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Abstract
A 67-year-old woman experienced pruritus, an urticarial rash, and acute, pressure-like chest pain following an insect sting. Initial electrocardiographic findings were notable for ST-segment elevations in the inferior leads without reciprocal changes, but a follow-up electrocardiogram showed pronounced ST-segment elevations in the inferior leads with reciprocal changes. Her troponin I level peaked at 3,053 pg/mL, and she was transferred to a large academic center for percutaneous coronary intervention. Balloon angioplasty was performed for 95% thrombotic occlusion of the mid-right coronary artery, and a drug-eluting stent was placed. The patient's presentation was consistent with type II Kounis syndrome.
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Affiliation(s)
- Rahul V. Annabathula
- Section of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Mahesh A. Chandrasekhar
- Section of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Luke A. Peters
- Section of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Çevrim Ö, Boydak B, Yürüktümen A, Kiyan G, Ersel M, Uz İ, Özçete E, Başol G. The Diagnostic Value of Echocardiography Performed by an Emergency Medicine Physician in the Diagnosis of Acute Coronary Syndrome: A Comparative Study With Cardiologist. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2022. [DOI: 10.1177/87564793221138100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective: Early recognition of acute coronary syndromes (ACSs) is crucial in the emergency department. This study was designed to determine the diagnostic value of echocardiography, which was performed by an emergency medicine (EM) physician, to diagnosis ACS. Materials and Methods: This prospective and cross-sectional study was conducted between June 2011 and December 2011. All patients who were admitted with chest pain, to the EM department, and fulfilled the inclusion criteria were enrolled in this study. The focused echocardiography was performed by the EM physician. All echocardiography videos recorded were shown to the cardiologist. The final comments were compared with EM physician’s early findings. Results: Out of 48 patients, four were diagnosed with ACS. Three out of four patients diagnosed with ACS were detected by the EM physician with echocardiography. The EM physician’s prediction value with echocardiography in ACS diagnosis was 75% (95% confidence interval [CI] range 59%–100%), and the negative predictive value was 97% (95% CI range 77,9%-100%). There was no major cardiac event in the patient in whom the EM physician failed to detect a wall motion defect. Conclusion: Echocardiography is a bedside, noninvasive test for diagnosis of ACS. The EM physician who participated in this study was able to recognize ACS with the absence of a segmental wall motion defect, as well as the cardiologist providing the final report.
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Affiliation(s)
- Özgür Çevrim
- Department of Emergency, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Bahar Boydak
- Department of Internal Medicine, Faculty of Medicine, Ege University, İzmir, Turkey
| | - Aslıhan Yürüktümen
- Department of Emergency Medicine, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - G.Selahattin Kiyan
- Department of Emergency Medicine, Faculty of Medicine, Ege University, İzmir, Turkey
| | - Murat Ersel
- Department of Emergency Medicine, Faculty of Medicine, Ege University, İzmir, Turkey
| | - İlhan Uz
- Department of Emergency Medicine, Faculty of Medicine, Ege University, İzmir, Turkey
| | - Enver Özçete
- Department of Emergency Medicine, Faculty of Medicine, Ege University, İzmir, Turkey
| | - Güneş Başol
- Department of Biochemistry, Faculty of Medicine, Ege University, İzmir, Turkey
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3
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Takasaki A, Kurita T, Yanagisawa M, Ino A, Hiramatsu D, Ikami A, Ito H, Kato T, Fukuoka S, Sugimoto T, Nakata T, Masuda J, Tanabe M, Kakimoto H, Dohi K. Demographic Trends and Changes in the Pre- and In-Hospital Medical Management of Acute Myocardial Infarction During the First 12 Months of the COVID-19 Pandemic in Mie Prefecture ― Report From the Mie ACS Registry ―. Circ Rep 2022; 4:412-421. [PMID: 36120481 PMCID: PMC9437476 DOI: 10.1253/circrep.cr-22-0050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/10/2022] [Accepted: 07/11/2022] [Indexed: 11/09/2022] Open
Abstract
Background: Even though hospital admissions for acute myocardial infarction (AMI) decreased globally during the COVID-19 pandemic in early 2020, limited information is available on subsequent demographic trends in the number of cases and management of AMI through the first 12 months of the COVID-19 pandemic. Methods and Results: We assessed demographic trends, patient characteristics, and AMI outcomes (n=730) during the first 12 months of the COVID-19 pandemic and compared them with corresponding months during the control period (February 2016–January 2020; n=2,742) using data from the Mie ACS Registry. Although a 25.8% reduction in hospitalizations for AMI was observed in the 3 months following the declaration of a state of emergency (47.7 vs. 64.3/month; P=0.002), the total number of AMI patients was similar between the 12-month COVID-19 and control periods (60.8 vs. 57.2/month; P=0.58). The number of patients requiring direct ambulance transport was lower in the first half of the COVID-19 than control period (44.4% vs. 51.5; P=0.028). In-hospital mortality was higher in the second half of the COVID-19 than control period (8.9% vs. 5.8%; P=0.032). Conclusions: Through the first 12 months of the COVID-19 pandemic, the number of AMI cases was similar to that in previous years. The COVID-19 pandemic changed the behavior of AMI patients and both pre- and in-hospital medical management, which significantly affected the severity and prognosis of AMI.
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Affiliation(s)
- Akihiro Takasaki
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Tairo Kurita
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | | | - Ayaka Ino
- Department of Cardiology, Ise Red Cross Hospital
| | | | | | - Hiromasa Ito
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Takashi Kato
- Department of Cardiology, Mie Prefecture General Medical Center
| | | | - Tadafumi Sugimoto
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | | | - Jun Masuda
- Department of Cardiology, Mie Prefecture General Medical Center
| | - Masaki Tanabe
- Department of Infection Control and Prevention, Mie University Hospital
| | | | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
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Kounis Syndrome Secondary to Laxative Administration. Case Rep Med 2022; 2022:6087176. [PMID: 35783461 PMCID: PMC9242800 DOI: 10.1155/2022/6087176] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/13/2022] [Indexed: 11/28/2022] Open
Abstract
Kounis syndrome (KS) is defined as an acute coronary syndrome triggered by the release of inflammatory mediators after an allergic attack. It usually occurs secondary to allergic injuries from foods, medications, and insect bites. However, there are no known reports of KS secondary to the intake of laxatives. This article reports the case of a 43-year-old woman who, after ingesting a dose of sodium phosphate monobasic/sodium phosphate dibasic, presented a maculopapular rash on the trunk and extremities. The electrocardiogram showed ST depression in V4-V5-V6 and signs of prolonged QTc; troponin I uptake was positive. Due to presumed myocardial injury and high suspicion of coronary disease, coronary angiography was requested, which showed epicardial coronary arteries, without angiographically significant stenosis, thus confirming the presence of KS secondary to the ingestion of a laxative.
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Roumeliotis A, Davlouros P, Anastasopoulou M, Tsigkas G, Koniari I, Mplani V, Hahalis G, Kounis NG. Allergy Associated Myocardial Infarction: A Comprehensive Report of Clinical Presentation, Diagnosis and Management of Kounis Syndrome. Vaccines (Basel) 2021; 10:vaccines10010038. [PMID: 35062699 PMCID: PMC8781167 DOI: 10.3390/vaccines10010038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 12/25/2021] [Accepted: 12/26/2021] [Indexed: 12/12/2022] Open
Abstract
Kounis syndrome (KS) has been defined as acute coronary syndrome (ACS) in the context of a hypersensitivity reaction. Patients may present with normal coronary arteries (Type I), established coronary artery disease (Type II) or in-stent thrombosis and restenosis (Type III). We searched PubMed until 1 January 2020 for KS case reports. Patients with age <18 years, non-coronary vascular manifestations or without an established diagnosis were excluded. Information regarding patient demographics, medical history, presentation, allergic reaction trigger, angiography, laboratory values and management were extracted from every report. The data were pulled in a combined dataset. From 288 patients with KS, 57.6% had Type I, 24.7% Type II and 6.6% Type III, while 11.1% could not be classified. The mean age was 54.1 years and 70.6% were male. Most presented with a combination of cardiac and allergic symptoms, with medication being the most common trigger. Electrocardiographically, 75.1% had ST segment elevation with only 3.3% demonstrating no abnormalities. Coronary imaging was available in 84.8% of the patients, showing occlusive lesions (32.5%), vascular spasm (16.2%) or normal coronary arteries (51.3%). Revascularization was pursued in 29.4% of the cases. In conclusion, allergic reactions may be complicated by ACS. KS should be considered in the differential diagnosis of myocardial infarction with non-obstructive coronary arteries.
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Affiliation(s)
- Anastasios Roumeliotis
- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA 02138, USA;
| | - Periklis Davlouros
- Division of Cardiology, Department of Internal Medicine, Medical School, University of Patras, 26500 Patras, Greece; (P.D.); (M.A.); (G.T.); (G.H.)
| | - Maria Anastasopoulou
- Division of Cardiology, Department of Internal Medicine, Medical School, University of Patras, 26500 Patras, Greece; (P.D.); (M.A.); (G.T.); (G.H.)
| | - Grigorios Tsigkas
- Division of Cardiology, Department of Internal Medicine, Medical School, University of Patras, 26500 Patras, Greece; (P.D.); (M.A.); (G.T.); (G.H.)
| | - Ioanna Koniari
- Manchester Heart Institute, Manchester University Foundation Trust, Manchester M23 9LT, UK;
| | - Virginia Mplani
- Intensive Care Unit, Medical School, University of Patras, 26500 Patras, Greece;
| | - Georgios Hahalis
- Division of Cardiology, Department of Internal Medicine, Medical School, University of Patras, 26500 Patras, Greece; (P.D.); (M.A.); (G.T.); (G.H.)
| | - Nicholas G. Kounis
- Division of Cardiology, Department of Internal Medicine, Medical School, University of Patras, 26500 Patras, Greece; (P.D.); (M.A.); (G.T.); (G.H.)
