Emergency Angioplasty Research Articles

Prognostic impact of sex on clinical outcomes following emergent coronary angioplasty in acute myocardial infarction

Several studies have shown that women had greater risk for adverse clinical outcomes following coronary angioplasty. We aimed to assess the impact of sex on clinical results following emergent coronary angioplasty in acute myocardial infarction. We used our database of patients treated for acute myocardial infarction using emergent coronary angioplasty between January 2001 and December 2003. Procedural and angiographic results and clinical outcomes up to 6 months were collected and adjudicated for major cardiac adverse events. The outcome of 352 patients with acute myocardial infarction (71 women, 281 men, no cardiogenic shock) undergoing emergent angioplasty was analyzed and compared according to sex. Acute myocardial infarction occurred at an older age among women who tended to suffer more from diabetes mellitus and hypertension. In addition, on average, women had smaller culprit vessel diameters than men. The immediate post-procedural data were notable for higher frequency of 'no/slow re-flow' angiographic phenomenon in women than in men (10.5 vs. 3.4%, P=0.04). In-hospital and 30-day mortality was three times higher in women than men (women vs. men: in hospital 7 vs. 2.1%, P=0.05; 30 days 9.9 vs. 3.2%, P=0.02). At 6 months, major adverse cardiac events rate was 28 vs. 15% among women vs. men (P=0.01). Multivariate analysis showed a strong trend towards increased mortality at 30 days among women undergoing acute myocardial infarction angioplasty although it was not significantly or independently related to increased mortality (odds ratio=3.1; confidence intervals=0.8-12.5; P=0.11). Our results indicate a trend towards higher early mortality among female patients sustaining acute myocardial infarction and treated using emergent percutaneous coronary intervention that was probably because of increased age and worse coronary flow restoration results among women compared with men.

The Potential Safety of Designated Cardiac Arrest Receiving Facilities

Background: Patients suffering from out-of-hospital cardiac arrest (OOHCA) are generally transported to the closest ED, presumably to presumably to expedite a hospital level of care and improve the chances of return of spontaneous circulation (ROSC). As hospital-based therapies for survivors of OOHCA are identified, such as hypothermia and emergency angioplasty, certain hospitals may be designated as cardiac arrest receiving facilities. The safety of bypassing non-designated facilities with such a regional system is not known.

Characteristics and clinical outcomes of patients with cardiogenic shock complicating acute myocardial infarction treated by emergent coronary angioplasty

Cardiogenic shock (CS) is a dreadful complication of acute myocardial infarction (AMI) associated with a poor prognosis. Percutaneous coronary intervention (PCI) is widely recommended by current treatment guidelines. To evaluate the in-hospital and 30-day mortality rate and to determine independent predictors of mortality in a cohort of unselected consecutive patients with CS. Rabin Medical Center cardiac catheterization laboratory database was analyzed between 1/2000 and 8/2003. Fifty of the 472 patients (10.6%) treated using emergent PCI for AMI had cardiogenic shock on presentation. Patients with cardiogenic shock were older, more likely to be female and with higher frequency of co-morbidities. The time from symptom onset until seeking medical treatment was longer in cardiogenic shock patients. In-hospital mortality rate was 48.0% in the cardiogenic shock group as compared to 3.3% in the non-cardiogenic shock group (P<0.0001). In patients with shock, total mortality after 30 days was 52% (26/50). Most of these patients (25/26) died within 48 hours following admission because of refractory cardiogenic shock. A multivariate analysis adjusted for baseline differences showed that age 75 years (odds ratio [OR]: 11; 95% confidence interval [CI]: 1.0-1.24, P=0.05), and the use of GP 2b/3a antagonist (OR: 0.97; 95% CI: 0.95-1.0, P=0.05), were independent predictors of all cause mortality at 30 days. Cardiogenic shock remains an important cause of mortality in AMI. Younger age and the use of GP 2b/3a antagonists during primary PCI for cardiogenic shock patients seems to be associated with better clinical outcomes.

