Troponin measurement is used in the assessment and risk stratification of patients presenting acutely with chest pain when the main cause of elevation is coronary artery disease. However, some patients have no coronary obstruction on angiography, leading to diagnostic uncertainty. We evaluated the incremental diagnostic value of cardiovascular magnetic resonance (CMR) in these patients. Sixty consecutive patients (mean age 44 years, 72% male) with a troponin-positive episode of chest pain and unobstructed coronary arteries were recruited within 3 months of initial presentation. All patients underwent CMR with cine imaging, T2-weighted imaging for detection of inflammation, and late gadolinium enhancement imaging for detection of infarction/fibrosis. An identifiable basis for troponin elevation was established in 65% of patients. The commonest underlying cause was myocarditis (50%), followed by myocardial infarction (11.6%) and cardiomyopathy (3.4%). In the 35% of patients where no clear diagnosis was identified by CMR, significant myocardial infarction/fibrosis was excluded. CMR is a valuable adjunct to conventional investigations in a diagnostically challenging and important group of patients with troponin-positive chest pain and unobstructed coronary arteries.
Introduction: Despite reperfusion therapy for acute myocardial infarction (AMI), heart failure remains a major sequel.Reperfusion leads to further damage, described as ischemiareperfusion-injury (IRI).This contributes up to 50% of the final infarct size.In pre-clinical models nitrite potently protects against IRI in the heart and other organs.Hypothesis: Intravenous (iv) sodium nitrite, administered immediately before opening of the infarctrelated artery, results in significant reduction of IRI in patients with acute ST elevation MI (STEMI).Methods: In this phase II, randomised, placebo-controlled, double-blind, multicentre trial, 220 patients with first acute STEMI and TIMI 0 or 1 flow were randomised in a double-blind fashion to 70micromol iv sodium nitrite or matching placebo over 5 minutes immediately preceding opening of the infarct-related artery.The primary end point was the difference in infarct size between sodium nitrite and placebo groups using cardiovascular magnetic resonance imaging (CMR) at 6-8 days following AMI, adjusted for area at risk (AAR), diabetes status and center.Secondary end points comprised (i) Infarct size (CMR) at six months; (ii) plasma CK and Troponin I measured over 72 hours after injection of the study medication; (iii) Infarct size corrected for AAR measured using T2 weighted CMR; (iv) left ventricular (LV) ejection fraction and LV end systolic volume index measured by CMR at 6-8 days and at six months.Results: Infarct size at 6-8 days by CMR did not differ between nitrite and placebo groups (effect size -0.7% 95%CI -2.2,+0.7;p=0.34).There were no significant differences in the predefined secondary end points.There was no treatment effect in non-diabetics, but in diabetics was -4.5% (95%CI -8.8,-0.2;p=0.041) but the interaction was not significant (p=0.067).Conclusion: Sodium nitrite administered iv immediately prior to reperfusion in patients with acute STEMI did not reduce infarct size.A potential benefit in diabetics warrants further study.Funding, Ethics,
During Primary Percutaneous Coronary Intervention (PPCI) post ST-Segment Myocardial Infarction (STEMI), distal embolisation of thrombus may lead to failure to re-establish normal flow in the infarct-related artery. Manual thrombus aspiration has been shown to improve coronary perfusion as assessed by time to ST-segment resolution and myocardial blush grade. Evidence supporting the benefit of thrombus aspiration on clinical outcomes, however, is limited and inconsistent. We aimed to assess the impact of manual thrombectomy on mortality in patients presenting with STEMI across all PPCI centres in London over a 5 year period from 2007 until 2012.
Methods
This was an observational cohort study of 9935 consecutive patients with STEMI treated with PPCI between 2007 and 2012 at eight tertiary cardiac centres across London, UK. Patient9s details were recorded at the time of the procedure into the British Cardiac Intervention Society (BCIS) database. Outcome was assessed by all-cause mortality. Anonymous datasets from the eight centres were merged for analysis. The primary end-point was all-cause mortality at a median follow-up of 2.0 years (IQR range 1.1–3.1 years).
