Multivessel approach in ST-elevation myocardial infarction: impact on in-hospital morbidity and mortality.

INTRODUCTION: Multivessel disease in ST-elevation myocardial infarction (STEMI) is associated with a worse prognosis. A multivessel approach at the time of primary percutaneous coronary intervention (PCI) is the subject of debate. OBJECTIVE: To assess the impact of a multivessel approach on in-hospital morbidity and mortality in patients with STEMI undergoing primary PCI. METHODS: We studied patients from the Portuguese Registry of Acute Coronary Syndromes with STEMI and multivessel disease who underwent primary PCI. The 257 patients were divided into two groups: those who underwent PCI of the culprit artery only and those who underwent multivessel PCI. Cardiovascular risk factors, STEMI location, in-hospital treatment, number and type of diseased and treated arteries, type of stent implanted and ejection fraction were recorded. The primary end-point was defined as in-hospital mortality and the secondary end-point as the presence of at least one of the following complications: major bleeding, need for transfusion, invasive ventilation, heart failure and reinfarction. RESULTS: Multivessel disease was found in 43.3% of the study population and a multivessel approach was adopted in 19.2% of these patients. There were no differences between the groups in cardiovascular risk factors or electrocardiographic presentation of STEMI. Patients undergoing multivessel PCI were more likely to be treated with drug-eluting stents and glycoprotein IIb/IIIa inhibitors, and less likely to receive heparin therapy. There were no differences between the groups with regard to in-hospital mortality or the incidence of complications. CONCLUSION: In our population of patients with STEMI, a multivessel approach appears to be safe and not associated with increased in-hospital mortality or morbidity.

Non-cardiac comorbidities in the very elderly with acute myocardial infarction: prevalence and influence on management and in-hospital mortality.

INTRODUCTION: Acute myocardial infarction (AMI) in the very elderly is common and is associated with increased mortality. Despite this, the majority of such patients do not receive the most effective cardiovascular therapies. The presence of non-cardiac comorbidities constitutes an additional challenge to the management of AMI in very elderly patients. OBJECTIVE: To determine the prevalence of non-cardiac comorbidities in the very elderly (age > or = 80 years) with AMI and how it influences their management and in-hospital mortality. METHODS: A total of 132 patients consecutively admitted with a diagnosis of AMI from January 2005 to December 2007 were analyzed retrospectively. Two groups were considered: patients with non-cardiac comorbidities (group 1) and those without non-cardiac comorbidities (group 2). Cardiovascular risk factors and non-cardiac comorbidities (anemia, chronic obstructive pulmonary disease, chronic renal failure, cancer, neurologic or psychiatric disorders, and prostatic hyperplasia in men) were recorded. Use of an invasive strategy and the therapy prescribed at discharge were compared between the groups. RESULTS: Non-cardiac comorbidities were found in 56.8% of patients, with the following prevalences: anemia 18.2%; chronic obstructive pulmonary disease 11.4%; chronic renal failure 25.8%; cancer 3.0%; neurologic or psychiatric disorders 11.4%; and prostatic hyperplasia 20.5%. Patients with comorbidities had longer hospital stay than those without (12.1 +/- 5.5 and 10.1 +/- 3.5 days, respectively; p = 0.014). An invasive strategy, with coronary angiography, was used in 12.1% of patients, with no differences between groups (12.3% in patients without comorbidities and 12.0% in those with, p = 0.82). At discharge, more than 70% of the patients were prescribed aspirin, statins and nitrates. With the exception of non-dihydropyridine calcium antagonists, which were more frequently prescribed in patients with comorbidities (15.9% vs. 2.2%; p = 0.04), no other differences in therapy were observed between the two groups. CONCLUSION: In our population of very elderly patients, the prevalence of non-cardiac comorbidities was high (56.8%), but this did not significantly influence the management of these patients.

Giant left atrial thrombus: an unexpected finding.

The incidence of left atrial thrombi is higher in patients with mitral valve stenosis. Its presence and location have important implications in deciding on the therapeutic approach, particularly the need for valve repair. We describe the case of a 63-year-old patient, with asymptomatic moderate mitral stenosis, hospitalized due to community-acquired pneumonia, in whom investigation to exclude pulmonary thromboembolism revealed a giant left atrial thrombus, which required urgent surgery.

Intraventricular gradients and acute coronary syndromes: a case report.

Left ventricular outflow tract obstruction (LVOTO) has traditionally been associated with hypertrophic obstructive cardiomyopathy, but can occur in other clinical scenarios such as acute myocardial infarction (AMI). In some patients, LVOTO is absent at rest, being detectable only with provocation tests such as stress echocardiography. Timely diagnosis of this phenomenon is very important, as it has therapeutic implications, and relies on clinical suspicion and on recognizing substrates in which LVOTO can occur. We report a case of syncope and AMI associated with LVOTO with systolic anterior motion of the mitral valve and a significant intraventricular gradient.