Transmural myocardial infarction with de Winter's sign on ECG. / Transmuralt hjerteinfarkt med de Winters tegn i EKG.

BACKGROUND: De Winter's sign represents a constellation of ECG changes including upward sloping ST depressions greater than 1 mm at the J-point, which end in tall, symmetrical T waves in the precordial leads and reciprocal ST elevation in aVR. The pattern is considered specific for acute occlusion of the LAD. CASE PRESENTATION: A previously healthy man in his forties was referred from urgent care with suspected non-ST-elevation myocardial infarction (NSTEMI) which presented with acute chest pain, ECG with ST depressions and positive troponin-T. Repeat ECG at the local hospital showed further changes, leading to echocardiogram which revealed pronounced cardiac hypokinesia both in the septum and apex. The patient was transferred to the closest interventional cardiology centre and underwent successful PCI. ECG findings were later interpreted as consistent with de Winter's sign. INTERPRETATION: This case illustrates the importance of recognising other ECG changes in addition to ST elevation as indicative of acute reperfusion therapy.

Gated SPECT offers improved interobserver agreement compared with echocardiography.

PURPOSE: Left ventricular ejection fraction (EF) is a powerful predictor of prognosis in coronary artery disease. The purpose of the present study was to measure interobserver differences for gated SPECT (GSPECT) software and echocardiography, and to compare these modalities regarding left ventricular volumes and EF. MATERIALS AND METHODS: Eighty-four patients scheduled for nuclear imaging underwent a 1-day GSPECT with Tc-99m-tetrofosmin. Images were processed by 2 raters who calculated volumes and EF using Cedar-Sinai quantitative gated-SPECT (QGS), Emory Cardiac Toolbox (ECT), and 4D-MSPECT of the University of Michigan. Echocardiographic volumes were measured by 2 raters. Interobserver reliability was assessed by intraclass correlation coefficient (ICC). Differences in volumes and EF between echocardiography and GSPECT were compared with t-tests. RESULTS: ICC was 0.61 for echocardiography, 0.94 for QGS, 0.88 for ECT, and 0.91 for 4D-MSPECT (P < 0.0001 compared with echocardiography). For small ventricles (ESV ≤30 mL), ICC was 0.58 for echocardiography and 0.90 for QGS (P = 0.008 compared with echocardiography); 0.77 and 0.73 for ECT and 4D-MSPECT, respectively (P = ns). End-diastolic and end-systolic volumes were significantly larger with GSPECT than with echocardiography, also echocardiographic ejection fraction was significantly different from GSPECT. CONCLUSIONS: There is better interobserver reliability in GSPECT as compared with echocardiography, and QGS seems more robust in this study especially when it comes to small ventricles.

Feasibility of using tissue Doppler velocities in stress echo during upright bicycle exercise.

BACKGROUND AND AIM: There are several studies on myocardial tissue Doppler velocities during dobutamine stress, but few studies on the same parameters during bicycle exercise. We wanted to examine how sample sites affected velocities, beat-to-beat variability and segments eligible for analysis. METHODS: Twenty patients with normal coronary arteries were included in the study. Echocardiograms were obtained at rest and at peak exercise on the exercise bike and were analyzed off line by two independent raters. RESULTS AND CONCLUSIONS: Tissue velocities decreased from base to apex. Mean difference between the raters was-0.02 cm/sec at rest and 0.45 cm/sec during exercise. Peak-to-peak variability was lowest in the mitral ring during rest (10-14%) and increased at peak exercise (15-21%). The proportion of segments eligible for analysis was 84% in the septum and 67% in the anterior wall during exercise. Thus, in patients with normal coronary arteries, tissue Doppler velocities decrease from base toward the apex during bicycle exercise. Interrater agreement is reduced during exercise and beat-to-beat variability is lowest in the mitral ring.

[Chest pain in a woman previously treated with irradiation]. / En tidligere strålebehandlet kvinne med brystsmerter.

