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Item does not contain fulltext OBJECTIVES: The aim of the present study was to determine the effect of a delayed versus an immediate invasive approach on final infarct size and clinical outcome up to 1 year. BACKGROUND: Up to 24% of patients with acute coronary syndromes present with ST-segment elevation myocardial infarction (STEMI) but show complete resolution of ST-segment elevation and symptoms before revascularization. Current guidelines do not clearly state whether these patients with transient STEMI should be treated with a STEMI-like or non-ST-segment elevation acute coronary syndrome-like intervention strategy. METHODS: In this multicenter trial, 142 patients with transient STEMI were randomized 1:1 to either delayed or immediate coronary intervention. Cardiac magnetic resonance imaging was performed at 4 days and at 4-month follow-up to assess infarct size and myocardial function. Clinical follow-up was performed at 4 and 12 months. RESULTS: In the delayed (22.7 h) and the immediate (0.4 h) invasive groups, final infarct size as a percentage of the left ventricle was very small (0.4% [interquartile range: 0.0% to 2.5%] vs. 0.4% [interquartile range: 0.0% to 3.5%]; p = 0.79), and left ventricular function was good (mean ejection fraction 59.3 +/- 6.5% vs. 59.9 +/- 5.4%; p = 0.63). In addition, the overall occurrence of major adverse cardiac events, consisting of death, recurrent infarction, and target lesion revascularization, up to 1 year was low and not different between both groups (5.7% vs. 4.4%, respectively; p = 1.00). CONCLUSIONS: At follow-up, patients with transient STEMI have limited infarction and well-preserved myocardial function in general, and delayed or immediate revascularization has no effect on functional outcome and clinical events up to 1 year.

Contains fulltext : 235369.pdf (Publisher’s version ) (Open Access) BACKGROUND: Up to 24% of patients presenting with ST-elevation myocardial infarction (STEMI) show resolution of ST-elevation and symptoms before revascularization. The mechanisms of spontaneous reperfusion are unclear. Given the more favorable outcome of transient STEMI, it is important to obtain further insights in differential aspects. METHODS: We compared 251 patients who presented with transient STEMI (n = 141) or persistent STEMI (n = 110). Clinical angiographic and laboratory data were collected at admission and in subset of patients additional index hemostatic data and at steady-state follow-up. Cardiac magnetic resonance imaging (CMR) was performed at 2-8 days to assess myocardial injury. RESULTS: Transient STEMI patients had more cardiovascular risk factors than STEMI patients, including more arterial disease and higher cholesterol values. Transient STEMI patients showed angiographically more often no intracoronary thrombus (41.1% vs. 2.7%, P < 0.001) and less often a high thrombus burden (9.2% vs. 40.0%, P < 0.001). CMR revealed microvascular obstruction less frequently (4.2% vs. 34.6%, P < 0.001) and smaller infarct size [1.4%; interquartile range (IQR), 0.0-3.7% vs. 8.8%; IQR, 3.9-17.1% of the left ventricle, P < 0.001] with a better preserved left ventricular ejection fraction (57.8 ± 6.7% vs. 52.5 ± 7.6%, P < 0.001). At steady state, fibrinolysis was higher in transient STEMI, as demonstrated with a reduced clot lysis time (89 ± 20% vs. 99 ± 25%, P = 0.03). CONCLUSIONS: Transient STEMI is a syndrome with less angiographic thrombus burden and spontaneous infarct artery reperfusion, resulting in less myocardial injury than STEMI. The presence of a more effective fibrinolysis in transient STEMI patients may explain these differences and might provide clues for future treatment of STEMI.

