[Mortality prognostic factors of cardiogenic shock complicating an acute myocardial infarction and treated by percutaneous coronary intervention]

OBJECTIVE

To determine the in-hospital prognosis and late outcome of cardiogenic shock complicating acute myocardial infarction treated by early (< 24 hours) percutaneous coronary intervention (PCI).

METHODS

Retrospective monocentric study of a consecutive cohort of patients undergoing early PCI (< 24 heures) for cardiogenic shock complicating acute myocardial infarction from 1994 to 2004.

RESULTS

The cohort included 175 patients (mean age = 65 +/- 14 years, 68% male). A successful PCI was obtained in 69% of patients. The in-hospital mortality was 43%. Independent risk factors associated with an increased mortality were: absence of TIMI three flow (P < 0.0001), absence of smoking (P < 0.009) and the need for mechanical ventilation (P < 0.002). Nor stent use or anti GP IIb/IIa infusions were predictors of a better outcome. At hospital discharge, mean left ventricular ejection fraction (LVEF) was 38 +/- 12%. Kaplan-Meier estimate of survival was 63% for in-hospital survivors (maximum follow-up = 9 years). Independent predictors of an impaired long-term outcome were: a LVEF < 0.3 (P < 0.028) and 3-vessel disease on coronary angiography (P < 0.004).

CONCLUSION

In-hospital mortality of patients suffering cardiogenic shock complicating acute myocardial infarction and treated by PCI remains high despite PCI improvement. The long-term survival appears, however, to be better than that of patients with coronary artery disease and low LVEF.

Abnormal transoesophageal Doppler coronary flow reserve in patients with dilated cardiomyopathy: relationship to exercise capacity

1. In patients with dilated cardiomyopathy, abnormal myocardial blood flow may contribute to poor myocardial function. 2. The aim of this study was to investigate the possible contribution of abnormal myocardial blood flow to the limitation of exercise capacity in patients with dilated cardiomyopathy. 3. Coronary flow reserve was assessed in 16 patients with dilated cardiomyopathy and 9 matched normal control individuals. All participants had angiographically normal coronary arteries. At rest and after dipyridamole infusion (0.56 mg/kg intravenously), peak systolic and diastolic coronary flow velocities were measured in the proximal left anterior descending coronary artery using transoesophageal pulsed Doppler echocardiography, guided by colour flow imaging. Coronary flow reserve was calculated as the ratio of hyperaemic to basal diastolic and systolic peak coronary flow reserve. 4. Baseline diastolic and systolic coronary flow velocities were significantly higher in patients (50 +/- 6 and 30 +/- 4 cm/s respectively) compared with control individuals (37 +/- 3 and 20 +/- 1 cm/s respectively) (mean +/- S.E.M.) (P < 0.05). Diastolic and systolic peak coronary flow reserve were significantly lower in patients (1.60 +/- 0.14 and 1.40 +/- 0.09 respectively) compared with control individuals (2.89 +/- 0.15 and 2.17 +/- 0.17 respectively) (P < 0.001). Although peak VO2 and exercise time were significantly lower in patients compared with control individuals, coronary flow reserve did not correlate to exercise capacity in patients with dilated cardiomyopathy. 5. These results confirm the abnormalities of coronary flow reserve previously observed in patients with dilated cardiomyopathy, but suggest that such abnormalities do not contribute to the limitation of exercise capacity in these patients.

