Subject(s)
Coronary Artery Disease , Plaque, Atherosclerotic , Humans , Tomography, Optical Coherence/methods , Computed Tomography Angiography , Tomography, X-Ray Computed/methods , Coronary Artery Disease/complications , Coronary Artery Disease/diagnostic imaging , Hemorrhage/diagnostic imaging , Hemorrhage/etiology , Coronary Vessels/diagnostic imaging , Plaque, Atherosclerotic/diagnostic imaging , Coronary Angiography/methodsABSTRACT
BACKGROUND: Patients with aortic stenosis have a high prevalence of coronary artery disease, but there is little information about the association of coronary artery disease and carotid artery disease. METHODS: The study includes 317 consecutive patients with aortic stenosis, who underwent carotid and coronary angiography during the same catheterization before aortic valve replacement. RESULTS: At univariate analysis, the prevalence of coronary artery disease was associated with (1) presence of carotid artery disease (P < .001); (2) angina pectoris as presentation symptom (P < .001); (3) age more than 65 years (P < .05); and (4) hypertension (P < .05). At multivariate analysis, only carotid artery disease, angina, and age emerged as independent predictors of coronary artery disease. The combination of 2 variables (carotid artery disease, angina) allowed the identification of 4 groups, with decreasing prevalence of coronary artery disease: (1) angina+/carotid artery disease+: 85%; (2) angina-/ carotid artery disease+: 50%; (3) angina+/carotid artery disease-: 41%; (4) angina-/carotid artery disease-: 21% (P < .001). CONCLUSION: In patients with symptomatic aortic stenosis, the presence of significant carotid artery disease is a strong marker of significant coronary artery disease.
Subject(s)
Aortic Valve Stenosis/diagnostic imaging , Carotid Artery Diseases/diagnostic imaging , Coronary Angiography , Coronary Artery Disease/diagnostic imaging , Age Factors , Aged , Angina Pectoris/etiology , Aortic Valve Stenosis/complications , Aortic Valve Stenosis/epidemiology , Aortic Valve Stenosis/surgery , Carotid Artery Diseases/complications , Carotid Artery Diseases/epidemiology , Coronary Artery Disease/complications , Coronary Artery Disease/epidemiology , Female , Heart Valve Prosthesis Implantation , Humans , Hypertension/complications , Male , Middle Aged , Multivariate Analysis , Predictive Value of Tests , Prevalence , Prospective Studies , Risk Assessment , Risk FactorsABSTRACT
Drug-eluting stent (DES) implantation has reduced angiographic and clinical restenosis that actually develops in less than 10% of treated patients. DESs also tend to delay the endothelialisation process increasing the risk of stent thrombosis. Subacute stent thrombosis may complicate long-term success of coronary angioplasty; it is a sudden event and usually causes acute myocardial infarction or sudden cardiac death. Patients undergoing DES implantation should be treated with dual antiplatelet therapy for at least 3-6 months. We describe two cases presenting with ST-elevation acute myocardial infarction due to stent thrombosis that occurred late after deployment of a paclitaxel-eluting stent, after discontinuation of antiplatelet therapy. It is important, for clinical cardiologists and general practitioners, to know the potential risk of late thrombosis of DES patients and, consequently, the implications regarding management of antiplatelet therapy.
Subject(s)
Angioplasty, Balloon, Coronary , Myocardial Infarction/etiology , Paclitaxel/administration & dosage , Platelet Aggregation Inhibitors/administration & dosage , Stents/adverse effects , Thrombosis/complications , Adult , Angioplasty, Balloon, Coronary/methods , Coronary Angiography , Coronary Artery Disease/therapy , Delayed-Action Preparations/administration & dosage , Drug Administration Schedule , Humans , Male , Middle Aged , Myocardial Infarction/diagnostic imaging , Myocardial Infarction/prevention & control , Prosthesis Design , Thrombosis/diagnostic imaging , Thrombosis/etiology , Thrombosis/prevention & control , Time FactorsABSTRACT
To evaluate the existence, timing, and determinants of post-infarction left atrial remodeling, we studied a subgroup of 514 patients from the Third Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico Echo Substudy who underwent 4 serial 2-dimensional echocardiograms up to 6 months after acute myocardial infarction. This study is the first to demonstrate, in a large series of patients, the existence of early and late left atrial remodeling after low-risk acute myocardial infarction and the relation of left atrial remodeling to left ventricular remodeling.
