Relation of Proton Pump Inhibitor Use After Percutaneous Coronary Intervention With Drug-Eluting Stents to Outcomes.

Am J Cardiol. 2010 Mar 15;105(6):833-838

Authors: Gaglia MA, Torguson R, Hanna N, Gonzalez MA, Collins SD, Syed AI, Ben-Dor I, Maluenda G, Delhaye C, Wakabayashi K, Xue Z, Suddath WO, Kent KM, Satler LF, Pichard AD, Waksman R

Recent evidence has shown that clopidogrel and proton pump inhibitors (PPIs) are metabolized by the same pathway and that patients taking both drugs have greater levels of platelet reactivity and more adverse outcomes than patients taking only clopidogrel. We sought to examine the effect of a PPI at discharge from the hospital after percutaneous coronary intervention with drug-eluting stents on the incidence of major adverse cardiac events (MACE) at 1 year. We compared 502 patients who were not prescribed a PPI at discharge and 318 patients who were prescribed a PPI. All patients were taking clopidogrel. We followed patients for 1 year with regard to MACE, including death, Q-wave myocardial infarction, target vessel revascularization, and stent thrombosis. We performed multivariate Cox regression to adjust for confounding variables, including compliance with clopidogrel, to assess the effect of a PPI at discharge on the 1-year outcomes. The baseline characteristics of patients discharged with a PPI were similar to those of patients discharged without a PPI. Univariate survival analysis of the outcomes showed a greater rate of MACE (13.8% vs 8.0%, p = 0.008) and overall mortality (4.7% vs 1.8%, p = 0.02) in the PPI group. After multivariate analysis, the adjusted MACE hazard ratio for PPI at discharge was 1.8 (95% confidence interval 1.1 to 2.7, p = 0.01). In conclusion, in patients undergoing percutaneous coronary intervention with drug-eluting stents and receiving clopidogrel, the prescription of a PPI at discharge was associated with a greater rate of MACE at 1 year.

PMID: 20211327 [PubMed - as supplied by publisher]

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Results of Intracoronary Stem Cell Therapy After Acute Myocardial Infarction.

Am J Cardiol. 2010 Mar 15;105(6):804-812

Authors: Wöhrle J, Merkle N, Mailänder V, Nusser T, Schauwecker P, von Scheidt F, Schwarz K, Bommer M, Wiesneth M, Schrezenmeier H, Hombach V

To assess the effect of autologous bone-marrow cell (BMC) therapy in patients with acute myocardial infarction in a rigorous double-blind, randomized, placebo-controlled trial. Patients with reperfusion >6 hours after symptom onset were randomly assigned in a 2:1 ratio to receive intracoronary BMC or placebo therapy 5 to 7 days after symptom onset. The patients were stratified according to age, acute myocardial infarction localization, and left ventricular (LV) function. Rigorous double-blinding was ensured using autologous erythrocytes for the placebo preparation that was visually indistinguishable from the active treatment. Serial cardiac magnetic resonance imaging studies were performed before study therapy and after 1, 3, and 6 months. The primary end point was the difference in the LV ejection fraction from baseline to 6 months. The secondary end points included changes in the LV end-diastolic and end-systolic volume indexes and infarct size. A total of 42 patients were enrolled (29 in the BMC group and 13 in the placebo group) in the integrated pilot phase. A mean of 381 x 10(6) mononuclear BMCs were administered. The baseline clinical and cardiac magnetic resonance imaging parameters did not differ. Compared to baseline, the difference in LV ejection fraction for the placebo group versus BMC group was 1.7 +/- 6.4% versus -0.9 +/- 5.5% at 1 month, 3.1 +/- 6.0% versus 1.9 +/- 4.3% at 3 months, and 5.7 +/- 8.4% versus 1.8 +/- 5.3% at 6 months (primary end point; not significant). No difference was found in the secondary end points between the 2 groups, including changes in infarct size or LV end-diastolic and end-systolic volume indexes. In conclusion, in this rigorous double-blind, randomized, placebo-controlled trial, we did not observe an evidence for a positive effect for intracoronary BMC versus placebo therapy with respect to LV ejection fraction, LV volume indexes, or infarct size.

