Prognostic factors in infective endocarditis in general hospitals in the Netherlands.

INTRODUCTION: Despite advances in treatment, infective endocarditis (IE) still ranks amongst the most lethal infectious diseases. We sought to determine prognostic factors in general hospitals in the Netherlands as research in this setting is scarce. RESULTS: Between 2004 and 2011, we identified 216 cases of IE, 30.1 % of which were prosthetic valve IE. This leads to an annual incidence of IE of 5.7 new cases per 100,000 persons per year. Women were less likely to undergo surgical intervention (OR = 1.96, 95 % CI 1.06-3.61, p = 0.031). Also, ageing was an independent prognostic factor for not receiving surgery in a multivariate analysis (annual OR = 1.04, 95 % CI 1.02-1.06, p < 0.001). Female sex was a prognostic factor for mortality (OR = 2.35, 95 % CI 1.29-4.28, p = 0.005). Age was also an independent prognostic factor for mortality (OR = 1.05, 95% CI 1.03-1.08, p < 0.001). Conservative treatment was a prognostic factor for mortality (OR = 3.39, 95 % CI 1.80-6.38, p < 0.001) whereas surgical intervention was an independent prognostic factor for adverse events (OR = 3.03, 95% CI 1.64-5.55, p < 0.001). Staphylococcus aureus was an independent prognostic factor for adverse events (OR = 2.05, 95 % CI 1.10-3.84, p = 0.024) but not for mortality. CONCLUSION: This study shows that endocarditis in general hospitals has a high rate of morbidity and mortality. Even when treated, it ranks as one of the most lethal infectious diseases in the Netherlands, especially in women and the elderly.

Simultaneous transesophageal two-dimensional echocardiography and atrial pacing for detecting coronary artery disease.

This study describes a new technique for assessing wall motion abnormalities, combining transesophageal echocardiography (TEE) and transesophageal atrial pacing in 71 patients. Stable capture was reached in 70 patients (99%). In 3 patients (4%) pacing was discontinued prematurely because of discomfort. TEE during pacing was performed in 52 patients with and in 18 patients without coronary artery disease (CAD). In 43 of 52 patients with CAD, regional wall motion abnormalities occurred (sensitivity 83%). No wall motion abnormalities occurred in 17 of 18 patients without CAD (specificity 94%, positive predictive value 98%). Wall motion abnormalities related to another vascular region were observed in 17 of 22 patients with previous myocardial infarction (sensitivity 77%, specificity 100%, positive predictive value 100%). Simultaneous 12-lead electrocardiography during atrial pacing was performed in 57 patients and yielded positive results in 21 of 40 patients with (sensitivity 52%) and in 3 of 17 patients without (specificity 82%, positive predictive value 88%) CAD. Exercise stress testing was performed in 66 patients. Twenty-four of 48 patients with CAD had a positive exercise electrocardiogram (sensitivity 50%); a false-positive exercise electrocardiogram was observed in 3 of 18 patients (specificity 83%, positive predictive value 89%). It is concluded that TEE during transesophageal atrial pacing is a feasible and promising alternative technique for the assessment of CAD, with a higher sensitivity than simultaneous 12-lead and exercise electrocardiography.

Effects of early intervention with low-dose aspirin (100 mg) on infarct size, reinfarction and mortality in anterior wall acute myocardial infarction.

Recently, it was shown that aspirin given early in acute myocardial infarction (AMI) improves hospital survival, but the mechanisms involved are unclear. In a prospective, randomized placebo-controlled trial, the influence of early intervention with low-dose aspirin (100 mg/day) on infarct size and clinical outcome was studied in 100 consecutive patients with first anterior wall AMI. Infarct size was calculated by cumulative lactate dehydrogenase release in the first 72 hours after admission and was found to be (mean +/- standard deviation) 1,431 +/- 782 U/liter in the aspirin group (n = 50) and 1,592 +/- 1,082 U/liter in the placebo group (n = 50, p = 0.35). The study medication was given for 3 months, during which mortality was 10 (20%) in the aspirin patients and 12 (24%) in the placebo patients (p = 0.65). However, reinfarction occurred in 2 patients (4%) in the aspirin group and in 9 (18%) in the placebo group (p less than 0.03). Early intervention with low-dose aspirin showed, in comparison to placebo, a 10% decrease of infarct size, but this difference was not statistically significant. However, early low-dose aspirin effectively decreased the risk of reinfarction. Therefore, the favor able results of early aspirin on mortality in acute myocardial infarction are probably due more to prevention of reinfarction than to decrease of infarct size.

