Mortality from Acute Myocardial Infarction Before and After Establishment of a Coronary Care Unit

A retrospective study of the mortality rate of acute myocardial infarction in two groups of patients treated before and after a coronary care unit was established showed no difference between them. Though it is difficult to compare two series retrospectively so far there are no well controlled studies to demonstrate clearly the value of coronary care units.     

心肌梗死的诊断急救和治疗

心肌梗死是一种急性及严重的心脏状态,心肌因无法得到足够氧气而导致的损伤.心肌梗死是一种死亡率极高的心脏状况异常,但如果急救及时,也是一种救治有效率极高病例,因此,心肌梗死的及时急救和治疗是非常重要的.本研究系统地综述了心肌梗死的诊断、急救和治疗,以期为医护工作者、社会大众和科研人员提供理论和实践指导.     

小型猪心肌梗死介入治疗后无复流动物模型的制备

目的制备猪急性心肌梗死冠状动脉介入治疗（AMI—PCI）后无复流（no—reflow）动物模型。方法五指山小型猪26头,行左、右冠状动脉造影和左心室造影,记录有创血流动力学参数,通过球囊闭塞、微血栓注入造成左前降支无复流,监测体表和冠脉内心电图变化。结果制模共有21头猪成活,19头达到AMI—PCI后无复流动物模型标准,即TIMI血流≤2级,校正的TIMI血流记帧法（CTFC）≥36．2帧,制模成功率73．1％。无复流模型建立成功后心率增快,血压下降,心肌耗氧量增加,左心室舒张期末压和肺毛细血管楔压升高,较闭塞前均具有统计学差异（P〈0．05）。实验过程中,体表心电图和冠状动脉内心电图均出现类似人AMI再灌注的心电图演变规律。结论选择性冠状动脉前降支急性闭塞、再灌注、微血栓注入制备的无复流小型猪动物模型是可行的。     

Socioeconomic Position Early in Adolescence and Mode of Delivery Later in Life: Findings from a Portuguese Birth Cohort

Objective

This study assessed the influence of socioeconomic position at 12 years of age (SEP-12) on the variability in cesarean rates later in life.

Methods

As part of the Portuguese Generation XXI birth cohort we evaluated 7358 women with a singleton pregnancy who delivered at five Portuguese public hospitals serving the region of Porto (April/2005–September/2006). Based on the twelve items that described socioeconomic circumstances at age 12, a latent class analysis was used to classify women’s SEP-12 as high, intermediate and low. Multiple Poisson regression was used to estimate adjusted risk ratio (RR) and respective 95% confidence interval (95% CI).

Results

The cesarean rates in high, intermediate and low SEP-12 were, respectively, 40.9%, 37.5% and 40.5% (p = 0.100) among primiparous women; 14.2%, 11.6% and 15.5% (p = 0.04) among multiparous women with no previous cesarean and 78.6%, 72.2% and 70.0% (p = 0.08) among women with a previous cesarean. A low to moderate association between SEP-12 and cesarean rates was observed among multiparous women with a previous cesarean, illustrating that women from higher SEP-12 were more likely to have a surgical delivery (RR = 1.12;95%CI:1.01–1.24 comparing high with low SEP-12 and RR = 1.03:95%CI:0.94–1.14 comparing intermediate with low SEP-12) not explained by potential mediating factors. No such association was found either in primiparous or in multiparous women without a previous cesarean.

Conclusions

The association between SEP-12 and cesarean rates suggests the effect of past socioeconomic context on the decision concerning the mode of delivery, but only among women who experienced a previous cesarean. Accordingly, it appears that early-life socioeconomic circumstances drive cesarean rates but the effect can be modified by lived experiences concerning childbirth.     

