Clinical usefulness and prognostic value of elevated cardiac troponin I levels in acute pulmonary embolism

Background

Right ventricular myocardial ischemia and injury contribute to right ventricular dysfunction and failure during acute pulmonary embolism. The objective of this study was to evaluate the clinical usefulness of cardiac troponin I (cTnI) in the assessment of right ventricular involvement and short-term prognosis in acute pulmonary embolism

Methods

Thirty-eight patients with acute pulmonary embolism were included in the study. Clinical characteristics, right ventricular involvement, and clinical outcome were compared in patients with elevated levels of serum cTnI versus patients with normal levels of serum cTnI.

Results

Among the study population (n = 38 patients), 18 patients (47%) had elevated cTnI levels (mean ± SD 1.6 ± 0.7 ng/mL, range 0.7-3.7 ng/mL, median, 1.4 ng/mL), and comprised the cTnI-positive group. In the other 20 patients, the serum cTnI levels were normal (≤0.4 ng/mL), and they comprised the cTnI-negative group. In the cTnI-positive group (n = 18 patients), 12 patients (67%) had right ventricular dilatation/hypokinesia, compared with 3 patients (15%) in the cTnI-negative group (n = 20 patients, P = .004). Right ventricular systolic pressure was significantly higher in the cTnI-positive group (51 ± 8 mm Hg vs 40 ± 9 mm Hg, P = .002). Cardiogenic shock developed in a significantly higher number of patients with elevated serum cTnI levels (33% vs 5%, P = .01). In patients with elevated cTnI levels, the odds ratio for development of cardiogenic shock was 8.8 (95% CI 2.5-21).

Conclusions

Patients with acute pulmonary embolism with elevated serum cTnI levels are at a higher risk for the development of right ventricular dysfunction and cardiogenic shock. Serum cTnI has a role in risk stratification and short-term prognostication in patients with acute pulmonary embolism.     

Incremental value of cardiac imaging in patients presenting to the emergency department with chest pain and without ST-segment elevation: a multicenter study

Background

We hypothesized that imaging of regional myocardial function (RF) and perfusion (PER) will add incremental value for both diagnosis and short-term prognosis to routine demographic, clinical, and electrocardiographic findings in patients presenting to the emergency department (ED) with chest pain and without ST-segment elevation on the electrocardiogram.

Methods

We compared contrast echocardiography (CE) with gated single-photon emission computed tomography (SPECT) for this purpose. Both CE and SPECT readings included separate and composite assessments of both RF and PER. Adverse events in the first 48 hours after ED presentation included acute myocardial infarction, emergent revascularization, and cardiac-related death.

Results

Concordance between CE and SPECT was 77% (73% to 82%) for all territories, with a higher concordance for the anterior wall of 84% (78% to 89%). Of the 203 patients recruited for the study, 38 (19%) had a cardiac event within 48 hours of ED presentation: 21 had acute myocardial infarction, 16 underwent an urgent revascularization procedure, and 1 died. In multivariate logistic regression models, the number of abnormal segments on CE and SPECT were significant predictors (P < .05) of cardiac events. The composite scores on CE provided 17% incremental information (P = .009, n = 203) and gated SPECT provided 23.5% additional information (P = .020, n = 163) for predicting cardiac events compared with routine demographic, clinical, and electrocardiographic variables. RF and composite evaluation was superior on SPECT compared with CE, whereas PER alone was not.

Conclusions

Cardiac imaging of RF and PER at the time of ED presentation offers substantially greater diagnostic and prognostic information for early cardiac events in patients presenting to the ED with chest pain and no ST elevation than does the routine demographic, clinical, and electrocardiographic assessment.     

Incidental pulmonary nodules on cardiac computed tomography: prognosis and use

Background

Small asymptomatic lung nodules are found frequently in the course of cardiac computed tomography (CT) scanning. However, the utility of assessing and reporting incidental findings in healthy, asymptomatic subjects is unknown.

