Causes of elevated troponin I with a normal coronary angiogram.

BACKGROUND: The new definition of myocardial infarction (MI) emphasizes the pre-eminent role of troponin for diagnosis. Troponin rise indicates myocardial injury, but is not synonymous with infarction or ischaemia. AIMS: To review the precipitating event for troponin elevation in patients with angiographically normal coronary arteries, in a district general hospital. METHODS: Consecutive patients with elevated troponin I (TnI) who underwent angiography for suspected coronary disease were included in the present study if they had normal or mild disease (<50% diameter loss without complex features or thrombus). Precipitating event for TnI elevation was assigned on the totality of clinical evidence. RESULTS: Twenty-one patients qualified, with an average age of 50 years (range 33-73). Sixty-two per cent of participants were female. Troponin release was attributed to tachycardia in six patients, only two of whom had haemodynamic compromise. Physical exertion was the precipitating factor in two patients; pericarditis in two patients; and severe congestive heart failure in one patient. Ten of 21 patients had no identifiable cause for a rise in TnI concentration. Five of 21 patients had left-ventricular wall motion abnormalities. There were no deaths or MI at 41 +/- 24 weeks follow up. CONCLUSION: Troponin is a sensitive marker of myocardial injury and may rise following apparently minor insults. A rise in TnI concentration may have a cause other than acute coronary syndrome and may occur without significant angiographic coronary artery disease.

Effects of early captopril administration after thrombolysis on regional wall motion in relation to infarct artery blood flow.

OBJECTIVES: To determine whether early administration of captopril lessens infarct zone regional wall motion abnormalities when infarct artery blood flow is abnormal. BACKGROUND: The interaction between angiotensin-converting enzyme (ACE) inhibitor therapy, ventricular function and infarct artery blood flow has not been well described. METHODS: A total of 493 patients aged < or = 75 years with first infarctions, presenting within 4 h of symptom onset, were randomized to receive 6.25 mg captopril, increasing to 50 mg t.d.s. or a matching placebo 2.1+/-0.4 h after commencing intravenous streptokinase (1.5 x 10(6) U over 30 to 60 min). Trial therapy was stopped 48 h prior to angiography at 3 weeks, to determine regional wall motion and infarct artery flow. RESULTS: There were no differences in ejection fractions or end-systolic volumes between patients randomized to receive captopril and those randomized to receive a placebo. Among patients with anterior infarction (n = 216), randomization to captopril resulted in fewer hypokinetic chords (40+/-13; vs. 44+/-13; p=0.028) and a trend toward fewer chords >2 SD below normal (26+/-17 vs. 30+/-17; p=0.052) in the infarct zone. In patients randomized to receive captopril who had anterior infarction and Thrombolysis in Myocardial Infarction (TIMI) 0-2, flow there were fewer hypokinetic chords (44+/-12 vs. 50+/-9; p=0.043) and a trend toward fewer chords >2 SD below normal (33+/-15 vs. 39+/-13; p=0.057). Patients receiving captopril who had anterior infarction and corrected TIMI frame counts > 27 had fewer hypokinetic chords (42+/-13 vs. 46+/-12; p=0.015) and fewer chords >2 SD below normal (27+/-17 vs. 32+/-17; p= 0.047). Captopril had no effect in patients with inferior infarction. There were 20 late cardiac deaths (median follow-up 4 years) in the captopril group and 35 in the placebo group (p=0.036). CONCLUSIONS: Randomization to receive captopril 2 h after streptokinase improved regional wall motion at 3 weeks. The greatest benefit was seen in patients with anterior infarction particularly when infarct artery blood flow is reduced.

Comparison of aspirin with a thromboxane antagonist for patients with prolonged chest pain and ST segment depression.

AIM: To compare a thromboxane antagonist (GR3219) with aspirin in patients with prolonged chest pain and ST segment depression to see if the frequency of attacks of chest pain was reduced. METHODS: The trial was part of a study comparing GR3219 with aspirin, and streptokinase with placebo and comprised the GR3219/aspirin leg. Thirty one patients were randomly assigned to GR3219 80 mg twice daily and 28 to aspirin 300 mg daily. The patients were under the age of 76 and admitted to a coronary care unit within 6 hours of continuous chest pain. The ECG showed at least 1 mm of flat or down-going ST segment. The patients kept diaries of their pain over the subsequent 31 days. RESULTS: Seventy percent of patients developed further chest pain. There was no difference between the pattern of recurrent chest pain according to which drug was used. CONCLUSIONS: The hypothesis that specific thromboxane A blockade with GR3219 would be more efficacious than aspirin was not supported by these results.

Prospective evaluation of eligibility for thrombolytic therapy in acute myocardial infarction.

