Slipping while counting: gaze-gait interactions during perturbed walking under dual-task conditions.

Walking is a complex task. To prevent falls and injuries, gait needs to constantly adjust to the environment. This requires information from various sensory systems; in turn, moving through the environment continuously changes available sensory information. Visual information is available from a distance, and therefore most critical when negotiating difficult terrain. To effectively sample visual information, humans adjust their gaze to the terrain or-in laboratory settings-when facing motor perturbations. During activities of daily living, however, only a fraction of sensory and cognitive resources can be devoted to ensuring safe gait. How do humans deal with challenging walking conditions when they face high cognitive load? Young, healthy participants (N = 24) walked on a treadmill through a virtual, but naturalistic environment. Occasionally, their gait was experimentally perturbed, inducing slipping. We varied cognitive load by asking participants in some blocks to count backward in steps of seven; orthogonally, we varied whether visual cues indicated upcoming perturbations. We replicated earlier findings on how humans adjust their gaze and their gait rapidly and flexibly on various time scales: eye and head movements responded in a partially compensatory pattern and visual cues mostly affected eye movements. Interestingly, the cognitive task affected mainly head orientation. During the cognitive task, we found no clear signs of a less stable gait or of a cautious gait mode, but evidence that participants adapted their gait less to the perturbations than without secondary task. In sum, cognitive load affects head orientation and impairs the ability to adjust to gait perturbations.

Levosimendan in acute heart failure following primary percutaneous coronary intervention-treated acute ST-elevation myocardial infarction. Results from the LEAF trial: a randomized, placebo-controlled study.

AIMS: The calcium sensitizer levosimendan may counteract stunning after reperfusion of ischaemic myocardium, but no randomized placebo-controlled trials exist regarding its use in PCI-treated ST-segment elevation infarction (STEMI). We evaluated the efficacy and safety of levosimendan in patients with a primary PCI-treated STEMI complicated by symptomatic heart failure (HF). METHODS AND RESULTS: A total of 61 patients developing clinical signs of HF within 48 h after a primary PCI-treated STEMI (including cardiogenic shock) were randomized double-blind to a 25 h infusion of levosimendan or placebo. The primary endpoint was change in wall motion score index (WMSI) from baseline to day 5 measured by echocardiography. There was a significantly larger improvement in WMSI from baseline to day 5 in the levosimendan group compared with placebo (from 1.94 ± 0.20 to 1.66 ± 0.31 vs. 1.99 ± 0.22 to 1.83 ± 0.26, respectively, P = 0.031). There were significantly more episodes of hypotension during study drug infusion in the levosimendan group (67% vs. 36%, P = 0.029), but no significant difference in blood pressure at the end of infusion or in use of vasopressors. No significant between-group differences in changes in NT-proBNP levels, clinical composite score, frequency of atrial fibrillation or ventricular arrhythmia, infarct size at 6 weeks, or new clinical events up to 6 months were found. One and four patients died in the levosimendan and placebo group, respectively. CONCLUSIONS: Levosimendan treatment improved contractility in post-ischaemic myocardium in patients with PCI-treated STEMI complicated by HF. The treatment was well tolerated, without any increase in arrhythmias.

The career expectations of medical students: findings of a nationwide survey in Germany.

BACKGROUND: Demographic change, technical progress, and changing patterns of service use influence the future demand for physicians in the German health care system. The attitudes of medical students towards their later work in the health system is important for current health care planning. For that reason a nationwide survey aimed to identify major trends in preferred specialty, workplace characteristics (regional location, hospital) and perceived hindrances for clinical work. METHODS: A questionnaire consisting of 34 closed questions was developed at the University of Mainz in 2009 and administered over the Internet in June and July 2010 to all medical students in Germany. The questions addressed the students' intentions regarding specialty training, location of practice, workload, and regional preference, as well as potential reasons why they might choose not to practice clinical medicine in the future. RESULTS: 12 518 web-based questionnaires were filled in (approx. 15.7% of all medical students in Germany in 2010). The mean age was 24.9 years, with 64% female and 36% male. Favored specialties were internal medicine (42.6%), family medicine (29.6%), pediatrics (27.0%) and surgery (26.8%). Nearly all respondents (96%) stated that they attached importance to compatibility of work and family life. Working in a salaried position (92.2%) was preferred to working in private practice (77.7%). General practice, in particular in rural locations, was significantly less favored than work as a specialist in cities. CONCLUSION: Although the coming generation of physicians anticipate working in clincial settings in the future, shortfalls in the areas of primary care and in rural locations are likely if medical students adhere to their preferences stated in the questionnaire.

