Patients Underwent Emergency Coronary Angiography Research Articles

AN ACUTE MYOCARDIAL INFARCTION IN A VERY YOUNG MAN DUE TO HYPERHOMOCYSTEINEMIA

Abstract Introduction A young 17–year–old boy smoker and obese was admitted to our cardiology unit for continuous oppressive chest pain radiating to the left arm that had arisen three days earlier. In the emergency room, he had performed blood tests with evidence of an increased troponin and an electrocardiogram that showed mild ST–elevation in inferior leads with ST depression in aVL. We performed an urgent transthoracic echocardiography examination that was unremarkable Investigation Once diagnosed with acute ST–segment elevation myocardial infarction, the patient underwent emergency coronary angiography. Coronary angiography highlighted an intermediate stenosis of the first branch diagonal to the proximal tract and a possible occlusion of the periapical branch of the anterior descending artery. It was decided not to perform PTCA as we could not exclude a distal coronary dissection and considering the vessel was of small caliber. We decided to complete the diagnostic process by performing a cardiac MRI showing edema in the apex and distal inferior wall and transmural gadolinium enhancement at the level of the septum and inferior wall of the distal section. In the context of the damaged wall a focal area of hypointensity to be referred to the "no–reflow" phenomenon Management The patient was treated with DAPT, low molecular weight heparin and high dose statin. A few hours after the coronary angiography the patient stopped having chest pain and remained asymptomatic for the rest of the hospital stay. We performed complete blood tests including with evidence of hyperhomocysteinemia. The lipid panel was normal. Hematological consultation recommended folate and Vitamine B12 treatment. After 12 months the patient is asymptomatic, has stopped smoking and continues to take DAPT. He repeated the echocardiogram which showed no alterations. Genetic testing was performed after hospital discharge and was positive for Methylenetetrahydrofolate reductase (MTHFR) homozygous mutation Conclusion Our clinical case shows a rare case of acute myocardial infarction in a very young person. Diagnosis and treatment were complicated by the extreme distality of the occlusion and the few modifiable risk factors identified (smoker, obesity and hyperhomocysteinemia). Hyperhomocysteinemia is an often underestimated cardiovascular risk factor associated with a high risk of cardiovascular events and multivessel coronary disease that should be sought in all young patients with AMI.

Ventricular septal defect complicating anterior acute myocardial infarction : A Case of transcatheter closure

IntroductionPost-infarction ventricular septal defect (PIVSD) is one of the most serious mechanical complications of acute myocardial infarction (AMI). Over the last decade, percutaneous closure is increasingly undertaken, with results similar to cardiac surgery. We present a case of ST-elevated anterior AMI, complicated by apical PIVSD successfully treated with transcatheter closure. Case ReportAn 83-year-old man was hospitalized for chest pain occurred 18 hours before, during the night time. He was an active smoker. Clinical examination revealed normal heart sounds and pulmonary bibasilar crackles. ST-segment elevation with deep T waves inversion in anterior leads were detected on the electrocardiogram. A mildly-reduced ejection fraction (40%) was found by transthoracic echocardiogram. The patient underwent emergency coronary angiography, which revealed a subocclusive stenosis of the mid left anterior descending artery with a TIMI 2 flow, treated by balloon angioplasty and drug-eluting stent. Four days after revascularization, the patient developed an acute deterioration with signs of decompensated heart failure and a new holosystolic murmur with large irradiation. Inotropic agents’ administration was required to maintain a precarious hemodynamic condition. A bedside Echo revealed an apical VSD, measuring 15 × 10 mm, with left-to-right shunting, and pulmonary hypertension. The patient was scheduled for transcatheter PIVSD closure. The procedure was performed under fluoroscopic guide. Two vascular access sites were placed, femoral arterial and right internal jugular vein. Through the right internal jugular vein, a 24-mm Amplatzer atrial septal occluder on a 9 French Amplatzer TREVISIO™ intravascular delivery system was advanced via right ventricle into the PIVSD. Contrast fluoroscopy was used to assess apposition and the degree of shunt reduction before release. Echocardiographic evaluation performed 48 hours later confirmed a correct apposition of the device with insignificant residual shunt. At 6 months follow-up, he was asymptomatic, with unchanged prosthetic findings. ConclusionPercutaneous closure has been emerged as a valid cost-effective alternative to surgery and should be advised. However, debate remains on the optimal preprocedural optimization, timing of repair and modality of treatment.

