Multiple coronary micro-aneurysm formation after drug-eluting stent implantation.

Although there are limited data regarding the formation of coronary artery aneurysms (CAAs) after drug-eluting stent (DES) implantation, CAAs appear to be a rare complication of coronary stenting. The exact mechanism of CAA formation is unknown, but several hypotheses have been proposed. As the use of DES increases, the clinical significance of these findings will become clearer. We report on a patient who developed multiple CAAs in 2 different locations after sirolimus-eluting stent implantation.

Attitudes of healthcare professionals involved in cardiology practice towards key points of contemporary guidelines on resuscitation.

Hellenic J Cardiol. 2014; 55: 378-385. At the request of the authors, the name of the second author of this Original Research article has been changed from Athanasios Patialakas to Athanasios Patialiakas.

Attitudes of healthcare professionals involved in cardiology practice towards key points of contemporary guidelines on resuscitation.

INTRODUCTION: Cardiopulmonary resuscitation (CPR) is not always executed in compliance with contemporary guidelines and the quality of CPR may differ among hospitals within the same country or among categories of healthcare providers and medical specialties. The aim of this study was to assess attitudes of cardiology healthcare professionals towards CPR guidelines. METHODS: An anonymous questionnaire was posted online during 2009. Responders were asked about their age, gender, occupation, and training/experience in CPR. Responders' attitudes towards CPR were assessed using 7 questions regarding the accuracy of their opinions about the automated external defibrillator, public defibrillation programs, CPR performance, and therapeutic hypothermia. A score (0 to 7) was formed by assigning grade 1 to answers that accorded with European Resuscitation Council (ERC) guidelines and grade 0 to all other answers. The reliability analysis for this score yielded a Cronbach's alpha of 0.78. RESULTS: There were 544 responders (158 females), median age 34 years (30, 40). Median score was 5 (3, 6). Attending an ERC resuscitation course (beta=0.33, SE beta=0.05, p<0.001), age (beta=-0.15 SE beta=0.05, p=0.002), involvement in >10 CPRs /year (beta=0.19, SE beta=0.05, p<0.001), and being a physician (beta=0.17, SE beta=0.05, p=0.001) were all independent predictors of score. Attendance at an ERC course (OR: 2.7 [1.5 to 4.7]), being a physician (OR: 2 [1.3 to 5]) and involvement in >10 CPRs /year (OR: 1.7 [1.1 to 2.7]) were also independent predictors for attitudes that accorded with contemporary guidelines regarding therapeutic hypothermia. CONCLUSIONS: Attending an ERC resuscitation course, frequent involvement in CPR attempts, younger age, and being a physician were all independent predictors for more positive attitudes towards the guidelines. These factors, with the exception of age, were also associated with positive attitudes towards the implementation of therapeutic hypothermia.

Cardiac aetiology of cardiac arrest: percutaneous coronary interventions during and after cardiopulmonary resuscitation.

Management and prevention of cardiac arrest in the setting of heart disease is a challenge for modern cardiology. After reviewing the aetiology of sudden cardiac death and discussing the way to identify candidates at risk, we emphasise the role of percutaneous coronary interventions during and after cardiopulmonary resuscitation in the treatment of patients with return of spontaneous circulation after cardiac arrest.

Acute myocardial infarction in a patient with coronary artery aneurysm and Crohn's disease.

Crohn's disease is a chronic inflammatory disorder of unknown cause involving the gastrointestinal tract. Complications from the cardiovascular system seem to be uncommon in patients with Crohn's disease. We present a case of a 37-year-old man with a known history of Crohn's disease, who was admitted to our hospital with acute myocardial infarction. An aneurysm of a totally occluded circumflex coronary artery was revealed during the attempt at primary intervention. The artery was successfully opened and the aneurysm was sealed with the use of 2 covered stents.

Marked troponin elevation after implantation of a permanent antibradycardia pacemaker.

