Most of the evidences for beneficial effects of beta-blockers in patients with acute myocardial infarction (AMI) were from the clinical studies published in the pre-reperfusion era when anti-platelet drugs, statins or inhibitors of renin-angiotensin-aldosterone system which are known to reduce cardiovascular mortality of patients with AMI were not introduced. In the reperfusion era, beta-blockers’ benefit has not been clearly shown except in patients with reduced ejection fraction (EF; ≤40%). In the era of the early reperfusion therapy for AMI, a number of patients with mildly reduced EF (>40%, <50%) or preserved EF (≥50%) become increasing. However, because no randomized clinical trials are available until now, the benefit and the optimal duration of oral treatment with beta-blockers in patients with mildly reduced or preserved EF are questionable. Registry data have not showed the association of oral beta-blocker therapy with decreased mortality in survivors without heart failure or left ventricular systolic dysfunction after AMI. In the Korea Acute Myocardial Infarction Registry-National Institute of Health of in-hospital survivors after AMI, the benefit of beta-blocker therapy at discharge was shown in patients with reduced or mildly reduced EF, but not in those with preserved EF, which provides new information about beta-blocker therapy in patients without reduced EF. However, clinical practice can be changed when the results of appropriate randomized clinical trials are available. Ongoing clinical trials may help to answer the unresolved issues of beta-blocker therapy in patients with AMI.
Background Coronary atherosclerosis is the leading cause of coronary artery disease. Several investigations have indicated that tear-sensitive plaques contain macrophages and T cells. Neopterin is an essential cellular immune response biomarker. The main goal of this study was to see if there were any changes in biomarkers like unconjugated pteridines, neopterin, and biopterin, as well as kynurenine pathway enzymes like indoleamine 2,3-dioxygenase (IDO), which catalyzes the rate-limiting step in tryptophan degradation, in patients with the acute coronary syndrome (ACS) caused by angiographic atherosclerosis.
Methods High-performance liquid chromatography was used to determine the amounts of neopterin, biopterin, and creatinine in urine samples, as well as tryptophan and kynurenine in serum samples. The enzyme-linked immunosorbent assay was used to assess the amounts of neopterin in serum samples. The measured parameters were evaluated between ACS patients and controls.
Results The measured levels of neopterin, biopterin and the kynurenine to tryptophan ratio reflecting IDO activity, and the specifically known biomarkers such as cardiac troponin, creatine kinase, myoglobin, and natriuretic peptides are statistically higher in ACS patients compared to control subjects. On the other hand, the measured parameters are inadequate to classify the conventional kinds of ACS, ST-elevation- and non-ST-elevation- myocardial infarction.
Conclusions The study found that determining and using neopterin and IDO parameters as biomarkers in individuals with the ACS can support traditional biomarkers. However, it can be concluded that evaluating pteridine biomarkers solely have no privilege to clinical findings in ACS diagnosis and classification.
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Differential diagnosis of chest pain in the pediatric population is important but can be challenging. A 12-year-old boy with Duchenne muscular dystrophy presented with chest pain, cardiac enzyme elevation, and convex ST elevations in the inferior leads with reciprocal ST depression in the anterior leads on electrocardiogram. Echocardiography on admission revealed normal left ventricular function. Suspecting acute myocardial infarction, we performed invasive coronary angiography, which revealed normal coronary arteries. A follow-up electrocardiogram showed an acute pericarditis pattern with concave ST elevations in most leads and PR depression, and follow-up echocardiography revealed global left ventricular dysfunction, suggestive of acute perimyocarditis. Ibuprofen was administered for acute pericarditis, and a continuous milrinone infusion was commenced for myocardial dysfunction. The chest pain improved by the next day, and the ST segment elevations normalized on day 4. Echocardiography on day 9 revealed improved left ventricular function. The patient was discharged on day 11, and he is doing well without chest pain through 12 months of follow-up. The last electrocardiogram showed normal sinus rhythm without ST change. Differential diagnosis of acute myocardial infarction and acute perimyocarditis is important for proper treatment strategies and the different prognoses of these two conditions.