Subject(s)
Echocardiography , Myocardial Infarction/diagnostic imaging , Myocardial Infarction/physiopathology , Postoperative Complications/diagnostic imaging , Postoperative Complications/etiology , Postoperative Complications/physiopathology , Aged , Female , Follow-Up Studies , Heart Atria/diagnostic imaging , Heart Atria/physiopathology , Heart Ventricles/diagnostic imaging , Heart Ventricles/physiopathology , Humans , Male , Middle Aged , Multivariate Analysis , Severity of Illness Index , Statistics as Topic , Stroke Volume/physiology , Ventricular Remodeling/physiologyABSTRACT
BACKGROUND: The management of patients with acute chest pain is a common and difficult challenge for clinicians. In our emergency department (ED) a systematic protocol that involves the use of the exercise test for the management of patients with chest pain of suspected cardiac origin is presently running. The aim of the present study was to evaluate the feasibility of such a test in this setting, in terms of the safety and satisfactory follow-up of these patients discharged home. METHODS: Patients with chest pain lasting < or = 24 hours, aged > 18 years, without a history of trauma or of any other evident medical cause of chest pain and without high-risk characteristics were included in the present study. These patients, defined as low-risk patients for acute coronary events on admission, were evaluated in the ED area and submitted to serial ECG and blood sampling for the determination of the creatine kinase-MB mass and troponin I serum levels on admission and at 6 and 12 hours after admission. A symptom-limited maximal exercise was performed in the patients with a negative clinical observation and typical chest pain or atypical chest pain but multiple coronary risk factors. RESULTS: In the year 2000, 1370 patients were evaluated in the ED for chest pain. In 150 (11%) an exercise test was performed. The test was positive in 24 patients (16%). The criteria for a positive test were only clinical in 3 patients, only ECG in 13 patients, and both in 8 patients. Inconclusive tests were observed in 27 patients (18%) and the test was negative in 99 patients (66%). There were no complications during the exercise test. At a median follow-up of 237 days (range 11-443 days), 11 clinical events were recorded (4 acute coronary syndromes and 7 revascularization procedures). Patients with a non-negative exercise test had a significantly shorter event-free survival (p < 0.005). CONCLUSIONS: The exercise test performed in selected patients coming to the ED with acute chest pain is safe and useful for further risk assessment.
Subject(s)
Chest Pain/diagnosis , Emergency Service, Hospital , Exercise Test , Patient Selection , Acute Disease , Aged , Chest Pain/mortality , Chest Pain/therapy , Coronary Angiography , Coronary Stenosis/diagnosis , Coronary Stenosis/mortality , Coronary Stenosis/therapy , Disease-Free Survival , Electrocardiography , Feasibility Studies , Female , Follow-Up Studies , Humans , Italy , Male , Middle Aged , Myocardial Revascularization , Patient Admission , Time Factors , Tomography, Emission-Computed , Treatment OutcomeABSTRACT
Dynamic left ventricular outflow tract (LVOT) obstruction was thought to be a hallmark of hypertrophic obstructive cardiomyopathy, especially in those cases with isolated asymmetric septal hypertrophy and systolic anterior motion (SAM) of the mitral valve. Recently, several authors described the occurrence of a dynamic LVOT obstruction during acute coronary insufficiency in ventricles without significant myocardial hypertrophy. The LVOT gradient was reported to disappear following resolution of the ischemic syndrome. Furthermore, it was reported that LVOT obstruction in the setting of acute myocardial infarction could predispose to cardiac rupture. We describe four cases with acute anterior myocardial infarction complicated with a dynamic LVOT obstruction documented by transthoracic Doppler echocardiogram. The detection of the dynamic LVOT obstruction allowed us to optimize the pharmacological treatment in each case. In spite of therapy, two of our patients worsened progressively to fatal cardiogenic shock and cardiac rupture. In conclusion, the development of a LVOT obstruction during acute anterior myocardial infarction has to be considered a serious and potentially fatal complication.
