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Introduction If reperfusion can be performed within 120 minutes, pPCI is the ESC guideline recommended treatment in patients with ST-elevation myocardial infarction (STEMI). Aims Historically, prognosis is dependent on time from diagnosis to reperfusion in patients with STEMI. We sought to investigate this in a contemporary patient population by assessing mortality as function of time from ECG diagnosis to sheath insertion in the Norwegian registry for invasive cardiology (NORIC). Methods NORIC, which is a part of the Norwegian Cardiovascular Disease Registry, is a national, mandatory and non-consensual person-identifiable health registry. Data from NORIC were linked with the National Population Register. Data were registered from 1st of January 2013 to 31st of June 2019. Results During this period complete data were available for n=5754 patients with 526 events. ECG diagnosis to sheath insertion was a predictor of mortality with the 4th (>106 min) vs 1st quartile ( Nationally 62% percent of the patients received pPCI within the ESC recommended 90 minutes from ECG-diagnosis with large geographical variation (range 38–89%). Nationally 80% received pPCI within 115 minutes (range 75–202 minutes). Conclusion In a contemporary STEMI population, time from ECG diagnosis to sheath insertion is a strong predictor for mortality in patients admitted for pPCI for STEMI. However, the data also demonstrate large variations between different geographical health regions in Norway that should be addressed. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Haukeland University Hospital

ObjectivesWe aimed to report the angiographic and procedural results of the After Eighty study (ClinicalTrials.gov, NCT01255540), and to identify independent predictors of revascularisation.MethodsPatients of ≥80 years old with non-ST-elevation myocardial infarction and unstable angina pectoris were randomised to an invasive or conservative strategy. Angiographic and procedural results were recorded. Univariate and multivariate analyses were performed to explore variables predicting revascularisation.ResultsAmong 229 patients in the invasive group, 220 underwent immediate coronary angiography (90% performed via the radial artery). Of these patients, 48% had three-vessel disease or left main stenosis, 18% two-vessel disease, 16% one-vessel disease, 17% minor coronary vessel wall changes and two patients had normal coronary arteries. Six patients (3%) underwent coronary artery bypass graft. Percutaneous coronary intervention (PCI) was performed in 107 patients (49%), with 57% treated with bare metal stents, 37% drug-eluting stents and 6% balloon angioplasty. On average, 1.7 lesions were treated and 2 stents delivered per patient. Complications included 1 major PCI-related bleeding (successfully treated), 2 minor access site-related bleedings, 3 side branch occlusions during PCI and 11 periprocedural myocardial infarctions (considered end points). Sex, bundle branch block and smoking were independent predictors of revascularisation.ConclusionsPCI was performed in approximately half of the patients, similar to findings in younger populations. Procedural success was high, with few complications.Trial registration numberNCT01255540

Background Percutaneous coronary intervention in complex bifurcation lesions is prone to suboptimal implantation results and is associated with increased risk of subsequent clinical events. Angiographic ambiguity is high during bifurcation stenting, but it is unknown if procedural guidance by intravascular optical coherence tomography (OCT) improves clinical outcome. Methods and design OCTOBER is a randomized, investigator-initiated, multicenter trial aimed to show superiority of OCT-guided stent implantation compared to standard angiographic-guided implantation in bifurcation lesions. The primary outcome measure is a 2-year composite end point of cardiac death, target lesion myocardial infarction, and ischemia-driven target lesion revascularization. The calculated sample size is 1,200 patients in total, and allocation is 1:1. Eligible patients have stable or unstable angina pectoris or stabilized non–ST elevation myocardial infarction, and a coronary bifurcation lesion with significant main vessel stenosis and more than 50 % stenosis in a side branch with a reference diameter ≥2.5mm. Treatment is performed by the provisional side branch stenting technique or 2-stent techniques, and the systematic OCT guiding protocol is aimed to evaluate (1) plaque preparation, (2) lesion length, (3) segmental reference sizes, (4) lesion coverage, (5) stent expansion, (6) malapposition, (7) wire positions, and (8) ostial results. Implications A positive outcome of the OCTOBER trial may establish OCT as a routine tool for optimization of complex percutaneous coronary intervention, whereas a negative result would indicate that OCT remains a tool for ad hoc evaluation in selected cases.