Methods

The sample comprised 1023 60- to 69-year-old subjects free of clinical cardiovascular disease and cancer who participated in the Atherosclerotic Disease, VAscular functioN and genetiC Epidemiology Study. All subjects underwent cardiac CT for determination of coronary calcium between 2001 and 2004, and the first 459 subjects were assessed for incidental pulmonary findings. We used health plan clinical databases to ascertain 24-month health care use and clinical outcomes.

Results

Noncalcified pulmonary nodules were reported in 81 of 459 subjects (18%). Chest CT was performed on 78% of participants in the 24 months after notification, compared with 2.5% in the previous 24 months. Chest x-ray use increased from 28% to 49%. The mean number of chest CT scans per subject was 1.3 (range, 0-5). Although no malignant lesions were diagnosed in the group who had pulmonary findings read, 1 lung cancer case was diagnosed in the group who did not have lung findings read. Among the 63 participants followed up by CT, the original lesion was not identified in 22 participants (35%), the lesion had decreased or remained stable in 39 participants (62%), and there was interval growth in 2 participants (3%).

Conclusion

Reporting noncalcified pulmonary nodules resulted in substantial rescanning that overwhelmingly revealed resolution or stability of pulmonary nodules, arguing for benign processes.     

Adding banding ligation is effective as rescue therapy to prevent variceal rebleeding in haemodynamic non-responders to pharmacological therapy

Background

It is unknown which is the best therapy to treat haemodynamic non-responders to pharmacological therapy after variceal bleeding.

Aim

To evaluate the efficacy of adding banding ligation to drugs to prevent variceal rebleeding in haemodynamic non-responders to drugs.

Methods

Fifty-three cirrhotic patients with variceal bleeding underwent a hepatic venous pressure gradient (HVPG) measurement 5 days after the episode. Nadolol and nitrates were then titrated to maximum tolerated doses. A second HVPG was taken 14 days later. Responders (HVPG ≤12 mm Hg or ≥20% decrease from baseline) were maintained on drugs and non-responders had banding ligation added to drugs.

Results

Mean follow-up was 28 months. In 5 patients the second HVPG could not be performed because of early rebleeding. The remaining 48 patients were classified as responders (n = 24) and non-responders (n = 24), who had banding added. No baseline differences were observed between groups. Variceal rebleeding occurred in 12% of the 48 patients whose haemodynamic response was assessed. Responders on drug therapy presented a 16% rebleeding rate, whilst non-responders rescued with banding showed an 8% rebleeding rate. Rebleeding-related mortality was not different between groups.

Conclusion

In a HVPG-guided strategy, adding banding ligation to drugs is an effective rescue strategy to prevent rebleeding in haemodynamic non-responders to drug therapy.     

Anxiety in patients undergoing percutaneous coronary interventions

Objective

Many patients undergoing percutaneous coronary intervention (PCI) experience symptoms of anxiety; however, it is unclear whether anxiety is an issue in the early recovery period and the types of factors and patient concerns that are associated. This study set out to determine the patterns of anxiety and concerns experienced by patients undergoing PCI and the contributing factors in the time period surrounding PCI.

Methods

A convenience sample of patients undergoing PCI (n = 100) were recruited, and anxiety was measured using the Spielberger State Anxiety Inventory immediately before the PCI, the first day postprocedure, and 1 week postdischarge. Patients were also asked to identify their most important concern at each time. Independent predictors of anxiety at each time were determined by multiple regression analysis.

