P6212The NAILED ACS trial - telephone-based long-term follow-up reduces risk factors after 36 months

Background

Cardiovascular secondary preventive strategies need improvement. The proportion of patients reaching guideline recommended treatment targets are low.

Purpose

We investigated if nurse-led, telephone-based follow-up including medical titration was superior to usual care in controlling blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) levels 36 months after an acute coronary syndrome (ACS).

Methods

All patients admitted with ACS at the local county hospital between 1st January 2010 and 31st December 2014 were screened for inclusion based on their ability to participate in a telephone-based follow-up. Participants were randomized into two parallel groups, an intervention group and a control group receiving usual care. BP and LDL-C were measured at one month, 12, 24 and 36 months. The intervention group received counseling and medical titration to attain treatment targets of BP (<140/<90 mmHG) and LDL-C (<2.5/<1.8 mmol/L). The primary outcome was LDL-C at 36 months.

Results

Out of 962 randomized patients, 797 were available for analysis after 36 months. In the intervention group, mean systolic blood pressure (SBP) was 4.1 mmHg lower (95% CI 1.7 - 6.4, p=0.001), diastolic blood pressure (DBP) was 2.8 mmHg lower (95% CI 1.4- 4.4, p<0.001) and mean LDL-C was 0.26 mmol/L lower (95% CI 0.12 - 0.4, p<0.001) when compared to the control group. The proportion of patients reaching treatment target goals was also significantly higher in the intervention group.

Conclusions

After 36 months of follow-up the nurse-led, telephone-based intervention led to significantly lower systolic blood pressure, diastolic blood pressure and LDL-C levels when compared to the control group. The intervention group also had a larger proportion of patients reaching target values.

Acknowledgement/Funding

The study received funding from the research and development unit, Region Jämtland Härjedalen.

Hand-held cardiac ultrasound examinations performed in primary care patients by nonexperts to identify reduced ejection fraction

BACKGROUND

Early identification of patients with reduced left ventricular ejection fraction (LVEF) could facilitate the care of patients with suspected heart failure (HF). We examined if (1) focused cardiac ultrasound (FCU) performed with a hand-held device (Vscan 1.2) could identify patients with LVEF < 50%, and (2) the distribution of HF types among patients with suspected HF seen at primary care clinics.

METHODS

FCU performed by general practitioners (GPs)/GP registrars after a training programme comprising 20 supervised FCU examinations were compared with the corresponding results from conventional cardiac ultrasound by specialists. The agreement between groups of estimated LVEF < 50%, after visual assessment of global left ventricular function, was compared. Types of HF were determined according to the outcomes from the reference examinations and serum levels of natriuretic peptides (NT-proBNP).

RESULTS

One hundred patients were examined by FCU that was performed by 1-4 independent examiners as well as by the reference method, contributing to 140 examinations (false positive rate, 19.0%; false negative rate, 52.6%; sensitivity, 47.4% [95% confidence interval [CI]: 27.3-68.3]; specificity, 81.0% [95% CI: 73.1-87.0]; Cohen's κ measure for agreement = 0.22 [95% CI: 0.03-0.40]). Among patients with false negative examinations, 1/7 had HF with LVEF < 40%, while the others had HF with LVEF 40-49% or did not meet the full criteria for HF. In patients with NT-proBNP > 125 ng/L and fulfilling the criteria for HF (68/94), HF with preserved LVEF (≥50%) predominated, followed by mid-range (40-49%) or reduced LVEF (< 40%) HF types (53.2, 11.7 and 7.4%, respectively).

CONCLUSIONS

There was poor agreement between expert examiners using standard ultrasound equipment and non-experts using a handheld ultrasound device to identify patients with reduced LVEF. Asides from possible shortcomings of the training programme, the poor performance of non-experts could be explained by their limited experience in identifying left ventricular dysfunction because of the low percentage of patients with HF and reduced ejection fraction seen in the primary care setting.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov (NCT02939157). Registered 19 October 2016.

Platelet aggregation and aspirin non-responsiveness increase when an acute coronary syndrome is complicated by an infection

BACKGROUND

Epidemiologic studies have shown that there is an association between acute respiratory infection and acute coronary syndrome. The aim of this study was to analyze the thrombotic risk, assessed by platelet aggregation and aspirin non-responsiveness, in patients with an acute coronary syndrome complicated by an infection.

