The role of modern cardiovascular imaging in (suspected) coronary artery disease in competitive athletes.

This overview addresses different non-invasive imaging methods in diagnosing CAD before clearing the athlete for participation in sports activity. Keep in mind the risks and benefits of exercising for the competitive athlete and to use the SCORE-information as a first evaluation tool. It is essential to gather relevant information and to complement anatomical evaluations with functional evaluations. Exercise testing also has an added value in athletes as it will inform both the physician and the athlete on the aerobic fitness of the individual, a key factor in risk assessment.

Effects of ex vivo platelet supplementation on platelet aggregability in blood samples from patients treated with acetylsalicylic acid, clopidogrel, or ticagrelor.

BACKGROUND: Transfusion of platelet concentrate is often used to treat bleeding in patients on platelet inhibitors, but little is known about its efficacy between different inhibitors. We assessed the effect of ex vivo platelet supplementation on platelet aggregability in blood samples from patients treated with acetylsalicylic acid (ASA), clopidogrel, or ticagrelor. METHODS: Platelet aggregability was investigated with multiple electrode aggregometry with adenosine diphosphate (ADP), arachidonic acid (to assess ASA-dependent aggregability), and thrombin receptor activating peptide-6 (TRAP) as activators in whole-blood samples from patients treated with ASA (n=10), ASA+clopidogrel (n=15), or ASA+ticagrelor (n=15), and from healthy controls (n=10). Aggregability was measured before and after supplementation of AB0-compatible fresh apheresis platelets (+46, +92, and +138×10(9) litre(-1)). RESULTS: Both ASA-dependent and ADP-dependent aggregability improved in a dose-dependent fashion after platelet supplementation. ASA-dependent aggregability was completely restored in all patient groups, but there was only a small improvement in ADP-dependent aggregability in patients on dual antiplatelet therapy. There was less effect of platelet supplementation on ADP- and ASA-dependent aggregability in ticagrelor-treated patients than in clopidogrel-treated patients [3.9 (95% confidence interval 1.6-6.3) vs 9.0 (5.2-12.8) AU×min (P=0.021) and 48 (36-59) vs 69 (60-78) AU×min (P=0.004), respectively, at the highest platelet dose]. CONCLUSIONS: Platelet supplementation improved platelet aggregability independently of antiplatelet therapy. The effect on ADP-dependent platelet inhibition was limited however. Reduced effect of platelet transfusion is more likely within 2 h of drug intake in patients treated with ASA+ticagrelor compared with ASA+clopidogrel.

Admission N-terminal pro-brain natriuretic peptide and its interaction with admission troponin T and ST segment resolution for early risk stratification in ST elevation myocardial infarction.

OBJECTIVE: To assess the long term prognostic value of N-terminal pro-brain natriuretic peptide (NT-proBNP) on admission and its prognostic interaction with both admission troponin T (TnT) concentrations and resolution of ST segment elevation in fibrinolytic treated ST elevation myocardial infarction (STEMI). DESIGN AND SETTING: Substudy of the ASSENT (assessment of the safety and efficacy of a new thrombolytic) -2 and ASSENT-PLUS trials. PATIENTS: NT-proBNP and TnT concentrations were determined on admission in 782 patients. According to NT-proBNP concentrations, patients were divided into three groups: normal concentration (for patients < or = 65 years, < or = 184 ng/l and < or = 268 ng/l and for those > 65 years, < or = 269 ng/l and < or = 391 ng/l in men and women, respectively); higher than normal but less than the median concentration (742 ng/l); and above the median concentration. For TnT, a cut off of 0.1 microg/l was used. Of the 782 patients, 456 had ST segment resolution (< 50% or > or = 50%) at 60 minutes calculated from ST monitoring. MAIN OUTCOME MEASURES: All cause one year mortality. RESULTS: One year mortality increased stepwise according to increasing concentrations of NT-proBNP (3.4%, 6.5%, and 23.5%, respectively, p < 0.001). In receiver operating characteristic analysis, NT-proBNP strongly trended to be associated more with mortality than TnT and time to 50% ST resolution (area under the curve 0.81, 95% confidence interval (CI) 0.72 to 0.9, 0.67, 95% CI 0.56 to 0.79, and 0.66, 95% CI 0.56 to 0.77, respectively). In a multivariable analysis adjusted for baseline risk factors and TnT, both raised NT-proBNP and ST resolution < 50% were independently associated with higher one year mortality, whereas raised TnT contributed independently only before information on ST resolution was added to the model. CONCLUSION: Admission NT-proBNP is a strong independent predictor of mortality and gives, together with 50% ST resolution at 60 minutes, important prognostic information even after adjustment for TnT and baseline characteristics in STEMI.

