[Late stent thrombosis thirteen months after drug-eluting stent implantation]. / Zakrzepica w stencie trzynascie miesiecy po wszczepieniu stentu powlekanego lekiem antyproliferacyjnym.

We present a case of a very late stent thrombosis which occurred 13 months after drug-eluting stent (DES) implantation. The DES was off-label used in a high-risk patient and was followed by 12-month clopidogrel administration. One month after the drug discontinuation the stent thrombosis occurred, resulting in acute myocardial infarction. The patient was successfully treated with balloon coronary angioplasty and was advised to use clopidogrel indefinitely.

Direct thrombin inhibition and stroke prevention in elderly patients with atrial fibrillation: experience from the SPORTIF III and V Trials.

BACKGROUND AND PURPOSE: Warfarin prevents stroke in atrial fibrillation (AF); however, concerns regarding international normalized ratio control and hemorrhage limit its use in the elderly. The oral direct thrombin inhibitors (DTIs) are potential alternatives to warfarin, offering fixed dosing without drug and dietary interactions and the need for international normalized ratio monitoring. Although ximelagatran, a DTI studied in the Stroke Prevention using an ORal Thrombin Inhibitor in atrial Fibrillation trials, has been withdrawn, development of other DTIs continues. We report our experience in elderly high-risk AF patients on ximelagatran compared with warfarin therapy. METHODS: Data from patients with AF and stroke risk factors randomized in Stroke Prevention using an ORal Thrombin Inhibitor in atrial Fibrillation III and V trials to ximelagatran or warfarin were analyzed for stroke/systemic emboli, bleeding, and raised alanine aminotransferase levels in those >or=75 (n=2804) and <75 (n=4525) years. RESULTS: Ximelagatran was as effective as warfarin in reducing stroke/systemic emboli in the elderly (2.23%/y with ximelagatran vs 2.27%/y with warfarin) as in younger patients (1.25%/y vs 1.28%/y). Total bleeds were significantly lower with ximelagatran compared with warfarin in elderly (40% vs 45%, P=0.01) and younger (27% vs 35%, P<0.001) patients. Raised alanine aminotransferase values (>3-fold elevation) among ximelagatran patients were more common in older (7.5% old vs 5.3% young) patients, particularly women (9.5% elderly women vs 6.1% elderly men). CONCLUSIONS: In high-risk elderly AF patients, ximelagatran is as effective as warfarin with less bleeding, but alanine aminotransferase elevations are common, particularly in elderly women. Oral DTIs for stroke prevention show promise in elderly patients.

[Electrocardiographic signs of anterior myocardial infarction caused by the occlusion of the right ventricular branch of the right coronary artery--a case report]. / Elektrokardiograficzne objawy zawalu serca sciany przedniej spowodowane zamknieciem galezi prawo-komorowej.

Elektrocardiographic signs of anterior myocardial infarction caused by the occlusion of the right ventricular branch. A case of a 72-year-old male with electrocardiographic symptoms of anterior myocardial infarction resulting from the right ventricular branch occlusion is presented. The mechanisms of eliscrepancy between angiographic and electrocardiographic findings are discussed and diagnostic as well as therapeutic procedures are described.

All-cause readmission and repeat revascularization after percutaneous coronary intervention.

BACKGROUND: Percutaneous coronary intervention (PCI) is one of the most frequently performed cardiac interventions. However, there is limited data regarding the cause of recurrent hospitalization and repeat revascularization. The aim of this study was to assess re-hospitalization and repeat revascularization within 30 days of the initial hospitalization for PCI, using data from Opolskie Voivodeship, National Health Fund (NHF) Registry. METHODS: The study population consisted of all PCI patients treated in three interventional cardiology laboratories in Opolskie Voivodeship in Poland between 1 July 2008 and 30 June 2009. All PCI patients who died during the initial hospitalization or who were transferred to other units were excluded from the analysis. The study end-point comprised 30 day all-cause readmission and repeat revascularization. RESULTS: A total of 2,039 PCI patients were included in the analysis. The all-cause 30-day readmission rate was 14.6%. The 30-day readmission rate of acute coronary syndrome (ACS) patients was significantly higher compared to the stable coronary disease patients (ACS 15.8%, non-ACS 10.7%, p = 0.008). The 30-day readmission rate did not differ between the three cardiac laboratories. Approximately half (46.2%) of all readmitted patients underwent a repeat revascularization procedure, mainly in the form of PCI. The overall all-cause 30-day mortality rate was 0.8%. Compared to the PCI patients who did not require readmission, the readmitted patients had a significantly higher all-cause 30-day mortality rate (3.6% vs 0.3%, p < 0.001). CONCLUSIONS: Almost one in seven PCI patients requires readmission within 30 days of hospital discharge. Approximately 50% of all readmitted PCI patients resulted in a repeat revascularization procedure. PCI patients who were readmitted within 30 days of an index PCI procedure had a significantly higher all-cause 30-day mortality rate.

Enoxaparin in primary and facilitated percutaneous coronary intervention A formal prospective nonrandomized substudy of the FINESSE trial (Facilitated INtervention with Enhanced Reperfusion Speed to Stop Events).

