Suspicion Of Acute Myocardial Infarction Research Articles

Very early risk modeling in patients with chest pain based on the pattern on admission ECG.

The aim was to investigate the prognostic accuracy of admission ECG and its usefulness in determining the population at the highest risk of worse outcomes. Fast and accurate assessment of chest pain patients remains a challenge for clinicians. Electrocardiogram (ECG) is performed in each case of suspicion of the cardiac origin of chest pain. Consecutive adult chest pain patients with suspicion of acute myocardial infarction (AMI) were enrolled in the study. The prognostic value of admission ECG changes alone and in combination with other clinical variables (cardiac troponin, diagnosis of AMI) were analyzed for the incidence of major adverse cardiac events (MACE) in a one‑year observation. The ischemic pattern on admission ECG was a single risk factor of MACE (HR 2.996 95% CI 1.31-6.86, p = 0.009), contrary to the single admission high-sensitivity cardiac troponin T assay (hs-cTnT) (HR 1.79 95% CI 0.695-4.61). The highest risk of MACE was identified in case of the presence of both ischemic-ECG and positive hs-cTnT (HR 3.19 95% CI 1.496-6.81, p = 0.003). The presence of ischemic changes in ECG in chest pain population with AMI suspicion increases the risk of MACE. The group at highest risk of MACE can by identified by the additional stratification with the admission single hs-TnT measurement (Tab. 2, Fig. 4, Ref. 40). Text in PDF www.elis.sk Keywords: acute coronary syndromes, cardiac troponin, electrocardiogram, emergency department, chest pain.

Significance of ST-Segment elevation in V4R lead in patients with anterior myocardial infarction.

BackgroundThere is some evidence of the association between ST‐segment elevation in the V4R chest lead and the likelihood of anterior wall myocardial infarction; however, the link of this phenomenon with the location and the severity of the coronary involvements in such patients remains uncertain. We aimed to investigate the ST‐segment elevation in V4R leads in patients with anterior myocardial infarction and also its effect on prognosis as well as the detection and prediction of the location of arterial stenosis in coronary angiography.MethodsData collection was performed by reviewing the hospital recorded files of 195 patients’ suspicion of acute myocardial infarction who have been referred within 2 h of the onset of cardiac symptoms. The patients were then categorized into two groups with and without ST elevation in the V4R chest lead.ResultsComparing two groups showed a significantly higher rate of concurrent ST‐segment elevation in V1 lead in those with ST‐segment elevation in V4R. Echocardiography on the day after anterior myocardial infarction showed LVEF <40% in 74% and 35.2% of patients with and without ST‐segment elevation in V4R, respectively, indicating a significant difference. The lesions on proximal LAD were more common in the group with ST‐segment elevation in V4R.ConclusionOur study emphasized a high likelihood of ST‐segment elevation in V4R lead concurrently with ST‐elevation in V1 lead. Also, the appearance of ST‐segment elevation in V4R lead can be accompanied with a lower LVEF, myocardial infarct size, involvement of proximal part of LAD, and Wrap around LAD.

Poor long-term prognosis in patients admitted with strong suspicion of acute myocardial infarction but discharged with another diagnosis.

Characteristics and prognosis of patients admitted with strong suspicion of myocardial infarction (MI) but discharged without an MI diagnosis are not well-described. To compare background characteristics and cardiovascular outcomes in patients discharged with or without MI diagnosis. The DETermination of the role of Oxygen in suspected Acute Myocardial Infarction (DETO2X-AMI) trial compared 6629 patients with strong suspicion of MI randomized to oxygen or ambient air. The main composite end-point of this subgroup analysis was the incidence of all-cause death, rehospitalization with MI, heart failure (HF) or stroke during a follow-up of 2.1years (median; range: 1-3.7years) irrespective of randomized treatment. 1619 (24%) received a non-MI discharge diagnosis, and 5010 patients (76%) were diagnosed with MI. Groups were similar in age, but non-MI patients were more commonly female and had more comorbidities. At thirty days, the incidence of the composite end-point was 2.8% (45 of 1619) in non-MI patients, compared to 5.0% (250 of 5010) in MI patients with lower incidences in all individual end-points. However, for the long-term follow-up, the incidence of the composite end-point increased in the non-MI patients to 17.7% (286 of 1619) as compared to 16.0% (804 of 5010) in MI patients, mainly driven by a higher incidence of all-cause death, stroke and HF. Patients admitted with a strong suspicion of MI but discharged with another diagnosis had more favourable outcomes in the short-term perspective, but from one year onwards, cardiovascular outcomes and death deteriorated to a worse long-term prognosis.