PMID: 20211323 [PubMed - as supplied by publisher]

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Usefulness of Soluble Fas Levels for Improving Diagnostic Accuracy and Prognosis for Acute Coronary Syndromes.

Am J Cardiol. 2010 Mar 15;105(6):797-803

Authors: Cardinal H, Brophy JM, Bogaty P, Joseph L, Hébert MJ, Boyer L, Madore F

Although both inflammation and apoptosis occur in acute coronary syndromes (ACSs), previous studies have not tested the diagnostic and prognostic utility of an approach that measures circulating markers of these pathways. The aim of the present study was to assess whether measuring soluble Fas (sFas) and high-sensitivity C-reactive protein (hs-CRP), as markers of apoptosis and inflammation, improve ACS diagnostic and prognostic accuracy. In a prospective cohort of consecutive subjects admitted to the hospital for suspicion of ACS, we measured sFas, hs-CRP, and troponin T in those who had a final noncardiac chest pain diagnosis (n = 100), those who had an ACS diagnosis and experienced (n = 218) or did not experience (n = 170) recurrent cardiac events during 1 year of follow-up. sFas was strongly and independently associated with a discharge diagnosis of an ACS versus noncardiac chest pain during the index hospitalization (odds ratio 16.16 for the second vs first tertile, 95% confidence interval [CI] 7.07 to 36.91; and odds ratio 25.40 for the third vs first tertile, 95% CI 9.38 to 68.75). However, hs-CRP was not. sFas significantly improved the diagnostic accuracy for ACSs (C statistic increased from 0.85 to 0.93, difference +0.08, 95% CI for the difference 0.05 to 0.11). The sFas levels were high and did not vary with time in the subjects having early versus late measurements (beta 0.00 ln pg/ml/hour, 95% CI -0.01 to 0.01). In contrast, troponin increased with time since the beginning of the symptoms (beta 0.07 ln mug/L/hour, 95% CI 0.04 to 0.10). Baseline sFas and hs-CRP did not predict recurrent cardiac events. In conclusion, our results suggest that in suspected ACS cases, sFas, but not hs-CRP, helps to improve the diagnostic accuracy and timeliness over and above standard diagnostic criteria.

PMID: 20211322 [PubMed - as supplied by publisher]

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Contrast-Induced Nephropathy in Patients Undergoing Emergency Percutaneous Coronary Intervention for Acute Coronary Syndrome.

Am J Cardiol. 2010 Mar 1;105(5):624-628

Authors: Senoo T, Motohiro M, Kamihata H, Yamamoto S, Isono T, Manabe K, Sakuma T, Yoshida S, Sutani Y, Iwasaka T

Contrast-induced nephropathy (CIN) is associated with significantly increased morbidity and mortality after coronary angiography and percutaneous coronary intervention (PCI). The aim of the present study was to assess the clinical features and in-hospital outcomes of CIN after emergency PCI. The serum creatinine (SCr) concentration was measured from days 0 to 30 in 338 consecutive patients with acute coronary syndrome undergoing emergency PCI. CIN was defined as an increase in SCr of >25% or >0.5 mg/dl within 2 days after PCI. Overall, 94 patients (28%) developed CIN. The mean SCr on admission was not significantly different between patients with CIN and those without CIN. The CIN group had significantly greater SCr at days 1, 2, and 30 than did the no CIN group. Multivariate analysis showed female gender (odds ratio [OR] 2.38, 95% confidence interval [CI] 1.12 to 5.07, p = 0.025), a culprit lesion in the left anterior descending artery (OR 2.37, 95% CI 1.31 to 4.27, p = 0.0042), contrast agent volume >200 ml (OR 3.60, 95% CI 1.96 to 6.62, p <0.001) and end-diastolic pulmonary arterial pressure >15 mm Hg (OR 2.03, 95% CI 1.02 to 4.04, p <0.01) to all correlate independently with CIN. The in-hospital mortality rate was greater in the CIN group than in the no CIN group (9.6% vs 3.3%, respectively; p = 0.025). In conclusion, CIN is a frequent complication of emergency PCI for acute coronary syndrome and is associated with a greater mortality rate and persistent renal dysfunction.

