The long-term predictive value of the neutrophil-to-lymphocyte ratio in Type 2 diabetic patients presenting with acute myocardial infarction.

BACKGROUND: Patients with diabetes mellitus have worse long-term outcomes after acute myocardial infarction (AMI) than non-diabetics. This may be related to differential contribution of neutrophil and lymphocyte to inflammation during AMI in diabetics vs. non-diabetics. We aim to determine the predictive value of neutrophil-to-lymphocyte ratio (NLR) for major adverse events post-AMI in Type 2 diabetics vs. non-diabetics. METHODS AND RESULTS: A total of 2559 consecutive patients admitted for AMI (61 ± 14 years, 73% male and 43% diabetic) were analyzed. A complete blood count was obtained and the NLR computed for each patient on admission. Across the cohort, the 1-year reinfarction rate was 8.4% (n = 214) and 1-year mortality was 14.5% (n = 370). Univariate determinants of the composite endpoint included age, hypertension, hyperlipidemia, smoking, revascularization and NLR (P < 0.001 for all). The cohort was divided into NLR quartiles. Admission NLR was significantly higher in the diabetic group, 5.2 ± 5.8 vs. 4.6 ± 5.4 (P = 0.007). A step-wise increase in the incidence of the composite endpoint was noted across NLR quartiles for diabetic subjects; hazard ratio (HR) was 2.41 for fourth vs. first quartile (95% confidence interval = 1.63-3.53, P < 0.001). Multivariate analysis of the diabetic group showed that NLR remains as an independent predictor of the composite endpoint (adjusted HR = 1.53, 95% confidence interval = 1.00-2.33, P = 0.048). However, in non-diabetics, HR for NLR was not significant (P = 0.35). CONCLUSION: Increased NLR post-AMI is an independent predictor of major adverse cardiac events in diabetics. Monitoring this easily obtainable new index allows prognostication and risk stratification.

Electrocardiography Series. ECGs of structural heart disease: Part 1.

Electrocardiogram (ECG) is a useful but imperfect investigation in the diagnosis and possible follow-up of structural heart disease such as ventricular hypertrophy. Different ECG criteria with different sensitivity and specificity are available to aid the detection of left or right ventricular hypertrophy. Subsequent echocardiography can help in the quantification of ventricular mass and identification of the aetiology.

Misleading ECG recordings.

Misleading electrocardiogram recordings are not uncommon, and can lead to misdiagnosis. This article highlights two examples and discusses the strategies to recognise them.

Acute myocardial infarction in young Asian women: a comparative study on Chinese, Malay and Indian ethnic groups.

INTRODUCTION: There is a paucity of data on acute myocardial infarction (AMI) in young Asian women and of comparative data among various ethnic groups with respect to risk factor profile and clinical outcomes. We present a comprehensive overview of the clinical characteristics of young Asian women with AMI and a comparative analysis among Chinese, Malay and Indian women in a multi-ethnic Asian country. METHODS: We studied 45 Asian female patients aged 50 years and below who were admitted to our hospital with a diagnosis of ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation myocardial infarction (NSTEMI). RESULTS: Overall, diabetes mellitus, hypertension and hyperlipidaemia were prevalent in the study population. Hyperlipidaemia was more prevalent among Indian patients, while diabetes mellitus was more common among Malay patients. Only a minority of the study patients were current smokers. Among the 20 patients admitted with STEMI, 17 (85 percent) received urgent reperfusion therapy. The mean symptom-to-balloon time and door-to-balloon time for the Malay patients were longer compared to those for other ethnic groups. Among the 25 patients admitted with NSTEMI, 12 (48 percent) underwent coronary revascularisation therapy. The average duration of hospital stay was 4 +/- 4.1 days, with no significant difference observed among the various ethnic groups. CONCLUSION: Many young Asian women with AMI have identifiable risk factors that are different from those found in the Western population. There seems to be an ethnic effect on the prevalence of these risk factors and door-to-balloon time.

Managing ventricular ectopics: are ventricular ectopic beats just an annoyance?

How important are PVCs and what should we do about them? PVCs are not a disease in themselves, but a marker of possible underlying conditions that may increase the risk of cardiac death. They serve as a flag to alert us to exclude structural heart disease, the presence of which is the strongest predictor of adverse events. However, it is important to know that PVCs are common in people with no structural heart disease. In this situation, the prognosis is generally excellent. Suppression of PVCs with antiarrhythmic medication is not indicated routinely, unless the patient is symptomatic or at risk of tachycardia-induced cardiomyopathy owing to the very high frequency of PVCs. Where pharmacological therapy has failed, there is now the option of radiofrequency ablation for elimination of frequent symptomatic PVCs. The ECG is a simple yet useful tool to improve risk assessment, especially in those with known cardiovascular disease.

Narrow QRS complex tachycardia presenting as palpitation.

Atrial fibrillation is the most common sustained cardiac arrhythmia. The rhythm in atrial fibrillation is irregular. Correct interpretation of the electrocardiogram (ECG) is essential. Atrial flutter can present as regular or irregular narrow QRS complex tachycardia. Knowledge of the ECG features of atrial flutter will help to differentiate it from paroxysmal supraventricular tachycardia. The treatment strategy in atrial fibrillation should focus on rhythm control vs. rate control, and anticoagulation should be started based on the calculated risk of systemic embolisation. Atrial flutter is a unique arrhythmia that has similar management strategies to those of atrial fibrillation; however, radiofrequency ablation is increasingly preferred due to its higher rate of efficacy and safety compared to pharmacological therapy.

Electrocardiography Series. What is the cause of the regular wide QRS complex tachycardia?

