Die koronare Herzkrankheit ist trotz wachsendem Lebensstandard und aller präventiven medizinischen Maßnahmen nach wie vor von hoher medizinischer und ökonomischer Bedeutung. Die Akutform stellt das akute Koronarsyndrom dar. Komplizierend kann sich im Rahmen eines akuten Koronarsyndroms ein kardiogener Schock manifestieren, welcher die häufigste Todesursache für Patienten mit akutem Myokardinfarkt nach Aufnahme ins Krankenhaus darstellt. Ziel dieser Arbeit war die Identifizierung von Risikofaktoren für die Krankenhaus- sowie Langzeitmortalität bei der chirurgischen Revaskularisation von Patienten mit akutem Koronarsyndrom und komplizierendem kardiogenen Schock. Wir führten hierfür eine retrospektive Datenanalyse an 302 konsekutiven Patienten durch, welche im akuten Koronarsyndrom und kardiogenen Schock mittels aortokoronarer Bypassoperation therapiert wurden. Insgesamt wurden 44 präoperative, 18 intraoperative und 28 postoperative binäre Items analysiert. Wir konnten zeigen, dass bei den Höchstrisiko-Patienten die Letalität stark vom präoperativen Risikoprofil und dem Ausmaß des kardiogenen Schocks abhängt. Insbesondere der präoperative Einsatz einer IABP sowie die Verwendung der linken Arteria mammaria als Bypassgefäß wirkten sich positiv aus. Das gute Langzeit-Ergebnis demonstriert den Benefit einer chirurgischen Revaskularisation bei den Patienten mit akutem Koronarsyndrom und kardiogenen Schock mit anderenfalls schlechter Prognose.

Background: Dual antiplatelet therapy (DAPT) is a mainstay treatment for hospital survivors of an acute myocardial infarction (AMI). However, there are extremely limited data on the prescribing patterns of DAPT among patients hospitalized with AMI. Objective: To examine decade-long trends (2001-2011) in the use of DAPT versus antiplatelet monotherapy and patient characteristics associated with DAPT use. Methods: The study population consisted of 2,389 adults hospitalized with an initial AMI at all 11 central Massachusetts medical centers on a biennial basis between 2001 and 2011. DAPT was defined as the discharge use of aspirin plus either clopidogrel or prasugrel. Logistic regression analysis was used to identify patient characteristics associated with DAPT use. Results: The average age of the study population was 65 years, and 69% of them were discharged on DAPT. The use of DAPT at the time of hospital discharge increased from 49% in 2001 to 74% in 2011; this increasing trend was seen across all age groups, both sexes, types of AMI, and in those who underwent a PCI. After multivariable adjustment, older age was the only factor associated with lower odds of receiving DAPT, while being male, receiving additional evidence-based cardioprotective therapy and undergoing cardiac stenting were associated with higher odds of receiving DAPT. Conclusions: Between 2001 and 2011, the use of DAPT increased markedly among patients hospitalized with AMI. However, a significant proportion of patients were not discharged on this therapy. Greater awareness is needed to incorporate DAPT into the management of patients with AMI.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第20228号 / 医博第4187号 / 新制||医||1019(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 小池 薫, 教授 福原 俊一, 教授 湊谷 謙司 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

No description available.

