Acute management--how should we intervene?

A crucial question in the acute management of the patient with unstable coronary artery disease (UCAD) is whether to carry out early intervention, performing angiography soon after presentation and following this with revascularization where appropriate, or whether to follow a noninvasive medical strategy as far as possible unless symptoms necessitate intervention. The body of literature addressing this question is sparse, but the recent Fast Revascularization during InStability in Coronary artery disease (FRISC II) study has provided new insights into the problem. Using a factorial design to randomize patients to invasive or noninvasive management strategies, and to short- or long-term treatment with the low-molecular-weight heparin (LMWH) dalteparin sodium (Fragmin), it was shown in FRISC II that early invasive treatment (within 7 days), when combined with optimal medical pretreatment with dalteparin sodium, aspirin, and appropriate antianginal medication, is associated with improved clinical outcomes, relative to a "watchful waiting" approach based on noninvasive therapy. Thus, an early invasive approach following aggressive medical pretreatment should be the preferred strategy for patients with UCAD who present with signs of ischemia on the electrocardiogram or raised biochemical markers of myocardial damage at admission.     

Risk stratification in unstable coronary artery disease--exercise test and troponin T from a gender perspective. FRISC-Study Group. Fragmin during InStability in Coronary artery disease

OBJECTIVES

The study was done to determine the prognostic yield of an early symptom-limited exercise test (ET) and measurement of troponin T (TnT) in men and women with unstable coronary artery disease (CAD), with special reference to gender differences.

BACKGROUND

Early risk assessment is essential for the application of appropriate treatment and further management in patients with unstable CAD. The early symptom-limited ET together with specific biochemical marker determination is an inexpensive, widely applicable method for early risk stratification. In women, however, the ET is considered less reliable, and there are few data on biochemical markers for risk stratification in women.

METHODS

In a substudy of the Fragmin during InStability in Coronary artery disease (FRISC I) trial, 395 women and 778 men with unstable CAD who performed an early ET were followed for six months. Blood samples for TnT determination were taken in 342 women and 621 men at inclusion.

RESULTS

Based on the ET results, low-, intermediate-, and high-risk response groups were identified with event rates of cardiac death or myocardial infarction (MI) of 1%, 9%, and 19%, respectively, among women and 8%, 14%, and 20%, respectively, among men. Patients who could not perform the ET had an event rate similar to the high-risk group. The TnT levels were divided into three groups: <0.06, 0.06–0.19, and ≥0.20 μg/liter with event rates of 1%, 10%, and 18%, respectively, among women and 9%, 14%, and 18%, respectively, among men. Combining the ET results with TnT levels identified a low-risk group with an event rate of 3% in the male population and no events in the female population.

CONCLUSIONS

Direct comparison between men and women from the same population with a high pretest likelihood of disease suggests that both TnT and the early symptom-limited ET are at least as useful as prognostic risk indicators in women as they are in men.     

Early symptom-limited exercise test for risk stratification in post menopausal women with unstable coronary artery disease. FRISC study group. Fragmin during Instability in Coronary Artery Disease.

AIMS: The exercise test is considered less reliable in women than in men both for diagnostic and prognostic purposes. The value, however, of the exercise test might vary with the population that is examined, the way the test is performed and which exercise test variables are taken into consideration in the analysis. The aim of the study was to evaluate an early symptom-limited exercise test as a tool for risk stratification in women with unstable coronary artery disease admitted to the coronary care unit. METHODS AND RESULTS: Of the 543 women in the FRISC I study, 395 stabilized on medical treatment and performed a symptom-limited exercise test 5-8 days after inclusion. Sixteen patients with a cardiac event before the scheduled exercise test were excluded. During the 6 months follow-up 17% of the women who did not perform the exercise test and 9% of the 395 women who did, died or had a myocardial infarction (P<0.01). Multivariate stepwise logistic regression analysis was performed to assess the value of clinical variables and findings at the predischarge exercise test to predict cardiac events. Based on the exercise test results three risk groups were identified with an event rate of 19%, 9% and 1%, respectively. The exercise test was better than any of the tested clinical variables in predicting cardiac events. CONCLUSION: Women with unstable coronary artery disease who do not stabilize within a few days have a high event rate early during follow-up. For women who are medically stabilized, considering not only variables like ST depression and chest pain but also parameters reflecting the cardiac performance such as maximal workload and increase in rate-pressure product, an early symptom-limited exercise test is a good predictor of future cardiac events.     

