Treatment and outcomes of patients with chronic lung disease and acute myocardial infarction: Insights from the nationwide AMIS plus registry.

BACKGROUND: Limited data are available on patients with chronic lung disease (CLD) presenting with acute myocardial infarction (AMI). We aimed to analyse baseline characteristics, treatment and outcome of those patients enrolled in the Swiss nationwide prospective AMIS Plus registry. METHODS: All AMI patients enrolled between January 2002 and December 2021 with data on CLD, as defined in the Charlson Comorbidity Index, were included. The primary endpoints were in-hospital mortality and major adverse cardiac and cerebrovascular events (MACCE), defined as all-cause death, reinfarction and cerebrovascular events. Baseline characteristics, in-hospital treatments and outcomes were analysed using descriptive statistics and logistic regression. RESULTS: Among 53,680 AMI patients enrolled during this time, 5.8% had CLD. Compared with patients without CLD, CLD patients presented more frequently with non-ST-elevation myocardial infarction (MI) and type 2 MI (12.8% vs. 6.5%, p < 0.001). With respect to treatment, CLD patients were less likely to receive P2Y12 inhibitors (p < 0.001) and less likely to undergo percutaneous coronary interventions (68.7% vs. 82.5%; p < 0.001). In-hospital mortality declined in AMI patients with CLD over time (from 12% in 2002 to 7.3% in 2021). Multivariable regression analysis showed that CLD was an independent predictor for MACCE (adjusted OR was 1.28 [95% CI 1.07-1.52], p = 0.006). CONCLUSION: Patients with CLD and AMI were less likely to receive evidence-based pharmacologic treatments, coronary revascularization and had a higher incidence of MACCE during their hospital stay compared to those without CLD. Over 20 years, in-hospital mortality was significantly reduced in AMI patients, especially in those with CLD.

Prognostic impact of systemic inflammatory diseases in elderly patients with congestive heart failure.

BACKGROUND AND AIMS: Inflammation is part of the pathophysiology of congestive heart failure (CHF). However, little is known about the impact of the presence of systemic inflammatory disease (SID), defined as inflammatory syndrome with constitutional symptoms and involvement of at least two organs as co-morbidity on the clinical course and prognosis of patients with CHF. METHODS AND RESULTS: This is an analysis of all 622 patients included in TIME-CHF. After an 18 months follow-up, outcomes of patients with and without SID were compared. Primary endpoint was all-cause hospitalization free survival. Secondary endpoints were overall survival and CHF hospitalization free survival. At baseline, 38 patients had history of SID (6.1%). These patients had higher N-terminal pro brain natriuretic peptide and worse renal function than patients without SID. SID was a risk factor for adverse outcome [primary endpoint: hazard ratio (HR) = 1.73 (95% confidence interval: 1.18-2.55, P = 0.005); survival: HR = 2.60 (1.49-4.55, P = 0.001); CHF hospitalization free survival: HR = 2.3 (1.45-3.65, P < 0.001)]. In multivariate models, SID remained the strongest independent risk factor for survival and CHF hospitalization free survival. CONCLUSION: In elderly patients with CHF, SID is independently accompanied with adverse outcome. Given the increasing prevalence of SID in the elderly population, these findings are clinically important for both risk stratification and patient management.

Peri-operative management of antiplatelet therapy in patients with coronary artery disease: joint position paper by members of the working group on Perioperative Haemostasis of the Society on Thrombosis and Haemostasis Research (GTH), the working group on Perioperative Coagulation of the Austrian Society for Anesthesiology, Resuscitation and Intensive Care (ÖGARI) and the Working Group Thrombosis of the European Society for Cardiology (ESC).

