Wolfgang von Scheidt

Amiodarone-induced pulmonary toxicity: an under-recognized and severe adverse effect?

Several forms of pulmonary disease occur among patients treated with amiodarone, i.e. chronic interstitial pneumonitis, organizing pneumonia, ARDS, a solitary pulmonary mass of fibrosis. The prevalence is estimated to be about 5%. Two major hypotheses of amiodarone-induced pulmonary injury include direct cytotoxicity and a hypersensitivity reaction. Given the frequency and potential severity of amiodarone-induced pulmonary toxicity, early detection is desirable. Unfortunately, there are no adequate predictors of pulmonary toxicity due to amiodarone. Patients who should benefit from amiodarone should be carefully selected and the lowest effective dosage of amiodarone should be taken. Amiodarone-induced pulmonary toxicity is a diagnosis of exclusion. Pulmonary evaluation with chest X-ray and pulmonary function testing, including diffusion capacity for carbon monoxide is recommended when amiodarone is started. A documented decline in the diffusing capacity of greater than 20% is useful in suggesting the need for closer monitoring or for further diagnostic testing. Although the optimal frequency of follow-up has not been determined, most cases of amiodarone-induced lung injury develop during the first 2xa0years of treatment and disease onset usually is slow. Pulmonary function tests and imaging may be performed every 3–6xa0months, depending on the presumed individual risk. Treatment of amiodarone pulmonary toxicity consists primarily of stopping amiodarone. Corticosteroid therapy can be life-saving for severe cases and for patients with less severe disease in whom withdrawal of amiodarone is not desirable. Due to its accumulation in fatty tissues and long elimination half-life, pulmonary toxicity may initially progress despite drug discontinuation and may recur after steroid withdrawal. The prognosis of amiodarone lung disease is generally favourable.

The patient’s interpretation of myocardial infarction symptoms and its role in the decision process to seek treatment: the MONICA/KORA Myocardial Infarction Registry

BackgroundThe patients’ misinterpretation of symptoms of an evolving acute myocardial infarction (AMI) is a major cause for prolonged pre-hospital delays. The objective of this study was to identify factors associated with an attribution of the symptoms to the heart and to investigate the association between symptom misinterpretation and time until first medical contact (delay time).MethodsThe study population comprised 1,684 men and 559 women, aged 25–74xa0years, hospitalized with a first-time AMI recruited from a population-based AMI Registry.ResultsA total of 50.3xa0% of the patients attributed their experienced symptoms to the heart. Logistic regression modeling revealed that symptoms like chest pain, pain in the left upper extremity, and fear of death facilitated a correct attribution to the heart, whereas symptoms like vomiting or pain in the right upper extremity made a correct labeling difficult. Female sex, low educational status, migration background, and current smoking were associated with a higher risk of misinterpretation of symptoms. A family history of AMI or a history of angina pectoris, hypertension, and hyperlipidemia were shown to facilitate a correct interpretation of symptoms. Variables associated with a misinterpretation of symptoms did not significantly differ between men and women. People with misinterpretation of symptoms had a 1.59-fold risk (95xa0% confidence interval 1.33–1.90) to have a delay time of at least 2xa0h, compared with persons who correctly attributed their symptoms.ConclusionsSymptom misinterpretation is common among patients with AMI, significantly related to symptoms, sociodemographic characteristics and individual risk factors, and associated with a prolonged delay time.

Fluoroscopy-guided aortic root imaging for TAVR: "follow the right cusp" rule.

Transcatheter aortic valve replacement (TAVR) has extended the treatment options for inoperable patients with symptomatic, severe aortic stenosis ([1][1]). The safety and proficiency of this procedure depend upon proper imaging during the selection process and intraoperatively. Recently, the 2012

Long-term survival among older patients with myocardial infarction differs by educational level: results from the MONICA/KORA myocardial infarction registry

