Successful Primary Percutaneous Coronary Intervention without Stenting: Insight from Optimal Coherence Tomography

For patients with acute myocardial infarction, current management guidelines recommend implantation of a drug-eluting stent, dual antiplatelet therapy (including potent P2Y12 inhibitors) for at least 1 year, and maintenance of life-long antiplatelet therapy. However, a pilot study showed favorable results with antithrombotic therapy without stent implantation when plaque erosion, not definite plaque rupture, was confirmed using optical coherence tomography (OCT), despite the patients having acute myocardial infarction. Here, we present a case where successful primary percutaneous coronary intervention was performed without stenting with the aid of OCT in a patient with ST-elevation myocardial infarction who developed thrombotic total occlusion of the right coronary artery.     

Postmortem diagnosis of acute myocardial infarction in patients with acute respiratory failure: demographics, etiologic and pulmonary histologic analysis

OBJECTIVES:

Acute respiratory failure is present in 5% of patients with acute myocardial infarction and is responsible for 20% to 30% of the fatal post-acute myocardial infarction. The role of inflammation associated with pulmonary edema as a cause of acute respiratory failure post-acute myocardial infarction remains to be determined. We aimed to describe the demographics, etiologic data and histological pulmonary findings obtained through autopsies of patients who died during the period from 1990 to 2008 due to acute respiratory failure with no diagnosis of acute myocardial infarction during life.

METHODS:

This study considers 4,223 autopsies of patients who died of acute respiratory failure that was not preceded by any particular diagnosis while they were alive. The diagnosis of acute myocardial infarction was given in 218 (4.63%) patients. The age, sex and major associated diseases were recorded for each patient. Pulmonary histopathology was categorized as follows: diffuse alveolar damage, pulmonary edema, alveolar hemorrhage and lymphoplasmacytic interstitial pneumonia. The odds ratio of acute myocardial infarction associated with specific histopathology was determined by logistic regression.

RESULTS:

In total, 147 men were included in the study. The mean age at the time of death was 64 years. Pulmonary histopathology revealed pulmonary edema as well as the presence of diffuse alveolar damage in 72.9% of patients. Bacterial bronchopneumonia was present in 11.9% of patients, systemic arterial hypertension in 10.1% and dilated cardiomyopathy in 6.9%. A multivariate analysis demonstrated a significant positive association between acute myocardial infarction with diffuse alveolar damage and pulmonary edema.

CONCLUSIONS:

For the first time, we demonstrated that in autopsies of patients with acute respiratory failure as the cause of death, 5% were diagnosed with acute myocardial infarction. Pulmonary histology revealed a significant inflammatory response, which has not previously been reported.     

Does diffuse coronary atherosclerosis affect the relation between coronary stenoses and uptake of thallium-201 after exercise?

It has been proposed that diffuse coronary atherosclerosis influences the myocardial perfusion. We performed a study of 94 young men with previous myocardial infarction in order to find out whether the presence and extent of diffuse coronary atherosclerosis affected the relation between maximal stenosis and myocardial perfusion in areas remote from the infarction. The patients were examined by planar-imaging thallium-201 scintigraphy, following exercise, and coronary angiography within 6 months after myocardial infarction. The maximal distinct stenosis and diffuse coronary atherosclerosis, comprising both plaque size and extent, were semiquantitatively assessed. The correlation coefficients between maximal stenosis within the LAD, RCA, and LCX vascular territories and the corresponding initial uptake of thallium were 0.52 (P = 0.0001), 0.30 (P = 0.04), and 0.46 (P = 0.02), respectively. No change of the correlations was found, except for a slight increase of the r-value from 0.30 to 0.37 in regions corresponding to RCA, after controlling for the diffuse atherosclerosis score in a multiple stepwise regression analysis. These findings indicate no impact of diffuse coronary atherosclerosis on regional myocardial perfusion in areas remote from the infarction.     