Forgetfulness as the primary presenting symptom of type A acute aortic dissection.

Acute aortic dissection (AAD) is the most common lethal disease affecting the aorta. Neurological symptoms have been linked to AAD in some patients. Although aortic dissection patients have previously been shown to present with neurological symptoms, AAD with forgetfulness as the first manifestation is extremely rare. To increase the awareness of AAD among clinicians, we report the first case of a male Chinese patient with AD presenting with forgetfulness as the initial symptom. A 53-year-old man presented to the emergency department with forgetfulness. Based on the concept that "time is brain," stroke was initially considered in the differential diagnosis. The patient underwent emergency coronary angiography and was diagnosed with acute myocardial infarction. After contrast-enhanced computed tomography angiography, the patient was finally diagnosed with AAD. Because valuable time was lost in diagnosis rather than treatment, optimal timing for surgery missed. The patient died following an aortic dissection rupture while waiting for emergency surgery. When forgetfulness cannot be completely accounted for in patients presenting with acute myocardial infarction, AAD should be considered. We believe that this case report contains a worthwhile clinical lesson for clinicians.

Comparison of the feasibility and safety between distal transradial access and conventional transradial access in patients with acute chest pain: a single-center cohort study using propensity score matching

BackgroundDistal transradial access (dTRA) has been suggested to have great advantages over cTRA. However, there is a lack of preliminary data on dTRA in patients undergoing emergency coronary angiography (CAG) or percutaneous coronary intervention (PCI). To explore the feasibility and safety of distal transradial access in patients with acute chest pain.MethodsA total of 1269 patients complaining of acute chest pain in our emergency department from January 2020 to February 2022 were retrospectively included. The patients who met the inclusion criteria were divided into the conventional transradial access (cTRA) group (n = 238) and the dTRA group (n = 158). Propensity score matching was used to minimize the baseline differences.ResultsThe cannulation success rate in the dTRA group was significantly lower than that in the cTRA group (87.41% vs. 94.81%, p < 0.05). No significant differences in the puncture time and total procedure time were noted between the two groups (p > 0.05). Compared with the cTRA group, the hemostasis duration was significantly shorter [4(4, 4) h vs. 10(8, 10) h, p < 0.001) and the incidence of minor bleeding (BARC Type I and II) was significantly lower in the dTRA group than that in the cTRA group (0.85% vs. 5.48%, p = 0.045). Asymptomatic radial artery occlusion was observed in six patients (5.83%) in the cTRA group and one patient (1.14%) in the dTRA group (p = 0.126). The subgroup analysis of ST-elevation myocardial infarction (STEMI) showed no significant differences in the puncture time, D-to-B time or total procedure time between the two groups.ConclusionsThe dTRA for emergency CAG or PCI has an acceptable success rate and puncture time, a shorter hemostasis time, and a downward trend in RAO rate compared to the cTRA. The dTRA did not increase the D-to-B time in emergency coronary interventions in STEMI patients. On the contrary, a low incidence of RAO by the dTRA created an opportunity for future coronary interventions in non-culprit vessels in the same access.Trial registrationRetrospectively registered in Chinese Clinical Trial Registry (registry number: ChiCTR2200061104, date of registration: June 15, 2022).

De Winter syndrome or inferior STEMI?

BackgroundThe de Winter electrocardiography (ECG) pattern is associated with acute total or subtotal occlusion of the left anterior descending coronary artery (LAD) characterized by upsloping ST-segment depression at the J point in leads V1–V6 without ST-segment elevation.Case presentationWe report an atypical style case of the de Winter ECG pattern accompanied by ST elevation in inferior leads. The patient underwent emergency coronary angiography, which revealed total occlusion of the proximal LAD with no observable stenosis in the right coronary artery.ConclusionECG-related changes in acute total LAD occlusion can present with the de Winter pattern and ST elevation in inferior leads. Recognizing this atypical ECG pattern is critical for immediate reperfusion therapy.

