Volkhard Kurowski

Independent Prognostic Value of Cardiac Troponin T in Patients With Confirmed Pulmonary Embolism

BACKGROUND Cardiac troponin T (cTnT) is a sensitive and specific marker, allowing the detection of even minor myocardial cell injury. In patients with severe pulmonary embolism (PE), myocardial ischemia may lead to progressive right ventricular dysfunction. It was therefore the purpose of this study to test the presence of cTnT and its prognostic implications in patients with confirmed PE. METHODS AND RESULTS Fifty-six consecutive patients with confirmed PE were enrolled in this prospective study. PE was confirmed by pulmonary angiography, lung scan, or echocardiography and subsidiary analyses. Severity of PE was assessed by a clinical scoring system, and cTnT was measured within 12 hours after admission. cTnT was elevated (>/=0.1 microg/L) in 18 (32%) patients with massive and moderate PE but not in patients with small PE. In-hospital death (odds ratio 29. 6, 95% CI 3.3 to 265.3), prolonged hypotension and cardiogenic shock (odds ratio 11.4, 95% CI 2.1 to 63.4), and need for resuscitation (odds ratio 18.0, 95% CI 2.6 to 124.3) were more prevalent in patients with elevated cTnT. cTnT-positive patients more often needed inotropic support (odds ratio 37.6, 95% CI 5.8 to 245.6) and mechanical ventilation (odds ratio 78.8, 95% CI 9.5 to 653.2). After adjustment, cTnT remained an independent predictor of 30-day mortality (odds ratio 15.2, 95% CI 1.22 to 190.4). CONCLUSIONS cTnT may improve risk stratification in patients with PE and may aid in the identification of patients in whom a more aggressive therapy may be warranted.

Score-based immunoglobulin G therapy of patients with sepsis : The SBITS study

Objective: Intravenous immunoglobulin as an adjunctive treatment in sepsis was regarded as promising by a Cochrane meta‐analysis of smaller trials. In this phase III multicenter trial, we assessed whether intravenous immunoglobulin G (ivIgG) reduced 28‐day mortality and improved morbidity in patients with score‐defined severe sepsis. Design: Randomized, double‐blind, placebo‐controlled, multicenter trial. Setting: Twenty‐three medical and surgical intensive care units in university centers and large teaching hospitals. Patients: Patients (n = 653) with score‐defined sepsis (sepsis score 12–27) and score‐defined sepsis‐induced severity of disease (Acute Physiology and Chronic Health Evaluation II score 20–35). Interventions: Patients were assigned to receive either placebo or ivIgG (day 0, 0.6 g/kg body weight; day 1, 0.3 g/kg body weight). Measurements and Main Results: The prospectively defined primary end point was death from any cause after 28 days. Prospectively defined secondary end points were 7‐day all‐cause mortality, short‐term change in morbidity, and pulmonary function at day 4. Six hundred fifty‐three patients from 23 active centers formed the intention‐to‐treat group, 624 patients the per‐protocol group (placebo group, n = 303; ivIgG group, n = 321). The 28‐day mortality rate was 37.3% in the placebo group and 39.3% in the ivIgG group and thus not significantly different (p = .6695). Seven‐day mortality was not reduced, and 4‐day pulmonary function was not improved. Drug‐related adverse events were rare in both groups. Exploratory findings revealed a 3‐day shortening of mechanical ventilation in the surviving patients and no effect of ivIgG on plasma levels of interleukin‐6 and tumor necrosis factor receptors I and II. Conclusions: In patients with score‐defined severe sepsis, ivIgG with a total dose of 0.9 g/kg body weight does not reduce mortality.

Risk Stratification in Patients With Inferior Acute Myocardial Infarction Treated by Percutaneous Coronary Interventions The Role of Admission Troponin T