PMID: 20185007 [PubMed - as supplied by publisher]

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Effect of Anemia in High-Risk Groups of Patients With Acute Myocardial Infarction Treated With Percutaneous Coronary Intervention.

Am J Cardiol. 2010 Mar 1;105(5):611-618

Authors: Kurek T, Lenarczyk R, Kowalczyk J, Swi?tkowski A, Kowalski O, Stabry?a-Deska J, Honisz G, Lekston A, Kalarus Z, Kukulski T

The significance of anemia in patients with acute myocardial infarction (AMI) treated with percutaneous coronary intervention (PCI) remains controversial. The aim of the present study was to evaluate the effect of anemia on the short- and long-term prognosis of patients with AMI treated with PCI, including high-risk subgroups. The study group consisted of 1,497 consecutive patients with AMI treated in the acute phase with PCI. Anemia was defined using World Health Organization criteria (hemoglobin level <13 g/dl for men and <12 g/dl for women). The study population was divided into 2 major groups (patients with [n = 248, 16.6%] and without [n = 1,249, 83.4%] anemia) and 6 subgroups (diabetes mellitus, impaired renal function, age >70 years, left ventricular dysfunction, incomplete revascularization, and multivessel disease). A comparative analysis was performed between both groups within the whole population and within the particular subgroups. Significantly greater 30-day (13.2% vs 7.3%), 1-year (20.5% vs 11.3%), and total (24.1% vs 12.7%; all p <0.05) mortality rates were observed in the anemic group. Multivariate analysis identified anemia as an independent predictor of any-cause death in the whole population during the observation period (covariate-adjusted hazard ratio 1.46, 95% confidence interval 1.31 to 1.61, p <0.05). Anemia was significantly associated with excessive long-term mortality in the multivessel disease group (adjusted hazard ratio 1.54, 95% confidence interval 1.34 to 1.74) and in the incomplete revascularization group (hazard ratio 1.67, both p <0.05). In conclusion, anemia on admission in patients with AMI treated in the acute phase with PCI was independently associated with increasing short- and long-term mortality, especially in the subgroups with incomplete revascularization and multivessel disease.

PMID: 20185005 [PubMed - as supplied by publisher]

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Thromboembolism in Atrial Fibrillation.

Am J Cardiol. 2010 Feb 15;105(4):502-510

Authors: Menke J, Lüthje L, Kastrup A, Larsen J

Thromboembolism is a severe complication in atrial fibrillation. This overview presents thromboembolic disease as a single entity, ranging from stroke through mesenteric ischemia to acute limb ischemia. The PubMed, Embase, and Cochrane databases were systematically searched for the terms “atrial fibrillation” and “thromboembolism” in reports published from January 1986 to September 2009. The information of 10 evidence-based practice guideline documents and 61 further sources was systematically extracted. In atrial fibrillation, the average annual stroke risk is increased by 2.3% (lethality 30%). The annual incidence of acute mesenteric ischemia is 0.14% (lethality 70%), and that of acute limb ischemia is 0.4% (lethality 16%). In total, approximately 80% of embolism-related deaths are from stroke and 20% from other systemic thromboembolism. The ischemic symptoms generally have an acute onset but may mimic other diseases, particularly in mesenteric ischemia. Early diagnosis and treatment can limit or even prevent tissue infarction. Guideline-recommended therapy with aspirin or warfarin reduces the thromboembolic risk. Suitable patients may optimize their warfarin therapy by self-monitoring of the international normalized ratio (INR). New oral and parenteral anticoagulants with more stable pharmacokinetics are being developed. In conclusion, atrial fibrillation predisposes to thromboembolism. If ischemic stroke or systemic thromboembolism occurs, early diagnosis and treatment can improve outcomes. The thromboembolic risks are reduced by guideline-adherent antithrombotic therapy with warfarin or aspirin. Future directions may include self-monitoring of the international normalized ratio and novel anticoagulants.

PMID: 20152245 [PubMed - as supplied by publisher]

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Relation Between Red Cell Distribution Width and Clinical Outcomes After Acute Myocardial Infarction.

