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Camaj A, Fuster V, Giustino G, Bienstock SW, Sternheim D, Mehran R, Dangas GD, Kini A, Sharma SK, Halperin J, Dweck MR, Goldman ME. Left Ventricular Thrombus Following Acute Myocardial Infarction: JACC State-of-the-Art Review. J Am Coll Cardiol 2022; 79:1010-1022. [PMID: 35272796 DOI: 10.1016/j.jacc.2022.01.011] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/13/2022] [Accepted: 01/13/2022] [Indexed: 12/11/2022]
Abstract
The incidence of left ventricular (LV) thrombus following acute myocardial infarction has markedly declined in recent decades caused by advancements in reperfusion and antithrombotic therapies. Despite this, embolic events remain the most feared complication of LV thrombus necessitating systemic anticoagulation. Mechanistically, LV thrombus development depends on Virchow's triad (ie, endothelial injury from myocardial infarction, blood stasis from LV dysfunction, and hypercoagulability triggered by inflammation, with each of these elements representing potential therapeutic targets). Diagnostic modalities include transthoracic echocardiography with or without ultrasound-enhancing agents and cardiac magnetic resonance. Most LV thrombi develop within the first 2 weeks post-acute myocardial infarction, and the role of surveillance imaging appears limited. Vitamin K antagonists remain the mainstay of therapy because the efficacy of direct oral anticoagulants is less well established. Only meager data support the routine use of prophylactic anticoagulation, even in high-risk patients.
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Affiliation(s)
- Anton Camaj
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA. https://twitter.com/acamajmd
| | - Valentin Fuster
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gennaro Giustino
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA. https://twitter.com/g_giustinomd
| | - Solomon W Bienstock
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA. https://twitter.com/swbienmd
| | - David Sternheim
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA. https://twitter.com/drroxmehran
| | - George D Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA. https://twitter.com/georgedangas
| | - Annapoorna Kini
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA. https://twitter.com/doctorkini
| | - Samin K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jonathan Halperin
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Martin E Goldman
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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2
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Mehana EM, Shawky AM, Abdelrahman HS. Insights on the left ventricular thrombus in patients with ischemic dilated cardiomyopathy. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2021. [DOI: 10.1186/s43055-021-00628-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Left ventricular thrombus (LVT) formation represents a common complication of dilated cardiomyopathy (DCM). LVT is usually underestimated with transthoracic echocardiography (TTE) while cardiac magnetic resonance imaging (CMRI) is promising as an alternative imaging modality for cardiac thrombus detection. The study aims to compare TTE and CMRI in their ability to detect LVT, also, to assess the clinical and imaging parameters to determine variables that may predispose for thrombus formation. The study population includes seventy-six patients with ischemic DCM. They were divided into 2 groups based on the presence of LVT as detected by delayed-enhancement CMRI (DE-CMRI) [Group A included 20 patients with a LVT and Group B included 56 patients without].
Results
All of the current study population had ischemic DCM with left ventricular ejection fraction (LVEF) < 50%. DE-CMR detected thrombus in 20 cases of the studied population that represented group A. From group A, conventional TTE detected LVT only in 8 and cine-CMR detected 13 cases out of the out of 20 cases. The ejection fraction of the left ventricle as measured by functional CMRI was significantly lower in group A (P = 0.045). Interestingly, the myocardial scarring in group A was seen significantly more extensive than in group B (the P value is < 0.00001), paralleling the increased prevalence of thrombus.
Conclusions
DE-CMRI provides superiority for the detection of LVT compared with standard TTE or cine-CMRI and the amount of myocardial scarring detected by DE-CMRI can be considered an independent marker for thrombus presence.
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John S, Hegde S, Hussain S, Bukharovich I, Graham-Hill S, Mallappallil M, Pedalino R. COVID-19 Pneumonia Precipitating Acute Anterior Wall Myocardial Infarction With Large Left Ventricular Apical Thrombus. J Med Cases 2021; 12:251-255. [PMID: 34429797 PMCID: PMC8279283 DOI: 10.14740/jmc3687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 03/12/2021] [Indexed: 11/11/2022] Open
Abstract
Initial reports suggest an increased thrombotic risk in coronavirus disease 2019 (COVID-19). We present a case of COVID-19 pneumonia that precipitated chest pain, an acute anterior wall ST-elevation myocardial infarction on the fifth day of hospitalization resulting in large left ventricular apical thrombus.
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Affiliation(s)
- Sabu John
- Division of Cardiovascular Disease, Department of Medicine, Kings County Hospital Center, Brooklyn, NY 11203, USA
| | - Sudhanva Hegde
- Division of Cardiovascular Disease, Department of Medicine, Kings County Hospital Center, Brooklyn, NY 11203, USA
| | - Syed Hussain
- Division of Cardiovascular Disease, Department of Medicine, Kings County Hospital Center, Brooklyn, NY 11203, USA
| | - Inna Bukharovich
- Division of Cardiovascular Disease, Department of Medicine, Kings County Hospital Center, Brooklyn, NY 11203, USA
| | - Suzette Graham-Hill
- Division of Cardiovascular Disease, Department of Medicine, Kings County Hospital Center, Brooklyn, NY 11203, USA
| | - Mary Mallappallil
- Division of Cardiovascular Disease, Department of Medicine, Kings County Hospital Center, Brooklyn, NY 11203, USA
| | - Ronald Pedalino
- Division of Cardiovascular Disease, Department of Medicine, Kings County Hospital Center, Brooklyn, NY 11203, USA
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Chen R, Wang Y, Yang J, Cheng X, Wang J, Huang L. Recurrent pheochromocytoma with catecholamine cardiomyopathy and left ventricular thrombus: a case report. J Int Med Res 2021; 49:3000605211007723. [PMID: 33884914 PMCID: PMC8074535 DOI: 10.1177/03000605211007723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Pheochromocytoma is a rare and usually benign tumor of the adrenal glands. We report a case of a 40-year-old woman with recurrent pheochromocytoma and catecholamine cardiomyopathy. She had no history of other types of tumors or connective tissue disease. She had already undergone surgery twice to remove the pheochromocytoma, which had now recurred for the second time. A thrombus in the left ventricle was also noted upon imaging examination, which dissipated after anticoagulation therapy using dabigatran, allowing the patient to opt for an elective third surgery. This paper describes the clinical outcome of using the anticoagulant dabigatran to treat left ventricular thrombosis in this rare case of recurrent pheochromocytoma, and thus further contributing to the knowledge of the clinical management of this rare and complicated disease.
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Affiliation(s)
- Renzheng Chen
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Yong Wang
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jie Yang
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Xiaofeng Cheng
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jiang Wang
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Lan Huang
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
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Zykov MV, Butsev VV, Suleymanov RR. Myocardial Infarction Complicated by Ischemic Stroke: Risk Factors, Prognosis, Unresolved Problems and Possible Methods of Prevention. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-02-09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The present work is devoted to the analysis of modern publications on various aspects of the development and course of ischemic stroke in the presence of acute myocardial infarction. A literature search was conducted on the websites of cardiological and neurological societies, as well as on the PubMed, EMBASE, eLibrary databases using the keywords: myocardial infarction, acute coronary syndrome, stroke, acute cerebrovascular accident, myocardial infarction, acute coronary syndrome, stroke. The authors of this review found that although stroke is a relatively rare complication of myocardial infarction, its prevention is an extremely significant task, since it is associated with high mortality, disability and a significant increase in the cost of treatment. So, it is extremely important to detect thrombosis of the left ventricular cavity in a timely manner, to register preexisting atrial fibrillation that occurs earlier or for the first time, followed by the appointment of anticoagulant therapy. Timely reperfusion treatment, the use of statins and modern dual antithrombotic therapy can reduce the risk of developing cerebrovascular accident in patients with myocardial infarction. It is likely that a decrease in the activity of subclinical inflammation after myocardial infarction will also reduce the risk of stroke, as was recently shown in the COLCOT study. Currently, it remains relevant to search for new knowledge about the risk factors for stroke, which complicated the course of myocardial infarction, which will allow developing more effective and personalized preventive measures in a patient with acute coronary syndrome.
