A comparative study of markers of inflammation for the assessment of cardiovascular risk in patients presenting to the emergency department with acute chest pain suggestive of acute coronary syndrome

BACKGROUND: The role of inflammation in the pathogenesis of acute coronary syndrome (ACS) is established. Little is known however, regarding the use of inflammatory markers as predictors of future cardiovascular events in patients presenting to the emergency department (ED) with suspected ACS. HYPOTHESIS: To assess whether biomarkers that predict cardiovascular risk in apparently healthy individuals and coronary artery disease patients are useful predictors of future cardiovascular events in patients presenting to the ED with chest pain suggestive of ACS. METHODS: We compared the abilities of serum C-reactive protein (hs-CRP), albumin and leukocyte count to identify subjects with ACS and those who are at high risk of developing events during a 30-day follow-up. RESULTS: 144 patients (mean age 62+/-13 years, 45 female) presenting to the ED <3 h after the onset of symptoms suggestive of ACS were evaluated. Final hospital diagnoses were non-ischemic chest pain in 43 (30%) and ACS in 101 (70%) patients. Patients with ACS had significantly higher leukocyte count (p<0.0001) and hs-CRP levels (p<0.02) and lower albumin concentrations, compared to patients with NICP (p<0.0001). Lower albumin concentrations (p=0.03) and hs-CRP (p=0.049) were predictors of recurrent events at 30 days. On multivariate analysis, however, only leukocyte count was a predictor of ACS (OR 20.9; 95% CI: 3.7-19.5; p=0.01) and high hs-CRP levels were a predictor of clinical outcome (OR 2.8; 95% CI: 1.5-5.2; p=0.001). CONCLUSIONS: Leukocyte count is an independent predictor of ACS in patients presenting to the ED with chest pain suggestive of ACS and high hs-CRP levels are an independent predictor of clinical outcome in ACS patients.     

Use of ischemia-modified albumin in diagnosis of coronary artery disease

OBJECTIVE: The diagnosis of coronary artery disease (CAD) is an important clinical problem. Ischemia-modified albumin (IMA) has been demonstrated to be a helpful marker in detecting myocardial ischemia. In this study, we have investigated the diagnostic importance of IMA in CAD. METHOD AND RESULTS: Fifty patients with chest pain were enrolled in the study. IMA levels were measured on admission and within 30-60 min after exercise by albumin cobalt-binding test. Coronary angiography was performed in all patients after the exercise test. The mean preexercise IMA level was 83+/-27 U/ml in the patient group. IMA levels before the exercise test were similar in both patient and control groups (P>0.05). The mean IMA level in the patient group was, however, higher than in the control group after the exercise test (P=0.001). The sensitivity, specificity and positive and negative predictive values of the postexercise IMA levels >85 in diagnosis of CAD were 78, 73, 0.81 and 0.73%; respectively. Postexercise IMA levels were higher in patients with chest pain, ST depression and downsloping and horizontal ST depression of 2 mm or more. CONCLUSION: IMA levels after the exercise test increased in patients with CAD. Our study results indicate that postexercise IMA levels can be helpful markers in the diagnosis of stable CAD in clinical practice.     

缺血修饰白蛋白对急性心肌缺血早期诊断价值的探讨

目的探讨缺血修饰白蛋白（IMA）测定对急性心肌缺血的早期诊断价值。方法采用白蛋白钴结合试验检测830例健康体检者（健康对照组）、492例急性冠状动脉综合征患者（ACS组）、74例单纯性高血压病患者（高血压组）、78例病毒性心肌炎患者（病毒性心肌炎组）、395例急性胸痛者（急性胸痛组,包括急诊ACS患者133例与随诊胸痛患者262例）和68例接受经皮冠状动脉介入治疗术患者（PCI组）血清或血浆IMA水平,并对其中急诊ACS患者进行IMA水平动态观察及血清肌钙蛋白I（cTnI）和心电图检测。结果根据ROC曲线,当临界值为0．45时综合评价最佳。ACS组和病毒性心肌炎组IMA水平分别为（0．55±0．11）吸光度单位（ABSU）和（0．38±0．11）ABSU,高于健康对照组[（0．34±0．08）ABSU,P〈0．05],且ACS组和病毒性心肌炎组之间IMA差异有统计学意义（P〈0．05）。急性胸痛组中急诊ACS患者IMA水平及阳性率分别为（0．54±0．12）ABSU和77．4％,高于随诊者的（0．44±0．12）ABSU和39．3％（P〈0．01）。在133例急诊ACS患者中,首诊1h内IMA阳性率为82．O％,高于同期cTnI阳性率40．6％（P〈0．01）,就诊后6—24hIMA与cTnI水平及阳性率较首诊1h内显著升高（P〈0．01）。在72例急性胸痛发作3h内入院且cTnI均为阴性的ACS患者中,首诊IMA阳性率为86．1％,心电图阳性率为72．2％,两者联合测定阳性率为93．1％。PCI术后即刻患者动脉血浆IMA水平较术前IMA明显升高（P〈0．05）。首诊ACS患者IMA水平高于临界值,于入院1天达峰值,且持续升高,后缓慢下降,入院14天IMA均值接近正常水平。结论IMA早期诊断急性心肌缺血具有临床应用价值。     

