Smokers benefit much more than non-smokers but are at increased risk of bleeding

Objectives: Despite the recommendations to initiate beta-blockade to all patients with an ST-segment elevation myocardial infarction, data concerning the timing of the administration of beta-blockers are controversially discussed. In view of these controversies, we analyzed the effect of immediate vs. delayed beta-blockade on all-cause mortality of patients with ST-segment elevation myocardial infarction in the Lower Austrian Myocardial Infarction Network.Design: Nonrandomized, prospective observational cohort study.Setting: Myocardial infarction network including the out-of-hospital emergency services, five primary-care hospitals and a percutaneous coronary intervention-capable hospital in the western part of Lower Austria.Patients: The data of all patients with ST-segment elevation myocardial infarction defined according to the American Heart Association criteria and treated according to the treatment protocol of the network were consecutively collected. For the purpose of survival analyses, the baseline survival time was set to 48 hours after the first electrocardiogram, and in all patients with recurrent MI within the observational period, only the first MI was regarded.Interventions: The treatment protocol recommended either the immediate oral administration of 2.5 mg bisoprolol (within 30 min after the first electrocardiogram) or 24 hours after acute myocardial infarction (delayed beta-blockade).Measurements and Main Results: In total, out of the 664 patients with ST-segment elevation myocardial infarction, 343 (n = 52%) received immediate beta-blockade and 321 (48%) received delayed beta-blockade. The probability of any death (baseline survival time: 48 hours after first electrocardiogram; 640 patients) was 19.2% in the delayed treatment group and 10.7% in the immediate treatment group (p = 0.0022). Also the probability of cardiovascular mortality was significantly lower in the immediate beta-blocker treatment group (immediate treatment group: 9 (5.2%); delayed treatment group: 30 (13.4%); p = 0.0002). Multivariable Cox regression analysis identified immediate beta-blocker therapy to be independently protective against death of any cause (odds ratio: 0.55, p = 0.033).Conclusion: Immediate beta-blocker administration in the emergency setting is associated with a reduction of all-cause and cardiovascular mortality in patients with ST-segment elevation myocardial infarction and seems to be superior to a delayed beta-blockade in our patient cohort. (Crit Care Med 2013; 41: 1396-1404)

Introduction: Acute kidney injury (AKI) is common in acute myocardial infarction (AMI) patients and has serious prognostic implications. The early identification of patients at risk of developing AKI at the emergency department (ED) can reduce its incidence.Methods: Patients with ST-segment elevation myocardial infarction (STEMI) at the ED were included. Associated factors playing a role at ED presentation and during hospitalization were collected, and independent risk factors of developing AKI were assessed.Results: Mean age among patients (n = 406, 69.7% male) was 62.5 +/- 12.5 years. At ED admission, the mean glomerular filtration rate (GFR) was 70.5 +/- 28.1 mL/min per 1.73m(2), and 140 (34.5%) patients had a GFR <60 mL/min per 1.73m(2). Eighty-three patients (20.4%) developed AKI: 47 (11.6%) with stage 1, 26 (6.4%) with stage 2 and 10 (2.5%) with stage 3. Mortality was 11.8% and was higher in patients with AKI (34.9% vs 5.9%, P < .0001). Univariate analysis disclosed age, reduced GFR at presentation, severe Killip class, heart rate and longer door-to-needle time as risk factors to develop AKI. Moreover, these patients received less beta-blocker and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker in the ED. Multivariate analysis revealed that age, Killip class, heart rate, door-to-needle time, and beta-blocker non-use were independent factors associated with AKI. These factors provided the ED physician with good accuracy in identifying patients at high risk of developing AKI.Conclusion: Factors associated with AKI in STEMI patients allowed physicians to identify patients at high risk in the ED. Moreover, reduced door-to-needle time and beta-blocker use were associated with renal protection in AMI patients. (C) 2012 Elsevier Inc. All rights reserved.

