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Shaban EE, Shaban AE, Shokry A, Iftikhar H, Zaki HA. Atrial Fibrillation With Decompensated Heart Failure Complicated With Non-ST Elevation Myocardial Infarction. Cureus 2022; 14:e21050. [PMID: 35155017 PMCID: PMC8824455 DOI: 10.7759/cureus.21050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2022] [Indexed: 12/03/2022] Open
Abstract
Non-ST-elevation myocardial infarction (NSTEMI) has a less severe ratio of acute coronary syndromes compared with ST-segment elevation myocardial infarction (STEMI), arising from complete occlusion of a major coronary artery. The name implies a syndrome that does not exhibit the dramatic ST-elevation seen in the traditional 12-lead ECG in chest pain patients with a confirmed diagnosis of STEMI. The crucial clinical significance of NSTEMI is that delay in diagnosis can lead to increased morbidity, risk of arrhythmia, and death. It was recently reported that atrial fibrillation (AF) correlates with the risk rise of myocardial infarction (MI), although the mechanism underlying this association is currently unknown. Does atrial fibrillation with decompensated heart failure (DHF) get complicated with NSTEMI? In this article, we describe the case of a 77-year-old male patient diagnosed and admitted as NSTEMI complicated by DHF.
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Lin M, Jiang M, Zhao M, Ukwatta E, White J, Chiu B. Cascaded triplanar autoencoder M-Net for fully automatic segmentation of left ventricle myocardial scar from three-dimensional late gadolinium-enhanced MR images. IEEE J Biomed Health Inform 2022; 26:2582-2593. [DOI: 10.1109/jbhi.2022.3146013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Glomerular Filtration Rate as a Predictor of Outcome in Acute Coronary Syndrome Complicated by Atrial Fibrillation. J Clin Med 2020; 9:jcm9051466. [PMID: 32422873 PMCID: PMC7290385 DOI: 10.3390/jcm9051466] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 05/12/2020] [Indexed: 01/09/2023] Open
Abstract
The close relationship between kidney and heart is well known. Cardiovascular impairment contributes to the worsening of renal function and kidney failure worsens cardiovascular health. Atrial fibrillation (AF) is a frequent issue in patients with Chronic Kidney Disease (CKD) and several studies have demonstrated that AF impacts negatively on their quality of life and outcomes. Understanding the mechanisms leading to the progression of CKD, new-onset AF and acute myocardial infarction (AMI) is a key issue. The evaluation of Glomerular Filtration Rate (GFR) could make the difference in this equilibrium and suggests specific strategies in the treatment of the population at major risk of cardiovascular events. This intriguing connection paves the way for necessary further investigations.
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Maffei E, Seitun S, Guaricci AI, Cademartiri F. Chest pain: coronary CT in the ER. Br J Radiol 2016; 89:20150954. [PMID: 26866681 PMCID: PMC4985473 DOI: 10.1259/bjr.20150954] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 01/14/2016] [Accepted: 01/20/2016] [Indexed: 01/16/2023] Open
Abstract
Cardiac CT has developed into a robust clinical tool during the past 15 years. Of the fields in which the potential of cardiac CT has raised more interest is chest pain in acute settings. In fact, the possibility to exclude with high reliability obstructive coronary artery disease (CAD) in patients at low-to-intermediate risk is of great interest both from the clinical standpoint and from the management standpoint. Several other modalities, with or without imaging, have been used during the past decades in the settings of new onset chest pain or in acute chest pain for both diagnostic and prognostic assessment of CAD. Each one has advantages and disadvantages. Most imaging modalities also focus on inducible ischaemia to guide referral to invasive coronary angiography. The advent of cardiac CT has introduced a new practice diagnostic paradigm, being the most accurate non-invasive method for identification and exclusion of CAD. Furthermore, the detection of subclinical CAD and plaque imaging offer the opportunity to improve risk stratification. Moreover, recent advances of the latest generation CT scanners allow combining both anatomical and functional imaging by stress myocardial perfusion. The role of cardiac CT in acute settings is already important and will become progressively more important in the coming years.
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Affiliation(s)
- Erica Maffei
- Centre de Recherché/Department of Radiology, Montréal Heart Institute/Universitè de Montréal, Montréal, Quebec, Canada
| | - Sara Seitun
- Department of Radiology, IRCCS San Martino University Hospital—IST, Genoa, Italy
| | | | - Filippo Cademartiri
- Centre de Recherché/Department of Radiology, Montréal Heart Institute/Universitè de Montréal, Montréal, Quebec, Canada
- Department of Radiology, Erasmus Medical Center University, Rotterdam, Netherlands
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Kern DM, Mellström C, Hunt PR, Tunceli O, Wu B, Westergaard M, Hammar N. Long-term cardiovascular risk and costs for myocardial infarction survivors in a US commercially insured population. Curr Med Res Opin 2016; 32:703-11. [PMID: 26709864 DOI: 10.1185/03007995.2015.1136607] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To quantify clinical and cost long-term outcomes in cardiovascular stable post-myocardial-infarction patients. RESEARCH DESIGN AND METHODS Subjects with a history of myocardial infarction (MI) who were 50-64 years old and MI- and stroke-free for ≥12 months (index date) were identified in a large US claims database. Individuals were followed for up to 5 years (mean: 2.0 years) after their index date. MAIN OUTCOME MEASURES Rates of MI, stroke, all-cause death, and a composite of these were analyzed via Cox regression models, adjusted for covariates. Results are reported for the overall population and the subgroups of those with type 2 diabetes, additional prior MI, and non-end-stage renal disease. As a secondary endpoint healthcare costs were evaluated at baseline and during each year of follow-up. Results Over the follow-up period, which averaged 2 years, 7.6% of all 13,492 subjects (10.5% vs. 5.4% with and without the selected risk factors, respectively) experienced at least one of the outcome events. The cumulative incidence rates over the entire follow-up period for the primary composite outcome were 20.8% and 12.2% for those with and without the selected atherothrombotic risk factors, respectively. The cardiovascular-related per-person-per-year healthcare costs during follow-up were higher in those with ≥1 additional risk factor compared to those without: $15,247 versus $7521. Costs were elevated over baseline costs throughout follow-up. LIMITATIONS Administrative claims data lack clinical detail. Generalizability of results is limited to the US commercially insured population of a similar age to that included in this study. CONCLUSIONS High risk MI survivors who have been event free for ≥1 year remained at substantial risk of CV events and had increased healthcare costs for up to 5 years post-MI. These long-term risks have not been previously demonstrated in a working-age US population and suggest an unmet need for continuing secondary prevention long-term post-MI.
