Thomas Stefenelli

“overestimation” of catheter gradients by doppler ultrasound in patients with aortic stenosis: a predictable manifestation of pressure recovery

OBJECTIVESnThis study sought to evaluate whether pressure recovery can cause significant differences between Doppler and catheter gradients in patients with aortic stenosis, and whether these differences can be predicted by Doppler echocardiography.nnnBACKGROUNDnPressure recovery has been shown to be a source of discrepancy between Doppler and catheter gradients across aortic stenoses in vitro. However, the clinical relevance of this phenomenon for the Doppler assessment of aortic stenosis has not been evaluated in patients.nnnMETHODSnTwenty-three patients with various degrees of aortic stenosis were studied with Doppler echocardiography and catheter technique within 24 h. Using an equation previously validated in vitro, pressure recovery was estimated from peak transvalvular velocity, aortic valve area and cross-sectional area of the ascending aorta and compared with the observed differences between Doppler and catheter gradients. Doppler gradients were also corrected by subtracting the predicted pressure recovery and then were compared with the observed catheter gradients.nnnRESULTSnPredicted differences between Doppler and catheter gradients due to pressure recovery ranged from 5 to 82 mm Hg (mean +/- SD, 19 +/- 16 mm Hg) and 3 to 54 mm Hg (12 +/- 11 mm Hg) for peak and mean gradients, respectively. They compared well with the observed Doppler-catheter gradient differences, ranging from -5 to 75 mm Hg (18 +/- 18 mm Hg) and -7 to 48 mm Hg (11 +/- 13 mm Hg). Good correlation between predicted pressure recovery and observed gradient differences was found (r = 0.90 and 0.85, respectively). Both the noncorrected and the corrected Doppler gradients correlated well with the catheter gradients (r = 0.93-0.97). However, noncorrected Doppler gradients significantly overestimated the catheter gradients (slopes, 1.36 and 1.25 for peak and mean gradients, respectively), while Doppler gradients corrected for pressure recovery showed good agreement with catheter gradients (slopes, 1.03 and 0.96; standard error of estimate [SEE] 8.1 and 6.9 mm Hg; mean difference +/- SD 0.4 +/- 8.0 mm Hg and 1.1 +/- 6.8 mm Hg for peak and mean gradients, respectively).nnnCONCLUSIONSnSignificant pressure recovery can occur in patients with aortic stenosis and can cause discrepancies between Doppler and catheter gradients. However, pressure recovery and the resulting differences between Doppler and catheter measurements may be predicted from Doppler velocity, aortic valve area and size of the ascending aorta.

Urinary Excretion of Apo(a) Fragments: Role in Apo(a) Catabolism

The biosynthesis and assembly of lipoprotein(a) [Lp(a)], a marker for atherosclerotic disease, appears to be well understood. However, information is lacking concerning the mode and site of Lp(a) catabolism. Apo(a) is reported to be excreted into the urine. To study the effect of this pathway on the overall catabolism of Lp(a), urinary apo(a) was characterized by immunoblotting. More than 10 distinct apo(a) bands with molecular masses between 30 and 160 kD were observed. Apo(a) fragments were not complexed to apoB. In more than 30 individuals the size of apo(a) bands was comparable irrespective of their apo(a) phenotype, although marked differences in the relative intensities of the bands were observed. Eight batches of 24-hour urine collections collected from one proband at 2-week intervals exhibited a significant correlation between creatinine and apo(a) concentrations as measured by DELFIA (r=.93; P<.01). In 193 healthy volunteers a highly significant correlation was found between urinary apo(a) concen...