Low-molecular-weight heparin as a bridge to timely revascularization in unstable coronary artery disease -- an update of the Fragmin during Instability in Coronary Artery Disease II Trial

This article summarizes the design and findings -- both at 3 months and at 1 year follow-up -- of the Fragmin during Instability in Coronary Artery Disease (FRISC) II trial. This multicentre randomized trial compared both an early invasive with an early non-invasive stategy, and prolonged treatment with dalteparin as opposed to placebo, in patients with unstable coronary artery disease. The results show that an early invasive strategy with coronary angiography and, if appropriate, revascularization procedures within 7 days after admission reduces the subsequent rate of mortality and myocardial infarction. The benefits of the invasive treatment were noticeably more marked in patients with any high-risk indicator -- for example, male gender, age above 65 years, previous severe angina, or signs of ischaemia (ST depression on ECG) or of myocardial damage (elevated levels of troponin T). Treatment with dalteparin reduced the risk of death and myocardial infarction in high-risk (i.e. troponin-positive) patients, particularly during the first month of treatment. However, continuation with dalteparin therapy after revascularization procedures conferred no benefit. It is concluded that extended treatment with dalteparin is useful as a bridge to revascularization in this high-risk subgroup of patients with unstable coronary artery disease.     

Is early invasive treatment of unstable coronary artery disease equally effective for both women and men? FRISC II Study Group Investigators.

BACKGROUND: The Fragmin and fast Revascularization during InStability in Coronary artery disease (FRISC II) trial compared the effectiveness of an early invasive versus a noninvasive strategy in terms of the incidence of death and myocardial infarction (MI) in patients with unstable coronary artery disease (CAD). OBJECTIVES: In this subanalysis, we sought to evaluate gender differences in the effect of these different strategies. METHODS: The patients (749 women and 1,708 men) were randomized to early invasive or noninvasive strategies. Coronary angiography was performed within the first 7 days in 96% and 10% of the invasive and noninvasive groups, respectively, and revascularization was performed within the first 10 days in 71% and 9% of the invasive and noninvasive groups, respectively. RESULTS: Women presenting with unstable CAD were older, but fewer had previous infarctions, left ventricular dysfunction and elevated troponin T levels. Women had fewer angiographic changes. There was no difference in MI or death at 12 months among women in the invasive and noninvasive groups (12.4% vs. 10.5%, respectively), in contrast to the favorable effect in the invasively treated group of men (9.6% vs. 15.8%, p < 0.001). In an interaction analysis, there was a different effect of the early invasive strategy for the two genders (p = 0.008). CONCLUSIONS: Women with symptoms and/or signs of unstable CAD are older, but still have less severe CAD and a better prognosis compared with men. In contrast to its beneficial effect in men, an early invasive strategy did not reduce the risk of future events among women. Further research is warranted to identify the most appropriate treatment strategy in women with unstable CAD.     

Clinical performance of three cardiac troponin assays in patients with unstable coronary artery disease (a FRISC II substudy)

The assay of cardiac-specific troponins (cTroponins) is a sensitive and specific means to diagnose myocardial injury. Several assays for the measurement of cardiac-specific troponin I (cTnI), but only 1 for the assay of cardiac specific troponin T (cTnT), are commercially available. The aim of this study was to compare 3 of these assays (i.e., Access AccuTnI [cTnI], AxSym [cTnI], and Elecsys 3(rd) generation [cTnI]) and their clinical performances in a group of patients (n = 1,763) with unstable coronary artery disease (Fragmin and fast Revascularisation during InStability in Coronary artery disease [FRISC II] trial). Clinical events after 1-year follow-up, such as death and death and/or acute myocardial infarction, were recorded and the effects of invasive or noninvasive treatment evaluated in relation to cTroponin levels. Overall the 2 cTnI methods showed good correlation (r(s) = 0.96), whereas correlations to the cTnT assay were somewhat lower (r(s) = 0.93). Patients with nonelevated levels, as measured with any of the 3 biomarkers, had a significantly better prognosis than patients with elevated levels (p <0.001). A cohort of 10% to 12.4% of patients with a poor prognosis was identified only by the Access AccuTnI assay. Invasive treatment reduced clinical events only in the group of patients with elevated cTroponin levels. We conclude that stratification of patients with unstable coronary artery disease by means of cTroponin measurements is important in clinical management. It is also apparent that assays with superior sensitivity, such as the Access AccuTnI, identify more patients with poor prognosis who are candidates for early invasive procedures.     

