In-hospital Congestive Heart Failure Research Articles

Registry Study of Clinical Data and in Hospital Outcome in Patients Admitted with Acute Coronary Syndrome at Tanta University Hospital in 2019

Background: A quick but thorough assessment of the patient’s history and findings on physical examination, electrocardiography, and cardiac biomarker tests permit accurate diagnosis and aid in early risk stratification. This work aimed to analyze the diagnostic and prognostic tools, the modalities of management, and the hospital outcome of patients with acute coronary syndrome (ACS) at Tanta University Hospital in one year.
 Methods: This ACS registry at Tanta university hospital is a prospective observational registry for 200 consecutive admitted patients with proven ACS from January 2019 to January 2020.
 Results: A higher percent of hypertension, family history of ischemic heart disease and SCD, previous history of chronic kidney disease (CKD), and lower percent of a previous history of IHD in STEMI compared to NSTEMI/UA. In-hospital death, in-hospital reinfarction, and reduced ejection fraction are higher in STEMI than in NSTEMI/UA patients. (P value = 0.015, 0.018 and 0.001 respectively) without significant differences regarding in-hospital congestive heart failure (CHF) and ischemic stroke. History of CKD, higher Killip class, and in-hospital stroke were independently affecting in-hospital mortality. Also, the history of higher Killip class was independently affecting in-hospital reinfarction and in-hospital CHF. Old age and occurrence of in-hospital reinfarction were independently affecting in-hospital stroke.
 Conclusion: Hypertension, diabetes, dyslipidemia, and smoking are the major risk factors for ACS so, controlling these risk factors will improve in-hospital outcomes. In STEMI, most patients underwent PPCI, which was reflected in the outcome. In NSTEMI/UA patients, both conservative and invasive management was done, taking into consideration the risk stratification of each patient, making management easier and with a good outcome.

Impact of beta blockers on patients undergoing transcatheter aortic valve replacement: the OCEAN-TAVI registry

ObjectiveThere is paucity of data on optimal medical treatment, including use of beta blockers for patients undergoing transcatheter aortic valve replacement (TAVR). The study aimed to investigate the association of...

Association of postprocedural aortic regurgitation with mitral regurgitation worsened after transcatheter aortic valve replacement.

There is a paucity of investigation which demonstrates a predictor of mitral regurgitation (MR) worsened after aortic valve replacement (TAVR). The aim of this study was to identify the predictor of worsened MR after transcatheter TAVR. We retrospectively studied a total of 209 patients with mild or less MR at baseline who underwent TAVR for the treatment of severe aortic stenosis with the balloon-expandable device. We found the presence of MR worsened after TAVR in 6% (12 patients) of all patients. Moderate or more postprocedural aortic regurgitation (AR) (odds ratio, 8.104; 95% confidence interval, 1.78-36.87; P=.007) was identified as a predictor of MR worsening after TAVR. In-hospital outcomes indicated that patients within whom MR worsened suffered congestive heart failure more than those with unchanged or improved MR after TAVR (P<.05). Significant postprocedural AR was associated with MR worsened from mild or less to moderate or more after TAVR. Worsened MR might affect in-hospital congestive heart failure.

