Alpha 1-antitrypsin in acute myocardial infarction

Alpha 1-antitrypsin serum levels were measured in 48 patients with acute myocardial infarction and in 19 control patients either with coronary heart disease without necrosis, or with neither coronary disease nor inflammation. Alpha 1-antitrypsin was significantly raised in the group of patients with acute myocardial infarction. As some patients individually showed no change in alpha 1-antitrypsin levels, however, they were divided into two groups according to the maximum serum levels attained. Patients with non-increasing levels of alpha 1-antitrypsin showed increased mortality and a higher incidence of cardiogenic shock, whereas reinfarction occurred more frequently in the group with high alpha 1-antitrypsin levels. Our findings may suggest that the course of a myocardial infarction is determined not only by the severity of the ischaemic event, but also by the response of the "acute" phase reaction" mechanism. We conclude that a failure of alpha 1-antitrypsin levels to increase after myocardial infarction may be associated with a worse clinical course.

Repeated balloon rupture during coronary stenting due to a calcified lesion: an intravascular ultrasound study

We describe a patient in whom balloon rupture occurred three times during inflation in a stent with restenosis in the left anterior descending artery. The cause of rupture was detected by intravascular ultrasound: a calcified ridge that protruded between the stent struts in the distal stent body.

Excess long-term mortality among hospital survivors of acute myocardial infarction. Soroka Acute Myocardial Infarction (SAMI) project

OBJECTIVES

We evaluated long-term survival after acute myocardial infarction (AMI) in unselected 'real life' patients according to the various risk groups, and it's persistence with time after AMI as compared with the matched general population.

STUDY DESIGN

Retrospective study.

METHODS

Data were collected from 2671 AMI hospital survivors (tertiary medical centre in Israel), which included demographics, clinical characteristics of AMI, comorbidities, interventions and test results. All-cause mortality during the 10-year follow-up period was compared with age-, sex- and ethnicity/religion-matched general population using standardized mortality ratios (SMRs).

RESULTS

Overall mortality of AMI patients (48.6%) was higher than the general population (SMR, 2.2; P < 0.001). Mortality rates and SMRs tended to be greater in higher risk strata of patients, Jews vs Muslims, women vs men, non-ST-elevation acute myocardial infarction (NSTEMI) vs ST-elevation acute myocardial infarction (STEMI), non-invasive treatment vs invasive treatment, and recurrent vs first AMI. Mortality rates increased with age, but SMRs were highest in the youngest group. Through the follow-up period, SMR was highest during the first year after discharge (SMR, 4.85; P < 0.001) and higher in 7th-10th years compared with 2nd-6th years.

CONCLUSION

Patients who survived hospital admission with AMI continue to be at higher (approximately twice) risk of death compared with the general population for at least 10-year follow-up period and especially throughout the first and 7th-10th years after AMI, young women, high-risk patients, Jews, NSTEMI, non-invasively treated and recurrent AMI. These findings can assist healthcare providers and decision makers prioritizing targets of secondary prevention and allocation of resources.

Serum calcium levels independently predict in-hospital mortality in patients with acute myocardial infarction

BACKGROUND AND AIM

Serum calcium levels (sCa) were reported to be associated with cardiovascular risk factors, incidence of coronary artery disease and acute myocardial infarction (AMI). The current study evaluated the association between sCa and in-hospital mortality among AMI patients.

METHODS AND RESULTS

Patients admitted in a tertiary medical center for AMI throughout 2002-2012 were analyzed. For each patient, mean sCa, corrected to albumin, was calculated and categorized to seven equally-sized groups: <8.9, 8.9-9.12, 9.12-9.3, 9.3-9.44, 9.44-9.62, 9.62-9.86, ≥9.86 mg/dL. The primary outcome was all-cause in-hospital mortality. Out of 12,121 AMI patients, 11,446 were included, mean age 67.1 ± 14 years, 68% Males. Mean number of sCa values for patient was 4.2 ± 7.3. Mean sCa was 9.4 ± 0.53 mg/dL, range 5.6-13.2 mg/dL sCa was significantly associated with cardiovascular risk-factors, in-hospital complications, more frequent 3-vessel coronary artery disease and decreased rate of revascularization, often in a U-shaped association. Overall 794 (6.9%) patients died in-hospital. Multivariate analysis showed a significant U-shaped association between sCa and in-hospital mortality with sCa below 9.12 mg/dL and above 9.86 mg/dL as independent predictors of significantly increased in-hospital mortality: OR = 2.4 (95% CI:1.7-3.3) and 1.7 (95%CI:1.2-2.4), for Ca<8.9 and Ca≥9.86 mg/dL respectively p < 0.01, as compared with middle rage sCa group (9.3-9.44 mg/dL).