A 34-year-old woman developed chest pain during exercise. She had been treated for Hodgkin lymphoma with irradiation (mantle field) and cytotoxic drugs (ABVD) 15 years earlier, and had risk factors for coronary artery disease (smoker status and family history). An exercise ECG showed significant ST depressions and an echocardiogram was normal. She underwent coronary angiography, which revealed three vessel disease (including stenosis of the left main stem); bypass grafting was successfully performed. This case illustrates the fact that even young women may develop extensive coronary disease and that development of coronary artery disease may be accelerated after irradiation of the thorax.

[Acute myocardial infarction in Bodø over a period of 15 years]. / Akutt hjerteinfarkt i Bodø gjennom 15 år.

BACKGROUND: Studies show that both incidence and mortality in acute myocardial infarction are declining. It was expected that introduction of the troponin biomarkers in 2000 would lead to an increase in the number of diagnosed myocardial infarctions. We aimed at establishing how introduction of troponin and the fact that elderly comprise an increasing part of the population with an inherent increased risk for myocardial infarction, affected myocardial infarctions in our region with respect to incidence, age distribution and mortality. MATERIAL AND METHODS: All patients admitted to our hospital with a diagnosis of acute myocardial infarction (ICD 9 and 10) from 1990 to 2005 were included in the study. Data were imported from our electronic journal system with a database tool (Qlikview). Information about the incidence of myocardial infarction in all of Norway was taken from The Norwegian Inpatient Registry and population data were taken from Statistics Norway. Data were transferred from Qlikview to Excel and SPSS for statistical analysis. RESULTS: The incidence of myocardial infarction varied from year to year in our hospital area; it increased from 2000, but then decreased during the last two years. The proportion of patients aged 80 and older increased from 13 to 36% (p < 0.0001) in our hospital during the 15 years. One-year mortality declined for the following age groups from 1990 to 2004; 0-59 years (p = 0.0005), 60-69 years (p = 0.009) and 70-79 years (p = 0.003). This decline was not seen in the age group of 80 years and older (p = 0.66). In 2003, one-year mortality in these four age groups was 3, 15, 23 and 45% respectively. INTERPRETATION: The incidence of myocardial infarction increased in our hospital after the introduction of troponin in 2000; but decreased the last two years of the study in our area, but not in Norway in general. The proportion of patients from 80 years and older increased more than what the general increase in the population would warrant. Mortality decreased in all age groups over the 15-year period, except for those aged 80 years and older.

Anti-inflammatory effect of cardiac resynchronization therapy.

BACKGROUND: Congestive heart failure (CHF) is associated with persistent immune activation. Medical therapy has been shown to exert only limited anti-inflammatory effects. Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in a subset of patients with heart failure, but it is not known whether this treatment affects the immune system as well. To test this hypothesis, eight patients with heart failure scheduled for CRT were investigated for immune activation before and 6 months after CRT treatment. METHODS AND RESULTS: After 6 months, all patients had improved in NYHA-class and LVEF, and there was a statistically significant reduction in serum N-terminal pro brain natriuretic peptide (BNP). Furthermore, there was a statistically significant reduction in plasma levels of the chemokines monocyte chemoattractant protein 1 (MCP-1) and interleukin 8 (IL-8) and the cytokine interleukin 6 (IL-6). We observed no changes in the levels of interleukin 1beta (IL-1beta), tumor necrosis factor alpha (TNF-alpha), interleukin 10 (IL-10), or complement activation products. There was a significant correlation between changes in BNP and IL-6 (r = 0.74, P = 0.037). CONCLUSION: Although based upon a limited number of patients, this report indicates that CRT reduces peripheral markers of immune activation in patients with CHF. Further large scale studies are warranted to verify these findings.

Pericardial effusion in a patient with lymphangioleiomyomatosis.

A 60-y-old woman with known lymphangioleiomyomatosis presented with a pericardial effusion. Chylous fluid was drained by pericardiocentesis, and EBV was demonstrated in the pericardial effusion. Treatment with a systemic antiviral agent removed the virus from the effusion. The effusion itself was treated surgically.