The impact of adjunctive eptifibatide therapy with percutaneous coronary intervention for acute myocardial infarction

The role of small molecules anti-glycoprotein (GP) IIb/IIIa pharmacotherapy during acute myocardial infarction (AMI) has not been established. The purpose of our study was to evaluate the clinical outcomes of patients sustaining AMI who underwent emergent percutaneous coronary intervention (PCI) and who were distinguished by the use of the anti-GP IIb/IIIa agent eptifibatide. We studied a consecutive group of 216 patients who underwent PCI for acute ST-elevation myocardial infarction and compared the outcomes of patients who received eptifibatide just prior and following the procedure (n=167) to those who were not on anti GP IIb/IIIa inhibitors (n=49). On average, patients treated using eptifibatide were younger and were more likely to be men, hypertensive, and smokers. The eptifibatide treated patients were less likely to have diabetes and renal failure and had worse angiographic characteristics. There were no significant differences between the groups in any of the clinical outcomes, including the composite endpoint (e.g. death, MI, repeat revascularization) and the rate of sub-acute stent thrombosis. Nonetheless, there was a non-significant trend towards lower 30 day mortality in the eptifibatide group (4.8% versus 12%, P=0.09). We concluded that in our comparative study of periprocedural administration of eptifibatide during emergent AMI angioplasty, there was a non-significant trend towards better short-term survival among eptifibatide treated patients although the composite endpoint did not differ between patients distinguished by the use of anti GP IIb/IIIa small molecule pharmacotherapy.

Tissue Doppler echocardiographic quantification. Comparison to coronary angiography results in Acute Coronary Syndrome patients

BackgroundMultiples indices have been described using tissue Doppler imaging (DTI) capabilities. The aim of this study was to assess the capability of one or several regional DTI parameters in separating control from ischemic myocardium.MethodsTwenty-eight patients with acute myocardial infarction were imaged within 24-hour following an emergent coronary angioplasty. Seventeen controls without any coronary artery or myocardial disease were also explored. Global and regional left ventricular functions were assessed. High frame rate color DTI cineloop recordings were made in apical 4 and 2-chamber for subsequent analysis. Peak velocity during isovolumic contraction time (IVC), ejection time, isovolumic relaxation (IVR) and filling time were measured at the mitral annulus and the basal, mid and apical segments of each of the walls studied as well as peak systolic displacement and peak of strain.ResultsDTI-analysis enabled us to discriminate between the 3 populations (controls, inferior and anterior AMI). Even in non-ischemic segments, velocities and displacements were reduced in the 2 AMI populations. Peak systolic displacement was the best parameter to discriminate controls from AMI groups (wall by wall, p was systematically < 0.01). The combination IVC + and IVR< 1 discriminated ischemic from non-ischemic segments with 82% sensitivity and 85% specificity.ConclusionDTI-analysis appears to be valuable in ischemic heart disease assessment. Its clinical impact remains to be established. However this simple index might really help in intensive care unit routine practice.

Women Wait Longer for Emergency Angioplasty

Women Wait Longer for Emergency Angioplasty

Immediate and Long-Term Outcome After Angioplasty With Stenting of the Left Main Coronary Artery

Coronary artery bypass graft surgery is the treatment of choice for severe left main coronary artery stenosis. The results of a number of multicenter trials have suggested angioplasty with stenting as a possible alternative treatment. The aim of the present study was to analyze the immediate and long-term results of angioplasty with stenting of the left main coronary artery, and to identify factors predictive of death. A total of 38 nonconsecutive patients (mean age 69 [8] years) with a severe lesion in the left main coronary artery were treated with angioplasty and stenting between November 1997 and March 2003. The procedure was elective in 27 patients and urgent in the remaining 11. In 23 patients (60.5%) the left main coronary artery was not protected by aortocoronary bypass. All patients underwent clinical follow-up examination at 25 (20) months. Angiographically documented success was obtained in all patients. However, one patient died from acute occlusion one hour after the operation. Four patients (10%) had a non-Q-wave myocardial infarction. In-hospital mortality was 15.8% (6/38 patients). Five of the 11 patients (45.4%) who underwent emergency angioplasty and stenting died in the hospital from acute myocardial infarction complicated by severe (Killip grade III-IV) heart failure. However, only one of 27 patients (3.7%) in the elective surgery group died (P=.007). Major clinical cardiac events during follow-up occurred in 5 patients (13%); 3 died and the other 2 had recurrent angina. All patients who died had an unprotected left main coronary artery. Cumulative survival rates for the elective group were 92 (0.5)% at 6 months, 88 (0.6)% at 1 year and 86 (0.7)% at 3 years, respectively. For the emergency surgery group cumulative survival rate was 54 (0.2)% at 6 months (P<.05). Elective angioplasty and stenting of the left main coronary artery in selected patients was associated with a high immediate success rate. In patients who underwent elective angioplasty and stenting, the incidence of major cardiac events during follow-up was relatively low. Emergency angioplasty and signs of left ventricular dysfunction were the main predictors of in-hospital mortality.

