Comparison of protective effects of preinfarction angina pectoris in acute myocardial infarction treated by thrombolysis versus by primary coronary angioplasty with stenting.

The protective effects of preinfarction angina were evaluated in acute myocardial infarction (AMI) treated by primary percutaneous transluminal coronary angioplasty (PTCA) and stenting. We studied 613 patients with AMI. Group 1 (n = 306) was treated by conventional medical therapies and coronary thrombolysis and group 2 (n = 307) was treated by primary PTCA supported by stenting. Each group was subdivided into those with and without preinfarction angina within 24 hours before the onset of AMI. There was no significant difference in clinical characteristics between the subgroups of groups 1 and 2. In group 1, there were differences between patients with preinfarction angina (n = 84) and those without (n = 222) in in-hospital mortality (11% vs 18%), pump failure (Killip classes 3 and 4) (11% vs 21%, p <0.05), left ventricular ejection fraction at discharge (52 +/- 13% vs 48 +/- 14%, p <0.05), and peak creatine kinase (2,106 +/- 1,637 vs 2,764 +/- 2,154 U/L, p <0.02). In group 2, however, there was no significant difference between those with preinfarction angina (n = 82) and those without (n = 225) in mortality (6% vs 6%), pump failure (12% vs 12%), left ventricular ejection fraction (50 +/- 13% vs 50 +/- 13%) and peak creatine kinase (3,285 +/- 2,306 vs 3,291 +/- 2,262 U/L). Multivariate analysis indicated that preinfarction angina was an independent determinant of in-hospital death and pump failure in group 1, but not in group 2. We conclude that the protective effects of preinfarction angina in AMI are not evident in those treated by primary PTCA and stenting, possibly because of the overwhelming protective effects of complete coronary revascularization provided by primary PTCA and stenting.     

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.     

Emergency percutaneous transluminal coronary angioplasty during acute myocardial infarction for patients more than 70 years of age

Thirty-five patients greater than 70 years of age with acute myocardial infarction (AMI) were treated with emergency percutaneous transluminal coronary angioplasty (PTCA). Seventeen (49%) patients received previous thrombolytic therapy: streptokinase (10 patients), tissue plasminogen activator (6) and combined tissue plasminogen activator and urokinase (1). Infarct-related artery patency was achieved in 26 patients (74%) after PTCA. Total in-hospital mortality was 34%. Univariate analysis showed a higher in-hospital mortality in patients with an occluded vessel after PTCA (78%) than in those patients with a patient infarct-related artery (19%) (p = 0.003). Symptomatic coronary reocclusion occurred in 3 patients (15%) during the hospital stay. Compared with emergency PTCA in 200 consecutively treated patients less than 70 years of age, the in-hospital mortality was increased (34 vs 6%, p less than 0.001), and the primary success rate was reduced (66 vs 90%, p less than 0.001). At a mean follow-up of 28 months, there has been a 13% out-of-hospital mortality rate in the elderly patients (3 patients died). Of the 20 surviving patients, 14 are asymptomatic and 6 have class II angina. In conclusion, emergency PTCA for AMI in elderly patients is associated with a decreased success rate and a higher mortality rate. However, the in-hospital mortality rate is not dissimilar to that in elderly AMI patients treated with conventional therapy or thrombolytic therapy alone, and the postdischarge mortality rates are low.     

Myocardial perfusion grade and survival after percutaneous transluminal coronary angioplasty in patients with cardiogenic shock

We sought to evaluate myocardial reperfusion and its prognostic value after percutaneous transluminal coronary angioplasty (PTCA) in patients admitted for cardiogenic shock. Lack of myocardial reperfusion despite restored coronary flow affects the survival of patients with acute myocardial infarction (AMI). Myocardial blush grade (MBG) is an angiographic measure of myocardial perfusion. We assessed MBG in 41 consecutive patients admitted to our department within 12 hours from the onset of AMI and in cardiogenic shock. PTCA was successful in 83% of patients. Thrombolysis In Mycardial Infarction (TIMI) grade 3 flow was demonstrated in 22 patients (53%). MBG 2/3 was found in 14 patients (34%); among them, 12 had TIMI 3 flow. Compared with patients with MBG 2/3, those with MBG 0/1 were older (71 +/- 11 vs 57 +/- 13 years, p = 0.001), had a higher prevalence of diabetes (48% vs 14%, p = 0.04) and hypertension (63% vs 29%, p = 0.04), showed a trend toward longer ischemic time (6.1 +/- 2.4 vs 4.9 +/- 1.1), and had larger enzymatic infarct size (peak creatine kinase 7,690 +/- 3,516 vs 5,500 +/- 2,977 IU/L). Mortality was higher in patients with MBG 0/1 both in the hospital (81% vs 14%, p <0.001) and at follow-up (81% vs 29%, p = 0.001). After adjustment by multivariate analysis, MBG 0/1 (odds ratio 16, p = 0.01) and age (odds ratio 3.8/10 years, p = 0.04) were correlated with in-hospital mortality. MBG 2/3 was achieved in a few patients in cardiogenic shock after AMI who were treated with PTCA; this was a strong predictor of in-hospital survival. Also, risk stratification after mechanical revascularization should include assessment of restoration of myocardial reperfusion.     

