Myocardial inefficiency is an early indicator of exercise-induced myocardial fatigue.

Background: The effect of prolonged, high-intensity endurance exercise on myocardial function is unclear. This study aimed to determine the left ventricular (LV) response to increased exercise duration and intensity using novel echocardiographic tools to assess myocardial work and fatigue. Materials and methods: LV function was assessed by echocardiography before, immediately, and 24 h after a cardiopulmonary exercise test (CPET) and a 91-km mountain bike leisure race. Cardiac Troponin I (cTnI) was used to assess myocyte stress. Results: 59 healthy recreational athletes, 52 (43-59) years of age, 73% males, were included. The race was longer and of higher intensity generating higher cTnI levels compared with the CPET (p < 0.0001): Race/CPET: exercise duration: 230 (210, 245)/43 (40, 45) minutes, mean heart rate: 154 ± 10/132 ± 12 bpm, max cTnI: 77 (37, 128)/12 (7, 23) ng/L. Stroke volume and cardiac output were higher after the race than CPET (p < 0.005). The two exercises did not differ in post-exercise changes in LV ejection fraction (LVEF) or global longitudinal strain (GLS). There was an increase in global wasted work (p = 0.001) following the race and a persistent reduction in global constructive work 24 h after exercise (p = 0.003). Conclusion: Increased exercise intensity and duration were associated with increased myocardial wasted work post-exercise, without alterations in LVEF and GLS from baseline values. These findings suggest that markers of myocardial inefficiency may precede reduction in global LV function as markers of myocardial fatigue.

Regular consumption of cod liver oil is associated with reduced basal and exercise-induced C-reactive protein levels; a prospective observational trial : A NEEDED (The North Sea Race Endurance Exercise Study) 2014 sub-study.

BACKGROUND: Dietary supplement use among recreational athletes is common, with the intention of reducing inflammation and improving recovery. We aimed to describe the relationship between omega-3 fatty acid supplement use and inflammation induced by strenuous exercise. METHODS: C-reactive protein (CRP) concentrations were measured in 1002 healthy recreational athletes before and 24 h after a 91-km bicycle race. The use of omega-3 fatty acid supplements was reported in 856 out of 1002 recreational athletes, and the association between supplement use and the exercise-induced CRP response was assessed. RESULTS: Two hundred seventy-four subjects reported regular use of omega-3 fatty acid supplements. One hundred seventy-three of these used cod liver oil (CLO). Regular users of omega-3 fatty acid supplements had significantly lower basal and exercise-induced CRP levels as compared to non-users (n = 348, p < 0.001). Compared to non-users, regular users had a 27% (95% confidence interval (CI): 14-40) reduction in Ln CRP response (unadjusted model, p < 0.001) and 16% (95% CI: 5-28, p = 0.006) reduction after adjusting for age, sex, race duration, body mass index, delta creatine kinase, MET hours per week, resting heart rate and higher education. CLO was the primary driver of this response with a 34% (95% CI: 19-49) reduction (unadjusted model, p < 0.001) compared to non-users. Corresponding numbers in the adjusted model were 24% (95% CI: 11-38, p < 0.001). CONCLUSION: Basal CRP levels were reduced, and the exercise-induced CRP response was attenuated in healthy recreational cyclists who used omega-3 fatty acid supplements regularly. This effect was only present in regular users of CLO. TRIAL REGISTRATION: NCT02166216 , registered June 18, 2014 - Retrospectively registered.

High-Sensitivity Cardiac Troponin I and T Response Following Strenuous Activity is Attenuated by Smokeless Tobacco: NEEDED (North Sea Race Endurance Exercise Study) 2014.