Prognostic significance of ischemia-modified albumin in patients with acute coronary syndrome

To improve prognosis in acute coronary syndrome, new clinical applications in terms of diagnosis, risk stratification, and treatment strategies are still under investigation. Ischemia-modified albumin was one of the novel markers of myocardial ischemia. In our study, we aimed to determine the prognostic significance of the albumin cobalt binding capacity test in patients with acute coronary syndromes. We compared the ischemia-modified albumin levels of patients with acute coronary syndrome with those of patients with stable coronary artery disease and those of normal individuals and found them to be significantly higher in the first group (P<0.05). A cutoff value of ischemia-modified albumin of 477 U/ml was found by using receiver operating characteristic curve analysis. Mortality in groups of patients whose ischemia-modified albumin levels were above 477 U (50%) was found to be significantly higher than in those whose levels were below 477 U (8.3%) (P<0.05). The sensitivity and specificity of the cutoff value, 477 U/ml, for the 1-year mortality were found to be 70 and 82%, respectively. Using the Cox regression model the relation of albumin cobalt binding capacity test results with mortality was statistically significant (beta=1.013, confidence interval 95%, P=0.01) and independent of the existence of hypertension, diabetes, and advanced age. In conclusion, ischemia-modified albumin was found to be significantly related to 1-year mortality. Prognostic significance of ischemia-modified albumin should be evaluated in large populated and randomized study groups. Afterwards, ischemia-modified albumin could be used in risk stratification modality in patients with acute coronary syndrome.     

Diagnostic efficacy of ischemia modified albumin and its correlation with lipid profile,oxidative stress in acute myocardial infarct patients on admission

ObjectiveTo evaluate the diagnostic efficacy of ischemia modified albumin (IMA) and its correlation with lipid profile, oxidative stress in acute myocardial infarct (AMI) patients attending Cardiology Emergency Department (ED).MethodsAt presentation serum IMA in conjunction with electrocardiogram (ECG) and cardiac troponin T (CTnT) was evaluated in 35 AMI patients attending the ED within 6 hours of chest pain. These patients were subjected to standardized diagnostic procedures and treatment. Thirty five healthy volunteers were enrolled as control.ResultsIMA showed a higher level in ischemic patients than in control with the highest sensitivity (77%) in comparison to CTnT and ECG. With CTnT or ECG, IMA documented a sensitivity of 83% and 88%, respectively. Whereas with both CTnT and ECG, IMA identified 94% of AMI patients with the highest negative predictive value (90%).ConclusionsIMA has evolved as a cost effective, highly sensitive, early diagnostic marker of cardiac ischemia and an earlier rule out test in AMI patients.     

联合测定缺血修饰白蛋白等生化标志物对急性冠脉综合征早期诊断的价值（英文）

目的：探讨生化标志物联合检测对急性冠脉综合征（ACS）的早期诊断价值。方法：对156例因胸痛4 h就诊患者,以冠状动脉造影（CAG）为诊断依据,分为ACS组（112例）和非缺血性胸痛（NICP）组（44例）。在胸痛〈4 h和4~8 h分别抽血测定缺血修饰白蛋白（IMA）,乳酸脱氢酶（LDH）,肌酸激酶（CK）,肌酸激酶同工酶（CK-MB）及心脏肌钙蛋白I（cTnI）等心脏生化标志物,并结合CAG检查结果进行综合分析。结果：在发病4h内对ACS诊断敏感性最高的是IMA（87.50%）,特异性最高的是cTnI达95.45%,准确性最高的是IMA达80.77%;4~8h对ACS诊断敏感性最高的是IMA,达91.07%,特异性最高的是cTnI（97.73%）,准确性最高的是CK和IMA,二者分别为85.90%,85.25%,无显著差异,并列第一。综合判断,无论是〈4h,还是4~8h,敏感性和准确性最高的是IMA,特异性最高的是cTnI。4 h内IMA等5项指标联合检测可提高敏感性达89.28%,特异性达95.45%,准确性达91.02%,均为最高水平。结论：对于诊断急性冠脉综合征,IMA的敏感性和准确性最高,cTnI的特异性最高,IMA等5种指标联合检测可将其诊断提高到最高水平     