Outcome of women is impaired in patients undergoing emergency coronary artery bypass grafting for failed PTCA

There is an ongoing debate whether female gender is associated with increased cardiovascular morbidity and mortality, especially after coronary interventions. The impact of gender on the outcome of patients undergoing emergency coronary artery bypass grafting (CABG) for failed PTCA was analyzed. Clinical and procedural data of all patients who underwent PTCA and subsequent emergency CABG at our institution from 1989 to 1998 were assessed. During these 10 years, 6681 PTCA procedures were performed, 1312 in women (19.6%). Subsequently, 110 patients underwent emergency CABG of whom 32 were females (29.1%). Postoperatively, 9 women and 5 men died (mortality 12.7%). Women presented with higher age (61.2 +/- 2.1 vs. 58.3 +/- 1.0 years, n.s.), smaller height (1.61 +/- 0.01 vs. 1.76 +/- 0.01 m, p < 0.0001), lower weight (67.7 +/- 2.4 vs. 82.1 +/- 1.2 kg, p < 0.0001), smaller body surface area (1.70 +/- 0.04 vs. 1.98 +/- 0.02 m2, p < 0.0001), and higher comorbidity as expressed by their Cleveland score (7.9 +/- 0.3 vs. 7.1 +/- 0.2, p = 0.013). The risk for failure of PTCA with subsequent emergency CABG was higher in women than in men (2.4% vs. 1.5%, p = 0.012, odds ratio 1.66) as well as for postoperative death (28.1% vs. 6.4%, p = 0.004, odds ratio 4.39). Women had longer in-hospital stays (19.7 +/- 4.2 vs. 12.9 +/- 1.3 days, p = 0.044). Logistic regression analyses found lower weight (p = 0.003), higher number of diseased coronary vessels (p = 0.024) and higher Cleveland score (p = 0.023) to be independent predictors of operative mortality. A Kaplan-Meier model (follow-up 5.3 +/- 2.5 years) showed an increased in-hospital mortality in women (p = 0.0034, log rang test), but a comparable long-term survival. Women had an increased risk for failure of PTCA and a markedly higher operative mortality after emergency CABG. In multivariate analyses, however, gender was not an independent predictor of postoperative death.     

Sex differences in early and long-term results of coronary angioplasty in the NHLBI PTCA Registry

To assess whether gender influenced the outcome of percutaneous transluminal coronary angioplasty (PTCA), we analyzed data from the NHLBI PTCA Registry. Early results were compared in 705 women and 2374 men. Women were older (p less than .01) and had more unstable angina (p less than .01), and class 3 or 4 angina (p less than .01). Men had more multivessel disease (p less than .01), prior bypass surgery (p less than .01), and abnormal left ventricular function (p less than .05). Women had a lower angiographic success rate (60.3 vs 66.2%; p less than .01) and had a lower clinical success rate (56.6% vs 62.2%; p less than .01). More women had complications (27.2% vs 19.4%; p less than .01), but overall frequency of major complications (death, myocardial infarction, emergency surgery) was not different (9.8% vs 9.3%). Women had a higher incidence of coronary dissection (p less than .05) and higher in-hospital mortality (1.8% vs 0.7%; p less than .01). PTCA-related mortality was nearly six times higher in women (1.7% vs 0.3%; p less than .001) and mortality with emergency surgery was more than five time higher (17.4% vs 3.2%; p less than .001). Multivariate analysis indicated that female gender was an independent predictor for lower success (p less than .05) and early mortality (p less than .05) and was the only baseline predictor for PTCA-related mortality.(ABSTRACT TRUNCATED AT 250 WORDS)     

Half-dose thrombolysis to begin with, when immediate coronary angioplasty in acute myocardial infarction is not possible.