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Affiliation(s)
- M. V. Zykov
- Research Institute for Complex Issues of Cardiovascular Diseases;
Sochi City Hospital №4
| | | | - R. R. Suleymanov
- District Cardiology Dispensary, Center for Diagnosis and Cardiovascular Surgery
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YILMAZ M, BALLI M, GÜR M. Predictors Of Left Ventricular Apical Thrombus Formation in Patients With Acute Anterior Myocardial Infarction and Treated Primary Percutaneous Coronary Intervention: Importance of Syntax Score. KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNIVERSITESI TIP FAKÜLTESI DERGISI 2020. [DOI: 10.17517/ksutfd.823196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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7
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Sabzi F, Faraji R. Large In-transient Left Ventricular Thrombus due to Anabolic Steroid-induced Cardiomyopathy. Indian J Crit Care Med 2017; 21:51-54. [PMID: 28197053 PMCID: PMC5278592 DOI: 10.4103/0972-5229.198328] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The presence of small or moderate size thrombosis is not uncommon in left ventricle (LV) as results of basic co-moribund disease, but huge LV thrombosis that protrudes to aortic valve in the LV outflow tract (LVOT) tract is an exceptionally rare phenomenon. We report a 34-year-old bodybuilder athlete with cardiomyopathy and massive LV thrombosis. The thrombosis extended to LVOT and protruded through the aortic valve in systole and posed a high risk of systemic emboli. The patient underwent open heart surgery, and the clot was removed. The operation was complicated by low cardiac output syndrome that managed by intra-aortic balloon pump and high dose of inotropic drugs and hemodialysis. The patient died on the 15th day after surgery with multiorgan failures.
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Affiliation(s)
- Feridoun Sabzi
- Preventive Cardiovascular Research Centre Kermanshah, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Reza Faraji
- Preventive Cardiovascular Research Centre Kermanshah, Kermanshah University of Medical Sciences, Kermanshah, Iran
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8
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Driesman A, Hyder O, Lang C, Stockwell P, Poppas A, Abbott JD. Incidence and Predictors of Left Ventricular Thrombus After Primary Percutaneous Coronary Intervention for Anterior ST-Segment Elevation Myocardial Infarction. Clin Cardiol 2015; 38:590-7. [PMID: 26417910 DOI: 10.1002/clc.22450] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 07/27/2015] [Accepted: 07/30/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The role of warfarin in anterior ST-segment elevation myocardial infarction (STEMI) complicated by left ventricular (LV) dysfunction in patients treated with primary percutaneous coronary intervention (PCI) and dual antiplatelet therapy is unclear. Warfarin may prevent cardioembolic events but significantly increases bleeding in the setting of dual antiplatelet therapy. HYPOTHESIS The incidence of LV thrombus in anterior STEMI patients treated with PCI is low, and clinical predictors might be valuable in determining patients at risk. METHODS We performed a retrospective, single-center study of 687 consecutive patients with anterior STEMI treated with PCI from 2006 to 2013. Baseline variables were evaluated in 310 patients at high risk for LV thrombus based on echocardiographic criteria. Patients with definite, probable, and no LV thrombus were compared by ANOVA, χ(2), or t test where appropriate. Logistic regression analysis was performed. RESULTS The incidence of LV thrombus was 15% (n = 47 probable/definite thrombus). Cardiac arrest was the only independent characteristic associated with increased risk of LV thrombus (odds ratio [OR]: 4.06, 95% confidence interval [CI]: 1.3-12.7). Trends were observed for a lower risk in cardiogenic shock (OR: 0.33, 95% CI: 0.10-1.05) and aspirin use at baseline (OR: 0.43, 95% CI: 0.17-1.1). Treatment variables associated with LV thrombus included unfractionated heparin use post-PCI (OR: 2.43, 95% CI: 1.16-5.1) and use of balloon angioplasty without stent. CONCLUSIONS In contemporary practice with primary PCI, definite LV thrombus following anterior STEMI with LV dysfunction is challenging to predict. Further investigation is needed to determine if there is a subset of patients that should be treated with prophylactic warfarin.
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Affiliation(s)
- Adam Driesman
- Cardiovascular Institute, Rhode Island Hospital, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Omar Hyder
- Cardiovascular Institute, Rhode Island Hospital, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Christopher Lang
- Cardiovascular Institute, Rhode Island Hospital, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Phillip Stockwell
- Cardiovascular Institute, Rhode Island Hospital, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Athena Poppas
- Cardiovascular Institute, Rhode Island Hospital, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - J Dawn Abbott
- Cardiovascular Institute, Rhode Island Hospital, Warren Alpert Medical School, Brown University, Providence, Rhode Island
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9
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Affiliation(s)
- Ronak Delewi
- Department of Cardiology, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, The Netherlands
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10
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Potu C, Tulloch-Reid E, Baugh D, Madu E. Left ventricular thrombus in patients with acute myocardial infarction:Case report and Caribbean focused update. Australas Med J 2012; 5:178-83. [PMID: 22952564 DOI: 10.4066/amj.20121103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Despite the well documented benefit of echocardiography in acute coronary syndromes, its wide-scale use in the Caribbean is limited by access, health literacy and affordability. Because of the limited use of echocardiography in the region, routine complications of acute myocardial infarction (AMI) are not fully appreciated and may go unrecognized, further contributing to increased cardiovascular morbidity and mortality. It is therefore necessary to bring focus to this common clinical condition and highlight the clinical utility of echocardiography in facilitating timely and accurate diagnosis. We report here a case of large left ventricular (LV) thrombus in a patient with AMI. Coronary angiography showed completely occluded left anterior descending artery (LAD) with angiographically normal remaining vessels. Immediate anticoagulation was commenced with heparin and overlapped with warfarin. No Primary Angioplasty (PA) was done based on the evidence from occluded artery trial. LV thrombus was completely resolved on echocardiography at three months. No evidence of thrombo-embolism was found during the resolution of LV thrombus.
