One-week and 6-month cardiovascular magnetic resonance outcome of the pharmacoinvasive strategy and primary angioplasty for the reperfusion of ST-segment elevation myocardial infarction

Introduction and objectives

Pharmacoinvasive strategy represents an attractive alternative to primary angioplasty. Using cardiovascular magnetic resonance imaging we compared the left ventricular outcome of the pharmacoinvasive strategy and primary angioplasty for the reperfusion of ST-segment elevation myocardial infarction.

Methods

Cardiovascular magnetic resonance was performed 1 week and 6 months after infarction in two consecutive cohorts of patients included in a prospective university hospital ST-segment elevation myocardial infarction registry. During the period 2004-2006, 151 patients were treated with pharmacoinvasive strategy (thrombolysis followed by routine non-immediate angioplasty). During the period 2007-2008, 93 patients were treated with primary angioplasty. A propensity score matched population was also evaluated.

Results

At 1-week cardiovascular magnetic resonance, pharmacoinvasive strategy and primary angioplasty patients showed a similar extent of area at risk (29 ± 15 vs. 29 ± 17%, P = .9). Non-significant differences were detected by cardiovascular magnetic resonance at 1 week and at 6 months in infarct size, salvaged myocardium, microvascular obstruction, ejection fraction, end-diastolic volume index and end-systolic volume index (P > .2 in all cases). The same trend was observed in 1-to-1 propensity score matched patients. The rate of major adverse cardiac events (death and/or re-infarction) at 1 year was 6% in pharmacoinvasive strategy and 7% in primary angioplasty patients (P = .7).

Conclusions

A pharmacoinvasive strategy including thrombolysis and routine non-immediate angioplasty represents a widely available and logistically attractive approach that yields identical short-term and long-term cardiovascular magnetic resonance-derived left ventricular outcome compared to primary angioplasty.Full English text available from:www.revespcardiol.org     

Effets de la réduction de la précharge sur les paramètres échographiques de la fonction systolique et diastolique du ventricule gauche de l’enfant en insuffisance rénale terminale : étude comparative avant et après hémodialyse

Purpose

Contrasting data exist about the hemodialysis induced changes of ventricular diastolic and systolic functions in adults. Few data in children with end-stage renal disease (ESRD) are reported. The aim of the present study was to evaluate the effect of a single hemodialysis (HD) session on left ventricular (LV) systolic and diastolic function using conventional pulsed-Doppler echocardiography and pulsed tissue Doppler imaging (TDI) in hemodialysis children.

Methods

Thirty-five children with chronic renal failure (15 males, aged 12.8 ± 3.8 years) on maintenance hemodialysis underwent conventional 2D and Doppler Echo together with measurement of longitudinal mitral annular motion velocities. Echocardiographic parameters were obtained 30 minutes before and 30 minutes after HD. Paired data were compared.

Results

Hemodialysis led to reduction in LV end-diastolic volume (p = 0.001), end-systolic volume (p = 0.05), left atrium area (p < 0.0001), peak early (E wave) transmitral flow velocity (p = 0.005), peak S velocity of pulmonary vein flow (p = 0.002), aortic time velocity integral (p < 0.0001) and aortic ejection time (p < 0.0001). No significant change in Tei Index was observed after HD. Regarding TDI measures, velocities were not affected by preload reduction. Only the early diastolic velocities on the septal side of the mitral annulus decreased significantly (p = 0.001) and the systolic velocities on the lateral side of the mitral annulus increased significantly (p = 0.042) after hemodialysis.

Conclusions

Most of Doppler-derived indices of diastolic function are preload-dependant. TDI velocities and Tei Index were not or minimally affected by preload reduction in hemodialysis children.     

Valeur prédictive comparée de mortalité hospitalière du peptide natriurétique de type B et de l’albuminémie chez le sujet âgé hospitalisé pour insuffisance cardiaque aiguë sévère

Objective

To address the clinical relevance of serum albumin and B-type natriuretic peptide (BNP) concentration in the prediction of in-hospital death in elderly patients with acute severe heart failure.

