NT-proBNP Level Predicts Extent of Myonecrosis and Clinical Adverse Outcomes in Patients with ST-Elevation Myocardial Infarction: A Pilot Study.

BACKGROUND AND HYPOTHESIS: The initial assessment of late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR) reflects cardiac damage and is an important prognostic factor in patients with acute ST-elevation myocardial infarction (STEMI). N-Terminal prohormone of brain natriuretic peptide (NT-proBNP) is released following cardiomyocytes injury. However, the relationship between NT-proBNP levels, myocardial damage and clinical outcomes after STEMI has not been well defined. METHODS: Plasma levels of NT-proBNP, troponin I and creatinine kinase (CK) were assessed in 75 patients with STEMI. Echocardiography and CMR were performed prior to hospital discharge. Cardiac damage was quantified using peak biomarker levels and LGE. Patients were followed for a median of 975 days (IQR 823-1098 days) for major adverse cardiac events (MACE) (all-cause mortality, recurrent myocardial infraction, unplanned recurrent revascularization and recurrent hospitalization for heart failure). RESULTS: Plasma levels of NT-proBNP increased following STEMI to peak at 24 hours. The dynamic changes in plasma NT-proBNP were similar to those noted with troponin I and its delayed peak but not those observed with plasma CK levels. Peak NT-proBNP levels correlated positively with indices of myocardial damage such as peak troponin I (R2 =0.38, P <0.001), peak CK (R2 =0.22, P = 0.01) and LGE examination (R2 = 0.46, P <0.001). Peak plasma level of NT- proBNP was strongly predictive of MACE during the follow-up period. CONCLUSIONS: Peak levels of NT-proBNP following STEMI are predictive of the extent of myocardial damage and clinical outcomes. These results suggest an important prognostic role for NT-proBNP assessment in STEMI patients.

Comparison of intracoronary versus intravenous adenosine-induced maximal hyperemia for fractional flow reserve measurement: A systematic review and meta-analysis.

OBJECTIVE: We sought to perform a systematic review and meta-analysis of the available literature comparing fractional flow reserve (FFR) measurements after administration of adenosine using intracoronary (IC) bolus versus standard continuous intravenous (IV) infusion. BACKGROUND: FFR is considered the gold standard for invasive assessment of coronary lesions of intermediate severity. IV adenosine is recommended to induce hyperemia; however, IC adenosine is widely used for convenience. The difference between IV and IC administration in lesions assessment is not well studied. METHODS: We systematically searched MEDLINE and relevant databases for studies comparing IV with IC adenosine administration for FFR measurement. We reviewed data pertaining to adenosine doses, side effects, and FFR values. RESULTS: Eight studies addressing the primary question were identified. Dose of IC adenosine varied between 36 and 600 µg. Compared to IV adenosine infusion, the sensitivity of IC administration is 0.805 (95% confidence interval [95% CI]: 0.664-0.896; p < .001), specificity is 0.965 (95% CI: 0.932-0.983; p < .001), positive likelihood ratio is 24.218 (95% CI: 12,263-47.830; p < .001), negative likelihood ratio is 0.117 (95% CI: 0.033-0.411; p < .01), and diagnostic odds ratio is 274.225 [95% CI: 92.731-810.946; p < .001]. Overall, hemodynamic side effects and symptoms were reported more frequently with IV adenosine. CONCLUSIONS: The available literature suggests that IC adenosine is well tolerated and may provide equivalent diagnostic accuracy compared to IV administration. However, variability in dosing regimens does not allow definitive conclusions regarding noninferiority of IC approach compared to IV administration.

Pneumomediastinum and ST-Segment Elevation.

Although acute myocardial infarction is the most clinically significant cause of ST-segment elevation, other serious clinical conditions have been reported with this electrocardiographic abnormality. We report a patient with pneumomediastinum who presented with dyspnea and electrocardiographic changes mimicking ST-segment elevation myocardial infarction. Coronary angiography demonstrated no evidence of myocardial injury and the electrocardiographic abnormality promptly resolved with the resolution of the pneumomediastinum.

Predictors, Morbidity, and Costs Associated with Pneumothorax during Electronic Cardiac Device Implantation.