Background Use of snus, a smokeless tobacco product, is increasing in Scandinavia. Strenuous physical activity is associated with an acute increase in high-sensitivity cardiac troponin (swhs-cTn) concentrations. Current smoking is associated with lower hs-cTn, but whether this also holds true for smokeless tobacco and whether tobacco affects the hs-cTn response to exercise remain unknown. Methods and Results We measured hs-cTnI and hs-cTnT concentrations in 914 recreational athletes before and 3 and 24 hours after a 91-km bicycle race. Self-reported snus tobacco habits were reported as noncurrent (n=796) and current (n=118). The association between snus use and change in log-transformed hs-cTnI and hs-cTnT concentrations (ie, the differences between concentrations at baseline and 3 hours and 24 hours ) were assessed by multivariable linear regression analysis. Concentrations of hs-cTn at baseline were lower in current than in noncurrent snus users (hs-cTnI median, 1.7 ng/L; Q1 to Q3: 1.6-2.3 versus 2.0 ng/L; Q1 to Q3: 1.6-3.2 [P=0.020]; and hs-cTnT: median, 2.9 ng/L, Q1 to Q3: 2.9-3.5 versus 2.9 ng/L, Q1 to Q3: 2.9-4.3 [P=0.021]). In fully adjusted multivariable models, use of snus was associated with lower change in hs-cTn concentrations from baseline to 3 hours (hs-cTnI: -29% [P=0.002], hs-cTnT: -18% [P=0.010]) and 24 hours (hscTnI: -30% [P=0.010], hs-cTnT -19%, [P=0.013]). Conclusions Resting hs-cTn concentrations are lower and the exercise-induced cardiac troponin response is attenuated in current users of smokeless tobacco compared with nonusers. Further insight into the pathophysiological processes underlying the attenuated cardiac troponin response to exercise in tobacco users is needed. Registration URL: https://www.clini​caltr​ials.gov; Unique identifier: NCT02166216.

Duration of Elevated Heart Rate Is an Important Predictor of Exercise-Induced Troponin Elevation.

Background The precise mechanisms causing cardiac troponin (cTn) increase after exercise remain to be determined. The aim of this study was to investigate the impact of heart rate (HR) on exercise-induced cTn increase by using sports watch data from a large bicycle competition. Methods and Results Participants were recruited from NEEDED (North Sea Race Endurance Exercise Study). All completed a 91-km recreational mountain bike race (North Sea Race). Clinical status, ECG, blood pressure, and blood samples were obtained 24 hours before and 3 and 24 hours after the race. Participants (n=177) were, on average, 44 years old; 31 (18%) were women. Both cTnI and cTnT increased in all individuals, reaching the highest level (of the 3 time points assessed) at 3 hours after the race (P<0.001). In multiple regression models, the duration of exercise with an HR >150 beats per minute was a significant predictor of both cTnI and cTnT, at both 3 and 24 hours after exercise. Neither mean HR nor mean HR in percentage of maximum HR was a significant predictor of the cTn response at 3 and 24 hours after exercise. Conclusions The duration of elevated HR is an important predictor of physiological exercise-induced cTn elevation. Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT02166216.

Endurance exercise training volume is not associated with progression of coronary artery calcification.

BACKGROUND: Recent cross-sectional studies have suggested a dose-dependent relationship between lifelong exposure to physical activity and the burden of calcified coronary artery disease (CAD). No longitudinal studies have addressed this concern. HYPOTHESIS: Exercise volume is associated with progression of coronary artery calcium (CAC), defined as ≥10 units increase in CAC score. METHODS: Sixty-one recreational athletes who were assessed by coronary computed tomography angiography (CCTA) as part of the NEEDED 2013/14 study were re-assessed 4-5 years later, in 2018. RESULTS: Subjects were 45.9 ± 9.6 years old at inclusion, and 46 (74%) were male. Between 2013 and 2018, the participants reported median 5 (range: 0-20, 25th-75th percentile: 4-6) hours of high-intensity exercise per week. None of the included subjects smoked during follow-up. At inclusion, 21 (33%) participants had coronary artery calcifications. On follow-up CCTA in 2018, 15 (25%) subjects had progressive coronary calcification (≥10 Agatston units increase in CAC). These subjects were older (53 ± 9 vs 44 ± 9 years old, P = .002) and had higher levels of low-density lipoprotein at baseline (3.5 (2.9-4.3) vs 2.9 (2.3-3.5) mmol/L, P = .031) as compared to subjects with stable condition. No relationship was found between hours of endurance training per week and progression of coronary artery calcification. In multiple regression analysis, age and baseline CAC were the only significant predictors of progressive CAC. CONCLUSION: No relationship between exercise training volume and the progression of coronary artery calcification was found in this longitudinal study of middle-aged recreational athletes.