Ischemia Modified Albumin for the assessment of patients presenting to the emergency department with acute chest pain but normal or non-diagnostic 12-lead electrocardiograms and negative cardiac troponin T

BACKGROUND: The diagnosis of myocardial ischemia in patients with acute chest pain at rest but non-diagnostic electrocardiograms (ECG) is problematic. Ischemia Modified Albumin (IMA) is a new biochemical marker of ischemia, which may be useful to characterise acute coronary syndrome (ACS) patients. METHODS: We studied 131 patients (mean age 58.5 years; 95 male) presenting to the emergency department with symptoms suggestive of ACS but with normal or non-diagnostic ECGs. Cardiac troponin T (cTnT) and IMA were measured within 3 h of last chest pain episode. Based on hospital diagnostic test results, patients were classified as having ACS or non-ischemic chest pain (NICP), by two independent cardiologists unaware of IMA results. RESULTS: Mean IMA levels (U/ml) were higher in patients with ACS (98.3+/-11) compared to patients with NICP (85.5+/-15); p<0.0001. IMA levels >93.5 U/ml demonstrated a sensitivity and specificity of 75% for the diagnosis of ACS; area under the receiver operator characteristic curve 0.78 (95% CI: 0.70-0.85). If we applied the manufacturer cutoff point of 85 U/ml, the sensitivity of IMA increased to 90.6% with a specificity of 49.3% (negative predictive value=84.6%). In combination with cTnT (6-12 h) (>0.05 ng/ml), the sensitivity increased to 92.2%. After multivariate analysis, IMA levels >85 U/ml (odds ratio=14.6 [95% CI 4.4-48.4]; p<0.0001), age and prior myocardial infarction were independent predictors of ACS. CONCLUSION: IMA may be a useful biomarker for the identification of ACS in patients presenting with typical acute chest pain but normal or non-diagnostic ECGs.     

Prognostic significance of troponin T elevation in patients without chest pain

Increased cardiac troponin with chest pain is important for the diagnosis, triage, and treatment of patients in the emergency department. However, the use of troponin for the diagnosis and triage of patients without chest pain is poorly established. The aim of this study was to determine 30-day and 1-year mortality and morbidity of troponin T increases in patients without chest pain. This retrospective study compared 92 hospitalized patients without (study group) and 91 patients with chest pain (control group), followed up for 1 year. Study group patients had troponin T >0.04 mug/L, normal creatine kinase or creatine kinase-MB fraction <5%, and no electrocardiographic ischemia. Excluded were high-risk patients with end-stage kidney disease, those with left ventricular ejection fraction <40%, and the critically ill. Outcome variables included 30-day and 1-year death, myocardial infarction, unstable angina, and coronary revascularization rates. Thirty-day (13.0% vs 4.4%; p = 0.032) and 1-year (33% vs 4.6%; p <0.001) mortality rates were significantly higher in the study group, whereas myocardial infarction, unstable angina, and revascularization were infrequent. In conclusion, patients with increased troponin T and no chest pain had a high mortality rate and required careful follow-up.     