Regular broad QRS complex tachycardias may be ventricular in origin or due to supraventricular tachycardia with aberrancy. Antidromic atrioventricular re-entrant tachycardia occurring in Wolff-Parkinson-White syndrome is a third possibility. The electrocardiogram is a key tool for distinguishing these tachycardias, which have differing causes, prognoses and treatment strategies. Ventricular tachycardia may be monomorphic or polymorphic. The management of ventricular tachycardia depends on clinical symptoms and is influenced by the presence of structural heart disease.

Variations of atrioventricular block.

Atrioventricular (AV) block comprises a spectrum of cardiac conduction delays with varying clinical presentations. It is commonly encountered in both hospital as well as ambulatory settings, and recognition of the type of AV conduction delay is essential for appropriate subsequent management. The electrocardiogram is a key tool for identification of patients with AV conduction delays. Contrasting management strategies should be employed for differing levels of conduction block.

Regular narrow complex tachycardia.

We discuss cases of paroxysmal supraventricular tachycardia (PSVT), including the patient's presentations and clinical courses. Correct interpretation of electrocardiogram (ECG) and detailed analyses are important in differentiating the various types of PSVT. This is crucial in the immediate and long-term management of these patients.

ECG delta waves in patients with palpitation.

It is important to recognise Wolff-Parkinson-White (WPW) syndrome in electrocardiograms (ECG), as it may mimic ischaemic heart disease, ventricular hypertrophy and bundle branch block. In addition, ECG can aid in the localisation of the accessory pathway. Recognising WPW syndrome allows for risk stratification, the identification of associated conditions and the institution of appropriate management.

ECG ST segment elevation in patients with chest pain.

We discussed three cases of ST elevation myocardial infarction with ST elevation in the inferoposterior territory and anterior territory, and more uncommonly, concomitant ST elevations in the anterior and inferior electrocardiography (ECG) leads. Correct interpretation of the ECG is crucial in recognising this cardiac emergency, which often necessitates urgent coronary revascularisation. In addition, ECG aids localisation of the infarct-related artery and adds prognostic value.

Prevalence and predictors of premature discontinuation of dual antiplatelet therapy after drug-eluting stent implantation: importance of social factors in Asian patients.

AIM: Premature discontinuation of antiplatelet therapy is an independent predictor of late stent thrombosis. We sought to determine the prevalence and predictors of premature discontinuation of antiplatelet therapy after drug-eluting stent implantation among patients in Asia. METHODS: A total of 207 consecutive patients who underwent drug-eluting stent implantation at our institution was followed up after 1 year. Premature discontinuation of antiplatelet therapy was defined as omission of aspirin and/or clopidogrel for 1 week or more. RESULTS: Four (1.9%) patients died and the remaining 203 patients formed the study population. Prevalence of premature discontinuation of antiplatelet therapy was 12.8% (n= 26, aspirin, n= 12; clopidogrel, n= 9; both, n= 5). The median duration between stent implantation and discontinuation of antiplatelet therapy was 2.8 months. Reasons for discontinuation included cost (n= 1), gastric discomfort (n= 1), allergy (n= 3), bleeding (n= 3), advice from doctors (n= 7) and no reason (n= 11). Logistic regression showed that living alone was the only independent predictor of premature discontinuation of dual antiplatelet therapy (50.0% vs 11.3%, P= 0.001). CONCLUSION: Among Asian patients who have undergone drug-eluting stent implantation, 12.8% discontinued dual antiplatelet therapy within 12 months. Living alone is associated with a fivefold increase in risk of premature drug discontinuation.

Utilisation of emergency medical service among Singapore patients presenting with ST-segment elevation myocardial infarction: prevalence and impact on ischaemic time.

BACKGROUND: Previous studies in Western countries found that the emergency medical service (EMS) was under-used in patients with myocardial infarction. AIM: We sought to determine the prevalence of immediate EMS utilisation among Singapore patients presenting with ST-segment elevation myocardial infarction (STEMI), and correlated the use of the EMS with the symptom-to-balloon and door-to-balloon times. METHODS: We studied 252 patients admitted with STEMI to our institution from August 2008 to September 2009. Information regarding demographic characteristics, whether EMS was used, reperfusion procedural details and mortality rates were collected prospectively. RESULTS: Among the recruited patients, 89 (35.3%) used the EMS (EMS group) and 163 (64.7%) did not use the EMS (non-EMS group). In the latter group, 98 (60.1%) arrived at our institution through their own transport, 56 (34.4%) first consulted general practitioners, and 9 (5.5%) initially consulted another hospital without acute medical services. Among the 245 (out of 252, 97.2%) patients who received percutaneous coronary intervention (PCI), the EMS group was more likely to undergo primary PCI (P= 0.003) while the non-EMS group was more likely to undergo non-urgent PCI (P= 0.002). In patients who underwent primary PCI, the EMS group had a shorter symptom-to-balloon time (average difference 81.6 min, P= 0.002). The door-to-balloon time was similar for both groups. CONCLUSION: Despite the availability of a centralised EMS, 64.7% of patients with STEMI did not contact EMS at presentation. These patients were less likely to receive primary PCI and had a significantly longer symptom-to-balloon time.

Simultaneous thromboses of multiple coronary arteries in acute myocardial infarction.

Simultaneous thrombotic occlusion of multiple coronary arteries in acute myocardial infarction is a well-recognised phenomenon. Studies have reported diffuse destabilisation of atherosclerotic plaques in patients with acute myocardial infarction, leading to the concept of "pan-coronaritis". The putative mechanism is attributed to a systemic thrombophilic and inflammatory state. We report the occurrence of this phenomenon in two middle-aged male patients.