CONCLUSION

sCa is an independent predictor of in-hospital mortality in patients with AMI with a U-shaped association. Both increased and decreased sCa levels are associated with increased risk of in-hospital mortality.

Long-term prognosis of low-risk, post-MI patients: the importance of subjective perception of disease

In 1980, 87 male patients (age range 34-60 years), hospitalized after their first myocardial infarction (MI), were asked why they believed they got the infarct and what would help them cope with it. In a multiple regression analysis, their causal attributions accounted for 15% of the explained variance in their physical, sexual, social and work functioning after 6 and 18 months, their level of education accounted for 25% and the severity of their infarct for 10%. This result was replicated in a cross-cultural study. A follow-up study shows that 12 years after the MI, the patients' initial causal attributions still accounted for part of their rehabilitation and life expectancy. Of the original 87, 23 had died between 1980-1992 from cardiac causes and 50 male patients were located and re-interviewed at the Soroka ICCU, in 1992. This suggests a very low-risk post-MI sample. The only risk-factor, accounting for the difference between the surviving and the deceased patients, was the initial obesity of the latter. The functional capacity outcome of the survivors was accounted for by their age (24%) and initial causal attributions (26%). Also the initial causal attributions (5%) still accounted for the subjective perception of functioning among the survivors. These results suggest that the initial causal attributions may have created positive or negative self-fulfilling prophecies which had long-term consequences, especially in a low-risk, post-MI population, in which risk factors hardly effected long-term prognosis.

Incidence and clinical significance of bacteremia and sepsis among cardiac patients treated with intra-aortic balloon counterpulsation pump

In this prospective study, a significant incidence of fever (47%), true bacteremia (15%), and sepsis (12%), were found in 60 cardiac patients treated with an intra-aortic balloon counterpulsation pump. The benefit of antibiotic prophylaxis in this setting should therefore be evaluated.

Unusual bleeding complications of thrombolytic therapy after cardiopulmonary resuscitation. Three case reports

The authors present three case reports retrospectively casting doubt on the benefit of thrombolysis after external cardiac massage.

The "door-to-needle blitz" in acute myocardial infarction: the impact of a CQI project

BACKGROUND

A continuous quality improvement (CQI) project was conducted at Soroka Medical Center in Beer-Sheva, Israel, in an effort to identify and address causes of delays in thrombolytic therapy in patients arriving at a high-volume (160,000 patients per year) emergency department with acute myocardial infarction and thereby reduce the "door-to-needle time" (DTNT). The study had four phases: preintervention survey, peri-intervention process redesign, postintervention evaluation, and follow-up evaluation. CQI TEAM: The CQI team followed a seven-step protocol: problem definition, present-state screening, factors analysis, solution development, outcome evaluation, standardization, and conclusions.

RESULTS

A DTNT of 45 minutes was considered acceptable for this data set, and accordingly, patients were divided into an "early" group (n = 50, DTNT < 45 minutes), and a "late" group (n = 50, DTNT > or = 45 minutes). After the CQI intervention, the mean DTNT decreased from 61.8 +/- 32.5 (mean +/- standard deviation) to 47.6 +/- 18.5 minutes (p < 0.029). The prolonged DTNT time intervals of the late versus the early groups was primarily due to extended decision-making time (36.0 +/- 22.7 versus 13.6 +/- 6.7 minutes, p < 0.003), followed by time until therapy was initiated (26.2 +/- 14.2 versus 11.1 +/- 5.8 minutes, p < 0.002).

CONCLUSIONS

Results suggest that the 30-minute DTNT suggested by the American College of Cardiology/American Heart Association is appropriate for patients with a clear diagnosis and no contraindications for thrombolysis, but when the risk-benefit ratio of thrombolytic therapy raises concerns, a 45- to 60-minute DTNT may still be acceptable. Further CQI projects should address technical triage of simple cases and clinical estimation of risk-benefit ratio in complicated patients.