Clinical characteristics and outcomes in young patients with myocardial infarction

Abstract Background Young people hold a stable or increasing percentage of patients with acute myocardial infarction in many countries. However, data on clinical characteristics and outcomes in young patients are lacking. Purpose To compare clinical characteristics and outcomes between patients aged ≤45 years and those aged &amp;gt;45 years with acute myocardial infarction. Methods A total of 24125 patients with acute myocardial infarction between January 2013 and September 2014 from China Acute Myocardial Infarction (CAMI) registry were included in this study. Clinical characteristics, in-hospital and 2-year outcomes were compared between patients aged ≤45 years (young) and those aged &amp;gt;45 years (older). Gender disparity in prognosis of myocardial infarction was analyzed among young patients. Results Of 24125 patients, 2042 (8.5%, 116 female) were aged ≤45 years. Compared with patients aged &amp;gt;45 years, young patients were more often male, current smokers, having medical history of hyperlipidemia and family history of premature coronary artery disease. Young patients were significantly more likely to have clear trigger factor, present with persistent chest pain and suffer ST-segment elevation myocardial infarction. Symptom onset to admission time was shorter in patients aged ≤45 years. For patients undergoing emergency coronary angiography, those aged ≤45 years were more likely to suffer left anterior descending coronary artery related myocardial infarction. Young patients were significantly more likely to receive percutaneous coronary intervention and other medications at discharge, including dual antiplatelet therapy, statins, angiotensin converting enzyme inhibitors or angiotensin II receptor blockers and β blockers. Compared with patients aged &amp;gt;45 years, young patients experienced significantly lower in-hospital and 2-year mortality and major adverse cardiac and cerebrovascular events (MACCE, a composite of death, reinfarction and stroke) rates (Table 1). Among young patients, women experienced higher in-hospital mortality and MACCE rates than men (Table 2). Women who survived at discharge experienced significantly higher 2-year mortality (1.4% vs 3.8%, Log-rank P=0.0412, Table 2). Conclusions Compared with the older patients, young patients were more likely to present with typical symptoms and receive guideline-recommended medications. Clinical outcomes of patients aged ≤45 years were significantly better than older patients. However, our results showed significant gender disparity in both short- and long-term outcomes of young patients. More efforts are needed to improve prognosis in young patients with acute myocardial infarction. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Twelfth Five-Year Planning Project of the Scientific and Technological Department of China

A rare cause of acute ST-elevation myocardial infarction: a case of coronary embolism secondary to calcified bicuspid aortic valve

Abstract Coronary embolism is an uncommon cause of acute myocardial infarction, which can have a similar clinical presentation to a plaque rupture event with acute onset of ischaemic symptoms, ST segment elevation on electrocardiogram (ECG) and significant elevation in cardiac troponin, requiring immediate intervention. We report the case of a middle-aged female with a background history of previous non-ST elevation myocardial infarction, bicuspid aortic valve with severe stenosis and metastatic breast cancer. The patient underwent emergency coronary angiography following acute onset central chest pain and evidence of anterior ST segment elevation on ambulance 12-lead ECG. The procedure revealed complete occlusion of the mid left anterior descending coronary artery with immediate flow restoration following embolus aspiration and subsequent normal appearance of the left anterior descending coronary artery. Gross examination of the aspirated specimen resembled a calcified hard lump, which was further confirmed on microscopic examination revealing calcified fibrous tissue most likely an embolus from the calcified bicuspid aortic valve. The patient had evidence of near transmural myocardial infarction in the distribution of the left anterior descending coronary on cardiac magnetic resonance imaging (MRI). She made full recovery and was discharged on short-term dual antiplatelet therapy followed by lifelong aspirin and further assessment for aortic stenosis management.

Predominant subtype of heart failure after acute myocardial infarction is heart failure with non-reduced ejection fraction.