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Affiliation(s)
- Cr Potu
- Department of Medicine, Division of Cardiovascular Medicine, Heart Institute of the Caribbean, Kingston, Jamaica
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Cresti A, Capati E, Guerrini F, Cesareo F, Severi S. Embolic storm: an unusual complication of acute myocardial infarction. J Cardiovasc Med (Hagerstown) 2012; 14:902-4. [PMID: 22801075 DOI: 10.2459/jcm.0b013e328356a453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Alberto Cresti
- Division of Cardiology, Misericordia Hospital Grosseto, Grosseto, Italy
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12
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Udell JA, Wang JT, Gladstone DJ, Tu JV. Anticoagulation after anterior myocardial infarction and the risk of stroke. PLoS One 2010; 5:e12150. [PMID: 20730096 PMCID: PMC2921337 DOI: 10.1371/journal.pone.0012150] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2009] [Accepted: 06/08/2010] [Indexed: 12/23/2022] Open
Abstract
Background Survivors of anterior MI are at increased risk for stroke with predilection to form ventricular thrombus. Commonly patients are discharged on dual antiplatelet therapy. Given the frequency of early coronary reperfusion and risk of bleeding, it remains uncertain whether anticoagulation offers additional utility. We examined the effectiveness of anticoagulation therapy for the prevention of stroke after anterior MI. Methods and Findings We performed a population-based cohort analysis of 10,383 patients who survived hospitalization for an acute MI in Ontario, Canada from April 1, 1999 to March 31, 2001. The primary outcome was four-year ischemic stroke rates compared between anterior and non-anterior MI patients. Risk factors for stroke were assessed by multivariate Cox proportional-hazards analysis. Warfarin use was determined at discharge and followed for 90 days among a subset of patients aged 66 and older (n = 1483). Among the 10,383 patients studied, 2,942 patients survived hospitalization for an anterior MI and 20% were discharged on anticoagulation therapy. Within 4 years, 169 patients (5.7%) were admitted with an ischemic stroke, half of which occurred within 1-year post-MI. There was no significant difference in stroke rate between anterior and non-anterior MI patients. The use of warfarin up to 90 days was not associated with stroke protection after anterior MI (hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.37–1.26). The use of angiotensin-converting-enzyme inhibitors (HR, 0.65; 95% CI, 0.44–0.95) and beta-blockers (HR, 0.60; 95% CI, 0.41–0.87) were associated with a significant decrease in stroke risk. There was no significant difference in bleeding-related hospitalizations in patients who used warfarin for up to 90 days post-MI. Conclusion Many practitioners still consider a large anterior-wall MI as high risk for potential LV thrombus formation and stroke. Among a cohort of elderly patients who survived an anterior MI there was no benefit from the use of warfarin up to 90 days post-MI to prevent ischemic stroke. Our data suggests that routine anticoagulation of patients with anterior-wall MI may not be indicated. Prospective randomized trials are needed to determine the optimal antithrombin strategy for preventing this common and serious adverse outcome.
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Affiliation(s)
- Jacob A Udell
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
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13
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Value of contrast echocardiography for left ventricular thrombus detection postinfarction and impact on antithrombotic therapy. Coron Artery Dis 2009; 20:462-6. [DOI: 10.1097/mca.0b013e328330d58f] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Osherov AB, Borovik-Raz M, Aronson D, Agmon Y, Kapeliovich M, Kerner A, Grenadier E, Hammerman H, Nikolsky E, Roguin A. Incidence of early left ventricular thrombus after acute anterior wall myocardial infarction in the primary coronary intervention era. Am Heart J 2009; 157:1074-80. [PMID: 19464419 DOI: 10.1016/j.ahj.2009.03.020] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2009] [Accepted: 03/26/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Rapid reperfusion has been shown to decrease mortality and improve left ventricular (LV) function. Previous studies have reported that LV thrombus (LVT) is a major complication of ST-segment elevation acute anterior wall myocardial infarction (AMI). There are little data on LVT in the current primary percutaneous coronary intervention (PPCI) era. We sought to demonstrate the incidence of LVT after AMI in patients treated with PPCI compared with those treated with thrombolysis or with conservative management. METHODS In a 6-year period, 642 patients with anterior wall AMI and echocardiography were treated with PPCI (n = 297), thrombolysis (n = 128), or conservative treatment (n = 217). Left ventricular thrombus was defined as an echodense mass adjacent to an abnormally contracting myocardial segment. RESULTS The rate of LVT among anterior wall AMI was 6.2%. Predictors for LVT were reduced ejection fraction (adjusted relative risk 0.71, 95% CI 0.52-0.96) and severe mitral regurgitation (adjusted relative risk 2.48, 95% CI 1.0-6.44). There was no statistical difference in LVT rate according to treatment: 21 (7.1%) of 297 patients in the PPCI group, 10 (7.8%) of 128 patients in the thrombolytic group, and 9 (4.1%) of 217 patients in the conservative group (P = .28). Those in the thrombolytic group were characterized by shorter duration from symptom onset and were generally also treated with heparin/low-molecular weight heparin. CONCLUSIONS This is the largest report to evaluate the incidence of LVT formation after AMI. In the current era of rapid reperfusion by PPCI, the rate of thrombus formation is similar to that reported in the past and not different than for patients currently treated conservatively or with thrombolysis.
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Ileri M, Tandoğan I, Koşar F, Yetkin E, Büyükaşik Y, Kütük E. Influence of thrombolytic therapy on the incidence of left ventricular thrombi after acute anterior myocardial infarction: role of successful reperfusion. Clin Cardiol 2009; 22:477-80. [PMID: 10410292 PMCID: PMC6656132 DOI: 10.1002/clc.4960220708] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Previous studies have reported controversial results regarding the effectiveness of systemic thrombolysis in preventing left ventricular (LV) thrombus after acute myocardial infarction (MI). HYPOTHESIS This study was performed to evaluate the influences of thrombolysis, and particularly successful reperfusion, on the incidence of LV thrombus formation after acute anterior MI. METHODS In all, 191 patients suffering from a first attack of acute anterior MI were prospectively evaluated by two-dimensional echocardiography and coronary angiography, performed at the end of the first week and within the first two weeks of MI, respectively. Of these, 98 who presented within 12 h of onset of symptoms received intravenous streptokinase (1.5 million IU), while the remaining 93 patients who, either because of contraindications or late admission, did not receive thrombolytic treatment served as control group. All patients received aspirin and full-dose anticoagulation with intravenous heparin. Successful reperfusion in the streptokinase group was assessed by enzymatic and electrocardiographic evidence. RESULTS The overall incidence of LV thrombi was 24.6% (47/191). When all patients were evaluated, no statistically significant difference was found between the frequency of LV thrombi in the patients who had thrombolysis (22.4%) and those who did not (26.8%), despite a trend toward the formation of fewer thrombi in the initial group (p > 0.05). However, the patients who had successful reperfusion with streptokinase (n = 64) had significantly reduced incidence of LV thrombi compared with those who did not receive thrombolytic therapy (20 vs. 26.8%, p < 0.05). Stepwise multivariate analysis suggested that LV abnormal wall motion score (p = 0.01) and presence of LV aneurysm were independent predictors of LV thrombus formation in patients with acute anterior MI. CONCLUSION Not all patients who received streptokinase for acute anterior MI, but only those with successful reperfusion had reduced incidence of LV thrombi. The favorable effects of thrombolysis on LV thrombus formation are probably due to the preservation of global LV systolic function.
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Affiliation(s)
- M Ileri
- Department of Cardiology, Türkiye Yüksek Ihtisas Hospital, Ankara, Turkey
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16
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Zielinska M, Kaczmarek K. Abciximab and left ventricular thrombus formation in early period of acute myocardial infarction treated with successful primary stenting. J Thromb Thrombolysis 2008; 27:447-52. [DOI: 10.1007/s11239-008-0226-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2008] [Accepted: 04/21/2008] [Indexed: 12/24/2022]
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17
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Predictors of Left Ventricular Thrombus Formation in Acute Myocardial Infarction Treated With Successful Primary Angioplasty With Stenting. Am J Med Sci 2008; 335:171-6. [DOI: 10.1097/maj.0b013e318142be20] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Acute Coronary Syndromes and Acute Myocardial Infarction. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50033-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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19
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Lipke C, Katoh M, Franke A, Krombach G, Buecker A, Kühl HP. The value of non-contrast harmonic transthoracic echocardiography for the detection of left ventricular thrombi in patients with cardiomyopathy: comparison with contrast-enhanced magnetic resonance imaging. Int J Cardiovasc Imaging 2006; 23:479-87. [PMID: 17160424 DOI: 10.1007/s10554-006-9190-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2006] [Accepted: 10/30/2006] [Indexed: 10/23/2022]
Abstract
We sought to assess the value of non-contrast enhanced transthoracic harmonic echocardiography (TEE) for the visualization of left ventricular thrombi in 34 patients with cardiomyopathy. Results were compared to contrast-enhanced magnetic resonance imaging as reference standard. Maximal thrombus size was quantified with both modalities. Magnetic resonance imaging demonstrated thrombi in 15 patients. In these subjects echocardiography was negative in seven patients. Thrombi were excluded in 19 patients with magnetic resonance while echocardiography was deemed positive in 5 subjects. Thrombus size by ce-CMR was not different for clots visualized or not visualized by echocardiography (P = 0.71). Moreover, observer agreement was superior for ce-CMR (kappa = 0.94) as compared to TTE (kappa= 0.71). Non-contrast-enhanced harmonic TTE has limited value for the visualization of thrombi in patients with cardiomyopathy.