血液流变学在心肌梗死诊断、治疗和预后判断方面的研究进展

血液流变学是一门研究血液流动与变型的新型学科,其范围包括血液流量、流速、流态、血液凝固性,血液中有形成分及血管变形性与弹性、微循环、微血管血液流变性等。它是心肌梗死发病的一个重要因素之一,其突出表现是红细胞聚集症和高粘滞血症。血液流变学不但在心肌梗死疾病中的诊断,药物、介入等方面作为临床治疗与疗效的评估指标,而且对心肌梗死疾病的预后及对临床观察病情变化及疗效判定等具有重要意义。     

血液流变学在心肌梗死诊断、治疗和预后判断方面的研究进展

血液流变学是一门研究血液流动与变型的新型学科,其范围包括血液流量、流速、流态、血液凝固性,血液中有形成分及血管变形性与弹性、微循环、微血管血液流变性等。它是心肌梗死发病的一个重要因素之一,其突出表现是红细胞聚集症和高粘滞血症。血液流变学不但在心肌梗死疾病中的诊断,药物、介入等方面作为临床治疗与疗效的评估指标,而且对心肌梗死疾病的预后及对临床观察病情变化及疗效判定等具有重要意义。     

Association of Urinary Cadmium with Mortality in Patients at a Coronary Care Unit

Background

Determine the effect of the day 1 urinary excretion of cadmium (D1-UE-Cd) on mortality of patients admitted to a coronary care unit (CCU).

Methods

A total of 323 patients were enrolled in this 6-month study. Urine and blood samples were taken within 24 h after CCU admission. Demographic data, clinical diagnoses, and hospital mortality were recorded. The scores of established systems for prediction of mortality in critically ill patients were calculated.

Results

Compared with survivors (n = 289), non-survivors (n = 34) had higher levels of D1-UE-Cd. Stepwise multiple linear regression analysis indicated that D1-UE-Cd was positively associated with pulse rate and level of aspartate aminotransferase, but negatively associated with serum albumin level. Multivariate Cox analysis, with adjustment for other significant variables and measurements from mortality scoring systems, indicated that respiratory rate and D1-UE-Cd were independent and significant predictors of mortality. For each 1 μg/day increase of D1-UE-Cd, the hazard ratio for CCU mortality was 3.160 (95% confidence interval: 1.944–5.136, p < 0.001). The chi-square value of Hosmer-Lemeshow goodness-of-fit test for D1-UE-Cd was 10.869 (p = 0.213). The area under the receiver operating characteristic curve for D1-UE-Cd was 0.87 (95% confidence interval: 0.81–0.93).

Conclusions

The D1-UE-Cd, an objective variable with no inter-observer variability, accurately predicted hospital mortality of CCU patients and outperformed other established scoring systems. Further studies are needed to determine the physiological mechanism of the effect of cadmium on mortality in CCU patients.     

Diagnostic Ultrasound Induced Inertial Cavitation to Non-Invasively Restore Coronary and Microvascular Flow in Acute Myocardial Infarction

Ultrasound induced cavitation has been explored as a method of dissolving intravascular and microvascular thrombi in acute myocardial infarction. The purpose of this study was to determine the type of cavitation required for success, and whether longer pulse duration therapeutic impulses (sustaining the duration of cavitation) could restore both microvascular and epicardial flow with this technique. Accordingly, in 36 hyperlipidemic atherosclerotic pigs, thrombotic occlusions were induced in the mid-left anterior descending artery. Pigs were then randomized to either a) ½ dose tissue plasminogen activator (0.5 mg/kg) alone; or same dose plasminogen activator and an intravenous microbubble infusion with either b) guided high mechanical index short pulse (2.0 MI; 5 usec) therapeutic ultrasound impulses; or c) guided 1.0 mechanical index long pulse (20 usec) impulses. Passive cavitation detectors indicated the high mechanical index impulses (both long and short pulse duration) induced inertial cavitation within the microvasculature. Epicardial recanalization rates following randomized treatments were highest in pigs treated with the long pulse duration therapeutic impulses (83% versus 59% for short pulse, and 49% for tissue plasminogen activator alone; p<0.05). Even without epicardial recanalization, however, early microvascular recovery occurred with both short and long pulse therapeutic impulses (p<0.005 compared to tissue plasminogen activator alone), and wall thickening improved within the risk area only in pigs treated with ultrasound and microbubbles. We conclude that although short pulse duration guided therapeutic impulses from a diagnostic transducer transiently improve microvascular flow, long pulse duration therapeutic impulses produce sustained epicardial and microvascular re-flow in acute myocardial infarction.     

