Neutrophil/lymphocyte ratio is associated with right ventricular dysfunction in patients with acute inferior ST-segment elevation myocardial infarction.

BACKGROUND: Acute inferior ST-segment elevation myocardial infarction (STEMI) is associated with increased in-hospital morbidity and mortality particularly among patients with coexisting right ventricular (RV) involvement. High neutrophil to lymphocyte ratio (NLR) is an independent predictor of major adverse cardiac events and mortality in patients with myocardial infarction. This study evaluated the relationship between the NLR and RV dysfunction (RVD) in patients with inferior STEMI who underwent primary percutaneous coronary intervention (PCI). METHODS: A total of 213 subjects with inferior STEMI were divided into two groups according to the presence of RVD. The groups were compared according to NLR and receiver operating characteristic (ROC) analysis was performed to access the predictability of NLR on having RVD. RESULTS: The NLR was significantly higher in the group with RVD compared to that without RVD (p < 0.001). In ROC analysis, NLR > 3.5 predicted RVD with sensitivity of 83% and specificity of 55%. In a multivariate regression analysis, NLR remained an independent predictor of RVD (OR 1.55, 95% CI 1.285-1.750, p < 0.001). CONCLUSIONS: NLR was an independent predictor of RVD in patients with inferior STEMI undergoing primary PCI.

[The changes of inflammatory cytokines and their clinical significance in patients of inferior ST-segment elevation acute myocardial infarction with anterior ST-segment depression].

OBJECTIVE: To investigate the level of Hs-CRP, Fib,IL-6, TNF-α,MDA, SOD, and analyse the correlation between the level of plasma inflammatory cytokines and clinical significance in patients with anterior ST-segment depression. METHODS: We choose 360 patients with inferior ST Segment elevation acute myocardial infarction from May 2007 to Sep 2012 in rescue Center of Anzhen Hospital, in Anzhen Hospital, and all the patients received percutaneous coronary intervention treatment and the vascular lesions besides culprit vessel were observed. All the patients were divided into two groups: control group (n = 180) and anterior ST-segment depression group (n = 180). 8ml venous blood was obtained from all the patients, and then plasma were separated. The level of plasma Hs-CRP, Fib, IL-6, TNF-α, MDA, SOD were investigated by Biochemistry and ELISA. And the relativity between the level of plasma inflammatory cytokines and anterior ST-segment depression in patients with inferior acute myocardial infarction was analysed. RESULTS: The proportion of double vessel coronary disease, three coronary artery lesion is higher in anterior ST-segment depression group compared with control group (P < 0.01) . Compared with control group, the level of Hs-CRP, Fib, IL-6, TNF-α,MDA, SOD of anterior ST-segment depression group are inclined significantly (P < 0.01). CONCLUSION: The level of plasma inflammatory cytokines and the degree of lipid peroxidation can reflect the severity of coronary artery disease and may have certain value in predicting the severity of disease.

Should furosemide be avoided in acute right ventricular myocardial infarction?

BACKGROUND: Diuretics are conventionally prohibited in acute right ventricular myocardial infarction. AIMS: To assess the benefit of diuretics compared to fluid expansion in patients with inferior myocardial infarction extended to the right ventricule. METHODS: Of 295 patients admitted for inferior or posterior acute myocardial infarction between November 2008 and November 2010, 77 had a right ventricular extension. Among these 77 patients, 19 presented with oligoanuria (<0.5 mL/kg per hour) and no criteria for cardiogenic shock. Overall, 11 patients were treated by low dose of furosemide (40 to 80 mg) and eight received fluid expansion using isotonic saline solution. RESULTS: Baseline right ventricular dilatation and dysfunction, systolic blood pressure and heart rate were similar between the groups. Twenty-four hours after treatment, urine output was similar between the two groups but only the patients in the diuretic group improved their blood pressure (103 ± 16 mmHg versus 127 ± 20 mmHg, P < 0.001), heart rate (71 ± 15 bpm versus 76 ± 13 bpm, P = 0.03), creatinin level and alanine aminotrasferase plasmatic level. Hospitalization duration and the need of inotropic support were similar in the two groups. CONCLUSIONS: Diuretics and fluid expansion provide similar efficiency for triggering diuresis in patients with right ventricular infarction and oligoanuria but only diuretics seem to be associated with improvement in hemodynamic status and venous congestion.

A rare case of myocardial infarction related to diagnostic intravascular ultrasound.