OBJECTIVE Arterial hypertension is the most frequently observed vascular risk factor. Physical and rehabilitative interventions may affect arterial blood pressure. The frequency of hypertensive patients in an outpatient clinic of physical medicine is unknown. DESIGN Prospective data collection. PATIENTS Overall, 3,826 patients admitted to the outpatient clinic for physical and rehabilitative interventions were included to assess arterial blood pressure, additional vascular risk factors, history of cardiovascular events and antihypertensive drug treatment. METHODS Arterial blood pressure was measured using an oscillometric method on the non-dominant arm. The patients were divided into sufficiently treated (< 140/90 mmHg, drug treatment), insufficiently treated (≥ 140/90 mmHg, drug treatment and history of hypertension) or de novo hypertensive patients (≥ 140/90 mmHg, no history of hypertension). RESULTS Arterial hypertension was observed in 48% of all patients (n = 1,840). In 719 (19%) of patients blood pressure above normal values. Due to significant hypertension 189 (5.2%) patients were either not permitted to start treatment or had to interrupt their physical treatment. CONCLUSION Insufficiently treated hypertension or previously undiagnosed hypertension is relatively common in a physical medicine clinic. We therefore recommend the implementation of arterial blood pressure measurement into the admission procedures in order to reduce such events.

Objectives: Patients with acute myocardial infarction are at high risk of dying within the first hours after onset of coronary ischemia. Therefore, pharmacological intervention should be started in the prehospital setting. This study investigates the effect of the prehospital administration of bivalirudin on short-term morbidity and mortality compared to heparin plus abciximab in patients with ST-segment-elevation myocardial infarction (STEMI).Methods: One hundred ninety-eight patients with STEMI treated with bivalirudin in the prehospital setting were prospectively collected. Coronary angiography was performed to identify the infarct-related artery. In case of a percutaneous coronary intervention, bivalirudin was given according to the guidelines. The historic control group consisted of 171 consecutive patients from the same myocardial infarction network treated with unfractioned heparin and abciximab administration before the admission to the emergency department of the percutaneous coronary intervention center. The primary outcome parameter was the incidence of major adverse cardiac events (recurrent myocardial infarction, stroke, death, target vessel revascularization for ischemia) within 30 days after the primary event.Results: The overall rate of major adverse cardiac events was significantly lower in the bivalirudin group compared to the abciximab group (7.6% vs 14.6%; P = .04). The number of major bleedings was significantly higher in the abciximab group compared to the bivalirudin group (11.8% vs 3.8%; P = .03).Conclusions: The use of bivalirudin in the prehospital setting leads to a reduced rate of major cardiovascular events compared to a standard treatment with abciximab plus heparin. Bivalirudin is a reasonable choice of treatment in the prehospital setting for patients with STEMI. (C) 2012 Elsevier Inc. All rights reserved.

OBJECTIVE:Pharmacologic cardioversion of atrial fibrillation (AF) is a reasonable mode of treatment if the arrhythmia is of recent onset. Results concerning the response rates of different drugs, respectively, in daily clinical practice and data with regard to the parameters associated with successful cardioversion are not very prevalent. METHODS:Three-hundred seventy-six patients who were admitted to the emergency department with acute AF and a duration of shorter than 48 hours were enrolled into the AF registry. RESULTS:The most effective drugs were flecainide and ibutilide (95% and 76%). Low response rates were observed with amiodarone (36%) and the individual use of digoxin or diltiazem (19% and 18%). Factors associated with a successful cardioversion were a lower blood pressure on admission (P = .002), a shorter time interval between the onset of AF and admission to the ED (P = .003), and adherence to treatment guidelines (P < .0001). CONCLUSION:The use of flecainide and ibutilide is associated with a much higher rate of cardioversion than other drugs we studied.

A total of 1,429 serum samples from 389 consecutive patients with acute chest pain were analyzed with the goal to aid the rapid diagnosis of acute myocardial infarction. To the best of our knowledge this is the largest and most comprehensive study on mid-infrared spectroscopy in cardiology. We were able to identify those signatures in the mid-infrared spectra of the samples, which were specific to either acute myocardial infarction or chest pain of other origin (angina pectoris, oesophagitis, etc). These characteristic spectral differences were used to distinguish between the cause of the donor's acute chest pain using robust linear discriminant analysis. A sensitivity of 88.5% and a specificity of 85.1% were achieved in a blind validation. The area under the receiver operating characteristics curve amounts to 0.921, which is comparable to the performance of routine cardiac laboratory markers within the same study population. The biochemical interpretation of the spectral signatures points towards an important role of carbohydrates and potentially glycation. Our studies indicate that the "Diagnostic Pattern Recognition (DPR)" method presented here has the potential to aid the diagnostic procedure as early as within the first 6 hours after the onset of chest pain.

