Early Myocardial Revascularization Research Articles

Clinical and hemodynamic particularities of patients with acute ST-segment elevation myocardial infarction subjected to late interventional treatment

To save the viability of the ischemic myocardium in a patient with ST-segment elevation myocardial infarction and improve the survival, coronary blood flow must be restored as soon as possible, preferably within the first 12 hours after the onset of pain. The current dilemma of interventional cardiologists is the decision about the possibility of performing interventional myocardial reperfusion in the patients with delayed presentation (more than 12 hours from the onset) and establishing the predictive factors of the procedures performed in this category of patients. In ths study 63 patients with STEMI were included, divided into 2 groups: the first one included 33 patients presentetd at the emergency department within the first 12 hours after the onset of STEMI, and the second group consited of 30 subjects with STEMI in whom the first medical contact was more than 12 hours after the onset of symptoms. The groups were compared with each other according to the well-established criteria. The primary end points were the assessment of major cardiovascular events (MACE), as well of ventricular myocardium remodeling/reverse-remodeling and predictors of interventional procedures. The improvement of left ventricular myocardial contractile function (LVEF), seems to be associated with early myocardial revascularization. Early presentation in STEMI can be considered an independent predictor of the improvement of the regional kinetics affected by AMI. The contractile function of the LV myocardium represented by the ejection fraction is considered an independent predictor of long-term and short-term mortality in patients with STEMI. The preliminary results of the research highlight the applicative value of PCI procedures also for patients with delayed presentation - more than 12 hours from the onset of the disease and the first medical contact.

SUCCESSFUL MYOCARDIAL REVASCULARIZATION IN A 92-YEAR-OLD FEMALE PATIENT: A CASE REPORT

Introduction. Patients with acute myocardial infarction should be treated with early revascularization. Patients over 73 years have a higher risk of infarct-related cardiogenic shock, which is a leading cause of lethality. Unfortunately, little is known about myocardial revascularization care for elderly people in Ukraine. We presented a 92-year-old lady with an acute chest pain case report, which was not revealed by analgesics.
 Important clinical findings. Coronary angiography revealed thrombotic occlusion of the distal segment of the left anterior descending artery (LAD) and floated thrombus in LAD mid-segment; stenosis of the left circumflex artery (LCx) close to the first obtuse marginal artery (OM1).
 The main diagnosis. Acute myocardial infarction with ST-segment elevation of the left ventricle anterior wall (anterior-STEMI). Calcific aortic valve disease, severe aortic valve stenosis, significant mitral and tricuspid valve regurgitation, pulmonary hypertension. Heart failure with reduced LVEF (<40%), NYHA class III symptoms.
 Intervention. The decision was to perform urgent stenting in LAD and balloon angioplasty in LCx. Successful hospital discharge was after 14 days.
 Conclusions. Take-away lessons: Elderly patients with acute myocardial infarction can be successfully treated in Ukraine. Age and comorbidities are not a contraindication for early myocardial revascularization.

Benefit of Early Revascularization Based on Inducible Ischemia and Left Ventricular Ejection Fraction

BackgroundThe utility of performing early myocardial revascularization among patients presenting with inducible myocardial ischemia and low left ventricular ejection fraction (LVEF) is currently unknown. ObjectivesIn this study, we sought to assess the relationship between stress-induced myocardial ischemia, revascularization, and all-cause mortality (ACM) among patients with normal vs low LVEF. MethodsWe evaluated 43,443 patients undergoing stress-rest single-photon emission computed tomography myocardial perfusion imaging from 1998 to 2017. Median follow-up was 11.4 years. Myocardial ischemia was assessed for its interaction between early revascularization and mortality. A propensity score was used to adjust for nonrandomization to revascularization, followed by multivariable Cox modeling adjusted for the propensity score and clinical variables to predict ACM. ResultsThe frequency of myocardial ischemia varied markedly according to LVEF and angina, ranging from 6.7% among patients with LVEF ≥55% and no typical angina to 64.0% among patients with LVEF <45% and typical angina (P < 0.001). Among 39,883 patients with LVEF ≥45%, early revascularization was associated with increased mortality risk among patients without ischemia and lower mortality risk among patients with severe (≥15%) ischemia (HR: 0.70; 95% CI: 0.52-0.95). Among 3,560 patients with LVEF <45%, revascularization was not associated with mortality benefit among patients with no or mild ischemia, and was associated with decreased mortality among patients with moderate (10%-14%) (HR: 0.67; 95% CI: 0.49-0.91) and severe (≥15%) (HR: 0.55; 95% CI: 0.38-0.80) ischemia. ConclusionsWithin this cohort, early myocardial revascularization was associated with a significant reduction in mortality among both patients with normal LVEF and severe inducible myocardial ischemia and patients with low LVEF and moderate or severe inducible myocardial ischemia.