Occult obstructive coronary artery disease is associated with prolonged cardiac troponin elevation following strenuous exercise.

BACKGROUND: Sudden cardiac death among middle-aged recreational athletes is predominantly due to myocardial ischaemia. This study examined whether measuring cardiac troponin I and T (cTnI and cTnT) after strenuous exercise could identify occult obstructive coronary artery disease. DESIGN: Prospective observational study. METHODS: Subjects were recruited from 1002 asymptomatic recreational cyclists completing a 91-km mountain bike race (North Sea Race Endurance Exercise Study). No subject had known cardiovascular disease or took cardiovascular medication. Blood samples were collected within 24 h before and 3 h and 24 h after the race. Coronary computed tomography angiography was performed in 80 participants with the highest post-exercise cTnI and in 40 reference subjects with moderately elevated cTnI values. RESULTS: Study subjects (N = 120) were 45 (36-52) years old and 74% were male. There were similar demographics in the High-cTnI group and the Reference group. The cTn concentrations were highest at 3 h post-race: cTnI, 224 (125-304) ng/L; cTnT, 89 (55-124) ng/L. Nine subjects had obstructive coronary artery disease on coronary computed tomography angiography, eight of whom were High-cTnI responders. Two subjects had myocardial bridging, both High-cTnI responders. Troponin concentrations at 24 h post-race were higher in subjects with obstructive coronary artery disease than in the rest of the cohort (n = 109): cTnI, 151 (72-233) ng/L vs. 24 (19-82) ng/L, p = 0.005; cTnT, 39 (25-55) ng/L vs. 20 (14-31) ng/L, p = 0.002. The areas under the receiver operating characteristic curves for predicting obstructive coronary artery disease were 0.79, p = 0.005 (cTnI) and 0.82, p = 0.002 (cTnT). CONCLUSION: In subjects with occult obstructive coronary artery disease there was a prolonged elevation of cTn following strenuous exercise.

Race duration and blood pressure are major predictors of exercise-induced cardiac troponin elevation.

BACKGROUND: The underlying mechanisms of the exercise-induced increase in cardiac troponins (cTn) are poorly understood. The aim of this study was to identify independent determinants of exercise-induced cTn increase in a large cohort of healthy recreational athletes. METHODS: A total of 1002 recreational cyclists without known cardiovascular disease or medication, participating in a 91-km mountain bike race were included. Median age was 47 years and 78% were males. Blood samples were obtained 24 h prior to, and 3 and 24 h after the race. RESULTS: Cardiac TnI concentrations increased markedly from baseline [1.9 (1.6-3.0) ng/L] to 3 h after the race [52.1 (32.4-91.8) ng/L], declining at 24 h after the race [9.9 (6.0-20.0) ng/L]. Similarly, cTnT increased from baseline [3.0 (3.0-4.2) ng/L] to 3 h after the race [35.6 (24.4-54.4) ng/L], followed by a decline at 24 h after the race [10.0 (6.9-15.6) ng/L]. The 99th percentile was exceeded at 3 h after the race in 84% (n = 842) of subjects using the cTnI assay and in 92% (n = 925) of study subjects using the cTnT assay. Shorter race duration and higher systolic blood pressure (SBP) at baseline were highly significant (p < 0.001) independent predictors of exercise-induced cTn increase both in bivariate and multivariable analysis. The age, gender, body mass index, training experience and cardiovascular risk of participants were found to be less consistent predictors. CONCLUSION: Systolic blood pressure and race duration were consistent predictors of the exercise-induced cTn increase. These variables likely reflect important mechanisms involved in the exercise-induced cTn elevation. TRIAL REGISTRATION NUMBER: NCT02166216 https://clinicaltrials.gov/ct2/show/NCT02166216.

The cardiac troponin response following physical exercise in relation to biomarker criteria for acute myocardial infarction; the North Sea Race Endurance Exercise Study (NEEDED) 2013.