Introduction Limitations of the current reports on prognosis in ST elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI), are that they are based on selected samples from hospitals voluntary registries, trials and surveys and thereby lack full population coverage. In contrast to most developed countries, Sweden and the UK were for a long term, the only two countries worldwide that had continuous national clinical registries for acute coronary syndrome with mandated participation for all hospitals. This is now also the case in Norway. Of all STEMIs admitted to hospital in Norway, 77% is treated with PCI (2016). Since 2013 invasive coronary procedures is registered in The Norwegian registry for invasive cardiology (NORIC). Purpose The purpose of the current report from NORIC was to assess the mortality rates in patients treated with PCI for STEMI in Norway. Moreover we sought to assess the relationship between mortality and age at admission in this population. Methods NORIC, which is a part of the Norwegian Cardiovascular Disease Registry (NCDR), is a national person-identifiable health registry that does not require consent from the registered individual. Data were registered from 1st of January 2013 to 13th of June 2018. Results During this period 10524 patients were registered with a STEMI. The incidence is calculated for the years of 2015–2017 when the registry had full national coverage. The incidence of STEMI treated with PCI in Norway was (53 in 2015, 50 in 2016 and 52 in 2017 per 100 000). For patients younger than 80 years at admission, the mortality rates were 4.9%, 6.8% and 8.0% at 30 days, 365 days and 730 days respectively. For patients older than 80 years at admission the mortality rates were 8.3%, 15.6% and 19.0% at 30 days, 365 days and 730 days respectively. The mortality rates stratified by age are illustrated in figure 1. Survival stratified by age Conclusions Mortality in STEMI patients offered primary PCI in Norway is equal or even lower than the mortality reported from well-established national registries from UK and Sweden. This indicates a well functioning treatment strategy despite challenging geography. Age is an important determinant of mortality.

Assessment of global longitudinal strain (GLS) is superior to ejection fraction (EF) in the evaluation of left ventricular (LV) function in patients with stable coronary artery disease (CAD). However, the role of mechanical dispersion (MD) in this context remains unresolved. We aimed to evaluate the potential role of MD as a marker of LV dysfunction and long-term prognosis in stable CAD. EF, GLS and MD were assessed in 160 patients with stable CAD, 1 year after successful coronary revascularization. Serum levels of high-sensitivity cardiac troponin I (hs-cTnI) and amino-terminal pro B-type natriuretic peptide (NT-proBNP) were quantified as surrogate markers of LV dysfunction. The primary endpoint was defined as all-cause mortality, the secondary endpoint was defined as the composite of all-cause mortality and hospitalization for acute myocardial infarction or heart failure during follow-up. Whereas no associations between EF and the biochemical markers of LV function were found, both GLS and MD correlated positively with increasing levels of hs-cTnI (R = 0.315, P

