Electrocardiographic Signs Of Ischemia Research Articles

Objective electrocardiographic documentation of ‘walk- through angina’ phenomenon during treadmill stress electrocardiography using Bruce protocol

The term ‘walk through angina’ is used when angina is relieved inspite of continued exertion. Objective documentation of ‘walk-through angina’ is rare. Two cases of ‘walk - through angina’ phenomenon with objective electrocardiographic documentation during treadmill stress test are reported. In both cases relief in angina was associated with reduction in electrocardiographic signs of ischemia. In one case, relief of angina was associated with reduction in rate - pressure product. In the second case angina reduced even when the rate pressure product was higher than at the onset of angina. Several factors could reduce angina inspite of increase in work load. Relief in anxiety, reduction in stress of exercise testing, coronary vasodilation, increased flow through collaterals or some adaptive process, alone or in combination, could contribute to relief in angina. Treatment is similar to chronic stable angina.

Spontaneous thrombus formation in native aortic root in patients with hypoplastic left heart syndrome: clinical presentation, treatment, and outcomes.

We report a neonate who presented with spontaneous thrombus formation in the native aortic root after Norwood palliation for hypoplastic left heart syndrome. Thrombus formation led to myocardial ischaemia due to decreased coronary blood flow with electrocardiographic signs of ischaemia and elevated cardiac enzymes. Aggressive thrombolysis and anticoagulation therapy were major contributors to successful outcome.

Pseudo ST segment elevation and terminal negative deflection of T wave during treadmill test could be due to damping problem in the printer

ST segment elevation during treadmill stress testing, in the leads without Q waves, is considered suggestive of transmural ischemia due to high grade proximal coronary arterial lesions. We observed six consecutive, asymptomatic individuals who had ST segment elevation and terminal negative deflection of the T waves in leads V1 to V3 during treadmill stress testing. Resting electrocardiograms recorded from another machine just before treadmill test were normal. Detailed echocardiographic evaluation just before treadmill test did not reveal any regional wall motion abnormalities in any case. All patients could complete the stress test without any clinical or electrocardiographic signs of ischemia. After careful analysis of resting electrocardiograms, clinical profile, heart rate and blood pressure responses and electrocardiographic findings during stress test, we felt that ST segment elevation and terminal negative deflection of the T wave recorded only during treadmill test were artefacts due to under damping (overshoot) of the stylus of the printer of the particular treadmill stress test system. Detailed findings are given and differential diagnosis is discussed. Repair resulted in normal tracing in subsequent patients. Keywords: Artefacts; Electrocardiography; Stress test; ST segment; T wave; Treadmill test

Importance of confirming the underlying diagnosis in patients with myocardial infarction and non-obstructive coronary arteries (MINOCA): a single-centre retrospective cohort study

BackgroundMany patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) are discharged without a known aetiology for their clinical presentation. This study sought to assess the effect of this ‘indeterminate MINOCA’ diagnosis on the prevalence of recurrent cardiovascular events and presentations to the Cardiac Emergency Department (CED).MethodsWe retrospectively analysed all patients meeting the diagnostic MINOCA criteria presenting at a large secondary hospital between January 2017 and April 2019.ParticipantsPatients were divided into the (1) ‘indeterminate MINOCA’, or (2) ‘MINOCA with diagnosis’ group. The primary outcome was the occurrence of major adverse cardiac events (MACE) defined as the composite of all-cause mortality, non-fatal myocardial infarction, stroke and any revascularisation procedure. Secondary outcomes were all recurrent visits at the CED, and MACE including unplanned cardiac hospitalisation.ResultsIn 62/198 (31.3%) MINOCA patients, a conclusive diagnosis was found (myocardial infarction, (peri)myocarditis, cardiomyopathy, or miscellaneous). MINOCA patients with a confirmed diagnosis were younger compared to those with an indeterminate diagnosis (56.7 vs. 62.3 years, p = 0.007), had higher maximum troponin-T [238 ng/L vs. 69 ng/L, p < 0.001] and creatine kinase (CK) levels [212U/L vs. 152U/L, p = 0.007], and presented more frequently with electrocardiographic signs of ischaemia (71.0% vs. 47.1%, p = 0.002). Indeterminate MINOCA patients more often showed recurrent CED presentations (36.8% vs. 22.6%, p = 0.048), however the occurrence of cardiovascular events was equal (8.8 vs. 8.1%, p = 0.86). Multivariable analysis showed that elevated levels of troponin-T and CK, ST-segment deviation on electrocardiography, reduced left ventricular ejection fraction, regional wall motion abnormalities, and performance of additional examination methods were independent predictors for finding the underlying MINOCA cause.ConclusionsOnly in one-third of MINOCA patients a conclusive diagnosis for the acute presentation was identified. Recurrent CED visits were more often observed in the indeterminate MINOCA group, while the occurrence of cardiovascular events was similar across groups.Trial registrationRetrospectively registered

