Presence of bacterial DNA in thrombotic material of patients with myocardial infarction.

Infectious agents have been suggested to be involved in etiopathogenesis of Acute Coronary Syndrome (ACS). However, the relationship between bacterial infection and acute myocardial infarction (AMI) has not yet been completely clarified. The objective of this study is to detect bacterial DNA in thrombotic material of patients with ACS with ST-segment elevation (STEMI) treated with Primary Percutaneous Coronary Intervention (PPCI). We studied 109 consecutive patients with STEMI, who underwent thrombus aspiration and arterial peripheral blood sampling. Testing for bacterial DNA was performed by probe-based real-time Polymerase Chain Reaction (PCR). 12 probes and primers were used for the detection of Aggregatibacter actinomycetemcomitans, Chlamydia pneumoniae, viridans group streptococci, Porphyromonas gingivalis, Fusobacterium nucleatum, Tannarella forsythia, Treponema denticola, Helycobacter pylori, Mycoplasma pneumoniae, Staphylococus aureus,  Prevotella intermedia and Streptococcus mutans. Thus, DNA of four species of bacteria was detected in 10 of the 109 patients studied. The most frequent species was viridans group streptococci (6 patients, 5.5%), followed by Staphylococus aureus (2 patients, 1.8%). Moreover, a patient had DNA of Porphyromonas gingivalis (0.9%); and another patient had DNA of Prevotella intermedia (0.9%). Bacterial DNA was not detected in peripheral blood of any of our patients. In conclusion, DNA of four species of endodontic and periodontal bacteria was detected in thrombotic material of 10 STEMI patients. Bacterial DNA was not detected in the peripheral blood of patients with bacterial DNA in their thrombotic material. Bacteria could be latently present in plaques and might play a role in plaque instability and thrombus formation leading to ACS.

Comparison of the performance of the CRUSADE, ACUITY-HORIZONS, and ACTION bleeding risk scores in STEMI undergoing primary PCI: insights from a cohort of 1391 patients.

AIMS: To compare the performance of the CRUSADE, ACUITY-HORIZONS, and ACTION risk models in the ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). METHODS: We studied all consecutive patients with STEMI who underwent PPCI at our institution between 2006 and 2010 (n=1391). The CRUSADE, ACUITY-HORIZONS, and ACTION risk scores were calculated based on the patients' clinical characteristics. The occurrence of in-hospital major bleeding (defined as the composite of intracranial or intraocular bleeding, access site haemorrhage requiring intervention, reduction in haemoglobin ≥4 g/dl without or ≥3g/dl with overt bleeding source, reoperation for bleeding, or blood transfusion) reached 9.8%. Calibration and discrimination of the three risk models were evaluated by the Hosmer-Lemeshow test and the C-statistic, respectively. We compared the predictive accuracy of the risk scores by the DeLong non-parametric test. RESULTS: Calibration of the three risk scores was adequate, given the non-significant results of Hosmer-Lemeshow test for the three risk models. Discrimination of CRUSADE, ACUITY-HORIZONS, and ACTION models was good (C-statistic 0.77, 0.70, and 0.78, respectively). The CRUSADE and ACTION risk scores had a greater predictive accuracy than the ACUITY-HORIZONS risk model (z=3.89, p-value=0.0001 and z=3.51, p-value=0.0004, respectively). There was no significant difference between the CRUSADE and ACTION models (z=0.63, p=0.531). CONCLUSIONS: The CRUSADE, ACUITY-HORIZONS, and ACTION scores are useful tools for the risk stratification of bleeding in STEMI treated by PPCI. Our findings favour the CRUSADE and ACTION risk models over the ACUITY-HORIZONS risk score.

Prevalence of donor-transmitted coronary artery disease and its influence on heart transplant outcomes.

BACKGROUND: It is uncertain whether donor-transmitted coronary artery disease (DTCAD) affects heart transplant (HT) recipients. METHODS: This retrospective analysis includes records of all patients who underwent a HT at our center over an 8-year period, who survived for at least 1 month, and who were examined by coronary angiography within 2 months post-HT. We distinguished angiographically from keep ultrasonography (IVUS) detected DTCAD. Major adverse cardiovascular events (MACE) comprised death, myocardial infarction, unstable angina, coronary revascularization, and admission because of heart failure not due to an acute rejection episode. RESULTS: Among the 171 patients of mean age 53±13 years and including 83% men, 65 (38%) were evaluated by IVUS. Donors were aged 40±14 years (range=14-73). Angiographic DTCAD affected seven patients (4.1%), and IVUS-detected DTCAD, 35 (53.8% of those examined by IVUS). DTCAD donors were older than non-DTCAD donors, by an average of 13 years (P=.001) for angiographic DTCAD and 18 years (P<.0001) for IVUS-detected DTCAD. Two patients underwent percutaneous revascularization upon detection of angiographic DTCAD. The angiographic- and IVUS-detected DTCAD groups did not differ significantly from the corresponding non-DTCAD groups as regards MACE incidence during 54±41 and 38±20 months follow-up, respectively. Cox regression analysis with adjustment for relevant confounders confirmed that IVUS-detected DTCAD was not a predictor of MACE (hazard ratio 1.2, 95% confidence interval 0.2-8.1). CONCLUSIONS: Among HT patients surviving≥1 month, angiographic- and IVUS-detected DTCAD showed prevalences of <10% and >50%, respectively. Neither detection method was associated with a greater long-term incidence of MACE.