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Coronary artery ectasia (CAE) is a rare condition defined as the dilatation of coronary artery to at least 1.5 times larger than the normal adjacent coronary artery. Clinical manifestations of CAE vary, ranging from asymptomatic to ST-segment elevation myocardial infarction (STEMI). Because of its rarity and clinical diversity, the best treatment strategy and prognosis for CAE remain unclear. We describe a case of STEMI caused by intracoronary thrombus formation within an ectatic area in a patient with liver cirrhosis (LC). The patient was successfully managed by thrombus aspiration only, without balloon angioplasty or stent implantation, and maintained by dual antiplatelet therapy with aspirin and ticagrelor, a potent new P2Y12 inhibitor.
A 51-year-old male patient was referred for a sudden out-of-hospital cardiac arrest. Upon arrival, he was conscious and had no chest pain complaints. There was no abnormality in initial electrocardiographic and echocardiographic examinations. However, episodes of recurrent ventricular fibrillation (VF) were documented on rhythm monitoring. Each VF episode was triggered by an isolated monomorphic ventricular premature complex (VPC).
Suspecting idiopathic VF, emergency radiofrequency catheter ablation was planned for the VPCs. However, when coronary angiography was performed to exclude silent ischemia, the results showed a total occlusion of the right coronary artery posterolateral branch, which is thought to supply the left ventricular inferior and septal wall. After successful reperfusion, VF episodes and the triggering VPCs disappeared. We are documenting this case to emphasize the potential for silent myocardial infarction to cause out-of-hospital sudden cardiac arrest even in a patient without any symptom or sign of acute coronary syndrome.
Kawasaki disease (KD) is an acute, systemic vasculitis of childhood. The early mortality of KD results from coronary complications, mainly aneurysmal thrombosis with myocardial infarction, and the subacute phase of KD has the highest risk of mortality. Although there have been reports of ischemic heart disease as late cardiologic sequelae of KD in young adults, acute myocardial infarction caused by coronary complications in the subacute phase of KD is rare. We experienced one pediatric patient who developed coronary artery aneurysm and acute myocardiac infarction (AMI) during the subacute phase of incomplete and intravenous immunoglobulin (IVIG)-nonresponsive KD. The patient was given a good prognosis due to close monitoring and early recognition of AMI. Physicians should carefully monitor KD patients who do not respond to initial IVIG therapy and who show progressive coronary artery dilatation. If such a patient complaints of chest pain and the ECG shows hyperacute T waves, the physician should suspect development of AMI.
BACKGROUND Limited data are available for gender-based differences among patients with acute myocardial infarction (AMI) undergoing coronary revascularization in Korea. The purpose of this study is to identify gender-based differences in clinical characteristics, risk factors and outcomes among Korean patients undergoing percutaneous coronary intervention (PCI). METHODS Patients with AMI undergoing PCI between Jan 2009 and Sep 2011 were included (n = 457) in the study. Clinical characteristics and cardiovascular risk factors as well as major adverse cardiac events (MACE), including death after PCI, were compared between women (n = 134) and men (n = 323). RESULTS Women were older (69.8 +/- 10.7 vs. 60.0 +/- 11.7 years, p < .001) and had more comorbidities, such as diabetes (44.0% vs. 32.8%, p = .025) and hypertension (64.9% vs. 48.9%, p = .002) compared to men. Women were less likely to have a smoking history (p < .001). There were no significant differences in all causes of death and in MACE between women and men. By the multivariate analysis, age, HDL-cholesterol and left ventricle ejection fraction are associated with mortality and MACE. CONCLUSIONS In this study, women did not emerge as an independent predictor for MACE; however, they were older and had a higher incidence of hypertension and diabetes than men.