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Affiliation(s)
| | | | | | | | - Bingcao Wu
- a HealthCore Inc. , Wilmington , DE , USA
| | | | - Niklas Hammar
- b AstraZeneca Pharmaceuticals , Mölndal , Sweden
- e Institute of Environmental Medicine, Karolinska Institutet , Stockholm , Sweden
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Qaderdan K, Ishak M, Heestermans AA, de Vrey E, Jukema JW, Voskuil M, de Boer MJ, van‘t Hof AW, Groenemeijer BE, Vos GJA, Janssen PW, Bergmeijer TO, Kelder JC, Deneer VH, ten Berg JM. Ticagrelor or prasugrel versus clopidogrel in elderly patients with an acute coronary syndrome: Optimization of antiplatelet treatment in patients 70 years and older--rationale and design of the POPular AGE study. Am Heart J 2015; 170:981-985.e1. [PMID: 26542508 DOI: 10.1016/j.ahj.2015.07.030] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 07/20/2015] [Indexed: 10/23/2022]
Abstract
RATIONALE Dual antiplatelet therapy with acetylsalicylic acid in combination with a more potent P2Y12- inhibitor (ticagrelor or prasugrel) is recommended in patients with acute coronary syndrome without ST-segment elevation (NSTE-ACS) to prevent atherothrombotic complications. The evidence on which this recommendation is based shows that ticagrelor and prasugrel reduce atherothrombotic events at the expense of an increase in bleeding events when compared with clopidogrel. However, it remains unclear whether ticagrelor or prasugrel has a better net clinical benefit in elderly patients with NSTE-ACS when compared with clopidogrel. The POPular AGE trial is designed to address the optimal antiplatelet strategy in elderly NSTE-ACS patients. STUDY DESIGN POPular AGE is a multicenter, open-label, randomized controlled trial that aims to include 1000 patients ≥70years of age with NSTE-ACS. Patients are randomly assigned to receive either clopidogrel or a more potent P2Y12 inhibitor (ticagrelor or prasugrel). The first primary end point is any bleeding event requiring medical intervention. The second primary end point is the net clinical benefit, a composite of all-cause mortality, nonfatal myocardial infarction, nonfatal stroke, "PLATelet inhibition and patient Outcomes" major bleeding, or "PLATelet inhibition and patient Outcomes" minor bleeding. Patients will be followed for 1 year after randomization, and analyses will be performed on the basis of intention to treat. CONCLUSION The POPular AGE is the first randomized controlled trial that will assess whether the treatment strategy with clopidogrel will result in fewer bleeding events without compromising the net clinical benefit in patients ≥70years of age with NSTE-ACS when compared with a treatment strategy with ticagrelor or prasugrel.
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Soliman EZ, Lopez F, O'Neal WT, Chen LY, Bengtson L, Zhang ZM, Loehr L, Cushman M, Alonso A. Atrial Fibrillation and Risk of ST-Segment-Elevation Versus Non-ST-Segment-Elevation Myocardial Infarction: The Atherosclerosis Risk in Communities (ARIC) Study. Circulation 2015; 131:1843-50. [PMID: 25918127 DOI: 10.1161/circulationaha.114.014145] [Citation(s) in RCA: 122] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 03/19/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND It has recently been reported that atrial fibrillation (AF) is associated with an increased risk of myocardial infarction (MI). However, the mechanism underlying this association is currently unknown. Further study of the relationship of AF with the type of MI (ST-segment-elevation MI [STEMI] versus non-ST-segment-elevation MI [NSTEMI]) might shed light on the potential mechanisms. METHODS AND RESULTS We examined the association between AF and incident MI in 14 462 participants (mean age, 54 years; 56% women; 26% blacks) from the Atherosclerosis Risk in Communities (ARIC) study who were free of coronary heart disease at baseline (1987-1989) with follow-up through December 31, 2010. AF cases were identified from study visit ECGs and by review of hospital discharge records. Incident MI and its types were ascertained by an independent adjudication committee. Over a median follow-up of 21.6 years, 1374 MI events occurred (829 NSTEMIs, 249 STEMIs, 296 unclassifiable MIs). In a multivariable-adjusted model, AF (n=1545) as a time-varying variable was associated with a 63% increased risk of MI (hazard ratio,1.63; 95% confidence interval, 1.32-2.02). However, AF was associated with NSTEMI (hazard ratio, 1.80; 95% confidence interval, 1.39-2.31) but not STEMI (hazard ratio, 0.49; 95% confidence interval, 0.18-1.34; P for hazard ratio comparison=0.004). Combining the unclassifiable MI group with either STEMI or NSTEMI did not change this conclusion. The association between AF and MI, total and NSTEMI, was stronger in women than in men (P for interaction <0.01 for both). CONCLUSIONS AF is associated with an increased risk of incident MI, especially in women. However, this association is limited to NSTEMI.
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Affiliation(s)
- Elsayed Z Soliman
- From Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention (E.Z.S., Z.-M.Z.), Department of Internal Medicine, Section on Cardiology (E.Z.S.), and Department of Internal Medicine (W.T.O.), Wake Forest School of Medicine, Winston Salem, NC; Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (F.L., L.B., A.A.); Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis (L.Y.C.); Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (L.L.); and Department of Medicine, University of Vermont, Burlington (M.C.).
| | - Faye Lopez
- From Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention (E.Z.S., Z.-M.Z.), Department of Internal Medicine, Section on Cardiology (E.Z.S.), and Department of Internal Medicine (W.T.O.), Wake Forest School of Medicine, Winston Salem, NC; Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (F.L., L.B., A.A.); Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis (L.Y.C.); Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (L.L.); and Department of Medicine, University of Vermont, Burlington (M.C.)
| | - Wesley T O'Neal
- From Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention (E.Z.S., Z.-M.Z.), Department of Internal Medicine, Section on Cardiology (E.Z.S.), and Department of Internal Medicine (W.T.O.), Wake Forest School of Medicine, Winston Salem, NC; Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (F.L., L.B., A.A.); Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis (L.Y.C.); Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (L.L.); and Department of Medicine, University of Vermont, Burlington (M.C.)
| | - Lin Y Chen
- From Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention (E.Z.S., Z.-M.Z.), Department of Internal Medicine, Section on Cardiology (E.Z.S.), and Department of Internal Medicine (W.T.O.), Wake Forest School of Medicine, Winston Salem, NC; Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (F.L., L.B., A.A.); Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis (L.Y.C.); Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (L.L.); and Department of Medicine, University of Vermont, Burlington (M.C.)