A multicentre, randomized, controlled open-label trial to compare an Accelerated Rule-Out protocol using combined prehospital copeptin and in-hospital high sensitive troponin with standard rule-out in patients suspected of acute Myocardial Infarction \u2013 the AROMI trial

BackgroundSuspicion of acute myocardial infarction (AMI) is among the most common reasons for admission to hospital in Denmark. Owing to this suspicion, an estimated 50,000 patients are admitted every year. Only 15–20% are finally diagnosed with AMI, whereas 40% are discharged after rule-out of AMI and without initiation of any treatment or need for further admission. In patients discharged after rule-out, the current diagnostic protocol, using consecutive troponin measurements, results in an average length of stay (LOS) of 8–12 h. This leads to overcrowding in both the emergency departments and coronary care units. Measuring copeptin and high-sensitivity cardiac troponin (hs-cTn) upon hospital arrival has shown potential for early rule-out of AMI. However, the diagnostic performance may be improved by accelerating the copeptin measurement of blood sampled already in the pre-hospital phase. Additional evidence on LOS reduction and safety of the rule-out strategy in a large cohort of all-comers is needed.Methods/designThe rule-out potential is being evaluated in a randomized controlled trial including 4800 patients admitted to hospital for suspicion of AMI. Patients are randomized to either standard rule-out (consecutive troponin measurements) or accelerated rule-out (copeptin measured in a blood sample acquired before hospital admission, combined with troponin measured in the first blood sample upon admission).DiscussionSampling blood for copeptin analysis already in the pre-hospital phase and combining this with a later hs-cTn measurement may be the optimal timing for achieving the best diagnostic performance in an AMI rule-out protocol/strategy. Moreover, we are directly comparing pre-hospital and in-hospital blood sample results to address this issue of timing, and we also are comparing single-marker strategies with dual-marker strategies. If the combination of copeptin and hs-cTn is confirmed to rule out AMI safely, implementation of this fast rule-out protocol could optimize patient flow, reduce health care expenses and enable allocation of resources to patients with confirmed illness. In future, when point-of-care analyses of copeptin and hs-cTn are available, hospitalization of the large proportion of patients with symptoms raising suspicion of AMI could potentially be avoided.Trial registrationClinicalTrials.gov, NCT02666326. Registered on January 24, 2016.

Case report: Apical variant hypertrophic cardiomyopathy simulating an acute inferior myocardial infarction

We present a female patient who arrived to the emergency department with chest pain without known medical history at the time of consultation. Considering her risk factors and electrocardiographic findings, it was decided to perform a coronary catheterization under the suspicion of acute myocardial infarction. The catheterization and another studies was negative for coronary artery disease. Additional studies were conclusive for apical variant hypertrophic cardiomyopathy or Yamaguchi syndrome.

Factors associated with performing urgent coronary angiography in out-of-hospital cardiac arrest patients.

Factors associated with performing urgent coronary angiography (UCA) in patients with out-of-hospital cardiac arrest (OHCA) were identified. Current guidelines for resuscitated OHCA patients recommend UCA if there is ST-elevation on post-arrest electrocardiogram or high suspicion of acute myocardial infarction. Some have advocated for UCA in all OHCA regardless of suspected etiology. The reasons for variations in performing UCA are not well understood. A retrospective analysis of subjects presenting with resuscitated OHCA to a single academic medical center from 12/15/2007 to 8/31/2014 was conducted. Demographic and clinical characteristics of patients undergoing UCA, defined as angiography within 6 hr of presentation, were compared with those not undergoing UCA. Logistic regression was used to determine predictors of UCA. A total of 323 resuscitated OHCA patients (mean age, 64 years; women, 35%) were included in the analysis; 107 (33.1%) underwent coronary angiography during their hospitalization and 66 (20.4%) underwent UCA. Multivariable adjusted factors associated with UCA were ST-elevation [odds ratio (OR) 14.66, 95% confidence interval (CI) 6.28-34.24, P < 0.001], initial shockable rhythm (OR 3.69, 95% CI 1.52-8.97, P = 0.004), and history of coronary artery disease (CAD) (OR 3.37, 95% CI 1.43-7.95, P = 0.005). Higher age (OR 0.71 per decade, 95% CI 0.55-0.92, P = 0.01) and obvious non-cardiac cause of arrest (OR 0.08, 95% CI 0.02-0.38, P = 0.001) were negatively associated with UCA. In resuscitated out-of-hospital cardiac arrest patients, ST-elevation, shockable rhythm, and history of CAD were associated with performing urgent coronary angiography; older patients and those with obvious non-cardiac causes of arrest were negatively associated.

