The Comparison of Physician to Computer Interpreted Electrocardiograms on ST-elevation Myocardial Infarction Door-to-balloon Times.

OBJECTIVE: The purpose of the project was to study the impact that immediate physician electrocardiogram (ECG) interpretation would have on door-to-balloon times in ST-elevation myocardial infarction (STEMI) as compared with computer-interpreted ECGs. METHODS: This was a retrospective cohort study of 340 consecutive patients from September 2003 to December 2009 with STEMI who underwent emergent cardiac catheterization and percutaneous coronary intervention. Patients were stratified into 2 groups based on the computer-interpreted ECG interpretation: those with acute myocardial infarction identified by the computer interpretation and those not identified as acute myocardial infarction. Patients (n = 173) from September 2003 to June 2006 had their initial ECG reviewed by the triage nurse, while patients from July 2006 to December 2009 (n = 167) had their ECG reviewed by the emergency department physician within 10 minutes. Times for catheterization laboratory activation and percutaneous coronary intervention were recorded in all patients. RESULTS: Of the 340 patients with confirmed STEMI, 102 (30%) patients were not identified by computer interpretation. Comparing the prior protocol of computer ECG to physician interpretation, the latter resulted in significant improvements in median catheterization laboratory activation time {19 minutes [interquartile range (IQR): 10-37] vs. 16 minutes [IQR: 8-29]; P < 0.029} and in median door-to-balloon time [113 minutes (IQR: 86-143) vs. 85 minutes (IQR: 62-106); P < 0.001]. CONCLUSION: The computer-interpreted ECG failed to identify a significant number of patients with STEMI. The immediate review of ECGs by an emergency physician led to faster activation of the catheterization laboratory, and door-to-balloon times in patients with STEMI.

Significance of high sensitivity C-reactive protein and D-dimer in evaluating intracardiac thrombus and spontaneous echo contrast in patients referred for transesophageal echocardiography: a prospective study.

BACKGROUND: Intra-cardiac thrombus (ICT) and spontaneous echo contrast (SEC) are considered hypercoagulable and inflammatory conditions. We aimed to determine if high sensitivity C-reactive protein (CRP) and D-dimer (DD), in combination with variables of lower thrombotic risk (normal ejection fraction [NEF], sinus rhythm [NSR]), may predict the absence of ICT/SEC. METHODS AND RESULTS: Consecutive patients referred for transesophageal echocardiogram (TEE) for evaluation of cardioembolic source were prospectively enrolled. CRP and DD levels were determined at the time of TEE. 124 patients were enrolled, of whom 21 had ICT/SEC. The combination of NSR/NEF had a negative predictive value (NPV) of 98.6% for absence of ICT/SEC. The NPVs of CRP and DD were 93.6% and 85%, respectively. Adding either CRP or DD to NSR/NEF combination increased the NPV to 100%. Log CRP was significantly associated with ICT/SEC. CONCLUSIONS: The presence of NSR and NEF may defer the need for TEE for ICT/SEC evaluation. CRP association with ICT/SEC suggests that inflammation plays a role in ICT/SEC formation. Whether CRP and DD should become routine in the triage process of TEE for ICT/SEC evaluation requires further large scale prospective studies.

Safety of adenosine pharmacologic stress myocardial perfusion imaging in orthotopic cardiac transplant recipients: a single center experience of 102 transplant patients.

Denervation super-sensitivity to adenosine is well described in cardiac transplant (CT) patients particularly early after transplant. The safety and hemodynamic effects of adenosine SPECT (A-SPECT) has not been described in a large series of CT patients. Single center retrospective study of 102 CT patients undergoing A-SPECT were compared to an age-gender matched patients in a 2:1 fashion who underwent A-SPECT in the same time period. Multivariate logistic regression model were used to identify independent predictors of advanced AV block. The average time from CT to A-SPECT was 8.5 ± 4.5 years. Average age was 57 years with 80% males. In comparison to the control group, adenosine infusion was associated with a higher incidence of sinus pause (4.9% vs. 0%), 2nd (11.8% vs. 4.9%) and 3rd degree AVB (2.9% vs. 0%) in CT patients (all P < 0.05). Prior use of aspirin and baseline 1st degree AVB were significant independent predictors of adenosine induced AVB. Baseline right or left bundle branch block, beta-blockers, calcium blockers or digoxin were not associated with occurrence of AVB. Only 1.9% of A-SPECT studies were terminated due to bradyarrythmia with 1 patient requiring aminophylline. There were no significant immediate or long term adverse events in these patients. Adenosine pharmacologic stress is associated with a higher incidence of AVB and sinus pause in CT patients reflecting persistence of super sensitivity late after CT. Nevertheless these bradyarrythmias are transient without any sequelae suggesting that A-SPECT can be performed safely in CT patients.

The relationship between spontaneous echocontrast, transesophageal echocardiographic parameters, and blood hemoglobin levels.

