Thrombolysis Plus Aortic Counterpulsation: Improved Survival in Patients Who Present to Community Hospitals With Cardiogenic Shock

Objectives. We sought to explore the potential benefit of combining intraaortic balloon counterpulsation (IABP) with thrombolysis for acute myocardial infarction (MI) complicated by cardiogenic shock.

Background. In community hospitals, this condition is usually managed with thrombolysis alone.

Methods. We reviewed the charts of 335 patients from two community hospitals who presented with acute MI and had cardiogenic shock between 1985 and 1995.

Results. Of 46 patients who underwent thrombolysis within 12 h of acute infarction with confirmed cardiogenic shock, 27 underwent IABP and 19 did not. Age, systolic blood pressure with shock, pulmonary artery catheter use, pulmonary capillary wedge pressure and the incidence of diabetes mellitus and anterior MI did not differ between groups. Patients treated with IABP were somewhat more likely to have prior MI and had a significantly greater cardiac index (2.0 vs. 1.5 liters/min per m², p = 0.04). Although no deaths occurred within 2 h of presentation, patients not treated with IABP tended to die earlier (6.8 ± 5 vs. 23.8 ± 19 h, p = 0.13). Patients treated with IABP had a significantly higher rate of community hospital survival (93% vs. 37%, p = 0.0002), and more of them were transferred for revascularization (85% vs. 37%). Of 30 patients transferred for revascularization, 27 underwent angioplasty or bypass surgery; hospital survival was 74%. Patients treated with IABP also had a significantly higher overall hospital and 1-year survival rate (67% vs. 32%, p = 0.019).

Conclusions. Survival may be enhanced and transfer for revascularization facilitated when community hospitals use both thrombolysis and IABP to treat patients with acute MI complicated by cardiogenic shock.

(J Am Coll Cardiol 1997;29:1454–8)     

Argentine Randomized Study: Coronary Angioplasty with Stenting versus Coronary Bypass Surgery in patients with Multiple-Vessel Disease (ERACI II): 30-day and one-year follow-up results. ERACI II Investigators

OBJECTIVE: The purpose of this study was to compare percutaneous transluminal coronary revascularization (PTCR) employing stent implantation to conventional coronary artery bypass graft surgery (CABG) in symptomatic patients with multivessel coronary artery disease. BACKGROUND: Previous randomized studies comparing balloon angioplasty versus CABG have demonstrated equivalent safety results. However, CABG was associated with significantly fewer repeat revascularization procedures. METHODS: A total of 2,759 patients with coronary artery disease were screened at seven clinical sites, and 450 patients were randomly assigned to undergo either PTCR (225 patients) or CABG (225 patients). Only patients with multivessel disease and indication for revascularization were enrolled. RESULTS: Both groups had similar clinical demographics: unstable angina in 92%; 38% were older than 65 years, and 23% had a history of peripheral vascular disease. During the first 30 days, PTCR patients had lower major adverse events (death, myocardial infarction, repeat revascularization procedures and stroke) compared with CABG patients (3.6% vs. 12.3%, p = 0.002). Death occurred in 0.9% of PTCR patients versus 5.7% in CABG patients, p < 0.013, and Q myocardial infarction (MI) occurred in 0.9% PTCR versus 5.7% of CABG patients, p < 0.013. At follow-up (mean 18.5 +/- 6.4 months), survival was 96.9% in PTCR versus 92.5% in CABG, p < 0.017. Freedom from MI was also better in PTCR compared to CABG patients (97.7% vs. 93.4%, p < 0.017). Requirements for new revascularization procedures were higher in PTCR than in CABG patients (16.8% vs. 4.8%, p < 0.002). CONCLUSIONS: In this selected high-risk group of patients with multivessel disease, PTCR with stent implantation showed better survival and freedom from MI than did conventional surgery. Repeat revascularization procedures were higher in the PTCR group.     