Subject(s)
Myocardial Infarction/complications , Ventricular Outflow Obstruction/etiology , Aged , Aged, 80 and over , Echocardiography, Doppler , Female , Humans , Male , Middle Aged , Myocardial Infarction/drug therapy , Ventricular Outflow Obstruction/diagnostic imaging , Ventricular Outflow Obstruction/drug therapySubject(s)
Aortic Valve Stenosis/physiopathology , Stroke Volume/physiology , Ventricular Function, Left/physiology , Adult , Aged , Aged, 80 and over , Aortic Valve Stenosis/complications , Aortic Valve Stenosis/diagnostic imaging , Blood Flow Velocity/physiology , Echocardiography, Doppler , Female , Humans , Hypertrophy, Left Ventricular/complications , Hypertrophy, Left Ventricular/diagnostic imaging , Hypertrophy, Left Ventricular/physiopathology , Italy , Male , Middle Aged , Predictive Value of Tests , Sensitivity and Specificity , Severity of Illness IndexABSTRACT
BACKGROUND: The management of patients with acute chest pain is a common and difficult challenge from the epidemiological, clinical, organizational and malpractice points of view. Our purpose was to test and implement a simple clinical protocol for the management of patients with acute chest pain and at low-risk for an acute coronary syndrome (ACS) at the time of admission to the Emergency Department (ED). METHODS: During a 5-month study period, 570 consecutive patients were admitted to the ED with acute chest pain: 224 patients were excluded owing to the presence of a clear diagnosis of an ACS or of high-risk factors. The remaining 346 were considered, at the time of admission, as being at low risk for an ACS and constituted the study group (208 males, 138 females, mean age 65 years). These 346 patients were evaluated in the ED area by means of multiple ECGs and multiple blood sampling for the creatine kinase-MB mass and troponin I serum levels at the time of admission and 6 and 12 hours later. In selected cases a treadmill stress test was requested in order to further clarify the diagnosis. RESULTS: The ECG at the time of admission was normal or nearly normal in 79% of the patients. Stress testing was performed in 79 patients (25%). Sixty-six/346 low-risk patients (19%) were admitted to the coronary care unit during ED observation: 38 patients because of positive markers, 10 because of a positive ECG, 13 because of positive markers and ECG, and 5 because of a positive stress test. Two hundred and eighty low-risk patients without evidence of acute ischemia were definitively discharged and classified as having non-ischemic chest pain. At 1 month of follow-up, 1 patient underwent coronary artery bypass grafting, 1 patient was again admitted to the ED for acute pulmonary edema, and 2 patients had acute extracardiac events. Within 1 year of follow-up 4 deaths occurred: 2 were cancer-related and 2 were sudden deaths. CONCLUSIONS: The tested strategy, based on integrated clinical, ECG and multimarker data, and on a short "test of time" period of low-risk patient observation, can allow the identification of patients having an ACS on the one hand and of those for whom a safe, rapid and early discharge is possible on the other, in a low-cost environment.
Subject(s)
Chest Pain/etiology , Clinical Protocols , Emergency Service, Hospital , Myocardial Ischemia/diagnosis , Adult , Aged , Aged, 80 and over , Creatine Kinase/blood , Creatine Kinase, MB Form , Electrocardiography/methods , Exercise Test , Female , Humans , Isoenzymes/blood , Male , Middle Aged , Myocardial Ischemia/complications , Patient Admission , Patient Discharge , Predictive Value of Tests , Prospective Studies , Time Factors , Troponin I/bloodABSTRACT
BACKGROUND: In addition to the conventional "flow-corrected" parameters (continuity equation and aortic valve resistance), new and simpler Doppler echocardiographic indexes of the severity of aortic stenosis have recently been introduced. These measures can be classified as "function-corrected" indexes (fractional shortening-velocity ratio and ejection fraction-velocity ratio) and "pressure-corrected" indexes (percent stroke work loss). Little information however is available about the diagnostic accuracy of each of these parameters in identifying patients with severe aortic stenosis in low-flow states, in which the diagnosis and clinical decision-making are more difficult and challenging. METHODS: We analyzed 161 patients with aortic stenosis (96 males, 65 females, mean age 68 +/- 9 years) and a low cardiac output (thermodilution cardiac index < or = 2.5 l/min/m2). All patients underwent both cardiac catheterization and echocardiography within 48 hours one of the other. The invasive Gorlin valve area was used as gold standard (severe aortic stenosis = Gorlin < or = 0.8 cm2). Echocardiographic indexes were assessed by an investigator who was unaware of the hemodynamic findings. RESULTS: The mean Gorlin aortic valve area was 0.7 +/- 0.3 cm2; cardiac catheterization allowed the identification of 129 patients with severe aortic stenosis and of 32 with mild-to-moderate aortic stenosis. The diagnostic accuracy of the Doppler gradient alone was low (sensitivity 55%). The best linear correlation with the Gorlin value was found using the "function-corrected" ejection fraction-velocity ratio (r = 0.85). Similarly, the best combination of sensitivity and specificity in identifying patients with severe aortic stenosis, as assessed by cardiac catheterization, was observed using the ejection fraction-velocity ratio (sensitivity 87%, specificity 88%). CONCLUSIONS: In patients with aortic stenosis and a low cardiac output, the "function-corrected" ejection fraction-velocity ratio offers the better diagnostic accuracy, as compared with the cardiac catheterization valve area calculation.
