Usefulness of hospital admission risk stratification for predicting nonfatal acute myocardial infarction or death six months later in unstable angina pectoris. RESCATE Study Group. Resources Used in Acute Coronary Syndromes and Delays in Treatment.

The aim of this study was to assess the clinical course of unstable angina and the prognostic value of clinical and electrocardiographic variables measured during admission in a prospective, multicenter cohort study with 6-month follow-up. The population corresponds to 4 general teaching hospitals in Catalonia, Spain. The clinical course was analyzed in 839 consecutive patients aged up to 80 years with primary unstable angina, without myocardial infarction or previous coronary bypass. The main outcome measures were cardiac mortality and nonfatal myocardial infarction. Patients involved in the present analysis belonged to the Resources Used in Acute Coronary Syndromes and Delays in Treatment (RESCATE) study. Six-month overall mortality, cardiac mortality, and nonfatal myocardial infarction rates were 4.6%, 4.1%, and 3.9%, respectively. Six-month cardiac mortality or myocardial infarction rate did not differ among clinical forms of presentation. Peripheral artery disease (RR 3.5, 95% confidence interval [CI] 1.88 to 6.50, p = 0.0001), ST-T-wave electrocardiographic changes on admission (RR 2.22, 95% CI 1.13 to 4.36, p = 0.0203), and age >65 years (RR 1.74, 95% CI 1.04 to 2.91, p = 0.0356) independently predicted 6-month cardiac mortality or nonfatal myocardial infarction. Their positive predictive values were 21%, 10%, and 11%, respectively, whereas their negative predictive value was > or = 93% in all cases. Prevalences were 9%, 70%, and 41%, respectively. In this prospective study, patients with unstable angina without prior myocardial infarction have a relatively low, although not negligible, 6-month severe complication rate. Stratification risk can easily be established with clinical and electrocardiographic characteristics measured during admission. Their absence almost rules out future adverse events, while their presence does not necessarily imply bad prognosis.

Reliability of electromechanical dissociation in the diagnosis of left ventricular free wall rupture in acute myocardial infarction.

The reliability of electromechanical dissociation (EMD) in diagnosing acute left ventricular free wall rupture (LVFWR) was assessed in 479 consecutive patients with acute myocardial infarction (AMI). EMD was the mechanism of death in 193 patients, 140 without heart failure (group A, 74%), and 53 with heart failure (group B, 26%). Autopsies performed on 121 patients with EMD showed LVFWR in 81 (95%) of 85 from group A and in 7 (17%) of 36 from group B. Of the 106 patients without EMD (group C) autopsied, 5 (4.7%) had LVFWR. Excluding the eight patients with associated septal rupture, LVFWR occurred in 79 (95.2%) of 83 patients from group A, 4 (12.1%) of 33 from group B, and 2 (1.9%) of 103 from group C. Predictive accuracy of EMD for LVFWR in group A was 95% but only 17% in group B. Moreover, in 13 consecutive cases with a first AMI without heart failure and EMD, emergency surgery demonstrated LVFWR in all. Thus EMD has a highly predictive accuracy in diagnosing LVFWR in patients with a first AMI without overt heart failure.

Relevance of electrocardiographic findings, heart failure, and infarct site in assessing risk and timing of left ventricular free wall rupture during acute myocardial infarction.

