Comparison of conventional and high-sensitivity troponin in patients with chest pain: a collaborative meta-analysis.

BACKGROUND: Multiple studies have evaluated the diagnostic and prognostic performance of conventional troponin (cTn) and high-sensitivity troponin (hs-cTn). We performed a collaborative meta-analysis comparing cTn and hs-cTn for diagnosis of acute myocardial infarction (AMI) and assessment of prognosis in patients with chest pain. METHODS: MEDLINE/PubMed, Cochrane CENTRAL, and EMBASE were searched for studies assessing both cTn and hs-cTn in patients with chest pain. Study authors were contacted and many provided previously unpublished data. RESULTS: From 17 included studies, there were 8,644 patients. Compared with baseline cTn, baseline hs-cTn had significantly greater sensitivity (0.884 vs 0.749, P < .001) and negative predictive value (NPV; 0.964 vs 0.935, P < .001), whereas specificity (0.816 vs 0.938, P < .001) and positive predictive value (0.558 vs 0.759, P < .001) were significantly reduced. Based on summary receiver operating characteristic curves, test performance for the diagnosis of AMI was not significantly different between baseline cTn and hs-cTn (0.90 [95% CI 0.85-0.95] vs 0.92 [95% CI 0.90-0.94]). In a subanalysis of 6 studies that alternatively defined AMI based on hs-cTn, cTn had lower sensitivity (0.666, P < .001) and NPV (0.906, P < .001). Elevation of baseline hs-cTn, but negative baseline cTn, was associated with increased risk of death or nonfatal myocardial infarction during follow-up (P < .001) compared with both negative. CONCLUSION: High-sensitivity troponin has significantly greater early sensitivity and NPV for the diagnosis of AMI at the cost of specificity and positive predictive value, which may enable early rule in/out of AMI in patients with chest pain. Baseline hs-cTn elevation in the setting of negative cTn is also associated with increased nonfatal myocardial infarction or death during follow-up.

Patients with non-insulin depending diabetes mellitus and metabolic syndrome are suboptimal treated in Swiss primary care.

The prevalence of complicated hypertension is increasing in America and Europe. This survey was undertaken to assess the status quo of primary care management of hypertension in patients with the high-risk comorbid diseases metabolic syndrome (MetS) and/or type 2 diabetes mellitus (non-insulin depending diabetes mellitus (NIDDM)). Data of anti-hypertensive treatment of 4594 Swiss patients were collected over 1 week. We identified patients with exclusively NIDDM (N = 95), MetS (N = 168), and both (N = 768). Target blood pressure (TBP) attainment, frequency of prescribed substance-classes, and correlations to comorbidities/end-organ damages were assessed. In addition, we analyzed the prescription of unfavorable beta-blockers (BB) and high-dose diuretics (Ds). In NIDDM, Ds (61%), angiotensin receptor blockers (ARBs) (40%), and angiotensin converting enzyme inhibitors (ACEIs) (31%) were mostly prescribed, while in MetS, drugs prevalence was Ds (68%), ARBs (48%), and BB (41%). Polypharmacy in patients with MetS correlated with body mass index; older patients (>65 years) were more likely to receive dual-free combinations. TBP was attained in 25.2% of NIDDM and in 28.7% of MetS patients. In general, low-dose Ds use was more prevalent in NIDDM and MetS, however, overall, Ds were used excessively (NIDDM: 61%, MetS: 68%), especially in single-pill combination. Patients with MetS were more likely to receive ARBs, ACEIs, CCBs, and low-dose Ds than BBs and/or high-dose Ds. Physicians recognize DM and MetS as high-risk patients, but select inappropriate drugs. Because the majority of patients may have both, MetS and NIDDM, there is an unmet need to define TBP for this specific population considering the increased risk in comparison to patients with MetS or NIDDM alone.

Long-term prognosis of adult patients with isolated congenital left ventricular aneurysm or diverticulum and abnormal electrocardiogram patterns.

