Ischemia In Acute Coronary Syndromes Research Articles

Abstract 11257: Septal Ischemia in Acute Coronary Syndromes and the Risk of Cardiac Arrest

Introduction: The interventricular septum may play an important role in circuits that lead to ventricular tachycardia and ventricular fibrillation. Hypothesis: Among patients with ST-segment myocardial infarction elevation (STEMI), those presenting with cardiac arrest are more likely to have septal ischemia, defined as ST-elevation > 1 mm in V1, than those with other clinical presentations. Methods: A single-center retrospective review was conducted for all patients presenting with a STEMI from January 1, 2016-December 31, 2021. This identified a total of 60 consecutive patients with pre-intervention cardiac arrest and the first 60 patients in this time frame who presented without cardiac arrest. Both groups had had similar baseline characteristics. ( Table 1). Results: A higher proportion of patients presenting with cardiac arrest had evidence of septal ischemia ( Figure 1, 29/60 versus 17/60, p<0.02). These findings remained statistically significant in a sub-group analysis of patients drawn from the same series with lesions of the right coronary artery (RCA) and left circumflex (LCx) without proximal left anterior descending (LAD) lesions ( 7/23 versus 2/32, p<0.02 ) . Conclusions: Patients presenting with cardiac arrest in the setting of ACS were more likely to have evidence of septal ischemia.

Atrioventricular block as a predictor of major adverse cardiac events in acute coronary syndrome patients

Abstract Funding Acknowledgements Type of funding sources: None. OnBehalf Portuguese Registry of Acute Coronary Syndromes Background Atrioventricular block (AVB) can be a consequence of ischemia in acute coronary syndrome (ACS). Then, its expected, that AVB occurrence is associated with higher rates of major adverse cardiac events (MACE). Objective Evaluate if sustained AVB was a predictor of MACE in ACS hospitalized patients. Methods Multicenter retrospective study, based on the Portuguese Registry of ACS between 1/10/2010-3/05/2020. Patients were divided into two groups: A – patients without AVB, and B – patients that presented AVB. Were excluded patients without a previous cardiovascular history or clinical data regarding AVB occurrence. MACE was defined as re-infarction, congestive heart failure, cardiogenic shock, a mechanical complication of myocardial infarction, completed atrioventricular block, sustained ventricular tachycardia, cardiac arrest, stroke, major hemorrhage, transfusion and hospitalization death. Univariate logistic regression was performed to assess if AVB in ACS patients was a predictor of MACE. Results A total of 32157 patients was analyze and 23774 had information regarding AVB. From the group of patients that presented AVB, 214 (0.9%) had re-infarction, 3847 (16.2%) had congestive heart failure, 1018 (4.3%) had cardiogenic shock, 1069 (4.5%) had atrial fibrillation, 152 (0.6%) had a mechanical complication of myocardial infarction, 354 (1.5%) had sustained ventricular tachycardia, 706 (3.0%) had cardiac arrest, 152 (0.6%) had stroke, 364 (1.5%) had major hemorrhage, 353 (1.5%) had blood transfusion and 928 (3.0%) died. AVB did not predict re-infarction (p = 0.145), congestive heart failure (p = 0.334), atrial fibrillation (p = 0.171), mechanical complication of myocardial infarction (p = 0.465) and cardiac arrest (p = 0.142). Logistic regression revealed that AVB in ACS patients was a predictor of cardiogenic shock (odds ratio (OR) 2.350, p = 0.012, confidence interval (CI) 1.207-4.572), sustained ventricular tachycardia (OR 2.269, p = 0.013, CI 1.187-4.340), stroke (OR 2.231, p < 0.001, CI 1.779-5.852), major hemorrhage (OR 3.863, p < 0.001, CI 2.667-5.558), blood transfusion (OR 4.291, p < 0.001, CI 3.002-6.137) and hospitalization death (OR 2.699, p < 0.001, CI 1.725-4.222). Conclusions AVB in ACS patients predict MACE, namely cardiogenic shock, sustained ventricular tachycardia, stroke, major hemorrhage, blood transfusion and hospitalization death.

Patient Directed Recording of a Bipolar Three-Lead Electrocardiogram using a Smartwatch with ECG Function.