METHODS

Patients with an acute coronary syndrome who were admitted to the intensive care unit and hospitalized for at least 3 days in 2002 and 2003 were eligible for the study. Three hundred and fifty-eight patients were included, of whom 66 had an infection during their hospital stay. Platelet aggregation was analyzed by an aggregometer using laser light (PA-200, laser light scattering). Aspirin non-responsiveness was defined as a closure time of

RESULTS

Platelet aggregation was more pronounced during an infectious complication (P < 0.001). The subgroups of patients with persistent fever, urinary tract infection, and pneumonia all had a higher level of aggregates than the group of patients without an infection (P = 0.007, P = 0.04, and P = 0.01, respectively). Aspirin non-responsiveness was more frequent in the group of subjects with pneumonia compared with those without an infection, 90% vs. 46% (P = 0.006). The CRP levels were independently associated with platelet aggregation and aspirin non-responsiveness (P < 0.001, P < 0.001, respectively).

CONCLUSION

An infectious complication during the course of an acute coronary syndrome leads to more pronounced platelet aggregation. Aspirin non-responsiveness is more frequent in severe infections, such as pneumonia. CRP is an independent predictor of platelet aggregation and aspirin non-responsiveness in the setting of an acute coronary syndrome.

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MESH Headings

• Acute Disease
• Aged
• Aged, 80 and over
• Aspirin/pharmacology
• Aspirin/therapeutic use
• Biomarkers/blood
• C-Reactive Protein/metabolism
• Drug Resistance
• Female
• Humans
• Linear Models
• Male
• Middle Aged
• Myocardial Ischemia/blood
• Myocardial Ischemia/complications
• Myocardial Ischemia/drug therapy
• Platelet Aggregation/drug effects
• Platelet Aggregation Inhibitors/pharmacology
• Platelet Aggregation Inhibitors/therapeutic use
• Platelet Function Tests
• Pneumonia/blood
• Pneumonia/complications
• Predictive Value of Tests
• Prognosis
• Risk Assessment
• Severity of Illness Index
• Syndrome
• Thrombosis/blood
• Thrombosis/etiology
• Thrombosis/prevention & control
• Treatment Failure
• Urinary Tract Infections/blood
• Urinary Tract Infections/complications

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Sleep-disordered breathing and coronary artery disease: long-term prognosis

The evidence linking sleep-disordered breathing to increased mortality and cardiovascular morbidity has been conflicting and inconclusive. We hypothesized that a potential adverse effect of disordered breathing would be more obvious in patients with established vascular disease. In a prospective cohort study 408 patients aged 70 yr or younger with verified coronary disease were followed for a median period of 5.1 yr. An apnea-hypopnea index (AHI) of > or = 10 and an oxygen desaturation index (ODI) of > or = 5 were used as the diagnostic criteria for sleep-disordered breathing. The primary end point was a composite of death, cerebrovascular events, and myocardial infarction. There was a 70% relative increase and a 10.7% absolute increase in the primary composite end point in patients with disordered breathing defined as an ODI of > or = 5 (risk ratio 1.70, 95% confidence interval [CI] 1.15-2.52, p = 0.008). Similarly, patients with an AHI of > or = 10 had a 62% relative increase and a 10.1% absolute increase in the composite endpoint (risk ratio 1.62, 95% CI 1.09-2.41, p = 0.017). An ODI of > or = 5 and an AHI of > or = 10 were both independently associated with cerebrovascular events (hazard ratio 2.62, 95% CI 1.26-5.46, p = 0.01, and hazard ratio 2.98, 95% CI 1.43-6.20, p = 0.004, respectively). We conclude that sleep-disordered breathing in patients with coronary artery disease is associated with a worse long-term prognosis and has an independent association with cerebrovascular events.