An increasing number of patients suffering from cardiovascular disease, especially coronary artery disease (CAD), are treated with aspirin and/or clopidogrel for the prevention of major adverse events. Unfortunately, there are no specific, widely accepted recommendations for the perioperative management of patients receiving antiplatelet therapy. Therefore, members of the Perioperative Haemostasis Group of the Society on Thrombosis and Haemostasis Research (GTH), the Perioperative Coagulation Group of the Austrian Society for Anesthesiology, Reanimation and Intensive Care (ÖGARI) and the Working Group Thrombosis of the European Society of Cardiology (ESC) have created this consensus position paper to provide clear recommendations on the perioperative use of anti-platelet agents (specifically with semi-urgent and urgent surgery), strongly supporting a multidisciplinary approach to optimize the treatment of individual patients with coronary artery disease who need major cardiac and non-cardiac surgery. With planned surgery, drug eluting stents (DES) should not be used unless surgery can be delayed for ≥12 months after DES implantation. If surgery cannot be delayed, surgical revascularisation, bare-metal stents or pure balloon angioplasty should be considered. During ongoing antiplatelet therapy, elective surgery should be delayed for the recommended duration of treatment. In patients with semi-urgent surgery, the decision to prematurely stop one or both antiplatelet agents (at least 5 days pre-operatively) has to be taken after multidisciplinary consultation, evaluating the individual thrombotic and bleeding risk. Urgently needed surgery has to take place under full antiplatelet therapy despite the increased bleeding risk. A multidisciplinary approach for optimal antithrombotic and haemostatic patient management is thus mandatory.

Role of RAS inhibition in the regulation of Cu/Zn-SOD in the cardiac and peripheral arterial beds in humans.

Inhibition of the renin-angiotensin system (RAS) improves hemodynamics and may ameliorate oxidative stress in heart failure (HF). Through activation of nicotinamide adenine dinucleotide phosphate oxidase, angiotensin II induces superoxide, which is primarily cleared by cytosolic copper-zinc superoxide dismutase (Cu/Zn-SOD). We examined the interdependency of hemodynamics and levels of Cu/Zn-SOD and oxidized low-density lipoprotein (oxLDL) in HF patients, using a randomized, double-blinded, crossover design to compare (i) the outcomes of single-agent therapy with either benazepril or valsartan alone vs. the combination thereof and (ii) the outcome of single-agent treatment with benazepril vs. single-agent treatment with valsartan. After each treatment, arterial (ART) and coronary sinus (CS) blood samples were collected. Cu/Zn-SOD and oxLDL levels were higher in CS samples than in ART samples. Furthermore, patients under combined treatment exhibited the highest CS levels of Cu/Zn-SOD, whereas there was no significant difference between the groups on either benazepril or valsartan alone. This finding suggests an augmentation of the cardiac antioxidative potential under more complete RAS inhibition. Cu/Zn-SOD and oxLDL levels correlated with measures of afterload rather than preload, which in turn suggests a beneficial effect of afterload reduction on oxidative stress in HF.

Patterns of alcohol consumption and acute myocardial infarction: a case-crossover analysis.

BACKGROUND: Alcohol consumption has been causally related to the incidence of coronary heart disease, but the role of alcohol before the event has not been explored in depth. This study tested the hypothesis that heavy drinking (binge drinking) increases the risk of subsequent acute myocardial infarctions (AMI), whereas light to moderate drinking occasions decrease the risk. METHODS: Case-crossover design of 250 incident AMI cases in Switzerland, with main hypotheses tested by conditional logistic regression. RESULTS: Alcohol consumption 12 h before the event significantly increased the risk of AMI (OR 3.1; 95% CI 1.4-6.9). Separately, the effects of moderate and binge drinking before the event on AMI were of similar size but did not reach significance. In addition, AMI patients showed more binge drinking than comparable control subjects from the Swiss general population. CONCLUSIONS: We found no evidence that alcohol consumption before the event had protective effects on AMI. Instead, alcohol consumption increased the risk.

How accurately are maximal metabolic equivalents estimated based on the treadmill workload in healthy people and asymptomatic subjects with cardiovascular risk factors?