OBJECTIVES: To determine the proportion of patients presenting with acute myocardial infarction who are eligible for thrombolytic therapy. DESIGN: Cohort follow up study. SETTING: The four coronary care units in Auckland, New Zealand. SUBJECTS: All 3014 patients presenting to the units with suspected myocardial infarction in 1993. MAIN OUTCOME MEASURES: Eligibility for reperfusion with thrombolytic therapy (presentation within 12 hours of the onset of ischaemic chest pain with ST elevation > or = 2 mm in leads V1-V3, ST elevation > or = 1 mm in any other two contiguous leads, or new left bundle branch block); proportions of (a) patients eligible for reperfusion and (b) patients with contraindications to thrombolysis; death (including causes); definite myocardial infarction. RESULTS: 948 patients had definite myocardial infarction, 124 probable myocardial infarction, and nine ST elevation but no infarction; 1274 patients had unstable angina and 659 chest pain of other causes. Of patients with definite or probable myocardial infarction, 576 (53.3%) were eligible for reperfusion, 39 had definite contraindications to thrombolysis (risk of bleeding). Hence 49.7% of patients (537/1081) were eligible for thrombolysis and 43.5% (470) received this treatment. Hospital mortality among patients eligible for reperfusion was 11.7% (55/470 cases) among those who received thrombolysis and 17.0% (18/106) among those who did not. CONCLUSIONS: On current criteria about half of patients admitted to coronary care units with definite or probable myocardial infarction are eligible for thrombolytic therapy. Few eligible patients have definite contraindications to thrombolytic therapy. Mortality for all community admissions for myocardial infarction remains high.

Effects of streptokinase in patients presenting within 6 hours of prolonged chest pain with ST segment depression.

BACKGROUND: The effects of streptokinase on the occurrence of a combined clinical outcome in patients presenting with recent chest pain and ST depression were investigated in view of the role of thrombus in the pathogenesis of acute ischaemic syndromes. METHODS: 112 patients aged < or = 75 years presenting within 6 h of the last episode of ischaemic chest pain of least 20 min duration with > or = 1 mm ST depression were randomised in a double blind manner to receive either streptokinase 1.5 million units over 30 min (n = 57) or placebo (n = 55). The primary end point was the combination of death, frequency of myocardial infarction (defined as peak creatine kinase > 600 U/ml), need for angiography because of uncontrollable ischaemia, and an exercise test within 35 days showing > or = 1 mm ST depression at < or = 6 min. The secondary end points were safety, frequency of chest pain, readmission with myocardial infarction or unstable angina, or need for revascularisation between 35 days and 1 year. The severity of ST depression on presentation was analysed with respect to clinical outcome. RESULTS: The frequency of the combined hierarchical end point of death, myocardial infarction, early angiography, and a positive exercise test was 82% (47 of 57 patients) with streptokinase and 75% (41 of 55 patients) with placebo. There were four deaths, two in each group. 27 patients (47%) receiving streptokinase and 22 (40%) receiving placebo developed myocardial infarction. 11 patients (eight streptokinase and three placebo) required coronary arteriography and subsequent revascularisation because of angina uncontrolled by medical treatment. 44 patients (22 in each group) had a positive exercise test. There were three further cardiac deaths (one streptokinase, two placebo), and three noncardiac deaths within 1 year. A conservative approach to intervention was adopted and over a period of 1 year 29 patients (26%) (13 streptokinase and 16 placebo) underwent revascularisation procedures. Three patients (two streptokinase and one placebo) required transfusion. ST depression > or = 3 mm had 90% specificity but only 60% positive predictive value for myocardial infarction at presentation (P = 0.008, stepwise logistic regression). ST depression > or = 2 mm was predictive of death, late development of myocardial infarction, or a need for angiography (P = 0.02). CONCLUSION: Patients presenting with ischaemic chest pain and ST depression frequently develop myocardial infarction. Severe ST depression is predictive of an adverse outcome. The 35 day (3.6% cardiac and total) and 1 year mortality (8.9% total, 6.3% cardiac) are low with conservative management and expeditious revascularisation. Streptokinase treatment within 6 h of the last episode of pain does not seem to be beneficial.

Aspirin does not improve early arterial patency after streptokinase treatment for acute myocardial infarction.