Cardiac rhythm in patients with sleep-disordered breathing and coronary artery disease

We examined the effect of sleep-disordered breathing on heart rates and arrhythmias in men and women with disabling angina pectoris and verified coronary artery disease by an overnight sleep study and Holter recording. The number of oxyhaemoglobin desaturations > or =4% (ODI) and number of apnoea-hypopnoeas per hour of sleep (AHI) were recorded. ODI > or =5 and AHI > or =10 were used as measures of disordered breathing and patients below these limits formed the control groups. One-hundred and forty-one men and 98 women < or =70 years of age were randomly included. Thirty-eight percent of the men and 36% of the women had an ODI > or =5. No serious ventricular arrhythmias occurred. Women with disordered breathing (ODI > or =5) had higher heart rates (mean 63.3 vs 59.1, p < 0.05) and a higher occurrence of ventricular premature contractions (VPCs) during sleep (75th percentiles 2.5 vs 0.5 per hour, p < 0.01). In men, however, no significant association between disordered breathing and heart rates or arrhythmias was found. We conclude that serious arrhythmias are infrequent in unselected patients with coronary artery disease and mild to moderate sleep-disordered breathing. Disordered breathing in women is associated with higher heart rates and a higher occurrence of VPCs during sleep.

Sleep-disordered breathing and myocardial ischemia in patients with coronary artery disease

STUDY OBJECTIVES

To examine the occurrence of nocturnal myocardial ischemia and its relationship to sleep-disordered breathing (apneas and oxygen desaturations) in randomly selected men and women undergoing coronary angiography because of angina pectoris.

DESIGN

An observational study using an overnight sleep study and Holter recording to examine disordered breathing (oxyhemoglobin desaturations > or = 4% and apnea-hypopneas), heart rates, and ST-segment depressions (> or = 1 mm, > or = 1 min).

SETTING

University Hospital, Umeå, a teaching hospital in northern Sweden.

PATIENTS

One hundred thirty-two men and 94 women referred for consideration of coronary intervention were randomly included, by lot.

RESULTS

ST-segment depressions occurred in 59% (134 of 226) of the patients, and nocturnal ST-segment depressions occurred in 31% (69 of 226). A ST-segment depression occurred within 2 min after an apnea-hypopnea or desaturation in 12% (27 of 226) of patients. This temporal association was seen in 19% of nocturnal ST-segment depressions (71 of 366), more frequently in men (p < 0.01) and in more severely disordered breathing (p < 0.001). Most of these ST-segment depressions were preceded by a series of breathing events: three or more apnea-hypopneas or desaturations or both in 70% (50 of 71).

CONCLUSION

Episodes of nocturnal myocardial ischemia are common in patients with angina pectoris. However, a temporal relationship between sleep-disordered breathing and myocardial ischemia is present only in a minority of the patients, but occurs more frequently in men and in more severely disordered breathing.

Ischemic stroke. Impact of a recent myocardial infarction

BACKGROUND AND PURPOSE

The risk of ischemic stroke is increased after a myocardial infarction. We quantified the stroke risk and evaluated ischemic stroke characteristics after an acute myocardial infarction.

METHODS

A case-control study including patients with first-ever stroke was undertaken. Cases (n=103) were recorded prospectively in the population-based Northern Sweden World Health Organization Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) study. Two controls per case with a stroke but without a recent myocardial infarction were matched for age, sex, and year of stroke onset.

RESULTS

The sudden onset of neurological symptoms (76.7% versus 54.9%, P<0.001), impairment of consciousness (35.0% versus 18.4%, P<0.01), and a progression in neurological deficits (19.4% versus 8.7%, P<0.01) were more common in cases, while the onset of stroke during sleep was rarer in cases (6.8% versus 21.4%, P<0.01). In cases and controls, the clinical subclasses of stroke were as follows: total anterior circulation infarcts, 51.5% versus 37.9% (P<0.05); partial anterior circulation infarcts, 28.2% versus 26.7% (P=NS); lacunar infarcts, 4.8% versus 27.2% (P<0.001); and posterior circulation infarcts, 15.5% versus 8.2% (P=0.051). During the first 28 days after myocardial infarction, the daily rate of stroke declined rapidly from approximately 9 to 1 stroke per 10 000 myocardial infarction patients compared with an age-adjusted average daily stroke rate of 0.14 per 10 000 in the MONICA population.