AimsPatients who survive acute myocardial infarction (AMI) are at risk of being rehospitalized owing to the occurrence of acute decompensated heart failure (HF). However, the clinical characteristics of HF after AMI, especially the frequency of each HF subtype, are unclear.Methods and resultsWe retrospectively studied 1055 patients with AMI. We excluded 257 patients, who were admitted >48 h after the onset of AMI, died during hospitalization or after discharge, and whose echocardiogram data at index hospitalization and follow‐up data were missing. The remaining 798 patients (mean age: 66.5 ± 11.7 years) were investigated for a mean follow‐up period of 4.9 years. All patients underwent emergency coronary angiography. The mean maximum creatine kinase levels were 2898 ± 2627 IU/L, and mean left ventricular ejection fraction (LVEF) was 58.9 ± 10.2%. Eighty‐one patients (10.2%) were rehospitalized because of unexpected worsening of HF. Echocardiography data were available for 74 of the 81 patients during the acute phase of the second hospitalization, of which 30, 20, and 24 patients (41%, 27%, and 32%, respectively) were diagnosed as having HF with preserved LVEF (LVEF ≥ 50%), HF with mid‐range LVEF (40% ≤ LVEF < 50%), and HF with reduced LVEF (LVEF < 40%), respectively. The ejection fraction during index hospitalization was 58.3 ± 9.7% in the HF with preserved LVEF group, 53.3 ± 10.2% in the HF with mid‐range LVEF group, and 43.3 ± 10.5% in the HF with reduced LVEF group (P < 0.001).ConclusionsThe predominant subtypes of HF after AMI were HF with mid‐range ejection fraction and preserved ejection fraction, or HF with non‐reduced ejection fraction.

Predictive value of random blood glucose versus fasting blood glucose on in-hospital adverse events in patients with ST-segment elevation acute myocardial infarction

BackgroundWe aim to find out the relationship between random blood glucose (RBG), fasting blood glucose (FBG) and in-hospital adverse events in ST-segment elevation acute myocardial infarction (STEMI) patients. We evaluate and compare the predictive value of RBG and FBG on in-hospital adverse events, and give an appropriate cut-off value of RBG and FBG.MethodA retrospective study enrolled 958 consecutive AMI patients undergoing emergency coronary angiography at Zhongda Hospital were enrolled from January 1, 2016, to December 31, 2018 was performed. RBG and FBG, baseline data and adverse events were recorded. Major adverse cardiovascular and cerebrovascular events (MACCE) were defined as death, nonfatal recurrent myocardial infarction and stroke. Other adverse events included malignant arrhythmia, cardiac shock and hemorrhage. Patients with RBG > 11.1 mmol/L were divided into elevated RBG group. Patients with FBG > 6.1 mmol/L were divided into elevated FBG group. The incidence of in-hospital adverse events were compared in elevated RBG/FBG group and the control group. ROC curve was used to evaluate the predictive value of RBG and FBG on in-hospital adverse events.ResultThe incidence of death, hemorrhage, cardiac shock and malignant arrhythmia significantly increases in elevated RBG and FBG group. Binary logistic regression showed that age, hypertension, diabetes, FBG and RBG were independent risk factors for in-hospital adverse events in STEMI patients. The AUC and 95% CI of RBG and FBG in predicting death of AMI patients were 0.789, 0.759~0.816; 0.810, 0.783~0.835, respectively. The cut-off values ​were 13.82 and 7.35 mmol/L. RBG and FBG also had fine predictive value on cardiac shock and malignant arrhythmia, no statistical difference was found in the predictive value on in-hospital adverse events (P = 0.462, P = 0.570, P = 0.694).ConclusionIncidence of in-hospital adverse events significantly increases in AMI patients combined with elevated RBG or FBG. Both RBG and FBG were independent risk factors for in-hospital adverse events, they had good value on predicting in-hospital adverse events and there was no statistical difference in their predictive value.

Spontaneous coronary artery dissection: Case series from two institutions with literature review.

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS). Consequently, its presentation and optimal treatment are yet to be clearly defined. In the current literature, all case series report less than 50 patients, most of whom are either young peripartum women or women who have used oral contraceptives over long periods. All information in this study was compiled by the database service from two hospitals, the first one between 2003 and 2012 and the second one between 2007 and 2012, to include the clinical characteristics, angiography. and treatment approaches in the study population. The study population consisted in four women (50%) and four men (50%) whose ages ranged between 28 and 57 years. Two women had a history of oral contraceptive use and three women presented during peripartum. None of the patients had traditional cardiovascular risk factors or previous heart disease. In 88% of the cases, the principal diagnoses were non-ST segment elevation myocardial infarction and unstable angina. All patients underwent emergency coronary angiography and percutaneous coronary intervention. Half of them were treated with drug-eluting stents and the other half with bare metal stents. The most frequent type of dissection was NIHBL Type E, and the right coronary artery was the most frequently compromised. SCAD is a rare cause of ACS; however, its identification has improved due to the availability of angiography and new complementary techniques. Regarding treatment, PCI seems effective with adequate long-term results.