Abstract 9740: Factors Associated With Performing Urgent Coronary Angiography in Out-of-Hospital Cardiac Arrest

Introduction: Out-of-hospital cardiac arrest (OHCA) is associated with high mortality and is most commonly caused by cardiovascular disease. Current guidelines recommend urgent coronary angiography (UCA) if ST-elevation myocardial infarction (STEMI) or high suspicion of acute myocardial infarction exist. Some have advocated for UCA in all OHCA without an obvious non-cardiac cause of arrest. The reasons for large clinical variation in performance of UCA in OHCA are not well understood. Objective: We sought to identify factors associated with performing UCA in OHCA. Methods: A retrospective chart review was conducted on 535 consecutive cardiac arrest patients who achieved return of spontaneous circulation (ROSC) and were admitted at a tertiary academic medical center from January 2008 to August 2014. Exclusion criteria included in-hospital cardiac arrests (201), outside hospital UCA (8), and lack of medical records (1). Univariable analysis followed by multivariable forward selection forcing age and gender were used to determine correlates of performing UCA, defined as within 6 hours of presentation. Results: Out of 325 resuscitated OHCA patients (mean age, 64; women, 35%), 69 were taken to UCA. Factors associated with performing UCA were history of coronary artery disease (CAD) (OR 2.76, 95% CI 1.22-6.28), initial shockable rhythm (OR 3.04, 95% CI 1.31-7.06), following commands post-ROSC (OR 2.77, 95% CI 1.06-7.25), and STEMI (OR 15.17, 95% CI 6.57-35.04). Increasing age (OR 0.97, 95% CI 0.95-0.999) and obvious non-cardiac cause of arrest (OR 0.10, 95% CI 0.03-0.37) were negatively associated. Gender, prior stroke, dementia, bystander cardiopulmonary resuscitation, hypotension, contraindication to anticoagulant, presenting from nursing home or rehabilitation, do not resuscitate order prior to admission, non-English primary language, and presenting during off-hours were not associated with the decision for UCA. Conclusions: In resuscitated out-of-hospital cardiac arrest patients, history of CAD, shockable rhythm, ability to follow commands, and STEMI were associated with performing urgent coronary angiography. Older patients and those with an obvious non-cardiac cause of arrest were less likely to receive coronary angiography.

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.

A false positive case of cardiac troponin I: Which diagnostic approach?