Long term risk stratification of patients with acute coronary syndromes: characteristics of troponin T testing and continuous ST segment monitoring.

OBJECTIVE: To examine the long term prognostic characteristics of troponin T testing and continuous multi-lead ST segment monitoring in combination with clinical and 12 lead ECG risk indicators in patients with acute coronary syndromes (ACS). PATIENTS AND DESIGN: Patients with suspected ACS (n = 213) were studied. Troponin T was analysed in blood samples collected during the first 12 hours after admission. Continuous vectorcardiography ST segment monitoring was performed for 24 hours and the number of ST vector magnitude episodes was registered. Patients were followed up for a median of 28 months. The end point was a composite of cardiac death and acute myocardial infarction. RESULTS: Thirty eight (18%) patients reached the composite end point. The median (interquartile range) time from study inclusion to the time of the composite end point was longer for patients predicted to be at risk by troponin T testing (n = 27) than for those predicted to be at risk by ST segment monitoring (n = 20) (8.4 (0.2-15) months v 0.3 (0.1-4.3) months, p = 0.04). Significant univariate predictors of the composite end point were age > or = 65 years, diabetes, previous myocardial infarction, congestive heart failure, use of beta blockers or diuretics at admission, 12 lead ECG ST segment depression at admission, troponin T concentration > or = 0.10 microg/l, and > or = 1 ST vector magnitude episodes. Age > or = 65 years, previous myocardial infarction, and troponin T concentration > or = 0.10 microg/l provided independent prognostic information after multivariate analysis of potential risk variables. The prognostic value of transient ischaemic episodes in ACS seems to be confined to the short term. CONCLUSIONS: Both biochemical and continuous ECG markers reflect an increased risk for patients with ACS; however, the methods exhibit different temporal risk characteristics.

Continuous ST-segment monitoring of patients with left bundle branch block and suspicion of acute myocardial infarction.

OBJECTIVES: Patients with left bundle branch block comprise 5-9% of all patients with acute myocardial infarction. Limited data exist on the usefulness of continuous electrocardiographic monitoring of these patients. We have investigated prospectively the usefulness of real-time continuous vectorcardiography for monitoring patients with left bundle branch block and suspicion of acute myocardial infarction. DESIGN: A prospective multi-centre study. SETTING: Fourteen Swedish coronary care units. SUBJECTS: Patients with left bundle branch block and suspicion of acute myocardial infarction with <6-h symptom duration were included. MAIN OUTCOME MEASURES: All patients were monitored with continuous vectorcardiography for 12-24 h. RESULTS: One hundred thirty-three patients were included, 47% had acute myocardial infarction. Patients with acute myocardial infarction showed a marked relative decrease in ST-vector than those without (P = 0.0002). These changes were most marked in the first 90 min. When comparing patients with acute myocardial infarction receiving thrombolytic therapy or not, those treated with thrombolytics showed more marked decline in ST-vector magnitude (P < 0.0001) and in shorter time (P = 0.0017). All patients showed STC-vector magnitude changes that were more marked in patients with acute myocardial infarction (P = 0.0002). An STC-vector magnitude cut-off value of 65 microV after 90 min of monitoring gave 54% sensitivity and 72% specificity for diagnosis of acute myocardial infarction. CONCLUSION: Real-time continuous vectorcardiographic monitoring of patients with left bundle branch and suspicion of acute myocardial infarction shows significant differences between those with and without acute myocardial infarction and could be of use for early diagnosis and subsequent monitoring.

Continuous multilead ST-monitoring identifies patients with unstable coronary artery disease who benefit from extended antithrombotic treatment.