BackgroundCardiac troponin T (cTnT) elevations on admission indicate a high-risk subgroup of patients with ST-segment elevation acute myocardial infarction (AMI). This finding has been attributed to less effective reperfusion after thrombolytic therapy. The aim of this study was to determine the role of admission cTnT on the efficacy of percutaneous coronary interventions (PCIs) in inferior AMI. Methods and ResultsOne hundred fifty-nine consecutive patients with inferior ST-segment AMI were enrolled and followed up for a mean of 448 days. Patients were stratified by cTnT on admission. A cTnT ≥0.1 &mgr;g/L was found in 58% of patients. These patients had longer time intervals from onset of symptoms to therapy (P <0.001) and higher 30-day (10.8% versus 1.5%, P =0.027) and long-term (17.2% versus 4.5%, P =0.023) cardiac mortalities. Rates of the combined end point of death, nonfatal reinfarction, and need for repeated target vessel revascularization procedures were not different in cTnT groups (log rank, 0.69;P =0.41). PCI was attempted in 93.3% of cTnT-positive and 98.5% cTnT-negative patients (P =0.24) but was less frequently successful in patients with cTnT ≥0.1 &mgr;g/L (77.9% versus 96.9%, P <0.001). Coronary stenting reduced 30-day and long-term cardiac mortality, particularly among cTnT-positive patients. In a multivariate analysis, cTnT indicated an ≈5-fold-higher risk (adjusted OR, 4.6; 95% CI, 0.79 to 27.11;P =0.089) and was a strong albeit not independent risk predictor. ConclusionsIn inferior AMI, a positive admission cTnT is associated with lower success rates of direct PCI and higher rates of cardiac events over the short and long term. These patients benefit from coronary stenting.

Impact of Infarct-Related Artery Flow on QT Dynamicity in Patients Undergoing Direct Percutaneous Coronary Intervention for Acute Myocardial Infarction

Background—Complete coronary artery reperfusion in acute myocardial infarction (AMI) has been shown to significantly improve survival. Electrical stability may be the decisive mechanism for this beneficial effect. Because electrical stability is largely dependent on ventricular repolarization, we sought to determine the impact of a modern reperfusion strategy (ie, direct percutaneous coronary intervention [PCI]) on QT dynamicity in AMI and examined its association with infarct-related artery flow. Methods and Results—We prospectively investigated QT dynamicity in 128 patients undergoing direct PCI for a first AMI. Slopes and correlation coefficients of the linear QT/RR regression were determined in the time interval before reperfusion, within the initial hour after reperfusion, and within the remaining recording period from Holter ECG recordings, which were initiated on admission. Subgroup analysis based on TIMI 3 (n=100) and TIMI 2 (n=28) flow after PCI revealed no significant differences in QT/RR slope before PCI (0.145±0.12 versus 0.160±0.19, P =NS). After PCI, QT/RR slopes increased only in the TIMI 2 subgroup (P <0.05). In TIMI 2 patients, QT/RR slopes were significantly steeper in the hour after PCI and in the remaining recording period, respectively (0.155±0.12 versus 0.192±0.15, P <0.05, and 0.159±0.10 versus 0.210±0.17, P <0.01). Conclusions—Alterations of QT dynamicity in patients with incomplete reperfusion may suggest an altered electrical restitution, potentially providing a substrate for serious ventricular arrhythmias. Thus, our findings offer new insights into mechanisms by which complete reperfusion may affect electrical stability.

Angiographic correlates of a positive troponin T test in patients with unstable angina.

Objective To study the angiographic correlates of cardiac troponin T (cTnT)-positive and -negative patients with unstable angina pectoris. Background A positive cTnT test identifies a high-risk subgroup of unstable angina pectoris patients. Only the high-risk cTnT-positive patients seem to benefit from a more aggressive antithrombotic treatment regimen. The underlying coronary pathology in cTnT-positive and -negative patients that explains the predictive power of cTnT on prognosis and response to antithrombotic therapy is largely unknown. Methods A total of 197 subsequently admitted patients with unstable angina pectoris underwent cTnT testing by a rapid bedside assay and early qualitative and quantitative angiography. Long-term follow-up was 12 months. Results Patients with cTnT-positive tests revealed more critical stenoses of culprit lesions (p = .041), more severe reductions of thrombolysis in myocardial infarction flow grades (p < .037), a higher prevalence of intracoronary thrombus (p = .079), and a poorer left ventricular function (p = .047). The odds ratio of cTnT was 5.8 (p < .0001) for presence of thrombus, reduced thrombolysis in myocardial infarction flow, and/or critical stenosis (>90%), and was 3.1 (p = .005) for presence of three-vessel disease, left main disease, and/or reduced left ventricular ejection fraction. Coronary bypass grafting was more frequently performed in the cTnT-positive group. However, event-free survival was not different in our cohort characterized by a high rate of percutaneous coronary interventions. Conclusions A positive cTnT test in patients with unstable angina pectoris indicates presence of more severe coronary artery disease and poorer left ventricular function. This finding could explain the differences in short- and long-term outcome and treatment responses to antithrombotic regimens.

Effectiveness of end-tidal carbon dioxide tension for monitoring thrombolytic therapy in acute pulmonary embolism.