- Correspondence:
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6
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Dong S, Liu Y, Sun W, Wang C, Wang Y, Zhao W, Zhao S, Chu Y. Analysis of Characteristics of Patients with Non-ST-Segment Elevation Myocardial Infarction by Cardiac Magnetic Resonance Imaging. Med Sci Monit 2021; 27:e933220. [PMID: 34667142 PMCID: PMC8544020 DOI: 10.12659/msm.933220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND In this study, cardiac magnetic resonance imaging was used to investigate the characteristics of patients who have total coronary occlusion but manifest with non-ST-segment elevation myocardial infarction (NSTEMI), and we assessed the extent of infarct transmurality and myocardial necrosis size in NSTEMI patients. MATERIAL AND METHODS We enrolled all patients diagnosed at our hospital with subtotal or total occlusion of the culprit artery (TOCA), based on the coronary angiography, who successfully underwent PCI within 12 h of admission, and who had CMR imaging performed within 2 days after the PCI. RESULTS Based on 12-lead ECG findings, 48% of patients were categorized as having STEMI and 52% as having NSTEMI. TOCA was detected by coronary angiography in 43% of NSTEMI patients, and in 60% and 33% of normal ST segment and ST-segment depression MI patients, respectively. The transmural segments were found in 78% of STEMI patients and 31% of NSTEMI patients (P<0.05). Transmural infarction segments were found in 64% of NSTEMI patients with TOCA and in 8% of NTOCA patients (P<0.05). Moreover, the number of transmural segments in ST-segment depression MI patients was the lowest (P<0.05). Infarct size in STEMI patients was significantly larger than in patients with NSTEMI (P<0.05), whereas there was no statistically significant difference in patients with normal ST segment and ST-segment depression MI patients (P>0.05). CONCLUSIONS Identification TOCA by coronary angiography and transmural infarction by DE-MRI can be challenging in AMI patients with non-ST-segment elevation. In approximately 30% of non-ST-segment elevation MI patients, transmural infarction was detected by DE-MRI. Therefore, TOCA accompanied by transmural infarction in non-ST-segment-elevation MI patients is not uncommon.
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Affiliation(s)
- Shujuan Dong
- Department of Cardiology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China (mainland)
| | - Yunbo Liu
- Department of Radiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China (mainland)
| | - Wenjing Sun
- Department of Cardiology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China (mainland)
| | - Chunqiu Wang
- Department of Radiology, Henan Provincial People's Hospital, Zhengzhou, Henan, China (mainland)
| | - Yan Wang
- Department of Radiology, Henan Provincial People's Hospital, Zhengzhou, Henan, China (mainland)
| | - Wenbo Zhao
- Department of Cardiology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China (mainland)
| | - Shenghui Zhao
- Department of Cardiology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China (mainland)
| | - Yingjie Chu
- Department of Cardiology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Zhengzhou, Henan, China (mainland)
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7
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Kounis syndrome associated with COVID-19 infection: cause or coincidence? COR ET VASA 2021. [DOI: 10.33678/cor.2021.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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8
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Engheta M, Urbanczyk J, Fidone E, Escobedo Y, Mixon T. Kounis syndrome presenting as ST elevation acute myocardial infarction. Proc (Bayl Univ Med Cent) 2021; 34:500-502. [PMID: 34219938 DOI: 10.1080/08998280.2021.1907095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Allergic acute coronary syndrome, Kounis syndrome, is a rare cause of ST-segment elevation myocardial infarction triggered by an allergic reaction to a drug or environmental allergen, resulting in atheromatous plaque rupture or coronary artery vasospasm. We report three cases of Kounis syndrome presenting as ST-segment elevation myocardial infarction.
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Affiliation(s)
- Michael Engheta
- Division of Cardiology, Department of Internal Medicine, Baylor Scott and White Medical Center - Temple and Texas A&M Health Science Center, Temple, Texas
| | - Jonathan Urbanczyk
- Division of Cardiology, Department of Internal Medicine, Baylor Scott and White Medical Center - Temple and Texas A&M Health Science Center, Temple, Texas
| | - Erica Fidone
- Division of Cardiology, Department of Internal Medicine, Baylor Scott and White Medical Center - Temple and Texas A&M Health Science Center, Temple, Texas
| | - Yissela Escobedo
- Division of Cardiology, Department of Internal Medicine, Baylor Scott and White Medical Center - Temple and Texas A&M Health Science Center, Temple, Texas
| | - Timothy Mixon
- Division of Cardiology, Department of Internal Medicine, Baylor Scott and White Medical Center - Temple and Texas A&M Health Science Center, Temple, Texas
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9
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Sharma I, Behl T, Bungau S, Sachdeva M, Kumar A, Zengin G, Arora S. Understanding the role of Inflammasome in Angina Pectoris. Curr Protein Pept Sci 2020; 22:CPPS-EPUB-112184. [PMID: 33292150 DOI: 10.2174/1389203721999201208200242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 10/08/2020] [Accepted: 10/19/2020] [Indexed: 11/22/2022]
Abstract
Angina pectoris, associated with coronary artery disease, a cardiovascular disease where, pain is caused by adverse oxygen supply in myocardium, resulting in contractility and discomfort in chest. Inflammasomes, triggered by stimuli due to infection and cellular stress have identified to play a vital role in the progression of cardiovascular disorders and thus, causing various symptoms like angina pectoris. Nlrp3 inflammasome, a key contributor in the pathogenesis of angina pectoris, requires activation and primary signaling for the commencement of inflammation. Nlrp3 inflammasome elicit out an inflammatory response by emission of pro inflammatory cytokines by ROS (reactive oxygen species) production, mobilization of K+ efflux and Ca2+ and by activation of lysosome destabilization that eventually causes pyroptosis, a programmed cell death process. Thus, inflammasome are considered to be one of the factors involved in the progression of coronary artery diseases and have an intricate role in development of angina pectoris.
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Affiliation(s)
- Ishita Sharma
- Chitkara College of Pharmacy, Chitkara University, Punjab,. India
| | - Tapan Behl
- Chitkara College of Pharmacy, Chitkara University, Punjab,. India
| | - Simona Bungau
- Department of Pharmacy, Faculty of Medicine of Pharmacy, University of Oradea, Oradea,. Romania
| | - Monika Sachdeva
- Fatima College of Health Science, Al Ain,. United Arab Emirates
| | - Arun Kumar
- Chitkara College of Pharmacy, Chitkara University, Punjab,. India
| | - Gokhan Zengin
- Department of Biology, Faculty of Science, University Campus, Konya,. Turkey
| | - Sandeep Arora
- Chitkara College of Pharmacy, Chitkara University, Punjab,. India
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Giovannini M, Alletto A, Koniari I, Mori F, Favilli S, Sarti L, Barni S, Liccioli G, Lodi L, Indolfi G, Novembre E, Kounis NG. Kounis Syndrome: a pediatric perspective. Minerva Pediatr 2020; 72:383-392. [DOI: 10.23736/s0026-4946.20.06007-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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11
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Sunder A, Mohanty B, Singh A. Kounis syndrome: A rare case. J Family Med Prim Care 2020; 9:2514-2516. [PMID: 32754533 PMCID: PMC7380822 DOI: 10.4103/jfmpc.jfmpc_355_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 03/28/2020] [Accepted: 04/15/2020] [Indexed: 11/19/2022] Open
Abstract
Allergic angina and allergic myocardial infarction are ubiquitous diseases covering a wide spectrum of mast cell activation disorders, which are associated with acute coronary syndromes and are referred to as ''Kounis Syndrome''. Here, we report a case admitted with dyspnea and mild chest heaviness secondary to bee sting, later diagnosed as Kounis syndrome.
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Affiliation(s)
- Ashok Sunder
- Department of Medicine, Tata Main Hospital, Jamshedpur, Jharkhand, India
| | - Bijaya Mohanty
- Department of Medicine, Tata Main Hospital, Jamshedpur, Jharkhand, India
| | - Abha Singh
- Department of Medicine, Tata Main Hospital, Jamshedpur, Jharkhand, India
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Yang S, Bhatia N, Xu M, McPherson JA. Incidence and Predictors of Obstructive Coronary Artery Disease and the Role of Cardiac Troponin Assays in Patients with Unstable Angina. Tex Heart Inst J 2019; 46:161-166. [PMID: 31708695 DOI: 10.14503/thij-17-6329] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In a time when cardiac troponin assays are widely used to detect myocardial injury, data remain scarce concerning the incidence and predictors of substantial obstructive coronary artery disease that causes unstable angina. This retrospective single-center study included consecutive patients hospitalized for unstable angina from January 2015 through January 2016. Patients with troponin I levels above the upper reference limit and those who did not undergo angiography were excluded. Multivariate logistic regression analysis was used to identify predictors of obstructive coronary artery disease that warranted revascularization and of major adverse cardiac events up to 6 months after discharge from the hospital. Of the 114 patients who met the inclusion criteria, 46 (40%) had obstructive coronary artery disease. In the univariate analysis, male sex, white race, history of coronary artery disease, prior revascularization, hyperlipidemia, chronic kidney disease, aspirin use, long-acting nitrate use, and Thrombolysis in Myocardial Infarction score ≥3 were associated with obstructive coronary artery disease. History of coronary artery disease, prior revascularization, hyperlipidemia, and long-acting nitrate use were associated with major adverse cardiac events. Male sex was an independent predictor of obstructive coronary artery disease (adjusted odds ratio=4.82; 95% CI, 1.79-13; P=0.002) in the multivariate analysis. Our results showed that coronary artery disease warranting revascularization is present in a considerable proportion of patients who have unstable angina. The association that we found between male sex and obstructive coronary artery disease suggests that the risk stratification of patients presenting with unstable angina may need to be refined to improve outcomes.
