ECG evaluation in patients with pacemaker and suspected acute coronary syndrome: Which score should we apply?

BACKGROUND/PURPOSE: In patients with right ventricular pacing, the ECG shows a left bundle branch block (LBBB) pattern. There are several criteria to diagnose ST-elevation myocardial infarction (STEMI) in patients with LBBB. The aim of this study was to validate and compare Sgarbossa's with two new scores - Selvester's and Smith's - in this context. METHODS: We identified pacemaker patients submitted to coronary angiography due to acute coronary syndrome. ECGs were analyzed by 2 blinded cardiologists. STEMI was defined according to angiographic and biochemical criteria. Sensitivity, specificity, positive and negative predictive values were calculated. RESULTS: Forty-three patients with ventricular pacing were included for analysis. STEMI was diagnosed in 26 patients (60%). The most sensitive score was Selvester's (38.5%; 95% CI: 20.2-59.4) while the most specific was Sgarbossa's (100%; 95% CI: 80.5-100). CONCLUSIONS: The sequential application of these scores proved to be clinically useful in the context of STEMI.

Ultrasound-guided thrombin-gelatin injection is effective for the treatment of iatrogenic femoral artery pseudoaneurysms: initial results.

OBJECTIVES: To describe the technique of ultrasound (US)-guided percutaneous thrombin-gelatin injection for the treatment of femoral artery pseudoaneurysms (FAPs). BACKGROUND: FAPs are a possible complication from percutaneous angiographic procedures. US-guided thrombin injection is currently the preferential therapeutic option, limited by a low risk of potentially catastrophic femoral thrombosis; transluminal injection of collagen is another effective and safe option, although a more invasive one; surgical repair is associated with significant comorbidity. We hypothesized that US-guided combined thrombin and gelatin injection (UG-TGI) would also be effective while minimizing the risk of limb thrombosis. METHODS: Review of the results, complications and length of hospital admission after the injection into the FAP sac of combined human-origin thrombin and bovine-origin gelatin matrix (FloSeal(®), Baxter), under direct US-guidance. RESULTS: We treated 13 patients (mean age 64 ± 9.46 years, 38% male), who developed a FAP following a percutaneous procedure: isolated coronariography in five (38%); angioplasty in four (31%); other cardiac procedures in four (31%). Immediate success was obtained in all (100%) patients, assessed by US; no allergic reactions, local infection, or embolic events occurred on 30-day follow-up. Median (interquartile range) admission time after the UG-TGI was 2 days (1.25-2.0); median time of total admission was 8 days (6.5-16.25). CONCLUSIONS: In this small study, UG-TGI for the treatment of FAP was feasible and had short-term effectiveness, without a learning curve effect. Despite the need for further experience, a trial comparing different therapies for FAP should include this procedure.

Utility of Pacemaker With Sleep Apnea Monitor to Predict Left Ventricular Overload and Acute Decompensated Heart Failure.

Pacemakers with sleep apnea monitor (SAM) provide an easy tool to assess obstructive sleep apnea over long periods of time. The link between respiratory disturbances at night and the incidence of acute decompensated heart failure (ADHF) is not well established. We aimed at (1) determining the ability of SAM pacemakers to evaluate the extent of left ventricular overload and (2) assess the impact of respiratory disturbances at night on the occurrence of ADHF over 1-year of follow-up. We conducted a single-center prospective study. Consecutive patients with SAM pacemakers were comprehensively assessed. SAM automatically computes a respiratory disturbance index (RDI, apneas/hypopneas per hour - AH/h) in the previous night and the percentage of nights with RDI >20 AH/h in the previous 6 months. Thirty-seven patients were included (79.3 ± 11.2 years, 46% males). A high RDI in the previous night and a higher %nights with increased RDI were associated with increased NT-proBNP values (p = 0.008 and p = 0.013, respectively) and were the sole predictors of increased noninvasive pulmonary capillary wedge pressures (PCWP) in the morning of assessment (p = 0.031 and p = 0.044, respectively). Receiver operating characteristic curve analysis revealed an area under the curve of 0.804 (95% confidence interval 0.656 to 0.953, p = 0.002) for %nights with RDI >20 AH/h in the prediction of high PCWP. Patients with >12.5% of nights with RDI >20AH/h tended to have more ADHF during follow-up (log-rank p = 0.067). In conclusion, a high burden of apneas/hypopneas at night is associated with elevated NT-proBNP and PCWP values and an increased risk of ADHF over 1 year. These patients might benefit from early tailored clinical management.