Patient-reported symptoms improve prediction of acute coronary syndrome in the emergency department.

Early diagnosis is critical in the management of patients with acute coronary syndrome (ACS), particularly ST-elevation myocardial infarction (STEMI), because effective therapies are time-dependent. Aims of this secondary analysis were to determine: (i) the prognostic value of symptoms for an ACS diagnosis in conjunction with electrocardiographic (ECG) and troponin results; and (ii) if any of 13 symptoms were associated with prehospital delay in those presenting to the emergency department (ED) with potential ACS. Patients receiving a cardiac evaluation in the ED were eligible for the study. Thirteen patient-reported symptoms were assessed in triage. Prehospital delay time was calculated as the time from symptom onset until registration in the ED. A total of 1,064 patients were enrolled in five EDs. The sample was 62% male, 70% white, and had a mean age of 60.2 years. Of 474 participants diagnosed with ACS, 118 (25%) had STEMI; 251 (53%) had non-ST elevation myocardial infarction (NSTEMI); and 105 (22%) had unstable angina. Sweating (OR = 1.42 CI [1.01, 2.00]) and shoulder pain (OR = 1.64 CI [1.13, 2.38]) added to the predictive value of an ACS diagnosis when combined with ECG and troponin results. Shortness of breath (OR = 0.71 CI [0.50, 1.00]) and unusual fatigue (OR = 0.60 CI [0.42, 0.84]) were predictive of a non-ACS diagnosis. Sweating predicted shorter prehospital delay (HR = 1.35, CI [1.10, 1.67]); shortness of breath (HR = 0.73 CI [0.60, 0.89]) and unusual fatigue (HR = 0.72, CI [0.57, 0.90]) were associated with longer prehospital delay. Patient-reported symptoms are significantly associated with ACS diagnoses and prehospital delay. Sweating and shoulder pain combined with ECG signs of ischemia may improve the timely detection of ACS in the ED.

Effects of ranolazine in symptomatic patients with stable coronary artery disease. A systematic review and meta-analysis

BackgroundRanolazine (R), as add-on therapy in symptomatic patients with chronic stable coronary artery disease (CAD), has been tested in randomized clinical studies. Aim of the study was to assess in a meta-analysis the effects of R on angina, nitroglycerin consumption, functional capacity, electrocardiographic signs of ischemia and hemodynamic parameters in patients with chronic CAD. MethodsRandomized trials assessing the effects of R compared to control on exercise duration, time to onset of angina, time to 1mm ST-segment depression, weekly nitroglycerin consumption and weekly angina frequency were included in the analysis. The effects of R compared to control on heart rate and blood pressure were also analyzed. ResultsSix trials enrolling 9223 patients were included in the analysis. At trough and peak levels, R compared to control significantly improved exercise duration, time to onset of angina and time to 1mm ST-segment depression. Additionally, R compared to control significantly reduced weekly angina frequency and weekly nitroglycerin consumption. Finally, R compared to control did not significantly reduce supine systolic and diastolic blood pressure as well as heart rate, standing heart rate and diastolic blood pressure, whereas it modestly reduced standing systolic blood pressure. At sensitivity analysis, results were not influenced by concomitant background therapy. ConclusionsIn symptomatic patients with chronic CAD, R, added to conventional therapy, effectively reduces angina frequency and sublingual nitroglycerin consumption while prolonging exercise duration as well as time to onset of ischemia and to onset of angina with no substantial effects on blood pressure and heart rate.