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13
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Kounis NG, Koniari I, Velissaris D, Tzanis G, Hahalis G. Kounis Syndrome—not a Single-organ Arterial Disorder but a Multisystem and Multidisciplinary Disease. Balkan Med J 2019; 36:212-221. [PMID: 31198019 PMCID: PMC6636655 DOI: 10.4274/balkanmedj.galenos.2019.2019.5.62] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Coronary symptoms associated with conditions related to mast cell activation and inflammatory cell interactions, such as those involving T-lymphocytes and macrophages, further inducing allergic, hypersensitivity, anaphylactic, or anaphylactic insults, are currently referred to as the Kounis syndrome. Kounis syndrome is caused by inflammatory mediators released during allergic insults, post-inflammatory cell activation, and interactions via multidirectional stimuli. A platelet subset of 20% with high- and low-affinity IgE surface receptors is also involved in this process. Kounis syndrome is not just a single-organ but also a complex multisystem and multi-organ arterial clinical condition; it affects the coronary, mesenteric, and cerebral arteries and is accompanied by allergy–hypersensitivity–anaphylaxis involving the skin, respiratory, and vascular systems in the context of anesthesia, surgery, radiology, oncology, or even dental and psychiatric medicine; further, it has significantly influences both morbidity and mortality. Kounis syndrome might be caused by numerous and continuously increasing causes, with broad clinical symptoms and signs, via multi-organ arterial system involvement, in patients of any age, thereby demonstrating predominant anaphylactic features in terms of a wide spectrum of mast cell-association disorders. Cardiac symptoms, such as chest pain, coronary vasospasm, angina pectoris, myocardial infarction, stent thrombosis, acute cardiac failure, and sudden cardiac death associated with subclinical, clinical, acute, or chronic allergic reactions, constitute the clinical manifestations of this syndrome. Since its first description, a common pathway between allergic and non-allergic coronary events has been demonstrated. The hypothesis is based on the existence of a much higher degree of mast cell degranulation at plaque erosion or rupture sites compared with at the adjacent areas or even more distant segments in post-acute myocardial infarction of non-allergic etiology. Although mast cell activation, differentiation, and mediator release takes days or weeks, the mast cell degranulation may occur just before any acute coronary event, further resulting in coronary artery vasoconstriction and atheromatous plaque rupture. It seems that medications and natural molecules stabilizing the mast cell membrane as well as monoclonal antibodies protecting the mast cell surface can emerge as novel therapeutic modalities for acute coronary and cerebrovascular event prevention.
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Affiliation(s)
- Nicholas G. Kounis
- Department of Cardiology, Patras University School of Medicine, Patras, Greece
| | - Ioanna Koniari
- Electrophysiology and Device Department University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Dimitrios Velissaris
- Department of Internal Medicine, Patras University School of Medicine, Patras, Greece
| | - George Tzanis
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Via Madonna di Genova, Cotignola RA, Italy
| | - George Hahalis
- Department of Cardiology, Patras University School of Medicine, Patras, Greece
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Sillesen H, Sartori S, Sandholt B, Baber U, Mehran R, Fuster V. Carotid plaque thickness and carotid plaque burden predict future cardiovascular events in asymptomatic adult Americans. Eur Heart J Cardiovasc Imaging 2018; 19:1042-1050. [PMID: 29059296 DOI: 10.1093/ehjci/jex239] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 10/12/2017] [Indexed: 01/08/2024] Open
Abstract
Introduction Prediction of cardiovascular events improves using imaging, i.e. coronary calcium score and ultrasound assessment of carotid plaque. This study analysed the predictive value of two ultrasound measures of carotid plaque size: carotid plaque thickness and carotid and intima-media thickness (IMT). Methods and results A total of 6102 asymptomatic persons underwent assessment of conventional risk factors and imaging by carotid ultrasound. Carotid plaque burden (cPB) and maximum carotid plaque thickness (cPTmax) were measured from 'cross-sectional sweep' video acquisition of the carotid artery. IMT was measured from distal common carotid artery images. All participants were followed up for ∼3 years, and major cardiovascular events (MACE) were collected and adjudicated. All data were available for 5808 participants, in whom 216 first MACE events were observed. Increasing both cPB and cPTmax were associated with increasing the risk of future MACE when compared with participants without carotid atherosclerosis. Fully adjusted for risk factors, hazard ratios for cPTmax were 1.96 [95% confidence interval (CI) 0.91-4.25, P = 0.015] for primary MACE and 3.13 (95% CI 1.80-5.51, P < 0.001) for secondary MACE, similar to that of cPB. IMT did not improve risk prediction significantly. Non-categorical net reclassification index (NRI) for cPTmax was 0.178 (95% CI 0.027-0.299, P = 0.032) for primary MACE and 0.173 (95% CI 0.109-0.243, P < 0.001) for secondary MACE, which is almost similar to cPB. IMT assessment did not result in significant NRI. Conclusion The simpler cPTmax predicted cardiovascular events similarly to the more comprehensive cPB, whereas IMT did not. Awaiting true 3D ultrasound technology cPTmax may be a simple useful measure for prediction of future ASCVD.
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Affiliation(s)
- Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen, Denmark
| | - Samantha Sartori
- Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Benjamin Sandholt
- Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen, Denmark
| | - Usman Baber
- Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Roxana Mehran
- Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Valentin Fuster
- Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Kounis NG, Cervellin G, Koniari I, Bonfanti L, Dousdampanis P, Charokopos N, Assimakopoulos SF, Kakkos SK, Ntouvas IG, Soufras GD, Tsolakis I. Anaphylactic cardiovascular collapse and Kounis syndrome: systemic vasodilation or coronary vasoconstriction? ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:332. [PMID: 30306071 DOI: 10.21037/atm.2018.09.05] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The first reported human anaphylactic death is considered to be the Pharaoh Menes death, caused by a wasp sting. Currently, anaphylactic cardiovascular events represent one of most frequent medical emergencies. Rapid diagnosis, prompt and appropriate treatment can be life saving. The main concept beyond anaphylaxis lies to myocardial damage and ventricular dysfunction, thus resulting in cardiovascular collapse. Cardiac output depression due to coronary hypoperfusion from systemic vasodilation, leakage of plasma and volume loss due to increased vascular permeability, as well as reduced venous return, are regarded as the main causes of cardiovascular collapse. Clinical reports and experiments indicate that the human heart, in general, and the coronary arteries, in particular, could be the primary target of the released anaphylactic mediators. Coronary vasoconstriction and thrombosis induced by the released mediators namely histamine, chymase, tryptase, cathepsin D, leukotrienes, thromboxane and platelet activating factor (PAF) can result to further myocardial damage and anaphylaxis associated acute coronary syndrome, the so-called Kounis syndrome. Kounis syndrome with increase of cardiac troponin and other cardiac biomarkers, can progress to heart failure and cardiovascular collapse. In experimental anaphylaxis, cardiac reactions caused by the intracardiac histamine and release of other anaphylactic mediators are followed by secondary cardiovascular reactions, such as cardiac arrhythmias, atrioventricular block, acute myocardial ischemia, decrease in coronary blood flow and cardiac output, cerebral blood flow, left ventricular developed pressure (LVdp/dtmax) as well as increase in portal venous and coronary vascular resistance denoting vascular spasm. Clinically, some patients with anaphylactic myocardial infarction respond satisfactorily to appropriate interventional and medical therapy, while anti-allergic treatment with antihistamines, corticosteroids and fluid replacement might be ineffective. Therefore, differentiating the decrease of cardiac output due to myocardial tissue hypoperfusion from systemic vasodilation and leakage of plasma, from myocardial tissue due to coronary vasoconstriction and thrombosis might be challenging during anaphylactic cardiac collapse. Combined antiallergic, anti-ischemic and antithrombotic treatment seems currently beneficial. Simultaneous measurements of peripheral arterial resistance and coronary blood flow with newer diagnostic techniques including cardiac magnetic resonance imaging (MRI) and myocardial scintigraphy may help elucidating the pathophysiology of anaphylactic cardiovascular collapse, thus rendering treatment more rapid and effective.
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Affiliation(s)
- Nicholas G Kounis
- Department of Cardiology University of Patras Medical School, Rion, Patras, Achaia, Greece
| | | | - Ioanna Koniari
- Department of Electrophysiology, Queen Elizabeth Hospital, Birmingham, England
| | - Laura Bonfanti
- Emergency Department, Academic Hospital of Parma, Parma, Italy
| | | | - Nikolaos Charokopos
- Division of Pneumology, Department of Internal Medicine, General Hospital of Pirgos, Pirgos, Greece
| | - Stelios F Assimakopoulos
- Department of Internal Medicine, Division of Infectious Diseases, University of Patras Medical School, Patras, Greece
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Ioannis G Ntouvas
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - George D Soufras
- Department of Cardiology, "Saint Andrews State General Hospital", Patras, Achaia, Greece
| | - Ioannis Tsolakis
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
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Adachi H, Ihara M, Nojima Y, Kurimoto T, Nanto S. Kounis syndrome caused by anaphylaxis without skin manifestations after cefazolin administration. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:317-319. [PMID: 29902529 DOI: 10.1016/j.jaip.2018.05.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 05/22/2018] [Accepted: 05/23/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Hidenori Adachi
- Department of Cardiology, Nishinomiya Municipal Central Hospital, Nishinomiya City, Hyogo, Japan.