BACKGROUND: Low-dose lytic drugs are sometimes administered to patients with ST-elevation acute myocardial infarction (AMI) as a bridge to coronary angioplasty (facilitated PTCA). Reports are scarce. The characteristics and outcomes of a recent series of consecutive patients treated in our Center are presented. METHODS: In August 2000 facilitated PTCA with half-dose reteplase was started in our Center in all cases when the cath lab was not immediately (< 30 min) available, or the patient had to be transferred to us. Since August 2000, 153 patients were admitted to our cath lab to undergo facilitated (n = 80) or primary (n = 73) PTCA. The data of all patients were prospectively collected, and were analyzed on an "intention-to-treat" basis. RESULTS: No significant differences were found between facilitated and primary PTCA patients with regard to: gender, diabetes, hypertension, previous PTCA/bypass surgery, heart rate at admission, systolic blood pressure, anterior AMI, number of leads with ST-segment elevation, total ST-segment deviation, collateral flow to the infarct-related artery, and three-vessel disease. In our series, facilitated vs primary PTCA patients had a better risk profile: they were younger (61 +/- 13 vs 66 +/- 11 years, p = 0.016), less frequently had a previous AMI (7 vs 24%, p = 0.01), had a shorter time from pain onset to first emergency room admission (122 +/- 104 vs 168 +/- 162 min, p = 0.045), and a trend to a shorter total time to the cath lab (209 +/- 121 vs 255 +/- 183 min, p = 0.073) despite a similar emergency room-to-cath lab component (89 +/- 50 vs 98 +/- 92 min, median 74 vs 65 min, p = NS). Moreover, they presented with a lower Killip class on admission (1.1 +/- 0.4 vs 1.5 +/- 0.98, p = 0.01), with more patients in Killip class 1 (95 vs 74%, p = 0.001). One vs 8% of patients were in shock. Facilitated vs primary PTCA patients had an initial TIMI 2-3 flow in 42 vs 25% of cases (p = 0.031), a final TIMI 3 flow in 82 vs 71% (p = NS), > or = 50% ST-segment resolution in 73 vs 58% (p = NS), and both of the latter in 62 vs 45% (p = 0.099); distal coronary embolization occurred in 9 vs 14% of cases (p = NS); intra-aortic balloon counterpulsation was used in 5 vs 12% and glycoprotein IIb/IIIa inhibitors in 10% of the whole population. The overall in-hospital mortality was 3.7 vs 9.6% (p = NS), and 2.5 vs 4.5% (p = NS) when patients in shock at admission were not considered. Reinfarction occurred in 2 patients submitted to facilitated PTCA (who had had no immediate PTCA, due to full reperfusion) and in none of the patients submitted to primary PTCA; no patient presented with stroke or major bleeding. CONCLUSIONS: Pre-treatment with thrombolysis often provides a patent vessel before PTCA, appears to be safe, and may improve reperfusion after PTCA. In this setting, the additional use of glycoprotein IIb/IIIa inhibitors before PTCA only in non-reperfused patients may be significantly risk- and cost-effective.     

Angiographic findings,time course of regional and global left ventricular function,and clinical outcome in diabetic patients with acute myocardial infarction treated with primary percutaneous transluminal coronary angioplasty

There is scarce information available about the outcome of diabetic patients with acute myocardial infarction (AMI) treated with percutaneous transluminal coronary angioplasty (PTCA). We sought to compare left ventricular (LV) function, and angiographic and clinical outcomes in diabetics versus nondiabetics with AMI treated with primary PTCA. This study examined 720 consecutive patients with AMI treated with primary PTCA, 102 of whom had diabetes. Six-month follow-up coronary angiography was obtained in 560 patients (88% of eligible patients). In a subgroup of 284 patients, LV function was serially determined by 2-dimensional echocardiography. During 6-month follow-up no significant differences were observed between diabetics and nondiabetics with regard to restenosis rates (31.6% vs 28.2%, p = 0.6), recovery of LV function (6-month wall motion score index: 1.8 +/- 0.7 vs 1.8 +/- 0.7, p = 0.88; 6-month LV ejection fraction: 48.5 +/- 12% vs 51.2 +/- 13%, p = 0.173), nonfatal re-AMI rates (2.9% vs 1.3%, p = 0.2), and target vessel revascularization rates (21.6% vs 16.8%, p = 0.2). Early and late mortality were higher in diabetics than in nondiabetic patients (8.8% vs 4.2%, p = 0.045 and 11.7% vs 5.5%, p = 0.016, respectively). By Cox analysis, diabetes was an independent predictor of both early (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.1 to 5.3, p = 0.03) and late mortality (OR 2.37, 95% CI 1.16 to 4.84, p = 0.017) as well as 6-month major adverse cardiac events (MACEs): death, re-AMI, target vessel revascularization (OR 1.51, 95% CI 1.04 to 2.18, p = 0.03). Thus, diabetes is an independent predictor of clinical outcome even if PTCA is used as the primary reperfusion strategy.     

Comparison of short-term outcomes following coronary artery stenting in men versus women.

