James M. Atkins

A New Method for Radionuclide Imaging of Acute Myocardial Infarction in Humans

A new method of visualizing acute myocardial infarction in humans following intravenous injection of 15 mCi-5 mg of 99mTc stannous pyrophosphate in 23 patients is reported. Fifteen patients had histories suggestive of acute myocardial infarction and subsequently developed electrocardiogram and enzyme changes that confirmed the clinical diagnosis. Eleven of the 15 patients were scanned 3-5 days postinfarction, and all had positive scintigrams. The four remaining patients were scanned 7-10 days after their myocardial infarction; two had positive scintigrams. In those 8 patients with chest pain but without ECG and enzyme changes suggestive of myocardial infarction, scintigrams were negative. Positive scintigrams in the patients with myocardial infarction are thought to be due to incorporation of pyrophosphate into the crystalline structure of the hydroxyapatite found within the mitochondria of irreversibly damaged myocardial cells. The location of the acute myocardial infarction by scintigram correlated well with ECG localization in the 13 patients with positive scintigrams. This imaging method shows promise in 1) identifying the presence of acute myocardial infarction in patients with chest pain, 2) determining the location of acute myocardial infarction with a high degree of accuracy, 3) detecting the extension of the infarction, and 4) the possibility of determining the size of acute myocardial infarctions.

The clinical significance of bundle branch block complicating acute myocardial infarction. 1. Clinical characteristics, hospital mortality, and one-year follow-up.

SUMMARY To provide an understanding of the clinical characteristics of patients with acute myocardial infarction (MI) and bundle branch block, experience from five centers was accumulated. Patients in whom bundle branch block first appeared after the onset of cardiogenic shock were excluded. In 432 patients, the most common types of block were left (38%) and right with left anterior fascicular block (34%). In 42% of the patients, bundle branch block was new. Progression to high degree (second or third degree) atrioventricular (AV) block via a Type II pattern occurred in 22% of the patients.Hospital and first year follow-up mortality rates were 28% and 28%, respectively. Only 46% of the patients developed pulmonary edema or shock (Killip Class III or IV), and hospital mortality was related to the amount of heart failure (8%, 7%, 27%, 83% for Killip Classes I-IV, respectively). Patients with progression to second degree or third degree AV block via a Type II pattern had increased hospital mortality compared with patients without this complication (47% vs 23%, P < 0.001). In the absence of pulmonary edema or shock, patients with Type lI second degree or third degree AV block still had a higher mortality rate than patients without advanced AV block (31% vs 2%, P < 0.005), with nearly all the deaths due to abrupt development of AV block.Thus, in many patients MI with bundle branch block is associated with severe heart failure. However, this was not true for a majority of the patients, in whom therapy aimed at preventing morbidity and mortality due to the bradyarrhythmia of advanced AV block might be beneficial.

Out-of-Hospital Administration of Intravenous Glucose-Insulin-Potassium in Patients With Suspected Acute Coronary Syndromes: The IMMEDIATE Randomized Controlled Trial