BACKGROUND: The aim of this study was to investigate troponin (cTn) dynamics for both genders, compared the different release patterns to the gender specific 99th percentile and to current biomarker criteria for diagnosing myocardial infarction (MI). METHODS: Serum was collected from 97 recreational cyclists 24 h before and immediately, 3 and 24 h following a 91-km bike race. hs-cTnI (Abbott) and hs-cTnT (Roche) were measured. Conventional or CT coronary angiography was performed in the 13 participants with the highest hs-cTnI (>140 ng/L). Three subjects with obstructive coronary artery disease were excluded from the statistical analysis. RESULTS: There was a significant (p < 0.001) post-race increase in cTnI and cTnT; cTnT peaked immediately, cTnI peaked after 3 h. Relative to the gender specific 99th percentile values, women had the largest increase. The biomarker criteria for MI were met in 76-87% for hs-cTnI, and 96-95% for hs-cTnT (p value <0.05), within the first 3 h post-race. CONCLUSION: Post-race cardiac troponin concentrations exceeded diagnostic criteria for MI in the majority of subjects, more often for hs-cTnT than for hs-cTnI, and more pronounced in women than in men. The current biomarker criteria for MI discriminate poorly between an exercise induced troponin increase and acute MI.

The copeptin response after physical activity is not associated with cardiac biomarkers or asymptomatic coronary artery disease: The North Sea Race Endurance Exercise Study (NEEDED) 2013.

BACKGROUND: Copeptin concentrations increase both during acute coronary syndrome and following physical exercise. The relationship between copeptin increase following physical exercise and coronary artery disease (CAD) is uncertain. The aim of this study was to 1) describe the copeptin response following strenuous physical exercise, and 2) investigate the determinants of exercise induced copeptin concentrations, particularly in relation to cardiac biomarkers and CAD. METHODS: Serum samples were collected from 97 recreational cyclists 24h before, and immediately, 3 and 24h after a 91-km bike race. Three subjects were subsequently diagnosed with significant asymptomatic CAD. Delta copeptin concentrations were correlated to patient characteristics and to biomarker concentrations. RESULTS: Participants were 42.8±9.6years, and 76.3% were male. Copeptin concentrations increased to maximal levels immediately after the race and were normalized in >90% after 3h. A total of 53% and 39% exceeded the 95th and 99th percentile of the assay (10 and 19pmol/L) respectively. In multivariate models, race time, serum sodium, creatinine and cortisol were significant predictors of copeptin levels. There was no correlation between changes in copeptin and changes in cardiac biomarkers (hs-cTnI, hs-cTnT and BNP). Copeptin concentrations were normal in the subjects with asymptomatic CAD. CONCLUSIONS: The moderate, short-term, exercise induced copeptin increase observed in the present study was not related to hs-cTn or BNP levels. Copeptin was normal in three asymptomatic recreational athletes with significant CAD.

Highly increased Troponin I levels following high-intensity endurance cycling may detect subclinical coronary artery disease in presumably healthy leisure sport cyclists: The North Sea Race Endurance Exercise Study (NEEDED) 2013.

Background Circulating cardiac troponin levels increase following prolonged intense physical exercise. The aim of this study was to identify participants with highly elevated cardiac troponins after prolonged, high intensity exercise, and to evaluate these for subclinical coronary artery disease. Methods and results Ninety-seven recreational cyclists without known cardiovascular disease or diabetes, participating in a 91 km mountain bike race were included, 74 (76%) were males, age: 43 ± 10 years, race duration: 4.2 (3.6-4.7) h. Blood samples, rest electrocardiogram and physical examination were obtained 24 h prior to, and at 0, 3 and 24 h following the race. Median cardiac troponin I level at baseline: 3.4 (2.1-4.9) ng/l (upper limit of normal: 30.0 ng/l). There was a highly significant ( p < 0.0001) increase in circulating cardiac troponin I in all participants: immediately following the race; 50.5 (28.5-71.9) ng/l, peaking at 3 h 69.3 (42.3-97.7) ng/l and declining at 24 h: 14.2 (8.5-27.9) ng/l. No cyclist had symptoms or rest electrocardiogram changes compatible with coronary artery disease during or following the race. Coronary artery disease was detected by coronary angiography in the three cyclists with the three of the four highest cardiac troponin values (>370 ng/l) at 3 and 24 h following the race. Computed tomographic coronary angiography was performed in an additional 10 riders with the subsequently highest cardiac troponin I values, without identifying underlying coronary artery disease. Conclusions This study suggests that there is a pathologic cardiac troponin I response following exercise in individuals with subclinical coronary artery disease. This response may be associated with an excessive cardiac troponin I increase at 3 and 24 h following prolonged high-intensity exercise.

