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In ST-elevation myocardial infarction (STEMI) the pre-hospital phase is the most critical, as the administration of the most appropriate treatment in a timely manner is instrumental for mortality reduction. STEMI systems of care based on networks of medical institutions connected by an efficient emergency medical service are pivotal. The first steps are devoted to minimize the patient's delay in seeking care, rapidly dispatch a properly staffed and equipped ambulance to make the diagnosis on scene, deliver initial drug therapy and transport the patient to the most appropriate (not necessarily the closest) cardiac facility. Primary PCI is the treatment of choice, but thrombolysis followed by coronary angiography and possibly PCI is a valid alternative, according to patient's baseline risk, time from symptoms onset and primary PCI-related delay. Paramedics and nurses have an important role in pre-hospital STEMI care and their empowerment is essential to increase the effectiveness of the system. Strong cooperation between cardiologists and emergency medicine doctors is mandatory for optimal pre-hospital STEMI care. Scientific societies have an important role in guideline implementation as well as in developing quality indicators and performance measures; health care professionals must overcome existing barriers to optimal care together with political and administrative decision makers. [ABSTRACT FROM AUTHOR]

The chest pain unit (CPU) provides a service for patients at moderate-to-low risk for acute coronary syndrome (ACS). Although the number of CPUs has continued to grow worldwide, little has been written on the specific role and contribution of nursing in CPUs. The stay of patients in the CPU can be divided into six stages: triage, diagnosis, treatment, observation/monitoring, discharge, and follow-up. CPU nurses are in a unique position to promote evidence-based practice during all of these stages. Deeper insight into the unique role of nurses in CPUs will promote understanding of what type of knowledge, skills, and attitudes are required to provide the services that will contribute to improved quality of care for chest pain patients. [ABSTRACT FROM AUTHOR]

Background There are limited data regarding the immediate and long-term effect of balloon angioplasty on the coronary flow reserve evaluated in a multicentre setting.Methods and Results A total of 86 patients with one-vessel disease and normal left ventricular function were analysed before and after optimal balloon angioplasty (diameter stenosis <35%) and at 6-month follow-up. Coronary flow reserve was assessed with a Doppler guide wire. A low coronary flow reserve (≤2·5) after PTCA, due to an increased baseline blood flow velocity, was encountered in 42 of the 86 patients (49%). Recurrence of angina and target lesion revascularization were more frequent in these patients than in patients with a coronary flow reserve >2·5 (46% vs 23% and 36% vs 16%, respectively;P<0·05) due to a trend towards restenosis (29% vs 16%;P=0·15) or a low coronary flow reserve at follow-up due to persistent elevated baseline blood flow velocity. Patients without restenosis showed a decrease or increase of coronary flow reserve during follow-up, determined by alterations of hyperaemic blood flow velocity.Conclusions Patients with an impaired coronary flow reserve directly after optimal balloon angioplasty showed a higher target lesion revascularization rate compared to patients with a coronary flow reserve >2·5. This patient group consists of patients prone to develop restenosis, while other patients are characterized by a persistently low coronary flow reserve, probably secondary to disturbed autoregulation and/or diffuse mild coronary atherosclerosis. Coronary flow reserve alterations in patients without restenosis were related to changes in hyperaemic blood flow velocity, suggesting that this phenomenon relates to epicardial remodelling. [ABSTRACT FROM PUBLISHER]

Aims Evaluation of angiographical and intracoronary Doppler-derived parameters of coronary stenosis severity.Methods and Results A total of 225 patients with one-vessel disease were studied before PTCA and at 6 months follow-up. Exercise electrocardiography was performed to document presence (n=157) or absence (n=138) of an ST segment shift (≥0·1mV). Intracoronary blood flow velocity analysis was performed to determine the proximal/distal flow velocity ratio, the distal diastolic/systolic flow velocity ratio and coronary flow velocity reserve. Receiver operator characteristic curves were calculated to assess the predictive value of these variables compared with the exercise test. The distal coronary flow velocity reserve demonstrated the best linear correlation for both percentage diameter stenosis and minimum lumen diameter (r=0·67 and r=0·66;P<0·01), compared to the diastolic/systolic flow velocity ratio (r=0·19 and r=0·14;P<0·01) and the proximal/distal flow velocity ratio (r=0·03 and r=0·07; not significant). The areas under the curve were 0·84±0·02; 0·82±0·03 and 0·83±0·03 for diameter stenosis, minimum lumen diameter and coronary flow velocity reserve, respectively. Logistic regression analysis revealed that the percentage diameter stenosis or minimum lumen diameter and coronary flow velocity reserve were independent predictors for the result of stress testing.Conclusions The distal coronary flow velocity reserve is the best intracoronary Doppler parameter for evaluation of coronary narrowings. Angiographical estimates of coronary lesion severity and distal coronary flow velocity reserve are good and independent predictors for the assessment of functional severity of coronary stenosis, emphasizing the complementary role of these parameters for clinical decision making. [ABSTRACT FROM PUBLISHER]