Effect of Metformin Treatment on Lipoprotein Subfractions in Non-Diabetic Patients with Acute Myocardial Infarction: A Glycometabolic Intervention as Adjunct to Primary Coronary Intervention in ST Elevation Myocardial Infarction (GIPS-III) Trial

Objective

Metformin affects low density lipoprotein (LDL) and high density (HDL) subfractions in the context of impaired glucose tolerance, but its effects in the setting of acute myocardial infarction (MI) are unknown. We determined whether metformin administration affects lipoprotein subfractions 4 months after ST-segment elevation MI (STEMI). Second, we assessed associations of lipoprotein subfractions with left ventricular ejection fraction (LVEF) and infarct size 4 months after STEMI.

Methods

371 participants without known diabetes participating in the GIPS-III trial, a placebo controlled, double-blind randomized trial studying the effect of metformin (500 mg bid) during 4 months after primary percutaneous coronary intervention for STEMI were included of whom 317 completed follow-up (clinicaltrial.gov Identifier: {"type":"clinical-trial","attrs":{"text":"NCT01217307","term_id":"NCT01217307"}}NCT01217307). Lipoprotein subfractions were measured using nuclear magnetic resonance spectroscopy at presentation, 24 hours and 4 months after STEMI. (Apo)lipoprotein measures were obtained during acute STEMI and 4 months post-STEMI. LVEF and infarct size were measured by cardiac magnetic resonance imaging.

Results

Metformin treatment slightly decreased LDL cholesterol levels (adjusted P = 0.01), whereas apoB remained unchanged. Large LDL particles and LDL size were also decreased after metformin treatment (adjusted P<0.001). After adjustment for covariates, increased small HDL particles at 24 hours after STEMI predicted higher LVEF (P = 0.005). In addition, increased medium-sized VLDL particles at the same time point predicted a smaller infarct size (P<0.001).

Conclusion

LDL cholesterol and large LDL particles were decreased during 4 months treatment with metformin started early after MI. Higher small HDL and medium VLDL particle concentrations are associated with favorable LVEF and infarct size.     

Prevalence of Chlamydia in Young Adulthood and Association with Life Course Socioeconomic Position: Birth Cohort Study

Background

Few estimates are available of chlamydia prevalence in the general population. Existing studies have limited scope to explore potential selection bias or associations with socioeconomic position.

Methods

We examined the prevalence of Chlamydia trachomatis infection and associations with life-course socioeconomic position in the Avon Longitudinal Study of Parents and Children in England. Chlamydia infection was measured through nucleic acid amplification test of urine specimens.

Results

4864 (51%) of those invited attended the clinic (mean age 17.8; SD 0.37 years). (60%) provided a urine specimen. Prevalence was 1.0% (95% CI 0.6 to 1.6) among participants reporting sexual activity. Risk of infection was strongly associated with life course social disadvantage and with recent sexual behaviour. After adjustment for other measures of disadvantage and for sexual behaviour the strongest risk factors for infection were lower maternal educational attainment (OR 9.1 (1.1, 76.7)) and lower participant educational attainment at age 11 (OR 5.0 (1.5, 16.5)). Both clinic attendance and agreement to test were lower amongst the disadvantaged. Adjustment for selective participation based on detailed information on non-participants approximately doubled prevalence estimates. Prevalence was higher in sexually active women (1.4% (0.7 to 2.4) than men (0.5% (0.1 to 1.3)).

Conclusions

Chlamydia prevalence in this general population sample was low even after adjustment for selective participation in testing. These estimates of prevalence and patterns of association with socioeconomic position may both reflect recent screening efforts. Prevalence was higher amongst the disadvantaged who were also less likely to engage in testing. Our results reveal the importance of monitoring and addressing inequalities in screening programme participation and outcomes.     

协同护理干预对心肌梗死患者康复及照顾者的生活质量和照顾能力的影响

目的：探讨协同护理对心肌梗死患者康复及照顾着生活质量的护理效果。方法：选取60例心肌梗死患者,随机分为对照组和试验组,各30例。对照组采用常规护理,试验组在对照组的基础上采用协同护理进行干预,观察两组患者在死亡、再梗死、梗死后心绞痛、严重心律失常、心力衰竭等临床并症状及生活自理能力方面的差异,采用总体健康状况量表及照顾能力测量表评价干预前后照顾者生活质量与照顾能力。结果：两组患者生活自理能力无差异（P〉0．05）,试验组梗死后心绞痛的发生率低于对照组（P〈0．05）;试验组照顾者的照顾能力及生活质量显著优于对照组,差异有统计学意义（P〈0．01）。结论：协同护理能明显提高心肌梗死患者照顾者的照顾能力及生活质量,利于患者康复。     