Impact of "off-label" utilization of drug-eluting stents on clinical outcomes in patients undergoing percutaneous coronary intervention

The utilization of drug-eluting stents (DES) in "real world" practice has deviated from Food and Drug Administration-approved indications. Safety concerns have arisen from recent reports that suggested increased mortality and nonfatal myocardial infarction (MI) with DES usage. Little is known about the clinical outcomes of patients undergoing intracoronary DES implantation for unapproved indications as a group compared with outcomes after bare metal stent (BMS) placement. The clinical outcomes of 546 patients undergoing DES implantation for >or=1 non-Food and Drug Administration-approved ("off label") indication since the approval of the device were assessed. The group was then matched by propensity score with 546 patients receiving BMSs prior to DES approval for the same indications. The primary endpoint was major adverse cardiac events (cardiac death, nonfatal Q-wave myocardial infarction [MI], and target vessel revascularization) at 12 months. Baseline clinical and angiographic characteristics were well matched between BMS and DES groups. The use of debulking devices was higher in the BMS group. Patients in the BMS group were more likely to be treated with larger diameter and shorter stents. There was no significant difference in the rate of in-hospital and 30-day adverse cardiac events. At 12 months, the primary endpoint of major adverse cardiac events was significantly reduced in the DES group (23.6% vs 16.7%, p=0.004), driven by reductions in the need for repeat revascularization (target lesion revascularization: 16.4% vs 7.8%, p<0.001; target vessel revascularization: 20.2% vs 13.1%, p=0.003). There was no significant difference in freedom from cardiac death or nonfatal Q-wave MI between groups (p=0.27). In conclusion, the utilization of DES for non-Food and Drug Administration-approved indications proved to be efficacious and safe when compared with a BMS cohort matched by propensity score. The advantage for DES was driven by reductions in repeat revascularization. "Off-label" DES use was not associated with increased rates of cardiac death and nonfatal MI at 12 months.     

Comparison of left ventricular ejection fraction and inducible ventricular tachycardia in ST-elevation myocardial infarction treated by primary angioplasty versus thrombolysis

Electrophysiologic studies predict the risk for sudden death after myocardial infarction (MI). Although primary angioplasty has become the preferred method of treatment for ST-elevation MI, intravenous thrombolysis remains the first-line treatment in 30% to 70% of cases worldwide. Rates of ventricular tachyarrhythmias may vary according to type of reperfusion treatment. This study was undertaken to examine the hypothesis that the left ventricular ejection fraction (LVEF) and rates of inducible ventricular tachycardia may be more favorable in treatment with primary angioplasty rather than thrombolysis. Consecutive patients receiving primary angioplasty (n = 225) or thrombolysis (n = 195) for ST-elevation MI were included. The mean LVEF was 48 +/- 12% for the primary angioplasty group and 46 +/- 13% for the thrombolysis group (p = 0.30). The proportion of patients with LVEFs <40% was 30% in the primary angioplasty group and 30% in the thrombolysis group (p = 0.98). Patients with LVEFs <40% underwent electrophysiologic studies. Ventricular tachycardia was inducible in 23 of 66 primary angioplasty patients (34.8%) compared with 21 of 55 (38.1%) thrombolysis patients (p = 0.69). Implantable cardiac defibrillators were inserted in 30 patients, of whom 8 (27%) had appropriate device activations. The mean time from MI to first spontaneous activation was 387 +/- 458 days. In conclusion, patients treated with thrombolysis or primary angioplasty for ST-elevation MIs had similar resultant LVEFs and rates of inducible ventricular tachycardia. There was a surprisingly high rate of spontaneous defibrillator activations, often occurring late after MI.     

Midterm outcome of patients with asymptomatic restenosis after coronary balloon angioplasty.

Although many patients with restenosis after balloon coronary angioplasty have recurrence of angina, others remain asymptomatic. To assess the clinical implications of asymptomatic coronary restenosis, we analyzed clinical and angiographic characteristics of 277 consecutive patients with restenosis, 133 (48%) of whom were asymptomatic (group I) and 144 (52%) symptomatic (group II). Restenosis was documented 6 to 9 months after the index procedure, or earlier if angina recurred, and was defined as a greater than 50% lumen narrowing (visual estimation). Group I (asymptomatic group) included fewer female (9% vs. 18%, p less than 0.05) and hypertensive patients (38% vs. 56%, p less than 0.005) and more patients with a previous myocardial infarction (48% vs. 28%, p less than 0.05) and single-vessel disease (67% vs. 55%, p less than 0.05). Before angioplasty, symptoms had lasted for a shorter period (10 +/- 25 vs. 23 +/- 42 months, p less than 0.001), ischemia after a recent infarction was a more frequent indication (21% vs. 10%, p less than 0.05) and total revascularization more frequently obtained (74% vs. 63%, p less than 0.05) in group I than in group II patients. Only a normal blood pressure, previous myocardial infarction, single-vessel disease and a shorter duration of symptoms were independent correlates of asymptomatic restenosis. No differences were found in stenosis severity before angioplasty (90% in both groups) or after angioplasty (22% +/- 12% vs. 24% +/- 16%).(ABSTRACT TRUNCATED AT 250 WORDS)     