Cardiac arrhythmias and cardiovascular diseases are a major public health problem in developed countries. A major goal in preventive medicine is the reduction of cardiovascular death by early detection of atrial fibrillation (AF), which may cause stroke, or early detection of life-threatening myocardial ischemia in acute coronary syndrome. Detection of arrhythmia is often challenging if symptoms occur when patients have no chance for immediate electrocardiogram (ECG) diagnostic testing, or if the observation time period is short or an immediate visit to their doctor is not possible. Smartwatches and other wearable devices are able to record a single lead ECG recording, but a single lead ECG is often not sufficient for diagnosis of cardiovascular disorders. Even diagnosis of AF can be difficult with only information from a single lead bipolar ECG. Some smart devices use photoplethysmography for detection of cardiac rhythm, but this technique can only give indirect hints of the underlying cardiac rhythm, is prone to interferences, and cannot be used for detection of myocardial ischemia. A three-lead bipolar ECG like the Einthoven leads used in regular ECGs can add useful information concerning arrhythmia detection or even diagnosis of other cardiovascular diseases like ischemia. Therefore, we describe a protocol for the patient-directed recording of an Einthoven three-lead ECG using a smartwatch.

Prevalence, Temporal Evolution, and Impact on Survival of Ventricular Conduction Blocks in Patients With Acute Coronary Syndrome and Cardiogenic Shock

Changes in QRS duration and pattern are regarded to reflect severe ischemia in acute coronary syndromes (ACS), and ventricular conduction blocks (VCBs) are recognized high-risk markers in both ACS and acute heart failure. Our aim was to evaluate the prevalence, temporal evolution, association with clinical and angiographic parameters, and impact on mortality of VCBs in ACS-related cardiogenic shock (CS). Data of 199 patients with ACS-related CS from a prospective multinational cohort were evaluated with electrocardiogram data from baseline and day 3. VCBs including left or right bundle branch block, right bundle branch block and hemiblock, isolated hemiblocks, and unspecified intraventricular conduction delay were assessed. Fifty percent of patients had a VCB at baseline; these patients were older, had poorer left ventricular function and had more often left main disease compared with those without VCB. One-year mortality was over 2-fold in patients with VCB compared with those without VCB (68% vs 32%, p<0.001). All types of VCBs at baseline were associated with increased mortality, and the predictive value of a VCB was independent of baseline variables and coronary angiography findings. Interestingly, 37% of the VCBs were transient, i.e., disappeared before day 3. However, 1-year mortality was much higher in these patients (69%) compared to patients with persistent (38%) or no VCB (15%, p<0.001). Indeed, a transient VCB was a strong independent predictor of 1-year mortality. In conclusion, our findings propose that any VCB in baseline electrocardiogram, even if transient, identifies very early patients at particularly high mortality risk in ACS-related CS.

DYNAMIC EKG CHANGES ARE NOT ALWAYS ACUTE CORONARY SYNDROME

The typical finding of “giant” T-wave inversion in apical hypertrophic cardiomyopathy (AHC) can be mistaken for ischemia in acute coronary syndrome. An 85-year-old woman with a history of transient ischemic attack, hypertension and hyperlipidemia presented with epigastric pain. EKG revealed

Red Blood Cell Transfusion in the Emergency Department

BackgroundTransfusion of red blood cells (RBCs) is the primary management of anemia, which affects 90% of critically ill patients. Anemia has been associated with a poor prognosis in various settings, including critical illness. Recent literature has shown a hemoglobin transfusion threshold of 7 g/dL to be safe. This review examines several aspects of transfusion. ObjectiveWe sought to provide emergency physicians with an updated review of indications for RBC transfusion in the emergency department. DiscussionThe standard hemoglobin transfusion threshold was 10 g/dL. However, the body shows physiologic compensatory adaptations to chronic anemia. Transfusion reactions and infections are rare but can have significant morbidity and mortality. Products stored for <21 days have the lowest risk of reaction and infection. A restrictive threshold of 7 g/dL is recommended in the new American Association of Blood Banks guidelines and multiple meta-analyses and supported in gastrointestinal bleeding, sepsis, critical illness, and trauma. Patients with active ischemia in acute coronary syndrome and neurologic injury require additional study. The physician must consider the patient's hemodynamic status, comorbidities, risks and benefits of transfusion, and clinical setting in determining the need for transfusion. ConclusionsRBC transfusion is not without risks, including transfusion reaction, infection, and potentially increased mortality. The age of transfusion products likely has no effect on products before 21 days of storage. A hemoglobin level of 7 g/dL is safe in the setting of critical illness, sepsis, gastrointestinal bleeding, and trauma. The clinician must evaluate and transfuse based on the clinical setting and patient hemodynamic status rather than using a specific threshold.