Effects of an early invasive strategy on ischemia and exercise tolerance among patients with unstable coronary artery disease

BACKGROUND: An early invasive approach after an episode of unstable coronary artery disease has beneficial effects on mortality and myocardial infarction, but its effects on exercise capacity and ischemia have not been investigated. METHODS: In the Fast Revascularisation during InStability in Coronary disease (FRISC) II trial, 2457 patients with unstable coronary artery disease were assigned randomly to an early invasive or noninvasive strategy. A symptom-limited bicycle exercise test was performed before discharge in the noninvasive group and after 3 months in both groups. RESULTS: At 3 months, 86% (1046/1222) of the patients in the invasive group and 81% (995/1235) in the noninvasive group performed the exercise test. Before the test, revascularization had been performed in 78% (n = 819) of these patients in the invasive group compared with 28% (n = 281) of those in the noninvasive group. The mean (+/- SD) exercise capacity was higher (6.4 +/- 1.9 vs. 6.2 +/- 1.9 metabolic equivalents [METS], P <0.01), and the occurrence of ischemia lower (23% [229/1004] vs. 36% [352/966], P <0.001) in the invasive group. In the noninvasive group, 882 patients performed an exercise test both predischarge and at 3 months. If a revascularization procedure was performed (n = 210), exercise tolerance increased from 5.1 +/- 1.4 to 6.0 +/- 1.8 METS (P <0.001) and the number of patients with ST depression decreased from 65% (131/203) to 31% (63/203) (P <0.001). Without revascularization (n = 670), exercise tolerance increased from 5.9 +/- 2.2 to 6.3 +/- 1.9 METS (P <0.001), and there were no differences in the occurrence of ischemia. CONCLUSION: In unstable coronary artery disease, an invasive strategy improves exercise tolerance and reduces exercise-induced ischemia.     

Long-term management--the way forward?

The mainstay of treatment for unstable coronary artery disease (UCAD) currently consists of antithrombotic therapy with aspirin plus unfractionated heparin (UFH), together with anti-ischemic treatment with beta blockers and nitrates. Recently, there has been a trend toward replacement of UFH with low-molecular-weight heparins (LMWHs), since these products offer significant advantages over the parent compound. Several lines of evidence suggest that prolongation of treatment with LMWHs beyond the acute phase may be appropriate in patients with UCAD. The Fragmin and Fast Revascularization during InStability in Coronary artery disease (FRISC II) study was designed to evaluate this hypothesis using the LMWH dalteparin sodium (Fragmin). A factorial design was used to randomize patients enrolled in the FRISC II study to an invasive or noninvasive management strategy, and to treatment with dalteparin sodium or placebo. Treatment with dalteparin sodium significantly reduced incidences of death and/or myocardial infarction (MI) during the first months of treatment (the reduction in the relative risk of double endpoint events was statistically significant at 47.0% at 1 month, and remained so at 2 months, but was no longer statistically significant at the 3-month assessment). However, risk, as defined by the triple endpoint of death, MI, and revascularization, was significantly lower (13.0% relative risk reduction) at 3-month follow-up in the treatment group randomized to dalteparin sodium than among patients receiving placebo. In patients in whom revascularization procedures were carried out, the risk of new, postprocedural events was low in both the placebo and dalteparin sodium arms. Thus, dalteparin sodium appears to protect patients from cardiac events until they undergo invasive procedures, and it can therefore be used as a bridge to revascularization.     