Maximal exercise capacity expressed as metabolic equivalents (METs) is rarely directly measured (measured METs; mMETs) but estimated from maximal workload (estimated METs; eMETs). We assessed the accuracy of predicting mMETs by eMETs in asymptomatic subjects. Thirty-four healthy volunteers without cardiovascular risk factors (controls) and 90 patients with at least one risk factor underwent cardiopulmonary exercise testing using individualized treadmill ramp protocols. The equation of the American College of Sports Medicine (ACSM) was employed to calculate eMETs. Despite a close correlation between eMETs and mMETs (patients: r = 0.82, controls: r = 0.88; p < 0.001 for both), eMETs were higher than mMETs in both patients [11.7 (8.9 - 13.4) vs. 8.2 (7.0 - 10.6) METs; p < 0.001] and controls [17.0 (16.2 - 18.2) vs. 15.6 (14.2 - 17.0) METs; p < 0.001]. The absolute [2.5 (1.6 - 3.7) vs. 1.3 (0.9 - 2.1) METs; p < 0.001] and the relative [28 (19 - 47) vs. 9 (6 - 14) %; p < 0.001] difference between eMETs and mMETs was higher in patients. In patients, ratio limits of agreement of 1.33 (*/ divided by 1.40) between eMETs and mMETs were obtained, whereas the ratio limits of agreement were 1.09 (*/ divided by 1.13) in controls. The ACSM equation is associated with a significant overestimation of mMETs in young and fit subjects, which is markedly more pronounced in older and less fit subjects with cardiovascular risk factors.

How to set up and apply reference levels in fluoroscopy at a national level.

A nationwide survey was launched to investigate the use of fluoroscopy and establish national reference levels (RL) for dose-intensive procedures. The 2-year investigation covered five radiology and nine cardiology departments in public hospitals and private clinics, and focused on 12 examination types: 6 diagnostic and 6 interventional. A total of 1,000 examinations was registered. Information including the fluoroscopy time (T), the number of frames (N) and the dose-area product (DAP) was provided. The data set was used to establish the distributions of T, N and the DAP and the associated RL values. The examinations were pooled to improve the statistics. A wide variation in dose and image quality in fixed geometry was observed. As an example, the skin dose rate for abdominal examinations varied in the range of 10 to 45 mGy/min for comparable image quality. A wide variability was found for several types of examinations, mainly complex ones. DAP RLs of 210, 125, 80, 240, 440 and 110 Gy cm2 were established for lower limb and iliac angiography, cerebral angiography, coronary angiography, biliary drainage and stenting, cerebral embolization and PTCA, respectively. The RL values established are compared to the data published in the literature.

N-terminal pro-brain natriuretic peptide used for the prediction of coronary artery stenosis.

BACKGROUND: The level of the inactive N-terminal fragment of pro-brain (B-type) natriuretic peptide (NT-proBNP) is a prognostic marker in patients with acute and chronic coronary artery disease (CAD). It might also be valuable for non-invasive diagnosis of coronary artery disease. MATERIALS AND METHODS: The NT-proBNP was measured in 781 consecutive patients with normal left ventricular function referred for coronary angiography owing to symptoms or signs of CAD. The diagnostic value of NT-proBNP was assessed for predicting CAD at angiography. RESULTS: Elevated NT-proBNP levels were associated with the extent of CAD and with the female sex (P < 0.001). The ability of NT-proBNP to predict significant coronary disease at angiography was assessed separately for men using a cut-off point of 85 pg mL(-1), positive likelihood ratio 2.2 (95% CI, 1.7-3.0), negative likelihood ratio 0.53 (95% CI 0.45-0.63) and area under the receiver-operating-characteristic (ROC) curve 0.72: for women, it was assessed using a cut-off point of 165 pg mL(-1), positive likelihood ratio 2.4 (95% CI, 1.7-3.4), negative likelihood ratio 0.55 (95% CI, 0.44-0.70) and area under ROC curve 0.71. In multiple logistic-regression analysis, NT-proBNP added significant independent predictive power to other clinical variables in models predicting CAD (odds ratio 2.76, 95% CI, 1.76-4.32, P < 0.001). CONCLUSIONS: The NT-proBNP is a marker of non-obstructive CAD and of significant coronary stenosis. In conjunction with other clinical information, measurement of NT-proBNP with the use of sex-specific reference ranges may improve the non-invasive prediction of CAD.

Bland-White-Garland syndrome and atrial septal defect - rare association and diagnostic challenge.