BACKGROUND: Congenital left ventricular aneurysm (LVA) and diverticulum (LVD) are rare cardiac anomalies frequently associated with electrocardiogram (ECG) abnormalities. The aim of this study was to evaluate the long-term prognosis in such patients. METHODS AND RESULTS: A total of 108 patients with LVA or LVD having ECG-abnormalities were assessed. The patients were classified into 2 groups according to ECG abnormalities: a distinct ECG group (8 ECG patterns known to be frequently associated with LVA/LVD); and a control group (all other ECG abnormalities). The primary endpoint was a composite of cardiac death, rhythm disturbances, syncope, embolic events, and hospitalization for cardiovascular events. Mean patient age was 64±10 years; 45 (42%) were male; median follow-up (FU) was 50 months. The primary endpoint occurred in 12/27 patients from the distinct ECG group and in 15/81 patients in the control group (44% vs. 19%; P=0.01). Cardiac event rate per year (CER) was 1.8% vs. 0.8%, respectively. There were no cardiac deaths during FU. Symptoms (arrhythmia-related symptoms, syncope, and embolic events) at time of diagnosis increased the incidence of adverse events during FU (70% vs. 28%; P=0.05; CER 2.9% vs. 1.1%). Age ≥64 years, presence of LVD, gender, and location of the anomaly did not affect the incidence of adverse events. CONCLUSIONS: The incidence of adverse events in symptomatic patients with isolated LVA or LVD and distinct abnormal ECG patterns is increased during long-term FU. None of the present patients, however, experienced cardiac death.

Low level myocardial parvovirus B19 persistence is a frequent finding in patients with heart disease but unrelated to ongoing myocardial injury.

While myocardial parvovirus B19 (B19V), aside from enteroviruses (EV) and adenoviruses (ADV), has recently been found often in patients with myocarditis and idiopathic dilated cardiomyopathy (IDC), the pathogenetic significance of B19V genomes in those patients has not yet been sufficiently elucidated. In the present study, left ventricular endomyocardial biopsies from 24 patients with left ventricular ejection fraction (LVEF) below 55% due to IDC, and tissue from the right atrial appendage of 10 control patients undergoing bypass surgery with normal LVEF (>55%) were investigated for B19V, ADV, and EV genomes by specific nested polymerase chain reaction (PCR), by real time PCR or by reverse-transcription PCR, respectively. The myocardial tissue samples from the 10 controls were analyzed each in three different virological laboratories for B19V. In the IDC group, the frequency of the myocardial virus genomes found in 54% (13/24) of the patients was as follows: B19V: 50% (12/24), EV: 8% (2/24), including one patient with B19V and EV, and ADV: 0% (0/24). For comparison, the prevalence of B19V genomes was between 30% and 60% in the control group as detected in three different laboratories, but all these control subjects were EV- and ADV-negative. The number of B19V gene copies, however, was very low and similar both in the IDC and control group. In the majority of patients myocardial B19V persistence was associated with a low virus load irrespective of the underlying heart disease so that it may be of no importance in the pathogenesis of IDC.

Tako-Tsubo-like cardiomyopathy: specific ECG findings, characterization and clinical findings in a European single center.

OBJECTIVES: A newly discovered heart syndrome mimicking acute coronary syndrome has been termed 'Tako-Tsubo cardiomyopathy' (TTC). Differentiation from acute myocardial infarction using the ECG is an important issue in clinical practice. METHODS: We retrospectively analyzed patients admitted for cardiac catheterization between September 2003 and September 2006. RESULTS: From 26,593 cardiac catheterization procedures, we identified 21 patients with suggested TTC (0.08%). Trigger mechanisms were present in 38.1%; all patients had elevated troponin levels (mean 3.9 ng/ml). Median age was 68.4 years; 90.5% were female. Hypertension was seen in 85.7% and atrial fibrillation in 19.1%. Specific ECG findings related to a TTC are: a mild elevation of the ST segment arising from the S curve of the QRS complex, where the maximum ST segment elevation at the basis of the T wave is <1.5 mm, T-wave inversion, absence of ST segment depression and a summated amplitude of the S curve in V1 plus R in V6 <1.5 mV. An intraventricular gradient was seen in 9.5%; coronary atherosclerosis was detected in 57.1%. Follow-Up Data: Mean follow-up was 13.2 months. 47.6% were free from angina or dyspnea, most of the patients received beta-blockers/ACE inhibitors (76.2%). One patient had a sudden cardiac death (4.8%), 1 patient became an implantable cardioverter-defibrillator primarily due to resuscitation. CONCLUSION: TTC is a rare syndrome mimicking acute coronary syndrome that shows a specific ECG pattern and does not appear to be an unambiguously benign disease.