入院24 h平均血糖对急性ST段抬高型心肌梗死患者近期预后的影响

目的 探讨人院24 h平均血糖(mean blood glucose,MBG)与急性ST段抬高型心肌梗死(STEMI)患者近期病死率及不良心血管事件的相关性.比较MBG与入院血糖(admission glucose,AG)对顶后影响的顶测价值.方法 人选病例来自2001至2004年间我国274家中心参加CREATE(Clinical trial of reviparin and metabolic modulation in acute myocardial infarction treatment evaluation)研究数据库、症状出现12 h内STEMI的中国患者7446例,将入院即刻、6 h、24 h血糖值计箅均值,以入院第1个24 h的MBG水平分成6组,即MBG＜4.5 mmol/L组、4.5～5.5 mmol/L组、5.6～7.0 mmol/L组、7.1～8.5 mmol/L组、8.6～11.0 mmol/L组和MBG＞11.0 mmol/L组.以MBG 4.5～5.5 mmol/L组作为对照组,其他血糖水平组与之进行比较.分析7 d和30 d病死率及联合终点事件发生情况.比较MBG与AG对上述事件预测价值的影响.结果 单因素分析显示,7 d、30 d病死率、联合终点事件发生率随着MBG水平升高而逐渐升高.MBG 7.1～8.5 mmol/L及以上组与MBG 4.5～5.5 mmol/L组的患者比较,差异均有统计学意义.多因素logistic回归分析显示MBG 7.1～8.5 mmol/L及以上各组是STEMI患者7 d、30 d病死率、联合终点事件的独立危险因素.MBG 7.1～8.5 mmol/L、8.6～11.0 mmol/L和＞11.0 mmol/L的患者7 d死亡危险分别比对照组患者增加56%(P=0.022)、61%(P=0.018)和230%(P＜0.001),30 d死亡危险分别比对照组患者增加41%(P=0.048)、40%(P=0.032)和185%(P＜0.001).MBG＜4.5 mmol/L组30 d联合终点事件发生危险无明显增加(P=0.085).应用Nested模型对AG及24 h MBG对病死率以及联合终点事件预测模型比较显示,24 hMBG较AG预测价值更大(均P＜0.001).结论 24 h MBG≥7.1 mmol/L与STEMI患者7 d、30 d病死率增高相关.24 h MBG较AG对预后具有更好的预测价值.     

Limitations of clinical history for evaluation of patients with acute chest pain, non-diagnostic electrocardiogram, and normal troponin

Decision making and risk stratification for patients with acute chest pain, nondiagnostic electrocardiogram results, and normal troponin levels are challenging. The aim of this study was to optimize the clinical history for the evaluation of these patients. A total of 1,011 patients presenting to an emergency department were included. The following data were collected: clinical presentation (pain characteristics and number of pain episodes), coronary risk factors, previous ischemic heart disease, and extracardiac vascular disease (peripheral artery disease, stroke, or creatinine >1.4 mg/dl). Two different predictive models were calculated according to the end points: model 1 for 1-year major events (death or myocardial infarction) and model 2 for 30-day cardiac events (major events or revascularization). For 1-year major events, model 1 showed optimal discrimination capacity (C statistic = 0.80), which was significantly better than that of model 2 (C statistic = 0.77, p = 0.04). With respect to 30-day cardiac events, however, discrimination was lower in the 2 models, without differences between them (C statistic = 0.74 vs 0.75, p = NS). Using model 1, a large low-risk subgroup with <3 predictive variables could be defined, including 442 patients (44% of the total population) with a 1.4% rate of 1-year major events; however, the incidence of 30-day cardiac events (8%) was not negligible, mainly because of revascularizations. In conclusion, in patients with acute chest pain of uncertain coronary origin, clinical predictive models afford good risk stratification for long-term major events. Short-term outcomes, including revascularization, however, are not predicted as well. Therefore, ancillary tools, such as noninvasive stress tests, should be implemented for decision making at initial hospitalization or discharge.     

Electrocardiographic Predictors of Morbidity and Mortality in Patients With Acute Myocarditis: The Importance of QRS-T Angle

Background

Acute myocarditis carries a variable prognosis. We evaluated the morbidity and mortality rates in patients with acute myocarditis and admission electrocardiographic predictors of outcome.

Comparison of the diagnostic accuracy of ischemia-modified albumin and echocardiography in patients with acute chest pain

BACKGROUND:

Several imaging tests and biomarkers have been proposed for the identification of patients with unstable angina among those presenting to the emergency department with acute chest pain. Preliminary data suggest that ischemia-modified albumin (IMA) may represent a potentially useful biomarker in these patients.

OBJECTIVE:

To compare IMA and echocardiography in excluding unstable angina in patients with acute chest pain.

METHODS:

Thirty-three patients (mean [± SD] age 59.8±10.8 years; 28 men) presenting to the emergency department with acute chest pain lasting <3 h suggestive of acute coronary syndrome, with normal or non-diagnostic electrocardiograms, and creatine kinase MB and troponin levels within the normal range, were included in the present study.