Combined Abciximab REteplase Stent Study in acute myocardial infarction (CARESS in AMI)

Background Most patients with acute myocardial infarction (AMI) are admitted to hospitals without percutaneous transluminal coronary angioplasty (PTCA) facilities or are initially managed in a prehospital mobile unit. Thrombolysis remains the most readily available reperfusion treatment in those settings, but the optimal subsequent strategy in those patients is unclear. If a mechanical recanalization is likely to be performed in an emergency, it is probably desirable that the patient receives abciximab, the glycoprotein IIb/IIIa antagonist with the strongest evidence of benefit for angioplasty in AMI. Objective The aim of this trial is to compare the effects on clinical outcome and cost-effectiveness of 2 strategies after immediate treatment with abciximab and half-dose reteplase for ST-elevation AMI: to manage the patients conservatively (referring them for rescue PTCA only if needed) or to immediately send all patients for emergency coronary angioplasty. Methods The Combined Abciximab RE-teplase Stent Study in Acute Myocardial Infarction (CARESS in AMI) is an open, prospective, randomized, multicenter clinical trial conducted in patients with high-risk ST-segment elevation AMI treated within 12 hours from symptom onset in hospitals without PTCA facilities or in a prehospital mobile intensive care unit. Apart from contraindications to thrombolysis, the main exclusion criteria are age ≥75 years and a past history of CABG surgery or a percutaneous coronary intervention procedure involving the infarct-related artery. Enrollment will be performed in hospitals without PTCA facilities or directly in the ambulance if a dedicated system is in place for prehospital diagnosis and treatment of AMI. Patients will receive half-dose reteplase and full-dose abciximab and will subsequently be randomized to conventional medical therapy (with referral for emergency rescue PTCA allowed in selected cases) or emergency angioplasty. The primary end point is the 30-day combined incidence of mortality, reinfarction, and refractory ischemia. In order to obtain a 95% power (2-sided) to detect a 42% reduction in the primary end point, 900 patients are required in each arm of the study. Secondary end points include the 1-year composite end point of mortality, reinfarction, refractory ischemia, and hospital readmission because of heart failure; resource use at 30 days and 1 year; and the incidence of inhospital stroke and bleeding complications in the 2 groups. Results Seventy-four patients have been randomized (as of March 10, 2004); results are expected in June 2005. Conclusion This study will establish whether angioplasty must be started as soon as possible in all patients who receive combined pharmacologic reperfusion with the glycoprotein IIb/IIIa inhibitor abciximab and half-dose thrombolysis or whether it can be postponed or skipped in patients with signs of successful reperfusion, with obvious organizational advantages.