Impact of newly diagnosed abnormal glucose regulation on long-term prognosis in low risk patients with ST-elevation myocardial infarction: A follow-up study.

BACKGROUND: Patients with acute myocardial infarction and newly detected abnormal glucose regulation have been shown to have a less favourable prognosis compared to patients with normal glucose regulation. The importance and timing of oral glucose tolerance testing (OGTT) in patients with acute myocardial infarction without known diabetes is uncertain. The aim of the present study was to evaluate the impact of abnormal glucose regulation classified by an OGTT in-hospital and at three-month follow-up on clinical outcome in patients with acute ST elevation myocardial infarction (STEMI) without known diabetes. METHODS: Patients (n = 224, age 58 years) with a primary percutanous coronary intervention (PCI) treated STEMI were followed for clinical events (all-cause mortality, non-fatal myocardial re-infarction, recurrent ischemia causing hospital admission, and stroke). The patients were classified by a standardised 75 g OGTT at two time points, first, at a median time of 16.5 hours after hospital admission, then at three-month follow-up. Based on the OGTT results, the patients were categorised according to the WHO criteria and the term abnormal glucose regulation was defined as the sum of impaired fasting glucose, impaired glucose tolerance and type 2-diabetes. RESULTS: The number of patients diagnosed with abnormal glucose regulation in-hospital and at three-month was 105 (47%) and 50 (25%), respectively. During the follow up time of (median) 33 (27, 39) months, 58 (25.9%) patients experienced a new clinical event. There were six deaths, 15 non-fatal re-infarction, 33 recurrent ischemia, and four strokes. Kaplan-Meier analysis of survival free of composite end-points showed similar results in patients with abnormal and normal glucose regulation, both when classified in-hospital (p = 0.4) and re-classified three months later (p = 0.3). CONCLUSIONS: Patients with a primary PCI treated STEMI, without previously known diabetes, appear to have an excellent long-term prognosis, independent of the glucometabolic state classified by an OGTT in-hospital or at three-month follow-up. TRIAL REGISTRATION: The trial is registered at http://www.clinicaltrials.gov, NCT00926133.

Extraosseous uptake with DPD (Teceos(®)).

OBJECTIVE: During a short period of 10 days, four patients presented with intense extraosseous uptake of a technetium-labelled bone-seeking agent, three in the heart and one in the liver at our hospital. During the next 6 weeks, identical heart uptake was found in another two patients. Two patients were re-examined, with identical uptake on the second occasion. A search for a possible cause was initiated. METHODS: Bone scintigraphy with Teceos(®) was performed after labelling the kit as described in the Summary of Product Characteristics [IBA, http://www.iba-molecular.com/sites/default/files/spcT1901E.pdf (in french, 29/3/2011)]. On two occasions, the kit used was retrospectively analysed, without any apparent abnormality. Two patients were re-examined 1 month later, with identical cardiac and liver uptake on repeat examination. Contact with referring physicians and blood test screening did not show any consistent reason for these extraosseous uptakes. Additionally, five cases at other hospitals in Norway have been brought to our attention. RESULTS: In at least ten patients, intense cardiac uptake has been recorded, all in relatively old patients, and one young patient had massive liver uptake. No abnormalities in labelling or composition of 3,3-diphospho-1,2-propanedicarboxylic acid were found. DISCUSSION: Liver and cardiac uptakes of bone-seeking agents have been described in amyloidosis, and for the heart, after myocardial infarction. We have ruled out any possible contamination by interfering radiopharmaceuticals and cannot find any reason for these findings. Eleven patients with amyloidosis seem one of several hypotheses that is highly improbable.

Elevated serum osteoprotegerin levels measured early after acute ST-elevation myocardial infarction predict final infarct size.