RESULTS:

After further diagnostic evaluation, five patients (15.2%) were diagnosed with unstable angina. The sensitivity, specificity, positive predictive value and negative predictive (NPV) value of echocardiography for diagnosing unstable angina was 60.0%, 89.3%, 50.0% and 92.6%, respectively. The area under the ROC curve for diagnosing unstable angina based on the serum IMA levels was 0.193 (95% CI 0.047 to 0.339; P<0.05). Based on ROC curve analysis, serum IMA levels ≥31.95 IU/mL yielded the optimal combination of sensitivity and specificity for diagnosing unstable angina. The sensitivity, specificity, positive predictive value and NPV of serum IMA levels ≥31.95 IU/mL for diagnosing unstable angina was 40.0%, 28.6%, 9.1% and 72.7%, respectively.

CONCLUSIONS:

Measurement of serum IMA levels appears to represent a useful tool for excluding unstable angina in patients presenting to the emergency department with acute chest pain. Moreover, IMA shows an NPV that is comparable with echocardiography.     

胸痛6h内缺血修饰白蛋白对急性心肌梗死预后的价值研究

目的探讨胸痛6 h内缺血修饰白蛋白(IMA)对急性心肌梗死(AMI)预后的预测价值。方法收集武汉大学人民医院心血管内科2009年10月至2010年4月确诊为AMI患者85例。所有患者于胸痛6 h内测定IMA和心脏肌钙蛋I(cTnI),按照指南进行标准化治疗。随访6个月内心血管事件的发生情况。根据心血管事件的发生与否进行分组,分为心血管事件组和无心血管事件组。结果 85例患者中,80例随访有效,其中心血管事件组19例(23.75%),无心血管事件组61例(76.25%),心血管事件组的血清IMA高于无心血管事件组[(107.34±14.04)U/mL对(86.9±12.27)U/mL,P<0.01]。对其他心血管危险因素进行校正后,IMA仍然是心血管事件的独立危险因素(OR=1.64,95%CI:1.2~2.14,P=0.01)。结论胸痛6 h内的IMA对急性心肌梗死患者6个月心血管事件有很好的预测作用。     

N-terminal pro B-type natriuretic peptide identifies patients with chest pain at high long-term cardiovascular risk

Background

Little is known about the long-term prognostic value of N-terminal pro B-type natriuretic peptide (NT-proBNP) and C-reactive protein (CRP) in low-risk patients with chest pain.

Methods

Between June 1997 and January 2000, a standard rule-out protocol was performed in patients presenting to the emergency department within 6 hours of onset of chest pain with a normal or nondiagnostic electrocardiogram (ECG) on admission at the Academic Medical Center Amsterdam, VU University Medical Center Amsterdam and Medical Center Alkmaar, The Netherlands. Patients with acute coronary syndrome were identified by troponin T, recurrent angina, and serial ECGs. CRP and NT-proBNP on admission were measured using standardized methods.

Results

A total of 524 patients were included (145 with acute coronary syndrome and 379 with rule-out acute coronary syndrome). Long-term follow-up was successfully carried out in 96% of the study population. Death occurred in 78 patients (15%), 43 (11%) in the rule-out acute coronary syndrome group and 35 (24%) in the acute coronary syndrome group (P < .001). In the rule-out acute coronary syndrome group, 21 patients (42%) died of a cardiovascular cause compared with 24 patients (69%) in the acute coronary syndrome group (P < .001). In multivariate Cox regression analysis, age more than 65 years, previous myocardial infarction, known chronic heart failure, a nondiagnostic ECG on admission, and elevated NT-proBNP levels (>87 pg/mL, as derived from the receiver operating characteristic curve) were independent predictors of long-term cardiovascular mortality in the rule-out acute coronary syndrome group. In the acute coronary syndrome group, these predictors were age more than 65 years, documented coronary artery disease, and elevated NT-proBNP levels. Elevated levels of CRP were an independent predictor for cardiovascular mortality in patients with rule-out acute coronary syndrome at 3-year follow-up only. In patients with rule-out acute coronary syndrome with normal CRP and NT-proBNP levels, the cardiovascular mortality incidence rate was 4.7 per 1000 person-years, compared with a death rate of 20 in patients with both biomarkers elevated, which was comparable to the 17.9 per 1000 person-years incidence rate in patients with acute coronary syndrome.