The ability of brief periods of ischaemia to protect the heart from subsequent ischaemia has been termed ‘ischaemic preconditioning’. In order to assess the role of adenosine receptor stimulation in this phenomenon we studied the ischaemic preconditioning effect during angioplasty in 10 control patients and in 10 patients pre-treated with 5 mg kg−1 aminophylline, an adenosine receptor antagonist.The ischaemic response was assessed by analysis of the intracoronary electrocardiogram every 10 s during three consecutive inflations of 90 s with a reperfusion time of 180 s. The severity of transmural local ischaemia was expressed as the magnitude of the ST segment shift in relation to the time during each inflation. The control patients showed an improved tolerance to myocardial ischaemia: ST segment shift decreased from 1·42±0·49 mV at the end of the first inflation to 1·03±0·44 mV at the end of the third inflation (P<0·001). However, in patients pre-treated with aminophylline, the ischaemic response was not significantly different during three inflations.Conclusion Aminophylline inhibits ischaemic preconditioning, as assessed by analysis of the intracoronary ST segment changes during angioplasty. This suggests that ischaemic preconditioning is mediated by adenosine receptor stimulation in humans. [ABSTRACT FROM PUBLISHER]

The purpose of this study was to evaluate the accuracy of adenosine Tc-99m sestamibi single photon emission computed tomography (SPECT) in the detection of jeoparidized myocardium early after acute myocardial infarction. Coronary arteriography and myocardial scintigraphy were performed in 50 consecutive patients with an uncomplicated myocardial infarction. Myocardium was considered jeopardized if a significant infarct-related vessel stenosis (> 50% diameter stenosis) supplied an infarct area with residual viable tissue. Perfusion reversibility in the infarct region occurred in 25 patients (50%) and was almost solely observed in the presence of jeopardized myocardium. Non-reversible perfusion defects in the infarct region were found in patients without jeopardized myocardium. This subgroup consisted of either patients without significant vessel stenosis or patients without significant residual viability in the infarct region. Adenosine Tc-99m sestamibi SPECT had an accuracy of 88% for the detection of jeopardized myocardium. Side effects during adenosine infusion were frequently observed but well tolerated. These results suggest that adenosine Tc-99m sestamibi SPECT is an accurate non-invasive method for detecting jeopardized myocardium after acute myocardial infarction and may be a valuable non-invasive test for the early selection of patients at risk for future ischaemic events. [ABSTRACT FROM PUBLISHER]

This study assesses the value of P wave measurements on the surface ECG at implantation, in the prediction of atrial fibrillation in VVI paced patients. From a consecutive series of 320 pacemaker implantations 172 VVI paced patients for symptomatic atrioventricular block (AVB) (n = 126; mean age 69 ± 14) or sick sinus syndrome (SSSJ (n = 56; mean age 68.6 ± 12) and in sinus rhythm at implantation were used in this study. P wave duration in V1 is correlated with the incidence of atrial fibrillation during 5 years of follow-up. V1 at implantation was significantly longer (114.6 ± 2.7 msec) in the patients who developed atrial fibrillation than in those who did not (91.9 ± 2.7 msec) (P > 0.001). Although positive predictive accuracy increases progressively for higher V1 values for AVB and SSS, the negative predictive and diagnostic accuracy of V1 criteria were Jess in SSS. Application of the Bayes' theorem showed that in SSS the probability to develop atrial fibrillation is 33% for V1 < 110 msec and is for V1 < 90 msec still higher than that reported in DDD paced patients. In the AVB group the probability to develop atrial fibrillation is 8% for V1 < 110 msec and 6% for V1 < 100 msec. It seems, therefore, that atrial stimulation (AAI or DDD) is always indicated in SSS. In AVB with V1 < 100 msec, DDD pacing, if not needed for other indications, apparently does not offer much benefit in the prophylaxis of atrial fibrillation. [ABSTRACT FROM AUTHOR]

