Evaluation Of Acute Myocardial Infarction Research Articles

Is there an Electro-Angiographic Correlation in RD Infarction?

Introduction: Coronary angiography is the examination of choice in the evaluation of coronary anatomy during acute myocardial infarction, particularly of the right ventricle (RV), whose diagnosis remains difficult. The electrocardiogram reflects the pathophysiology of myocardial ischemia, thus allowing prediction of the culprit lesion.
 Objective: To investigate the correlation between electrical and coronary data and to judge the reproducibility of the electrocardiogram in identifying the culprit lesion in RV infarction.
 Materials and Methods: Retrospective study of patients hospitalized in the Cardiology Department of the Mohammed VI University Hospital in Marrakech over a period of 24 months for MDI extended to the RV.
 Results: During the study period, 120 patients were hospitalized for MI with RV extension.
 Inferior MI represented 70% of all cases of infarction extended to the RV. It is represented electrically by isolated ST-segment elevation in V3R found in 76%, as well as in association with an elevation in V4R in 45% of cases.
 Conduction disorders were noted in 38% of cases, presented essentially by first degree atrioventricular block, without any electrical specificity.
 Coronary angiography was performed in 91% of patients, half of whom underwent coronary angioplasty. A bi-truncular involvement (RC + VIA) was found in 40% of cases, the middle DC is the culprit lesion in almost half of the cases of VD infarction.
 The presence of an ST elevation in the isolated V3R shunt is a specific criterion of right middle coronary involvement, found in 48% of patients.
 Conclusion: The ECG remains an essential tool in the early prediction of the artery responsible for the infarction. Because of its complementary nature, the combination of ECG and coronary angiography is essential for a better evaluation of acute myocardial infarction.

Quantitative evaluation of acute myocardial infarction by feature-tracking cardiac magnetic resonance imaging.

To assess the value of feature-tracking cardiac magnetic resonance (FT-CMR) imaging in the quantitative evaluation of acute myocardial infarction (AMI). We retrospectively analyzed medical records of patients with acute myocardial infarction (AMI) diagnosed in the Department of Cardiology of Hubei No.3 People's Hospital of Jianghan University from April 2020 to April 2022, who underwent feature-tracking cardiac magnetic resonance (FT-CMR) examination. Based on the electrocardiogram (ECG) findings, patients were divided into ST-elevation myocardial infarction (STEMI) (n=52) and non-STEMI (NSTEMI) (n=48) groups. We compared myocardial strain parameters between the two groups and applied the Pearson's test to reveal any correlations between the left ventricular myocardial strain parameters and the number of late gadolinium enhancement (LGE) positive segments; we assessed the clinical value of FT-CMR for predicting STEMI using a receiver operating characteristic (ROC) curve. The number of LGE-positive segments in the STEMI group was significantly higher than that in the NSTEMI group. The myocardial radial, circumferential and longitudinal strains in the STEMI group were significantly lower than those in the NSTEMI group (p<0.05). The number of LGE-positive segments in patients with AMI negatively correlated with the radial, circumferential and longitudinal strains. The results of the ROC curve analysis showed that radial, circumferential and longitudinal strain values have a diagnostic value for STEMI (p<0.05). FT-CMR, a non-invasive and rapid method for analyzing myocardial strains, has a high diagnostic value for AMI and should be helpful for the prevention and intervention of ventricular remodeling after myocardial infarctions.

Time of the low-level cardiopulmonary exercise test does not affect the evaluation of acute myocardial infarction in stable status.

