[Warfarin combined with blood platelet inhibition]. / Warfarin saman med blodplatehemming.

Dual antiplatelet therapy (acetylsalicylic acid and a thienopyridine) is essential after coronary stent implantation, and in the treatment of acute coronary syndrome. Many patients also need oral anticoagulation. Unfortunately, there are no prospective randomised trials to guide therapy. Triple antithrombotic therapy with acetylsalicylic acid, clopidogrel and warfarin is most commonly used. This regimen can reduce the risk of thrombosis and thromboembolism, but is associated with an increased risk of bleeding. Measures that reduce the risk of complications are reduction of INR with careful monitoring, a short duration of triple therapy (when possible) and use of radial access and a bare metal stent.

[Acute myocardial infarction in Mid-Norway: transportation for thrombolytic treatment or primary percutaneous coronary intervention?]. / Akutt hjerteinfarkt i Midt-Norge--transport for primaer PCI-behandling eller trombolyse?

BACKGROUND: Occluded coronary arteries should be opened urgently in patients who have acute myocardial infarction and ST-elevation in ECG. When transport times are long, thrombolytic treatment is a good alternative to primary percutaneous coronary intervention (PCI). The purpose of this study was to assess choice of treatment strategy in cases where time after start of symptoms and transport time are decisive for the outcome. MATERIAL AND METHODS: A cohort study of 379 patients, who had myocardial infarction and ST-elevation, and were admitted to St. Olav's Hospital, Trondheim, Norway in the period 1.11.2007-31.1.2009. RESULTS: 268 patients (71 %) were treated with PCI, and 111 patients (29 %) with thrombolytic treatment. 173 patients (46 %) were transported by helicopter. The counties in Mid-Norway used markedly different treatment strategies for these patients. INTERPRETATION: Great regional differences were observed in the use of PCI and thrombolytic treatment in Mid-Norway.

Gated SPECT offers improved interobserver agreement compared with echocardiography.

PURPOSE: Left ventricular ejection fraction (EF) is a powerful predictor of prognosis in coronary artery disease. The purpose of the present study was to measure interobserver differences for gated SPECT (GSPECT) software and echocardiography, and to compare these modalities regarding left ventricular volumes and EF. MATERIALS AND METHODS: Eighty-four patients scheduled for nuclear imaging underwent a 1-day GSPECT with Tc-99m-tetrofosmin. Images were processed by 2 raters who calculated volumes and EF using Cedar-Sinai quantitative gated-SPECT (QGS), Emory Cardiac Toolbox (ECT), and 4D-MSPECT of the University of Michigan. Echocardiographic volumes were measured by 2 raters. Interobserver reliability was assessed by intraclass correlation coefficient (ICC). Differences in volumes and EF between echocardiography and GSPECT were compared with t-tests. RESULTS: ICC was 0.61 for echocardiography, 0.94 for QGS, 0.88 for ECT, and 0.91 for 4D-MSPECT (P < 0.0001 compared with echocardiography). For small ventricles (ESV ≤30 mL), ICC was 0.58 for echocardiography and 0.90 for QGS (P = 0.008 compared with echocardiography); 0.77 and 0.73 for ECT and 4D-MSPECT, respectively (P = ns). End-diastolic and end-systolic volumes were significantly larger with GSPECT than with echocardiography, also echocardiographic ejection fraction was significantly different from GSPECT. CONCLUSIONS: There is better interobserver reliability in GSPECT as compared with echocardiography, and QGS seems more robust in this study especially when it comes to small ventricles.

Feasibility of using tissue Doppler velocities in stress echo during upright bicycle exercise.

BACKGROUND AND AIM: There are several studies on myocardial tissue Doppler velocities during dobutamine stress, but few studies on the same parameters during bicycle exercise. We wanted to examine how sample sites affected velocities, beat-to-beat variability and segments eligible for analysis. METHODS: Twenty patients with normal coronary arteries were included in the study. Echocardiograms were obtained at rest and at peak exercise on the exercise bike and were analyzed off line by two independent raters. RESULTS AND CONCLUSIONS: Tissue velocities decreased from base to apex. Mean difference between the raters was-0.02 cm/sec at rest and 0.45 cm/sec during exercise. Peak-to-peak variability was lowest in the mitral ring during rest (10-14%) and increased at peak exercise (15-21%). The proportion of segments eligible for analysis was 84% in the septum and 67% in the anterior wall during exercise. Thus, in patients with normal coronary arteries, tissue Doppler velocities decrease from base toward the apex during bicycle exercise. Interrater agreement is reduced during exercise and beat-to-beat variability is lowest in the mitral ring.

Cardiac and psychiatric diagnoses among patients referred for chest pain and palpitations.