BACKGROUND: Spontaneous echocontrast (SEC) or "smoke" is an intracavitary echocardiographic finding seen in situations of stasis or low blood flow. Increased hematocrit and fibrinogen levels have been associated with SEC in prior studies. Whether low hemoglobin (Hb) levels are an independent predictor of lower prevalence of SEC is a question that remains unanswered. METHODS: A total of 266 transesophageal echocardiographic (TEE) studies were reviewed. Hb levels within 1 month from the TEE study were used as the baseline Hb before the study (75% had Hb on the same day of the TEE study). Clinical characteristics and demographics, and all relevant TEE variables including left atrial (LA) size, LA appendage emptying velocity (LAAEV), and presence or absence of SEC, were obtained using electronic patient information system search of TEE reports. Multivariate regression analysis was performed to identify the independent predictors of SEC. RESULTS: Two groups were analyzed SEC (n = 45) or no SEC (n = 221). Only 7 patients had both LA and right atrial SEC. On univariate analysis, male sex, greater age, prior coronary artery bypass grafting, low ejection fraction (<50%), atrial fibrillation, renal failure, aortic atheroma, dilated LA, and decreased LAAEV (<40 cm/s) predicted SEC whereas low Hb levels were significantly associated with a lower prevalence of SEC (P = .01). However, after adjusting for clinical and echocardiographic variables, low Hb levels did not independently predict absence of SEC. Low LAAEV (P < .001), dilated LA (P = .001), and prior statin therapy (P = .001) were the most powerful independent predictors of SEC. CONCLUSION: A low Hb level is not associated with a lower prevalence of SEC when controlled for clinical and echocardiographic variables. Our study confirms the importance of LAAEV and dilated LA in determining presence of SEC, but also raises interesting questions of the relationship between statins and SEC that warrant further study.

Positive troponin in diabetic ketoacidosis without evident acute coronary syndrome predicts adverse cardiac events.

BACKGROUND: Elevated troponin I has been associated with increased mortality in critically ill patients without acute coronary syndrome (ACS). However, the prognostic significance of troponin elevation in patients with diabetic ketoacidosis (DKA) without evident ACS has not been studied. METHODS: Retrospective study of all patients admitted to a U.S. tertiary center between 01/98 and 12/00 with DKA and had troponin I level measured. Patients with evidence of ACS or who met the American College of Cardiology/European Society of Cardiology (ACC/ESC) definition for myocardial infarction were excluded. Baseline characteristics, cardiac evaluation and 2 year major adverse coronary event (MACE) rate were compared between patients with positive and negative troponin. RESULTS: Ninety-six patients fulfilled the inclusion criteria of this study, 26 had positive troponin. There were no differences in baseline characteristics between the two groups. After a 2 year follow-up, there was significantly increased mortality in patients with elevated troponin (50.0% versus 27.1%, hazard-ratio (HR) 2.3, 95% confidence interval (CI) 1.2-4.8, p = 0.02). Patients with elevated troponin also had significantly increased MACE rate at 2 years (50.0% versus 28.6%, HR 2.6, 95% CI 1.3-5.3, p = 0.007) driven primarily by mortality. Using Cox Proportional Hazard Analysis, elevated troponin was a predictor of increased MACE after adjusting for confounding variables. (Adjusted HR 2.3, 95% CI 1.1-4.6, p = 0.02) CONCLUSIONS: Elevated troponin I in diabetic patients admitted with DKA identifies a group at very high risk for future cardiac events and mortality. Whether cardiac risk stratification of these patients will improve long term outcome remains to be studied.

The efficacy and safety of combination glycoprotein IIbIIIa inhibitors and reduced-dose thrombolytic therapy-facilitated percutaneous coronary intervention for ST-elevation myocardial infarction: a meta-analysis of randomized clinical trials.

OBJECTIVE: We reviewed the literature and performed a meta-analysis comparing the safety and efficacy of adjunctive use of reduced-dose thrombolytics and glycoprotein (Gp) IIbIIIa inhibitors to the sole use of Gp IIbIIIa inhibitors before percutaneous coronary intervention (PCI) in patients presenting with acute ST-segment elevation myocardial infarction (STEMI). BACKGROUND: Early reperfusion in STEMI is associated with improved outcomes. The use of reduced-dose thrombolytic and Gp IIbIIIa inhibitors combination before PCI in the setting of acute STEMI remains controversial. METHODS: We performed a literature search and identified randomized trials comparing the use of combination therapy-facilitated PCI versus PCI done with Gp IIbIIIa inhibitor alone. Included studies were reviewed to determine Thrombolysis in Myocardial Infarction (TIMI)-3 flow at baseline, major bleeding, 30-day mortality, TIMI-3 flow after PCI, and 30-day reinfarction. We performed a random-effect model meta-analysis. We quantified heterogeneity between studies with I2. A value >50% represents substantial heterogeneity. RESULTS: We identified 4 clinical trials randomizing 725 patients; 424 patients were pretreated with combination therapy before PCI, and 301 patients had Gp IIbIIIa inhibitor alone during PCI. Combination therapy-facilitated PCI was associated with a 2-fold increase in TIMI-3 flow upon arrival to the catheterization laboratory compared with the sole use of upstream Gp IIbIIIa inhibitors (192/390 patients [49%] versus 60/284 [21%]; relative risk [RR], 2.2; P < .00001). However, post-PCI TIMI-3 flow was similar between the 2 groups (279/319 patients [87%] versus 188/212 [88%]; RR, 0.99; P = .85). Major bleeding events significantly increased in the combination therapy group (40/420 patients [9.5%] versus 14/299 [4.7%]; RR, 2.2; P = .007). The 30-day mortality (15/424 patients [3.5%] versus 5/301 [1.7%]; RR, 1.47; P = .46) and 30-day reinfarction rate (5/424 patients [1.1%] versus 3/301 [1.0%]; RR, 0.96; P = .96) were similar in the 2 treatment groups. CONCLUSIONS: Awaiting the results of the ongoing clinical trials, the current cumulative evidence does not support the routine use of combination of reduced-dose thrombolytic and Gp IIbIIIa inhibitor therapy-facilitated PCI for the treatment of STEMI.