Lesion left main coronary artery and / or multivessel coronary artery disease

The article describes the clinical and electrocardiograph|y features of the lesion left main coronary artery (LMCA). LMCA stenosis of more than 50% allows to classificated such patients as a high risk of sudden death, which occurs 3-4 times more often compared with coronary artery disease in other localizations. Another feature characteristic of this category of patients is the presence of multifocal atherosclerosis (MFA). In patients without carotid stenosis, LMCA lesions are detected in 5% of cases, while in patients with MFA (with lesions of the carotid arteries) - in 40%. Despite some clinical signs that allow the patient to suspect the presence of LMCA, the most informative and reliable method is invasive coronary angiography (CAG). Evaluation of CAG using fractional flow reserve (FFR) and intravascular ultrasound (IVUS) help to improve the diagnosis of the degree of LMCA stenosis, assess the nature of the plaque, the true diameter of the vessel and is an important step towards early myocardial revascularization. The article also presents the clinical analysis of lectrocardiogram with lesions of LMCA and multivessel lesions of the coronary arteries (three vessels or more).

Complete percutaneous myocardial revascularization in patients with STEMI complicated by cardiogenic shock

Background/Aim. Despite considerable progress in terms of early myocardial revascularization and the use of mechanical circulatory support, cardiogenic shock continues to be the leading cause of death in acute myocardial infarction. The current recommendations of the European Society of Cardiology advocate early revascularization of all critical stenosis or highly unstable lesions in the state of cardiogenic shock, while recently published studies favour the early revascularization of the infarct related artery only, in patients with acute myocardial infarction with the ST segment elevation (STEMI) presenting with cardiogenic shock. The aim of the study was to assess the impact of the complete early percutaneous myocardial revascularization in an acute myocardial infarction complicated by cardiogenic shock on intra- hospital mortality. Methods. The research was conducted as a retrospective observational analysis of data obtained from the hospital registry for cardiogenic shock. The study group consisted of 235 patients treated in the period from August 2007 until October 2016 for STEMI complicated by cardiogenic shock. Three groups were formed. The first group consisted of patients with one vessel disease who underwent revascularization of infarct related artery; the second group of patients had multi-vessel disease and only culprit lesions were revascularized and the third one consisted of patients with multi-vessel disease and the complete myocardial revascularization performed. Additional subgroups were formed in reference to the intra-aortic balloon pump (IABP) implantation. Intra-hospital mortality was analyzed in all groups and subgroups. Results. Revascularization of the culprit lesion alone among patients with multivessel disease was performed in 142 (60.4%) patients while the complete revascularization (revascularization of ?culprit? and other significant lesions) was performed in 28 (11.9%) patients with multi-vessel disease. There were 65 (27.7%) patients with single-vessel disease who underwent revascularization of infarct related artery. The lowest mortality was found in the group of patients with multi-vessel coronary disease who underwent complete myocardial revascularization and had IABP implanted (mortality was 35.7%). The difference in the mean value of the left ventricular ejection fraction (EF) between the surviving and deceased patients was statistically significant (p &lt; 0.005). The average EF of survivors was 44% (35%?50%) while 30% (25%?39.5%) deceased of patients. Based on the obtained data, the mathematically predictive model was tested. The receiver operating characteristic (ROC) curve showed that our model is a good predictor of fatal outcome (p &lt; 0.0005; AUROC = 0.766) with the sensitivity of 80.3%, and the specificity of 67%. Conclusion. STEMI complicated by cardiogenic shock is still associated with a high mortality rate. Complete myocardial revascularization independently as well as in combination with an IABP, significantly reduces mortality in patients with acute STEMI complicated by cardiogenic shock.