The finding of elevated cardiac troponin levels (i.e. values above the99thpercentilevalueofthereferencepopulation)notrelatedtoischemicmyocardial injury in patients admitted to the emergency department(ED) with suspected acute myocardial infarction (AMI), represents arelevant clinical problem, increasingly observed in the last few years,following the implementation of cardiac troponin (cTnI, cTnT) measure-ment with high-sensitivity immunoassays [1]. Indeed, the majority ofpatients (up to 70%) admitted to the ED with more than one elevatedtroponin level may actually have myocardial injury unrelated to acutecoronary syndrome (ACS), especially when they have an age of morethan 70 years, heart failure, and/or other comorbidities [2,3]. In suchpatients, the incidence of “falsepositive”cases,i.e.the findingof troponinelevations in the absence of clinically documented myocardial injury, isactually unknown. Clinical observation however suggests that the per-centage of “false positive” troponin elevations is extremely low.Inapaperrecentlypublishedinthejournal[4],aclinicalcaseofapa-tient presenting to the ED with suspicion of AMI and non-diagnosticECG that shows a false positive cTnI result due to the presence in theblood sample of an analytical interference caused by heterophilic anti-bodies,hasbeenpublished.Theauthorssuggesttheadoptionofanalgo-rithm that allows the prompt detection of the supposed false-positiveresult. The described protocol considers the systematic measurementof CK-MB reflex testing in all troponin-positive samples as a reliabletool for the identification of biological and analytical interference. Thisreflextestingisbasedontheuseofawellknownbutoutdatedbiomark-erwhichlackssensitivityandspecificityforthedetectionofmyocardialinjury when compared with cardiac troponin. In addition the Authorsseemtoignorecurrentinternationalguidelines[5],whichbasethediag-nosis of myocardial infarction, along with the documentation of objec-tive evidence of myocardial ischemia, on the correct interpretation ofserialcardiactroponintesting.Infacttheanalysisofthereleasekineticsof troponin may permit the distinction between myocardial damagecaused by myocardial ischemia from myocardial injury caused byother factors and, possibly, from “false positive” troponin elevations[5,6]. According to these criteria, the detection of a rise and/or fall pat-tern of troponin with at least one value above the 99th percentileupper reference limit, is needed to make the diagnosis. It is well know,instead, that theinterference ofaheterophilicantibodytypically causesa constant (chronic) increase in troponin values, which cannot beconfused with the typical kinetic of the biomarker in AMI patients.Therefore, the interference by heterophilic antibodies should be differ-entiated from the huge number of clinical conditions which can causea chronic increase in troponin levels [5].Reflex testing is usually per-formed when the result of a first screening test is positive, in order toimprovethespecificity,althoughatthecostoflowersensitivity.Thisdi-agnostic strategy, therefore, should be adopted in clinical laboratorypractice to improve specificity employing a second text more specific(but more expensive and time consuming) than the screening text.Inthe case of the proposed reflex testing [4], the cardiac specificity of thesecond test (i.e. CK-MB) is significantly lower than the specificity ofthe screening test (i.e. cardiac troponin) and significantly less sensitivefor cardiac damage. As a consequence, the potential clinical advantageof using a very sensitive and cardio-specific screening test, such as thecardiactroponins, appearsto be, intheproposed “reflextesting” strate-gy, completely lost. A huge number of clinical studies have definitivelydemonstrated that cardiac troponins (particularly when assayed withhigh-sensitivity methods) represent a more cardiac-specific and sensi-tive biomarker than CK-MB in cardiovascular risk stratification, both inthe general population as well as in patients with cardiac disease [1,7]confirmingthatthemeasurementof CK-MBisnowobsolete.Moreover,considering that the incidence of heterophilic antibodies in the generalpopulationvariesgreatlyindifferentstudies(from0.17to40%)[8,9]thereflextestingproposed,ifappliedsystematicallyinallpatientsadmittedto the ED with increased troponin values, may allow the detection of

Følges retningslinjene for behandling av hjerteinfarkt?

New guidelines recommend early invasive evaluation and treatment for most patients with acute myocardial infarction--including patients with myocardial infarction without ST elevation in the ECG. This study examines compliance with the new guidelines at Sørlandet Hospital Arendal. All patients admitted to Sørlandet Hospital Arendal with acute myocardial infarction in 2012 were registered in the Norwegian Myocardial Infarction Register. Data from the register were used to analyse the time that passed from symptom onset to coronary angiography and revascularisation. In 2012, 788 patients were admitted to Sørlandet Hospital Arendal with acute myocardial infarction. Of these, 269 (34.1%) had ST elevation mycardial infarction (STEMI) and 519 (65.9%) had non-ST elevation myocardial infarction (NSTEMI). Most patients with ST elevation infarction (220 (81.8%)) were admitted directly to Sørlandet Hospital Arendal, and the median time from admission to revascularisation was 31 minutes. 347 (66.9%) of the patients with non-ST elevation infarction were first admitted to a local hospital before being transferred to Sørlandet Hospital Arendal. Only four (1.2%) of them underwent angiography within two hours of admission to the first hospital. 13 (9.0%) of the patients with non-ST elevation infarction who were admitted directly and underwent angiography (n = 144) had an angiogram within two hours of admission. Angiography was performed within 24 hours in 119 (34.3%) of those transferred (n = 347) and in 82 (56.9%) of the directly admitted patients who underwent angiography (n = 144). Many patients with non-ST elevation infarction did not receive revascularisation with percutaneous coronary intervention (PCI) within the recommended time frame. Where there is a strong clinical suspicion of acute myocardial infarction, more patients should be admitted directly to hospitals with PCI preparedness.