EVOLUTION OF A REGIONAL STEMI REPERFUSION MODEL: THE 6-YEAR VANCOUVER COASTAL HEALTH AUTHORITY EXPERIENCE

BACKGROUND: Guidelines strongly recommend that regional systems of STEMI care include the assessment and continuous quality improvement of EMS and hospitalbased activities. We describe the evolution of the Vancouver Coastal Health Authority (VCHA) STEMI program, including the impact of individual care components on reperfusion times and clinical outcomes over a 75-month period. METHODS: All patients with confirmed STEMI presenting within the VCHA from June 2007 to September 2013 were included (n 1⁄4 2041). Primary analysis was performed by care component phase: Phase 1, regionalization of the STEMI program (n 1⁄4 278, June 2007 to May 2008); Phase 2, introduction of pre-hospital ECGs (n 1⁄4 979, May 2008 to May 2011); and Phase 3, implementation of an inter-facility transfer protocol for primary PCI (pPCI) (n 1⁄4 784, May 2011 to September 2013)). A total of 1353 patients received pPCI across all phases. RESULTS: Baseline clinical characteristics were similar between phases. Amongst patients receiving pPCI, median first medical contact-to-device times decreased over the 3 phases, whether the initial presentation was at a PCI capable hospital (116 min, 92 min, 95 min; p < 0.001 for trend) or PCI non-capable hospital (174 min, 146 min, 123 min; p < 0.001 for trend) (Figure). Moreover, the proportion of STEMI patients receiving successful pPCI increased across each phase (44.2%, 63.8%, 74.5%; p < 0.001). Overall in-hospital mortality was not significantly different across each phase (9.4%, 8.8%, 10.6%; p 1⁄4 0.44). However, overall rates of in-hospital congestive heart failure (15.8%, 19.7%, 23.9%; p 1⁄4 0.008) and major bleeding (9.0%, 16.0%, 14.8%; p 1⁄4 0.014) increased over time. CONCLUSION: Within a geographically defined cohort of STEMI patients, a phased roll out of regional pPCI significantly reduced reperfusion times and increased the proportion of patients receiving timely pPCI over a 6-year period. However, in-hospital mortality was unchanged during this same period despite improvements in pPCI performance and access, and both in-hospital congestive heart failure and major bleeding increased over this time period. This suggests that variables beyond receiving timely pPCI are important in determining clinical endpoints. Therefore, in addition to optimizing reperfusion strategies, further understanding and optimization of these variables will be critical to improve STEMI outcomes. 122 DELAYED EDUCATIONAL REMINDERS FOR LONG-TERM MEDICATION ADHERENCE IN ST-ELEVATION MYOCARDIAL INFARCTION (DERLA -STEMI)

Consideration of ICD-9 Code-Derived Disease-Specific Safety Indicators in CKD

The Agency for Healthcare and Research Quality patient safety indicators track adverse safety events in hospitalized patients but overlook safety incidents specific to CKD. This study considers candidate CKD-pertinent patient safety indicators and compares them with the Agency for Healthcare and Research Quality patient safety indicators. Using a national Veterans Health Administration database of hospitalized veterans from fiscal year 2005, 247,160 hospitalized veterans with prehospitalization measures of renal function were retrospectively examined for proposed CKD patient safety indicators versus Agency for Healthcare and Research Quality patient safety indicators using International Classification of Diseases, Ninth Revision diagnosis codes. Candidate CKD-pertinent patient safety indicators included in-hospital acute kidney failure; in-hospital congestive heart failure (and related diagnostic codes); electrolyte disturbances; and medication errors, poisoning, and intoxication. Patients with a prehospital estimated GFR<60 ml/min per 1.73 m(2) (CKD group) were compared with a non-CKD group. For CKD patient safety indicators, hospitalizations were excluded if the admitting condition was a potential cause of the secondary condition. Regression methods were used to present adjusted rates in study groups of interest. The CKD patient safety indicators were generally more common than the Agency for Healthcare and Research Quality patient safety indicators in all groups, tended to occur in different patients than those patients who experienced Agency for Healthcare and Research Quality patient safety indicators, and were more common in the CKD group than the non-CKD group, except for hypoglycemia, hypokalemia, and hyponatremia. The adjusted composite CKD patient safety indicators rate (per 1000 patient-hospitalizations) was 398.0 (95% confidence interval, 391.2 to 405.0) for patients in the CKD group and 250.0 (95% confidence interval, 247.4 to 252.7) for patients in the non-CKD group. The prevalence ratio of CKD patient safety indicators to Agency for Healthcare and Research Quality patient safety indicators was 23.4 (95% confidence interval, 21.9 to 25.0). The candidate CKD patient safety indicators that occur in hospitalized patients are distinct from the Agency for Healthcare and Research Quality patient safety indicators and tend to be more common in CKD than non-CKD patients. These measures have the potential to serve as sentinel tools for identifying patients with CKD who warrant examination for disease-pertinent safety events.

Relationship between Cognitive Function, Depression/Anxiety and Functional Parameters in Patients Admitted for Congestive Heart Failure.