Urinary apo(a) discriminates coronary artery disease patients from controls

Increased plasma lipoprotein (a) (Lp(a)) levels are associated with premature cardiovascular diseases and stroke. Since Lp(a) immune reactivity is found in urine we compared urinary apolipoprotein (a) (apo(a)) with plasma Lp(a) levels in 116 patients suffering from angiographically proven coronary artery diseases with that of 109 controls. Urinary apo(a) investigated by immuno blotting, revealed a distinct apo(a) fragmentation pattern with molecular weights between 50 and 160 kDa. Apolipoprotein B however was not secreted into urine. Lp(a) and apo(a) were measured by a fluorescence immuno assay. Within single individuals, urinary apo(a) levels correlated significantly with creatinine (Rho, 0.98; P < 0.0005). Medians and 25/75 percentiles of urinary apo(a) in coronary artery disease (CAD) patients were 5.70, 3.25 and 10.35 microg/dl and in controls 2.64, 1.43 and 3.50 microg/dl respectively. At cut-off levels of 30 mg/dl for plasma Lp(a) and 10 microg/dl of urinary apo(a) respectively, both paramenters showed comparable sensitivities (33.8% vs. 26.7%), yet the specificity (76.1% vs. 91.7%) and the positive predictive value (60.0% vs.76.4%) of urinary apo(a) were much higher. In receiver-operating characteristic plots, urinary apo(a) was much more sensitive at high specificities i.e. greater than 60% as compared to Lp(a). Urinary secretion of apo(a) fragments normalized to creatinine is stable in a given individual and significantly associated with coronary artery disease.

Left Ventricular Echinococcosis With Peripheral Embolization

A 20-year-old man from Rumania was admitted with signs of acute peripheral limb ischemia and reduced vigilance. Ultrasound and angiography showed complete occlusion of the right femoropopliteal artery. Thrombectomy revealed specimens of amorphous lamellar shell-like structures among thrombotic material (Figure, A). Cranial CT scan suggested unilateral thalamic bleeding (Figure, B). Echocardiography showed a large cystic tumor (45×20 mm) adherent to the posterolateral wall of the left ventricle and to the posterior leaflet …

Clinical predictors of patient related delay in the VIENNA ST-elevation myocardial infarction network and impact on long-term mortality

Background: While contributors to system delay in ST-elevation myocardial infarction (STEMI) are well described, predictors of patient-related delays are less clear. The aim of this study was to identify predictors that cause delayed diagnosis of STEMI in a metropolitan system of care (VIENNA STEMI network) and to investigate a possible association with long-term mortality. Methods: The study population investigated consisted of 2366 patients treated for acute STEMI in the Vienna STEMI registry from 2003–2009. Multivariable regression modelling was performed for (a) onset of pain to first medical contact (FMC) as a categorical variable (pain-to-FMC⩽60 min versus >60 min: ‘early presenters’ versus ‘late presenters’); and for (b) onset of pain-to-FMC (min) as a continuous variable. Results: After multivariable adjustment, female sex (odds ratio (OR) 1.348; 95% confidence interval (CI) 1.013–1.792; p=0.04) and diabetes mellitus (OR 1.355; 95% CI 1.001–1.835; p=0.05) were independently associated with late presentation in STEMI patients, whereas cardiogenic shock (OR 0.582; 95% CI 0.368–0.921; p=0.021) was a predictor of early diagnosis. When onset of pain-to-FMC was treated as a continuous variable, female sex (p=0.003), anterior infarction (p=0.004) and diabetes mellitus (p=0.035) were independently associated with longer delay, while hyperlipidaemia (p=0.002) and cardiogenic shock (p=0.017) were strong predictors of short pain-to-FMC times. Three-year-all cause mortality was 9.6% and 11.3% (p=0.289) for early and late presenters, respectively. After adjustment for clinical factors (sex, age, diabetes, current smoking, hypertension, hyperlipidaemia, cardiogenic shock and location of myocardial infarction) only a trend for increased risk of all-cause death was observed for longer pain-to-FMC times in a cox regression model (hazard ratio (HR) 1.012; 95% CI 0.999–1.025 for every 10 min of delay; p=0.061). Interestingly, early presentation within one hour of symptom onset was not associated with three-year mortality survival (HR 1.031; 95% CI 0.676–1.573; p=0.886). Conclusion: In this all-comers study of STEMI patients in the VIENNA STEMI network, cardiogenic shock was the strongest predictor of short patient-related delays, whereas a history of diabetes and female sex were independent associated with late diagnosis in STEMI. After adjustment for clinical confounders, patient related delay did not significantly impact on long-term all-cause mortality.