BACKGROUND: Increased serum osteoprotegerin has been shown to be associated with increased mortality and heart failure development in patients with acute coronary syndromes. The aim of the present study was to elucidate a possible association between serum osteoprotegerin measured acutely in patients with ST-elevation myocardial infarction (STEMI) and final infarct size. METHODS Serum osteoprotegerin was measured in fasting blood samples from 199 patients with acute STEMI, sampled at a median time of 16 h after primary percutaneous coronary intervention (PCI). After 3 months, final infarct size (in percentage of left ventricular mass; LVM) was assessed by single-photon emission CT. The outcome variable final infarct size was dichotomised using the 75th percentile as the cutoff value (large infarct size ≥ 29.0%). A multivariable analysis was performed adjusting for multiple clinical and biochemical covariates. RESULTS: Median (IQR) osteoprotegerin concentration was 1.4 (1.0, 2.1) ng ml⁻¹ and patients with high osteoprotegerin level (> median) at baseline had larger infarct size at 3 months compared with patients with low osteoprotegerin levels (< median) (25 (8, 40) vs 6 (0, 19)% of LVM, respectively, p < 0.0001). A high osteoprotegerin level was also associated with an approximately sevenfold increase in the odds of developing a large myocardial infarct (OR 7.0; 3.2, 15.5, p < 0.001). After adjustment for potential confounders including peak troponin T, the adjusted OR was 5.2 (2.0, 13.1) p < 0.001. CONCLUSION: High levels of circulating osteoprotegerin measured the first morning after a PCI-treated acute STEMI were strongly associated with final infarct size.

Increased levels of CRP and MCP-1 are associated with previously unknown abnormal glucose regulation in patients with acute STEMI: a cohort study.

BACKGROUND: Inflammation plays an important role in the pathophysiology of both atherosclerosis and type 2 diabetes and some inflammatory markers may also predict the risk of developing type 2 diabetes. The aims of the present study were to assess a potential association between circulating levels of inflammatory markers and hyperglycaemia measured during an acute ST-elevation myocardial infarction (STEMI) in patients without known diabetes, and to determine whether circulating levels of inflammatory markers measured early after an acute STEMI, were associated with the presence of abnormal glucose regulation classified by an oral glucose tolerance test (OGTT) at three-month follow-up in the same cohort. METHODS: Inflammatory markers were measured in fasting blood samples from 201 stable patients at a median time of 16.5 hours after a primary percutaneous coronary intervention (PCI). Three months later the patients performed a standardised OGTT. The term abnormal glucose regulation was defined as the sum of the three pathological glucose categories classified according to the WHO criteria (patients with abnormal glucose regulation, n = 50). RESULTS: No association was found between inflammatory markers and hyperglycaemia measured during the acute STEMI. However, the levels of C-reactive protein (CRP) and monocyte chemoattractant protein-1 (MCP-1) measured in-hospital were higher in patients classified three months later as having abnormal compared to normal glucose regulation (p = 0.031 and p = 0.016, respectively). High levels of CRP (≥ 75 percentiles (33.13 mg/L)) and MCP-1 (≥ 25 percentiles (190 ug/mL)) were associated with abnormal glucose regulation with an adjusted OR of 3.2 (95% CI 1.5, 6.8) and 7.6 (95% CI 1.7, 34.2), respectively. CONCLUSION: Elevated levels of CRP and MCP-1 measured in patients early after an acute STEMI were associated with abnormal glucose regulation classified by an OGTT at three-month follow-up. No significant associations were observed between inflammatory markers and hyperglycaemia measured during the acute STEMI.

Left ventricular function in acute myocardial infarction treated with thrombolysis followed by early versus late invasive strategy.

BACKGROUND: Thrombolysis remains the treatment of choice in acute ST-segment elevation myocardial infarction (STEMI) when primary percutaneous coronary intervention (PCI) cannot be performed within 90 to 120 minutes. The optimal treatment after thrombolysis is still debated, but several studies have shown improved clinical outcomes with early transfer for PCI. The aim of this study was to investigate whether an early invasive strategy after thrombolysis preserved left ventricular function better than a late invasive strategy. METHODS: This was a substudy of the NORwegian study on DIstrict treatment of ST-Elevation Myocardial Infarction. Patients with STEMI of <6 hours of duration and >90 minutes of expected transfer delays to PCI were treated with aspirin, tenecteplase, enoxaparin, and clopidogrel and randomized to early or late invasive strategy (N = 266). Left ventricular volumes and ejection fraction were assessed by single-photon emission computed tomography, echocardiography, and magnetic resonance imaging 3 months after the index infarction. RESULTS: Noninvasive imaging was completed in 241 patients (91%). Median end-diastolic and end-systolic volumes after 3 months did not differ between groups. Median ejection fraction was well preserved and also without differences: 63% (interquartile range 51-70) in the early invasive versus 65% (interquartile range 55-71) in the late invasive group when assessed by single-photon emission computed tomography (P = .30), 55% versus 55% when assessed by echocardiography (P = .88), and 57% versus 57% when assessed by magnetic resonance imaging (P = .99). CONCLUSION: In this group of STEMI patients treated with thrombolysis, no difference in left ventricular function after 3 months was found between patients treated with early versus late invasive strategy.

