Jan Bech

Field Triage Reduces Treatment Delay and Improves Long-Term Clinical Outcome in Patients With Acute ST-Segment Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention

OBJECTIVESnWe evaluated the independent impact of field triage on treatment delay and long-term clinical outcome in a large contemporary, consecutive population of ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI).nnnBACKGROUNDnReduction of treatment delay is crucial for patients with STEMI.nnnMETHODSnFrom January 2005 to July 2008, 1,437 STEMI patients were treated with pPCI at a single high-volume invasive center. We present the 1-year outcome in this observational registry study.nnnRESULTSnA total of 616 patients were admitted by field triage and 821 by emergency departments. Baseline and angiographic variables were similar in the 2 populations. Patients admitted by field triage had a significantly shorter median door-to-balloon time compared with patients admitted by emergency department triage (83 min, interquartile range 67 to 100 min vs. 103 min, interquartile range 80 to 135 min; p<0.001). Door-to-balloon times of less than the recommended 90 min were achieved in 61% of field triage patients, but only in 36% of nonfield-triage patients (p<0.001). After adjustment for relevant baseline variables, patients admitted by field triage had a reduced risk of reaching the combined end point of all-cause mortality or nonfatal myocardial infarction (hazard ratio: 0.67; 95% confidence interval: 0.46 to 0.97; p=0.035).nnnCONCLUSIONSnThis study shows that field triage of STEMI patients to pPCI significantly reduces treatment delay and improves outcome. These results emphasize the value of field triage as an important tool in the quest to improve clinical outcomes in STEMI patients undergoing pPCI.

Global longitudinal strain is not impaired in type 1 diabetes patients without albuminuria: the Thousand & 1 study

OBJECTIVESnThe purpose of this study was to investigate if systolic myocardial function is reduced in all patients with type 1 diabetes (T1DM) or only in patients with albuminuria.nnnBACKGROUNDnHeart failure is a common cause of mortality in T1DM, and a specific diabetic cardiomyopathy has been suggested. It is not known whether myocardial dysfunction is a feature of T1DM per se or primarily associated with diabetes with albuminuria.nnnMETHODSnThis cross-sectional study compared 1,065 T1DM patients without known heart disease from the outpatient clinic at the Steno Diabetes Center with 198 healthy control subjects. Conventional echocardiography and global longitudinal strain (GLS) by 2-dimensional speckle-tracking echocardiography was performed and analyzed in relation toxa0normoalbuminuria (nxa0= 739), microalbuminuria (nxa0= 223), and macroalbuminuria (nxa0= 103). Data were analyzed in univariable and multivariable linear regression models adjusted for confounding factors including conventional risk factors, medication, and systolic and diastolic dysfunction. Investigators were blinded to degree of albuminuria.nnnRESULTSnMean age was 49.5 years, 52% men, mean glycated hemoglobin 8.2% (66 mmol/mol), mean body mass index 25.5 kg/m(2), and mean diabetes duration 26.1 years. In unadjusted analyses, GLS differed significantly between T1DM patients and control subjects (pxa0= 0.02). When stratified by degrees of albuminuria, the difference in GLS compared with control subjects wasxa0-18.8 ± 2.5% versusxa0-18.5 ± 2.5% for normoalbuminuria (pxa0= 0.28), versusxa0-17.9 ± 2.7% for microalbuminuria (pxa0= 0.001), and versusxa0-17.4 ± 2.9% for macroalbuminuria (pxa0< 0.001). Multivariable analyses, including clinical characteristics, diastolic and systolic dysfunction, and use of medication, did not change this relationship.nnnCONCLUSIONSnSystolic function assessed by GLS was reduced in T1DM compared with control subjects. This difference, however, was driven solely by decreased GLS in T1DM patients with albuminuria. T1DM patients with normoalbuminuria have systolic myocardial function similar to healthy control subjects. These findings do not support the presence of specific diabetic cardiomyopathy without albuminuria.

