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Background: We aimed to investigate coronary angiographic findings in unselected out-of-hospital cardiac arrest patients referred to immediate coronary angiography (ICA) irrespective of their first postresuscitation ECG and to determine whether this ECG is useful to select patients with no need of ICA., Methods and Results: All resuscitated patients admitted after out-of-hospital cardiac arrest without a clear noncardiac cause underwent ICA. Patients were retrospectively grouped according to the postresuscitation ECG blinded for ICA results: (1) ST elevation or presumably new left bundle branch block, (2) other ECG signs indicating myocardial ischemia, and (3) no ECG signs indicating myocardial ischemia. All coronary angiograms were reevaluated blinded for postresuscitation ECGs. Two hundred and ten patients were included with mean age 62±12 years. Six-months survival with good neurological outcome was 54%. Reduced Thrombolysis in Myocardial Infarction flow (0-2) was found in 55%, 34%, and 18% and a ≥90% coronary stenosis was present in 25%, 27%, and 19% of patients in group 1, 2, and 3, respectively. An acute coronary occlusion was found in 11% of patients in group 3. ST elevation/left bundle branch block identified patients with reduced Thrombolysis in Myocardial Infarction (0-2) flow with 70% sensitivity and 62% specificity. Among patients with initial nonshockable rhythms (24%), 32% had significantly reduced Thrombolysis in Myocardial Infarction flow., Conclusions: Initial ECG findings are not reliable in detecting patients with an indication for ICA after experiencing a cardiac arrest. Even in the absence of ECG changes indicating myocardial ischemia, an acute culprit lesion may be present and patients may benefit from emergent revascularization. CLINICAL TRIAL REGISTRATIONURL: http://www.clinicaltrials.gov. Unique identifier: NCT01239420., (© 2015 American Heart Association, Inc.)

Background: No data from controlled trials exists regarding the inflammatory response in patients with de novo heart failure (HF) complicating ST-elevation myocardial infarction (STEMI) and a possible role in the recovery of contractile function. We therefore explored the time course and possible associations between levels of inflammatory markers and recovery of impaired left ventricular function as well as levosimendan treatment in STEMI patients in a substudy of the LEvosimendan in Acute heart Failure following myocardial infarction (LEAF) trial., Methods: A total of 61 patients developing HF within 48 hours after a primary PCI-treated STEMI were randomised double-blind to a 25 hours infusion of levosimendan or placebo. Levels of IL-6, CRP, sIL-6R, sgp130, MCP-1, IL-8, MMP-9, sICAM-1, sVCAM-1 and TNF-α were measured at inclusion (median 22 h, interquartile range (IQR) 14, 29 after PCI), on day 1, day 2, day 5 and 6 weeks. Improvement in left ventricular function was evaluated as change in wall motion score index (WMSI) by echocardiography., Results: Only circulating levels of IL-8 at inclusion were associated with change in WMSI from baseline to 6 weeks, r = ÷ 0.41 (p = 0.002). No association, however, was found between IL-8 and WMSI at inclusion or peak troponin T. Furthermore, there was a significant difference in change in WMSI from inclusion to 6 weeks between patients with IL-8 levels below, compared to above median value, ÷ 0.44 (IQR ÷ 0.57, ÷ 0.19) vs. ÷ 0.07 (IQR ÷ 0.27, 0.07), respectively (p < 0.0001). Levosimendan did not affect the levels of inflammary markers compared to control., Conclusion: High levels of IL-8 in STEMI patients complicated with HF were associated with less improvement in left ventricular function during the first 6 weeks after PCI, suggesting a possible role of IL-8 in the reperfusion-related injury of post-ischemic myocardium. Further studies are needed to confirm this hypothesis., Trial Registration: ClinicalTrials.gov NCT00324766.

