Non-chest pain symptoms and likelihood of coronary occlusion in emergency department patients with ST segment elevation undergoing emergent coronary angiography.

OBJECTIVES: Patients presenting with suspected ST segment elevation myocardial infarction frequently have symptoms in addition to chest pain, including dyspnea, nausea or vomiting, diaphoresis, and lightheadedness or syncope. These symptoms are often regarded as supporting the diagnosis of infarction. We sought to determine the prevalence of the non-chest pain symptoms among patients who were confirmed as having a critically diseased coronary vessel as opposed to those with no angiographic culprit lesion. METHODS: Data from 1393 consecutive patients with ST segment elevation who underwent emergent coronary angiography were analyzed. Records were reviewed in detail for symptoms, ECG findings, prior history, angiographic findings, and in-hospital outcomes. RESULTS: Dyspnea was present in 50.8% of patients, nausea or vomiting in 36.5%, diaphoresis in 51.2%, and lightheadedness/syncope in 16.8%. On angiography, 1239 (88.9%) patients had a culprit lesion and 154 (11.1%) were found not to have a culprit. Only diaphoresis had a higher prevalence among the patients with, as compared with those without a culprit, with an odds ratio of 2.64 (P < 0.001). The highest occurrence of diaphoresis was among patients with a totally occluded artery, with an intermediate frequency among patients with a subtotal stenosis, and the lowest prevalence among those with no culprit. These findings were consistent regardless of ECG infarct location, affected vessel, patient age, or sex. Among the subset of patients who presented without chest discomfort, none of the symptoms were associated with the presence of a culprit. CONCLUSION: The presence of diaphoresis, but not dyspnea, nausea, or lightheadedness is associated with an increased likelihood that patients presenting with ST elevation will prove to have a culprit lesion. In patients who present with ST elevation but without chest discomfort, these symptoms should not be regarded as 'chest pain equivalents'. Further objective data among patients with angiographic confirmation of culprit lesion status is warranted.

Likelihood of myocardial infarction, revascularization and death following catheterization laboratory activation in patients with vs. without both chest pain and ST elevation.

BACKGROUND: Emergent cardiac catheterization laboratory activation (CCLA) for patients with suspected ST-elevation myocardial infarction (STEMI) is employed to expedite acute revascularization (AR). The incidence of false-positive CCLA, in which AR is not performed, remains high. The combination of chest pain (CP) and electrocardiographic ST elevation (STE) are the hallmarks of STEMI. However, CCLA is sometimes initiated for patients lacking this combination. The study objective was to quantify the difference in likelihood of AR and mortality in patients with vs. without both CP and STE. METHODS: Retrospective analysis of 1621 consecutive patients for whom CCLA was initiated in a six-hospital network. We assessed the likelihood of acute myocardial infarction (AMI), presence of a culprit lesion (CL), performance of AR, and hospital mortality among patients with both CP and STE (+CP/+STE) compared with patients lacking one or both [non(CP/STE)]. RESULTS: 87.0% of patients presented with CP, 82.4% with STE, and 73.7% with both. Among +CP/+STE patients, AMI was confirmed in 90.4%, a CL in 88.9%, and AR performed in 83.1%. The corresponding values among non(CP/STE) patients were 35.8, 31.9, and 28.1%, respectively (P < 0.0001 for each). Nevertheless, mortality among non(CP/STE) patients was three-fold higher than in +CP/+STE patients (13.3% vs. 4.5%; P < 0.0001), with non-coronary deaths 24-fold more likely. CONCLUSION: Patients lacking the combination of CP and STE have a markedly lower likelihood of AMI and AR than +CP/+STE patients, but significantly higher mortality. Protocols aimed at rapid, focused evaluation of non(CP/STE) patients prior to CCLA are needed.

Recent Trends in Management and Inhospital Outcomes of Acute Myocardial Infarction in Renal Transplant Recipients.

