (median 73 mm Hg. P < 0.001) (4) ALT and AST (median 259 IU/dl and 586 IU/dl, P < 0.000 for each). (5) BUN and Creatinine (median 29 mg/dl, P < 0.002, median 1.4 mg/dl, P < 0.01, respectively). (6) Hemoglobin (median 7.2 g/dl, P < 0.003). Lactate Level > 3.3 mmol/L(95% CI −.9 to −.25, P < 0.001) and high ALT (95% CI −.002 to .000, P < 0.001) are predictors of SMD. High Lactate had a sensitivity of 90.9%, specificity of 89.9% with positive predictive value of 83.3%, negative predictive value of 94.1% and accuracy of 90%. for SMD. Patients with SMD had significant mortality.ConclusionSubtle myocardial dysfunction is detected in infants with severe sepsis and septic shock. SMD should be suspected in those patients showing high ALT and Lactate level > 3.3 mmol/L.     

Fonction ventriculaire droite après un premier épisode d’embolie pulmonaire : apport du strain 2D

BackgroundAnalysis of right ventricular (RV) function during the acute phase of pulmonary embolism (PE) was widely reported in the literature. However, few studies analysed its function long term after the acute phase. Our aim was to evaluate the RV function long term after a first episode of PE.MethodsIn this study, we compared echocardiographic parameters of right ventricular function in 25 patients with a first episode of non-severe PE for more than six months with 25 healthy controls subject.ResultsIn the study of RV function, we noted that the mean values of the standard parameters were significantly lower in the EP group compared to the control group but their values remained within the normal range. The global RV longitudinal strain had a mean value lower than the control group statistically significant (−21 ± 4,8% vs. −25 ± 2,4%; P = 0,28). The longitudinal strain of the free wall of the RV was altered in the EP group, however, there was no significant difference between the EP group and the control group (−19,4 ± 16% vs. −24 ± 17%; P = 0,28).ConclusionThis study has shown that there is a systolic dysfunction late after a first episode of PE and this despite the absence of the symptoms and pulmonary hypertension.     

Differences in ST-elevation and T-wave amplitudes do not reliably differentiate takotsubo cardiomyopathy from acute anterior myocardial infarction

BackgroundPrevious efforts to distinguish acute anterior ST-elevation myocardial infarction (anterior-STEMI) from various forms of takotsubo cardiomyopathy (TTC) by electrocardiography (ECG) have produced differing results.MethodsWe performed a retrospective comparison of acute ECGs between 48 apical and 9 mid-ventricular TTC patients, with 96 anterior-STEMI patients. ECG was recorded in acute phase (< 24 h from onset of pain), and analyzed for ST-changes, negative T-waves, abnormal Q-waves and QT-interval duration. Time from onset of pain to ECG was gathered from patient records.ResultsAnterior-STEMI patients had ST-elevation in lead V₁ more frequently than apical (70% vs 15%, p < 0.0001) or mid-ventricular TTC patients (70% vs 0%, p < 0.0001), and higher ST-elevation amplitudes in leads V₂–V₅ (p < 0.02). Lack of ST-elevation in lead V₁ and ST-elevation amplitude < 2 mm in lead V₂ distinguished TTC from anterior-STEMI patients with 63% sensitivity and 93% specificity, with 79% predictive value.ConclusionsIn patients with anterior ST-elevation and acute chest pain, lack of ST-elevation in lead V₁ and ST-elevation amplitude < 2 mm in lead V₂ suggests a TTC diagnosis. However, this criterion is not reliable enough in clinical practice to distinguish between TTC and anterior-STEMI patients.     