Electrical performance and automatic capture characteristics of a 3.5-mm(2) passive fixation lead during 1-year follow-up.

BACKGROUND: Bipolar low polarization electrodes are recommended for a regular AutoCapture (St. Jude Medical, Inc., Sylmar, CA, USA) function in order to effectively detect the evoked response (ER) signal. The objective of this national multicenter registry was to evaluate the electrical performance and the AutoCapture characteristics of the bipolar ventricular pacing lead IsoFlex S, model 1636T or 1646T (St. Jude Medical), in combination with single- and dual-chamber pacemakers. METHODS: Ventricular pacing and sensing thresholds, lead impedance, ER amplitude, and polarization signals were measured at discharge and routine follow-up visits after 1, 3, 6, 9, and 12 months. AutoCapture activation was recommended based on the results of the ER sensitivity test. RESULTS: Of the 252 patients initially included, 109 (43%) have completed the follow-up. The mean ventricular pacing threshold was 0.43 +/- 0.19 V at discharge and 0.68 +/- 0.32 V at 12 months postimplant. The values for the ventricular sensing threshold were between 9.51 +/- 4.12 and 9.99 +/- 4.09 mV at discharge and at the 12-month follow-up. The unipolar lead impedance decreased from 533 +/- 94 to 476 +/- 73 ohms during the follow-up. The mean ER amplitude was 16.47 +/- 6.70 mV at discharge and 17.42 +/- 7.43 mV after 12 months, and the corresponding mean polarization signals were 0.59 +/- 1.00 and 0.74 +/- 1.24 mV, respectively. AutoCapture activation was recommended in at least 95% of the patients investigated over the 12-month follow-up. CONCLUSION: The bipolar ventricular pacing lead IsoFlex S 1636/1646T shows a good electrical performance and is mostly compatible with the AutoCapture algorithm.

Dizziness and near syncope due to sinus bradycardia and sinoatrial block associated with obesity and daytime tiredness. A clear indication for pacemaker implantation?

BACKGROUND: The symptomatic sick sinus syndrome presents a classic indication for the implantation of a dual-chamber pacemaker according to the current national and international guidelines. However, in cases where dizziness and near syncope due to a sinus node dysfunction are found together with clinical characteristics of a sleep apnea-hypopnea syndrome (SAHS), screening for sleep apnea would be prudent before deciding for a pacemaker. CASE STUDY: The case report presented herein describes a patient with symptomatic sinus bradycardia and second-degree SA block with a Wenckebach periodicity, in whom the primary decision to implant a pacemaker was altered in favor of treatment with nCPAP (nasal continuous positive airway pressure) because after a careful and thorough evaluation of the patient's history and symptoms, a severe mixed SAHS was diagnosed. CONCLUSION: On diagnosing SAHS with an obstructive component in patients with symptomatic bradycardia and SA block, there is no primary need for a pacemaker, but rather for implementing treatment with nCPAP. Thus, a pacemaker should only be considered in patients with intolerance or bad compliance regarding nCPAP, or in those in whom no significant reduction of bradyarrhythmia is achieved.

Studies on intragastric PCO2 at rest and during exercise as a marker of intestinal perfusion in patients with chronic heart failure.