Aims: The calcium sensitizer levosimendan may counteract stunning after reperfusion of ischaemic myocardium, but no randomized placebo-controlled trials exist regarding its use in PCI-treated ST-segment elevation infarction (STEMI). We evaluated the efficacy and safety of levosimendan in patients with a primary PCI-treated STEMI complicated by symptomatic heart failure (HF)., Methods and Results: A total of 61 patients developing clinical signs of HF within 48 h after a primary PCI-treated STEMI (including cardiogenic shock) were randomized double-blind to a 25 h infusion of levosimendan or placebo. The primary endpoint was change in wall motion score index (WMSI) from baseline to day 5 measured by echocardiography. There was a significantly larger improvement in WMSI from baseline to day 5 in the levosimendan group compared with placebo (from 1.94 ± 0.20 to 1.66 ± 0.31 vs. 1.99 ± 0.22 to 1.83 ± 0.26, respectively, P = 0.031). There were significantly more episodes of hypotension during study drug infusion in the levosimendan group (67% vs. 36%, P = 0.029), but no significant difference in blood pressure at the end of infusion or in use of vasopressors. No significant between-group differences in changes in NT-proBNP levels, clinical composite score, frequency of atrial fibrillation or ventricular arrhythmia, infarct size at 6 weeks, or new clinical events up to 6 months were found. One and four patients died in the levosimendan and placebo group, respectively., Conclusions: Levosimendan treatment improved contractility in post-ischaemic myocardium in patients with PCI-treated STEMI complicated by HF. The treatment was well tolerated, without any increase in arrhythmias.

Background: Inflammation plays an important role in the pathophysiology of both atherosclerosis and type 2 diabetes and some inflammatory markers may also predict the risk of developing type 2 diabetes. The aims of the present study were to assess a potential association between circulating levels of inflammatory markers and hyperglycaemia measured during an acute ST-elevation myocardial infarction (STEMI) in patients without known diabetes, and to determine whether circulating levels of inflammatory markers measured early after an acute STEMI, were associated with the presence of abnormal glucose regulation classified by an oral glucose tolerance test (OGTT) at three-month follow-up in the same cohort., Methods: Inflammatory markers were measured in fasting blood samples from 201 stable patients at a median time of 16.5 hours after a primary percutaneous coronary intervention (PCI). Three months later the patients performed a standardised OGTT. The term abnormal glucose regulation was defined as the sum of the three pathological glucose categories classified according to the WHO criteria (patients with abnormal glucose regulation, n = 50)., Results: No association was found between inflammatory markers and hyperglycaemia measured during the acute STEMI. However, the levels of C-reactive protein (CRP) and monocyte chemoattractant protein-1 (MCP-1) measured in-hospital were higher in patients classified three months later as having abnormal compared to normal glucose regulation (p = 0.031 and p = 0.016, respectively). High levels of CRP (≥ 75 percentiles (33.13 mg/L)) and MCP-1 (≥ 25 percentiles (190 ug/mL)) were associated with abnormal glucose regulation with an adjusted OR of 3.2 (95% CI 1.5, 6.8) and 7.6 (95% CI 1.7, 34.2), respectively., Conclusion: Elevated levels of CRP and MCP-1 measured in patients early after an acute STEMI were associated with abnormal glucose regulation classified by an OGTT at three-month follow-up. No significant associations were observed between inflammatory markers and hyperglycaemia measured during the acute STEMI.

A man in his sixties had acute ST-elevation myocardial infarction (treated with PCI [percutaneous coronary intervention] and antithrombotic medication) complicated by recurrent stent thrombosis. Excessive haematuria and discovery of a urinary bladder cancer complicated the antithrombotic treatment. Due to recurrent stent thrombosis the patient underwent a total of four PCIs and received the glycoprotein IIb/IIIa-inhibitor abciximab on two occasions. After the last administration of abciximab he developed excessive bleeding within an hour; a blood sample revealed severe thrombocytopenia (2 x 10(9)/l). Severe thrombocytopenia is a rare, but well-known complication to glycoprotein IIb/IIIa-inhibitor treatment and is most often seen after readministration of abciximab. The problem of recurrent coronary stent thrombosis was solved by aorto-coronary bypass surgery, which should always be considered in patients with recurrent stent thrombosis and complications to anti-thrombotic treatment. When bleeding occurs in connection with abciximab treatment, especially within the first month after previous treatment, severe thrombocytopenia should always be considered as a possible cause. Abciximab should be avoided in patients with a history of severe abciximab-related thrombocytopenia.