Thallium-201 myocardial scintigraphy during dipyridamole-induced coronary hyperaemia. First experiences with a new regional washout programme

Eight patients with severe peripheral vascular atherosclerosis scheduled for abdominal aortic surgery were investigated to detect coexisting coronary artery disease. None of the patients had a history of angina pectoris or previous myocardial infarction. Preoperative computerised thallium-201 dipyridamole myocardial scintigraphy was abnormal in all patients, showing either myocardial scar tissue and/or ischaemia with redistribution and/or low washout. In all but one patient, the serum level of creatin kinase was elevated during the first postoperative days. In two patients, the serum concentrations of aspartate aminotransferase and lactate dehydrogenase were elevated. None of the patients showed clinical or electrocardiographical signs of acute myocardial infarction. Thallium-201 dipyridamole myocardial imaging is a new noninvasive method for detection of ischaemic heart disease in patients with severe peripheral atherosclerosis who are unable to perform a bicycle exercise test. The new programme for determination of regional washout appeared to be very precise and may be especially applicable in the case of low washout values.     

从CT数据到带纤维走向的全心脏有限元模型的建立

心脏计算机模型是研究生理/病理心脏功能及心律失常治疗方法的有力工具,心脏有限元解剖模型是构建各种心脏模型的基础。从病人的临床影像数据建立个性化的心脏有限元模型,可为临床诊断治疗提供极大便利。研究一种由人体胸腔CT影像数据建立全心脏有限元模型的方法,具体步骤包括:基于胸腔CT影像,通过MIMICS建立心脏解剖面片模型;根据HyperMesh修复面片模型,得到心脏实体有限元模型。由于心肌纤维走向与心脏的电/机械活动密切相关,在从影像数据重建心脏解剖结构之后,又特别研究心肌纤维走向确定方法。首先,利用规则库方法(rule-based approach)确定心室肌纤维走向;之后,在使用规则库方法的基础上,利用结构张量分析(structure tensor analysis)进行平滑滤波,得到心房肌纤维走向。为验证心肌纤维走向的正确性,分析使用该方法计算得到的巴克曼束、左心房后部、左上心房后部、房间沟等几个典型部位处心肌纤维方向与X轴的夹角,分别为4.97°±4.84°(均值±标准差)、111.99°±3.72°、178.89°±3.73°、86.48°±4.01°,符合文献报道的心肌纤维走向的观测结果。所提出的方法可从心脏影像数据构建包含心肌纤维走向的心脏有限元模型,为各类心脏建模仿真研究打下基础。     

Cardiac ruptures in northern Norway. A retrospective study of 104 cases

In 4,649 autopsies performed, in 1972-1985, 824 cases of acute myocardial infarction were found. Of these, 104 (12.6%) had cardiac rupture. Ten cases had rupture of the interventricular septum. The clinical and pathological records were reviewed, and the rupture group was compared with a control group of 100 patients who died from acute myocardial infarction without rupture. Of the patients with rupture, 85% died during the first week after the onset of myocardial infarction; three patients with rupture died suddenly without previous clinical evidence of myocardial infarction. Rupture occurred only in hearts with transmural infarcts, and predominantly in the anteroseptal wall. Patients with rupture had significantly higher blood pressure, fewer previous infarcts, higher frequency of coronary thrombi, less myocardial scar tissue and lower heart weight compared to the control group. There were no significant differences regarding age and sex distribution, physical effort at the symptom debut or death, medication, previous and present diseases other than infarcts, complications or the degree of atherosclerosis in the coronary arteries or aorta.     

Blocking Interleukin-1 as a Novel Therapeutic Strategy for Secondary Prevention of Cardiovascular Events

The inflammatory hypothesis of atherosclerosis postulates that inflammation within the plaque promotes plaque progression and complications. Interleukin-1 (IL-1) is a key pro-inflammatory cytokine responsible for the amplification of the inflammatory response following injury. Animal studies show that IL-1 blockade is effective in limiting atherosclerosis and atherothrombosis and improving outcomes in acute myocardial infarction and ischemic stroke. Preliminary data in patients with acute myocardial infarction, ischemic stroke, and heart failure are promising. A large secondary prevention trial with canakinumab in patients with prior acute myocardial infarction is currently ongoing. Many unanswered questions remain regarding the optimal use of IL-1 blockade and the preferred agent.     