CONCLUSIONS

We conclude that the clinical characteristics of the stroke differ between patients with and without a recent myocardial infarction. The risk of a first-ever ischemic stroke is highest during the first few days after a myocardial infarction, but it then declines rapidly, and the absolute number of stroke events is low.

Ischemic stroke after acute myocardial infarction. A population-based study

BACKGROUND AND PURPOSE

Modern treatment may have influenced the risk of stroke after myocardial infarction (MI). The purpose of this study was to examine the incidence of ischemic stroke during the first month after an acute MI in an unselected population, to identify predictors of MI-related stroke, and to investigate the secular trend in MI-related stroke incidence.

METHODS

In this case-control study, from a population of approximately 310000 25- to 74-year-old inhabitants, case subjects with a stroke within 1 month after an MI were prospectively recorded in the population-based Northern Sweden MONICA (Monitoring of Trends and Determinants in Cardiovascular Disease) study from 1985 to 1994. The same number of control subjects with an MI but without a stroke were matched for age, sex, and year when MI occurred.

RESULTS

One hundred twenty-four case subjects were recorded. Fifty-one percent (63/124) of the strokes occurred within 5 days after onset of MI. The odds ratios (ORs) of an MI-related stroke were for a history of hypertension 1.7 (95% confidence interval [CI], 1.0 to 3.2), previous stroke 2.4 (CI, 1.0 to 6.1), chronic atrial fibrillation 3.0 (CI, 1.1 to 9.2), onset of atrial fibrillation during the hospital stay 3.5 (CI, 1.4 to 10.1), ST-segment elevation 2.4 (CI, 1.4 to 4.6), and anterior infarction 1.5 (CI, 0.9 to 2.6). In a conditional multiple logistic regression model, previous stroke (OR, 2.8; CI, 1.1 to 7.6), chronic atrial fibrillation (OR, 3.8; CI, 1.3 to 11.0), new-onset atrial fibrillation (OR, 4.6; CI, 1.6 to 12.8), and ST-segment elevation (OR, 3.4; CI, 1.6 to 7.4) were independent predictors of stroke. MIs preceding stroke were larger and in 51% were located anteriorly. There was a decrease in the incidence and event rate of MI-related stroke during the study period (P < .01 and P < .05, respectively).

CONCLUSIONS

The risk of stroke is highest the first 5 days after MI. Only approximately half of the strokes occurring the first month after an MI are preceded by an anterior MI. The most important predictors of MI-related stroke are atrial fibrillation (chronic or new onset), ST elevation, and a history of a previous stroke. There is a long-term trend toward a lower incidence of MI-related stroke. These findings have important implications concerning both the pathophysiology and prevention of MI-related stroke.

Sleep-disordered breathing in women: occurrence and association with coronary artery disease

PURPOSE

To examine the occurrence of sleep apnea and nocturnal hypoxemia in women with and without coronary artery disease (CAD) and to investigate the relationship between sleep-disordered breathing and coronary artery disease.

PATIENTS AND METHODS

In a case-control study, 102 cases were randomly selected among women with angina pectoris and angiographically verified coronary disease. Fifty age-matched controls without known heart disease were selected from the population registry. Pulse oximetry, oronasal thermistors, body position indicator, and recording of body and respiratory movements were used to quantify oxygen desaturations (the number of desaturations > or = 4% per hour of sleep, oxygen desaturation index [ODI]) and apneas (the number of apneas or hypopneas per hour of sleep, apnea-hypopnea index [AHI]).

RESULTS

Women with CAD had a high occurrence of disordered breathing measured as AHI > or = 5, 54% (n = 54), AHI > or = 10, 30% (n = 30) or ODI > or = 5, 34% (n = 35) while the same proportions in controls were 20% (n = 10, P < 0.0001), 10% (n = 5, P < 0.01) and 18% (n = 9, P < 0.05), respectively. In a multiple logistic regression model, sleep apnea (AHI > or = 5), hypertension, and smoking habits were independent predictors of CAD with odds ratios of 4.1 (95% confidence interval [CI] 1.7 to 9.7, P < 0.01), 3.4 (CI 1.3 to 8.9, P < 0.05) and 2.4 (CI 1.0 to 5.7, P < 0.05), respectively.