A 71-year-old man underwent intracoronary stent implantation for acute inferior myocardial infarction (MI). Immediately after diagnostic intravascular ultrasound (IVUS) at 8 months' follow-up, an acute occlusion of the sinus node (SN) artery appeared, which developed sinus arrest with junctional escape rhythm. The serum level of high-sensitivity troponin T (TpT) was markedly elevated on the day after the procedure (2.1-32.5 ng/l), which was indicative of MI related to IVUS. Under continuous intravenous infusion of unfractionated heparin, the escape rhythm changed to lower atrial rhythm on the 4th day, and recovered to sinus rhythm on the 14th day. Coronary angiography (CAG) on 15th day showed a recanalization of the SN artery, but optical coherence tomography identified that disrupted plaque and white thrombus still existed in the ostium of the SN artery. The patient was discharged on maintenance anticoagulation therapy. We hypothesized from this case that IVUS-related myocardial injury may exist without clinical problems. Our retrospective investigation showed that the median levels of high-sensitivity TpT in 20 patients who underwent CAG and subsequent diagnostic IVUS significantly increased from 0.6 (interquartile range 0.3-1.1) to 1.6 (0.7-3.6) ng/l (P < 0.05), suggesting that IVUS may induce very low levels of myocardial injury. In conclusion, we experienced a rare case of IVUS-related MI caused by an acute occlusion of the SN artery. This case reaffirms that we should pay more attention to manipulation of IVUS catheters.

N-terminal pro-brain natriuretic peptide and electrocardiographic variables associated with increased risk of complete atrioventricular block and mortality in patients with acute inferior myocardial infarction.

BACKGROUND: Although brain natriuretic peptide (BNP) levels are shown to be an important prognostic factor in patients with acute myocardial infarction (MI), the relationship between arrhythmias and BNP levels is not known. This study assessed whether baseline clinical factors, N-terminal-proBNP (NT-proBNP) levels and electrocardiographic patterns of acute inferior MI are associated with greater risk of developing complete atrioventricular block (CAVB) and mortality. METHODS AND RESULTS: Seventy-nine consecutive patients (52 male, 27 female with an avarage age of 64.2 ± 10.9 years) with CAVB and 119 control patients (93 male, 16 female with an average age of 57.7 ± 11.4 years) without CAVB were enrolled. Regression analysis revealed that NT-proBNP levels 〉 104 pg/mL increased the development of CAVB by 16.7 folds, 〉 1 mm ST elevation in RV4 by 2.7 folds, ratio of elevation in lead III:II 〉 1.5 by 10.1 folds but the thrombolytic therapy decreased the development of CAVB by 2.8 folds. NT-proBNP 〉 92 pg/mL increased the mortality by 8.9 folds, a ratio of ST-segment elevation in lead III:II 〉 1 by 3.1 folds, ST segment elevation 〉 1 mm in RV4 by 3.5 folds, ejection fraction 〈 35% by 24.2 folds, age 〉 65 years by 8.3 folds and CAVB by 6.8 folds, on contrary thrombolytic treatment decreased the mortality by 3.3 folds. CONCLUSIONS: Simple electrocardiographic measurements and NT-proBNP levels at admission can be used as a screening test for development of complications such as CAVB, right ventricular involvement and mortality during acute inferior wall MI.

Superior early diagnostic performance of a sensitive cardiac troponin assay as compared to a standard troponin test in the diagnosis of acute myocardial infarction.

BACKGROUND: New generation cardiac troponin assays have sufficient precision to detect and quantify plasma troponin concentrations below the lower threshold of detection of the currently employed troponin tests. However, diagnostic performance of the newer generation assays in daily clinical practice is not well established. AIM: To evaluate the diagnostic performance of a sensitive assay as compared to a standard assay in a single reading at admission in the diagnosis of acute myocardial infarction (AMI) in patients presenting to the Emergency Department with chest pain. METHODS: The study comprised 187 consecutive patients admitted to the Institute of Cardiology in Warsaw in June and July 2010 with chest pain in whom the attending physician ordered troponin assay to rule AMI in or out. In all of these patients, in addition to the standard Dimension Flex Troponin I (Siemens Healthcare Diagnostics, Inc.) the sensitive Architect Stat Troponin I (Abbott Diagnostics) test was assayed. The triage of patients as well as all diagnostic and treatment decisions were left to the discretion of the attending physician who was blinded to the sensitive troponin test readings. The final diagnosis was adjudicated by a team of two cardiologists on the basis of all the available medical records except for sensitive troponin test results. RESULTS: Mean age of the study cohort (n = 187) was 64.3 ± 13.9 years and 119 (63.6%) were males. The final diagnosis of AMI was adjudicated in 84 (44.9%) patients (mean age 67.5 ± 12.9 years; 119 [63.6%] males). Receiver operating characteristic (ROC) analysis showed greater area under the curve (AUC) for the sensitive cardiac troponin assay compared to the standard assay (AUC = 0.916, 95% CI = 0.866-0.951 vs AUC = 0.863, 95% CI = 0.806-0.909, respectively; p = 0.02) in a single reading at admission. Sensitive assay was characterised by higher sensitivity (87%), specificity (88%), positive (86%) and negative (89%) predictive values in the detection of AMI compared to the standard troponin test (82%, 81%, 78%, and 85% respectively). CONCLUSIONS: The newer generation sensitive cardiac troponin assay presented superior diagnostic accuracy in the diagnosis of AMI compared to the standard troponin test in a single reading at admission with improved sensitivity and specificity. The sensitive troponin assay has the potential to improve early detection and/or exclusion of AMI.