CONTEXT Laboratory studies suggest that in the setting of cardiac ischemia, immediate intravenous glucose-insulin-potassium (GIK) reduces ischemia-related arrhythmias and myocardial injury. Clinical trials have not consistently shown these benefits, possibly due to delayed administration. OBJECTIVE To test out-of hospital emergency medical service (EMS) administration of GIK in the first hours of suspected acute coronary syndromes (ACS). DESIGN, SETTING, AND PARTICIPANTS Randomized, placebo-controlled, double-blind effectiveness trial in 13 US cities (36 EMS agencies), from December 2006 through July 31, 2011, in which paramedics, aided by electrocardiograph (ECG)-based decision support, randomized 911 (871 enrolled) patients (mean age, 63.6 years; 71.0% men) with high probability of ACS. INTERVENTION Intravenous GIK solution (n = 411) or identical-appearing 5% glucose placebo (n = 460) administered by paramedics in the out-of-hospital setting and continued for 12 hours. MAIN OUTCOME MEASURES The prespecified primary end point was progression of ACS to myocardial infarction (MI) within 24 hours, as assessed by biomarkers and ECG evidence. Prespecified secondary end points included survival at 30 days and a composite of prehospital or in-hospital cardiac arrest or in-hospital mortality, analyzed by intent-to-treat and by presentation with ST-segment elevation. RESULTS There was no significant difference in the rate of progression to MI among patients who received GIK (n = 200; 48.7%) vs those who received placebo (n = 242; 52.6%) (odds ratio [OR], 0.88; 95% CI, 0.66-1.13; P = .28). Thirty-day mortality was 4.4% with GIK vs 6.1% with placebo (hazard ratio [HR], 0.72; 95% CI, 0.40-1.29; P = .27). The composite of cardiac arrest or in-hospital mortality occurred in 4.4% with GIK vs 8.7% with placebo (OR, 0.48; 95% CI, 0.27-0.85; P = .01). Among patients with ST-segment elevation (163 with GIK and 194 with placebo), progression to MI was 85.3% with GIK vs 88.7% with placebo (OR, 0.74; 95% CI, 0.40-1.38; P = .34); 30-day mortality was 4.9% with GIK vs 7.7% with placebo (HR, 0.63; 95% CI, 0.27-1.49; P = .29). The composite outcome of cardiac arrest or in-hospital mortality was 6.1% with GIK vs 14.4% with placebo (OR, 0.39; 95% CI, 0.18-0.82; P = .01). Serious adverse events occurred in 6.8% (n = 28) with GIK vs 8.9% (n = 41) with placebo (P = .26). CONCLUSIONS Among patients with suspected ACS, out-of-hospital administration of intravenous GIK, compared with glucose placebo, did not reduce progression to MI. Compared with placebo, GIK administration was not associated with improvement in 30-day survival but was associated with lower rates of the composite outcome of cardiac arrest or in-hospital mortality. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00091507.

The clinical significance of bundle branch block complicating acute myocardial infarction. 2. Indications for temporary and permanent pacemaker insertion.

The indication for prophylactic temporary and permanent pacing during acute myocardial infarction (MI) complicated by bundle branch block is high risk of progression via a Type II pattern to second or third degree (high degree) AV block during hospitalization or follow-up. In this study, determinants of high degree AV block during hospitalization and sudden death or recurrent high degree block during the first year of follow-up were examined in 432 patients with MI and bundle branch block. Timing of onset of bundle branch block, the involved fascicles, and the PR interval were examined as determinants of risk of progression to high degree AV block during MI. At highest risk were 186 patients with blocks involving the right bundle and at least one fascicle of the left bundle which were not documented on prior electrocardiograms. Risk was similar with (38%) or without (31%) accompanying first degree AV block. Patients with transient high degree AV block during MI had a 28% incidence of sudden death or recurrent high degree block during the first year of follow-up. Patients not continuously paced had a higher incidence of sudden death or recurrent high degree block than patients continuously paced (65% vs 10%, P less than 0.001). Sudden death during follow-up also occurred in 13% of patients without high degree block during MI. A subgroup with 1) documented prior MI, 2) anterior or indeterminant acute MI, and 3) no symptoms of cardiac failure had a 35% risk of sudden death. The role of permanent pacing in this group is unknown. Thus, patients at high risk of high degree AV block should receive prophylactic temporary pacing. Patients who survive high degree block with MI should receive temporary and then permanent pacing. Patients without high degree AV block during MI who nervertheless have a high risk of sudden death may benefit from permanent pacing.

Ventricular conduction blocks and sudden death in acute myocardial infarction. Potential indications for pacing.