Background Up to 24% of acute coronary syndrome patients present with ST-elevation but show complete resolution of ST-elevation and symptoms before revascularization. The current guidelines do not clearly state whether these transient ST-elevation myocardial infarction (TSTEMI) patients should be treated with a ST-elevation myocardial infarction (STEMI)-like or a non-STEMI-like invasive approach. Purpose The aim of the present study is to determine the effect of an immediate versus a delayed invasive strategy on infarct size measured by 4-month cardiac magnetic resonance imaging (CMR) and clinical outcome up to one year. Methods In this multicenter trial, 142 TSTEMI patients were randomized 1:1 to either an immediate or a delayed intervention. CMR was performed at four days and at 4-month follow-up to assess infarct size and myocardial function. Clinical follow-up was performed at four months and one year. Results Both in the immediate (0.4 h) and the delayed invasive group (22.7 h) CMR-derived infarct size at four months was very small and left ventricular function was good. In addition, major adverse cardiac events and all-cause mortality at one year were low and not different between both groups (table 1). CMR and clinical outcomes up to one year Outcome Immediate invasive group (n=70) Delayed invasive group (n=72) p-value Myocardial infarct size (% of LV), median (IQR) 0.4 (0.0–3.5) 0.4 (0.0–2.5) 0.79 LVEF (%), mean ± SD 59.9±5.4 59.3±6.5 0.63 LVEF recovery (%), mean ± SD 2.2±5.4 1.7±5.3 0.66 MVO present, No. (%) 0 (0.0) 1 (1.9) 0.50 MACE (death, reinfarction, target lesion revascularization), No. (%) 3 (4.4) 4 (5.7) 1.00 Death from any cause, No. (%) 0 (0.0) 3 (4.3) 0.24 Reinfarction, No. (%) 2 (3.0) 1 (1.4) 0.62 Target lesion revascularization, No. (%) 2 (3.0) 1 (1.4) 0.62 Definite stent thrombosis, No. (%) 1 (1.5) 1 (1.4) 1.00 Abbreviations: IQR, interquartile range; LV, left ventricle; LVEF, left ventricle ejection fraction; MACE, major adverse cardiac events; MVO, microvascular obstruction; NA, not applicable; SD, standard deviation. Conclusions We demonstrated that patients with TSTEMI have limited infarct size and preserved left ventricular function and that an immediate or delayed approach has no effect on clinical outcome up to one year. Therefore, patients with TSTEMI can be treated with both an immediate or a delayed invasive strategy with similar outcome. These findings extend our current knowledge about the optimal timing of coronary intervention in patients with TSTEMI and complement the guidelines. Acknowledgement/Funding AstraZeneca, Biotronik

Up to 24% of acute coronary syndrome patients present with ST-elevation but show complete resolution of ST-elevation and symptoms before revascularization therapy. The current guidelines do not clearly state whether these transient ST-elevation myocardial infarction (TSTEMI) patients benefit from an

Contains fulltext : 202703.pdf (Publisher’s version ) (Closed access) Aims: Patients with acute coronary syndrome who present initially with ST-elevation on the electrocardiogram but, subsequently, show complete normalization of the ST-segment and relief of symptoms before reperfusion therapy are referred to as transient ST-segment elevation myocardial infarction (STEMI) and pose a therapeutic challenge. It is unclear what the optimal timing of revascularization is for these patients and whether they should be treated with a STEMI-like or a non-ST-segment elevation myocardial infarction (NSTEMI)-like invasive approach. The aim of the study is to determine the effect of an immediate vs. a delayed invasive strategy on infarct size measured by cardiac magnetic resonance imaging (CMR). Methods and results: In a randomized clinical trial, 142 patients with transient STEMI with symptoms of any duration were randomized to an immediate (STEMI-like) [0.3 h; interquartile range (IQR) 0.2-0.7 h] or a delayed (NSTEMI-like) invasive strategy (22.7 h; IQR 18.2-27.3 h). Infarct size as percentage of the left ventricular myocardial mass measured by CMR at day four was generally small and not different between the immediate and the delayed invasive group (1.3%; IQR 0.0-3.5% vs. 1.5% IQR 0.0-4.1%, P = 0.48). By intention to treat, there was no difference in major adverse cardiac events (MACE), defined as death, reinfarction, or target vessel revascularization at 30 days (2.9% vs. 2.8%, P = 1.00). However, four additional patients (5.6%) in the delayed invasive strategy required urgent intervention due to signs and symptoms of reinfarction while awaiting angiography. Conclusion: Overall, infarct size in transient STEMI is small and is not influenced by an immediate or delayed invasive strategy. In addition, short-term MACE was low and not different between the treatment groups.

