Primary percutaneous coronary intervention and mild induced hypothermia in comatose survivors of ventricular fibrillation with ST-elevation acute myocardial infarction.

Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for ST-elevation acute myocardial infarction (STEMI). In comatose survivors of cardiac arrest, mild induced hypothermia (MIH) improves neurological recovery. In the present study, we investigated feasibility and safety of combining primary PCI and MIH in comatose survivors of ventricular fibrillation with signs of STEMI after reestablishment of spontaneous circulation. Forty consecutive patients undergoing primary PCI and MIH from November 1, 2003 to December 31, 2005 were compared to 32 consecutive patients who underwent primary PCI but no MIH between January 1, 2000 and November 1, 2003. There were no significant differences between the MIH and no MIH groups in general characteristics, cardiac arrest circumstances and angiographic features. Except for decreases in heart rate during hypothermia interval, there was no difference between the MIH and no MIH groups in arterial pressure, peak arterial lactate (5.1 mmol/l versus 5.7 mmol/l; p = .56), need for vasopressors (65% versus 53%; p = .44), inotropes (48% versus 59%; p = .44), aortic balloon counterpulsation (20% versus 22%; p = .92), repeat cardioversion/defibrillation (30% versus 34%; p=.89) and use of antiarrhythmics (33% versus 53%; p = .13). There was also no difference in inspired oxygen requirements during mechanical ventilation and in renal function. Hospital survival with cerebral performance category 1 and 2 was significantly better in MIH group (55% versus 16%; p=.001). Our preliminary experience indicates that primary PCI and MIH are feasible and may be combined safely in comatose survivors of ventricular fibrillation with signs of STEMI. Such a strategy may improve survival with good neurological recovery.

Case report: fatal poisoning with Colchicum autumnale.

INTRODUCTION: Colchicum autumnale, commonly known as the autumn crocus, contains alkaloid colchicine with antimitotic properties. CASE REPORT: A 76-year-old man with a history of alcoholic liver disease and renal insufficiency, who mistakenly ingested Colchicum autumnale instead of wild garlic (Aliium ursinum), presented with nausea, vomiting and diarrhea 12 hours after ingestion. On admission the patient had laboratory signs of dehydration. On the second day the patient became somnolent and developed respiratory insufficiency. The echocardiogram showed heart dilatation with diffuse hypokinesia with positive troponin I. The respiratory insufficiency was further deteriorated by pneumonia, confirmed by chest X-ray and later on by autopsy. Laboratory tests also revealed rhabdomyolysis, coagulopathy and deterioration of renal function and hepatic function. The toxicological analysis disclosed colchicine in the patient's urine (6 microgram/l) and serum (9 microgram/l) on the second day. Therapy was supportive with hydration, vasopressors, mechanical ventilation and antibiotics. On the third day the patient died due to asystolic cardiac arrest. DISCUSSION AND CONCLUSION: Colchicine poisoning should be considered in patients with gastroenterocolitis after a meal of wild plants. Management includes only intensive support therapy. A more severe clinical presentation should be expected in patients with pre-existing liver and renal diseases. The main reasons for death are cardiovascular collapse, respiratory failure and leukopenia with infection.

Blood pressure and heart rate during an episode of unstable angina as predictors of in-hospital outcome.

PURPOSE: Risk stratification in patients with unstable angina remains a challenging task. Troponins, electrocardiographic changes and clinical characteristics are the most widely employed parameters. Blood pressure and heart rate are proven predictors of short-term outcome; no study, however, has investigated the dynamics of these variables. We postulated that measurements of these parameters performed at the beginning of an ischemic episode would reflect the extent of coronary disease and would predict short-term outcome. METHODS: Analysis of variance and multivariate logistic regression were used to analyze the relationship of systolic blood pressure and heart rate during ischemic episodes with the occurrence of adverse ischemic events (death, infarction, need for revascularization) prior to hospital discharge. RESULTS: In a group of 193 patients mortality rate was 4.2%, infarction rate 8.4% and revascularization rate 42.4%. Systolic blood pressure increased during ischemic episodes compared to baseline values in the group of survivors (p < 0.0001), while there were no significant changes in the group of non-survivors. The rise in heart rate during ischemic episodes was greater in non-survivors, even though significant changes were observed in both groups. Systolic pressure and heart rate were independent predictors of mortality (p = 0.01 and p = 0.003, respectively), but were not predictive of infarction or revascularization. CONCLUSION: Low systolic blood pressure and high heart rate at the beginning of an ischemic episode predict higher in-hospital mortality in patients with unstable angina. Clinical presentation during the ischemic episode should be considered in risk stratification.