Doron Zahger

Incidence, Risk Factors, Management and Outcomes of Coronary Artery Perforation During Percutaneous Coronary Intervention

Coronary artery perforation (CP) is a rare, sometimes lethal complication of percutaneous coronary intervention. There are limited controlled contemporary data regarding its predictors, incidence, and outcomes. The aim of this study was to define the incidence, associated factors, and outcomes of CP in the current era of coronary intervention. All patients who had CP during percutaneous coronary intervention at a large tertiary center from January 2001 to December 2008 were identified. Demographic, clinical, and procedural data and outcome variables were obtained. Patients with CP were compared with a randomly assigned control group. Fifty-seven patients with CP were identified among 9,568 interventions performed during the study period (0.59%); these patients were compared with 171 who underwent percutaneous coronary intervention without CP. Vessels were perforated by wires (52.6%), balloons (26.3%), and stents (21.1%). Perforations were classified using the Ellis classification. CP was associated with mortality and tamponade rates of 7% and 16%, respectively, but all these serious complications occurred with grade III perforations. Most grade I and II perforations were managed conservatively. Multivariate analysis identified the treatment of chronic total occlusion as the strongest independent predictor of CP; other independent variables included calcium in the coronary artery that was the site of intervention and non-ST elevation myocardial infarction.

Routine Laboratory Results and Thirty Day and One-Year Mortality Risk Following Hospitalization with Acute Decompensated Heart Failure

Introduction Several blood tests are performed uniformly in patients hospitalized with acute decompensated heart failure and are predictive of the outcomes: complete blood count, electrolytes, renal function, glucose, albumin and uric acid. We sought to evaluate the relationship between routine admission laboratory tests results, patient characteristics and 30-day and one-year mortality of patients admitted for decompensated heart failure and to construct a simple mortality prediction tool. Methods A retrospective population based study. Data from seven tertiary hospitals on all admissions with a principal diagnosis of heart failure during the years 2002–2005 throughout Israel were captured. Results 8,246 patients were included in the study cohort. Thirty day mortality rate was 8.5% (701 patients) and one-year mortality rate was 28.7% (2,365 patients). Addition of five routine laboratory tests results (albumin, sodium, blood urea, uric acid and WBC) to a set of clinical and demographic characteristics improved c-statistics from 0.76 to 0.81 for 30-days and from 0.72 to 0.76 for one-year mortality prediction (both p-values <0.0001). Three dichotomized abnormal laboratory results with highest odds ratio for one-year mortality (hypoalbuminaemia, hyponatremia and elevated blood urea) were used to construct a simple prediction score, capable of discriminating from 1.1% to 21.4% in 30-day and from 11.6% to 55.6% in one-year mortality rates between patients with a score of 0 (1,477 patients) vs. score of 3 (544 patients). Discussion A small set of abnormal routine laboratory results upon admission can risk-stratify and independently predict 30-day and one-year mortality in patients hospitalized with acute decompensated heart failure.

Cell free DNA detected by a novel method in acute ST-elevation myocardial infarction patients

Abstract Background: High levels of circulating cell free DNA (CFD) have been associated with poor prognosis in various diseases. Data pertaining to CFD in acute myocardial infarction (MI) are scarce. The available data have been obtained by either electrophoresis or polymerase chain reaction. We evaluated a novel method for the detection of CFD in patients with ST elevation myocardial infarction (STEMI) and examined its correlation with established markers of necrosis and ventricular function. Methods: Serum concentrations of CFD, troponin-T and creatine kinase (CK) were measured simultaneously in 16 randomly selected acute STEMI patients upon admission and at three more time points. 47 healthy subjects served as a control group. CFD was quantified by a novel rapid fluorometric assay. Ejection fraction (EF) was assessed by echocardiography. Results: Peak CFD levels were significantly higher in patients compared with controls (P = 0.001) and correlated with peak levels of CK and troponin-T (R = 0.79, P <0.001); R = 0.65, P = 0.006, respectively). Peak CFD levels tended to be associated with lower EF (P = 0.075). Conclusion: With this method, CFD levels correlated with the levels of established markers of myocardial necrosis but not with EF. The kinetic pattern of CFD release after STEMI and its prognostic value require further investigation.