OBJECTIVES: The aim of this study was to assess the risk-benefit of enoxaparin (Sanofi-Aventis, Paris, France) in primary percutaneous coronary intervention (PCI). BACKGROUND: Randomized studies have demonstrated the superiority of enoxaparin over unfractionated heparin (UFH) in acute ST-segment elevation myocardial infarction (STEMI) treated with fibrinolytics. METHODS: In the FINESSE (Facilitated INtervention with Enhanced Reperfusion Speed to Stop Events) trial--a double-blind, placebo-controlled study-2,452 patients with STEMI were randomized to primary PCI or facilitated PCI with abciximab alone or with half-dose reteplase. In this prospective FINESSE substudy, centers pre-specified use of either enoxaparin (0.5 mg/kg intravenous [IV], 0.3 mg/kg subcutaneous [SC]) or UFH (40 U/kg IV, 3,000 U maximum) with PCI. A logistic-regression model and a propensity multivariate model, both adjusted for baseline variables, were used to evaluate primary safety and secondary efficacy end points for enoxaparin versus UFH. RESULTS: Enoxaparin was administered to 759 patients and UFH to 1,693 patients. Nonintracranial Thrombolysis In Myocardial Infarction (TIMI) major/minor bleeding was not significantly different, but lower nonintracranial TIMI major bleeding was found with enoxaparin (2.6% vs. UFH 4.4%, logistic-regression adjusted odds ratio [OR]: 0.55; 95% confidence interval [CI]: 0.31 to 0.99, p = 0.045), whereas intracranial hemorrhage was similar (0.27% vs. 0.24%, adjusted OR: 1.03; 95% CI: 0.11 to 9.68, p = 0.980). Lower death, myocardial infarction, urgent revascularization, or refractory ischemia through 30 days was also associated with enoxaparin (5.3%) versus UFH (8.0%, adjusted OR: 0.47, 95% CI: 0.31 to 0.72, p = 0.0005) as was all-cause mortality through 90 days (3.8% vs. 5.6%, respectively, adjusted OR: 0.59, 95% CI: 0.35 to 0.99, p = 0.046). End points evaluating the net clinical benefit also significantly favored enoxaparin over UFH. CONCLUSIONS: Enoxaparin seems to be associated with a lower risk of cardiovascular outcomes compared with UFH in patients with STEMI undergoing primary PCI. Confirmation of these findings in a randomized study is warranted. (A Study of Abciximab and Reteplase When Administered Prior to Catheterization After a Myocardial Infarction [Finesse]; NCT00046228).

Alterations of an average heart rate change heart rate variability due to mathematical reasons.

In the article, we demonstrate how the mathematical rules may bias the results of heart rate variability analysis. We also propose the way how to get rid of this problem.

Left ventricular apical rupture caused by takotsubo cardiomyopathy--comprehensive pathological heart investigation.

An 81-year-old woman with emotionally-induced takotsubo cardiomyopathy developed a fatal left ventricular (LV) apical rupture. During the hospitalization persistent ST-segment elevation with no electrocardiographic time evolution was observed on the ECG, characteristic for takotsubo cardiomyopathy. Histopathologically, transmural myocardial necrosis with hemorrhage was found at the rupture site, but there were foci of coagulation and contraction band necrosis with mononuclear lymphocyte infiltrations in other heart regions, and the intensity and distribution of these pathological changes corresponded to the distribution of the LV contraction abnormalities seen on ventriculography. The article concludes that: the LV functional disorder in takotsubo cardiomyopathy may be caused by distracted foci of coagulation and contraction band necrosis in the myocardium; contraction band necrosis (a sign of catecholamine cardiotoxicity) may reflect the sympathetic hyperactivity in this disease; persistent myocardial damage expressed by persistent ST-segment elevation without an electrocardiographic time evolution should be carefully observed with sequential echocardiographic examinations because of the possibility of cardiac rupture.

Different methods of heart rate variability analysis reveal different correlations of heart rate variability spectrum with average heart rate.

UNLABELLED: Heart rate variability (HRV) spectrum can be calculated from the R-R or the sequence of instantaneous heart rates (IHRs). Because these signals are reciprocal, their use in the determination of the correlation of HRV with average HR may yield opposite results. AIM: The aim of this study is to reveal how HRV parameters correlate with HR depending on the kind of signal used and whether the normalization procedure or use of corrected signals affect the correlations. METHODS: Electrocardiographic recordings (512 beats) of 55 patients were considered in the analysis. RR and IHRs were calculated. Both signals were divided by their average values yielding the corrected RR and IHR. Heart rate variability spectra were estimated from these 4 kinds of signals. Total power (TP), low frequency (LF) and high frequency (HF) components, LF/HF ratio, and normalized values (ie, nLF, nHF) were calculated. RESULTS: Total power and LF estimated from RR correlated negatively with HR, but those calculated from IHR revealed a trend toward a positive correlation (respective correlation coefficients significantly differed, P < .01). The sign of correlation between HF and HR was the same regardless of the type of signal applied. The application of corrected signals made the results almost identical despite different signal origins (RR or IHR). The correlations of LF/HF, nLF, and nHF with HR were similar in all cases. CONCLUSIONS: The type of signal determines the sign of correlation among TP, LF, and HR. The parameters obtained from corrected signals, normalized quantities, and LF/HF reveal a consistent relationship with HR.