Background: A high prevalence of impaired glucose tolerance and unknown type 2-diabetes in patients with coronary heart disease and no previous diagnosis of diabetes have been reported. The aims of the present study were to investigate the prevalence of abnormal glucose regulation (AGR) 3 months after an acute ST-elevation myocardial infarction (STEMI) in patients without known glucometabolic disturbance, to evaluate the reliability of a 75-g oral glucose tolerance test (OGTT) performed very early after an acute STEMI to predict the presence of AGR at 3 months, and to study other potential predictors measured in-hospital for AGR at 3 months., Methods: This was an observational cohort study prospectively enrolling 224 STEMI patients treated with primary PCI. An OGTT was performed very early after an acute STEMI and was repeated in 200 patients after 3 months. We summarised the exact agreement observed, and assessed the observed reproducibility of the OGTTs performed in-hospital and at follow up. The patients were classified into glucometabolic categories defined according to the World Health Organisation criteria. AGR was defined as the sum of impaired fasting glucose, impaired glucose tolerance and type 2-diabetes., Results: The prevalence of AGR at three months was 24.9% (95% CI 19.1, 31.4%), reduced from 46.9% (95% CI 40.2, 53.6) when measured in-hospital. Only, 108 of 201 (54%) patients remained in the same glucometabolic category after a repeated OGTT. High levels of HbA1c and admission plasma glucose in-hospital significantly predicted AGR at 3 months (p < 0.001, p = 0.040, respectively), and fasting plasma glucose was predictive when patients with large myocardial infarction were excluded (p < 0.001)., Conclusion: The prevalence of AGR in STEMI patients was lower than expected. HbA1c, admission plasma glucose and fasting plasma glucose measured in-hospital seem to be useful as early markers of longstanding glucometabolic disturbance. An OGTT performed very early after a STEMI did not provide reliable information on long-term glucometabolic state and should probably not be recommended.

Objectives: Women with acute myocardial infarction (AMI) previously received less invasive evaluation and experienced higher mortality than men. After improvements in AMI care it is unclear whether gender differences still exist in management and outcome of AMI., Methods: All patients admitted to Ullevål University Hospital for AMI during 2006 and 2007 were included in this cohort study. Predefined data were recorded during the hospital stay, and the survival status of the patients was ascertained on June 30, 2008., Results: A total of 931 women and 2,174 men were included. No gender differences were observed in treatment delay or age-adjusted odds ratio (OR) of invasive evaluation in ST-elevation myocardial infarction (STEMI). In non-ST-elevation myocardial infarction (NSTEMI), women were less likely than men to undergo coronary angiography (adjusted OR 0.72, 95% CI 0.53-0.99, p = 0.044) and percutaneous coronary intervention (adjusted OR 0.60, 95% CI 0.47-0.76, p = 0.0001). Age-adjusted in-hospital mortality and long-term survival were similar between men and women., Conclusions: Women with STEMI experienced similar treatment delays and odds of invasive evaluation as men. However, gender differences in invasive evaluation were still observed in NSTEMI patients. No sex differences were observed in age-adjusted early and long-term mortality., (Copyright 2009 S. Karger AG, Basel.)

Background: The effects on left ventricular function of intracoronary injection of bone marrow cells in acute myocardial infarction (AMI) have been studied with conflicting results. The aim of this substudy of the ASTAMI trial was to examine the effects of this novel treatment on exercise capacity and quality of life., Methods: We studied 100 patients with anterior wall ST-elevation AMI. All had percutaneous coronary intervention with stent in the proximal or mid left anterior descending coronary artery 2 to 12 hours after start of symptoms. Patients were randomized to intracoronary injection of mononuclear bone marrow cells (mBMCs) in left anterior descending coronary artery 6 +/- 1.3 days after AMI (n = 50) or control (n = 50). Assessment of physical capacity by maximal symptom-limited bicycle ergometer exercise tests and quality of life by the Short Form 36 health survey was performed 2 to 3 weeks and 6 months after the AMI., Results: There was a significantly greater improvement in exercise time in the mBMC group than in the control group (treatment effect 0.9 minute, 95% CI 0.3-1.6, P < .01), and a similar improvement in peak oxygen consumption in the groups (2.8 +/- 3.9 mL/[kg min] in the mBMC group vs 2.4 +/- 3.5 mL/[kg min] in controls, P = .62). Peak heart rate and percentage of heart rate reserve increased significantly more in the treatment group than in the control group. Treatment with mBMCs did not influence quality of life., Conclusions: In this randomized open-labeled study, the mBMC group significantly improved exercise time and heart rate responses to exercise compared with the control group. There was no treatment effect on peak oxygen consumption.

