Prognostic significance of an ST segment depression of patients with an acute coronary attack

An ST-segment depression was studied in the ECGs recorded on the first and third day after admission of 580 patients with an acute heart attack. An acute myocardial infarction was found in 86% of the 115 patients in whose ECG the J-point was depressed 2 mm. or more and the ST-segment was horizontal or sloping downwards in at least one lead (a definite ST-segment depression).The degree of the J-point depression was deemed of prognostic significance. During the first four weeks, the mortality rate was lowest (4.7%) in patients with a J-point depression less than one millimeter or no depression. The corresponding figure for patients with a definite ST-segment depression was three times (21.7%) that of the patients without the pattern (7.3%).The definite ST-segment depression in an acute coronary attack seemed to be accompanied by a severe degree of coronary heart disease. Significant differences between the patients with a definite ST-segment depression and those without the pattern were found in the $\text{C}\text{T}$ ratio, in the degree of pulmonary congestion, in the ECG signs of LVH, and in the digitalis treatment.It is concluded that the definite ST-segment depression has an important clinical and prognostic significance in cases of acute coronary attacks.     

Changes in the QRS complex and ST segment in transmural and subendocardial myocardial infarctions. A clinicopathologic study.

The QRS complex and ST segment in the ECGs of 80 patients who died of an acute myocardial infarction (MI) were studied in relation to the extent of the MI (subendocardial vs. transmural). Changes in the QRS complex developed in nine out of the 15 cases with an acute subendocardial MI. Five of these cases fulfilled the conventional QRS criteria for a myocardial infarction. A definite ST segment depression (a J point depression of 2 mm. or more in at least one lead, and a horizontal or downward sloping ST segment with a minimum duration of 0.08 sec.) occurred most frequently in connection with a circumferential subendocardial MI (88 per cent), but it was also found in a regional subendocardial (43 per cent) and transmural MI (43 per cent). In 17 per cent of the cases with a transmural MI, this was the only ECG abnormality. It is concluded that cases with a subendocardial MI cannot always be distinguished from transmural MI on the basis of the presence or absence of the QRS changes, and that an ST segment depression, as defined in this study, can give additional information in the evaluation of an acute phase of an MI.     

Usefulness of M-mode echocardiography in the diagnosis of heart failure

The utility of M-mode echocardiography in the diagnosis of heart failure (HF) was evaluated in a study of 70 patients with suspected HF (26 men and 44 women) and 63 control persons (26 men and 37 women), all aged 45-74 years. The patients were classified according to the certainty of HF diagnosis using the Boston criteria: 27 patients were defined as 'unlikely' to have HF, 19 as having 'possible' HF, and 24 as having 'definite' HF. In calculations of the sensitivities and specificities for echocardiographic variables in detecting 'definite' HF, the 95% confidence limits in the control group were used as cut-off point values. Sensitivities thus attained were 91% for mitral valve E point-septal separation (EPSS), 73% for left ventricular (LV) fractional shortening (FS), and 64% for peak rate of increase of LV diameter (PLR), respectively, and the specificities were 73, 88, and 78%, respectively. When EPSS, FS and PLR were all normal, the likelihood of 'definite' HF was as low as 7%. We conclude that M-mode echocardiography is actually a useful method in the diagnostic evaluation of patients with suspected HF, and it is more reliable in excluding than confirming the presence of HF.     

Low‐grade systolic murmurs in healthy middle‐aged individuals: innocent or clinically significant? A 35‐year follow‐up study of 2014 Norwegian men

Abstract. Bodegard J, Skretteberg PT, Gjesdal K, Pyörälä K, Kjeldsen SE, Liestøl K, Erikssen G, Erikssen J (Oslo University Hospital, Oslo; University of Oslo, Oslo; University of Eastern Finland, Kuopio; University of Oslo, Oslo; Oslo University Hospital, Oslo). Low‐grade systolic murmurs in healthy middle‐aged individuals: innocent or clinically significant? A 35‐year follow‐up study of 2014 Norwegian men. J Intern Med 2012; 271 : 581–588. Objective. To determine whether a low‐grade systolic murmur, found at heart auscultation, in middle‐aged healthy men influences the long‐term risk of aortic valve replacement (AVR) and death from cardiovascular disease (CVD). Setting and subjects. During 1972–1975, 2014 apparently healthy men aged 40–59 years underwent an examination programme including case history, clinical examination, blood tests and a symptom‐limited exercise ECG test. Heart auscultation was performed under standardized conditions, and murmurs were graded on a scale from I to VI. No men were found to have grade V/VI murmurs. Participants were followed for up to 35 years. Results. A total of 1541 men had no systolic murmur; 441 had low‐grade murmurs (grade I/II) and 32 had moderate‐grade murmurs (grade III/IV). Men with low‐grade murmurs had a 4.7‐fold [95% confidence interval (CI) 2.1–11.1] increased age‐adjusted risk of AVR, but no increase in risk of CVD death. Men with moderate‐grade murmurs had an 89.3‐fold (95% CI 39.2–211.2) age‐adjusted risk of AVR and a 1.5‐fold (95% CI 0.8–2.5) age‐adjusted increased risk of CVD death. Conclusions. Low‐grade systolic murmur was detected at heart auscultation in 21.9% of apparently healthy middle‐aged men. Men with low‐grade murmur had an increased risk of AVR, but no increase in risk of CVD death. Only 1.6% of men had moderate‐grade murmur; these men had a very high risk of AVR and a 1.5‐fold albeit non‐significant increase in risk of CVD death.     