Subject(s)
Aortic Valve Stenosis/diagnostic imaging , Cardiac Output, Low/diagnostic imaging , Echocardiography, Doppler , Aged , Aortic Valve/diagnostic imaging , Aortic Valve Stenosis/complications , Aortic Valve Stenosis/diagnosis , Aortic Valve Stenosis/physiopathology , Blood Flow Velocity , Cardiac Catheterization , Cardiac Output, Low/complications , Cardiac Output, Low/diagnosis , Female , Hemodynamics , Humans , Male , Myocardial Contraction , ROC Curve , Sensitivity and SpecificityABSTRACT
Cardiac troponin T and I are highly sensitive and specific biochemical markers for the detection of myocardial damage and they are now considered the preferred markers for the diagnosis of myocardial infarction. Despite this, in some cases elevations in the serum levels of cardiac troponin T and I are not associated with a final diagnosis of cardiac necrosis. These false-positive results are to be related to different interferences in immunometric assays. We report 2 cases of false-positive troponin I results due to heterophilic antibodies. Two women admitted to the Emergency Department with acute chest pain persistently showed, in serial blood samples, elevated and constant values of troponin I serum levels. The results were confirmed as being false positives by treatment of the samples with heterophilic blocking reagent (Scantibodies Laboratory, Santee, CA, USA). Coronary artery disease was excluded at coronary angiography and at stress testing in the first case and at stress myocardial perfusion imaging in the second case. In clinical practice, in case of persistently elevated but constant values of cardiac troponin without the time interval of release characteristic of acute syndromes, it is important to bear in mind the possible occurrence of false-positive cardiac troponin results due to the presence of heterophilic antibodies.
Subject(s)
Antibodies, Heterophile/blood , Troponin I/blood , Biomarkers/blood , False Positive Reactions , Female , Humans , Middle AgedABSTRACT
The present study was designed: (1) to establish the effects of transesophageal echocardiography (TEE) on arterial oxygen saturation (SAO(2)%); (2) to verify the possible clinical consequences of this phenomenon; and (3) to study the possibility of predicting modifications of SAO(2)% by clinical or hemodynamic variables or by specific factors related to the TEE procedure. We prospectively studied 116 unselected patients, aged 61 +/- 12 years, who underwent diagnostic TEE for various clinical indications. Thirty-seven patients had mitral valve disease, 19 aortic valve disease, 14 combined mitroaortic disease, 8 congenital heart disease, and 38 other cardiovascular diseases. Eight patients were affected by chronic obstructive pulmonary disease. Ninety-seven patients were sedated by 4 +/- 2 mg of diazepam IV SAO(2)% (5-min average) (Ohmeda Biox 3700 pulse oxymeter finger probe), heart rate (HR), and blood pressure (BP) were considered during baseline transthoracic examination, after pharmacological sedation but before the introduction of the probe, and finally during TEE. Neither clinical complications nor major arrhythmias were observed. Baseline SAO(2)%, HR and BP were, respectively, 93.6 +/- 3.3%, 76 +/- 14 beats/min, and 129 +/- 20/75 +/- 10 mmHg. Pharmacological sedation did not modify SAO(2)%, HR, and BP (P > 0.1). During TEE a small but significant reduction in SAO(2)% by an average of 1.2 +/- 3.2% was observed (P < 0.005), as well as a small and significant increase in HR by an average of 3 +/- 10 beats/min (P < 0.01). BP did not change significantly (P > 0.1 for both systolic and diastolic). The changes of SAO(2)% and HR were not interrelated and were not related to the duration of the procedure and to any of the clinical and hemodynamic variables taken into consideration. TEE can induce a small but significant drop in SAO(2)% and a small increase in HR even without any clinical relevance. No clinical or hemodynamic variable or specific factors related to the TEE procedure were related to these changes.