Myocardial infarction due to malposition of ECMO cannula

Dear Editor, The most reported complications of veno-venous extracorporal membrane oxygenation (ECMO) are bleeding and infections [1]. Recently, a double lumen cannula was introduced, making introduction of two separated cannulas unnecessary. This single cannula is inserted via the right internal jugular vein and positioned with the tip resting in the inferior vena cava. Through ports in the superior and inferior caval veins, blood is returned directly into the right atrium. There have been reports describing ambulatory patients on veno-venous ECMO [2] with this type of cannula. To date, only “minor” complications have been described such as displacement of the cannula tip from the inferior vena cava into the right atrium [3]. Here we describe a case of a displaced Avalon double lumen cannula, which caused compression of the right coronary artery, 14 days after initiation of ECMO. A 61-year-old (height 1.80 m) man suffering from severe H1N1 pneumonitis for 4 days was referred to our tertiary center for ECMO. One day after admission at our center, a 27-Fr Avalon Elite bi-caval dual lumen catheter (Avalon Laboratories, Rancho Dominguez, CA, USA) was percutaneously inserted into the right jugular vein under fluoroscopy. With the catheter fully inserted, fluoroscopy showed that the tip just reached the inferior vena cava. The first X-ray confirmed this correct position. On the third day, X-ray showed that the ECMO cannula projected into the right atrium. Many attempts to reposition the cannula under fluoroscopic control failed to obtain a stable position. The team therefore had to accept the position of the tip in the right atrium. On the 14th ECMO day, cardiac markers were elevated. Echocardiography showed septal and inferior wall motion abnormalities and that the tip of the cannula was in the right atrium without crossing the tricuspid valve. On the suspicion of acute myocardial infarction, emergency coronary angiography was performed. Coronary angiography showed occlusion of the right coronary artery due to compression by the ECMO cannula (see electronic supplement: angiography in two directions). The suggested anatomic location of the compression of the right coronary artery is marked in Fig. 1. Withdrawal of the cannula resulted in a good coronary flow and after many attempts the tip of the cannula was placed in the inferior vena cava. On the 21st day, the patient was successfully weaned from the ECMO. On the 23rd day, the patient was transferred back to the referring hospital. Right ventricular function was normal and due to hypokinesia in the inferior segments; left ventricular function was moderate. Six months after hospital discharge, he had made an excellent recovery. Fig. 1 Three-dimensional computed tomography of the right atrium and right ventricle of the heart of a healthy subject (not the described patient). Note the right coronary artery (RCA) traveling on the epicardium between the right atrium and right ventricle. ... We conclude that when the cannula is short in relation to patient anatomy, misplacement of the cannula can easily occur and this could have serious complications.

Value of heart-type fatty acid binding protein in the clinical diagnosis of early acute myocardial infarction

A total of 115 patients with acute chest pain under the suspicion of acute myocardial infarction (AMI) were selected.By the onset time of chest pain,they were divided into two periods of ＜3 h and 3 -6 h respectively. Heart-type fatty acid binding protein (H-FABP)and such traditional cardiac biochemical markers as cardiac troponin T (cTnT),creatine kinase isoenzyme (CK-MB) and myoglobin (MYO) were tested to compare the sensitivity and specificity in the early diagnosis of AMI.The sensitivity of H-FABP was significantly higher than those of cTnT,CK-MB and MYO (P =0.026,0.005,0.048 ) ; the specificity of H-FABP was lower than those of cTnT,CK-MB in the diagnosis of AMI ( P ＞ 0.05 ).The sensitivities of H-FABP were 81.6％ and 78.1％ in the ST-elevation myocardial infarction (STEMI) and nonST elevation myocardial infarction (NSTEMI) groups respectively ( P =0.095 ).Regardless of the onset of chest pain at ＜ 3 h or 3 -6 h,the combination of H-FABP and cTnT had a higher sensitivity than those of cTnT,CK-MB and MYO in the early diagnosis of AMI (P =0.005,0.028).In the early and rapid diagnosis of AMI patients,H-FABP has a high sensitivity and a poor specificity.And it has some reference value. Key words: Heart-type fatty acid binding protein; Myocardial infarction

Paroxysmal mechanical aortic valve prosthesis dysfunction: capturing the right moment