Sirolimus-eluting stent implantation for unprotected left main coronary artery stenosis: comparison with bare metal stent implantation

OBJECTIVES: This study was designed to compare the clinical and angiographic outcomes of sirolimus-eluting stent (SES) and bare metal stent (BMS) implantation for unprotected left main coronary artery (LMCA) stenosis. BACKGROUND: The safety and effectiveness of SES implantation for unprotected LMCA stenosis have not been ascertained. METHODS: Elective SES implantation for de novo unprotected LMCA stenosis was performed in 102 consecutive patients with preserved left ventricular function from March 2003 to March 2004. Data from this group were compared to those from 121 patients treated with BMS during the preceding two years. RESULTS: Compared to the BMS group, the SES group received more direct stenting, had fewer debulking atherectomies, had a greater number of stents, had more segments stented, and underwent more bifurcation stenting. The procedural success rate was 100% for both groups. There were no incidents of death, stent thrombosis, Q-wave myocardial infarction (MI), or emergent bypass surgery during hospitalization in either group. Despite less acute gain (2.06 +/- 0.56 mm vs. 2.73 +/- 0.73 mm, p < 0.001) in the SES group, SES patients showed a lower late lumen loss (0.05 +/- 0.57 mm vs. 1.27 +/- 0.90 mm, p < 0.001) and a lower six-month angiographic restenosis rate (7.0% vs. 30.3%, p < 0.001) versus the BMS group. At 12 months, the rate of freedom from death, MI, and target lesion revascularization was 98.0 +/- 1.4% in the SES group and 81.4 +/- 3.7% in the BMS group (p = 0.0003). CONCLUSIONS: Sirolimus-eluting stent implantation for unprotected LMCA stenosis appears safe with regard to acute and midterm complications and is more effective in preventing restenosis compared to BMS implantation.     

Gender-related risk factors and outcomes for non-Q wave myocardial infarction patients receiving in-hospital PTCA

BACKGROUND: We analyzed the risk factors and outcomes associated with non-Q wave myocardial infarction (MI) in females and males. We studied 376 consecutive patients N 275 males (73%) and 101 females (27%) N who presented with non-Q wave MI and had percutaneous transluminal coronary angioplasty (PTCA) prior to discharge during the period between January 1992 and February 1996. RESULTS: Females were significantly older (68 +/- 10 years vs. 61 +/- 11 years; p < 0.001) and had more hypertension (67% vs. 51%; p < 0.01). Males had a slightly lower ejection fraction (47 +/- 11%) compared to females (50 +/- 10%; p < 0.001). Angioplasty was equally successful for women and men (96% vs. 97%; p = NS) with a statistically significant smaller number of lesions dilated per patient in females (1.38 vs. 1.51; p < 0.04). There were no significant differences in unstable angina, prior coronary artery bypass graft (CABG) surgery, saphenous vein graft PTCA, single vessel versus multiple vessel disease or history of prior MI. In-hospital complications (i.e., the need for CABG or repeat PTCA, recurrent MI, and stroke) were not statistically significant for either females or males. There was a trend for a higher in-hospital death rate in females after a non-Q wave MI, but it was not statistically significant (4% vs. 1%; p = 0.058). However, at one-year follow-up females had a significantly worse survival rate than men (89% vs. 95%; p < 0.04), although event-free survival rate was similar (61% female, 66% male; p = NS). CABG was performed less commonly in women by the end of one year (p < 0.02) than in men, while the performance of PTCA was similar. CONCLUSIONS: Although women with non-Q wave MI presented with more risk factors than men, in-hospital revascularization was equally successful with few complications and morbid events and similar event-free outcome at one year. However, one year mortality was worse for women, suggesting a need for more aggressive follow-up evaluation and treatment. For both women and men, this aggressive percutaneous revascularization strategy resulted in much better outcome than previously reported for medical treatment of non-Q wave MI.     