Management Strategies for a Better Outcome in Unstable Coronary Artery Disease

Unstable coronary artery disease is a term encompassing both unstable angina and non-Q-wave (non-ST-segment elevation) myocardial infarction. Patients with these conditions are at risk of early progression to acute myocardial infarction and death. Thus, management of these conditions must aim to reduce long-term mortality and morbidity. Risk stratification is crucial for the identification of patients whose risk of early progression is high; they may require coronary angiography and (if suitable) either percutaneous transluminal coronary angioplasty or coronary artery bypass surgery. No single variable can accurately predict risk, but considerable data are emerging to show that biochemical markers of myocardial injury, such as troponin-T and troponin-I, are valuable in combination with electrocardiographic findings and clinical features. Routine early invasive procedures (coronary angiography with or without revascularization) have not yet been shown to have any significant advantage over conservative regimens for the majority of patients. Antiplatelet, anticoagulant, and anti-ischemic agents remain the mainstay of treatment in the acute phase. New agents, such as glycoprotein IIb/IIIa receptor inhibitors and low-molecular-weight heparins, as well as antithrombins and Factor Xa inhibitors add to the treatments currently available. Thrombolytic agents are contraindicated in the absence of ST-segment elevation. After clinical stabilization, ongoing assessment should include exercise testing for all patients who are able; other imaging techniques should be used for patients unable to exercise. A profile indicating a high risk of future events is an indication for elective angiography and consideration for revascularization.     

NT-proBNP in unstable coronary artery disease--experiences from the FAST, GUSTO IV and FRISC II trials

BACKGROUND: Risk stratification is important in patients with unstable coronary artery disease (CAD), i.e. unstable angina or non-ST-elevation myocardial infarction. This article focuses on the emerging role of N-terminal pro brain natriuretic peptide (NT-proBNP) and the results from the FAST, GUSTO IV and FRISC II trials. METHODS: In the FAST study, NT-proBNP was measured on admission in 755 patients admitted because of symptoms suggestive of unstable CAD. Follow up was performed after 40 months. The GUSTO IV and the FRISC II-trials included patients with unstable CAD and NT-proBNP was analyzed in 6806 and 2019 patients, with follow up after 1 and 2 years, respectively. RESULTS: In the FAST study, patients in the 2nd, 3rd, and 4th NT-proBNP quartile had a relative risk of subsequent death of 4.2 (1.6-11.1), 10.7 (4.2-26.8) and 26.6 (10.8-65.5), respectively. In the GUSTO IV trial, increasing quartiles of NT-proBNP were related to short and long term mortality which at 1 year was; 1.8%, 3.9%, 7.7% and 19.2% (P<0.001), respectively. In multivariable analyses including well-known predictors of outcome, NT-proBNP level was independently associated to mortality in all three studies. In the FRISC II trial, the NT-proBNP level, especially if combined with a marker of inflammation, identified those with the greatest benefit from an early invasive strategy. CONCLUSION: NT-proBNP is strongly associated with mortality in patients with suspected or confirmed unstable CAD and, combined with a marker of inflammation, seems helpful in identifying those with greatest benefit from an early invasive strategy.     

Cost-effectiveness of an invasive strategy in unstable coronary artery disease; results from the FRISC II invasive trial. The Fast Revascularisation during InStability in Coronary artery disease.

AIMS: The utilization and timing of revascularization in unstable coronary artery disease varies, which could have important consequences for patients and for treatment costs. The FRISC II invasive trial compared an early invasive strategy vs a non-invasive strategy with respect to the composite end-point of death and myocardial infarction as well as costs. METHODS AND RESULTS: A total of 2457 patients, median age 66 years, comprising 70% men, were randomized. We prospectively recorded the patients' use of the health service. The results were analysed in a societal perspective. There was a significant 1.7% absolute reduction in deaths and a 3.7% absolute reduction in deaths and myocardial infarctions in the invasive compared to the non-invasive group after 12 months. During the initial hospitalization a patient in the invasive group spent on average 3.9 more days in hospital than a patient in the non-invasive group. Opposite results were found for rehospitalizations. The difference in mean total costs is SEK 23 876 (P<0.001). The incermental cost-effective ratio for choosing the invasive instead of the non-invasive strategy is SEK 1 404 000 per avoided death and SEK 645 000 per avoided death or myocardial infarction. CONCLUSION: The high cost at the beginning of the invasive strategy is substantial. The clinical results of the FRISC II study provided evidence that the invasive strategy reduces the rate of death and myocardial infarction in patients with unstable coronary artery disease. For policy discussions concerning whether or not to implement the invasive strategy, these positive results should be balanced against the cost-consequences of the strategy.     

