Procedural success versus clinical risk status in determining discharge of patients after primary angioplasty for acute myocardial infarction.

OBJECTIVES: We evaluated whether patients' clinical status, angioplasty success, or both, should guide discharge after primary angioplasty (i.e., percutaneous coronary intervention [PCI]) for acute myocardial infarction (AMI). BACKGROUND: Current guidelines do not address a discharge strategy for AMI patients undergoing successful PCI. METHODS: Patients who underwent PCI in Primary Angioplasty in Myocardial Infarction (PAMI) studies (N = 3,188) were classified as "high clinical risk" if they had either age >70 years, Killip class >1, heart rate >100 beats/min, systolic blood pressure <100 mm Hg, anterior MI, or left bundle branch block, and as "low clinical risk" if none was present. Successful PCI patients were compared with those with unsuccessful PCI in both groups for 30-day major adverse cardiac events (MACE). RESULTS: Percutaneous coronary intervention was successful in 668 (90%) of 745 low-risk clinical and 2,104 (86%) of 2,443 high-risk clinical patients. Regardless of clinical risk status, patients with successful PCI had lower 30-day MACE than those with unsuccessful PCI (low-risk group: 4.6% vs. 22%, p < 0.0001; high-risk group: 7% vs. 21%; p < 0.0001). Moreover, successful PCI patients with either risk status had few MACE after day 4, whereas unsuccessful PCI patients had more MACE. The success of PCI was the strongest independent predictor of 30-day MACE (odds ratio [OR] 3.7, 95% confidence interval [CI] 2.8 to 5.0). A constellation of three or more high-risk clinical features also predicted higher 30-day MACE (OR 2.25, 95% CI 1.62 to 3.12). CONCLUSIONS: The success of PCI is the prime determinant of clinical outcome after PCI for AMI. The majority of AMI patients with less than three high-risk clinical features who undergo successful PCI may be discharged from the hospital by day 4. In contrast, patients with more than two high-risk clinical features or unsuccessful PCI may need longer observation.

Constrictive pericarditis versus restrictive cardiomyopathy: challenges in diagnosis and management.

This is the case of a patient who presented with severe right-sided heart failure due to diastolic dysfunction that caused a dilemma of differential diagnosis between restrictive cardiomyopathy and constrictive pericarditis. Restrictive cardiomyopathy was diagnosed based on noninvasive and invasive hemodynamic testing. However, the patient did not respond to therapy and succumbed to worsening heart failure and multiple comorbidities. Clinical features of right heart failure with edema, ascites, jugular venous distention, and tender hepatomegaly are commonly seen in clinical practice. When systolic function is determined to be normal, diastolic causes of heart failure must be ruled out. These include myocardial disorders with a broad range of pathologies leading to restrictive physiology, of which amyloidosis is a prototype. Pericardial disorders leading to diastolic heart failure are usually in the form of constrictive physiology, when pericardial tamponade is ruled out. Differentiation between restrictive and constrictive pathologies is often difficult and requires careful attention to hemodynamic and Doppler echocardiographic features. We report a case of severe right heart failure illustrating some of the complexities in decision-making and the importance of meticulous hemodynamic and ancillary testing in the diagnosis and treatment of this often fatal condition.