Myocardial infarction after coronary bypass surgery. Associated factors and prognosis

This paper studies the factors associated with perioperative myocardial infarction after coronary bypass surgery and assesses the medium-term prognosis of these patients. Four hundred and seventy patients underwent coronary bypass surgery between January 1983 and December 1986. The appearance and persistence of pathological Q waves, absent on the preoperative ECG, was the unique criterion of perioperative infarction. This complication was observed in 36 patients (7.65%). A comparison of these patients with a random group of 144 of teh 434 patients without perioperative infarction showed that they had a higher incidence of crescendo angina (55% vs 21%; p less than 0.001), ST-T wave changes on the resting ECG (78% vs 46%; p less than 0.001) and poor distal left anterior descending network (33% vs 13%; p less than 0.001): in addition, the group with infarction had a lower left ventricular ejection fraction (0.58 vs 0.64, p less than 0.01), incomplete myocardial revascularisation procedures (58% vs 32%; p less than 0.01), longer cardiopulmonary bypass times (86 mn vs 69 mn; p less than 0.001) and longer aortic clamping times (44.5 mn vs 37.4 mn p less than 0.05). The acute phase of the perioperative infarct was characterised by a higher incidence of major cardiac complications such as low output states (30.5% vs 2.02%; p less than 0.001). The hospital mortality was higher in the infarct group (8.3% vs 2.01%) but this was not statistically significant. After an average follow-up of 44 +/- 3 months, the 5 year survival rate was 95.4 +/- 2.1 per cent in patients without infarction and 76.5 +/- 6.9 per cent in those with perioperative infarction (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Insensitivity of the electrocardiogram in apical myocardial infarction

The ability of the standard ECG to identify myocardial infarction (MI) involving primarily the left ventricular (LV) apex is controversial. Therefore, the ECGs of 62 consecutive patients with acute infarction and isolated akinesia or dyskinesia of the LV apex on gated blood pool scintigraphy performed at rest 9 +/- 4 days after MI, were reviewed. The following distribution of Q waves was found: none, 26%; inferior leads only, 23%; anterior leads only, 32%; inferior + 1 or more V leads, 13%; lead I and/or aVL + 1 or more V leads, 6%. Only 12 patients (19%) demonstrated one of the "combination" Q-wave patterns thought to indicate apical infarction. Although the 20 patients with a history of MI did not differ in age or ejection fraction from those with a first MI, the combination of inferior and anterior Q waves was present in 6 of them (30%), vs only 2 of the remaining 42 patients (5%) (p less than 0.02). The 24 patients with apical dyskinesia had a lower ejection fraction (36 +/- 14 vs 48 +/- 12, p less than 0.001), a lower prevalence of isolated inferior Q waves (8 vs 32%, p less than 0.05) and a greater prevalence of isolated anterior Q waves (46 vs 24%, p = 0.09) than those with akinesia. Thus, in patients with recent MI localized to the LV apex on radionuclide ventriculography, pathologic Q waves are commonly confined to the anterior or inferior leads or absent altogether. The insensitivity of the various proposed criteria for the electrocardiographic diagnosis of apical MI emphasizes the value of imaging techniques in detecting this common clinical entity.     

Plasma and pericardial fluid natriuretic peptide levels in postinfarction ventricular dysfunction

AIMS: In the present study we examined plasma and pericardial fluid ANP and BNP concentrations in postinfarction ventricular dysfunction. The association of peptide levels to left ventricular (LV) dysfunction and to the localization of the myocardial infarction (MI) was studied. METHODS AND RESULTS: Plasma and pericardial fluid samples were obtained from 37 patients undergoing coronary bypass surgery. According to the ECG and preceding coronary angiography, the patients were divided into three groups: previous anterior myocardial infarction (MI) (n=12), previous inferior/posterior MI (n=15) and no history of MI (n=10). When compared to the control group with no MI, the patients with anterior MI had elevated plasma ANP and BNP (134+/-13 vs. 81+/-15 pg/ml, P<0.01 and 95+/-10 pg/ml vs. 26+/-8 pg/ml, P<0.01, respectively) and pericardial fluid BNP (473+/-60 pg/ml vs. 57+/-8 pg/ml, P<0.001) levels. The plasma natriuretic peptide concentrations were not increased in the patients with inferior/posterior MI, but the pericardial fluid BNP concentrations were greater than in the patients with no history of MI (129+/-35 pg/ml vs. 57+/-8 pg/ml, P<0.05). Six of the 12 patients with previous anterior MI had LVEF> or =45%. Despite their normal LV systolic function, these patients had increased plasma and pericardial fluid BNP levels when compared to the group with no history of MI (68+/-18 pg/ml vs. 26+/-8 pg/ml, P<0.05 and 534+/-258 pg/ml vs. 57+/-8 pg/ml, P<0.01, respectively). CONCLUSIONS: Previous anterior myocardial infarction was associated with increased cardiac BNP production even if the LV systolic function was normal (LVEF> or =45%). The high pericardial fluid BNP concentrations in postinfarction patients suggest that the BNP synthesis and release are augmented in the ventricular myocardium independent from the LVEF.     