ObjectiveIn acute massive pulmonary embolism with hemodynamic instability, monitoring of pulmonary artery pressure can be used to assess the efficacy of thrombolytic therapy. As a noninvasive alternative to pulmonary artery catheterization, we investigated the efficacy of continuous monitoring of end-tidal CO2 tension. DesignIn 12 patients with massive pulmonary embolism who required mechanical ventilation, mean pulmonary arterial pressure (MPAP) and end-tidal carbon dioxide tension (ETco2) were registered continuously during thrombolytic therapy. Paco2, cardiac index as estimated by thermodilution catheter and respiratory ratio of arterial oxygen tension and inhaled oxygen concentration (Pao2/Fio2) were determined every 60 mins. Measurements and Main ResultsBefore thrombolysis, MPAP (34.5 ± 9.8 mm Hg) and the difference between Paco2 and ETco2 (10.1 ± 4.7 mm Hg) were markedly increased compared with normal values. Continuously monitored MPAP was related to ETco2 for both all patients (r2 = .42;p < .001) and individually (mean r2 = .92; range, .79-.98;p < .001). In ten survivors, the mean cardiac index and Pao2/Fio2 increased during therapy from 1.7 ± 0.4 to 2.8 ± 0.6 L/min·m2 and 125 ± 27 to 285 ± 50 mm Hg (p < .01, respectively). In these patients, the difference between Paco2 and ETco2 decreased from 9.8 ± 4.5 to 2.8 ± 0.9 mm Hg (p < .001). Recurrent embolism was detected in two patients by sudden reduction of ETco2. ConclusionsAnalysis of ETco2 allows monitoring of the efficacy of thrombolysis and may reflect recurrent embolism. Thus, on the basis of this small study, analysis of ETco2 appears to be useful for noninvasive monitoring in mechanically ventilated patients with massive pulmonary embolism.

Catheter-induced dissection of the left main coronary artery, the nemesis of an invasive cardiologist A case report and review of the literature.

Bei einem älteren Patienten mit hochgradigen Stenosen des Ramus interventricularis anterior (RIVA) und des Ramus circumflexus trat während der Koronarangiographie eine Hauptstammdissektion auf. Die Läsionen sowohl des Hauptstammes als auch des RIVA konnten in der gleichen Sitzung mittels Katheterintervention (Stenting) versorgt werden. Der Patient blieb beschwerdefrei, eine Kontrollangiographie nach 6 Monaten wies ein weiterhin gutes Interventionsergebnis an beiden Gefäßabschnitten auf. Die katheterinduzierte Hauptstammdissektion als seltene aber mit einem sehr hohen Risiko behaftete Komplikation der elektiven Koronarangiographie war hier durch eine konsekutive Katheterintervention beherrschbar. Der vorliegende Fall bietet Gelegenheit zu einer Literaturübersicht über Hauptstammdissektionen als Folge der invasiven Koronardiagnostik und deren Behandlung. An elderly gentleman had a dissection of the left main coronary artery (LMCA) during coronary angiography. There were critical lesions in the left anterior descending (LAD) and left circumflex arteries. Both the LMCA and the LAD lesions were successfully stented in the same sitting. Thereafter the patient remained symptom free and the six-month follow-up angiogram revealed good angioplasty results in both lesions. We report this case for two reasons – first, acute dissection of the LMCA is a rare but devastating complication of selective coronary angiography and the situation becomes graver if the branch vessels have critical stenosis; that this could be managed percutaneously needs to be highlighted, and second, the case offers an opportunity to review literature pertinent to this awesome occurrence in the catheterization laboratory.

Catheter-induced dissection of the left main coronary artery, the nemesis of an invasive cardiologist

Bei einem älteren Patienten mit hochgradigen Stenosen des Ramus interventricularis anterior (RIVA) und des Ramus circumflexus trat während der Koronarangiographie eine Hauptstammdissektion auf. Die Läsionen sowohl des Hauptstammes als auch des RIVA konnten in der gleichen Sitzung mittels Katheterintervention (Stenting) versorgt werden. Der Patient blieb beschwerdefrei, eine Kontrollangiographie nach 6 Monaten wies ein weiterhin gutes Interventionsergebnis an beiden Gefäßabschnitten auf. Die katheterinduzierte Hauptstammdissektion als seltene aber mit einem sehr hohen Risiko behaftete Komplikation der elektiven Koronarangiographie war hier durch eine konsekutive Katheterintervention beherrschbar. Der vorliegende Fall bietet Gelegenheit zu einer Literaturübersicht über Hauptstammdissektionen als Folge der invasiven Koronardiagnostik und deren Behandlung. An elderly gentleman had a dissection of the left main coronary artery (LMCA) during coronary angiography. There were critical lesions in the left anterior descending (LAD) and left circumflex arteries. Both the LMCA and the LAD lesions were successfully stented in the same sitting. Thereafter the patient remained symptom free and the six-month follow-up angiogram revealed good angioplasty results in both lesions. We report this case for two reasons – first, acute dissection of the LMCA is a rare but devastating complication of selective coronary angiography and the situation becomes graver if the branch vessels have critical stenosis; that this could be managed percutaneously needs to be highlighted, and second, the case offers an opportunity to review literature pertinent to this awesome occurrence in the catheterization laboratory.