| | - Lindsay Bengtson
- From Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention (E.Z.S., Z.-M.Z.), Department of Internal Medicine, Section on Cardiology (E.Z.S.), and Department of Internal Medicine (W.T.O.), Wake Forest School of Medicine, Winston Salem, NC; Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (F.L., L.B., A.A.); Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis (L.Y.C.); Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (L.L.); and Department of Medicine, University of Vermont, Burlington (M.C.)
| | - Zhu-Ming Zhang
- From Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention (E.Z.S., Z.-M.Z.), Department of Internal Medicine, Section on Cardiology (E.Z.S.), and Department of Internal Medicine (W.T.O.), Wake Forest School of Medicine, Winston Salem, NC; Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (F.L., L.B., A.A.); Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis (L.Y.C.); Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (L.L.); and Department of Medicine, University of Vermont, Burlington (M.C.)
| | - Laura Loehr
- From Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention (E.Z.S., Z.-M.Z.), Department of Internal Medicine, Section on Cardiology (E.Z.S.), and Department of Internal Medicine (W.T.O.), Wake Forest School of Medicine, Winston Salem, NC; Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (F.L., L.B., A.A.); Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis (L.Y.C.); Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (L.L.); and Department of Medicine, University of Vermont, Burlington (M.C.)
| | - Mary Cushman
- From Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention (E.Z.S., Z.-M.Z.), Department of Internal Medicine, Section on Cardiology (E.Z.S.), and Department of Internal Medicine (W.T.O.), Wake Forest School of Medicine, Winston Salem, NC; Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (F.L., L.B., A.A.); Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis (L.Y.C.); Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (L.L.); and Department of Medicine, University of Vermont, Burlington (M.C.)
| | - Alvaro Alonso
- From Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention (E.Z.S., Z.-M.Z.), Department of Internal Medicine, Section on Cardiology (E.Z.S.), and Department of Internal Medicine (W.T.O.), Wake Forest School of Medicine, Winston Salem, NC; Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (F.L., L.B., A.A.); Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis (L.Y.C.); Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (L.L.); and Department of Medicine, University of Vermont, Burlington (M.C.)
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Jakl M, Stasek J, Kala P, Rokyta R, Kanovsky J, Ondrus T, Hromadka M, Widimsky P. Acute myocardial infarction complicated by shock: outcome analysis based on initial electrocardiogram. SCAND CARDIOVASC J 2013; 48:13-9. [PMID: 24228641 DOI: 10.3109/14017431.2013.865074] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To assess the relation between initial ECG findings, presence of risk factors, coronary angiography findings, and clinical outcomes in patients with acute myocardial infarction complicated by cardiogenic shock (CS). DESIGN Data from a total of 5572 acute myocardial infarction patients admitted to the four tertiary hospitals during a period of 3 years were analyzed. CS on admission was present in 358 patients (6.4%). They were divided into four groups based on the admission ECG: ST-segment elevation (STEMI), ST-segment depression (STDMI), bundle branch block (BBBMI), and other ECG acute myocardial infarction. RESULTS CS developed most frequently among BBBMI patients (in 12.1% of all BBBMIs, p < 0.001 vs. STEMI), followed by STEMI (6.7%), STDMI (4.4%), and other ECG acute myocardial infarction (2.3%). The risk of CS development was similar in patients with left bundle branch block (LBBB) (13.3%) and right bundle branch block (RBBB) (11.2%). The one-year mortality was highest among RBBBMI patients (66.7%, p < 0.001), followed by LBBBMI (48.6%), other ECG (47.1%), STEMI (41.7%), and STDMI patients (38.1%). CONCLUSIONS RBBB on admission ECG is associated with the highest risk of CS development, frequent left main coronary artery affection, and unsuccessful revascularization. It is also an independent predictor of one-year mortality.
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Affiliation(s)
- Martin Jakl
- 1st Department of Internal Medicine - Cardioangiology, University Hospital Hradec Kralove , Czech Republic
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Temperature, myocardial infarction, and mortality: effect modification by individual- and area-level characteristics. Epidemiology 2013; 24:439-46. [PMID: 23462524 DOI: 10.1097/ede.0b013e3182878397] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Although several studies have examined associations between temperature and cardiovascular-disease-related mortality, fewer have investigated the association between temperature and the development of acute myocardial infarction (MI). Moreover, little is known about who is most susceptible to the effects of temperature. METHODS We analyzed data from the Worcester Heart Attack Study, a community-wide investigation of acute MI in residents of the Worcester (MA) metropolitan area. We used a case-crossover approach to examine the association of apparent temperature with acute MI occurrence and with all-cause in-hospital and postdischarge mortality. We examined effect modification by sociodemographic characteristics, medical history, clinical complications, and physical environment. RESULTS A decrease in an interquartile range in apparent temperature was associated with an increased risk of acute MI on the same day (hazard ratio = 1.15 [95% confidence interval = 1.01-1.31]). Extreme cold during the 2 days prior was associated with an increased risk of acute MI (1.36 [1.07-1.74]). Extreme heat during the 2 days prior was also associated with an increased risk of mortality (1.44 [1.06-1.96]). Persons living in areas with greater poverty were more susceptible to heat. CONCLUSIONS Exposure to cold increased the risk of acute MI, and exposure to heat increased the risk of dying after an acute MI. Local area vulnerability should be accounted for as cities prepare to adapt to weather fluctuations as a result of climate change.
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Neurogenic differentiation of human adipose-derived stem cells: relevance of different signaling molecules, transcription factors, and key marker genes. Gene 2012; 511:427-36. [PMID: 23000064 DOI: 10.1016/j.gene.2012.09.038] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 07/16/2012] [Accepted: 09/12/2012] [Indexed: 01/13/2023]
Abstract
Since numerous diseases affect the central nervous system and it has limited self-repair capability, a great interest in using stem cells as an alternative cell source is generated. Previous reports have shown the differentiation of adipose-derived stem cells in neuron-like cells and it has also been proved that the expression pattern of patterning, proneural, and neural factors, such as Pax6, Mash1, Ngn2, NeuroD1, Tbr2 and Tbr1, regulates and defines adult neurogenesis. Regarding this, we hypothesize that a functional parallelism between adult neurogenesis and neuronal differentiation of human adipose-derived stem cells exists. In this study we differentiate human adipose-derived stem cells into neuron-like cells and analyze the expression pattern of different patterning, proneural, neural and neurotransmitter genes, before and after neuronal differentiation. The neuron-like cells expressed neuronal markers, patterning and proneural factors characteristics of intermediate stages of neuronal differentiation. Thus we demonstrated that it is possible to differentiate adipose-derived stem cells in vitro into immature neuron-like cells and that this process is regulated in a similar way to adult neurogenesis. This may contribute to elucidate molecular mechanisms involved in neuronal differentiation of adult human non-neural cells, in aid of the development of potential therapeutic tools for diseases of the nervous system.