Value of immediate coronary angioplasty following intracoronary thrombolysis in acute myocardial infarction

A total of 533 patients with acute myocardial infarction of less than 4-h duration were enrolled in the multicenter randomized trial of intracoronary thrombolysis compared to conventional treatment. In two of the five participating centers, an additional coronary angioplasty immediately after thrombolysis was attempted in 46 patients. According to the treatment allocation and early and late patency of the infarct related vessel, patients were subdivided into three groups: conventionally treated (group A); successful coronary angioplasty following thrombolysis with persistent patent infarct related vessel (group B); and late patency of the infarct related vessel postthrombolytic therapy without angioplasty (group C). The highest global ejection fractions were observed in group B (54% +/- 10%) and group C (55% +/- 13%), while the lowest ejection fraction was found in group A (47% +/- 14%). The sequential changes in global ejection fraction from the acute to the chronic stage was + 4% (p = 0.05) in group B, while no significant changes could be demonstrated in group C. Furthermore, in the group successfully treated by angioplasty, the improvement in global ejection fraction was more pronounced and persisted up to three months after the intervention. This was supported by analysis of regional myocardial function of the infarct zone (+ 16% improvement, p = 0.01). The long-term clinical follow-up (median 24 months) of the patients successfully treated by combined procedure of thrombolysis and angioplasty (group B) was most favourable with a lower incidence of re-infarction (6%), and late coronary bypass surgery (13%) and/or (re)-percutaneous transluminal coronary angioplasty (3%) was performed less frequently. These results suggest that reperfusion may need to be supplemented by additional revascularization procedures in order to optimize the changes of obtaining full functional recovery and so to improve the prognosis.     

Clinical and angiographic results of delayed revascularization by angioplasty or bypass after intravenous thrombolysis in myocardial infarction]

Between 1988 and 1990, 150 patients treated for an infarction by intravenous thrombolysis underwent coronary arteriography. Sixty seven were managed by revascularisation by angioplasty (n = 49) or bypass (n = 18) more than 48 hours after thrombolysis. In this delayed revascularisation group, the time before initial fibrinolysis was 114 +/- 55 minutes. The artery responsible for the infarction was patent in 88 per cent of cases at 12 +/- 9 days, with ejection fraction being 56 +/- 12 per cent. Indications for revascularisation were: recurrence of angina, Thallium stress test showing redistribution (n = 9), diffuse lesions (n = 11) or tight (greater than 75 per cent) proximal stenosis without vessel wall sequelae (n = 10). Comparison of the bypass and angioplasty groups showed a lower ejection fraction in the former than the latter (47% VS 58%, p less than 0.01), more frequent three-vessel disease (50% VS 6%, p less than 0.01) and more frequent revascularisation of the anterior interventricular (100% VS 37%, p less than 0.01). There were 2 deaths and 5 recurrences of infarction at one year. Follow-up arteriography was performed between at 2 and 6 months in 72% of the patients: 16 had restenosis after angioplasty and 4 occlusion of the graft after bypass. A second revascularisation procedure was necessary 15 times (14 angioplasties, 1 bypass). The outcome after bypass or angioplasty was favourable in 90% of cases in this group of patients exposed to a recurrence of infarction.     