Objectives: Thrombolysis is the treatment of choice for patients with ST-elevation myocardial infarction (STEMI) living in rural areas with long transfer delays to percutaneous coronary intervention (PCI). This trial compares two different strategies following thrombolysis: to transfer all patients for immediate coronary angiography and intervention, or to manage the patients more conservatively., Design: The NORwegian study on DIstrict treatment of STEMI (NORDISTEMI) is an open, prospective, randomized controlled trial in patients with STEMI of less than 6 hours of duration and more than 90 minutes expected time delay to PCI. A total of 266 patients will receive full-dose thrombolysis, preferably pre-hospital, and then be randomized to either strategy. Our primary endpoint is the one year combined incidence of death, reinfarction, stroke or new myocardial ischaemia. The study is registered with ClinicalTrials.gov, number NCT00161005., Results: By April 2006, 109 patients have been randomized. Thrombolysis has been given pre-hospital to 52% of patients. The median transport distance from first medical contact to catheterization laboratory was 155 km (range 90-396 km). Results of the study are expected in 2008.

Objectives: To assess if myocardial perfusion scintigraphy (MPS) at rest can be of value in elucidating myocardial perfusion, ischaemia and perioperative myocardial infarction (PMI) associated with coronary artery bypass graft (CABG) surgery., Design: This was a prospective randomized study of patients undergoing elective CABG. Forty-eight patients in the control group underwent serial ECG recordings and measurements of CK-MB and cTnT. Fifty-four patients in the study group were additionally examined with MPS preoperatively and 2-4 days and 6 weeks postoperatively., Results: The study showed a highly significant (p < 0.001) improvement in myocardial radionuclide uptake from preoperatively to 2-4 days postoperatively. Judged from ECG and enzymatic changes, two control patients and one study patient only had PMI and no additional cases of PMI were demonstrated by MPS., Conclusion: MPS at rest showed that CABG significantly improved myocardial perfusion, by demonstrating an increase in radionuclide uptake. In diagnosing PMI, we found that MPS provided no additional information beyond cardiac biochemical markers and ECG changes.

Background: Previous studies have shown improvement in left ventricular function after intracoronary injection of autologous cells derived from bone marrow (BMC) in the acute phase of myocardial infarction. We designed a randomized, controlled trial to further investigate the effects of this treatment., Methods: Patients with acute ST-elevation myocardial infarction of the anterior wall treated with percutaneous coronary intervention were randomly assigned to the group that underwent intracoronary injection of autologous mononuclear BMC or to the control group, in which neither aspiration nor sham injection was performed. Left ventricular function was assessed with the use of electrocardiogram-gated single-photon-emission computed tomography (SPECT) and echocardiography at baseline and magnetic resonance imaging (MRI) 2 to 3 weeks after the infarction. These procedures were repeated 6 months after the infarction. End points were changes in the left ventricular ejection fraction (LVEF), end-diastolic volume, and infarct size., Results: Of the 50 patients assigned to treatment with mononuclear BMC, 47 underwent intracoronary injection of the cells at a median of 6 days after myocardial infarction. There were 50 patients in the control group. The mean (+/-SD) change in LVEF, measured with the use of SPECT, between baseline and 6 months after infarction for all patients was 7.6+/-10.4 percentage points. The effect of BMC treatment on the change in LVEF was an increase of 0.6 percentage point (95% confidence interval [CI], -3.4 to 4.6; P=0.77) on SPECT, an increase of 0.6 percentage point (95% CI, -2.6 to 3.8; P=0.70) on echocardiography, and a decrease of 3.0 percentage points (95% CI, 0.1 to -6.1; P=0.054) on MRI. The two groups did not differ significantly in changes in left ventricular end-diastolic volume or infarct size and had similar rates of adverse events., Conclusions: With the methods used, we found no effects of intracoronary injection of autologous mononuclear BMC on global left ventricular function., (2006 Massachusetts Medical Society)

Background: Diabetes and impaired glucose tolerance are associated with increased mortality in patients with acute myocardial infarction. We have used standardised oral glucose tolerance tests shortly after a myocardial infarction., Methods: 109 patients admitted with acute myocardial infarction were prospectively enrolled in the study. An oral glucose tolerance test was performed the first morning the patients were stable, without pain, nausea or hyperglycaemia. The patients were classified into normal glucose tolerance, impaired glucose tolerance or diabetes, according to the results of the oral glucose tolerance test and fasting plasma glucose levels., Results: 109 patients (25 women) were included. Eight patients were previously diagnosed with diabetes type 2. Oral glucose tolerance was tested for 90 patients, usually the day after admission. The test was positive in 47 patients; 32 of them had 2-h plasma glucose levels between 7.8 and 11.0 mmol/L and were classified as having impaired glucose tolerance, and 15 had 2-h plasma glucose > or = 11.1 mmol/L and were classified as newly diagnosed diabetes patients. Similar body mass indexes and lipid values were found in patients with different glycometabolic states. Smoking was associated with a positive oral glucose tolerance test., Interpretation: More than half of the patients with acute myocardial infarction had undiagnosed impaired glucose tolerance or diabetes type 2, as determined by an oral glucose tolerance test. The test could easily be performed shortly after a myocardial infarction in most of the patients. Oral glucose tolerance testing should be considered in all patients with coronary heart disease without a history of diagnosed diabetes.