The role of IMA in ruling out ischemia in patients presenting with chest pain, and its relation with the extent of coronary artery disease

BackgroundIschemia modified albumin (IMA) is an albumin that has an altered binding capacity to bind metal ions and can be used to detect myocardial ischemia in acute coronary syndrome (ACS) patients. Aim of workTo study the IMA level in patients presenting with non-ST segment elevation ACS and its diagnostic and prognostic value. Patients and methodsThis study was conducted on 50 patients with a mean age of 54.7 ± 9 yrs. Patients were grouped into group 1: unstable angina (13 patients), group 2: NSTEMI (17 patients), and group 3: control group. All patients were subjected to routine labs, cardiac biomarkers and predischarge coronary angiography and were followed up for 2 months to detect any major adverse cardiac event. IMA level was measured upon admission for all patients. All data were statistically analyzed. ResultsIMA was statistically significantly higher in groups 1 and 2 compared to group 3 patients (P value < 0.05). The optimal cutoff value to diagnose ischemic patients was 4 ng/ml. The mean IMA level was significantly cardiac biomarkers including troponin, TIMI risk score and number of the affected vessels but not correlated with the modified Gensini score (MGS), and short term prognosis. The optimal cutoff value for IMA levels to predict poor prognosis was 9.65 ng/ml. ConclusionSerum IMA is a useful marker to rule out non ischemic patients presented with suspected ACS and is significantly related to the number of affected vessels.

Admission Haemoglobin Levels and Its Related Factors at Percutaneous Coronary Intervention for the Management of Acute Coronary Syndrome in Octogenarian Patients: Assessment of Gender Differences and In-Hospital Outcomes

Anaemia has the potential to worsen the myocardial ischemia in acute coronary syndrome. In this paper, admission haemoglobin levels and the factors related to haemoglobin concentrations and in-hospital outcomes of percutaneous coronary intervention were analysed for the management of acute coronary syndrome in female and male octogenarian patients. We analyzed data of 2.256 consecutive patients who underwent percutaneous coronary intervention with bare metal and/or drug eluting stent implantation. Either the femoral artery or brachial artery approach was used. 50 of 2256 consecutive patients were octogeneric and Hb and white blood cell levels were analyzed. Mean admission haemoglobin levels were significantly elevated in male octogenarian patients as compared with female octogenarian patients (12.10 ± 1.37 mg/dl, 11.24 ± 1.03 mg/dl, p=0.02, respectively). Pearson correlation analysis between haemoglobin and clinical, angiographic, procedural characteristics, biochemical and hematologic values showed that haemoglobin was only correlated negatively with leukocytes (r=-0.35; p=0.01). Admission haemoglobin concentrations were significantly elevated in male octogenarian patients as compared with female. Only blood leukocyte levels were found to be significantly associated with haemoglobin concentration. Therefore, anaemia and leucocytosis may be associated with worse in-hospital outcomes at percutaneous coronary intervention for the management of acute coronary syndrome in female octogenarian patients

Electrocardiographic presentation of global ischemia in acute coronary syndrome predicts poor outcome

Background. Global ischemia (GI) electrocardiogram (ECG), wide-spread ST depression with inverted T waves maximally in leads V4–5, and lead aVR ST elevation (STE), is a marker of an adverse outcome in patients with non-ST elevation acute coronary syndromes (ACS), perhaps because this pattern is indicative of left main stenosis. The prognostic value of this ECG pattern has not been established.Aims. The distribution of ECG changes and the prognostic value of the GI ECG were studied.Methods. ECGs of consecutive patients admitted with suspected ACS (n = 1,188) were classified into seven ECG categories: STE, Q waves without STE, left bundle branch block, left ventricular hypertrophy, GI ECG, other ST depression and/or T wave inversion, and other findings.Results. The GI ECG pattern predicted a high rate (48%) of composite end-points (mortality, re-infarction, unstable angina, resuscitation, or stroke) at 10-month follow-up compared to the other ECG categories (36%) (HR 1.78; CI 95% 1.31–2.41; P < 0.001). In multivariate analysis, the GI ECG pattern was associated with a higher rate of composite end-points (HR 1.40; CI 95% 1.02–1.91; P = 0.035). The multivariate analysis furthermore identified age, creatinine level, and diabetes as independent predictors of prognosis.Conclusions. The GI ECG pattern predicted an unfavorable outcome, when compared to other ECG patterns in patients with ACS.