Early heart rate variability alterations after acute myocardial infarction.

In order to assess early changes in heart rate variability, we studied 81 patients with acute myocardial infarction during the initial 24 hours after thrombolytic therapy. The standard deviation of the mean heart rate and the low (0 to 0.05 Hz), mid (0.05 to 0.20 Hz), and high (0.20 to 0.35 Hz) frequency band power were evaluated with 24-hour ECG Holter recordings. We found diminished variance in the time domain and reduced power spectrum in the frequency domain compared with a group of 41 normal subjects (p < 0.01). Patients with anterior infarction had significantly (p < 0.01) higher heart rates and lower heart rate variability values than patients with inferior infarction. Reduction in heart rate variability occurred within the first 8 hours in patients with anterior infarction; a significant fall (p < 0.03) was especially noted in the high-frequency band after a decline in ST-segment elevation. Heart rate variability alterations in patients with inferior infarction were most evident in the final 8-hour interval. These findings may be viewed in terms of sympathovagal imbalance and may be related to clinical signs of intense autonomic nervous system activity that are observed early in the course of acute anterior and inferior myocardial infarction.

Euro Heart Survey 2009 Snapshot: Regional variations in presentation and management of patients with AMI in 47 countries

Aims: Detailed data on patients admitted for acute myocardial infarction (AMI) on a European-wide basis are lacking. The Euro Heart Survey 2009 Snapshot was designed to assess characteristics, management, and hospital outcomes of AMI patients throughout European Society of Cardiology (ESC) member countries in a contemporary ‘real-world’ setting, using a methodology designed to improve the representativeness of the survey. Methods: Member countries of the ESC were invited to participate in a 1-week survey of all patients admitted for documented AMI in December 2009. Data on baseline characteristics, type of AMI, management, and complications were recorded using a dedicated electronic form. In addition, we used data collected during the same time period in national registries in Sweden, England, and Wales. Data were centralized at the European Heart House. Results: Overall, 4236 patients (mean age 66±13 years; 31% women) were included in the study in 47 countries. Sixty per cent of patients had ST-segment elevation myocardial infarction, with 50% having primary percutaneous coronary intervention and 21% fibrinolysis. Aspirin and thienopyridines were used in >90%. Unfractionated and low-molecular-weight heparins were the most commonly used anticoagulants. Statins, beta-blockers, and angiotensin-converting enzyme inhibitors were used in >80% of the patients. In-hospital mortality was 6.2%. Regional differences were observed, both in terms of population characteristics, management, and outcomes. Conclusions: In-hospital mortality of patients admitted for AMI in Europe is low. Although regional variations exist in their presentation and management, differences are limited and have only moderate impact on early outcomes.

Pre-hospital treatment of STEMI patients. A scientific statement of the working group acute cardiac care of the European society of cardiology

In ST-elevation myocardial infarction (STEMI) the pre-hospital phase is the most critical, as the administration of the most appropriate treatment in a timely manner is instrumental for mortality reduction. STEMI systems of care based on networks of medical institutions connected by an efficient emergency medical service are pivotal. The first steps are devoted to minimize the patients delay in seeking care, rapidly dispatch a properly staffed and equipped ambulance to make the diagnosis on scene, deliver initial drug therapy and transport the patient to the most appropriate (not necessarily the closest) cardiac facility. Primary PCI is the treatment of choice, but thrombolysis followed by coronary angiography and possibly PCI is a valid alternative, according to patients baseline risk, time from symptoms onset and primary PCI-related delay. Paramedics and nurses have an important role in pre-hospital STEMI care and their empowerment is essential to increase the effectiveness of the system. Strong cooperation between cardiologists and emergency medicine doctors is mandatory for optimal pre-hospital STEMI care. Scientific societies have an important role in guideline implementation as well as in developing quality indicators and performance measures; health care professionals must overcome existing barriers to optimal care together with political and administrative decision makers.