Assessment of left ventricular function with magnetic resonance imaging vs. echocardiography, contrast echocardiography, and single-photon emission computed tomography in patients with recent ST-elevation myocardial infarction.

AIMS: Magnetic resonance imaging (MRI) is often considered to be the gold standard in measuring left ventricular function and volumes. The aim of this study was to assess the agreements between standard echocardiography (standard echo), contrast echocardiography (contrast echo), single-photon emission computed tomography (SPECT), and MRI in the determination of left ventricular ejection fraction (EF) and end-diastolic volumes (EDV) in patients treated for acute ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS: Standard echo, contrast echo, SPECT and MRI were performed on the same day, 3 months after STEMI in 150 patients participating in the NORwegian Study on District Treatment of ST-Elevation Myocardial Infarction (NORDISTEMI). Bland-Altman analysis of EF measured by all four imaging modalities showed generally low mean differences but wide limits of agreement. The mean EDV difference, however, was consistently higher when MRI was compared with standard echo (54.9 mL), contrast echo (41.7 mL) and SPECT (54.6 mL), and the limits of agreement were wider. The mean EDV differences between contrast echo vs. standard echo, SPECT vs. standard echo and contrast echo vs. SPECT were small. CONCLUSION: Our data suggest that all four imaging modalities measured EF closely similar after STEMI as demonstrated by a very small bias. The limits of agreement were however wide. EDV measured by MRI was consistently higher when compared with the other methods which may be caused by different tracing-methods and imaging principles. As echocardiography is preferable from a cost-benefit point of view, further analysis would be needed to clarify the nature of such differences.

[Medical service centres: are they really the future of ambulatory care in Germany?]. / Medizinisches Versorgungszentrum--Ausnahmefall oder Regelversorgung der Zukunft? Eine Bestandsaufnahme.

Due to governmental regulation in 2004 new options to establish ambulatory care facilities have become available and are widely used by healthcare providers. Medical service centres (Medizinische Versorgungszentren, MVZs) are characterised by the obligation for interdisciplinary teams of physicians, extended options for the employment of physicians and finally by flexible avenues of investment regarding the establishment of medical service centres. Medical service centres aim to improve ambulatory healthcare provision via an integrated service approach and offer opportunities for hospitals and third-party payers to set foot into the ambulatory healthcare sector. The rise of MVZs has therefore been closely and quite sceptically watched by the medical profession. The spread of MVZs is constant but limited to a modest growth rate. 250 MVZs are set up annually; in summer 2009 a total number of about 1300 had been reached, which is fairly small compared to 92,000 individual and group practices. The prominent specialities include general medicine, internal medicine, and surgery. The majority of MVZs are located in urban and suburban areas. Especially hospitals have, however, been using this approach to establish and operate ambulatory care centres with employed physicians. It remains to be seen whether and to what extent MVZs will improve service provision to the benefit of patients or mainly represent a new business model compromising existing structures. Continuous evaluation of trends is therefore essential for the further development of new ambulatory care structures.

Scintigraphic demonstration of myocardial perfusion and ischaemia associated with coronary artery bypass grafting.

OBJECTIVES: To assess if myocardial perfusion scintigraphy (MPS) at rest can be of value in elucidating myocardial perfusion, ischaemia and perioperative myocardial infarction (PMI) associated with coronary artery bypass graft (CABG) surgery. DESIGN: This was a prospective randomized study of patients undergoing elective CABG. Forty-eight patients in the control group underwent serial ECG recordings and measurements of CK-MB and cTnT. Fifty-four patients in the study group were additionally examined with MPS preoperatively and 2-4 days and 6 weeks postoperatively. RESULTS: The study showed a highly significant (p < 0.001) improvement in myocardial radionuclide uptake from preoperatively to 2-4 days postoperatively. Judged from ECG and enzymatic changes, two control patients and one study patient only had PMI and no additional cases of PMI were demonstrated by MPS. CONCLUSION: MPS at rest showed that CABG significantly improved myocardial perfusion, by demonstrating an increase in radionuclide uptake. In diagnosing PMI, we found that MPS provided no additional information beyond cardiac biochemical markers and ECG changes.