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Gonzalez MA, Eilen DJ, Marzouq RA, Porterfield CP, Hazarika S, Nasir S, Patel AA, Gonzalez KDJ, Burris MB, Prieto-Gonzalez M, Rose JD, Cascio WE. The universal classification is an independent predictor of long-term outcomes in acute myocardial infarction. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2011; 12:35-40. [DOI: 10.1016/j.carrev.2009.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Revised: 11/17/2009] [Accepted: 11/20/2009] [Indexed: 11/26/2022]
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Gonzalez MA, Porterfield CP, Eilen DJ, Marzouq RA, Patel HR, Patel AA, Nasir S, Lim HM, Babb JD, Rose JD, Cascio WE. Quartiles of peak troponin are associated with long-term risk of death in type 1 and STEMI, but not in type 2 or NSTEMI patients. Clin Cardiol 2010; 32:575-83. [PMID: 19911352 DOI: 10.1002/clc.20662] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The prognostic value of peak cardiac troponin (cTn) in different types of acute myocardial infarction (AMI) under the universal clinical classification is unknown. HYPOTHESIS We tested the hypothesis that the prognostic value of cTn varies with its peak level and type of AMI. METHODS We studied 345 consecutive patients with AMI with mean follow-up of 30.6 months according to quartiles of peak cTn level (QPTL) and the type of AMI. The study outcomes were the major adverse cardiovascular events (MACE; composite of all causes of mortality and recurrent AMI) and the individual components of MACE. RESULTS The study included patients with AMI Type 1 (n = 276), type 2 (n = 54), ST-segment elevation myocardial infarction (STEMI; n = 159), and non-ST-segment elevation myocardial infarction (NSTEMI; n = 186). Overall, peak cTn level was an independent predictor of MACE (hazard ratio [HR]: 1.001, 95% confidence interval [CI]: 1.000-1.003, P = 0.01) and death (HR: 1.002, 95% CI: 1.001-1.004, P = 0.003), but not of recurrent AMI. The highest risk of MACE and death was in the highest QPTL (61.6%, P = .016 and 66.3%, P = 0.021, respectively) while the highest risk of recurrent AMI was in the lowest QPTL (83.7%, P = 0.04). Quartiles of peak cTn level were significantly associated with increased risk of MACE and death in patients with Type 1 (all P = 0.01) and STEMI (P = 0.01 and P = 0.02, respectively), but no association existed in type 2 or NSTEMI patients. CONCLUSIONS Overall, peak cTn predicts the risk of MACE and death but not the risk of AMI. While in Type 1 and STEMI patients, QPTL are associated with risk of MACE and death, no association exists in type 2 or NSTEMI patients.
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Affiliation(s)
- Manuel A Gonzalez
- East Carolina Heart Institute at East Carolina University, Greenville, North Carolina 27834, USA.
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Three-dimensional phase-sensitive inversion-recovery turbo FLASH sequence for the evaluation of left ventricular myocardial scar. AJR Am J Roentgenol 2009; 193:W381-8. [PMID: 19843715 DOI: 10.2214/ajr.08.1952] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate a new free-breathing 3D phase-sensitive inversion-recovery (PSIR) turbo FLASH pulse sequence for the detection of left ventricular myocardial scar. SUBJECTS AND METHODS Patients with suspected myocardial scar were examined on a 1.5-T MR scanner for myocardial late enhancement after the administration of gadopentetate dimeglumine using a segmented 2D PSIR turbo FLASH sequence followed by a navigator-gated 3D PSIR turbo FLASH sequence. Image quality was scored by two independent readers using a 4-point Likert scale (0 = poor, nondiagnostic; 1 = fair, diagnostics may be impaired; 2 = good, some artifacts but not interfering in diagnostics; 3 = excellent, no artifacts). Scars were compared quantitatively in volume and graded qualitatively on the basis of size (area) and location. RESULTS Thirty-three patients were scanned using both techniques. In 25 patients, the quality of the 3D PSIR images was acceptable. Scars were detected in 12 patients. Hyperenhanced scar volumes (p = 0.43), qualitative analysis of scar area (p = 0.78), and scar location (p = 0.68) were similar for both techniques. More small hyperenhanced scars, corresponding mostly to nonischemic distribution patterns, were detected using 3D PSIR than 2D PSIR. Although 2D and 3D results were found to be highly correlated for scar volume, Bland-Altman analysis indicated a systematic smaller infarct volume on the 2D PSIR scans (R(2) = 0.84). CONCLUSION Free-breathing 3D PSIR turbo FLASH imaging is a promising technique for the assessment of left ventricular scar particularly for scar quantification and the detection of small nonischemic scars in the myocardium.
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Chan MY, Sun JL, Newby LK, Shaw LK, Lin M, Peterson ED, Califf RM, Kong DF, Roe MT. Long-term mortality of patients undergoing cardiac catheterization for ST-elevation and non-ST-elevation myocardial infarction. Circulation 2009; 119:3110-7. [PMID: 19506116 DOI: 10.1161/circulationaha.108.799981] [Citation(s) in RCA: 164] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There are limited contemporary data comparing long-term outcomes after cardiac catheterization for ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI). METHODS AND RESULTS We studied patients undergoing cardiac catheterization for STEMI (n=2413) and NSTEMI (n=1974) between 1999 and 2005 with at least 1 significant coronary lesion > or =75%. We compared adjusted mortality rates over restricted time intervals and the differential impact of early revascularization on mortality stratified by ST-elevation status. Between 1999 and 2007, 1274 patients died, with a median follow-up of 4 years. A piece-wise analysis showed a higher adjusted mortality risk for STEMI during the first 2 months (adjusted hazard ratio, 1.85; 95% confidence interval, 1.45 to 2.38) and a lower adjusted mortality risk for STEMI after 2 months (adjusted hazard ratio, 0.68; 95% confidence interval, 0.59 to 0.83). Compared with late or no revascularization, early revascularization was associated with a lower adjusted risk of mortality for both STEMI (adjusted hazard ratio, 0.73; 95% confidence interval, 0.58 to 0.90) and NSTEMI (adjusted hazard ratio, 0.76; 95% confidence interval, 0.65 to 0.89) (P for interaction=0.22). CONCLUSIONS Among a contemporary cohort of acute MI patients with significant coronary disease during cardiac catheterization, STEMI was associated with a higher risk of short-term mortality, but NSTEMI was associated with a higher risk of long-term mortality. Early revascularization was associated with a similar improvement in long-term outcomes for both STEMI and NSTEMI. These data suggest that in clinical investigations of early revascularization among patients with NSTEMI, extended follow-up may be necessary to demonstrate treatment benefit.