Safety and health status following early discharge in patients with acute myocardial infarction treated with primary PCI: a randomized trial.

BACKGROUND: Early discharge after uncomplicated primary percutaneous coronary intervention (PPCI) is common but the evidence supporting this practice is lacking. We therefore performed a randomized, prospective trial comparing outcomes in low risk PPCI randomized to early discharge or usual care. DESIGN AND METHODS: Over a two years period, all surviving PPCI patients at a single teaching hospital were considered eligible if the Zwolle risk score ≤3. They were randomized to either discharge ≤3 days or usual care. All included patients had routine medical treatment, counselling and follow-up. Health status and all readmissions up to 30 days follow-up were tracked. RESULTS: Of 425 consecutive PPCI patients, 215 (50.6%) were randomized to either early discharge (n = 108) or usual routine discharge (n = 107). The mean index length of stay (LOS) plus the 30 days readmissions length of stay in the early discharge group was lower than in the usual discharge group: 2.7 ± 0.5 days vs 3.0 ± 0.7 days (p = 0.001). During follow-up there were no deaths, and similar readmission rate (4 (3.7%) vs 3 (2.8%), p = 0.69 in the early vs usual discharge group respectively). There was no difference in the 30 days health status measurements. The excluded high-risk group (n = 210) had longer index LOS (total sum 1314 vs 501 days, p = 0.001), and a trend towards more readmissions (10 (4.8%) vs 7 (3.3%) (p = 0.19)). CONCLUSION: It is feasible and safe to discharge low-risk PPCI patients within three days.

Gender-specific ambulance priority and delays to primary percutaneous coronary intervention: a consequence of the patients' presentation or the management at the emergency medical communications center?

BACKGROUND: Women with ST-elevation myocardial infarction (STEMI) tend to have longer treatment delays than men. This may partly be due to women delaying calling for help, difficulties for the emergency medical communication (EMC) service in interpreting a different constellation of presenting symptoms than men, or gender-specific ambulance delays due to differences in the management by the EMC service. METHODS AND RESULTS: We studied the EMC audio logs and medical records of 244 consecutive STEMI patients (65 women and 179 men) who contacted the EMC center at a single hospital directly. Patient demographics, clinical findings, and outcome after primary percutaneous coronary intervention were similar for the 2 genders. More women than men reported chest discomfort and discomfort in other areas of the upper body as debuting symptoms. The combined effects of longer patients delay and system delay led to longer total ischemic time in women (total ischemic time: median [interquartile range] 142 [180] vs 135 [83] minutes, women vs men, P = .024). Despite similar presentation, women had lower priority for emergent ambulance service (78.7% and 89.4% of women vs men, P = .035). Lower priority for ambulance service was associated with longer total ischemic time. CONCLUSION: Despite similar presentation and clinical findings, women with STEMI were given significantly lower priority for emergent ambulance service than men.

Long-term prognostic value of CK-MB and the troponins after angioplasty in patients with stable angina.

OBJECTIVES: The long-term prognostic value (> 5 years) of elevated cardiac biomarkers after elective coronary angioplasty is yet not clear. Most previous studies have included high risk, unstable patients and with conflicting results. The aim of this study was to determine the prognostic value of CK-MB mass vs. the cardiac troponins (values ≥ 3 times the reference) after elective angioplasty in low-risk patients with stable angina. METHODS: A total of 202 consecutive patients were included in the final analysis. Patients with elevated values at baseline, and those suffering an acute coronary syndrome < 1 month before the time of inclusion, were excluded. Blood samples were drawn just before, 1-3 hours and 4-8 hours after the procedure and the next morning. Using a cutoff value of three times the reference, patients with high and low values (= controls) of CK-MB mass, cardiac troponin T (TnT) and troponin I (TnI) were compared. No patient developed new Q-waves on ECG. The median follow-up time was 82 months equalising 1600 patient years. RESULTS: None of the patients died during the procedure or within the first 30 days after angioplasty, confirming a low risk cohort. There was an increasingly number of patients with levels ≥ 3 times the reference post procedure in TnT (10.4%) and TnI (16.8%) vs. CK-MB (6.9%). All cause mortality, readmission for acute coronary syndromes and target lesion revascularisation were more frequent in patients with high CK-MB, 42.9% vs. 22.3 %, p = 0.05 (log-rank test). Corresponding values for TnT were 33.3% vs. 22.7%, p = 0.22. In the TnI patients, there were more adverse events in controls vs. the high group, 25.0% vs. 17.6%, p = 0.34. CONCLUSIONS: CK-MB mass values ≥ 3 times, contrary to the cardiac troponins, predicts worse long-term event-free survival after elective angioplasty in low-risk patients.