Intracoronary injection of mononuclear bone marrow cells in acute myocardial infarction.

BACKGROUND: Previous studies have shown improvement in left ventricular function after intracoronary injection of autologous cells derived from bone marrow (BMC) in the acute phase of myocardial infarction. We designed a randomized, controlled trial to further investigate the effects of this treatment. METHODS: Patients with acute ST-elevation myocardial infarction of the anterior wall treated with percutaneous coronary intervention were randomly assigned to the group that underwent intracoronary injection of autologous mononuclear BMC or to the control group, in which neither aspiration nor sham injection was performed. Left ventricular function was assessed with the use of electrocardiogram-gated single-photon-emission computed tomography (SPECT) and echocardiography at baseline and magnetic resonance imaging (MRI) 2 to 3 weeks after the infarction. These procedures were repeated 6 months after the infarction. End points were changes in the left ventricular ejection fraction (LVEF), end-diastolic volume, and infarct size. RESULTS: Of the 50 patients assigned to treatment with mononuclear BMC, 47 underwent intracoronary injection of the cells at a median of 6 days after myocardial infarction. There were 50 patients in the control group. The mean (+/-SD) change in LVEF, measured with the use of SPECT, between baseline and 6 months after infarction for all patients was 7.6+/-10.4 percentage points. The effect of BMC treatment on the change in LVEF was an increase of 0.6 percentage point (95% confidence interval [CI], -3.4 to 4.6; P=0.77) on SPECT, an increase of 0.6 percentage point (95% CI, -2.6 to 3.8; P=0.70) on echocardiography, and a decrease of 3.0 percentage points (95% CI, 0.1 to -6.1; P=0.054) on MRI. The two groups did not differ significantly in changes in left ventricular end-diastolic volume or infarct size and had similar rates of adverse events. CONCLUSIONS: With the methods used, we found no effects of intracoronary injection of autologous mononuclear BMC on global left ventricular function.

Myocardial perfusion in ST-elevation myocardial infarction treated successfully with primary angioplasty.

OBJECTIVES: To study myocardial perfusion in ST-elevation myocardial infarction (STEMI) treated successfully with primary angioplasty. Additionally, to evaluate the predictive value of perfusion on subsequent infarct size. DESIGN: Fifty patients with acute STEMI and restoration of normal epicardial flow after primary angioplasty were included in the study. TIMI myocardial perfusion (TMP) grades were determined at the end of the procedure. Contrast enhanced magnetic resonance imaging (MRI) including first-pass perfusion and delayed enhancement imaging were performed within five days and after three months. RESULTS: The patients were divided into two groups: A=TMP 0-1, B=TMP 2-3. The early MRI showed significantly reduced myocardial perfusion in the infarct zone compared to remote myocardium in both groups (p<0.001), but the reduction was more pronounced in group A. The infarct sizes were smaller (p=0.0017) and the ejection fractions higher (p=0.0001) in group B than in group A at follow-up. CONCLUSIONS: In STEMI, early impairments in myocardial perfusion were observed in spite of successful treatment with angioplasty. Marked early impairments in perfusion were associated with larger infarct sizes on MRI after three months.

Total-body irradiation--role and indications: results from the German Registry for Stem Cell Transplantation (DRST).