Unusual cause of chest pain mimicking acute myocardial infarction: congenital left ventricular aneurysm.

A 36-year-old man without any cardiac history presented to the emergency room with ongoing chest pain. The Electrocardiography (ECG) showed diffuse ST segment elevations on the anterior leads compatible with acute anterolateral wall myocardial infarction [Table/Fig-1]. The patient was a current smoker with a family history of coronary artery disease (CAD). He had a stable hemodynamic status with normal blood pressure and pulse rate. Initial examination revealed mild systolic murmur along the left sternal border as well as lateral displacement of the apical pulse. Lung auscultation was completely normal and all peripheral pulses were palpable. He was evaluated with transthoracic echocardiography that showed reduced ejection fraction of 38% with hypokinesis of the anterior wall along with a diffuse aneurysmal apical segment [Table/Fig-2]. Depending on the high clinical suspicion of acute myocardial infarction, the patient underwent emergency coronary angiography that revealed normal coronary arteries. In order to further define the anatomy, cardiac magnetic resonance imaging (MRI) was performed [Table/Fig-3][Video-1 and 2]. Left ventricular cavity was seen to expand at the apical level associated with thinning of the myocardium concordant with a true aneurysm. The aneurysmal pouch had a size of 4x5 cm without any thrombus inside. The myocardium did not display contrast enhancement excluding evidence for fibrosis or scar tissue. The wall thickness at the apex was measured as 2 mm showing a risk for ventricular rupture. Since there was no history of trauma or recent infarction, the patient was estimated as having a congenital aneurysm. As the aneurysmal sac was a substrate for arrhythmia and thrombus formation, it was decided to be surgically repaired. The patient underwent a Dor procedure represented by reconstruction of the ventricular cavity with endoventricular patch-plasty [1]. Perioperative course was free of complications. The patient was discharged uneventfully provided that the left ventricular volumes were reduced along with improvement in systolic function. [Table/Fig-1]: 12-lead ECG of the patient on presentation showing marked ST elevations on the D1-aVL and V4-6 derivations [Table/Fig-2]: Transthoracic echocardiographic image of the apical aneurysm shown by asterisk in the apical four-chamber view [Table/Fig-3]: Cardiac magnetic resonance image showing thinning of the myocardium at the apex (arrows) along with an aneurysmal pouch (asterisk) This case appears to call attention to a rare cardiac malformation that can present to the emergency room with typical signs and symptoms of acute myocardial infarction. In the literature, congenital left ventricular aneurysms have a wide-spectrum of presentations [2,3]. Although mostly asymptomatic [4], life-threatening ventricular arrhythmias [5], embolic events due to thrombus formation [6] and sudden cardiac death due to rupture [7] have been reported so far. In our case, CAD risk factors of the patient as well as the ECG findings led to an initial misdiagnosis of acute myocardial infarction.The precise diagnosis of a congenital left ventricular aneurysm in such a case necessitates demonstration of the true aneurysm by cardiac MRI and exclusion of CAD by angiography.

Autopulse facilitated coronary angiography for out of hospital cardiac arrest

Purpose: Out of hospital cardiac arrest (OHCA) is often caused by cardiac ischemia of which the majority present with acute coronary occlusion. The main cause of death remains central nervous system injury and myocardial failure. Optimal basic life support and early reperfusion therapy are thought to improve outcome. Basic life support can be facilitated by mechanical chest compressions. Methods: Between June 2008 and January 2012 all patients presented to the emergency room after an OHCA with suspected cardiac origin, were eligible for emergent coronary angiography. Only patients without return of spontaneous circulation (ROSC) while still on mechanical chest compression support, are presented. Results: A total of 18 patients underwent emergency coronary angiography. Percutaneous coronary intervention was attempted in 13 patients and successful in 11. Despite absence of ROSC before coronary angiography 1-day survival was 22%. Long-term survival was 17%. All survivors presented with ventricular fibrillation as initial rhythm. View this table: Table 1. Patient characteristics Conclusion: Performing coronary angiography during mechanical chest compressions for out of hospital resuscitation is feasible. Although survival remains poor, our figures suggest an improvement in survival if early revascularisation is performed. Further studies are needed to define patients that benefit from mechanical chest compressions and early coronary intervention.