Plasma catecholamines and N-terminal proBNP in patients with acute myocardial infarction undergoing primary angioplasty

Hintergrund: Bei Patienten mit akutem Myokardinfarkt und direkter PTCA sind bisher die Konzentrationen und der prognostische Wert der neurohormonalen Marker NT-proBNP, Adrenalin und Noradrenalin nicht prospektiv untersucht. Methoden und Ergebnisse: Die Plasmaspiegel von Noradrenalin, Adrenalin und N-terminalem proBNP (NT-proBNP) wurden bei 118 konsekutiven Patienten mit akutem Myokardinfarkt und erfolgreicher Reperfusion (TIMI 2 und 3) durch direkte PTCA vor, sowie 60 Minuten und 10 Tage nach der Angioplastie gemessen. Die Konzentrationen der Katecholamine (Mittelwert±Standardfehler) erreichten ihren Maximalwert 60 Minuten nach der Angioplastie (Noradrenalin: 602±44ng/l, Adrenalin: 213±24ng/l) und kehrten nach 10 Tagen in den Normbereich zurück. Im Gegensatz dazu fand sich bei den NT-proBNP-Konzentrationen ein weiterer Anstieg von 799±44pmol/l vor Angioplastie auf 924±54pmol/l nach 10 Tagen. Lag die 60-Minuten-NT-proBNP Konzentration über dem Median, fand sich während der 18–36 Monate Nachbeobachtung eine signifikant erhöhte Rate schwerwiegender kardialer Ereignisse (n=27) (Odds Ratio 5,9; Konfidenzintervall 1,7–20,3). Dieser Marker war den Katecholaminen, der linksventrikulären Auswurffraktion und anderen etablierten Risikoparametern nach Infarkt hinsichtlich seiner prognostischen Wertigkeit überlegen. Schlussfolgerung: In einem Niedrigrisiko-Kollektiv von Infarktpatienten mit erfolgreicher Reperfusion mittels Angioplastie finden sich für mindestens 10 Tage erhöhte NT-proBNP-Konzentrationen im Serum. Die prognostische Wertigkeit von NT-proBNP in der frühen Postinfarktphase sollte im Hinblick auf seine Eignung zur Risikostratifizierung weiter untersucht werden. Background: Neither profiles nor prognostic values of neurohormonal markers have been prospectively evaluated in patients with acute myocardial infarction (AMI) undergoing primary angioplasty. Methods and results: In 118 consecutive patients with AMI undergoing successful reperfusion (TIMI 2 and 3) by primary angioplasty, plasma concentrations of norepinephrine, epinephrine and N-terminal proBNP (NT-proBNP) were measured before, 60 min and 10 days after angioplasty. Catecholamine concentrations (mean±SEM) rose to a maximum in the first hour after angioplasty (norepinephrine: 602±44ng/L, epinephrine: 213±24ng/L) and returned to normal at day 10. Conversely, NT-proBNP levels maintained a further increase from 799±44pmol/L at baseline to 924±54pmol/L at day 10. A NT-proBNP concentration above median at 60 min post-angioplasty predicted major adverse cardiac events (n=27) during the 18–36 month follow-up with an odds ratio of 5.9 (1.7–20.3) and was superior to catecholamines, to left ventricular ejection fraction and to other established postinfarction risk markers. Conclusions: In a low-risk cohort of patients with AMI undergoing successful reperfusion therapy, plasma NT-proBNP concentrations are elevated for at least ten days. The prognostic value of early plasma NT-proBNP should be further evaluated concerning its ability to facilitate risk stratification of infarct patients.