A 62-year-old female presented to the emergency room under suspicion of acute myocardial infarction. While shopping she suddenly experienced severe chest pain and nearly collapsed. Her medical history revealed aortic valve replacement (Medtronic Hall 22 mm) 8 years before and since 5 years repeated presentations to the emergency room because of intermittent chest pain. An initial electrocardiogram (ECG) showed sinus tachycardia with transient ST elevation in leads aVR and V1 and ST depression in leads I, II, III, aVF and V3–V6 (Fig. 1), which resolved within 5 min. Physical examination, laboratory results and transthoracic echocardiography were unremarkable. Fig. 1 ECG at presentation during chest pain, showing sinus tachycardia with ST elevation in leads aVR and V1 and ST depression in leads I, II, III, aVF and V3-V6 Under suspicion of an acute coronary syndrome, coronary angiography was performed and showed a 70% stenosis in the second diagonal branch of the left descending artery. Because of the discrepancy between the ECG at presentation and the coronary angiography, it was decided not to perform a percutaneous coronary intervention. Immediately after the coronary angiography the patient had recurrent chest pain with remarkable ST depression. A second coronary angiography was performed which revealed non-closure of the mechanical aortic valve, causing severe aortic regurgitation (Movies 1 and 2). The patient was scheduled for valve revision. At operation dysfunction of the mechanical disk became apparent. When the disk was opened a pannus overgrowth beneath the valve was clearly visible. This was causing a block of the disk in opening position with temporarily massive aortic regurgitation (Fig. 2). After removing the mechanical prosthesis, the circular pannus overgrowth was most evident (Fig. 3). The pannus was removed and a bioprosthesis (Edwards Life Sciences Perimount Magna 23 mm) was implanted. The patient made an uncomplicated recovery. She has had no recurrent chest pain 5 months after the valve replacement. Fig. 2 The mechanical prosthesis is opened. A pannus overgrowth is visible behind the prosthesis (indicated by arrows). AO: ascending aorta Fig. 3 After removing the mechanical prosthesis, the circular pannus is entirely visible (indicated by arrows) Intermittent severe aortic regurgitation due to pannus overgrowth of a mechanical prosthetic aortic valve is a serious complication and has been reported before [1–4]. The clinical presentation is varied and due to the intermittent appearance of the malfunctioning valve, the diagnosis is often difficult and can be easily overlooked. In this specific patient it was possible to diagnose this clinical problem due to the findings on angiography. However, simple cinefluoroscopy of the mechanical valve during symptoms would have diagnosed mechanical valve immobility earlier.

Three-dimensional echocardiographic assessment of left ventricular function in takotsubo cardiomyopathy

We evaluated left ventricular (LV) function by three-dimensional echocardiography (3DE) in a patient with takotsubo cardiomyopathy (TC). An 82-year-old man was admitted to our hospital with a suspicion of acute myocardial infarction but was diagnosed as TC by coronary angiography and left ventriculography (LVG). Three-dimensional echocardiography showed circular asynergy from the midventricle to the apex associated with hyperkinesis of the base and volumetric data very close to those obtained by LVG. Thus, 3DE is a useful tool in evaluating regional wall motion abnormalities and LV volume in patients with TC.

Epidemiology of acute myocardial infarction with the emphasis on patients who did not reach the coronary care unit and non-AMI admissions

Objectives To describe the characteristics and outcome of patients with acute myocardial infarction (AMI) in a community, with particular emphasis on those who never reached a Coronary Care Unit (CCU) and those in whom the primary diagnosis was something other than a heart attack. Methods Patients hospitalised in the city of Göteborg, Sweden, and discharged (dead or alive) with a diagnosis of AMI. Results Among 1423 patient admissions the mean overall age was 75 years (81 years and 79 years in the two subsets). Among all patients, 33% had a history of heart failure and 20% had a history of cerebrovascular disease. The figures were even higher in the two subsets which were evaluated. In overall terms, an invasive strategy (coronary angiography) was used in 32% (in 5% and 9% in the two subsets respectively). The overall one-year and three-year mortality rate was 30% and 44% respectively. The three-year mortality rate among patients not admitted to a CCU was 65% and, among patients with no suspicion of a heart attack on admission, it was 68%. Conclusion Even in the 21st century, patients with AMI who reach hospital alive run a high risk of death and nearly half are dead within the first three years. In overall terms, patients are characterised by high age and high co-morbidity. Among patients who do not reach a CCU and among patients with no suspicion of AMI on admission, approximately two thirds are dead within the subsequent three years.

Tako-Tsubo Phenomenon: Dual-Source Computed Tomography and Conventional Coronary Angiography

