Acute impact of right ventricular infarction on early hemodynamic course after inferior myocardial infarction.

BACKGROUND: Right ventricular myocardial infarction (RVMI) is the major cause of hypotension and/or shock (HpS) after acute inferior myocardial infarction (inferior AMI). It is, however, unclear how RVMI affects the acute hemodynamic course. METHODS AND RESULTS: In the present study, 153 patients with inferior AMI caused by right coronary artery occlusion were examined. Associations between in-hospital outcome and HpS before admission (preER-HpS) or HpS after admission (postER-HpS) were assessed using multivariate logistic regression analysis. Multivariate analysis was also conducted to determine a predictor for postER-HpS, including clinical findings in the emergency room as independent variables. HpS developed in 48.4% of patients with inferior AMI. Patients with RVMI more frequently had HpS than their counterparts in the first 6 h after infarction onset. RVMI was, however, not associated with preER-HpS, but was independently with postER-HpS (odds ratio (OR): 10.1; 4.0-27.7), whereas left ventricular failure was associated with preER-HpS, but not with postER-HpS. Furthermore, RVMI (OR: 9.4; 3.6-27.1) identified at presentation predicted postER-HpS. CONCLUSIONS: Independent of concomitant left ventricular involvement, RVMI was significantly associated with postER-HpS, but not with preER-HpS. These findings highlight the importance of identifying RVMI immediately after admission in the setting of inferior AMI. (Circ J 2010; 74: 148 - 155).

Primary stenting for left-main shock syndrome.

AIMS: Acute myocardial infarction (AMI) complicated by unprotected left-main shock (LMS) remains a highly morbid event among acute coronary syndromes. Whether early percutaneous coronary intervention (PCI) in the stent era improves the clinical outcome remains poorly defined. METHOD AND RESULTS: 25 consecutive patients who presented with LMS were treated by primary stenting of bare metal stents for the unprotected left main lesion with an aid of conventional supportive measures. Mean age of the patients was 67 (range, 46-89), 84% were male, with an initial mean systolic BP of 88mmHg (range, 40-120), HR of 82 bpm (range, 38-130), and symptom onset to reperfusion of 4.8hours (range, 1.5-17). An initial TIMI grade 0 flow was noted on the emergent CAG among 56% of the patients, but after PTCA and stenting, TIMI grade 3 flow was obtained among 84%. 30-day mortality was 32%, while one patient underwent emergent CABG for subacute stent thrombosis and 3 patients required elective CABG for residual disease during admission. Among 11 patients who were discharged alive, one required further institutionalization for ischemic brain injury, and the 2 required target vessel revascularization for restenoses. The major adverse cardiac events (death, re-infarction, stroke, and target vessel revascularization) occurred in 68% (17/25) over a 12-month follow-up, including 40% of mortality. CONCLUSIONS: AMI complicated by unprotected LMS could be treated effectively with a prompt application of stenting and result in an acceptable mortality and morbidity.

Beta-blockers are effective in congestive heart failure patients with atrial fibrillation.

BACKGROUND: It is controversial whether or not beta-blockers are effective in patients with congestive heart failure (CHF) who are complicated by persistent atrial fibrillation (AF). METHODS: We attempted to determine the potential differences in the efficacy between atrial fibrillation and sinus rhythm in 70 CHF patients with NYHA class II-IV and radionuclide ejection fraction (LVEF) <40% who received metoprolol or carvedilol over 16 weeks. RESULTS: Left ventricular end-diastolic dimension was decreased in AF group (n=24) 4 weeks (early) and 16 to 48 weeks (late) after introduction of beta-blockers (P<.05, P<.001), but not in the sinus rhythm (NSR) group (n=46). End-systolic dimension was decreased in both the AF group (P<.01, P<.0001) and the NSR group (P<.01, P<.0001). LVEF was increased in both the AF group (P<.0005, P<.0001) and the NSR group (P<.0001, P<.0001) early and late after the therapy. Increase in LVEF by the therapy tended to be higher in the AF group than in the NSR group (P=.056). Plasma brain natriuretic peptide level did not change significantly throughout the observation period, although the level tended to be lowered in the AF group late after introduction of beta-blockers (P=.093). CONCLUSIONS: Because beta-blockers are effective in both NSR and AF patients with CHF, such a mode of therapy should be recommended in patients with AF.