Tor Melberg

Coronary blood flow and perfusion pressure during coronary angiography in patients with ongoing mechanical chest compression: A report on 6 cases

Patients with pulseless electrical activity or refractory ventricular fibrillation have a very bad prognosis. Coronary angiography and angioplasty may be required to restore an effective circulation, but this must be performed whilst chest compressions are continued. The LUCAS chest compression device is suitable for this purpose. So far there are no reports on the effect of this device on coronary circulation in humans. We monitored the coronary perfusion pressure assessed invasively as the difference between the diastolic pressures at the coronary ostium and right atrium, and compared these pressures with coronary flow graded using the TIMI scale in 6 patients. In 4 out of 6 we found a satisfactory coronary artery perfusion pressure and TIMI grade 3 flow (normal) on coronary angiography. Two of these patients survived the first 24h. Two patients did not have a satisfactory perfusion pressure and adequate flow rate was not seen.

Safety and health status following early discharge in patients with acute myocardial infarction treated with primary PCI: a randomized trial

Background Early discharge after uncomplicated primary percutaneous coronary intervention (PPCI) is common but the evidence supporting this practice is lacking. We therefore performed a randomized, prospective trial comparing outcomes in low risk PPCI randomized to early discharge or usual care. Design and methods Over a two years period, all surviving PPCI patients at a single teaching hospital were considered eligible if the Zwolle risk score ≤3. They were randomized to either discharge ≤3 days or usual care. All included patients had routine medical treatment, counselling and follow-up. Health status and all readmissions up to 30 days follow-up were tracked. Results Of 425 consecutive PPCI patients, 215 (50.6%) were randomized to either early discharge (n = 108) or usual routine discharge (n = 107). The mean index length of stay (LOS) plus the 30 days readmissions length of stay in the early discharge group was lower than in the usual discharge group: 2.7 ± 0.5 days vs 3.0 ± 0.7 days (p = 0.001). During follow-up there were no deaths, and similar readmission rate (4 (3.7%) vs 3 (2.8%), p = 0.69 in the early vs usual discharge group respectively). There was no difference in the 30 days health status measurements. The excluded high-risk group (n = 210) had longer index LOS (total sum 1314 vs 501 days, p = 0.001), and a trend towards more readmissions (10 (4.8%) vs 7 (3.3%) (p = 0.19)). Conclusion It is feasible and safe to discharge low-risk PPCI patients within three days.

Long-term prognostic value of cardiac troponin I and T versus creatine kinase-MB mass after cardiac surgery in low-risk patients with stable symptoms.

The long-term prognostic value of elevated cardiac biomarkers after elective cardiac surgery is not clear. The recent guidelines for diagnosing perioperative infarcts have advocated the use of similar thresholds for creatine kinase-MB (CK-MB) mass and the cardiac troponins. However, few previous data are available comparing these biomarkers after cardiac surgery, and it is not clear whether postoperative elevations of the troponins can be treated the same as elevations of CK-MB. We sought to compare the prognostic value of the cardiac troponins versus the CK-MB mass after elective cardiac surgery in low-risk patients with stable symptoms. A total of 204 consecutive patients undergoing cardiac surgery were included in the final analysis. Blood samples were drawn just before and 1 to 3 and 4 to 8 hours after the procedure, and every morning for 3 days thereafter. Patients with elevated baseline values were excluded. Using a cutoff value of 5 times the reference, patients with high and low values (controls) of CK-MB mass, cardiac troponin T (cTnT) and cardiac troponin I (cTnI) were compared. The median follow-up time was 92 months. None developed new Q-waves on the electrocardiogram. The incidence of the composite end point of all-cause mortality, readmission for acute coronary syndrome, and target vessel revascularization in the high CK-MB group was 41.2% compared to 21.8% in the controls (p = 0.004). The corresponding values for cTnT were 33.3% and 20.4% (p = 0.075) and for cTnI were 27.0% and 34.6% (p = 0.237). The p value in the isolated coronary artery bypass grafting subgroup (n = 156) was p = 0.043 for CK-MB, p = 0.137 for cTnT, and p = 0.795 for cTnI. High CK-MB (p = 0.001), ejection fraction (p = 0.002), and body mass index (p = 0.010) were the only variables independently related to reduced event-free survival. No such relation was found for high cTnT and cTnI. In conclusion, CK-MB was superior to the cardiac troponins (values > or =5 times the reference) in predicting long-term event-free survival after elective cardiac surgery in low-risk patients with stable symptoms undergoing coronary artery bypass grafting and/or valve surgery.