AIMS: Prolongation of anticoagulant treatment might reduce subsequent cardiac events in patients with unstable coronary artery disease. Multilead ST-segment monitoring identifies patients with a high risk of adverse outcome. The aim was to assess the value of multilead ST-monitoring in prospectively identifying patients who respond to extended anticoagulant treatment with low-molecular weight heparin when treated by a primarily non-invasive strategy. METHODS AND RESULTS: In this substudy of the FRISC II trial, ST-monitoring with a continuous 12-lead ECG or vectorcardiography was performed for 24 h in 629 patients with unstable coronary artery disease randomized to receive either the low-molecular weight heparin dalteparin, or placebo for 3 months after at least 5 days' dalteparin treatment in all patients. Ischaemic episodes were detected in 34% during ST-monitoring. In the group with ischaemic episodes, the extended dalteparin treatment was associated with a lower rate of death, myocardial infarction, or revascularization (35.2% vs 53.4%, relative risk reduction: 34%, P=0.01). In patients without ischaemic episodes, long-term dalteparin treatment had no effect. CONCLUSIONS: In patients with unstable coronary artery disease treated primarily with a non-invasive strategy, ischaemic episodes revealed while on multilead ST-monitoring identifies patients who benefit most from extended treatment with anticoagulants.

ST variability during the first 4 hours of acute myocardial infarction predicts 1-year mortality.

BACKGROUND: Early and complete myocardial reperfusion is the goal when treating a patient with acute myocardial infarction. To achieve this in each individual, an on-line, accurate, easily handled and preferably noninvasive technique to monitor flow alterations is needed. Recurrent ST-segment elevation has been shown to reflect cyclic disturbances in perfusion. METHODS: We have retrospectively analyzed ST variability in 102 patients with acute myocardial infarction randomized to 100 mg of rt-Pa or placebo. Patients were monitored for 24 hours using vectorcardiography. RESULTS: Patients alive at one year (86%) had significantly less ST variability during the first four hours: 4.3 versus 7.1 episodes, P = 0.007. Patients having six or more ST episodes showed a 31.3% one-year mortality as compared to no mortality in patients having no ST variability. Furthermore ST variability was reduced by fibrinolysis. CONCLUSION: Early ST variability detectable in real time is associated with worse outcome.

Continuous ST monitoring: a bedside instrument? A report from the Assessment of the Safety of a New Thrombolytic (ASSENT 2) ST monitoring substudy.

BACKGROUND: Continuous ST monitoring has during the past decade become widespread in coronary care units (CCU) and is now even recommended by international task forces to survey patients with acute coronary syndromes. ST monitoring has also been shown to be a well-validated technology to predict prognosis and coronary artery patency in patients with acute ST-elevation infarction. However, all evaluations in previously presented trials have been made inside a core laboratory by specially trained personnel. METHODS: In the Assessment of the Safety and Efficacy of a New Thrombolytic (ASSENT 2) ST-monitoring substudy, 448 patients with ST-elevation infarction from 22 hospitals were monitored by vectorcardiography. The local nurse responsible for the patient made an evaluation of the ST trend curve. This was compared with a blinded core laboratory evaluation and examined versus 30-day mortality. RESULTS: No significant differences were found between the local and central evaluations of ST-segment recovery. The accuracy of the local evaluation, compared with the central one, in deciding whether patients had > or = 50% ST-segment recovery at 60 or 90 minutes was > 90%. A large low-risk group (30% of the patients) with 0.8% 30-day mortality could be identified by the local evaluation. CONCLUSIONS: ST monitoring with vectorcardiography can accurately be done in the clinical setting. The local evaluation was as least as accurate as the core laboratory evaluation in predicting prognosis.

Clinical implications of early ST-segment variability. A report from the ASSENT 2 ST-monitoring sub-study.