Objective To show that limiting dual antiplatelet therapy (DAPT) to six months in patients with event-free ST-elevation myocardial infarction (STEMI) results in a non-inferior clinical outcome versus DAPT for 12 months. Design Prospective, randomised, multicentre, non-inferiority trial. Setting Patients with STEMI treated with primary percutaneous coronary intervention (PCI) and second generation zotarolimus-eluting stent. Participants Patients with STEMI aged 18 to 85 that underwent a primary PCI with the implantation of second generation drug-eluting stents were enrolled in the trial. Patients that were event-free at six months after primary PCI were randomised at this time point. Interventions Patients that were taking DAPT and were event-free at six months were randomised 1:1 to single antiplatelet therapy (SAPT) (ie, aspirin only) or to DAPT for an additional six months. All patients that were randomised were then followed for another 18 months (ie, 24 months after the primary PCI). Main outcome measures The primary endpoint was a composite of all cause mortality, any myocardial infarction, any revascularisation, stroke, and thrombolysis in myocardial infarction major bleeding at 18 months after randomisation. Results A total of 1100 patients were enrolled in the trial between 19 December 2011 and 30 June 2015. 870 were randomised: 432 to SAPT versus 438 to DAPT. The primary endpoint occurred in 4.8% of patients receiving SAPT versus 6.6% of patients receiving DAPT (hazard ratio 0.73, 95% confidence interval 0.41 to 1.27, P=0.26). Non-inferiority was met (P=0.004 for non-inferiority), as the upper 95% confidence interval of 1.27 was smaller than the prespecified non-inferiority margin of 1.66. Conclusions DAPT to six months was non-inferior to DAPT for 12 months in patients with event-free STEMI at six months after primary PCI with second generation drug-eluting stents. Trial registration Clinicaltrials.gov NCT01459627 .

Aims Acute coronary artery occlusion (ACO) occurs in ∼30% of patients with non-ST-segment elevation-acute coronary syndrome (NSTE-ACS). We investigated the ability of a regional non-invasive myocardial work index (MWI) to identify ACO. Methods and results Segmental strain analysis was performed before coronary angiography in 126 patients with NSTE-ACS. Left ventricular (LV) pressure was estimated non-invasively using a standard waveform fitted to valvular events and scaled to systolic blood pressure. MWI was calculated as the area of the LV pressure-strain loop. Empirical cut-off values were set to identify segmental systolic dysfunction for MWI (

N-terminal pro-B-type natriuretic peptide (NT-proBNP) and cardiac troponins (cTns) measured with sensitive assays provide strong prognostic information in patients with stable coronary artery disease. However, the relationship between these biomarkers and myocardial contractile function, as well as infarct size, in this patient group, remains to be defined. The study population consisted of 160 patients referred to a follow-up echocardiography scheduled 1 year after coronary revascularization. Concentrations of NT-proBNP, high-sensitive cTnT (hs-cTnT) and sensitive cTnI assays were assessed. Left ventricular function was measured as global peak systolic longitudinal strain by speckle tracking echocardiography and infarct size was assessed by late-enhancement MRI. NT-proBNP and sensitive cTnI levels were significantly associated with left ventricular function by peak systolic strain (R-values 0.243 and 0.228, p = 0.002 and 0.004) as well as infarct size (R-values 0.343 and 0.366, p = 0.014 and p = 0.008). In contrast, hs-cTnT did not correlate with left ventricular function (R = 0.095, p = 0.231) and only marginally with infarct size (R = 0.237, p = 0.094). NT-proBNP and sensitive cTnI levels correlate with left ventricular function and infarct size in patients with stable coronary artery disease after revascularization. As opposed to hs-cTnT, NT-proBNP and cTnI seem to be indicators of incipient myocardial dysfunction and the extent of myocardial necrosis.

