The American journal of cardiology
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Comparative Study
Value of definitive diagnostic testing in the evaluation of patients presenting to the emergency department with chest pain.
The optimal diagnostic evaluation of patients presenting to the emergency department (ED) with chest pain but without myocardial infarction or unstable angina is controversial. We performed a prospective, nonrandomized, observational study of 1,195 consecutive patients presenting to the ED with chest pain but who had normal or nondiagnostic electrocardiograms and negative cardiac biomarkers. Patients (mean +/- SD age 61 +/- 15 years; 55% women) were admitted to the hospital and a standard protocol for evaluation and treatment was suggested. ⋯ During the 3-month follow-up period, patients with a normal stress perfusion study during their index hospitalization had fewer return visits (4%) compared with patients with abnormal perfusion studies (19%), those who underwent catheterization directly (16%), or patients with no initial diagnostic evaluation (15%) (p <0.001). In addition, patients who had a diagnostic evaluation during their index hospitalization had a lower incidence of either acute myocardial infarction (0.9% vs 2.1%) or death (0.4% vs 3.0%, p <0.001) in the 3-month follow-up period. Accordingly, we strongly advocate provocative stress MPI early after presentation for chest pain in all patients with risk factors for coronary artery disease.
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Comparative Study
Relation of mortality of primary angioplasty during acute myocardial infarction to door-to-Thrombolysis In Myocardial Infarction (TIMI) time.
For primary angioplasty of acute myocardial infarction (AMI), the relation of treatment benefit and time has been debated. The present study aimed to evaluate, in a single-center cohort of patients with ST-segment elevation AMI, which time intervals were carefully and consistently measured, and the relations among ischemic time, in-hospital delays, and in-hospital survival. We included 499 patients (mean age 59 years; 80% men) who underwent successful primary percutaneous transluminal coronary angioplasty (PTCA) for AMI admitted < or =6 hours after symptom onset. ⋯ The in-hospital mortality rate was 3.2%. There was no significant relation between the various tertiles of time intervals and in-hospital mortality. After linear logistic regression, only age (odds ratio [OR] 1.79 per 10 years), female gender (OR 3.56), and door-to-TIMI 3 time (OR 1.27 per 15 minutes) were independently correlated with in-hospital mortality.
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The aim of this study was to compare the accuracy of harmonic power Doppler imaging (HPDI) and dobutamine stress echocardiography (DSE) in predicting recovery of myocardial function after bypass surgery. HPDI using triggering imaging with the administration of Levovist (Shering AG, Berlin, Germany) and DSE were performed in 34 patients (mean age 64 +/- 5 years) with left ventricular dysfunction. A repeat echocardiogram at rest was performed 3 months after revascularization. ⋯ The presence of contrast enhancement within the revascularized area resulted in a significant improvement after revascularization in wall motion score index and ejection fraction compared with areas with residual contrast defect (1.9 +/- 0.3 vs 2.3 +/- 0.3, p<0.01; 36 +/- 6% vs 29 +/- 5%, p<0.01, respectively). Significant correlations were observed between the contrast score index and the follow-up wall motion score index (r = -0.67) and between the contrast score index and the follow-up ejection fraction change (r = 0.65). Triggered HPDI has high sensitivity in detecting hibernating myocardium and can accurately predict the potential for recovery of ischemic left ventricular dysfunction 3 months after revascularization.
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Currently, the prediction of improvement of left ventricular (LV) ejection fraction (EF) after revascularization in patients with ischemic cardiomyopathy relies only on viable myocardium extent, whereas both the amount of viable and scar tissue may be important. A model was developed, based on the amount of viable and nonviable myocardium, to predict functional recovery. Viable and scarred myocardium was defined by dobutamine stress echocardiography (DSE) in 108 consecutive patients. ⋯ A regression function, based on the number of scar and biphasic segments, showed that the likelihood of recovery was 85% in patients with extensive biphasic tissue and no scars and 11% in patients with extensive scars and no biphasic myocardium. Patients with a mixture of scar and biphasic tissue had an intermediate likelihood of improvement (50%). In patients with ischemic cardiomyopathy and a mixture of viable and nonviable tissue, both numbers of viable and nonviable segments should be considered to accurately predict functional recovery after revascularization.