Cardiopulmonary exercise test (CPET) provides the means to evaluate the cardiopulmonary function and guide cardiac rehabilitation. The performance of acute myocardial infarction (AMI) patients at different times is different on CPET. This was a cross-sectional study. Patients diagnosed as AMI in stable status were included and performed the low- level CPET (RAMP 10W). CPET variables at different times were compared among four groups. Sixty and one patients with AMI conducted the low-level CPET from 3 to 15 days after AMI. Patients were stratified according to quartiles of CPET's time: 5 in 3-6 days group, 34 in 7-9 days group, 14 in 10-12 days group, 8 in 13-15 days group. Only VO2/HR at rest showed statistically different among the four groups.VO2/HR at rest in 3-6 days group and 10-12 days group were higher than in 13-15 days group (3.4 ± 0.85, 3.18 ± 0.78 vs. 2.50 ± 0.49 ml/beat, p < 0.05). Patients with complete revascularization had higher peak heart rate and blood pressure product and peak breathing reserve (BR), and lower Borg score compared with incomplete revascularization. And patients with LVEF >50% had higher peak BR compared with LVEF 40-50%. It was safe and efficient to conduct the low-level CPET in stable AMI patients 3 days after onset. Time was not an effector on cardiopulmonary function and exercise capacity and prognosis in AMI during CPET. Complete revascularization and normal LVEF should be good for exercise test in AMI.

Three-Dimensional Echocardiography and Coagulation Function Detection in the Prognosis Evaluation of Patients with Acute Myocardial Infarction.

This research was aimed at discussing the application value of coagulation function detection and three-dimensional echocardiography in the prognosis evaluation of acute myocardial infarction (AMI) patients. 72 patients with AMI were divided into the recovered group (good recovery) and unrecovered group (poor recovery) according to the results of postoperative ultrasonography. The left ventricular parameters of the patients were detected by three-dimensional ultrasound, and the coagulation function was also detected. The results showed that 3 months after surgery, the regional end-systolic volume (rESV) and regional end-diastolic volume (rEDV) of the left ventricle in the patients were smaller than the measured values 1 week after surgery. The left ventricular regional ejection fraction (rEF) was greater than the value measured 1 week after surgery, and all the differences were statistically significant (P < 0.05). For the end-systolic volume (ESV), end-diastolic volume (EDV), and ejection fraction (EF) (%), the two-dimensional ultrasound results were significantly lower than the three-dimensional ultrasound results, and there were significant differences (P < 0.05). Tmsvle6-Dif% of the recovered patients was 14.99 ± 9.88 and 14.37 ± 9.78 3 months and 6 months after surgery, respectively. These were smaller than 30.91 ± 18.63 and 33.51 ± 17.96 of the unrecovered patients; the differences were of statistical significance (P < 0.05). Tmsvl6-SD% of recovered patients was 3.69 ± 2.47 and 3.61 ± 1.83 3 months and 6 months after surgery, respectively, which were also smaller than 7.38 ± 4.06 and 7.96 ± 2.82 of unrecovered patients, showing statistically significant difference (P < 0.05). The postoperative Tmsvle6-Dif% and Tmsvl6-SD% of the recovered group were lower than those of the unrecovered patients, with the statistically significant differences (P < 0.05). The level of coagulation factors in the recovered group was also significantly lower than that in the unrecovered group with the difference statistically significant (P < 0.05). The results suggested that three-dimensional echocardiography played an important role in the evaluation of cardiac conditions in AMI patients. The level of coagulation factors varied with the AMI condition of patients, and there was an obvious relationship between them, which could provide a reference value for the prognosis evaluation of patients.

Global longitudinal strain in acute myocardial infarction and incidence of in-hospital heart failure.

