Clinical features of myocardial infarction and myocarditis in young adults: a retrospective study.

OBJECTIVES: To evaluate the prevalence and clinical presentation of myocardial infarction (MI) and myocarditis in young adults presenting with chest pain (CP) and an elevated serum troponin I (TnI) to the emergency department (ED). DESIGN: Retrospective, observational, single-centre study. PARTICIPANTS: All consecutive patients 18-40 years old admitted to the ED for CP with an elevated TnI concentration. PRIMARY OUTCOME MEASURES: Prevalence of MI, myocarditis and the characterisation of clinical presentation. RESULTS: 1588 patients between 18 and 40 years old were admitted to the ED with CP during 30 consecutive months. 49 (3.1%) patients with an elevated TnI (>0.09 μg/l) were included. 32.7% (16/49) were diagnosed with MI (11 ST-elevation myocardial infarction (STEMI) and 5 non-ST-elevation myocardial infarction (NSTEMI)) and 59.2% (29/49) with myocarditis. Compared with patients with myocarditis, MI patients were older (34.1±3.8 vs 26.9±6.4, p=0.0002) with more cardiovascular risk factors (mean 2.06 vs 0.69). Diabetes (18.8% vs 0%, p=0.0039), dyslipidaemia (56.2% vs 3.4%, p<0.0001) and family history of coronary artery disease (CAD) (37.5% vs 10.3% p=0.050) were associated with MI. Fever or recent viral illness were present in 75.9% (22/29) of patients with myocarditis, and in 0% of MI patients (p<0.0001). During follow-up, two patients with myocarditis were re-admitted for CP. CONCLUSIONS: In this study, 32.7% of patients <40-year-old admitted to an ED with CP and elevated TnI had a diagnosis of MI. Key distinctive clinical factors include diabetes, dyslipidaemia, family history of CAD and fever or recent viral illness

The Norumbega Fault Zone, Maine: a mid-to shallow-level crustal section within a transcurrent shear zone

From studies of structure, metamorphism, and geochronology we have evidence that the Norumbega Fault Zone represents a transition from mid- to shallow crustal levels in a dextral, transcurrent shear zone within the northern Appalachian Orogen. The Norumbega Fault Zone strikes parallel to the orogen (northeast-southwest), is ~5 to 30 km wide, and is characterized by distributed ductile dextral shear fabrics in the southwestern section with a transition to brittle fabrics toward the northeast. Within the zone of distributed shear, deformation is partitioned into local zones of very high strain. Upright, isoclinal folds are common in areas of high and low strain. Metamorphic grade decreases from amphibolite facies in the southwest to sub-green schist facies in the northeast. 40Ar/39Ar mineral ages from recrystallized minerals in a high strain zone, regional cooling ages in areas of lower strain, and metamorphic textures are consistent with a polyphase history of deformation. We interpret a younging trend in 40Ar/39Ar cooling ages toward the northeast, together with the deformational fabrics andmetamorphic features, to represent exhumation of the southwestern section of the Norumbega Fault Zone from mid-crustal levels during the polyphase history of this transcurrent zone. The Norumbega Fault Zone may therefore serve as a model for deformational processes at mid- to shallow crustal levels in active strike-slip systems. RÉSUMÉ Des études de la structure, du métamorphisme et de la géochronologic nous fournissent la preuve que la zone faillée de Norumbega représente une transition des niveaux crustaux moyens à des niveaux peu profonds dans une zone de cisaillement transversal dextrale à l'intérieur de la partie septentrionale de l'orogene appalachien. La zone faillée de Norumbega suit une direction paralléle a l'orogéne (nord-est-sud-ouest); die a cinq à 30 km de largeur; et elle est caractérisec par des structures cisaillées dextrales déformables se ramifiant dans la section sud-ouest avec une transition a des structures cassantes vers le nord-est. A l'intérieur de la zone de cisaillement ramifié, la déformation est divisée en zones locales de très forte contrainte. Les plis droits isoclinaux sont courants dans les secteurs de forte et faible contrainte. L'intensité du métamorphisme décroit d'un faciès à amphibolite dans le sud-ouest à un faciès secondaire de schistes verts dans le nord-est. Les périodes minérales 40Ar/39Ar des minéraux recristallises dans une zone de forte contrainte, les périodes de refroidissement régional dans les secteurs de faible contrainte et les textures métamorphiques correspondent à une orogénese polyphasée. Nous interprétons la tendance de rajeunissement dans les périodes de refroidissement 40Ar/39Ar vers le nord-est, de même que les textures de déformation et les caractéristiqucs métamorphiques, comme une exhumation de la section sud-ouest de la zone faillée de Norumbega depuis les niveaux crustaux moyens pendant l'histoire polyphasée de cette zone transversale. La zone faillée de Norumbega pourrait, par consequent, servir de modèle pour les processus de déformation aux niveaux variant de moyens à peu profonds dans les systèmes a décrochement. [Traduit par la rédaction

Sediment flux and composition changes in canyons on a carbonate-siliciclastic margin: evidence from turbidite deposits along the Great Barrier Reef margin