Noninvasive assessment of cutaneous wound healing using ultrahigh-resolution optical coherence tomography

Ultrahigh-resolution optical coherence tomography (OCT) was used for noninvasive in vivo evaluation of the wound healing process. Cutaneous wounds were induced by 2.5-mm diameter full-thickness punch biopsies on the dorsal surface of seven mice. OCT imaging was performed to assess the structural characteristics associated with the healing process. The OCT results were compared to corresponding histology. Two automated quantitative analysis routines were implemented to identify the dermal-epidermal junction and segment the OCT images. Hallmarks of cutaneous wound healing such as wound size, epidermal migration, dermal-epidermal junction formation, and differences in wound composition were readily identified on the OCT images. Blister formation was also observed. Preliminary findings suggest OCT is a viable tool to noninvasively monitor wound healing in vivo.     

巨噬细胞极化在心血管疾病中的作用

心血管病,尤其是急性心肌梗死和收缩性心功能衰竭已成为西方国家患者死亡的主要原因,在发展中国家也呈明显上升趋势.缺血性的心脏病已经成为普遍现象,是引起病人死亡的主要原因.尽管早期血管再建和药物治疗能够明显提高心肌梗死后的生存率,但仍有大量病人发展成心力衰竭.巨噬细胞除了具有免疫防御和维持组织稳态功能,还在心肌梗死诱导的病理生理过程中发挥重要作用.巨噬细胞的亚群已被证实参与心血管疾病(动脉粥样硬化、心肌梗死、心肌缺血、心肌纤维化)的发生和发展,在心脏损伤和心肌重塑中有重要作用,研究基于巨噬细胞调控治疗心血管疾病的治疗策略很有价值.     

Cost effectiveness of thrombolytic therapy with streptokinase in elderly patients with suspected acute myocardial infarction.

BACKGROUND. There is a lack of consensus among cardiologists about the potential benefit of thrombolytic therapy for suspected acute myocardial infarction in older patients. To investigate this issue, we constructed a decision-analytic model for patients 75 years of age or older who present with ST-segment elevation within six hours of the onset of symptoms suggesting acute myocardial infarction. METHODS. The variables incorporated in this model were the probability that the patient has an acute myocardial infarction, the probability of in-hospital death among patients with acute myocardial infarction who do not receive thrombolytic therapy, the probability of a fatal or incapacitating complication resulting from thrombolytic therapy, and the expected relative reduction in the risk of death associated with thrombolytic therapy in patients with acute myocardial infarction. Our analyses were based primarily on the use of streptokinase as the thrombolytic agent. RESULTS. Given our base-line assumptions, the probability of dying in the hospital was 21.4 percent if thrombolytic therapy was given and 24.4 percent if it was not given. In one-way sensitivity analyses, thrombolytic therapy decreased the risk of dying if the probability that the patient had an acute myocardial infarction was assumed to be greater than 9 percent, if the probability of dying in the hospital after an acute myocardial infarction without thrombolytic therapy was assumed to be greater than 3 percent, if the rate of fatal or incapacitating complications due to thrombolytic therapy was assumed to be 4 percent or less, or if the relative reduction in the risk of death associated with thrombolytic therapy was assumed to be greater than 1 percent. On the basis of our base-line assumptions, our estimate of the cost effectiveness of streptokinase therapy (the cost per year of life saved) for an 80-year-old patient with suspected acute myocardial infarction was $21,200. For a wide range of assumptions about risks, benefits, and costs, the cost per year of life saved remained less than $55,000. CONCLUSIONS. Within the limitations imposed by the assumptions used in our analysis, thrombolytic therapy with streptokinase was found to be a beneficial and cost-effective treatment for suspected acute myocardial infarction in elderly patients in a wide variety of clinical circumstances.     