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Affiliation(s)
- Mark Y Chan
- MBBS, MHS, National University Heart Center, 5 Lower Kent Ridge Road, Singapore, Singapore 119074.
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15
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Improvements in Long-Term Mortality After Myocardial Infarction and Increased Use of Cardiovascular Drugs After Discharge. J Am Coll Cardiol 2008; 51:1247-54. [DOI: 10.1016/j.jacc.2007.10.063] [Citation(s) in RCA: 144] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2007] [Revised: 10/12/2007] [Accepted: 10/17/2007] [Indexed: 11/23/2022]
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16
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Jaber WA, Holmes DR. Outcome and quality of care of patients who have acute myocardial infarction. Med Clin North Am 2007; 91:751-68; xii-xiii. [PMID: 17640546 DOI: 10.1016/j.mcna.2007.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Coronary artery disease is the number-one killer in developed countries, with lifetime prevalence of up to 50% in American men, and is the topic of much medical literature. Recently, multiple therapies have emerged to save lives after acute myocardial infarction (AMI), backed by well-conducted studies; however, appropriate implementation of therapy guidelines is less than optimal. Recent efforts have focused on improving the quality of care (QC) after AMI in order to improve outcomes. This article illustrates how outcome after AMI is related to QC, describes the underuse of evidence-based therapies, and discusses factors associated with poor guideline adherence. It also reviews current quality improvement projects, and some available means to measure and optimize the QC for patients with AMI.
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Affiliation(s)
- Wissam A Jaber
- Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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17
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Petrina M, Goodman SG, Eagle KA. The 12-lead electrocardiogram as a predictive tool of mortality after acute myocardial infarction: current status in an era of revascularization and reperfusion. Am Heart J 2006; 152:11-8. [PMID: 16824827 DOI: 10.1016/j.ahj.2005.11.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2005] [Accepted: 11/11/2005] [Indexed: 12/22/2022]
Abstract
Many recently published studies established the admission electrocardiogram as an excellent source of prognostic information in patients presenting with acute myocardial infarction. Using our search criteria, we identified a large number of articles but selected only the most relevant in each category. The best predictors of increased short-term mortality are ventricular tachycardia (odds ratio [OR] 6.1, 95% CI 4.6-8.3), ST-segment deviations (OR 5.1, 95% CI 4.6-8.3), high-degree atrioventricular block (OR 5.1, 95% CI 2.1-11.9), and long QRS duration (OR 4.2, 95% CI 1.8-10.4). For increased long-term mortality, the best predictors were ST-segment depression (OR 5.7, 95% CI 2.8-11.6), ST-segment elevation (OR 3.3, 95% CI 2.1-5.1), and left bundle-branch block (OR 2.8, 95% CI 1.8-4.3). In addition, our review discusses electrocardiographic markers of poor outcome that were not independent risk factors on multivariate analysis, conflicting findings, and knowledge gaps that can help plan future research efforts.
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Affiliation(s)
- Mircea Petrina
- University of Michigan Medical Center, Ann Arbor, MI, USA.
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18
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Wagner A, Mahrholdt H, Holly TA, Elliott MD, Regenfus M, Parker M, Klocke FJ, Bonow RO, Kim RJ, Judd RM. Contrast-enhanced MRI and routine single photon emission computed tomography (SPECT) perfusion imaging for detection of subendocardial myocardial infarcts: an imaging study. Lancet 2003; 361:374-9. [PMID: 12573373 DOI: 10.1016/s0140-6736(03)12389-6] [Citation(s) in RCA: 876] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Myocardial infarcts are routinely detected by nuclear imaging techniques such as single photon emission computed tomography (SPECT) myocardial perfusion imaging. A newly developed technique for infarct detection based on contrast-enhanced cardiovascular magnetic resonance (CMR) has higher spatial resolution than SPECT. We postulated that this technique would detect infarcts missed by SPECT. METHODS We did contrast-enhanced CMR and SPECT examinations in 91 patients with suspected or known coronary artery disease. All CMR and SPECT images were scored, using a 14-segment model, for the presence, location, and spatial extent of infarction. To compare each imaging modality to a gold standard, we also acquired contrast-enhanced CMR and SPECT images in 12 dogs with, and three dogs without, myocardial infarction as defined by histochemical staining. FINDINGS In animals, contrast-enhanced CMR and SPECT detected all segments with nearly transmural infarction (>75% transmural extent of the left-ventricular wall). CMR also identified 100 of the 109 segments (92%) with subendocardial infarction (<50% transmural extent of the left-ventricular wall), whereas SPECT identified only 31 (28%). SPECT and CMR showed high specificity for the detection of infarction (97% and 98%, respectively). In patients, all segments with nearly transmural infarction, as defined by contrast-enhanced CMR, were detected by SPECT. However, of the 181 segments with subendocardial infarction, 85 (47%) were not detected by SPECT. On a per patient basis, six (13%) individuals with subendocardial infarcts visible by CMR had no evidence of infarction by SPECT. INTERPRETATION SPECT and CMR detect transmural myocardial infarcts at similar rates. However, CMR systematically detects subendocardial infarcts that are missed by SPECT.
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Affiliation(s)
- Anja Wagner
- Northwestern University Medical School Feinberg Cardiovascular Research Institute, Chicago, IL, USA
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19
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Packham C, Gray D, Weston C, Large A, Silcocks P, Hampton J. Changing the diagnostic criteria for myocardial infarction in patients with a suspected heart attack affects the measurement of 30 day mortality but not long term survival. Heart 2002; 88:337-42. [PMID: 12231586 PMCID: PMC1767392 DOI: 10.1136/heart.88.4.337] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2002] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To explore the effects of alternative methods of defining myocardial infarction on the numbers and survival patterns of patients identified as having sustained a confirmed myocardial infarct. DESIGN An inclusive historical cohort of patients admitted with a suspected heart attack. Patients were recoded from raw clinical data (collected at the index admission) to the epidemiological definitions of myocardial infarction used by the Nottingham heart attack register (NHAR), the World Health Organization (MONICA), and the UK heart attack study. SETTING Single health district. PATIENTS The NHAR identified all patients admitted in 1992 with suspected myocardial infarction. OUTCOME MEASURES Survival at 30 days and four year postdischarge. RESULTS 2739 patients were identified, of whom 90% survived to discharge. Recoding increased the numbers of patients defined as having confirmed myocardial infarction from 26% under the original NHAR classification to 69%, depending on the classification system used. In confirmed myocardial infarction, subsequent 30 day survival from admission varied from 77-86% depending on the classification system; four year survival after discharge was not affected. The distribution of important prognostic variables differed significantly between groups of patients with confirmed myocardial infarction defined by different systems. Patients with suspected but unconfirmed myocardial infarction under all classification systems had a worse postdischarge mortality. CONCLUSIONS The classification system used had a substantial effect on the numbers of patients identified as having had a myocardial infarct, and on the 30 day survival. There were significant numbers of patients with more atypical presentations, not labelled as myocardial infarction, who did badly following discharge. More research is needed on these patients.