Patients and methods

Seventy-four consecutive patients >70 years of age admitted for acute heart failure in NYHA class IV were prospectively included. BNP concentration was measured on admission and serum albumin concentration after clinical stabilization.

Results

Mean age was 86.6 ± 5.7 years. Sixty-five percent of patients had a normal left ventricular ejection fraction. Eighteen patients died during the in-hospital stay. Those patients who died were older, had higher blood urea nitrogen and BNP concentration, had lower systolic blood pressure and serum albumin concentration than patients who survived. Heart rate, rhythm, left ventricular ejection fraction, serum creatinine and hemoglobin did not differ according to outcome. By multivariate analysis, albumin (p = 0.0017), BNP (p = 0.016) and age (p = 0.03) were independent predictors of in-hospital death. Serum troponin I measured on admission in 71 patients was predictive of in-hospital death (p = 0.01), as well as serum total cholesterol measured after stabilization in 66 patients (p = 0.004). However, these two variables no longer predicted outcome in multivariate models, unlike serum albumin and BNP.

Conclusion

Serum albumin and BNP offer independent, additional information for the prediction of in-hospital death in elderly patient with acute severe heart failure regardless of left ventricular ejection fraction.     

Infarctus du myocarde chez le sujet fumeur de moins de 50 ans traité par angioplastie coronaire. Évolution hospitalière et sur le long terme d’une série consécutive de 93 patients

Aims of the study

The study evaluated in-hospital and long-term outcome of patients less than 50 years old with myocardial infarction within 12 hours after symptom onset treated by coronary angioplasty.

Patients and method

This is a retrospective study with survival analysis by Kaplan-Meier method in patients included from December 2003 to February 2008.

Results

We included 93 patients aged 42,8 ± 5,2 years old with smoking estimated at 27,7 ± 12,7 pack-years. Thirty-one patients (33,3%) were dyslipidemic and 36 patients had family history of coronary artery disease. Thirty patients (32,3%) had an anterior myocardial infarction and four patients (4.4%) had Killip greater than 2. Coronary angioplasty was performed within 4.5 ± 3.0 hours after symptom onset with TIMI 3 final flow in the culprit vessel in 96.8%. One patient died from cardiogenic shock. With a follow-up of 85 patients during 20.0 ± 15.6 months, the survival without death was 98.2% and survival without major cardiac complication was 87.9% at 24 months. Seventy-two patients (85.7%) were taking a betablocker, 81 patients (96.4%) aspirin, 75 patients (89.3%) a statin and 64 patients (76.2%) an angiotensin-converting inhibitor. Only 50 patients (58.8%) were nonsmokers.

Conclusion

Thus, young smokers with acute MI treated by coronary angioplasty have a good prognosis during in-hospital stay and long-term outcome. Secondary medical treatment prevention is well followed but there is a low rate of smoking cessation.     

Infarctus par occlusion aiguë du tronc commun non protégé : à propos de six cas traités par angioplastie

Aim

Acute main left coronary artery occlusion is rarely observed during primary angioplasty in myocardial infarction. This retrospective study reports the results of six patients treated by angioplasty in a hospital without cardiac surgery department.

Patients and methods

From 2002 to 2009, 746 patients were treated by primary angioplasty for acute coronary syndromes with ST elevation. Among those patients, six (0,7%) had acute non protected main left coronary occlusion. We report clinical, angiographical data and follow-up.

Results

The population was composed of six patients (five males) with an average age of 64 ± 7 years. Five patients were admitted with cardiogenic shock and four were mechanically ventilated. Distal occlusion of main left coronary artery and dominant right coronary artery were noted in all cases. Sub-occluded lesion of right coronary artery was noted in one case. Successful procedure with bare metal stent was achieved in five cases. Mortality rate was 66% (n = 4): three patients died in hospital and another 1 or 2 months later of congestive heart failure. Coronary artery bypass grafting was performed at 4 and 12 months later for two patients. They are alive after 12 and 72 months of follow-up.