Is transport with platelet GP IIb/IIIa inhibition for primary percutaneous coronary intervention more efficient than on-site thrombolysis in patients with STEMI admitted to community hospitals? Randomised study. Early results

INTRODUCTION: The advantage of primary percutaneous coronary intervention (pPCI) in the management of ST-elevation myocardial infarction (STEMI) over thrombolytic therapy has been demonstrated. However, an optimal medical treatment of STEMI patients admitted to regional hospitals without catheterisation facilities has not yet been established. Delay in initiation of pPCI resulting from transportation to the catheterisation laboratory may diminish the benefits of such therapy in comparison with thrombolysis administered in a regional hospital. Early initiation of therapy with platelet glycoprotein IIb/IIIa receptor inhibitor, which provides protection for the transportation, may be a reasonable solution to maintain the advantage of pPCI over thrombolysis alone in STEMI patients. METHODS: The studied group comprised patients with STEMI (infarct duration time <12 hours, typical clinical and electrocardiographic criteria of MI) who were randomly assigned in 13 regional hospitals located 20 to 150 km from invasive centre to one of two subgroups, either to thrombolysis in the community hospital or to transport after thrombolysis initiation with platelet GP IIb/IIIa receptor inhibitor (tirofiban; 10 mg/kg in intravenous bolus in the emergency room of the community hospital followed by continuous intravenous infusion of 0.1 mg/kg/min during transport as well as coronary procedure) in order to receive pPCI. All patients with cardiogenic shock on admission were routinely treated with PCI and were excluded from the study. RESULTS: 341 patients were included in the study (169 were randomised to receive thrombolytic therapy and 172--transport with intention to perform PCI). Mean time between onset of MI and randomisation was similar in the transport and thrombolysis groups, (139+/-133 min. vs 143+/-117 min., respectively, p=0.94). Mean infusion time of tirofiban to the beginning of PCI in the transport group was 121+/-36 min. Anterior MI was present in 42.6% of patients in the PCI group and in 41.5% in the thrombolytic group (p=0.085). Mean time from randomisation to pPCI was 158+/-60 min., and to thrombolysis initiation in 44+/-43 min. (p <0.0001). None of the patients died during transfer. In a 30-day follow-up we noted (pPCI vs thrombolytic group, respectively): mortality 3.49% vs 8.88% (p=0.04); reinfarction 1.16% vs 5.92% (p=0.02), stroke 0.58% vs 1.18% (p=0.55). In-hospital stay was significantly shorter in the transport group (9+/-3 days vs 14+/-7 days, p <0.0001). During hospitalisation, 17 (10.05%) patients initially assigned to thrombolysis alone had to be transferred to the catheterisation laboratory to undergo PCI (rescue PCI or PCI for postinfarction angina). Combined end-point (death/reinfarction/stroke) was reached more frequently in the thrombolytic group (15.98% vs 5.23%, p=0.001). CONCLUSIONS: A strategy of invasive therapy involving transport with GP IIb/IIIa receptor inhibitor and pPCI in STEMI patients admitted to hospital without catheterisation facilities was found to be more effective than thrombolytic therapy alone employed in the regional hospitals.     

Thrombolysis and intravenous beta-blockaders in the acute phase of myocardial infarction

Since proof exists of the individual efficacy of thrombolytics and intravenous beta-blockers in the acute phase of myocardial infarction (MI), it seemed to us logical and interesting to combine them. The aim of this retrospective study was to evaluate the safety and potential benefit of this drug combination for left ventricular function. We compared 40 patients (group I) of mean age 53.9 +/- 8.5 years admitted for MI in the six hours following the onset of symptoms treated by thrombolysis and intravenous beta-blockers (metoprolol or atenolol), with 27 patients (group II) of mean age 57.1 +/- 9.4 years treated within the same time lapse by thrombolysis alone. All patients underwent coronary arteriography and only two in group I were not examined by ventriculography. The two groups were comparable in terms of age, coronary history, localization of MI, clinical status at the outset, and time lapse before administration of the thrombolytic. Only heart rate differed at the outset (lower in group II; p = 0.05). A significant reduction in heart rate of 18% was seen in group I. When administration of the two drugs was simultaneous (less than or equal to 30-min lapse between each drug) this reduction was greater (22%) than when they were given separately (13%). In group II, the drop in heart rate was not significant (63%). In contrast, the decrease in systolic pressure in both groups was significant and comparable (group I: 16.6%; group II: 14.5%) even in the case of simultaneous administration (22%). There was no between-group difference in left ventricular ejection fraction (LVEF).(ABSTRACT TRUNCATED AT 250 WORDS)     

Clinical outcome of percutaneous transluminal coronary rotational atherectomy in patients with end-stage renal disease.

