Usefulness of pretreatment with high-dose clopidogrel in patients undergoing primary angioplasty for ST-elevation myocardial infarction.

Am J Cardiol. 2009 Aug 15;104(4):514-8

Authors: Fefer P, Hod H, Hammerman H, Segev A, Beinart R, Boyko V, Behar S, Matetzky S

We evaluated the effect and optimal dose of clopidogrel pretreatment in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention (PPCI). The study included 383 consecutive patients with ST-elevation myocardial infarction who had undergone PPCI and were prospectively followed up for a prespecified primary end point of recurrent acute coronary syndrome, stent thrombosis, congestive heart failure, and/or death at 30 days. Of these patients, 217 (57%) received clopidogrel loading before and 166 (43%) after PPCI. A similar number received low (300 mg) and high (600 mg) clopidogrel doses before and after PPCI. Clopidogrel loading before, compared with after, PPCI was associated with a lower incidence of the primary end point (21.7% vs 33.7%, p = 0.008). Clopidogrel pretreatment remained a significant predictor of the primary outcome after adjusting for potential confounders (odds ratio 0.54, 95% confidence interval 0.42 to 0.91). When patients were further stratified into 4 groups according to the timing and dosage of clopidogrel loading, the incidence of the primary outcome was 16% and 27% in those receiving 600 and 300 mg before and 28% and 39% in those receiving 600 and 300 mg after PPCI, respectively (p for trend <0.01). In conclusion, both the timing and the dosage of clopidogrel loading are important and affect the outcome in patients with ST-elevation myocardial infarction undergoing PPCI.

PMID: 19660604 [PubMed - in process]

Relation of N-terminal pro-B-type natriuretic peptide to symptoms, severity, and left ventricular remodeling in patients with organic mitral regurgitation.

Am J Cardiol. 2009 Aug 15;104(4):559-64

Authors: Potocki M, Mair J, Weber M, Hamm C, Burkard T, Hiemetzberger R, Peters K, Jander N, Cron TA, Hess N, Hoffmann A, Gekeler H, Gohlke-Bärwolf C, Buser P, Mueller C

Natriuretic peptides reflect cardiac stress and may therefore be useful in the management of patients with valvular heart disease. Data regarding these biomarkers in organic mitral regurgitation (MR) are sparse. In this study, 144 patients with moderate or severe organic MR were prospectively enrolled in an observational, multicenter study to analyze the relation of N-terminal-pro-B-type natriuretic peptide (NT-pro-BNP) to symptoms, severity of MR, and echocardiographic parameters. NT-pro-BNP levels (median 373 pg/ml, interquartile range 150 to 997) were associated with age, gender, creatinine, New York Heart Association (NYHA) functional class, atrial fibrillation, left ventricular (LV) end-systolic dimension, and the LV ejection fraction. Independent predictors of increased NT-pro-BNP levels were NYHA functional class (p = 0.003), atrial fibrillation (p = 0.005) and LV end-systolic dimension (p = 0.029). MR severity and left atrial dimension were not independently associated with NT-pro-BNP levels. NT-pro-BNP levels increased significantly with NYHA class (p <0.001) but not with MR severity (p = 0.144). NT-pro-BNP levels were significantly higher in symptomatic patients than in asymptomatic patients (582 pg/ml [interquartile range 246-1,360] vs 157 pg/ml [interquartile range 64 to 256], p <0.0001). The area under the receiver-operating characteristic curve to predict symptoms for NT-pro-BNP was 0.80 (95% confidence interval 0.71 to 0.88), which was significantly higher than for all echocardiographic variables (p <0.001 for all). In conclusion, NYHA functional class, atrial fibrillation, and LV end-systolic dimension are independent predictors of increased NT-pro-BNP levels in patients with moderate or severe organic MR. Therefore, NT-pro-BNP may be helpful in the clinical evaluation and management of patients with MR, especially when it is doubtful whether symptoms are related to MR or not.

PMID: 19660612 [PubMed - in process]

Cardiac physical diagnosis in the digital age: an important but increasingly neglected skill (from stethoscopes to microchips).

Am J Cardiol. 2009 Aug 15;104(4):590-5

Authors: Conn RD, O'Keefe JH

With the advent of readily available imaging modalities, the time-honored skills in physical examination of the cardiac patient have eroded and are no longer the hallmark of the expert cardiologist. Although auscultation continues to be the primary focus in the examination, this is a skill in which competency is only achieved through continuous exposure, and does not quantitate the physiologic status of the patient. Accuracy in the examination is best achieved by evaluating the physiologic variables that characterize cardiac function (pulse amplitude, blood pressure, jugular venous pressure, and makers of neurohumoral activation), and the identification of which cardiac chambers are involved using precordial motion and the electrocardiogram. Practical methods for the acquisition of these clinical observations are discussed. These clinical data are often more quantitative and easier to acquire for many clinicians than is proficiency in auscultation, and facilitate accurate diagnosis of cardiac conditions including murmur interpretation. In conclusion, even in the digital age, the physical examination remains uniquely relevant to patient care, particularly when focused on the physiologic status of the cardiac patent.

PMID: 19660617 [PubMed - in process]