BackgroundSocioeconomic disparities in survival after acute myocardial infarction (AMI) have been found in many countries. However, population-based results from Germany are lacking so far. Thus, the objective of this study was to examine the association between educational status and long-term mortality in a population-based sample of people with AMI.MethodsThe sample consisted of 2,575 men and 844 women, aged 28–74xa0years, hospitalized with a first-time AMI between 1 January 2000 and 31 December 2008, recruited from a population-based AMI registry. Patients were followed up until December 2011. Data on education, risk factors and co-morbidities were collected by individual interviews; data on clinical characteristics and AMI treatment by chart review. Cox proportional hazards models were used to assess the relationship between educational status and long-term mortality.ResultsDuring follow-up, 19.1% of the patients with poor education died compared with 13.1% with higher education. After adjustment for covariates, no effect of education on mortality was found for the total sample and for patients aged below 65xa0years. In older people, however, low education level was significantly associated with increased mortality (hazard ratio (HR) 1.44, 95% confidence interval (CI) 1.05–1.98, pu2009=u20090.023). Stratified analyses showed that women older than 64xa0years with poor education were significantly more likely to die than women in the same age group with higher education (HR 1.57, 95% CI 1.02–2.41, pu2009=u20090.039).ConclusionsElderly, poorly educated patients with AMI, and particularly women, have poorer long-term survival than their better educated peers. Further research is required to illuminate the reasons for this finding.

Gender-Specific Short and Long-Term Mortality in Diabetic Versus Nondiabetic Patients With Incident Acute Myocardial Infarction in the Reperfusion Era (the MONICA/KORA Myocardial Infarction Registry)

The aim of this study was to investigate gender-specific short- and long-term mortalities after a first acute myocardial infarction (AMI) in patients with and without diabetes mellitus (DM). The study was based on 505 men and 196 women with DM and 1,327 men and 415 women without DM consecutively hospitalized with a first-ever AMI from January 1998 to December 2003 recruited from a population-based MI registry. Patients were followed until December 31, 2005 (median follow-up time 4.3 years). In men and women, no significantly independent association between DM and short-term mortality was observed. After multivariable adjustment odds ratios (95% confidence intervals [CIs]) for 28-day case fatality were 1.45 (95% CI 0.90 to 2.34) in men with DM compared to men without DM and 1.44 (95% CI 0.66 to 3.15) in women with DM compared to women without DM. Conversely, in 28-day AMI survivors DM was significantly associated with long-term mortality in age-adjusted analyses, in which men with DM had a hazard ratio (HR) of 1.57 (95% CI 1.18 to 2.10) for all-cause mortality compared to non-DM men; the corresponding HR in women with DM was 2.91 (95% CI 1.82 to 4.65). After multivariable adjustment the strong association in women with DM remained significant (HR 2.56, 95% CI 1.53 to 4.27); however, in men with DM it became borderline significant (HR 1.36, 95% CI 1.00 to 1.85). In conclusion, short-term mortality was not significantly increased in men and women with DM after a first-ever AMI, although estimates were relatively high, indicating a possible relation. However, long-term mortality was higher in patients with AMI and DM, particularly in women.

Presenting symptoms of myocardial infarction predict short- and long-term mortality: The MONICA/KORA Myocardial Infarction Registry

BACKGROUNDnIt is unknown whether clinical outcomes differ with specific symptoms of an acute myocardial infarction (AMI). The objective of this study was to investigate the association between 13 self-reported symptoms and 28-day case fatality or long-term all-cause mortality in patients with AMI.nnnMETHODSnThe sample consisted of 1,231 men and 415 women aged 25 to 74 years hospitalized with a first-time AMI recruited from a population-based AMI registry. Multivariable logistic regression modeling was used to assess the relationship between symptom occurrence and 28-day case fatality. Cox proportional hazards models were used to determine the effects on long-term mortality. Analyses were adjusted for sex, age, type of AMI, diabetes, prehospital delay time, and reperfusion therapy.nnnRESULTSnThe median observation time was 4.1 years (interquartile range 15 years). Twenty-eight-day case fatality was 6.1%, and long-term mortality was 10.6%. Patients who experienced fear of death (odds ratio [OR] 0.11, 95% confidence interval [CI] 0.03-0.47), diaphoresis (OR 0.45, 95% CI 0.25-0.82), or nausea (OR 0.45, 95% CI 0.22-0.95) had a significantly decreased risk of dying within 28 days, whereas syncope (OR 5.36, 95% CI 2.65-10.85) was associated with a higher risk. A decreased risk for long-term mortality was found for people with pain in the upper abdomen (hazard ratio 0.43, 95% CI 0.19-0.97), whereas dyspnea was related to an increased risk (hazard ratio 1.50, 95% CI 1.11-2.06). The absence of chest symptoms was associated with a 1.85-fold risk for long-term mortality (95% CI 1.13-3.03).nnnCONCLUSIONSnSpecific symptoms are associated with mortality. Further research is required to illuminate the reasons for this finding.