The clinical results of percutaneous transluminal coronary rotational atherectomy (PTCRA) in dialysis patients were retrospectively evaluated in comparison with coronary artery bypass grafting (CABG). From 1997 to 2001, 44 consecutive dialysis patients with 61 lesions underwent PTCRA and 55 consecutive dialysis patients underwent CABG. The initial success rate of PTCRA was 98%. The PTCRA group had a shorter hospital stay (13+/-17 vs 60+/-35 days, p=0.0001) and a lower rate of complications (11% vs 42%, p=0.001) than the CABG group. Although neither event-free survival without death nor myocardial infarction (MI) was significantly different between the CABG and PTCRA groups during the mean follow-up period of 21+/-14 months, 20 patients (45%) in the PTCRA group needed repeat revascularization of the target lesion. In conclusion, PTCRA may be a safe alternative modality for revascularization of high-risk CABG candidates, with excellent short-term results although the long-term outcome is inferior to that of CABG because of the higher restenosis rate.     

Predictive factors of coronary lesions in aortic stenosis in adults

The frequent coexistence in adults of a tight aortic stenosis and coronary arterial lesions raises problems of therapeutic and diagnostic approach. In an attempt at selecting indications for coronary arteriography, we studied 253 patients with severe aortic stenosis who were explored by that method. 177 patients (70 p. 100) had no coronary disease (group I); 76 patients (30 p. 100) had significant coronary lesions (group II). Group II patients differed from group I patients in several respects: they were older: 65 +/- 9 years on average as against 61 +/- 9 years (p less than 0.01); there was a greater proportion of men in that group: 76 p. 100 vs 58 p. 100 (p less than 0.01); more patients had a history of myocardial infarction: 7 p. 100 vs 0.5 p. 100 (p less than 0.05); calcifications of the coronary arteries were found in 43 p. 100 of the cases as against 15 p. 100 in group I (p less than 0.001); the transvalvular pressure gradient was lower: 50 +/- 30 mmHg vs 72 +/- 31 mmHg (p less than 0.01). There were no other significant differences in risk factors between the two groups, except for overweight which was greater in group II. Attacks of angina were not statistically more frequent in group II (80 p. 100) than in group I (73 p. 100, N.S.). A multifactorial analysis enabled us to establish a discriminant relation involving the patient's age, sex and history of infarction as well as coronary calcifications.(ABSTRACT TRUNCATED AT 250 WORDS)     

Relation of peak creatine kinase levels during acute myocardial infarction to presence or absence of previous manifestations of myocardial ischemia (angina pectoris or healed myocardial infarction)

The hypothesis that acute myocardial infarction (MI) is more extensive in patients without previous angina or healed MI was evaluated in 177 patients with documented recent acute MI. Ninety-nine patients (56%) had no previous angina or healed MI (negative history group), and the remaining 78 patients (44%) had a previous history of angina or healed MI (positive history group). The mean peak creatine kinase (CK) level in the negative history group was 784 compared with 419 IU in the positive history group (p less than 0.0001). The mean peak CK-MB level in the negative history group was 128 compared with 76 IU in the positive history group (p less than 0.001). The mean peak CK-MB level was higher in the negative history group after controlling for age, streptokinase administration, previous coronary artery bypass grafting or treatment with beta-blocking agents. Despite the high frequency of healed MI in the positive history group (73%), the rates of in-hospital complications were similar for the 2 groups. Patients with acute MI without previous angina or healed MI have substantially higher peak CK and CK-MB levels; this implies a larger MI than in patients with previous angina or healed MI.     