AIMS: The aim of this study was to investigate mesenteric ischaemia by determining intragastric PCO(2) (iPCO(2)) with gastric tonometry during rest and exercise stress testing in patients with chronic heart failure (CHF). In CHF inflammatory immune activation is hypothesized to result from a chronic endotoxin challenge due to bacterial translocation of hypoperfused intestinal mucosa. METHODS AND RESULTS: In 10 patients with CHF and ten healthy controls a tonometry catheter was inserted into the stomach. IPCO(2) was measured at rest and during bicycle exercise every 5 min. At rest arterial pCO(2) (aPCO(2)), intragastric pCO(2) (iPCO(2)) and the intragastric/arterial gap did not differ between patients and controls. During low level exercise (25 W), patients showed an increase in iPCO(2) compared to resting iPCO(2), whereas controls did not show an increase in iPCO(2) (change in iPCO(2): 12+/-2% vs. 1+/-0.4%, P<0.001). In CHF, iPCO(2) during peak exercise was 25+/-3% higher than at rest, compared to controls (increase 2+/-1, P<0.0001). CONCLUSIONS: Patients with CHF already at low level exercise develop an increase in iPCO(2). This is likely to reflect hypoperfusion of the intestinal mucosa, which may contribute to the development of bacterial translocation.

Increasing complexity: which drug class to choose for treatment of hypertension in the elderly?

Treatment of hypertension in the elderly is expected to become more complex in the coming decades. Based on the current landscape of clinical trials, guideline recommendations remain inconclusive. The present review discusses the latest evidence derived from studies available in 2013 and investigates optimal blood pressure (BP) and preferred treatment substances. Three common archetypes are discussed that hamper the treatment of hypertension in the very elderly. In addition, this paper presents the current recommendations of the NICE 2011, JNC7 2013-update, ESH/ESC 2013, CHEP 2013, JNC8 and ASH/ISH guidelines for elderly patients. Advantages of the six main substance classes, namely diuretics, beta-blockers (BBs), calcium channel blockers (CCBs), angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and direct renin inhibitors (DRIs) are discussed. Medical and economic implications of drug administration in the very elderly are presented. Avoidance of treatment-related adverse effects has become increasingly relevant. Current substance classes are equally effective, with similar effects on cardiovascular outcomes. Selection of substances should therefore also be based on collateral advantages of drugs that extend beyond BP reduction. The combination of ACEIs and diuretics appears to be favorable in managing systolic/diastolic hypertension. Diuretics are a preferred and cheap combination drug, and the combination with CCBs is recommended for patients with isolated systolic hypertension. ACEIs and CCBs are favorable for patients with dementia, while CCBs and ARBs imply substantial cost savings due to high adherence.

Diagnostic accuracy of combined cardiac troponin and copeptin assessment for early rule-out of myocardial infarction: a systematic review and meta-analysis.

AIMS: This systematic review aimed to investigate the diagnostic accuracy of combined cardiac troponin (cTn) and copeptin assessment in comparison to cTn alone for early rule-out of acute myocardial infarction (AMI). METHODS: Primary studies were eligible if they evaluated diagnostic accuracy for cTn with and without copeptin in patients with symptoms suggestive of AMI. AMI was defined according to the universal definition, using detection of cTn as a marker for myocardial necrosis. Eligible studies were identified by searching electronic databases (Medline, EMBASE, Science Citation Index Expanded, CINAHL, Pascal, and Cochrane) from inception to March 2013, reviewing conference proceedings and contacting field experts and the copeptin manufacturer. RESULTS: In 15 studies totalling 8740 patients (prevalence of AMI 16%), adding copeptin improved the sensitivity of cTn assays (from 0.87 to 0.96, p=0.003) at the expense of lower specificity (from 0.84 to 0.56, p<0.001). In 12 studies providing data for 6988 patients without ST-segment elevation, the summary sensitivity and specificity estimates were 0.95 (95% CI 0.89 to 0.98) and 0.57 (95% CI 0.49 to 0.65) for the combined assessment of cTn and copeptin. When a high-sensitivity cTnT assay was used in combination with copeptin, the summary sensitivity and specificity estimates were 0.98 (95% CI 0.96 to 1.00) and 0.50 (95% CI 0.42 to 0.58). CONCLUSION: Despite substantial between-study heterogeneity, this meta-analysis demonstrates that copeptin significantly improves baseline cTn sensitivity. Management studies are needed to establish the effectiveness and safety of measuring copeptin in combination with high-sensitivity cTnT for early rule-out of AMI without serial testing.