BACKGROUND: Myocardial strain is a good prognostic factor independent of ejection fraction for outcomes in heart failure. We evaluated the prognostic role of global longitudinal strain in acute myocardial infarction to identify the likelihood of in-hospital heart failure. METHODS: Forty participants with acute myocardial infarction were included, ranked according to Killip class, and classified into 2 groups: patients complicated by in-hospital heart failure (Killip class II — IV) on admission or during hospital stay (n = 16) and patients with no clinical evidence of in-hospital heart failure (Killip class I) on admission or during hospital stay (n = 24). All participants underwent reperfusion by percutaneous intervention or fibrinolytic therapy followed by transthoracic echocardiography within 72 hours of admission. RESULTS: There were statistically significant differences between both groups regarding the global longitudinal strain, ejection fraction and the wall motion score index. In patients with mildly reduced ejection fraction, there was a statistically significant difference between both groups regarding the global longitudinal strain and statistically non-significant differences regarding the ejection fraction and wall motion score index. Global longitudinal strain was the only echocardiographic parameter with statistically significant difference between Killip class I and class II. CONCLUSIONS: Global longitudinal strain was superior to ejection fraction and wall motion score index in detection of in-hospital heart failure in Killip class II and in evaluation of myocardial dysfunction in patients with mildly reduced ejection fraction. Global longitudinal strain could be considered as a part of the routine echocardiographic evaluation of acute myocardial infarction for detection of in-hospital heart failure and risk stratification of patients with acute myocardial infarction especially those with mildly reduced ejection fraction and those without overt heart failure (Killip class II).

Machine Learning to Assess for Acute Myocardial Infarction Within 30 Minutes.

Variations in high-sensitivity cardiac troponin I by age and sex along with various sampling times can make the evaluation for acute myocardial infarction (AMI) challenging. Machine learning integrates these variables to allow a more accurate evaluation for possible AMI. The goal was to test the diagnostic and prognostic utility of a machine learning algorithm in the evaluation of possible AMI. We applied a machine learning algorithm (myocardial-ischemic-injury-index [MI3]) that incorporates age, sex, and high-sensitivity cardiac troponin I levels at time 0 and 30 minutes in 529 patients evaluated for possible AMI in a single urban emergency department. MI3 generates an index value from 0 to 100 reflecting the likelihood of AMI. Patients were followed at 30-45 days for major adverse cardiac events (MACEs). There were 42 (7.9%) patients that had an AMI. Patients were divided into 3 groups by the MI3 score: low-risk (≤ 3.13), intermediate-risk (> 3.13-51.0), and high-risk (> 51.0). The sensitivity for AMI was 100% with a MI3 value ≤ 3.13 and 353 (67%) ruled-out for AMI at 30 minutes. At 30-45 days, there were 2 (0.6%) MACEs (2 noncardiac deaths) in the low-risk group, in the intermediate-risk group 4 (3.0%) MACEs (3 AMIs, 1 cardiac death), and in the high-risk group 4 (9.1%) MACEs (4 AMIs, 2 cardiac deaths). The MI3 algorithm had 100% sensitivity for AMI at 30 minutes and identified a low-risk cohort who may be considered for early discharge.

External validation of a high-sensitive troponin I algorithm for rapid evaluation of acute myocardial infarction in a Danish cohort.

An accelerated diagnostic algorithm for ruling-in or ruling-out myocardial infarction (MI) after 1 hour (1 h) has recently been derived and internally validated for the Siemens ADVIA Centaur TNIH assay. We aimed to validate the diagnostic performance of the TNIH 0 h/1 h algorithm ad modum Boeddinghaus in a Danish cohort. Patients with chest pain suggestive of MI were prospectively enrolled. High-sensitive troponin I (TNIH) was measured at admission (0 h) and after 30 minutes (30 m), 1 h, and 3 hours (3 h). We externally validated the TNIH 0 h/1 h algorithm ad modum Boeddinghaus in Danish patients. Moreover, we applied the algorithm using the second TNIH measurement at 30 m instead of 1 h. We enrolled 1003 patients: median (Q1-Q3) age 64 (52-74) years, 42% female, and 23% with previous MI. Myocardial infarction was the final diagnosis in 9% of patients. Median (Q1-Q3) times from admission to 30 m and 1 h blood draw were 35 min (30-37 min) and 67 min (62-75 min), respectively. Using the 0 h and 1 h results, 468 (47%) patients were assigned to rule-out, 104 (10%) to rule-in, and 431 (43%) to the observational zone. This resulted in a negative predictive value of 100% (95% confidence interval: 99.2-100%), sensitivity of 100% (95.9-100%), positive predictive value of 79.8 (70.8-87.0%), and specificity of 97.7% (96.5-98.6%). The diagnostic performance after 30 m was similar. The TNIH 0 h/1 h algorithm ad modum Boeddinghaus performed excellently for rule-out of MI in a Danish cohort. The Boeddinghaus algorithm also performed excellently after only 30 m. NCT03634384. Rapid Use of High-Sensitive Cardiac Troponin I for Ruling-in and Ruling-out Acute Myocardial Infarction (RACING-MI), https://clinicaltrials.gov/ct2/show/NCT03634384.