Relation Between Hemoglobin Level and Recurrent Myocardial Ischemia in Acute Coronary Syndromes Detected by Continuous Electrocardiographic Monitoring

Anemia has been associated with adverse outcomes in patients with acute coronary syndromes (ACS). However, the underlying pathophysiologic mechanisms have not been well elucidated. We sought to determine the independent relation between the hemoglobin level and recurrent ischemia in patients with non-ST-segment elevation ACS using continuous electrocardiographic monitoring. In the Integrilin and Enoxaparin Randomized Assessment of Acute Coronary Syndrome Treatment (INTERACT) trial, 746 patients presenting with non-ST-segment elevation ACS underwent continuous ST-segment monitoring for 48 hours. The data were analyzed independently at a core laboratory. We stratified the study population according to their hemoglobin level on presentation. The primary outcome of the study was recurrent ischemia, defined as ST-segment shifts on continuous electrocardiographic monitoring. Of the 705 patients with analyzable data, 64 had a baseline hemoglobin level <120 g/L, 259 had a level of 120 to 139 g/L, 315 had a level of 140 to 159 g/L, and 67 had a level >160 g/L. The corresponding rates of recurrent ischemia were 39.1%, 22.0%, 15.6%, and 11.9% (p for trend <0.001). A lower hemoglobin level was associated with advanced age, co-morbidities, and a higher GRACE risk score. In multivariable analysis adjusting for these confounders, lower hemoglobin levels retained a significant independent association with recurrent ischemia (p for trend = 0.004). In conclusion, a lower hemoglobin level at presentation was independently associated with recurrent ischemia detected by continuous electrocardiographic monitoring in the setting of non-ST-segment elevation ACS. This suggests that anemia might predispose patients to recurrent ischemia, which could be an important underlying mediator of worse outcomes in patients with lower hemoglobin levels.

Myocardial Ischemia in Acute Coronary Syndrome: Assessment Using 64-MDCT

We investigated the performance of 64-MDCT myocardial imaging in assessing myocardial ischemia in acute coronary syndrome (ACS). Cardiac CT was performed in 35 patients with ACS: 24 patients with acute myocardial infarction (AMI) and 11 patients with unstable angina pectoris (UAP). We reconstructed 2D myocardial images at diastolic and systolic phases using the same raw data as those used for coronary CT angiography. The CT number in the myocardium was used as an estimate of ischemia. The myocardium was shown using a color scale that depicts faint low-density areas more clearly than gray scale. We evaluated the variations in myocardial enhancement during the cardiac cycle in the territory of the culprit lesion. In addition, we classified patients on the basis of the transmurality of myocardial enhancement and examined whether this feature correlates with myocardial damage. Myocardial imaging at systole showed myocardial hypoenhancement in territories of the culprit lesion in 91% of patients with ACS, 96% of patients with AMI, and 75% of patients with UAP. The hypoenhancement areas at systole tended to be more extensive than those at diastole. The transmural extent of hypoenhancement at systole correlated with myocardial damage, which was shown by myocardial biomarkers. CT myocardial imaging can be used to assess myocardial ischemia in the appropriate region of ACS with high sensitivity.

Management of vasospastic angina--role of nicorandil.

Clinical and experimental observations have confirmed that an episodic increase in the vasomotor tone of a major coronary artery may play a pathogenetic role not only in "variant angina" but also in other, more common anginal syndromes. In chronic stable angina, dynamic changes of vascular smooth muscle tone at the site of eccentric atheromatous plaques are responsible for "mixed angina." Abnormal coronary vasomotion contributes to myocardial ischemia in acute coronary syndromes as well. Studies have shown that a "primary" reduction of coronary blood flow, usually associated with plaque fissuring and thrombus formation, causes infarction and unstable angina. Abnormal vasoconstriction associated with the release of vasoactive substances by platelets and other constituents of the thrombus can contribute to coronary flow reduction in patients with unstable angina and myocardial infarction. Better understanding of the complex interactions among atherosclerotic coronary obstructions, the vascular smooth muscle, and the vascular endothelium has resulted in novel therapeutic approaches and has stimulated the search for more efficacious and safer coronary vasodilators. Recently interest has focused on vasodilator agents such as nicorandil that influence coronary arterial tone by acting through potassium channel activation. Nicorandil appears to be effective for treatment of vasospastic angina, as suggested by studies in Japan and Europe. In addition to its "antivasospastic" properties, nicorandil dilates coronary artery stenoses in patients with stable angina pectoris.(ABSTRACT TRUNCATED AT 250 WORDS)