Initial Cardiac Rhythm Correlated to Emergency Department Survival

Background This study attempted to correlate the initial cardiac rhythm and survival from prehospital cardiac arrest, as a secondary end-point. Methods Prospective, randomized, double-blinded clinical intervention trial where bicarbonate was administered to 874 prehospital cardiopulmonary arrest patients in prehospital urban, suburban, and rural emergency medical service environments. Results This group's manifested an overall survival rate of 13.9% (110 of 793) of prehospital cardiac arrest patients. The most common presenting arrhythmia was ventricular fibrillation (VF) (45.0%), asystole (ASY) (34.4%), and pulseless electrical activity (PEA) (15.7%). Less commonly found were normal sinus rhythm (NSR) (1.8%), other (1.8%), ventricular tachycardia (VT) (0.6%), and atrioventricular block (AVB) (0.5%) as prearrest rhythms. The best survival was noted in those with a presenting rhythm of AVB (57.1%), VT (33.3%), VF (15.7%), NSR (14.3%), PEA (11.2%), and ASY (11.1%) (p = 0.02). However, there was no correlation between the final cardiac rhythm and outcome, other than an obvious end-of-life rhythm. Conclusion The most common presenting arrhythmia was VF (45%), while survival is greatest in those presenting with AVB (57.1%).

Acute Coronary Syndrome in Pregnancy

Acute coronary syndrome (ACS) in pregnancy has traditionally been considered to be a rare event, but the combination of normal physiological changes of pregnancy and more prevalent cardiovascular risk factors are increasing its incidence in this population. The present report describes a 39 year-old woman that is seven weeks pregnant presenting with a non ST elevation myocardial infarction. The incidence, risk factors, pathophysiology and management of ACS in pregnancy are discussed.

Platypnea-Orthodeoxia Syndrome in Two Previously Healthy Adults: A Case-based Review

We describe here the clinical manifestations of platypnea-orthodeoxia in two patients with interatrial shunting. In both cases, the patients were asymptomatic prior to developing additional cardiopulmonary issues that apparently enhanced right-to-left intracardiac shunting. The patients were both treated with percutaneously deployed occlusion devices, with excellent results. Symptoms and positional oxygen desaturation resolved after device placement in both cases. In addition, these patients remain symptom-free 30 months after device implantation.

The Threshold of Admission Glycemia as a Predictor of Adverse Events in Diabetic and Non-Diabetic Patients with Acute Coronary Syndrome

Recent studies indicated a high prevalence of hyperglycemia in non-diabetic patients presenting with acute coronary syndrome (ACS). However, the threshold of admission glucose (AG) as a predictor of adverse events in ACS is unclear. Objective The aim of this study was to assess the threshold of admission glucose (AG) as a predictor of adverse events including Major Acute Cardiac Events (MACE) and mortality, during the first week of admitting patients presenting with ACS. Material and Methods The data of 551 patients with ACS were extracted and evaluated. Patients were stratified according to their blood glucose on admission into three groups: group 1: <7 mmol/L (n = 200, 36.3%) and group 2: >7 mmol/L and <15 mmol/L (n = 178, 32.3%) and group 3: ≥15 mmol/L (n = 173, 31.4%). Stress hyperglycemia was arbitrarily defined as AG levels > 7 mmol/L (group 2 and 3). Patients with ACS were sub-divided into two groups: patients with unstable angina (UA, n = 285) and those with ST segment elevation myocardial Infarction (STEMI, n = 266) and data were analyzed separately using multiple regression analysis. Results The mean age of patients was 59.7 ± 14.8 years and 63% were males. The overall mortality in the population was 8.5% (5.4% in STEMI and 3.1% in UA) patients. In STEMI patients, the odds ratio of stress hyperglycemia as predictor of mortality in group 3 compared with group 1 was 3.3 (CI 0.99-10.98, P < 0.05), while in group 2 compared with group 1 was 2.4 (CI: 0.75-8.07, P = 0.065) after adjustment for age and sex. Similarly, in UA patients, the odds ratio of stress hyperglycemia in group 3 compared with group 1 was 2.7 (CI 0.37-18.98, P < 0.05), while in group 2 compared with group 1 was 2.4 (CI: 0.4-15.2, P = 0.344) after adjustment for age and sex. The incidence of more than 2 MACE in both STEMI and UA patients was higher in group 3 compared with the other two groups. Regression analysis showed that history of DM, high level of LDL cholesterol, high level of HbA1c, and anterior infarction were significant predictors of adverse events while other risk factors such as BMI, history of hypertension and smoking were of no significance. Conclusion This study indicates that the stress hyperglycemia on admission is a powerful predictor of increased major adverse events and hospital mortality in patients with acute coronary syndrome.