Effect of intraoperative dobutamine on splanchnic tissue perfusion and outcome after Whipple surgery

PurposeSplanchnic hypoperfusion during abdominal surgery contributes to postoperative gut sepsis and mortality. Dobutamine is an inotrope with vasodilator properties that improve hepatosplanchnic perfusion. The aim of this study was to examine the effect of intraoperative dobutamine infusion during Whipple surgery on splanchnic perfusion, hemodynamic, and overall postoperative outcome. MethodsSixty patients were randomly allocated to receive intraoperatively (3 μg/kg per minute or 5 μg/kg per minute) doses of dobutamine or saline. Baseline measurements included hemodynamic parameters, gastric tonometric parameters, and arterial and mixed venous gases. These patients had a follow-up for development for in-hospital morbidity and mortality. ResultsIntraoperative use of dobutamine increased oxygen-derived parameters as evidenced by increased mixed venous oxygen saturation. Tonometered gastric mucosal pH, a surrogate for splanchnic perfusion, increased in patients who received intraoperative dobutamine. Patients in the dobutamine groups demonstrated significant higher heart rates, premature ventricular contraction arrhythmias, and electrocardiographic signs of ischemia. Mean arterial blood pressure demonstrated no significant difference among groups. The overall incidence of postoperative complications was higher in control group 70 % vs 20% to 40% in dobutamine groups. ConclusionIntraoperative use of dobutamine improved global oxygen delivery, splanchnic perfusion, and postoperative outcome after Whipple surgery. These findings may be of clinical importance when the therapeutic goal is to improve gut perfusion.

Outside the Box: Extra-Pericardial Tamponade Due to Acute Recurrence of Hiatus Hernia

Cardiac tamponade is defined as a life-threatening, slow or rapid compression of the heart due to the pericardial accumulation of fluid, pus, thrombus or gas as a result of effusion, trauma, or myocardial rupture. We describe the case of a lady who developed classic signs of cardiac tamponade immediately after an open hiatus hernia repair. Computed tomographic imaging revealed extrapericardial hernia recurrence causing cardiac compression. We believe this is the first such reported case. We conclude that cardiac tamponade from acute recurrence of hiatus hernia must be considered in the unstable postoperative patient and that the definition of cardiac tamponade is expanded to include extrapericardial pathologies.

Ranolazine: an anti-anginal drug with further therapeutic potential

Ranolazine is a novel drug approved for the treatment of chronic angina pectoris. In randomized trials, it significantly reduced the frequency of anginal attacks and the need for use of short-acting nitroglycerine. It improved exercise capacity and delayed onset of anginal symptoms or electrocardiographic signs of ischemia during exercise in patients with chronic stable angina. Unlike other drugs used for the treatment of chronic angina, ranolazine has negligible effects on blood pressure and heart rate. A major mechanism believed to contribute to this clinical efficacy is its inhibitory effect on late sodium influx during the cardiac action potential of cardiomyocytes, which is particularly important in ischemic or hypoxic conditions. Ranolazine thereby reduces intracellular sodium and calcium accumulation during ischemia, as shown in various animal research models. In this review we discuss the pharmacological profile of ranolazine and discuss the current and potential future applications in cardiovascular disease for this drug.