Background— The Navvus pressure sensor–equipped microcatheter allows to measure functional stenosis severity over a work-horse guidewire and is used as a more feasible alternative to regular sensor-equipped wires. However, Navvus is larger in diameter than contemporary sensor-equipped guidewires and may, thereby, influence functional measurements. The present study evaluates the hemodynamic influence of the Navvus microcatheter. Methods and Results— In patients with intermediate coronary stenosis, coronary pressure and flow velocity were measured using a dual sensor–equipped guidewire before and after introduction of Navvus. Patients were randomized to microcatheter-first or guidewire-first measurement. The primary end point was the difference in hyperemic stenosis resistance index between measurements before and after introduction of Navvus. Measurements were completed in 28 patients (28 stenoses). Mean hyperemic stenosis resistance was 0.37±0.19 Hg/cm/s for wire-only assessment and 0.48±0.26 Hg/cm/s after Navvus introduction ( P P =0.001). Passing–Bablok analysis revealed absence of a constant difference but significant proportional difference between the methods. Mean fractional flow reserve was 0.86±0.06 for wire-only assessment and 0.82±0.07 after Navvus introduction ( P P =0.036). Passing–Bablok analysis revealed significant constant and proportional differences between methods. Similar results were documented for resting indices of stenosis severity. Conclusions— Introduction of the Navvus microcatheter leads to clinically relevant stenosis severity overestimation in intermediate stenosis.

An estimated 4-24% of patients presenting with ST-segment elevation myocardial infarction (STEMI) subsequently show resolution of ST-segment elevation and relief of symptoms before revascularization. The mechanisms of spontaneous reperfusion in STEMI are unclear. Given the more favourable outcome of

Aims The combined use of cardiac computed tomography (CT) coronary angiography (CTCA) and myocardial perfusion imaging allows the non-invasive evaluation of coronary morphology and function. Cardiovascular magnetic resonance (CMR) imaging has several advantages: it can simultaneously assess myocardial perfusion, ventricular and valvular function, cardiomyopathy, and aortic disease and does not involve any additional ionizing radiation. We investigated the combined use of cardiac CT and CMR for the diagnostic evaluation of patients with suspected coronary artery disease (CAD) in clinical practice. Methods and results A total of 192 patients with low or intermediate pre-test probability of CAD underwent CTCA and CMR. All patients with obstructive CAD on CTCA and/or myocardial ischaemia on CMR were referred for invasive coronary angiography (ICA). Fractional flow reserve was measured in case of intermediate lesions (30–70% diameter stenosis) on ICA. Additional cardiac and extra-cardiac findings by CTCA and CMR were registered. The combination of CTCA and CMR significantly improved specificity and overall accuracy (94 and 91%) for the detection of significant CAD compared with their use as a single technique (CTCA 39 and 57%, P < 0.0001; CMR 82 and 83%, P = 0.016). No events were recorded during follow-up (18 ± 6 months) in 104 patients who did not undergo ICA. Furthermore, the combined strategy provided an alternative diagnosis in 19 patients. Conclusion The combined use of CTCA and CMR significantly improved specificity and overall diagnostic accuracy for the detection of significant CAD and allowed the detection of alternative (extra-)cardiac disease in patients without significant CAD.

The combined use of cardiac computed tomography coronary angiography (CTCA) and myocardial perfusion imaging allows the non-invasive evaluation of coronary morphology and function. Cardiovascular magnetic resonance imaging (CMR) has several advantages: it can simultaneous assess myocardial perfusion, ventricular and valvular function, cardiomyopathy and aortic disease and does not involve any ionizing radiation.

Background: Several studies have investigated the diagnostic performance of computed tomography coronary angiography (CTCA) for the detection of significant coronary artery disease (CAD). These studies were performed in patients that were already referred for invasive coronary angiography (ICA) and prevalence of significant CAD was high. Although the negative predictive value of CTCA was consistently high, a wide range of positive predictive values (PPVs) was reported. Thus, the PPV of CTCA in patients that undergo CTCA as part of a clinical diagnostic evaluation remains unclear. This study investigated the PPV of CTCA for the detection of significant CAD in clinical practice. Methods: A total of 181 patients with low to intermediate pre-test probability CAD that were referred for non-invasive evaluation of chest pain underwent 64-slice CTCA. CTCA was scored per segment as normal, non-obstructive CAD or obstructive CAD (> 50% diameter stenosis). All patients with obstructive CAD according to CTCA, underwent ICA. Significant CAD was defined as > 50% diameter stenosis on ICA. Results: According to CTCA, 65 (35.9%) patients had obstructive CAD. In 26 (14.4%) patients, significant CAD was found by ICA. The PPV for detection of significant CAD per patient, per vessel and per segment were 40.0% (26/65, 95% CI: 30.6-50.2%), 31.3% (36/115, 95% CI: 24.7-38.8%) and 25.5% (42/165; 95% CI: 20.3-31.4%), respectively. Conclusions: The PPV of CTCA for detection of significant CAD in patients with low to intermediate probability CAD that are clinically referred for non-invasive evaluation of chest pain is markedly lower than generally reported. © 2010 Elsevier Ireland Ltd. All rights reserved.