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Affiliation(s)
- Claudia Lipke
- Medical Clinic I, University Hospital of the RWTH Aachen, Pauwelsstrasse 30, 52057 Aachen, Germany
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Rehan A, Kanwar M, Rosman H, Ahmed S, Ali A, Gardin J, Cohen G. Incidence of post myocardial infarction left ventricular thrombus formation in the era of primary percutaneous intervention and glycoprotein IIb/IIIa inhibitors. A prospective observational study. Cardiovasc Ultrasound 2006; 4:20. [PMID: 16600036 PMCID: PMC1458359 DOI: 10.1186/1476-7120-4-20] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2006] [Accepted: 04/06/2006] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Before the widespread use of primary percutaneous coronary intervention (PCI) and glycoprotein IIb/IIIa inhibitors (GP IIb/IIIa) left ventricular (LV) thrombus formation had been reported to complicate up to 20% of acute myocardial infarctions (AMI). The incidence of LV thrombus formation with these treatment modalities is not well known. METHODS 92 consecutive patients with ST-elevation AMI treated with PCI and GP IIb/IIIa inhibitors underwent 2-D echocardiograms, with and without echo contrast agent, within 24-72 hours. RESULTS Only 4/92 (4.3%) had an LV thrombus, representing a significantly lower incidence than that reported in the pre-PCI era. Use of contrast agents did not improve detection of LV thrombi in our study. CONCLUSION The incidence of LV thrombus formation after acute MI, in the current era of rapid reperfusion, is lower than what has been historically reported.
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Affiliation(s)
- Arshad Rehan
- Department of Cardiology, St John Hospital and Medical Centre, Wayne State University, 22101 Moross Road, Detroit, Michigan 48230, USA
| | - Manpreet Kanwar
- Department of Cardiology, St John Hospital and Medical Centre, Wayne State University, 22101 Moross Road, Detroit, Michigan 48230, USA
| | - Howard Rosman
- Department of Cardiology, St John Hospital and Medical Centre, Wayne State University, 22101 Moross Road, Detroit, Michigan 48230, USA
| | - Sujood Ahmed
- Department of Cardiology, St John Hospital and Medical Centre, Wayne State University, 22101 Moross Road, Detroit, Michigan 48230, USA
| | - Arshad Ali
- Department of Cardiology, Guthrie Clinic Sayre, Guthrie Square, Sayer, Pennsylvania 18840, USA
| | - Julius Gardin
- Department of Cardiology, St John Hospital and Medical Centre, Wayne State University, 22101 Moross Road, Detroit, Michigan 48230, USA
| | - Gerald Cohen
- Department of Cardiology, St John Hospital and Medical Centre, Wayne State University, 22101 Moross Road, Detroit, Michigan 48230, USA
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Zibaeenezhad MJ, Mowla A, Salahi R, Nikseresht AR, Shariat H, Ashjaezadeh N, Banani SJ. Cardiac sources of embolic cerebral infarction in transesophageal echocardiography. Ann Saudi Med 2006; 26:43-5. [PMID: 16521874 PMCID: PMC6078544 DOI: 10.5144/0256-4947.2006.43] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Porter A, Kandalker H, Iakobishvili Z, Sagie A, Imbar S, Battler A, Hasdai D. Left ventricular mural thrombus after anterior ST-segment-elevation acute myocardial infarction in the era of aggressive reperfusion therapy ??? still a frequent complication. Coron Artery Dis 2005; 16:275-9. [PMID: 16000884 DOI: 10.1097/00019501-200508000-00003] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Left ventricular mural thrombus (LVMT) is a well-known complication of anterior ST-elevation acute myocardial infraction (AMI). It remains unknown how modern therapies have impacted on its occurrence. OBJECTIVES To define the frequency of LVMT among contemporary patients with anterior ST-elevation AMI, the clinical and echocardiographic predictors of LVMT formation, and the intermediate-term outcomes of patients with LVMT. METHODS We retrospectively analysed patients (in the years 1997-2002) with a diagnosis of anterior ST-elevation AMI and no prior AMI, and who underwent a thorough echocardiographic assessment within 72 h of admission. Stepwise logistic regression analysis was used to define predictors of LVMT formation. Survival was calculated by the Kaplan-Meier product-limit method. RESULTS Of the 153 patients with complete data, LVMT was detected in 36 (23.5%). There were no significant differences in baseline demographic and clinical variables between LVMT and non-LVMT patients, or in treatments (all patients received reperfusion treatment). The mean wall motion score index was higher in LVMT than non-LVMT patients (0.88+/-1.79 versus 0.65+/-0.36, respectively; P=0.01), indicating worse cardiac systolic function. LVMT patients were treated with warfarin for 3-6 months. The incidence of death was similar between the groups (11.1% for LVMT patients versus 12.8% for non-LVMT patients, P=0.79) over a mean follow-up of 71-72 months. The only independent predictor found for LVMT occurrence was worse regional wall motion of the apex (odds ratio, 2.04, 95% confidence interval, 1.39-3.03; P<0.001). CONCLUSIONS In the contemporary 'real-world scenario', despite aggressive reperfusion treatment and anti-aggregant use, the incidence of LVMT remained high after anterior ST-elevation AMI. LVMT was not related to increased intermediate-term mortality when patients were treated with warfarin, and the only predictor of LVMT occurrence was regional function of the apex.
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Affiliation(s)
- Avital Porter
- Department of Cardiology, Rabin Medical Centre and Sackler Faculty of Medicine, Tel Aviv University, Israel
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23
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Pellizzon GG, Grines CL, Cox DA, Stuckey T, Tcheng JE, Garcia E, Guagliumi G, Turco M, Lansky AJ, Griffin JJ, Cohen DJ, Aymong E, Mehran R, O'Neill WW, Stone GW. Importance of mitral regurgitation inpatients undergoing percutaneous coronary intervention for acute myocardial infarction: the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial. J Am Coll Cardiol 2004; 43:1368-74. [PMID: 15093869 DOI: 10.1016/j.jacc.2003.11.046] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2003] [Revised: 11/04/2003] [Accepted: 11/13/2003] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We sought to determine the prognostic importance of mitral regurgitation (MR) in patients undergoing percutaneous coronary intervention for acute myocardial infarction (AMI). BACKGROUND Mitral regurgitation has been associated with a poor prognosis in patients treated with thrombolytic therapy for AMI. The prognostic significance of MR in patients undergoing mechanical reperfusion therapy for AMI is unknown. METHODS Left ventriculography was performed during the index procedure in 1,976 (95%) of 2,082 non-shock patients enrolled in a prospective, multicenter, randomized trial of mechanical reperfusion strategies in AMI. The severity of operator-assessed MR was divided into four strata: none (n = 1,726), mild (n = 192), and moderate/severe (n = 58). RESULTS Patients with progressively more severe MR were older (p < 0.0001), were more often women (p < 0.0001), and had higher Killip class (p = 0.0007). More severe grades of MR correlated with triple-vessel disease (p < 0.0001) and lower left ventricular ejection fraction (LVEF) as measured during the index procedure (p = 0.0004). Increasingly severe MR was strongly associated with a higher mortality at 30 days (1.4% vs. 3.7% vs. 8.6%, respectively; p < 0.0001) and at one year (2.9%, 8.5%, 20.8%, respectively; p < 0.0001). By multivariate analysis, the presence of even mild MR was an independent predictor of long-term mortality (mild MR, relative risk [RR] = 2.40, p = 0.005; moderate/severe MR, RR = 2.82, p = 0.006). CONCLUSIONS Mitral regurgitation of any degree present on the baseline left ventriculogram during the index procedure is a powerful, independent predictor of mortality in patients undergoing mechanical reperfusion therapy for AMI. The presence of MR identifies high-risk patients in whom close out-patient follow-up is warranted, and who may benefit from aggressive adjunctive medical or surgical therapies.