Am J Cardiol. 2010 Feb 1;105(3):312-317

Authors: Dabbah S, Hammerman H, Markiewicz W, Aronson D

Increased red blood cell distribution width (RDW) has been associated with adverse outcomes in heart failure and stable coronary disease. We studied the association between baseline RDW and changes in RDW during hospital course with clinical outcomes in patients with acute myocardial infarction (AMI). Baseline RDW and RDW change during hospital course were determined in 1,709 patients with AMI who were followed for a median of 27 months (range 6 to 48). The relation between RDW and clinical outcomes after hospital discharge were tested using Cox regression models, adjusting for clinical variables, baseline hemoglobin, mean corpuscular volume, and left ventricular ejection fraction. Compared to patients in the first RDW quintile, the adjusted hazard ratios for death progressively increased with higher quintiles of RDW (second quintile 1.1, 95% confidence interval [CI] 0.6 to 2.1; third quintile 1.8, 95% CI 1.0 to 3.2; fourth quintile 2.0, 95% CI 1.1 to 3.4; fifth quintile 2.8, 95% CI 1.6 to 4.7, p for trend <0.0001). An increase in RDW during hospital course was also associated with subsequent mortality (adjusted hazard ratio 1.13 for 1-SD increase in RDW, 95% CI 1.02 to 1.25). Similar results were obtained for the end point of heart failure. The association between increased RDW and worse outcome was evident in patients with and without anemia. In conclusion, there is a graded, independent association between increased RDW and mortality after AMI. An increase in RDW during hospitalization also portends adverse clinical outcome.

PMID: 20102941 [PubMed - as supplied by publisher]

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Diagnostic accuracy of 64-slice multislice computed tomographic coronary angiography in patients with an intermediate pretest likelihood for coronary artery disease.

Am J Cardiol. 2010 Feb 1;105(3):302-5

Authors: van Werkhoven JM, Heijenbrok MW, Schuijf JD, Jukema JW, Boogers MM, van der Wall EE, Schreur JH, Bax JJ

Data on the diagnostic accuracy of multislice computed tomographic coronary angiography (CTA) have been mostly derived from patients with a high pretest likelihood of coronary artery disease. Systematic comparisons with invasive angiography in patients with an intermediate pretest likelihood are scarce. The purpose of the present study was to determine the diagnostic accuracy of CTA in patients without known coronary artery disease with an intermediate pretest likelihood. A total of 61 patients (61% men, average age 57 + or – 9 years) who had been referred for invasive coronary angiography underwent additional 64-slice CTA. A total of 920 segments were identified by invasive coronary angiography, of which 885 (96%) were interpretable on CTA. Invasive coronary angiography identified a significant stenosis (> or = 50% luminal narrowing) in 29 segments, of which 23 were detected on CTA. Thus, the sensitivity, specificity, positive predictive value, and negative predictive value was 79%, 98%, 61%, and 99%, respectively, for CTA. On a patient level, the sensitivity, specificity, positive predictive value, and negative predictive value was 100%, 89%, 76%, and 100%, respectively. CTA correctly ruled out the presence of significant stenosis in 40 (66%) of the 61 patients. In conclusion, the results from the present study have confirmed that CTA has excellent diagnostic accuracy in the target population of patients with an intermediate pretest likelihood. The high negative predictive value allowed us to rule out significant stenosis in a large proportion of patients. CTA can, therefore, be used as a highly effective gatekeeper for invasive coronary angiography.

PMID: 20102939 [PubMed - in process]

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Quality of care and in-hospital outcomes in patients with coronary heart disease in rural and urban hospitals (from Get With the Guidelines-Coronary Artery Disease Program).