Conclusion

We demonstrate the feasibility of percutaneous coronary intervention of acute main left coronary occlusion. Inspite successful procedure, intrahospital mortality rate is still high and prognosis is related to cardiogenic shock.     

Résultats à court et long terme du remplacement valvulaire mitral par prothèse mécanique à bille et à ailettes (à propos d’une série de 236 patients consécutifs avec un suivi moyen de 11 ans)

Objectives

To study the early and late results of mitral valve replacement (MVR) by Starr-Edwards caged-ball and bileaflet mechanical prosthesis.

Material and methods

We retrospectively analyzed 236 MVR performed in 236 patients: 127 by Starr-Edwards prosthesis (group 1) and 109 by bileaflet prosthesis (group 2).

Results

During the early period (30 days), the mortality rate was higher in group 1 (6.3 % vs 1.8 %; p = 0.0001), while hemorrhagic, thromboembolic and infectious complications were comparable in the two groups. In the late period (> 30 days) and with an average follow-up of 11.5 ± 5.7 years, mortality was higher in group 1 (9.4 % vs 4.6 %; p < 0.0001). The same was true for thromboembolic complications (20.8 % vs 6.4 %; p < 0.0001), hemorrhagic complications (13.4 % vs 7.3 %; p = 0.02), infectious complications (3.1 % vs 0.9 %; p = 0.02) and cardiac complications that were not due to the prosthesis (32.3 % vs 14.7 %; p = 0.02). The hemodynamic profile of the bileaflet prostheses was better than that of the Starr-Edwards prostheses (average functional prosthetic surface area was 2.37 ± 0.44 cm² and average pressure gradient was 5.6 ± 1.1 mmHg vs 2.04 ± 0.52 cm² and 7.6 ± 4.9 mmHg).

Conclusion

Our work confirms the superiority of bileaflet mechanical prostheses, with rates of early and late mortality, thromboembolic and hemorrhagic complications lower than those of the Starr-Edwards prostheses in more than 11 years of follow-up. However, one should not forget that the prevention of infective endocarditis, good observance of oral anticoagulant treatment and early surgery before left ventricular dysfunction occurs remain the best guarantee a good result of the MVR.     

Influence des leucocytes sur la réserve coronaire, la fonction systolique ventriculaire gauche, et les complications hospitalières, dans l’infarctus antérieur aigu traité par angioplastie primaire

Objective

To assess the relationship between leukocyte count, non invasive coronary flow reserve (CFR), left ventricular systolic function, and in-hospital adverse events in acute anterior myocardial infarction (AMI) treated by primary angioplasty.

Methods

Leukocyte count at admission and within 24 h after angioplasty, and differential count at admission were obtained in 72 consecutive patients with a first AMI (mean age 56 ± 12 years) successfully treated by primary angioplasty. Transthoracic Doppler echocardiography was performed within 24 h after angioplasty and 3 months later to assess the CFR (using intravenous adenosine), in the left anterior descending artery (LAD), left ventricular ejection fraction (LVEF) and the wall motion score index using the nine segments assigned to the LAD territory (WMSi-lad). In hospital events were defined as death, heart failure (Killip ≥ 2) and reinfarction.

Results

Leukocyte count was higher before and after angioplasty in patients with impaired acute CFR (< 1.7), when compared to patients without such impairment (P ≤ 0.01), and a significant correlation was found between CFR and leukocyte, neutrophil and monocyte count (P < 0.05). Leukocyte (before and after angioplasty), and neutrophil count, were lower in patients with recovery of global and regional LV function (P < 0.05). A significant correlation was found between leukocyte count before and after angioplasty, and, initial and follow-up LVEF, and WMSi-lad (all, P ≤ 0.01). Leukocyte (before and after angioplasty) and monocyte count were higher in patients with in-hospital events (n = 14), by comparison to patients without events (all, P < 0.01). In multivariate analysis, leukocyte count after angioplasty was an independent predictor of CFR, and in-hospital events, and neutrophil count of WMSi-lad at follow-up (all, P < 0.05).