Conclusion

A positive biomarker panel discriminates patients with rule-out acute coronary syndrome chest pain with a normal or nondiagnostic ECG who have a high risk for long-term cardiovascular mortality.     

Effect of radiofrequency catheter ablation on the biochemical marker ischemia modified albumin

Ischemia-modified albumin (IMA) levels were measured after radiofrequency (RF) catheter ablation to evaluate the effect of direct myocardial necrosis on IMA formation. IMA levels have been shown to increase in patients after RF catheter ablation compared with those who undergo diagnostic electrophysiologic studies. The results of this study suggest that IMA may be a marker of myocardial injury.     

B-type natriuretic peptide in the early diagnosis and risk stratification of acute chest pain

Background

Myocardial ischemia is a strong trigger of B-type natriuretic peptide (BNP) release. As ischemia precedes necrosis in acute myocardial infarction, we hypothesized that BNP might be useful in the early diagnosis and risk stratification of patients with acute chest pain.

Methods

In a prospective, international multicenter study, BNP was measured in 1075 unselected patients with acute chest pain. The final diagnosis was adjudicated by 2 independent cardiologists. Patients were followed long term regarding mortality.

Results

Acute myocardial infarction was the adjudicated final diagnosis in 168 patients (16%). BNP levels at presentation were significantly higher in acute myocardial infarction as compared with patients with other diagnoses (median 224 pg/mL vs. 56 pg/mL, P <.001). The diagnostic accuracy of BNP for the diagnosis of acute myocardial infarction as quantified by the area under the receiver operating characteristic curve (AUC) (0.74; 95% confidence interval [CI], 0.70-0.78) was lower compared with cardiac troponin T at presentation (AUC 0.88; 95% CI, 0.84-0.92; P <.001). Cumulative 24-month mortality rates were 0.5% in the first, 2.1% in the second, 7.0% in the third, and 22.9% in the fourth quartile of BNP (P <.001). BNP predicted all-cause mortality independently of and more accurately than cardiac troponin T: AUC 0.81 (95% CI, 0.76-0.86) versus AUC 0.70 (95% CI, 0.62-0.77; P <.001). Net reclassification improvement for BNP was 0.10 (P = .04), and integrated discrimination improvement 0.068 (P = .01).

Conclusions

BNP accurately predicts mortality in unselected patients with acute chest pain independently of and more accurately than cardiac troponin T, but does not seem to help in the early diagnosis of acute myocardial infarction.     

Role of “Ischemia Modified Albumin” (IMA) in acute coronary syndromes

Background

Diagnosis of acute coronary syndrome (ACS) is important, due to the associated very high mortality. Failure to diagnose ACS is a problem both for the patients and the clinicians. Ischemia modified albumin (IMA) has already been licensed by the US Food and Drug Administration for the diagnosis of suspected myocardial ischemia.

Methods

Patients attending the emergency department (ED) within 6 h after having features of ACS were selected. IMA was done on admission. Blinded to the IMA results patients were fully evaluated and a diagnosis of non-ischemic chest pain (NICP), unstable angina (UA) or myocardial infarction (MI) was made. Later IMA results were correlated in each group.

Results

Mean IMA value was 56.38 ± 23.89 u/ml in NICP group whereas in UA group it was 89.00 ± 7.76 u/ml and MI group was 87.50 ± 9.62 u/ml. This showed a sensitivity of 92% and specificity of 87%. The positive predictive value of the test was 88% and negative predictive value was 94%. In 16 patients an early diagnosis could be made when compared with Trop-T. Of the 89 patients 11 patients died in hospital. The IMA value was compared between this group and the patients who survived. Patients who died had a mean IMA value of 88.5 with a standard deviation of 5.33 whereas in patients who survived the mean value was 78.26 which was not statistically significant.

Conclusion

In conclusion the benefit of the test would be to rule out ACS in patients who present early to ED with inconclusive diagnosis.     