One-year mortality in patients with acute ST-elevation myocardial infarction in the Vienna STEMI registry

SummaryBackground and aimSystems of care to treat acute ST-elevation myocardial infarction (STEMI) have been developed world wide in the past decade. Their effectiveness can only be proven by including and analyzing outcome data of consecutive patients in registries, which is not the case in the majority of STEMI networks. This study investigates 1-year mortality in STEMI patients in Vienna included over a 14 months time interval. The Vienna STEMI network is organized by a specific rotational system and offers both, primary percutaneous intervention (PPCI) and thrombolytic therapy (TT) as reperfusion strategies according to the recent guidelines.MethodsAt the time of investigation, the Vienna STEMI network consisted of the Viennese Ambulance Systems and five high-volume interventional cardiology departments. This network has been organized in order to increase the number of STEMI patients admitted for PPCI and to offer the fastest available reperfusion strategy, in the majority PPCI but in selected patients also TT (STEMI of short duration, mainly anterior wall MI and mainly patients younger than 75 years), followed by rescue PCI in non-responders and elective angiography with/without PCI in responders to TT during the index hospital stay.ResultsOne-year all-cause mortality rates in the Vienna STEMI network by use of the fastest available reperfusion strategy were 13.4u2009% in patients who received reperfusion therapy after 2xa0h of symptom onset and 7.4u2009% in patients treated within 2xa0h; (pu2009=u20090.017). Whereas PPCI and TT demonstrated a nonsignificant difference in 1-year mortality rates when initiated within 2xa0h of symptom onset (10.0u2009% vs 5.7u2009%; pu2009=u20090.59), PPCI was more effective in acute STEMI of >u20092xa0h duration as compared to TT but this difference did not reach statistical significance (12.1u2009% vs 18.2u2009%; pu2009=u20090.07).ConclusionsThe reassuring long-term results of the Viennese STEMI network are another example of a specific regional system of care to offer timely diagnosis, transfer and reperfusion in patients with STEMI. In contrast to other metropolitan areas where TT has almost completely abandoned, we still use pharmacological reperfusion as a backup in case of expected and unacceptable time delays for PPCI in order to reduce myocardial damage especially in patients with larger infarctions of short duration with a low risk of bleeding complications.

Impact of time of admission on short- and long-term mortality in the Vienna STEMI registry

BACKGROUNDnSeveral studies have shown contradictive findings regarding mortality and hospital admission time in patients presenting with ST-elevation myocardial infarction (STEMI). The aim of this study was to assess the impact of on- or off-hour admission on short- and long-term all-cause mortality of patients in the advanced Vienna STEMI network between 2003 and 2009.nnnMETHODS AND RESULTSnIn total, 2829 patients were included into this analysis. Patients were stratified according to admission time into on-hour admission (07:30 until 15:00h on weekdays) and off-hour admission (15:00-7:30h on weekdays and 24h on weekends). As endpoint of interest, all-cause mortality was investigated after 30days and 3years of follow-up, the latter for all patients and as Landmark analysis for survivors of the index event. Mean age was 60.5±13.3years, 2048 (72.4%) patients were male and 1260 (44.5%) patients presented with anterior wall infarction. 683 (24.1%) patients were admitted on-hours, 2146 (75.9%) patients were admitted off-hours. All-cause death occurred in 176 (6.2%) patients after a follow-up of 30days and in 337 (11.9%) patients after 3years. For short- and long-term all-cause mortality no significant differences could be detected between on- and off-hour admission in univariate and multivariate Cox proportional hazard analyses as well as for propensity score adjusted outcome analysis.nnnCONCLUSIONnIn the Vienna STEMI network, on- or off-hour admission had no impact on short- and long-term mortality for all-comers presenting with acute STEMI. Our findings confirm the imperative need for well-structured STEMI networks of care, as previous data repeatedly demonstrated increased adverse cardiovascular outcome for off-hour admission.