Cognitive impairment, anxiety and depression have been described in patients with congestive heart failure (CHF). We analyzed in-hospital CHF patients before discharge with neuropsychological tests attempting to correlate with prognostic parameters. All subjects underwent a mini mental state examination (MMSE), geriatric depression scale (GDS), anxiety and depression scale test (HADS). We evaluated NYHA class, brain natriuretic peptide (BNP), left ventricular ejection fraction (LVEF) and non-invasive cardiac output (CO). Three-hundred and three CHF patients (age 71.6 ys) were analysed. The mean NYHA class was 2.9±0.8, LVEF was 43.4±15.8%; BNP plasma level and CO were calculated as 579.8±688.4 pg/ml and 3.9±1.1 l/min, respectively. In 9.6% a pathological MMSE score emerged; a depression of mood in 18.2% and anxiety in 23.4% of patients were observed. A significant correlation between MMSE and age (r=0.11 p=0.001), BNP (r=0.64 p=0.03) but not between MMSE and NYHA class and LVEF was observed. GDS and HADS were inversely correlated with NYHA class (r=0.38 p=0.04) and six-minute walking test (r=0.18 p=0.01) without an association with objective parameters in CHF (BNP, LVEF and cardiac output). At multivariate analysis only MMSE and BNP are inversely correlated significantly (p=0.019 OR=-0.64, CI=-042-0.86). in-hospital CHF patients may manifest a reduction of MMSE and important anxiety/depression disorders. The results of the study suggest that the presence of cognitive impairment in older CHF patients with higher BNP plasma level should be considered. In admitted CHF patients anxiety and depression of mood are commonly reported and influenced the perception of the severity of illness.

Metalloproteinases-2 and -9 Predict Left Ventricular Remodeling after Myocardial Infarction

The role of serum metalloproteinases (MMP) after myocardial infarction (MI) is unknown. The aim of this study was to evaluate the role of serum MMP-2 and -9 as predictors of ventricular remodeling six months after anterior MI. We prospectively enrolled patients after their first anterior MI. MMP activity was assayed 12 to 72 hours after the MI. An echocardiogram was performed during the hospitalization and six months later. We included 29 patients; 62% exhibited ventricular remodeling. The patients who exhibited remodeling had higher infarct size based on creatine phosphokinase (CPK) peak values (p = 0.037), higher prevalence of in-hospital congestive heart failure (p = 0.004), and decreased ejection fraction (EF) (p = 0.007). The patients with ventricular remodeling had significantly lower serum levels of inactive MMP-9 (p = 0.007) and significantly higher levels of the active form of MMP-2 (p = 0.011). In a multivariate logistic regression model, adjusted by age, CPK peak, EF and prevalence of heart failure, MMP-2 and -9 serum levels remained associated with remodeling (p = 0.033 and 0.044, respectively). Higher serum levels of inactive MMP-9 were associated with the preservation of left ventricular volumes, and higher serum levels of the active form of MMP-2 were a predictor of remodeling 6 months after MI.

Echocardiographic predictors of early in-hospital heart failure during first ST-elevation acute myocardial infarction: does myocardial performance index and left atrial volume improve diagnosis over conventional parameters of left ventricular function?

BackgroundLeft ventricular ejection fraction (LVEF) has been considered a major determinant of early outcome in acute myocardial infarction (AMI). Myocardial performance index (MPI) has been associated to early evolution in AMI in a heterogeneous population, including non ST-elevation or previous AMI. Left atrial volume has been related with late evolution after AMI. We evaluated the independent role of clinical and echocardiographic variables including LVEF, MPI and left atrial volume in predicting early in-hospital congestive heart failure (CHF) specifically in patients with a first isolated ST-elevation AMI.MethodsEchocardiography was performed within 30 hours of chest pain in 95 patients with a first ST-elevation AMI followed during the first week of hospitalization. Several clinical and echocardiographic variables were analyzed. CHF was defined as Killip class ≥ II. Multivariate regression analysis was used to select independent predictor of in-hospital CHF.ResultsEarly in-hospital CHF occurred in 29 (31%) of patients. LVEF ≤ 0.45 was the single independent and highly significant predictor of early CHF among other clinical and echocardiographic variables (odds ratio 17.0; [95% CI 4.1 - 70.8]; p < 0.0001). MPI alone could not predict CHF in first ST-elevation AMI patients. Left atrial volume was not associated with early CHF in such patients.ConclusionFor patients with first, isolated ST-elevation AMI, LVEF assessed by echocardiography still constitutes a strong and accurate independent predictor of early in-hospital CHF, superior to isolated MPI and left atrial volume in this particular subset of patients.