ObjectivesThe aim of this study was to test the hypothesis that strain echocardiography might improve arrhythmic risk stratification in patients after myocardial infarction (MI).BackgroundPrediction of ventricular arrhythmias after MI is challenging. Left ventricular ejection fraction (LVEF) 40 days after acute MI were included, 268 of whom had ST-segment elevation MIs and 301 non–ST-segment elevation MIs. By echocardiography, global strain was assessed as average peak longitudinal systolic strain from 16 left ventricular segments. Time from the electrocardiographic R-wave to peak negative strain was assessed in each segment. Mechanical dispersion was defined as the standard deviation from these 16 time intervals, reflecting contraction heterogeneity.ResultsVentricular arrhythmias, defined as sustained ventricular tachycardia or sudden death during a median 30 months (interquartile range: 18 months) of follow-up, occurred in 15 patients (3%). LVEFs were reduced (48 ± 17% vs. 55 ± 11%, p < 0.01), global strain was markedly reduced (−14.8 ± 4.7% vs. −18.2 ± 3.7%, p = 0.001), and mechanical dispersion was increased (63 ± 25 ms vs. 42 ± 17 ms, p < 0.001) in patients with arrhythmias compared with those without. Mechanical dispersion was an independent predictor of arrhythmic events (per 10-ms increase, hazard ratio: 1.7; 95% confidence interval: 1.2 to 2.5; p < 0.01). Mechanical dispersion and global strain were markers of arrhythmias in patients with non–ST-segment elevation MIs (p < 0.05 for both) and in those with LVEFs >35% (p < 0.05 for both), whereas LVEF was not (p = 0.33). A combination of mechanical dispersion and global strain showed the best positive predictive value for arrhythmic events (21%; 95% confidence interval: 6% to 46%).ConclusionsMechanical dispersion by strain echocardiography predicted arrhythmic events independently of LVEF in this prospective, multicenter study of patients after MI. A combination of mechanical dispersion and global strain may improve the selection of patients after MI for implantable cardioverter-defibrillator therapy, particularly in patients with LVEFs >35% who did not fulfill current implantable cardioverter-defibrillator indications.

Sensitive troponin assays have substantially improved early diagnosis of myocardial infarction. However, the role of sensitive cardiac troponin (cTn) assays in prediction of significant coronary lesions and long-term prognosis in non-ST-elevation acute coronary syndrome (NSTE-ACS) remains unresolved.This prospective study includes 458 consecutive patients with NSTE-ACS admitted for coronary angiography. Serum levels of 4 commercial available sensitive troponin assays were analyzed (Roche high-sensitive cTnT [hs-cTnT; Roche Diagnostics, Basel, Switzerland], Siemens cTnI Ultra [Siemens, Munich, Germany], Abbott-Architect cTnI [Abbott, Abbott Park, IL], Access Accu-cTnI [Beckman Coulter, Nyon, Switzerland]), as well as a standard assay (Roche cTnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP), before coronary angiography.The relationship between the analyzed biomarkers and significant coronary lesions on coronary angiography, as quantified by area under the receiver operating characteristic curve, was significantly higher with Roche hs-cTnT, Siemens cTnI Ultra, and Access Accu-cTnI as compared with standard troponin T assay (P.001 for all comparisons). This difference was mainly caused by increased sensitivity below the 99th percentile. Also, NT-proBNP was associated with the presence of significant coronary lesions. Cardiac troponin values were correlated with cardiac death (primary end point) during 1373 (1257-1478) days of follow-up. In both univariate and multivariate Cox regression analyses, NT-proBNP was superior to both hs-cTnT and cTnI in prediction of cardiovascular mortality. Troponin values with all assays were correlated with the need for repeated revascularization (secondary end point) during follow-up.Sensitive cTn assays are superior to standard cTnT assay in prediction of significant coronary lesions in patients with NSTE-ACS. However, this improvement is primary caused by increased sensitivity below the 99th percentile. N-terminal pro-B-type natriuretic peptide is superior to cTns in prediction of long-term mortality.

