Cardiogenic shock: thrombolysis or angioplasty?

Cardiogenic shock (CGS) occurs in 3 to 20% of patients presenting with acute myocardial infarction (MI), and it generally involves dysfunction of at least 40% of the total myocardial mass. Prior to the advent of balloon angioplasty and thrombolysis, in-hospital mortality was greater than 75%. This mortality rate has been consistent in reported series despite the advent of cardiac intensive care units, vasopressor, inotropic, and vasodilator therapy. Intra-aortic balloon counterpulsation therapy provides hemodynamic improvement, and it may provide some mortality benefit when used in conjunction with appropriate revascularization. Survival studies have shown that patency of the infarct-related artery is a strong predictor of survival. No randomized trials have been completed to examine which reperfusion therapy best treats this emergent situation. Subgroup analysis of large scale, multicenter trials, although underpowered, has shown no improvement in mortality with use of thrombolytic agents, leading many to advise use of mechanical intervention. In patients who present with acute MI with contraindications to thrombolysis, primary angioplasty is the treatment of choice. At selected centers, primary angioplasty is comparable to or better than thrombolytic therapy for patients presenting with acute MI, with or without CGS. Studies examining angioplasty in patients with CGS have shown high procedural success rates (75%) and reduced in-hospital mortality (44%), particularly in those patients with successful revascularization. Emergency bypass surgery may improve survival, but it is costly, unavailable to many, and often leads to excessive delays in therapy. If available, we believe that primary angioplasty is the treatment of choice for patients with CGS.     

Exploring Mental Health and Substance use Treatment Needs of Commercially Sexually Exploited Youth Participating in a Specialty Juvenile Court

The study sought to: (1) describe the mental health and substance use profiles among participants of a specialty trafficking court program (the Succeed Though Achievement and Resilience Court); (2) describe youths' mental health and substance use treatment prior to participating in the program; and (3) examine whether abuse influences report of mental health problems and/or substance use. Retrospective case review of court files was performed on commercially sexually exploited youth who volunteered to participate in the court from 2012 to 2014 (N = 184). All participants were female. Mental health problems and report of substance use was high among this population. Substance use differed at statistically significant levels between youth with a documented abuse history compared to those with no abuse history. Substance use also differed by report of mental health problems. Unexpected findings included the high rate of hospitalization for mental health problems and relatively low substance use treatment prior to STAR Court participation. Opportunities for improvement in critical points of contact to identify commercially sexually exploited youth and address their health needs are discussed.     

The clinical and pathophysiologic implications of pain, ST abnormalities, and scintigraphic changes induced during dipyridamole infusion: their relationships to the peripheral hemodynamic response

In order to determine their significance during dipyridamole perfusion scintigraphy, symptomatic, ECG, and scintigraphic findings were related to each other, to the hemodynamic response, and to angiographic findings in 73 consecutive patients having coronary angiography within 3 months of scintigraphy. The group having induced "cardiac" pain differed from the group without induced pain only in their higher incidence of induced ischemic ST changes, the "marked" hemodynamic response, and their lower incidence of an "absent" hemodynamic response (all p less than 0.01). Induced ST depression was found only in patients with coronary disease. In this population, dipyridamole-induced pain was a moderately specific marker and induced ST abnormalities a more highly specific marker for coronary disease. However, both were insensitive for coronary disease diagnosis. If induced pain or ST abnormalities in the presence of significant coronary disease were accepted as indicators of ischemia, then scintigraphic abnormalities appeared to be produced by dipyridamole in roughly equal incidence by ischemic and nonischemic mechanisms. Induced ischemia related frequently to an exaggerated hypotensive response with no change in double product, suggesting its cause to be an induced increase in myocardial oxygen demand. Dipyridamole-induced image defects were noted even in the absence of a peripheral hemodynamic response. This indicates that the peripheral response does not always correlate with its central coronary effect and an absent peripheral hemodynamic response does not necessarily invalidate scintigraphic results.     