OBJECTIVE: To investigate the hypothesis that the magnitude of the life saving effect of aspirin in the second international study of infarct survival (ISIS-2) trial cannot be explained solely by prevention of late reocclusion of the infarct related artery. The aim of this study was to discover whether or not aspirin in combination with streptokinase had an adjuvant thrombolytic effect. DESIGN: Aspirin (150 mg) or placebo was given at the start of streptokinase infusion to 200 patients seen within six hours of the start of prolonged ischaemic cardiac pain and ST segment elevation. All patients received active aspirin at three hours. Patency of the infarct related artery was assessed non-invasively by the normalised rise of creatine kinase activity at three hours after starting streptokinase in these 200 patients and in a further 52 patients who had already taken aspirin within one week of the start of infarction. MAIN OUTCOME MEASURE: Rise in creatine kinase activity from baseline to > or = 20% or < 20% of the peak rise of activity in blood taken at three hours after starting infusion of streptokinase. This correlates with patency or occlusion of the infarct related coronary artery at about 2.5 hours after starting streptokinase. RESULTS: Assessed in this way, patency of the infarct related artery was 60% in patients given aspirin, 63% in those given placebo, and 62% in patients who had already taken aspirin within one week of infarction. CONCLUSION: The magnitude of the life saving effect of aspirin remains unexplained. Further investigation is needed into the mechanism of action of antiplatelet treatment in relation to thrombolytic treatment.

A pair of monozygotic twins who are concordant for myasthenia gravis but became discordant for systemic lupus erythematosus post-thymectomy.

We describe a pair of monozygotic twins who are concordant for myasthenia gravis but discordant for systemic lupus erythematosus (SLE). SLE developed in twin 1 18 years post-thymectomy and has been characterized by recurrent transverse myelitis and optic neuritis. Twin 2 remains well post-thymectomy, except for a skin rash and persistent leukopenia. Both twins have developed autoimmune thyroid disease. We review genetic and environmental factors of importance in the pathogenesis of SLE and discuss the possible role of thymectomy in the etiology of the disease.

Effect of intravenous streptokinase as compared with that of tissue plasminogen activator on left ventricular function after first myocardial infarction.

In a double-blind trial comparing two thrombolytic agents as treatment for acute myocardial infarction, we randomized 270 consecutive patients an average (+/- SD) of 2.5 +/- 0.6 hours after the onset of chest pain from a first myocardial infarction--135 to receive intravenous streptokinase (1.5 million units over 30 minutes) and 135 to receive intravenous recombinant tissue plasminogen activator (rt-PA) (100 mg over three hours). The primary end point was left ventricular function as assessed by cineangiography performed three weeks after infarction. The effects of the two agents on left ventricular function were similar. The ejection fraction was identical (58 +/- 12 percent) in both groups. The end-systolic volume was 61 +/- 29 ml in the streptokinase group and 66 +/- 31 ml in the rt-PA group (P not significant). Patency rates at three weeks for the infarct-related artery were also similar (75 percent in the streptokinase group and 76 percent in the rt-PA group). Reinfarction rates at 30 days were the same (5 percent) in both groups. One patient had a fatal intracerebral hemorrhage 13 hours after receiving rt-PA, and another had a fatal cerebellar hemorrhage 21 hours after receiving rt-PA for reinfarction nine days after treatment with streptokinase. An intention-to-treat analysis revealed that mortality at 30 days was 3.7 percent in the rt-PA group as compared with 7.4 percent in the streptokinase group (P greater than 0.2). Follow-up for a mean of 9.0 months revealed no significant difference in survival; we observed 12 deaths (8.9 percent) in the streptokinase group and 8 deaths (5.9 percent) in the rt-PA group (P = 0.34). We conclude that rt-PA and streptokinase, in the doses given, have similar effects on left ventricular function after a first myocardial infarction. Because of the small number of deaths, it is not possible to determine whether their effects on mortality are similar.

Reiter's syndrome: chronicity of symptoms and employment.

To assess the chronicity of symptoms and long term prospects for employment in patients with Reiter's syndrome, a follow-up study of 111 patients was performed. Ninety-eight patients were available for follow-up; these had a mean disease duration of 7.9 years (range two months to 39 years). At follow-up, 55 patients had symptomatic joints and 26 objective evidence of synovitis, but only seven had chronic joint deformity. Seven patients fulfilled criteria for ankylosing spondylitis. Ninety-three patients were in functional class I or II, 86 patients were working, 26 had changed employment, and 11 were unemployed because of the disease. No prognostic features of value were identified. The tissue antigen HLA B27 was associated significantly with anterior uveitis and radiological sacroiliitis.

HLA-B27 associated cross-reactive marker on the cells of New Zealand patients with ankylosing spondylitis.