| | - Madoka Ihara
- Department of Cardiology, Nishinomiya Municipal Central Hospital, Nishinomiya City, Hyogo, Japan
| | - Yuhei Nojima
- Department of Cardiology, Nishinomiya Municipal Central Hospital, Nishinomiya City, Hyogo, Japan
| | - Tetsuya Kurimoto
- Department of Cardiology, Nishinomiya Municipal Central Hospital, Nishinomiya City, Hyogo, Japan
| | - Sinsuke Nanto
- Department of Cardiology, Nishinomiya Municipal Central Hospital, Nishinomiya City, Hyogo, Japan
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Figueras J, Otaegui I, Marti G, Domingo E, Bañeras J, Barrabés JA, del Blanco BG, Garcia-Dorado D. Area at risk and collateral circulation in a first acute myocardial infarction with occluded culprit artery. STEMI vs non-STEMI patients. Int J Cardiol 2018; 259:14-19. [DOI: 10.1016/j.ijcard.2018.01.047] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 01/09/2018] [Accepted: 01/10/2018] [Indexed: 11/28/2022]
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Feinberg J, Nielsen EE, Greenhalgh J, Hounsome J, Sethi NJ, Safi S, Gluud C, Jakobsen JC. Drug-eluting stents versus bare-metal stents for acute coronary syndrome. Cochrane Database Syst Rev 2017; 8:CD012481. [PMID: 28832903 PMCID: PMC6483499 DOI: 10.1002/14651858.cd012481.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Approximately 3.7 million people died from acute coronary syndrome worldwide in 2012. Acute coronary syndrome, also known as myocardial infarction or unstable angina pectoris, is caused by a sudden blockage of the blood supplied to the heart muscle. Percutaneous coronary intervention is often used for acute coronary syndrome, but previous systematic reviews on the effects of drug-eluting stents compared with bare-metal stents have shown conflicting results with regard to myocardial infarction; have not fully taken account of the risk of random and systematic errors; and have not included all relevant randomised clinical trials. OBJECTIVES To assess the benefits and harms of drug-eluting stents versus bare-metal stents in people with acute coronary syndrome. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, SCI-EXPANDED, and BIOSIS from their inception to January 2017. We also searched two clinical trials registers, the European Medicines Agency and the US Food and Drug Administration databases, and pharmaceutical company websites. In addition, we searched the reference lists of review articles and relevant trials. SELECTION CRITERIA Randomised clinical trials assessing the effects of drug-eluting stents versus bare-metal stents for acute coronary syndrome. We included trials irrespective of publication type, status, date, or language. DATA COLLECTION AND ANALYSIS We followed our published protocol and the methodological recommendations of Cochrane. Two review authors independently extracted data. We assessed the risks of systematic error by bias domains. We conducted Trial Sequential Analyses to control the risks of random errors. Our primary outcomes were all-cause mortality, major cardiovascular events, serious adverse events, and quality of life. Our secondary outcomes were angina, cardiovascular mortality, and myocardial infarction. Our primary assessment time point was at maximum follow-up. We assessed the quality of the evidence by the GRADE approach. MAIN RESULTS We included 25 trials randomising a total of 12,503 participants. All trials were at high risk of bias, and the quality of evidence according to GRADE was low to very low. We included 22 trials where the participants presented with ST-elevation myocardial infarction, 1 trial where participants presented with non-ST-elevation myocardial infarction, and 2 trials where participants presented with a mix of acute coronary syndromes.Meta-analyses at maximum follow-up showed no evidence of a difference when comparing drug-eluting stents with bare-metal stents on the risk of all-cause mortality or major cardiovascular events. The absolute risk of death was 6.97% in the drug-eluting stents group compared with 7.74% in the bare-metal stents group based on the risk ratio (RR) of 0.90 (95% confidence interval (CI) 0.78 to 1.03, 11,250 participants, 21 trials/22 comparisons, low-quality evidence). The absolute risk of a major cardiovascular event was 6.36% in the drug-eluting stents group compared with 6.63% in the bare-metal stents group based on the RR of 0.96 (95% CI 0.83 to 1.11, 10,939 participants, 19 trials/20 comparisons, very low-quality evidence). The results of Trial Sequential Analysis showed that we did not have sufficient information to confirm or reject our anticipated risk ratio reduction of 10% on either all-cause mortality or major cardiovascular events at maximum follow-up.Meta-analyses at maximum follow-up showed evidence of a benefit when comparing drug-eluting stents with bare-metal stents on the risk of a serious adverse event. The absolute risk of a serious adverse event was 18.04% in the drug-eluting stents group compared with 23.01% in the bare-metal stents group based on the RR of 0.80 (95% CI 0.74 to 0.86, 11,724 participants, 22 trials/23 comparisons, low-quality evidence), and Trial Sequential Analysis confirmed this result. When assessing each specific type of adverse event included in the serious adverse event outcome separately, the majority of the events were target vessel revascularisation. When target vessel revascularisation was analysed separately, meta-analysis showed evidence of a benefit of drug-eluting stents, and Trial Sequential Analysis confirmed this result.Meta-analyses at maximum follow-up showed no evidence of a difference when comparing drug-eluting stents with bare-metal stents on the risk of cardiovascular mortality (RR 0.91, 95% CI 0.76 to 1.09, 9248 participants, 14 trials/15 comparisons, very low-quality evidence) or myocardial infarction (RR 0.98, 95% CI 0.82 to 1.18, 10,217 participants, 18 trials/19 comparisons, very low-quality evidence). The results of the Trial Sequential Analysis showed that we had insufficient information to confirm or reject our anticipated risk ratio reduction of 10% on cardiovascular mortality and myocardial infarction.No trials reported results on quality of life or angina. AUTHORS' CONCLUSIONS The current evidence suggests that drug-eluting stents may lead to fewer serious adverse events compared with bare-metal stents without increasing the risk of all-cause mortality or major cardiovascular events. However, our Trial Sequential Analysis showed that there currently was not enough information to assess a risk ratio reduction of 10% for all-cause mortality, major cardiovascular events, cardiovascular mortality, or myocardial infarction, and there were no data on quality of life or angina. The evidence in this review was of low to very low quality, and the true result may depart substantially from the results presented in this review.More randomised clinical trials with low risk of bias and low risks of random errors are needed if the benefits and harms of drug-eluting stents for acute coronary syndrome are to be assessed properly. More data are needed on the outcomes all-cause mortality, major cardiovascular events, quality of life, and angina to reduce the risk of random error.
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Affiliation(s)
- Joshua Feinberg
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen, Denmark, 2100
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Smyth A, O'Donnell M, Lamelas P, Teo K, Rangarajan S, Yusuf S. Physical Activity and Anger or Emotional Upset as Triggers of Acute Myocardial Infarction: The INTERHEART Study. Circulation 2017; 134:1059-1067. [PMID: 27753614 DOI: 10.1161/circulationaha.116.023142] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 08/31/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Physical exertion, anger, and emotional upset are reported to trigger acute myocardial infarction (AMI). In the INTERHEART study, we explored the triggering association of acute physical activity and anger or emotional upset with AMI to quantify the importance of these potential triggers in a large, international population. METHODS INTERHEART was a case-control study of first AMI in 52 countries. In this analysis, we included only cases of AMI and used a case-crossover approach to estimate odds ratios for AMI occurring within 1 hour of triggers. RESULTS Of 12 461 cases of AMI 13.6% (n=1650) engaged in physical activity and 14.4% (n=1752) were angry or emotionally upset in the case period (1 hour before symptom onset). Physical activity in the case period was associated with increased odds of AMI (odds ratio, 2.31; 99% confidence interval [CI], 1.96-2.72) with a population-attributable risk of 7.7% (99% CI, 6.3-8.8). Anger or emotional upset in the case period was associated with an increased odds of AMI (odds ratio, 2.44; 99% CI, 2.06-2.89) with a population-attributable risk of 8.5% (99% CI, 7.0-9.6). There was no effect modification by geographical region, prior cardiovascular disease, cardiovascular risk factor burden, cardiovascular prevention medications, or time of day or day of onset of AMI. Both physical activity and anger or emotional upset in the case period were associated with a further increase in the odds of AMI (odds ratio, 3.05; 99% CI, 2.29-4.07; P for interaction <0.001). CONCLUSIONS Physical exertion and anger or emotional upset are triggers associated with first AMI in all regions of the world, in men and women, and in all age groups, with no significant effect modifiers.
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Affiliation(s)
- Andrew Smyth
- From Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada (A.S., M.O., P.L., K.T., S.R., S.Y.); and HRB Clinical Research Facility Galway, National University of Ireland Galway, Galway, Ireland (A.S., M.O.)
| | - Martin O'Donnell
- From Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada (A.S., M.O., P.L., K.T., S.R., S.Y.); and HRB Clinical Research Facility Galway, National University of Ireland Galway, Galway, Ireland (A.S., M.O.)
| | - Pablo Lamelas
- From Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada (A.S., M.O., P.L., K.T., S.R., S.Y.); and HRB Clinical Research Facility Galway, National University of Ireland Galway, Galway, Ireland (A.S., M.O.)
| | - Koon Teo
- From Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada (A.S., M.O., P.L., K.T., S.R., S.Y.); and HRB Clinical Research Facility Galway, National University of Ireland Galway, Galway, Ireland (A.S., M.O.)
| | - Sumathy Rangarajan
- From Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada (A.S., M.O., P.L., K.T., S.R., S.Y.); and HRB Clinical Research Facility Galway, National University of Ireland Galway, Galway, Ireland (A.S., M.O.)
| | - Salim Yusuf
- From Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada (A.S., M.O., P.L., K.T., S.R., S.Y.); and HRB Clinical Research Facility Galway, National University of Ireland Galway, Galway, Ireland (A.S., M.O.).
