The modified Selvester QRS score: Can we predict successful ST segment resolution in patients with myocardial infarction receiving fibrinolytic therapy?

Background: We sought to explore whether the simplified Selvester QRS scoring system could predict ST segment resolution in patients with first acute ST segment elevation myocardial infarction who receive pharmacological reperfusion therapy. Methods: We enrolled 60 consecutive patients admitted to the critical care unit with the diagnosis of first acute ST segment elevation myocardial infarction presenting within 24 hours from symptom onset, and eligible for reperfusion therapy. All patients received streptokinase in the usual dose regimen. Patients underwent resting high-quality 12-lead electrocardiogram recordings to calculate the modified QRS score and estimate the sum of ST segment elevation before (STE1) and 90 minutes after (STE2) streptokinase. The difference between STE1 and STE2 was then measured and accepted as the sum of ST segment resolution, expressed as &#931;STR. Patients were classified into two groups: those with &#931;STR &#8805; 50% of STE1 (the resolution group) and those with &#931;STR < 50% (the non-resolution group). Results: The mean QRS score was significantly lower in the resolution group compared to the non-resolution group (2.88 &#177; 1.34 vs 5.93 &#177; 1.56, respectively, p < 0.001). There was a highly significant negative correlation between QRS score and SSTR with a correlation coefficient r = -0.76. Using a cut-off value of &#8805; 4, the QRS score had a sensitivity of 93%, specificity of 72%, positive and negative predictive values of 74% and 92% respectively, for predicting &#931;STR < 50%. Conclusions: The Selvester QRS score can reliably predict adequate ST segment resolution in patients with first acute ST segment elevation myocardial infarction receiving fibrinolytic therapy, with a high sensitivity and an acceptable specificity. (Cardiol J 2010; 17, 4: 367-373

Accuracy and safety of low-dose dobutamine stress echocardiography early after acute anterior myocardial infarction

Objectives: We sought to explore the safety and prognostic accuracy of low-dose dobutamine stress echocardiography (DSE), performed early in the course of acute anterior ST elevation myocardial infarction (STEMI), in patients who received thrombolytic therapy.Methods: We enrolled 73 consecutive patients presenting with first acute anterior STEMI, who had significant coronary stenosis/occlusion of the culprit artery amenable for revascularization. Low-dose DSE was performed within 2-7 (3.8 ± 1.8) days of the index hospitalization. Patients underwent coronary revascularization. Follow-up echocardiography was performed 2-3 months after revascularization to assess regional wall motion abnormality. Predicted viability by low-dose DSE was compared with actual contractility improvement seen at follow-up echocardiography.Results: Considering a per-patient analysis, low-dose DSE early after anterior STEMI predicted viability with a sensitivity of 88.9%, specificity of 75.7%, PPV of 78%, NPV of 87.5%. Based on a per-segment analysis, low-dose DSE achieved a sensitivity of 86.9%, specificity of 92.5%, PPV of 73.2%, NPV of 96.8%. Based on a per-segment analysis performed individually for hypokinetic segments, low-dose DSE achieved a sensitivity of 88%, specificity of 85.4%, PPV of 74%, NPV of 93.8%. For akinetic segments, low-dose DSE achieved a sensitivity of 82.4%, specificity of 97%, PPV of 70%, NPV of 98.5%.Conclusion: Low-dose DSE performed early in patients presenting with acute anterior STEMI who received thrombolytic therapy, is safe with a high sensitivity but a modest specificity for predicting contractile improvement after revascularization, based on a per-patient analysis. However, based on a per-segment analysis, both sensitivity and specificity are high

Multi-slice computed tomography: Can it adequately rule out left main coronary disease in patients with an intermediate probability of coronary artery disease?

Background: Multi-slice computed tomography (MSCT) is a fast-growing technology that permits a non-invasive, yet reliable, assessment of coronary atherosclerosis. We sought to explore the diagnostic accuracy of MSCT angiography in the detection of significant stenosis of the left main coronary artery (LMCA) in a series of patients with an intermediate pre-test likelihood of coronary artery disease (CAD). Methods: We prospectively enrolled 30 consecutive patients with an intermediate pre-test likelihood of CAD. Patients underwent 64-slice MSCT angiography to detect significant stenosis of the LMCA (defined as &#8805; 50% luminal obstruction). They subsequently underwent invasive coronary angiography according to the standard technique. Results: The mean age was 52.7 &#177; 6.3 years, 24 (80%) being males. Three (10%) patients had significant stenosis of the LMCA by invasive coronary angiography, while four (13.3%) patients were categorized as having significant LMCA stenosis by MSCT coronary angiography. MSCT coronary angiography was able to detect significant LMCA stenosis with a sensitivity of 100%, specificity of 96.3%, positive and negative predictive values of 75% and 100% respectively, and a diagnostic accuracy of 96.7%, with reference to invasive coronary angiography. Conclusions: In patients with an intermediate pre-test likelihood of CAD, MSCT coronary angiography provides a highly accurate diagnostic modality for ruling out significant LMCA stenosis, with reference to invasive coronary angiography. (Cardiol J 2010; 17, 6: 594-598