Trends in the history and fate of patients hospitalized for acute myocardial infarction

The aim of the study is to report on the history of ischemic heart disease (IHD), clinical course and early and late mortality in 1291 middle-aged men (<65 years) hospitalized for acute myocardial infarction in the 2006a2016 period. All patients admitted within 24h (90% of patients) underwent angiography on arrival; urgent infarct-related artery PCI was performed in 85.4% of all patients; of these 14.6% had PCI on another (non-infarct related) artery PCI while 7.7% had coronary artery bypass grafting (CABG). Primary ventricular fibrillation and cardiogenic shock occurred in 8.6% and 5.1% of patients, respectively. Cardiogenic shock-related mortality was 53%. Twenty-eight-day mortality in our entire patient cohort was 4.8%, with one-year mortality (28 days onward to 1 year) being 1.7%. Long-term mortality of our cohort, monitored until end of 2015, was adversely affected by older age, pre-existing coronary heart disease [finding based on data above previous PCI or CABG, or previous myocardial infarction (p<0.040)], low left ventricular ejection fraction on admission (p<0.001; <35%) and manifestations of acute heart failure (shock; Killip III; p<0.001). A total of 1158 patients lived longer than one year, of which number 79.3% were available for outpatient assessment at 1 year. Another non-fatal event occurred in only 8 patients (0.9%), with angina reported by 54 men (5.9%).Another aim of our study was to document changes in the history of IHD, clinical picture and death rates occurring in men in the above age category between 1970 and 2016. Analysis and comparison of these parameters were made using the World Health Organization (WHO) and European Society of Cardiology (ESC) registries as well as of our own datasets obtained between 1970 and 1977, in the 1991a1995 period (thrombolytic era) and the most recent dataset collected between 2006 and 2016. In-hospital (28-day) mortality decreased from 15 to 16.6% in the pre-reperfusion therapy period through 8.7% in the thrombolytic era down to the most recent 4.8% reported in the 2006a2016 period. This was paralleled by a decrease in one-year mortality (28+ to 365 days) declining as it did from 11.5% to the current 1.6%. Marked changes were likewise seen in the past history of patients. The incidence of pre-existing angina decreased from 42% in the 1970s to 24% in the predominantly thrombolytic era down to the current 6.1%. A similar downward trend was noted in the incidence of previous myocardial infarction, falling from 25 to 30% to the current 9.6%.The lower incidence of angina prior to the event as well as previous myocardial infarction can be attributed not only to more effective medication and secondary prevention but, also, to the current strategies of revascularization in patients with angina and early myocardial revascularization in individuals experiencing a coronary event.Taken together, the factors behind the reduced mortality of patients hospitalized for acute myocardial infarction are not only early infarct-related artery recanalization but, also, a lower incidence of a previous myocardial infarction plus better status of the coronary vascular bed in patients with previously diagnosed angina and previous myocardial infarction.

Intra-aortic balloon pump in cardiogenic shock: state of the art.