Prevalence of systolic and diastolic dysfunction in patients with type 1 diabetes without known heart disease: the Thousand & 1 Study

Aims/hypothesisHeart failure is one of the leading causes of mortality in type 1 diabetes. Early identification is vitally important. We sought to determine the prevalence and clinical characteristics associated with subclinical impaired systolic and diastolic function in type 1 diabetes patients without known heart disease.MethodsIn this cross-sectional examination of 1,093 type 1 diabetes patients without known heart disease, randomly selected from the Steno Diabetes Center, complete clinical and echocardiographic examinations were performed and analysed in uni- and multivariable regression models.ResultsThe mean (SD) age was 49.6 (15)u2009years, 53% of participants were men, and the mean duration of diabetes was 25.5 (15)u2009years. Overall, 15.5% (nu2009=u2009169) of participants had grossly abnormal systolic or diastolic function, including 1.7% with left ventricular ejection fraction (LVEF)u2009<u200945% and 14.4% with evidence of long-standing diastolic dysfunction. In univariable models, clinical characteristics associated with abnormal myocardial function were: age (per 10xa0years), OR (95% CI) 2.1 (1.8, 2.4); diabetes duration (per 10xa0years), 1.7 (1.4, 1.9); systolic BPu2009≥u2009140xa0mmHg, 2.7 (1.9, 3.8); diastolic BPu2009≥u200990xa0mmHg, 1.8 (1.0, 3.1); estimated (e)GFRu2009<u200960xa0ml min−1 1.73xa0m−2, 3.8 (2.5, 5.9); microalbuminuria, 2.0 (1.3, 3.0); macroalbuminuria, 5.9 (3.8, 9.3); proliferative retinopathy, 3.6 (2.3, 5.8); blindness, 10.1 (3.2, 31.6); and peripheral neuropathy, 3.8 (2.7, 5.3). In multivariable models only age (2.1 [1.7, 2.5]), female sex, (1.9 [1.2, 2.8]) and macroalbuminuria (5.2 [2.9, 10.3]) remained significantly associated with subclinical grossly abnormal myocardial function.Conclusions/interpretationSubclinical myocardial dysfunction is a common finding in type 1 diabetes patients without known heart disease. Type 1 diabetes patients with albuminuria are at greatly increased risk of having subclinical abnormal myocardial function compared with patients without albuminuria. Echocardiography may be particularly warranted in patients with albuminuria.

High prevalence of smoking in young patients with acute myocardial infarction.

Of 35 patients with acute myocardial infarction (AMI) at the age of 40 years or less, 32 (91%) smoked and only three patients were non-smokers. The age at AMI related significantly to the extent of smoking (p < 0.001, Kruskall-Wallis test). Five patients with AMI at the age < 30 years smoked more heavily than the 30 with AMI at the age of 30-40 years (p = 0.04, Mann Whitney U test). Heavy smoking men > 30 years at the AMI had a Q-wave infarction as often (11 of 13 (85%)) as those with multivessel disease or a coronary artery occlusion (8 of 9 (89% ) and 14 of 16 (88% ) respectively) on coronary arteriography after the infarction. Smoking may be the most important modifiable risk factor in young patients with AMI.

Tissue Doppler echocardiography reveals distinct patterns of impaired myocardial velocities in different degrees of coronary artery disease