The shelf edge and slope of the Great Barrier Reef is heavily incised by submarine canyons which terminate in the Queensland Trough. Traditionally, sedimentation on the margin has been investigated within the framework of idealized siliciclastic or carbonate systems, depending on whether rivers or shallow marine carbonate producers dominate supply. The widely accepted paradigm ('reciprocal' sedimentation) states that sea-level strongly influences shelf, slope and basin sedimentation, with siliciclastics dominating lowstand periods and carbonates dominating transgressions/highstands. However, recent work (e.g., Dunbar and Dickens, 2003) on cores from the slope and basin has challenged this view. These workers argue that accumulation of both siliciclastic and carbonate sediments varies in phase, with the highest rates observed during transgressions, lowest rates during lowstands and moderate sedimentation during highstands. Irrespective of which model is correct, exactly how the sediment (carbonate or siliciclastic) moves from the shelf to the basin, and the role of submarine canyons in this process is not understood. We address this problem directly by investigating sedimentation in the canyons bordering the GBR. Combining new multibeam bathymetry and seismic data with x-radiograph, magnetic susceptibility, insitu reflectance spectroscopy, grain size, CNS, petrologic, pollen and 14C AMS analyses of canyon cores off Cooktown and Cairns, we aim to establish the source, timing and frequency of turbidite events deposited in the canyons over the last glacial to interglacial cycle, thereby testing the competing models. Our preliminary data confirm that: (1) the canyons record a distinct sedimentary shift from siliciclastic turbidites to calciturbidites; (2) the siliciclastic turbidites were deposited before 28 ka - providing strong support for the "reciprocal" model of margin sedimentation; and (3) the canyons have been active throughout the last deglaciation and into the late Holocene

Timing of cardiac resynchronization therapy implantation

Aims The optimum timing of cardiac resynchronization therapy (CRT) implantation is unknown. We explored long-term outcomes after CRT in relation to the time interval from a first heart failure hospitalization (HFH) to device implantation. .Methods A database covering the population of England (56.3 million in 2019) was used to quantify clinical outcomes after CRT im- and results plantation in relation to first HFHs. From 2010 to 2019, 64 968 patients [age: 71.4 ± 11.7 years; 48 606 (74.8%) male] underwent CRT implantation, 57% in the absence of a previous HFH, 12.9% during the first HFH, and 30.1% after ≥1 HFH. Over 4.54 (2.80–6.71) years [median (interquartile range); 272 989 person-years], the time in years from the first HFH to CRT implantation was associated with a higher risk of total mortality [hazard ratio (HR); 95% confidence intervals (95% CI)] (1.15; 95% CI 1.14–1.16, HFH (HR: 1.26; 95% CI 1.24–1.28), and the combined endpoint of total mortality or HFH (HR: 1.19; 95% CI 1.27–1.20) than CRT in patients with no previous HFHs, after co-variate adjustment. Total mortality (HR: 1.67), HFH (HR: 2.63), and total mortality or HFH (HR: 1.92) (all P < 0.001) were highest in patients undergoing CRT ≥2 years after the first HFH. Conclusion In this study of a healthcare system covering an entire nation, delays from a first HFH to CRT implantation were associated with progressively worse long-term clinical outcomes. The best clinical outcomes were observed in patients with no previous HFH and in those undergoing CRT implantation during the first HFH. Condensed The optimum timing of CRT implantation is unknown. In this study of 64 968 consecutive patients, delays from a first heart abstract failure hospitalization (HFH) to CRT implantation were associated with progressively worse long-term clinical outcomes. Each year from a first HFH to CRT implantation was associated with a 21% higher risk of total mortality and a 34% higher risk of HFH. The best outcomes after CRT were observed in patients with no previous HFHs and in those undergoing implantation during their first HFH. The left upper panel shows the timing (y-axis) and numbers (x-axis) of cardiac resynchronization therapy (CRT) implantations in relation to the timing of first heart failure hospitalizations (HFHs); the right upper panel shows CRT implantations undertaken during a first HFH as a percentage of all implantations, according to year. Patients were regarded as not having had a HFH if this had not occurred within 5 years prior to CRT implantation. The left lower panel shows the Kaplan–Meier survival curve for total mortality. Event rates (per 100 person-years) for the three endpoints according to the timing of CRT implantation in relation to a first HFH are shown in the right lower panel

Determinants and outcomes of stroke following percutaneous coronary intervention by indication

Background and Purpose—Stroke after percutaneous coronary intervention (PCI) is a serious complication, but its determinants and outcomes after PCI in different clinical settings are poorly documented. Methods—The British Cardiovascular Intervention Society (BCIS) database was used to study 560 439 patients who underwent PCI in England and Wales between 2006 and 2013. We examined procedural-type specific determinants of ischemic and hemorrhagic stroke and the likelihood of subsequent 30-day mortality and in-hospital major adverse cardiovascular events (a composite of in-hospital mortality, myocardial infarction or reinfarction, and repeat revascularization). Results—A total of 705 stroke cases were recorded (80% ischemic). Stroke after an elective PCI or PCI for acute coronary syndrome indications was associated with a higher risk of adverse outcomes compared with those without stroke; 30-day mortality and major adverse cardiovascular events outcomes in fully adjusted model were odds ratios 37.90 (21.43–67.05) and 21.05 (13.25–33.44) for elective and 5.00 (3.96–6.31) and 6.25 (5.03–7.77) for acute coronary syndrome, respectively. Comparison of odds of these outcomes between these 2 settings showed no differences; corresponding odds ratios were 1.24 (0.64–2.43) and 0.63 (0.35–1.15), respectively. Conclusions—Hemorrhagic and ischemic stroke complications are uncommon, but serious complications can occur after PCI and are independently associated with worse mortality and major adverse cardiovascular events outcomes in both the elective and acute coronary syndrome setting irrespective of stroke type. Our study provides a better understanding of the risk factors and prognosis of stroke after PCI by procedure type, allowing physicians to provide more informed advice around stroke risk after PCI and counsel patients and their families around outcomes if such neurological complications occur