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Affiliation(s)
- Gregory G Pellizzon
- Mid-America Heart Institute, Saint Luke's Hospital, Kansas City, Missouri, USA
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Abstract
Stroke is a major cause of morbidity and mortality in an aging population. The current understanding of the pathophysiology of atherosclerotic diseases, the most common cause of stroke, and the evidence for existing therapeutic interventions for the prevention of stroke are presented. Specifically, we review the evidence for antiplatelet agents, anticoagulants, antihypertensive medications, lipid-lowering agents and carotid endarterectomy for stroke prevention.
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Affiliation(s)
- Fintan O'Rourke
- Stroke Prevention Clinic, University of Alberta Hospital, Mackenzie Health Sciences Centre
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26
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Domenicucci S, Chiarella F, Bellone P. Role of echocardiography in the assessment of left ventricular thrombus embolic potential after anterior acute myocardial infarction. CONGESTIVE HEART FAILURE (GREENWICH, CONN.) 2001; 7:250-255. [PMID: 11832663 DOI: 10.1111/j.1527-5299.2001.00268.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The contribution of cardiac ultrasound in assessment of the embolic potential of left ventricular thrombi after anterior acute myocardial infarction was verified in a prospective study of serial echocardiograms (mean, 18.9 examinations per patient) obtained over a long-term period (1-72 months; mean, 38±12). The study population comprised 222 patients (162 men; age, 64±11 years) with a first anterior acute myocardial infarction, treated with thrombolysis (group A) or receiving no antithrombolic therapy (group B). Embolism occurred in a total of 12 patients (11 with a left ventricular thrombus; p<0.005) and was more frequent in group B (10 patients; p<0.04). Predictors of embolism were the absence of thrombolysis, detection of a left ventricular thrombus, protrusion or mobility of the thrombus, and morphologic changes in the thrombus over time. Patients in group A had a lower incidence of each of these predictors, and a higher thrombus resolution rate. An appropriate echocardiographic protocol is crucial to assessment of the embolic potential of left ventricular thrombi after anterior acute myocardial infarction and may help to identify candidates for aggressive antithrombotic therapy (c)2001 CHF, Inc.
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Affiliation(s)
- S Domenicucci
- Division of Cardiology, Ente Ospedaliero Ospedali Galliera, 14-16167 Genova, Italy
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Cairns JA, Théroux P, Lewis HD, Ezekowitz M, Meade TW. Antithrombotic agents in coronary artery disease. Chest 2001; 119:228S-252S. [PMID: 11157652 DOI: 10.1378/chest.119.1_suppl.228s] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- J A Cairns
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
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28
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Kalra A, Jang IK. Prevalence of early left ventricular thrombus after primary coronary intervention for acute myocardial infarction. J Thromb Thrombolysis 2000; 10:133-6. [PMID: 11005935 DOI: 10.1023/a:1018710425817] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The prevalence of left ventricular (LV) thrombus after acute myocardial infarction (AMI) has been reported high at 20-60%. Current reperfusion therapies such as thrombolysis have shown a trend toward reducing the incidence of LV thrombosis. However, the prevalence of LV thrombus after primary percutaneous coronary intervention (PCI) for AMI has not been systematically studied. At Massachusetts General Hospital 71 consecutive patients who underwent primary PCI for acute ST elevation MI were reviewed for the prevalence of LV thrombus evaluated by echocardiography. Echocardiography was performed within 5 days of infarction. PCI was successful in all patients. The time delay from symptom onset to intervention was 191 minutes. Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow was achieved in more than 80% of cases. Only 3 patients (4%) had echocardiographic evidence of LV thrombus. All 3 patients had anterior infarctions. The incidence among patients with anterior MI was 10% (3 of 30 patients). The prevalence of LV thrombus in patients treated with primary PCI for AMI is low (4%).
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Affiliation(s)
- A Kalra
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA
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29
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Yet SF, Perrella MA, Layne MD, Hsieh CM, Maemura K, Kobzik L, Wiesel P, Christou H, Kourembanas S, Lee ME. Hypoxia induces severe right ventricular dilatation and infarction in heme oxygenase-1 null mice. J Clin Invest 1999; 103:R23-9. [PMID: 10207174 PMCID: PMC408281 DOI: 10.1172/jci6163] [Citation(s) in RCA: 334] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Heme oxygenase (HO) catalyzes the oxidation of heme to generate carbon monoxide (CO) and bilirubin. CO increases cellular levels of cGMP, which regulates vascular tone and smooth muscle development. Bilirubin is a potent antioxidant. Hypoxia increases expression of the inducible HO isoform (HO-1) but not the constitutive isoform (HO-2). To determine whether HO-1 affects cellular adaptation to chronic hypoxia in vivo, we generated HO-1 null (HO-1(-/-)) mice and subjected them to hypoxia (10% oxygen) for five to seven weeks. Hypoxia caused similar increases in right ventricular systolic pressure in wild-type and HO-1(-/-) mice. Although ventricular weight increased in wild-type mice, the increase was greater in HO-1(-/-) mice. Similarly, the right ventricles were more dilated in HO-1(-/-) mice. After seven weeks of hypoxia, only HO-1(-/-) mice developed right ventricular infarcts with organized mural thrombi. No left ventricular infarcts were observed. Lipid peroxidation and oxidative damage occurred in right ventricular cardiomyocytes in HO-1(-/-), but not wild-type, mice. We also detected apoptotic cardiomyocytes surrounding areas of infarcted myocardium by terminal deoxynucleotide transferase-mediated dUTP nick end-labeling (TUNEL) assays. Our data suggest that in the absence of HO-1, cardiomyocytes have a maladaptive response to hypoxia and subsequent pulmonary hypertension. J.Clin. Invest. 103:R23-R29 (1999).
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Affiliation(s)
- S F Yet
- Cardiovascular Biology Laboratory, Harvard School of Public Health, Boston, Massachusetts 02115, USA
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30
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Domenicucci S, Chiarella F, Bellotti P, Bellone P, Lupi G, Vecchio C. Long-term prospective assessment of left ventricular thrombus in anterior wall acute myocardial infarction and implications for a rational approach to embolic risk. Am J Cardiol 1999; 83:519-24. [PMID: 10073854 DOI: 10.1016/s0002-9149(98)00906-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To prospectively assess the predictive value of left ventricular (LV) thrombus anatomy for defining the embolic risk after acute myocardial infarction (AMI), 2 comparable groups of patients with a first anterior AMI (group A, 97 thrombolysed patients; group B, 125 patients untreated with antithrombotic drugs [total 222]) underwent prospective serial echocardiography (follow-up 39 +/- 13 months) at different time periods. LV thrombi were detected in 26 patients in group A (27%) and in 71 in group B (57%; p <0.005). Embolism occurred in 12 patients (5.4%; 1 in group A [1%] vs 11% in group B [9%], p < 0.04). At multivariate analysis, thrombus morphologic changes were the most powerful predictor of embolism (p <0.001), followed by protruding shape (p <0.01) and mobility (p <0.02). In patients untreated with thrombolysis, a higher occurrence of thrombus morphologic changes (48% vs 8%, p <0.002) and protruding shape (69% vs 31%, p <0.002) were observed, whereas thrombus mobility was similar in the 2 groups (18% vs 8%, p = NS). Thrombus resolution occurred more frequently in thrombolysed patients (85% vs 56%, p <0.002). Thus, after anterior AMI, changes in LV thrombus anatomy frequently occur and appear the most powerful predictor of embolization. A minor prevalence of thrombus, a more favorable thrombus anatomy, and a higher resolution rate may contribute to reduce embolic risk after thrombolysis.
