K.E.J. Airaksinen

PR depression is useful in the differential diagnosis of myopericarditis and ST elevation myocardial infarction.

Background: Deviation of the PR segment is a common but often ignored ECG finding in acute myopericarditis, but seems to be rare in the acute phase of ST elevation myocardial infarction (STEMI). Since rapid bedside differential diagnosis of acute myopericarditis and STEMI is essential, we decided to assess the diagnostic power of PR depressions in patients presenting with ST elevations in the emergency room.

Underuse of anticoagulation in stroke patients with atrial fibrillation – the FibStroke Study

Current guidelines recommend oral anticoagulation (OAC) for patients with atrial fibrillation (AF) and increased risk of thromboembolic events. The reasons for not using OAC in AF patients suffering stroke or transient ischaemic attack (TIA) were assessed.

Comparison of Additional Versus No Additional Heparin During Therapeutic Oral Anticoagulation in Patients Undergoing Percutaneous Coronary Intervention

Uninterrupted oral anticoagulation (OAC) therapy can be the preferred strategy in patients with atrial fibrillation at moderate to high risk of thromboembolism undergoing percutaneous coronary intervention (PCI). To evaluate the need for additional heparins in addition to therapeutic peri-PCI OAC, we assessed bleeding complications and major adverse cardiac and cerebrovascular events in 414 consecutive patients undergoing PCI during therapeutic (international normalized ratio 2 to 3.5) periprocedural OAC. Patients were divided into those with no (n = 196) and with (n = 218) additional use of periprocedural heparins. No differences in major adverse cardiac and cerebrovascular events (4.1% vs 3.2%, p = 0.79) or major bleeding (1.0% vs 3.7%, p = 0.11) were detected, but access site complications (5.1% vs 11.0%, p = 0.032) were less frequent in those without additional heparins. When adjusted for propensity score, patients with additional heparins had a higher risk of access site complications (odds ratio 2.6, 95% confidence interval 1.1 to 6.1, p = 0.022) without any increased risk of any other adverse event. Analysis of 1-to-1 propensity-matched pairs showed a significantly higher risk of access site complication in patients receiving additional AC (13.1% vs 5.7%, p = 0.049). In conclusion, therapeutic warfarin treatment seems to provide sufficient AC for PCI. Additional heparins are not needed and may increase access site complications.

Clinical significance and determinants of the universal definition of perioperative bleeding classification in patients undergoing coronary artery bypass surgery

OBJECTIVES We evaluated the clinical significance and identified the predictors of the universal definition of perioperative bleeding (UDPB) classes in patients undergoing isolated coronary artery bypass grafting (CABG). METHODS Data on antithrombotic medication, perioperative bleeding, blood transfusion, and adverse events were available for 2764 patients who had undergone isolated CABG. RESULTS The Papworth risk score correlated significantly with the UDPB classes (rate of UDPB class 3-4 and Papworth risk score of 0, 12.1%; 1, 23.9%; 2, 37.5%; and 3, 45.0%; P<.0001). Ordinal regression showed that increased age, female sex, low body mass index, low estimated glomerular filtration rate, low hemoglobin, dialysis, urgent or emergency operation, critical status, on-pump surgery, potent antiplatelet drug pause of <5 days, and warfarin pause of <2 days were independent predictors of high UDPB classes. These risk factors also predicted UDPB classes 3-4 in logistic regression analysis. Increasing UDPB classes were associated with an increased risk of in-hospital mortality (P=.002), stroke (P=.023), low cardiac output (P<.0001), prolonged use of inotropes (P<.0001), renal replacement therapy (P<.0001), length of stay in the intensive care unit (P<.0001), and late mortality (P<.0001) as assessed by multilevel propensity score-adjusted analysis. Similar findings were observed in the propensity score-adjusted analysis for the most severe grades of perioperative bleeding (ie, UDPB class 3-4). CONCLUSIONS High UDPB classes were associated with significantly poorer immediate and late outcomes. The UDPB classification seems to be a valuable research tool to estimate the severity of bleeding and its prognostic impact affect after coronary surgery.

Stroke recurrence in patients with atrial fibrillation: concomitant carotid artery stenosis doubles the risk

Atrial fibrillation (AF) and significant carotid artery stenosis (CAS) often coexist in patients with acute stroke but whether CAS affects the stroke recurrence rate in anticoagulated AF patients is largely unknown. The effect of concomitant CAS on both short‐ and long‐term prognosis after stroke in patients with AF was evaluated.

Permanent work disability in patients ≤50 years old after percutaneous coronary intervention and coronary artery bypass grafting (the CRAGS study)

Background The aim of this study was to investigate the incidence of permanent working disability (PWD) in young patients after percutaneous or surgical coronary revascularization. Methods and Results The study included 1035 consecutive patients ≤50 years old who underwent coronary revascularization [910 and 125 patients in percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) groups, respectively] between 2002 and 2012 at 4 Finnish hospitals. The median follow-up time was 41 months. The overall incidence of PWD was higher after CABG compared to PCI (at 5 years, 34.8 vs. 14.7%, P < 0.001). Freedom from PWD in the general population aged 45 was 97.2% at 4 years follow-up. Median time to grant disability pension was 11.6 months after CABG and 24.4 months after PCI (P = 0.018). Reasons for PWD were classified as cardiac (35.3 vs. 36.9%), psychiatric (14.7 vs. 14.6%), and musculoskeletal (14.7 vs. 15.5%) in patients undergoing CABG vs. PCI. Overall freedom from PWD was higher in patients without major adverse cardiac and cerebrovascular event (MACCE) (at 5 years, 85.6 vs. 71.9%, P < 0.001). Nevertheless, rate of PWD was high also in patients without MACCE and patients with preserved ejection fraction during follow-up. Conclusions Although coronary revascularization confers good overall survival in young patients, PWD is common especially after CABG and mostly for cardiac reasons even without occurrence of MACCE. Supportive measures to preserve occupational health are warranted concomitantly with coronary revascularization at all levels of health care.

Pocket Hematoma: A Call for Definition

Pocket hematoma is a common complication of cardiac implantable electronic device procedures and a potential risk factor for device infections, especially in patients on oral anticoagulation or antiplatelet treatment. There is a wide variability in the incidence of pocket hematoma and bleeding complications in the literature and the major cause for this seems to be the variability of the used definitions for hematomas. The lack of generally accepted definition for pocket hematoma renders the comparisons across the studies difficult. In this article, we briefly review the current literature on this issue and propose a uniform definition for pocket hematoma and criteria for grading the severity of hematoma in clinical practice and research.