BACKGROUND High-sensitivity cardiac troponin (hs-cTn) T and I assays are established as crucial tools for the diagnosis of acute myocardial infarction (AMI), as they have been found superior to old troponin assays. However, eventual differences between the assays in prediction of significant coronary lesions and long-term prognosis in patients with acute coronary syndrome (ACS) have not been fully unraveled. METHODS Serum concentrations of hs-cTnT (Roche), hs-cTnI (Abbott), and amino-terminal pro-B-type natriuretic peptide (NT-proBNP; Roche) in 390 non-ST-elevation (NSTE) ACS patients were evaluated in relation to significant coronary lesions on coronary angiography (defined as a stenosis >50% of the luminal diameter, with need for revascularization) and prognostic accuracy for cardiovascular mortality, all-cause mortality, as well as the composite end point of cardiovascular mortality and hospitalizations for AMI or heart failure. RESULTS The mean (SD) follow-up was 2921 (168) days. Absolute hs-cTnI concentrations were significantly higher than the hs-cTnT concentrations. The relationship between analyzed biomarkers and significant coronary lesions on coronary angiography, as quantified by the area under the ROC curve (AUC), revealed no difference between hs-cTnT [AUC, 0.81; 95% CI, 0.77–0.86] and hs-cTnI (AUC, 0.81; 95% CI, 0.76–0.86; P = NS). NT-proBNP was superior to both hs-cTn assays regarding prognostic accuracy for both cardiovascular and all-cause mortality and for the composite end point during follow-up, also in multivariate analyses. CONCLUSIONS The hs-cTnT and hs-cTnI assays displayed a similar ability to predict significant coronary lesions in NSTE-ACS patients. NT-proBNP was superior to both hs-cTn assays as a marker of long-term prognosis in this patient group.

Our aim was to investigate the associations between B-type natriuretic peptide (NT-proBNP), troponin T (TnT) and C-reactive protein (CRP) and changes in left ventricular function and size after acute coronary syndrome.In 119 patients admitted for non-ST-elevation acute coronary syndrome, echocardiography and blood sampling were performed prior to coronary angiography. Echocardiography was repeated at follow-up after 8 ± 3 months. Left ventricular function was assessed by speckle tracking echocardiography. In 50 patients, infarct size was determined by magnetic resonance imaging. The associations between baseline levels of NT-proBNP, TnT and CRP and myocardial functional recovery, left ventricular intraventricular volumes and infarct size were determined by linear regression.All three biomarkers were associated with myocardial dysfunction at baseline. However, high levels of NT-proBNP were associated with better myocardial recovery, as measured by global longitudinal strain, even after adjusting for other factors potentially influencing myocardial recovery.Elevated levels of NT-proBNP at baseline are independently associated with improved myocardial performance 8 months after non-ST-elevation acute coronary syndrome.

The optimal timing of coronary angiography in patients with non-ST elevation (NSTE) acute coronary syndromes (ACS) is debated. American Heart Association and American College of Cardiology guidelines recommend an early invasive strategy12 to 48 hours after the onset of symptoms. The objective of the present study was to determine possible changes in myocardial function in patients with NSTE ACS awaiting coronary angiography. One hundred two patients with suspected NSTE ACS were enrolled, including 56 with NSTE myocardial infarctions (NSTEMIs), 23 with unstable angina pectoris, and 23 with noncoronary chest pain. Global and regional myocardial function was measured as longitudinal and circumferential strain using speckle-tracking echocardiography. Measurements were performed at admission and immediately before coronary angiography (30 + or - 16 hours after admission). In patients with NSTEMIs, there was deterioration in longitudinal global strain from -16.1 + or - 2.6% at admission to -15.0 + or - 2.6% before coronary angiography (p0.001). This was due to deterioration in longitudinal strain in the territory supplied by the infarct-related artery from -14.2 + or - 4.2% to -12.0 + or - 4.1% (p0.001). Patients with NSTEMIs due to acute coronary occlusion underwent prominent worsening in longitudinal and circumferential strains (-15.7 + or - 2.9% to -13.9 + or - 3.0%, p = 0.001, and -16.7 + or - 4.0% to -15.0 + or - 3.9%, p = 0.01, respectively) compared to patients with NSTEMIs without occlusions. There were no changes in strain in patients with unstable angina pectoris or noncoronary chest pain. In patients with NSTEMIs without acute coronary occlusions, myocardial function improved after revascularization, whereas patients with acute occlusions demonstrated no improvement. In conclusion, myocardial function deteriorates in patients with NSTEMIs awaiting coronary angiography. Patients with acute coronary occlusions have the most prominent deterioration, and this subgroup shows no recovery of function after revascularization.