Results

Anxiety scores were highest pre-procedure (35.72, standard deviation [SD] 11.75), decreasing significantly by the postprocedure time (31.8, SD 10.20) and further still by the postdischarge time (28.79, SD 9.78) (repeated-measures analysis of variance: F = 39.72, P < .001). The concerns patients identified most frequently as most important were the outcome of the PCI and the possibility of surgery pre-procedure (37%) and postdischarge (31%), and the limitations and discomfort arising from the access site wound and immobility postprocedure (25%). The predictor of anxiety at the pre-procedure time was taking medication for anxiety and depression (b = 7.12). The predictors of anxiety at the postprocedure time were undergoing first-time PCI (b = 4.44), experiencing chest pain (b = 7.63), and experiencing pre-procedural anxiety (b = .49). The predictors of anxiety at the postdischarge time were reporting their most important concern as the future progression of CAD (b = 7.51) and pre-procedural anxiety (b = .37).

Conclusion

Symptoms of anxiety were common, particularly before PCI. These symptoms are important to detect and treat because pre-procedural anxiety is predictive of anxiety on subsequent occasions. Patients who have had chest pain or their first PCI should be targeted for intervention during the early recovery period after PCI, and information on CAD should be provided postdischarge.     

Differences in care-seeking behavior for acute chest pain in the United States and Japan

Background

Delay from onset of acute myocardial infarction symptoms to the delivery of medical care is a major determinant of prognosis. Although studies have explored patient factors for delay in seeking care, there are limited data on international differences in care-seeking behavior.

Methods

We surveyed 1032 people in the United States and 1422 people in Japan in January 1997 on decision-making responses to a chest pain scenario representing acute MI. Participants were asked about how they would seek initial care and how promptly they would seek care.

Results

The mean age was 43.6 years in the United States and 48.3 years in Japan. For the hypothetical scenario, US respondents were more likely to seek care at an emergency department (22.9% vs 16.2% in Japan) or through emergency medical services/911 (55.9% vs 32.9% in Japan, P = .001). American subjects were also more likely to seek care immediately (83.1% vs 56.4% in Japan, P = .001).

Conclusion

Respondents in the United States and Japan differed substantially in their responses to a hypothetical chest pain scenario. Whether these differences result from cultural or health care system factors and whether these apparent attitudes produce gaps in real responses to acute coronary syndromes must be explored in further studies.     

The utility of routine admission chest X-ray films on patient care

Background

Routine chest X-rays are the most widely obtained radiological studies during hospital admissions. In this study, we evaluated the utility of routine admission chest X-rays on patient care in patients admitted to The Brooklyn Hospital center.

Methods

We included consecutive patients admitted to the medical floors during a 4-month period who had a chest X-ray done on admission. The medical records of patients who had chest X-ray on admission were reviewed to identify any impact of chest X-ray on patient care during the course of hospitalization.

Results

Chest X-ray was noted to be done in 229 patients on admission. Chest X-rays of 100 (43.6%) patients were deemed medically necessary because of the presenting complaints which included cough (15.2%), fever (13.1%), dyspnea (6.1%), hemoptysis (1.7%), and combined symptoms (7.4%). Routine chest X-rays were done in 129 (56.3%) patients to rule out occult findings in the absence of any symptoms. Chest X-ray abnormalities were noted in 56 of 129 (43.4%) patients. In 51 of 56 patients, abnormalities were chronic, stable and previously known and did not contribute to patient care. In only 5 of 129 (3.87%) patients, there were findings which necessitated a change in patient care.

Conclusion

We conclude that routine chest films rarely reveal clinically unsuspected findings. The overall impact on patient care based on these findings is small when compared to the risks associated with repeated exposure to radiation. We recommend that routine chest X-ray films should not be ordered solely because of hospital admission.     

Circulating leptin and insulin in obese patients with and without type 2 diabetes mellitus: relation to ghrelin and oxidative stress

Aim

This case control study aimed to investigate relationship between appetite hormones (ghrelin and leptin) and body mass index (BMI), insulin and oxidative stress in simple obese and type 2 diabetes (T2DM) obese patients.

Methods

Thirty healthy controls; 30 simple obese and 30 T2DM obese patients were enrolled. Demographic and clinical data of all participants were reported. Serum levels of fasting blood glucose (FBG), postprandial blood glucose (PBG), lipid peroxide (LPO) and nitric oxide (NO) were measured by chemical methods while, insulin, leptin and ghrelin by ELISA kits.