Impact of Emergency Coronary Angiography on In-Hospital Outcome of Unconscious Survivors After Out-of-Hospital Cardiac Arrest

Acute coronary thrombotic occlusion is the most common trigger of cardiac arrest. The aim of the present study was to assess the impact of an invasive strategy characterized by emergency coronary angiography and subsequent percutaneous coronary intervention (PCI), if indicated, on in-hospital survival of resuscitated patients with out-of-hospital cardiac arrest (OHCA) and no obvious extracardiac cause who do not regain consciousness soon after recovery of spontaneous circulation. Ninety-three consecutive patients (67 ± 12 years old, 76% men) were included in the study. Clinical characteristics and coronary angiographic and in-hospital outcome data were retrospectively collected. Multivariate Cox proportional-hazards analysis was performed to identify independent determinants of in-hospital survival. Coronary angiography was performed in 66 patients (71%). Forty-eight patients underwent emergency coronary angiography; in the remaining 18 patients, mean time from OHCA to coronary angiography was 13 ± 10 days. In patients referred to emergency coronary angiography, successful emergency PCI of a culprit coronary lesion was performed in 25 patients (52%). In-hospital survival rate was 54%. At multivariate analysis, emergency coronary angiography (hazard ratio 2.32, 95% confidence interval 1.23 to 4.38, p = 0.009) and successful emergency PCI (hazard ratio 2.54, 95% confidence interval 1.35 to 4.8, p = 0.004) were independently related to in-hospital survival in the overall study population; delay in performing coronary angiography (hazard ratio 0.95, 95% confidence interval 0.92 to 0.99, p = 0.013) was independently related to in-hospital mortality in patients referred to coronary angiography. In conclusion, an invasive strategy characterized by emergency coronary angiography and subsequent PCI, if indicated, seems to improve in-hospital outcome of resuscitated but unconscious patients with OHCA without obvious extracardiac cause.

Oxidative stress and severity of coronary artery disease in young smokers with acute myocardial infarction

Cigarette smoking increases the oxidative stress mediated vascular dysfunction in young adults. We aimed to investigate the relation between the oxidative stress indices and coronary artery disease (CAD) severity in young patients presenting with acute myocardial infarction (AMI). Young patients (aged 〈 35 years) who were admitted consecutively to our hospital with a diagnosis of AMI were included in the study. Age matched healthy subjects were selected as controls. Oxidative stress indices including lipid hydroperoxide (LOOH), total antioxidant status (TAS), total oxidant status (TOS), oxidative stress index (OSI), paraoxonase (PON) and arylesterase (ARE) activities were measured in serum. CAD severity was assessed by calculating the SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery Study) score. We analyzed the association between the oxidative indices and CAD severity. Forty two young patients were admitted to the hospital with AMI (age 32.4 ± 2.6 years; 39 males, 3 females). Current and heavy smoking was commonly observed among the patients (79%). All patients underwent emergency coronary angiography. Twenty-eight healthy subjects were selected as controls. Patients had significantly higher OSI and TOS levels (median, interquartile range) [0.44 (0.26-1.75) vs 0.25 (0.22-0.30), p < 0.001 and 6.0 (4.4-20.8) vs 4.1 (3.7-4.6), p < 0.001], respectively, and lower TAS and LOOH levels [1.6 ± 0.1 vs 1.7 ± 0.1, p = 0.02 and 3.0 ± 0.8 vs 3.6 ± 0.4, p = 0.001], respectively, compared to the control group. CAD severity correlated positively with OSI (r = 0.508, p = 0.001) and TOS levels (r = 0.471, p = 0.002). Subjects with an intermediate to high SYNTAX score (≥ 22) demonstrated significantly higher OSI (median, interquartile range) [0.40 (0.34-1.75) vs 0.34 (0.26-0.68), p = 0.01] and TOS [6.9 (4.4-20.8) vs 5.8 (4.5-11.4), p = 0.01] levels compared to subjects with low SYNTAX score. Oxidative stress is an important contributor to CAD severity among young smokers. Elevated OSI and TOS levels reflect disease severity and vascular damage related to heavy smoking in early onset CAD.

