Factors affecting smoking resumption after acute coronary syndromes.

INTRODUCTION: Many patients who are hospitalised for acute ischaemic episodes stop smoking; however, many of them relapse and resume smoking again within three months from their hospitalisation. The aim of this study was to study the factors that might affect smoking resumption in patients who have suffered an acute coronary syndrome. METHODS: We studied 420 patients, active smokers at the time of admission, who were hospitalised for an acute coronary episode. The patients' data (history, risk factors, smoking habits) were retrieved from their medical files. During their hospitalisation they were asked to stop smoking and to attend the smoking cessation clinic to be advised about this. The patients were followed for one year and logistic regression analysis was used to evaluate the independent predictors of smoking resumption and continuation. RESULTS: Of the total patient population, 280 (66.67%) visited the smoking cessation clinic and followed a special programme. Most relapses were recorded during the first 3 months of follow up, after which time 223 (53.1%) were still smoking, compared with 256 (61.43%) at 1 year. Independent predictors of smoking resumption were: non-participation in the smoking cessation programme (odds ratio, OR: 4.32, p=0.0007); the use of antidepressants (OR: 2.28, p=0.01); a history of vascular disease (OR: 2.32, p=0.03); a history of chronic obstructive pulmonary disease (OR: 1.35, p=0.001; and a decree of nicotine dependency >8 on the Fagerström scale, as recorded in questionnaires (OR: 1.42, p=0.04). CONCLUSIONS: Smokers with acute coronary syndromes should be encouraged to participate in special secondary prevention programmes. Smoking cessation clinics contribute significantly to a reduction in smoking in this group of patients.

Spontaneous coronary artery dissection and acute myocardial infarction during pregnancy.

Spontaneous coronary artery dissection is a rare cause of infarction in the general population, but a common cause of myocardial infarction during pregnancy, and even nowadays carries a high risk of mortality. We describe the case of a 31-year-old primigravida who presented during the 34th week of pregnancy with the chief complaint of chest pain and was found to suffer from myocardial infarction. She was otherwise healthy and had no known risk factors for coronary artery disease. The patient was treated conservatively with nitrates, aspirin, heparin and beta-blockers, eventually sustained a large myocardial infarction and, after an initial period of instability, remained asymptomatic. A week later she delivered 3 healthy babies. A coronary angiogram performed 3 months after the initial event revealed an extensive obstructive dissection of the circumflex coronary artery. The decision whether to pursue percutaneous coronary intervention, surgical revascularisation or appropriate medical therapy, is based on clinical presentation, the extent of the dissection, and the amount of ischaemic myocardium at risk. Cardiologists must be aware of this rare entity during pregnancy or postpartum, since early diagnosis and treatment are crucial for the survival of the mother and the foetus.

External cardioversion of atrial fibrillation: the role of electrode position on cardioversion success.

The optimal method to perform external electrical cardioversion of atrial fibrillation has not been fully determined yet. In order to define the effects of different pad positions on cardioversion success rates, shock energy requirements and serum myocardial proteins levels we studied 62 patients with persistent atrial fibrillation who underwent elective external electrical cardioversion using a standardized step-up protocol of increasing energy levels. Electrode positions were randomly assigned as anterolateral (Group A) or anteroposterior (Group B). After all shocks were delivered there was no difference in the cardioversion success rate between the two groups. However, a significantly greater proportion of patients in group B were restored to sinus rhythm after the second shock of 300 J was delivered (p=0.005). Mean shock energy requirements and peak serum creatine kinase levels were lower for group B than for group A (p=0.049 and p=0.021 respectively). Troponin T serum levels were not increased after the cardioversion attempts in either group. We conclude that an anteroposterior electrode position is more effective in achieving restoration of sinus rhythm in lower energy shock levels compared to the anterolateral position.

Acute myocardial infarction following the combined use of cocaine and alcohol.

We describe the case of a 37-year-old man who presented with inferior wall myocardial infarction shortly after the concomitant use of cocaine and ethanol. The patient showed prompt ST resolution after thrombolytic therapy. Within two hours from his arrival at the hospital the patient had an episode of ventricular fibrillation, which was successfully treated with electrical cardioversion. Coronary angiography showed normal coronary arteries. The number of patients with acute myocardial infarction after the use of cocaine alone, or in combination with ethanol, is increasing in the USA and other countries; most are young adults. In Greece such cases are still rare, because of the lesser extent of cocaine abuse in the general population and the low sensitivity in recognising cocaine users who present with chest pain in the emergency department.