Usefulness of two-dimensional echocardiography for immediate detection of myocardial ischemia in the emergency room.

Inappropriate discharge from the emergency room of patients with acute chest pain may have serious consequences. Regional asynergy is one of the first signs of myocardial ischemia and can be detected with 2-dimensional echocardiography (2-DE). This study determines the value of 2-DE in the emergency room for immediate detection of myocardial ischemia causing acute chest pain at the time the electrocardiogram was nondiagnostic. Forty-three patients (32 men and 11 women) with a normal or nondiagnostic electrocardiogram during acute chest pain were studied with 2-DE. Only patients without a previous myocardial infarction and without known coronary artery disease (CAD) were studied. The entire left ventricular wall was examined for presence of regional asynergy. Coronary angiography was performed within 3 weeks. Cardiac enzyme levels were measured serially to establish or rule out an acute myocardial infarction. Sensitivity of 2-DE for detection of myocardial ischemia was 88% (22 of 25), specificity 78% (14 of 18), negative predictive accuracy 82% (14 of 17) and positive predictive accuracy 85% (22 of 26). Sensitivity of 2-DE for detection of acute myocardial infarction was 92% (12 of 13), specificity 53% (16 of 30) and negative predictive accuracy 94% (16 of 17). Thus, 2-DE during pain and a nondiagnostic electrocardiogram can readily identify patients with CAD in the emergency room, and it can accurately rule out an acute myocardial infarction.

Left ventricular thrombus incidence and behavior studied by serial two-dimensional echocardiography in acute anterior myocardial infarction: left ventricular wall motion, systemic embolism and oral anticoagulation.

Serial two-dimensional echocardiography was performed to detect left ventricular thrombus in 92 consecutive patients with a confirmed first acute anterior myocardial infarction. Thirty left ventricular thrombi were diagnosed in these 92 patients. The cumulative percent of identified thrombus in each echocardiographic examination in the surviving patients was 27% at less than 24 h; 57% at 48 to 72 h; 75% at 1 week and 96% at 2 weeks. The thrombus shape was defined as mural in 53% and protruding in 47% of patients. Systemic embolism (stroke) was noted during hospitalization in two patients with a protruding thrombus. At 12 weeks of follow-up, patients with thrombus had poorer (and almost unchanged from baseline) global left ventricular function as expressed by wall motion score compared with that of patients without thrombus, who exhibited significant improvement. Global left ventricular wall motion in patients with persisting or resolved thrombus was similar during follow-up. Apical wall motion worsened in 70% of the patients with persisting thrombus and in 25% of the patients with resolved thrombus (p less than 0.1). In the 22 surviving patients with thrombus, resolution or change in thrombus shape or size was noted in 14 of the 15 patients receiving anticoagulant therapy and in 4 of the 7 untreated patients. Six of the 18 patients with an early- (48 to 72 h) and none of the 12 patients with a later-formed thrombus died. Maximal serum enzyme levels, percent with Killip functional class III to IV and left ventricular wall motion score were higher in the patients with an early- than in those with a later-formed thrombus.(ABSTRACT TRUNCATED AT 250 WORDS)

Emergency room infusion of intravenous streptokinase in acute myocardial infarction: feasibility, safety, and hemodynamic consequences.