Door‐to‐balloon times are reduced in ST‐elevation myocardial infarction by emergency physician activation of the cardiac catheterisation laboratory and immediate patient transfer

To assess whether a collaborative interdepartmental pathway involving emergency department (ED) physicians activating the cardiac catheterisation laboratory (CCL) with immediate patient transfer to the CCL reduces door-to-balloon (DTB) times for patients with suspected ST-elevation myocardial infarction (STEMI). A quasi-experimental before-and-after observational study using a prospective database, supplemented by chart review, of consecutive patients transferred from the ED to the CCL for suspected STEMI, from January 2007 to October 2009, at Sir Charles Gairdner Hospital, an adult tertiary-care hospital, Western Australia. Median DTB time and proportion of patients with DTB time of < 90 minutes. Secondary outcomes, based on analysis of predefined subgroups, included door-to-activation time, activation-to-balloon time and false-positive activations of the CCL. Two hundred and thirty-four patients underwent emergency coronary angiography for suspected STEMI, with 188 (80%) undergoing percutaneous coronary intervention (118 before and 70 after implementation of the new pathway). Following implementation of the new pathway, median DTB time reduced from 97 to 77 minutes (P < 0.001), median door-to-activation time from 28 to 15 minutes (P = 0.002) and median activation-to-balloon time from 66 to 53 minutes (P < 0.001). The proportion of patients with recommended DTB time of < 90 minutes increased from 41% to 77% (P < 0.001) with no change in false positive CCL activation rates (12% v 11%; P = 0.38). ED physician activation of CCL with immediate patient transfer is associated with highly significant improvements in DTB time without increased false positive rates.

Field Triage Reduces the Incidence and Mortality of Ischaemic Cardiogenic Shock in Patients with Acute Myocardial Infarction

reduce door to balloon (DTB) time in STEMI. Shorter DTB times are associated with reduced mortality. The main barrier to implementing ED CCL activation is concern of inappropriate activation of the CCL. Aim:Tocompare falsepositive ratesof suspectedSTEMI patients undergoing emergency coronary angiography by cardiology verses senior ED activation of the CCL. Methods: All patients undergoing emergency cardiac catheterisation forSTEMI from2007 to2009wereanalysed. Falsepositive rateswere comparedbefore andafter implementing a protocol enabling independent ED activation of the CCL (2007–2008 vs. 2009). Some patient characteristics required ED to communicate with cardiology prior to CCL activation (elderly, borderline ECG changes, out of hospital arrest, LBBB, significant co-morbidities). Patient files, ECGs, coronary angiograms and left ventriculograms were reviewed in all patients undergoing emergency angiography without percutaneous coronary intervention to determine diagnosis, management and cause of the false positive cases. Results: Cardiology 2008–2009 (n= 150) ED 2009 (n= 84) Primary PCI 118 (79%) 70(83%) Medical management 11 (7%) 4 (5%) Surgery 3 (2%) 1 (1) False positive 18 (12%) 9 (11%) (NS) Causes of false positives: Chest pain of unclear cause with either early repolarisation of ST segments or LBBB (63%, 7/27). Takotsubo cardiomyopathy (22%, 6/27), myo/pericarditis (11%, 3/27) and pulmonary embolism (5%, 1/27). Conclusion: False positive rates in patients undergoing emergency angiography for suspected STEMI is not increasedwithacontrolledsystemofemergencyphysician activation of the cardiac catheterisation laboratory. doi:10.1016/j.hlc.2010.06.975

False Positive Rates in Patients Undergoing Emergency Coronary Angiography for Suspected STEMI is Not Increased with Emergency Physician Activation of The Cardiac Catheterisation Laboratory

False Positive Rates in Patients Undergoing Emergency Coronary Angiography for Suspected STEMI is Not Increased with Emergency Physician Activation of The Cardiac Catheterisation Laboratory

Rescue angioplasty after failed fibrinolysis foracute myocardial infarction: Predictors of a failed procedure and 1‐year mortality