Conclusion

In the first AMI treated successfully by primary angioplasty, leukocyte count is inversely correlated to CFR, and global and regional LV systolic function at follow-up. These links are higher after than before reperfusion. And, leukocyte count after angioplasty is an independent predictor of in-hospital adverse events.     

Altération de la variabilité sinusale chez les malades en hémodialyse chronique

Background and aim

Decrease in heart rate variability (HRV) is a known risk factor for cardiovascular morbidity and mortality. The aim of our study is to evaluate HRV in chronic hemodialysis patients and to determine factors that might decrease or increase it.

Methods

This is a retrospective study including 51 patients, 23 males and 28 females, with a mean of age of 64.5 years (23-84 years) on chronic hemodialysis for end stage renal disease due to various causes. Twenty-four-hour heart rate monitoring was recorded in all patients to evaluate HRV. HRV of hemodialysis patients was compared to normal patients (control). We also looked for correlation between HRV and a number of clinical and biological factors.

Results

All HRV parameters were decreased in chronic hemodialysis patients compared to normal controls with a significant difference (p < 0.0005). HRV decreases with age (p = 0.012), and is lower in diabetic patients (p = 0.026). Interestingly, we found that chronic hemodialysis patients on beta-blockers had higher HRV with p = 0.011.

Conclusion

HRV is reduced in chronic hemodialysis patients mainly in old and diabetic patients, but this decrease is less important in those receiving beta-blockers.     

Évaluation de la ration calcique dans la population de Marrakech et de sa région : à propos de mille cas

Objectives

The aim of our work is to evaluate the calcium intake in population of Marrakesh and its region by the translated version in Moroccan Arabic dialect of Fardellone questionnaire.

Subjects and methods

The version translated into Arabic dialect Fardellone questionnaire is tested on a sample of 1000 subjects. The subjects aged less than 15 years accounted for 30.9% (n = 309), those aged 15 to 59 62% (n = 620) and those aged over 60 years 7.1% (n = 71). The distribution by age group is calculated on the distribution of the Moroccan population.

Results

The study population includes 60.6% women (n = 606), 39.4% of men (n = 394). The mean calcium intake was respectively 5875 mg by week (that means 839 mg/day), 4899 mg by week (that means 699 mg/day), 3053 mg by week (that means 436 mg/day), in subjects aged less than 15, those aged 15 to 59, and those aged over 60 years. The average consumption of calcium per day is significantly lower than the recommended daily amount for the three age groups. Patients aged over 60 years is the age group most under nourished calcium. The comparison of both gender found a deficit higher among women than among men.

Conclusion

Evaluation of the calcium intake is an essential tool for better management of metabolic bone diseases.     

Prognostic implication of hyperglycemia in myocardial infarction and primary angioplasty

Purpose

The study assessed the relationship of admission blood glucose level to in-hospital mortality in patients presenting with an ST-segment elevation myocardial infarction and treated with primary angioplasty.

Methods

A total of 980 patients presenting with an ST-segment elevation myocardial infarction and treated exclusively with primary angioplasty were evaluated. Patients were divided into quartiles based on their admission blood glucose level: group 1 (≤6.6 mmol/L [≤119 mg/dL]), group 2 (6.7-7.8 mmol/L [120-140 mg/dL]), group 3 (7.9-10.0 mmol/L [141-180 mg/dL], and group 4 (≥10.1 mmol/L [≥181 mg/dL]. The primary end point was in-hospital mortality.

Results

The mean age of the patient cohort was 62 years, 260 (27%) of whom were female. The mean admission blood glucose level was 9.1 ± 4.4 mmol/L (164 ± 79 mg/dL). At admission, 16% of this group were known to have diabetes. The in-hospital mortality rate was 3.8% (n = 37), 5.2% in the diabetic group (n = 8) and 3.5% (n = 29) in the nondiabetic group. In-hospital mortality rates were significantly increased in patients with an elevated admission blood glucose level (P <.001). The in-hospital deaths in each admission blood glucose level quartile were 0.4% (n = 1) in group 1, 2% (n = 6) in group 2, 2% (n = 6) in group 3, and 10% (n = 24) in group 4.