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Affiliation(s)
- C Packham
- University Division of Public Health Sciences, Queens Medical Centre, Nottingham, UK.
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20
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Abstract
PURPOSE To review the trends in treatment and survival for patients with acute myocardial infarction over the last 20 years. MATERIAL AND METHODS Studies were identified through MEDLINE searches and review of study bibliographies. Additional data were obtained from the Health Care Financing Administration including data from Medicare claims files (part A). Thirty-day mortality rates were calculated using Medicare data and case fatality rates from the National Hospital Discharge Survey. Published meta-analyses were used to determine treatment effects. Published studies were included if they reported the use of therapies for acute myocardial infarction at a population level. Trends in the demographic characteristics of the patients as well as infarct characteristics, medication use, and revascularization were recorded. RESULTS The use of acute treatments that are known to improve survival among patients with myocardial infarction has increased markedly during the last 20 years, leading to an estimated 9.6% reduction (from 27.0% to 17.4%) in 30-day mortality. After adjusting for potential interactions between therapies, the increase in use of aspirin, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and reperfusion can explain 71% of the decrease in the 30-day age- and sex-adjusted mortality rate from 1975 to 1995. The greatest effect of a given therapy was that of aspirin, which accounted for 34% of the decrease in 30-day mortality, followed by thrombolysis (17%), primary angioplasty (10%), beta-blockers (7%), and ACE inhibitors (3%). If other treatments (such as heparin or nonprimary angioplasty), whose effects on mortality are less certain, are included, up to 90% of the decrease in 30-day mortality can be explained by changes in treatment. CONCLUSIONS The primary reason for the decrease in early mortality from myocardial infarction during the last 20 years appears to be increased use of effective treatments.
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Affiliation(s)
- P A Heidenreich
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
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21
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Abstract
The use of cardiac markers to identify high-risk patients in the observation unit is undeniable. As the literature reviewed here reveals, the history and ECG miss a significant portion of patients with acute cardiac ischemia. It appears that acute MI and some high-risk "unstable angina" observation unit patients can be identified within 6 hours of hospital presentation using a combination of cardiac markers. Testing these patients soon after symptom onset or on arrival in the ED for myoglobin, CK-MB subforms, or CK-MB delta appears to provide the best diagnostic usefulness. For testing later in the clinical course, CK-MB troponin I, or troponin T are of clear diagnostic and prognostic value. The markers currently used are unable to identify the significant subset of patients with "non-AMI" coronary syndromes, however. These patients require further testing with appropriate noninvasive or invasive diagnostic studies.
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Affiliation(s)
- B J O'Neil
- Department of Emergency Medicine, Wayne State University School of Medicine,Detriot, Michigan USA
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Engström G, Göransson M, Hansen O, Hedblad B, Tydén P, Tödt T, Janzon L. Trends in long-term survival after myocardial infarction: less favourable patterns for patients from deprived areas. J Intern Med 2000; 248:425-34. [PMID: 11123507 DOI: 10.1046/j.1365-2796.2000.00757.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE New treatments have improved the prognosis for patients with acute myocardial infarction. However, studies on long-term survival are not unequivocally in favour of an improved long-term prognosis. This study aimed to analyse trends in 3-year survival in relation to sex, age and socioeconomic level of residential area. SETTING The Malmö myocardial infarction register, Sweden. PARTICIPANTS All men and women in the city who, between 1978 and 1995, were admitted for a first acute myocardial infarction (n = 11 226). MAIN OUTCOME MEASURES Age-standardized 3-year survival rates. RESULTS Both 28-day and 3-year survival rates improved markedly during the study period. Age-standardized 3-year survival (per 100 patients) amongst men and women who survived 28 days increased, between 1978-81 and 1991-95, from 64 to 78 in men and from 66 to 77 in women, an annual increase of 1.4% (95% CI = 1.1-1.7) and 1.2% (0.8-1.5), respectively. There were marked differences in survival between residential areas with different socioeconomic circumstances. The 3-year survival rates amongst men correlated significantly with the socioeconomic circumstances in the areas expressed in terms of a socioeconomic score (men: r = 0.60, n = 17, P = 0.01; women: r = 0.37, P = 0.15). Trends tended to be less favourable in deprived areas. CONCLUSION Three-year survival after first myocardial infarction has continuously improved for men and women in all age groups. Prognosis was worse and trends tended to be less favourable for patients from deprived areas.
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Affiliation(s)
- G Engström
- Department of Community Medicine, Malmö University Hospital, Malmö, Sweden.
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23
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Haim M, Behar S, Boyko V, Hod H, Gottlieb S. The prognosis of a first Q-wave versus non-Q-wave myocardial infarction in the reperfusion era. Am J Med 2000; 108:381-6. [PMID: 10759094 DOI: 10.1016/s0002-9343(00)00309-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
PURPOSE To compare the prognosis of patients with a first Q-wave versus non-Q-wave myocardial infarction (MI) in the reperfusion era. METHODS Patients with a first MI were compared according to type of infarct-Q-wave (n = 1,786) versus non-Q-wave (n = 722)-and by treatment with thrombolysis. RESULTS Patients with non-Q-wave MI were more likely to be female and to have undergone previous coronary revascularization. Their 30-day mortality rate was 7%, as compared with a rate of 9% among patients with Q-wave infarction (adjusted odds ratio [OR] = 0.6, 95% confidence interval [CI]: 0.4 to 0.9). However, the subsequent 30-day to 1-year mortality rates were similar in patients with Q-wave or non-Q-wave MI. Patients who were not treated with thrombolysis and who had a non-Q-wave MI had a lower 30-day mortality rate (OR = 0.6, 95% CI: 0.3 to 0.9) but a similar 30-day to 1-year mortality rate (hazard ratio [HR] = 1.5, 95% CI: 0.9 to 2.5) as compared with their counterparts who developed Q-wave infarction. Among thrombolysis-treated patients, 30-day (OR = 0.8, 95% CI: 0.4 to 1.5) as well as 30-day to 1-year (HR = 1.2, 95% CI: 0.5 to 3.0) mortality rates were similar between patients who developed either Q-wave or non-Q-wave MI. CONCLUSIONS Patients who received thrombolysis had similar early and late mortality rates after the index infarction regardless of whether they had a Q-wave or non-Q-wave MI. Conversely, among patients who were not treated with thrombolysis, patients with a non-Q-wave MI had lower early mortality rates but similar long-term mortality rates as those with Q-wave MI.