OBJECTIVES: Evolution of the ST-segment during acute myocardial infarction has been shown to yield more information on prognosis than invasive measurements. By continuous ST-monitoring even very occasional dynamic changes can be analysed. We have recently suggested these variations to be of prognostic importance and possibly reflect individual abilities to deal with a vascular event. We wanted to confirm these findings. METHODS: Four hundred and forty-eight patients were included in the vectorcardiographic sub-study of the second Assessment of Safety and Efficacy of a New Thrombolytic (ASSENT 2) trial. Patients underwent 24 h of ST-monitoring. ST-trend curves were blindly analysed by two independent observers. RESULTS: ST-variability, defined as an increase of the ST-segment shift of > or = 25 microV for 2 min or more, was found to predict death, reinfarction at 30 days or urgent revascularization. By combining variability with resolution of the ST-segment elevation we could identify a high-risk group with 9.9%, and a low-risk group with only 0.8% 30-day mortality. Hypertensive patients, suggested to have an impaired secretion of endogenous t-PA, expressed significantly more ST-variability, possibly a non-invasive marker of impaired capability of dissolving and preventing thrombi. CONCLUSION: Small variations in ST-segment shift during the first 4 h of acute myocardial infarction predict worse outcome.

Vectorelectrocardiography in coronary artery disease.

Continuous ST-segment monitoring by either continuous 12-lead ECG or continuous vectorcardiography provides reliable information regarding ST changes in patients with ongoing myocardial ischemia with or without concurrent chest pain. ST-segment monitoring enables the clinician to continuously follow the dynamic changes that characterize unstable angina and acute myocardial infarction syndromes. It provides important information for risk stratification in unstable coronary syndromes and helps in differentiating between extra-cardiac chest pain and acute coronary disease. The use of VECG for detection of perioperative myocardial damage is promising but much work still needs to be done to clarify the prognostic and clinical value of VECG in this setting.

ECG criteria in diagnosis of acute myocardial infarction in the presence of left bundle branch block.

BACKGROUND: The diagnosis of acute myocardial infarction in the presence of left bundle branch block is difficult. Recently a diagnostic ECG scoring system was suggested, showing good diagnostic abilities. This scoring system has never been tested in a prospective manner; we have done so and investigated if it might bear prognostic information. METHODS: A prospective multi-centre study. Consecutive patients with left bundle branch block and suspicion of acute myocardial infarction, admitted to 14 Swedish coronary care units. Recruitment from March 1996 to December 1997. ECG registered on admission and after 12-24 h. RESULTS: One hundred and fifty-eight patients were included, mean age 74.9 years. Seventy-six patients (48%) had an acute myocardial infarction. The proposed cut-off total score of > or = 3 of the ECG scoring system for the diagnosis of acute myocardial infarction had a sensitivity of 17.1% (95% CI 8.6-25.6%) and specificity of 94.0% (95% CI 88.9-99.1%). Clinical judgement of acute myocardial infarction resulted in a sensitivity of 15.8% (95% CI 7.6-24%) and specificity of 96.0% (CI 92.3-100%). No difference was seen in 3-month or 1-year survival between those with total ECG score > or = 3 versus total score < 3. CONCLUSION: The diagnostic abilities of the proposed ECG criteria are low and not better than the clinical judgement. The criteria are therefore not suitable for screening patients with suspicion of acute myocardial infarction in the presence of left bundle branch block, nor do they seem to identify high risk patients.

Comparison of continuous vectorcardiography and continuous 12-lead electrocardiography of patients with unstable coronary artery disease: do they identify the same population?

BACKGROUND: Continuous vectorcardiography (cVCG) and continuous 12-lead electrocardiography (c12ECG) are important tools for assessing patients with unstable coronary artery disease. OBJECTIVE: To compare the incidences of ischemia detected by the two methods, and examine whether the patients identified belonged to the same population, with respect to various clinical variables. METHODS: Within a randomized prospective trial (FRISC II) including patients with unstable coronary artery disease, ST-segment monitoring was performed either by cVCG or by c12ECG for 24 h after admission for 1016 patients. RESULTS: cVCG and c12ECG were performed for 730 and 286 patients, respectively. Transient ischemic episodes in 253 (34.7%) patients were detected by cVCG and such episodes were detected in 91 (31.8%) patients by c12EGG. When patients in whom transient ischemic episodes had been detected by cVCG and c12ECG were compared, the groups were similar with respect to baseline characteristics, signs of myocardial damage (67.5 versus 70.5%), occurrence of exercise-induced ischemia (59.0 versus 60.0%), and presence of severe coronary lesions (57.0 versus 51.3%). CONCLUSIONS: Results of this study suggest that these two methods identify the same high-risk population, and that these patients can be considered one group when results obtained using either system are analyzed in multicenter studies. This also implies that results concerning the occurrence of episodes of resting ischemia obtained using one system may also be applicable for the other.