Conclusions

In this cohort of patients who were admitted with an ST-segment elevation myocardial infarction and treated exclusively with primary angioplasty, elevated admission blood glucose level is significantly associated with an increase in in-hospital mortality.     

Association of VKORC1 −1639 G > A polymorphism with carotid intima-media thickness in type 2 diabetes mellitus

Aims

Media calcification is a predictor of cardiovascular mortality in type 2 diabetes mellitus (T2DM). Undercarboxylation of some vitamin K-dependent proteins, due to genetic polymorphisms of VKORC1, can lead to calcification. We examined a potential association between VKORC1 −1639 G > A polymorphism and T2DM and, also, the association of this polymorphism with carotid intima-media thickness (cIMT).

Methods

VKORC1 −1639 G > A polymorphism was determined in 299 T2DM patients and 328 controls of Caucasian origin using PCR-RFLP. cIMT was measured in a subgroup of 118 T2DM patients.

Results

The frequency of VKORC1 genotypes between diabetic and nondiabetic subjects differed significantly (p = 0.01). VKORC1 genotype was associated with T2DM in an adjusted model (OR 1.36, p = 0.009). A statistically significant difference was observed in the maximum value of cIMT among different genotypes. VKORC1 −1639 G > A polymorphism was an independent predictor of cIMT (p = 0.029) after adjusting for established risk factors.

Conclusions

The association between VKORC1 −1639 G > A polymorphism and risk of T2DM could be due to the higher prevalence of calcification in T2DM patients. This is supported by the independent association between VKORC1 −1639 G > A polymorphism and maximum cIMT in T2DM patients which is likely due to atherosclerosis characterized by increased calcification.     

Can troponin elevation predict worse prognosis in patients with acute pericarditis?

Introduction

Myopericarditis are common in clinical practice: up to 15% of acute pericarditis have a significant myocardial involvement as assessed by biological markers. This prospective, bicentric study is aimed at describing a myopericarditis population, the clinical and MRI follow-up, and search for prognosis markers.

Patients and methods

Between May 2005 and September 2007, 103 patients hospitalised for acute pericarditis were prospectively enrolled. Physical examination, ECG, echocardiography, biological screening and cardiac MRI, in case of myopericarditis defined as acute pericarditis with troponin I elevation, were performed. Between December 2007 and July 2008, patients were contacted for new clinical and MRI evaluation.

Results

Among the initial population of 103 patients admitted for acute pericarditis, 14 myopericarditis and 38 pericarditis were included. Compared with pericarditis, the myopericarditis group was associated with the following features: younger age (34.9 years [95% CI 28.3-41.2]; p = 0.01), ST-segment elevation (nine patients between 14; p = 0.03), higher troponin I (7.3 μg/L [95% CI 4.4-10.2]; p < 10^-4) and lower systemic inflammation (CRP peak 38.1 mg/L [95% CI 7-69.2]; p = 0.01). In the case of myopericarditis, infectious etiologies were predominant (12 patients among 14; p = 0.002) and patients stayed longer in hospital (5.8 days [95% CI 4.7-6.8]; p = 0.01). Follow-up showed no difference in terms of functional status (p = 0.3) and global complications (p = 0.9) between paired myopericarditis and pericarditis. Nevertheless, cardiac mortality was higher for myopericarditis (p = 0.04). MRI follow-up showed myocardial sequelae without clinical impact.

Conclusion

Myopericarditis significantly distinguished from pericarditis. Three years follow-up showed no difference in terms of global complications but a higher cardiac mortality for myopericarditis. MRI myocardial lesions did not develop into symptomatic sequelae.     

Les réponses sympathiques dans l’hypertension artérielle essentielle

High blood pressure (BP) is a major cause of cardiovascular disease and primary hypertension is a frequent pathological condition. Sympathetic hyperactivity may be involved in primary hypertension. The purpose of this study was mainly to evaluate sympathetic activity when performing cardiovascular autonomic profile examination in patients with primary hypertension in comparison with normotensive subjects.