Treatment of small coronary arteries with a paclitaxel-coated balloon catheter

Treatment of lesions in small coronary arteries by percutaneous transluminal coronary intervention is limited by a high recurrence rate. We assessed the use of a paclitaxel-coated balloon in this indication. One-hundred eighteen patients with stenoses in small coronary vessels were treated by a paclitaxel-coated balloon (3 microg/mm(2)). The main inclusion criteria encompassed diameter stenosis of > or =70% and < or =22 mm in length with a vessel diameter of 2.25-2.8 mm. Follow-up angiography was performed at scheduled 6-month post-intervention or whenever driven by clinical or electrocardiographic signs of ischemia. The primary endpoint was angiographic in-segment late lumen loss. Eighty-two of 118 patients (70%) with a vessel diameter of 2.35 +/- 0.19 mm were treated with the drug-coated balloon only, while 32 patients required additional stent deployment. The mean in-segment late lumen loss was 0.28 +/- 0.53 mm. In patients treated with the drug-coated balloon only, the in-segment late lumen loss was 0.16 +/- 0.38 mm. At 12 months, the rate of major adverse cardiac events was 15% which was primarily due to the need for target lesion revascularization in 14 patients (12%). In those with additional bare metal stent implantation geographical mismatch between coated-balloon dilatation and stent implantation was significantly associated with the occurrence of restenosis. Treatment of coronary stenosis in small coronary vessels with the paclitaxel-coated balloon was well tolerated. It may offer an alternative to the implantation of a drug-eluting stent (ClinicalTrials.gov Identifier: NCT00404144).

Tako-Tsubo syndrome: an important differential diagnosis in patients with acute chest pain

The syndrome of Tako-Tsubo cardiomyopathy (TTC) is characterized by the occurrence of acute chest pain, electrocardiographic signs of ischemia, and transient balloon-like abnormalities in cardiac wall motion mostly involving the left ventricular apex. Significant obstructive coronary artery disease is absent. Owing to its clinical and imaging characteristics, TTC is frequently misdiagnosed as an acute coronary syndrome. Tako-Tsubo syndrome was first described in the 1990s in Japan, but meanwhile has been increasingly identified in other parts of the world also. TTC predominantly affects postmenopausal women, and may involve up to 2% of all patients with acute ST-segment elevation myocardial infarction (STEMI). Apart from single case reports, no systematic data from Austria are currently available. We analyzed prevalence, diagnostic characteristics and the clinical course of patients with TTC admitted to our cardiology department during a period of four years (May 2004 - December 2008). Diagnosis of TTC was established by the presence of the typical apical ballooning pattern of the left ventricle shown by ventriculography or echocardiography and by the absence of a significant coronary artery stenosis as demonstrated by coronary angiography. Among 448 patients with suspected acute STEMI and 963 patients with non-STEMI, 31 patients (2.2%) were diagnosed as having TTC. The majority of identified patients with TTC were postmenopausal women (90.3% women, mean age 75 +/- 10.2 years). At the time of acute hospital admission, the principal symptom was chest pain in 24 patients (77.4%), dyspnea in 10 (32.3%) and hypotension in one (3.2%). Preceding emotionally or physically stressful events were identified in 24 patients (77.4%: emotional 29%, physical 48.4%). Acute ST-segment elevation was present in 13 patients (42%) and ST/T wave abnormalities were found in 18 (58%). All patients demonstrated a distinct increase in levels of cardiac enzymes and biomarkers. Significant coronary artery stenosis was absent in all patients. After a clinical follow-up period of 172.4 +/- 342.8 days, three patients had died from non-cardiac causes, TTC had recurred in another patient 13 months after the index event, and the other 27 patients were free from cardiac symptoms and the electrocardiographic and echocardiographic abnormalities had resolved. Patients with TTC display clinical symptoms and electrocardiographic findings that mimic acute myocardial infarction. A history of a preceding stressful event in elderly women, typical echocardiographic findings of TTC, and only a mild elevation of cardiac markers will be informative. Acute-coronary angiography should be performed in order to rule out acute coronary occlusion and to avoid inadequate treatment such as thrombolysis.