Am J Cardiol. 2010 Jan 15;105(2):139-43

Authors: Ambardekar AV, Fonarow GC, Dai D, Peterson ED, Hernandez AF, Cannon CP, Krantz MJ,

Previous studies have suggested that patients with coronary artery disease (CAD) in rural areas may have worse outcomes due to limited availability of specialists, fewer resources, and less institutional funding. Data were collected from hospitals participating in the Get With the Guidelines-Coronary Artery Disease Program (GWTG-CAD) from January 2000 to December 2008. In-hospital outcomes and quality of care were stratified by care at rural versus urban hospitals. Multivariate logistic regression analysis was used to determine the association of rural locale with in-hospital mortality, length of stay, and compliance with the GWTG-CAD performance measurements including (1) early aspirin use, (2) smoking cessation counseling and discharge prescriptions of (3) aspirin, (4) angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers for left ventricular systolic dysfunction, (5) beta-blockers, and (6) lipid-lowering therapy and a composite of all 6 measurements. Data were collected from 22,096 patients at 71 rural centers and 329,938 patients at 477 urban centers. Unadjusted rates of compliance with performance measurements were lower in rural (range 82.4% to 90.5%) compared to urban (range 81.3% to 95.0%) hospitals including the composite (74.7% vs 80.6%, p <0.0001). In multivariate analysis, rural status was not independently associated with lower compliance with any of the performance measurements. Unadjusted mortality rates were higher in rural versus urban hospitals (5.7% vs 4.4%, p <0.0001), but this was not significant in multivariate analysis (odds ratio 1.05, 95% confidence interval 0.87 to 1.26). In conclusion, within the GWTG-CAD quality improvement initiative, patients with CAD treated at rural hospitals receive similar quality of care and have similar outcomes as those at urban centers.

PMID: 20102907 [PubMed - in process]

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Predictors of short-term (seven-day) cardiac outcomes after emergency department visit for syncope.

Am J Cardiol. 2010 Jan 1;105(1):82-6

Authors: Gabayan GZ, Derose SF, Asch SM, Chiu VY, Glenn SC, Mangione CM, Sun BC

Syncope is a common reason for emergency department (ED) visits, and patients are often admitted to exclude syncope of cardiovascular origin. Population-based data on patterns and predictors of cardiac outcomes may improve decision-making. Our objective was to identify patterns and predictors of short-term cardiac outcomes in ED patients with syncope. Administrative data from an integrated health system of 11 Southern California EDs were used to identify cardiac outcomes after ED presentation for syncope from January 1, 2002, to December 31, 2005. Syncope and cause of death were identified by codes from the International Classification of Disease, Ninth Revision. Cardiac outcomes included cardiac death and hospitalization or procedure consistent with ischemic heart disease, valvular disease, or arrhythmia. Predictors of cardiac outcomes were identified through multivariate logistic regression. There were 35,330 adult subjects who accounted for 39,943 ED visits for syncope. Risk of cardiac outcome sharply decreased following the 7 days after syncope. A 7-day cardiac outcome occurred in 893 cases (3%). Positive predictors of 7-day cardiac outcomes included age >/=60 years, male gender, congestive heart failure, ischemic heart disease, cardiac arrhythmia, and valvular heart disease. Negative predictors included dementia, pacemaker, coronary revascularization, and cerebrovascular disease. There was an age-dependent relation between 7-day cardiac outcomes and arrhythmia and valvular disease, with younger patients (<60 years of age) having greater risk of an event compared to their same-age counterparts. In conclusion, ED decision-making should focus on risk of cardiac event in the first 7 days after syncope and special attention should be given to younger patients with cardiac co-morbidities.

PMID: 20102895 [PubMed - in process]

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Impact of prophylactic beta-blocker therapy to prevent stroke after noncardiac surgery.

Am J Cardiol. 2010 Jan 1;105(1):43-7

Authors: van Lier F, Schouten O, Hoeks SE, van de Ven L, Stolker RJ, Bax JJ, Poldermans D

beta Blockers are widely used to improve the postoperative cardiac outcome in patients with coronary artery disease scheduled for noncardiac surgery. However, recently serious concerns regarding the safety of perioperative beta blockers have emerged. To assess the incidence, risk factors, and beta-blocker use associated with postoperative stroke in the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE) trials, we evaluated all 3,884 patients of the DECREASE trials for postoperative stroke. All cardiac risk factors and medication use were assessed. The incidence of stroke within 30 days after surgery was recorded. The incidence of postoperative stroke in the DECREASE trials was 0.46% (18 of 3,884). For the beta-blocker users, the incidence was 0.5%. All the strokes had an ischemic origin. A history of stroke was associated with a greater incidence of postoperative stroke (odds ratio [OR] 3.79, 95% confidence interval [CI] 1.2 to 11.6). Statins and anticoagulants were not associated with postoperative stroke (OR 0.85, 95% CI 0.3 to 2.4; and OR 1.27, 95% CI 0.4 to 4.6, respectively). No association with bisoprolol therapy was found (OR 1.16, 95% CI 0.4 to 3.4). In conclusion, with a low-dose bisoprolol regimen started > or =30 days before surgery, no association was observed between beta-blocker use and postoperative stroke.