We have previously shown that antibodies raised in rabbits to certain enteric bacteria will specifically lyse, in a 51Cr release assay, the peripheral blood lymphocytes (PBL) of 80% of HLA-B27 positive patients with ankylosing spondylitis (B27+ AS+) but not the PBL of HLA-B27 positive normal controls (B27+ AS-). Other laboratories have been unable to reproduce these findings. This study was designed to ascertain whether this lack of reproducibility was due to a peculiarity of our B27+ AS+ patients or to technical difficulties in the complement mediated 51Cr release assay. We have shown in this blind study that the PBL of 16 out of 18 B27+ AS+ patients from a New Zealand population were lysed by our antisera but none of the PBL of 20 B27+ AS- normal controls were lysed. The phenomenon of 'cross reactivity' between certain enteric bacteria and B27+ AS+ PBL is not confined to the Sydney AS population.

Clinical features of meningococcal arthritis: a report of four cases.

Four patients with Neisseria meningitidis infection complicated by arthritis are described. Three patients had an acute polyarthritis which responded quickly to antimicrobial therapy. A fourth patient developed a prolonged arthritis which occurred after the initial infection had been successfully treated. Tenosynovitis occurred as a complication in one case. Attention is drawn to possible confusion with gonococcal infection, and postulated pathological mechanisms are discussed.

The functional significance of sacroiliitis and ankylosing spondylitis in Reiter's syndrome.

The frequent development of sacroiliitis and ankylosing spondylitis (AS) in patients suffering from Reiter's Syndrome (RS) has been stressed by a number of authors. This study was designed to ascertain the frequency of these problems in our RS patients, whether they were related to other clinical features of RS and what was the extent of the resulting disability. Fifty-five patients (50 men and 5 women) with RS with a mean duration of 9.3 years were assessed radiologically to determine the prevalence of sacroiliitis and thoracolumbar syndesmophyte formation. These radiological findings were correlated with HLA-B27, clinical features and functional status. Sacroiliitis was found in 22 patients (40%) but was mild in severity, frequently asymmetrical and very rarely associated with syndesmophyte formation. Sacroiliitis occurred significantly more commonly in patients with iritis and/or a prolonged disease duration (p less than 0.05) but although it was also found more frequently in HLA-B27 positive patients this was not significant (0.1 greater than p greater than 0.05). Some restriction in back movement was observed in 31 patients (56.3%) but only two patients satisfied New York criteria for AS and just one was functionally impaired by his back disease. Although the frequent finding of sacroiliitis in RS may provide an interesting insight into the interrelationship between RS and AS, our study shows that this sacroiliitis is commonly asymptomatic and does not provide a problem in management.

A patient with hemosiderosis and multiple liver abscesses due to Yersinia enterocolitica.

A 72 yr-old man presented with clinical features suggestive of disseminated malignancy, and at autopsy was found to have hemosiderosis and multiple liver abscesses due to Yersinia enterocolitica. The literature is reviewed, with emphasis on the role of abnormal iron metabolism in disseminated infection with this organism.

Use of the HLA B27 test in Auckland.

An assessment was made of the probability of HLA B27 associated disease in 74 patients who had recently been tested. Six patients had definite, 31 possible, and 37 very unlikely HLA B27 associated disease. Thirteen patients were HLA B27 positive. Fourteen tests were ordered by rheumatologists (43% HLA B27 + ve) and 60 by other doctors (12% HLA B27 + ve) p less than 0.01. Non-rheumatologists ordered an excessive number of tests in patients with a low probability of HLA B27 associated disease.

Employment in ankylosing spondylitis.

All patients with ankylosing spondylitis attending our rheumatology clinics were reviewed to assess the effect of their disease on employment. Back movement was measured in three planes, chest expansion determined, and peripheral joint involvement was noted to see whether these correlated with work capability. Sixty patients were reviewed (47 men, 13 women; mean disease duration 24.3 years). Nine were unemployed, but only four of these attributed this condition to ankylosing spondylitis. Although all four had severe neck, back, and hip involvement, this did not differentiate them from other patients who were fully employed. There was no relationship between disease duration and employment. The prospect for continued employment in ankylosing spondylitis is good even when the disease is long standing and severe.

Ethnic difference in the prevalence of systemic lupus erythematosus.

A retrospective study of systemic lupus erythematosus (SLE) was carried out in Auckland, New Zealand, for the years 1975 to 1980 inclusive. One hundred and fifty-one patients were found of which 106 fulfilled the American Rheumatism Association criteria. There were 15 deaths. Age-adjusted prevalence rates per 100 000 were estimated for all cases at the end of 1980 as follows: white 14.6, Polynesian 50.63, and other 19.11. There was a preponderance of females in each ethnic group, average 87% of all cases. Age-adjustment mortality rates per million patient years were: white 2.5 and Polynesians 13.0. Survival curves for both ethnic groups were similar. The prevalence rate in New Zealand Polynesian is significantly higher than in white counterparts which confirms the observation that the disease is commoner in the pigmented races.