Impact of diabetes mellitus on long-term outcome after unstable angina and non-ST-segment elevation myocardial infarction treated with a very early invasive strategy

Aims/hypothesis We sought to evaluate the impact of diabetes mellitus on long-term outcome in patients with unstable angina and non-ST-segment elevation myocardial infarction treated with a very early invasive strategy.Methods We carried out a prospective cohort study in 270 diabetic and 1163 non-diabetic patients with unstable angina and non-ST-segment elevation myocardial infarction. All patients underwent coronary angiography and, if appropriate, subsequent revascularisation within 24 hours of admission. The primary endpoint was all-cause mortality during follow-up for up to 60 months.Results Diabetic patients had less favourable baseline characteristics including more advanced coronary artery disease and more severe unstable angina and non-ST-segment elevation myocardial infarction. Percutaneous coronary intervention was performed in 53% of diabetic patients and 56% of non-diabetic patients. Coronary artery bypass grafting was done in 21% of diabetic patients and 12% of non-diabetic patients. In-hospital mortality (4.1% vs 1.3%; hazard ratio 3.47; 95% CI: 1.57 to 7.64; p=0.002) and long-term mortality (9.7% vs 4.9%; hazard ratio 2.11; 95% CI: 1.33 to 3.36; p=0.002) were significantly higher in diabetic patients. After adjustment for differences in baseline characteristics, diabetes mellitus was no longer an independent predictor of long-term mortality (hazard ratio 1.43; 95% CI: 0.74 to 2.78; p=0.292).Conclusions/interpretation Diabetic patients treated with a very early invasive strategy for unstable angina and non-ST-segment elevation myocardial infarction have a higher in-hospital and long-term mortality that is largely explained by their less favourable baseline characteristics including more advanced coronary artery disease and more severe unstable angina and non-ST-segment elevation myocardial infarction.Abbreviations CK creatine phosphokinase - FRISC Fragmin and fast Revascularisation during InStability in Coronary artery disease - OASIS Organisation to Assess Strategies for Ischemic Syndromes - TACTICS-TIMI 18 Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy—Thrombolysis In Myocardial Infarction 18 - UA/NSTEMI unstable angina and non-ST-segment elevation myocardial infarction     

Benefits of extended treatment with dalteparin in patients with unstable coronary artery disease eligible for revascularization.

AIMS: The FRISC II trial demonstrated that, for patients with unstable coronary artery disease, an early invasive strategy following acute treatment with dalteparin and aspirin, was superior to a more conservative approach. We evaluated whether it is beneficial to extend treatment with dalteparin to patients eligible for revascularization but for whom these procedures are performed after the initial hospital stay. METHODS AND RESULTS: As a subanalysis of FRISC II, the efficacy and clinical safety of extended dalteparin treatment (5000 or 7500 IU.12h(-1) to day 90) compared with placebo was assessed in 1601 patients randomized to a non-invasive group who underwent revascularization only when necessary because of recurring symptoms, (re)infarction, or severe ischaemia. By day 90, 440 patients had undergone revascularization: 267 of these procedures occurred during the double-blind period. All patients initially received acute treatment (5-7 days from day 1) with dalteparin (120 IU/kg(-1) 12h(-1)). The incidence of death and/or myocardial infarction was monitored until revascularization or day 45 and until revascularization or day 90. There was a significant difference in the estimated probability of death and/or myocardial infarction until revascularization or day 90 in favour of dalteparin (log-rank test, P=0.0415) and there was a significant reduction in death and/or myocardial infarction in favour of extended dalteparin treatment at day 45, with a 57% relative risk reduction (P=0.0004). At day 90 the relative risk reduction was 29%. The safety profile of extended dalteparin treatment was similar to that of acute usage. CONCLUSION: Extended dalteparin treatment for up to 45 days is effective and safe as a bridging therapy for patients with unstable coronary artery disease awaiting revascularization.     

