Acute Myocardial Infarction: Routine Early Angioplasty after Thrombolysis

Adjunctive percutaneous coronary intervention (PCI) performed between 2 and 24 hours after thrombolysis administered to a patient with an ST elevation myocardial infarction (STEMI) appears beneficial and safe. The rationale for routinely following fibrinolysis with PCI is that many patients have a persistent reduction in flow in the infarct-related artery; although fibrinolysis restores patency (TIMI grade 2 or 3) in 80% of infarct-related arteries, normalization of blood flow (TIMI grade 3) is seen in only 50 to 60% of arteries. Adjunctive PCI has been directly compared to a strategy of fibrinolysis and standard care (either PCI for a clinical indication or routine late PCI) in the TRANSFER AMI, GRACIA-1, NORDISTEMI, CARESS-in-AMI, and SIAM III trials, and found to have better outcomes. Based on these results, the 2010 European Society of Cardiology (ESC) guidelines recommend routine urgent PCI after successful fibrinolysis within 24 hours (class I recommendation, level of evidence A)

Floppy mitral valve/mitral valve prolapse syndrome: Beta-adrenergic receptor polymorphism may contribute to the pathogenesis of symptoms

AbstractBackgroundCertain patients with floppy mitral valve (FMV)/mitral valve prolapse (MVP) may have symptoms that cannot be explained on the severity of mitral valvular regurgitation (MVR) alone; hypersensitivity to adrenergic stimulation has been suggested in this group defined as the FMV/MVP syndrome.MethodsNinety-eight patients (75 men, 23 women) with mitral valve surgery for FMV/MVP were studied. Of those 41 (42%) had symptoms consistent with FMV/MVP syndrome [29 men (39%), 12 women (52%)]; median age of symptom onset was 30 years (range 10–63 years) and median duration of symptoms prior to valve surgery was 16 years (range 3–50 years). Ninety-nine individuals (70 men, 29 women) without clinical evidence of any disease were used as controls. Genotyping of β1 and β2 adrenergic receptors was performed.Resultsβ-Adrenergic receptor genotypes (β1 and β2) were similar between control and overall FMV/MVP patients. Subgroup analysis of patients, however, demonstrated that the genotype C/C at position 1165 resulting in 389 Arg/Arg of the β1 receptor was more frequent in women compared to those without FMV/MVP syndrome and to normal control women (p<0.025). This polymorphism may be related to hypersensitivity to adrenergic stimulation as reported previously in these patients.ConclusionThis study shows a large proportion of patients with FMV/MVP, predominantly women, had symptoms consistent with the FMV/MVP syndrome for many years prior to the development of significant MVR, and thus symptoms cannot be attributed to the severity of MVR alone. Further, women with FMV/MVP syndrome, symptoms at least partially may be related to β1-adrenergic receptor polymorphism, which has been shown previously to be associated with a hyperresponse to adrenergic stimulation