The effects of the angiotensin II receptor blocker candesartan and the angiotensin‐converting enzyme inhibitor lisinopril on the fibrinolytic system were investigated in a double‐blinded, prospective, randomized study. Seventy‐seven hypertensive patients taking candesartan (n=41) and lisinopril (n=36) with a systolic blood pressure >130 mm Hg and/or a diastolic blood pressure >80 mm Hg obtained by 24‐hour ambulatory blood pressure measurement were included in the study. Blood pressure, plasminogen activator inhibitor 1 (PAI‐1), tissue plasminogen activator (tPA), and the molar ratio of PAI‐1/tPA were determined before treatment and 6 weeks later. Blood pressure decreased in both groups (candesartan, 155/85 mm Hg to 140/84 mm Hg; P <.05; lisinopril, 152/85 mm Hg to 138/83 mm Hg; P <.05). The fibrinolytic balance was significantly different between treatment groups (molar ratio of PAI‐1/tPA: candesartan, 3.66 [2.2]; lisinopril, 5.44 [2.6]; P <.05). In contrast to lisinopril, the balance between coagulation and fibrinolytic activity shifted toward fibrinolysis during candesartan treatment.

Objective To determine whether patients with hypertensive urgency have a higher risk for subsequent cardiovascular events compared with hypertensive patients without this event.Methods Overall, 384 patients with hypertensive urgency and 295 control patients were followed up for at least 2 years. Hypertensive urgency was defined as a systolic blood pressure above 220 mmHg and/ or a diastolic blood pressure above 120mmHg without any evidence of acute end-organ damage. The control group consisted of patients admitted to the emergency department with a systolic blood pressure between 135 to 180 mmHg and a diastolic blood pressure between 85-110mmHg. The number of cardiovascular events defined as acute coronary syndrome, acute stroke, atrial fibrillation, acute left ventricular failure and aortic aneurysm were consecutively analyzed during follow-up. The median follow-up time was 4.2 years ( interquartile range 2.9-5.7 years). Twenty-six patients of the urgency group and 23 patients of the control group were lost for follow-up.Results Overall, 117 (17%) patients had nonfatal clinical cardiovascular events and 13 had (2%) fatal cardiovascular events. The frequency of cardiovascular events was significantly higher in patients with hypertensive urgencies ( 88 vs. 42; P = 0.005). The Cox regression analysis identified age ( P < 0.001) and hypertensive urgencies ( P = 0.035) as independent predictors for subsequent cardiovascular events.Conclusions Hypertensive urgencies are associated with an increased risk for subsequent cardiovascular events in patients with arterial hypertension.

A prospective multicenter study including 1410 chest pain patients with suspected acute coronary syndromes was carried out to examine the predictive value of biological cardiac markers for adverse events measured by a point-of-care system. Admission cardiac troponin T (cTnT) and myoglobin were measured in parallel on a point-of-care system in the emergency department and -- together with CK-MB mass -- on lab analyzers. In a one-year follow-up, cardiac and non-cardiac death, acute myocardial infarction, unstable angina pectoris and need for revascularization were registered. Median time between onset of symptoms and admission was 285 min; 172 patients (12.2%) had no event during follow-up. If the cTnT, measured either by the point-of-care system or a conventional lab analyzer, was >0.05 microg/L, then the chance of a cardiac event during the follow-up period was doubled (18% vs. 9%). Serial cTnT measurement did not add any further value to the predictive power of the admission cTnT. Myoglobin and CK-MB mass identified increasing risk with increasing concentration quartiles; cardiac event rates were 2.8- to 4.4-fold higher between the quartiles with the lowest and those with the highest analyte concentration, respectively. There was no difference in non-cardiac death rates between any concentration quartiles. In conclusion, the prediction of clinical events by cardiac troponin T and myoglobin measured with a point-of-care analyzer in the emergency department was as good as that of the same cardiac markers and CK-MB mass measured on lab analyzers.