Head-to-head comparison between bicycle exercise testing and coronary calcium score and coronary stenoses on multislice computed tomography

To perform a head-to-head comparison between signs of ischemia during bicycle exercise testing and coronary atherosclerosis on multislice computed tomography (MSCT) in patients with suspected coronary artery disease (CAD). Two hundred and one patients underwent exercise testing, followed by 64-slice MSCT. A subgroup of 63 (31%) patients also underwent conventional coronary angiography. The exercise test was positive or negative based on electrocardiographic signs of ischemia. On MSCT, total calcium score was obtained. Based on MSCT angiography, the patients were classified as having normal MSCT or coronary atherosclerosis [with nonobstructive and obstructive CAD (>/=50% luminal narrowing) present]. In 178 patients with interpretable examinations, the exercise test was positive in 36 (20%) and negative in 142 (80%) patients. Calcium score was identical in patients with a positive [median (interquartile range) 11 (0-343)] and a negative exercise test [18 (0-335), P=NS]. The prevalence of nonobstructive CAD was the same in two patients groups [13 (36%) patients with a positive vs. 54 (38%) patients with a negative exercise test, P=NS]. Although obstructive CAD was observed in 15 (42%) patients having a positive exercise test, obstructive lesions were also present in 38 (27%) patients without ischemia on exercise testing. The findings were confirmed by conventional coronary angiography. No correlation was observed between ischemia on exercise testing and both calcium scoring and nonobstructive CAD on MSCT. A large proportion of obstructive lesions on MSCT were not observed on exercise testing. Potentially, MSCT may provide additional information on CAD.

Transapical off-pump removal of the native aortic valve: A proof-of-concept animal study

This study evaluates the feasibility of off-pump native aortic valve removal in preparation for transapical aortic valve replacement. Off-pump aortic valve replacement is performed by balloon predilatation of the native valve followed by insertion of a stented prosthesis. In patients with calcified annuli and cusps, particulate embolization, suboptimal prosthesis sizing, and perivalvular leaks may occur. Therefore, native valve removal may improve outcomes after transapical aortic valve replacement. The aortic cusps were sequentially removed from 10 pigs in an off-pump procedure. A temporary valve was inserted percutaneously into the ascending aorta to prevent aortic regurgitation. The electrocardiogram, coronary blood flow, and arterial, left atrial, and ventricular pressures were continuously monitored. Removal of the aortic cusps caused a drop in diastolic arterial pressure and its equalization with left ventricular diastolic pressure. Systolic pressure decreased by 13.5%. Left atrial pressure increased by 86.0%. Coronary blood flow decreased by 39.9% and its pattern changed from mostly diastolic to mostly systolic. Electrocardiographic signs of ischemia appeared almost immediately. Percutaneous insertion of a temporary valve in the ascending aorta increased diastolic pressure and caused a tendency toward echocardiographic normalization. Aortic valve removal in a healthy beating heart causes acute massive aortic regurgitation, hemodynamic instability, and the rapid onset of myocardial ischemia. Reduction of left ventricular volume overload, by placement of a temporary valve in the ascending aorta, mitigates myocardial distress, helps stabilize hemodynamic parameters, and may be a useful tool to allow surgical manipulations of the aortic valve and annulus during transapical aortic valve replacement procedures.

Unconventional Electrocardiographic Signs of Ischemia During Exercise Testing

Because of the failure to consider some of the unconventional electrocardiographic signs of ischemia during exercise testing, its sensitivity and specificity are lower than optimum. Two cases are presented to illustrate how precordial peaking of the T waves and lead-strength calculations in patients with low-voltage R waves can be used to improve the diagnostic power of exercise testing. Other rarely used electrocardiographic changes during exercise testing include ST elevation in lead aVR, an increase in P-wave duration, and ST depression in premature ventricular complexes. In conclusion, this experience demonstrates that the routine consideration of these electrocardiographic changes will result in significant increases in the sensitivity and specificity of exercise testing.