OBJECTIVES: The purpose of this study was to assess the prevalence of cardiac and psychiatric diagnoses in patients with chest pain and palpitations. DESIGN: Consecutive patients (n=198), aged between 18 and 65, referred to a cardiac outpatient unit for evaluation for chest pain or palpitations, were asked to participate. Patients with a previous history of heart disease, confirmed by a cardiologist, were excluded. The final sample comprised 160 patients. The cardiac evaluation comprised a bicycle stress test, myocardial scintigraphy, coronary angiography, or Holter monitoring. The psychiatric evaluation consisted of a diagnostic interview. RESULTS: The prevalence of coronary heart disease was 4%. No cases of arrhythmia in need of treatment were detected. The prevalence of psychiatric disorders, among those without coronary heart disease, was 39%: 14% panic disorder, 14% somatoform disorders, and 5% major depression. CONCLUSION: Cardiac conditions were rare, and the prevalence of panic and somatoform disorders was about three times higher than that of cardiac disease. The study illustrates the importance of having a strategy to identify psychiatric disorders in patients referred for chest pain or palpitations.

[Antithrombotic therapy after percutanous coronary intervention with stenting]. / Antitrombotisk behandling etter perkutan koronar intervensjon med stent.

BACKGROUND: Patients with stent thrombosis have a serious prognosis and a high mortality. Insufficient blood platelet inhibition may be the cause of the condition. This article reviews patients--with stents in their coronary arteries--that have had documented effects of long-term blood platelet treatment. MATERIAL AND METHODS: The article is based on literature identified through a Pubmed search and own experience. RESULTS: Premature discontinuation of acetylsalicylic acid and/or clopidogrel, and non-cardiac surgery shortly after stenting are commonly associated with stent thrombosis. Elective non-cardiac surgery should be done without discontinuation of blood platelet inhibitors when possible. It should be delayed for a minimum of 6 weeks after implantation of bare metal stents and for a minimum of 6 months after drug-eluting stents. For patients who need anticoagulation bare metal stents are preferred, and a combination of warfarin, acetylsalicylic acid and clopidogrel should be used as antithrombotic medication. CONCLUSION: It is important to provide adequate information about correct antithrombotic drug use to patients, physicians and pharmacies in order to avoid stent thrombosis and acute myocardial infarction.

[Chest pain in a woman previously treated with irradiation]. / En tidligere strålebehandlet kvinne med brystsmerter.

A 34-year-old woman developed chest pain during exercise. She had been treated for Hodgkin lymphoma with irradiation (mantle field) and cytotoxic drugs (ABVD) 15 years earlier, and had risk factors for coronary artery disease (smoker status and family history). An exercise ECG showed significant ST depressions and an echocardiogram was normal. She underwent coronary angiography, which revealed three vessel disease (including stenosis of the left main stem); bypass grafting was successfully performed. This case illustrates the fact that even young women may develop extensive coronary disease and that development of coronary artery disease may be accelerated after irradiation of the thorax.

[Acute coronary syndrome--ECG-changes without ST-elevation]. / EKG-forandringer ved akutt koronarsyndrom uten ST-elevasjon.

BACKGROUND: Patients with acute coronary syndrome without ST-segment elevation in ECG have a serious prognosis with increased risk of a new myocardial infarction and death. The prognosis depends on the artery involved. MATERIAL AND METHODS: The value of ECG at rest for detection of proximal stenosis in the left descending coronary artery (LAD) was evaluated prospectively in 138 consecutive patients with acute coronary syndrome without ST-segment elevation. RESULTS: Negative or biphasic T-wave in lead V 2-V 3 was observed in 31/138 (22%) patients. Ichemia-related stenosis in proximal LAD was found in 25/138 (18%) patients. Negative or biphasic T-wave in V 2-V 3 was observed more often in patients with ischemia-related LAD stenosis than in other patients (76% versus 11%, p < 0.01). Troponin T or clinical risk score did not identify patients with ischemia-related LAD stenosis. CONCLUSIONS: A biphasic or negative T-wave in lead V 2-V 3 can be used as a reliable method to diagnose proximal LAD stenosis in acute coronary syndrome, and should be used as a selection criterion for referral of patients to urgent coronary angiography and intervention.

Effect of the cardiac cycle on the coronary anastomosis assessed by ultrasound.

Anastomosis of the left internal mammary artery to the left anterior descending artery was performed in 9 pigs to evaluate the effect of changes in the cardiac cycle and the choice of ultrasound mode on assessment of graft morphology. The length of the anastomosis and the diameters of the left anterior descending artery at the toe and heel of the anastomosis, as well as downstream, were measured in end-systole and end-diastole with both B-mode and color Doppler imaging. None of the diameters were influenced by the cardiac cycle using either ultrasound mode. B-mode yielded larger diameters at all points except the toe of the anastomosis. It was concluded that provided the scanning is perpendicular to the vessel, the morphology of an anastomosis can be assessed without paying much attention to the phase of the cycle or the mode of ultrasound applied.

Incidence of procedural related myocardial infarction following percutaneous coronary intervention. A matter of definitions.