心肌梗死模型家猪存活心肌的磁共振延迟成像评价

背景：心脏磁共振延迟成像被认为是极有前景的无创性判断心肌存活状态的影像检查手段。目前常用的对比剂Gd-DTPA存在过高或过低评价存活心肌和不可逆性梗死心肌,而坏死亲和性对比剂ECIII-600可以准确地反映坏死心肌的面积。 目的：对比冠脉内注射坏死亲和性对比剂在猪再灌注急性心肌梗死存活心肌诊断中的应用价值。 方法：三四个月龄普通家猪12头,建立急性再灌注心肌梗死动物模型,分别冠脉内注射0.1 mmol/kg Gd-DTPA或         0.005 mmol/kg ECIII-600。胸导R波触发心电门控,T1加权FAST序列,短轴面延迟强化扫描成像。扫描结束后沿短轴面将心脏切成6 mm断面行氯化三苯基四氮唑染色和光镜检查。比较相应层面的MRI延迟强化区和氯化三苯基四氮唑染色所示梗死区的关系。 结果与结论：注射Gd-DTPA的延迟成像10 min时强化区面积与氯化三苯基四氮唑染色相比过高估计梗死心肌面积约21%,30 min时强化区面积与氯化三苯基四氮唑染色结果一致,之后则过低估计坏死心肌的面积;注射ECIII-600的延迟磁共振成像在坏死区显示强烈而持续的对比增强,强化区面积与氯化三苯基四氮唑染色所示心肌梗死面积一致。说明ECIII-600增强磁共振延迟成像可以准确反映急性心肌梗死面积。Gd-DTPA评价心肌梗死面积不稳定,观察时间窗短,心脏磁共振成像应在对比剂注射后1 h以内完成。     

Optical coherence tomography for imaging the vulnerable plaque

While our understanding of vulnerable coronary plaque is still at an early stage, the concept that certain types of plaques predispose patients to developing an acute myocardial infarction continues to be at the forefront of cardiology research. Intracoronary optical coherence tomography (OCT) has been developed to both identify and study these lesions due to its distinct resolution advantage over other imaging modalities. We review clinical research conducted at the Massachusetts General Hospital over the past five years to develop, validate, and utilize this technology to improve our understanding of vulnerable plaque. Our results show that intracoronary OCT may be safely conducted in patients and that it provides abundant information regarding plaque microscopic morphology, which is essential to the identification and study of high-risk lesions. Even though many basic biological, clinical, and technological challenges must be addressed prior to widespread use of this technology, the unique capabilities of OCT ensure that it will have a prominent role in shaping the future of cardiology.     

Right ventricular involvement in anterior myocardial infarction: a tissue Doppler-derived strain and strain rate study

OBJECTIVE:

Strain and strain rate imaging is currently the most popular echocardiographic technique that reveals subclinical myocardial damage. There are currently no available data on this imaging method with regard to assessing right ventricular involvement in anterior myocardial infarction. Therefore, we aimed to evaluate right ventricular regional functions using a derived strain and strain rate imaging tissue Doppler method in patients who were successfully treated for their first anterior myocardial infarction.

METHODS:

The patient group was composed of 44 patients who had experienced their first anterior myocardial infarction and had undergone successful percutaneous coronary intervention. Twenty patients were selected for the control group. The right ventricular myocardial samplings were performed in three regions: the basal, mid, and apical segments of the lateral wall. The individual myocardial velocity, strain, and strain rate values of each basal, mid, and apical segment were obtained.

RESULTS:

The right ventricular myocardial velocities of the patient group were significantly decreased with respect to all three velocities in the control group. The strain and strain rate values of the right mid and apical ventricular segments in the patient group were significantly lower than those of the control group (excluding the right ventricular basal strain and strain rate). In addition, changes in the right ventricular mean strain and strain rate values were significant.

CONCLUSION:

Right ventricular involvement following anterior myocardial infarction can be assessed using tissue Doppler based strain and strain rate     

Can free radicals induce coronary vasospasm and acute myocardial infarction?

