Background: Since the definition of Non-ST-Elevation Myocardial Infarction (NSTEMI) in 2000, its in-hospital management is rapidly developing. There is only a few available data, though, to describe the long-term changes in clinical characteristics, treatment patterns and outcomes in “real world” unselected patients and provide a feedback regarding guideline implementation. Methods and results: We conducted a retrospective data collection of all consecutive patients admitted to our clinic with an acute myocardial infarction (AMI) between 2000 and 2009 (Myocardial Infarction Registry Ludwigshafen- MIRLU). From the overall 6119 patients included, 2976 were diagnosed with NSTEMI (48.6%). The median age was 67.9 ± 11.9 years and 68.5% were men. 93.4% underwent coronary angiography, 60.6% of them received percutaneous coronary intervention (PCI) and 4.8% immediate emergency bypass surgery. The rate of guideline adherent medical therapy was high at admission and at discharge. The most common in-hospital complications were post-infarction angina (4.4%), congestive heart failure (4.0%), cardiogenic shock (2.8%) and blood loss requiring transfusion (2.8%). Average in-hospital mortality was 4.2%. Over the period of ten years we observed an increase of 4.4 years in mean age (p for trend <0.01) and no changes in gender proportion (p=0.25). The rates of coronary angiography, PCI and stent implantation increased, while emergency bypass surgery rate declined (p<0.01). The complications’ rate remained unchanged (p=0.13). In-hospital mortality showed no significant variation (p=0.71). In a multivariate analysis cardiogenic shock, moderately and severely impaired left ventricular function and increasing age were independent mortality predictors. Conclusion: The observation of NSTEMI patients over 10 years showed an increase in mean age, rates of coronary angiography and PCI with stent implantation, while emergency bypass surgery declined. Administration rate of guideline adherent medical therapy was high. However, overall mortality remained unchanged. Cardiogenic shock, significantly reduced left ventricular function and increasing age were the strongest predictors of in-hospital mortality.

OBJECTIVES This study compared the timing of onset of antiplatelet action after treatment with clopidogrel and prasugrel at first medical contact in patients with ST-segment elevation myocardial infarction (STEMI) scheduled for primary percutaneous coronary intervention (PPCI).BACKGROUND Little is known about the timing of onset of antiplatelet action after a pre-percutaneous coronary intervention (PCI) loading dose of clopidogrel or prasugrel in patients with STEMI.METHODS This double-blind, prospective study randomized 62 patients with STEMI scheduled for PPCI in the ambulance or the emergency department to 60 mg prasugrel (n = 31) or 600 mg clopidogrel (n = 31). The primary endpoint was the platelet reactivity index (PRI) measured with the vasodilator-stimulated phosphoprotein assay 2 h after intake of the study medication. Secondary endpoints were PRI after 4 h, TIMI (Thrombolysis In Myocardial Infarction) patency of the infarct-related artery before and after PCI, and clinical events until day 30.RESULTS The PRI after 2 h (50.4 +/- 32.7% vs. 66.3 +/- 22.2%; p = 0.035) and after 4 h (39.1 +/- 27.5% vs. 54.5 +/- 49.3%; p = 0.038) were significantly lower with prasugrel compared with clopidogrel. In addition, the rate of patients with a PRI <50% tended to be higher with prasugrel compared with clopidogrel after 2 h (46.7% vs. 28.6%; p = 0.15) and after 4 h (63.0% vs. 38.9%; p = 0.06). There were no significant differences in TIMI 2/3 patency before PCI (39.2% vs. 31.0%; p = 0.43) and TIMI 3 patency after PCI (88.5% vs. 89.3%; p = 0.92).CONCLUSIONS The pre-PCI administration of prasugrel in patients with STEMI undergoing PPCI was associated with a significant faster platelet inhibition compared with clopidogrel. Therefore, prasugrel should be preferred to clopidogrel in this setting. (C) 2015 by the American College of Cardiology Foundation.

Einleitung: In den letzten Jahren hat sich die Vorstellung von der Behandlung erhöhter Blutzuckerwerte in der Intensivmedizin gewandelt. Inital wurden Blutzuckerwerte erst ab 200 – 250 mg/dl unter der Vorstellung einer permissiven Hyperglykämie gesenkt. Neuere Studien zeigten, dass Hyperglykämie mit erhöhter Morbidität und Mortalität einhergeht. Eine normnahe Blutzuckereinstellung senkte hingegen die Morbidität und Mortalität. Diese Ergebnisse lösten eine Vielzahl von Folgestudien aus, in denen sich allerdings eine erhöhte Hypoglykämierate und eine erhöhte Mortalität in Studienarmen mit normnaher Blutzuckereinstellung abzeichnete. Aktuell wird in den Leitlinien der ADA ein Blutzuckerziel von 140 – 180 mg/dl und die Vermeidung von Hypoglykämien empfohlen. Wir stellten daher auf der Intensivstation unser bisheriges Standardprotokoll mit normnahen Therapiezielen auf ein modifiziertes Yale- Protokoll mit dem Zielbereich 140 – 180 mg/dl um.