Systematic Characterization of Myocardial Inflammation,Repair, and Remodeling in a Mouse Model of Reperfused Myocardial Infarction

Mouse models of myocardial infarction are essential tools for the study of cardiac injury, repair, and remodeling. Our current investigation establishes a systematic approach for quantitative evaluation of the inflammatory and reparative response, cardiac function, and geometry in a mouse model of reperfused myocardial infarction. Reperfused mouse infarcts exhibited marked induction of inflammatory cytokines that peaked after 6 hr of reperfusion. In the infarcted heart, scar contraction and chamber dilation continued for at least 28 days after reperfusion; infarct maturation was associated with marked thinning of the scar, accompanied by volume loss and rapid clearance of cellular elements. Echocardiographic measurements of end-diastolic dimensions correlated well with morphometric assessment of dilative remodeling in perfusion-fixed hearts. Hemodynamic monitoring was used to quantitatively assess systolic and diastolic function; the severity of diastolic dysfunction following myocardial infarction correlated with cardiomyocyte hypertrophy and infarct collagen content. Expression of molecular mediators of inflammation and cellular infiltration needs to be investigated during the first 72 hr, whereas assessment of dilative remodeling requires measurement of geometric parameters for at least four weeks after the acute event. Rapid initiation and resolution of the inflammatory response, accelerated scar maturation, and extensive infarct volume loss are important characteristics of infarct healing in mice.     

CYP2C19 Phenotype,Stent Thrombosis,Myocardial Infarction,and Mortality in Patients with Coronary Stent Placement in a Chinese Population

Background

Several studies have indicated that CYP2C19 loss-of-function polymorphisms have a higher risk of stent thrombosis (ST) after percutaneous coronary interventions (PCIs). However, this association has not been investigated thoroughly in a Chinese population. In this study, we aimed to determine the effect of CYP2C19*2 and CYP2C19*3 loss-of-function polymorphisms on the occurrence of ST and other adverse clinical events in a Chinese population.

Methods

We designed a cohort study among 1068 consecutive patients undergoing intracoronary stent implantation after preloading with 600 mg of clopidogrel. CYP2C19*2 and CYP2C19*3 were genotyped by using polymerase chain reaction-restriction fragment length polymorphism analysis. The adverse clinical events recorded were ST, death, myocardial infarction (MI), and bleeding events. The primary end point of the study was the incidence of cumulative ST within 1 year after PCI. The secondary end point was other adverse clinical outcomes 1 year after the procedure.

Results

The cumulative 1-year incidence of ST was 0.88% in patients with extensive metabolizers (EMs) (CYP2C19*1/*1 genotype), 4.67% in patients with intermediate metabolizers (IMs) (CYP2C19*1/*2 or *1/*3 genotype), and 10.0% in patients with poor metabolizers (PMs) (CYP2C19*2/*2, *2/*3, or *3/*3 genotype) (P<0.001). The one-year event-free survival was 97.8% in patients with EMs, 96.5% in patients with IMs, and 92.0% in patients with PMs (P = 0.014). Multivariate analysis confirmed the independent association of CYP2C19 loss-of-function allele carriage with ST (P = 0.009) and total mortality (P<0.05).

Conclusion

PM patients had an increased risk of ST, death, and MI after coronary stent placement in a Chinese population.     

Sex Differences in Clinical Characteristics,Hospital Management Practices,and In-Hospital Outcomes in Patients Hospitalized in a Vietnamese Hospital with a First Acute Myocardial Infarction

Background

Cardiovascular disease is one of the leading causes of morbidity and mortality in Vietnam. We conducted a pilot study of Hanoi residents hospitalized with acute myocardial infarction (AMI) at the Vietnam National Heart Institute in Hanoi. The objectives of this observational study were to examine sex differences in clinical characteristics, hospital management, in-hospital clinical complications, and mortality in patients hospitalized with an initial AMI.

Methods

The study population consisted of 302 Hanoi residents hospitalized with a first AMI at the largest tertiary care medical center in Hanoi in 2010.