Optimal Detection of Acute Myocardial Injury and Infarction with Cardiac Troponin: Beyond the 99th Percentile, into the High-Sensitivity Era.

Cardiac troponin (cTn) is the biomarker of choice for the diagnosis of acute myocardial infarction (MI); use of this biomarker has centered around the 99th percentile upper reference limit (URL) for healthy populations. Recent development and regulatory approval of high-sensitivity cardiac troponin (hs-cTn) assays have required a fresh look at utilization of the 99th percentile URL. This review covers issues regarding the 99th percentile URL and approaches for use of cTn as biomarker for detecting cardiac injury and diagnosis of acute myocardial infarction. Development of hs-cTn assays has allowed determination and use of sex-specific 99th percentile URLs for assessing cardiac injury and increased the utility of cTn values below the 99th percentile URL. This improved analytical performance for hs-cTn assays has allowed for development of accelerated diagnostic protocols (ADPs) for rapid assessment and disposition of patients based on serial sampling of cTn for use in acute MI diagnosis as soon as 0-1h after clinical presentation. The 99th percentile URLs of cTn is essential for detecting cardiac injury; however, use of the 99th percentile URLs in the era of hs-cTn results may be modified. ADPs have the potential to substantially decrease the time many patients spend under evaluation for acute MI, thereby potentiating improvement in patient satisfaction, decreased healthcare costs, and reducing the burden on emergency departments.

Characteristics and Clinical Outcomes of Patients With Spontaneous Coronary Artery Dissection.

BackgroundThe goal of this study is to report the characteristics and long‐term clinical outcomes of patients with spontaneous coronary artery dissection (SCAD) and to identify factors associated with recurrent SCAD.Methods and ResultsThis is a retrospective cohort study that included patients who underwent coronary angiography for evaluation of acute myocardial infarction between 2006 and 2016. Among 26 598 patients hospitalized with a principal diagnosis of acute myocardial infarction, 208 (0.78%) were diagnosed with SCAD. Patients with SCAD were younger (49.0±11.6 versus 65.6±12.2 years) and more likely to be women (88.9% versus 31.6%). Atherosclerotic risk factors, such as hypertension, hyperlipidemia, obesity, and diabetes mellitus, were less prevalent. Median follow‐up was 4.7 years. Mortality was lower in patients with SCAD (1‐year mortality: 2.4% versus 8.8%; P<0.001). After using propensity score matching to control for differences in age, sex, and comorbidities, the difference in mortality was no longer present, suggesting that lower mortality in patients with SCAD is attributed primarily to their baseline characteristics. Recurrent SCAD occurred in 22 patients (10.6%). Multivariate Cox regression modeling showed concomitant fibromuscular dysplasia (hazard ratio, 5.1; 95% CI, 1.6–15.8; P=0.005) and migraine headaches (hazard ratio, 3.4; 95% CI, 1.4–8.4; P=0.008) to be associated with increased risk of recurrent SCAD.ConclusionsAmong patients with acute myocardial infarction, patients with SCAD have a lower risk of mortality, which is attributed primarily to their younger age, female sex, and low prevalence of atherosclerotic risk factors. Risk of recurrent SCAD persists years after the initial presentation. Patients with fibromuscular dysplasia and migraine are at higher risk for recurrent SCAD.