This study sought to determine whether women have more adverse in-hospital outcomes after percutaneous transluminal coronary angioplasty (PTCA) and stenting compared with men. There is still controversy regarding whether female gender is an independent predictor of mortality after PTCA. No study has examined gender differences in outcomes following the dissemination of stenting. Data were obtained from the Nationwide Inpatient Sample. In 1997, there were 118,548 angioplasties (36% occurred in women and 59% involved placement of stents). Outcomes included same-admission mortality and coronary artery bypass grafting (CABG). Analyses were performed separately for patients with and without acute myocardial infarction (AMI). In 1997, women had a roughly twofold higher mortality than men in every comparison group, including conventional PTCA alone and stents. Mortality rates after stenting were 4.0% for women and 2.0% for men with AMI (p <0.0001), and 1.1% and 0.5%, respectively, for patients without AMI (p <0.0001). The adjusted odds ratios were 1.47 (95% confidence interval 1.23 to 1.75), and 1.65 (95% confidence interval 1.33 to 2.04), respectively. Similarly, following stenting, women had significantly higher CABG rates than men in both the AMI (1.6% vs 1.2%, p = 0.025) and no AMI groups (1.5% vs 1.0%, p <0.0001). After multivariate adjustment, the results retained significance in the no AMI setting, whereas there was a trend toward significance in the AMI group. This study demonstrates that, despite improved overall outcomes in patients who received stents, women who underwent stenting had higher rates of same-admission mortality and CABG compared with men. Furthermore, it confirms that female gender is an independent predictor of mortality after conventional PTCA.     

Pre-Hospital Fibrinolysis Followed by Angioplasty or Primary Angioplasty in Acute Myocardial Infarction: The Long-Term Clinical Outcome

BACKGROUND: Randomized trials comparing primary angioplasty and in-hospital fibrinolysis in acute myocardial infarction (AMI) have shown an advantage for primary angioplasty. The long-term follow-up of pre-hospital fibrinolysis followed by elective or rescue coronary angioplasty versus primary angioplasty is not well established after acute myocardial infarction. This study sought to assess the long-term clinical outcome of patients with AMI having either received pre-hospital fibrinolysis optimized by coronary angioplasty or primary angioplasty. METHODS: We conducted a retrospective analysis involving 318 patients who either underwent primary angioplasty ( n = 157) or received pre-hospital fibrinolysis followed by an angioplasty (rescue or elective) ( n = 161) within 6 hours of the onset of chest pain. RESULTS: The groups were similar regarding their baseline characteristics except for the ages. No difference was noted for in-hospital mortality (primary PTCA group: 2.48%, combined group: 2.54%; p = ns) with no increased risk of hemorrhage. The 3-year mortality was not significantly different in the two groups (9.7% vs. 4.9%; p = 0.15). Regarding major adverse cardiac events (29.5% vs. 37.5%; p = 0.23), reintervention (22.5% vs. 23.2%; p = 0.99) or target lesion revascularization (16.1% vs. 14.7%; p = 0.68), the groups were statistically similar. CONCLUSION: These data from real-life practice emphasize the safety and similar benefits on the long-term clinical outcome of AMI patients having undergone either pre-hospital fibrinolysis followed by angioplasty or primary angioplasty.     

Beneficial effect of preinfarction angina on in-hospital outcome is preserved in elderly patients undergoing coronary intervention for anterior acute myocardial infarction.

BACKGROUND: Preinfarction angina improves survival after acute myocardial infarction (AMI) in nonelderly but not elderly patients in the thrombolytic era. However, it remains unclear whether preinfarction angina has a beneficial effect on clinical outcome in elderly patients undergoing percutaneous coronary intervention (PCI). METHODS AND RESULTS: The study group comprised 484 anterior AMI patients who were admitted within 24 h of onset and underwent emergency PCI. Patients were divided into 2 groups: those aged < 70 years (nonelderly patients, n = 290) and those aged > or = 70 years (elderly patients, n = 194). Angina within 24 h before AMI was present in 42% of nonelderly patients and in 37% of elderly patients. In nonelderly patients, preinfarction angina was associated with a lower in-hospital mortality rate (1% vs 7%, p = 0.02). Similarly, in elderly patients, preinfarction angina was associated with a lower in-hospital mortality rate (6% vs 16%, p = 0.03). Multivariate analysis showed that the absence of preinfarction angina was an independent predictor of in-hospital mortality in both nonelderly (odds ratio 4.20; 95% confidence interval (CI) 1.20-10.6; p = 0.04) and elderly patients (odds ratio 3.04; 95%CI 1.06-18.1; p = 0.04). CONCLUSIONS: Angina within the 24 h before AMI is associated with better in-hospital outcomes in elderly and nonelderly patients.     