Thrombolysis and Counterpulsation to Improve Survival in Myocardial Infarction Complicated by Hypotension and Suspected Cardiogenic Shock or Heart Failure: Results of the TACTICS Trial

Background: Sustained hypotension, cardiogenic shock, and heart failure all imply a poor prognosis in acute myocardial infarction (MI). We assessed the benefit of adding 48 hours of intra-aortic balloon counterpulsation (IABP) to standard treatment for MI, in an international trial among hospitals without primary angioplasty capabilities.Methods: We randomized 57 patients with MI complicated by sustained hypotension, possible cardiogenic shock, or possible heart failure to receive either fibrinolytic therapy and IABP or fibrinolysis alone. The primary end point was all-cause mortality at 6 months.Results: In all, IABP was inserted in 27 of 30 assigned patients a median 30 minutes after fibrinolysis began and continued for a median 34 hours. Of the 27 patients assigned to fibrinolysis alone, 9 deteriorated such that IABP was required. The IABP group was at slightly higher risk at baseline, but the incidence of the primary end point did not differ significantly between groups (34% for combined treatment versus 43% for fibrinolysis alone; adjusted P = 0.23). Patients with Killip class III or IV showed a trend toward greater benefit from IABP (6-month mortality 39% for combined therapy versus 80% for fibrinolysis alone; P = 0.05).Conclusions: While early IABP use was not associated with a definitive survival benefit when added to fibrinolysis for patients with MI and hemodynamic compromise in this small trial, its use suggested a possible benefit for patients with the most severe heart failure or hypotension.Abbreviated Abstract. We assessed the benefit of adding 48 hours of intra-aortic balloon counterpulsation to fibrinolytic therapy among 57 patients with acute myocardial infarction complicated by sustained hypotension, possible cardiogenic shock, or possible heart failure. The primary end point, mortality at 6 months, did not differ between groups (34% for combined treatment versus 43% for fibrinolysis alone [n = 27]; adjusted P = 0.23), although patients with Killip class III or IV did show a trend toward greater benefit from IABP (39% for combined therapy versus 80% for fibrinolysis; P = 0.05).     

Impact of acute hyperglycemia on left ventricular function after reperfusion therapy in patients with a first anterior wall acute myocardial infarction

Objective

This study was undertaken to assess the relationship between acute hyperglycemia and left ventricular function after reperfusion therapy for acute myocardial infarction (AMI).

Methods

This study consisted of 529 patients with a first anterior wall AMI who underwent coronary angiography followed by coronary angioplasty or thrombolysis within 12 hours after the onset of chest pain. Plasma glucose was measured at the time of hospital admission. Acute hyperglycemia was defined as plasma glucose >10 mmol/L.

Results

Although acute hyperglycemia was associated with both lower acute left ventricular ejection fraction (LVEF) (46% ± 12% vs 48% ± 10%, P = .026) and lower predischarge LVEF (51% ± 15% vs 56% ± 15%, P = .001), the difference was more pronounced in the latter and the change in LVEF was significantly smaller in patients with acute hyperglycemia (4.8% ± 11.2% vs 8.0% ± 13.8%, P = .022). Multivariable analysis showed that there was a significant correlation between plasma glucose and impaired predischarge LVEF, even after adjustment of acute LVEF (r = −0.13, P = .005). Thirty-day mortality tended to be higher in patients with acute hyperglycemia than in patients without (7.1% vs 3.5%, P = .06). Multivariable analysis showed that plasma glucose (per 1 mmol/L increase) was an independent predictor of 30-day mortality after AMI (odds ratio 1.12, 95% CI 1.03-1.22, P = .009).

Conclusion

Acute hyperglycemia was independently associated with impaired left ventricular function and higher 30-day mortality after AMI. These results may provide a potential explanation for poor outcomes of patients with AMI and acute hyperglycemia.     

Frequency and clinical correlates of changes in Thrombolysis In Myocardial Infarction risk score during observation period at emergency department in "low-risk" patients with acute chest pain

Among 4,333 patients who were triaged in the emergency department (ED) over a 1-year period in 2003 because of acute chest pain, 1,747 (40%) were stratified as "low risk" on the basis of a Thrombolysis In Myocardial Infarction (TIMI) risk score of 0 to 2. Results showed that, during ED stay, TIMI risk score increased to > or =3 in 63% of patients and that such patients were more likely to be diabetic, hypertensive, hyperlipidemic, and smokers, and to have had previous myocardial infarction or revascularization. Patients with changes in TIMI risk score were admitted more often to the hospital, whereas more patients with unchanged TIMI risk score were discharged home directly from the ED. In conclusion, TIMI risk score may change soon after arrival to the ED in 50% of patients with acute chest pain who are initially triaged as low risk. Changes in TIMI risk score are more common in patients with multiple risk factors and/or previous diagnosis of coronary artery disease. Serial, frequent assessments of TIMI score during the ED observation period are mandatory, particularly in these subsets of patients.