INTRODUCTIONWe report a case of neurogenic pulmonary oedema (NPO) following massive left cerebral infarct, which was initially misdiagnosed as acute myocardial infarction (AMI).

CLINICAL PICTUREThis 52-year-old man presented with acute loss of consciousness with normal brain computed tomography (CT). He was treated as non-ST-elevation AMI complicated with pulmonary oedema based on findings of chest radiograph (bilateral pulmonary oedema), electrocardiogram (marked ST-T changes in leads V3 to V6), and cardiac enzymes [elevated creatinine kinase (CK) and CK-MB]. However, coronary angiogram and serial cardiac enzymes were inconclusive. Anisocoria developed after admission and a repeat brain CT was evident for large left cerebral infarct.

TREATMENTDecompressive craniectomy was carried out.

OUTCOMEMortality.

CONCLUSIONSThe diagnosis of NPO can be challenging when it occurs without abnormal findings on preliminary brain CT. It can be mistaken for cardiogenic pulmonary oedema secondary to AMI.

Cerebral Infarction ; physiopathology ; Coma ; Diagnosis, Differential ; Diagnostic Errors ; Humans ; Male ; Middle Aged ; Myocardial Infarction ; diagnosis ; Pulmonary Edema ; diagnosis ; physiopathology ; Radiography, Thoracic ; Taiwan

PURPOSE: The present study aimed to investigate the impact of high-sensitivity C-reactive protein (hs-CRP) and renal dysfunction on clinical outcomes in acute myocardial infarction (AMI) patients. MATERIALS AND METHODS: The study involved a retrospective cohort of 8332 patients admitted with AMI. The participants were divided into 4 groups according to the levels of estimated glomerular filtration rate (eGFR) and hs-CRP: group I, no renal dysfunction (eGFR > or =60 mL.min(-1).1.73 m(-2)) with low hs-CRP (< or =2.0 mg/dL); group II, no renal dysfunction with high hs-CRP; group III, renal dysfunction with low hs-CRP; and group IV, renal dysfunction with high hs-CRP. We compared major adverse cardiac events (MACE) over a 1-year follow-up period. RESULTS: The 4 groups demonstrated a graded association with increased MACE rates (group I, 8.8%; group II, 13.8%; group III, 18.6%; group IV, 30.1%; p<0.001). In a Cox proportional hazards model, mortality at 12 months increased in groups II, III, and IV compared with group I [hazard ratio (HR) 2.038, 95% confidence interval (CI) 1.450-2.863, p<0.001; HR 3.003, 95% CI 2.269-3.974, p<0.001; HR 5.087, 95% CI 3.755-6.891, p<0.001]. CONCLUSION: High hs-CRP, especially in association with renal dysfunction, is related to the occurrence of composite MACE, and indicates poor prognosis in AMI patients.
Aged ; C-Reactive Protein/*metabolism ; Coronary Angiography ; Female ; Humans ; Kidney/*physiopathology ; Male ; Middle Aged ; Myocardial Infarction/*metabolism/*radiography ; Retrospective Studies

PURPOSE: Coronary flow reserve (CFR) in the non-infarcted myocardium is often impaired following acute myocardial infarction (AMI). However, the clinical significance of CFR in the non-infarcted myocardium is not fully understood. The objective of the present study was to assess whether a relationship exists between CFR and left ventricular remodeling following AMI. MATERIALS AND METHODS: We enrolled 18 consecutive patients undergoing coronary intervention. Heart function was analyzed using real-time myocardial contrast echocardiography at one week and six months after coronary angioplasty. Ten subjects were enrolled as the control group and were examined using the same method at the same time to assess CFR. Cardiac troponin I (cTnI) levels were routinely analyzed to estimate peak concentration. RESULTS: CFR was 1.55+/-0.11 in the infarcted zone and 2.05+/-0.31 in the remote zone (p<0.01) at one week following AMI. According to CFR values in the remote zone, all patients were divided into two groups: Group I (CFR <2.05) and Group II (CFR >2.05). The levels of cTnI were higher in Group I compared to Group II on admission (36.40 vs. 21.38, p<0.05). Furthermore, left ventricular end diastolic volume was higher in Group I compared to Group II at six months following coronary angioplasty. CONCLUSION: Microvascular dysfunction is commonly observed in the remote myocardium. The CFR value accurately predicts adverse ventricular remodeling following AMI.
Aged ; Coronary Angiography ; Coronary Circulation/physiology ; Female ; Humans ; Male ; Middle Aged ; Myocardial Infarction/*physiopathology/radiography ; Myocardium/*pathology ; Ventricular Remodeling/*physiology