Results

The average age of study patients was 66 years and one third were women. Women were older (70 vs. 64 years) and were more likely than men to have had hyperlipidemia previously diagnosed (10% vs. 2%). During hospitalization, women were less likely to have undergone percutaneous coronary intervention (PCI) compared with men (57% vs. 74%), and women were more likely to have developed heart failure compared with men (19% vs. 10%). Women experienced higher in-hospital case-fatality rates (CFRs) than men (13% vs. 4%) and these differences were attenuated after adjustment for age and history of hyperlipidemia (OR: 2.64; 95% CI: 1.01, 6.89), and receipt of PCI during hospitalization (OR: 2.09; 95% CI: 0.77, 5.09).

Conclusions

Our pilot data suggest that among patients hospitalized with a first AMI in Hanoi, women experienced higher in-hospital CFRs than men. Full-scale surveillance of all Hanoi residents hospitalized with AMI at all Hanoi medical centers is needed to confirm these findings. More targeted and timely educational and treatment approaches for women appear warranted.     

Rapid and Efficient Production of Coronary Artery Ligation and Myocardial Infarction in Mice Using Surgical Clips

Aims

The coronary artery ligation model in rodents mimics human myocardial infarction (MI). Normally mechanical ventilation and prolonged anesthesia period are needed. Recently, a method has been developed to create MI by popping-out the heart (without ventilation) followed by immediate suture ligation. Mortality is high due to the time-consuming suture ligation process while the heart is exposed. We sought to improve this method and reduce mortality by rapid coronary ligation using a surgical clip instead of a suture.

Methods and Results

Mice were randomized into 3 groups: clip MI (CMI), suture MI (SMI), or sham (SHAM). In all groups, heart was manually exposed without intubation through a small incision on the chest wall. Unlike the conventional SMI method, mice in the CMI group received a metal clip on left anterior descending artery (LAD), quickly dispensed by an AutoSuture Surgiclip^™. The CMI method took only 1/3 of ligation time of the standard SMI method and improved post-MI survival rate. TTC staining and Masson’s trichrome staining revealed a similar degree of infarct size in the SMI and CMI groups. Echocardiograph confirmed that both SMI and CMI groups had a similar reduction of ejection fraction and fraction shortening over the time. Histological analysis showed that the numbers of CD68⁺ macrophages and apoptotic cells (TUNEL-positive) are indistinguishable between the two groups.

Conclusion

This new method, taking only less than 3 minutes to complete, represents an efficient myocardial infarction model in rodents.     

血栓抽吸联合PCI术前阿托伐他汀强化治疗急性ST段抬高型心肌梗死

目的:探讨急性ST段抬高型心肌梗死急诊经皮冠状动脉介入治疗(PCI)中应用GOODMAN血栓抽吸装置联合术前阿托伐他汀强化治疗对心肌组织灌注及临床预后的影响.方法:选择梗死相关血管心肌梗死溶栓试验血流0级的急性ST段抬高型心肌梗死患者80例,随机分为血栓抽吸联PCI术前阿托伐他汀强化治疗组(试验组)40例和标准PCI治疗组(对照组)40例.比较两组患者术后心肌梗死溶栓试验(TIMI)血流分级、TIMI心肌灌注分级(TMPG)、心电图ST段回落百分比、左心室射血分数(LVEF)及住院期间主要心血管不良事件(MACE).结果:试验组TIMI血流分级、TMPG、ST段回落百分比、LVEF均明显优于对照组(P＜0.05).两组患者住院期间MACE发生率比较,差异无统计学意义(P＞0.05).结论:在急性ST段抬高型心肌梗死急诊经皮冠状动脉介入治疗(PCI)中应用血栓抽吸联合术前阿托伐他汀强化治疗安全可行,可有效清除冠状动脉内血栓,改善心肌组织灌注及术后心脏功能,并且不增加主要心血管事件的发生率.     

Genome-Wide Association Study for Incident Myocardial Infarction and Coronary Heart Disease in Prospective Cohort Studies: The CHARGE Consortium

Background

Data are limited on genome-wide association studies (GWAS) for incident coronary heart disease (CHD). Moreover, it is not known whether genetic variants identified to date also associate with risk of CHD in a prospective setting.