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Feinberg J, Nielsen EE, Greenhalgh J, Hounsome J, Sethi NJ, Safi S, Gluud C, Jakobsen JC. Drug-eluting stents versus bare-metal stents for acute coronary syndrome. Cochrane Database Syst Rev 2016. [DOI: 10.1002/14651858.cd012481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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21
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de Hoog VC, Lim SH, Bank IEM, Gijsberts CM, Ibrahim IB, Kuan WS, Ooi SBS, Chua T, den Ruijter HM, Pasterkamp G, Tai ES, Gao F, Doevendans PA, Wildbergh TX, Mosterd A, Richards AM, de Kleijn DPV, Timmers L. Ethnic differences in clinical outcome of patients presenting to the emergency department with chest pain. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 5:32-40. [DOI: 10.1177/2048872615623064] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Vince C de Hoog
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, The Netherlands
- ICIN – Netherlands Heart Institute, The Netherlands
- Department of Medicine, National University of Singapore, Singapore
| | - Swee Han Lim
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Ingrid EM Bank
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, The Netherlands
- Department of Cardiology, Meander Medical Center, The Netherlands
| | - Crystel M Gijsberts
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, The Netherlands
- ICIN – Netherlands Heart Institute, The Netherlands
| | - Irwani B Ibrahim
- Department of Emergency Medicine, National University Hospital, Singapore
| | - Win Sen Kuan
- Department of Emergency Medicine, National University Hospital, Singapore
| | - Shirley BS Ooi
- Department of Emergency Medicine, National University Hospital, Singapore
| | | | - Hester M den Ruijter
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, The Netherlands
| | - Gerard Pasterkamp
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, The Netherlands
- Department of Clinical Chemistry and Hematology, UMC Utrecht, The Netherlands
| | - E Shyong Tai
- Department of Medicine, National University of Singapore, Singapore
| | - Fei Gao
- National Heart Center Singapore, Singapore
- Center for Quantitative Medicine, Duke-NUS Graduate Medical School, Singapore
| | | | | | - Arend Mosterd
- Department of Cardiology, Meander Medical Center, The Netherlands
- Department of Cardiology, UMC Utrecht, The Netherlands
| | - A Mark Richards
- Medicine NUS and Cardiovascular Research Institute, NUHS, Singapore
- Christchurch Heart Institute, University of Otago, New Zealand
| | - Dominique PV de Kleijn
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, The Netherlands
- ICIN – Netherlands Heart Institute, The Netherlands
- Surgery NUS and Cardiovascular Research Institute, NUHS, Singapore
| | - Leo Timmers
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, The Netherlands
- Department of Cardiology, UMC Utrecht, The Netherlands
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Canpolat U, Turak O, Özcan F, Öksüz F, Mendi MA, Yayla Ç, Aydoğdu S. Impact of free thyroxine levels and other clinical factors on bare metal stent restenosis. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2016; 61:130-136. [PMID: 28489156 PMCID: PMC10118861 DOI: 10.1590/2359-3997000000197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Accepted: 03/07/2016] [Indexed: 11/22/2022]
Abstract
Objective Thyroid hormones have both direct and indirect effects on thermogenesis such as modulating vascular smooth muscle cell proliferation. However, the influence of more subtle changes in thyroid hormones on coronary atherosclerosis remains a matter of speculation. Smooth muscle cells play a crucial role in the pathogenesis of in-stent restenosis (ISR). However, the relationship between free thyroxine (fT4) and ISR has not been studied. In the present study, we aimed to assess the role of preprocedural serum fT4 level on the development of ISR in patients undergoing coronary bare metal stent (BMS) implantation. Materials and methods We enrolled and analyzed clinical, biochemical, and angiographic data from 705 consecutive patients without a history of primary thyroid disease [mean age 60.3 ± 9.3 years, 505 (72%) male]; all patients had undergone BMS implantation and further control coronary angiography owing to stable or unstable angina pectoris. Patients were divided into 3 tertiles based on preprocedural serum fT4 levels. Results ISR was observed in 53 (23%) patients in the lowest tertile, 82 (35%) patients in the second tertile, and 107 (46%) patients in the highest fT4 tertile (p < 0.001). Using multiple logistic regression analysis, five characteristics emerged as independent predictors of ISR: diabetes mellitus, smoking, HDL-cholesterol, stent length, and preprocedural serum fT4 level. In receiver operating characteristics curve analysis, fT4 level > 1.23 mg/dL had 70% sensitivity and 73% specificity (AUC: 0.75, p < 0.001) in predicting ISR. Conclusion Higher preprocedural serum fT4 is a powerful and independent predictor of BMS restenosis in patients with stable and unstable angina pectoris.
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Affiliation(s)
- Uğur Canpolat
- Türkiye Yüksek Ihtisas Training and Research Hospital, Cardiology Clinic, Ankara, Turkey
| | - Osman Turak
- Türkiye Yüksek Ihtisas Training and Research Hospital, Cardiology Clinic, Ankara, Turkey
| | - Fırat Özcan
- Türkiye Yüksek Ihtisas Training and Research Hospital, Cardiology Clinic, Ankara, Turkey
| | - Fatih Öksüz
- Türkiye Yüksek Ihtisas Training and Research Hospital, Cardiology Clinic, Ankara, Turkey
| | - Mehmet Ali Mendi
- Türkiye Yüksek Ihtisas Training and Research Hospital, Cardiology Clinic, Ankara, Turkey
| | - Çağrı Yayla
- Türkiye Yüksek Ihtisas Training and Research Hospital, Cardiology Clinic, Ankara, Turkey
| | - Sinan Aydoğdu
- Türkiye Yüksek Ihtisas Training and Research Hospital, Cardiology Clinic, Ankara, Turkey
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Alsancak Y, Ali S, Duran M, Polat M, Sivri S, Bilge M. A rare case of Kounis syndrome provoked by mad honey poisoning. INTERNATIONAL JOURNAL OF THE CARDIOVASCULAR ACADEMY 2016. [DOI: 10.1016/j.ijcac.2016.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Fanning JP, Nyong J, Scott IA, Aroney CN, Walters DL. Routine invasive strategies versus selective invasive strategies for unstable angina and non-ST elevation myocardial infarction in the stent era. Cochrane Database Syst Rev 2016; 2016:CD004815. [PMID: 27226069 PMCID: PMC8568369 DOI: 10.1002/14651858.cd004815.pub4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND People with unstable angina and non-ST elevation myocardial infarction (UA/NSTEMI) are managed with a combination of medical therapy, invasive angiography and revascularisation. Specifically, two approaches have evolved: either a 'routine invasive' strategy whereby all patients undergo coronary angiography shortly after admission and, if indicated, coronary revascularisation; or a 'selective invasive' (also referred to as 'conservative') strategy in which medical therapy alone is used initially, with a selection of patients for angiography based upon evidence of persistent myocardial ischaemia. Uncertainty exists as to which strategy provides the best outcomes for these patients. This Cochrane review is an update of a Cochrane review originally published in 2006, to provide a robust comparison of these two strategies in the early management of patients with UA/NSTEMI. OBJECTIVES To determine the benefits and harms associated with the following.1. A routine invasive versus a conservative or 'selective invasive' strategy for the management of UA/NSTEMI in the stent era.2. A routine invasive strategy with and without glycoprotein IIb/IIIa receptor antagonists versus a conservative strategy for the management of UA/NSTEMI in the stent era. SEARCH METHODS We searched the following databases and additional resources up to 25 August 2015: the Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library, MEDLINE and EMBASE, with no language restrictions. SELECTION CRITERIA We included prospective randomised controlled trials (RCTs) that compared invasive with conservative or 'selective invasive' strategies in participants with acute UA/NSTEMI. DATA COLLECTION AND ANALYSIS Two review authors screened the records and extracted data in duplicate. Using intention-to-treat analysis with random-effects models, we calculated summary estimates of the risk ratio (RR) with 95% confidence intervals (CIs) for the primary endpoints of all-cause death, fatal and non-fatal myocardial infarction (MI), combined all-cause death or non-fatal MI, refractory angina and re-hospitalisation. We performed further analysis of included studies based on whether glycoprotein IIb/IIIa receptor antagonists were used routinely. We assessed the heterogeneity of included trials using Pearson χ² (Chi² test) and variance (I² statistic) analysis. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, we assessed the quality of the evidence and the GRADE profiler (GRADEPRO) was used to import data from Review Manager 5.3 (Review Manager) to create Summary of findings (SoF) tables. MAIN RESULTS Eight RCTs with a total of 8915 participants (4545 invasive strategies, 4370 conservative strategies) were eligible for inclusion. We included three new studies and 1099 additional participants in this review update. In the all-study analysis, evidence did not show appreciable risk reductions in all-cause mortality (RR 0.87, 95% CI 0.64 to 1.18; eight studies, 8915 participants; low quality evidence) and death or non-fatal MI (RR 0.93, 95% CI 0.71 to 1.2; seven studies, 7715 participants; low quality evidence) with invasive strategies compared to conservative (selective invasive) strategies at six to 12 months follow-up. There was appreciable risk reduction in MI (RR 0.79, 95% CI 0.63 to 1.00; eight studies, 8915 participants; moderate quality evidence), refractory angina (RR 0.64, 95% CI 0.52 to 0.79; five studies, 8287 participants; moderate quality evidence) and re-hospitalisation (RR 0.77, 95% CI 0.63 to 0.94; six studies, 6921 participants; moderate quality evidence) with routine invasive strategies compared to conservative (selective invasive) strategies also at six to 12 months follow-up.Evidence also showed increased risks in bleeding (RR 1.73, 95% CI 1.30 to 2.31; six studies, 7584 participants; moderate quality evidence) and procedure-related MI (RR 1.87, 95% CI 1.47 to 2.37; five studies, 6380 participants; moderate quality evidence) with routine invasive strategies compared to conservative (selective invasive) strategies.The low quality evidence were as a result of serious risk of bias and imprecision in the estimate of effect while moderate quality evidence was only due to serious risk of bias. AUTHORS' CONCLUSIONS In the all-study analysis, the evidence failed to show appreciable benefit with routine invasive strategies for unstable angina and non-ST elevation MI compared to conservative strategies in all-cause mortality and death or non-fatal MI at six to 12 months. There was evidence of risk reduction in MI, refractory angina and re-hospitalisation with routine invasive strategies compared to conservative (selective invasive) strategies at six to 12 months follow-up. However, routine invasive strategies were associated with a relatively high risk (almost double the risk) of procedure-related MI, and increased risk of bleeding complications. This systematic analysis of published RCTs supports the conclusion that, in patients with UA/NSTEMI, a selectively invasive (conservative) strategy based on clinical risk for recurrent events is the preferred management strategy.
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Affiliation(s)
- Jonathon P Fanning
- The Prince Charles HospitalSchool of Medicine, The University of QueenslandRode RoadChermsideBrisbaneAustralia4032
| | - Jonathan Nyong
- FARR Institute UCLClinical Epidemiology222 Euston RoadLondonGreater LondonUKNW1 2DA
| | - Ian A Scott
- Princess Alexandra HospitalInternal Medicine Department and Clinical Services Evaluation UnitBrisbaneAustralia
| | - Constantine N Aroney
- The Prince Charles HospitalDepartment of CardiologyRode RdChermsideBrisbaneAustralia
| | - Darren L Walters
- The Prince Charles HospitalExecutive Chair Prince Charles Heart and Lung InstituteRoad RdBrisbaneQueenslandAustralia4032
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Li Z, Li Y, Zhang T, Miao W, Su G. Comparison of the influence of ticagrelor and clopidogrel on inflammatory biomarkers and vascular endothelial function for patients with ST-segment elevation myocardial infarction receiving emergency percutaneous coronary intervention: study protocol for a randomized controlled trial. Trials 2016; 17:75. [PMID: 26865043 PMCID: PMC4750211 DOI: 10.1186/s13063-016-1168-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 01/11/2016] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The Platelet Inhibition and Patient Outcomes (PLATO, Eur J Prev Cardiol 22(6):734-42, 2015) trial shows that, in patients who have an acute coronary syndrome, treatment with ticagrelor as compared with clopidogrel significantly reduced the rate of death, but the reason is still uncertain. Both inflammation and vascular endothelian cell dysfunction play important roles in the pathophysiology of atherosclerotic plaques, but whether ticagrelor has superior anti-inflammatory effect and can improve vascular endothelial cell function to a great extent is unknown. METHODS/DESIGN Patients with STEMI who are scheduled to undergo emergency percutaneous coronary intervention (PCI) will be randomly assigned to receive a loading dose of ticagrelor 180 mg as the treatment group or clopidogrel 600 mg as the control group. After PCI, the treatment group will be treated with ticagrelor 90 mg twice daily while the control group will be treated with clopidogrel 75 mg once daily. The vascular endothelial function will be tested by circulating endothelial cells, and levels of inflammation will be tested by CD40 ligand (CD40L), high sensitivity C-reactive protein (hsCRP) and P-selectin. The estimated enrollment sample size will be 350 patients, including 175 in the treatment group and 175 in the control group. DISCUSSION This study will compare the influence of ticagrelor and clopidogrel on inflammatory biomarkers and vascular endothelial function firstly for STEMI patients receiving emergency PCI and will provide evidence to identify whether ticagrelor inhibits inflammation and improves vascular endothelial cell function to a greater extent than clopidogrel or not. TRIAL REGISTRATION This trial was registered with Clinicaltrials.gov (identifier: NCT02123004) on 20 April 2014.