Long-term prognostic value of cardiac troponin I and T versus creatine kinase-MB mass after cardiac surgery in low-risk patients with stable symptoms.

The long-term prognostic value of elevated cardiac biomarkers after elective cardiac surgery is not clear. The recent guidelines for diagnosing perioperative infarcts have advocated the use of similar thresholds for creatine kinase-MB (CK-MB) mass and the cardiac troponins. However, few previous data are available comparing these biomarkers after cardiac surgery, and it is not clear whether postoperative elevations of the troponins can be treated the same as elevations of CK-MB. We sought to compare the prognostic value of the cardiac troponins versus the CK-MB mass after elective cardiac surgery in low-risk patients with stable symptoms. A total of 204 consecutive patients undergoing cardiac surgery were included in the final analysis. Blood samples were drawn just before and 1 to 3 and 4 to 8 hours after the procedure, and every morning for 3 days thereafter. Patients with elevated baseline values were excluded. Using a cutoff value of 5 times the reference, patients with high and low values (controls) of CK-MB mass, cardiac troponin T (cTnT) and cardiac troponin I (cTnI) were compared. The median follow-up time was 92 months. None developed new Q-waves on the electrocardiogram. The incidence of the composite end point of all-cause mortality, readmission for acute coronary syndrome, and target vessel revascularization in the high CK-MB group was 41.2% compared to 21.8% in the controls (p = 0.004). The corresponding values for cTnT were 33.3% and 20.4% (p = 0.075) and for cTnI were 27.0% and 34.6% (p = 0.237). The p value in the isolated coronary artery bypass grafting subgroup (n = 156) was p = 0.043 for CK-MB, p = 0.137 for cTnT, and p = 0.795 for cTnI. High CK-MB (p = 0.001), ejection fraction (p = 0.002), and body mass index (p = 0.010) were the only variables independently related to reduced event-free survival. No such relation was found for high cTnT and cTnI. In conclusion, CK-MB was superior to the cardiac troponins (values > or =5 times the reference) in predicting long-term event-free survival after elective cardiac surgery in low-risk patients with stable symptoms undergoing coronary artery bypass grafting and/or valve surgery.

Competing risk analysis of events 10 years after revascularization.

OBJECTIVES: To evaluate the influence of competing risk (CR) non-cardiac death during long-term follow-up of revascularized patients on the interpretation of the cardiac outcomes. METHODS: Retrospectively, we compared outcomes estimated with the Kaplan-Meier and the cumulative incidence function (CIF) methods after a median 10.8 years follow-up in 1,234 consecutive patients (594 CABG, 640 PCI) undergoing first time non-emergent revascularization in a community cohort. RESULTS: Overall 301 (24.4%) patients died (27.3% in the CABG vs. 21.7% in the PCI group, p = 0.02). The causes of death were cardiac (10.3%) and non-cardiac (14.1%). CR analysis showed a similar probability of cardiac death (CIF 0.10 (95% CI 0.092, 0.18) vs. 0.093 (0.07, 0.12)) in the CABG and PCI treated patients, respectively. The probability for acute myocardial infarction (CIF 0.12 vs. 0.16 p < 0.001), congestive heart failure (CIF 0.15 vs. 0.09 p = 0.007) in the CABG and PCI group respectively, differed. The differences were also statistically significant after multivariate adjustment for the competing risks of death. For all outcomes the Kaplan-Meier method overestimated risk estimates. CONCLUSIONS: The competing risk adjusted probability for cardiac death, but not other cardiac endpoints are comparable in patients treated with either CABG or PCI after very long-term follow-up. The risk for all-cause death was mainly predicted by the occurrence of non-cardiac diseases.