Predictors and importance of congestive heart failure in patients with acute inferior myocardial infarction

Inferior myocardial infarction (MI) is considered to have a more favorable prognosis than anterior wall MI but includes high risk groups with increased mortality and morbidity. It is well known that congestive heart failure (CHF) complicating acute MI has poor prognosis. In this study we assessed the clinical and prognostic significance of CHF and the predictive value of the baseline demographic and clinical variables for CHF in patients with acute inferior MI. A total of 350 patients with acute inferior MI were included. In group A there were 26 patients (7.4%) with CHF, and in group B there were 324 patients (92.6%) without this complication. Baseline clinical and demographic characteristics and in-hospital complications of the groups were assessed. In group A patients were older (67.6±9.5 vs 53.7±10.9 years, p<0.0001) and there were more female patients (50% vs 15%, p<0.00001) compared to group B. The prevalence of diabetes mellitus (58% vs 16%) and precordial ST segment depression on admission ECG (81% vs 50%) were significantly higher in group A compared to group B (p<0.00001 and p=0.002 consecutively). In group A there was a higher rate of righ ventricular (25% vs 23%), posterior (26% vs 24%) and posterolateral myocardial infarction (19% vs 14%), but the differences were not statistically different. In group A patients had significantly higher rate of second- or third-degree AV block (46% vs 8%, p<0.00001), cardiogenic shock (35% vs 1%, p<0.00001) and mortality (46% vs 3%, p<0.00001) compared to group B. In a multivariate regression analysis diabetes mellitus (p=0.0003) and precordial ST segment depression on admission ECG (p=0.002) were found as the independent predictors of in-hospital CHF in patients with acute inferior MI. CHF and ST segment depression on admission ECG were found as the independent predictors of in-hospital mortality (p<0.00001, p=0.04 consecutively). Patients with CHF complicating acute inferior MI have more unfavorable demographic and clinical characteristics on admission, higher rate of in-hospital complications and mortality. History of diabetes mellitus and precordial ST segment depression on admission ECG have an independent predictive value for CHF in this particular group of patients.

Combining white blood cell count and thrombosis for predicting in-hospital outcomes after acute myocardial infraction

Introduction:Admission white blood cell (WBC) count and thrombosis in myocardial infarction (TIMI) risk score have been associated with adverse outcomes after acute myocardial infarction (AMI). This study investigated the joint effect of WBC count and TIMI risk score on predicting in-hospital outcomes in patients with AMI.Materials and Methods:WBC count and TIMI risk score were measured at the time of hospital admission in 70 patients with AMI. Echocardiogram was done on prior to discharge by a cardiologist and ejection fraction (EF) was determined according to the Simpson formula. Patients were stratified into tertiles (low and high) based on WBC count and TIMI risk score.Results:Patients with a high WBC count had a 5.0-fold increase in-hospital congestive heart failure and 2.2 increases in mortality compared with those with a low WBC count. Patients with a high TIMI risk score had a 10-fold increase in congestive heart failure presentation and mortality compared with those with a low TIMI risk score. When a combination of different strata for each variable was analyzed, a stepwise increase in mortality was seen. There were a few number of patients with a high WBC count and low TIMI risk score or with a low WBC count and high TIMI risk score. These patients had an intermediate risk, whereas those with a high WBC count and TIMI risk score had the highest risk.Conclusion:These findings suggested that a simple combination of WBC count and TIMI risk score might provide further information for predicting outcomes in patients with AMI.

L’anémie dans l’insuffisance cardiaque

Anemia is a common disorder in congestive heart failure and an independant prognostic factor. The aims of this study are to evaluate the prevalence of anemia among a population of in-hospital congestive heart failure patients, to compare anemic patients (A) with non anemic patients (NA) and to study their cares. Results One hundred and thirty-two patients, 70 men (53%), et 62 women (47%) are enrolled. Mean age is 76.4 ± 13.5 years. The prevalence of anemia (WHO criteria) is 49%. Patients A are older than NA: 79.1 ± 13.8 years versus 73.8 ± 12.9 years ( p = 0.025), renal function is more altered in A than in NA, creatinine clearance is 56.5 ml/min (A) versus 76.2 ml/min (NA) ( p = 0.003). Ejection fraction (EF) is lower in A than in NA: 35.1 ± 15.3% versus 50.9 ± 15.9%, ( p < 0.0001.) Anemia is less frequent in preserved EF (28%) than in low EF (63%) ( p < 0.0001). Hospitalization duration is longer in A than in NA: 10.7 ± 10.1 days versus 6.9 ± 3.7 days ( p = 0.005). There are more re hospitalized patients among A than NA: 38 versus 10 ( p = 0.0001). There is a significant difference of survival of NA versus A at day 614 ( p = 0.03). Conclusion Anemia is frequent in our population, and is associated with others prognostic factors and comorbidity.