Purpose of the study was to evaluate the prognostic impact of hypertensive urgencies on cardiovascular events. The study was performed at the Hypertension Unit of the Department of Emergency Medicine in Vienna. Inclusion criteria were diagnosis of hypertensive urgency defined as blood pressure over 210 and/or 120 mm Hg without signs of end organ damage or uncontrolled hypertension defined as blood pressure at and over 140 and/or 90 mm Hg but below 210 and/or 120 mm Hg on admission. Patients with secondary hypertension were excluded. The incidence of cardiovascular events during follow-up was recorded. Overall 679 patients (332; 49% female) divided in 384 (57%) patients with hypertensive urgency and 295 (43%) patients with uncontrolled hypertension could be enrolled into the study. Patients with hypertensive urgencies were older (56 vs. 50 years; p=0.0001) had a higher frequency of left ventricular hypertrophy (p=0.024), a higher rate of microalbuminuria (p=0.013), dyslipidemia was more frequent (p=0.038) and more patients were unaware of hypertension (21% vs. 15%; p=0.026). Clinic systolic and diastolic blood pressure values were significantly higher in patients with hypertensive urgency (p=0.0001 and 0.008, respectively). Median time of observation was 4.2 years (IQR 2.9–5.7 years). During the period of follow-up blood pressure control, defined as blood pressure values below 140 and 90 mm Hg was achieved in 197 (51%) patients after hypertensive urgency and in 169 (57%) patients with primarily uncontrolled hypertension (p=0.121). Overall 117 (17%) patients had non-fatal clinical cardiovascular event and 13 (2%) patients died of cardiovascular reason. We found a statistically significant higher frequency of cardiovascular events in the patients with hypertensive urgency (p=0.04). In a cox regression analysis including hypertensive urgency, age, left ventricular hypertrophy, clinical blood pressure, microalbuminuria, dyslipidemia, and unknown hypertension only age (p=0.0001) and hypertensive urgency (p=0.029) were independent predictors of cardiovascular events. In conclusion patients with hypertensive urgency had a higher rate of major risk factors and target organ damage in comparison to patients with uncontrolled hypertension. Nevertheless besides age, hypertensive urgency per se seemed to be an independent predictor for the incidence of cardiovascular events in hypertension. Am J Hypertens (2004) 17, 194A–194A; doi: 10.1016/j.amjhyper.2004.03.512

Hirschl, MM; Derhaschnig, U; Collinson, P; Gaze, D; Haass, M; Chwallek, F; Katus, HA; Müller–Bardorff, M; Kellett, J; Ordóñez–Llanos, J; Santaló–Bel, M; Sylvén, C; Schulz, I; Zerback, R Author Information

The goal of this study was to examine whether point-of- care testing of cardiac markers in emergency departments or coronary care units generates a substantial reduction of the turnaround time compared with central laboratory testing. A total of 4609 samples from patients with suspected acute coronary syndromes attending each of 5 participating hospitals were used to measure cardiac troponin T on a point-of-care system at the bedside, and 3447 of these samples were simultaneously sent to each hospital's central laboratory for an emergency determination of total CK. The time to central laboratory result varied broadly (from 52-147 minutes) from hospital to hospital. There was little difference between the hospitals in the time to result for the point-of-care system (range, 12-22 minutes). The overall gain in time from point-of-care testing compared with central laboratory measurements was 65 minutes (range, 34-135 minutes).

This study was carried out to compare the time-dependent diagnostic sensitivity and specificity for acute myocardial infarction of 2 point-of-care tests for troponin T and myoglobin measured in routine use of coronary care units with those of the respective laboratory tests. A total of 794 consecutive patients with suspected acute coronary syndromes admitted to the coronary care units of 6 hospitals were enrolled in the study. Point-of-care tests and laboratory tests were measured in parallel from samples obtained serially on admission, and at 1, 2, 4, 6 to 8, 12, 24, and 48 hours from admission. The point-of-care tests achieved maximum sensitivities of 96% (troponin T) and 72% (myoglobin); and the maximum sensitivities of the laboratory tests were 96%, 81%, and 83% for troponin T, myoglobin, and CK-MB mass respectively. The specificities varied from 90 to 94% for point-of-care troponin T, 83 to 93% for point-of-care myoglobin, 97 to 99% for laboratory troponin T, 79 to 85% for laboratory myoglobin, and 95 to 100% for laboratory CK-MB mass. The following maximum areas under receiver-operator characteristics curves were obtained (at different times): point-of-care troponin T, 0.97; point-of-care myoglobin, 0.87; laboratory troponin T, 0.99; laboratory myoglobin, 0.89; and laboratory CK-MB mass, 0.96. In conclusion the point-of-care tests had a comparable clinical performance as established cardiac markers performed in the laboratory.

