Stefano Lucreziotti

Prevention of Contrast‐induced Nephropathy: A Single Center Randomized Study

Contrast‐induced nephropathy (CIN) is the third cause of acute deterioration of renal function in hospitalized patients.

A comparison between two different definitions of contrast-induced acute kidney injury in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

BACKGROUND Contrast-induced acute kidney injury (CI-AKI) is associated with significantly increased mortality after primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI). The prognostic value of CI-AKI depends on the definitions used to define it. We compare the predictive accuracy of long-term mortality of two definitions of CI-AKI on consecutive patients undergoing pPCI for STEMI. METHODS Incidence, risk factors and long-term prognosis of CI-AKI were assessed according to two different definitions: the first as an increase in serum creatinine ≥ 25% or ≥ 0.5 mg/dl from baseline within 72 h after pPCI (contrast-induced nephropathy (CIN) criteria), the second one according to Acute Kidney Injury Network (AKIN) classification system. RESULTS A total of 402 patients were enrolled. The median follow-up period was 12 ± 4 months. Long-term mortality rate was 9.5%. Independent predictors of long-term mortality were: older age, basal renal impairment, left ventricular ejection fraction <40%, in-hospital major bleedings and CI-AKI. A significant correlation was found between mortality and CI-AKI as assessed by both CIN (HR 4.84, 95% CI: 2.56-9.16, p=0.000) and AKIN (HR 9.70, 95% CI: 5.12-18.37, p=0.000) definitions. The area under the receiver operating curve was significantly larger for predicting mortality with AKIN classification than with CIN criteria (0.7984 versus 0.7759; p=0.0331). CONCLUSIONS In patients with STEMI treated by pPCI, CI-AKI is a frequent complication irrespective of the criteria used for its definition. AKIN, however, seems to provide a better accuracy in predicting long-term mortality than CIN criteria.

Myocardial infarction in major noncardiac surgery: Epidemiology, pathophysiology and prevention

The number of subjects undergoing major noncardiac surgery who are at risk for perioperative myocardial infarction (MI) is growing worldwide. It has been estimated that 500,000 to 900,000 patients suffer major perioperative cardiovascular complications every year, with consequent heavy, long-term prognostic implications and costs. It is well known that perioperative MIs don’t share the same pathophysiology as nonsurgical MIs but the relative role of the different, potential triggers has not been completely clarified. Many aspects of the perioperative management, including risk-stratification and prophylactic or postoperative interventions have also not been completely defined. Throughout recent years many resources have been invested to clarify these aspects and experts have developed indices and algorithm-based strategies to better assess the cardiac risk and to guide the perioperative management. The scope of the present review is to discuss the main aspects of perioperative MI in noncardiac surgery, with particular regard to epidemiology, pathophysiology, preoperative risk stratification, prophylaxis and therapy.

Intracoronary Epinephrine for Contrast-Medium-Induced Microvascular Obstruction in a Chronically Hemodialyzed Patient

istered intravenously. The fi rst injection of the non-ionic, iso-osmolar CM iodixanol revealed an apparently normal fl ow in the whole left coronary, but at the following angiogram a distal stagnation of previously injected CM was detected ( fi g. 1 ). Coronary Dear Sir, Due to their burden of coronary artery disease, end-stage renal disease (ESRD) patients often need cardiac catheterization procedures. Coronary angiography performed in ESRD patients is associated with a high incidence of complications, mostly radiographic contrast medium (CM)-induced nephropathy [1] . Nevertheless, no data exist about CM-related coronary vasomotor or thrombogenic effects in this population. Epinephrine improves coronary fl ow in patients with no-refl ow after coronary percutaneous intervention [2] , but, to our knowledge, its use in the treatment of coronary fl ow impairment of other etiologies has never been described. Here, we report the use of intracoronary epinephrine in an ESRD patient who experienced a case of sudden impairment in myocardial perfusion during a coronary angiography. A 68-year-old Caucasian male underwent coronary angiography for dilated cardiomyopathy. He presented with hypertension and ESRD treated by hemodialysis. Home therapy consisted of carvedilol 6.25 mg daily, calcitriol 0.25 g daily, calcium carbonate 0.5 g daily, polystyrene sulfonate 30 g daily and erythropoietin 2,000 U every 2 weeks. Blood analysis showed potassium 5.3 mmol/l, sodium 147 mmol/l, creatinine 6 mg/dl, urea 97 mg/dl and hemoglobin 11.5 mg/dl. Basal electrocardiogram revealed a sinus rhythm and a left bundle branch block. Before cardiac catheterization, 1,000 U of heparin were adminReceived: September 29, 2004 Accepted: October 4, 2004 Published online: April 12, 2005

Acute myocardial infarction as first manifestation of left atrial myxoma in a young woman: role of echocardiography.

We report the case of a young woman with an acute myocardial infarction secondary to coronary embolization from a left atrial myxoma, as unusual presentation of a cardiac tumor.We also describe the role of transthoracic echocardiograpy in the multidisciplinary approach to diagnosis and treatment of this life-threatening condition.