Three‐dimensional MRI assessment of regional wall stress after acute myocardial infarction predicts postdischarge cardiac events

To determine the prognostic significance of systolic wall stress (SWS) after reperfused acute myocardial infarction (AMI) using MRI. A total of 105 patients underwent MRI 7.8 +/- 4.2 days after AMI reperfusion. SWS was calculated by using a three-dimensional (3D) MRI approach to left ventricular (LV) wall thickness and to the radius of curvature. Between hospital discharge and the end of follow-up, an average of 4.1 +/- 1.7 years after AMI, 19 patients experienced a major cardiac event, including cardiac death, nonfatal reinfarction or heart failure (18.3%). The results were mainly driven by heart failure outcome. In univariate analysis the following factors were predictive of postdischarge major adverse cardiac events: 1) at the time of AMI: higher heart rate, previous calcium antagonist treatment, in-hospital congestive heart failure, proximal left anterior descending artery (LAD) occlusion, a lower ejection fraction, higher maximal ST segment elevation before reperfusion, and ST segment reduction lower than 50% after reperfusion; 2) MRI parameters: higher LV end-systolic volume, lower ejection fraction, higher global SWS, higher SWS in the infarcted area (SWS MI) and higher SWS in the remote myocardium (SWS remote). In the final multivariate model, only SWS MI (odds ratio [OR]: 1.62; 95% confidence interval [CI]: 1.01-2.60; P = 0.046) and SWS remote (OR: 2.17; 95% CI: 1.02-4.65; P = 0.046) were independent predictors. Regional SWS assessed by means of MRI a few days after AMI appears to be strong predictor of postdischarge cardiac events, identifying a subset of at risk patients who could qualify for more aggressive management.

Predictive factors of recurrent angina after acute coronary syndrome: the global registry acute coronary events from China (Sino-GRACE)

Many patients with acute coronary syndrome (ACS) develop recurrent angina (RA) during hospitalization. The aim of this non-randomized, prospective study was to investigate the predictive factors of RA in unselected patients with ACS enrolled in the global registry acute coronary events (GRACE) during hospitalization in China. Between March 2001 and October 2004, enrolled were 1433 patients with ACS, including ST segment elevation myocardial infarction (662, 46.2%), non-ST segment elevation myocardial infarction (239, 16.7%) and unstable angina (532, 37.1%). The demographic distribution, medical history and clinical data were collected to investigate the predictive factors of RA by Logistic regression. During hospitalization 275 (19.2%) patients were documented with RA including unstable angina (53.2%), non-ST segment elevation myocardial infarction (27.5%), ST segment elevation myocardial infarction (19.3%). A comorbidity of dyslipidemia, prior angina, percutaneous coronary intervention (PCI) within 6 months was more common in patients with RA, P < 0.05. In the patients with RA, a significantly higher proportion of patients with acute pulmonary edema was observed, 23 (8.4%) versus 43 (3.7%), P = 0.001. Acute renal failure was present in 8 (2.9%) of patients with RA versus 19 (1.6%) of patients without RA, P = 0.165. Hemorrhagic events were present in 6 (2.2%) of patients with RA versus 8 (0.7%) of patients without RA, ventricular tachycardia/ventricular fibrillation events in 12 patients (4.3%) versus 22 patients (1.9%), congestive heart failure in 69 patients (25.0%) versus 94 patients (8.1%), myocardial re-infarction in 28 patients (10.1%) versus 15 patients (1.3%), P < 0.05, respectively. A lower proportion of patients with RA underwent in-hospital PCI, 687 (59.3%) versus 114 (41.5%), P = 0.000. A higher proportion of patients with RA received heparin, 260 (94.5%) versus 1035 (89.4%), P = 0.006; and beta-blockers 176 (64.0%) versus 864 (74.5%), P = 0.000. Multivarible regression analysis showed that RA was associated with prior angina (OR 2.086, 95% CI 1.466 - 2.967), in-hospital PCI (OR 0.579, 95% CI 0.431 - 0.778), in-hospital congestive heart failure (OR 2.410, 95% CI 1.634 - 3.555), myocardial re-infarction (OR 7.695, 95% CI 3.701 - 15.999), beta-blocker (OR 0.626, 95% CI 0.458 - 0.855), and heparin (OR 3.411, 95% CI 1.604 - 7.382). In-hospital congestive heart failure, myocardial re-infarction, prior angina history and use of heparin are stronger independent predictors of RA; beta-blockers and PCI are also important predictive factors for RA.