Between September 1, 1986, and December 31, 1987, sixty-four consecutive patients younger than 70 years, with early (less than 4 hours) symptoms and signs of myocardial infarction, were treated with 1.5 million units streptokinase intravenously in the emergency room (ER group) before admission to the coronary care unit. Data from these patients were compared in retrospect to those of 66 consecutive patients with myocardial infarction who were treated with intravenous streptokinase in the coronary care unit (CCU group) before September 1, 1986. Time between first symptoms and initiation of fibrinolytic therapy was significantly shorter in the ER group: 114 +/- 53 minutes vs 150 +/- 56 minutes in the CCU group (p less than 0.001). The incidence of in-hospital complications was similar in both groups. However, left ventricular stroke work index during the stay in the coronary care unit was 50 +/- 19 gm/m2 in the ER group vs 42 +/- 14 in the CCU group (p = 0.02). Also the echocardiographic left ventricular wall motion score at 48 hours after admission tended to be better in the ER group: 6.7 +/- 4.0 compared to that in the CCU group (7.6 +/- 4.5; p = 0.29). In conclusion, infusion of intravenous streptokinase in the emergency room is feasible and safe and results in a significant time gain leading to a better hemodynamic profile. Within the hospital the emergency room is the ideal place for intravenous fibrinolytic therapy in eligible patients with acute myocardial infarction.

Comparison of two latex agglutination test kits for serum myoglobin in the exclusion of acute myocardial infarction.

The Myolex (Orion) and the RapiTex (Behringwerke) latex agglutination tests for the rapid detection of elevated levels of serum myoglobin were studied prospectively in patients suspected of acute myocardial infarction, who were admitted to hospital within 8 h of pain onset. Using admission blood samples drawn 3.4 +/- 2.0 h (mean +/- SD) after onset of symptoms, the negative predictive values of both tests were too low to use these assays in the early exclusion of myocardial infarction in the emergency department. However, the negative predictive values obtained with the second blood samples, drawn 4 h later, indicated that the myoglobin agglutination test could be of value in the exclusion of myocardial infarction.

Effect of low dose acetylsalicylic acid on the frequency and hematologic activity of left ventricular thrombus in anterior wall acute myocardial infarction.

In this prospective, randomized, placebo-controlled trial the effect of 100 mg acetylsalicylic acid (ASA) once daily on the incidence, hematologic activity and embolic potential of left ventricular (LV) thrombosis was studied in 100 consecutive patients with a first anterior wall acute myocardial infarction (AMI). Patients were randomized to ASA or placebo less than 12 hours after onset of symptoms. Heparin, 5,000 IU subcutaneously twice daily, was given to all patients during immobilization. Echocardiography was performed less than 24 hours, 48 to 72 hours and 1, 2, and 12 weeks after AMI. LV thrombosis was detected by echocardiography in 30 (33%) of the 92 evaluable patients (15 patients given ASA and 15 given placebo). Indium-111 platelet scintigraphy was done in 17 of the 22 patients with an LV thrombus at the second week echocardiogram. Among 7 ASA-treated patients, 4 had positive images; among 10 placebo patients, 5 had positive images. LV thrombus resolution was noted in 3 of 9 patients with a positive scan and in 5 of 8 patients with a negative platelet scan. In 7 of 10 ASA-treated patients and 5 of 12 placebo-treated patients thrombus resolution was observed (difference not significant). Systemic embolism occurred in 2 patients, both given ASA, during the first week after AMI. Thus, low dose ASA has no effect on the incidence, hematologic activity and embolic potential of LV thrombosis in anterior wall AMI.

Predictive value of two-dimensional echocardiographic and hemodynamic measurements on admission with acute myocardial infarction.

To identify high-risk patients with acute myocardial infarction, we compared admission values of two-dimensional echocardiography and hemodynamic monitoring. Left ventricular wall motion score (WMS), left ventricular stroke work index (LVSWI), and pulmonary capillary pressure (PCP) were obtained in 77 patients without clinical signs of heart failure. Progression into Killip grade 3 or 4 was found in 16 of 77 patients (21%) within 32 +/- 6 hours (mean +/- 1 standard deviation) after admission. Mean WMS, LVSWI, and PCP in those patients who developed severe pump failure were significantly different from those who did not: 13.4 +/- 4.9 versus 7.3 +/- 4, 30 +/- 4 versus 46 +/- 11 gm/m2, and 21 +/- 8 versus 12 +/- 6 mm Hg, respectively. Sensitivity of WMS of greater than 7 and LVSWI of less than 35 gm/m2 in predicting Killip grade 3 or 4 was 88% and 94%, specificity was 57% and 87%, positive predictive value was 35% and 65%, and negative predictive value was 95% and 98%. Sensitivity of PCP was low (50%). Early identification of patients developing myocardial rupture or reinfarction was limited by both methods. We conclude that echocardiographic examination on admission in patients with acute myocardial infarction provides an alternative approach for early identification of low-risk patients.