A systematic review and collaborative meta-analysis to determine the incremental value of copeptin for rapid rule-out of acute myocardial infarction.

Multiple studies have evaluated copeptin, a surrogate for arginine vasopressin, in the diagnosis of acute myocardial infarction (AMI) with mixed results. A systematic review and collaborative meta-analysis were performed for diagnosis of AMI and assessment of prognosis in patients presenting to the emergency department with chest pain. MEDLINE/PubMed, Cochrane CENTRAL, and EMBASE were searched for studies assessing copeptin in such patients. Study investigators were contacted, and many provided previously unpublished data. Random-effects methods were used to compare the data for copeptin, troponin, and their combination. There were a total of 9,244 patients from the 14 included studies. Mean age was 62 years; 64% were men; and 18.4% were ultimately diagnosed with AMI. Patients with AMI had a higher presentation copeptin level than those without AMI (22.8 vs 8.3 pmol/L, respectively, p <0.001). Although troponin had better diagnostic accuracy than copeptin for AMI, the combination of copeptin and troponin significantly improved the sensitivity (0.905 [0.888 to 0.921] vs 0.686 [0.661 to 0.710], respectively, p <0.001) and negative predictive value (0.97 [0.964 to 0.975] vs 0.93 [0.924 to 0.936], respectively, p <0.001) compared with troponin alone. Elevation in copeptin carried a similar risk of all-cause mortality to an elevation in troponin (odds ratio 5.84 vs 6.74, respectively, p = 0.67). In conclusion, copeptin not only identifies patients at risk of all-cause mortality, but its addition to troponin improved the sensitivity and negative likelihood ratio for diagnosis of AMI compared with troponin alone. Thus, copeptin may help identify patients who may be safely discharged early from the emergency department.

Cryptogenic transient ischemic attack after nose blowing: association of huge atrial septal aneurysm with patent foramen ovale as potential cause.

Association of atrial septal aneurysm (ASA) with patent foramen ovale (PFO) is considered an important risk factor for cardioembolism frequently forwarding paradoxical embolism in patients with cryptogenic or unexplained cerebral ischemic events. We herein describe the case of a 69-year-old male patient reporting uncontrolled movements of the right arm due to a muscle weakness, slurred speech, and paresthesia in the oral region some seconds after he had blown his nose. These neurological symptoms had improved dramatically within a few minutes and were completely regressive at admission to our hospital about two hours later. On transesophageal echocardiography (TEE) a huge ASA associated with PFO was detected. Diagnosis of the large-sized ASA was also confirmed by cardiac magnetic resonance imaging. Due to the early complete recovery from his neurological symptoms, the patient was diagnosed with a transient ischemic attack (TIA). After nine days he was discharged in a good clinical condition under the treatment with oral anticoagulation. It is concluded that in cryptogenic or unexplained stroke or TIA TEE should always be performed to rule out ASA and PFO as potential sources for paradoxical embolism in those inconclusive clinical situations.

Cardiac catheterisation in nonagenarians: Single center experience.

OBJECTIVE: To explore the treatment, procedure related risks, and outcomes of patients older than 90 years of age undergoing cardiac catheterization. METHODS: We retrospectively studied 32 patients ≥ 90 years (93.0 ± 1.2 years) who underwent cardiac catheterisation in a tertiary specialist hospital (0.2% of 14,892 procedures during three years). The results were compared to a patient cohort younger than 90 years of age. RESULTS: Baseline characteristics revealed a higher prevalence of diabetes (P < 0.001), chronic obstructive pulmonary disease (P < 0.04), previous myocardial infarction (P < 0.02), and complex coronary anatomy (SYNTAX score 33 vs. 19) in nonagenarians. Patients < 90 years of age showed more hyperlipidemia (P < 0.01) and previous percutaneous coronary interventions (P < 0.015). Nonagenarians underwent coronary angiography more often for acute coronary syndrome (ACS) (P < 0.003), were presented more often in cardiogenic shock (P < 0.003), and were transferred faster to coronary angiography in cases of ACS (P < 0.0001). The observed in-hospital mortality rate (13% study group vs. 1% control group; P < 0.003) in nonagenarians was lower than the calculated rate of thrombolysis in myocardial infarction (TIMI) and global registry of acute cardiac events (GRACE) mortality and strongly influenced by the severity of clinical presentation and the presence of co-morbidities. CONCLUSION: Despite the common scepticism that cardiac catheterisation exposes patients ≥ 90 years to an unwarranted risk, our data demonstrate an acceptable incidence of complications and mortality in this group of patients.