Dilated cardiomyopathy: long-term follow-up and predictors of survival

To determine long-term survival and the prognostic factors of dilated cardiomyopathy, we retrospectively studied a consecutive series of 111 patients (95 men, 16 women, mean age: 45.5 +/- 8.1 years) undergoing cardiac catheterization and diagnostic coronary angiography from January 1970 to December 1979. The inclusion criteria were: normal coronary angiography, diffuse hypokinesia of the left ventricle and left ventricular ejection fraction less than 50%. Base-line clinical data were collected from the hospital records and follow-up data were obtained from the general practitioners and cardiologists. A questionnaire was sent to all living patients. The length of follow-up ranged from 6 to 16 years. Six patients (5%) were lost to follow-up. At the time of catheterization, a majority of the patients had dyspnea and were in New York Heart Association (NYHA) classes II (41%) and III (31%). Clinical history revealed an excessive alcohol consumption in 56% of the patients. During follow-up, 66 patients (63%) died (heart failure: 37%; sudden death: 19%; non-cardiac death: 15%; unknown cause: 27%). Actuarial survival was 90, 50, and 33% at 1, 5, and 10 years, respectively. Univariate analysis revealed that 10-year mortality was related to: left ventricular ejection fraction less than 30%; left ventricular end-diastolic pressure greater than 10 mm Hg; cardiothoracic ratio greater than 54%; episodes of heart failure; left ventricular end-diastolic volume greater than 200 ml/m2, dyspnea of NYHA class III or IV; absence of smoking; absence of moderate systemic hypertension; electrocardiographic evidence of left ventricular hypertrophy and mean systemic arterial pressure greater than 95 mm Hg.(ABSTRACT TRUNCATED AT 250 WORDS)

[Measurement of cardiac output by thoracic electrical bioimpedance or thermodilution]

The present study was designed to assess a new non invasive method for measuring cardiac output. The thoracic electrical bioimpedance method was compared with the reference one, thermodilution. The measurements were made simultaneously with NCCOM3 (bioimpedance) using the freeze data mode, and with a Swan-Ganz catheter and a haemodynamic computer (thermodilution). The study involved 11 spontaneously breathing patients in a steady haemodynamic state. Ten measurements were carried out with both methods for each patient. Statistical analysis of the 110 paired values was carried out by computer. The various statistical tests applied confirmed that there was a highly significant correlation between values for cardiac output obtained by each of these two methods (r = 0.818; p less than 0.005); they also showed a significantly more important dispersion of the measures for each patient with thermodilution. The mean value of the thermodilution "standard deviation" (0.64 l.min-1) was significantly more important (p less than 0.005) than the one with NCCOM3 (0.24 l.min-1). Thoracic electrical bioimpedance appeared a safe method for measuring cardiac output, providing the limits of the method are kept. The objective is not to replace the Swan-Ganz catheter, but to propose an alternative method for measuring cardiac output. This method is very interesting in many circumstances, particularly for intensive care patients: it is a non invasive technique, continual measurement is not time-limited, and its use is very easy.

[Prognostic value of a new perfusion index calculated from coronarography]

A new perfusion index was determined from the study of the coronary vascular bed in 8 myocardial territories: upper septal, lower septal, upper anterior, lower anterior, apical, lateral, posterior and inferior. Stenosis of a vessel reduces perfusion in all territories fed by that vessel, downstream of the stenosis. The perfusion index is calculated by adding up the lesions in all 8 territories. In a population of 418 consecutive patients who had undergone coronary arteriography in 1972 and 1973, survival was evaluated according to the perfusion index and to those parameters which classically have the greatest influence on survival. The perfusion index came out as the most important prognostic factor since such parameters as the number of stenotic vessels and ventricular kinetics lose their prognostic value when adjusted to that index. According to the perfusion index, the 8-year prognosis is the same as in subjects without coronary disease when the reduction in overall perfusion does not exceed 40%. With a 40 to 79% reduction the death risk at 8 years is 30% whatever the exact percentage in each individual. When perfusion is reduced by 80% the death risk at 8 years rises to 72%. This perfusion index, easy to determine, provides a better evaluation of prognosis than the conventional parameters.

[10-year outcome of patients with isolated anterior interventricular stenosis technically accessible to coronary angioplasty]

Between April 1972 and March 1976, 70 patients were found to have an isolated stenosis of the left anterior descending artery at coronary angiography which could have been treated by coronary angioplasty, had the technique been available at that time. A questionnaire was sent to these patients and 65 (93 p. 100) replies were received 9 to 13 years after initial coronary angiography. They provided information about 61 men and 4 women with an average age of 48.1 +/- 8.4 years. Thirty eight patients had undergone surgery and 27 were treated medically, each group having distinct clinical characteristics. The 10 year survival rate was excellent (91 p. 100) and was high in both groups. The quality of life was good: 56 p. 100 claimed to be in good or very good health and 67 p. 100 were improved with respect to their functional state at the time of coronary angiography; only one quarter of these patients had been readmitted to hospital for cardiac problems during the follow up period, and 76 p. 100 of patients in work before the coronary angiography had returned to work. This date illustrates the excellent results of classical medical and surgical management of potential candidates for coronary angioplasty for isolated left anterior descending artery stenosis.