Determination of adequate coronary stent expansion using StentBoost, a novel fluoroscopic image processing technique.

OBJECTIVE: We tested the hypothesis that the use of motion-corrected fluoroscopic images results in enhanced coronary stent visualization and improved detection of inadequate stent expansion. BACKGROUND: Intravascular ultrasound (IVUS) more accurately detects inadequate stent expansion when compared with coronary angiography. Stent under-expansion is associated with stent restenosis and thrombosis. Developing a technique to improve fluoroscopic-based assessment of stent expansion is desirable. METHODS: We analyzed measurements of 48 coronary stents implanted in 30 patients using quantitative coronary angiography (QCA), IVUS, and StentBoost (SB), a novel fluoroscopic image processing technique. Correlations of stent diameter between the modalities were determined. Using established IVUS criteria for adequate stent deployment, we assessed the diagnostic test characteristics of SB to detect inadequate stent expansion. RESULTS: Correlations of minimum stent diameter were highest between IVUS and SB (r=0.75; P<0.0001) when compared with QCA and IVUS (r=0.65; P<0.0001), and QCA and SB (r=0.49; P=0.0004). IVUS and SB demonstrated a small difference in minimum stent diameter, 0.043 mm (95% CI: 0.146-0.061 mm). The correlation between IVUS and SB was lower for vessels with intimal calcification (r=0.57; P=0.002) when compared with vessels with deeper calcification (r=0.84; P<0.0001). A SB minimum diameter of <2.5 mm predicted inadequate stent expansion by IVUS with 88% sensitivity, 70% specificity, and a positive likelihood ratio of 2.9. CONCLUSIONS: SB had superior correlations for stent expansion measured by IVUS when compared with QCA. A minimum stent diameter by SB measurement<2.5 mm is associated with inadequate stent expansion using IVUS criteria.     

Hypertrophic obstructive cardiomyopathy. Effects of acute and chronic verapamil treatment on left ventricular systolic and diastolic function

Changes in left ventricular systolic and diastolic function and outflow gradient were evaluated in patients with obstructive hypertrophic cardiomyopathy after intravenous acute treatment with verapamil (15 patients) and after six months of oral chronic treatment (11 patients). All patients had severe symptoms despite beta blockade, and the condition of all but two improved appreciably after chronic treatment with verapamil. Resting left ventricular outflow tract gradient decreased in six of 15 patients after intravenous verapamil, and in five of 11 patients after long term treatment, but there was no change in provocable gradients nor any correlation between changes in gradient and improvement in symptoms. Left ventricular ejection rate did not change after intravenous or oral treatment. End systolic pressure/end systolic volume index remained unchanged after oral verapamil treatment. Whereas left ventricular total stroke volume index and end diastolic volume index increased without any significant change in left ventricular end diastolic pressure, indicating improved left ventricular diastolic function. In some patients the left ventricular diastolic pressure-volume curve shifted downwards or to the right or both. These findings suggest that improvement in symptoms with verapamil in patients with obstructive hypertrophic cardiomyopathy is unlikely to be related to changes in left ventricular outflow gradient or in systolic function and may be related to improved diastolic function.     

Comparison of haemodynamic effects of oral hydralazine and prazosin hydrochloride in patients with chronic congestive heart failure

The comparative haemodynamic effects of oral prazosin hydrochloride and hydralazine were evaluated in 11 patients with chronic congestive heart failure. The maximum total dose of prazosin received by an individual varied up to 25 mg. Ten patients received a maximum of 75 mg and one received 50 mg of hydralazine at six-hour intervals. There was no significant change in heart rate with either drug. Decrease in mean arterial and left ventricular filling pressures were modest and similar with both agents. With prazosin, the average cardiac index increased 20 per cent and systemic vascular resistance decreased 20 per cent. By contrast, hydralazine increased cardiac index by 58 per cent and decreased systemic vascular resistance by 40 per cent. The increase in stroke work and stroke volume indices was significantly greater with hydralazine than with prazosin. These findings suggest that in some patients with severe chronic congestive heart failure, improvement in left ventricular performance may be greater with hydralazine than with prazosin.     