Coronary blood flow and perfusion pressure during coronary angiography in patients with ongoing mechanical chest compression: a report on 6 cases.

Patients with pulseless electrical activity or refractory ventricular fibrillation have a very bad prognosis. Coronary angiography and angioplasty may be required to restore an effective circulation, but this must be performed whilst chest compressions are continued. The LUCAS chest compression device is suitable for this purpose. So far there are no reports on the effect of this device on coronary circulation in humans. We monitored the coronary perfusion pressure assessed invasively as the difference between the diastolic pressures at the coronary ostium and right atrium, and compared these pressures with coronary flow graded using the TIMI scale in 6 patients. In 4 out of 6 we found a satisfactory coronary artery perfusion pressure and TIMI grade 3 flow (normal) on coronary angiography. Two of these patients survived the first 24h. Two patients did not have a satisfactory perfusion pressure and adequate flow rate was not seen.

A comparison of the health status after percutaneous coronary intervention at a hospital with and without on-site cardiac surgical backup: a randomized trial in nonemergent patients.

BACKGROUND: Prospective randomized trials comparing the coronary artery disease-related health status outcomes (changes in symptom grade, physical functional capacity and health-related quality of life) after percutaneous coronary intervention at hospitals with and without on-site cardiac surgical backup have not been reported earlier. METHODS: We randomly assigned 609 consecutive patients fulfilling pre-specified procedural low-risk criteria to undergo percutaneous coronary intervention at either a community hospital without or a regional hospital with on-site surgical backup. Five hundred and seventy-six patients completed the health status evaluation at baseline and at 6 months follow-up. RESULTS: At baseline, 91.4% had symptoms, and the mean (standard deviation) Canadian Cardiovascular Society's classification was 2.5 (0.9). The procedural success rates and the changes in health status measures were similar at the two hospitals. Overall there was a substantial relief of symptoms with a reduction in Canadian Cardiovascular Society's classification of 1.9 (1.2), increase in exercise time [1.4 (1.9) min] and reduction in use of antianginal drugs [0.6 (0.9) less drugs] at follow-up compared with baseline (all P<0.001). Health-related quality of life was evaluated with the Short-Form 36 health survey. There were significant and similar improvements in nearly all multi-item and summary scores from baseline to follow-up at the two hospitals. The largest improvements were seen in items related to physical functioning [overall change in Physical Component Score from baseline to follow-up 6.9 (9.1) points, P<0.001] and lowest in the mental health domains [change in Mental Component Score 3.3 (10.7) points, P<0.001]. INTERPRETATION: This study shows that a substantial and comparable gain in coronary artery disease-related health status can be achieved at hospitals both with and without surgical backup.

The activity of pregnancy-associated plasma protein A (PAPP-A) as expressed by immunohistochemistry in atherothrombotic plaques obtained by aspiration thrombectomy in patients presenting with a ST-elevation myocardial infarction: a brief communication.

BACKGROUND: The expression of pregnancy-associated plasma protein A (PAPP-A) was identified by immunohistochemistry (IHC) in culprit atherothrombotic plaque specimens harvested from patients admitted with ST-segment elevation myocardial infarction (STEMI). METHODS: The atherothrombotic samples were collected from a consecutive cohort consisting of 20 individuals admitted with STEMI to Stavanger University Hospital, Norway, from 2005-2006, presenting angiographically with an acute thrombotic occlusion of a coronary artery characterized by TIMI flow 0. The atherothrombotic plaques were obtained by aspiration thrombectomy during percutaneous coronary intervention within 12 hours from the onset of symptoms and prepared for IHC analysis. RESULTS: In the IHC analysis staining for PAPP-A occurred in the extracellular matrix of the plaques and no evidence of staining for PAPP-A was found in the thrombi. CONCLUSION: Our results indicate that in vivo PAPP-A is strongly expressed in atherothrombotic plaques harvested from patients admitted with STEMI, as documented by IHC. TRIAL REGISTRATION: biobankregisteret@fhi.no1846.