Purpose: To determine the timing of first ambulation during hospitalization among patients admitted for acute myocardial infarction (AMI) and to identify the predictors of first ambulation. Methods: This retrospective cohort study included 500 AMI patients admitted during 2004 to one of three hospitals that form the Hamilton Health Sciences Corporation in Hamilton, Ontario, Canada. The patients were randomly selected from a total of 1,014 charts from the Hamilton Health Sciences Computerized Health Records (SOVERA). Using a chart abstraction tool, the following data were collected from each patient's chart: demographic information, past medical history, treatment, complications, and patterns of ambulation while in hospital. The primary outcome was first ambulation, defined as the first time patients walked during their hospital stay. Secondary outcomes included heart rate at discharge and mortality during hospitalization. The relationship between patient and care-related factors and the time of first ambulation after AMI was explored through a time to event analysis using Cox regression; the associations were expressed as hazard ratios. The fit for the proportional hazard model was assessed and a stratified proportional hazard model was performed for age. Results: Of the 500 charts, 60 were excluded. Of the 440 patients who were included in the final analysis, 340 (77.3%) walked during hospitalization. One hundred fifteen (26.1 %) walked during the first 48 hours (early walking), 98 (22.3%) walked between 49-96 hours (intermediate walking), and 127 (28.9%) walked after 96 hours (late walking). A total of 100 patients (22.7%) were categorized as non-walkers. Factors that emerged in the survival analysis that were positively associated with early ambulation after AMI and that proved the proportionality on the assessment of the fit of the model were: having a family history of cardiovascular disease (HR 1.33; 95% Cl 1.00, 1.44; p=0.05), receiving thrombolysis (HR 1.47; 95% Cl 1.11, 1.49; p=0.007), receiving nitroglycerin (HR 1.51; 95% Cl 1.19, 1.93; p<0.001 ), and taking calcium channel blockers (HR 1.58; 95% Cl 1.22, 2.05; p<0.001 ). Factors that were negatively associated with early ambulation after AMI were age >59 years (HR 0.98; 95% Cl 0.97, 0.99; p<0.001 ), having an arrhythmia in-hospital (HR 0.48; 95% Cl 0.22, 0.94; p=0.04), taking inotropic drugs (HR 0.72; 95% Cl 0.53, 0.98; p<0.001 ), and undergoing coronary artery bypass surgery (HR 0.51; 95% Cl 0.33, 0.78; p=0.002). Conclusion: There is variability in the timing of first ambulation among patients hospitalized with an AMI. Furthermore, those who walked early were more likely to have a family history of cardiovascular disease, have received thrombolysis, and be taking nitroglycerin or calcium channel blockers. Those least likely to walk early were older (>59 years), were more likely to have had an arrhythmia inhospital, to be taking inotropic drugs, and to have undergone coronary artery bypass surgery. / Thesis / Doctor of Philosophy (PhD)

Background: There is evidence that monocyte chemoattractant protein-1 (MCP-1) levels reflect the intensity of the inflammatory response in patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI) and have a predictive value for clinical outcomes. However, little is known about the effect of mild therapeutic hypothermia (MTH) on the inflammatory response in patients with CS complicating AMI. Therefore, we conducted a biomarker study to investigate the effect of MTH on MCP-1 levels in patients with CS complicating AMI. Methods: In the randomized mild hypothermia in cardiogenic shock (SHOCK-COOL) trial, 40 patients with CS complicating AMI were enrolled and assigned to MTH (33 ◦C) for 24 h or normothermia at a 1:1 ratio. Blood samples were collected at predefined time points at the day of admission/day 1, day 2 and day 3. Differences in MCP-1 levels between and within the MTH and normothermia groups were assessed. Additionally, the association of MCP-1 levels with the risk of all-cause mortality at 30 days was analyzed. Missing data were accounted for by multiple imputation as sensitivity analyses. Results: There were differences in MCP-1 levels over time between patients in MTH and normothermia groups (P for interaction = 0.013). MCP-1 levels on day 3 were higher than on day 1 in the MTH group (day 1 vs day 3: 21.2 [interquartile range, 0.25–79.9] vs. 125.7 [interquartile range, 87.3–165.4] pg/mL; p = 0.006) and higher than in the normothermia group at day 3 (MTH 125.7 [interquartile range, 87.3–165.4] vs. normothermia 12.3 [interquartile range, 0–63.9] pg/mL; p = 0.011). Irrespective of therapy, patients with higher levels of MCP-1 at hospitalization tended to have a decreased risk of all-cause mortality at 30 days (HR, 2.61; 95% CI 0.997–6.83; p = 0.051). Conclusions: The cooling phase of MTH had no significant effect on MCP-1 levels in patients with CS complicating AMI compared to normothermic control, whereas MCP-1 levels significantly increased after rewarming. Trial registration: NCT01890317.

Mortality in infarct-related cardiogenic shock (CS) remains high, reaching 40–50%. In refractory CS, active mechanical circulatory support devices including veno-arterial extracorporeal membrane oxygenation (VA-ECMO) are rapidly evolving. However, supporting evidence of VA-ECMO therapy in infarct-related CS is low. The current review aims to give an overview on the basics of VA-ECMO therapy, current evidence, ongoing trials, patient selection and potential complications.