Three-year clinical outcome of percutaneous treatment of bifurcation lesions in multivessel coronary artery disease with the sirolimus-eluting stent: insights from the Arterial Revascularisation Therapies Study, part II (ARTS II).

AIMSnThe long-term impact of treating bifurcation lesions on the overall outcome of patients with multivessel coronary disease treated percutaneously with drug-eluting stents is unknown. This analysis determined the influence of bifurcation treatment using sirolimus-eluting stents on 3-year clinical outcomes.nnnMETHODS AND RESULTSnOf the 607 patients (2,160 lesions) in the ARTS II study, 324 patients underwent revascularisation procedures involving treatment of at least one bifurcation (465 lesions). Three-year outcomes were compared to those without bifurcations. Despite more diffuse and complex disease in the bifurcation group, survival free of adverse events was equivalent in the two groups. At 3-years, there was no difference in rate of overall MACCE (20.2% vs. 18.5%, p=NS) or any of the component events between the bifurcation and the non-bifurcation group. There was a trend for a higher rate of definite stent thrombosis in the bifurcation group (4.6 vs 2.1%, p=0.1), but in multivariate analysis the CK value post-procedure served as the only independent predictor of definite stent thrombosis (p=0.015), with the presence of a bifurcation lesion of borderline significance (p=0.056).nnnCONCLUSIONSnIn multivessel disease treated by PCI with DES, the presence of bifurcation disease had no adverse influence on 3-year clinical outcomes.

Association of obesity and long-term mortality in patients with acute myocardial infarction with and without diabetes mellitus: results from the MONICA/KORA myocardial infarction registry

BackgroundParadoxically, beneficial effects of overweight and obesity on survival have been found in patients after cardiovascular events such as acute myocardial infarction (AMI). This obesity paradox has not been analyzed in AMI patients with diabetes even though their cardiovascular morbidity and mortality is increased compared to their counterparts without diabetes. Therefore, the objective of this long-term study was to analyze the association between body mass index (BMI) and all-cause mortality in AMI patients with and without diabetes mellitus.MethodsIncluded in the study were 1190 patients with and 2864 patients without diabetes, aged 28-74 years, recruited from a German population-based AMI registry. Patients were consecutively hospitalized between 1 January 2000 and 31 December 2008 with a first ever AMI and followed up until December 2011. Data collection comprised standardized interviews and chart reviews. To assess the association between BMI and long-term mortality from all causes, Cox proportional hazards models were calculated adjusted for risk factors, co-morbidities, clinical characteristics, in-hospital complications as well as medical and drug treatment.ResultsAMI patients of normal weight (BMI 18.5-24.9 kg/m2) had the highest long-term mortality rate both in patients with and without diabetes with 50 deaths per 1000 person years and 26 deaths per 1000 person years, respectively. After adjusting for a selection of covariates, a significant, protective effect of overweight and obesity on all-cause mortality was found in AMI patients without diabetes (overweight: hazard ratio (HR) 0.73, 95% confidence interval (CI) 0.58-0.93; p=0.009; obesity: HR 0.64, 95% CI 0.47-0.87; p=0.004). In contrast, an obesity paradox was not found in AMI patients with diabetes. However, stratified analyses showed survival benefits in overweight AMI patients with diabetes who had been prescribed statins prior to AMI (HR 0.51, 95% CI 0.29-0.89, p=0.018) or four evidence-based medications at hospital-discharge (HR 0.52, 95% CI 0.34-0.80, p=0.003).ConclusionIn contrast to AMI patients without diabetes, AMI patients with diabetes do not experience a survival benefit from an elevated BMI. To investigate the underlying reasons for these findings, further studies stratifying their samples by diabetes status are needed.