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Affiliation(s)
- M Haim
- Department of Internal Medicine, Meir General Hospital, Kfar-Saba, Israel
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24
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Briassoulis G, Kalabalikis P, Thanopoulos V, Hatzis T. Non-Q wave acute myocardial infarction in acute meningococcemia in a 10-year-old girl. Pediatr Emerg Care 2000; 16:33-8. [PMID: 10698142 DOI: 10.1097/00006565-200002000-00011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Children with acute meningococcemia may have impaired myocardial function resulting in low cardiac output despite normal intravascular volume. Severe meningococcal infection has been associated with acute interstitial myocarditis, endocarditis, and pericarditis, but not with myocardial infarction. CASE We present the case of a 10-year-old girl with positive family history for premature myocardial infarction who sustained an acute myocardial infarction temporally related to meningococcemia. DISCUSSION This is the first pediatric case of non-Q wave acute myocardial infarction associated with purpura fulminans in meningococcemia. Similarly, the association of high troponin I levels and meningococcemia has not been described previously. Although, the patient's genetic predisposition for myocardial infarction might have been a potential contributing factor, there was no angiographic evidence of coronary artery disease in this patient. Thereby, other factors related to shock, endotoxin, microthrombi of meningococcemia, and their treatment might have been also contributing. We propose possible mechanisms for this rare but serious complication of meningococcemia and review the literature.
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Affiliation(s)
- G Briassoulis
- Pediatric Intensive Care Unit, Aghia Sophia Children's Hospital, Athens, Greece.
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25
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Gottlieb S, Boyko V, Harpaz D, Hod H, Cohen M, Mandelzweig L, Khoury Z, Stern S, Behar S. Long-term (three-year) prognosis of patients treated with reperfusion or conservatively after acute myocardial infarction. Israeli Thrombolytic Survey Group. J Am Coll Cardiol 1999; 34:70-82. [PMID: 10399994 DOI: 10.1016/s0735-1097(99)00152-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES This survey sought to assess the frequency of the use of thrombolytic therapy, invasive coronary procedures (ICP) (angiography, percutaneous transluminal coronary angioplasty and coronary artery bypass grafting [CABG]), variables associated with their use, and their impact on early (30-day) and long-term (3-year) mortality after acute myocardial infarction (AMI). BACKGROUND Few data are available regarding the implementation in daily practice of the results of clinical trials of treatments for AMI and their impact on early and long-term prognosis in unselected patients after AMI. METHODS A prospective community-based national survey was conducted during January-February 1994 in all 25 coronary care units operating in Israel. RESULTS Among 999 consecutive patients with an AMI (72% men; mean age 63+/-12 years) acute reperfusion therapy (ART) was used in 455 patients (46%; thrombolysis in 435 patients [44%] and primary angioplasty in 20 [2%]). Its use was independently associated with anterior AMI location and hospitals with on-site angioplasty facilities, whereas advancing age, prior myocardial infarction (MI) and prior angioplasty or CABG were independently associated with its lower use. The three-year mortality of patients treated with ART was lower than in counterpart patients (22.0% vs. 31.4%, p = 0.0008), mainly as the result of 30-day to 3-year outcome (12.4% vs. 21.1%; hazard ratio = 0.73, 95% confidence interval [CI] 0.52 to 1.03). Independent predictors of long-term mortality were: age, heart failure on admission or during the hospitalization, ventricular tachycardia or fibrillation and diabetes. The outcome of patients not treated with ART differed according to the reason for the exclusion, where patients with contraindications experienced the highest three-year (50%) mortality rate. After ART, coronary angiography, angioplasty and CABG were performed in-hospital in 28%, 12% and 5% of patients, respectively. Their use was independently associated with recurrent infarction or ischemia, on-site catheterization or CABG facilities, non-Q-wave AMI and anterior infarct location. In the entire study population, and in patients with a non-Q-wave AMI, performance of ICP was associated with lower 30-day mortality (odds ratio [OR] = 0.53, 95% CI 0.25 to 0.98, and OR = 0.21, 0.03 to 0.84, respectively), but not thereafter. CONCLUSIONS This survey demonstrates the extent of implementation in daily practice of ART and ICP and their impact on early and long-term prognosis in an unselected population after AMI.
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Affiliation(s)
- S Gottlieb
- Neufeld Cardiac Research Institute, Sheba Medical Center, Tel Hashomer, Israel.
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26
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Abstract
Acute coronary syndromes, including unstable angina, myocardial infarction, and sudden death, account for more than 250,000 deaths annually. They are the manifestation of a progressive atherosclerotic process, which culminates in the rupture of atherosclerotic plaques and the formation of mural thrombi. This article reviews recent and current research, which has shed light on key events and evolutionary processes leading to acute coronary syndromes. The article details the development of vulnerable plaques, factors that promote plaque rupture, and triggering events related to plaque rupture. Also discussed are sequelae of acute coronary syndromes, including Q wave and non-Q wave infarction and left ventricular remodeling.
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Affiliation(s)
- L V Doering
- UCLA School of Nursing, Los Angeles, California, USA
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27
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Haim M, Benderley M, Hod H, Reicher-Reiss H, Goldbourt U, Behar S. The outcome of patients with a first non-Q wave acute myocardial infarction presenting with ST segment depression, ST segment elevation, or no ST deviations on the admission electrocardiogram. Int J Cardiol 1998; 67:39-46. [PMID: 9880199 DOI: 10.1016/s0167-5273(98)00243-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
UNLABELLED We evaluated the prognosis of patients with a first non-Q wave myocardial infarction according to their admission electrocardiogram. Hospital and 1-year mortality rates in patients with ST elevation (15%, and 21% respectively) and ST depression (17%, and 27% respectively) were similar and significantly higher than in patients with no ST changes (3%, and 10% respectively). Likewise, the adjusted hospital and 1-year mortality risks of patients with ST elevation or depression were comparable but higher than the corresponding mortality risk of patients with no ST deviations. The cumulative 5-year mortality rate was highest among patients with ST segment depression (51%) compared to patients with ST elevation (34%) or no ST deviation (21%), (p<0.001 for both comparisons). The adjusted 5-year mortality risk of patients with ST depression was higher (HR: 1.83, 95% C.I., 1.17-2.83) compared to patients with baseline ST elevation (HR-1.33, 95% C.I., 0.83-2.12) or patients with no ST changes (reference group). Patients with baseline ST segment elevation and coexistent ST segment depression in other electrocardiogram leads, had a higher in-hospital mortality rate (19%) compared to counterparts without concomitant ST depression (10%) and a tendency for higher in-hospital mortality risk but not for subsequent 1- and 5-year mortality risks. CONCLUSIONS Patients with a first non-Q wave MI with ST elevation or depression on admission have similar hospital and 1-year mortality risk, but the long-term mortality risk is higher among patients with ST segment depression. Patients with ST elevation and concomitant ST segment depression are at increased risk for mortality during the index hospitalization.