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Affiliation(s)
- Zhenhua Li
- Department of Cardiology, Jinan Central Hospital, Shandong, China.
| | - Yueyan Li
- Department of Cardiology, Jinan Central Hospital, Shandong, China.
| | - Tao Zhang
- Department of Orthopedics, Jinan Central Hospital, Shandong, China.
| | - Wei Miao
- Department of Cardiology, Jinan Central Hospital, Shandong, China.
| | - Guohai Su
- Department of Cardiology, Jinan Central Hospital, Shandong, China.
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Kounis NG. Kounis syndrome: an update on epidemiology, pathogenesis, diagnosis and therapeutic management. ACTA ACUST UNITED AC 2016; 54:1545-59. [DOI: 10.1515/cclm-2016-0010] [Citation(s) in RCA: 180] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 02/03/2016] [Indexed: 12/14/2022]
Abstract
AbstractKounis syndrome has been established as a hypersensitivity coronary disorder induced by various conditions, drugs, environmental exposures, foods and coronary stents. Allergic, hypersensitivity, anaphylactic and anaphylactoid reactions are associated with this syndrome. Vasospastic allergic angina, allergic myocardial infarction and stent thrombosis with occluding thrombus infiltrated by eosinophils and/or mast cells constitute are the three reported, so far, variants of this syndrome. Apart from coronary arteries, it affects the cerebral and mesenteric arteries. Its manifestations are broadening and its etiology is continuously increasing. Kounis syndrome is a ubiquitous disease which represents a magnificent natural paradigm and nature’s own experiment in a final trigger pathway implicated in cases of coronary artery spasm and plaque rupture. Kounis syndrome seems to be not a rare disease but an infrequently diagnosed clinical entity which has revealed that the same mediators released from the same inflammatory cells are also present and in acute coronary events of non allergic etiology. These cells are not only present in the culprit region before plaque erosion or rupture but they release their contents just before an actual coronary event. Therefore, awareness of etiology, epidemiology, pathogenesis and clinical manifestations seems to be important for its prognosis, diagnosis, treatment, prevention.
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Elevated Circulating Levels of Inflammatory Markers in Patients with Acute Coronary Syndrome. Int J Vasc Med 2015; 2015:805375. [PMID: 26504600 PMCID: PMC4609512 DOI: 10.1155/2015/805375] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 09/13/2015] [Accepted: 09/16/2015] [Indexed: 02/06/2023] Open
Abstract
Objective. We evaluated inflammatory cytokines and chemokine in peripheral blood mononuclear cells (PBMCs) in patients with either acute coronary syndrome (ACS) or stable coronary artery disease (CAD). Methods. We enrolled 20 ACS patients and 50 stable CAD patients without previous history of ACS who underwent cardiac catheterization. Patients with an estimated glomerular filtration rate of ≤30 mL/min/1.73 m(2) and C-reactive protein of ≥1.0 mg/dL were excluded. Blood samples were collected from the patients just before catheterization, and PBMCs were isolated from the whole blood. The levels of inflammatory cytokines and chemokine were measured by using real-time quantitative polymerase chain reaction and immunoassays. Results. The expression of tumor necrosis factor alpha (TNF-α), interleukin- (IL-) 6, IL-10, IL-23A, IL-27, and IL-37 was significantly higher in the ACS group than in the CAD group (P < 0.05). In contrast, the expression of IL-33 was significantly lower in the ACS group than in the CAD group (P < 0.05). The ACS patients had higher plasma levels of TNF-α, IL-6, and IL-10 in the ACS group than in the CAD group. Conclusion. Circulating levels of pro-/anti-inflammatory cytokines, including IL-23A, IL-27, IL-33, and IL-37, may be associated with the pathogenesis of atherosclerosis in ACS patients.
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Cervellin G, Lippi G, Kounis NG. Letter by Cervellin et al Regarding Article, “Allergic Inflammation Is Associated With Coronary Instability and a Worse Clinical Outcome After Acute Myocardial Infarction”. Circ Cardiovasc Interv 2015; 8:CIRCINTERVENTIONS.115.003166. [DOI: 10.1161/circinterventions.115.003166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Giuseppe Lippi
- Laboratory of Clinical Chemistry and Hematology, Academic Hospital of Parma, Parma, Italy
| | - Nicholas G. Kounis
- Department of Medical Sciences, Southwestern Greece Highest Institute of Education and Technology, Patras, Achaia, Greece
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Sueda S, Sasaki Y, Habara H, Kohno H. Editorial: Kounis syndrome (allergic angina and allergic myocardial infarction) for cardiologists. J Cardiol Cases 2015; 12:110-112. [PMID: 30546570 PMCID: PMC6281834 DOI: 10.1016/j.jccase.2015.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Indexed: 11/08/2022] Open
Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Ehime Prefectural Niihama Hospital, Ehime, Japan
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Abstract
This article discusses the approach to the management of myocardial infarction (MI) in the intensive care unit setting. It includes an overview of the definition, classification, and underlying pathologic conditions of acute MI and specifically discusses the diagnosis and management of unstable angina, non-ST elevation MI, and ST-segment elevation MI. Diagnosis and treatment of the acute complications of MI are also reviewed.
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Affiliation(s)
- Akram W Ibrahim
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Emory University Hospital Midtown, Medical Office Tower, 550 Peachtree Street, Atlanta, GA 30308, USA
| | - Thomas C Riddell
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Emory University Hospital Midtown, Medical Office Tower, 550 Peachtree Street, Atlanta, GA 30308, USA
| | - Chandan M Devireddy
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Emory University Hospital Midtown, Medical Office Tower, 550 Peachtree Street, Atlanta, GA 30308, USA.
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Baber U, Mehran R, Sartori S, Schoos MM, Sillesen H, Muntendam P, Garcia MJ, Gregson J, Pocock S, Falk E, Fuster V. Prevalence, impact, and predictive value of detecting subclinical coronary and carotid atherosclerosis in asymptomatic adults: the BioImage study. J Am Coll Cardiol 2015; 65:1065-74. [PMID: 25790876 DOI: 10.1016/j.jacc.2015.01.017] [Citation(s) in RCA: 335] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Revised: 01/06/2015] [Accepted: 01/11/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although recent studies suggest that measuring coronary artery calcification (CAC) may be superior to indirect atherosclerotic markers in predicting cardiac risk, there are limited data evaluating imaging-based biomarkers that directly quantify atherosclerosis in different vascular beds performed in a single cohort. OBJECTIVES The BioImage Study (A Clinical Study of Burden of Atherosclerotic Disease in an At-Risk Population) sought to identify imaging biomarkers that predict near-term (3-year) atherothrombotic events. METHODS The BioImage Study enrolled 5,808 asymptomatic U.S. adults (mean age: 69 years, 56.5% female) in a prospective cohort evaluating the role of vascular imaging on cardiovascular risk prediction. All patients were evaluated by CAC and novel 3-dimensional carotid ultrasound. Plaque areas from both carotid arteries were summed as the carotid plaque burden (cPB). The primary endpoint was the composite of major adverse cardiac events (MACE) (cardiovascular death, myocardial infarction, and ischemic stroke). A broader secondary MACE endpoint also included all-cause death, unstable angina, and coronary revascularization. RESULTS Over a median follow-up of 2.7 years, MACE occurred in 216 patients (4.2%), of which 82 (1.5%) were primary events. After adjustment for risk factors, and compared with individuals without any cPB, hazard ratios for MACE were 0.78 (95% confidence interval [CI]: 0.31 to 1.91), 1.45 (95% CI: 0.67 to 3.14), and 2.36 (95% CI: 1.13 to 4.92) with increasing cPB tertile, with similar results for CAC. Net reclassification significantly improved with either cPB (0.23) or CAC (0.25). MACE rates increased simultaneously with higher levels of both cPB and CAC. CONCLUSIONS Detection of subclinical carotid or coronary atherosclerosis improves risk predictions and reclassification compared with conventional risk factors, with comparable results for either modality. Cost-effective analyses are warranted to define the optimal roles of these complementary techniques. (BioImage Study: A Clinical Study of Burden of Atherosclerotic Disease in an At-Risk Population; NCT00738725).
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Affiliation(s)
- Usman Baber
- Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Roxana Mehran
- Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Samantha Sartori
- Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Mikkel Malby Schoos
- Department of Vascular Surgery, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | | | - Mario J Garcia
- Division of Cardiology, Montefiore Medical Center, Bronx, New York
| | - John Gregson
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Erling Falk
- Department of Cardiology, Aarhus University Hospital, Skejby, Aarhus, Denmark
| | - Valentin Fuster
- Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York, New York.
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Schlett CL, Hoffmann U, Geisler T, Nikolaou K, Bamberg F. Cardiac computed tomography for the evaluation of the acute chest pain syndrome: state of the art. Radiol Clin North Am 2015; 53:297-305. [PMID: 25726995 DOI: 10.1016/j.rcl.2014.11.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Coronary computed tomography angiography (CCTA) is recommended for the triage of acute chest pain in patients with a low-to-intermediate likelihood for acute coronary syndrome. Absence of coronary artery disease (CAD) confirmed by CCTA allows rapid emergency department discharge. This article shows that CCTA-based triage is as safe as traditional triage, reduces the hospital length of stay, and may provide cost-effective or even cost-saving care.
