The American journal of cardiology
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Randomized Controlled Trial Comparative Study
Percutaneous coronary intervention with off-site cardiac surgery backup for acute myocardial infarction as a strategy to reduce door-to-balloon time.
We investigated whether primary percutaneous coronary intervention (PCI) for patients admitted with an acute ST-segment elevation myocardial infarction could be performed more rapidly and with comparable outcomes in a community hospital versus a tertiary center with cardiac surgery. We started the first PCI with an off-site surgery program in The Netherlands in 2002 and report the results of 439 consecutive patients. In the safety phase, 199 patients presenting with ST-segment elevation myocardial infarction were randomly assigned to treatment at our off-site center versus a more distant cardiac surgery center. ⋯ None of the 439 patients in the study required emergency surgery for failed primary PCI. In conclusion, time to treatment with primary PCI can be significantly shortened when treating patients in a community hospital setting with off-site cardiac surgery backup compared with transport for PCI to a referral center with on-site surgery. PCI at hospitals with off-site cardiac surgery backup can be considered a needed strategy to improve access to primary PCI for a larger segment of the population and can be delivered with a very favorable safety profile.
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This study was conducted to assess the ability of preoperative B-type natriuretic peptide levels to predict medium-term mortality in patients who undergo major noncardiac surgery. During a median of 654 days of follow-up, 33 patients from a total cohort of 204 patients (16%) died, 17 from cardiovascular causes. ⋯ This was associated with a 3.5-fold increase in the hazard of death (p = 0.001) and a 6.9-fold increase in the hazard of cardiovascular mortality (p = 0.003). In conclusion, these findings extend recent work demonstrating that B-type natriuretic peptide levels obtained before major noncardiac surgery can be used to predict perioperative morbidity and indicate that they also forecast medium-term mortality, particularly cardiovascular death.
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Comparative Study
Usefulness of B-type natriuretic peptide levels to predict left ventricular filling pressures in patients with body mass index >35, 31 to 35, and < or =30 kg/m2.
Noninvasive left ventricular (LV) pressure estimation in obese patients has not been well described. Simultaneous B-type natriuretic peptide (BNP) and echocardiographic Doppler examinations were performed in patients with dyspnea undergoing cardiac catheterization. Patients were divided into body mass index (BMI) >35 (markedly obese), 31 to 35 (obese), and < or =30 kg/m2 (nonobese). ⋯ In markedly obese patients with dyspnea, BNP did not correlate with invasively measured LV filling pressure, whereas this correlated in obese and nonobese patients. However, mitral E/Ea significantly correlated with LV filling pressures in all BMI groups. In conclusion, BNP is not recommended for LV filling pressure estimation in ambulatory patients with dyspnea with BMI >35 kg/m2.
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Currently, left ventricular (LV) ejection fraction (EF) and/or LV volumes are the established predictors of mortality in patients with coronary artery disease (CAD) and severe LV dysfunction. With contrast-enhanced magnetic resonance imaging (MRI), precise delineation of infarct size is now possible. The relative merits of LVEF/LV volumes and infarct size to predict long-term outcome are unknown. ⋯ Nineteen patients (8.2%) died during a median follow-up of 1.7 years (interquartile range 1.1 to 2.9). Cox proportional hazards analysis revealed that infarct size defined as spatial extent (hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.1 to 1.6, chi-square 6.7, p=0.010), transmurality (HR 1.5, 95% CI 1.1 to 1.9, chi-square 8.9, p=0.003), or total scar score (HR 6.2, 95% CI 1.7 to 23, chi-square 7.4, p=0.006) were stronger predictors of all-cause mortality than LVEF and LV volumes. In conclusion, infarct size on contrast-enhanced MRI may be superior to LVEF and LV volumes for predicting long-term mortality in patients with healed myocardial infarction.
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Randomized Controlled Trial Comparative Study
Prevalence and prognostic implications of ST-segment deviations from ambulatory Holter monitoring after ST-segment elevation myocardial infarction treated with either fibrinolysis or primary percutaneous coronary intervention (a Danish Trial in Acute Myocardial Infarction-2 Substudy).
Ambulatory Holter monitoring has been shown to be useful in stratifying cardiovascular risk after acute myocardial infarction. However, it remains unclear whether ST-segment deviations might predict clinical outcomes in a population treated with primary percutaneous coronary intervention (PCI) compared with thrombolysis. Holter monitoring was initiated at discharge from ST-segment elevation myocardial infarction in 958 patients followed for 2,773 patient-years, randomized to immediate revascularization with either fibrinolysis (n=474) or PCI (n=484). ⋯ In PCI-treated patients, there was no association between either STe or STd and outcome. In conclusion, immediate revascularization with PCI during STe myocardial infarction does not affect the subsequent prevalence of ST-segment deviation compared with fibrinolysis. However, although STe is an independent predictor of mortality and nonfatal major cardiovascular events in patients treated with fibrinolysis, it does not predict outcome after PCI, perhaps because of more complete revascularization.