Complicaciones vasculares pospunción de la arteria femoral en cateterismos cardíacos / Vascular complications following puncture of the femoral artery in cardiac catheterisation

Introducción. El tratamiento de las complicaciones femorales pospunción ha evolucionado desde la reparación quirúrgica hasta técnicas menos invasivas. Por ello, analizamos las complicaciones femorales de una serie de cateterismos cardíacos: su incidencia, resultados del tratamiento y discusión de alternativas terapéuticas actuales. Pacientes y métodos. Análisis retrospectivo de las complicaciones pospunción en 9.395 cateterismos realizados a 7.898 pacientes. El diagnóstico se confirmó con eco-Doppler y se aplicó el tratamiento que procedía en cada caso. Entre uno y tres meses se realizó un control ecográfico. Resultados. Hubo 63 pacientes (0,79%) con complicaciones femorales (38 pseudoaneurismas, 22 fístulas arteriovenosas y 3 isquemias agudas). El factor de riesgo más frecuente fue la hipertensión en 42 pacientes (66%). Del grupo de pseudoaneurismas, 11 (29%) se trataron quirúrgicamente de urgencia, 20 (52%) con compresión dirigida por ultrasonidos con resultado favorable en 14 (70%), 4 (10%) con inyección de trombina y 3 (7%), menores de 1,5 cm, se trombosaron espontáneamente. Entre las fístulas arteriovenosas, 6 (27%) se intervinieron precozmente por ser sintomáticas, y de las asintomáticas se resolvieron espontáneamente 13 (72%) en un plazo de tres meses. De las isquemias, una se trató con trombectomía y dos con anticoagulación. No se detectaron recidivas. Hubo dos exitus tardíos. Conclusiones. Las complicaciones femorales secundarias a cateterismos cardíacos tienen una frecuencia próxima al 1%. En los pseudoaneurismas, que son la complicación más frecuente, la inyección percutánea de trombina es, en nuestra experiencia a partir del año 2000, el tratamiento de primera elección. En las fístulas arteriovenosas asintomáticas se aconseja demorar su tratamiento tres meses

INTRODUCTION. The treatment of femoral complications following puncture has progressed from the days of surgical repair to today’s less invasive techniques. Hence, in this study we analyse the femoral complications in a series of cardiac catheterisations and we discuss their incidence, outcomes of the treatment and current therapeutic alternatives. PATIENTS AND METHODS. We present a retrospective analysis of the complications that occurred following puncture in 9395 catheterisations performed on 7898 patients. Diagnosis was confirmed with Doppler ultrasound and the treatment best indicated in each case was the one that was applied. A control examination was carried out using ultrasonography recording at between one and three months. RESULTS. There were 63 patients (0.79%) with femoral complications (38 pseudo-aneurysms, 22 arteriovenous fistulas and 3 acute ischaemias). The most frequent risk factor was hypertension in 42 patients (66%). Of the subjects in the pseudo-aneurysm group, 11 (29%) were treated by emergency surgical interventions, 20 (52%) with ultrasound-guided compression with favourable outcomes in 14 (70%), 4 (10%) with thrombin injections and 3 (7%), which were smaller than 1.5 cm, thrombosed spontaneously. Among the cases of arteriovenous fistulas, 6 (27%) were submitted to early surgical intervention due to being symptomatic and 13 (72%) of the asymptomatic cases resolved spontaneously within three months. Of the cases of ischaemias, one was treated by thrombectomy and two with anticoagulation therapy. No relapses were detected. Two late deaths occurred. CONCLUSIONS. The frequency of femoral complications secondary to cardiac catheterisations is about 1%. From our own experience gained since the year 2000, in pseudo-aneurysms, which are the most common complication, percutaneous injection of thrombin is the preferred treatment. In cases of asymptomatic arteriovenous fistulas it is advisable to delay treatment for three months

[Acute myocardial infarction after anaphylactic reaction to amoxicillin]. / Infarto agudo de miocardio tras reacción anafiláctica por amoxicilina.

A 62-year-old man was admitted to the hospital in a state of shock with electrocardiographic signs of inferior-wall acute myocardial infarction. He was initially diagnosed of cardiogenic shock. An urgent coronary angiography showed an irregular stenosis of 90% in the right coronary artery. Coronary angioplasty was performed, and a stent was placed in this lesion. In-depth questioning of the family revealed that the patient had taken an oral dose of amoxicillin 15 minutes before the onset of the symptoms. Further tests proved that he was allergic to amoxicillin, and was diagnosed of anaphylactic shock, complicated with acute myocardial infarction. There are several reports of myocardial infarction as a complication of anaphylactic reaction. We have found very few cases related to antibiotics, and none associated with amoxicillin. The most frequently quoted mechanism in these cases is coronary artery spasm due to the mediators of anaphylaxis. In the case reported herein, the irregular lesion suggests that disruption of an atherosclerotic plaque and platelet aggregation have occurred.