Spontaneous acute occlusion of the coronary artery produces regional myocardial ischemia and infarction. This coronary occlusion could be due to rapid progression of atherosclerosis or vasospasm. The factors that can precipitate an acute attack of myocardial infarction or coronary spasm are not known. It is proposed that a stress-induced rise of unesterified arachidonic acid could trigger a leukocyte respiratory burst with the release of free radicals such as superoxide anion (O2-), hydrogen peroxide, hydroxyl radical, and singlet oxygen. These free radicals have the ability to inhibit prostacyclin (PGI2) formation and enhance the breakdown of endothelium-derived vascular relaxing factor (EDRF) which are potent vasodilators and platelet anti-aggregators. This may lead to rapid progression of atherosclerosis or coronary vasospasm leading to acute myocardial infarction. If this is true, free radical quenchers and inhibitors of leukocyte oxidative burst may be useful in the prevention of progression of atherosclerosis and coronary vasospasm.     

Sudden vascular death: the roles of the liver and anaphylaxis in sudden cerebro or cardiovascular infarction

Much has been written about how coronary and cerebrovascular atherosclerosis, and how it increases the risk of myocardial or cerebral infarction. The cardiologists and pathologists whose articles appear in scientific journals are dealing in detail with the progress of the arterial disease, but are still seeking the cause of the sudden event that leads to an acute myocardial or cerebral infarction. A new concept is herewith presented for consideration, regarding the cause of an acute myocardial infarction or cerebrovascular thrombosis. It is conceivable that these catastrophic events occur during the anaphylactic reaction of the liver. Experimental evidence and clinical observations are briefly presented.     

Optical coherence tomography: technology and applications for neuroimaging

Optical coherence tomography (OCT) is an emerging imaging technology with applications in biology, medicine, and materials investigations. Attractive features include high cellular-level resolution, real-time acquisition rates, and spectroscopic feature extraction in a compact noninvasive instrument. OCT can perform "optical biopsies" of tissue, producing images approaching the resolution of histology without having to resect and histologically process tissue specimens for characterization and diagnosis. This article will review several of the current technological developments in OCT. To illustrate the potential of this technology for neuroimaging, applications for imaging neural development, the neural retina, tumors of the central nervous system, and the microsurgical repair of peripheral nerves will be presented. This technology offers a potential investigative tool for addressing many of the present challenges in neuroimaging.     

Chemokine receptor (CCR2) genotype is associated with myocardial infarction and heart failure in patients under 65 years of age

Inflammation is associated with atherosclerosis of coronary arteries. Chemokines have an important role in inflammation. The CCR2 chemokine receptor mediates leukocyte chemoattraction, which is involved in the pathogenesis of coronary heart disease. We prospectively studied 1960 consecutive patients aged under 65 years and referred for a first-time left ventricular catheter. Left heart catheters were analyzed by two independent cardiologists for the presence of myocardial infarction (regional wall motion abnormality) and moderate or severely reduced left ventricular function on cineventriculography and presence of coronary atherosclerosis on angiography. Genotyping for CCR2 V64I polymorphism was performed. The presence of the rare allele of the CCR2 gene was significantly associated with a higher prevalence of myocardial infarction on cinventriculography (32.0% vs. 24.2%, moderately or severely reduced left ventricular function (14.0% vs. 9.5%) and NYHA class III or IV (16.7% vs. 12.2%). The association of the CCR2 genotype with heart failure was not independent of the presence of myocardial infarction in multivariate analysis. There was no association of the CCR2 genotype with coronary atherosclerosis. The CCR2 genotype seems to predispose patients for myocardial infarction before the age of 65 years. The higher prevalence of heart failure in gene carriers with the rare alle might be a consequence of myocardial infarction. If the CCR2 genotype is associated with higher mortality in the general population must be investigated in further studies.     