Routine Invasive Versus Conservative Management Strategies in Acute Coronary Syndrome: Time for a “Hybrid” Approach

The acute coronary syndrome is most often caused by plaque rupture and can result in a variety of clinical conditions. There are two general strategies (early invasive versus conservative) currently employed in the treatment of unstable angina or non-ST elevation myocardial infarction. Pooled data from recent clinical trials have demonstrated that high-risk patients benefit from a routine or early invasive approach while certain low-risk subgroups have similar outcomes with a conservative approach. Most patients in the USA are treated aggressively given advances in technology and the relative ease of interventional therapy. The routine invasive approach, however, remains controversial and has important limitations that are not well identified in trials. Furthermore, data from trials are difficult to interpret given their relevance to contemporary practice in today’s cost conscious, health care environment. The decision to pursue an invasive or conservative approach should be based upon an individual patient’s risk profile, and the level of medical therapy should be based on the underlying pathophysiology. The best strategy incorporates aggressive anti-atherosclerotic therapy with early risk stratification and invasive therapy when appropriate—the so-called hybrid approach. Identifying plaque rupture helps identify patients that would benefit from potent antiplatelet, antithrombotic, and anti-inflammatory therapies, and further insight into the natural history of coronary artery disease coupled with continued advances in diagnostic and interventional approaches will hopefully help guide long-term primary and secondary management.     

Cardiac disorders: a guide to assessing risk in the elderly

Coronary artery disease can have various clinical manifestations, from the presence of "silent" ischemia to the occurrence of an acute myocardial infarction and congestive myopathy. At each point in the clinical manifestation of coronary artery disease, the practitioner has an evolving number of techniques available to guide decisions regarding prognosis and therapy. Guidelines exist for defining which patients with "silent" ischemia need further evaluation. The clinically manifested occurrence of angina pectoris is commonly encountered in the elderly. Prognostic stratification can occur using both invasive and non-invasive techniques. Even patients with unstable angina have different outcomes depending upon clinical presentation and therapeutic management. Finally, a large pool of patients who survive an acute myocardial infarction have a varied prognosis depending upon certain risk markers as documented with widely available non-invasive testing. This article summarizes the evaluations and decisions the physician can make regarding patients who present with the various manifestations of coronary artery disease and provides a summary of recent data supporting decisions regarding prognosis and therapy.     

Gender differences in patients with suspected non-ST-segment elevation acute coronary syndromes. Implications for invasive management

Sex differences have been observed in the clinical profile, prognosis, and treatment of patients with unstable ischemic heart disease. Men tend to receive more invasive management. We assessed these differences in 823 consecutive patients (543 men) with possible acute coronary syndrome without ST-segment elevation who were seen since our chest pain unit opened. A protocol for the management of unstable ischemic heart disease was followed. Women had a worse baseline clinical profile but men more frequently had a positive exercise stress test. Univariate analysis showed that angiography and revascularization procedures were performed more often in men. However, multivariate analysis did not confirm male sex as an independent predictor of the need for a more invasive strategy. The inauguration of a chest pain unit and application of a protocol for the management of unstable ischemic heart disease has helped to correct case stratification and optimize the application of invasive treatments.     

Value of gated SPECT myocardial perfusion imaging for individual cardiac risk assessment

Myocardial perfusion imaging enables not only accurate diagnosis of disease but also entails prognostic value. Myocardial perfusion SPECT contributes to assessment of future cardiac events independently of other clinical parameters. A normal stress myocardial perfusion scan is associated with a favorable prognosis independent of history, symptoms, and exercise electrocardiography test variables. Cardiac risk and benefit from invasive therapeutic strategies increase in relation to the severity of the abnormality of perfusion and function assessed by gated myocardial perfusion SPECT. Thus, stress myocardial perfusion imaging may serve as a gatekeeper for referral to coronary angiography enabling effective risk stratification in patients with suspected or documented coronary artery disease.     

Comparison of continuous vectorcardiography and continuous 12-lead electrocardiography of patients with unstable coronary artery disease: do they identify the same population?