Elevaciones de la troponina I cardiaca tras la cirugía torácica. Incidencia y correlaciones con las características clínicas basales, la proteína C reactiva y los parámetros perioperatorios

Resumen Introduccion y objetivos La incidencia real de las elevaciones de la troponina I cardiaca tras la cirugia toracica y su correlacion con otros parametros clinicos no esta plenamente definida. El objetivo de este estudio fue evaluar la frecuencia de las elevaciones postoperatorias de la troponina I cardiaca despues de cirugia pulmonar o pleural por sospecha de cancer e investigar las correlaciones con los perfiles clinicos basales, con la proteina C reactiva y los parametros perioperatorios. Metodos Se registro a 50 pacientes consecutivos y se midieron los siguientes parametros en cada paciente: variables clinicas basales y concentracion de la proteina C reactiva, concentracion de troponina I cardiaca en los dias 1, 3 y 5 del postoperatorio, electrocardiograma, presion arterial, y frecuencia cardiaca diarias desde el dia de la operacion hasta el dia 5 del postoperatorio. Resultados Se produjeron elevaciones postoperatorias de la troponina I cardiaca en el 20% de los pacientes y estas estaban significativamente asociadas con los antecedentes de coronariopatia o mas de 2 factores de riesgo coronario (el 80 frente al 32,5%; p = 0,011), los antecedentes de tratamiento antiagregante plaquetario cronico (el 50 frente al 17,5%; p = 0,046), la neumonectomia comparada con los procedimientos menos invasivos (el 40 frente al 10%; p = 0,041), la pericardiotomia (el 30 frente al 2,5%; p = 0,022) y las modificaciones transitorias del segmento ST en el electrocardiograma perioperatorio (el 60 frente al 20%; p = 0,02). No se observo correlacion significativa entre las elevaciones de la troponina I cardiaca y la proteina C reactiva basal. Conclusiones Las elevaciones de la troponina I cardiaca despues de la cirugia toracica son frecuentes y estan asociadas con marcadores clinicos de coronariopatia, procedimientos quirurgicos extensos y cambios isquemicos en el electrocardiograma perioperatorio.

Cardiac Troponin-I Elevations After Thoracic Surgery. Incidence and Correlations With Baseline Clinical Characteristics, C-Reactive Protein and Perioperative Parameters

INTRODUCTION AND OBJECTIVES The exact incidence of cardiac troponin-I elevation after thoracic surgery and its correlation with other clinical parameters have not been fully described. The aims of this study were to determine the frequency of postoperative cardiac troponin-I elevation following lung or pleural surgery for suspected cancer, and to investigate correlations with baseline clinical characteristics, the C-reactive protein level, and perioperative parameters. METHODS Fifty consecutive patients were enrolled in the study. In each patient, the following parameters were measured: clinical characteristics and C-reactive protein level at baseline, cardiac troponin-I level on postoperative days 1, 3 and 5, and blood pressure, heart rate and ECG parameters every day from the day of the operation until postoperative day 5. RESULTS The cardiac troponin-I level was elevated postoperatively in 20% of patients. There were significant associations with either a history of coronary artery disease or the presence of more than two coronary risk factors (80% vs. 32.5%; P=.011), a history of chronic antiplatelet therapy (50% vs. 17.5%; P=.046), pneumonectomy compared with less invasive procedures (40% vs. 10%; P=.041), pericardiotomy (30% vs. 2.5%; P=.022), and transient ST-segment alterations on perioperative ECGs (60% vs. 20%; P=.02). No significant correlation was found between cardiac troponin-I elevation and the baseline C-reactive protein level. CONCLUSIONS Cardiac troponin-I elevation occurs frequently after thoracic surgery and it is associated with clinical markers of coronary artery disease, extensive surgical procedures, and ischemic changes observed on perioperative ECGs.

COMPARISON OF CRUSADE AND ACUITY-HORIZONS BLEEDING RISK SCORES IN PATIENTS WITH ACUTE CORONARY SYNDROMES

BACKGROUND Compare the discriminative performance of two validated bleeding risk models for in-hospital bleeding events in a non-selected cohort of acute coronary syndrome (ACS) patients. METHODS CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines) and ACUITY-HORIZONS (Acute Catheterization and Urgent Intervention Triage strategY-Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) scores were calculated in 501 consecutive patients (median age 68 years (IQR 57-77), 31% female) admitted for ACS to the coronary care unit (CCU) of San Paolo Hospital in Milan (Italy). In-hospital haemorrhagic events and mortality were recorded and calibration and discrimination of the two risk models were evaluated using the Hosmer-Lemeshow test and the C-statistic, respectively. RESULTS Overall bleeding events were observed in 32 patients and major bleedings in 11 (with an incidence of 6.4% and 2.2%, respectively). In-hospital mortality was 2.6%. Regarding major bleedings both risk scores demonstrated an adequate calibration (H-L test p>0.20) and a moderate discrimination with no significant difference in predictive accuracy between the two models (C-statistic 0.69 for CRUSADE and 0.73 for ACUITY-HORIZONS). We also tested the performance of the two risk models in predicting in-hospital mortality, showing an adequate calibration and a very good discrimination (C-statistic 0.88 and 0.89 for the CRUSADE and ACUITY-HORIZONS scores, respectively), with no significant difference in predictive accuracy. CONCLUSIONS In our ACS population the CRUSADE and the ACUITY-HORIZONS risk scores showed a fairly good and comparable predictive accuracy regarding in-hospital bleeding events and they appeared to be very good predictors of in-hospital mortality.

A rare case of large intracoronary thrombosis in advanced breast cancer patient treated with epirubicin and cisplatin.

&NA; Cancer is associated with a prothrombotic or hypercoagulable state. Intracoronary thrombosis is a rare and potentially life-threatening complication in cancer patients. We describe a rare case of large nonocclusive intracoronary thrombosis successfully treated by means of medical therapy.

Coronary angiography and computed tomography angiography in the diagnosis of extrinsic compression of left internal mammary artery

Department ofDiagnostic and Interventional Radiology, San Paolo Hospital, Milan, ItalyCorrespondence to Dr Stefano Lucreziotti, Cardiologia, A.O. S. Paolo, Via diRudini` 8, 20142 Milan, ItalyTel: +39 02 81844261; fax: +39 02 81844261; e-mail: lucre.sp@libero.itReceived 26 May 2009 Revised 25 June 2009Accepted 2 September 2009