Characteristics of T cell receptor repertoires of patients with acute myocardial infarction through high-throughput sequencing

BackgroundT cells are key regulators of immunity and one of the cells recruited in atherosclerosis and participated in various stages of the development of atherosclerosis. Characterizing T-cell receptor (TCR) repertoires is a priority of great scientific interest and potential clinical utility for the early diagnosis, risk stratification and prognostic evaluation of acute myocardial infarction (AMI).MethodsThe TCR repertoires in 21 subjects including 7 patients with non-ST-segment elevation myocardial infarction (NSTEMI), 6 patients with ST-segment elevation myocardial infarction (STEMI) and 8 subjects with normal coronary artery (NCA) as control were characterized by using high-throughput sequencing. Bioinformatics analysis were performed.ResultsPatients with NSTEMI displayed more diverse TCR sequences than NCA controls, but they had lower percentage of top 200 TCR sequences. However, no significant differences were observed between the patients with STEMI and NCA controls, but STEMI group had lower percentage of top 200 TCR sequences. T cells from patients with AMI and NCA controls showed a differential V and J gene usage, especially, significant difference was observed in frequencies of V gene (TRBV2, TRBV29-1, TRBV30 and TRBV12-3) and J gene (TRBJ2-1) usage. Furthermore, significantly differences in average overlap was observed in groups of AMI and NCA control. The results showed that patients with AMI had distinct TCR repertoires which revealed the association between cardiovascular condition and T-cell clonotypes.ConclusionsOur findings revealed the differences of TCR repertoires between patients with AMI and NCA controls, which might be potential biomarkers for evaluating risk stratification or diagnosis of acute coronary syndrome.

Implementation of High-Sensitivity Cardiac Troponin: Challenges From the International Experience.

Implementation of the newly approved high-sensitivity cardiac troponin (hs-cTn) in the United States presents a challenge for clinical practice. Sex-specific cutoffs, clinical protocols, and workflows will likely require modifications before implementation. We conducted a cross-sectional survey of international physicians and laboratorians already utilizing hs-cTn for the evaluation of acute myocardial infarction. Twenty-two of 54 (41%) eligible participants completed the survey, representing 9 countries and 18 hospitals. All reported successful hs-cTn implementation and diagnostic utility (mean 8.6 + 1.2 out of 10 for best implementation). The major perceived benefit was more rapid evaluation of acute myocardial infarction (14/19, 74%), and the most frequently cited limitation was an increase in the number of measurable hs-cTn values that required further evaluation (8/18, 44%). Institutions using the hs-cTnI assay favored sex-specific cutoffs (5/6, 83%), whereas institutions employing the hs-cTnT assay favored a combined cutoff (12/12, 100%). Timing of serial hs-cTn measurements varied, with 0-3 hours (8/17, 47%) most frequent, followed by 0-2 hours (4/17, 24%), 0-1 hour (3/17, 18%), and other (2/17, 12%). Our survey of hs-cTn implementation at international institutions reveals satisfaction with new assays but reflects important variations in clinical practice. The use of sex-specific vs. combined cutoffs and timing of serial hs-cTn measurements varies across institutions and are subjects that United States centers must define without consensus from international practices.

GW28-e0947 ABCC4 is one of the susceptibility genes that predicts the risk of acute myocardial infarction

We aim to discover the role of acute myocardial infarction (AMI). To explore whether the low expression of ABCC4 in peripheral blood can be the molecular marker in the genetic evaluation of acute myocardial infarction or not and to discuss the possible mechanism of ABCC4 gene involved in the

High expression of long chain acyl-coenzyme A synthetase 1 in peripheral blood may be a molecular marker for assessing the risk of acute myocardial infarction.