A case of Prinzmetal angina diagnosed by Holter monitoring who survived a sudden cardiac death: Case report.

A 47-year-old female patient was admitted to our hospital after a syncope. She reported episodes of angina in previous weeks. On admission, there were no electrocardiographic changes but elevated troponin. Coronary angiogram showed minimal arteriosclerosis and normal left ventricle. Holter monitoring showed severe ST-segment changes during an anginal episode.With calcium antagonists, the patient experienced no further episodes of angina or ST changes during telemetry.Six weeks later, calcium antagonist was stopped for unknown reason. After that, the patient experienced a second prolonged syncope with cardiopulmonary resuscitation and defibrillation of ventricular fibrillation. DISCUSSION: "A variant form of angina pectoris" was first described by Myron Prinzmetal. He postulated coronary vasospasm as the underlying cause, however, after 50 years the exact pathophysiology is still not known.Patients with "variant angina" usually present with "spontaneous" attacks of typical retrosternal anginal pain during rest or normal activities, but not with physical exercise.Sudden cardiac deaths were reported in patients with Prinzmetal angina in only a few case reports. CONCLUSION: In cases of variant angina accompanied by syncope, a provocation test and an electrophysiological study should be considered.

Use of an atrial lead with very short tip-to-ring spacing avoids oversensing of far-field R-wave.

OBJECTIVE: The AVOID-FFS (Avoidance of Far-Field R-wave Sensing) study aimed to investigate whether an atrial lead with a very short tip-to-ring spacing without optimization of pacemaker settings shows equally low incidence of far-field R-wave sensing (FFS) when compared to a conventional atrial lead in combination with optimization of the programming. METHODS: Patients receiving a dual chamber pacemaker were randomly assigned to receive an atrial lead with a tip-to-ring spacing of 1.1 mm or a lead with a conventional tip-to-ring spacing of 10 mm. Postventricular atrial blanking (PVAB) was programmed to the shortest possible value of 60 ms in the study group, and to an individually determined optimized value in the control group. Atrial sensing threshold was programmed to 0.3 mV in both groups. False positive mode switch caused by FFS was evaluated at one and three months post implantation. RESULTS: A total of 204 patients (121 male; age 73±10 years) were included in the study. False positive mode switch caused by FFS was detected in one (1%) patient of the study group and two (2%) patients of the control group (p = 0.62). CONCLUSION: The use of an atrial electrode with a very short tip-to-ring spacing avoids inappropriate mode switch caused by FFS without the need for individual PVAB optimization. TRIAL REGISTRATION: ClinicalTrials.gov NCT00512915.

Combined determination of highly sensitive troponin T and copeptin for early exclusion of acute myocardial infarction: first experience in an emergency department of a general hospital.

BACKGROUND: The purpose of this observational study was to test the diagnostic performance of the Elecsys® troponin T high-sensitive system combined with copeptin measurement for early exclusion of acute myocardial infarction (MI) in clinical practice. METHODS: Troponin T high-sensitive (diagnostic cutoff: <14 pg/mL) and copeptin (diagnostic cutoff: <14 pmol/L) levels were determined at admission in addition to other routine laboratory parameters in patients with suspected acute MI presenting to the emergency department of a general hospital over a period of five months. RESULTS: Data from 142 consecutive patients (mean age 71.2 ± 13.5 years, 76 men) were analyzed. Final diagnoses were acute MI in 13 patients (nine ST elevation MI, four non-ST elevation MI, 9.2%) unstable angina pectoris in three (2.1%), cardiac symptoms not primarily associated with myocardial ischemia in 79 (55.6%), and noncardiac disease in 47 patients (33.1%). The patients with acute MI were younger and had higher troponin T high-sensitive and copeptin values than patients without acute MI. Seventeen patients had very high copeptin values (>150 pmol/L), one of whom had a level of >700 pmol/L and died of pulmonary embolism. A troponin T high-sensitive level of <14 pg/mL in combination with copeptin <14 pmol/L at initial presentation ruled out acute MI in 45 of the 142 patients (31.7%), each with a sensitivity and negative predictive value of 100%. CONCLUSION: According to this early experience, a single determination of troponin T high-sensitive and copeptin may enable early and accurate exclusion of acute MI in one third of patients, even in an emergency department of a general hospital.