AIM: To define the incidence of procedural related myocardial infarction (MI) in patients undergoing elective PCI using different definitions of MI, especially focusing on the criteria proposed by the European Society of Cardiology (ESC) and the American College of Cardiology (ACC) for the definition of MI. METHODS AND RESULTS: A prospective study including 220 patients scheduled for elective PCI. To be included, preprocedural values of the following biochemical markers had to be normal; aspartate aminotransferase (AST), creatine kinase (CK) , creatinine kinase MB fraction (mass concentration) (CK-MBmass) and cardiac troponin I (cTnI).According to different definitions the incidence of procedural related MI following PCI differed from 0,9% (previous WHO definition) to 26,4% (ESC/ACC criteria). Other commonly used definitions of MI resulted in incidence rates between these values. CONCLUSIONS: Depending on definitions used the incidence of procedural MI following elective PCI may vary by a factor of 30. This makes comparison of MI rates between institutions difficult. Furthermore, outcome and conclusions in interventional studies with MI as an endpoint may differ according to definitions used for procedural MI. A clear description of the applied definition of procedural MI following PCI is mandatory. For epidemiological and other reasons a separate ICD code is proposed for MIs caused by PCI.

Blood haemoglobin is an independent predictor of B-type natriuretic peptide (BNP).

BNP (B-type natriuretic peptide) and anaemia are both associated with adverse outcome in patients with chronic heart failure. Whether low haemoglobin levels are independently predictive of elevated BNP levels in subjects without heart failure is unknown. In the present study, we examined the relationship between haemoglobin and BNP levels in 234 patients with suspected coronary heart disease without a history of chronic heart failure, adjusting for known predictors of BNP levels. By univariate analysis, haemoglobin levels were inversely related to logarithmically transformed BNP values (r = -0.30, P < 0.0001). After adjustment for patient age, gender, body mass index, history of myocardial infarction, use of diuretics, angiotensin-converting enzyme inhibitors and beta-blockers, estimated creatinine clearance rate, extent of coronary disease, left ventricular ejection fraction and left ventricular end-diastolic pressure, blood haemoglobin remained an independent predictor of plasma BNP (standardized beta-coefficient = -0.253, P < 0.0001). A similar relationship was observed between haematocrit and BNP (standardized beta-coefficient -0.215, P < 0.0001). We conclude that haemoglobin levels are independently predictive of plasma BNP levels in patients with suspected coronary heart disease without heart failure. Anaemia may contribute to elevated BNP levels in the absence of heart failure, and may represent an important confounder of the relationship between BNP, cardiac function and prognosis.

B-type natriuretic peptide and long-term survival in patients with stable coronary artery disease.

Circulating B-type natriuretic peptide (BNP) is a strong predictor of survival in patients with acute coronary syndromes and in patients with congestive heart failure. Whether circulating BNP levels are predictive of long-term survival in patients with angiographically documented, clinically stable coronary artery disease is unknown. We studied 186 patients with stable angina pectoris and angiographic evidence of significant coronary artery disease. Patients with a recent myocardial infarction, electrocardiographic evidence of ongoing ischemia, anginal pain at rest, or symptomatic congestive heart failure were excluded from the study. During a follow-up of 7.4 years, 23 patients died. By Cox proportional-hazards regression, patient age (p = 0.031), pathologic Q waves on the electrocardiogram (p = 0.037), left ventricular ejection fraction (p = 0.016), and plasma BNP (p = 0.008) were significantly associated with long-term survival. In a stepwise forward multivariate model, BNP (p = 0.005) provided prognostic information above and beyond conventional risk markers. In patients with clinically stable, angiographically documented coronary artery disease, plasma BNP levels are independently related to long-term survival.

[Angioplasty or fibrinolytic therapy in acute myocardial infarction with ST elevation?]. / Angioplastikk eller fibrinolytisk behandling ved akutt hjarteinfarkt med ST-elevasjon?

Early and complete opening of the thrombotic occluded coronary artery is the best treatment of acute myocardial infarction with ST-segment elevation in ECG. Mechanical reperfusion with coronary angioplasty and pharmacological opening with fibrinolytic drugs are alternative therapies. Primary coronary angioplasty is the best therapy in hospitals with the necessary facilities, giving lower mortality, less reinfarction and stroke. Patients with transport time of less than 90 minutes should be treated with angioplasty. Patients in need of longer transport should have fibrinolytic therapy in their local hospital. The patient should be given analgesics and acetylsalicylic acid before transport to hospital. The value of prehospital fibrinolytic therapy and the use of glucoprotein IIb/IIIa receptor inhibitors before transport are disputed. After failed fibrinolytic treatment, rescue angioplasty can be done with good outcomes.

Coronary aneurysm after implantation of a paclitaxel-eluting stent.

Formation of coronary aneurysm is a rare complication of stenting with bare metal stents, but based on experimental studies drug-eluting stents may induce toxic effects on the vessel wall with incomplete stent apposition, aneurysm formation and with the potential of stent thrombosis or vessel rupture. We present a 43-year-old man who developed a coronary aneurysm in the right coronary artery 6 months after receiving a paclitaxel-eluting stent. The patient was asymptomatic and the aneurysm was detected in a routine control. Angiography and intracoronary ultrasound demonstrated lack of contact between stent and vessel wall in a 15-mm long segment with maximal aneurysm diameter of 6.0 mm. The patient was successfully treated with a graft stent.