The current study aimed to investigate whether the increased expression of long chain acyl-coenzymeA synthetase 1 (ACSL1) in peripheral blood leukocytes (PBL) may be a molecular marker for the genetic evaluation of acute myocardial infarction (AMI). The mechanism of action of ACSL1 in the pathogenesis of AMI was also investigated. A total of 75 patients with AMI and 70 individuals without coronary heart disease were selected to participate in the present study. The demographic and clinical information of the enrolled subjects was recorded. Reverse transcription quantitative polymerase chain reaction and western blot analysis were applied to measure the expression of ACSL1 at the mRNA and protein levels. It was demonstrated that the expression of ACSL1 mRNA and protein in PBL was increased in patients with AMI compared with controls. Logistic regression analysis indicated that ACSL1 expression in PBL was an independent risk factor of AMI. There was a significant positive association between the level of ACSL1 expression and the degree of atherosclerosis in the coronary artery. Furthermore, patients with AMI exhibited an increased risk of atherosclerosis due to increased fasting blood glucose, total cholesterol, triglyceride and lipoprotein levels and decreased high-density lipoprotein levels, compared with controls. Therefore, the current study demonstrated that ACSL1 expression was increased in the PBLs of patients with AMI. The elevated expression of ACSL1 acts an independent risk factor of AMI and may act as a potential biomarker when determining the risk of AMI.

Acute myocardial infarction in non-cardiac critically ill patients: a clinical-pathological study

In patients admitted to the Intensive Care Unit (ICU) for non cardiac disease, the diagnosis of acute coronary syndromes can be challenging. The aim of the study was to define the rate of discrepancies concerning the diagnosis of acute myocardial infarction and to evaluate the presence of risk factors that could be helpful in identifying patients at higher risk of missed diagnosis. We compared clinical and autopsy records of 600 critically ill patients who died in our ICU in a 10-years period. We identified patients in whom acute myocardial infarction was reported as the cause of death on the clinical records or was discovered only at post-mortem examination. These subjects were subsequently divided into two Groups: patients in Group 1 underwent diagnostic evaluation for acute myocardial infarction whereas those in Group 2 were not investigated for. In Group 1, a definite clinical diagnosis was reached in 11 patients (14,7%) but remained undetermined in 37 patients (48%). The diagnosis was totally missed in 8 patients in Group 1 (10,6%) and in 20 patients of Group 2 (26,6%). The diagnostic discrepancy was higher in septic patients, in whom the correct diagnosis of acute myocardial infarction was established at a rate lower than 50% in respect to non-septic patients. Our experience strengthens the role of post-mortem examination as a source of feed-back of the overall diagnostic and therapeutic approach especially in septic patients, where the diagnostic error is more frequent.

CMR of microvascular obstruction and hemorrhage in myocardial infarction.

Microvascular obstruction (MO) or no-reflow phenomenon is an established complication of coronary reperfusion therapy for acute myocardial infarction. It is increasingly recognized as a poor prognostic indicator and marker of subsequent adverse LV remodeling. Although MO can be assessed using various imaging modalities including electrocardiography, myocardial contrast echocardiography, nuclear scintigraphy, and coronary angiography, evaluation by cardiovascular magnetic resonance (CMR) is particularly useful in enhancing its detection, diagnosis, and quantification, as well as following its subsequent effects on infarct evolution and healing. MO assessment has become a routine component of the CMR evaluation of acute myocardial infarction and will increasingly play a role in clinical trials of adjunctive reperfusion agents and strategies. This review will summarize the pathophysiology of MO, current CMR approaches to diagnosis, clinical implications, and future directions needed for improving our understanding of this common clinical problem.

The Reevaluation of MIBI as the Ligand of &lt;Sup&gt;99m&lt;/Sup&gt;Tc-MIBI Radiopharmaceutical for Myocardial Imaging