We report on a 40-year-old woman referred for evaluation of a cardiac murmur and dyspnea on exertion. The electrocardiogram (ECG) showed incomplete right bundle branch block, and echocardiography revealed a large atrial septal defect (ASD, ostium secundum type) with dilated right-sided heart chambers. At cardiac catheterization, a large left-to-right shunt (78% of the pulmonary blood flow) was found, and surprisingly, the additional diagnosis of anomalous origin of the left coronary artery from pulmonary artery (ALCAPA) was established. After ASD closure and left coronary artery ligation with implantation of a vein graft to the left anterior descending artery, she had an uneventful 18-years follow-up. We discuss the interaction of the two associated conditions, and based on the herein reported unusual combination, we highlight typical features of non-invasive examinations including auscultation, ECG, and echocardiography in adult patients with ALCAPA.

Pregnancy-associated spontaneous coronary artery dissection: impact of medical treatment. Case report and systematic review.

We report on a 22- year-old woman with postpartum dissection of the left anterior descending artery and the intermediate branch. The patient was treated with acetylsalicylic acid (ASA), clopidogrel, and betablocker only. Coronary angiography performed 20 months later revealed complete resolution of the dissection sites. The patient's cardiovascular risk factors included mild smoking and high total cholesterol and low-density-lipoprotein-cholesterol levels, which showed a marked fall after pregnancy without pharmacological cholesterol-modifying therapy raising the question whether pregnancy-related hypercholesterolemia contributed to the pathogenesis of pregnancy-associated spontaneous coronary artery dissection (P-SCAD). In a systematic review of the literature, 16 women [median age 34 (31-36.5) years] with P-SCAD and angiographic follow-up were identified. The majority (69%) of P-SCAD cases occurred postpartum [median time after delivery: 13 (7-21) days]. In 10/16 (63%) patients medical treatment including betablocker and antiplatelet therapy was given leading to complete resolution of the dissection in 5 of them (31% of all patients) at follow-up, whereas in the other 5 patients the dissections were persisting or even progressive. Of the medically treated patients, 80% were free of symptoms suggestive for ischemia at follow-up. In 5/16 patients percutaneous coronary intervention (PCI) was performed as first-line therapy. Three patients underwent coronary artery bypass grafting, which was performed primarily in one patient, and secondarily in two patients with persisting dissections and ongoing ischemic symptoms after previous medical treatment or PCI without stenting, respectively. In conclusion, medical treatment including ASA, clopidogrel and betablocker therapy results in an excellent clinical and angiographic result in approximately one third of patients with P-SCAD.

Time course of serial cystatin C levels in comparison with serum creatinine after application of radiocontrast media.

BACKGROUND: The delayed increase of creatinine after radiocontrast application is a potential reason for overlooking radiocontrast nephrotoxicity. Cystatin C may be more useful to rapidly assess a decrease in glomerular filtration rate (GFR). We compared cystatin C and creatinine to examine their kinetics after application of radiocontrast media. PATIENTS AND METHODS: Forty-one patients (60.8 +/- 8.8 years, 68% males) with normal to subnormal GFR scheduled for coronary angiography (27% with angioplasty), were studied for serum cystatin C and creatinine levels before, 5 h, 24 h and 48 h after angiography. Furthermore, alpha1-microglobulin was checked for evidence of tubular damage. RESULTS: At 5 hours after angiography, there was no significant change compared to baseline in either serum creatinine nor cystatin C. In comparison with the value immediately before coronary angiography, the increase of cystatin C achieved a maximum at 24 h after the application of the contrast agent (+7.2%). Within 48 h, cystatin C decreased to the level before angiography. Serum creatinine increased at 24 h (+7.7%) and continued to increase at 48 h (+11.3%). CONCLUSION: Cystatin C increases earlier after radiocontrast application compared with creatinine. Therefore, cystatin C needs to be investigated as a potential early marker for nephrotoxicity, especially in the upcoming setting of short-time hospitalizations for coronary angiographies and interventions. Thus, further studies in patients with renal failure undergoing radiocontrast application are warranted to assess the usefulness of cystatin C in respect of an earlier detection of radiocontrast nephrotoxicity.

[A case of coronary vasospasm treated with stent placement]. / Diagnose und Stent-Therapie eines symptomatischen Koronarspasmus.