UNLABELLEDnAim To determine how the left ventricular wall motion assessed by echocardiographic Tissue Doppler Imaging (TDI) is affected by increasing severity of coronary artery disease (CAD) among patients with stable angina pectoris and preserved ejection fraction.nnnMETHODS AND RESULTSnThis study comprises 82 patients with suspected angina pectoris, no previous cardiac history, and a normal ejection fraction, who were all examined with colour TDI prior to coronary angiography. Patients without significant stenoses (n = 35) constituted the control group and patients with significant stenoses (n = 47) were divided into three groups according to significant one-, two-, or three-vessel disease (n = 18, n = 14, and n = 15, respectively). Regional longitudinal peak systolic (s), early (e), and late diastolic (a) myocardial velocities were measured at six mitral annular sites and averaged to provide global estimates. Each patient with significant coronary disease was matched with a control of the same age, sex, body mass index, and status regarding diabetes and hypertension. Global systolic and diastolic performance by TDI (in terms of global s and E/e) were negatively correlated to the number of vessels with significant stenoses (both P < 0.05). Regional analyses revealed that in one- and two-vessel disease, e decreased significantly in the segments supplied by a stenotic artery. In patients with one-vessel disease, a increased compensatorily with a significant reduction of e/a-ratio (0.86 +/- 0.24 vs. 1.00 +/- 0.28, P < 0.05). Both regional and global s was significantly reduced in patients with three-vessels disease.nnnCONCLUSIONnColour TDI performed at rest in patients with stable angina and preserved ejection fraction reveals both diastolic and systolic dysfunction and the nature of the dysfunction depends on the extent of the CAD.

Tissue Doppler echocardiography improves the diagnosis of coronary artery stenosis in stable angina pectoris

UNLABELLEDnAim To determine if colour tissue Doppler imaging (TDI) performed at rest in patients with suspected stable angina pectoris (SAP) is able to predict the presence of significant coronary artery disease (CAD).nnnMETHODS AND RESULTSnThis study comprises 296 consecutive patients with clinically suspected SAP, no previous cardiac history, and a normal ejection fraction. All patients were examined by colour TDI, exercise electrocardiogram (ECG), and coronary angiography (CAG). Regional longitudinal systolic (s), early diastolic (e), and late diastolic (a) myocardial velocities were measured by colour TDI at six mitral annular sites and averaged to provide global estimates. Duke score (DS), including ST depression, chest pain, and exercise capacity, was used as the outcome of the exercise ECG. Patients with an area stenosis of ≥70% in at least one epicardial coronary artery were categorized as having a significant CAD (n= 108) and were compared with patients without significant CAD (n= 188). Both e [odds ratio (OR): 1.5 (1.1-1.9, P < 0.01) per cm/s decrease] and s [OR: 1.7 (1.1-2.5, P < 0.05) per cm/s decrease] remained independent predictors of CAD after multivariable adjustment for baseline, exercise ECG, and conventional echocardiographic parameters. Area under the receiver operating characteristic curve (AUC) for exercise ECG and TDI in combination was significantly higher than AUC for exercise ECG alone (0.84 vs. 0.79, P < 0.01).nnnCONCLUSIONnIn patients with suspected SAP colour TDI performed at rest is an independent predictor of significant CAD, and colour TDI improves the diagnostic performance of exercise ECG.

Yield of 5,536 diagnostic coronary arteriographies: Results from a data registry

The number of coronary arteriographies (CAG) has increased tremendously all over the industrialised world over the past years. Even though the potential benefit is high in patients with angina pectoris, for example, with expected life prolongation in case of three-vessel disease or left main stenosis with subsequent coronary artery bypass grafting (CABG), the indication for treatment is not as dramatic in all patients and at the same time CAG is a procedure with at least, some risk, and costs are not negligible. It is therefore pertinent, and hence also the purpose of the present analysis, to make observations on indications, clinical and angiographic findings and their combinations which could be helpful in clinical practice/decision-making. Furthermore, the purpose was to analyse the consequences of CAG with respect to revascularisations such as percutaneous transluminal coronary angioplasty (PTCA) or CABG.

Metformin is associated with improved left ventricular diastolic function measured by tissue Doppler imaging in patients with diabetes