Rescue angioplasty (rPCI) for failed fibrinolysis is associated with a low mortality if successful, but a high mortality if it fails. The latter may reflect a high-risk group or harm in some patients. Predictors of success or failure of rPCI may aid selection of patients to be treated. Unselected patients referred for rPCI from March 1994 to March 2005 were studied to determine the predictors of a failed procedure and 1-year mortality. Of 440 patients undergoing emergency coronary angiography for failed fibrinolysis (1-year mortality 18%), 101 had thrombolysis in myocardial infarction flow grade (TFG) 3 in the infarct-related vessel. rPCI was attempted in 318 of 339 patients with <TFG 3 flow, but not in 21 patients (angiography-produced TFG 3 [n = 7] or unsuitable anatomy [n = 14]). Of the rPCI cohort, 77% had a successful procedure (no in-lab death or emergency coronary artery bypass grafting and TFG 3 in the infarct-related vessel); rPCI failed in 23%. One-year mortality rates for successful and failed rPCI were 14 and 43%, respectively. Patients with failed rPCI were older and more likely to be diabetic, have anterior MI, be interhospital transfers, be in cardiogenic shock, and less likely to be a current smoker. Shock was the only independent predictor of failed rPCI. Age group >75 years, shock, and final TFG < 3 were independent predictors of 1-year mortality. Cardiogenic shock is an independent predictor of a failed rPCI. Age group >75 years and shock were the only independent clinical predictors of 1-year mortality. These clinical variables may help in selecting patients for either a strategy of rescue angioplasty after failed fibrinolysis, or in selecting specific patients who might do better with a policy of primary angioplasty.

Tako-tsubo-like transient left ventricular dysfunction—A new cause of diastolic heart failure

A 49-year-old women presented with severe chest pain typical of myocardial infarction with vomiting and sweating during emotional stress (funeral). The initial ECG revealed normal sinus rhythmwith STelevation in leadsV1–V3,T-wave inverted in I, aVL, V5–V6 (Fig. 1-1). Admission Troponin I (1.4 ng/ml — normalb0.1 ng/ml) and creatinine kinase-MB (5.4 ng/ml, normalb3.6 ng/ml) level were positive. Other laboratory tests were normal. The patient underwent emergency coronary angiography which revealed normal coronary arteries (Fig. 2-1, 2). However contrast left ventriculography demonstrated typical view of tako-tsubo cardiomyopathy with markedly reduced left ventricular ejection fraction (Fig. 2-3). This observation was confirmed in transthoracic echo. Subsequent echocardiography performed 4 days after admission revealed a normal ejection fraction of 55% with grossly normal wall motion but with a relaxation abnormality. No valvular and right ventricular dysfunctions were observed in those examinations. The patient remained clinically and hemodynamically stable during 6 days of hospitalization and was discharged home (ECG at discharge — Fig. 1-2). Discharged medications included an aspirin, beta-blocker, calcium channel antagonist and statin. After 1 month patient had signs of heart failure and the transthoracic echo showed preserved left ventricular function with normal ejection fraction (Fig. 3-1, 2) and impaired

Prevalence of stress-induced myocardial stunning (Tako-Tsubo cardiomyopathy) among patients undergoing emergency coronary angiography for suspected acute myocardial infarction

Stress-induced myocardial stunning is defined as a syndrome of acute chest pain, ST-T changes on the ECG and transient left ventricular apical wall motion abnormalities mimicking acute myocardial infarction but with surprisingly normal coronary angiography findings. The aim of this retrospective study is to assess the prevalence of stress-induced myocardial stunning among patients undergoing urgent coronary angiography for suspected acute myocardial infarction. During a four-year period (2002–2005), a total of 5876 patients underwent urgent coronary angiography for suspected acute myocardial infarction at three tertiary centers. Four patients fulfilled the diagnostic criteria for stress-induced myocardial stunning. Thus, the cath-lab prevalence of stress-induced myocardial stunning (i.e. among patients undergoing urgent coronary angiography for suspected acute myocardial infarction) was estimated as 1 per 1469 ST-elevation coronary angiograms (i.e. 0.07%) The estimated annual population incidence of this rare disorder was calculated as 0.00006%. Stress-induced myocardial stunning is an extremely rare syndrome among patients undergoing emergency coronary angiography for suspected acute myocardial infarction.