Implications and Treatment of Acute Hyperglycemia in the Setting of Acute Myocardial Infarction

A 52-year-old obese male without a prior history of diabetes mellitus (DM) presented with angina and an anterior ST-segment–elevation myocardial infarction (STEMI). Physical examination and chest x-ray were consistent with congestive heart failure. Admission glucose was 230 mg/dL. Coronary angiography revealed an occluded left anterior descending coronary artery, and stenting reestablished TIMI grade 2 flow in that artery within 90 minutes of symptom onset. Left ventricular ejection fraction was 35% with severe anterior hypokinesis. Peak creatine kinase was 600 IU. The next day, fasting glucose was 180 mg/dL. An echocardiogram performed 6 weeks after discharge revealed an ejection fraction of 35% without change in the anterior wall motion. Fasting glucose as an outpatient was 156 mg/dL. The scenario described above is commonly encountered and illustrates how hyperglycemia can affect the outcome of patients with STEMI. Hyperglycemia could have affected the following features of this case: (1) Congestive heart failure was present despite only modest myocardial injury by creatine kinase level; (2) despite successful percutaneous coronary intervention, subnormal coronary perfusion was observed; and (3) left ventricular recovery after STEMI did not occur. Cardiologists need to be cognizant of the hazards associated with hyperglycemia in this setting because these patients will be encountered more frequently as a result of the increasing prevalence of insulin resistance syndromes. Acute hyperglycemia is common in patients with STEMI even in the absence of a history of type 2 DM. Hyperglycemia is encountered in up to 50% of all STEMI patients, whereas previously diagnosed DM is present in only 20% to 25% of STEMI patients.1 The prevalence of type 2 DM or impaired glucose tolerance may be as high as 65% in MI patients without prior DM when oral glucose tolerance testing is performed.2 Elevated …

Correlation between Cognitive Impairment and Prognostic Parameters in Patients with Congestive Heart Failure

Cognitive impairment has been observed in patients with congestive heart failure (CHF). We analyzed in-hospital CHF patients with neuropsychological tests attempting to correlate the results with prognostic parameters. All subjects underwent a mini-mental state examination (MMSE), memory and learning tests (Corsi Block-tapping test, Verbal Span test, Prose Memory test, Visual Search), anxiety and depression scale test. New York Hospital Association (NYHA) class, brain natriuretic peptide (BNP) and left ventricular ejection fraction (LVEF) were evaluated. Sixty patients (mean age 65.5 years) were analyzed. NYHA class was 2.9 +/- 0.9, LVEF was 32.9 +/- 13.7%, BNP plasma level 683.3 +/- 864.3 pg/mL. In 23.3% of cases a pathological MMSE score emerged; memory and learning test results were abnormal in 3.4-37%. A positive correlation between MMSE and age (r = 0.18, p = 0.01), BNP (r = 0.25, p = 0.02) was observed but not between MMSE and years of education, NYHA class and LVEF. The Corsi Block-tapping test was related to educational duration (r = 0.12, p = 0.02) with a positive trend for BNP (r = 0.2, p = 0.07). The Prose Memory test and Visual Search were influenced by the patients' educational level (r = 0.36, p = 0.0001; r = 0.27, p = 0.0001). CHF patients manifest an impairment of MMSE and memory and learning test performance. In our population MMSE correlates to plasma BNP and advanced age.