Right ventricular systolic echocardiographic parameters in chronic systolic heart failure and prognosis

BackgroundRight ventricular (RV) dysfunction is associated with poor prognosis in patients with heart failure (HF). Several RV echocardiographic parameters have been proposed as sensitive markers to detect patients at risk.ObjectiveThe aim is to compare the predictive value of several RV systolic echocardiographic parameters for adverse outcome in patients with chronic systolic HF.MethodsWe assessed 117 patients with chronic systolic HF and left ventricular ejection fraction (LVEF) <40% for the following: (i) RV fractional area change (RVFAC), (ii) tricuspid annular plane systolic excursion (TAPSE), (iii) integral of the systolic wave (ISW_tdi), and (iv) peak systolic velocity (Sa_tdi). ISW_tdi and Sa_tdi were measured using tissue Doppler imaging at the tricuspid annulus. The primary endpoint was death, urgent transplantation, or acute HF episode requiring hospital admission. The follow-up extended for one year.ResultsFifty-two patients reached the primary endpoint. The cut-off thresholds for RVFAC, TAPSE, Sa_tdi, and ISW_tdi defined using receiver-operating characteristic curves were 30%, 15.5 mm, 10.0 cm/s, and 2.4 cm, respectively. The area under the curve and the 95% confidence interval for RVFAC, TAPSE, Sa_tdi, and ISW_tdi were 0.71(0.65–0.85), 0.66(0.55–0.76), 0.85(0.70–0.96), and 0.75(0.64–0.86), respectively. NYHA > 2, and Sa_tdi were found to be independent predictors of adverse outcome.ConclusionSa_tdi is an independent predictor of adverse outcome in HF at a threshold value of 10.0 cm/s and appears to be superior to other RV systolic echocardiographic parameters.     

NT-proAtrial Natriuretic Peptide as a possible biomarker of cardiopulmonary involvement in sarcoidosis

BackgroundLung diffusion for carbon monoxide (DL_CO) has been shown to associate with the risk of pulmonary arterial hypertension development and, most likely, with right ventricular (RV) myocardial dysfunction in sarcoidosis patients. Besides its known role as a marker of left ventricular dysfunction, experimental evidence suggests a role of NT-proAtrial Natriuretic Peptide (NT-proANP) also in modulating pulmonary circulation. We therefore investigated possible relationships between NT-proANP, lung diffusion impairment and RV dysfunction.MethodsThirty-two pulmonary sarcoidosis outpatients and eighteen volunteers underwent full clinical assessment, including full lung function tests and Doppler echocardiography integrated with tissue Doppler imaging (TDI) study. Resting circulating NT-proBNP and NT-proANP plasma levels were also determined.ResultsNT-proANP and RV-myocardial performance index (RV-MPI) were significantly higher in those patients with the greatest DL_CO impairment, whereas no differences were found for NT-proBNP values. At multivariable analysis, only DL_CO (β: ? 0.496; standard error: 3.38; p = 0.000) and RV-MPI (β: 0.373; standard error: 6.56; p = 0.031) remained significantly associated with NT-proANP levels.ConclusionsOur finding may support a key role of NT-proANP in the complex mechanisms underlying modulation of lung function. An early increase in pulmonary vascular resistance may stimulate NT-proANP increase, thus explaining its association with signs of early RV myocardial dysfunction. This hypothesis warrants further confirmation.     

Effect of isoprenaline chronic stimulation on APD restitution and ventricular arrhythmogenesis

BackgroundIsoprenaline (ISO) acts through β-adrenergic receptors to increase the intracellular Ca²⁺, which has effects on action potential duration (APD) restitution and arrhythmogenesis. Thus, we investigated the effect of chronic stimulation with isoprenaline on APD restitution and ventricular tachyarrhythmias (VA) in the rabbit heart.Methods and resultsRabbits were randomly selected to receive an injection of isoprenaline (ISO group) or an equal volume of 0.9% saline (CTL group). The S₁–S₂ protocol (n = 15) and S₁ dynamic pacing (n = 15) were performed to construct APD restitution and to induce APD alternans or arrhythmia in 10 sites of Langendorff-perfused hearts. Compared with the same sites in the control group, long-term ISO administration (7 days) shortened the APD₉₀ and the effective refractory period (ERP), and greatly increased the spatial dispersion of APD and ERP (p < 0.01). Compared to CTL group, the APD restitution curves were significantly changed (p < 0.01) and showed increased spacial dispersion of maximal slope (S_max) among each site in the ISO group (p < 0.05). In induction of VA and APD alternans, the threshold of VA and alternans was both decreased in each site of the ISO group.ConclusionChronic stimulation with ISO facilitated VA, possibly through the increased spatial dispersion of APD restitution.     