The clinical definition of cardiogenic shock is that of a low cardiac output and evidence of tissue hypoxia in the presence of adequate blood volume. Cardiogenic shock is the main cause of death related to acute myocardial infarction (AMI), with a mortality rate of 45-70% in the absence of aggressive and highly specialized technical care. The intra-aortic balloon pump (IABP) is one of the most widely used mechanical assisting devices. During the last two decades, about 42% of patients with AMI who evolved with cardiogenic shock received mechanical circulatory assistance with IABP. Its clinical indication has been based on non-randomized studies and registry data. Recent studies have shown that the use of IABP did not reduce 30-day mortality in patients with AMI and cardiogenic shock treated with the strategy of early myocardial revascularization as the planned primary objective. The guidelines of the American Heart Association and of the European Society of Cardiology have reassessed their recommendations based on the results of meta-analyzes, including the IABP-SCHOCK II Trial study, which did not evidence an increase in survival of patients who received mechanical support with IABP. This review article addresses the clinical impact of IABP use in the cardiogenic shock caused by AMI. RESUMO A definição clínica de choque cardiogênico é a de um quadro de baixo débito cardíaco e evidência de hipóxia tecidual, na presença de volemia adequada. O choque cardiogênico representa a principal causa de óbito relacionada ao infarto agudo do miocárdio (IAM), com índice de mortalidade em torno de 45% a 70%, na ausência de cuidados técnicos agressivos e altamente especializados. O balão intra-aórtico (BIA) é um dos dispositivos de assistência mecânica mais utilizados no mundo. Nas duas últimas décadas, cerca de 42% dos pacientes com IAM, que evoluíram com choque cardiogênico, receberam assistência circulatória mecânica com BIA. Sua indicação clínica tem sido baseada em estudos não randomizados e dados de registro. Estudos recentes têm demonstrado que o uso do BIA não reduziu a mortalidade hospitalar (30 dias) em pacientes com IAM e choque cardiogênico, tratados com a estratégia de revascularização precoce do miocárdio como objetivo primário planejado. As diretrizes da Associação Americana de Cardiologia e da Sociedade Europeia de Cardiologia reavaliaram suas recomendações, baseadas nos resultados de metanálises, incluindo o estudo IABP-SCHOCK II Trial, que não evidenciou aumento na sobrevida de pacientes que receberam suporte mecânico com BIA. Este artigo de revisão aborda o impacto clínico do uso do BIA no choque cardiogênico ocasionado pelo IAM.

VENTRICULAR EXTRASYSTOLY WITH HIGH RISK OF LIFE-THREATENING ARRHYTHMIAS DEVELOPMENT IN ACUTE CORONARY SYNDROME WITHOUT ST ELEVATION: EVALUATION OF REVASCULARIZATION EFFECTIVENESS

Aim. To study the role of early myocardial revascularization in the clinical course of the acute coronary syndrome (NSTEACS) without ST elevation, complicated with ventricular extrasystoly (VE) and high risk of life-threatening ventricular arrhythmias (LVA) development. Material and methods. Totally 124 patients with NSTEACS with VE II-V Lown and high risk of LVA that was assessed if there are pathologic values of linear shift of preectopic VE interval and LVA index, ≤10 ms and ≤0,5, respectively. To all patients having informed consent during the first 24 h since admittance the evaluation of coronary arteries flow grade was performed and for those having indications — revascularization preformed. In refusion of invasive treatment — in addition to conservative therapy the drugs of III class were used (mostly amiodarone). Results. The best positive effect of revascularization in NSTEACS with VE and LVA risk was if it had been performed during the first 2 h since hospitalization: fatal ventricular arrhythmias during hospitalization and before were not registered. Efficacy of fatal arrhythmias prevention in NSTEACS with VE and high risk of LVA during 2-24 h after hospitalization and with revascularization if indicated, was nearly same with the use of additional III class drugs — i.e. amiodarone, and was about 76,19% and 79,41%, resp. Conclusion. All patients with NSTEACS with VE and high risk of LVA the revascularization is indicated if indicated, in first 2 h after hospitalization.

0373 : Thrombolysis of myocardial infarction with ST segment elevation: Moroccan experience of Military Hospital of Instruction Mohammed V

Management of STEMI is based on early myocardial revascularization alone guarantees a better prognosis of patents. The aim of our study was to evaluate the management of patients with STEMI undergoing intra-hospital thrombolysis in a center where the thrombolysis is made by cardiologist while the first contact with the patients is done by the emergency doctor. Prospective study conducted over a period of 2 years including 55 patients with undergoing intra-hospital thrombolysis, clinical and therapeutic patient’s data and the results of coronary angiography were collected and analyzed, our results were compared to those in the literature. The mean age of patients was 59.5 ± 13.69 years with a sex ratio M / F = 3, smoking and diabetes have been at the forefront of cardiovascular risk factors, 67% of patients arrived to the hospital on their own, and 33% by ambulance. The average time of presentation of patients to the emergency room from the beginning of the pain was 3.2h [45 min-8h], the average arrival to the emergency / thrombolysis was 40 minutes [10- 90 min]. Coronary angiography was performed within an average of 25H [2-75 H] after thrombolysis. Success judged on clinical and electrical criteria was achieved in 75% of cases, 15% of patients had clinical succees with the coronary flow TIMI less than 2. 52% of patients had single-vessel lesion, 27% double-vessel and 21% tri-vessel or left main artery disease. Rescue angioplasty was performed in 18% of patients. The total number of stent used was 72 (1.3 stent / patient. 11% of patients underwent surgery, and 2 patients died during the hospitalization. The management of STEMI in our climate still suffers from a delay attributable to patient consultation delay but also a significant delay between first medical contact and pharmacological revascularization, all public health policy efforts should be deployed to reduce this delay which affects the prognosis of patients.