Methoxy isobutyl isonitrile labelled with technetium-99m ( 99m Tc) radionuclide can be used for the evaluation of acute myocardial infarction. The 99m Tc-MIBI radiopharmaceutical is available in the lyophilized-kit, which is separately packed with its radionuclide. Recently, in CNTMR-BATAN Bandung, 99m Tc-MIBI radiopharmaceutical was prepared using MIBI ligand synthesized in 1996 as lyophilized-kits having the radiochemical purity less than 90 % and not accumulated in the myocardium. It could be caused by several factors, among others were technical preparation of lyophilized dry-kit and the quality of MIBI; therefore the reevaluation of the ligand for the quality improvement was needed. Firstly, MIBI ligand was recristallized. It was found that MIBI as [Cu(MIBI) 4 ]BF 4 salt was a glassy solid with the melting point of 98 -99 o C. The infra red analysis showed the presence of spectra vibration at 1085, 1180 cm -1 and 2180, 2220 cm -1 for –OCH 3 and N≡C groups, respectively. The preparation of 99m Tc-MIBI was performed by adding 99m Tc radionuclide into new MIBI liquid-kit, then boiled in water bath for minimum period of 10 minutes. The radiochemical purity of 99m Tc-MIBI was analysed by thin layer chromatographic method using absolute ethanol as a mobile phase. The pre-clinical evaluation was observed in Wistar rat and clinical studies were performed in volunter using gamma camera. It is revealed that the radiochemical purity of more than 90 % i.e. 96.83 ± 1.43 % was still stable until 24 hours storage at room temperature. The stability studies of 99m Tc-MIBI in human blood plasma showed that in 6 hours, the radiochemical purity was decreased to 90.89 ± 2.90 %. Clinical application of 99m Tc-MIBI with tomography techniques using gamma camera showed the distinct accumulation of radioactivity in the heart.

Should creatine kinase-MB index be eliminated in patients with indeterminate troponins in the ED?

ObjectivesThe objective of this study is to determine whether creatine kinase-MB (CK-MB) index (CK-MBi) is useful in the evaluation of acute myocardial infarction (AMI) in patients with indeterminate troponin (Tn) in the emergency department (ED). MethodsA retrospective cohort study was conducted of patients at an urban academic ED with over 55 000 annual visits who underwent Tn T (Roche, Indianapolis, IN) and CK-MB testing. One year of ED patients who had Tn testing were identified, and their corresponding CK-MBi was examined to find patients with indeterminate Tn (0.01-0.09) and positive CK-MBi (>6.0). Subsequent cardiac enzymes and hospital course were reviewed to identify patients diagnosed with AMI. A 95% confidence interval around point estimates were used in data analysis. ResultsOver 1 year, 11 718 initial Tn were identified. Indeterminate Tn was seen in 2512 cases. Of these, 28 had positive CK-MBi. Of the 28, 5 were judged by treating physicians to be having AMI and underwent cardiac catheterization. Of the 5 patients, 4 had subsequent positive Tns on serial enzyme testing. One of the patients thought to be having AMI had no coronary artery disease on catheterization. The rate of true positive CK-MBi with indeterminate Tn was 0.16% (95% confidence interval, 0.04%-0.41%). ConclusionInitial results identify rare cases of AMI where CK-MBi is positive in the setting of indeterminate Tn. However, most patients with indeterminate Tn and positive CK-MBi were not judged to be having AMI. In most cases, CK-MBi is not positive with indeterminate Tn and when positive more commonly confuses the picture. This suggests CK-MBi could be eliminated in patients with indeterminate Tns.