PURPOSE: Coronary flow reserve (CFR) in the non-infarcted myocardium is often impaired following acute myocardial infarction (AMI). However, the clinical significance of CFR in the non-infarcted myocardium is not fully understood. The objective of the present study was to assess whether a relationship exists between CFR and left ventricular remodeling following AMI. MATERIALS AND METHODS: We enrolled 18 consecutive patients undergoing coronary intervention. Heart function was analyzed using real-time myocardial contrast echocardiography at one week and six months after coronary angioplasty. Ten subjects were enrolled as the control group and were examined using the same method at the same time to assess CFR. Cardiac troponin I (cTnI) levels were routinely analyzed to estimate peak concentration. RESULTS: CFR was 1.55+/-0.11 in the infarcted zone and 2.05+/-0.31 in the remote zone (p<0.01) at one week following AMI. According to CFR values in the remote zone, all patients were divided into two groups: Group I (CFR <2.05) and Group II (CFR >2.05). The levels of cTnI were higher in Group I compared to Group II on admission (36.40 vs. 21.38, p<0.05). Furthermore, left ventricular end diastolic volume was higher in Group I compared to Group II at six months following coronary angioplasty. CONCLUSION: Microvascular dysfunction is commonly observed in the remote myocardium. The CFR value accurately predicts adverse ventricular remodeling following AMI.
Aged ; Coronary Angiography ; Coronary Circulation/physiology ; Female ; Humans ; Male ; Middle Aged ; Myocardial Infarction/*physiopathology/radiography ; Myocardium/*pathology ; Ventricular Remodeling/*physiology

This was designed to assess the outcomes of side branch (SB) stenosis after implantation of three drug-eluting stents (DES). From 2,645 patients in the ZEST (Comparison of the Efficacy and Safety of Zotarolimus-Eluting Stent with Sirolimus-Eluting and PacliTaxel-Eluting Stent for Coronary Lesions) Trial, 788 patients had 923 bifurcation lesions with SB > or = 1.5 mm were included. SB was treated in 150 lesions, including 35 (3.8%) receiving SB stenting. Of untreated SB with baseline stenosis < 50%, the incidences of periprocedural SB compromise was similar in the zotarolimus (15.8%), sirolimus (17.2%), and paclitaxel (16.6%) stent groups (P = 0.92). At follow-up angiography, delayed SB compromise occurred in 13.9%, 3.2%, and 9.4% (P = 0.010) of these groups. When classified into four groups (< 50%, 50%-70%, 70%-99%, and 100%), 9.0% of untreated SB were worsened, whereas improvement and stationary were observed in 9.6% and 81.4%. In a multivariable logistic regression model, main branch (MB) stenosis at follow-up (%) was the only independent predictor of SB stenosis worsening (odds ratio, 1.03; 95% confidence interval, 1.01-1.04; P < 0.001). After MB stenting in bifurcation lesions, a minority of SB appears to worsen. DES with strong anti-restenotic efficacy may help maintain SB patency.
Acute Disease ; Aged ; Blood Vessels/physiopathology ; Cardiovascular Agents/*therapeutic use ; Coronary Angiography ; Coronary Stenosis/*drug therapy/physiopathology/radiography ; Drug-Eluting Stents/*adverse effects ; Female ; Follow-Up Studies ; Humans ; Logistic Models ; Male ; Middle Aged ; Myocardial Infarction/etiology/radiography ; Myocardial Revascularization ; Odds Ratio ; Paclitaxel/*therapeutic use ; Predictive Value of Tests ; Sirolimus/*analogs & derivatives/*therapeutic use ; Thrombosis/etiology ; Treatment Outcome

BACKGROUND: The detection of residual stenosis of infarct related artery (IRA) at early stage after acute myocardial infarction (AMI) is crucial in clinical decision making for interventional revascularization. The aim of this study was to evaluate the relevancy of early dipyridamole stress myocardial SPECT to detect functionally and luminologically significant residual stenosis of IRA after AMI. METHOD: Twenty five consecutive patients (M:F=19:6, age: 56+/-13yrs) with AMI underwent SPECT and coronary angiography within 5 days of the attack. Infarct related arteries with FFR < 0.75 and diameter stenosis (DST) >70% were regarded to have functionally and morphologically significant residual stenosis. Reversible perfusion defect was defined if there was improvement of the perfusion score more than one grade in infarct segments on rest images of SPECT compared with stress images. RESULTS: Mean FFR and DST were 0.76+/-0.14 and 74+/-15%. SPECT showed no significant correlation with both FFR and DST with Kendall's coefficiency of 0.28 (p=0.05) and 0.13 (p=0.35). The sensitivity and specificity of SPECT to detect functionally and morphologically significant residual stenosis were 92%, 31% and 83%, 29%. CONCLUSION: The early dipyridamole stress myocardial SPECT after AMI does not seem to be a useful non-invasive test for the detection of functionally and luminologically significant residual stenosis of IRA.
Adult ; Aged ; Blood Flow Velocity ; Comparative Study ; *Coronary Angiography ; Coronary Circulation ; Coronary Stenosis/physiopathology/radiography/*radionuclide imaging ; Dipyridamole/diagnostic use ; *Exercise Test ; Female ; Human ; Male ; Middle Age ; Myocardial Infarction/physiopathology/radiography/*radionuclide imaging ; Sensitivity and Specificity ; Severity of Illness Index ; *Tomography, Emission-Computed, Single-Photon