Early assessment of long-term risk with continuous ST-segment monitoring among patients with unstable coronary syndromes. Results from 1-year follow-up in the TRIM study.

A total of 323 patients who took part in the TRIM trial underwent an initial 24 h continuous electrocardiogram ST-segment monitoring. A ST vector magnitude (ST-VM) maximum > or = 144 microV predicted death or myocardial infarction within 1 year with a 78% specificity and a 52% sensitivity, an area under the ST-VM trend curve > or = 162 mu with a 86% specificity and a 42% sensitivity and presence of ST-VM episodes with a 70% specificity and a 68% sensitivity. Patients who had neither ST-VM episodes nor a ST-maximum > or = 144 microV had only a 4.5% incidence of death or myocardial infarction within one year as compared to 18% among those patients who met any of these criteria. ST-segment monitoring with continuous vectorcardiography is feasible for risk stratification at least up to 1 year after an episode of unstable coronary artery disease and several vectorcardiographic parameters may be used.

Changes in the use of medications after acute myocardial infarction: possible impact on mortality after myocardial infarction and long-term outcome.

OBJECTIVE: To describe the change in the use of medication after acute myocardial infarction (AMI) and discuss its possible impact on risk and risk indicators for death. PATIENTS: All patients discharged alive after hospitalization for AMI at Sahlgrenska Hospital (covering half the community of Göteborg, i.e. 250,000 of 500,000 inhabitants) during 1986-1987 (period I) and at Sahlgrenska Hospital and Ostra Hospital (covering the whole community of Göteborg, 500,000 inhabitants) during 1990-1991 (period II). METHODS: Overall mortality was retrospectively evaluated during 5 years of follow-up. RESULTS: In all, 740 patients were included in the study during period I and 1448 during period II. The 5-year mortalities were 44.1% for period I patients and 39.3% for period II patients (P = 0.036). The relative risk of death for period II patients was 0.78 [95% confidence interval (CI) 0.67-0.89, P = 0.0005] after adjustment for differences at baseline. There was a significant interaction with a history of congestive heart failure; improvement in duration of survival was found only for patients without such a history. During period I, only 3% of patients were administered fibrinolytic agents, compared with 33% of patients during period II (P < 0.0001). During period I, aspirin was prescribed for 13% of patients discharged from hospital compared with 79% during period II. Other changes in treatment on going from period I to period II included increases in prescription of beta-blockers and angiotensin converting enzyme inhibitors. After adjustment for various risk indicators for death, relative risk of death for those administered fibrinolytic agents was 0.60 (95% CI 0.18-2.02) for patients in the period-I cohort and 0.68% (95% CI 0.51-0.91) for those in the period-II cohort. Adjusted relative risk of death for those prescribed aspirin upon discharge from hospital was 0.81 (95% CI 0.52-1.25) for period-I patients and 0.71 (95% CI 0.56-0.91) for period-II patients. The adjusted relative risk of death for those administered beta-blockers was 0.72 (95% CI 0.55-0.96) for period-I patients and 0.70 (95% CI 0.55-0.90) for period-II patients. CONCLUSION: Increased use of fibrinolytic agents and aspirin for AMI as well as a moderate increase in use of beta-blockers and angiotensin converting enzyme inhibitors was associated with a parallel reduction in age-adjusted mortality during the 5 years after discharge from hospital. However, this improvement was seen only for patients without histories of congestive heart failure.

Early reperfusion assessment and repeated thrombolysis in acute myocardial infarction estimated by repeated standard electrocardiography. A randomised, double-blind, placebo-controlled pilot study.

Thrombolytic therapy with streptokinase (SK) in acute myocardial infarction (AMI) does not result in early reperfusion in approximately 25% of patients. We hypothesized that early repeated thrombolysis with rt-PA in patients with early failed reperfusion would result in myocardial reperfusion. Fifty-nine AMI patients with a symptom delay of <6 h, treated with SK were included. ECG was taken on admission and after 90 and 180 min. An ST recovery of > or =25% at 90 min was interpreted as successful reperfusion. Sixteen patients had failed reperfusion at 90 min and were randomized to repeated thrombolysis with rt-PA or placebo. At 180 min from SK start, ST recovery was higher in the placebo group than in the rt-PA group (71 vs. 40%, p = 0.05). No serious bleeding complications were observed. Due to the limited sample size it was not possible to draw prominent conclusions.