[Exertion isotope tests in coronary insufficiency. Comparison with isotopic ventriculography and myocardial scintigraphy]

Very few studies have been described comparing the value of exercise myocardial scintigraphy and left ventricular angioscintigraphy. The authors designed a study comparing these two investigations with conventional exercise stress testing and coronary angiography. The isotopic investigations were carried out within 48 hours of coronary angiography. A total of 143 patients undergoing coronary angiography (35 normal, 108 coronary patients: 36 single vessel, 36 double vessel and 36 triple vessel disease) were included in this study. The lesions were located of the LAD (77 cases), left circumflex (77 cases) and right coronary arteries (62). The sensitivity and specificity of both radionuclide investigations were evaluated to assess their diagnostic value; the best results were obtained with myocardial scintigraphy (sensitivity 86 p. 100; specificity 100 p. 100); angioscintigraphy had a sensitivity of 71 p. 100 and specificity of 97 p. 100, and conventional exercise stress testing of 42 p. 100 and 70 p. 100 respectively. The sensitivity seemed to increase with the degree of stenosis; although the sensitivity of myocardial scintigraphy increased progressively, that of angioscintigraphy doubled in cases of stenosis 90 p. 100 (stenosis less than 90 p. 100, sensitivity = 37 p. 100; stenosis greater than 90 p. 100, sensitivity = 73 p. 100). The sensitivity of myocardial scintigraphy with respect to the severity of the coronary artery disease was best in cases of right coronary artery stenosis (sensitivity in cases of RCA stenosis = 74 p. 100; sensitivity in LAD stenosis = 58 p. 100; sensitivity in left circumflex stenosis = 43 p. 100). The sensitivity of left ventricular angioscintigraphy was best in LAD stenosis (RCA stenosis = 50 p. 100, LAD stenosis = 64 p. 100, left circumflex stenosis = 36 p. 100). The sensitivity of both investigations was poor in left circumflex artery stenosis even when severely diseased. The sensitivity of both investigations was better in diffuse coronary artery disease: myocardial scintigraphy (single vessel disease: 72 p. 100, double vessel disease: 92 p. 100, triple vessel disease: 94 p. 100), left ventricular angioscintigraphy (61 p. 100, 69 p. 100, and 83 p. 100 respectively). Although the association of these two radioisotopic investigations does not improve diagnostic sensitivity, it does provide more information about the localisation and extension of the coronary artery disease especially in LAD and right coronary artery stenosis. These results suggest that these investigations are complementary in the evaluation of patients with coronary artery disease.(ABSTRACT TRUNCATED AT 400 WORDS)

[Results of coronary transluminal angioplasty following Prinzmetal's angina or fixed stenosis with associated spasm]

Transluminal coronary angioplasty (TCA) was carried out in 130 patients (109 men and 21 women) with an average age of 51 years (range 20 to 76 years) between April 1980 and December 1982. The most commonly affected artery was the LAD (100). All patients were on heparin, coronary vasodilators and calcium antagonists before the procedure, and on calcium antagonists and platelet antiaggregant drugs after TCA. The material and methods used were those described by Gruntzig. In this population, we identified a group of patients, Group I, with fixed stenosis and associated coronary spasm--either Prinzmetal angina (13 cases, 6 of which had both ST-T elevation and other ECG changes) or spontaneous spasm with a variable degree of stenosis (2 cases). The stenosis remained greater than or equal to 70% in all cases after intracoronary injection of nitrate derivatives. There were no differences between this group and that of fixed stenosis (Group II) with respect to age and type of diseased vessel (although the right coronary artery was more commonly involved in cases of spasm). The overall primary success rate was 72.8% (14/15--93%--in Group I, and 85/121--70.2%--in Group II: no statistically significant difference). The angiographic relapse rate at 6 months was significantly higher in Group I (8/12: 67%) than in Group II (15/63: 23.8%) p less than 0.02. When "redilatation" with stable success is taken into consideration the difference is not significant (33% and 22.2% respectively). The relapses may be dissociated in Group I (2 cases with recurrent spastic angina and normal angiography).(ABSTRACT TRUNCATED AT 250 WORDS)