BACKGROUND: Continuous vectorcardiography (cVCG) and continuous 12-lead electrocardiography (c12ECG) are important tools for assessing patients with unstable coronary artery disease. OBJECTIVE: To compare the incidences of ischemia detected by the two methods, and examine whether the patients identified belonged to the same population, with respect to various clinical variables. METHODS: Within a randomized prospective trial (FRISC II) including patients with unstable coronary artery disease, ST-segment monitoring was performed either by cVCG or by c12ECG for 24 h after admission for 1016 patients. RESULTS: cVCG and c12ECG were performed for 730 and 286 patients, respectively. Transient ischemic episodes in 253 (34.7%) patients were detected by cVCG and such episodes were detected in 91 (31.8%) patients by c12EGG. When patients in whom transient ischemic episodes had been detected by cVCG and c12ECG were compared, the groups were similar with respect to baseline characteristics, signs of myocardial damage (67.5 versus 70.5%), occurrence of exercise-induced ischemia (59.0 versus 60.0%), and presence of severe coronary lesions (57.0 versus 51.3%). CONCLUSIONS: Results of this study suggest that these two methods identify the same high-risk population, and that these patients can be considered one group when results obtained using either system are analyzed in multicenter studies. This also implies that results concerning the occurrence of episodes of resting ischemia obtained using one system may also be applicable for the other.     

Prognostic value of exercise echocardiography in patients with classic angina pectoris

The role of stress echocardiography in the prognostic evaluation of patients with angina pectoris is not well defined. This study included 437 patients (241 men and 196 women) with angina pectoris and a pretest probability of coronary artery disease (CAD) of > or = 0.7 who were referred for exercise echocardiography. No patient had a history of acute myocardial infarction or coronary revascularization. Mean age was 65 +/- 10 years. During a median follow-up of 2.7 years, hard cardiac events (cardiac death or nonfatal myocardial infarction) occurred in 19 patients and 53 patients underwent coronary revascularization. Event-free survival rates in patients with normal versus abnormal stress echocardiograms were 98% versus 83% at 1 year, 96% versus 75% at 3 years, and 87% versus 69% at 5 years, respectively. In a multivariate analysis of clinical, exercise stress, and echocardiographic parameters, independent predictors of hard cardiac events were Q waves on the electrocardiogram (chi-square 8.7, p = 0.003) and the presence of wall motion abnormalities during exercise in multivessel distribution (chi-square 5.3, p = 0.02). In an incremental model of clinical, exercise, and echocardiographic variables for the prediction of all cardiac events, the addition of echocardiographic data increased the chi-square of the model from 62 to 78 (p = 0.0003). Exercise echocardiography provides useful information in the risk stratification of patients with suspected CAD and a high pretest probability of CAD. Patients with normal exercise echocardiograms have a low event rate and therefore can be exempted from invasive procedures during the 3 years after a normal exercise echocardiogram.     

Continuous multilead ST-monitoring identifies patients with unstable coronary artery disease who benefit from extended antithrombotic treatment.

AIMS: Prolongation of anticoagulant treatment might reduce subsequent cardiac events in patients with unstable coronary artery disease. Multilead ST-segment monitoring identifies patients with a high risk of adverse outcome. The aim was to assess the value of multilead ST-monitoring in prospectively identifying patients who respond to extended anticoagulant treatment with low-molecular weight heparin when treated by a primarily non-invasive strategy. METHODS AND RESULTS: In this substudy of the FRISC II trial, ST-monitoring with a continuous 12-lead ECG or vectorcardiography was performed for 24 h in 629 patients with unstable coronary artery disease randomized to receive either the low-molecular weight heparin dalteparin, or placebo for 3 months after at least 5 days' dalteparin treatment in all patients. Ischaemic episodes were detected in 34% during ST-monitoring. In the group with ischaemic episodes, the extended dalteparin treatment was associated with a lower rate of death, myocardial infarction, or revascularization (35.2% vs 53.4%, relative risk reduction: 34%, P=0.01). In patients without ischaemic episodes, long-term dalteparin treatment had no effect. CONCLUSIONS: In patients with unstable coronary artery disease treated primarily with a non-invasive strategy, ischaemic episodes revealed while on multilead ST-monitoring identifies patients who benefit most from extended treatment with anticoagulants.