Background: Based on data from the literature, it has been suggested that elderly patients with acute myocardial infarction will benefit more from primary angioplasty than from thrombolysis., Material and Methods: Data for 100 consecutive patients, age 75 years or more, presenting with an acute ST elevation myocardial infarction (STEMI) without cardiogenic shock and treated with primary angioplasty were analysed retrospectively. Some variables were compared with previously published data on a group of 100 younger patients (mean age 59) with STEMI., Results: Angiographically, the success rate of revascularization was similar between the elderly (mean age 80) and the younger STEMI patients. Mortality, both at 30 days and at 1 year, was higher among the elderly patients compared with the younger (15% vs. 1% and 21% vs. 3% respectively, both p < 0.001). In the same time period, primary angioplasty was performed in seven patients > or = 75 years who presented with cardiogenic shock at admission. All of these died during hospitalization., Interpretation: Technically, the success rate of primary angioplasty in elderly patients with STEMI was similar to that in younger STEMI patients. Mortality after 30 days was significantly higher among the elderly patients, but the mortality rate from 30 days to 1 year after the infarction was similar to that of the same age group in the general population. Patients > or = 75 years presenting with STEMI and cardiogenic shock had no benefit of angioplasty; all died during hospitalization.

Background: Achieving reperfusion as soon as possible is essential in order to reduce myocardial infarction size and thus improve prognosis. An increasing number of patients with myocardial infarction are treated with primary percutaneous coronary intervention (PCI). Technetium 99m-tetrofosmin myocardial perfusion tomography (SPECT) is a valid test for assessing myocardium at risk and final infarct size expressed by a hypoperfusion index (HPI) of the left ventricular mass., Material and Methods: 20 patients with acute ST-elevation myocardial infarction were treated with primary percutaneous coronary intervention within six hours of onset of symptoms. Myocardium at risk and final infarct size were assessed by Technetium 99m-tetrofosmin immediately before and a few hours, one week and six weeks after., Results: The hypoperfusion index immediately before percutaneous coronary intervention was 31%, four to six hours after PCI 25%, one week later 16% and six weeks later 12%, i.e. a relative reduction of 60% (p < 0.01). Anterior wall infarctions had a higher level of myocardium at risk before primary PCI compared to inferior wall infarctions (36% vs. 24%), but anterior wall infarctions had a higher salvage index compared to inferior wall infarctions., Interpretation: This non-controlled study shows a marked reduction in final infarction size in patients with acute ST-elevation myocardial infarction treated with primary PCI.

Background: There is little information available on long-term changes in left ventricular function and infarct size after acute myocardial infarction treated with primary angioplasty., Material and Methods: From 1996 to 1998, 100 consecutive patients were treated with primary angioplasty for acute ST-elevation myocardial infarction. Left ventricular ejection fraction was determined by radionuclide ventriculography before discharge, after six weeks and after a mean follow-up time of 20 months (range 11-37). Infarct size was assessed by technetium 99m-tetrofosmin myocardial perfusion tomography (SPECT) at rest, performed at the same time intervals., Results: Mean ejection fraction was 56% at discharge, 55% after six weeks and 57% after 20 months of follow-up. A mean perfusion defect of 19% was measured by SPECT after one week. After six weeks and 20 months of follow-up, the mean perfusion defects were reduced to 14% (p < 0.001) and 15%, respectively., Interpretation: Left ventricular function was well preserved and infarct sizes small to moderate 20 months (range 11-37) after primary angioplasty for acute myocardial infarction, demonstrating that the initial successful effect of the treatment was maintained.

This article presents a letter to the editor in response to an article entitled "ST-segment elevation in conditions other than acute myocardial infarction," published in the November 27, 2003 issue.