Hirurška revaskularizacija miokarda kod bolesnika sa akutnim koronarnim sindromom

Although surgical myocardial revascularization is one of the most frequently performed surgical procedures in general, with a mortality rate of about 1 % in elective cases, there is a distinct dislike for urgent surgery in patients with acute coronary syndrome among cardiac surgeons. The advantage of early myocardial revascularization include limitation of infarct expansion, avoidance of left ventricular dysfunction, and heart failure. The main danger include ischemia - reperfusion injuries after myocardial revascularization which may lead to hemorrhagic infarction, with all its complications, as well as the potential hemorrhagic complications resulting from the previous dual antiplatelet therapy. According to personal surgical experience and data from the literature, it can be concluded that surgical myocardial revascularization in acute coronary syndrome may be not only a safe procedure, but the procedure that should never be avoided, because the utility of these interventions can be invaluable for patient.

Age Related Issues in Reperfusion of Myocardial Infarction

Advances in pharmacological treatment and effective early myocardial revascularization have led to improved clinical outcomes in patients with acute myocardial infarction (AMI). However, it has been suggested that compared to younger subjects, elderly AMI patients are less likely to receive evidence-based treatment. Several reasons have been postulated to explain this trend, including uncertainty regarding the benefits of the commonly used interventions in the older age group as well as increased risk associated with comorbidities. The diagnosis, management, and post-hospitalization care of elderly patients presenting with an acute coronary syndrome (ACS) pose many difficulties at present due, at least in part, to the fact that trial data are scanty as elderly patients have been poorly represented in most clinical trials. Thus it appears that these high-risk individuals are often managed with more conservative strategies, compared to younger patients. This article reviews current evidence regarding management of AMI in the elderly.

The rationale for cardiomyocyte resuscitation in myocardial salvage

Clinical heart failure results from the cumulative loss of functioning myocardium from any cause. At the cellular level, cardiac myocytes die from three causes, individually or in combination: Necrosis occurs when external conditions are not sufficient to sustain minimal cellular functions, as with ischemia, and there is a general and unorganized breakdown of cell organelles, engendering an inflammatory response that may have harmful collateral tissue effects. Apoptosis, or cell suicide, occurs when specific external or internal conditions provoke a highly structured sequence of events to shut down cellular functions and remove the cell, with minimal consequences to surrounding tissue. Autophagy is a normal response to cell starvation that is induced under conditions of chronic metabolic or other stress. Current therapeutics, such as early myocardial revascularization after myocardial infarction, are focused exclusively upon minimizing cardiac myocyte necrosis and may even contribute to secondary apoptosis and autophagy. This review explores possible approaches to bring cardiac myocytes that are destined to die, back to life, i.e., cellular resuscitation. Two pro-apoptotic proteins in particular, Bnip3 and Nix, are transcriptionally upregulated specifically in response to myocardial ischemia and pathological hypertrophy and have been examined as therapeutic targets. In Bnip3 and Nix genetic mouse models, prevention of cardiac myocyte apoptosis in ischemic and hemodynamically overloaded hearts salvaged myocardium, minimized late ventricular remodeling, and enhanced ventricular performance. Cardiomyocyte resuscitation by preventing programmed cell death shows promise as an additive approach to minimizing necrosis for long-term prevention of heart failure.