ECONOMIC IMPACT OF THE UNIVERSAL DEFINITION OF ACUTE MYOCARDIAL INFARCTION ON AN INNER CITY TEACHING HOSPITAL

i p The universal definition of myocardial infarction provides criteria for the diagnosis and classification of the type of acute myocardial infarction (AMI) and recommends the measurement of cardiac troponin (cTn) for the detection of myocardial necrosis. Despite this, many institutions still use creatinine kinase-MB as part of the standard laboratory evaluation for AMI. The aim of this study was to ascertain the cost benefit of using only cTn for the diagnosis of acute coronary syndromes. A survey was done of Kansas City hospitals and the University HealthSystem Consortium list server for comparison of whether other institutions use 1 or both biomarkers. Locally, most of the responding hospitals in Kansas City and 57% of responding university hospitals surveyed use the 2 biomarkers for the diagnosis of AMI. After initiating medical staff education, the investigators’ institution’s standard order sets were changed to use only cTnI for the assessment of AMI. The cost savings by eliminating creatine kinase-MB on the order sets was based on the annual volume of processed specimens. The cost of supplies, equipment, and materials was determined on a per test basis. After initiation of the new standard order sets, the creatine kinase-MB testing rate decreased to 50 per month, from 1,098, for an annualized savings of $86,786. In conclusion, as the health care system is challenged to improve care while containing cost, the use of a single biomarker (cTn) in the diagnosis of AMI fulfills this promise without sacrificing patient care. The diagnostic value of cardiac troponin (cTn) measurement is well established. However, less well appreciated is the potential economic benefit from using a single marker instead of a panel of biomarkers that traditionally have included creatine kinase-MB (CK-MB). Expert consensus underscores using cTn determinations only for better clinical care and a reduction in cost. The elimination of muliple biomarkers, including CK-MB, in the diagnosis of cute coronary syndromes (ACS) relies on evidence-based edicine consistent with the universal definition of acute yocardial infarction (AMI). We report our experience in ost savings after developing standard order sets with cTnI s the only marker on chest pain, ACS, and post–percutaeous coronary intervention orders. Our hypothesis was that significant cost savings would be realized without comromising patient care.

Contrast-enhanced magnetic resonance imaging guided decision making after primary percutaneous coronary intervention for acute ST-elevation inferior myocardial infarction

Coronary occlusion of large epicardial branches leads to profound ischemia at the infarct core, resulting in simultaneous necrosis of myocytes and endothelial cells. This process leads to microvascular obstruction in the infarct core, described as the no-reflow region in basic studies and documented in humans by contrast-enhanced magnetic resonance imaging and ultrasound. After coronary occlusion, contrast-enhanced magnetic resonance identifies myocardial infarction as a hyperenhanced region containing a hypoenhanced core. There is growing interest in incorporating its assessment into the evaluation of acute myocardial infarction because it is the key in defining specific therapeutic strategies and in directing the interventional therapy. We report a rare case of right ventricular infarction where contrast-enhanced magnetic resonance produced detailed images of myocardial perfusion pattern and tissue damage and directed the treatment after acute myocardial infarction.

Heart-type Fatty acid-binding protein in Acute Myocardial infarction Evaluation (FAME): background and design of a diagnostic study in primary care.

BackgroundCurrently used biomarkers for cardiac ischemia are elevated in blood plasma after a delay of several hours and therefore unable to detect acute coronary syndrome (ACS) in a very early stage. General practitioners (GPs), however, are often confronted with patients suspected of ACS within hours after onset of complaints. This ongoing study aims to evaluate the added diagnostic value beyond clinical assessment for a rapid bedside test for heart-type fatty-acid binding protein (H-FABP), a biomarker that is detectable as soon as one hour after onset of ischemia.MethodsParticipating GPs perform a blinded H-FABP rapid bedside test (Cardiodetect®) in patients with symptoms suggestive of ACS such as chest pain or discomfort at rest. All patients, whether referred to hospital or not, undergo electrocardiography (ECG) and venapunction for a plasma troponin test within 12–36 hours after onset of complaints. A final diagnosis will be established by an expert panel consisting of two cardiologists and one general practitioner (blinded to the H-FABP test result), using all available patient information, also including signs and symptoms. The added diagnostic value of the H-FABP test beyond history taking and physical examination will be determined with receiver operating characteristic curves derived from multivariate regression analysis.ConclusionReasons for presenting the design of our study include the prevention of publication bias and unacknowledged alterations in the study aim, design or data-analysis. To our knowledge this study is the first to assess the diagnostic value of H-FABP outside a hospital-setting. Several previous hospital-based studies showed the potential value of H-FABP in diagnosing ACS. Up to now however it is unclear whether these results are equally promising when the test is used in primary care. The first results are expected in the end of 2008.