Long-term outcome in congenitally corrected transposition of the great arteries: a multi-institutional study.

OBJECTIVES: The purpose of this study was to determine long-term outcome in adults with congenitally corrected transposition of the great arteries (CCTGA), with particular emphasis on systemic ventricular dysfunction and congestive heart failure (CHF). BACKGROUND: Patients with CCTGA have the anatomical right ventricle as their systemic pumping chamber, with ventricular dysfunction and CHF being relatively common in older adults. METHODS: Retrospective analysis of records of 182 patients from 19 institutions were reviewed to determine current status and possible risk factors for systemic ventricular dysfunction and CHF. Factors considered included age, gender, associated cardiac defects, operative history, heart block, arrhythmias and tricuspid (i.e., systemic atrioventricular) regurgitation (TR). RESULTS: Both CHF and systemic ventricular dysfunction were common in groups with or without associated cardiac lesions. By age 45, 67% of patients with associated lesions had CHF, and 25% of patients without associated lesions had this complication. The rates of systemic ventricular dysfunction and CHF were higher with increasing age, the presence of significant associated cardiac lesions, history of arrhythmia, pacemaker implantation, prior surgery of any type, and particularly with tricuspid valvuloplasty or replacement. Aortic regurgitation (a previously unreported problem) was also relatively common in this patient population. CONCLUSIONS: Patients with CCTGA are increasingly subject to CHF with advancing age; this complication is extremely common by the fourth and fifth decades. Tricuspid (systemic atrioventricular) valvular regurgitation is strongly associated with RV (anatomical right ventricle connected to aorta in CCTGA patients; systemic ventricle in CCTGA) dysfunction and CHF; whether it is causative or a secondary complication remains speculative.

Reduced thiamine phosphate, but not thiamine diphosphate, in erythrocytes in elderly patients with congestive heart failure treated with furosemide.

OBJECTIVES: To measure the concentrations of thiamine and thiamine esters by high-pressure liquid chromatography (HPLC) in elderly patients treated with furosemide for heart failure and in a control group. DESIGN: A cross-sectional study of blood thiamine and thiamine ester concentrations. SUBJECTS: Forty-one patients admitted to hospital for heart failure and 34 elderly living at home. No vitamin supplementation was allowed. RESULTS: Compared with the healthy controls, furosemide-treated patients had significantly reduced whole blood thiamine phosphate (TP; 4.4 +/- 2.2 vs. 7.6 +/- 2.0 nmol L-1) and thiamine diphosphate (TPP; 76 +/- 21.5 vs. 91 +/- 19.8 nmol L-1) (mean +/- SD). When the thiamine concentrations were related to the haemoglobin concentrations, which were reduced in the heart failure patients, the levels of TP (nmol g-1 Hb) were 0.38 +/- 0.26 vs. 0.54 +/- 0.17 (P < 0.0001), and of TPP were 6.35 +/- 1.76 vs. 6.37 +/- 1.29 (P = 0.95). There were no differences in T and TP concentrations in plasma between the two groups. CONCLUSIONS: The elderly patients with heart failure treated with furosemide have not reduced the storage form of thiamine, TPP, but only TP. This change is most likely not an expression of a thiamine deficiency, but rather of an altered metabolism of thiamine, which is not understood at present.

[Perimyocarditis--a diagnostic dilemma with good prognosis]. / Perimyokardit--diagnostiskt dilemma med god prognos.

Ninety-five patients diagnosed as having perimyocarditis were followed up after a median follow-up time of 66 months. Ninety patients were alive and one patient had died a noncardiac death. Forty-one patients (44%) had leakage of markers of myocardial damage (CKMB or CK) in the acute stage. Seventy-nine patients (83%) were reached for a telephone interview. Sixty patients were in class I, 16 patients were in class II and two patients were in NYHA class III. There was no relation between leakage of myocardial markers and functional class. We conclude that uncomplicated perimyocarditis is a benign disease with excellent prognosis for longterm survival. Leakage of myocardial markers is common, but does not seem to be associated with worse prognosis.