Comparison of prognostic outcome between left circumflex artery-related and right coronary artery-related acute inferior wall myocardial infarction undergoing primary percutaneous coronary intervention.

BACKGROUND: This study evaluated the 30-day clinical outcome of patients with acute inferior wall ST-elevation myocardial infarction (AIW-STEMI) from occlusion of the left circumflex artery (LCX) vs the right coronary artery (RCA) undergoing primary percutaneous coronary intervention (PCI). HYPOTHESIS: The clinical outcomes of AIW-STEMI caused by RCA and LCX occlusion may be different for patients undergoing primary PCI. METHODS: Between May 2002 and September 2009, 646 consecutive patients with AIW-STEMI undergoing primary PCI were enrolled. Of these patients, 520 (80.5%) with AIW-STEMI caused by RCA occlusion were categorized into group 1, whereas the remaining 126 (19.5%) whose AIW-STEMI was caused by LCX occlusion served as group 2. RESULTS: The results demonstrated that the frequency of advanced congestive heart failure, respiratory failure requiring mechanical ventilatory support, and 30-day mortality were remarkably higher in group 2 than in group 1 (all P < 0.01). Conversely, the incidence of right ventricular infarction and complete heart block were notably higher in group 1 than in group 2 (all P < 0.001). Additionally, the peak level of creatine kinase-isoenzyme MB was significantly higher, whereas the left ventricular ejection fraction was notably lower in group 2 than in group 1. Multivariate analysis demonstrated that advanced CHF, high serum creatinine level, low systolic blood pressure, low left ventricular ejection fraction, and LCX as the infarct-related artery were significantly and independently predictive of 30-day mortality (all P < 0.05). CONCLUSIONS: The 30-day prognostic outcome was less favorable in LCX-related AIW-STEMI compared with RCA-related AIW-STEMI undergoing primary PCI.

Optimal positioning in the detection of inferior wall infarct size with myocardial perfusion scintigraphy: prone vs. supine.

OBJECTIVE: The prone position is commonly utilized to reduce false positive perfusion defects because this position overcomes the diaphragmatic inferior wall attenuation in single-photon emission computerized tomography (SPECT) studies. We investigated whether the prone position had an important advantage over the supine position in determining the severity and extent of infarct in patients with acute inferior myocardial infarction (MI). METHODS: Twenty-nine male patients (mean age 61 ± 10 years) with acute inferior MI were enrolled in the cross-sectional study. After injection of thallium-201 (201Tl) under resting conditions, redistribution SPECT imaging was twicely performed in each subject, in both the supine and prone positions, consecutively. The extent and severity scores of the perfusion defects were calculated from the sum of individual segment scores. Myocardial infarction size was also evaluated using peak cardiac troponin T (cTnT) levels. Wilcoxon rank and Spearman's rank correlation tests were used for statistical analyses of data. RESULTS: For the supine vs. prone positions, the median defect severity scores were 8 (4-13) vs. 5 (0.5-8.5) and the defect extent scores were 4 (3-5.5) vs. 3 (0.5-4.5), respectively. Both perfusion defect scores in the prone position were significantly lower than those in the supine position (p=0.001). The mean peak cTnT level during hospitalization was 7.2 ± 3.9 µg/l. Peak cTnT levels were correlated with all SPECT parameters. However, the correlation was greater in the prone position (defect severity: r=0.712, p=0.001) (defect extent: r=0.790, p=0.001) than in the supine position (defect severity: r=0.495, p=0.01) (defect extent: r=0.481, p=0.01). CONCLUSION: In patients with inferior MI, the SPECT results revealed a significant difference between the supine and prone images. The perfusion extent and severity scores of SPECT in the inferior wall with prone imaging correlates better with the peak troponin compared to the supine position. Comparative studies that use advanced imaging tools are needed to verify our present findings.