Organization of Care for Acute Myocardial Infarction in Rural and Urban Hospitals in Kansas

One in 4 Americans lives in a rural community and relies on rural hospitals and medical systems for emergent care of acute myocardial infarctions (AMI). The infrastructure and organization of AMI care in rural and urban Kansas hospitals was examined. Using a nominal group process, key elements within hospitals that might influence quality of AMI care were identified, including personnel, equipment, organizational systems, and quality improvement activities. These elements were included in a survey of 45 rural and 12 urban Kansas hospitals. Though emergency 911 systems were widely available in both urban and rural communities, paramedics and advanced cardiac life support were less likely to be available in rural communities. Few rural hospitals were capable of emergent catheterization, angioplasty, or coronary artery bypass surgery; cardiologists, though readily available by phone, were rarely available on-site. Nevertheless, most rural ambulances could not bypass local hospitals. Most rural hospitals transferred the vast majority of their patients to urban medical centers within an average distance of 78 miles. Standardized protocols were used for emergent AMI care in 67% of urban and 62% of rural hospitals. Hospitals included aspirin in 53% and beta-blockers in 28% of either protocols or standing orders. Although faced with more limited resources, some rural hospitals, like their urban counterparts, have implemented protocols to address emergent care of AMI patients. Nevertheless, many of these protocols omit crucial aspects of AMI care. Rural and urban hospitals should jointly develop systems that assure consistent, rapid delivery of AMI care.

Transfer for primary angioplasty vs. immediate thrombolysis in acute myocardial infarction: a meta-analysis

Although both prehospital fibrinolysis and primary angioplasty provide a clinical benefit over in-hospital fibrinolysis in acute myocardial infarction, they have not been directly compared. Our aim was to find out whether primary angioplasty was better than prehospital fibrinolysis.We did a randomised multicentre trial of 840 patients (of 1200 planned) who presented within 6 h of acute myocardial infarction with ST-segment elevation, initially managed by mobile emergency-care units. We assigned patients to prehospital fibrinolysis (n=419) with accelerated alteplase or primary angioplasty (n=421), and transferred all to a centre with access to emergency angioplasty. Our primary endpoint was a composite of death, non-fatal reinfarction, and non-fatal disabling stroke at 30 days. Analyses were by intention to treat.The median delay between onset of symptoms and treatment was 130 min in the prehospital-fibrinolysis group and 190 min (time to first balloon inflation) in the primary-angioplasty group. Rescue angioplasty was done in 26% of the patients in the fibrinolysis group. The rate of the primary endpoint was 8·2% (34 patients) in the prehospital-fibrinolysis group and 6·2% (26 patients) in the primary-angioplasty group (risk difference 1·96, 95% CI−1·53 to 5·46). 16 (3·8%) patients assigned prehospital fibrinolysis and 20 (4·8%) assigned primary angioplasty died (p=0·61).A strategy of primary angioplasty was not better than a strategy of prehospital fibrinolysis (with transfer to an interventional facility for possible rescue angioplasty) in patients presenting with early myocardial infarction.

Improving the Assessment of Outcomes in Stroke: Use of a Structured Interview to Assign Grades on the Modified Rankin Scale

Improving the Assessment of Outcomes in Stroke: Use of a Structured Interview to Assign Grades on the Modified Rankin Scale

Outcome in patients treated with primary angioplasty for acute myocardial infarction due to left main coronary artery occlusion