PMID: 20102888 [PubMed - in process]

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Effect of implementing routine early invasive strategy on one-year mortality in patients with acute myocardial infarction.

Am J Cardiol. 2010 Jan 1;105(1):36-42

Authors: Aune E, Endresen K, Fox KA, Steen-Hansen JE, Roislien J, Hjelmesaeth J, Otterstad JE

The aim of the present study was to investigate whether the implementation of an early invasive strategy for unselected patients with acute myocardial infarction (AMI) would be associated with reduced long-term mortality compared to a conservative approach. In this prospective observational cohort study of consecutive patients admitted for AMI in 2003 (conservative cohort, n = 311) and 2006 (invasive cohort [IC], n = 307), an 11% absolute and 41% relative reduction in 1-year mortality was found for patients with AMI in the IC compared to the conservative cohort (p = 0.001). These findings were consistent after adjustment for age, gender, previous AMI, previous stroke, diabetes, smoking status, previous left ventricular systolic dysfunction, and serum creatinine at admission (hazard ratio 0.54, 95% confidence interval 0.38 to 0.78) and Global Registry of Acute Coronary Events risk score (hazard ratio 0.67, 95% confidence interval 0.46 to 0.97). More patients with ST-segment elevation myocardial infarction received primary percutaneous coronary intervention in the IC (57% vs 3%, p <0.001), and a sixfold (25% vs 4%, p <0.001) increase in early percutaneous coronary intervention (<72 hours) for patients with non-ST-segment elevation myocardial infarction was observed. A greater proportion of patients in the IC received clopidogrel, aspirin, and statins during follow-up; otherwise, the secondary prevention measures were similar in the 2 cohorts. In conclusion, the introduction of a strategy for routine transfer to a high-volume percutaneous coronary intervention center for early invasive therapy was accompanied by a substantial reduction in mortality among unselected patients with AMI. Differences in unmeasured confounders might have accounted for a part of the difference in outcome.

PMID: 20102887 [PubMed - in process]

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Effect of Blood Glucose Concentrations on Admission in Non-Diabetic Versus Diabetic Patients With First Acute Myocardial Infarction on Short- and Long-Term Mortality (from the MONICA/KORA Augsburg Myocardial Infarction Registry).

Am J Cardiol. 2009 Dec 15;104(12):1607-12

Authors: Beck JA, Meisinger C, Heier M, Kuch B, Hörmann A, Greschik C, Koenig W

The aim of this study was to investigate the association between increased admission glucose in nondiabetic (ND) patients and in patients with type 2 diabetes mellitus (T2DM) with first acute myocardial infarctions (AMIs) and 28-day as well as 1- and 3-year case fatality. The Monitoring Trends and Determinants in Cardiovascular Disease (MONICA)/Cooperative Health Research in the Region of Augsburg (KORA) myocardial infarction registry database in Augsburg, Germany, was used, and 1,631 patients without and 659 patients with T2DM (aged 25 to 74 years) who were admitted from 1998 to 2003 with first AMIs were included. Mortality follow-up was carried out in 2005. ND patients with AMIs with admission glucose >152 mg/dl (top quartile) compared with those in the bottom quartile had an odds ratio of 2.82 (95% confidence interval [CI] 1.30 to 6.12) for death within 28 days after multivariate adjustment; correspondingly, patients with T2DM with admission glucose >278 mg/dl (top quartile) compared with those in the bottom quartile (<152 mg/dl) showed a nonsignificantly increased odds ratio of 1.45 (95% CI 0.64 to 3.31). After the exclusion of patients who died within 28 days, a nonsignificantly increased relative risk (RR) was seen between admission blood glucose and 1-year mortality in ND subjects (RR 2.71, 95% CI 0.90 to 8.15), whereas no increased RR was found in subjects with diabetes (RR 0.99, 95% CI 0.34 to 2.82). After 3 years, there was no increased risk for death in patients with high admission blood glucose levels, neither for ND patients nor for those with T2DM. In conclusion, elevated admission blood glucose is associated with increased short-term mortality risk in patients with AMIs, particularly in ND subjects. These patients constitute a high-risk group needing aggressive, comprehensive polypharmacotherapy.