Results

Serum levels of insulin, leptin, LPO were significantly higher while, ghrelin was significantly lower in simple obese and obese patients with diabetes versus controls. Insulin resistance was found in 76.67% simple obese and 93.33% obese patients with diabetes. Ghrelin showed a positive correlation with PBG in controls; but negative correlation with BMI in simple obese and with NO in obese patients with diabetes. Positive correlations were found between LPO and FBG, insulin, homeostasis model assessment of insulin resistance (HOMA-IR) and between leptin and FBG in obese patients with diabetes.

Conclusions

Our results suggested that hyperinsulinemia and hyperleptinemia may be most important mechanisms in decreasing ghrelin and inducing oxidative stress in simple obese and T2DM obese patients.     

Microaxial devices for ventricular failure: a multicentre, population-based experience

Background

Impella microaxial devices provide circulatory assistance for patients with acute decompensated heart failure. This study reviews the population-based provincial experience in British Columbia.

Methods

We performed a retrospective review of the prospectively maintained database. Impella devices were inserted for acute cardiogenic shock refractory to maximal therapy, as a bridge to decision or to long-term mechanical support.

Results

Between August 2007 and September 2009, 35 patients received 37 Impella devices (Impella LP 2,5, n = 2; Impella LP 5,0, n = 29; and Impella RD 5.0, n = 6) (Abiomed Inc, Danvers, MA). Devices were inserted in the setting of dilated cardiomyopathy (n = 13), acute myocardial infarction (n = 6), postcardiotomy shock (n = 6), and other etiologies (n = 12). Mean age was 53.0 ± 13.7 years. Mean left ventricular ejection fraction was 19 ± 9% at the time of insertion. Nineteen patients required aggressive resuscitation, all patients were on inotropic support, 97% of patients were intubated, and 46% of patients received mechanical circulatory support prior to insertion of the Impella devices. Mean duration of support was 3.7 ± 3.0 days. In all, 49% were successfully weaned, and 22% were transferred to long-term mechanical support. Four patients have subsequently undergone successful cardiac transplantation. The 30-day mortality was 40%, and 6-month mortality was 49%. Complications included gastrointestinal bleeding (n = 1), hemoptysis (n = 1), and thrombocytopenia (n = 4). There were no cardiovascular or cerebrovascular events.

Conclusion

Temporary support with Impella microaxial ventricular assist devices adds a valuable therapeutic option in selected patients with acute decompensated heart failure.     

Metoprolol CR/XL in postmyocardial infarction patients with chronic heart failure: experiences from MERIT-HF

Background

The benefit of β-blockers post-myocardial infarction (MI) was established in the late 1970s. Major advances in the treatment of MI have since occurred. However, patients with chronic heart failure (CHF) were excluded from those trials. The purpose of this study was to assess the effect of β-blockers in post-MI patients with CHF receiving contemporary management.

Methods

This was a prespecified subgroup analysis of a double-blind, randomized trial: the Metoprolol CR/XL Randomized Intervention Trial in Heart Failure (MERIT-HF). Patients with CHF in New York Heart Association class II to IV with an ejection fraction (EF) ≤0.40 and a history of being hospitalized for an acute MI (n = 1926) were randomized to metoprolol succinate controlled release/extended release (CR/XL) versus placebo. Mean EF was 0.28, and the mean follow-up was 1 year.

Results

Metoprolol CR/XL reduced total mortality by 40% (95% CI 0.20-0.55, P = .0004), and sudden death by 50% (95% CI 0.26-0.66, P = .0004). The combined end point of all-cause mortality/hospitalization for worsening CHF was reduced by 31% (95% CI 0.16-0.44, P < .0001), and cardiac death/nonfatal acute MI by 45% (95% CI 0.26-0.58, P < .0001). A post-hoc analysis showed that the outcome in patients with earlier revascularization (44%) and outcome in those with more severe CHF (20%) was similar to the entire post-MI population.