INTRODUCTION: Transvenous insertion of endocardial leads for permanent pacing is often accompanied by minor myocardial damage, detected thanks to the high sensitivity of cardiac troponins. It is unknown whether higher troponin levels, commensurate with more severe myocardial damage, can be encountered after implantation procedures. METHODS: Over a 3-year period, 283 patients underwent an implantation of a full antibradycardia pacemaker system (pulse generator plus leads). Patients were required to have normal levels of cardiac troponin I (CTNI) on a venous blood sample taken immediately prior to elective pacemaker insertion. Post implantation CTNI levels were measured in all patients 6 hours after the procedure. Repeated samples were taken if high CTNI levels were found at 6 hours. RESULTS: Elevated CTN-I levels were found in 167 patients (59%, 95% CI: 0.53-0.64), but only 5 of them (1.8%, 95% CI=0.8 to 4.1%) had peak CTN-I levels far exceeding the range of minimal myocardial damage (i.e. CTN-I >1.5 ng/ml). Implantation of the devices was successful in all patients and we did not observe any complications. None had clinical evidence of an acute coronary event before or during the pacemaker implantation procedure and coronary angiography revealed no significant lesions in the coronary arteries. CONCLUSIONS: CTN-I elevations after pacemaker implantation may far exceed levels corresponding to minimal myocardial damage. This should be a matter of concern, especially if an early discharge is planned after pacemaker implantation.

Brain natriuretic peptide: a marker of cardiac dysfunction with ventricular or dual-chamber pacing.

BACKGROUND/OBJECTIVES: The inability of trials to exhibit the superiority in survival of atrioventricular compared to ventricular pacing can be partially explained by the apical stimulation of the right ventricle, which adversely affects both short- and long-term ventricular performance. We evaluated the impact of pacing mode (DDDR vs. VVIR) on the brain natriuretic peptide (BNP) level in patients with sick-sinus syndrome (SSS). METHODS: Sixty-seven patients were treated with DDDR pacemaker implantation due to SSS. They were randomized during the first post-implant day either to DDDR or WIR pacing mode and were reevaluated after 30 days. Group A comprised 35 patients on DDDR pacing mode and group B 32 patients on WIR pacing mode. Peripheral blood samples were drawn for BNP measurement at the time of randomization and one month later. RESULTS: BNP levels increased significantly in both groups at 30 days (group A: 85.6 +/- 29.5 pg/ml to 107.2 +/- 34.6 pg/ml, group B: 82.7 +/- 27.6 pg/ml to 253.1 +/- 60.2 pg/ml). On day 30, BNP levels in group B were significantly higher than in group A (P < 0.0001). CONCLUSIONS: Pacing from the apex of the right ventricle provokes an increase in the BNP levels regardless of the pacing mode. BNP is probably a very early marker predicting the structural and/or functional heart changes after long-term pacing from the apex of the right ventricle.

Rapid desensitisation of patients with aspirin allergy who undergo coronary angioplasty.

INTRODUCTION: Although aspirin is the cornerstone of medication in patients with coronary artery disease, a minority of these patients have aspirin sensitivity. The aim of this study was to evaluate the efficacy and safety of an aspirin desensitisation protocol in patients scheduled for coronary angioplasty and stenting. METHODS: We used a challenge-desensitisation protocol in 11 patients (6 men, mean age 56 ± 9.6 years) who reported allergy to aspirin and were to undergo percutaneous coronary intervention with stent implantation. Eight had a history of cutaneous sensitivity, 1 had rhinitis, 1 reported urticaria and rhinitis, while another patient showed a respiratory response in the form of an asthma attack after taking aspirin in the past. Eight successive doses of aspirin were given (0.1, 0.3, 10, 30, 40, 81, 162, 325 mg) at intervals of 15-25 min over a total period of 2 h 15 min. RESULTS: All patients with aspirin sensitivity completed the desensitisation therapy successfully, without adverse effects, and subsequently underwent angioplasty and stenting. During follow up, the patients continued to take aspirin over 6-19 months without any problems. CONCLUSIONS: Rapid aspirin desensitisation is an effective and safe procedure for patients with aspirin allergy who are to undergo coronary angioplasty and stenting, allowing them to receive the optimum treatment.

B-type natriuretic peptide blood levels identify patients with non-ST elevation acute coronary syndromes at high risk for complications during intravenous beta-blocker infusion.