Management and outcomes of patients transferred for rescue coronary angioplasty in acute myocardial infarction.

BACKGROUND: Rescue coronary angioplasty (PTCA), though recommended by the guidelines, is not regularly performed after failed lysis in patients with ST-elevation acute myocardial infarction (AMI), and data from large contemporary studies are not available. The outcomes of a recent series of consecutive patients in our Center are presented. METHODS: Between August 2000 and November 2003, 270 patients with AMI < 12 hours were referred to our cath lab for emergency PTCA: 117 (43%) for rescue PTCA after failed lysis, and 153 for primary or facilitated PTCA. The baseline, procedural and outcome data of all patients were prospectively collected, analyzed on an "intention-to-treat" basis and compared. Cineangiographic data were reviewed by three angiographers who were unaware of the clinical data. RESULTS: No significant differences were found between rescue PTCA and primary/facilitated PTCA patients as to: age, female gender, diabetes, hypertension, previous AMI, time from pain onset to the first emergency room admission, heart rate at admission, systolic blood pressure, number of leads with ST-segment elevation, total ST-segment deviation, collateral flow to the infarct-related artery, initial TIMI 2-3 flow, and three-vessel disease. Patients with rescue PTCA, as compared to primary/facilitated PTCA, had a longer time from pain onset to the cath lab (336 +/- 196 vs 229 +/- 155 min, p = 0.0001) and more frequently had an anterior AMI (52 vs 38%, p = 0.027), a higher Killip class (1.5 +/- 0.98 vs 1.26 +/- 0.7, p = 0.02), shock (11 vs 5%, p = 0.073), and intra-aortic balloon pump use (17 vs 8%, p = 0.048); fewer patients were in Killip class 1 (74 vs 85%, p = 0.043). PTCA was performed immediately in 78 vs 95% of patients (p = 0.0001); 8 vs 3 patients had PTCA of the infarct-related artery and 8 vs 1 had bypass surgery later during hospitalization. Patients with rescue PTCA, as compared to primary/facilitated PTCA, had a final TIMI 3 flow in 62 vs 76% of cases (p = 0.017), > or = 70% ST-segment resolution in 36 vs 50% (p = 0.086), and both of the latter in 24 vs 45% (p = 0.006); the overall hospital mortality was 12 vs 6.5%, and 5.8 vs 3.4% when patients in shock on admission were not considered; reinfarction and stroke occurred in 0.9 vs 1.3% and in 2.6 vs 0% of the patients respectively. CONCLUSIONS: Due to referral, rescue PTCA patients were admitted to the cath lab later after the onset of infarction, and had a higher risk profile, as compared to primary/facilitated PTCA patients; both recanalization and reperfusion were less satisfactory, as were the outcomes. Thrombolysis is often ineffective but, as long as it remains a widespread treatment, efforts should be made to improve reperfusion and survival in these patients, possibly by an earlier referral for rescue PTCA.     

Reasons for higher in-hospital mortality >24 hours after percutaneous transluminal coronary angioplasty in women compared with men

Women have a higher in-hospital mortality rate than men after percutaneous transluminal coronary angioplasty (PTCA). To determine reasons for this, we analyzed the outcome of PTCA at our institution from 1989 to 1995 for 5,989 patients (2,101 women). Women were older than men (66.8 +/- 10.9 vs 61.0 +/- 11.2 years, respectively; p <0.0001) and more likely to have diabetes mellitus, hypertension, or a history of congestive heart failure than men. In-laboratory complications at the time of PTCA were similar for women and men. During the first 24 hours after PTCA, women were more likely than men to become hypotensive (0.33% vs 0.08%, p = 0.04) and had a higher rate of vascular injury than men (1.6% vs 0.6%, p <0.001). More than 24 hours after the procedure, women had a significantly higher mortality rate (1.2% vs 0.52%, p = 0.017), which was no longer significantly different after adjustment for age (odds ratio 0.72, 95% confidence interval 0.39 to 1.32). Multivariate correlates of death >24 hours after PTCA were age, a prior history of congestive heart failure, vascular injury, and use of thrombolytic agents. Of those dying >24 hours after the procedure, 67% of women suffered a noncardiac-related death compared with only 10% of men (p <0.001). The noncardiac death rate was 0.8% for women and 0.05% for men. These deaths were related to renal failure, vascular complications, bleeding, hypotension, and stroke, especially hemorrhagic stroke. In conclusion, immediate procedural complications at PTCA were similar for women and men; however, mortality was higher for women >24 hours after PTCA and before discharge due to a higher rate of noncardiac death.     

Survival analysis within one year of first acute myocardial infarction: comparison between non-Q and Q wave myocardial infarction.