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Affiliation(s)
- S Domenicucci
- Division of Cardiology, E.O. Ospedali Galliera, Genova, Italy.
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31
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Cairns JA, Théroux P, Lewis HD, Ezekowitz M, Meade TW, Sutton GC. Antithrombotic agents in coronary artery disease. Chest 1998; 114:611S-633S. [PMID: 9822067 DOI: 10.1378/chest.114.5_supplement.611s] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- J A Cairns
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
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32
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Abstract
Left ventricular thrombus formation and resolution were studied by serial echocardiography in 38 patients with acute anterior myocardial infarction. Twenty (52.6%) patients developed thrombus. Cumulative rates were: 12/20 (60%) at 24 h (+/-24 h), 17/20 (85%) at 72 h (+/-24 h), and 19/20 (95%) at 120 h (+/-24 h). Early thrombus formation was associated with worse left ventricular wall motion relative to those with delayed thrombus development (P=0.00016). In patients with initially normal echocardiograms, subsequent thrombus formation was associated with wall motion deterioration (P=0.016). A thrombus occurred in 16/28 (57.1%) patients given streptokinase. Heparin and warfarin were given in case of thrombus formation. Among survivors with thrombus, resolution occurred with a cumulative rate of 1/18 (5.6%) at 72 h (+/-24 h), 2/18 (11.1%) at 120 h (+/-24 h), 10/18 (55.6%) at 3 months (+/-1 week) and 16/18 (88.9%) at 6 months (+/-1 week). No embolic events occurred. Left ventricular thrombus formation occurs often and early after acute anterior myocardial infarction, even when streptokinase is given. Delayed thrombus formation is associated with wall motion deterioration. Thrombus resolution occurs frequently during anticoagulation and seems not associated with increased embolic risk.
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Affiliation(s)
- F Kontny
- Department of Cardiology, Aker University Hospital, Oslo, Norway
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Chiarella F, Santoro E, Domenicucci S, Maggioni A, Vecchio C. Predischarge two-dimensional echocardiographic evaluation of left ventricular thrombosis after acute myocardial infarction in the GISSI-3 study. Am J Cardiol 1998; 81:822-7. [PMID: 9555769 DOI: 10.1016/s0002-9149(98)00003-4] [Citation(s) in RCA: 114] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Left ventricular (LV) thrombosis can be found in patients with acute myocardial infarction (AMI). No wide multicenter trial on AMI has provided information about LV thrombosis until now. The protocol of the GISSI-3 study included the search for the presence of LV thrombosis in patients from 200 coronary care units that did not specifically focus on LV thrombosis. We examined the GISSI-3 database results related to 8,326 patients at low to medium risk for LV thrombi in which a predischarge echocardiogram (9 +/- 5 days) was available. LV thrombosis was found in 427 patients (5.1%): 292 of 2,544 patients (11.5%) with anterior AMI and in 135 of 5,782 patients (2.3%) with AMI in other sites (p <0.0001). The incidence of LV thrombosis was higher in patients with ejection fraction < or = 40% (151 of 1,432 [10.5%] vs 276 of 6,894 [4%]; p <0.0001) both in the total population and in the subgroup with anterior AMI (106 of 597 [17.8%] vs 186 of 1,947 [9.6%]; p <0.0001). Multivariate analysis showed that only the Killip class > I and early intravenous beta-blocker administration were independently associated with higher LV thrombosis risk in the subgroup of patients with anterior AMI (odds ratio 1.75, 95% confidence interval 1.28 to 2.39; odds ratio 1.32, 95% confidence interval 1.02 to 1.72, respectively). In patients with anterior AMI, oral beta-blocker therapy given or not given after early intravenous beta-blocker administration does not influence the occurrence of LV thrombosis. The rate of LV thrombosis was similar in patients treated or not treated with nitrates and lisinopril both in the total population and in patients with anterior and nonanterior AMI. In conclusion, in the GISSI-3 population at low to medium risk for LV thrombi, the highest rate of occurrence of LV thrombosis was found among patients with anterior AMI and an ejection fraction < 40%. Killip class > I and the early intravenous beta-blocker administration were the only variables independently associated with a higher predischarge incidence of LV thrombosis after anterior AMI.
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Affiliation(s)
- F Chiarella
- Divisione di Cardiologia, E.O. Ospedali Galliera, Genova, Italy
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34
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Tanne D, Gottlieb S, Hod H, Reicher-Reiss H, Boyko V, Behar S. Incidence and mortality from early stroke associated with acute myocardial infarction in the prethrombolytic and thrombolytic eras. Secondary Prevention Reinfarction Israeli Nifedipine Trial (SPRINT) and Israeli Thrombolytic Survey Groups. J Am Coll Cardiol 1997; 30:1484-90. [PMID: 9362406 DOI: 10.1016/s0735-1097(97)00330-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES This study sought to compare the incidence of early cerebrovascular events and subsequent mortality in two cohorts of consecutive patients with acute myocardial infarction (AMI), admitted to coronary care units (CCUs) in Israel, in the prethrombolytic and thrombolytic eras. BACKGROUND During the past decade, substantial changes have occurred in the medical treatment of AMI, and important new therapies have been introduced that could all affect stroke risk and type by diverse mechanisms. Yet the overall impact of these new therapeutic modalities on the incidence of stroke complicating AMI is not clear. METHODS We compared the incidence and mortality rates of cerebrovascular events complicating AMI within CCUs among 5,839 consecutive patients admitted in the period 1981 to 1983 versus 2,012 patients from two prospective nationwide surveys conducted in all CCUs operating in Israel in 1992 and 1994. RESULTS The demographic and clinical characteristics of patients with AMI in both periods were comparable. Patients admitted in the period 1981 to 1983 did not receive thrombolysis and reperfusion therapy; those admitted in 1992 and 1994 received thrombolysis (45%) and coronary angioplasty or coronary artery bypass graft surgery (14%), and antiplatelet and anticoagulant treatments were more frequently used. The incidence of early cerebrovascular events was 0.74% (43 of 5,839) in 1981 to 1983 versus 0.75% (15 of 2,012) in the 1992 to 1994 cohort. Patients with an AMI who experienced a cerebrovascular event were somewhat older in both groups and had a high rate of previous cerebrovascular events, congestive heart failure and atrial and ventricular arrhythmias during the hospital period. Mortality declined by one-third between the two periods. However, the mortality rate of patients with AMI who sustained a cerebrovascular event remained high (> or =40% for 30 days, 60% for 1 year). CONCLUSIONS The overall incidence of early cerebrovascular events complicating AMI remained similar (0.75%) in the prethrombolytic and thrombolytic eras. Mortality rates of patients with an AMI but no cerebrovascular events decreased substantially over the past decade but not in patients with AMI with a cerebrovascular event.