Conclusions

In post-MI patients with symptomatic CHF, β-blockade continues to exert a profound reduction in mortality and morbidity in the presence of contemporary management that includes early and late revascularization, angiotensin-converting enzyme inhibitors, aspirin, and statins.     

Hyperuricemia in sickle cell disease in France

Purpose

Hyperuricemia has been reported to be a common feature of sickle cell disease occurring between 32 to 41% of the patients, in studies conducted during the 1970's. Since then, this notion has been rarely challenged. The objective of this study was to assess the prevalence of hyperuricemia and gout in adult patients with sickle cell disease in France.

Methods

Between May 2007 and March 2009, serum and urinary urate concentration, creatininemia and hemogram were prospectively assessed in all consecutive sickle cell patients, followed in our sickle cell disease centre. All subjects were in a clinically steady state. Clinical acute gout history was also recorded.

Results

Sixty-five patients (mean age 31 ± 10.3 years) were investigated. Mean uric acid serum level was 281.6 ± 74 μmol/L. Hyperuricemia was evidenced in six patients only (9.2%) (95% IC: 3.5-19.0). None of the patient had a medical history of acute gout. Patients in the higher serum uric acid tertile concentration had higher serum creatinine level (62.3 ± 17.1 μmol/L vs 51.5 ± 12.6 μmol/L, P < 0.01), lower fractional excretion of urate (4.5% vs 6.8%, P < 0.03) and higher reticulocyte count (median 219 500/mm³ vs 144 000/mm³, P = 0.08) compared to the other patients.

Conclusion

Hyperuricemia and gout are not a clinical problem in sickle cell disease in our country. Nevertheless, our findings indicate that kidney function has to be fully explored if serum uric acid level is elevated or significantly deteriorates during follow-up. Serum uric acid level could be an early marker of renal dysfunction in sickle cell disease patients.     

Cardiac pathologic findings reveal a high rate of sudden cardiac death of undetermined etiology in younger women

Background

Between 1989 and 1998 there was a 21% increase in estimated sudden cardiac death among US women aged 35 to 44 years. In contrast, the sudden cardiac death rate in age-matched men showed a decreasing trend (−2.8%). Due to under-representation of younger adults in published autopsy series, etiologies of sudden cardiac death merit further investigation.

Methods

We reviewed autopsy and detailed cardiac pathologic findings in younger women (age 35-44 years) from a 270-patient, 13-year (1984-1996) autopsy series of sudden cardiac death, and performed comparisons with findings in age-matched men.

Results

Women aged 35 to 44 years constituted 32% of all women in the series compared to men, who constituted 24% of total men (P = .004 vs women). A presumptive cause of sudden cardiac death could not be determined in 13 women (50%). Among women, 6 cases (22%) had significant coronary artery disease. Findings in others included coronary artery anomalies (n = 3), myocarditis (n = 2), hypertrophic cardiomyopathy (n = 1), coronary artery dissection (n = 1) and accessory pathway (n = 1). In younger men, a presumptive cause of sudden cardiac death remained undetermined in only 24% (P = .025 vs younger women), and coronary artery disease accounted for 40% of cases.

Conclusions

In younger women, despite autopsy and detailed cardiac pathologic examination, an attributable cause of sudden cardiac death was not determined in 50% of cases; a 2-fold increase compared to men of the same age. Given the dynamic and multifactorial nature of sudden cardiac death, comprehensive population-based investigations are likely to be necessary to further investigate this unexpected sex-based disparity.     