We report about a 49 year old woman with repeated chest pain at rest. During hyperventilation significant ST-segment elevation in leads V1-V5 appeared. Bicycle stress test did not provoke any ECG changes. Coronary angiography showed a significant stenosis of the left anterior descending coronary artery. Successful balloon angioplasty followed by stent implantation was performed. After an uneventful course of twelve months, hyperventilation could provoke neither chest pain nor ECG changes again without any antispastic medical treatment. Impact of fixed atherosclerotic lesions for the occurrence of coronary vasospasm, usefulness of hyperventilation as a non-invasive provocation test and therapy are discussed.

[Spontaneous coronary artery dissection as a rare cause of an acute coronary syndrome]. / Spontane Koronararterien-Dissektion: seltene Ursache eines akuten Koronarsyndromes.

Spontaneous coronary artery dissection is a rare cause of an acute coronary syndrome. This report describes a previously healthy woman without cardiovascular risk factors who presented with an acute anterior non-ST elevation myocardial infarction. Coronary angiography revealed an isolated longitudinal dissection in the middle part of the left anterior descending coronary artery (LAD) with normal flow of the contrast media. The patient was treated conservatively with heparin, aspirin, clopidogrel, and beta-receptor blocker. Stress exercise test was normal at discharge. After an event-free follow-up of three and a half months coronary angiography showed a completely normal LAD. Literature about epidemiology, pathogenesis, diagnosis and treatment of spontaneous coronary artery dissection is reviewed.

Symptomatic mechanical heart valve thrombosis: high morbidity and mortality despite successful treatment options.

BACKGROUND: Recommendations for treatment of mechanical prosthetic heart valve thrombosis (PVT) include systemic thrombolysis and/or reoperation. Data on complications and outcome are limited. METHODS: Clinical and echocardiographic findings of 17 patients with mechanical PVT were reviewed. Complications and outcome of surgery and/or thrombolysis were analysed. Prospective follow-up was obtained. RESULTS: Symptomatic PVT occurred 8.4 +/- 7.2 years after mechanical valve replacement at mean age 55 +/- 15 years. Thrombosis involved the mitral valve in 12 patients (71%), the aortic valve in 4 (24%) and the tricuspid valve in one (6%). The reason for PVT was inadequate anticoagulation in 11 patients (65%), endomyocardial fibrosis in 2 (12%) and unknown in 4 (24%). Prior to diagnosis, systemic emboli occurred in 6 patients (35%). Thirteen patients (76%) presented in functional class NYHA IV. Haemodynamic valve obstruction was documented by echocardiography in 15 patients (88%). Treatment included primary reoperation in 12 patients (71%), thrombolysis with urokinase in 3 (18%) (with reoperation in 1), reinstitution of adequate anticoagulation in one (6%); death occurred before treatment in one (6%). Intraoperatively, both pannus and thrombus were found in 5 of 13 patients (38%). Treatment-related emboli occurred in 5 patients (29%), to the brain in 3, to the legs in one and to a coronary artery in one. Five patients died (mortality 29%) within 30 days due to multiorgan failure/septicaemia (3 patients), congestive heart failure (1), or cerebral emboli (1). Follow-up after 28 +/- 28 months in the 12 surviving patients was unremarkable. CONCLUSIONS: The most common aetiology for obstructive PVT is thrombus formation due to inadequate anticoagulation. PVT remains a serious complication with high morbidity and mortality despite aggressive treatment by thrombolysis and/or surgery. Surgery is often needed due to the frequent presence of pannus and/or large thrombi. However, long-term prognosis after successful treatment of PVT is excellent.

Early sheath removal after coronary artery interventions with use of a suture-mediated closure device: clinical outcome and results of Doppler US evaluation.

PURPOSE: To evaluate the safety and efficacy of a suture-mediated closure device by comparing clinical outcomes of its use to those of manual compression and by using Doppler ultrasound (US) examination. MATERIALS AND METHODS: One hundred patients were randomized to treatment with either suture-mediated closure (n = 50) or manual compression (n = 50) after percutaneous transluminal coronary angioplasty (PTCA). The 50 patients randomized to receive suture-based treatment were allowed to get out of bed 4 hours after the procedure, whereas bed rest was required for 1 day in the patients treated with manual compression. All patients underwent clinical and US examination before getting out of bed and before discharge from the hospital. RESULTS: Forty-seven of 50 patients randomized to undergo suture-mediated closure were ambulatory the day of intervention, in 6.2 hours +/- 4.7 (mean +/- SE) after undergoing PTCA. The results of the US examination for these patients demonstrated the absence of bleeding complications after getting out of bed. All patients treated with use of manual compression were ambulatory the following day, 18.3 hours +/- 2.2 after undergoing PTCA. There was no difference in the occurrence of vascular complications between the two groups. CONCLUSION: Suture-based closure is a safe and effective method of achieving immediate hemostasis and shorter bed rest without increasing the risk of bleeding complications in PTCA procedures.