The aim of the study was to investigate the clinical significance of additional ST-segment elevation that occurs during thrombolytic therapy. Therefore, we classified 153 patients with a first acute myocardial infarction (MI) into two groups: Group A, 55 patients with additional ST-segment elevation >-1 mm above the initial ST elevation during thrombolytic therapy and Group B, 98 patient without this electrocardiographic pattern. Among the patients with anterior MI, Group A (n=33) had no reduction from ST-predicted to final QRS-estimated infarct size (+12% versus −27%; p=0.0005) and a larger final infarct size (QRS-score; 18% versus 12%: p=0.0002) than Group B (n=41). Among the patients with inferior MI, Group A (n=22) had a smaller reduction from ST-predicted to final QRS-estimated infarct size (−30% versus −53%; p=0.03) and a larger final infarct size (QRS-score; 15% versus 9%; p=0.03) than Group B (n=57). The area under the curve (AUC) of CK and CK-MB was higher in patients from Group A compared with those from Group B (anterior MI: AUC-CK: 22048 versus 19490 U.h.I−1; p=0.07; AUC-MB: 2227 versus 2016 U.h.l−1; p=0.11; inferior MI: AUC-CK: 17206 versus 11004 U.h.l.−1; p=0.01; AUC-MB: 2193 versus 1046 U.h.l−1; p-0.007). Both global left ventricular function and ST-segment elevation resolution were significantly better in Group B. Two and three vessel disease was observed more frequently in Group A. Additional ST-segment elevation during thrombolytic therapy suggests reduced myocardial salvage by thrombolytic therapy and thus may result in larger final infarct size.

OBJECTIVE:Comparison of oscillometric blood pressure measurement with two different devices (M3000A using a new algorithm and M1008A using an established algorithm, both Hewlett Packard) and evaluation of current recommendations concerning the relation between cuff size and upper arm circumference in critically ill patients. DESIGN:Prospective data collection. SETTING:Emergency department in a 2000-bed inner-city hospital. PATIENTS:A total of 30 patients categorized into three groups according to their upper arm circumference (I, 18-25 cm; II, 25.1-33 cm; III, 33.1-47.5 cm) were enrolled in the study protocol. INTERVENTIONS In each patient, two noninvasive blood pressure devices with three different cuff sizes were used to perform oscillometric blood pressure measurement. Invasive mean arterial blood pressure measurement was done by cannulation of the radial artery. MEASUREMENT AND MAIN RESULTS:Overall, 1,011 pairs of simultaneous oscillometric and invasive blood pressure measurements were collected in 30 patients (group I, n = 10; group II, n = 10; group III, n = 10). The overall discrepancy between both methods with the M3000A was -2.4 +/- 11.8 mm Hg (p <.0001) and, with the M1008A, -5.3 +/- 11.6 mm Hg (p <.0001) if the recommended cuff size according to the upper arm circumference was used (352 measurements). If smaller cuff sizes than recommended were used (308 measurements performed in group II and III), the overall discrepancy between both methods with the M3000A was 1.3 +/- 13.4 mm Hg (p <.024) and, with the M1008A, -2.3 +/- 11.5 mm Hg (p <.0001). CONCLUSION:The new algorithm reduced the overall bias of the oscillometric method but still showed a significant discrepancy between both methods of blood pressure measurement, primarily due to the mismatch between upper arm circumference and cuff size. The improvement of the algorithm alone could not result in a sufficient improvement of oscillometric blood pressure measurement. A reevaluation of the recommendations concerning the relation between upper arm circumference and cuff size are urgently required if oscillometric blood pressure measurement should become a reasonable alternative to intra-arterial blood pressure measurement in critically ill patients.