Adult cardiac surgery during the first 50 years of the Southern Thoracic Surgical Association

This is a review of some of the outstanding adult cardiac surgical papers presented during the first 50 years of the Southern Thoracic Surgical Association to commemorate the 50th Anniversary meeting. Since the founding of the Southern Thoracic Surgical Association in 1954 there have been a total 512 adult cardiac surgery and great vessels papers presented, 138 from 1954 to 1970, 157 from 1971 to 1986, and 217 from 1987 to 2002. Since 1964 most of these papers have been published in The Annals of Thoracic Surgery. Forty-three papers were reviewed, the first having been presented in 1956 and the last in 2002. Not all of the papers could be located but the vast majority were retrievable and reviewed. This paper presents a broad spectrum of adult cardiac surgery beginning with early pump technology, early myocardial revascularization including the Vineberg procedure followed by coronary bypass as we know it today, valvular surgery, including several papers on aortic valve homograft and autograft procedures, ventricular aneurysms, aortic aneurysms and aortic dissections. Evaluations of various valve prostheses, cardiac transplantation, mitral valve reconstruction, quality assurance in cardiac surgery, neurobehavioral outcome after cardiac surgery, endocarditis and off-pump coronary bypass surgery were reviewed. We hope that this article is representative of the broad spectrum of issues that have characterized the specialty of cardiothoracic surgery over the second half of the 20th century and the beginning of the 21st century.

Survival benefits of early myocardial revascularization after stress echocardiography: A propensity analysis

Background:Although myocardial revascularization is often performed to alleviate dwumented myocardial ischemia, the impact of this practice on survival has not been demonstrated in randomized trials. Standard obsewatlonal analyses suffer from severe confounding and selection biases. Methods:We used propensity analysis to determine whether revascularization following stress echocardiography (STE) improved survival among 7957 patients in 3 different institutions. During the first 3 months after STE, 317 (4%) underwent revascularization. We generated a propensity score using logistic modeling involving 13 demographic, clinical, and echocardiographic variables. Results: Patients who underwent revascularization were older (64 vs. 61 years) and more likely to have ischemia (63% vs. 20%). We propensity matched these 317 patients with 317 patients who did not undergo revascularization with resulting similarities of age (64 vs 64 years) and equivalent rates of ischemia (63% vs 62%). During 5 years of follow- up, 75 patients (25%) who did not undergo revascularization died, whereas only 50 patients (16%) who did undergo revascularization died (propensity and covariate adjusted hazard ratio after 3 months 0.51, 95% Cl 0.31-0.83, P=O.O073). Absolute benefits were primarily noted in patients with ischemia in 12 vascular territories (Figure). Conclusion: Early myocardial revascularization is likely to lead to a survival benefit, especially among patients with inducible multivessel ischemia.

Early Result of Surgical Revascularization for Acute Myocardial Infarction

Background and Objectives:There are relatively few studies that have evaluated the optimal timing, risk of mortality, and outcome for patients with coronary artery bypass graft surgery (CABG) performed in the setting of acute myocardial infarction (AMI). Materials and Methods:We reviewed our 18 patients who underwent CABG within 14 days after AMI, between June 1994 and June 1997. Thirteen of the patients were male and 5 were female. Their ages ranged from 41 to 77 years (mean age, 60.6±10.4 years), and the amount of time between AMI and CABG ranged from 4 hours to 14 days (mean time, 7.0±4.7 days). There were 11 anteroseptal infarctions and 7 inferior wall infarctions. Eleven patients had transmural infarctions and 7 had subendocardial infarctions. Indications of operations were postinfarction angina, cardiogenic shock and intractable ventricular arrhythmia. Six patients required preoperative intra-aortic balloon pump (IABP) support, and 3 additional patients required IABP to be separated from cardiopulmonary bypass. An average of 3.4±0.5 vessels per patient were bypassed. Results:The early mortality rate for these 18 patients was 5.6% and late mortality rate was 5.9%, and 2-year actuarial survival rates were 89.5%. Univariate analysis of mortality showed that an ejection fraction less than 30% was associated with risk factor (p value=0.016). Age, sex, time to CABG, emergency operations, locations of infarctions were not significant. Conclusion: Although our studies have weak points in that there was only a small number of patients and the lack of longterm results, we could conclude that early myocardial revascularization is relatively safe after AMI for those individuals with an ejection fraction greater than 30%. (Korean Circulation J 1998;28(8):1287-1292)