Age-Related Alteration of Risk Profile, Inflammatory Response, and Angiographic Findings in Patients with Acute Coronary Syndrome

Background Coronary artery disease (CAD) is a major public health problem which in turn imposes a significant burden on health care systems because of high morbidity and mortality. Although the multifactorial etiology of CAD increases with age, but in recent years, the incidence is increasing among younger age groups. Objectives In this study we aimed to evaluate the effect of age on risk profile, inflammatory response and the angiographic findings in patients with ACS. Patients and Methods The study comprised 253 ACS patients. Seventy six (30%) with UA, 56 (22%) with NSTEMI and 121(48%) with STEMI diagnosis. The value of Hs-CRP, lipid profile, cardiac enzymes, risk factors, EF% and angiographic score were analyzed and compared in different age groups. Results Group 1 (n = 68) with age <45 years, group II (n = 110) with age ≥45-<65 years and group III (n = 75) ≥65 years. Group I had more prevalence of male sex, smoking, family history, hypertriglyceridemia and low levels of HDL (P < 0.01), higher incidence of STEMI (P < 0.01) and lower prevalence of UA (P < 0.01). Diabetes mellitus, hypertension, and female gender were more common in older groups. Hs-CRP was significantly lower in the young age (group I). Group I showed a preponderance of single-vessel disease, lower coronary atherosclerotic score and prevalent left anterior descending artery (LAD) involvement compared with older age groups. Hs-CRP was positively correlated to severity of CAD only in older groups. Stepwise multiple regression analysis showed that age, male gender, cardiac enzymes and EF% were common predictors of multivessel disease. Smoking was independent predictor in young patients <45 years while diabetes and Hs-CRP was the key predictor in older patient groups. Conclusion Young patients with ACS had different clinical, angiographic and biochemical profile. Hs-CRP peak concentration did not correlate with angiographic findings in young patients that could be attributed to different risk profile and discrete underlying mechanism.

Assessment of Myocardial Scar; Comparison between 18F-FDG PET, CMR and 99Tc-Sestamibi

Objective Patients with heart failure and ischaemic heart disease may obtain benefit from revascularisation if viable dysfunctional myocardium is present. Such patients have an increased operative risk, so it is important to ensure that viability is correctly identified. In this study, we have compared the utility of 3 imaging modalities to detect myocardial scar. Design Prospective, descriptive study. Setting Tertiary cardiac centre. Patients 35 patients (29 male, average age 70 years) with coronary artery disease and symptoms of heart failure (>NYHA class II). Intervention Assessment of myocardial scar by 99Tc-Sestamibi (MIBI), 18F-flurodeoxyglucose (FDG) and cardiac magnetic resonance (CMR). Outcome Measure The presence or absence of scar using a 20-segment model. Results More segments were identified as nonviable scar using MIBI than with FDG or CMR. FDG identified the least number of scar segments per patient (7.4 +/- 4.8 with MIBI vs. 4.9 +/- 4.2 with FDG vs. 5.8 +/- 5.0 with CMR, p = 0.0001 by ANOVA). The strongest agreement between modalities was in the anterior wall with the weakest agreement in the inferior wall. Overall, the agreement between modalities was moderate to good. Conclusion There is considerable variation amongst these 3 techniques in identifying scarred myocardium in patients with coronary disease and heart failure. MIBI and CMR identify more scar than FDG. We recommend that MIBI is not used as the sole imaging modality in patients undergoing assessment of myocardial viability.

Relationship between the Plasma Concentration of C-Reactive Protein and Severity of Peripheral Arterial Disease

Objective To determine whether the increase in plasma levels of C-Reactive Protein (CRP), a non-specific reactant in the acute-phase of systemic inflammation, is associated with clinical severity of peripheral arterial disease (PAD). Methods and Results This is a cross-sectional study at a referral hospital center of institutional practice in Madrid, Spain. A stratified random sampling was done over a population of 3370 patients with symptomatic PAD from the outpatient vascular laboratory database in 2007 in the order of their clinical severity: the first group of patients with mild chronological clinical severity who did not require surgical revascularization, the second group consisted of patients with moderate clinical severity who had only undergone only one surgical revascularization procedure and the third group consisted of patients who were severely affected and had undergone two or more surgical revascularization procedures of the lower extremities in different areas or needed late re-interventions. The Neyman affixation was used to calculate the sample size with a fixed relative error of 0.1. A homogeneity analysis between groups and a unifactorial analysis of comparison of medians for CRP was done. The groups were homogeneous for age, smoking status, Arterial Hypertension HTA, diabetes mellitus, dyslipemia, homocysteinemia and specific markers of inflammation. In the unifactorial analysis of multiple comparisons of medians according to Scheffe, it was observed that the median values of CRP plasma levels were increased in association with higher clinical severity of PAD (3.81 mg/L [2.14-5.48] vs. 8.33 [4.38-9.19] vs. 12.83 [9.5-14.16]; p < 0.05) as a unique factor of tested ones. Conclusion Plasma levels of CRP are associated with not only the presence of atherosclerosis but also with its chronological clinical severity.