Patients and methods

This prospective study included one group of hypertensive patients (n = 120, mean age 54 years) compared with a control group (n = 120, mean age 52 years) of normotensive subjects. Autonomic tests included deep-breathing (DB), hand-grip (HG) and echostress test (ES). Comparison tests between the two groups, similar in age, were expressed as mean ± SE and made using the t Student test, p < 0.05 was considered significant.

Results

Alpha-adrenergic sympathetic response using ES method produced a BP response of 20,0% ± 9,8 in hypertensive patients group and 15,2% ± 8,6 in the control group (p < 0.001). Alpha-adrenergic sympathetic response using three minutes HG test was of 16,7% ± 7,5 in hypertensive patients group and 13,3% ± 6,5 in the control group (p < 0.001). Vagal stimulation in hypertensive group after DB showed that electrocardiographic: ECG (EKG) waves R (RR) interval variation was of 30,2% ± 8,1 meanwhile in the control group this RR variation was of 46,1% ± 21,1 p < 0.001, and the one of HG of 15 seconds was 17,6% ± 10,2 versus 32,5% ± 12,7 p < 0.001.

Conclusion

Hypertensive patients had a significantly higher sympathetic response to central and peripheral stimulations and a significantly lower parasympathetic response when compared to normotensive controls.     

Are shock index and adjusted shock index useful in predicting mortality and length of stay in community-acquired pneumonia?

Background

Community Acquired Pneumonia (CAP) is a common infection which is associated with a significant mortality. Shock index, heart rate divided by blood pressure, has been shown to predict mortality in several conditions including sepsis, acute myocardial infarction and traumatic injuries. Very little is known about the prognostic value of shock index in community acquired pneumonia (CAP).

Objective

To examine the usefulness of shock index (SI) and adjusted shock index (corrected to temperature) (ASI) in predicting mortality and hospital length of stay in patients admitted to hospital with CAP.

Methods

A prospective study was conducted in three hospitals in Norfolk & Suffolk, UK. We compared risk of mortality and longer length of stay for low (=<1.0, i.e. heart rate =< systolic BP) and high (> 1.0, i.e. heart rate > systolic BP) SI and ASI adjusting for age, sex and other parameters which have been shown to be associated with mortality in CAP.

Results

A total of 190 patients were included (males = 53%). The age range was 18-101 years (median = 76 years). Patients with SI & ASI > 1.0 had higher likelihood of dying within 6 weeks from admission. The adjusted odds ratio for 30 days mortality were 2.48 (1.04-5.92; p = 0.04) for SI and 3.16 (1.12-8.95; p = 0.03) for ASI. There was no evidence to suggest that they predict longer length of stay.

Conclusion

Both SI and ASI of > 1.0 predict 6 weeks mortality but not longer length of stay in CAP.     

Associations des facteurs environnementaux avec le risque de la maladie coronaire à Tlemcen (Algérie)

Purpose

In the purpose of studying the effect of the environmental factors on risk of coronary artery disease, we established a case-control study in Tlemcen.

Method and results

A sample of 568 men and women aged 25 to 64 years, was studied; 170 had had myocardial infarction or angina and 398 controls. Variables associated with CAD were age, sex, tobacco consumption, hypertension, diabetes, obesity, family history of cardiovascular disease, total cholesterol, triglycerides, HDL-cholesterol and LDL-cholesterol. Adjusted odds-ratio and their 95 % CIs were calculated by logistic regression. Hypertension (OR = 2.48 [1.68; 3.67]), diabetes (OR = 2.86 [1.89; 4.34]), obesity (OR = 1.21 [0.76; 1.92]), family history of cardiovascular disease (OR = 3.49 [1.39; 8.73]), total cholesterol (OR = 0.99 [0.51; 1.92]), triglycerides levels (OR = 1.76 [0.93; 3.35]), HDL-cholesterol (OR = 2.48 [1.69; 3.66]) and LDL-cholesterol (OR = 1.09 [0.59; 2.01]). The variables differing most significantly and independently between cases and controls were identified by stepwise logistic regression analysis (p < 0.05), variables concerned hypertension and diabetes (p < 0.0001), decrease HDL-cholesterol (p = 0.0002) and tobacco consumption (p = 0.005), with stronger associations in cases than in controls.