Comparison of S-(+)-ketamine- with sufentanil-based anaesthesia for elective coronary artery bypass graft surgery: effect on troponin T levels

BackgroundS-(+)-ketamine anaesthesia carries potential benefits for the cardiovascularly compromised patient. However, the use of S-(+)-ketamine in ischaemic coronary artery disease is controversial. In a prospective, randomized, clinical trial, we have investigated whether an S-(+)-ketamine-based anaesthetic protocol leads to increased cardiac troponin T levels (cTnT) after coronary artery bypass grafting (CABG). MethodsTwo hundred and nine patients undergoing elective CABG were randomized to receive either i.v. anaesthesia with sufentanil–midazolam–propofol (SMP; n=108) or S-(+)-ketamine–midazolam–propofol (KMP; n=101). Haemodynamic variables were maintained within the normal range. Invasive haemodynamic monitoring was performed using a pulmonary artery catheter. Plasma cTnT levels were sampled before induction and 1, 6, and 24 h after aortic unclamping. Cardiovascular adverse events, such as electrocardiographic signs of ischaemia, perioperative myocardial infarction, and death, were recorded. ResultsPatient characteristics, cardiac profile, intraoperative management, and the incidence of cardiovascular adverse events were comparable between the groups. Plasma cTnT levels increased after operation in both groups. cTnT levels were significantly lower in the KMP group 6 h after aortic unclamping compared with the SMP group (P=0.004), but did not differ 24 h after aortic unclamping [median (range): SMP 0.4 (0.01–3.9) vs KMP 0.4 (0.07–6.6) μg litre−1, P=0.338]. ConclusionsS-(+)-ketamine does not accentuate postoperative cTNT rises in haemodynamically stable elective CABG patients.

Vasomotor function of endothelium in patients with coronary artery disease and ventricular arrhythmias occurring during myocardial ischemia

Purpose: To compare vasomotor endothelial function in patients with coronary artery disease (CAD) with and without VA occurring during myocardial ischemia. Methods: We studied 48 patients with CAD who had electrocardiographic signs of ischemia during ergometer exercise testing. All patients were divided into 2 equal groups: group I with VA occurred at peak exercise or during recovery and group II without VA. Exercise test duration was similar in the groups I and II. None of the patients had severe arterial hypertension, diabetes mellitus or signs of heart failure. Assessment of endothelial-dependent flow-mediated vasodilation (FMD) and endothelial-independent nitroglycerin-mediated vasodilation of brachial artery (BA) was performed using high-resolution ultrasound. Plasma endothelin-1 levels were measured by immunoassay method. Results: FMD of BA was lower and duration of ischemic changes of ECG during recovery was greater in the group I compared with group II. There were no significant differences in plasma ET-1 levels among the groups I and II. Conclusions: The patients with CAD and VA occurring during ischemia have FMD impaired to a greater degree and duration of ischemic changes of ECG in recovery longer compared with ones without VA.

Pheochromocytoma mimicking an acute myocardial infarction

We report a 42-year-old female who presented with retrosternal pain, dyspnoea and nausea. Electrocardiography suggested a recent anterior myocardial infarction. However, emergency coronary angiography showed normal blood flow through all the coronary arteries. Paroxysmal hypertension raised the suspicion of a pheochromocytoma. Indeed, abdominal ultrasonography and computed tomography revealed a mass in the left adrenal gland. Elevated levels of plasma and urine catecholamines supported the diagnosis of pheochromocytoma. Left adrenalectomy was performed without complications and pathological examination revealed a 5.5 cm pheochromocytoma. After surgery, all antihypertensive medication was discontinued and the blood pressure returned to normal within several days. Currently, the patient is asymptomatic, has normal catecholamine levels and the electrocardiographic signs of ischaemia have resolved entirely. This case illustrates that a rare clinical entity such as pheochromocytoma should be considered in the differential diagnosis of acute coronary syndrome. (Neth Heart J 2007;15:248-51.).