A quality guarantee in acute coronary syndromes: The American College of Cardiology's Guidelines Applied in Practice program taken real-time

Wide variation exists in the management of acute coronary syndromes (ACSs), which includes an apparent underutilization of evidence-based therapies. We have previously demonstrated that application of the American College of Cardiology Guidelines Applied in Practice (GAP) tools can improve quality indicator rates and outcomes of patients hospitalized with ACS. To determine whether a real-time system for monitoring key quality-of-care indicators using GAP would improve both process indicators and outcomes beyond those of the initial implementation of GAP. Prospective patient identification, prospective chart coding, retrospective data abstraction. All patients with ACS admitted (N = 3189) to our institution between January 1, 1999, and December 2004; 2019 studied before real-time implementation from January 1, 1999, to June 30, 2002, and 1170 studied during real-time implementation from July 1, 2002, to December 31, 2004. The effect of real-time monitoring of key quality indicators on inhospital therapy and outcomes, and 6-month outcomes in patients admitted with ACS. The real-time GAP implementation correlated with more frequent use of inhospital angiotensin-converting enzyme inhibitors (72.7% vs 63.7%, P < .0001), beta blockers (93.0% vs 89.7%, P = .0016), statins (81.2% vs 65.9%, P < .0001), antiplatelet agents (69.2% vs 22.5%, P < .0001), and glycoprotein IIb/IIIa inhibitors (35.5% vs 26.7%, P < .0001). There were fewer episodes of inhospital congestive heart failure (3.85% vs 8.77%, P < .0001) and major bleeding events (3.2% vs 7.9%, P < .0001) after the real-time system was adopted. Real-time GAP also resulted in higher discharge rates of aspirin (92.1% vs 86.5%, P < .0001), beta blockers (86.8% vs 79.1%, P < .0001), statins (81.2% vs 64.7%, P < .0001), and angiotensin-converting enzyme inhibitors (67.1% vs 55.5%, P < .0001). Real-time GAP implementation was associated with fewer rehospitalizations for heart disease (19.8% vs 25.2%, P = .0014), myocardial infarction (3.5% vs 5.4%, P = .0243), and combined death/cerebrovascular accident/myocardial infarction (9.5% vs 13.9%, P = .0009) during the first 6 months after discharge. The institution of a formal system to review and "guarantee" key quality-of-care indicators real time in the hospital is associated with improved outcomes in patients admitted with ACS. The combination of American College of Cardiology's GAP program and its real-time implementation leads to higher use of evidence-based therapies and correspondingly better outcomes than those associated with the initial GAP implementation.

Impact of Congestive Heart Failure in Patients With Non–ST-Segment Elevation Acute Coronary Syndromes

The presence of congestive heart failure (CHF) has been associated with treatment disparities and worse outcomes in patients with ST-segment elevation myocardial infarction, but the incidence and effect of CHF in patients with non-ST-segment elevation acute coronary syndromes (NSTE ACSs) has not been well characterized. We evaluated 45,744 patients with NSTE ACS (positive cardiac markers and/or ischemic ST-segment changes) who were treated at 424 hospitals in the CRUSADE Quality Improvement Initiative between March 2000 and March 2003. Treatment patterns and in-hospital outcomes in patients with signs of CHF on presentation and those who developed in-hospital CHF were compared with those in patients without CHF. In total, 10,398 patients (22.7%) had signs of CHF on presentation, and 1,664 patients (3.6%) later developed in-hospital CHF. Compared with patients without CHF, early (<24 hours from presentation) medications and invasive cardiac procedures were used less often in patients with signs of CHF on presentation. Likewise, patients with in-hospital CHF were less likely than those without CHF to receive acute antiplatelet agents and undergo cardiac catheterization but more likely to receive acute beta blockers, angiotensin-converting enzyme inhibitors, and heparin and to undergo coronary artery bypass grafting. Adjusted mortality was higher in patients with signs of CHF on presentation (odds ratio 2.64, 95% confidence interval 2.31 to 3.01) and those with in-hospital CHF (odds ratio 4.93, 95% confidence interval 4.05 to 5.99) than in patients without CHF. In conclusion, CHF occurs frequently in patients with NSTE ACS but is associated with less aggressive treatment and a higher risk of mortality. Further study is needed to determine the causes of these treatment differences and the optimal therapeutic approach for patients with NSTE ACS and concomitant CHF.

Is the outcomes of early ST-segment resolution after thrombolytic therapy in acute myocardial infarction always favorable?

