The American journal of cardiology
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Randomized Controlled Trial
Relation between myocardial infarct size and ventricular tachyarrhythmia among patients with preserved left ventricular ejection fraction following fibrinolytic therapy for ST-segment elevation myocardial infarction.
In the era of early reperfusion therapy for ST-segment elevation myocardial infarction, preserved left ventricular (LV) function is common. Despite preservation of LV ejection fraction (LVEF), there remains a spectrum of risk for adverse cardiovascular events, including ventricular tachycardia (VT) and ventricular fibrillation (VF). Larger infarct size has been independently associated with death, VT/VF, and heart failure in the post-myocardial infarction population. ⋯ The median LVEF in this group was 55% (interquartile range 45% to 65%), and most patients (n = 814 [87.1%]) had LVEF > or =40%. Among patients with LVEF > or =40%, the ratio of peak CK-MB to the upper limit of normal was significantly associated with the incidence of VT/VF through 30 days (2.2%, 3.7%, and 5.5% across tertiles, respectively, p = 0.041 for trend) and the incidence of the composite of cardiovascular death, heart failure, shock, and VT/VF through 30 days (3.7%, 6.0%, 8.5%, respectively, p = 0.018 for trend). In conclusion, in patients with ST-segment elevation myocardial infarction with preserved LV function after reperfusion therapy, larger infarct size, as estimated by peak serum CK-MB concentration, is significantly associated with VT/VF as well as other adverse clinical outcomes.
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Guidelines support percutaneous coronary intervention (PCI) of the noninfarct-related artery during primary PCI for ST-segment elevation myocardial infarction (STEMI) in patients with hemodynamic compromise; however, in patients without hemodynamic compromise, PCI of the noninfarct-related artery is given a class III recommendation. We analyzed the National Cardiovascular Data Registry (n = 708,481 admissions, 638 sites) to determine the prevalence, predictors, and in-hospital outcomes of primary multivessel PCI from 2004 to 2007. Patients with STEMI and multivessel coronary artery disease who were undergoing primary PCI were identified (n = 31,681). ⋯ Among patients with STEMI and cardiogenic shock (n = 3,087), those receiving multivessel PCI had greater in-hospital mortality (36.5% vs 27.8%; adjusted odds ratio 1.54, 95% confidence interval 1.22 to 1.95). In conclusion, these data suggest that performing multivessel PCI during primary PCI for STEMI does not improve short-term survival even for patients with cardiogenic shock. These findings suggest the need for definitive studies to evaluate the utility of noninfarct-related artery PCI among patients with STEMI.
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Multicenter Study
Relation of N-terminal pro-B-type natriuretic peptide to symptoms, severity, and left ventricular remodeling in patients with organic mitral regurgitation.
Natriuretic peptides reflect cardiac stress and may therefore be useful in the management of patients with valvular heart disease. Data regarding these biomarkers in organic mitral regurgitation (MR) are sparse. In this study, 144 patients with moderate or severe organic MR were prospectively enrolled in an observational, multicenter study to analyze the relation of N-terminal-pro-B-type natriuretic peptide (NT-pro-BNP) to symptoms, severity of MR, and echocardiographic parameters. ⋯ The area under the receiver-operating characteristic curve to predict symptoms for NT-pro-BNP was 0.80 (95% confidence interval 0.71 to 0.88), which was significantly higher than for all echocardiographic variables (p <0.001 for all). In conclusion, NYHA functional class, atrial fibrillation, and LV end-systolic dimension are independent predictors of increased NT-pro-BNP levels in patients with moderate or severe organic MR. Therefore, NT-pro-BNP may be helpful in the clinical evaluation and management of patients with MR, especially when it is doubtful whether symptoms are related to MR or not.
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Heart donor candidates have severe neurologic injuries that have been associated with significant prolongation of the corrected QT (QTc) interval. Screening for an underlying abnormality of cardiac repolarization such as the long-QT syndrome thus becomes difficult. The aims of this study were to establish normal values and determine factors associated with prolongation of pre- and post-transplantation QTc intervals in a large cohort of heart transplantation donors and recipients. ⋯ Fewer than 5% of the donor population was found to have QTc interval > or =580 ms. For those afflicted by gunshot wounds, <5% had QTc intervals > or =550 ms. This information can be used in pre-transplantation donor assessment, and post-transplantation management can be tailored to avoid the occurrence of ventricular arrhythmia.
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Although intra-aortic balloon pump (IABP) counterpulsation is increasingly being used for the treatment of patients with cardiogenic shock from acute myocardial infarction, data on the long-term outcomes are lacking. The aim of the present study was to evaluate the 30-day and long-term mortality and to identify predictors for 30-day and long-term all-cause mortality of patients with acute myocardial infarction complicated by cardiogenic shock who were treated with IABP. From January 1990 to June 2004, 300 consecutive patients treated with IABP were included. ⋯ The adjusted predictors of long-term mortality were arrhythmias during the intensive cardiac care unit stay (hazard ratio [HR] 1.8, 95% confidence interval [CI] 1.2 to 2.9) and renal failure during the intensive cardiac care unit stay (HR 2.5, 95% CI 1.3 to 5.1). After adjustment, treatment with primary percutaneous coronary intervention (HR 0.5, 95% CI 0.3 to 0.9) and coronary artery bypass grafting (HR 0.4, 95% CI 0.2 to 0.8) were associated with lower long-term mortality. In conclusion, in patients with acute myocardial infarction complicated by cardiogenic shock treated with IABP, the 30-day survival improved with time and an encouraging number of patients survived in the long term.