PMID: 19962462 [PubMed - in process]

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Usefulness of Fragmented QRS on a 12-Lead Electrocardiogram in Acute Coronary Syndrome for Predicting Mortality.

Am J Cardiol. 2009 Dec 15;104(12):1631-7

Authors: Das MK, Michael MA, Suradi H, Peng J, Sinha A, Shen C, Mahenthiran J, Kovacs RJ

Electrocardiographic signs of a non-ST elevation myocardial infarction (NSTEMI) are nonspecific, and therefore the diagnosis of NSTEMI during acute coronary syndromes (ACS) depends mainly on cardiac biomarker levels. Fragmented QRS (fQRS) represents myocardial conduction abnormalities due to myocardial infarction (MI) scars in patients with coronary artery disease. However, the time of appearance of fQRS during ACS has not been investigated. It was postulated that in patients with ACS, fQRS on 12-lead electrocardiography occurs within 48 hours of presentation with NSTEMI as well as ST elevation MI and that fQRS predicts mortality. Serial electrocardiograms from 896 patients with ACS (mean age 62 +/- 11 years, 98% men) who underwent cardiac catheterization were studied. Four hundred forty-one patients had MIs, including 337 patients with NSTEMIs, and 455 patients had unstable angina (the control group). Serial electrocardiograms were obtained every 6 to 8 hours during the first 24 hours after the diagnosis of MI and the next day (<48 hours). Fragmented QRS on 12-lead electrocardiography was defined by the presence of single or multiple notches in the R or S wave, without a typical bundle branch block, in >/=2 contiguous leads in 1 of the major coronary artery territories. Fragmented QRS developed in 224 patients (51%) in the MI group and only 17 (3.7%) in the control group (p <0.001). New Q waves developed in 122 (28%), 76 (23%), and 2 (0.4%) patients in the MI, NSTEMI, and control groups, respectively. The sensitivity values of fQRS for ST elevation MI and NSTEMI were 55% and 50%, respectively. The specificity of fQRS was 96%. Kaplan-Meier survival analysis revealed that patients with fQRS had significantly decreased times to death compared to those without fQRS. Fragmented QRS, T-wave inversion, and ST depression were independent predictors of mortality during a mean follow-up period of 34 +/- 16 months. In conclusion, fQRS on 12-lead electrocardiography is a moderately sensitive but highly specific sign for ST elevation MI and NSTEMI. Fragmented QRS is an independent predictor of mortality in patients with ACS.

PMID: 19962466 [PubMed - in process]

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Relation of nausea and vomiting in acute myocardial infarction to location of the infarct.

Am J Cardiol. 2009 Dec 15;104(12):1638-40

Authors: Fuller EE, Alemu R, Harper JF, Feldman M

To determine whether the incidence of nausea and vomiting in patients with acute myocardial infarction (AMI) varies with infarct location, we studied 180 patients who had been admitted to our hospital for ST-segment elevation AMI or AMI associated with left bundle branch block. The presenting symptoms (chest pain, nausea, and vomiting), initial electrocardiographic findings, and additional demographic, clinical, laboratory, and outcome data were extracted from the medical records and correlated with the infarct location. Of the 180 patients with AMI, 108 (60%) had inferior and 72 (40%) had anterior infarcts. Nausea was reported in almost 2/3 of all patients, and vomiting in nearly 1/3. Both nausea and vomiting showed a trend toward a greater incidence in patients with inferior than with anterior infarcts (69% vs 56% and 33% vs 26%, respectively). However, the differences were not statistically significant. In conclusion, nausea and vomiting are common presenting symptoms in patients with either inferior or anterior wall AMI, but their frequency is unrelated to the infarct location.

PMID: 19962467 [PubMed - in process]

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