MRI-Based Safety Evaluation of the Ventrica Magnetic Coronary Anastomotic System

The Ventrica Magnetic Vascular Positioner system is a novel automatic anastomotic coupling device for distal coronary artery anastomosis. There is concern that enormous magnetic fields may negatively affect graft anastomosis or coronary artery blood flow, or that they may lead to disconnection of the magnetic ports. Forty-five domestic swine (26.6 +/- 5.9 kg) underwent magnetic resonance imaging after a single Ventrica anastomosis of the left internal mammary artery to the left anterior descending artery. Group A (n = 15) underwent magnetic resonance imaging immediately after surgery, group B (n = 15) was studied after 1 week, and group C (n = 15) after 2 weeks. The animals were sacrificed and the anastomotic sites were examined. All animals survived the imaging procedure. Mean imaging time was 25 +/- 6 min. Although imaging artifacts occurred in the area surrounding the Ventrica port, there were no disconnections or electrocardiographic signs of ischemia during the study period. Upon sacrifice, all anastomoses were patent without alterations in the alignment of the magnetic components. Clinically relevant tests such as cranial magnetic resonance imaging may be safe after use of the Ventrica system for coronary artery revascularization.

Cardiac Complications of Major Elective Non-Cardiac Surgery: Incidence and Risk Factors

Previous estimates of the incidence of cardiac complications following major elective surgery have all been obtained in populations with specific risk factors or in contexts that differ from those found in Spain. Our aims were to estimate the frequency of postoperative cardiac complications following major elective non-cardiac surgery in patients aged 40 years or more, and to identify associated risk factors. Prospective observational study of consecutive patients undergoing surgery between November 1997 and October 1999. The overall incidence of postoperative cardiac complications was 9.6 (95% CI, 5.3-16): it was 1.9 (95% CI, 0.5-7.5) for superficial surgery, 36.2 (95% CI, 15.1-87) for deep surgery, and 150 (95% CI, 67.4-334) for peripheral vascular surgery. The risk of cardiac complications was greater in patients aged 75 years or more (relative risk [RR]=9.5; 95% CI, 2.6-34.9), in those with type-I diabetes (RR=7.1; 95% CI, 2.1-24.1), systolic blood pressure > or =180 mmHg (RR=5.8; 95% CI, 1.3-25.4), or electrocardiographic signs of ischemia (RR=25.3; 95% CI, 6-106.8), in those who had undergone deep or peripheral vascular surgery (RR=21; 95% CI, 5.4-81.6), and in those who experienced hypotensive episodes during surgery (RR=8.9; 95% CI, 2-39.1). Cardiac complications occurred in 1% of consecutive patients aged 40 years or more in the three months following major elective non-cardiac surgery.

High incidence of myocardial ischemia during postpartum hemorrhage.

Postpartum hemorrhage remains a major cause of global maternal morbidity and mortality, even in developed countries, despite the use of intensive care units. This study sought to (1) assess whether myocardial ischemia could be associated with and even aggravate hemorrhagic shock in young parturients admitted for postpartum hemorrhage, and (2) identify the independent risk factors for myocardial ischemia. On their referral to the intensive care unit, a multidisciplinary team managed parturients with severe postpartum hemorrhage. Ventilation, transfusion, catecholamines, surgery, or angiography with uterine embolization were provided as clinically indicated. Plasma cardiac troponin I levels were used as a surrogate marker of acute myocardial injury and electrocardiograms of myocardial ischemia. A total of 55 parturients were referred with severe postpartum hemorrhage, all in hemorrhagic shock. Twenty-eight parturients (51%) had elevated serum levels of cardiac troponin I (9.4 microg/l [3.7-26.6 microg/l]), which were associated with electrocardiographic signs of ischemia and deteriorated myocardial contractility and correlated with the severity of hemorrhagic shock. Indeed, multivariate analysis identified low systolic and diastolic arterial blood pressure (< 88 and < 50 mmHg, respectively) and increased heart rate (> 115 beats/min) as independent predictors of myocardial injury. In addition, all patients who were given catecholamines also had elevated cardiac troponin I levels. These results suggest that treatment of postpartum hemorrhage-induced hemorrhagic shock should be coupled with concomitant prevention of myocardial ischemia, even in young parturients.