In the United States, individuals of Hispanic ethnicity receive disproportionately lower-quality healthcare. These healthcare disparities exacerbate unequal access to quality healthcare services, including disparities in cardiovascular disease (CVD) and human immunodeficiency virus (HIV) care. Research on the role of ethnicity on the CVD outcomes of people living with HIV (PLWH) has been limited. We hypothesize that immunological (CD4+ cell count) and virological (HIV viral load) control may play a role in the development of acute myocardial infarction (AMI) among PLWH, and that Hispanic ethnicity may worsen these outcomes. To verify our hypotheses, we conducted a retrospective cross-sectional study to investigate the strength and direction of association between CD4+ cell count (immunological cohort, n=513) and HIV viral load (virological cohort, n=261) on AMI among respondents of the All of Us Research Program. Hispanic and non-Hispanic respondents for both cohorts were comparable in terms of demographic characteristics, except for a significantly different distribution by race. While we identified increased proportion of non-Hispanic individuals with AMI in the immunologic (6.0% vs. 1.0%; P=0.04) and virologic (5.8% vs. 0%; P=0.007) cohorts, we were not able to identify CD4+ cell count or viral load as significant predictors significantly increasing the likelihood of AMI. Potential explanations discussed include self-selection bias resulting in incomplete laboratory data and an underpowered sample size. While the sample in this study did not support an increased likelihood of AMI by ethnicity, the results should be interpreted carefully in light of the limitations and the established pathophysiological and epidemiological associations posited, underscoring the importance of future research efforts that better represent ethnic minorities and the associations between HIV infection and CVD.

Remarkable advances have been made in the treatment of cardiovascular diseases (CVD), however, CVD still accounts for the most deaths in industrialized nations. Ischemic heart disease (IHD) can lead to acute coronary syndrome (ACS) (myocardial infarction [MI]). The standard of care is reperfusion therapy followed by pharmacological intervention to attenuate clinical symptoms related to the MI. While survival from MI has dramatically increased with the implementation of reperfusion therapy, these individuals will inevitably suffer progressive pathological remodeling leaving them predispose to develop heart failure (HF). HF is a clinical syndrome defined as the impairment of the heart to maintain organ perfusion at rest and/or during times of exertion (i.e. exercise intolerance). Clinically, this is accompanied by dyspnea, pulmonary or splanchnic congestion and peripheral edema. Physiologically, there is neurohormal activation through the classical β–adrenergic and PKA–dependent signalin / Physiology

Background Cardiovascular diseases, including myocardial infarction and stroke, are the main reason of death in Sweden and Western Europe. High iron stores are believed to produce oxygen radicals, which is the presumed putative mechanism behind lipid peroxidation, atherosclerosis and subsequent cardiovascular disease. Iron levels are associated with the hemochromatosis associated HFE single nucleotide polymorphisms C282Y and H63D. Bilirubin is an antioxidant present in relatively high levels in the human body. Several previous studies have found an association between high bilirubin levels and a lower risk for cardiovascular disease. Bilirubin levels are highly influenced by the common promoter polymorphism TA-insertion UGT1A1*28, the main reason for benign hyperbilirubinemia in Caucasians. There is a lack of prospective studies on both the association of iron and bilirubin levels, and the risk for myocardial infarction and ischemic stroke. Material and methods Iron, transferrin iron saturation, TIBC, ferritin and bilirubin were analyzed and HFE C282Y, HFE H63D and UGT1A1*28 were determined in myocardial infarction and stroke cases, and their double matched referents within the Northern Sweden Health and Disease Study Cohort. Results There were no associations between iron levels in the upper normal range and risk for myocardial infarction or stroke. No associations were seen for HFE-genotypes, except for a near fivefold increase in risk for myocardial infarction in HFE H63D homozygous women. Plasma bilirubin was lower in cases vs. referents both in the myocardial infarction and the stroke cohort. Despite a strong gene-dosage effect on bilirubin levels in both cases and referents, the UGT1A1*28 polymorphism did not influence the risk for myocardial infarction or stroke. Conclusion High iron stores are not associated with increased risk for neither myocardial infarction, nor stroke. There was no association between UGT1A1*28 and the risk for myocardial infarction or stroke. Consequently data suggests that other factors, which also may lower bilirubin, are responsible for the elevated risk observed in conjunction with lower bilirubin levels.