Aims Patients with acute coronary occlusion may lack typical signs of myocardial infarction in the electrocardiogram. We tested the ability of different echocardiographic modalities to identify coronary occlusion by quantifying myocardial dysfunction in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS). Methods and results One hundred and fifty patients were examined by echocardiography immediately prior to coronary angiography, 2.2 ± 0.7 days (mean ± SD) after hospitalization for a first NSTE-ACS. Thirty-three patients (22%) had acute coronary occlusion. These patients had impaired left ventricular function as ejection fraction was reduced (54.9 ± 9.6 vs. 59.1 ± 7.6%, P = 0.02). Regional myocardial function was assessed in a 16-segment model by two methods: longitudinal strain by speckle tracking echocardiography and wall motion score (WMS) by visual assessment. Patients with acute coronary occlusion had an increased number of adjacent dysfunctional segments. The median size of the dysfunctional area by strain was 7 [inter-quartile range (IQR) 4.5–9] vs. 2 (IQR 0–5) segments ( P < 0.001). An area of ≥4 adjacent dysfunctional segments (strain greater than or equal to −14%) had the best ability to identify patients with acute coronary occlusion, with sensitivity 85% and specificity 70%. WMS demonstrated slightly less accuracy than strain. Conclusion Strain echocardiography identifies NSTE-ACS patients with acute coronary occlusion, who may benefit from urgent reperfusion therapy.

Background Many patients with suspected non–ST-segment elevation acute coronary syndrome (NSTE-ACS) do not have significant coronary artery disease. The current diagnostic approach of repeated electrocardiography and cardiac biomarker assessment requires observation for >6 to 12 hours. This strategy places a heavy burden on hospital facilities. The objective of this study was to investigate whether myocardial strain assessment by echocardiography could exclude significant coronary artery stenosis in patients presenting with suspected NSTE-ACS. Methods Sixty-four patients presenting to the emergency department with suspected NSTE-ACS without known coronary artery disease, inconclusive electrocardiographic findings, and normal cardiac biomarkers at arrival were enrolled. Twelve-lead electrocardiography, troponin T assay, and echocardiography were performed at arrival, and all patients underwent coronary angiography. Significant coronary stenosis was defined as >50% luminal narrowing. Global myocardial peak systolic longitudinal strain was measured using speckle-tracking echocardiography. Left ventricular ejection fraction and wall motion score index were calculated. Results No significant stenosis in any coronary artery was found in 35 patients (55%). Global peak systolic longitudinal strain was superior to conventional echocardiographic parameters in distinguishing patients with and without significant coronary artery stenosis (area under the curve, 0.87). Sensitivity and specificity were calculated as 0.93 and 0.78, respectively, and positive predictive value and negative predictive value as 0.74 and 0.92, respectively. Feasibility of the strain measurements was excellent, with 97% of segments analyzed. Conclusions Myocardial strain by echocardiography may facilitate the exclusion of significant coronary artery stenosis among patients presenting with suspected NSTE-ACS with inconclusive electrocardiographic findings and normal cardiac biomarkers.

Mitral annular displacement (MAD) is a simple marker of left ventricular (LV) systolic function. The aim of this study was to test the hypothesis that MAD can distinguish patients with non-ST-segment elevation myocardial infarctions (NSTEMIs) from those with significant coronary artery disease without infarctions, identify coronary occlusion, and predict mortality in patients with NSTEMIs. MAD was compared with established indices of LV function.In this retrospective study, 167 patients with confirmed NSTEMIs were included at two Scandinavian centers. Forty patients with significant coronary artery disease but without myocardial infarctions were included as controls. Doppler tissue imaging was performed at the mitral level of the left ventricle in the three apical planes, and velocities were integrated over time to acquire MAD. LV ejection fraction, global longitudinal strain (GLS), and wall motion score index were assessed according to guidelines.MAD and GLS could accurately distinguish patients with NSTEMIs from controls. During 48.6 ± 12.1 months of follow-up, 22 of 167 died (13%). MAD, LV ejection fraction, and GLS were reduced and wall motion score index was increased among those who died compared with those who survived (P.001, P .001, P.001, and P = .02, respectively). Multivariate Cox proportional-hazards analyses revealed that MAD was an independent predictor of death (hazard ratio, 1.36; 95% confidence interval, 1.07-1.73; P = .01). MAD and GLS were reduced and wall motion score index was increased in patients with coronary artery occlusion compared with those without occlusion (P = .006, P = .001, and P = .02), while LV ejection fraction did not differ (P = .20).MAD accurately identified patients with NSTEMIs, predicted mortality, and identified coronary occlusion in patients with NSTEMIs.