Ruling Out Myocardial Infarction with Troponin T and Creatine Kinase MB Mass: Diagnostic and Prognostic Aspects

Objective - To investigate the time window for ruling out myocardial infarction (MI) with troponin T (TnT) and creatine kinase isoenzyme MB mass (CK-MBm) and the prognosis of patients with ruled-out MI diagnosis. Design - The study was based on 397 patients admitted with a suspected acute coronary syndrome but with relief of symptoms within 24 h. Results - MI diagnosis was confirmed with elevated TnT (> 0.10 µg/l) in 108 patients, in 91% within 12-24 h from the onset of symptoms, and in 99% within 12 h from admission. In 94 of these patients CK-MBm became elevated (> 5.0 µg/l), in 95% within 10-12 h from the onset of symptoms, and in 99% within 6 h from admission. Among patients with ruled-out MI diagnosis, the 1-year incidence of recurrent coronary events was 29% in those with positive history of coronary heart disease (CHD) but only 7% in those without prior CHD ( p < 0.001). Conclusion - Using TnT or CK-MBm, MI can be ruled out within 12 h from admission in the majority of patients. Among patients with ruled-out MI diagnosis, positive history of CHD is an important determinant of prognosis.     

How do tutors intervene when conflicts on knowledge arise in tutorial groups?

Recent research on problem-based learning (PBL) has shown that students need support when dealing with conflicting ideas in PBL-tutorial discussions. In the present study, we examined tutor facilitation during tutorial discussions, and particularly how the facilitation helped students to collaboratively resolve conflicts on knowledge. The study involved four PBL-tutorial sessions that included altogether 33 first-year medical and dental students. The sessions were videotaped and analysed using qualitative interaction analysis. Our aim was to find out how the tutor interventions encouraged students to elaborate on conflicting ideas, and how the interventions differed between conflict and non-conflict situations. We also examined how the tutors intervened during conflicts about factual or conceptual knowledge. The tutorial discussions included 92 tutor intervention episodes and 43 conflict episodes. The tutors intervened during 24 of the conflict episodes and resolved 13 of these episodes. Generally, the tutors often intervened by confirming what the students had said or by giving explanations, but they rarely asked questions that would stimulate the elaboration of knowledge. During conflicts on knowledge the tutors gave more explanations, but did little to encourage the students to deal with conflicting ideas. The tutors more often resolved conflicts on factual knowledge than conceptual knowledge. The findings suggest that tutor training should focus on promoting tutors’ understanding on when to give direct explanations, and when and how to encourage students to collaboratively elaborate on conflicting ideas.     

Left radial approach for coronary angiography: Results of a prospective study

Although radial approach has been shown to be feasible for coronary angiography, angioplasty, and even stent placement, there have been no prospective evaluations of ease and safety of left radial approach for coronary angiogram. We examined procedural duration and success as well as complications in 415 consecutive patients. Radial artery occlusion was assessed immediately post-procedure and at 2 month follow-up using echo-Doppler measurements. Procedure failure rate was 9%, mean time for sheath insertion was 4.7 ± 4.7 min, and mean procedure duration was 19.1 ± 8.2 min. No major complications occurred. Asymptomatic radial artery occlusion was noted in 71% of the first 49 patients, decreased to 24% in the next 119 receiving 2,000–3,000 units of heparin, and to 4.3% in the last 210 receiving 5000 (p < 0.05). Comparison with the femoral approach in the same laboratory suggested that the radial approach took longer, but provided similarly high-quality results without great difficulty in coronary cannulation. Hence, the left radial approach for coronary angiography (with heparin administration) allows immediate ambulation and may be especially useful for outpatients and when the femoral approach is not possible. © 1996 Wiley-Liss, Inc.     

NF-E2-related factor 2 activation boosts antioxidant defenses and ameliorates inflammatory and amyloid properties in human Presenilin-1 mutated Alzheimer's disease astrocytes

Alzheimer's disease (AD) is a common dementia affecting a vast number of individuals and significantly impairing quality of life. Despite extensive research in animal models and numerous promising treatment trials, there is still no curative treatment for AD. Astrocytes, the most common cell type of the central nervous system, have been shown to play a role in the major AD pathologies, including accumulation of amyloid plaques, neuroinflammation, and oxidative stress. Here, we show that inflammatory stimulation leads to metabolic activation of human astrocytes and reduces amyloid secretion. On the other hand, the activation of oxidative metabolism leads to increased reactive oxygen species production especially in AD astrocytes. While healthy astrocytes increase glutathione (GSH) release to protect the cells, Presenilin-1-mutated AD patient astrocytes do not. Thus, chronic inflammation is likely to induce oxidative damage in AD astrocytes. Activation of NRF2, the major regulator of cellular antioxidant defenses, encoded by the NFE2L2 gene, poses several beneficial effects on AD astrocytes. We report here that the activation of NRF2 pathway reduces amyloid secretion, normalizes cytokine release, and increases GSH secretion in AD astrocytes. NRF2 induction also activates the metabolism of astrocytes and increases the utilization of glycolysis. Taken together, targeting NRF2 in astrocytes could be a potent therapeutic strategy in AD.