BACKGROUND: Pneumothorax (PTX) is a major cause of morbidity associated with cardiac implantable electronic devices (CIEDs). We sought to evaluate predictors of PTX at our centers during CIED implantations, including the venous access technique utilized, as well as to determine morbidity and costs associated with PTX. METHODS: We reviewed records of all patients undergoing cardiac device implant or revision with new venous access at our institutions between 2008 and 2014. Common demographic and procedure characteristics were collected including age, sex, body mass index (BMI), comorbidities, and method of venous access (axillary vein vs classic proximal subclavian vein technique). RESULTS: We identified 1,264 patients who met criteria for our analysis, with a total of 21 PTX cases during CIED implantation. The strongest predictor for PTX was the venous access strategy: 0 of 385 (0%) patients with axillary vein approach versus 21 of 879 (2.4%) with traditional subclavian vein approach, P = 0.0006. Additional predictors of PTX included advanced age, female sex, low BMI, and a new device implant (vs device upgrade). The occurrence of PTX was associated with increased length of stay: 3.0 days (median; interquartile range [IQR] 3) versus 1.0 day (median; IQR: 1), P = 0.0001, with a cost increase of 361.4%. CONCLUSION: An axillary vein vascular access strategy was associated with greatly reduced risk of iatrogenic PTX versus the traditional subclavian approach for CIED placement. Similarly, device upgrade with patent vascular access carried less risk of PTX compared to new device implantation. PTX occurrence significantly prolonged hospitalization and increased costs.

Systematic Review and Meta-Analysis of Major Cardiovascular Outcomes for Radial Versus Femoral Access in Patients With Acute Coronary Syndrome.

OBJECTIVES: Radial artery access (RA) for left heart catheterization and percutaneous coronary interventions (PCIs) has been demonstrated to be safe and effective. Despite consistent data showing less bleeding complications compared with femoral artery access (FA), it continues to be underused in the United States, particularly in patients with acute coronary syndrome (ACS) in whom aggressive anticoagulation and platelet inhibition regimens are needed. This systematic review and meta-analysis aims to compare major cardiovascular outcomes and safety endpoints in patients with ACS managed with PCI using radial versus femoral access. METHODS: Randomized controlled trials and cohort studies comparing RA versus FA in patients with ACS were analyzed. Our primary outcomes were mortality, major adverse cardiac event, major bleeding, and access-related complications. A fixed-effects model was used for the primary analyses. RESULTS: Fifteen randomized controlled trials and 17 cohort studies involving 44,854 patients with ACS were identified. Compared with FA, RA was associated with a reduction in major bleeding (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.33-0.61, P < 0.001), access-related complications (OR 0.27, 95% CI 0.18-0.39, P < 0.001), mortality (OR 0.64, 95% CI 0.54-0.75, P < 0.001), and major adverse cardiac event (OR 0.70, 95% CI 0.57-0.85, P < 0.001). These significant reductions were consistent across different study designs and clinical presentations. CONCLUSIONS: Based on this large meta-analysis, RA for primary PCI in the setting of ACS is associated with reduction in cardiac and safety endpoints when compared with FA in both urgent and elective procedures. This should encourage a wider adoption of this technique among centers and interventional cardiologists.

Trauma induced myocardial infarction.

Chest Trauma in athletes is a common health problem. However, myocardial infarction secondary to coronary dissection in the setting of blunt chest trauma is extremely rare. We report a case of acute inferior wall myocardial infarction following blunt chest trauma. A 32-year-old male with no relevant medical problems was transferred to our medical center for retrosternal chest pain after being elbowed in the chest during a soccer game. Few seconds later, he started experiencing sharp retrosternal chest pain that was severe to that point where he called the emergency medical service. Upon arrival to the trauma department patient was still complaining of chest pain. ECG demonstrated ST segment elevation in the inferior leads with reciprocal changes in the lateral leads all consistent with active ischemia. After rolling out aortic dissection, patient was loaded with ASA, ticagerlor, heparin and was emergently taken to the cardiac catheterization lab. Coronary angiography demonstrated 100% thrombotic occlusion in the distal right coronary artery with TIMI 0 flow distally. After thrombus aspiration, a focal dissection was noted on the angiogram that was successfully stented. Two days after admission patient was discharged home. Echocardiography prior to discharge showed inferior wall akinesis, normal right ventricular systolic function and normal overall ejection fraction.