BACKGROUND AND PURPOSE: Total-body irradiation (TBI) is a key part of the conditioning regimen before hematopoietic stem cell transplantation (HSCT). The exact role of TBI as part of the conditioning regimen is largely unclear. In order to determine the relevance of TBI, the status of TBI utilization was analyzed on the basis of a nationwide registry. MATERIAL AND METHODS: 14,371 patients (1998-2002) documented in the German Stem Cell Transplantation Registry (DRST) were analyzed regarding TBI utilization prior to autologous or allogeneic transplantation, underlying disorder, type of donor, stem cell source, and size of the treatment center. RESULTS: For autologous HSCT approximately 10% of the patients (873/8,167) received TBI, with chronic lymphocytic leukemia (CLL, approximately 80%, 171/214) and low-grade non-Hodgkin's lymphoma (l-NHL, approximately 35%, 330/929) being the most important disorders. In the allogeneic setting 50% of the patients (2,399/4,904) received TBI, with acute lymphocytic leukemia (ALL, 85%, 794/930), acute myeloid leukemia (AML, 45%, 662/1,487) and chronic myeloid leukemia (CML, 49%, 561/1,156) being the key indications. The type of donor, stem cell source and center size did not strongly influence the use of TBI. CONCLUSION: TBI has only a limited role for the conditioning prior to autologous HCST. For allogeneic HSCT TBI is widely accepted with no major changes over the observation time. The use of TBI is generally accepted for ALL, whereas approximately half of the patients with CML or AML received TBI. Although a considerably large database was analyzed, no clear determinants for the use of TBI could be distinguished.

N-terminal pro-B-type natriuretic peptide in risk stratification after acute myocardial infarction in patients on long-term beta-adrenergic receptor blocker therapy.

BACKGROUND: N-terminal pro-B-type natriuretic peptide (NT-proBNP) appears to be a strong risk marker of mortality in patients with acute coronary syndrome. However, little information is available on NT-proBNP as a predictor of long-term serious cardiovascular events beyond that of left ventricular ejection fraction in patients with acute myocardial infarction (AMI), most of them treated with an early invasive strategy and on a uniform optimal secondary preventive medication including long-term beta-adrenergic receptor blockade. OBJECTIVE: To assess the prognostic impact of plasma NT-proBNP in patients with AMI who received optimal medical treatment including long-term beta-adrenergic receptor blockade. METHODS: Plasma NT-proBNP was measured in 219 patients (age range 31-80 years) with AMI at baseline, and then followed for a median duration of 1.63 years. The first occurrences of a serious cardiovascular event including cardiac mortality, nonfatal MI, and congestive heart failure were registered. RESULTS: Ninety serious cardiovascular events occurred. Left ventricular ejection fraction and reperfusion therapy with thrombolysis or percutaneous coronary intervention were identified as confounders. When adjusting for these factors in multivariate analysis, NT-proBNP was a strong predictor of serious cardiovascular events in patients with a plasma NT-proBNP of >162.2 pmol/l and aged <60 years (p = 0.001). The incidence rate was related to increasing NT-proBNP (p = 0.0017). The risk of serious cardiovascular events was higher in patients with NT-proBNP levels in the highest quartile (> or =162.2 pmol/l) than in those with levels in the three lowest quartiles (rate ratio = 2.5, 95% confidence interval = 1.6-3.9, p = 0.0001). CONCLUSION: AMI patients with high plasma NT-proBNP seem to be at an increased risk of serious cardiovascular events, but only those < or =60 years of age.

A comparison of the two beta-blockers carvedilol and atenolol on left ventricular ejection fraction and clinical endpoints after myocardial infarction. a single-centre, randomized study of 232 patients.

BACKGROUND: beta-Blockers have been found to reduce mortality and morbidity in postmyocardial infarction patients. However, it is not fully understood whether all beta-blockers have similar favourable cardiovascular effects. The aim of this study was to compare the effects of carvedilol and atenolol on global and regional left ventricular ejection fraction (LVEF) and on predefined cardiovascular endpoints. METHODS: In a single-centre, randomized, open, endpoint-blinded, parallel group study, 232 patients with acute myocardial infarction were randomized to treatment with carvedilol or atenolol. LVEF was measured by gated blood pool scintigraphy during the first week and after 12 months. The treatment was given orally within 24 h. The mean dose was 36.2 and 72.1 mg in the carvedilol and atenolol groups, respectively. RESULTS: No significant difference was found between the two study groups in the mean global and regional LVEF. There tended to be fewer first serious cardiovascular events in the carvedilol compared with the atenolol group (RR = 0.83, 95% CI 0.56-1.23, p = 0.39). Cold hands and feet were observed less frequently in the carvedilol group (20 vs. 33%, p = 0.025). CONCLUSION: In patients following an acute myocardial infarction, no difference in either global or regional LVEF was observed between baseline and 12 months when treatment with carvedilol was compared with atenolol.

[Reduction of myocardial infarction size after primary percutaneous coronary intervention]. / Reduksjon av infarktstørrelse etter primaer perkutan koronar intervensjon.