BACKGROUND: Non-Q wave Myocardial Infarction (non-Q AMI) is related pathophysiologically to Q wave AMI, as each represents different stages of plaque rupture and thrombosis. Post-hospital re-infarction and recurrent angina are more frequent in non-Q AMI than in Q wave AMI, offsetting the higher early risk with Q wave AMI, with one-year survival rates similar in the two types of MI. OBJECTIVES: 1--Evaluation of early (< or = 28 days) and one-year total mortality from first non-Q AMI in comparison to QMI. 2--Analysis of recurrent acute ischaemic events (non-fatal reinfarction and unstable angina) in both types of MI in the same periods of time. POPULATION AND METHODS: A retrospective study of 1146 patients, mean age 65 +/- 13 years, 65% male, admitted at CCU with a first MI, from January 1988 to December 1997 (minimum follow-up period of one year, mean follow-up 42 +/- 37 months). We compared the baseline demographics and clinical characteristics (coronary risk factors, previous angina, MI evolution, recurrent cardiac events, 28 day mortality and one year mortality) of patients with non-Q AMI (NQ group = 239) and Q wave AMI (Q group = 907). RESULTS: The NQ group patients were significantly older (mean age: 67 +/- 12.6 vs 65 +/- 12.5 years; p < 0.05), included fewer smokers (29% vs 43%; p < 0.001) and were more symptomatic before the index infarction (stable angina: 40% vs 30%; p < 0.05; unstable angina: 16% vs 6%; p < 0.001), when compared to the Q group patients. There were no significant differences in MI evolution, in Killip-Kimbal class > or = 2, recurrent angina and in-hospital mortality (Q-12% vs NQ-9%; ns), although there was a higher combined risk of arrhythmias and AV conduction disturbances in patients with QMI (Q-34% vs NQ-26%; p < 0.05). The combined risk of unstable angina and reinfarction at one year was significantly higher in group NQ (NQ-13% vs Q-8.1%; p < 0.05). The NQ group showed no significant difference in 28 day total mortality (NQ-14% vs Q-17%; ns) or at one year follow-up (NQ-24% vs Q-26%; ns) when compared to the Q group. CONCLUSION: 1--Despite a lower severity of non-Q AMI in the acute phase, 28 day and one year total mortality were similar in the two groups. 2--Patients with non-Q AMI showed a higher incidence of recurrent ischemic events at one year follow-up.     

First time myocardial revascularization in patients younger than 70 years. Single versus double internal mammary artery.

BACKGROUND: We evaluated the early and late outcomes of bilateral internal mammary artery (BIMA) grafting, with or without saphenous vein grafts (SVGs), compared to single internal mammary artery and SVGs in patients < 70 years undergoing first myocardial revascularization. METHODS: From September 1986 to December 1999, 1389 patients underwent first myocardial revascularization using the left internal mammary artery (LIMA) to the left anterior descending artery and SVGs (n = 480) or BIMA (one internal mammary artery on the left anterior descending artery) with or without SVGs (n = 909). Propensity score analysis was used to select 952 (476 of each group) patients with the same preoperative and operative characteristics. Thirty-day outcome and 10-year freedom from all-cause death, cardiac death, acute myocardial infarction (AMI), AMI in a grafted area, redo/percutaneous transluminal coronary angioplasty (PTCA), redo/PTCA in a grafted artery, cardiac events and any events, were evaluated. Follow-up ranged from 3.5 to 16.8 years (mean 8.8+/-4.0 years). RESULTS: Thirty-day mortality was 2.9% in the LIMA group and 1.9% in the BIMA group, p = NS; the BIMA group showed a better 10-year freedom from all-cause death (92.4+/-2.1 vs 87.5+/-3.5%, p = 0.0216), cardiac death (97.4+/-0.9 vs 91.9+/-1.4%, p = 0.0042), AMI (98.7+/-0.5 vs 94.2+/-1.2%, p = 0.0034), AMI in a grafted area (98.9+/-0.5 vs 94.7+/-1.3%, p = 0.0017), cardiac events (95.4+/-1.2 vs 86.8+/-1.8%, p = 0.0026) and any events (88.8+/-2.2 vs 80.7+/-2.1%, p = 0.0124). Cox analysis confirmed that LIMA + SVGs was a risk factor independent of lower freedom from all the above-mentioned events. CONCLUSIONS: Double mammary artery in patients < 70 years who had a first time myocardial revascularization gives a better clinical outcome even 10 years after the operation.     