The role of intravascular ultrasound and quantitative angiography in the functional assessment of intermediate coronary lesions: Correlation with fractional flow reserve

BackgroundThe correlation between fractional flow reserve (FFR) and intravascular ultrasound (IVUS) metrics including minimal lumen area (MLA), plaque burden and morphology remain a matter of debate.MethodsBetween June 2008 and May 2013, 132 intermediate stenoses in 109 patients were assessed by FFR, IVUS and quantitative angiography. Receiver-operating characteristic (ROC) curve analyses were used to identify MLA/lesion length/plaque burden cut-off values predictive of FFR < 0.80.ResultsFFR < 0.80 was observed in 39 lesions. In the entire cohort, MLA value < 2.70 mm² had 79.5% sensitivity, 76.3% specificity, 0.822 area under curve (AUC), 58.5% positive predictive value, 89.9% negative predictive value and 77.3% accuracy in predicting a positive FFR. In lesions with reference diameter vessel (RVD) ≥ 3.0 mm, the MLA cut-off value was 2.84 mm² (sensitivity 72.2%, specificity 83.0%, AUC 0.842) whereas in lesions with RVD < 3.0 mm, 2.59 mm² (sensitivity 90.5%, specificity 69.6%, AUC 0.823). A moderate correlation was observed between MLA and FFR (r = 0.429, p < 0.001). The cut-off lesion length predictive of FFR < 0.80 was 11.0 mm with a weak correlation between the two (r = − 0.348, p < 0.001). Plaque morphology did not significantly affect FFR (p = 0.485). On multivariable analysis, MLA (OR: 0.15; 95% CI: 0.05–0.40; p < 0.001) and plaque burden (OR: 1.11; 95% CI: 1.04–1.20; p < 0.003) were independent predictors of FFR < 0.80.ConclusionA modest, yet significant correlation was observed between MLA and FFR. The high negative predictive value of large MLAs (using afore-mentioned cut-off values) may provide some degree of confidence that the lesion in question is not functionally significant.     

Association between serotonin transporter (SERT) gene polymorphism and idiopathic pulmonary arterial hypertension: a meta-analysis and review of the literature

ObjectiveIdiopathic pulmonary arterial hypertension (IPAH) is a rare and often fatal disease of unknown etiology. Serotonin transporter (SERT) protein, whose genes can have two allelic forms, namely long (L) and short (S), is suspected to be related to IPAH risk. Several studies have investigated the association between SERT's different allelic forms and IPAH but showed conflicting results. A meta-analysis of published studies was performed to allow a more reliable estimate of this association.MethodsRelevant databases were searched to identify eligible studies published from 2000 to 2013. Odds ratios (OR) and 95% confidence intervals (CI) were determined for the gene–disease association using fixed or random effects models.ResultsA total of 6 studies with 451 IPAH subjects and 664 controls were included in this meta-analysis. A significant difference was found in the comparison between IPAH subjects and controls with LL vs. SS genotypes, and the pooled odds ratio (OR) with the fixed effects model was 1.446 (95% CI = 1.036–2.018, p = 0.030, I² = 38.8%). However, no statistically significant differences were observed for LL vs. LS or LL vs. LS + SS. The pooled OR indicated no significant differences in IPAH risk between carriers of SERT L and S alleles (OR_{L VS. S} = 1.327, 95% CI = 0.933–1.886, p = 0.115).ConclusionThis meta-analysis provides evidence suggesting an association between the SERT L/S polymorphism and IPAH. Individuals with the LL genotype have an obviously higher risk of developing IPAH than those with the SS genotype.     