Objectives. The aim of this study was to analyse the rate of major adverse clinical events in patients with coronary artery disease and a fractional flow reserve (FFR) of ≥0.75 and deferred for coronary intervention in daily practice. Methods. From 1 January to 31 December 2006, FFR measurement was initiated in 122 patients (5%) out of 2444 patients referred for coronary angiography. In two patients FFR measurement failed and in one patient the FFR value could no longer be traced in the documents. Thus, 119 patients (84 men, 64 years, range 41-85) were included in the evaluation (145 lesions). Major adverse clinical events (death, myocardial infarction, percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG)) and the presence of angina were evaluated at follow-up. Furthermore a cost-effectiveness analysis was performed.Results. In 93 patients (76%) the FFR value was ≥0.75. Seventy of these 93 patients (76%) were treated with medication alone or underwent PCI for a different lesion (medical treatment group). Average duration of follow-up of all 119 patients was 22 months (range 4 days to 30 months). In the medical treatment group seven patients (10%) experienced a major adverse clinical event related to the FFR-evaluated lesion during follow-up. In this study population, the use of FFR measurement is cost-reducing provided that at least 65% of the patients in the medical treatment group has had a PCI with stent implantation when the use of FFR measurement is impossible. In this case, the decision to use PCI with stent implantation is purely based on the angiogram. Conclusions. In patients with a coronary stenosis based on visual assessment and an FFR of ≥0.75 deferral of PCI or CABG is safe in daily clinical practice and saves money. (Neth Heart J 2010;18:402-7.).

To compare coronary computed tomographic (CT) angiography with first-pass magnetic resonance (MR) myocardial perfusion imaging in patients with chest pain and low to intermediate probability of coronary artery disease (CAD).Local ethics committee approval and patient written informed consent were obtained. Patients with chest pain and low to intermediate pretest probability of CAD underwent both coronary CT angiography and MR myocardial perfusion imaging. Coronary CT angiographic and MR myocardial perfusion images were analyzed qualitatively by blinded observers. Obstructive CAD was defined as more than 50% diameter stenosis at coronary CT angiography. Data were expressed with 95% confidence intervals (CIs) calculated from binomial expression.In 145 (94.2%) of 154 eligible patients, both coronary CT angiography and MR myocardial perfusion imaging were performed successfully. Mean age was 57 years +/- 10 (standard deviation), and 45.5% of patients were male. Mean interval between coronary CT angiography and MR myocardial perfusion imaging was 4.6 days +/- 3.0; median was 5.0 days. CT coronary angiography revealed obstructive CAD in 52 (35.9%) patients and 78 (17.9%) coronary arteries. At MR myocardial perfusion imaging, myocardial ischemia was demonstrated in 33 (22.8%) patients and 59 (13.6%) vessel territories. Of patients without CAD at coronary CT angiography, 90.5% (57 of 63; 95% CI: 82.6%, 95.0%) had normal myocardial perfusion at MR myocardial perfusion imaging. Of patients with nonobstructive CAD, 83.3% (25 of 30; 95% CI: 69.5%, 91.6%) had normal myocardial perfusion at MR myocardial perfusion imaging. Myocardial ischemia was detected at MR myocardial perfusion imaging in 42.3% (22 of 52; 95% CI: 29.5%, 56%) of patients with obstructive CAD at coronary CT angiography.MR myocardial perfusion imaging and coronary CT angiography have complementary roles in evaluation of patients who are suspected of having CAD. Coronary CT angiography can be used to reliably rule out CAD, but its capability to demonstrate hemodynamically significant CAD is limited. The combination of both techniques enables the clinician to evaluate morphology and functional relevance of CAD comprehensively and noninvasively.