Pre-test probability of obstructive coronary stenosis in patients undergoing coronary CT angiography: Comparative performance of the modified diamond-Forrester algorithm versus methods incorporating cardiovascular risk factors.

BACKGROUND: Current guidelines recommend the use of the Modified Diamond-Forrester (MDF) method to assess the pre-test likelihood of obstructive coronary artery disease (CAD). We aimed to compare the performance of the MDF method with two contemporary algorithms derived from multicenter trials that additionally incorporate cardiovascular risk factors: the calculator-based 'CAD Consortium 2' method, and the integer-based CONFIRM score. METHODS: We assessed 1069 consecutive patients without known CAD undergoing coronary CT angiography (CCTA) for stable chest pain. Obstructive CAD was defined as the presence of coronary stenosis ≥50% on 64-slice dual-source CT. The three methods were assessed for calibration, discrimination, net reclassification, and changes in proposed downstream testing based upon calculated pre-test likelihoods. RESULTS: The observed prevalence of obstructive CAD was 13.8% (n=147). Overestimations of the likelihood of obstructive CAD were 140.1%, 9.8%, and 18.8%, respectively, for the MDF, CAD Consortium 2 and CONFIRM methods. The CAD Consortium 2 showed greater discriminative power than the MDF method, with a C-statistic of 0.73 vs. 0.70 (p<0.001), while the CONFIRM score did not (C-statistic 0.71, p=0.492). Reclassification of pre-test likelihood using the 'CAD Consortium 2' or CONFIRM scores resulted in a net reclassification improvement of 0.19 and 0.18, respectively, which would change the diagnostic strategy in approximately half of the patients. CONCLUSIONS: Newer risk factor-encompassing models allow for a more precise estimation of pre-test probabilities of obstructive CAD than the guideline-recommended MDF method. Adoption of these scores may improve disease prediction and change the diagnostic pathway in a significant proportion of patients.

Aortic valve replacement for severe aortic stenosis in octogenarians: patient outcomes and comparison of operative risk scores.

INTRODUCTION AND AIM: Isolated aortic valve replacement (AVR) in octogenarians is associated with increased operative risk, due to higher prevalence of associated risk factors and other comorbidities, making outcome prediction essential. We sought to analyze operative mortality and morbidity and to compare the predictive accuracy of the logistic European System for Cardiac Operative Risk Evaluation score (EuroSCORE) I, EuroSCORE II and Society of Thoracic Surgeons (STS) score in this population. METHODS: We retrospectively enrolled 106 consecutive octogenarians with symptomatic severe aortic stenosis undergoing isolated AVR in a large-volume single center between January 2003 and December 2010 and calculated surgical risk scores. RESULTS: Mean logistic EuroSCORE I, EuroSCORE II and STS score were 14.6±11, 4.4±3.1 and 4.0±2.4%, respectively. Mean operative mortality was 5.7% (six patients). Two (1.9%) patients suffered an ischemic stroke, three (2.8%) required temporary hemodialysis and five (4.7%) had a permanent pacemaker implanted. Five (4.7%) required rethoracotomy. No myocardial infarction or sternal wound infection was observed. Calibration-in-the-large showed overestimation of operative mortality with logistic EuroSCORE I (p=0.036), whereas EuroSCORE II (p=1.0) and STS (p=1.0) showed good calibration. C-statistic values were 0.877 (95% CI 0.800-0.933) for logistic EuroSCORE I, 0.792 (95% CI 0.702-0.864) for EuroSCORE II and 0.702 (95% CI 0.605-0.787) for STS, without statistically significant differences. CONCLUSIONS: These results suggest that AVR can be performed safely in selected octogenarians. EuroSCORE II and STS demonstrated superior calibration and should be the preferred tools for risk assessment, at least for this population.