RESUMO
OBJECTIVES: To evaluate, using continuous 12-lead ECG ST-segment monitoring, the role of circulating levels of both cardiac troponin I (cTnI) and high-sensitivity C reactive protein (hs-CRP), on presentation, in the prediction of intravenous thrombolysis outcome in patients with ST-segment elevation myocardial infarction (STEMI). DESIGN AND SETTING: Prospective observational study in a tertiary referral centre. PATIENTS: 786 consecutive patients with STEMI, who received intravenous thrombolysis in the first 6 h from index pain. MAIN OUTCOME MEASURES: The incidence of failed thrombolysis and of cardiac death by 30 days. Failed thrombolysis was defined as the absence of abrupt and sustained > or =50% ST-segment recovery in the first 90 min after the initiation of intravenous thrombolysis. RESULTS: The incidence of failed thrombolysis and 30-day cardiac death was 57.4% and 11.8%, respectively. By multivariate logistic regression analysis according to tertiles of both cTnI (RR, 1.5; 95% CI 1.1 to 1.8, p = 0.004 for highest vs middle third; 2.2, 1.9 to 3.5, p<0.001 for highest vs lowest third; 1.5, 1.2 to 1.8, p = 0.001 for middle vs lowest third) and hs-CRP (RR, 2.0, 95% CI, 1.6 to 2.2; p<0.001 for highest vs middle third; 2.6, 2.1 to 3.5, p<0.001 for highest vs lowest third; 1.3, 1.2 to 1.7, p = 0.02 for middle vs lowest third), were independently associated with failed thrombolysis. Moreover, by multivariate Cox regression analysis according to tertiles of both cTnI (HR 1.2, 95% CI 1.1 to 1.8, p = 0.03 for highest vs middle third; 1.5, 1.2 to 2.2, p = 0.004 for highest vs lowest third; 1.1, 0.6 to 1.4, p = 0.6 for middle vs lowest third) and hs-CRP (HR1.2, 95% CI 1.1 to 1.6, p = 0.04 for highest vs middle third; 1.7, 1.3 to 2.6, p = 0.001 for highest vs lowest third; 1.1, 0.9 to 2.1, p = 0.1 for middle vs lowest third), were independently related with an increased risk of 30-day cardiac death. CONCLUSIONS: High circulating levels of both cTnI and hs-CRP are related with an independent increased risk of intravenous thrombolysis failure and 30-day cardiac death in patients who received intravenous thrombolysis in the first 6 h of STEMI.
Assuntos
Proteína C-Reativa/análise , Infarto do Miocárdio/sangue , Infarto do Miocárdio/terapia , Terapia Trombolítica , Troponina I/sangue , Idoso , Biomarcadores/sangue , Eletrocardiografia , Feminino , Fibrinolíticos/uso terapêutico , Seguimentos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Prognóstico , Modelos de Riscos Proporcionais , Estudos Prospectivos , Estreptoquinase/uso terapêutico , Falha de TratamentoRESUMO
OBJECTIVE: To assess the contribution of coronary artery ectasia, either isolated or in association with obstructive coronary artery disease, to morbidity and mortality from ischaemic heart disease. DESIGN: A retrospective study of patients undergoing coronary arteriography at a tertiary cardiac centre. PATIENTS AND METHODS: The epidemiological, clinical, arteriographic, and follow up characteristics of three groups of patients were examined: group A, 172 patients with coronary artery ectasia and coexisting significant coronary artery disease; group B, 31 patients with coronary artery ectasia only; group C, 165 patients with significant coronary artery disease but without ectasia, matched for sex and age with group A. RESULTS: Group A patients had a similar incidence of a previous myocardial infarction to group C patients (61.6% v 64.2%), exercise performance, severity of obstructive lesions (CASS score 2.19 v 2.14), and similar distribution of diseased vessels. At follow up of approximately two years they experienced a similar incidence of unstable angina (7.5% v 4.4%) and myocardial infarction plus cardiac death (4.9% v 6.1%). They underwent bypass surgery with similar frequency (39% v 42%) but there was a lower frequency of percutaneous transluminal coronary angioplasty (5.8% v 17%, P < 0.01). Patients with pure coronary ectasia (group B) had a lower incidence of a previous myocardial infarction (38.7%, 12/31, P < 0.05) than the two other groups. The infarct in all cases was related to an ectatic artery. Their exercise performance and ejection fraction (9 (SD 3) minutes and 56.5(9)%) were higher (P < 0.01) than group A (5 (2) minutes, 48.3(10)%) and group C (5.3 (2) minutes, 49.3(10)%). Group B had no myocardial infarctions, cardiac death, surgery, or intervention at follow up; 4.4% (5/115) developed unstable angina. The incidence of angina at study entry was similar in all three groups (38.7-49.7%). CONCLUSIONS: Coronary artery ectasia does not confer added risk in patients with coexisting obstructive coronary artery disease. Although there is a measurable incidence of previous myocardial infarction, patients with pure ectasia have a good prognosis. The wisdom of giving oral anticoagulants to such patients is questioned.
Assuntos
Aneurisma Coronário/mortalidade , Angiografia Coronária , Isquemia Miocárdica/mortalidade , Aneurisma Coronário/complicações , Aneurisma Coronário/diagnóstico por imagem , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Morbidade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/diagnóstico por imagem , Infarto do Miocárdio/mortalidade , Isquemia Miocárdica/complicações , Isquemia Miocárdica/diagnóstico por imagem , Estudos Retrospectivos , Fatores de RiscoRESUMO
A terminally ill patient with cardiac tamponade secondary to metastatic breast cancer was successfully treated by percutaneous balloon pericardiotomy. The procedure was performed through subxiphoid approach under local anaesthesia and its beneficial effect was maintained until the patient's death from her primary disease. A second, 86-year-old, debilitated patient and a third 52-year-old patient were managed likewise and both left hospital relieved from recurrent severe pericardial effusions. The later two patients have shown no signs of recurrence for fifteen and twelve months respectively.
Assuntos
Oclusão com Balão , Tamponamento Cardíaco/terapia , Cateterismo , Derrame Pericárdico/terapia , Pericardiectomia/métodos , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/patologia , Tamponamento Cardíaco/etiologia , Feminino , Neoplasias Cardíacas/complicações , Neoplasias Cardíacas/secundário , Humanos , Masculino , Pessoa de Meia-Idade , Pericardiectomia/instrumentação , Pericárdio , RecidivaRESUMO
Vasospasm of the saphenous vein and internal mammary grafts may develop spontaneously under several conditions. We present for the first time spasm of a left internal mammary artery bypass graft during coronary arteriography. A patient who underwent coronary artery bypass operation 4 years ago was recatheterized because he developed chest pain. Selective catheterization of the left internal mammary artery graft showed disappearance of its lumen at its distal part during systole, whereas the patient developed angina. These phenomena disappeared after intravenous nitroglycerin administration.