Comparison of coronary stent expansion by intravascular ultrasonic imaging in younger versus older patients with diabetes mellitus

The poor long-term outcome in young diabetic patients receiving stents is not well understood. The purpose of this study was to characterize the pastprocedural results of stent placement in diabetic patients using intravascular ultrasound to identify factors that might be associated with poor clinical outcome. The acute dimensions from intravascular ultrasound studies after stent deployment at 5 sites were measured from 39 coronary segments from patients with diabetes mellitus (DM) and 161 segments from nondiabetic patients (non-DM). Within these 2 groups, segments were subgrouped into young (y) and old (o) in reference to the mean study age of 64 years, forming 4 groups: yDM (n = 20), y non-DM (n = 65), oDM (n = 19), and o non-DM (n = 96). Results are reported as mean +/- 1 SD. Diabetic patients had smaller mean lumen area within the treated segment than o non-DM (8.37+/-2.59 vs. 9.11+/-3.35 mm2, p<0.01). These differences were more pronounced at the distal reference vessel lumen of yDM than y non-DM (7.6+/-2.3 vs. 10.3+/-4.5 mm2, p<0.003), and were associated with greater percent plaque area in the distal reference vessel (43.4+/-13% vs. 34.1+/-11.2%, p<0.003). In young diabetic patients undergoing elective stent placement, underexpansion of the stented segment is common, which may contribute to the relatively poor long-term outcome in these patients. We suggest that when stenting is the procedure of choice in this subgroup of high-risk patients, special attention should be given to optimizing lumen dimensions.

Jaundice induced by streptokinase

Streptokinase is the mainstream therapy for acute myocardial infarction. A fifty-seven-year-old man with acute MI was admitted to the intensive cardiac care unit and received streptokinase and heparin. At the time of admission, he was not receiving any drugs and denied any previous exposure to a hepatotoxic agent. Five hours later he developed a dramatic hypersensitivity reaction including high fever, pulmonary edema, cyanosis, and convulsions. Within twelve hours, his clinical state was stabilized. After forty-eight hours, he developed jaundice and transaminasemia, which subsided by the eighth day. Only a few reports of overt jaundice are associated with streptokinase.

Mid left anterior descending coronary artery originating from the right coronary artery

Dual connection of the left anterior descending coronary artery to the left and right coronary arteries is a very rare congenital anomaly. In this report we describe two cases in which the mid-position of the left anterior descending coronary artery is connected to the right coronary artery, one directly and the second by way of the infundibular artery. To the best of our knowledge, connection of the mid-position of the left anterior descending to the infundibular artery has not been previously described.

Anomalous origin of the posterior descending artery from the obtuse marginal

We describe a patient with an unusual coronary anatomic variant in which the obtuse marginal gives rise to the posterior descending artery. The angiographic features and clinical recognition of this anomaly are reviewed.

Original article: low regulatory volume decrease rate in platelets from ischemic patients: a possible role for hepoxilin a(3) in thrombogenicity

Hepoxilin-A(3) (Hx-A(3)) is produced by platelets in response to shear-stress. It has an antithrombotic effect on platelets. A low Hx-A(3) level may contribute to the high thrombogenic state that exists in patients with acute coronary syndromes. Since we have previously demonstrated that the regulatory volume decrease (RVD) of human platelets exposed to hypotonic solutions is controlled by Hx-A(3) it is possible that the RVD rate reflects Hx-A(3) activity. In this study, the RVD rate of platelets taken from a healthy control group (n=21) was compared to that of patients with chronic ischemic heart disease (n=23), acute ischemic heart disease (n = 24) and acute myocardial infarction (MI, n = 29). The RVD rate of the control group was significantly higher than the other three groups (P < 0.001). The addition of 100 nM of Hx-A, to the platelets of eight patients with MI increased their RVD rate to that of the controls. Patients with diabetes mellitus or hypertension have the lowest RVD rates. Medications such as aspirin, heparin, and streptokinase did not affect the Hx-A(3) activity of platelets obtained from patients with ischemic heart disease. The results of the present study indicate that patients with acute ischemia may have a low level of platelet Hx-A(3) activity. This possible low level of Hx-A, activity may be associated with a failure to develop an antithrombotic reaction to the shear-stress forces generated during acute ischemia.