Prediction of in‐hospital cardiac events using dipyridamole‐thallium scintigraphy performed very early after acute myocardial infarction

Ischemic complications occur frequently during hospitalization after acute myocardial infarction. Dipyridamole-thallium scintigraphy performed early after admission can detect residual ischemia, may have additional prognostic value and be useful in the management of these patients. Dipyridamole infusion and 201thallium imaging were performed on the third day of infarction in 114 consecutive patients. Coronary angiography was performed before hospital discharge in 90% of patients and exercise testing was performed at the time of discharge in patients without contraindications. Side effects occurred in 28 patients, but they were mild and transient or rapidly reversed with intravenous aminophylline. During hospitalization, three patients died and four had a nonfatal reinfarction. Patients with these major cardiac events had previously shown a higher prevalence of reversible perfusion defects during testing (71 vs. 31%, p < 0.05). In addition, 19 patients had early recurrent ischemia requiring early in-hospital revascularization. Overall, cardiac events defined as death, reinfarction, or early myocardial revascularization occurred in 22 patients. Of the patients with these events, 68% had thallium redistribution on initial myocardial scanning compared with 25% of patients without events (p = 0.0001). Patients with cardiac events also showed a higher number of myocardial segments with reversible perfusion defects (1.8 +/- 2.2 vs. 0.6 +/- 1.3, p = 0.001). Logistic regression analysis revealed that among all the other clinical, scintigraphic, and angiographic variables, the presence of thallium redistribution on the dipyridamole-thallium scan was the only independent predictor of cardiac events, increasing the risk by sixfold. Furthermore, during a 1-year follow-up, 14 other patients had ischemic events. Of these, 64% had previously shown thallium redistribution during early dipyridamole testing compared with 19% of patients without cardiac events (p < 0.001). Intravenous dipyridamole-thallium-scintigraphy performed very early after myocardial infarction is safe and useful to predict in-hospital ischemic events.

Early myocardial revascularization for postinfarction angina: Results and long-term follow-up

Within 30 days of acute myocardial infarction, 108 consecutive patients underwent urgent surgical myocardial revascularization for postinfarction angina between July 1976 and March 1983. There were 84 men and 24 women whose mean age was 59.6 +/- 9.5 years (range 34 to 80). Group I (15 patients, 14%) underwent surgery within 48 hours, Group II (47 patients, 43%) between 3 and 7 days and Group III (46 patients, 43%) within 30 days. Fifty-nine patients (55%) had transmural infarction. The ejection fraction was less than 40% in 21 patients (19%). Left ventricular end-diastolic pressure was 20 mm Hg or greater in 42 patients (39%). The incidence of single, double, triple vessel and 70% or greater left main coronary artery stenosis was 4, 20, 59 and 17%, respectively. There were two deaths (1.8%) within 30 days of operation. The incidence of intraaortic balloon pumping was higher in patients operated on earlier after myocardial infarction (53% of Group I versus 22% of Group III). Statistically, there were no differences in the use of inotropic agents or the occurrence of arrhythmias or postoperative myocardial infarction in the three groups. Late follow-up (mean 35 months, range 18 to 98) is complete for all patients (100%). There were four late myocardial infarctions and eight deaths. Actuarial survival was 87% at 5 years. Seventy-three percent of the 108 patients were free of angina and the condition of 14% improved. These results indicate that myocardial revascularization in the first 30 days after myocardial infarction can be accomplished with morbidity and mortality rates similar to those of an elective operation for chronic angina refractory to medical management.