Improvement of Young and Elderly Patient's Knowledge of Heart Failure after an Educational Session

Background Interest in the role of patient education sessions for optimizing the management of heart failure (HF) is increasing. We determined whether improvements in young and elderly patients' knowledge of HF and self-care behavior could be analyzed by administering a knowledge test before and after an educational session. Methods Stable heart failure patients (n = 115) were enrolled in a prospective cohort study from our Heart Failure educational centre in a university hospital. Patient knowledge of six major HF-related topics was assessed via a questionnaire distributed once before an educational session and twice afterward. Each answer was assigned a numerical value and the final score for each topic could range from 0 to 20. Scores ≥ 15/20 were considered representative of a good level of knowledge. Results The level of knowledge was low (9.7/20) before the educational session but was significantly higher (16.3/20) during the 1st quarter after the session, and this benefit was maintained for up to 12 months (16.6/20). Knowledge levels increased in both younger and elderly patients, and the number of patients who had a good level of knowledge also increased after the educational session. Conclusion This study confirms that an HF knowledge test is feasible and that educational sessions improve the knowledge and self-management of both younger and elderly patients.

Circulating CD34+ Cell Count is Associated with Extent of Subclinical Atherosclerosis in Asymptomatic Amish Men, Independent of 10-Year Framingham Risk

Background Bone-marrow derived progenitor cells (PCs) may play a role in maintaining vascular health by actively repairing damaged endothelium. The purpose of this study in asymptomatic Old Order Amish men (n = 90) without hypertension or diabetes was to determine if PC count, as determined by CD34+ cell count in peripheral blood, was associated with 10-year risk of cardiovascular disease (CVD) and measures of subclinical atherosclerosis. Methods and Results CD34+ cell count by fluorescence-activated cell sorting, coronary artery calcification (CAC) by electron beam computed tomography, and CVD risk factors were obtained. Carotid intimal-medial thickness (CIMT) also was obtained in a subset of 57 men. After adjusting for 10-year CVD risk, CD34+ cell count was significantly associated with CAC quantity ( p =0.03) and CIMT ( p < 0.0001). A 1-unit increase in natural-log transformed CD34+ cell count was associated with an estimated 55.2% decrease (95% CI: −77.8% to −9.3%) in CAC quantity and an estimated 14.3% decrease (95% CI: −20.1% to −8.1%) in CIMT. Conclusions Increased CD34+ cell count was associated with a decrease in extent of subclinical atherosclerosis in multiple arterial beds, independent of 10-year CVD risk. Further investigations of associations of CD34+ cell count with subclinical atherosclerosis in asymptomatic individuals could provide mechanistic insights into the atherosclerotic process.

Effects of Nebivolol on Endothelial Function and Exercise Parameters in Patients with Slow Coronary Flow

Objective Earlier studies have reported that a decrease in exercise capacity might indicate endothelial dysfunction. However, the effects of improvement of endothelial functions on exercise capacity have not been evaluated. The aim of the present study is to investigate the effects of nebivolol on flow-mediated dilatation (FMD), and on the exercise capacities of the patients with slow coronary flow (SCF). Methods The study population included 25 subjects with SCF (Group 1) documented by the thrombolysis in myocardial infarction (TIMI) frame count, and 25 control group (Group 2) subjects with normal coronary angiography, for a total of 50 subjects who underwent coronary angiography due to several indications and had no coronary lesion. The TIMI frame count (TFC) values of the subjects in Group I for left anterior descending artery, right coronary, and circumflex coronary artery were 61.8 ± 30.6, 37.2 ± 17.4, and 34.6 ± 17.4, respectively. All the subjects received nebivolol 5 mg/day. Results At the end of the first month of FMD, the mean exercise duration (MED) and the Duke Scores of the patients with SCF were significantly higher than the baseline values. However, the values by the sixth month did not differ from that at the first month. Although a numerical improvement compared to the baseline values was observed for the subjects in Group 2 by the measurements at the end of the first and the sixth month, this difference was not statistically significant. Conclusions Nebivolol treatment increases FMD in the subjects with SCF. The difference in the exercise parameters of these subjects is particularly dramatic, and such an outcome may indirectly indicate long-term improvement in endothelial function.