Cardiac perfusion by positron emission tomography

Myocardial perfusion imaging (MPI) with positron emission tomography (PET) is an established tool for evaluation of obstructive coronary artery disease (CAD). The contemporary 3-dimensional scanner technology and the state-of-the-art MPI radionuclide tracers and pharmacological stress agents, as well as the cutting-edge image reconstruction techniques and data analysis software, have all enabled accurate, reliable and reproducible quantification of absolute myocardial blood flow (MBF), and henceforth calculation of myocardial flow reserve (MFR) in several clinical scenarios. In patients with suspected coronary artery disease, both absolute stress MBF and MFR can identify myocardial territories subtended by epicardial coronary arteries with haemodynamically significant stenosis, as defined by invasive coronary fractional flow reserve measurement. In particular, absolute stress MBF and MFR offered incremental prognostic information for predicting adverse cardiac outcome, and hence for better patient risk stratification, over those provided by traditional clinical risk predictors. This article reviews the available evidence to support the translation of the current techniques and technologies into a useful decision-making tool in real-world clinical practice

Right heart thrombus-in-transit with pulmonary embolism in a patient with primary hypercoagulable state

A 25 year-old female with a history of Caesarian section ten weeks ago presented with symptoms suggestive of pulmonary embolism. Transthoracic echocardiography revealed a free- -floating large thrombus traversing the right atrial cavity. Transesophageal echocardiography confirmed the presence of an unattached thrombus that originated from the most proximal part of the inferior vena cava. Multi-slice computed tomography of the chest and abdomen revealed the thrombus to start from the intra-hepatic part of the inferior vena cava and extend through the right atrium. It also demonstrated multiple thrombi in the pulmonary vasculature, the largest being in the right main pulmonary artery and its lower lobe branch. The patient was triaged for surgical embolectomy under cardio-pulmonary bypass. Follow-up trans-thoracic and transesophageal echocardiography confirmed adequate removal of the thrombus. By genetic examination, she proved to have factor V &#8217;Leiden&#8217; gene and two thrombophilia genes, all of which were positive in the heterozygous state. She had also a high serum homocysteine. (Cardiol J 2010; 17, 4: 408-411

QT Interval and QT Dispersion in Patients Undergoing Hemodialysis: Revisiting the Old Theory

www.karger.com/nne This is an Open Access article licensed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 License (www.karger.com/OA-license), applicable to the online version of the article only. Distribution for non-commercial purposes only.

If current inhibitor ivabradine in patients with idiopathic dilated cardiomyopathy: Impact on the exercise tolerance and quality of life

Background: Evidence supported a beneficial effect of ivabradine on clinical outcome of patients with systolic heart failure, and a sinus heart rate (HR) ≥ 70 bpm. We explored the effect of ivabradine, vs. placebo, added to evidence-based treatment on exercise tolerance and quality of life in patients with idiopathic dilated cardiomyopathy. Methods: We enrolled 43 consecutive patients with dilated cardiomyopathy of no apparent cause, a left ventricular ejection fraction (LVEF) &lt; 40%, New York Heart Association class ≥ II, sinus HR ≥ 70 bpm, and background evidence-based anti-failure medications. Ischemic heart disease was ruled out. Patients were randomized (1:1) to receive ivabradine or placebo. Ivabradine was titrated up gradually till 7.5 mg twice daily, or a HR &lt; 60 bpm, and continued for 3 months. Symptom-limited exercise tolerance test was performed, and quality of life was assessed by the Minnesota Living With Heart Failure Questionnaire at 0, and 3 months. Results: Forty-three patients were randomized to ivabradine (n = 20), or placebo (n = 23). Mean age was 50.8 ± 14.5 years (53.5% males). Mean HR was 85 ± 12 bpm, and mean LVEF was 32 ± 6%. Mean dose of carvedilol was 31.2% of the target dose. Baseline HR, blood pressure, exercise tolerance, Minnesota questionnaire score, and left ventricular systolic function were comparable between the two groups (p &gt; 0.05 for all). At 3 months, mean dose of ivabradine was 6.8 mg bid. Ivabradine-treated patients had a lower HR, and improved left ventricular dimensions and systolic function, versus placebo-treated ones (p &lt; 0.05 for all). HR dropped by a mean of 14 bpm in the ivabradine group, corrected for placebo. Both exercise tolerance, and Minnesota questionnaire score were better in the ivabradine group (p &lt; 0.05 both). Ivabradine was well-tolerated. Conclusions: In symptomatic patients with idiopathic dilated cardiomyopathy, the addition of ivabradine, vs. placebo, to evidence-based treatment, reduced HR, and improved functional capacity, at short-term follow-up