This study is an investigation of the long-term effects of VVI pacing on the atrium as derived from the evolution of P wave characteristics of 285 patients. The occurrence of left and right atrial disease is demonstrated as well as the evolution of left atrial hypertrophy in some cases. A comparison is made with DDD pacing and special attention is given to the progression to atrial fibrillation. [ABSTRACT FROM AUTHOR]

To determine the diagnostic value of R wave amplitude changes occurring during exercise testing after myocardial infarction, exercise ECG's and coronary angiograms were reviewed in 76 postinfarction patients and in 40 patients with normal coronary arteries. During exercise, an increase in R wave amplitude (mean: +2.7±13 mm) was observed in the post infarction patients, significantly different (P<0.001) from the decrease (mean: –2.6± 1.1 mm) observed in the group with normal coronary arteries. Although this change increased with the number of diseased coronary arteries, the difference between 1-vessel andmulti- or 3-vessel disease was not significant. Extension of infarct size from one to more akinetic segments on the left ventricular angiogram was associated with a significant (P<0.001) increase of the R wave amplitude change during exercise (mean:+ l.6±l.lvs3.3+l.3mm). It is concluded that the abnormal increase in R wave amplitude observed during exercise testing after myocardial infarction is more strongly related to infarct size then to the number of diseased coronary arteries. Furthermore exercise induced R wave amplitude changes have no diagnostic value in the prediction ofmulti- or 3-vessel disease in postinfarction patients. [ABSTRACT FROM PUBLISHER]

An abstract of the article "Safety Assessment by Cardiac Troponin I Release of Symptom Limited Exercise and Combined Endurance/Resistance Versus Endurance Training in Patients With Chronic Heart Failure," by V. Conraads and colleagues, is presented.

An abstract of the article "Endothelial Dysfunction in the Non-Culprit Microcirculation After Myocardial Infarction," by A. Berges and colleagues is presented.

An abstract of the study "Continuous training maintains the cardiopulmonary effects of a cardiac rehabilitation programme in patients with chronic heart failure," by P. J. M. Beckers and colleagues is presented.

A 54-year-old man complained of severe angina shortly after a blunt chest trauma and coronary angiography showed an isolated subtotal occlusion of the mid-left anterior descending artery. Bypass grafting was uneventful. Posttraumatic angina or supposed myocardial contusion may be to coronary injury for which a specific treatment can be given to limit the extent of myocardial necrosis. [ABSTRACT FROM PUBLISHER]

We present a case of a 66-year-old man with a preexisting left ventricular pseudoaneurysm as a sequel of an old inferoposterior myocardial infarction. The patient currently presented with respiratory insufficiency and chest pain. Based on his admittance electrocardiogram, he was treated with fibrinolytics for a presumed acute inferior ST-elevation myocardial infarction (in fact, the ST-elevations were the hallmark of the pseudoaneurysm). This treatment caused extensive ischemic stroke, as a consequence of dissolution and embolization of thrombi that were abundantly present in the pseudoaneurysm. The admittance electrocardiogram pointed out to be misleading to the treating physician and led to the unnecessary administration of fibrinolytics with serious complications.Copyright © 2009 by Elsevier Inc. [ABSTRACT FROM AUTHOR]

An abstract of the article "Differential myocardial expression of E3-ubiquitin ligases in patients with recent myocardial infarction versus dilated cardiomyopathy," by V. Conraads and colleagues presented.

An abstract of the article "Apoptosis versus active gene transcription in skeletal muscle of chronic heart failure patients. The effect of exercise training," by V. Conraads and colleagues is presented.

An abstract of the study "Apoptosis Versus Active Gene Transcription in the Skeletal Muscle of Patients With Mild to Moderate Chronic Heart Failure. Relationship With Exercise Capacity," by V. Conraads and colleagues is presented.

A 57 year old man was referred because of non-anginal thoracic pain. He had been involved in a frontal car accident two years earlier, resulting in multiple bilateral rib fractures, bilateral pneumothorax, rupture of the spleen and liver, and fracture of a femur. Although recovery was uneventful he kept complaining of daily thoracic pain. His ECG at rest displayed a normal sinus rhythm. Radiography of the chest revealed focal bulging of the left mid-ventricular border. Ventriculography demonstrated a left ventricular aneurysm of the mid antenor wall.

An abstract of the article "Combined Endurance/Resistance Training Reduces Serum NT-proBNP in Patients With Moderate to Severe Chronic Heart Failure," by V. Conraads and colleagues, is presented.

An abstract of the study "Ramp treadmill tests generate higher workload and cardiopulmonary response than bicycle tests in chronic heart failure," by P. J. M. Beckers and colleagues is presented.