Abstract Of 425 patients with acute myocardial infarction admitted to a coronary-care unit 77 (18 per cent) had ventricular conduction blocks. Complete heart block developed in 43 per cent with right-bundle-branch block and left-axis deviation, in 17 per cent with left-bundle-branch block, and in 6 per cent without ventricular conduction blocks. In-hospital mortality was 30 per cent in patients with and 14 per cent without ventricular conduction block. Late sudden death occurred in five of six patients with right-bundle-branch block and left-axis deviation who had transient complete heart blocks during myocardial infarction, whereas eight similar patients with complete heart block with permanent pacing were alive. These findings suggest that patients with this form of block with an acute myocardial infarction should have temporary standby pacemakers inserted. If complete heart block develops in such cases in association with an acute myocardial infarction, even though transient, permanent pacing should be...

Phase II Trial of Postoperative Adjuvant Paclitaxel/Carboplatin and Thoracic Radiotherapy in Resected Stage II and IIIA Non–Small-Cell Lung Cancer: Promising Long-Term Results of the Radiation Therapy Oncology Group—RTOG 9705

PURPOSE To determine the overall survival, progression-free survival, and toxicity associated with concurrent paclitaxel/carboplatin and thoracic radiotherapy for completely resected patients with stage II and IIIA non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS Eighty-eight eligible patients had surgical resection for pathologic stage II or IIIA disease and received postoperative paclitaxel and carboplatin. Concurrent thoracic radiotherapy at 50.4 Gy in 28 fractions for 6 weeks (1.8 Gy/d, 5 days/wk) was given during cycles 1 and 2. A boost of 10.8 Gy in six fractions was given for extracapsular nodal extension or T3 lesions. RESULTS Treatment compliance was acceptable, with 93% compliance for radiation therapy and 86% for chemotherapy completion. The median duration of follow-up was 56.7 months (range, 17 to 61 months). The median overall survival time was 56.3 months, with 1-, 2-, and 3-year survival rates of 86%, 70%, and 61%, respectively. The 1-, 2-, and 3- year progression-free survival rates were 70%, 57%, and 50%, respectively. Brain metastasis occurred as the sole site of first failure in 11%, and 9% failed in other metastatic sites as first failure. Of the 43 patients who died, the cause of death was the treated cancer in 31 (35%). Local failure was a component of first failure in 15% of patients. Toxicities were acceptable. An overall survival comparison to Eastern Cooperative Oncology Group 3590 is favorable. CONCLUSION The mature results of this trial suggest an improved overall and progression-free survival in this group of resected NSCLC patients, compared with previously reported trials. A phase III trial comparing this treatment regimen with standard therapy seems warranted.

Sex-related differences in the presentation and outcome of out-of-hospital cardiopulmonary arrest: a multiyear, prospective, population-based study.

Objective To examine whether previously observed sex-related differences in coronary artery disease syndromes also apply to patients with out-of-hospital sudden cardiac arrest, a probable subset of patients with coronary artery disease who are easy to recognize and are treated in a standardized fashion. Design Prospective, population-based study conducted over a 6-yr period. Setting A large urban municipality (population, 1.1 million) served by a single emergency medical services system with centralized medical direction and standardized protocols. Patients All patients with out-of-hospital, nontraumatic, primary cardiac arrest. Interventions Standardized advanced cardiac life support protocols. Measurements and Main Results During the 6 yrs of the study, 4147 consecutive patients were studied, 42% of whom were women (p < .001). Although women were significantly older than men (mean age, 68.7 ± 18 vs. 61.7 ± 17 yrs;p = .001), there were no significant differences for the percentages of witnessed and unwitnessed arrests, response intervals, and the length and type of treatment provided. Although men were more likely to have ventricular fibrillation/ventricular tachycardia on presentation (41% vs. 30%), women had more asystole (8.8% vs. 7%) and (organized) pulseless electrical activity than men (24% vs. 18%;p < .001). Nevertheless, more women were resuscitated (13.5% vs. 10.7%;p = .005), particularly women with non-ventricular fibrillation/ventricular tachycardia presentation (12.6% vs. 9.6%;p < .02). These differences were more pronounced when controlling for age (95% confidence interval, 1.44 [1.25–1.74]). Conclusions In cases of out-of-hospital sudden cardiac arrest, women have significantly better resuscitation rates than men, especially when controlling for age, particularly among women with non-ventricular fibrillation/ventricular tachycardia presentations. Additional studies are required to validate these observations, not only for long-term survival and external validity, but also for other potential genetic factors and potential discrepancies with other studies.