Left ventricular end-diastolic pressure can be estimated by either changes in transmitral inflow pattern during valsalva maneuver or analysis of pulmonary venous flow.

We directly compared the transmitral inflow pattern during preload reduction and pulmonary venous flow velocities to determine left ventricular end-diastolic pressure (LVEDP) in 78 patients who underwent left heart catheterization. Transmitral inflow indexes (A-wave duration, ratio of peak flow velocity of early diastole [E] to peak flow velocity of late diastole during atrial contraction [A] [E/A ratio]) at rest and during the Valsalva maneuver (30 mm Hg for 15 seconds) and indexes of pulmonary venous flow (velocity and duration of the atrial reversal) were obtained. Fair correlations existed between LVEDP (mean 15+/-6 mm Hg) and the percentage decrease in the E/A ratio (r = 0.72), increase in duration of A wave during the Valsalva maneuver (r = 0.60), flow velocity of atrial reversal (r = 0.58), and difference of duration of atrial flow reversal and A wave (r = 0.62) (all P<.001). While sensitivity, specificity, and diagnostic accuracy to detect an elevated LVEDP were comparable, technically adequate Doppler recordings were obtained more often for the mitral inflow during the Valsalva maneuver than for the pulmonary venous flow (72 versus 66 patients, P< 0.05).

Frequency of collateral blood flow in the infarct-related coronary artery in rupture of the ventricular septum after acute myocardial infarction.

Patients with postinfarction ventricular septal rupture have poor residual or collateral blood flow in the infarct artery and do not benefit from ischemic preconditioning. This suggests that rupture of the ventricular septum occurs on an unprotected and unprepared myocardium.

Importance of AV synchronous pacing during low intensity exercise evaluated by oxygen kinetics.

It has been shown that dual chamber pacing with preservation of AV synchrony (DDD) is superior to fixed rate ventricular (VVI) or rate responsive ventricular (VVIR) pacing modes, as evaluated by ventilatory response to exercise. Previous studies have focused on the benefits of maintained AV synchrony at maximal exercise. However, there are limited data comparing O2 kinetics in different pacing modes during low intensity exercise, representing the majority of daily activities. This study aimed to provide an evaluation of different pacing modes using O2 kinetics during low intensity exercise. Nineteen patients (age 61 +/- 18 years) with complete AV block underwent low intensity treadmill exercise (35 W) with simultaneous evaluation of symptoms and O2 kinetics in three pacing modes. The first test was performed in DDD mode followed by a second test in VVIR mode with a programmed heart rate corresponding to the sinus rate during the first test. After 6 minutes of each test, the mode was switched from DDD to VVIR and vice versa. The third test was performed in VVI mode at 70 beats/min. O2 kinetics were defined as O2 deficit (time [rest to steady state] x delta VO2-sigma VO2 [rest to steady state]) and mean response time (MRT) of oxygen consumption (O2 deficit/delta VO2). The O2 deficit was 551 +/- 134 mL in DDD pacing, 634 +/- 139 mL in VVIR pacing, and 648 +/- 179 mL in VVI pacing (P = 0.001). MRT was 49 +/- 7.8 seconds in DDD pacing, 54.7 +/- 9.5 seconds in VVIR pacing, and 57.4 +/- 11.0 seconds in VVI pacing (P = 0.002). Ten (53%) patients developed symptoms during switch from DDD to VVIR mode whereas the switch from VVIR to DDD mode was not perceived by any patient (P < 0.001). In conclusion, our study shows an impact of AV synchronous pacing and heart rate adaptation on O2 kinetics during low intensity exercise that correspond to casual daily life activities. Our observations may have clinical implications for the management of patients with complete AV block.