Minoxidil therapy in chronic congestive heart failure: Acute plus long-term hemodynamic and clinical study

The hemodynamic response to minoxidil, an orally active, potent vasodilator, was evaluated in 11 patients with severe chronic congestive heart fallure (CHF). The hemodynamic response was determined following single doses of 10, 15, 20, 25, and 30 mg of minoxidil. The hemodynamic response was characterized by marked increases in cardiac index (+63%) and stroke volume index (+52%) and by decrease in systemic vascular resistance (?38%). There was also a slight decrease in pulmonary capillary wedge pressure from an average of 24 ± 8 to 21 ± 7 mm hg. Although the average mean arterial pressure remained unchanged, one patient developed significant hypotension. Chronic minoxidil therapy (eight patients) was associated with fluid retention and weight gain. In four patients in whom fluid retention could be minimized with larger doses of diuretics, a sustained clinical and hemodynamic improvement was observed. These findings suggest that minoxidil has the potential to improve cardiac function and may be useful in chronic vasodilator therapy of CHF, provided fluid retention can be controlled.     

Comparison of haemodynamic effects of oral hydralazine and prazosin hydrochloride in patients with chronic congestive heart failure.

The comparative haemodynamic effects of oral prazosin hydrochloride and hydralazine were evaluated in 11 patients with chronic congestive heart failure. The maximum total dose of prazosin received by an individual varied up to 25 mg. Ten patients received a maximum of 75 mg and one received 50 mg of hydralazine at six-hour intervals. There was no significant change in heart rate with either drug. Decrease in mean arterial and left ventricular filling pressures were modest and similar with both agents. With prazosin, the average cardiac index increased 20 per cent and systemic vascular resistance decreased 20 per cent. By contrast, hydralazine increased cardiac index by 58 per cent and decreased systemic vascular resistance by 40 per cent. The increase in stroke work and stroke volume indices was significantly greater with hydralazine than with prazosin. These findings suggest that in some patients with severe chronic congestive heart failure, improvement in left ventricular performance may be greater with hydralazine than with prazosin.     

Contribution of localized calcium deposits to dissection after angioplasty. An observational study using intravascular ultrasound.

BACKGROUND. Atherosclerotic plaque fracture and dissection of the arterial wall are frequent concomitants of the balloon angioplasty process. The composition and morphology of plaque within the vessel may be critical in determining the extent of plaque fracture and dissection during balloon angioplasty. To examine this potential association in the clinical setting, we studied patients with intravascular ultrasound imaging after balloon angioplasty. METHODS AND RESULTS. Forty-one patients were studied with intravascular ultrasound after angioplasty in both peripheral and coronary arteries. Ultrasound images representing the target lesion cross section were digitized, stored on computer, and analyzed off-line. The presence of intralesional calcium and the relative size of dissection for each lesion was computed. Thirty-one patients (76%) had ultrasound evidence of significant dissection or plaque fracture immediately after balloon dilation. In 23 of 31 (74%) of the lesions, the ultrasound scans showed significant localized calcium deposits within the plaque substance. In 87% of these cases, the dissections were adjacent to the calcific portion of the vessel wall. In addition, the relative size of dissections referenced to the neolumen area were significantly larger (p less than or equal to 0.002) in the calcified vessels (27.5 +/- 12.3%) compared with the size of the dissections in lesions without calcium (11.2 +/- 5.8%). CONCLUSIONS. The presence of calcium within the vessel wall appeared to be significantly associated with both the location and size of the dissected tissue arm from the vessel wall. These data suggest that localized calcium deposits have a direct role in promoting dissection, presumably by increasing shear stresses within the plaque.