Exercise tolerance in patients with and without ventricular aneurysm

To assess the role of a left ventricular aneurysm (VA) in affecting cardiac pump function, 36 patients with an echo-proved postmyocardial infarction (MI) VA underwent maximal symptom limited exercise testing. A control group was formed of 36 patients with a previous MI without VA. The two groups were matched for age, sex, and site of MI. No difference was found in maximal work capacity (MWC), heart rate (HR), systolic blood pressure (BP), delta HR/k rho m, delta BP and VO2max/kg during exercise. MWC in patients with VA and anterior MI was lower as compared to patients with VA and inferior MI (2,839.3 +/- 1,340.9 vs. 4,537.5 +/- 1,453.7, p less than 0.05) while no difference was found between anterior and inferior MI without VA. Patients with VA and anterior MI tolerated lower workloads as compared to those with anterior MI without VA (2,839.3 +/- 1,340.9 vs. 3,996.4 +/- 2,347.1, p less than 0.05). No difference was found between patients with inferior MI with or without VA. No major adverse cardiovascular events occurred during or after the tests. Patients were grouped for echo-estimated ejection fraction (EF) less than 30%, 30-50% and greater than 50%. Only 1 patient without VA was found among patients with EF less than 30%. In both groups MWC increased with the increase of EF. Patients with VA, anterior MI and EF less than 30% showed the lowest exercise tolerance (2,216.6 +/- 529.1), and no patient with VA and inferior MI exhibited EF less than 30%. In conclusion, in patients with VA, exercise testing is a safe and useful tool to evaluate the functional capacity of the residual 'non-aneurysmatic' myocardium.     

Emergency coronary artery revascularization: a possible therapy for acute myocardial infarction.

Cardiac muscle death caused by coronary artery occlusion is a dynamic process that often takes hours or days. Emergency revascularization (saphenous vein bypass graft (SVBG) during acute myocardial infarction (MI) can interrupt myocardial necrosis, salvage ischemic myocardium and revascularize vessels with obstructive lesions not involved in the MI. In this report we describe a preliminary experimental study of 75 patients in which emergency SVBG was the therapy for acute MI. Group 1, 16 patients, required vasoactive medications and/or intraaortic balloon pumping to maintain their blood pressure preoperatively. There was one operative death and two late deaths. Group 2 consisted of 59 hemodynamically stable patients. There were no deaths. The average preop CPK in group 1 was 892 vs 504 in group 2 (p greater than 0.05). Surgical techniques were routine. The average time from the onset of chest pain that continued to surgery was 6.5 hours. Forty patients were restudied. Post- vs presurgical hemodynamics revealed ejection fraction increased by 34% (p greater than 0.05), left ventricular end-diastolic pressure reduced by 40% (p greater than 0.01). End-systolic and end-diastolic volume reduced by 30% (p greater than 0.05), and 15% (p greater than 0.01), and stroke volume improved 25% (p greater than 0.05). Operative mortality was 1.3% and late mortality 2.8%. These results suggest that cautious continued trial of emergency SVBG in patients with evolving MI is warranted.     

Clinical study of late potentials--comparison of late potentials in myocardial infarction, cardiomyopathy and idiopathic ventricular tachycardia

Late potentials (LPs) were studied using the signal averaging technique in 80 patients with myocardial infarction (MI), idiopathic cardiomyopathy (CM) and idiopathic ventricular tachycardia (IVT). In MI, LP duration was 28.4 +/- 12.6 ms in the sustained VT group (I; 8 cases); 18.6 +/- 9.0 ms in the non-sustained VT group (II; 11 cases); and 14.4 +/- 8.6 ms in the non-VT group (III; 21 cases); (p less than 0.05 in I vs II, p less than 0.01 in I vs III and not significant in II vs III). In CM, it was 33.7 +/- 13.0 ms in group I (6 cases); 20.1 +/- 5.9 ms in group II (12 cases); and 7.1 +/- 9.2 ms in group III (14 cases); (p less than 0.01 in I vs II, I vs III and II vs III). The LP duration in IVT (8 cases) was 15.6 +/- 10.4 ms, which was significantly shorter than that of group I in MI and CM (p less than 0.05 vs MI and p less than 0.01 vs CM). Late potential duration was also compared between a pacing-inducible VT group and a non-inducible VT group. The mean value of LP duration in the inducible VT group of MI was significantly longer than that in the non-inducible group (27.8 +/- 3.9 ms in 4 cases vs 17.3 +/- 2.5 ms in 4 cases, p less than 0.05). However, there was no significant difference in LP duration between the inducible and non-inducible groups of CM (22.0 +/- 11.0 ms in 5 cases vs 22.2 +/- 13.6 ms in 5 cases).(ABSTRACT TRUNCATED AT 250 WORDS)