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Affiliation(s)
- D Tanne
- Department of Neurology and Neufeld Cardiac Research Institute, Sheba Medical Center, Tel Hashomer, Israel
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35
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Kontny F, Dale J, Abildgaard U, Pedersen TR. Randomized trial of low molecular weight heparin (dalteparin) in prevention of left ventricular thrombus formation and arterial embolism after acute anterior myocardial infarction: the Fragmin in Acute Myocardial Infarction (FRAMI) Study. J Am Coll Cardiol 1997; 30:962-9. [PMID: 9316525 DOI: 10.1016/s0735-1097(97)00258-1] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The present trial investigated the efficacy and safety of dalteparin in the prevention of arterial thromboembolism after an acute anterior myocardial infarction (MI). BACKGROUND Left ventricular (LV) thrombus formation is associated with increased risk of arterial embolism in patients with an acute MI. Thrombolytic and antiplatelet therapy do not prevent thrombus formation. METHODS A total of 776 patients were enrolled in a multicenter, randomized, double-blind, placebo-controlled trial of subcutaneous dalteparin (150 IU/kg body weight every 12 h during the hospital period). Thrombolytic therapy and aspirin were administered in 91.5% and 97.6% of patients, respectively. The primary study end point was the composite of thrombus formation diagnosed by echocardiography and arterial embolism on day 9 +/- 2. RESULTS Of 517 patients with echocardiographic recordings available for end point analysis, thrombus formation or embolism, or both, was found in 59 (21.9%) of 270 patients (59 with thrombus, none with embolism) in the placebo group and 35 (14.2%) of 247 patients (34 with thrombus, 1 with embolism) in the dalteparin group (p = 0.03). The risk reduction of thrombus formation associated with dalteparin treatment was 0.63 (95% confidence interval 0.43 to 0.92, p = 0.02). Analyses of all randomized patients (388 in each group) revealed no significant difference between the placebo and dalteparin groups with respect to arterial embolism (6 vs. 5 patients), reinfarction (8 vs. 6 patients) and mortality rates (23 vs. 23 patients, p = NS for all). Dalteparin was associated with an increased risk of hemorrhage: major in 11 dalteparin group patients (2.9%) verus 1 placebo group patient (0.3%, p = 0.006); minor in 52 dalteparin group patients (14.8%) versus 8 placebo group patients (1.8%, p < 0.001). CONCLUSIONS Dalteparin treatment significantly reduces LV thrombus formation in acute anterior MI but is associated with increased hemorrhagic risk.
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Affiliation(s)
- F Kontny
- Department of Cardiology, Aker University Hospital, Oslo, Norway.
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Mooe T, Teien D, Karp K, Eriksson P. Long term follow up of patients with anterior myocardial infarction complicated by left ventricular thrombus in the thrombolytic era. Heart 1996; 75:252-6. [PMID: 8800987 PMCID: PMC484281 DOI: 10.1136/hrt.75.3.252] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES To examine the appearance and resolution of left ventricular thrombi and to study the relation between thrombus and mortality during long term follow up after anterior myocardial infarction. DESIGN Ninety nine consecutive patients were prospectively studied until the last included patient had been followed for one year. Streptokinase and aspirin were used routinely, anticoagulants only after a decision by the attending physician. Echocardiography was performed within 3 d of admission, before discharge, and after one, three, and 12 months. SETTING Umeå University Hospital, a teaching hospital in Northern Sweden. MAIN OUTCOME MEASURES Left ventricular thrombus, segmental myocardial function, and mortality during follow up. RESULTS Thirty patients (30%) had a thrombus on discharge. One month, three months, and 12 months after hospital discharge, the thrombus had resolved in 81%, 84%, and 90% of the patients, respectively. The proportion of resolved thrombi at one month was high irrespective of whether anticoagulants were given (10/11, 91%) or not (12/16, 75%), P = 0.4. New thrombi appeared in 12 patients after discharge and resolution and reapperance of thrombi continued during the follow up period. Patients who developed a thrombus during the hospital stay (n = 44, 44%) had more extensive myocardial dysfunction on discharge (P < 0.001) and significantly higher mortality during the follow up period than those without a thrombus (23% v 7%, P < 0.01). CONCLUSIONS With routine thrombolytic and aspirin treatment of anterior myocardial infarction, left ventricular thrombi usually resolve during the first month after hospital discharge. Appearance and resolution of thrombi continue, however, in a significant proportion of the patients during long term follow up. A left ventricular thrombus during the initial hospital stay is associated with high long term mortality.
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Affiliation(s)
- T Mooe
- Department of Internal Medicine, Norrland University Hospital, Umeå, Sweden
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Abstract
Left ventricular mural thrombus is a well-recognized complication of acute myocardial infarction. In survivors of infarction, the incidence with which mural thrombus occurs is influenced by the location and magnitude of infarction, so that it occurs commonly in those with large anterior Q-wave infarctions, particularly in the presence of a left ventricular aneurysm. Echocardiography, radionuclide imaging with indium-111 labeled platelets, computerized tomography, and magnetic resonance imaging may be used to identify a left ventricular mural thrombus. Acute and chronic anticoagulation with heparin and warfarin, respectively, is given to prevent further thrombus formation and to reduce the incidence of systemic embolization.
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Affiliation(s)
- E C Keeley
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, USA
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38
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Cairns JA, Lewis HD, Meade TW, Sutton GC, Théroux P. Antithrombotic agents in coronary artery disease. Chest 1995; 108:380S-400S. [PMID: 7555191 DOI: 10.1378/chest.108.4_supplement.380s] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Affiliation(s)
- J A Cairns
- McMaster University Medical Center, Hamilton, ON, Canada
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39
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Mooe T, Teien D, Karp K, Eriksson P. Left ventricular thrombosis after anterior myocardial infarction with and without thrombolytic treatment. J Intern Med 1995; 237:563-9. [PMID: 7782728 DOI: 10.1111/j.1365-2796.1995.tb00886.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To examine the incidence of left ventricular thrombus in patients with anterior myocardial infarction, with and without streptokinase treatment. To identify predictors of thrombus development. DESIGN Consecutive patients prospectively studied during the hospitalized period. Echocardiography was performed within 3 days of admission and before discharge. SETTING Umeå University Hospital, a teaching hospital in Northern Sweden. SUBJECTS Ninety-nine patients with anterior myocardial infarction of whom 74 were treated with streptokinase. MAIN OUTCOME MEASURES Left ventricular thrombus and left ventricular segmental myocardial function. RESULTS During the hospital stay, a thrombus developed in 46% (95% confidence interval [CI], 35-57%) of the patients in the thrombolysis group and in 40% (95% CI, 21-59%) of the patients in the non-thrombolysis group. No difference in left ventricular segmental myocardial function was found between the thrombolysis and non-thrombolysis groups at hospital discharge. No embolic events were observed. The occurrence of a left ventricular thrombus at hospital discharge was significantly associated with previous myocardial infarction, peak enzyme levels, left ventricular global and segmental dysfunction and an increased dose of peroral diuretics or use of parenteral diuretics. In a multiple logistic regression model, left ventricular segmental dysfunction was the most important predictor of left ventricular thrombus. CONCLUSION Thrombolytic treatment with streptokinase does not prevent the development of a left ventricular thrombus but the risk of embolic complications is low. The left ventricular segmental myocardial score can be used to assess the risk of thrombus development, also, after thrombolysis.