Color of culprit lesion at 6 months after plain old balloon angioplasty versus stenting in patients with acute myocardial infarction

Background

Although the healing process of disrupted yellow plaques at myocardial infarction (MI) culprit lesions has been reported, the effect of stenting on this process has not been clarified. Stenting has been reported to deteriorate the endothelial function after percutaneous coronary intervention (PCI). Therefore, we compared the angioscopic morphology of culprit lesions at 6 months after plain old balloon angioplasty (POBA) and stenting to clarify the effect of stenting on the healing of disrupted culprit plaques of acute MI.

Methods

Patients with acute MI who had yellow culprit plaque, successful reperfusion therapy with POBA (n = 21) or stenting (n = 22), and a successful 6-month follow-up angioscopic examination were included in this study. Oral ticlopidine (200mg/day) was administered for 3 to 6 months after stenting.

Results

At 6 months after reperfusion therapy, the color of the culprit lesion became white in significantly more patients treated with stenting than treated with POBA (50% vs 14%; P = .01). However, the prevalence of thrombus appeared to be higher in patients treated with stenting than in patients treated with POBA (27% vs 5%; P = .04). Although there was some difference in the patients' characteristics in the groups, logistic regression analysis revealed no significant influence of those factors on the color of or on the prevalence of thrombus at the culprit lesion.

Conclusions

Coronary stenting in patients with acute MI leads to the disappearance of yellow color at a significantly higher rate than POBA; however, whether it stabilizes the plaque requires further investigation.     

Ischemia-induced repolarization response in relation to the size and location of the ischemic myocardium during short-lasting coronary occlusion in humans

Background

The ventricular repolarization (VR) response to short-lasting coronary occlusion has been characterized by 3-dimensional vectorcardiography (VCG) in humans; the T vector loop becomes distorted and more circular. The purpose of this study was to relate these changes to the size of the myocardium at risk (MAR) and its location.

Methods

Continuous VCG was applied during transient coronary occlusion in 35 elective angioplasty patients, and the size of the MAR was estimated by single-photon emission computed tomography. Three VR aspects were assessed at baseline vs maximum ischemia: the ST segment, the T vector angles, and the T vector loop morphology.

Results

The T loop morphology changes were significantly associated with MAR size, but also dependent of its location. In contrast, the early phase of VR reflected by the ST segment responded to acute ischemia in relation to the MAR size independent of location.

Conclusion

The VR changes were related both to the size and the location of the MAR and most pronounced during occlusion of the left anterior descending artery.     

The effect of the change in the Framingham Risk Score calculator between the 2006 and 2009 Canadian lipid guidelines

Background

Recent Canadian lipid guidelines changed the methodology used for calculating the Framingham Risk Score (FRS). We assessed the impact this would have on management when related to baseline lipid profiles and the possible need for statin drug therapy.

Methods

Patients with their FRS calculated between November 2006 and March 2010 were considered. There were 247 patients categorized as either low or intermediate risk.

Results

The study population consisted of 91 men and 156 women with a mean (SD) age of 52.7 ± 15.0 years. The average FRS was 5.6 ± 4.8 vs 11.5 ± 8.3 (2006 vs 2009) (P < .00010). The number of FRS patients categorized as low and intermediate risk requiring some form of lipid-lowering treatment increased from 35 (14.2%) to 81 (32.8%), a 2.3-fold increase. Of 41 high-risk patients, 40 had a baseline low-density lipoprotein cholesterol of ≥2.0 mmol/L and would qualify for not only health behaviour interventions but also statin drug treatment.

Conclusions

The new FRS increases the number of 2006 patients with low and intermediate scores who move from low to high risk (n = 11, 5.9%), from low to intermediate risk (n = 50, 26.9%), and from intermediate to high risk (n = 30, 49.2%), leading to a 2.3-fold increase in the need for lipid-lowering treatment. Therapies intended to improve lipid profiles and potentially patient outcomes include both health behaviour interventions alone or in combination with lipid-lowering drug therapy. Given the relationship between low-density lipoprotein cholesterol and cardiovascular events is linear, treating more patients is likely to lead to a further reduction in cardiovascular events.     