Background Left ventricular (LV) remodeling takes place after acute myocardial infarction (MI), potentially leading to overt heart failure (HF). Enhanced inflammation may contribute to LV remodeling. Our hypothesis was that the immunomodulating effects of intravenous immunoglobulin (IVIg) would be beneficial in patients with impaired myocardial function after MI by reducing myocardial remodeling and improving myocardial function. Methods Sixty-two patients with acute MI treated by percutaneous coronary intervention, with depressed LV ejection fraction (LVEF) were randomized in a double-blinded fashion to IVIg as induction therapy and thereafter as monthly infusions or placebo for 26weeks. The primary end point was changes in LVEF from baseline to 6months as assessed by MRI. Results Our main findings were: ( i ) LVEF increased significantly from 38±10 (mean±SD) to 45±13% after IVIg and from 42±9 to 49±12% after placebo with no difference between the groups. ( ii ) The scar area decreased significantly by 3% and 5% in the IVIg and placebo group, respectively, with no difference between the groups. ( iii ) During the induction therapy (baseline to day 5), IVIg induced both inflammatory (e.g., increase in tumor necrosis factor α and monocyte chemoattractant protein-1) and anti-inflammatory (e.g., increase in interleukin-10 and decrease in leukocyte counts) variables, but during maintenance therapy there were no differences in changes of inflammatory mediators between IVIg and placebo. Conclusions IVIg therapy after ST elevation MI managed by primary PCI does not affect LV remodeling or function. This illustrates the challenges of therapeutic intervention directed against the cytokine network, to prevent post-MI remodeling.

Early prediction of infarct size directs therapy in patients with acute myocardial infarction (AMI). Global strain by echocardiography describes myocardial deformation and correlates with infarct size. However, peak strain measures deformation at a single time point, whereas ischemia and necrosis influence deformation throughout the heart cycle. It was hypothesized that the measurement of myocardial deformation throughout the heart cycle by mean strain is a more comprehensive expression of myocardial deformation. The aim of this study was to assess the ability of mean strain to predict infarct size and to identify large infarctions at admission and after revascularization in patients with AMI.Seventy-six patients with AMI were included. Echocardiographic measurements were performed at admission and after revascularization. Myocardial strain was calculated using speckle-tracking echocardiography. Infarct size was measured using contrast-enhanced magnetic resonance imaging ≥3 months after revascularization.There were significant correlations between infarct size and longitudinal global mean strain, longitudinal global strain, and left ventricular ejection fraction (P.0001), both at admission and after revascularization. The correlations improved after revascularization. Longitudinal global mean strain had the best correlation with infarct size and the best ability to discriminate between different infarct size categories. At admission, a cutoff value of -7.6 had 89% sensitivity, 88% specificity, and an area under the receiver operating characteristic curve of 0.92 for the identification of large infarctions. Prediction of infarct size improved for all parameters after revascularization.Longitudinal global mean strain provides improved early prediction of infarct size in patients with AMI compared with longitudinal global strain and left ventricular ejection fraction.