[Long-duration electrocardiographic recording in 33 patients with obstructive cardiomyopathy]

A prospective study of arrhythmias was performed in 33 patients with hypertrophic cardiomyopathy with obstruction by Holter monitoring. The aim of the study was to assess the incidence of "occult" arrhythmias in this condition and to establish a "profile" of high risk patients from clinical, echocardiographic and haemodynamic data. The Holter monitoring demonstrated asymptomatic arrhythmias in 31 of the 33 patients (94%). A supraventricular arrhythmia was detected in 15 cases (45%), including 7 episodes of supraventricular tachycardia (21%). Ventricular arrhythmias were observed in 28 patients (85%), including 5 episodes of ventricular tachycardia (15%). Some patients presented several types of arrhythmia. A number of patients with arrhythmia including short bursts of ventricular tachycardia were asymptomatic during Holter monitoring; conversely, other patients complained of dizziness or syncope but had no arrhythmias. A retrospective study of clinical, echocardiographic and haemodynamic data showed no difference between patients with and patients without arrhythmias. Medium-dose betablocker therapy (propranolol, 110 mg/day) did not seem to protect patients with hypertrophic cardiomyopathy with obstruction from arrhythmias. We conclude that Holter monitoring should form part of the routine evaluation of patients with cardiomyopathy with obstruction, and that potentially dangerous arrhythmias should be treated by anti-arrhythmic agents other than betablockers. This attitude could reduce the incidence of syncope and eventually decrease the risk of sudden death in this condition.

[Early detection of myocardial alterations in mitral insufficiency with the angiotensin test]

Left ventricular function was assessed at rest and after increasing systemic arterial resistance by angiotensin in 40 patients with isolated mitral insufficiency. Angiotensin was administered intravenously at a dose of 0,4 micrograms/mn until the systolic blood pressure rose by at least 30 mm Hg. Left ventricular and aortic pressures, cardiac index and left ventriculography in the 30 degree right anterior oblique projection (50 frames per second) were recorded before and during angiotensin infusion. The mean rise in systolic left ventricular pressure was 40 +/- 2,8 mm Hg; the heart rate increased slightly but significantly; left ventricular and diastolic pressure rose from 12,0 +/- 1,0 to 24,0 +/- 1,2 mmHg. The systolic index (Fick's method) was significantly decreased (37 +/- 1,6 ml/m2 to 26 +/- 1,6 ml/m2) though the angiographic systolic index remained unchanged. This is explained by an increase in the regurgitant fraction (51 +/- 2,5% ao 65 +/- 3%). The end diastolic volume index was unchanged; the ejection fraction was significantly decreased. The resting hemodynamic status was only slightly disturbed in 29 patients (mean capillary pressure less than 15 mm Hg, 8,8 +/- 0,52 mmHg). The left ventricular function curves with angiotensin distinguished two groups of patients: Group A (20 patients) with left ventricular dysfunction induced by angiotensin, Group B (9 patients) who maintained the systolic index despite the increase in left ventricular end diastolic pressure. These results suggest that the angiotensin test may be useful for detecting early left ventricular dysfunction in patients with isolated mitral insufficiency and virtually normal resting hemodynamic parameters.

[Comparative study of different methods of evaluation of left ventricular volume by monoplane angiocardiography]

The authors compare 5 methods of evaluating left ventricular volume and the ejection fraction by monoplanar angiocardiography in the 30 degrees right oblique incidence: the method of Green (1 and 2), Snow and Dodge, and by trapezoidal integration which was used as a reference. The have calculated the regression ordinates and the correlation coefficients for various systolic and diastolic volumes as well as for various ejection fractions. For these latter, Dodge's quadratic equation can also be used. Provided there is no gross distorsion of ventricular contolr, there is fairly good correlation, but there is a marked discrepancy for large volumes or small ejection fractions (less than 0.40). When more elaborate methods are not available, it seems reasonable to use a single method to calculate these parameters, but it is essential to have recourse to other techniques when there are gross changes in the left ventricle.