A prospective study on the dose dependency of cardiotoxicity induced by mitomycin C.

Since 1975 mitomycin C (MMC) has been suggested to be cardiotoxic, especially when combined with or given following doxorubicin. Data on dose dependency or incidence concerning this side effect were not known. We have initiated a prospective study to obtain some more data on these subjects. Forty-four MMC-treated patients were studied, 37 of them could be evaluated. All patients were studied by repeated physical examinations, chest X-rays, electro- and echocardiography and radionuclide left ventricular ejection fraction (EF) determinations. The results were evaluated per cumulative dose level. One of the patients developed cardiac failure after 30 mg m-2 MMC and only 150 mg m-2 doxorubicin. The cardiac failure was predicted by a drop in EF determined during a cold pressor test. None of the other patients developed clinical cardiotoxicity, nor did the studied parameters change. The literature on this subject was also reviewed. Based on the combined data from the present study and the literature, we suggest that MMC-related cardiotoxicity is dose dependent, occurring at cumulative dose levels of 30 mg m-2 or more, mainly in patients also (previously or simultaneously) treated with doxorubicin. The incidence is likely to be less than 10% even for this risk group.

Prognostic implications of regional hyperkinesia and remote asynergy of noninfarcted myocardium.

To determine the clinical significance of regional hyperkinesia and remote asynergy of noninfarcted areas in patients with a first acute myocardial infarction (AMI), 2-dimensional echocardiography was performed in 113 consecutive patients within 12 hours after admission to the coronary care unit. In 98 patients (87%) all segments of the left ventricular wall were recorded. Infarct-associated asynergy was anterior in 63 and inferior in 35 patients. Regional hyperkinesia was present in 66 patients (67%)--44 of 63 with anterior (69%) and 22 of 35 with inferior (63%) infarcts--and was more frequently seen in patients with 1- and 2-vessel coronary artery disease (CAD) than in patients with 3-vessel CAD (87 and 72% vs 25%, p less than 0.001). In contrast to enzymatic infarct size, absence of regional hyperkinesia was significantly associated with a higher left ventricular wall motion score (p less than 0.01). Twenty patients died within 30 days after onset of AMI; in 15 (75%) regional hyperkinesia was absent. Absence of regional hyperkinesia, especially in anterior infarcts, was associated with a high mortality rate (13 of 19 patients [68%]). Remote asynergy, i.e., not adjacent to the infarct area and supposed to be related to another vascular region, was present in 17 of 98 patients (17%)--11 of 63 with anterior (17%) and 6 of 35 with inferior (17%) infarcts. Remote asynergy was present only in patients with multivessel CAD and was significantly related to a higher wall motion score (p less than 0.001), but not to enzymatic infarct size.(ABSTRACT TRUNCATED AT 250 WORDS)

Cross-over comparison of the fixed combination of hydrochlorothiazide and triamterene and the free combination of furosemide and triamterene in the maintenance treatment of congestive heart failure.

The fixed combination of hydrochlorothiazide 25 mg and triamterene 50 mg and the free combination of furosemide 40 mg and triamterene 50 mg were compared as maintenance treatment in patients who were in a stable condition after an episode of congestive heart failure. All the patients were on digitalis. The trial was of the cross-over design. The treatment order was randomized at each centre. Each treatment lasted for 8 weeks. Of the 37 patients entering the study 30 were suitable for analysis. Both treatments were equally effective in maintaining bodyweight at the same level and in influencing symptoms. The free combination decreased the blood pressure slightly more than the fixed combination, especially the systolic pressure. One-third of the patients were hypertensive at the outset (diastolic pressure greater than 95 mm Hg) and in them the effects of the two treatments were not significantly different. The majority of the patients (80%) preferred treatment with the fixed combination because it caused slower and less frequent micturition.