Spanish catheter ablation registry. 10th official report of the Spanish Society of Cardiology Working Group on Electrophysiology and Arrhythmias (2010)

Introduction and objectives

The findings of the 2010 Spanish Catheter Ablation Registry are presented.

Methods

Data were collected in two ways: retrospectively using a standardized questionnaire, and prospectively from a central database. Each participating center selected its own preferred method of data collection.

Results

Fifty-seven Spanish centers voluntarily contributed data to the survey. A total of 8762 ablation procedures was analyzed, averaging 154 (97) per center. The 3 main conditions treated were atrioventricular nodal reentrant tachycardia (n=2321; 27%), typical atrial flutter (n=1839; 22%), and accessory pathways (n=1738; 20%). Atrial fibrillation was the fourth most common condition treated (n=1309; 15%), and reflects mild growth. The overall success rate was 94%, major complications occurred in 1.7%, and the overall mortality rate was 0.06%.

Conclusions

Data from the 2010 registry show that the number of ablations carried out continued to increase and exceeded 8700 ablations for the second time. In addition, they show, in general, a higher success rate and a lower number of complications. Again, cavotricuspid isthmus ablation for typical atrial flutter was the second most common condition treated. The number of catheter ablations carried out for ventricular arrhythmias in Spain is growing compared to the previous year.Full English text available from:www.revespcardiol.org     

Enoxaparin versus tinzaparin in non-ST-segment elevation acute coronary syndromes: the EVET trial

Background

Low-molecular weight heparins have different pharmacokinetic and pharmacodynamic characteristics and may vary in efficacy. We compared the efficacy of enoxaparin with that of tinzaparin in the management of non-ST-segment elevation acute coronary syndromes (NSTACS).

Methods

A total of 438 patients with NSTACS were randomized to receive subcutaneous treatment with enoxaparin, 100 IU/kg twice daily (equivalent to 1 mg/kg twice daily; n = 220), or tinzaparin, 175 IU/kg once daily, (n = 218) for as long as 7 days. The primary composite end point was recurrent angina, myocardial infarction (or reinfarction), or death at day 7. Secondary end points were the primary end point at day 30 and the occurrence of individual events at days 7 and 30.

Results

The incidence of the primary end point was 12.3% in the enoxaparin group and 21.1% in the tinzaparin group (P = .015). At day 7, the rate of recurrent angina was lower with enoxaparin than with tinzaparin (11.8% vs 19.3%). At day 30, the incidences of the composite end point, recurrent angina, and myocardial infarction were also lower with enoxaparin, 17.7% vs 28.0% (P = .012), 17.3% vs 26.1% and 0.5% vs 2.8%, respectively. The rate of revascularization was lower in the enoxaparin group, 8.6% vs 17.9% (P = .010) at day 7 and 16.4% vs 26.1% (P = .019) at day 30. Rates of bleeding complications were similar in the 2 treatment groups.

Conclusions

This study indicates a benefit of enoxaparin (100 IU/kg twice daily) as compared with tinzaparin (175 IU/kg once daily) in the treatment of patients with NSTACS, which is sustained for at least 30 days.     

"Mirror-lake" serial relationship of electrocardiographic and biochemical indices for the detection of reperfusion and the prediction of salvage in patients with acute myocardial infarction

Background

Serial observations of biochemical markers in the blood and bioelectric markers on the electrocardiogram (ECG) have been used to evaluate the effectiveness of reperfusion therapy in acute myocardial infarction (AMI). This study presents a combined method for clinical use, based on the “mirror-lake” tendency of the serial changes in these markers.