Renal transplant recipients (RTR) are at high risk of cardiovascular events including acute myocardial infarction (AMI). We evaluated recent trends in AMI admissions in 9,243 RTR with functioning grafts using data from the 2003 to 2011 Nationwide Inpatient Sample database. Findings were compared with those of patients with end-stage renal disease without transplantation (ESRD-NRT, n = 160,932) and those without advanced kidney disease (non-ESRD/RT, n = 5,640,851) admitted with AMI. RTR comprised 0.2% of AMI admissions with increasing numbers during the study period (adjusted odds ratio [aOR] 1.04; 95% confidence interval [CI] 1.04 to 1.05; ptrend <0.001). Overall, 29.3% of admissions in RTR were for acute ST-segment elevation myocardial infarction (STEMI). Compared with non-ESRD/RT, history of renal transplantation was independently associated with a decreased likelihood of STEMI at presentation (aOR 0.73; 95% CI 0.65 to 0.80; p <0.001). Inhospital mortality among RTR admitted for NSTEMI decreased from 3.8% in 2003 to 2.1% in 2011 (aOR 0.85; 95% CI 0.78 to 0.93; p <0.001), whereas that for STEMI remained unchanged (7.6% in 2003; 9.3% in 2011, aOR 0.97; 95% CI 0.90 to 1.03; p = 0.36). Rates of percutaneous coronary interventions were higher, and inhospital mortality was lower among RTR compared with ESRD-NRT (p <0.001 for both). Treatment strategies appeared largely unchanged during the course of this study with the exception of an increase in primary percutaneous coronary intervention among RTR admitted with STEMI. In conclusion, RTR were frequently admitted with AMI, particularly NSTEMI, and were found to have multiple coronary artery disease risk factors despite their younger age. Compared with other forms of renal replacement therapy, renal transplant was associated with lower inhospital mortality.

The role of implantable cardioverter-defibrillators in patients with continuous flow left ventricular assist devices - A meta-analysis.

BACKGROUND: Left ventricular assist devices (LVADs) and implantable cardioverter defibrillators (ICD) are each known to improve mortality in patients with advanced congestive heart failure (CHF). If ICDs contribute to improved survival specifically in recipients of LVADs is currently unknown. AIM: To evaluate the impact of presence of ICD on mortality in continuous flow LVAD recipients. METHODS: A meta- analysis of available literature was performed. PubMed, Embase and Google Scholar databases were searched for studies that compared mortality in continuous flow LVAD patients with ICDs (new implantation or no de-activation) and without ICDs (including de-activation of existing implant). Pooled analysis using a fixed effects model was used for outcomes of interest. RESULTS: We included 3 observational studies for a total of 292 patients (203 (69.5%) with ICD versus 89 (30.5%) without ICD). The presence of an active ICD was not associated with improved survival [OR 0.63, 95% CI 0.33-1.18; p=0.15]. In bridge to transplantation [BT] patients (224 patients, 149 with ICD versus 75 without ICD), an active ICD was not associated with a higher probability of survivzal [OR 1.47, 95% CI 0.78-2.76; p=0.23]. There was no difference in the occurrence of severe right ventricular dysfunction or failure between two groups [OR 0.78, 95% CI 0.42-1.47; p=0.45]. The risk of LVAD related complications were similar [OR 0.68, 95% CI 0.35-1.31; P=0.25]. CONCLUSION: This meta-analysis demonstrates that there is no survival benefit with ICD in heart failure patients supported with continuous flow LVAD. There is an urgent need of large-scale randomized trials to specifically address this issue.

Myocardial viability in coronary artery chronic total occlusion.

Coronary artery chronic total occlusion (CTO) has rapidly become a popular target of percutaneous coronary intervention (PCI). Technical and technological advances required for approaching these anatomically complex and challenging lesions have progressed at an extraordinary pace and have led to amazing success rates. Patient selection, however, has primarily focused on patient symptoms, lesion characteristics, as well as the state of collateral circulation. Multiple national and international registries have been established to follow the progress of percutaneous CTO recanalization and have provided valuable information. Concern, however, exists that this challenging procedure will become the "standard of care" before its effectiveness and appropriateness is tested in prospective controlled trials. This manuscript reviews the current state of patient selection and the need for careful assessment of the presence and extent of myocardial viability prior to lengthy, resource-intensive, and potentially high-risk procedures.