Impact of age on short- and long-term mortality of patients with ST-elevation myocardial infarction in the VIENNA STEMI network

SummaryBackground and aimOur senescent society includes axa0growing number of elderly people suffering from ST-elevation myocardial infarction (STEMI); however, exactly this population is often underrepresented in randomized trials. Hence, our aim was to investigate the influence of age on patient characteristics, as well as short- and long-term outcome in the Vienna STEMI registry.MethodsWe included all patients of the Vienna STEMI registry (2003–2009). Patients were stratified into age cohorts (≤45, 46–59, 60–79 and ≥80 years, respectively). Differences between cohorts were investigated by descriptive statistics and regression models. Crude and adjusted mortality rates were investigated using log rank test and Cox regression models, respectively. The influence of treatment on mortality was further investigated using propensity score matching.ResultsA total of 4579 patients fulfilled the criteria for further investigation. With rising age of cohorts, the number of females, diabetes mellitus (DM), hypertension (HTN), previous myocardial infarction (MI), shock, no reperfusion therapy and anterior wall infarction significantly increased. In contrast, the number of patients with axa0positive family history, smoking and hyperlipidemia (HLP) significantly declined. Log rank analysis showed significant differences between age cohorts for short- and long-term mortality. Cox regression analysis for short-term mortality revealed an independent association for age at the event, HTN and shock, while age, smoking, DM, HTN, HLP, previous MI and shock independently influenced long-term mortality after correction for confounders. Also, we found axa0significant association of age and total ischemic time (TIT), which however had no influence on long-term mortality (interaction term pxa0= 0.236). Propensity score matching revealed reduced mortality rates for patients who received reperfusion therapy compared to conservative management, irrespective of age.ConclusionsIncreasing age independently influenced short- and long-term mortality in patients with STEMI in the Vienna STEMI network. The TIT significantly increased with baseline age, but had no impact on mortality. Furthermore, reperfusion therapy exerted beneficial effects irrespective of the patients’ age.

Gender differences in short- and long-term mortality in the Vienna STEMI registry

BACKGROUNDnData obtained from registries have shown that women diagnosed with STEMI are older, have more co-morbidities and a worse clinical outcome than men. Aim of this study was to investigate potential gender differences in in-hospital and long-term mortality in patients from Vienna STEMI registry (2003-2009).nnnPATIENTS AND METHODSnData from 4593 patients who were enrolled from January 2003 until December 2009 into the Vienna STEMI registry were analyzed. Gender-related differences in patient characteristics, time delays, reperfusion therapy, as well as short- and long-term all-cause mortality were investigated. A landmark analysis was performed to assess long-term all-cause mortality in patients after discharge. Multivariate regression analysis was performed in order to correct for confounders.nnnRESULTSnMean age, history of hypertension, diabetes mellitus and shock at presentation were significantly higher in women compared to men, whereas men were more frequently smokers, had more frequently a positive family history, a history of previous myocardial infarction and received more often GbIIb/IIIa inhibitors and reperfusion therapy. Overall the only significant difference in time delays was found in the onset of pain-to first medical contact time, which was significantly prolonged in women. Unadjusted in-hospital mortality, long-term mortality and long-term mortality for in-hospital survivors were statistically higher for women. After adjustment for confounders, multivariate analysis revealed no differences in mortalities between males and females.nnnCONCLUSIONnThe higher risk profile and the prolonged delay between onset of pain-to-first medical contact are responsible for the higher unadjusted mortality rates in women. Difference in short and long-term mortalities is no more existent after statistical correction for confounders such as age, co-morbidities and significantly different time delay.