C-Reactive protein predicts acute myocardial infarction during high-risk noncardiac and vascular surgery

BACKGROUND:

High-sensitivity C-reactive protein predicts cardiovascular events in a wide range of clinical contexts. However, the role of high-sensitivity C-reactive protein as a predictive marker for perioperative acute myocardial infarction during noncardiac surgery is not yet clear. The present study investigated high-sensitivity C-reactive protein levels as predictors of acute myocardial infarction risk in patients undergoing high-risk noncardiac surgery.

METHODS:

This concurrent cohort study included patients aged ≥50 years referred for high-risk noncardiac surgery according to American Heart Association/ACC 2002 criteria. Patients with infections were excluded. Electrocardiograms were performed, and biomarkers (Troponin I or T) and/or total creatine phosphokinase and the MB fraction (CPK-T/MB) were evaluated on the first and fourth days after surgery. Patients were followed until discharge. Baseline high-sensitivity C-reactive protein levels were compared between patients with and without acute myocardial infarction.

RESULTS:

A total of 101 patients undergoing noncardiac surgery, including 33 vascular procedures (17 aortic and 16 peripheral artery revascularizations), were studied. Sixty of the patients were men, and their mean age was 66 years. Baseline levels of high-sensitivity C-reactive protein were higher in the group with perioperative acute myocardial infarction than in the group with non-acute myocardial infarction patients (mean 48.02 vs. 4.50, p = 0.005). All five acute myocardial infarction cases occurred in vascular surgery patients with high CRP levels.

CONCLUSIONS:

Patients undergoing high-risk noncardiac surgery, especially vascular surgery, and presenting elevated baseline high-sensitivity C-reactive protein levels are at increased risk for perioperative acute myocardial infarction.     

Konzentration Thiobarbitursäure-reaktiver Substanzen (TBARS) im Serum nach Myokardinfarkt

Summary The serum concentration of thiobarbituric acid reactive substances (TBARS), which can be used in the characterization of O₂-radical metabolism, was analyzed in patients with myocardial infarction in the acute phase, 10–14 days, 1 month, and 6 months after infarction, and compared with the TBARS concentration of a healthy group and a group with atherosclerosis. After myocardial infarction we found increased TBARS concentration at all moments of investigation in comparison with the healthy and atherosclerosis groups. Maximum concentration was found 10–14 days after infarction, afterwards the TBARS concentration decreased, without however attaining the values which we found in the comparison groups. The increased TBARS concentration 6 months after myocardial infarction demonstrates a manifestation of disturbances in the O₂-radical metabolism. Such disturbances may be regarded as a high-risk factor to the cardiovascular system.

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Abkürzungsverzeichnis AS Patienten mit Atherosklerose - ASAT Aspartataminotransferase - Ca-ATPase Calzium-abhängige Adenosintriphosphatase - CK Creatinkinase - EKG Elektrokardiogramm - K Kontrollgruppe - MDA Malondialdehyd - Na,K-ATPase Natrium-Kalium-abhängige Adenosintriphosphatase - O₂-Radikal Sauerstoffradikal - TBARS Thiobarbitursäure-reaktive Substanzen - Vit. E Vitamin E (-Tocopherol)     

Inflammatory cell reaction and mast cells in aortic intima and pulmonary artery of humans at early stages of atherosclerosis

The study of inflammatory reaction and morphofunctional characteristics of mast cells in aortic intima and pulmonary artery at initial stages of atherosclerosis was performed in 62 persons who had died of accidental causes at the ages of 4-49 years and 44 males who had died of myocardial infarction at the age of 42-73 years. Histological, histochemical and immunocytochemical tests showed permanent presence of lymphocyte-monocytic cell reaction in combination with mast cell infiltration in arterial intima that progressed with age and development of atherosclerosis. Lipoidosis was associated with an increase of T lymphocytes with (CD4+) domination, monocytes/macrophages (CD11+) and mast cells in different functional activity. Marked hyperplasia and high secretory activity of mast cells (expressed in their massive degranulation) were observed in acute myocardial infarction in aortic intima and pulmonary artery.