Primary percutaneous transluminal coronary angioplasty (PTCA) has been shown to be superior to thrombolytic therapy for the treatment of patients with acute myocardial infarction (AMI), in terms of enzymatic infarct size, left ventricular function, and clinical outcome. 1 Zijlstra F. de Boer M.J. Hoorntje J.C. Reiffers S. Reiber J.H. Suryapranata H. A comparison of immediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction. N Engl J Med. 1993; 328: 680-684 Crossref PubMed Scopus (1175) Google Scholar , 2 Grines C.L. Browne K.F. Marco J. Rothbaum D. Stone G.W. O’Keefe J. Overlie P. Donohue B. Chelliah N. Timmis G.C. A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. The Primary Angioplasty in Myocardial Infarction Study Group. N Engl J Med. 1993; 328: 673-679 Crossref PubMed Scopus (1878) Google Scholar , 3 Zijlstra F. Hoorntje J.C.A. de Boer M.J. Reiffers S. Miedema K. Ottervanger J.P. van’t Hof A.W. Suryapranata H. Long-term benefit of primary angioplasty as compared with thrombolytic therapy for acute myocardial infarction. N Engl J Med. 1999; 341: 1413-1419 Crossref PubMed Scopus (601) Google Scholar The use of stents and glycoprotein IIb/IIIa inhibitors has resulted in a further improvement in clinical outcome. 4 Suryapranata H. van’t Hof A.W.J. Hoorntje J.C. de Boer M.J. Zijlstra F. Randomized comparison of coronary stenting with balloon angioplasty in patients with acute myocardial infarction. Circulation. 1998; 97: 2502-2507 Crossref PubMed Scopus (325) Google Scholar , 5 Stone G.W. Grines C.L. Cox D.A. Garcia E. Tcheng J.E. Griffin J.J. Guagliumi G. Stuckey T. Turco M. Carroll J.D. Rutherford B.D. Lansky A.J. Controlled Abciximab, and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) InvestigatorsComparison of angioplasty with stenting with or without abciximab, in acute myocardial infarction. N Engl J Med. 2002; 346: 957-966 Crossref PubMed Scopus (1193) Google Scholar However, only few and inconsistent data have been reported with regard to primary PTCA for AMI due to left main coronary occlusion (LMCO). 6 Erbel R. Meinertz T. Wessler I. Meyer J. Seybold-Epting W. Recanalization of occluded left main coronary artery in unstable angina pectoris. Am J Cardiol. 1984; 53: 1725-1727 Abstract Full Text PDF PubMed Scopus (37) Google Scholar , 7 Spiecker M. Erbel L. Rupprecht H.J. Meyer J. Emergency angioplasty of totally occluded left main coronary artery in acute myocardial infarction and unstable angina pectoris—institutional experience and literature review. Eur Heart J. 1994; 15: 602-607 Crossref PubMed Google Scholar , 8 Quigley R.L. Milano C.A. Smith L.R. White W.D. Rankin J.S. Glower D.D. Prognosis and management of anterolateral myocardial infarction in patients with severe left main stenosis disease and cardiogenic shock the left main shock syndrome. Circulation. 1993; 88: 65-70 Google Scholar , 9 Chauhan A. Zubaid M. Ricci D.R. Buller C.E. Moschovich M.D. Mercier B. Fox R. Penn I.M. Left main intervention revisited early and late outcome of PTCA and stenting. Cath Cardiovasc Diagn. 1997; 41: 21-29 Crossref PubMed Scopus (66) Google Scholar , 10 Marso S.P. Steg G. Plokker T. Holmes D. Park S.J. Kosuga K. Macaya C. Moses J. White H. Verstraete S.F. Ellis S.G. Catheter-based reperfusion of unprotected left main stenosis during an acute myocardial infarction (the ULTIMA experience). Am J Cardiol. 1999; 83: 1513-1517 Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar The aim of this study was to evaluate the efficacy of primary PTCA for LMCO, and to describe the clinical features, outcome, and prognostic determinants.

Invited commentary

While true left ventricular aneurysm is much less common now than 20 years ago because of aggressive thrombolytic therapy and emergent angioplasty for acute myocardial infarction, ischemic cardiomyopathy still affects millions of Americans. While the loss of functioning myocardium with infarct partially explains ventricular dysfunction and heart failure, the effect of the infarct or aneurysm on surrounding noninfarcted myocardium may also contribute to ventricular dysfunction. Better understanding of the interplay between global cardiac hemodynamics and regional aneurysm or infarct function will have significant influence on our treatment of patients with ischemic cardiomyopathy. In the last 15 years, medical treatment of ischemic cardiomyopathy and heart failure has been revolutionized with use of ACE inhibitors and beta blockers. Now, this elegant study by Bartel and colleagues provides insight into possible mechanisms of action of these drugs. A fluid mechanical model of the aneurysmal LV was employed to study the effects of various hemody-namic parameters (ie, preload, afterload, contractility, heart rate, etc.) on simulated aneurysm bulging. The authors found that afterload and heart rate correlated strongly with aneurysm bulging but contractility and preload had less influence. Interestingly, they found that aneurysm bulging was least with a heart rate around 80: bulging increases with heart rate less than or greater than 80. Furthermore, afterload strongly correlated with increased bulging. Beta blockers and ACE inhibitors have well-established roles in limiting infarct expansion and prolonging survival in patients with heart failure. Perhaps direct hemodynamic effects of these drugs on limiting infarct expansion and improving the function of surrounding myocardium explains some of their mechanism of action. The coexistence of experimental and theoretical and modeling approaches is the accepted paradigm in physics; however, this two-pronged approach is not as familiar yet in the study of cardiac physiology. Nevertheless, as demonstrated by this important study, there is much to be learned from thoughtful modeling of the pathologic heart. While limitations of this and other models are not insubstantial, it is precisely their ability to rigorously control the independent variables, as nicely displayed in this study, that gives modeling its important role in the study of cardiac physiology. The authors are to be congratulated on this important contribution to our knowledge of LV aneurysms.