Impact of prodromal angina pectoris and white blood cell count on outcome of patients with acute myocardial infarction

BACKGROUND: Elevation of white blood cell (WBC) count at admission is associated with adverse outcome after acute myocardial infarction (AMI). Prodromal angina, by the mechanism of ischemic preconditioning, improves left ventricular (LV) function and survival after reperfusion therapy in patients with AMI. Recent experimental studies have reported that preconditioning has anti-inflammatory effect. METHODS: This study consisted of 598 patients with first anterior wall AMI who underwent coronary angiography within 12 h after symptom onset. WBC count was measured at the time of hospital admission. Prodromal angina was defined as angina occurring within 24 h before the onset of AMI. Serial measurements of LV ejection fraction (EF) were obtained before reperfusion therapy and before discharge in 421 patients (71%). RESULTS: High WBC count (>10.2 x 103/mm3, n=297) was associated with higher 30-day mortality (8% vs. 4%, p=0.02) and lower predischarge LVEF (51+/-15% vs. 57+/-14%, p<0.001), although there was no significant difference in acute LVEF (47+/-10% vs. 49+/-11%, p=0.07). High WBC count was an independent predictor of 30-day mortality (p=0.009) and predischarge LVEF (p=0.002). Prodromal angina was associated with lower 30-day mortality (3% vs. 7%, p=0.02) and preserved predischarge LVEF (57+/-15% vs. 53+/-14%, p=0.006). Patients with prodromal angina had lower WBC count (10.0+/-3.3 x 10(3)/mm3 vs. 11.0+/-3.9 x 10(3)/mm3, p=0.001) and prodromal angina was an independent predictor of WBC count (p<0.001). CONCLUSIONS: Elevation of WBC count and lack of prodromal angina were associated with impaired LV function and mortality after reperfusion in patients with AMI. Prodromal angina might have contributed to favorable outcome after AMI through its anti-inflammatory effect.     

Clinical and angiographic outcomes in patients with previous coronary artery bypass graft surgery treated with primary balloon angioplasty for acute myocardial infarction. Second Primary Angioplasty in Myocardial Infarction Trial (PAMI-2) Investigators

OBJECTIVES: We sought to characterize the presenting characteristics of patients with previous coronary artery bypass graft surgery (CABG) and acute myocardial infarction (AMI) and to determine the angiographic success rate and clinical outcomes of a primary percutaneous transluminal coronary angioplasty (PTCA) strategy. BACKGROUND: Patients who have had previous CABG and AMI comprise a high risk group with decreased reperfusion success and increased mortality after thrombolytic therapy. Little is known about the efficacy of primary PTCA in AMI. METHODS: Early cardiac catheterization was performed in 1,100 patients within 12 h of onset of AMI at 34 centers in the prospective, controlled Second Primary Angioplasty in Myocardial Infarction trial (PAMI-2), followed by primary PTCA when appropriate. Data were collected by independent study monitors, end points were adjudicated and films were read at an independent core laboratory. RESULTS: Of 1,100 patients with AMI, 58 (5.3%) had undergone previous CABG. The infarct-related vessel in these patients was a bypass graft in 32 patients (55%) and a native coronary artery in 26 patients. Compared with patients without previous CABG, patients with previous CABG were older and more frequently had a previous myocardial infarction and triple-vessel disease. Coronary angioplasty was less likely to be performed when the infarct-related vessel was a bypass graft rather than a native coronary artery (71.9% vs. 89.8%, p = 0.001); Thrombolysis in Myocardial Infarction trial (TIMI) flow grade 3 was less frequently achieved (70.2% vs. 94.3%, p < 0.0001); and in-hospital mortality was increased (9.4% vs. 2.6%, p = 0.02). As a result, mortality at six months was 14.3% versus 4.1% in patients with versus without previous CABG (p = 0.001). By multivariate analysis, independent determinants of late mortality in the entire study group were advanced age, triple-vessel disease, Killip class and post-PTCA TIMI flow grade <3. CONCLUSIONS: Reperfusion success of a primary PTCA strategy in patients with previous CABG, although favorable with respect to historic control studies, is reduced as compared with that in patients without previous CABG. New approaches are required to treat patients with previous CABG and AMI, especially when the infarct-related vessel is a diseased saphenous vein graft.     