Detection of ventricular thrombosis in acute myocardial infarction: value of indium-111 platelet scintigraphy in relation to two-dimensional echocardiography and clinical course.

In order to detect left ventricular (LV) thrombosis, 111In-platelet scintigraphy and two-dimensional echocardiography were performed in 40 patients 15 days +/- 6 days after acute myocardial infarction. A dual isotope subtraction method, using 111In-platelet scintigraphy and 99mTc-blood pool scintigraphy, was used to assess LV platelet deposition expressed as LV counts per pixel. Seven patients (group A) had a positive 111In-platelet scintigram and 33 patients (group B) had a negative 111In-platelet scintigram (LV counts per pixel: 0.56 +/- 0.23 and 0.28 +/- 0.19, respectively, P less than 0.05). Three group A patients but no group B patients had a positive echocardiogram. Arterial embolism was noted in four patients, of whom two showed both positive echocardiogram and platelet scintigram. LV counts per pixel were 0.57 +/- 0.13 and 0.31 +/- 0.21, respectively (P less than 0.02) in patients with and without arterial embolism. Thus, both 111In-platelet scintigraphy and two-dimensional echocardiography can detect LV thrombosis. 111In-platelet scintigraphy may help to define patients at risk for embolization and may be used in conjunction with echocardiography to study the effect of antithrombotic therapy.

Usefulness of two-dimensional exercise echocardiography shortly after myocardial infarction.

To determine the clinical significance of transient remote asynergy after the first acute myocardial infarction (AMI), 2-dimensional echocardiography was performed at rest and directly after dynamic exercise in 49 consecutive patients within 3 weeks of AMI. In 43 patients (88%), technically adequate 2-dimensional echocardiographic examinations were obtained. Asynergy was found in all patients at rest. Immediately after exercise, new areas of asynergy, not adjacent to the infarcted area (i.e., transient remote asynergy), were present in 18 patients. Of these patients, 17 had multivessel coronary artery disease (CAD), compared with 5 of 25 patients without transient remote asynergy. Sensitivity of transient remote asynergy for detecting multivessel CAD was 77% and specificity was 95%. Left ventricular ejection fraction at rest and after exercise was measured in 39 patients (90%) and could only identify patients with 3-vessel CAD. New ischemic events, defined as reinfarction or recurrent angina pectoris, within a mean of 12 weeks (range 8 to 16) after discharge, occurred in 16 patients. Transient remote asynergy was present in 12 of these patients (75%). It is concluded that exercise-induced transient remote asynergy early after AMI can identify patients with multivessel CAD and a subgroup of patients prone to early new ischemic events. Left ventricular ejection fraction, however, is not only more laborious but also of lesser value in identifying patients with multivessel CAD.

Effects of spontaneous and streptokinase-induced recanalization on left ventricular function after myocardial infarction.

The effect of recanalization of the "infarct vessel" on left ventricular (LV) function was assessed 6-8 weeks after acute myocardial infarction (MI) in two groups: patients who had streptokinase-induced recanalization during the acute phase and control patients who had spontaneous recanalization. The ejection fraction and severity of LV wall motion abnormalities in 100 patients with recanalization were compared with those in 78 patients with persistent occlusion of the infarct vessel. Among patients with inferior MI, LV function was significantly better in those with spontaneous (n = 41, p less than 0.05) and streptokinase-induced recanalization (n = 15, p less than 0.02) than in those with persistent occlusion of the infarct vessel (n = 40) in the control group. The LV function was equally good in patients with spontaneous and streptokinase-induced recanalization. Among anterior MI patients, LV function was significantly better in those with streptokinase-induced recanalization (n = 10) than in those with spontaneous recanalization (n = 34, p less than 0.01) or persistent occlusion in the control group (n = 28, p less than 0.001). We conclude that recanalization has a beneficial effect on LV function in patients with MI.