A 75-year-old woman was admitted to our emergency department with severe chest pain and mild dyspnea that started soon after a marital quarrel with her husband. Her 12-lead electrocardiogaphy (ECG) demonstrated an ST elevation in the precordial leads, and the plasma troponin T level was elevated to 0.29 ng/mL. An acute myocardial infarction with ST elevation was assumed, and the patient was admitted for an emergency catheter coronary angiography. Her coronary arteries were normal, but left ventriculography demonstrated a severe systolic dysfunction involving the mid and apical myocardial segments, showing apical ballooning (Supplemental Data Movie I). Thus, the diagnosis of tako-tsubo phenomenon was made. The ejection fraction was decreased to 40%. Because of a history of pulmonary embolism, the patient was referred for chest computed tomography (CT) to rule out a recurrent pulmonary embolism. Contrast-enhanced, retrospectively ECG-gated dual-source CT excluded pulmonary embolism and similarly demonstrated systolic dysfunction with apical ballooning (Supplemenal Data Movie II). After 2 days, the patient’s symptoms ceased and echocardiography showed normalized left ventricular systolic function. Tako-tsubo phenomenon is characterized by transient left ventricular systolic dysfunction of unknown etiology. Initially described in Japan [1] and named after an octopustrapping pot with a round bottom and a narrow neck, it has also been recognized more and more in Western countries [2, 3]. It predominantly occurs in postmenopausal women and frequently after emotional stress. Importantly, such a psychological stressful trigger is not observed in all individuals, and its absence does not exclude the diagnosis. A few cases have been reported in younger women and males [4]. Rarely, patients present with syncope or an out-ofhospital cardiac arrest. Symptoms clinically mimic acute myocardial infarction, with the majority of patients presenting with chest pain, dyspnea, and mild ST-segment elevation in precordial leads followed by T-wave inversion involving most leads [2]. Plasma troponin T levels are either normal or only slightly increased and thus contrast the extent of systolic dysfunction in the acute phase. Patients are usually hemodynamically stable, but clinical findings of mild to moderate congestive heart failure commonly coexist. In a minority of patients, hypotension may occur from reduced stroke volume and occasionally from dynamic left ventricular outflow tract obstruction. Cardiogenic shock may be a rare complication. Patients with tako-tsubo phenomenon generally have a good prognosis in the absence of significant underlying comorbidity. The systolic dysfunction and the regional wall-motion abnormalities are transient and full recovery usually occurs in most cases without specific therapy [2, 3]. The initial imaging for patients with tako-tsubo phenomenon is usually performed with catheter coronary angiography because of the clinical suspicion of acute myocardial infarction. The left ventriculogram shows characteristic regional wall-motion abnormalities involving the mid and apical segments (Fig. 1). There is sparing of the basal systolic function, and the wall-motion abnormality extends beyond the distribution of any one single coronary artery. Apical sparing variants have also been described [5]. Echocardiography and magnetic resonance H. Scheffel P. Stolzmann C. Karlo B. Marincek H. Alkadhi (&) Institute of Diagnostic Radiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland e-mail: hatem.alkadhi@usz.ch

Continuous ST‐segment Monitoring of Patients with Right Bundle Branch Block and Suspicion of Acute Myocardial Infarction

Patients with right bundle branch block comprise 5-9% of all patients with acute myocardial infarction. In spite of this, limited data exist on early diagnosis or the usefulness of continuous electrocardiographic monitoring in these patients. A prospective multicenter study with 14 Swedish coronary care units. Patients with right bundle branch block and suspicion of acute myocardial infarction with less than 6 hours symptom duration were included. All patients were monitored with continuous vectorcardiography for 12-24 hours. Seventy-nine patients were included, 43% had acute myocardial infarction. Patients with acute myocardial infarction had significantly higher initial ST-vector magnitude values (P = 0.0014) compared to patients without acute myocardial infarction. Patients with acute myocardial infarction also showed gradual regression of ST-vector magnitude over time that was not seen for patients without acute myocardial infarction (P = 0.005). ST-vector magnitude measured at the J-point differentiated best between patients with and without acute myocardial infarction. A cutoff value of 125 microV for initial ST-vector magnitude resulted in 55% sensitivity and 87% specificity for the diagnosis of acute myocardial infarction. Over time, patients with acute myocardial infarction showed greater changes in QRS-vector difference compared to patients without acute myocardial infarction (P = 0.052). Vectorcardiographic monitoring shows good diagnostic abilities for patients with right bundle branch block and clinical suspicion of acute myocardial infarction and could be useful for continuous monitoring of these patients.

Continuous ST-segment monitoring of patients with left bundle branch block and suspicion of acute myocardial infarction.