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Affiliation(s)
- Christopher L Schlett
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, Heidelberg 69120, Germany; Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge St, Suite 400, Boston, MA 02114, USA
| | - Udo Hoffmann
- Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge St, Suite 400, Boston, MA 02114, USA
| | - Tobias Geisler
- Department of Cardiology and Cardiovascular Medicine University Hospital of Tübingen, Hoppe-Seyler-Straβe 3, Tübingen 72076, Germany
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Hoppe-Seyler-Straβe 3, Tübingen 72076, Germany
| | - Fabian Bamberg
- Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge St, Suite 400, Boston, MA 02114, USA; Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Hoppe-Seyler-Straβe 3, Tübingen 72076, Germany.
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Gunawardena MDVM, Weerasinghe A, Herath J, Amarasena N. Myocardial infarction associated with eosinophilia and plasma extravasation at multiple sites. A variant of Kounis syndrome. BMJ Case Rep 2015; 2015:bcr-2014-207987. [PMID: 25608982 DOI: 10.1136/bcr-2014-207987] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Myocardial infarction occurring during the course of type I hypersensitivity constitutes Kounis syndrome. We report a case of a 38-year-old man who presented with anterior ST elevation myocardial infarction and peripheral blood eosinophilia. He had rhinitis and malaise for several days prior to presentation. There was no urticarial rash or pruritus to suggest hypersensitivity. Coronary angiogram revealed only mild plaque disease. Blood investigations revealed moderate eosinophilia and elevated IgE levels. CT of the thorax revealed fluid extravasation at multiple sites. Screening for a possible secondary cause for eosinophilia revealed hypersensitivity to multiple antigens. A diagnosis of Kounis syndrome was made. Within days of starting steroids and antihistamines, the patient's eosinophil count returned to normal with improvement of clinical picture. This case differs from classical Kounis syndrome as there was no acute allergic reaction (except atopic rhinitis). Fluid extravasation at multiple sites has not been described in previous cases.
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Affiliation(s)
| | - Anura Weerasinghe
- Department of Medicine, Dr Neville Fernando Teaching Hospital, Malabe, Sri Lanka
| | - Jagath Herath
- Department of Cardiology, Sri Jayawardenapura Teaching Hospital, Colombo, Sri Lanka
| | - Naomali Amarasena
- Department of Cardiology, Sri Jayawardenapura Teaching Hospital, Colombo, Sri Lanka
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A Case with Repeated Recurrent Acute Coronary Syndrome due to Pseudoephedrine Use: Kounis Syndrome. Case Rep Med 2014; 2014:742905. [PMID: 25435880 PMCID: PMC4243469 DOI: 10.1155/2014/742905] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 10/16/2014] [Indexed: 11/18/2022] Open
Abstract
Allergic reaction-associated acute coronary syndrome picture is defined as Kounis syndrome. Although drug use is the most common cause of allergic reaction, foods and environmental factors may also play a role in the etiology. Herein, a case with acute coronary syndrome that developed two times at 8-month interval due to pseudoephedrine use for upper respiratory tract infection is presented.
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Jing BB, Li YX, Zhang H, Ren ST, Wang M, Li YP, Shen XL, Wang YL, Zang WJ, Wang B. Antithrombotic effect of Z4A5 on coronary thrombosis in a canine model of acute unstable angina. Br J Pharmacol 2014; 169:848-59. [PMID: 23083032 DOI: 10.1111/bph.12026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Revised: 08/30/2012] [Accepted: 09/24/2012] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND AND PURPOSE The glycoprotein IIb/IIIa receptor is the final common pathway of platelet aggregation, regardless of the agonist, and thus represents an ideal therapeutic target for blocking coronary thrombosis. In this study, the anti-platelet and antithrombotic actions of Z4A5, a new glycoprotein IIb/IIIa receptor inhibitor, were evaluated in a canine model of acute unstable angina. EXPERIMENTAL APPROACH Z4A5 was given i.v. as a bolus followed by 60 min of continuous infusion at doses of 30 μg·kg⁻¹ + 1 μg·kg⁻¹·min⁻¹, 30 μg·kg⁻¹ + 5 μg·kg⁻¹·min⁻¹ or 300 μg·kg⁻¹ + 5 μg·kg⁻¹·min⁻¹. Its antithrombotic effect was evaluated in a model of coronary thrombosis, the injured, stenosed left circumflex coronary artery, in which platelet-dependent cyclic flow reductions (CFRs) were induced by vascular compression and constriction to simulate clinical acute unstable angina. Platelet aggregation and coagulation parameters were determined in platelet-rich plasma and platelet poor plasma respectively. KEY RESULTS The Z4A5 infusion induced a dose-dependent reduction in CFR frequency, which returned to baseline levels after the termination of the infusion at low doses. At medium dose that inhibited most part of platelet aggregation, it increased tongue bleeding time marginally with no dramatic changes in haemodynamic and coagulation parameters. Furthermore, the inhibition of ADP-induced platelet aggregation and prolonged bleeding time observed during Z4A5 infusion reverted to baseline levels after the termination of the infusion. CONCLUSIONS AND IMPLICATIONS Z4A5 is an effective antithrombotic agent for coronary artery thrombosis with a rapid-on and rapid-off pharmacological profile, and could be used as an alternative treatment of coronary artery ischaemic syndromes.
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Affiliation(s)
- Bo-Bin Jing
- School of Medicine, Xi'an Jiaotong University, Xi'an, Shaanxi, China
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Abstract
Detection of a rise and/or fall of cardiac troponin (cTn) is the cornerstone in the diagnosis of myocardial infarction (MI). For the acute risk, it is hypothesized that cTn mirrors activated coagulation and platelet reactivity and indicates the presence of a ruptured plaque, which may help to identify patients at high risk who benefit particularly from aggressive pharmacological treatment and early invasive strategy. High-sensitivity assays using the 99th percentile as the threshold for positivity can achieve sensitivity at presentation of 90 % or more, and performance further improves with subsequent measurements within 3 to 6 h. By 3 h, negative predictive values of almost 100 % have been reported. However, use of assays with higher sensitivity lead ultimately to a loss of clinical specificity. Thus, other conditions than MI, such as stroke, pulmonary embolism, sepsis, acute perimyocarditis, Takotsubo, acute heart failure and tachycardia also can go with elevated troponin levels. The detection of brief rise and subsequent fall of troponin concentration in marathon runners, and even in healthy subjects, after a standardized exercise test has cast doubts on the hypothesis that troponin is released only upon irreversible damage. This kind of troponin leakage may originate from a cytosolic compartment of the cells and not from the necrosis of thin filaments.
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Affiliation(s)
- Stefan Agewall
- Department of Cardiology, Oslo University Hospital Ullevål, and Institute of Clinical Sciences, University of Oslo, Oslo, Norway,
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Turak O, Canpolat U, Özcan F, Mendi MA, Oksüz F, Işleyen A, Gürel OM, Çay S, Aras D, Aydoğdu S. Usefulness of preprocedural serum uric acid level to predict restenosis of bare metal stents. Am J Cardiol 2014; 113:197-202. [PMID: 24157191 DOI: 10.1016/j.amjcard.2013.09.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 09/07/2013] [Accepted: 09/07/2013] [Indexed: 11/18/2022]
Abstract
Serum uric acid (SUA) level is known as a significant predictor for cardiovascular diseases, partly through increased inflammatory response and smooth muscle cell proliferation. Inflammation and smooth muscle cells play a crucial role in the pathogenesis of in-stent restenosis (ISR). However, the relation between SUA and ISR has not been studied. The aim of the present study was to investigate the predictive value of preprocedural SUA on the development of ISR in patients who undergo coronary bare-metal stent implantation. Clinical, biochemical, and angiographic data from 708 consecutive patients (mean age 60.3 ± 9.3 years, 71% men) who had undergone bare-metal stent implantation and additional control coronary angiography for stable or unstable angina pectoris were analyzed. Patients were divided into tertiles on the basis of preprocedural SUA levels. Stent restenosis was observed in 54 patients (23%) in the lowest tertile, in 79 (34%) in the middle tertile, and in 109 (46%) in the highest tertile (p <0.001). Using multiple logistic regression analysis, diabetes mellitus, smoking, high-density lipoprotein cholesterol, stent length, C-reactive protein level, and preprocedural SUA level emerged as independent predictors of ISR. On receiver-operating characteristics curve analysis, SUA level >5.5 mg/dl had 75% sensitivity and 71% specificity (area under the curve 0.784, p <0.001) in predicting ISR. In conclusion, higher preprocedural SUA is a powerful and independent predictor of bare-metal stent restenosis in patients with stable and unstable angina pectoris.
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Affiliation(s)
- Osman Turak
- Türkiye Yüksek Ihtisas Training and Research Hospital, Cardiology Clinic, Ankara, Turkey
| | - Uğur Canpolat
- Türkiye Yüksek Ihtisas Training and Research Hospital, Cardiology Clinic, Ankara, Turkey.