Conclusion

It is concluded that hypertension and diabetes, decrease HDL-cholesterol in both sexes, an increase in concentration of triglyceride only in women and tobacco consumption in men, were significantly related to coronary artery disease in Tlemcen.     

Motivational interviewing delivered by diabetes educators: does it improve blood glucose control among poorly controlled type 2 diabetes patients?

Aim

To determine whether glycemic control is improved when motivational interviewing (MI), a patient-centered behavior change strategy, is used with diabetes self management education (DSME) as compared to DSME alone.

Methods

Poorly controlled type 2 diabetes (T2DM) patients (n = 234) were randomized into 4 groups: MI + DSME or DSME alone, with or without use of a computerized summary of patient self management barriers. We compared HbA1c changes between groups at 6 months and investigated mediators of HbA1c change.

Results

Study patients attended the majority of the four intervention visits (mean 3.4), but drop-out rate was high at follow-up research visits (35%). Multiple regression showed that groups receiving MI had a mean change in HbA1c that was significantly lower (less improved) than those not receiving MI (t = 2.10; p = 0.037). Mediators of HbA1c change for the total group were diabetes self-care behaviors and diabetes distress; no between-group differences were found.

Conclusions

DSME improved blood glucose control, underlining its benefit for T2DM management. However, MI + DSME was less effective than DSME alone. Overall, weak support was found for the clinical utility of MI in the management of T2DM delivered by diabetes educators.     

Glyburide increases risk in patients with diabetes mellitus after emergent percutaneous intervention for myocardial infarction — A nationwide study

Background

Sulfonylureas have been linked to an increased cardiovascular risk by inhibition of myocardial preconditioning. Whether individual sulfonylureas affect outcomes in diabetic patients after emergent percutaneous coronary intervention for myocardial infarction is unknown.

Methods

All Danish patients receiving glucose-lowering drugs admitted with myocardial infarction between 1997 and 2006 who underwent emergent percutaneous coronary intervention were identified from national registers. Multivariable Cox proportional hazards models were used to analyze the risk of cardiovascular mortality and morbidity associated with sulfonylureas.

Results

A total of 926 patients were included and 163 (17.6%) patients died during the first year of which 155 (16.7%) were cardiovascular deaths. The most common treatment was sulfonylureas which were received by 271 (29.3%) patients, and 129 (13.9%) received metformin. Cox proportional hazard regression analyses adjusted for age, sex, calendar year, comorbidity and concomitant pharmacotherapy showed an increased risk of cardiovascular mortality (hazard ratio [HR] 2.91, 95% confidence interval [CI] 1.26-6.72 ; p = 0.012), cardiovascular mortality and nonfatal myocardial infarction (HR 2.69 , 95% CI 1.21-6.00; p = 0.016), and all-cause mortality (HR 2.46, 95% CI 1.11-5.47; p = 0.027), respectively, with glyburide compared to metformin.

Conclusions

Glyburide is associated with increased cardiovascular mortality and morbidity in patients with diabetes mellitus undergoing emergent percutaneous coronary intervention after myocardial infarction. Early reperfusion therapy is the mainstay in modern treatment of myocardial infarction and the time may have come to discard glyburide in favour of sulfonylureas that do not appear to confer increased cardiovascular risk.     

Analysis of reperfusion delay in patients with acute myocardial infarction treated with primary angioplasty based on first medical contact and time of presentation

Introduction and objectives

In primary angioplasty, the interval between first medical contact (FMC) and reperfusion should be less than 120 minutes. The time to reperfusion varies depending on where FMC is established. Recent studies suggest longer times in patients presenting in off-hours. The objective is to evaluate the time intervals between the onset of symptoms and reperfusion according to where the FMC occurs and time of day of patient presentation.

