[Effect of chronic Chlamydia infection with non-specific inflammation on cardiovascular complications in acute myocardial infarct]

It is known that local and systemic inflammatory processes play an important role in the genesis and development of atheroclerotic lesions and in the pathophysiology of acute coronary syndromes. This hypothesis is supported by findings of elevated parameters of the "inflammatory" reaction in the affected blood vessels but also in the blood of atherosclerotic patients. Known risk factors do not explain quite satisfactorily epidemiological cardiovascular phenomena and different manifestations of coronary heart disease. It is very probable that also Chlamydia pneumoniae is a risk factor. This assumption is based on evaluation of seroepidemiological data, examination of atherosclerotic plaques not only in humans but also in animal models with chlamydial infection. Based on retrospective and prospective evaluation of case-records the authors analyzed the incidence of cardiovascular complications in 83 patients with acute myocardial infarction (AIM), incl. 51 patients (31 men and 20 women, mean age 64.4 +/- 3.4 years who had a non-specific inflammation and chlamydial infection, and 32 patients (24 men and 8 women, mean age 64.7 +/- 3.6 years) who had chlamydial infections but no non-specific inflammation (in the blood). These patients were selected from all patients hospitalized during 1998-2001. When diagnosing acute myocardial infarction we applied WHO criteria, and the presence of at least two of three criteria was necessary: a history of prolonged (more than 20 min). stenocardia, electrocardiographic changes typical for ischaemia and/or necrosis and elevation of myocardial enzymes in serum, Non-specific inflammatory activity was present in patients (i.e. positive) if the following laboratory parameters were recorded: C-reactive protein > 5 mg/l assessed by the radial immunodiffusion method; fibrinogen > 4 mg/l assessed by the coagulation method according to Claus; leukocytes > 9.6 x 10(3)/microliter, leukocytes were counted automatically in a Coulter chamber; lymphocytes > 3.4 x 10(3)/microliter. Red cell sedimentation rate > 20 mm/hour. The activity was evaluated as positive when all parameters were elevated. The presence of chronic infection with Chlamydia pneumoniae was assessed qualitatively by antibody positivity (IgG) in serum using the microimmunoflurescent method (using a set from Labsystems Co.). The incidence of associated risk factors (obesity, smoking, diabetes, hyperlipidaemia and hypertension) is higher in the sub-group of patients with Chlamydia infections without inflammation, however, the difference is not statistically significant. The incidence of cardiovascular attacks was higher in the sub-group of patients with chlamydial infection and concurrent inflammation as compared with the sub-group of patients with chlamydial infection without inflammation. In case of re-infarction of the myocardium, a sudden cerebrovascular attack, death and arrhythmia the difference was statistically significant, while in case of cardiac failure and cardiogenic shock the difference was not significant. Patients with acute myocardial infarction with chlamydial infection and a concurrent non-specific inflammation had to be treated more often by combined (i.e. more intense) treatment, thrombolytic treatment, PTCA and surgery (bypass) of the coronary vessels as compared with patients with Chlamydia infections but without inflammation. The authors assume therefore that not only different risk factors but also the effect of non-specific inflammation and Chlamydia infection contribute towards the increased number of cardiovascular postinfarction complications. Therefore a therapeutic approach involving eradication of infection and suppression of the inflammatory reaction should be considered.

Serum amylase determination in the emergency department evaluation of abdominal pain

We hypothesized that selective ordering of serum amylase in the emergency department (ED) is justified because (a) most patients with elevated amylase can be prospectively identified by characteristic clinical findings, and (b) the diagnosis of pancreatitis is usually predominantly based on clinical findings, since amylase is known to be neither sensitive nor specific for pancreatitis. The study population included 133 consecutive patients with a chief complaint of abdominal pain who had amylase drawn over a 2-week period at a university hospital ED. Patients with known major trauma were excluded. Emergency department and hospital charts were reviewed for selected clinical variables. The first part of our hypothesis was evaluated by comparing clinical characteristics of cases (elevated amylase) and controls; the second part was tested by comparing clinical findings and amylase in cases (patients diagnosed as having pancreatitis) and controls. We found that 17 patients with and 116 without elevated amylase were similar with regard to all clinical variables, and that no combination of findings could be used to predict elevated amylase. Amylase level was not predictive of an ultimate diagnosis of pancreatitis, which was, however, strongly related to classical clinical findings. Pancreatitis risk factors, epigastric pain and tenderness, radiation of pain to the back, and nausea and vomiting were each statistically more common in patients diagnosed as having pancreatitis (regardless of amylase) than in patients in whom pancreatitis was excluded despite elevated amylase; all patients diagnosed with pancreatitis had at least two of these. Thus, selective ordering of amylase on the basis of clinical characteristics fails to identify a large proportion of patients with elevated amylase.(ABSTRACT TRUNCATED AT 250 WORDS)