Prognostic value of global myocardial performance indices in acute myocardial infarction: comparison to measures of systolic and diastolic left ventricular function

STUDY OBJECTIVES: Assessment of global myocardial performance by a single index (ie, the myocardial performance index [MPI]) has been suggested as an appealing alternative to the individual assessment of systolic and diastolic left ventricular (LV) function We sought to test the prognostic value of MPI in comparison to clinical characteristics and echocardiographic parameters of LV filling and ejection in acute myocardial infarction (AMI). PATIENTS: Four hundred seventeen consecutive patients with AMI were examined within 24 h of hospital admission. INTERVENTIONS: Doppler echocardiographic measures of systolic, diastolic, and global myocardial performance were assessed within 24 h of hospital admission. In addition to MPI (ie, the sum of the isovolumic time intervals divided by ejection time), we determined the isovolumic/heterovolumic time ratio, which expresses the time "wasted" by the myocardium to generate and decrease LV pressure without moving blood. RESULTS: The end points of the study at 30 days were death (4.7%), congestive heart failure (23%), and recurrent infarction (4.8%), and occurred in 109 patients, who were compared as group B to 314 patients without an event (group A). Multivariate analysis identified only age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02 to 1.07), LV ejection fraction (LVEF) < or = 40% (OR, 3.82; 95% CI, 2.15 to 6.87), and E-wave deceleration time (EDT) of < or = 130 ms (OR, 2.29; 95% CI, 1.0 to 5.21) as independent predictors of adverse events. CONCLUSION: LVEF and EDT are powerful and independent echocardiographic predictors of poor outcome following AMI, and are superior to indexes of global LV performance. Both parameters should be taken into consideration when deciding about the management of these patients.     

Management and outcomes of elderly women and men with acute coronary syndromes in 2000 and 2002

BACKGROUND: Previous studies have suggested that women with myocardial infarction are treated less aggressively and have worse outcomes compared with men. The objective of this study was to evaluate sex differences in the management and outcomes of elderly (age > or = 70 years) women and men with acute coronary syndromes (ACSs) in the new millennium. METHODS: This study includes 1331 consecutive elderly patients with ACSs admitted to all intensive coronary care units and cardiology departments in Israel from 2 prospective nationwide ACS surveys conducted in 2000 and 2002. RESULTS: The mean age of women vs men was comparable (79 vs 78 years). Comorbidities were more frequent in women, whereas previous coronary disease and typical anginal pain on admission were more frequent in men. Medical treatments and revascularization procedures during the index hospitalization were comparable in both groups. Crude and covariate-adjusted mortality rates were higher in women at 7 days (12% vs 7%; P = .007; adjusted odds ratio [OR], 1.83; 95% confidence interval [CI], 1.15-2.91) but not at 6 months (21% vs 19%; adjusted OR, 1.10; 95% CI, 0.79-1.52). This difference was attributed to ST elevation (STE)-ACS in women vs men (19% vs 12%; P = .007; adjusted OR, 1.97; 95% CI, 1.14-3.46). Seven-day mortality rates were highest in patients with STE-ACS denied coronary angiography, especially women (23% vs 15%; P = .06). CONCLUSIONS: In the 2000s, elderly women and men with ACSs are receiving similar medical and invasive management during the index hospitalization; however, women with STE-ACS have higher mortality rates at 7 days but not at 6 months. Mortality rates are highest in patients with STE-ACS denied coronary angiography. The benefit of invasive procedures on mortality rates in elderly patients with STE-ACS needs further investigation.     

Aspirin, warfarin and a thienopyridine for acute coronary syndromes

BACKGROUND: Although clopidogrel and aspirin (dual therapy, DT) are used for acute coronary syndrome (ACS), sometimes treatment with warfarin (triple therapy, TT) is required. AIM: To determine the incidence, complications, and outcomes of TT. METHODS: We analyzed Israeli surveys of ACS from 2000 to 2004. RESULTS: In these surveys, 5,706 (96%) were discharged alive from hospital. Post-ACS TT and DT were 76 patients (1.3%) and 2,661 patients (46.7%), respectively. The TT group was older with more prior cardiac disease. During hospitalization, the TT patients received more intravenous anticoagulant and antithrombotic agents, and had more heart failure, arrhythmias, ischemia, and major bleeding (2.6 vs. 0.6%, p=0.03). There were no differences in adjusted 30-day and 6-month mortality between the 2 groups. CONCLUSION: TT is feasible among ACS patients who require concomitant warfarin treatment.     

Influence of the new definition of acute myocardial infarction on coronary care unit admission, discharge diagnosis, management and outcome in patients with non-ST elevation acute coronary syndromes: a national survey

BACKGROUND: Major changes occurred recently in the definition and recommended management of non-ST segment elevation acute coronary syndromes (NSTE ACS). The impact of these changes on the coronary care unit (CCU) is incompletely characterized. METHODS: ACSIS is a national survey gathering data every other year among all ACS patients in all CCUs in Israel. We compared case load, baseline variables, management, outcome and distribution of diagnoses among NSTE ACS patients admitted before (during 2000 [N = 729]) and after (during 2002 [N = 970]) the widespread introduction of troponin and the new AMI definition. RESULTS: The number of NSTE ACS patients in 2002 increased by 33% compared to 2000, with no change in the number of beds, while the number of ST elevation ACS patients remained unchanged. The rate of AMI rose by 16% and hospital stay decreased by 1 day (p = 0.005). The availability of troponin values increased from 20% in 2000 to 60% in 2002; The proportion of patients given the diagnosis of NSTE AMI rose significantly more in centers with high utilization of troponin (p = 0.023). During 2002 significant increases occurred in the utilization of guideline-recommended medications, as in the use of coronary angiography and intervention. Mortality at 30 days decreased by 35%. CONCLUSIONS: This is the first large registry of ACS to describe the significant actual changes which occurred in the CCU following the introduction of troponin and the new AMI definition. We observed a substantial increase in the burden of NSTE ACS coupled with a shortened length of stay. These changes may impact significantly upon patient care and resource utilization.