Patients with left bundle branch block comprise 5-9% of all patients with acute myocardial infarction. Limited data exist on the usefulness of continuous electrocardiographic monitoring of these patients. We have investigated prospectively the usefulness of real-time continuous vectorcardiography for monitoring patients with left bundle branch block and suspicion of acute myocardial infarction. A prospective multi-centre study. Fourteen Swedish coronary care units. Patients with left bundle branch block and suspicion of acute myocardial infarction with <6-h symptom duration were included. All patients were monitored with continuous vectorcardiography for 12-24 h. One hundred thirty-three patients were included, 47% had acute myocardial infarction. Patients with acute myocardial infarction showed a marked relative decrease in ST-vector than those without (P = 0.0002). These changes were most marked in the first 90 min. When comparing patients with acute myocardial infarction receiving thrombolytic therapy or not, those treated with thrombolytics showed more marked decline in ST-vector magnitude (P < 0.0001) and in shorter time (P = 0.0017). All patients showed STC-vector magnitude changes that were more marked in patients with acute myocardial infarction (P = 0.0002). An STC-vector magnitude cut-off value of 65 microV after 90 min of monitoring gave 54% sensitivity and 72% specificity for diagnosis of acute myocardial infarction. Real-time continuous vectorcardiographic monitoring of patients with left bundle branch and suspicion of acute myocardial infarction shows significant differences between those with and without acute myocardial infarction and could be of use for early diagnosis and subsequent monitoring.

Tako-Tsubo Transient Left Ventricular Apical Ballooning Is Associated With a Left Anterior Descendig Coronary Artery With a Long Course Along the Apical Diaphragmatic Surface of the Left Ventricle

Introduction and objectives Tako-tsubo-like transient left ventricular apical ballooning has been described in Japan, but few cases have been reported in Western countries. We report one of the first series outside Japan, which provides new information on the coronary anatomy of this disorder. Patients and Methods From January 1998 to February 2003 we observed 11 patients with a clinical suspicion of acute myocardial infarction, normal coronary arteries, and transient tako-tsubo-like systolic left ventricular apical ballooning. We compared the coronary artery anatomy in these 11 patients with that in 44 controls matched for age and sex: 22 with normal coronary arteries and 22 with acute myocardial infarction related with an obstructive thrombus in the left anterior descending coronary artery. Results As in Japanese patients, tako-tsubo syndrome in Caucasian patients frequently occurs in women in their seventh or eighth decades of life, and is usually preceded by emotional or physical stress. The left anterior descending in our patients with tako-tsubo syndrome was longer overall, and its recurrent diaphragmatic segment was longer, than in controls. To compare these groups we designed a measure termed recurrent segment index (left anterior descending recurrent segment length/total left anterior descending length x 100). In tako-tsubo syndrome this index was 22.3 (1.5)%, vs 10.9 (6.7)% in normal controls (P Conclusions All our patients with tako-tsubo syndrome had a left anterior descending with a long recurrent segment. The identical ventriculographic findings in patients with tako-tsubo syndrome and those with acute myocardial infarction with a long recurrent segment may be due to a common etiology.

Asociación del síndrome tako-tsubo con la arteria coronaria descendente anterior con extensa distribución por el segmento diafragmático

Tako-tsubo-like transient left ventricular apical ballooning has been described in Japan, but few cases have been reported in Western countries. We report one of the first series outside Japan, which provides new information on the coronary anatomy of this disorder. From January 1998 to February 2003 we observed 11 patients with a clinical suspicion of acute myocardial infarction, normal coronary arteries, and transient tako-tsubo-like systolic left ventricular apical ballooning. We compared the coronary artery anatomy in these 11 patients with that in 44 controls matched for age and sex: 22 with normal coronary arteries and 22 with acute myocardial infarction related with an obstructive thrombus in the left anterior descending coronary artery. As in Japanese patients, tako-tsubo syndrome in Caucasian patients frequently occurs in women in their seventh or eighth decades of life, and is usually preceded by emotional or physical stress. The left anterior descending in our patients with tako-tsubo syndrome was longer overall, and its recurrent diaphragmatic segment was longer, than in controls. To compare these groups we designed a measure termed recurrent segment index (left anterior descending recurrent segment length/total left anterior descending length x 100). In tako-tsubo syndrome this index was 22.3 (1.5)%, vs 10.9 (6.7)% in normal controls (P<.001), and 11.3 (7.7)% in acute myocardial infarction patients (P<.001). Patients with acute myocardial infarction and a high recurrent segment index (> or =16%) had ventriculographic findings of systolic apical ballooning identical to those in patients with tako-tsubo syndrome. All our patients with tako-tsubo syndrome had a left anterior descending with a long recurrent segment. The identical ventriculographic findings in patients with tako-tsubo syndrome and those with acute myocardial infarction with a long recurrent segment may be due to a common etiology.