Clinical and electrocardiographic features of 227 patients who died of an acute myocardial infarction (AMI) were compared with those of 150 survivors of a first AMI. Left ventricular (LV) free wall rupture was found in 93 patients aged > 50 years, but not in 134. The incidence of healed infarct (4 [4%] vs 50 [37%], p < 0.001), heart failure (11 [12%] vs 112 [84%], p < 0.001), and bundle branch block (11 [12%] vs 54 [40%], p < 0.001) was lower in patients with than without LV rupture. In patients with anterior AMI and early rupture (1 day), admission ST elevation was higher than in those with late LV rupture (> 1 day, 6.8 +/- 4.0 vs 4.0 +/- 2.7 mm, p < 0.01). However, lateral wall AMI had minimal ST elevation and accounted for 10% of ruptures. On day 2, the decrease in ST segment in patients with late LV rupture was less than in survivors (0.5 +/- 1.6 vs 3.2 +/- 2.9 mm, p < 0.001). Admission systolic blood pressure in patients who had early rupture was higher than in survivors (155 +/- 22 vs 137 +/- 22 mm Hg, p < 0.001) and in those with late rupture (135 +/- 23 mm Hg, p < 0.001). Late rupture was associated with infarct thinning and triggered by a physical strain in 18 of 45 patients (40%); infarct thinning, however, was present only in 4 of 48 patients (8%) with early rupture (p < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Giant cell myocarditis: monocytic immunophenotype of giant cells in a case associated with ulcerative colitis.

Giant cell myocarditis (GCM) is a rare condition whose histologic hallmark, the multinucleate giant cell, is of debated origin (monocytic v myogenic). We report the case of a 46-year-old woman with a previous diagnosis of ulcerative colitis who rapidly deteriorated and died as the result of refractory ventricular tachyarrhythmias. Postmortem examination showed a diffuse infiltration of the myocardium by round cells and multinucleate giant cells. Immunohistochemically, round cells were demonstrated to be T lymphocytes admixed with monocytes. Multinucleate giant cells expressed monocytic markers (MAC 387, lysozyme) and were negative for muscle markers (actin, desmin, myoglobin). This case illustrates the monocytic and macrophagic nature of multinucleate giant cells and lends support to the autoimmune hypothesis of GCM by the concurrence of the latter with ulcerative colitis.

[Intravenous streptokinase in acute myocardial infarction. Reduction of early in-hospital mortality]. / Estreptocinasa intravenosa en el infarto agudo de miocardio. Reducción de la mortalidad precoz intrahospitalaria.

A randomized study of the effects of intravenous streptokinase was performed in 214 patients with an acute myocardial infarction of less than 4 hours of whom 110 were included in the therapeutic group (SK) and 104 in the control group (C). Incidence of angiographic recanalization was higher in SK group (71 vs 28%, p less than 0.001) as that of non-significant residual coronary artery stenosis (less than 70%, 16% vs 3%, p less than 0.005), particularly in young patients (less than 45 years; 42% vs 8%, p less than 0.05). However, SK group presented a higher incidence of severe residual stenosis (90-99%) (SK, 42% vs C, 22%, p less than 0.01). Ejection fraction was higher among recanalized patients in both groups. Peak CPK-MB occurred earlier in SK group (13 vs 19 hours, p less than 0.001) and also among the recanalized patients of each group (SK, 12 vs 16 hours, p less than 0.001; C, 15 vs 21 hours, 0.002). The course of ST segment was similar in the 2 groups. The occurrence of ventricular arrhythmias within the first hour was greater in SK group (40% vs 20%, p less than 0.002), whereas the incidence of pericarditis (14% vs 35%, p less than 0.001) and of early mortality (less than 5 days, 2% vs 10%, p less than 0.02) was lower in SK group. The incidence of cardiac rupture, confirmed at necropsy in each of the 5 cases studied, was also lower in SK group (1 vs 8).(ABSTRACT TRUNCATED AT 250 WORDS)

[Left ventricular aneurysm. Correlations with coronary arteriography (author's transl)]. / Aneurisma ventricular izquierdo. Correlación con la coronariografía.

Ventricular aneurysm is the most severe segmental disorder of ventricular function. A group of 45 patients with ventricular aneurysms have been evaluated, correlating a total of 80 aneurysmatic segments with cineventriculographic findings. Seventy-one percent of the patients had multiple lesions. Except for three patients with normal coronary blood supply and apical aneurysm there was a positive correlation between the remaining aneurysmatic segments and significant lesions in the corresponding arteries. As in the three cases with normal coronary arteries, associated spasm was suspected in other eight cases showing significant vessel stenosis of less than 75 percent of the lumen. Detection of ventricular aneurysm in the cineventriculographic examination is highly suggestive of severe arterial damage.