Cardiac troponin T: A sensitive and specific indicator of myocardial injury in patients with cerebrovascular stroke

BackgroundUnsuspected morbidity and mortality in cerebrovascular stroke (CVS) patients remain a serious issue in critical medicine field. Patients with CVS are at increased risk of developing cardiac complications which explains the high morbidity and mortality rates among those patients. We examined the predictive value of cardiac troponin T (CTNT) in assessing myocardial injury and cardiac dysfunction in ischemic and hemorrhagic CVS.MethodsOne hundred and twenty patients with acute CVS (78 with infarction, 42 with hemorrhage) confirmed by brain CT scan were enrolled. CTNT assay was done within 24 h of stroke onset at 0, 12, and 24 h. Levels equal to or more than 0.1 ng/mL were deemed high. Echocardiographic evaluation was done at 3rd to 5th day for new segmental wall motion abnormalities (SWMA). Twelve lead electrocardiograms (ECGs) were done on day 1, 2, 3, and 5 from stroke onset. ST segment elevation or depression ⩾1 mm, and/or T wave flattening or inversion in three leads were considered significant. Patients with history of CAD, resting ST-T wave changes were excluded.ResultsCTNT was elevated in 24 patients (20%), 12 patients with infarction (15.3%), and 12 with hemorrhage (28.5%), P > 0.05. Abnormal ECGs were observed in 50 cases (12 had ST deviation, 38 had T wave changes). All troponin +ve patients showed abnormal ECG (100%), compared to only 26 patients out of the troponin −ve patients (27%) (P < 0.01). ST deviation occurred in 10 troponin +ve patients (41.6%), two troponin −ve patients (2.08%), (P < 0.01). T wave changes occurred in 14 troponin +ve patients (58.3%), 24 troponin −ve patients (25%), (P < 0.05). Resting SWMA were observed in 24 cases, all of which had +ve troponin, none of the troponin −ve patients showed SWMA (100% sensitivity, specificity, positive and negative predictive values) P < 0.001.ConclusionsMyocardial injury is not uncommon in patients with CVS. Silent ST-T wave changes and new resting SWMA are possible complications. We demonstrated highly significant correlation between positive troponin T and myocardial injury in these patients.     

Immediate versus staged complete myocardial revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease: A post hoc analysis of the randomized FLOWER-MI trial

BackgroundIn patients with ST-segment elevation myocardial infarction and multivessel disease, percutaneous coronary intervention for non-culprit lesions is superior to treatment of the culprit lesion alone. The optimal timing for non-infarct-related artery revascularization – immediate versus staged – has not been investigated adequately.AimWe aimed to assess clinical outcomes at 1 year in patients with ST-segment elevation myocardial infarction with multivessel disease using immediate versus staged non-infarct-related artery revascularization.MethodsOutcomes were analysed in patients from the randomized FLOWER-MI trial, in whom, after successful primary percutaneous coronary intervention, non-culprit lesions were assessed using fractional flow reserve or angiography during the index procedure or during a staged procedure during the initial hospital stay, ≤ 5 days after the index procedure. The primary outcome was a composite of all-cause death, non-fatal myocardial infarction and unplanned hospitalization with urgent revascularization at 1 year.ResultsAmong 1171 patients enrolled in this study, 1119 (96.2%) had complete revascularization performed during a staged procedure, and 44 (3.8%) at the time of primary percutaneous coronary intervention. During follow-up, a primary outcome event occurred in one of the patients (2.3%) with an immediate strategy and in 55 patients (4.9%) with a staged strategy (adjusted hazard ratio 1.44, 95% confidence interval 0.39–12.69; P = 0.64).ConclusionsStaged non-infarct-related artery complete revascularization was the strategy preferred by investigators in practice in patients with ST-segment elevation myocardial infarction with multivessel disease. This strategy was not superior to immediate revascularization, which, in the context of this trial, was used in a small proportion of patients. Further randomized studies are needed to confirm these observational findings.     