Primary angioplasty versus prehospital fibrinolysis in acute myocardial infarction: a randomised study

Although both prehospital fibrinolysis and primary angioplasty provide a clinical benefit over in-hospital fibrinolysis in acute myocardial infarction, they have not been directly compared. Our aim was to find out whether primary angioplasty was better than prehospital fibrinolysis. We did a randomised multicentre trial of 840 patients (of 1200 planned) who presented within 6 h of acute myocardial infarction with ST-segment elevation, initially managed by mobile emergency-care units. We assigned patients to prehospital fibrinolysis (n=419) with accelerated alteplase or primary angioplasty (n=421), and transferred all to a centre with access to emergency angioplasty. Our primary endpoint was a composite of death, non-fatal reinfarction, and non-fatal disabling stroke at 30 days. Analyses were by intention to treat. The median delay between onset of symptoms and treatment was 130 min in the prehospital-fibrinolysis group and 190 min (time to first balloon inflation) in the primary-angioplasty group. Rescue angioplasty was done in 26% of the patients in the fibrinolysis group. The rate of the primary endpoint was 8.2% (34 patients) in the prehospital-fibrinolysis group and 6.2% (26 patients) in the primary-angioplasty group (risk difference 1.96, 95% CI -1.53 to 5.46). 16 (3.8%) patients assigned prehospital fibrinolysis and 20 (4.8%) assigned primary angioplasty died (p=0.61). A strategy of primary angioplasty was not better than a strategy of prehospital fibrinolysis (with transfer to an interventional facility for possible rescue angioplasty) in patients presenting with early myocardial infarction.

Rescue percutaneous coronary intervention for failed thrombolysis: results from a district general hospital

Objective: To assess the outcome of a policy of emergency percutaneous coronary intervention (PCI) in patients with acute myocardial infarction and electrocadiographic (ECG) evidence of failed reperfusion after thrombolysis. Design:...