Results
Of the 9935 consecutive STEMI patients presenting for PPCI, 2859 had mechanical thrombectomy. Patients who had manual thrombectomy were significantly younger (average age 60.6 vs 62.9) and were less likely to have had a previous myocardial infarction (11.9% of thrombectomy patients vs 14.7% of non-thrombectomy patients). Patients receiving manual thromectomy were found to be significantly more likely to have had PPCI via a radial approach (33.1% in thrombectomy patients vs 19.9% in non-thromectomy patients). Procedural success (defined as TIMI 3 flow at the end of procedure) was found to be significantly more likely in patients receiving manual thrombectomy (89.5% vs 86.7%) (table 1). Patients with thrombectomy use had similar unadjusted all-cause mortality rates to those without thrombectomy use (12.7% vs 16.5%, p=NS) during the 5-year follow-up period (figure 1). After multivariable adjustment thrombectomy use was associated with significantly decreased mortality rates (HR: 0.82, 95% CI 0.68 to 0.9, p=0.04).
Conclusion
Mechanical thrombectomy use appears to be associated with improved outcome, in the form of decreased mortality, in this large observational trial.
Conventional coronary angiography can lead to infections, injuries to the arteries, and in rare cases, heart attack or death. Using the new, rapidly developing technique of contrast-enhanced angiography (CEA), also known as magnetic resonance angiography (MRA), cardiologists can now quickly and effectively evaluate a broad range of vascular abnorma
Hypertrophic cardiomyopathy (HCM) is the largest cause of sudden cardiac death in athletes. Differentiation between HCM and athletic cardiac adaptation is not always straightforward. Cardiopulmonary exercise testing (CPET) is useful in this context, with a peak VO2>120% predicted commonly used to differentiate athletes with HCM from those with physiological left ventricular hypertrophy. This value however is derived from a predominantly white population. Differences with ethnicity have been well documented on the ECG and echocardiogram of both athletes and individuals with HCM, however, ethnic differences in their physiology have not been well investigated to date.
Purpose
To assess if there is a significant difference on CPET in HCM patients of black and white ethnicity.
Methods
Cardiopulmonary exercise testing data was prospectively and retrospectively analysed from a cohort of 49 sedentary HCM patients assessed in a quaternary referral centre (36 white, 38 male; aged 15–65 years). Inclusion criteria: HCM patients of black or white ethnicity, NYHA 1, resting LVOT gradient<40 mmHg, no ICD in-situ and having completed a maximal CPET (defined as: R 1.1 and test terminated due to breathlessness/muscular fatigue).
Results
Statistical significance was assessed using the Mann-Whitney U test (for non-parametric data) and the Student’s T-test (for parametric data). Statistically significant differences between black and white HCM patients were noted in the% predicted peak power and% predicted peak VO2/kg. (Table 1)
Conclusion
Black HCM patients achieve a significantly lower% predicted peak power on CPET (24% lower) compared with white HCM patients. Black HCM patients also demonstrate a significantly lower% predicted peak VO2/kg (10% lower) compared to white HCM patients. Larger studies are required to corroborate these ethnic differences, however, this study suggests that the current standard cut-off of a peak VO2>120% predicted may be too high for a black athlete resulting in a false positive diagnosis of HCM.
Limited information exists regarding procedural success and clinical outcomes of ST-segment elevation myocardial infarction (STEMI) in patients with previous CABG undergoing primary PCI. We sought to compare outcomes in STEMI patients undergoing primary percutaneous coronary intervention (PCI) with or without previous coronary artery bypass grafts (CABG).
Methods
This was an observational cohort study of 10,920 patients with STEMI who were treated with PPCI between 2004 and 2011 at eight tertiary cardiac centres across London, UK. Patient9s details were recorded at the time of the procedure into the British Cardiac Intervention Society (BCIS) database. Outcome was assessed by all-cause mortality. Anonymous datasets from the eight centres were merged for analysis. The primary end-point was all-cause mortality at a mean follow-up of 3.0 years.
Results
347 (3.2%) patients had previous CABG. Patients with previous CABG were older and had more associated comorbidities than patients who have never had CABG. In patients with previous CABG, the infarct related artery (IRA) was split evenly between a bypass graft and a native vessel. Procedural success (defined as TIMI 3 flow at the end of procedure) was less likely in patients with previous CABG than in patients who had never undergone CABG (80.7 vs 88.2% respectively, p<0.001). Patients with previous CABG had higher all-cause mortality (30.1% vs 16.7%, p<=0.0001) during the follow-up period (figure 1). After multivariate adjustment this difference persisted (HR: 1.3, 95% CI 1.11 to 1.63, p=0.02). When stratifying prior CABG patients by the type of IRA (figure 2); long term MACE were significant more likely in patients who had bypass graft PCI than in patients that had native vessel PCI, 35.7% versus 20.4% (p=0.03).
Conclusions
Previous CABG patients with STEMI treated with primary PCI have higher long-term adverse events. The long-term outcome is also worse if the IRA is a bypass graft rather than a native coronary artery.
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