Acute Effects of Ethanol on Left Ventricular Performance

The cardiac effects of ethanol were studied in six conscious dogs chronically instrumented for measurement of left ventricular pressure, internal transverse diameter, and outflow. Successive intravenous infusions of ethanol produced blood levels of 120 ± 16 (SEM) mg% (infusion #1) and 311 ± 19 mg% (infusion #2). Stroke volume decreased from 20.1 ± 1.6 ml preinfusion to 17.2 ± 1.9 ml after infusion #1 (P < 0.01) and 13.6 ± 1.9 ml after infusion #2 (P < 0.01). Left ventricular end diastolic pressure increased 2.5 mm Hg with infusion #1 (P < 0.05) and 6.0 mm Hg with infusion #2 (P < 0.05). Left ventricular dp/dt max fell 17% with infusion #1 (P < 0.001) and 30% with infusion #2 (P < 0.01). Left ventricular diameter increased at end diastole and end systole with ethanol. Heart rate was unchanged with infusion #1 and increased with infusion #2; left ventricular systolic pressure was unaltered. Studies after pharmacological autonomic denervation with propranolol and atropine demonstrated changes in left ventricular dp/dt max, left ventricular end diastolic pressure, and stroke volume similar to unblocked results. Thus ethanol at blood levels commonly encountered in social usage is a potent myocardial depressant.

Control of Intractable Ventricular Tachycardia by Coronary Revascularization

Ventricular tachycardia (VT) is an arrhythmia that has an ischemic origin in up to 74% of cases and results in a 42 to 67% mortality when it is recurrent and paroxysmal. Present therapy is aimed at suppression of the abnormal rhythm but does not alter the prognosis of the underlying ischemic heart disease. A new concept of treatment of VT is introduced that is based on direct coronary revascularization by the aorta to coronary, saphenous vein-bypass technique. The method was successfully applied in a 61-year-old man who developed episodes of VT 2 months after myocardial infarction. Maximal medical therapy in a coronary care unit for 26 days did not abolish the arrhythmia which occurred as frequently as seven times an hour. Coronary angiography and aortocoronary bypass grafting were done when the patient developed electrocardiographic and enzyme evidence of subendocardial myocardial infarction and symptoms of cerebral ischemia. The patient remains free of arrhythmia 1 year later, and his exercise capability is now normal for his age. Follow-up coronary angiography is presented. Coronary revascularization has been shown to abolish angina pectoris. This report demonstrates that aortocoronary bypass grafting can abolish an arrhythmia of ischemic origin. When persistent or recurrent VT fails to respond to all medical therapy, direct coronary revascularization should be considered to control this ischemic arrhythmia.

Recommended guidelines for in-hospital cardiac monitoring of adults for detection of arrhythmia

Cardiac monitoring was initially employed in coronary care units during the 1950s and 1960s. Today, it is more broadly applied in a variety of critical and noncritical care hospital settings. Although cardiac monitoring is required by the Joint Commission on Hospital Accreditation (1) in all critical care areas, it now is being used more frequently in noncritical care settings to improve patient care, reduce medicolegal risk and serve as a laborsaving device. Despite nearly 30 years of in-hospital use of cardiac monitoring, only a few studies (2-9) have attempted to define its value and limitations. Most of those reports are of little relevance today, as newer, more specific and accurate arrhythmia recognition and alarm technology replaces earlier systems that were based on heart rate. In light of the expanding use of this technology, this document was developed for the American College of Cardiology by the Emergency Cardiac Care (ACC/ECC) Committee to provide guidelines for the application of in-hospital cardiac monitoring. Although such monitoring is often used to reduce medicolegal risk or as a laborsaving device, or both, the criteria proposed herein reflect medical rather than economic or personnel considerations.