Methods

Consecutive thrombolytic-treated patients with AMI (n = 43) had ST-segment monitoring (Mortara Eli 100) and frequent serum sampling of myoglobin (MG) concentration. Their acutely predicted and finally estimated AMI sizes and myocardial salvage extents were calculated from the 12-lead standard ECG. Patients having 2 positive reperfusion indices (ST resolution at least 50%, and an increase in MG at least 2.4 fold) at 2 hours after initiation of thrombolytic therapy were considered the “complete reperfusion” group, and patients with discordant or 2 negative reperfusion indices after 2 hours of thrombolytic therapy were considered the “limited reperfusion” group.

Results

Patients with complete reperfusion (n = 22) versus patients with limited reperfusion (n = 21) had +12% versus −1% myocardial salvage (P < .0001). The serial changes in the ST segment mirrored the serial changes in the MG concentration, and the rates of increase in MG correlated with the rates of resolution of the ST-segment elevation.

Conclusion

Myocardial salvage (measured by ECG indices) is greatest when an early increase in serum MG is “mirrored” by early resolution of ST-segment elevation.     

Electrophysiologic characteristics and results of radiofrequency catheter ablation in elderly patients with atrioventricular nodal reentrant tachycardia

Background

As in the general population, atrioventricular nodal reentrant tachycardia (AVNRT) is the most common regular supraventricular tachycardia in the elderly patients. We tried to compare electrophysiologic characteristics, efficacy, and risks of the radiofrequency (RF) catheter ablation of the slow pathway in elderly and young patients with AVNRT.

Methods

Between April 2001 and March 2005, 268 consecutive patients (190 females; mean age, 49 ± 14 years) with AVNRT underwent RF catheter ablation at our institution. The patients were categorized into 2 groups: group 1 consists of patients younger than 65 years (n = 156), and group 2 consists of patients 65 years or older (n = 112).

Results

Compared with the younger subgroup, elderly patients more often had structural heart disease (11.6% vs 2.5%, P = .004), but there were no statistically significant differences in sex and symptoms during tachycardia (all P > .05). AVNRT cycle length was significantly longer in group 2 than in group 1 patients (P = .005). Among the conduction intervals of tachycardia, only atrio-his interval was significantly longer in group 2 patients (P = .007). The ablation fluoroscopy time, RF pulse duration, target temperature, applied energy, and number of RF applications were comparable in the 2 groups (All P > .05). Risk of atrioventricular block, pericardial effusion, and vascular thrombosis were similar in both groups (All P > .05). During follow-up with duration of 14 months, similar rate of recurrence was observed in the 2 groups (P = .94).

Conclusions

In elderly patients, slow pathway ablation is as effective and safe as in younger patients. Therefore, when considering different treatment options in elderly patients, an increased risk of complications or lower efficacy should not be a factor in determining the best therapeutic approach.     

Role of occult hepatitis B virus in chronic hepatitis C patients with flare of liver enzymes

Background

Occult HBV infection is defined by detection of HBV DNA in the serum or liver tissue of patients who test negative for HBsAg. The prevalence of occult HBV is higher in hepatitis C virus (HCV) positive patients than HCV negative patients and may have an impact on their clinical outcome. In this study, we evaluated the role of occult hepatitis B virus infection in chronic hepatitis C patients with ALT flare.

Methods

Sixty HBsAg negative patients with chronic hepatitis C virus infection were included. Patients were divided into 2 groups according to their ALT level: 30 patients with normal or slightly high ALT and 30 patients with ALT flare (≥ 5 times normal values). Patients in both groups were examined for the detection of anti-HBs, anti-HBc IgM, and anti-HBc IgG. HBV DNA was detected using semi-nested PCR technique.

Results

In patients with normal or slightly high ALT, HBV DNA was detected in 4 (13.3%) patients, while in those with ALT flare, HBV DNA was detected in 19 (63.3%) patients (p < 0.001). No association was found between the presence of HBV DNA and various serology markers of HBV infection.

Conclusion

Presence of occult hepatitis B, with its added deleterious effect, must always be considered in chronic hepatitis C patients especially those with flare in liver enzymes; HBsAg should not be used alone for the diagnosis of HBV infection.