The activity of pregnancy-associated plasma protein A (PAPP-A) as expressed by immunohistochemistry in atherothrombotic plaques obtained by aspiration thrombectomy in patients presenting with a ST-elevation myocardial infarction: a brief communication

BackgroundThe expression of pregnancy-associated plasma protein A (PAPP-A) was identified by immunohistochemistry (IHC) in culprit atherothrombotic plaque specimens harvested from patients admitted with ST-segment elevation myocardial infarction (STEMI).MethodsThe atherothrombotic samples were collected from a consecutive cohort consisting of 20 individuals admitted with STEMI to Stavanger University Hospital, Norway, from 2005-2006, presenting angiographically with an acute thrombotic occlusion of a coronary artery characterized by TIMI flow 0. The atherothrombotic plaques were obtained by aspiration thrombectomy during percutaneous coronary intervention within 12 hours from the onset of symptoms and prepared for IHC analysis.ResultsIn the IHC analysis staining for PAPP-A occurred in the extracellular matrix of the plaques and no evidence of staining for PAPP-A was found in the thrombi.ConclusionOur results indicate that in vivo PAPP-A is strongly expressed in atherothrombotic plaques harvested from patients admitted with STEMI, as documented by IHC.Trial registrationbiobankregisteret@fhi.no1846

Competing risk analysis of events 10 years after revascularization

Abstract Objectives. To evaluate the influence of competing risk (CR) non-cardiac death during long-term follow-up of revascularized patients on the interpretation of the cardiac outcomes. Methods. Retrospectively, we compared outcomes estimated with the Kaplan-Meier and the cumulative incidence function (CIF) methods after a median 10.8 years follow-up in 1 234 consecutive patients (594 CABG, 640 PCI) undergoing first time non-emergent revascularization in a community cohort. Results. Overall 301 (24.4%) patients died (27.3% in the CABG vs. 21.7% in the PCI group, p=0.02). The causes of death were cardiac (10.3%) and non-cardiac (14.1%). CR analysis showed a similar probability of cardiac death (CIF 0.10 (95% CI 0.092, 0.18) vs. 0.093 (0.07, 0.12)) in the CABG and PCI treated patients, respectively. The probability for acute myocardial infarction (CIF 0.12 vs. 0.16 p<0.001), congestive heart failure (CIF 0.15 vs. 0.09 p=0.007) in the CABG and PCI group respectively, differed. The differences were also statistically significant after multivariate adjustment for the competing risks of death. For all outcomes the Kaplan-Meier method overestimated risk estimates. Conclusions. The competing risk adjusted probability for cardiac death, but not other cardiac endpoints are comparable in patients treated with either CABG or PCI after very long-term follow-up. The risk for all-cause death was mainly predicted by the occurrence of non-cardiac diseases.

A comparison of the health status after percutaneous coronary intervention at a hospital with and without on-site cardiac surgical backup: a randomized trial in nonemergent patients:

Background Prospective randomized trials comparing the coronary artery disease-related health status outcomes (changes in symptom grade, physical functional capacity and health-related quality of life) after percutaneous coronary intervention at hospitals with and without on-site cardiac surgical backup have not been reported earlier. Methods We randomly assigned 609 consecutive patients fulfilling pre-specified procedural low-risk criteria to undergo percutaneous coronary intervention at either a community hospital without or a regional hospital with on-site surgical backup. Five hundred and seventy-six patients completed the health status evaluation at baseline and at 6 months follow-up. Results At baseline, 91.4% had symptoms, and the mean (standard deviation) Canadian Cardiovascular Societys classification was 2.5 (0.9). The procedural success rates and the changes in health status measures were similar at the two hospitals. Overall there was a substantial relief of symptoms with a reduction in Canadian Cardiovascular Societys classification of 1.9 (1.2), increase in exercise time [1.4 (1.9) min] and reduction in use of antianginal drugs [0.6 (0.9) less drugs] at follow-up compared with baseline (all P >0.001). Health-related quality of life was evaluated with the Short-Form 36 health survey. There were significant and similar improvements in nearly all multi-item and summary scores from baseline to follow-up at the two hospitals. The largest improvements were seen in items related to physical functioning [overall change in Physical Component Score from baseline to follow-up 6.9 (9.1) points, P >0.001] and lowest in the mental health domains [change in Mental Component Score 3.3 (10.7) points, P >0.001]. Interpretation This study shows that a substantial and comparable gain in coronary artery disease-related health status can be achieved at hospitals both with and without surgical backup.

Long-Term Prognostic Value of Creatine Kinase-Myocardial Band Mass after Cardiac Surgery in Low-Risk Patients with Stable Angina

Objectives: The long-term prognostic value (>5 years) of elevated cardiac biomarkers after elective cardiac surgery is not clear. Most previous studies have included high-risk, unstable patients. The aim of this study was to determine the prognostic value of creatine kinase-myocardial band (CK-MB) mass after elective cardiac surgery in low-risk patients with stable angina. Methods: A total of 230 consecutive patients undergoing cardiac surgery were included in the final analysis. Blood samples were drawn just before and 1–3 and 4–8 h after the procedure, and every morning thereafter for 3 days. Using a cutoff value of 5 times the reference, 100 patients (43.6%) had peak CK-MB mass values ≥25 μg/l, and 130 patients had values <25 μg/l (defined as controls). No patient developed new Q waves on ECG. The median follow-up time was 95 months. Results: All-cause mortality and readmission for acute coronary syndromes were more frequent in the high-CK-MB group (30.0 vs. 17.9%, p = 0.022), as was target vessel revascularization (20.6 vs. 5.4%). Comparing the quartiles of peak CK-MB values in a Kaplan-Meier survival plot, event-free survival for the upper quartile (n = 60) was 68.3%, and for the lower quartile (n = 55), it was 83.6% (p = 0.046). In a multivariate logistic regression analysis, high CK-MB and ejection fraction were the only variables independently related to reduced event-free survival. Conclusions: CK-MB values ≥5 times the reference after elective cardiac surgery are associated with reduced long-term event-free survival.

