Background The Zwolle score is recommended to identify ST-segment elevation myocardial infarction (STEMI) patients with low-risk eligible for early discharge. Our aim was to ascertain if creatinine variation (Δ-sCr) would improve Zwolle score in the decision-making of early discharge after primary percutaneous coronary intervention (PCI). Methods and results A total of 3296 patients with STEMI that underwent primary PCI were gathered from the Portuguese Registry on Acute Coronary Syndromes. A Modified-Zwolle score, including Δ-sCr, was created and compared with the original Zwolle score. Δ-sCr was also compared between low (Zwolle score ≤3) and non-low-risk patients (Zwolle score >3). The primary endpoint is 30-day mortality and the secondary endpoints are in-hospital mortality and complications. Thirty-day mortality was 1.5% in low-risk patients (35 patients) and 9.2% in non-low-risk patients (92 patients). The Modified-Zwolle score had a better performance than the original Zwolle score in all endpoints: 30-day mortality (area under curve 0.853 versus 0.810, P < 0.001), in-hospital mortality (0.889 versus 0.845, P < 0.001) and complications (0.728 versus 0.719, P = 0.037). Reclassification of patients lead to a net reclassification improvement of 6.8%. Additionally, both original Zwolle score low-risk patients and non-low-risk patients who had a Δ-sCr ≥0.3 mg/dl had higher 30-day mortality (low-risk: 1% versus 6.6%, P < 0.001; non-low-risk 4.4% versus 20.7%, P < 0.001), in-hospital mortality and complications. Conclusion Δ-sCr enhanced the performance of Zwolle score and was associated with higher 30-day mortality, in-hospital mortality and complications in low and non-low-risk patients. This data may assist the selection of low-risk patients who will safely benefit from early discharge after STEMI.
Introduction Traditionally, severe left ventricular dysfunction is assumed to be the main predictor of CS afte acute myocardial infarction (AMI), however trials and registries show that in average left ventricular function is only moderately depressed in CS after acute myocardial infarction. Purpose To characterize the population of patients (Pts) with CS after AMI but without severe left ventricular dysfunction (defined as ejection fraction >30%) and assess their impact in mortality. Methods From a national multicenter registry, we evaluated 16332 Pts with AMI and ejection fraction (EF) >30%. We considered 2 groups: Group 1 – Pts who developed CS and Group 2 – Pts who didn't developed CS. We registered age, gender, cardiovascular and non-cardiovascular co-morbidities, electrocardiographic presentation and coronary anatomy. We also evaluated the following in-hospital complications: Re-Infarction, mechanical complications, high-grade atrial ventricular block, sustained ventricular tachycardia (VT) atrial fibrillation (AF) and stroke. We compared the in-hospital mortality. Results The presence of CS without severe left ventricular dysfunction was observed in 3,2% pts (n=518) with AMI, being CS present at admission in 46,8% of these pts. The mean EF was lower in group 1 pts (44% ± 11 vs 53±11%, p<0,001). Patients in group 1 were older (71±13 vs 65±13 years, p<0,001), more females (38,8% vs 26,6%, p<0,001), had a higher prevalence of previous valvular heart disease (6,1% vs 3,0%, p<0,001), heart failure (10,1% vs 4,8%, p<0,001, peripheral artery disease (7,5% vs 5,3%, p=0,03), chronic kidney disease (9,8% vs 5,4%, p<0,001), chronic pulmonary obstructive disease (9,1% vs 4,9%, p<0,001) and previous stroke (11,0% vs 7,2%, p<0,001). At admission, Group 1 pts had more ST-elevation AMI (72,6% vs 43,0%, p<0,001), more AF (11,4% vs 6,6%, p<0,001) and more right bundle block (9,9%% vs 5,8%, p<0,001). Group 1 patients received less coronary angiography (80,9% vs 88,2%, p<0,00. The presence of multivessel disease (64,3% vs 51,4%, p<0,001), left main disease (12,2% vs 7,2%, p<0,001), left anterior descending disease (72,4% vs 64,3%, p<0,001) and right coronary disease (64,8% vs 55,5%, p<0,001) were more prevalent in Group 1 pts. Group 1 pts had more in-hospital complications: Re-Infarction (4,4% vs 0,9%, p<0,001), AF (23,0% vs 4,3%, p<0,001), mechanical complications (8,9% vs 0,3%, p<0,001), high atrial ventricular block (21,9% vs 2,3%, p<0,001), VT (10,8% vs 1,2%, p<0,001) and major bleeding (8,9% vs 1,3%, p<0,001). In-hospital mortality was also much higher in Group 1 pts (29,5% vs 1,2%, p<0,001). Conclusions Cardiogenic shock is present in 3,2% of AMI pts without severe ventricular dysfunction. These pts were older, more frequent female, had higher morbidities and in-hospital complications. Even without severe ventricular dysfunction, cardiogenic shock in these patients was associated with a much higher in-hospital mortality. Funding Acknowledgement Type of funding source: None
Introduction Left ventricular (LV) pseudoaneurysms form when cardiac rupture is contained by adherent pericardium or scar tissue. LV pseudoaneurysm is one of the mechanical complications of myocardial infarctions (MI), particularly inferior wall MI. Although LV pseudoaneurysms are not common, the diagnosis is difficult and they are prone to rupture. Transthoracic echocardiography is commonly used in clinical practice and is usually sufficient to make the diagnosis of LV pseudoaneurysm. Regardless of treatment, patients with LV pseudoaneurysms had a high mortality rate, especially those who did not undergo surgery. Description of the clinical case 74 years-old woman, with previous history of hypertension, dyslipidaemia and type 2 diabetes and stable coronary disease. In June 2018 the patient underwent coronary angiography that revealed left main and 3 vessels coronary disease, Cardiac revascularization surgery was proposed that the patient refused. The patient was stable during 6 months. Four days before presenting to emergency department the patient mentioned intermittent pre-cordial pain associated with exertion. At admission day she felt intense pre-cordial pain, accompanied by sudoresis and nausea, relieving with sublingual nitrate. The patient was hemodynamically stable at admission. Electrocardiogram showed sinus rhythm 65 bpm with 2mm ST-elevation of inferior leads. Troponin I was positive 30 ng/dL. Echocardiogram revealed marked hypokinesia of inferior and lateral wall with moderate depression of global systolic function ans presence of slight circumferential pericardial effusion (6mm in diastole on lateral wall) Emergent coronariography was performed and revealed progression of coronary disease of the right coronary artery with sub-occlusion of the mid segment. Cardiac revascularization surgery was proposed and the patient accepted this time. Echocardiogram was repeated during hospitalization revealed a stable pericardial effusion with reduced dimension comparing to admission. After 3 weeks, while waiting surgery in the ward, the patient was a syncope that resulted in fracture of the distal peroneum. Ecocardiogram was performed and revealed a LV posterior wall pseudoaneurysm through a narrow neck in parasternal long axis view and the presence of large pericardial effusion (Fig 1). The patient was submitted to definitive reparative cardiac surgery with pericardium patch and coronary artery bypass graft from left internal mammary to anterior descending coronary artery. The patient recovered well from the cardiac surgery and at 2 months follow up is alive and without signs of heart failure. This case illustrates the complexity in the management of patients with LV pseudoaneurysm. These patients require substantial critical care, imaging and surgical expertise. A high clinical index of suspicion is needed to avoid missing the diagnosis LV pseudoaneurysm and transthoracic echocardiography is essential to establish the diagnosis. Abstract P260 Figure. Fig 1 - LV pseudoaneurysm
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.