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Affiliation(s)
- T Mooe
- Department of Internal Medicine, Umeå University Hospital, Sweden
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40
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Bodenheimer MM, Sauer D, Shareef B, Brown MW, Fleiss JL, Moss AJ. Relation between myocardial infarct location and stroke. J Am Coll Cardiol 1994; 24:61-6. [PMID: 7980764 DOI: 10.1016/0735-1097(94)90542-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES We sought to compare the likelihood of stroke in patients with anterior versus nonanterior myocardial infarction. BACKGROUND The association between anterior infarction and left ventricular thrombus has led to the assumption that embolization from thrombi is an important cause of stroke in patients with anterior infarction. We hypothesized that if anterior infarction is a cause of left ventricular thrombi, the number of strokes should be disproportionately higher in patients with anterior than nonanterior infarction. METHODS We performed a retrospective analysis of 2,466 patients randomized from day 3 to day 15 after infarction as part of a multicenter placebo-controlled study of diltiazem to prevent cardiac death or myocardial infarction. Any acute focal cerebral disorder resulting in localizing findings characterized as a stroke or transient ischemic attack was considered an event. RESULTS Of 91 events during a follow-up period of 12 to 52 months, 23 (3.2%) occurred in 724 patients with an anterior and 68 (3.9%) in 1,742 patients with a nonanterior myocardial infarction (relative risk 0.81; 95% confidence interval 0.51 to 1.30). Power analysis revealed that the negativity of the study was not the result of inadequate sample size. Life table analysis showed no difference in cumulative event rate (p = 0.42) according to site of infarction. Cox regression analysis showed that of 10 clinical covariates, only systolic blood pressure was predictive of stroke (p < 0.001). The use of warfarin did not contribute to the model. Finally, the addition of site of infarction (anterior vs. nonanterior) did not contribute significantly to the Cox model. CONCLUSIONS Although there is a significant incidence of stroke after acute myocardial infarction, there is no relation between the occurrence of stroke and site of infarction. These data do not support the presumed causal relation between anterior myocardial infarction, thrombus and stroke.
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Affiliation(s)
- M M Bodenheimer
- Harris Chasanoff Heart Institute, Department of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York 11042
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41
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Grambow DW, Valentini VV, Armstrong WF. Thrombolytic therapy and intravenous heparin in acute myocardial infarction do not affect the incidence of left ventricular mural thrombus formation. Am Heart J 1994; 127:1424-6. [PMID: 8172078 DOI: 10.1016/0002-8703(94)90069-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- D W Grambow
- Department of Medicine, University of Michigan, Ann Arbor 48109-0119
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42
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Fail PS, Maniet AR, Banka VS. Subcutaneous heparin in postangioplasty management: comparative trial with intravenous heparin. Am Heart J 1993; 126:1059-67. [PMID: 8237746 DOI: 10.1016/0002-8703(93)90655-s] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Abrupt closure of a coronary artery after successful angioplasty remains a problem for the interventionalist. Many laboratories continue to administer heparin intravenously for 12 to 24 hours in an attempt to alleviate this problem. But prolonged heparin therapy delays sheath removal and may lead to groin and vascular complications, and so prolong the hospital stay. To test the hypothesis that subcutaneous heparin was as efficacious as intravenous heparin in preventing acute closure while reducing the vascular complications associated with extended sheath placement, we prospectively randomized 151 patients to two groups. The intravenous group, 77 patients, received continuous intravenous heparin at 1000 units/hour for 12 to 18 hours; the subcutaneous group, 74 patients, received 12,500 units subcutaneously every 12 hours for three doses after sheath removal 2 to 3 hours after the angioplasty. The activated clotting time immediately after the angioplasty was 401 +/- 108 seconds in subcutaneous group, as compared with 368 +/- 67 seconds in the intravenous group (p = 0.028). Patients receiving subcutaneous heparin continued to show adequate anticoagulation, with a PTT of 85 +/- 21 seconds obtained approximately 12 hours after the procedure. The PTT at discharge was statistically greater in the subcutaneous group, at 49.2 +/- 21 seconds, versus 35.6 +/- 13 seconds in the intravenous group (p < 0.001). Abrupt occlusion was similar in both groups, but the hematomas and bleeding/oozing in the intravenous group was significantly higher when compared with that of the subcutaneous group, 16 versus 6 (p = 0.026) and 26 versus 7 (p < or = 0.002), respectively.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- P S Fail
- Episcopal Heart Institute, Episcopal Hospital, Philadelphia, PA 19125
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43
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Vaitkus PT, Barnathan ES. Embolic potential, prevention and management of mural thrombus complicating anterior myocardial infarction: a meta-analysis. J Am Coll Cardiol 1993; 22:1004-9. [PMID: 8409034 DOI: 10.1016/0735-1097(93)90409-t] [Citation(s) in RCA: 274] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES The management of mural thrombus complicating acute anterior myocardial infarction remains controversial in part because of the small size of studies on this topic. We performed a meta-analysis of published studies to address three questions: 1) What is the embolic risk of mural thrombi after myocardial infarction? 2) What is the impact of systemic anticoagulation in reducing the embolic risk of mural thrombi? 3) What is the impact of systemic anticoagulation, thrombolytic therapy and antiplatelet therapy in preventing mural thrombus formation? METHODS Studies were identified by a computerized and manual search and were included if they were published in manuscript form in the English-language literature. Pooling of data was performed by calculating the Mantel-Haenszel odds ratio and an event rate difference by the method of DerSimonian and Laird. RESULTS The odds ratio for increased risk of emboli in the presence of echocardiographically demonstrated mural thrombus (11 studies, 856 patients) was 5.45 (95% confidence interval [CI] 3.02 to 9.83), and the event rate difference was 0.09 (95% CI 0.03 to 0.14). The odds ratio of anticoagulation versus no anticoagulation in preventing embolization (seven studies, 270 patients) was 0.14 (95% CI 0.04 to 0.52) with an event rate difference of -0.33 (95% CI -0.50 to -0.16). The odds ratio of anticoagulation versus control in preventing mural thrombus formation (four studies, 307 patients) was 0.32 (95% CI 0.20 to 0.52), and the event rate difference was -0.19 (95% CI -0.09 to -0.28). The odds ratio for thrombolytic therapy in preventing mural thrombus (six studies, 390 patients) was 0.48 (95% CI 0.29 to 0.79) with an event rate difference of -0.16 (95% CI 0.10 to -0.42), whereas for antiplatelet agents (two studies, 112 patients) the odds ratio was 1.43 (95% CI 0.04 to 56.8) with an event rate difference of 0.16 (95% CI -0.20 to 0.52). CONCLUSIONS This analysis supports the hypotheses that 1) mural thrombus after myocardial infarction poses a significantly increased risk of embolization, 2) the risk of embolization is reduced by systemic anticoagulation, and 3) anticoagulation can prevent mural thrombus formation. Thrombolytic therapy may prevent mural thrombus formation, but evidence for a similar benefit of antiplatelet therapy is lacking.
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Affiliation(s)
- P T Vaitkus
- Cardiology Unit, Medical Center Hospital of Vermont, University of Vermont, Burlington 05401
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44
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Glikson M, Agranat O, Ziskind Z, Kaplinski E, Vered Z. From swirling to a mobile, pedunculated mass--the evolution of left ventricular thrombus despite full anticoagulation. Echocardiographic demonstration. Chest 1993; 103:281-3. [PMID: 8417899 DOI: 10.1378/chest.103.1.281] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
We describe the unusual evolution of a left ventricular thrombus following acute anterior myocardial infarction despite adequate anticoagulation. Serial echocardiographic examinations demonstrated the evolution from swirling in the left ventricle through a solid apical mass gradually dislodging into a mobile, pedunculated mass that was removed surgically to prevent embolization. This report emphasizes the need to follow echocardiographically left ventricular thrombi during treatment with anticoagulants, and to identify morphologic changes that may predict embolization. This case suggests that left ventricular thrombectomy should be considered in selected patients in whom a very high-risk thrombus morphology is detected.
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Affiliation(s)
- M Glikson
- Heart Institute, Tel Aviv University, Tel Hashomer, Israel
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45
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Gupta S, Foran J, Cherek P, Brennand-Roper DA. Blindness and myocardial infarction. Lancet 1992; 340:1110. [PMID: 1357513 DOI: 10.1016/0140-6736(92)93145-d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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46
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Affiliation(s)
- R G Hart
- Department of Medicine (Neurology), University of Texas Health Science Center, San Antonio 78284-7883
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