OBJECTIVEnTo examine the association between selected glucose-lowering medications and left ventricular (LV) diastolic function in patients with diabetes.nnnDESIGNnRetrospective cohort study (years 2005-2008).nnnMETHODSnEchocardiograms of 242 patients with diabetes undergoing coronary angiography were analyzed. All patients had an LV ejection fraction (LVEF) ≥20% and were without atrial fibrillation, bundle branch block, valvular disease, or cardiac pacemaker. Patients were grouped according to the use of metformin (n=56), sulfonylureas (n=43), insulin (n=61), and combination treatment (n=82).nnnRESULTSnMean age (66±10 years) and mean LVEF (45±11%) were similar across the groups. Mean isovolumic relaxation time (IVRT) was 66±31, 79±42, 69±23, and 66±29 ms in metformin, sulfonylureas, insulin, and combination treatment groups respectively (P=0.4). Mean early diastolic longitudinal tissue velocity (e) was 5.3±1.6, 4.6±1.6, 5.3±1.8, and 5.4±1.7 cm/s in metformin, sulfonylureas, insulin, and combination treatment groups (P=0.04). In adjusted linear regression models, the use of metformin was associated with a shorter IVRT (parameter estimate -9.9 ms, P=0.049) and higher e (parameter estimate +0.52 cm/s, P=0.03), compared with no use of metformin. The effects of metformin were not altered by concomitant use of sulfonylureas or insulin (P for interactions >0.4).nnnCONCLUSIONSnThe use of metformin is associated with improved LV relaxation, as compared with no use of metformin.

Long-Term Prognosis in an ST-Segment Elevation Myocardial Infarction Population Treated With Routine Primary Percutaneous Coronary Intervention From Clinical Trial to Real-Life Experience

Background—We sought to describe the long-term prognosis after routine primary percutaneous coronary intervention (pPCI) in a contemporary consecutive population of patients with presumed ST-segment elevation myocardial infarction, compare it with similar results from the landmark DANAMI-2 trial, and to identify a possible impact of time of presentation and referral pattern. Methods and Results—Long-term prognosis in 1019 presumed ST-segment elevation myocardial infarction patients, treated according to modern routine pPCI during the year 2004, was analyzed and compared with similar data from the DANAMI-2 trial. Furthermore, we analyzed the impact of patient presentation to the angioplasty center during “off hours” (4 pm to 8 am plus weekends and holidays) and the impact of being referred from noninvasive hospitals. At 3 years, 20.4% in the routinely treated population versus 19.6% in the DANAMI-2 trial reached the combined end point of death, reinfarction, or stroke (P=0.68), whereas the all-cause mortality was 13.0% and 13.7%, respectively (P=0.65). Patients admitted during off hours had the same risk of reaching the combined end point of death, reinfarction, or stroke compared with patients admitted during office hours (hazards ratio, 1.04; 95% CI, 0.8 to 1.5; P=0.81). Door-to-balloon times of less than 90 minutes were achieved in 60% among patients admitted directly to an invasive center but only in 40% among transferred patients (P<0.001). Despite this difference, no difference in unadjusted or adjusted long-term prognosis was found between the 2 groups. Conclusions—This study shows that ST-segment elevation myocardial infarction patients treated with contemporary routine pPCI achieve a similar long-term prognosis as patients in the landmark randomized pPCI trial (DANAMI-2). Furthermore, the long-term prognosis was the same regardless of whether the pPCI was performed during off hours or office hours. Thus, pPCI including transportation of patients from noninvasive centers can be applied successfully in a real-life population.

NT-ProBNP Independently Predicts Long-Term Mortality in Patients Admitted for Coronary Angiography

Recently, research interests are focussed on biomarkers to predict the outcome in patients with coronary artery disease (CAD). We examined whether the levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) could predict outcome in patients who underwent elective or acute coronary angiography (CAG). A total of 337 patients with suspected CAD who underwent elective or acute CAG were followed up for a mean period of 6.7 years. Primary end points were all-cause mortality (ACM) and the combined end point of ACM, nonfatal myocardial infarction, and revascularization. In all, 53 (16%) patients died and 88 (26%) patients reached the combined end point. Preprocedural NT-proBNP above 32 pmol/L independently predicted ACM (hazard ratio [HR] 3.11; confidence interval [CI]: 1.60-6.07; P = .001) and the combined end point (HR 2.44 [CI: 1.50-3.97]; P < .001). This study indicates that high NT-proBNP is an independent predictor of ACM on long-term follow-up. N-terminal-proBNP is a reliable predictive marker of mortality in the setting of stable or unstable angina.