Short- and long-term comparative study of anistreplase versus streptokinase in acute myocardial infarction

Streptokinase is well established as an effective thrombolytic. Anistreplase, a new thrombolytic drug, is a complex of streptokinase and acylated human plasminogen that can be administered by intravenous bolus and activates plasminogen at the clot site. Although both streptokinase and anistreplase are effected in treating myocardial infarction (MI), they have different pharmacologic properties. This study was designed to identify short- and long-term differences in their clinical effectiveness, safety in use, and survival rates in patients with acute MI. One hundred ten successive patients under seventy years of age admitted within three hours after onset of sustained chest pain suggestive of acute MI were randomized to receive either 30 units of anistreplase intravenously over five minutes or intravenous injection of 750,000 units of streptokinase over thirty to sixty minutes. Reperfusion was achieved in 34 of the 52 (65%) patients treated with anistreplase and in 41 of the 58 (71%) patients treated with streptokinase (p = NS). The two drugs were equally effective in preserving left ventricular ejection fraction, which was found to be significantly better in patients with anterior wall MI who had achieved reperfusion than it was in those who did not (p less than 0.02). One-month, twelve-month, and thirty-six-month survival rates were high (96% to 88%) with no significant difference between the two treatment groups. The authors conclude that the two drugs are equally effective thrombolytic agents but that anistreplase has the advantage that it can be administered as a bolus injection.

Cardiogenic shock: single center experience with and without on-site catheterization facilities

BACKGROUND

The beneficial effect of on-site catheterization facilities on the survival of all patients with myocardial infarction complicated by cardiogenic shock has been questioned. Our objective was to evaluate the impact of the availability of on-site catheterization facilities on the outcome of unselected patients with cardiogenic shock.

METHODS AND RESULTS

We studied the hospital records of 70 consecutive patients with cardiogenic shock admitted to our intensive coronary care unit during 1990-1996, and compared two groups of patients: those admitted before (n = 34) and after (n = 36) the opening of our catheterization laboratory. Patients admitted when the catheterization laboratory was available were of similar age, but included fewer males and fewer patients with prior myocardial infarction. Following the activation of the catheterization laboratory, utilization rates of coronary angiography, percutaneous transluminal coronary angioplasty and intra-aortic balloon pump increased, compared with the previous period. However, there was no improvement in in-hospital (88 vs. 83%; p = 0.7) and 30-day mortality (91 vs. 86%; p = 0.7) before versus after the activation of our catheterization laboratory. Twelve patients selected to cardiac catheterization (9 underwent percutaneous transluminal coronary angioplasty) experienced lower in-hospital and 30-day mortality compared with patients who were not selected (58 vs. 96, and 67 vs. 96%, respectively; p < 0.02).

CONCLUSIONS

Following the activation of the catheterization laboratory, the mortality of the entire population of cardiogenic shock patients remained relatively unchanged. Still, a small subgroup of these patients selected for urgent cardiac catheterization had a lower mortality compared with patients who were not selected.

Aneurysm of the left main coronary artery: progression of dilatation with concomitant deterioration of coronary stenoses

A left main aneurysm is a rare angiographic finding. We describe a 59-year-old male with a large aneurysm in the left main coronary artery. The aneurysm had enlarged in comparison to its diameter of 3.5 years previously, together with a progression of severity of his coronary stenoses.

Low-pressure deployment of stents: short- and long-term outcome

This study investigates a strategy of low-pressure stenting with concomitant anti-platelet treatment designed to prevent short- and long-term events after stenting. Ninety consecutive patients who underwent percutaneous transluminal coronary angioplasty with stenting using low-pressure stent deployment (mean 8.1 atmospheres) with concomitant anti-platelet therapy based on ticlopidine and aspirin were followed. The 30-day outcome revealed a stent thrombosis rate of 6.4%, while the 9-month major clinical event rate was 8.6%. Low-pressure stent deployment appears to confer added risk for acute or sub-acute thrombosis even when aspirin and ticlopidine are used. Conversely, low-pressure inflation is associated with excellent long-term results.

[Evaluation of verapamil for hypertension by an isometric exercise test]

Since the resting blood pressure (BP) does not predict round-the-clock values, in order to evaluate the disease and its response to treatment BP should be measured during exertion. Verapamil, either 120 mg or 160 mg, twice daily, was given to 60 hypertensives at rest and during isometric effort, according to our previously reported protocol. There was a significant response (p less than 0.005) to the treatments. Sustained release verapamil, 240 mg once a day, reduced systolic and diastolic BP significantly in 38 of 45 hypertensives at rest and during isometric effort. A simple, inexpensive, cost-effective, hand-grip method is strongly recommended as an integral part of treatment evaluation. The combination of highly effective drugs together with a simple method of BP evaluation may result in improved long-term treatment.