BACKGROUND: Achieving reperfusion as soon as possible is essential in order to reduce myocardial infarction size and thus improve prognosis. An increasing number of patients with myocardial infarction are treated with primary percutaneous coronary intervention (PCI). Technetium 99m-tetrofosmin myocardial perfusion tomography (SPECT) is a valid test for assessing myocardium at risk and final infarct size expressed by a hypoperfusion index (HPI) of the left ventricular mass. MATERIAL AND METHODS: 20 patients with acute ST-elevation myocardial infarction were treated with primary percutaneous coronary intervention within six hours of onset of symptoms. Myocardium at risk and final infarct size were assessed by Technetium 99m-tetrofosmin immediately before and a few hours, one week and six weeks after. RESULTS: The hypoperfusion index immediately before percutaneous coronary intervention was 31%, four to six hours after PCI 25%, one week later 16% and six weeks later 12%, i.e. a relative reduction of 60% (p < 0.01). Anterior wall infarctions had a higher level of myocardium at risk before primary PCI compared to inferior wall infarctions (36% vs. 24%), but anterior wall infarctions had a higher salvage index compared to inferior wall infarctions. INTERPRETATION: This non-controlled study shows a marked reduction in final infarction size in patients with acute ST-elevation myocardial infarction treated with primary PCI.

Diagnostic value of a rapid test for B-type natriuretic peptide in patients presenting with acute dyspnoe: effect of age and gender.

BACKGROUND: B-type natriuretic peptide (BNP) measurements are useful for diagnosing congestive heart failure (CHF) in patients presenting to the Emergency Department with acute dyspnoe. Whether the diagnostic accuracy of BNP is affected by the age and gender of the patients remains unknown. AIMS: To evaluate the accuracy of BNP testing for diagnosing CHF in an unselected group of patients admitted to the emergency department of a Norwegian teaching hospital with a principal complaint of shortness of breath and to assess whether the diagnostic accuracy of the test differs according to age and gender. METHODS: BNP levels in plasma were determined by a point-of-care device upon arrival in 155 patients presenting with acute dyspnoe. The diagnostic 'gold' standard for CHF was adjudicated by two independent cardiologists who were blinded to the BNP data. RESULTS: By univariate logistic regression analysis, BNP was strongly related to a diagnosis of CHF. In a multivariate model BNP provided additional prognostic information to patient age and gender, radiographic evidence of pulmonary congestion and cardiomegaly, and the presence of pulmonary rales and jugular vein distention by physical examination. There was no significant interaction between age and BNP or between gender and BNP with regard to the accuracy of diagnosing CHF. The area under the receiver-operating characteristics-curve was 0.86 (95% confidence interval 0.78-0.93) in women and 0.90 (0.82-0.97) in men. The area under the curves were 0.82 (0.73-0.92) and 0.88 (0.80-0.97) for patients (both genders) aged > or = 76 and <76 years, respectively. CONCLUSION: Point-of-care BNP measurement in the emergency department discriminates well between patients with dyspnoe of cardiac and non-cardiac origin regardless of age and gender.

[Left ventricular function and infarction size after primary angioplasty for acute myocardial infarction]. / Venstre ventrikkel-funksjon og infarktstørrelse etter primaer angioplastikk for akutt hjerteinfarkt.

BACKGROUND: There is little information available on long-term changes in left ventricular function and infarct size after acute myocardial infarction treated with primary angioplasty. MATERIAL AND METHODS: From 1996 to 1998, 100 consecutive patients were treated with primary angioplasty for acute ST-elevation myocardial infarction. Left ventricular ejection fraction was determined by radionuclide ventriculography before discharge, after six weeks and after a mean follow-up time of 20 months (range 11-37). Infarct size was assessed by technetium 99m-tetrofosmin myocardial perfusion tomography (SPECT) at rest, performed at the same time intervals. RESULTS: Mean ejection fraction was 56% at discharge, 55% after six weeks and 57% after 20 months of follow-up. A mean perfusion defect of 19% was measured by SPECT after one week. After six weeks and 20 months of follow-up, the mean perfusion defects were reduced to 14% (p < 0.001) and 15%, respectively. INTERPRETATION: Left ventricular function was well preserved and infarct sizes small to moderate 20 months (range 11-37) after primary angioplasty for acute myocardial infarction, demonstrating that the initial successful effect of the treatment was maintained.