Woo Seung Shin, Mi Youn Park, You Mi Hwang, Hui Kyung Jeon, Man Young Lee, Jong Min Lee, Byoung Joo Shim, Sung Sik Kim, Seung Jae Lee, Yong Seog Oh, Tai Ho Rho, Ki Bae Seung
BACKGROUND Atrial fibrillation (AF) has been linked to an increased risk for in-hospital and long-term mortality rates in patients with acute myocardial infarction (AMI). Obesity and metabolic syndrome (MS) are known to play an important role in cardiovascular morbidity and mortality. However, it is uncertain whether obesity and MS increase the risk of AF in patients with AMI. Therefore, we investigated independent risk factors for the occurrence of new-onset AF in patients with AMI who received optimal percutaneous coronary intervention (PCI). METHODS We prospectively analyzed the association between MS and the incidence of cardiac arrhythmia in 146 patients with AMI who underwent PCI. Twenty-four-hour Holter monitoring was performed 3 days after AMI. We divided the patients into two different groups based on the development of AF and analysed their obesity based on body mass index (BMI) (kg/m2) and evaluated the existence of MS, as well as visceral obesity with fat computed tomography. RESULTS Seventy-five patients (51.4%) were obese (BMI > or = 25) and 64 (44%) had MS. AF occurred in 33 (22.6%) patients. Age, MS, and visceral obesity were significantly associated with AF (p = 0.001, p = 0.003, and p = 0.03, respectively). There was no difference between obese and non-obese patients in the incidence of AF and VT.
Multivariate analysis revealed that age and MS were independent risk factors of post-AMI AF. CONCLUSIONS MS is an important and modifiable risk factor for new-onset AF especially in patients with AMI who underwent PCI.
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A 66-year-old male patient who suffered from chest pain and dyspnea was admitted to our hospital. He was diagnosed as having an acute myocardial infarction, and recovered from cardiogenic shock after cardiopulmonary-cerebral resuscitation. Under the support of extracorporeal membrane oxygenator (ECMO) he underwent successful percutaneous coronary intervention. After this, an intra-aortic balloon pump (IABP) was inserted to increase coronary perfusion and reduce the impedance to left ventricular ejection. After 6 days, the patient was weaned from ECMO support; however, IABP therapy and infusion of inotropic agents were required to maintain adequate hemodynamic status. One week later, cardiac transplantation was performed successfully without major complications.
A 56-year-old man presented with right coronary arterial spasm accompanied by ST segment elevation in the inferior leads. A reperfusion arrhythmia, accelerated idioventricular rhythm (AIVR), developed 1 hour after a nitroglycerin infusion. The AIVR was sustained for 5 days without hemodynamic instability, and resolved spontaneously during hemodynamic monitoring in the coronary intensive care unit.
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Eun Suk Shin, Myung Ho Jeong, Sang Chun Lim, Myung Ja Choi, Seon Young Jeong, Gill Yup Kim, Eun Jeong Lee, Su Mi Bang, Hyo Ran Lee, Young Joon Hong, Hyung Wook Park, Ju Han Kim, Weon Kim, Young Keun Ahn, Jeong Gwan Cho, Jong Chun Park, Jung Chaee Kang
BACKGROUND Recently the incidence of coronary artery disease has been increased rapidly in Korea. After the introduction of coronary care unit, the mortality rate of cardiovascular patients has been decreased. The predictive factors for mortality in patients admitted at Coronary Care Unit (CCU) are important in the management of acutely ill cardiovascular patients. METHODS: One thousand one hundred and thirty patients (64.8+/-14.5 years), who were admitted at CCU from January 2002 to June 2003, were analyzed. The patients were divided into two groups according to mortality: the survived group (Group I: n=1055, 63.3+/-13.3 years) and the moribund group (Group II: n=75, 64.8+/-14.1 years). Clinical characteristics, risk factors, clinical diagnosis, laboratory, echocardiographic and coronary angiographic findings were compared between the two groups. RESULTS The overall mortality at CCU was 6.6%, 75 out of 1130 patients. Age and sex were not different between both groups. Coronary artery disease was the most common cause of admission (886 out of 1130 patients) and death (46 out of 75 patients). Coronary angiographic findings were not different between the two groups. Left ventricular ejection fraction (LVEF) by echocardiogram was higher in Group I than in Group II (53.1+/-15.6% vs. 42.3+/-16.3%, p<0.05). Predictive factors for mortality by multiple logistic regression analysis were low LVEF (OR 11.4, 2.9-21.4 95%CI, p<0.001), no performance of percutaneous coronary intervention (PCI, OR 10.8, 2.5-17.8 95%CI, p<0.001) and clinical diagnosis of aortic dissection (OR 3.8, 1.3-9.8 95%CI, p=0.021). CONCLUSIONS The predictive factors for mortality at CCU were low LVEF, no PCI and aortic dissection.