Diabetes mellitus prevents ischemic preconditioning in patients with a first acute anterior wall myocardial infarction

OBJECTIVES: This study was undertaken to assess whether prodromal angina could have beneficial effects in diabetic patients with acute myocardial infarction (AMI). BACKGROUND: Prodromal angina occurring shortly before the onset of AMI is associated with favorable outcomes by the mechanism of ischemic preconditioning. However, little is known about the impact of diabetes on ischemic preconditioning. METHODS: We studied 611 patients with a first anterior wall AMI who underwent emergency catheterization within 12 h after the onset of chest pain: 490 patients without diabetes and 121 patients with non-insulin treated diabetes. Prodromal angina was defined as angina episode(s) occurring within 24 h before the onset of AMI. Serial contrast left ventriculograms were obtained in 424 patients at the time of acute and predischarge catheterization. RESULTS: In non-diabetic patients, prodromal angina was associated with lower peak creatine kinase (CK) value (3,068 +/- 2,647 IU/l vs. 3,601 +/- 2,462 IU/l, p = 0.037), larger increase in left ventricular ejection fraction (LVEF) (10.1 +/- 13.0% vs. 5.8 +/- 13.4%, p = 0.004) and lower in-hospital mortality (3.4% vs. 9.3%, p = 0.015). On the contrary, in diabetic patients, there was no significant difference in peak CK value (3,382 +/- 2,520 IU/l vs. 3,233 +/- 2,412 IU/l, p = NS), the change in LVEF (6.7 +/- 13.8% vs. 7.1 +/- 12.4%, p = NS) and in-hospital mortality (8.8% vs. 11.0%, p = NS) between patients with and patients without prodromal angina. CONCLUSIONS: Prodromal angina limited infarct size, enhanced recovery of LV function and improved survival in non-diabetic patients with AMI. However, such beneficial effects of prodromal angina were not observed in diabetic patients, suggesting that diabetes might prevent ischemic preconditioning.     

Effects of gender on the number of diseased vessels and clinical outcome in Japanese patients with acute coronary syndrome.

It has been reported that women with acute myocardial infarction (AMI) have a higher short-term mortality rate than men, but the reason is unclear and it is not known if it also applies to unstable angina pectoris (UAP). In addition, most previous studies have not presented angiographic findings. In the present study, the findings from 1,408 patients with AMI (group A: 361 women, 1,047 men) and 332 patients with UAP (group B: 103 women, 229 men) who underwent coronary angiography within 30 days of onset were analyzed. In both groups, the women were older and had a higher rate of hypertension and a lower rate of smoking than the men. There was no significant difference in Killip class or the number of diseased vessels between the women and men in both groups. Interventions (coronary angioplasty and coronary artery bypass grafting) were performed less frequently in the women than in the men (87.2% vs 91.8%, p=0.04) in group A, but not in group B (80.6% vs 81.2%, NS). In both groups, the overall mortality rate during hospitalization was higher in women than in men (group A: 14.4% vs 7.4%, p<0.0001, group B: 7.8% vs 1.7%, p=0.007). Multivariate analysis revealed that female gender was an independent predictor of in-hospital mortality in group B (odds ratio (OR): 6.4, 95% confidence interval (CI) 1.1-37.0, p=0.04), but not in group A (OR: 1.7, 95%CI 0.98-2.9, p=0.06). The independent predictors of in-hospital mortality, other than female gender were age, prior congestive heart failure, prior cerebrovascular disease and a higher Killip class in group A, and in both groups a higher number of diseased vessels. In conclusion, Japanese women with acute coronary syndromes present with similar angiographic findings and hemodynamics, but have a higher in-hospital mortality than male patients. Our results suggest that older age may be a potential explanation for the higher in-hospital mortality in women with AMI, but female gender itself may be an important predictor for it among those with UAP.     

Magnesium use in the treatment of acute myocardial infarction in the United States (observations from the Second National Registry of Myocardial Infarction)

The use of magnesium in patients with acute myocardial infarction (AMI) is debated, largely as a result of conflicting data from randomized controlled trials. This study evaluated the use and impact on mortality of intravenous magnesium in the treatment of patients with AMI in the United States based on data from the Second National Registry of Myocardial Infarction. Only 5.1% of 173,728 patients from 1,326 hospitals received intravenous magnesium within the first 24 hours after an AMI, and this was more common in the 59,798 patients who received thrombolytic therapy or who underwent primary percutaneous transluminal coronary angioplasty (PTCA) or coronary bypass grafting (CABG) than in the 113,930 patients who did not receive any reperfusion therapy (8.5% vs 3.4%, p <0.01). Magnesium use was associated with younger age, Q-wave AMI, congestive heart failure on admission, thrombolytic therapy, primary PTCA or CABG, ventricular tachycardia or ventricular fibrillation, and beta blocker or lidocaine use in the first 24 hours (all odds ratio > 1.2, p <0.001). Magnesium use was associated with increased mortality (odds ratio 1.25, 95% confidence interval 1.12 to 1.34) and with a higher mortality in patients without initial reperfusion therapy (20.2% vs 13.2%, p <0.0001) or who underwent primary PTCA or CABG (10.2% vs 7.3%, p = 0.002), but not in patients who received thrombolytic therapy (6.2% vs 5.9%, p = NS). Thus, magnesium is used infrequently in the treatment of AMI and may be associated with worse outcome.