Randomized comparison of pre-hospital-initiated facilitated percutaneous coronary intervention versus primary percutaneous coronary intervention in acute myocardial infarction very early after symptom onset: the LIPSIA-STEMI trial (Leipzig immediate prehospital facilitated angioplasty in ST-segment myocardial infarction).

OBJECTIVES: This multicenter trial sought to assess the merits of facilitated percutaneous coronary intervention (PCI) versus primary PCI in an ST-segment elevation myocardial infarction (STEMI) network with long transfer distances in patients presenting early after symptom onset. BACKGROUND: Facilitated PCI with fibrinolysis might be beneficial in specific high-risk STEMI situations to prevent myocardial necrosis expansion. METHODS: Patients with STEMI (<3 h after symptom onset) were randomized to either pre-hospital-initiated facilitated PCI using tenecteplase (Group A; n = 81) or primary PCI (Group B; n = 81) plus optimal antithrombotic comedication. The primary endpoint was infarct size assessed by delayed-enhancement magnetic resonance imaging. Secondary endpoints were microvascular obstruction and myocardial salvage, early ST-segment resolution, and a composite of death, repeated myocardial infarctions, and congestive heart failure within 30 days. RESULTS: The median time from symptom onset to randomization was 64 min (interquartile range [IQR]: 42 to 103 min) in Group A versus 55 min in Group B (IQR: 27 to 91 min; p = 0.26). Despite better pre-interventional TIMI (Thrombolysis In Myocardial Infarction) flow in Group A (71% vs. 35% TIMI flow grade 2 or 3; p < 0.001), the infarct size tended to be worse in Group A versus Group B (17.9% of left ventricle [IQR: 8.4% to 35.0%] vs. 13.7% [IQR: 7.5% to 24.0%]; p = 0.10). There was also a strong trend toward more early and late microvascular obstruction, (p = 0.06 and 0.09) and no difference in ST-segment resolution (p = 0.26). The combined clinical endpoint showed a trend toward higher event rates in Group A (19.8% vs. 13.6%; p = 0.13, relative risk: 0.52, 95% confidence interval: 0.23 to 1.18). CONCLUSIONS: In STEMI patients presenting early after symptom onset with relatively long transfer times, a fibrinolytic-based facilitated PCI approach with optimal antiplatelet comedication does not offer a benefit over primary PCI with respect to infarct size and tissue perfusion. ([LIPSIA-STEMI] The Leipzig Immediate Prehospital Facilitated Angioplasty in ST-Segment Myocardial Infarction; NCT00359918).

Medical treatment of patients with atrial fibrillation aged over 80 years in daily clinical practice: influence of age and CHADS(2) score.

The purpose of the present study was to evaluate clinical data and medical treatment of very elderly patients with atrial fibrillation (AF) who are under-represented in the majority of AF studies. In this retrospective study, patients over 80 years with AF admitted to the cardiology ward during a 1-year period were investigated with respect to the type of AF, clinical characteristics, and rate or rhythm control strategy. In addition, the influence of age and CHADS(2) score on antithrombotic therapy was examined. A total of 169 consecutive patients (mean+/-S.D. age: 84.7+/-4.0 years) were included in this study. Rate control medication was administered in 79% of the patients at discharge. Oral anticoagulation (OAC) was prescribed in only 27.5% of the patients with a CHADS(2) score of > or =2 for reasons of poor compliance or unfavorable clinical conditions. Moreover, patients older than 85 years received OAC less frequently than those aged between 80 and 84 years (7% vs. 36%, p<0.001). Our results indicate a real need for educational programs aimed at instructing all staff involved with this group of patients, so that the necessary pre-conditions for a maximum OAC therapy can be achieved in these very elderly AF patients.