Methods

Prospective observational study of acute myocardial infarction patients treated with primary angioplasty (February 2007 to May 2009). Depending on the FMC, patients were classified as belonging to the hospital group (hospital with primary angioplasty), the transfer group (hospital without primary angioplasty), or the emergency medical system (EMS) group (out-of-hospital care). For each group, the prehospital delay, diagnostic delay, delay in activation and/or transfer, and procedure delay were recorded.

Results

Primary angioplasty was performed in 457 patients: 155 in the hospital group, 228 in the transfer group and 72 in the EMS group. The median [interquartile range] door-to-reperfusion times were 80 [63-107], 148 [118-189] and 81 [66-98] minutes, respectively (P < .0001). The transfer group showed a greater delay in diagnosis (P < .0001) and delayed activation and/or transfer (P < .0001). The EMS group had the shortest total time due to a reduced prehospital delay (P = .001). No difference was found with regard to the time of presentation (P = .42).

Conclusions

Transfer group patients were treated later and EMS group patients much earlier. There were no differences in association with the time of presentation. The identification of inappropriate delays should enable the introduction of measures to improve the efficiency of treatment.Full English text available from: www.revespcardiol.org     

Serum lipids in primary sclerosing cholangitis

Background

Limited data are available regarding the serum lipids in primary sclerosing cholangitis.

Aims

To determine the lipid levels in patients with primary sclerosing cholangitis.

Methods

We monitored the serum lipid levels annually for up to 6 years in 157 patients included in three previous trials of ursodeoxycholic acid.

Results

The baseline lipid values were: total cholesterol = 207 mg/dL (127-433); high-density lipoprotein = 56 mg/dL (26-132); low-density lipoprotein = 129 mg/dL (48-334); triglycerides = 102 mg/dL (41-698). Cirrhotic stage was associated with lower levels of total cholesterol (186 mg/dL vs. 217 mg/dL, p = .02). A significant correlation between the liver biochemistries and total and low-density lipoprotein cholesterol levels was observed. Ursodeoxycholic acid, as compared to placebo, significantly decreased total (−27 mg/dL vs. 22 mg/dL, p = .0004) and low-density lipoprotein cholesterol (−24 mg/dL vs. 17 mg/dL, p = .0001). After extended follow-up, small changes in the lipid levels were noticed. The incidence of coronary artery disease was 4%.

Conclusions

Our findings suggest that the lipid levels in primary sclerosing cholangitis are often above levels where treatment with lipid-lowering agents is recommended. However, primary sclerosing cholangitis patients seem to have no elevated risk for cardiovascular events. The correlation of total and low-density lipoprotein cholesterol with liver biochemistries implies that mechanisms linked to cholestasis may regulate cholesterol metabolism.     

Extensive iatrogenic coronary dissection during coronary angioplasty: a series of 19 consecutive patients

Purpose of the study

Extensive coronary dissection is a rare complication of intraluminal angioplasty. We report a retrospective study of 19 patients who consulted in a general hospital without cardiac surgery.

Patients and methods

After consulting our coronarography and angioplasty database, we included the extensive coronary dissections (type D, E and F) in our study. The medical files of the selected patients were analysed.

Results

Between January 2003 and March 2010, 19 coronary angioplasty (total: 2542) were complicated with extensive dissections (incidence 0,75%). For 62,3% of the patients, the dissection was related to the guiding catheter. Eleven patients had type A and B1 lesions. The dissections affected the right coronary artery for 16 patients, the left anterior descending coronary artery for two patients and the left main coronary artery for one patient. After angioplasty, a final TIMI flow 3 was obtained for only 11 patients. In nine cases, we observed a limited extension to the aorta that did not need a chirurgical intervention and had no influence on the prognosis. The complications were common, such as death (n = 1), coronary bypass (n = 2), myocardial infarction (n = 8), cardiogenic shock (n = 2) and circulatory assistance (n = 2).

Conclusion

Extensive coronary dissection is a rare complication of angioplasty. The right coronary is the most frequent vessel concerned and an extension to aorta is usual. The treatment is usually based on sealing the entry with a coronary stent. The complications are common and serious and we did not find any predicting factors to extensive coronary dissections that are unpredictable.