Purpose: To investigate the incremental diagnostic value of dual-bolus over single-contrast-bolus first pass magnetic resonance myocardial perfusion imaging (MR-MPI) for detection of significant coronary artery disease (CAD). Materials and Methods: Patients (n = 49) with suspected CAD underwent first pass adenosine stress and rest MR-MPI and invasive coronary angiography (CA). Gadolinium diethylenetriamine pentaacetic acid (Gd-DTPA) was injected with a prebolus (1 mL) and a large bolus (0.1 mmol/kg). For the single-bolus technique, the arterial input function (AIF) was obtained from the large-contrast bolus. For the dual-bolus technique, the AIF was reconstructed from the prebolus. Absolute myocardial perfusion was calculated by Fermi-model constrained deconvolution. Receiver operating characteristic (ROC) analysis was used to investigate diagnostic accuracy of MR myocardial perfusion imaging for detection of significant CAD on CA at vessel-based analysis. Results: The area under the curve (AUC) of the minimal stress perfusion value for the detection of significant CAD using the single-bolus and dual-bolus technique was 0.85 ± 0.04 (95% confidence interval [CI], 0.77–0.93) and 0.77 ± 0.05 (95% CI, 0.67–0.86), respectively. Conclusion: In this study the dual-bolus technique had no incremental diagnostic value over single-bolus technique for detection of significant CAD with the used contrast concentrations. J. Magn. Reson. Imaging 2010;32:88–93. © 2010 Wiley-Liss, Inc.

As computed tomography coronary angiography (CTCA) has a reported excellent negative predictive value for detection of significant coronary artery disease (CAD), it is increasingly used as first line technique in the evaluation of patients with suspected CAD. However, positive predictive value is low and CTCA lacks information about myocardial perfusion. As first pass magnetic resonance myocardial perfusion imaging (MRMPI) can accurately assess myocardial perfusion and does not involve ionizing radiation, it may be a valuable additional technique to CTCA in the evaluation of patients with suspected CAD. Subsequently, their combined use may lower the number of unnecessary, costly invasive coronary angiographies (CAG).

A 31-year-old male presented with increasing exertional breathlessness. He had been healthy previously, with no recent chest pain or fever. The only notable abnormalities on blood testing were a microcytic anemia and an elevated lactate dehydrogenase level. The chest radiograph showed an increased cardiothoracic ratio and mild pulmonary congestion. Transthoracic echocardiography showed reasonable left ventricular …

Mild therapeutic hypothermia (MTH) is a worldwide used therapy to improve neurological outcome in patients successfully resuscitated after cardiac arrest (CA). Preclinical data suggest that timing and speed of induction are related to reduction of secondary brain damage and improved outcome. Aiming at a rapid induction and stable maintenance phase, MTH induced via continuous peritoneal lavage (PL) using the Velomedix® Inc. automated PL system was evaluated and compared to historical controls in which hypothermia was achieved using cooled saline intravenous infusions and cooled blankets. In 16 PL patients, time to reach the core target temperature of 32.5°C was 30 minutes (interquartile range (IQR): 19 to 60), which was significantly faster compare to 150 minutes (IQR: 112 to 240) in controls. The median rate of cooling during the induction phase in the PL group of 4.1°C/h (IQR: 2.2 to 8.2) was significantly faster compared to 0.9°C/h (IQR: 0.5 to 1.3) in controls. During the 24-hour maintenance phase mean core temperature in the PL patients was 32.38 ± 0.18°C (range: 32.03 to 32.69°C) and in control patients 32.46 ± 0.48°C (range: 31.20 to 33.63°C), indicating more steady temperature control in the PL group compared to controls. Furthermore, the coefficient of variation (VC) for temperature during the maintenance phase was lower in the PL group (VC: 0.5%) compared to the control group (VC: 1.5%). In contrast to 23% of the control patients, none of the PL patients showed an overshoot of hypothermia below 31°C during the maintenance phase. Survival and neurological outcome was not different between the two groups. Neither shivering nor complications related to insertion or use of the PL method were observed. Using PL in post-CA patients results in a rapidly reached target temperature and a very precise maintenance, unprecedented in clinical studies evaluating MTH techniques. This opens the way to investigate the effects on neurological outcome and survival of ultra-rapid cooling compared to standard cooling in controlled trials in various patient groups. See related letter by Esnault et al., http://ccforum.com/content/17/3/431 ClinicalTrials.gov: NCT01016236