CONCLUSION

Sleep apnea is common in women with CAD and remains as a significant predictor of coronary disease after adjustment for age, body mass index, hypertension, smoking habits, and diabetes.

Sleep-disordered breathing: a novel predictor of atrial fibrillation after coronary artery bypass surgery

BACKGROUND

Sleep-disordered breathing is a common condition associated with nocturnal hypoxaemia, sympathetic activation and haemodynamic stress that can trigger arrhythmias. We examined whether preoperatively diagnosed disordered breathing was associated with an increased incidence of atrial fibrillation after coronary artery bypass surgery.

METHODS

A sleep study was performed in 121 consecutive patients, who were monitored prospectively until discharge from hospital after surgery. Disordered breathing was defined as an apnoea-hypopnoea index (AHI) > or = 5 or an oxygen desaturation index (ODI) > or = 5. All episodes of atrial fibrillation requiring pharmacological intervention or cardioversion were included in the analysis.

RESULTS

Atrial fibrillation was diagnosed in 32% of patient with AHI > or = 5 (25 of 78) and in 18% patients with AHI < 5 (7 of 39, P = 0.11). Similarly, atrial fibrillation was diagnosed in 39% of patients with ODI > or = 5 (19 of 49) and in 18% of patients with ODI < 5 (13 of 72, P = 0.02). In a multiple-logistic regression model including age, left ventricular function, aortic cross clamp time, maximum postoperative level of lactate dehydrogenase and disordered breathing (ODI > or = 5), greater age and disordered breathing were independent predictors of postoperative atrial fibrillation. The relative risk of atrial fibrillation was 2.0 (95% confidence interval 1.1-3.8) for a 10-year increase in age and 2.8 (95% confidence interval 1.2-6.8) for disordered breathing (ODI > or = 5).

CONCLUSIONS

Pre-operatively diagnosed sleep-disordered breathing with nocturnal hypoxaemia is an independent predictor of atrial fibrillation after coronary bypass surgery.

Sleep-disordered breathing in men with coronary artery disease

OBJECTIVE

To examine the occurrence of sleep apnea and nocturnal hypoxemia in men with symptomatic coronary artery disease (CAD) and to evaluate the relationship between disordered breathing and coronary artery disease.

DESIGN

Case-control study. Cases were randomly selected from men undergoing coronary angiography because of angina pectoris. Controls were age matched and selected from the population registry. Pulse oximetry, oronasal thermistors, body position indicator, and recording of body and respiratory movements were used to quantify desaturations and apneas.

SETTING

Norrland University Hospital, a referral center for northern Sweden.

SUBJECTS

One hundred forty-two men with angina pectoris and angiographically verified CAD and 50 controls without known heart disease.

MAIN OUTCOME MEASURES

The number of arterial oxygen desaturations of 4% or more per hour of sleep, oxygen desaturation index (ODI), and the number of apneas or hypopneas per hour of sleep, apnea-hypopnea index (AHI).

RESULTS

Men with CAD had a high occurrence of sleep-disordered breathing measured as ODI of 5 or more, 39% (n=55), or AHI of 10 or more, 37% (n=50), while, the same proportions in controls were 22% (n=11, p<0.05) and 20% (n=10, p<0.05). Mean values of ODI in cases and controls were 6.4 and 2.7, respectively (p<0.001). Multiple logistic regression analysis identified ODI, AHI, body mass index, and hypertension as significant predictors of CAD (p<0.05).

CONCLUSION

Sleep- disordered breathing is common in men with CAD. A significant association between sleep apnea with nocturnal hypoxemia and CAD remains after adjustment for age, hypertension, body mass index, diabetes, and smoking.

Long term follow up of patients with anterior myocardial infarction complicated by left ventricular thrombus in the thrombolytic era

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.