Methods

We performed a two-stage GWAS analysis of incident myocardial infarction (MI) and CHD in a total of 64,297 individuals (including 3898 MI cases, 5465 CHD cases). SNPs that passed an arbitrary threshold of 5×10⁻⁶ in Stage I were taken to Stage II for further discovery. Furthermore, in an analysis of prognosis, we studied whether known SNPs from former GWAS were associated with total mortality in individuals who experienced MI during follow-up.

Results

In Stage I 15 loci passed the threshold of 5×10⁻⁶; 8 loci for MI and 8 loci for CHD, for which one locus overlapped and none were reported in previous GWAS meta-analyses. We took 60 SNPs representing these 15 loci to Stage II of discovery. Four SNPs near QKI showed nominally significant association with MI (p-value<8.8×10⁻³) and three exceeded the genome-wide significance threshold when Stage I and Stage II results were combined (top SNP rs6941513: p = 6.2×10⁻⁹). Despite excellent power, the 9p21 locus SNP (rs1333049) was only modestly associated with MI (HR = 1.09, p-value = 0.02) and marginally with CHD (HR = 1.06, p-value = 0.08). Among an inception cohort of those who experienced MI during follow-up, the risk allele of rs1333049 was associated with a decreased risk of subsequent mortality (HR = 0.90, p-value = 3.2×10⁻³).

Conclusions

QKI represents a novel locus that may serve as a predictor of incident CHD in prospective studies. The association of the 9p21 locus both with increased risk of first myocardial infarction and longer survival after MI highlights the importance of study design in investigating genetic determinants of complex disorders.     

An Anthelmintic Drug,Pyrvinium Pamoate,Thwarts Fibrosis and Ameliorates Myocardial Contractile Dysfunction in a Mouse Model of Myocardial Infarction

Metabolic adaptation to limited supplies of oxygen and nutrients plays a pivotal role in health and disease. Heart attack results from insufficient delivery of oxygen and nutrients to the heart, where cardiomyocytes die and cardiac fibroblasts proliferate – the latter causing scar formation, which impedes regeneration and impairs contractility of the heart. We postulated that cardiac fibroblasts survive metabolic stress by adapting their intracellular metabolism to low oxygen and nutrients, and impeding this metabolic adaptation would thwart their survival and facilitate the repair of scarred heart. Herein, we show that an anthelmintic drug, Pyrvinium pamoate, which has been previously shown to compromise cancer cell survival under glucose starvation condition, also disables cardiac fibroblast survival specifically under glucose deficient condition. Furthermore, Pyrvinium pamoate reduces scar formation and improves cardiac contractility in a mouse model of myocardial infarction. As Pyrvinium pamoate is an FDA-approved drug, our results suggest a therapeutic use of this or other related drugs to repair scarred heart and possibly other organs.     

Precipitation and Primary Health Care Visits for Gastrointestinal Illness in Gothenburg,Sweden

Background

The river Göta Älv is a source of freshwater for the City of Gothenburg, Sweden, and we recently identified a clear influence of upstream precipitation on concentrations of indicator bacteria in the river water, as well as an association with the daily number of phone calls to the nurse advice line related to acute gastrointestinal illnesses (AGI calls). This study aimed to examine visits to primary health-care centers owing to similar symptoms (AGI visits) in the same area, to explore associations with precipitation, and to compare variability in AGI visits and AGI calls.

Methods

We obtained data covering six years (2007–2012) of daily AGI visits and studied their association with prior precipitation (0–28 days) using a distributed lag nonlinear Poisson regression model, adjusting for seasonal patterns and covariates. In addition, we studied the effects of prolonged wet and dry weather on AGI visits. We analyzed lagged short-term relations between AGI visits and AGI calls, and we studied differences in their seasonal patterns using a binomial regression model.

Results

The study period saw a total of 17,030 AGI visits, and the number of daily visits decreased on days when precipitation occurred. However, prolonged wet weather was associated with an elevated number of AGI visits. Differences in seasonality patterns were observed between AGI visits and AGI calls, as visits were relatively less frequent during winter and relatively more frequent in August, and only weak short-term relations were found.

Conclusion

AGI visits and AGI calls seems to partly reflect different types of AGI illnesses, and the patients’ choice of medical contact (in-person visits versus phone calls) appears to depend on current weather conditions. An association between prolonged wet weather and increased AGI visits supports the hypothesis that the drinking water is related to an increased risk of AGI illnesses.