Long-term survival in patients with different combinations of evidence-based medications after incident acute myocardial infarction: results from the MONICA/KORA Myocardial Infarction Registry

AbstractBackgroundnUse of the four evidence-based medications [EBMs: antiplatelet agent, beta-blocker, statin and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEI/ARB)] after acute myocardial infarction (AMI) has a clear impact on 1-year survival. Aim of this study was to evaluate the association between different EBM combinations at discharge and long-term survival after AMI.MethodsFrom a German population-based AMI registry, 2,886 men and 958 women were included, aged 28–74xa0years, hospitalized with an incident AMI between 2000 and 2008. All data were collected by standardized interviews and chart review. All-cause mortality was assessed for all registered persons in 2010. Median follow-up time was 6.0xa0years (interquartile range 4.1xa0years). Survival analyses and multivariate Cox regression analysis were conducted.ResultsOf the 3,844 patients, 70.3xa0% were prescribed all four EBMs; 23.8xa0% received three, 4.6xa0% two, and 1.3xa0% were discharged with one or no EBM. Long-term survival was 71.7xa0% [95xa0% confidence interval (CI) 55.4–82.9xa0%], 64.7xa0% (95xa0% CI 59.2–69.6xa0%) and 60.2xa0% (95xa0% CI 51.9–67.5xa0%) in patients with four, three and <3 EBMs, respectively. Patients prescribed three or less EBMs without ACEI/ARB showed similar long-term survival to those receiving four EBMs. In Cox regression analysis after adjustment for confounding variables, the hazard ratio for long-term mortality in patients with four EBMs versus three or less EBMs was 0.63 (95xa0% CI 0.53–0.74).ConclusionsPrescribing of a combination of all four EBMs appeared to improve clinical outcomes in AMI patients by significantly reducing long-term mortality. Hospital discharge is a critical time for optimal long-term management.

Marital status shows a strong protective effect on long-term mortality among first acute myocardial infarction-survivors with diagnosed hyperlipidemia – findings from the MONICA/KORA myocardial infarction registry

BackgroundReduction of long term mortality by marital status is well established in general populations. However, effects have been shown to change over time and differ considerably by cause of death. This study examined the effects of marital status on long term mortality after the first acute myocardial infarction.MethodsData were retrieved from the population-based MONICA (Monitoring trends and determinants on cardiovascular diseases)/KORA (Cooperative Health Research in the Region of Augsburg)-myocardial infarction registry which assesses cases from the city of Augsburg and 2 adjacent districts located in southern Bavaria, Germany. A total of 3,766 men and women aged 28 to 74xa0years who were alive 28xa0days after their first myocardial infarction were included. Hazard ratios (HR) for the effects of marital status on mortality after one to 10xa0years of follow-up are presented.ResultsThe study population included 2,854 (75.8%) married individuals. During a median follow-up of 5.3xa0years, with an inter-quartile range of 3.3 to 7.6xa0years, 533 (14.15%) deaths occurred. Among married and unmarried individuals 388 (13.6%) and 145 (15.9%) deaths occurred, respectively. Overall marital status showed an insignificant protective HR of 0.76 (95% confidence interval (CI) 0.47-1.22). Stratified analyses revealed strong protective effects only among men and women younger than 60 who were diagnosed with hyperlipidemia. HRs ranged from 0.27 (95% CI 0.13-0.59) for a two-year survival to 0.43 (95% CI 0.27-0.68) for a 10-year survival. Substitution of marital status with co-habitation status confirmed the strata-specific effect [HR: 0.52 (95% CI 0.31-0.86)].ConclusionsMarital status has a strong protective effect among first myocardial infarction survivors with diagnosed hyperlipidemia, which diminishes with increasing age. Treatments, recommended lifestyle changes or other attributes specific to hyperlipidema may be underlying factors, mediated by the social support of spouses. Underlying causes should be examined in further studies.