Carvedilol inhibits platelet-derived growth factor-induced signal transduction in human cardiac fibroblasts.

In the current study, first the platelet-derived growth factor (PDGF)-induced stimulation of the PDGF-beta receptor kinase in human cardiac fibroblasts was examined, and then the possibility of counterbalancing this signal transduction by carvedilol, a beta-blocker with alpha1-blocking properties, was investigated. Human cardiac fibroblasts were cultured from myocardial biopsy samples taken from patients with idiopathic dilated cardiomyopathy. The stimulation of the PDGF-beta receptor kinase by recombinant human PDGF (BB) in the cells and the inhibitory effect of carvedilol (1, 5, 10, and 20 microM) were investigated by analyzing PDGF-induced PDGF receptor tyrosine phosphorylation using Western blotting and by measuring DNA synthesis with a colorimetric assay. In human cardiac fibroblasts, the PDGF receptor kinase could be stimulated with PDGF (100 ng/ml) and inhibited with carvedilol (5 microM). In addition, carvedilol at a concentration of 5 microM significantly decreased DNA synthesis by approximately 50%. The inhibition of PDGF-stimulated mitogenesis by carvedilol at concentrations of 10 and 20 microM was 64 or 75%, respectively. Other beta-adrenoceptor antagonists such as propranolol (10 microM) and metoprolol (10 microM) did not significantly affect the PDGF-induced beta-receptor autophosphorylation. These findings provide novel experimental support for the known beneficial clinical effects of carvedilol in the treatment of chronic heart failure associated with myocardial fibrosis.

Frequent detection of parvovirus B19 genome in the myocardium of adult patients with idiopathic dilated cardiomyopathy.

Aside from enteroviruses and other viruses, e.g., adenoviruses, which are known to be associated with idiopathic dilated cardiomyopathy (IDC), a cardiac tropism is also attributed to parvovirus B19 (PVB19). The purpose of the present study was to determine the prevalence of enterovirus, adenovirus and PVB19 genomes in the myocardium of adult patients with IDC and to analyze the significance of PVB19 with regard to the course of the disease, as compared to the other cardiotropic viruses. In 52 adult patients with IDC and 10 control patients with normal left ventricular ejection fraction (> or =55%) undergoing coronary artery bypass surgery, myocardial tissue samples were investigated for enteroviral RNA using polymerase chain reaction (PCR) and Southern blot hybridization of the PCR product. Specific nested PCR was used to assess the prevalence of adenovirus and PVB19 DNA, in addition to sequencing of the latter. The clinical and echocardiographic course of the disease was followed for a mean (+/- SD) period of 21.1+/-9.5 months. Fourteen of the 52 patients (27%) were enterovirus-positive, 2/52 (4%) patients were adenovirus-positive, 14/52 (27%) patients were PVB19-positive, 8/52 (15%) patients were enterovirus plus PVB19-positive, and in 14/52 (27%) patients no viral genomes were found. Six patients died during the follow-up period, without any significant difference between the patient groups: 1/14 (7%) in the enterovirus-positive, 0/2 (0%) in the adenovirus-positive, 2/14 (14%) in the PVB19-positive, 1/8 (12.5%) in the enterovirus plus PVB19-positive, and 2/14 (14%) in the virus-negative group. PVB19 genome was found in 4 of the 10 (40%) control patients, but no enterovirus or adenovirus genomes were detected in these patients. In conclusion, in the myocardium of patients with IDC, PVB19 is detectable as frequently as enteroviral genome. PVB19-positive patients with IDC have a rather favorable prognosis and do not differ significantly from the other virus-positive or virus-negative patient groups with respect to survival. Finally, the pathogenetic and prognostic significance of PVB19 in IDC still remains unclear.