High physical fitness is associated with reduction in basal- and exercise-induced inflammation

C‐reactive protein (CRP) increases after strenuous exercise. It has been a concern that prolonged strenuous exercise may be harmful and induce a deleterious inflammatory response. The purpose of this study was to (a) assess and quantify the magnitude of CRP response following an endurance cycling competition in healthy middle‐aged recreational cyclists. (b) Identify important determinants of this response. (c) Identify the relationship between CRP, myocardial damage (cardiac Troponin I (cTnI)), and myocardial strain (B‐type natriuretic peptide [BNP]). (d) Identify the relationship between CRP and clinical events, defined as utilization of healthcare services or self‐reported unusual discomfort. Race time was used as a measure of physical fitness. A total of 97 individuals (43±10 years of age, 74 [76%] males) were assessed prior to and 0, 3, and 24 hours following the 91‐km mountain bike race “Nordsjørittet” (Sandnes, Norway, June 2013). There was a highly significant increase in CRP from baseline to 24 hours (0.9 (0.5‐1.8) mg/L vs. 11.6 (6.0‐17.5) mg/L (median[IQR]), P<.001), with no correlation of CRP to cTnI and BNP at any time‐point. CRP was strongly correlated to race time at baseline (r=.38, P<.001) and at 24 hours following the race (r=.43, P<.001), In multivariate models, race time was an independent predictor of CRP both at baseline and at 24 hours (P<.01). There was no relationship between CRP levels and clinical events. In conclusion, high physical fitness was associated with reduction in both basal‐ and exercise‐induced CRP. No adverse relationship was found between high intensity physical exercise, CRP levels, and outcomes.

Highly increased Troponin I levels following high-intensity endurance cycling may detect subclinical coronary artery disease in presumably healthy leisure sport cyclists: The North Sea Race Endurance Exercise Study (NEEDED) 2013

Background Circulating cardiac troponin levels increase following prolonged intense physical exercise. The aim of this study was to identify participants with highly elevated cardiac troponins after prolonged, high intensity exercise, and to evaluate these for subclinical coronary artery disease. Methods and results Ninety-seven recreational cyclists without known cardiovascular disease or diabetes, participating in a 91 km mountain bike race were included, 74 (76%) were males, age: 43 ± 10 years, race duration: 4.2 (3.6–4.7) h. Blood samples, rest electrocardiogram and physical examination were obtained 24 h prior to, and at 0, 3 and 24 h following the race. Median cardiac troponin I level at baseline: 3.4 (2.1–4.9) ng/l (upper limit of normal: 30.0 ng/l). There was a highly significant (p < 0.0001) increase in circulating cardiac troponin I in all participants: immediately following the race; 50.5 (28.5–71.9) ng/l, peaking at 3 h 69.3 (42.3–97.7) ng/l and declining at 24 h: 14.2 (8.5–27.9) ng/l. No cyclist had symptoms or rest electrocardiogram changes compatible with coronary artery disease during or following the race. Coronary artery disease was detected by coronary angiography in the three cyclists with the three of the four highest cardiac troponin values (>370 ng/l) at 3 and 24 h following the race. Computed tomographic coronary angiography was performed in an additional 10 riders with the subsequently highest cardiac troponin I values, without identifying underlying coronary artery disease. Conclusions This study suggests that there is a pathologic cardiac troponin I response following exercise in individuals with subclinical coronary artery disease. This response may be associated with an excessive cardiac troponin I increase at 3 and 24 h following prolonged high-intensity exercise.

Variations in population-based levels of C-reactive protein, cardiovascular morbidity and all-cause mortality: An analysis of the relationship between C-reactive protein, Troponin-T, cardiovascular morbidity and death rates in an unselected population in Southwest Norway

BACKGROUND Large population-based studies link inflammation to the prospective development of cardiovascular events. We investigated the time-dependent associations between variations in infectious disease as reflected by alterations of C-reactive protein (CRP)-levels in the general population and the number of cardiovascular events and death rates. METHODS Retrospectively, we studied CRP- and Troponin T (TNT) values drawn for any clinical reason, the number of cardiovascular events and the death rates in the population of Southern Rogaland, Norway over a 2 year period. RESULTS The mean and the sum of CRP values per week were significantly correlated with the number of patients with a TNT> or =0.03 microg/l in the same week (R=0.42, R=0.43, respectively, p<0.001 for both analysis). Further, we found a significant correlation between the mean and the sum of CRP values per week and the number of patients admitted with a cardiovascular event 2 weeks later (R=0.20, R=0.26; p=0.047, p=0.009, respectively). The sum of CRP values per week was significantly correlated to the death rates in the following week (R=0.30, p=0.002). CONCLUSIONS These findings further support the hypothesis that inflammation assessed by CRP levels is linked to the prospective development of cardiovascular events and all cause mortality.