BACKGROUND: We hypothesized that measurement of B-type natriuretic peptide could identify patients with non-ST elevation acute coronary syndromes at high risk for complications during beta-blocker (esmolol) infusion. METHODS: We reviewed the records of 340 consecutive patients admitted with a non-ST elevation acute coronary syndrome. Seventy three (47 males, aged 62 ± 14 years) received esmolol up to a maximum dose of 300 µg/ kg/min until the symptoms were relieved or an adverse event occurred. RESULTS: The median infusion rate at steady state was 175 µg/kg/min (median infusion time 18 h). Infusion was halted in 14 patients. The frequency of drug discontinuation increased across admission BNP quartiles. BNP > 141 pg/ml at admission had a 95% predictive value for subsequent withdrawal of esmolol. The presence of BNP > 141 pg/ml in combination with systolic blood pressure < 130 mmHg and left ventricular ejection fraction < 50% identified a group of patients at high risk for drug interruption (interruption frequency = 83%, 95% CI: 55-95%). CONCLUSIONS: In conclusion, BNP measurement in combination with systolic blood pressure and 2D echocardiography may identify patients with non-ST elevation acute coronary syndromes at high risk for adverse events during esmolol infusion.

Effect of high doses of magnesium on converting ibutilide to a safe and more effective agent.

Ibutilide is a class III antiarrhythmic agent indicated for cardioversion of atrial fibrillation and atrial flutter to sinus rhythm (SR). The most serious complication of ibutilide is torsades de pointes (TdP). Magnesium has been successfully used for the treatment of TdP, but its use as a prophylactic agent for this arrhythmia has not yet been established. The present study investigated whether high dose of magnesium would increase the safety and efficacy of ibutilide administration. A total of 476 patients with atrial fibrillation or atrial flutter who were candidates for conversion to SR were divided into 2 groups. Group A consisted of 229 patients who received ibutilide to convert atrial fibrillation or atrial flutter to SR. Group B consisted of 247 patients who received an intravenous infusion of 5 g of magnesium sulfate for 1 hour followed by the administration of ibutilide. Then, another 5 g of magnesium were infused for 2 additional hours. Of the patients in groups A and B, 154 (67.3%) and 189 (76.5%), respectively, were converted to SR (p = 0.033). Ventricular arrhythmias (sustained, nonsustained ventricular tachycardia, and TdP) occurred significantly more often in group A than in group B (7.4% vs 1.2%, respectively, p = 0.002). TdP developed in 8 patients (3.5%) in group A and in none (0%) in group B (p = 0.009). The administration of magnesium (despite the high doses used) was well tolerated. In conclusion, the administration of high doses of magnesium probably makes ibutilide a much safer agent, and magnesium increased the conversion efficacy of ibutilide.

Association of VEGF gene polymorphisms with the development of heart failure in patients after myocardial infarction.

OBJECTIVES: Vascular endothelial growth factor (VEGF) is upregulated in vivoin the ischemic human myocardium. Since several polymorphisms have been shown to influence VEGF expression, we evaluated the contribution of such polymorphisms to the clinical outcome of patients after an acute myocardial infarction (AMI). METHODS: PCR and restriction fragment length polymorphism analysis was performed to genotype 10 VEGF polymorphisms in 102 patients who had suffered an AMI and in 98 age- and sex-matched healthy individuals. Distribution of these polymorphisms was assessed by logistic regression analysis. RESULTS: No significant differences were found between patients and normal individuals. However, when patients were subdivided into 2 groups based on the development of heart failure after their AMI judged by heart ultrasound measurements (ejection fraction <40%), the distribution of the -634 polymorphism differed significantly (p = 0.016). Specifically, patients with a CC genotype had 7 times higher risk of developing heart failure. Additionally, the co-inheritance of -634 with other VEGF polymorphisms was found to be significant for the development of heart failure between these 2 groups. CONCLUSIONS: Our data indicate that the -634 polymorphism and its co-inheritance with genotypes of other VEGF polymorphisms might be considered as risk factors playing a role in the clinical outcome of AMI patients.