Carotid artery stenting (CAS) is increasingly used for treatment of severe carotid artery stenosis, but only few procedural risk factors for complications of CAS are clearly defined yet. A possible impact of the patient's gender on the outcome of patients undergoing CAS has not been investigated properly and only little information about this topic is available so far.

To compare a loading dose of 600 mg clopidogrel given in the prehospital phase versus clopidogrel administered only after the diagnostic angiogram in patients with STEMI scheduled for primary PCI.

INTRODUCTION:Tako-tsubo cardiomyopathy (stress-induced cardiomyopathy or transient left ventricular ballooning) is characterized by clinical suspicion of an acute myocardial infarction with transient apical or midventricular dyskinesia of the left ventricle without significant coronary stenosis on angiography. The etiology of this disease remains obscure. One of the possible causes is myocardial ischemia induced by coronary vasospasm due to sympathetic activation. It has been hypothesized that the application of ergometrine could induce tako-tsubo cardiomyopathy.CASE PRESENTATION:We report the case of a 28-year-old Turkish woman who developed tako-tsubo cardiomyopathy after administration of ergometrine for release of placenta and prevention of bleeding during the post-partum phase in the course of an elective caesarean delivery. Tako-tsubo cardiomyopathy was diagnosed by echocardiography and urgent cardiac magnetic resonance imaging. A coronary angiography was not performed because of the absence of myocardial necrosis or ischemia and signs of myocarditis on cardiac magnetic resonance imaging.CONCLUSION:This life-threatening disease should be excluded in the differential diagnosis by comparing the symptoms with those of typical heart failure, particularly after use of ergometrine.

BACKGROUND:In the year 2000 a new definition of acute myocardial infarction (AMI) was introduced, now differentiating ST segment elevation AMI (STEMI) from non-ST segment elevation AMI (NSTEMI). The characterization of AMI patients according to this definition is still incomplete.METHODS AND RESULTS:888 consecutive AMI patients at a single interventional center were included: 493 (55.5%) STEMI and 395 (44.5%) NSTEMI patients. Median age of STEMI patients was four years lower compared to NSTEMI patients (62.8 versus 66.6 years, P<0.001). STEMI patients more often presented in cardiogenic shock (11.0% versus 2.0%, P<0.001) and after pre-hospital resuscitation (4.9% versus 0.8%, P<0.001). Catheterization was performed in 98.4% of STEMI and in 95.9% of NSTEMI patients (P<0.001). The circumflex artery was more often the culprit lesion in NSTEMI patients compared to STEMI patients (58.3% versus 48%, P=0.003). They also showed significantly more often a 3 vessel disease (41.4% versus 29.9%, P=0.002). Out of STEMI patients 10.1% were treated with medical therapy only compared to 27.2% of NSTEMI patients (P<0.001). Whereas PCI was performed more often in STEMI patients (84.3% versus 57.8%, P<0.001), CABG was used more often in NSTEMI patients (21.6% versus 9.1%, P<0.001). In-hospital death was 8.7% in STEMI compared to 4.8% in NSTEMI patients (P<0.001).CONCLUSIONS:In clinical practice STEMI and NSTEMI seem to occur with similar frequency. Invasive strategies were applied in a high percentage in both groups, however with different therapeutic consequences. In-hospital mortality was twice as high in STEMI compared to NSTEMI patients.

Objectives : To determine the influence of the side intervened upon on outcomes during carotid artery stenting (CAS). Background : Anatomic and technical aspects may influence the results of CAS. The value of the side intervened upon has not been analyzed yet. Methods : We analyzed data from the Carotid Artery Stent (CAS) – Registry. Results : A total of 3,165 CAS procedures, 1,613 (51%) at the left and 1,552 (49%) at the right carotid artery were included. There was a higher proportion of patients treated for symptomatic stenoses when CAS was performed at the left carotid artery (50.1% versus 45.8%, P = 0.016) and more patients already had prior carotid endarterectomy (8.5% versus 5.8%, P = 0.003). Interventions at the left side took 3 min longer than interventions at the right side (46.6 ± 24.3 versus 43.8 ± 23.6, P = 0.003). In patients treated at the left carotid artery amaurosis fugax (0.7% versus 0.1%, P = 0.005), ipsilateral stroke (3.1% versus 1.8%, P = 0.017), and the primary endpoint of in‐hospital death or stroke (4.1% versus 2.3%, P = 0.005) occurred significantly more often. Even after adjusting for confounding parameters, CAS procedures performed at the left carotid arteries remained an independent predictor of death or stroke (OR = 1.77, 95% CI: 1.15–2.72, P = 0.009). Conclusions : In current clinical practice, CAS is performed frequently at the right carotid artery as at the left carotid artery. CAS interventions have a higher in‐hospital complication rate if performed at the left carotid artery. Technical improvements might help to overcome this situation. © 2009 Wiley‐Liss, Inc.