Aims To determine whether the magnitude of ST-segment resolution after thrombolytic therapy (TT) predicts short- and long-term outcomes in an unselected population of patients with an acute myocardial infarction (AMI). Background Recent studies suggest that resolution of ST-segment elevation (STE) on the 2-hour post-TT electrocardiogram (ECG) is a useful predictor of prognosis. However, these studies were restricted to clinical trials where only 15% to 20% of the patients receiving TT were often enrolled. Methods The present study evaluated an unselected consecutive group of patients who received TT. All clinical, investigational, and follow-up data had been collected in a prospective manner. The analysis of ECGs was done retrospectively with the reader blinded to the clinical course. STE at 80 milliseconds after the J point was measured on the baseline and 90-minute ECG using a hand-held caliper. The resolution of STE was categorized as complete (≥70%), partial (30% to <70%), and none (<30%) as has been done in previous studies. Results Three hundred fifty-two patients (250 men, 102 women; age, mean ± SEM, 61.8 ± 1.0 years; peak creatine kinase, 1938 ± 185 μmol/L; door to needle time, 50.0 ± 6 minutes, <30 minutes, 50%; <45 minutes, 70%) with AMIs who received TT were included in the study. Inhospital deaths and recurrent AMI/postinfarct angina revealed no significant association with increasing ST-segment resolution ( P > .05). A 70% or higher ST-segment resolution was associated with a significantly lower incidence of inhospital congestive heart failure (CHF) and CHF/death ( P < .05). Similarly, with a 70% or higher ST-segment resolution, there was a lower incidence in the 1-year outcomes of CHF and death/CHF. However the 1-year occurrences of unstable angina or recurrent AMIs taken singly did not bear a correlation to increasing magnitudes of ST-segment resolution ( P > .05). Although as a composite measure, there was an increasing trend with ST-segment resolution. Conclusions Magnitude of ST-segment resolution after TT appears to demonstrate a dichotomous relationship to measured outcomes. Although there is a lower incidence of death/CHF with increasing ST-segment resolution, there appears to be a higher likelihood for recurrent AMI/unstable angina.

Correlation of ST Segment Elevation in Lead V1 and the Conal Branch of Right Coronary Artery in Patients with Acute Anterior Wall Myocardial Infarction

Background and Objectives：Dual blood supply to the anterior interventricular septum (IVS), derived from the septal branches of the left anterior descending artery (LAD) and the conal branch of the right coronary artery (RCA), may prevent ST segment elevation in lead V1 during an anterior acute myocardial infarction (AMI), and predict a favorable in-hospital clinical course. Subjects and Methods：The admission 12-lead electrocardiogram (ECG), and the coronary angiograms performed within 10 days of hospital admission, were evaluated in 67 patients with anterior wall AMI, as defined by a ST segment elevation ≥2mm in at least 2 of the V1 to 4 leads. The patients were divided into two groups according to the magnitude of the ST segment elevation in V1 lead：group 1 (ST 0.5 mm), reaching the IVS. Results：A large conal branch was found in 11 patients of each group 50 and 24%, respectively (p=0.04). There was no significant relation between the sites of the LAD lesion, whether proximal or distal to the first septal branch, and the presence of ST segment elevation in lead V1. The serum cardiac enzymes, Killip class and the incidence of in-hospital congestive heart failure, were not significantly different. Conclusion：The absence of ST segment elevation in lead V1 during an anterior AMI suggested that the IVS is protected by a large conal branch, in addition to the septal branch of the LAD, but this did not influence the in-hospital clinical course. (Korean Circulation J 2003;33 (10):871-877)

Value of the Doppler Index of Myocardial Performance in the Early Phase of Acute Myocardial Infarction

Prospective assessment of a nongeometric Doppler-derived index of combined systolic and diastolic myocardial performance was performed in 64 patients with acute myocardial infarction (MI) within 1 hour after their arrival to the hospital and in 39 age-matched healthy subjects. The index is defined as the sum of isovolumetric contraction time and relaxation time divided by ejection time, and is obtained by Doppler measurement from the mitral inflow and left ventricular outflow velocity-time intervals. The index was significantly higher in patients with MI compared with healthy subjects (P <.0001). In patients with MI and in-hospital congestive heart failure (CHF), the index was significantly higher compared with patients without CHF. In a multivariate regression analysis, the index >0.45 was the strongest independent predictor of the development of CHF. This simply obtained nongeometric Doppler index, assessed in the early phase of MI, detected and graded left ventricular dysfunction and identified patients at risk for the development of CHF. (J Am Soc Echocardiogr 2000;13:723-30.)