Interventions During and After Acute Myocardial Infarction

There is now evidence that infarct size in man can be reduced by early treatment and that some cases of threatened infarction can be aborted. Beta blockade, given intravenously within about 6-8 hours after the onset of pain can reduce infarct size and abort some infarctions. So far we have no conclusive data on mortality. Beta blockers may act by a number of mechanisms, namely reduction of cardiac contractility, heart rate and blood pressure thus reducing cardiac work and oxygen requirement, prevention of cardiac rupture by the same mechanism, and by an early effect on R on T ectopic beats and hence serious ventricular arrhythmia. Early myocardial revascularization either by coronary graft, percutaneous angioplasty or intracoronary streptokinase are all promising but so far unproven by adequate clinical trial. Randomized trials suggest that intravenous streptokinase may be effective and hyaluronidase appears promising, possibly by promotion of collateral vessel flow. Calcium channel blockade may also be helpful and there are some early studies which support this. Lowering work by sodium nitroprusside also reduces infarct size. Heparin may have a place in the treatment of threatened infarction. After recovery it now appears established that beta 1-blockade will lower mortality. We do not know how long this effect persists. Other agents are less well established perhaps because the trials have been too small. Anticoagulants may have a place but their use is not widespread. Anti-platelet agents are also controversial. Studies of dipyridamole and sulphinpyrazone have been suggestive but not conclusive; the studies of aspirin are moderately encouraging, when all trials are pooled. Anti-arrhythmic therapy after infarction has been disappointing, with the exception of beta blockade. Perhaps more emphasis should also be put upon changes in lifestyle, notably stopping smoking, reduction of fat intake and encouraging regular exercise.

Unstable angina: A clinicoarteriographic correlation and long-term results of early myocardial revascularization

Between June, 1973, and June, 1978, 71 patients with unstable angina underwent emergency coronary artery bypass grafting. Fifty-four patients (76%) gave a previous history of stable angina. Seventy patients (99%) were found to have left main-stem stenosis or severe disease in the anterior descending artery proximal to the first septal branch. Intra-aortic balloon counterpulsation was instituted prior to angiography in 12 patients and in a further nine patients prior to induction of anesthesia as a result of intractable and continuous angina. There were no deaths associated with investigations. All patients underwent operation within 48 hours of admission to hospital. A total of 188 grafts were inserted (2.7 grafts per patient). There were three early deaths (4.2%) and two late deaths (2.8%) during a follow-up period varying between 6 and 62 months (mean 29 months). Actuarial analysis showed a 92% survival rate at 4 years. Five patients (7%) sustained perioperative infarction and four patients (5.9%), late myocardial infarction. All patients were symptomatically improved following operation and 51 (80%) are entirely asymptomatic. Fifty-two patients were electively reinvestigated following operation at times varying between 2 weeks and 58 months (mean 20 months). The overall graft patency rate was 91%. Changes in left ventricular function were analyzed by computerized radial analysis of segmental wall motion in 39 patients. Significant improvement in segmental wall motion occurred in 14 (70%) of 20 patients with abnormal wall motion preoperatively and appeared to be closely related to graft patency. There was a significant increase in ejection fraction from a mean of 0.59 to a mean of 0.69 following operation. Patients with unstable angina may be safely investigated during the acute phase and subsequent revascularization may be undertaken with low early and late mortality rates. Intra-aortic balloon counterpulsation is a valuable adjunct to the management of these patients.

Early Myocardial Revascularization during Acute Myocardial Infarction

Coronary artery bypass operations are performed predominantly for patients with chronic stable angina pectoris. Recently, clear indications for surgery have arisen outside the elective process, and the clinical success derived from emergency procedures has been substantiated in reports from several institutions. 1 Cheanvechai C Effler DB Loop FD et al. Emergency myocardial revascularization.. Am J Cardiol. 1973; 32: 901 Abstract Full Text PDF PubMed Scopus (43) Google Scholar , 2 Cohn LH Gorlin R Herman MV et al. Aortocoronary bypass for acute coronary occlusion.. J Thorac Cardiovasc Surg. 1972; 64: 503 PubMed Google Scholar , 3 Reul GC Morris GC Howell JF et al. Emergency coronary artery bypass grafts in the treatment of myocardial infarction.. Circulation. 1973; 48: 177 Google Scholar , 4 Scanion PJ Nemickas R Tobin JR Jr et al. Myocardial revascularization during the acute phase of myocardial infarction.. JAMA. 1971; 218: 207 Crossref PubMed Scopus (26) Google Scholar In most cases, surgery was undertaken when signs of ischemia or infarction occurred immediately before or during angiographic evaluation or when unstable angina developed during postcatheterization convalescence.