Usefulness of Post-coronary Dilation to Prevent Recurrent Myocardial Infarction in Patients Treated With Percutaneous Coronary Intervention for Acute Coronary Syndrome (from the BASE ACS Trial)

Stent underexpansion is associated with worse outcome after stent implantation. Whether post-dilation (PD) improves outcome in patients with acute coronary syndrome (ACS) remains unclear. We performed post hoc analysis of outcome in patients from the BASE ACS (A prospective randomized comparison of titanium-nitride-oxide-coated bioactive stents with everolimus-eluting stents in acute coronary syndrome) trial who underwent PD versus those who did not. The BASE ACS trial randomized 827 patients (1:1) with ACS to receive either titanium-nitride-oxide coated bioactive stents or everolimus-eluting stents. The primary end point was major adverse cardiac events (MACE): a composite of cardiac death, nonfatal myocardial infarction (MI), or ischemia-driven target lesion revascularization. Follow-up was planned at 12 months and yearly thereafter for up to 7 years. Of 827 patients enrolled in the BASE ACS trial, 357 (43.2%) underwent PD. Median follow-up duration was 5 years. Patients who, underwent PD had less frequent nonfatal MI events at long-term follow-up, compared with those who did not (4.5% vs 8.5%, respectively, p = 0.02). The rates of MACE (15.7% vs 15.1%, respectively, p = 0.81), and the other endpoints, were not significantly different (p >0.5 for all). The results were consistent in propensity score matched analysis (270 pairs). In patients treated with bioactive stents, those who underwent PD had a trend for a fewer nonfatal MI events (p = 0.076). Comparably, in patients treated with everofimus-eluting stents, MACE and all the individual end points were comparable (p >0.5 for all). In conclusion, patients treated with early percutaneous coronary intervention for ACS who underwent PD had less frequent nonfatal MI events at long-term follow-up, compared with those who did not; MACE rates were not significantly different. (C) 2016 Elsevier Inc. All rights reserved.Peer reviewe

Long-term clinical outcome of elderly patients with acute coronary syndrome treated with early percutaneous coronary intervention : Insights from the BASE ACS randomized controlled trial Bioactive versus everolimus-eluting stents in elderly patients

Background: The BASE ACS trial demonstrated an outcome of titanium-nitride-oxide-coated bioactive stents (BAS) that was non-inferior to everolimus-eluting stents (EES) in patients presenting with acute coronary syndrome (ACS). We performed a post hoc analysis of elderly versus non-elderly patients from the BASE ACS trial. Methods: We randomized 827 patients (1:1) presenting with ACS to receive either BAS or EES. The primary end-point was major adverse cardiac events (MACE): a composite of cardiac death, non-fatal myocardial infarction (MI), or ischemia-driven target lesion revascularization (TLR). Follow-up was planned at 12 months and yearly thereafter for up to 7 years. Elderly age was defined as >= 65 years. Results: Of the 827 patients enrolled in the BASE ACS trial, 360 (43.5%) were elderly. Mean follow-up duration was 4.2 +/- 1.9 years. MACE was more frequent in elderly versus younger patients (19.7% versus 12.0%, respectively, p = 0.002), probably driven by more frequent cardiac death and non-fatal MI events (5.3% versus 1.5%, and 9.7% versus 4.5%, p = 0.002 and p = 0.003, respectively). The rates of ischemia-driven TLR were comparable (p > 0.05). In propensity score-matched analysis (215 pairs), only cardiac death was more frequent in elderly patients (6% versus 1.4%, respectively, p = 0.01). Diabetes independently predicted both MACE and cardiac death in elderly patients. Conclusions: Elderly patients treated with stent implantation for ACS had worse long-term clinical outcome, compared with younger ones, mainly due to a higher death rate. (C) 2016 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.Peer reviewe