Quality indicators for acute myocardial infarction: A position paper of the Acute Cardiovascular Care Association

Evaluation of quality of care is an integral part of modern healthcare, and has become an indispensable tool for health authorities, the public, the press and patients. However, measuring quality of care is difficult, because it is a multifactorial and multidimensional concept that cannot be estimated solely on the basis of patients’ clinical outcomes. Thus, measuring the process of care through quality indicators (QIs) has become a widely used practice in this context. Other professional societies have published QIs for the evaluation of quality of care in the context of acute myocardial infarction (AMI), but no such indicators exist in Europe. In this context, the European Society of Cardiology (ESC) Acute Cardiovascular Care Association (ACCA) has reflected on the measurement of quality of care in the context of AMI (ST segment elevation myocardial infarction (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI)) and created a set of QIs, with a view to developing programmes to improve quality of care for the management of AMI across Europe. We present here the list of QIs defined by the ACCA, with explanations of the methodology used, scientific justification and reasons for the choice for each measure.

What Have the New Definition of Acute Myocardial Infarction and the Introduction of Troponin Measurement Done to the Coronary Care Unit

Objective: To assess the impact of the new American College of Cardiology/European Society of Cardiology definition of acute myocardial infarction (AMI) and the introduction of troponin measurement on the coronary care unit (CCU). Methods: This was a retrospective cohort study performed in a tertiary care university hospital. All admissions to the CCU during the year before (period 1, year 2000, n = 1,134) and the year after (period 2, year 2002, n = 1,360) the introduction of troponin measurement and the new AMI definition were studied. We studied baseline characteristics, case load, distribution of admission diagnoses, management and outcome of patients in the two periods. Results: There was a 20% increase in the number of CCU admissions, driven solely by a 141% increase in the burden of non-ST elevation AMI (NSTEMI) (p < 0.01). This increase was not a mere reflection of a change in diagnostic criteria, as the overall burden of non-ST elevation acute coronary syndromes (ACS) (NSTEMI + unstable angina) increased by 46%, suggesting referral of many more patients to the CCU. Despite a 42% increase in the number of angiograms performed, the proportion of ACS patients who had an angiogram declined. AMI patients in period 2 were older and had higher rates of coronary risk factors but had a higher chance of receiving a guideline-based therapy. Length of CCU stay decreased by a whole day for all ACS patients. 30-day mortality for AMI patients did not change significantly. Conclusions: The new AMI definition had a dramatic impact on the CCU case load, case mix and length of stay and on the ability to provide early coronary angiography.

B-type natruiretic peptide levels stratify the risk for arrhythmia among implantable cardioverter defibrillator patients.

We sought to study the association between brain natriuretic peptide (BNP) levels and the occurrence of ventricular arrhythmias in patients with left ventricular dysfunction (LVD) and an implantable cardioverter defibrillator (ICD).

Incidence, predictors and outcome of upper gastrointestinal bleeding in patients with acute coronary syndromes.

BACKGROUND The broad utilization of revascularization and antithrombotic therapy in patients with acute coronary syndrome (ACS) is associated with a substantial risk of bleeding primarily related to arterial punctures, which can lead to worse outcome. AIM To define the characteristics and outcome of patients who develop upper gastrointestinal bleeding (UGIB) in the setting of ACS. METHODS We identified all patients admitted to the coronary care unit between 10/96 and 11/07 with ACS who developed UGIB. For each case 3 control cases were matched. Multiple baseline characteristics, as well as antithrombotic agents, revascularization strategy and endoscopy reports were assessed. Mortality at 30-day was the primary endpoint of the analysis. RESULTS Of 7240 ACS patients, 64 (0.9%) developed UGIB. There were no significant differences between groups in the prevalence of diabetes and other risk factors, revascularization strategy, or the use of proton pump inhibitors. Patients with UGIB suffered more from renal impairment and left ventricular dysfunction and were more frequently treated with thienopyridines (89% vs. 68%, p=0.002) and glycoprotein IIb/IIIa inhibitors (39% vs. 24%, p=0.03). The combination of unfractionated heparin (UFH) with glycoprotein IIb/IIIa inhibitors was strongly associated with UGIB (OR: 2.87, 95% CI 1.66-4.97). Patients who developed UGIB had a substantially higher 30-day mortality rate (33% vs. 5%, p<0.001). CONCLUSIONS UGIB in patients with ACS is associated with a markedly increased mortality. Previous peptic disease and the use of combined anti-platelet therapy, especially in conjunction with heparin, are strong risk factors for this serious complication.