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Affiliation(s)
- M Haim
- The Neufeld Cardiac Research Institute, Tel-Hashomer, Israel
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28
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Haim M, Gottlieb S, Boyko V, Reicher-Reiss H, Hod H, Kaplinsky E, Mandelzweig L, Goldbourt U, Behar S. Prognosis of patients with a first non-Q-wave myocardial infarction before and in the reperfusion era. SPRINT and the Israeli Thrombolytic Survey Groups. Secondary Prevention Reinfarction Israeli Nifedipine Trial. Am Heart J 1998; 136:245-51. [PMID: 9704685 DOI: 10.1053/hj.1998.v136.90800] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The reported incidence of non-Q-wave acute myocardial infarction (AMI) has increased in the thrombolytic era. Data comparing prognosis among these patients before and after the advent of the thrombolytic era are scarce. METHODS We compared the early and late prognosis among 2 cohorts of consecutive patients with a first non-Q-wave AMI hospitalized in the coronary care units operating in Israel: 610 patients from 1981 to 1983 and 225 patients in 1994. RESULTS The proportion of patients with non-Q-wave AMI increased from 14% in 1981 to 1983 to 32% in 1994. Baseline characteristics in both periods were comparable. In-hospital management of patients differed during the last decade. Patients in 1994 received aspirin, angiotensin-converting enzyme inhibitors, beta-blockers, and nitrates more frequently than in the period 1981 to 1983. Thrombolytic therapy, coronary angiography, and percutaneous transluminal coronary angioplasty or coronary artery bypass grafting were not used during the index hospitalization in the early 1980s, whereas in 1994 these procedures were used in 28%, 38%, 19%, and 6% of patients, respectively. In-hospital complications, including arrhythmias, conduction disturbances, and heart failure, were less frequent in 1994 compared with the period 1981 to 1983. The 7- and 30-day crude mortality rates were significantly lower in 1994 compared with the early 1980s (5% vs 9% and 5% vs 13%, respectively, P < .05 for both), whereas the 1-year crude mortality rate decreased slightly (15% vs 19%, P = .13). Multivariate analyses adjusting for pertinent variables revealed a decreased risk for death in 1994 versus 1981 to 1983; for 7-day (odds ratio = 0.49, 95% confidence interval 0.23 to 0.94), 30-day (odds ratio = 0.36, 95% confidence interval 0.18 to 0.69) and for 1-year (odds ratio = 0.65, 95% confidence interval 0.44 to 0.96). CONCLUSION The prognosis of patients with a first non-Q-wave AMI has improved considerably during the last decade. The introduction of new therapeutic modalities, including invasive cardiac procedures and new medications, probably played a major role in the favorable outcome of these patients.
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Affiliation(s)
- M Haim
- Neufeld Cardiac Research Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel
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29
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von Knorre GH. [The standard ECG: did its significance change?]. Herzschrittmacherther Elektrophysiol 1997; 8:217-22. [PMID: 19484322 DOI: 10.1007/bf03042610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/1997] [Accepted: 10/08/1997] [Indexed: 11/28/2022]
Abstract
Since introduction of electrocardiography as a clinical method its significance varied. In investigating atrial changes, ventricular hypertrophies and pericardial diseases imaging methods became superior to the ECG. In the diagnosis of coronary artery disease the significance of the standard ECG is different according to clinical picture and stage. Nevertheless it is indispensable in situations with acute ischemia. Knowledge from interventional electrophysiology made interpretations of the standard ECG in conduction disorders and arrhythmias more reliable. Up to now informations gathered from the repolarisation phase in the standard ECG are growing.Thus, despite a change of its significance within partial aspects of cardiology the nearly 100 year old clinical method of electrocardiography as standard ECG of to day is still of high practical value.
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Affiliation(s)
- G H von Knorre
- Abteilung für Kardiologie Klinik und Poliklinik für Innere Medizin, Universitätsklinik, Ernst-Heydemann-Strasse 6, 18055, Rostock
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30
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Haim M, Hod H, Reisin L, Kornowski R, Reicher-Reiss H, Goldbourt U, Boyko V, Behar S. Comparison of short- and long-term prognosis in patients with anterior wall versus inferior or lateral wall non-Q-wave acute myocardial infarction. Secondary Prevention Reinfarction Israeli Nifedipine Trial (SPRINT) Study Group. Am J Cardiol 1997; 79:717-21. [PMID: 9070547 DOI: 10.1016/s0002-9149(96)00856-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We evaluated the early and long-term prognosis of patients with a first non-Q-wave acute myocardial infarction (AMI) in relation to infarct site. Among 4,314 patients with a first AMI, 610 (14%) had a non-Q-wave AMI. Of them, 248 patients with anterior wall AMI were compared with 327 patients with inferior/lateral AMI. Baseline clinical characteristics were similar in both groups except for higher mean age in the anterior wall group. In-hospital complications were more common among patients with anterior wall AMI than in the inferior/lateral group. Patients with anterior wall AMI also had higher rates of in-hospital (15%), 1-year (12%), and 5-year (36%) postdischarge mortality compared with the inferior/lateral infarction group (10%, 6%, and 22%, respectively). The 1-year cardiac event rate (recurrent AMI and cardiac death) was significantly higher among the anterior wall AMI group than the inferior/lateral AMI group (14.2% and 4.8% respectively, p = 0.001). After adjustment for age, gender, systemic hypertension, diabetes mellitus, prior angina, and treatment with various medications, an increased risk for 1-year (odds ratio 1.31, 95% confidence interval [CI] 0.62 to 2.78) and 5-year mortality (relative risk 1.29, 95% CI 0.90 to 1.85) was observed, but it did not reach statistical significance. Anterior wall AMI location emerged as a predictor for higher 1-year cardiac event rate (odds ratio 3.15, 95% CI 1.59 to 6.78). These findings suggest that AMI location is an important prognostic variable for risk stratification of patients with a first non-Q-wave AMI.
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Affiliation(s)
- M Haim
- Neufeld Cardiac Research Institute, Sheba Medical Center, Tel Hashomer, Israel
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