| | - Firat Özcan
- Türkiye Yüksek Ihtisas Training and Research Hospital, Cardiology Clinic, Ankara, Turkey
| | - Mehmet Ali Mendi
- Türkiye Yüksek Ihtisas Training and Research Hospital, Cardiology Clinic, Ankara, Turkey
| | - Fatih Oksüz
- Türkiye Yüksek Ihtisas Training and Research Hospital, Cardiology Clinic, Ankara, Turkey
| | - Ahmet Işleyen
- Türkiye Yüksek Ihtisas Training and Research Hospital, Cardiology Clinic, Ankara, Turkey
| | - Ozgül Malçok Gürel
- Department of Cardiology, Turgut Özal University Faculty of Medicine, Ankara, Turkey
| | - Serkan Çay
- Türkiye Yüksek Ihtisas Training and Research Hospital, Cardiology Clinic, Ankara, Turkey
| | - Dursun Aras
- Türkiye Yüksek Ihtisas Training and Research Hospital, Cardiology Clinic, Ankara, Turkey
| | - Sinan Aydoğdu
- Türkiye Yüksek Ihtisas Training and Research Hospital, Cardiology Clinic, Ankara, Turkey
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Acikel S, Ertem AG, Arslantas U, Cimen T, Dogan M, Yeter E. From treatment to diagnosis of Kounis syndrome in the catherization laboratory: The resolution of vasospastic angina after intracoronary tirofiban and nitrate therapy. Int J Cardiol 2013; 168:2943-6. [DOI: 10.1016/j.ijcard.2013.03.172] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 03/31/2013] [Indexed: 11/28/2022]
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Zoghbi WA, Arend TE, Oetgen WJ, May C, Bradfield L, Keller S, Ramadhan E, Tomaselli GF, Brown N, Robertson RM, Whitman GR, Bezanson JL, Hundley J. 2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. Circulation 2013; 127:e663-828. [DOI: 10.1161/cir.0b013e31828478ac] [Citation(s) in RCA: 181] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Karadeniz M, Akyel A, Çelik İE, Cankurt T, Barış VÖ, Murat SN. An unusual etiology of Kounis syndrome; warble fly. Indian Heart J 2013; 65:358-9. [DOI: 10.1016/j.ihj.2013.04.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2012] [Accepted: 04/03/2013] [Indexed: 11/24/2022] Open
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Jneid H, Ettinger SM, Ganiats TG, Philippides GJ, Jacobs AK, Halperin JL, Albert NM, Creager MA, DeMets D, Guyton RA, Kushner FG, Ohman EM, Stevenson W, Yancy CW. 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013; 61:e179-347. [PMID: 23639841 DOI: 10.1016/j.jacc.2013.01.014] [Citation(s) in RCA: 373] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Qin YW, Teng X, He JQ, Du J, Tang CS, Qi YF. Increased plasma levels of intermedin and brain natriuretic peptide associated with severity of coronary stenosis in acute coronary syndrome. Peptides 2013; 42:84-8. [PMID: 23391507 DOI: 10.1016/j.peptides.2013.01.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Revised: 01/21/2013] [Accepted: 01/21/2013] [Indexed: 02/07/2023]
Abstract
Intermedin (IMD) is a newly discovered peptide with increased levels in plasma and cardiac tissue in mice with ischemia/reperfusion. Continuous administration of low dose IMD markedly elevated the mRNA abundance of myocardial BNP in rats. Plasma BNP levels may reflect the severity of degree of coronary stenosis in patients with acute coronary syndrome (ACS). However, the role of circulating IMD in coronary heart disease remains unclear. We aimed to examine the plasma content of IMD and brain natriuretic peptide (BNP) and its clinical significance in patients with ACS. We collected plasma samples from 41 patients with ACS and 31 controls and measured IMD and BNP levels by radioimmunoassay. The severity of coronary artery stenosis for patients with ACS was measured by coronary angiography. Plasma IMD and BNP levels were markedly higher in ACS patients than that in controls (P<0.05). The increased plasma IMD and BNP were positively correlated with degree of coronary stenosis in ACS patients (r=0.263 and r=0.238, respectively, both P<0.05). In addition, plasma levels of IMD were positively correlated with BNP levels.
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Affiliation(s)
- Yan-Wen Qin
- The Key Laboratory of Remodeling-related Cardiovascular Diseases, Beijing An Zhen Hospital, Capital Medical University, Ministry of Education, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
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Pleister A, Selemon H, Elton SM, Elton TS. Circulating miRNAs: novel biomarkers of acute coronary syndrome? Biomark Med 2013; 7:287-305. [PMID: 23547823 DOI: 10.2217/bmm.13.8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Acute coronary syndrome refers to any group of clinical symptoms compatible with acute myocardial infarction (AMI). AMI is a major cause of death and disability worldwide with the greatest risk of death within the first hours of AMI onset. Therefore, delays in ‘ruling in’ AMI may increase morbidity and mortality due to the time lag in initiating therapy. Likewise, since the majority of patients presenting with acute chest pain do not have AMI, the rapid ‘ruling out’ of AMI in those patients would increase emergency department triage efficiency, decrease medical costs, and reduce morbidity and mortality. Thus, the identification of novel biomarkers that improve current strategies and/or accurately identify subjects who are at risk of developing acute and chronic manifestations of cardiovascular disease are desperately needed. This article discusses the potential of peripheral blood microRNAs as clinical biomarkers for the diagnosis and prognosis of cardiovascular diseases such as AMI.
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Affiliation(s)
- Adam Pleister
- Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University, 473 West 12th Avenue, OH 43210, USA
| | - Helina Selemon
- Davis Heart & Lung Research Institute, The Ohio State University, 473 West 12th Avenue, OH 43210, USA
| | | | - Terry S Elton
- College of Pharmacy, Division of Pharmacology, The Ohio State University, 473 West 12th Avenue, OH 43210, USA
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Sim DS, Ahn Y. Novel inflammatory biomarkers in acute coronary syndrome. Korean J Intern Med 2013; 28:156-8. [PMID: 23526870 PMCID: PMC3604603 DOI: 10.3904/kjim.2013.28.2.156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 02/22/2013] [Indexed: 11/27/2022] Open
Affiliation(s)
- Doo Sun Sim
- Division of Cardiovascular Medicine, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Youngkeun Ahn
- Division of Cardiovascular Medicine, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
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Giglioli C, Cecchi E, Landi D, Valente S, Chiostri M, Romano SM, Spini V, Perrotta L, Simonetti I, Gensini GF. Early invasive strategy and outcomes of non-ST-elevation acute coronary syndrome patients: is time really the major determinant? Intern Emerg Med 2013; 8:129-39. [PMID: 21647690 DOI: 10.1007/s11739-011-0596-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Accepted: 04/19/2011] [Indexed: 10/18/2022]
Abstract
In non-ST-elevation acute coronary syndromes (ACS), an early invasive strategy is recommended for middle/high-risk patients; however, the optimal timing for coronary angiography is still debated. The aim of this study was to evaluate the prognostic implications of the time of angiography in ACS patients treated in accord with an early invasive strategy. We analyzed the relationship between the time of angiography and outcomes at follow-up in 517 ACS patients, of whom 482 were revascularized with percutaneous coronary intervention (PCI) (86.9%) or coronary artery by-pass graft (13.1%). We also evaluated the influence of clinical, biohumoral and angiographic variables on the patients' outcomes at follow-up. Among patients submitted to angiography at different time intervals from both hospital admission and symptom onset, significant differences neither in mortality nor in cardiac ischemic events at follow-up were observed. At univariate analysis, complete versus partial revascularization, longer hospital stay, higher TIMI risk score, diabetes mellitus, higher discharge creatinine and admission anemia were associated with mortality and cardiac ischemic events at follow-up; a lower left ventricular ejection fraction was associated with mortality; higher peak troponin I and previous PCI were associated with cardiac ischemic events at follow-up. At multivariate analysis longer hospital stay, higher discharge creatinine levels, and previous PCI were independent predictors of cardiac ischemic events at follow-up. Our evaluation in ACS patients treated with an early invasive strategy does not support the concept that angiography should be performed as soon as possible after symptom onset or hospital admission. Rather, an unfavorable long-term outcome is influenced principally by the clinical complexity of patients.
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Affiliation(s)
- Cristina Giglioli
- Department of Heart and Vessels, Azienda Ospedaliero-Universitaria Careggi, Viale Morgagni, 85, 50134, Firenze, Florence, Italy.
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Edmondson D, Newman JD, Whang W, Davidson KW. Emotional triggers in myocardial infarction: do they matter? Eur Heart J 2013; 34:300-6. [PMID: 23178642 PMCID: PMC3549526 DOI: 10.1093/eurheartj/ehs398] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 10/02/2012] [Accepted: 10/31/2012] [Indexed: 02/06/2023] Open
Abstract
Considerable excitement and interest have arisen recently concerning the role that acute emotional triggers may play in precipitating a myocardial infarction (MI). Observational studies have found repeatedly that patients report excessive anger, anxiety, sadness, grief, or acute stress immediately prior to onset of MI, and recent meta-analyses summarizing these findings reported strong associations between MI occurrence and many of these acute emotions. However, it is unclear whether and through what mechanisms acute emotional triggers might influence MI, and whether there is any clinical utility in knowing if or how emotions trigger MI. We debate whether emotional triggers matter by reviewing the recent evidence for the association between acute emotional triggers and MI and by describing the potential pathophysiological characteristics and mechanisms underlying this association and the preventive strategies that could be used to mitigate the risk of acute MI. We also examine whether the study of emotional triggers could influence clinical risk management or changes in clinical practice/management. We offer suggestions for research that might shed light on whether emotional triggers could initiate a paradigm shift in preventive cardiology, or whether acute emotional triggers are either intractable catalysts for, or merely an epiphenomenon of, some MIs.
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Affiliation(s)
| | | | | | - Karina W. Davidson
- Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical Center, New York, NY, USA
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Ahmed MS, Jadhav AB, Hassan A, Meng QH. Acute phase reactants as novel predictors of cardiovascular disease. ISRN INFLAMMATION 2012; 2012:953461. [PMID: 24049653 PMCID: PMC3767354 DOI: 10.5402/2012/953461] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Accepted: 04/01/2012] [Indexed: 12/21/2022]
Abstract
Acute phase reaction is a systemic response which usually follows a physiological condition that takes place in the beginning of an inflammatory process. This physiological change usually lasts 1-2 days. However, the systemic acute phase response usually lasts longer. The aim of this systemic response is to restore homeostasis. These events are accompanied by upregulation of some proteins (positive acute phase reactants) and downregulation of others (negative acute phase reactants) during inflammatory reactions. Cardiovascular diseases are accompanied by the elevation of several positive acute phase reactants such as C-reactive protein (CRP), serum amyloid A (SAA), fibrinogen, white blood cell count, secretory nonpancreatic phospholipase 2-II (sPLA2-II), ferritin, and ceruloplasmin. Cardiovascular disease is also accompanied by the reduction of negative acute phase reactants such as albumin, transferrin, transthyretin, retinol-binding protein, antithrombin, and transcortin. In this paper, we will be discussing the biological activity and diagnostic and prognostic values of acute phase reactants with cardiovascular importance. The potential therapeutic targets of these reactants will be also discussed.
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Affiliation(s)
- M S Ahmed
- Department of Medicine, Royal University Hospital, University of Saskatchewan, 107 Wiggins Road, Saskatoon, SK, Canada S7N 5E5 ; Department of Pharmacology, University of Saskatchewan, 107 Wiggins Road, Saskatoon, SK, Canada S7N 5E5
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