Resultado del tratamiento percutáneo de la reestenosis de stents farmacoactivos: ¿depende de si el stent tenía o no recubrimiento polimérico?

Introduction and objectivesOutcomes of patients undergoing percutaneous intervention for drug-eluting stent (DES) restenosis are poorer than those in patients with bare-metal stent restenosis. It is unknown if this is related to the presence of polymer coating. We sought to compare outcomes after interventions for in-stent restenosis (ISR) of polymer-free DES vs durable polymer DES.MethodsPatients enrolled in the ISAR-TEST 5 randomized trial who underwent repeat percutaneous intervention for ISR during follow-up were included. Angiographic outcomes at 6 to 8 months and clinical outcomes at 2 years were analyzed and compared between 2 groups according to whether the restenosed stent was a polymer-free or a durable polymer DES. Multivariate analysis was used to adjust for differences between groups.ResultsA total of 326 patients with ISR were included: 220 with ISR in polymer-free DES and 106 with ISR in durable polymer DES. Angiographic follow-up was available for 83.4% of patients. No difference was observed in recurrent binary restenosis between the 2 groups (31.7% vs 27.0%; P = .38; P_adjusted = .29). At 2 years, the composite of death, myocardial infarction, or repeat target lesion revascularization were similar between the 2 groups (35.7% vs 34.0%; HR = 1.04, 95%CI, 0.70-1.55; P = .83; P_adjusted = .79). The rate of repeat target lesion revascularization was also similar in the 2 groups (29.8% vs 31.5%; HR = 0.91, 95%CI, 0.60-1.39; P = .68; P_adjusted = .62).ConclusionsIn patients undergoing reintervention for DES-ISR, we found no evidence of differences in outcomes according to whether the restenosed stent was a polymer-free or durable polymer DES.     

Relationship between renal capacity to reabsorb glucose and renal status in patients with diabetes

AimsInterindividual variability in capacity to reabsorb glucose at the proximal renal tubule could contribute to risk of diabetic kidney disease. Our present study investigated, in patients with diabetes, the association between fractional reabsorption of glucose (FR_GLU) and degree of renal disease as assessed by urinary albumin excretion (UAE) and estimated glomerular filtration rate (eGFR).MethodsFR_GLU [1-(glucose clearance/creatinine clearance)] was assessed in 637 diabetes patients attending our tertiary referral centre, looking for correlations between FR_GLU and UAE (normo-, micro-, macro-albuminuria) and Kidney Disease: Improving Global Outcomes (KDIGO) eGFR categories: >90 (G1); 90–60 (G2); 59–30 (G3); and < 30–16 (G4) mL/min/1.73 m². Patients were stratified by admission fasting plasma glucose (FPG) into three groups: low (<6 mmol/L); intermediate (6–11 mmol/L); and high (>11 mmol/L).ResultsMedian (interquartile range, IQR) FR_GLU levels were blood glucose-dependent: 99.90% (0.05) for low (n = 106); 99.90% (0.41) for intermediate (n = 288); and 96.36% (12.57) for high (n = 243) blood glucose categories (P < 0.0001). Also, FR_GLU increased with renal disease severity in patients in the high FPG group: normoalbuminuria, 93.50% (17.74) (n = 135); microalbuminuria, 96.56% (5.94) (n = 77); macroalbuminuria, 99.12% (5.44) (n = 31; P < 0.001); eGFR G1, 94.13% (16.24) (n = 111); G2, 96.35% (11.94) (n = 72); G3 98.88% (7.59) (n = 46); and G4, 99.11% (2.20) (n = 14; P < 0.01). On multiple regression analyses, FR_GLU remained significantly and independently associated with UAE and eGFR in patients in the high blood glucose group.ConclusionHigh glucose reabsorption capacity in renal proximal tubules is associated with high UAE and low eGFR in patients with diabetes and blood glucose levels > 11 mmol/L.