To compare infarct size and left ventricular ejection fraction in patients with non-ST-elevation myocardial infarction (NSTEMI) with and without acute coronary occlusions, and determine if myocardial strain by speckle-tracking echocardiography can identify acute occlusions in patients presenting with non-ST-elevation acute coronary syndrome (NSTE-ACS).111 patients with suspected NSTE-ACS were enrolled shortly after admittance. Echocardiographic measurements were performed a median of 1 h (interquartile range 0.5-4) after admittance, and coronary angiography 36 ± 21 h after onset of symptoms. Territorial longitudinal and circumferential strain was calculated based on the perfusion territories of the three major coronary arteries in a 16-segment model of the left ventricle, and compared with traditional echocardiographic parameters. Long-term follow-up was by echocardiography and contrast-enhanced magnetic resonance imaging (ceMRI).Patients with NSTEMI due to acute coronary occlusion had higher peak troponin T than patients with NSTEMI without acute occlusions (4.9 ± 4.7 vs 0.9 ± 1.1 μg/l, p0.001), larger infarct size by ceMRI (13 ± 8% vs 3 ± 3%, p0.001) and poorer left ventricular ejection fraction (48 ± 6% vs 57 ± 6%, p0.001) at follow-up. Territorial circumferential strain was the best parameter for predicting acute coronary occlusion. A territorial circumferential strain value-10.0% had 90% sensitivity, 88% specificity and area under the curve=0.93 for identification of acute occlusions.Patients with NSTEMI due to acute coronary occlusions develop larger infarcts and more impaired left ventricular function than patients with NSTEMI without occlusions, regardless of infarct-related territory. Territorial circumferential strain by echocardiography enables very early identification of acute coronary occlusions in patients with NSTE-ACS and may be used for detection of patients requiring urgent revascularisation.

Background— Infarct size is a strong predictor of mortality and major adverse cardiovascular events after myocardial infarction. Acute reperfusion therapy limits infarct size and improves survival, but its use has been confined to patients with ST-segment–elevation myocardial infarction. The purpose of this study was to assess the relationship between echocardiographic parameters of left ventricular (LV) systolic function obtained before revascularization and final infarct size in patients with non–ST-segment–elevation myocardial infarction, as well as the ability of these parameters to identify patients with substantial infarction. Methods and Results— Sixty-one patients with non–ST-segment–elevation myocardial infarction were examined by echocardiography immediately before revascularization, 2.1�0.6 days after hospitalization. LV systolic function was assessed by ejection fraction, wall motion score index, and circumferential, longitudinal, and radial strain in a 16-segment LV model. Global strain represents average segmental strain values. Infarct size was assessed after 9�3 months by late-enhancement MRI, as a percentage of total LV myocardial volume. A good correlation was found between infarct size and wall motion score index ( r =0.74, P r =0.68, P −13.8% and wall motion score index >1.30 accurately identified patients with substantial infarction (≥12% of myocardium, n=13; area under the receiver operator curve, 0.95 and 0.92, respectively). Conclusions— Echocardiographic parameters of LV systolic function correlate to infarct size in patients with non–ST-segment–elevation myocardial infarction. Global longitudinal strain and wall motion score index are both excellent parameters to identify patients with substantial myocardial infarction, who may benefit from urgent reperfusion therapy.

A 48-year-old previously healthy woman suffered witnessed cardiac arrest in hospital. She achieved return of spontaneous circulation and was transferred to the intensive care unit. During the following 3 hours, she suffered a cardiac electrical storm with 98 episodes of Torsade de Pointes ventricular tachycardia rapidly degenerating to ventricular fibrillation. She was converted with a total of 99 defibrillations. There was no response to the use of any recommended anti arrhythmic drugs. However, the use of bretylium surprisingly stabilized her heart rhythm and facilitated placing of a temporary pacemaker. Overdrive pacing prevented further arrhythmias and was life saving. A number of beneficial factors may have contributed to the good neurological outcome. Further investigations gave no explanation for her cardiac electrical storm.