Risk factors for early reocclusion and luminal renarrowing in patients with acute coronary syndromes treated by direct PTCA with provisional stenting

Die Angioplastie beim akuten Koronarsyndrom wird durch eine hohe Rate früher Gefäß-Reokklusionen und Restenosen kompliziert. Daher wird bei der perkutanen transluminalen Koronarangioplastie (PTCA) im klinischen Alltag oft ein „stent-gleiches“ Ergebnis angestrebt und andernfalls eine intrakoronare Stentimplantation durchgeführt (provisional stenting).¶   Diese Studie sollte angiographische und patientenbezogene Risikofaktoren aufzeigen, die für Frühverschluss oder Lumeneinengung des Zielgefäßes nach Koronarintervention bei akutem Koronarsyndrom (AKS) prädisponieren.¶   In einer prospektiven Verlaufsbeobachtung untersuchten wir 161 Patienten mit AKS (akuter Myokardinfarkt und instabile Angina pectoris), die mittels PTCA behandelt wurden. Bei 140 Patienten konnte eine Verlaufsangiographie nach 10 Tagen durchgeführt werden. Alle Angiogramme wurden quantitativ durch computerunterstützte Auswertung analysiert.¶   Reokklusion und Lumeneinengung des Zielgefäßes traten bei 10 Patienten (7,1%) bzw. 19 Patienten auf (13,6%). Als signifikante Risikofaktoren (p <0,05) für Frühverschluss und Lumeneinengung zeigten sich in der univariaten Analyse Diabetes mellitus (relatives Risiko [RR] 6,1 und 5,0), arterieller Hypertonus (RR 7,7 und 3,3), postinterventionelle Läsionslänge ≥2,5 mm (RR 6,8 und 7,1), postinterventioneller minimaler Lumendiameter ≤2,5 mm (RR 9,0 und 5,8), Reststenose ≥25% (RR 4,8 und 3,5) und das Fehlen eines Stents (RR 4,1 und 3,2). Außerdem konnten in der multivariaten Analyse Hypertonus und postinterventionelle Läsionslänge als unabhängige Risikofaktoren für Reokklusion und Lumeneinengung identifiziert werden. Zusätzlich fand sich Diabetes mellitus als unabhängiger Risikofaktor für eine Lumeneinengung.¶   Schlussfolgerungen: In einer Verlaufsserie von Patienten mit AKS, die mittels PTCA und provisional stenting behandelt wurden, ist die Inzidenz für Frühverschluss und Lumeneinengung des Zielgefäßes niedriger als bisher für dieses Patientenkollektiv bei alleiniger PTCA beschrieben. Die genannten Komplikationen sind verknüpft mit dem Fehlen eines Stents, angiographischen Faktoren (Reststenose, postinterventionelle Läsionslänge und minimaler Lumendiameter) und patientenbezogenen Faktoren wie Diabetes oder Hypertonus. Angioplasty in acute coronary syndromes is complicated by a high rate of early vessel reocclusion and restenosis. Therefore, it is recommended to achieve a „stent-like” result by percutaneous transluminal coronary angioplasty (PTCA) or otherwise use coronary stenting (provisional stenting).¶   This study sought to determine angiographic and patient-related factors that are associated with early target vessel reocclusion or luminal renarrowing after coronary intervention in acute coronary syndromes (ACS).¶   In an observational prospective study we investigated 161 patients with ACS (acute myocardial infarction and unstable angina) submitted to PTCA. In 140 patients a follow-up angiography after 10 days was obtained. All angiograms were quantitatively evaluated by computerized measurements.¶   Target vessel reocclusion and early luminal renarrowing was observed in 10 patients (7.1%) and 19 patients (13.6%), respectively. Using univariate analysis, significant risk factors (P <0.05) for early reocclusion and renarrowing were diabetes mellitus (relative risk [RR] 6.1 and 5.0), arterial hypertension (RR 7.7 and 3.3), postprocedural lesion length ≥2.5mm (RR 6.8 and 7.1), postprocedural minimal lumen diameter ≤2.5 mm (RR9.0 and 5.8), residual stenosis ≥25% (RR 4.8 and 3.5) and absence of stents (RR 4.1 and 3.2). Moreover, in multivariate analysis hypertension and postprocedural lesion length could be identified as independent risk factors for reocclusion and renarrowing. Diabetes mellitus was found to be an independent risk factor for renarrowing.¶   Conclusions: In a consecutive series of patients with ACS undergoing PTCA with provisional stenting the occurrence of early target vessel reocclusion and luminal renarrowing is lower than previously reported for this subset of patients treated by PTCA alone. Adverse outcome is related to absence of stents, angiographic factors (residual stenosis, lesion length, minimal lumen diameter after procedure) and patient-related factors such as diabetes and hypertension.