Dipyridamole thallium-201 single-photon emission tomography in aortic stenosis: gender differences

Dipyridamole single-photon emission tomography (SPET) is used for the detection of coronary artery disease (CAD) and the method has also been applied in patients with aortic stenosis. This study was undertaken to establish the gender-specific normal limits of thallium-201 distribution in patients with aortic stenosis and to apply these normal limits in a larger group of patients with aortic stenosis to obtain the sensitivity and specificity for coexisting CAD. A low-dose dipyridamole protocol was used (0.56 mg/kg during 4 min). Thallium was injected 2 min later and tomographic imaging was performed. Following image reconstruction a basal, a midventricular and an apical short-axis slice were selected. The highest activity in each 6 degree segment was normalised to the maximal activity of each slice. The normal uptake for patients with aortic stenosis was obtained from ten men and ten women with aortic stenosis and a normal coronary angiography. Eighty-nine patients were prospectively evaluated. An area reduction of at least 75% in a coronary artery was considered to be a significant coronary lesion and was found in 57 (64%) patients. With gender-specific curves (-2.5 SD) sensitivity for detecting CAD was 100% and specificity was 75% in men, while sensitivity was 61% and specificity 64% in women. It is concluded that the gender-specific normal distribution of 201Tl uptake in patients with aortic stenosis, using dipyridamole SPET, yields a high sensitivity and specificity for coronary artery lesions in men but a lower sensitivity and specificity in women with aortic stenosis.

Dynamics of left ventricular thrombi in patients with acute anterior myocardial infarction treated with thrombolytics

BACKGROUND

Limited data exist concerning left ventricular thrombi during and after hospitalization in patients treated according to modern principles. The purpose of the present study was to examine the formation and resolution of left ventricular thrombi during the first month in patients with acute anterior myocardial infarction treated with streptokinase and aspirin.

METHODS

Seventy-seven consecutive patients were studied prospectively during the hospital stay and 1-month follow-up study. Aspirin was used routinely, whereas anticoagulants were only used after a decision by the attending physician. Echocardiography was performed within 3 days of admission, before hospital discharge and after 1 month of follow-up.

RESULTS

At the first examination, 17 of 77 patients (22%) had a thrombus. At discharge, 73 patients remained in the study. In five (31%) of the 16 patients with early thrombus, the thrombus persisted; in 18 (32%) of the 57 patients without early thrombus, a new thrombus was diagnosed. One month later, 65 patients remained eligible for follow-up study. In three of 20 patients (15%) the thrombus from the second examination persisted and in four of 45 patients (9%) a new thrombus was diagnosed. The disappearance rate between the second and third examination was high irrespective of whether patients were treated with anticoagulants (eight of nine, 89%) or not (nine of 11, 82%). Extensive left ventricular segmental dysfunction and signs of congestive heart failure were associated with the appearance of a left ventricular thrombus. No embolic events were recorded.

CONCLUSION

In patients with anterior myocardial infarction treated with streptokinase and aspirin the development and disappearance of left ventricular thrombi is a highly dynamic process. A large proportion of thrombi resolve without additional anticoagulant therapy.

Left ventricular thrombosis after anterior myocardial infarction with and without thrombolytic treatment

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.

Computer-assisted evaluation of dipyridamole thallium-201 SPECT in patients with aortic stenosis

Dipyridamole SPECT detects significant coronary artery disease (CAD) in patients without aortic stenosis. This study was done to establish normal 201Tl distribution limits in patients with aortic stenosis and to apply these normal limits to patients with aortic stenosis and angiographically significant CAD (> or = 75% area reduction).

METHODS

Fifty-two patients (mean age 68 yr; mean valve area 0.67 cm2) were examined with 201Tl SPECT after dipyridamole infusion (0.56 mg/kg during 4 min). After tomographic reconstruction, basal, mid-ventricular and apical short-axis slices were selected. The highest activity in each six-degree segment was normalized to the maximal activity of each slice.

RESULTS

Significant CAD was found in 24 patients. Five patients without CAD, but with localized hypokinesia or left bundle-branch block, were excluded from the reference group which finally consisted of 16 patients. Sensitivity for CAD was 88% when the lowest relative activity in each segment was used as the lower limit of normal. With -2 s.d. and -2.5 s.d. curves the sensitivity was 83% and 75%, respectively. Gender-specific limits were not used. Nonsignificant CAD was found in seven patients (< 75% stenoses).

CONCLUSIONS

This study presents the normal distribution of 201Tl uptake for patients with aortic stenosis, using dipyridamole SPECT. The range method had the highest sensitivity for detection of significant CAD.