Surgical Anterior Ventricular Restoration for Ischemic Cardiomyopathy

Emergency angioplasty or thrombolytic therapy for acute anterior wall infin'ction revascularizes the infarct-related artery. The damaged region includes the anterolateral left ventricle and septum. Revascularization avoids transmural scarring and suhsequent aneurysm because it spares the elficardial muscle. Regional akinesia develops due to damage to the inner two-thirds of the left ventricular and/or apical and anteroseptal wall. The epicardium, spared of transmural necrosis, may remain pink. The underlying midventricular and endoventricular muscles contain seglnental nonfllctional muscle with trabecular scarring. This region cannot thicken during systole to contribute to cardiac OUtlmt. Tile elulocardiuln often remains completely trabecuiated, so that the transmural thinning characteristic of aneuryslns is allsent. Akinesia of a large segment of ventricle resuhs in rclnodeling of the remaining ventricle, with increased sphericity and loss of elliptical apical contour. Occurring within hours of infarction, this may result in depressed ventricular flmetion that worsens over time as the remote, normally perfllsed nmscle dilates. The administration of lleta-blockers and ACE inhibitors early postinfarction has a salutary effect on tile remodeling process, but nevertheless about one-half of patients receiving aggressive treatment still display signs and SynllltOlnS of congestive heart failure due to progressive dihltion and sphericity of the noninfarcted muscle. For many )'ears, endoventricular circular patchplasty has been applied to the thinned dyskinetic ventricular aneurysm, llecause transmural necrosis avoids the thickened appearance that characterizes reperfused muscle. The anatomic changes lwo,luced l,y this rebuihling technique improve ventricular fimction as COnllmred to excision and linear closure. 1 Aneurysm is now uncolnmOl~ due to acute revascularization of the infarct-related artery. A similar ol,erative technique using an endoventricular l,atch has been al,l,lic,l to postinfarction akinesia, l This surgical al,l,roach is not commonly used because of surgical rehlctance to incise tile normal-appearing anterior wall due to epicardial muscle salvage. Tile ventricle surface may appear pink and rotate during systole. Ilowever, the underlying myocardium does,not thicken before bypass or collapse by venting during extracorporeal circulation. The recently organized RESTORE group includes an intermttional group of cardiac surgeons and cardiologists from four continents. One of its lnwposes has been to confirm the efficacy of surgical anterior ventrieular restoration (SAVI{) of postinfarction akinesia. This procedure was initially aplllied to akinetic muscle that does not collapse by venting due to epicardial sah'age by rewlscularization. Inferences allout intraoperative protection to preserve postcardiotomy ventricular function were drawn fi'om Batista's Ollerative techni(lue for llartial ventriculotomy using tile l,eating ol,en (as ol)posed to the cardiol)legically arrested) heart. This report describes the operative technique used in our 52-patient subsegment of RESTORE centers with the lleating open heart technique of protection. It outlines the SAVR technique applied to anterior akinetic postinfarction ventricle eardiomyolmthy and congestive heart failure (ejection fraction 28%, left ventriculogram systolic vohnne index [LVESVI] 132 mL/m2).

Emergent angioplasty for acute myocardial infarction at a community hospital without on-site cardiac surgery

Emergent angioplasty for acute myocardial infarction at a community hospital without on-site cardiac surgery

Trends in acute coronary heart disease mortality, morbidity, and medical care from 1985 through 1997: the Minnesota heart survey.

Coronary heart disease (CHD) mortality continued to decline from 1985 to 1997. We tabulated CHD deaths (ICD-9 codes 410 through 414) in the Minneapolis/St Paul, Minnesota, area. For 1985, 1990, and 1995, trained nurses abstracted the hospital records of patients 30 to 74 years old with a discharge diagnosis of acute CHD (ICD-9 codes 410 or 411). Acute myocardial infarction (AMI) events were validated and followed for 3-year all-cause mortality. Between 1985 and 1997, age-adjusted CHD mortality rates in Minneapolis/St Paul fell 47% and 51% in men and women, respectively; the comparable declines in US whites were 34% and 29%. In-hospital mortality declined faster than out-of-hospital mortality. The rate of AMI (ICD-9 code 410) hospital discharges declined almost 20% between 1985 and 1995, whereas the discharge rate for unstable angina (ICD-9 code 411) increased substantially. The incidence of hospitalized definite AMI declined approximately 10%, whereas recurrence rates fell 20% to 30%. Three-year case fatality rates after hospitalized AMI decreased consistently by 31% and 41% in men and women, respectively. In-hospital administration of thrombolytic therapy, emergency angioplasty, ACE inhibitors, beta-blockers, heparin, and aspirin increased greatly. Declining out-of-hospital death rates, declining incidence and recurrence of AMI in the population, and marked improvements in the survival of AMI patients all contributed to the 1985 to 1997 decline of CHD mortality in the Minneapolis/St Paul metropolitan area. The effects of early and late medical care seem to have had the greatest contribution to rates during this time period.

Cigarette Smoking Increases the Magnitude of Intracoronary Thrombus Observed During Acute Myocardial Infarction

P60 BACKGROUND: Smoking is a well known modifiable chronic risk factor for coronary disease. However, whether it can trigger acute myocardial infarction (MI) is unknown. To determine whether smoking predicts intracoronary thrombus burden in the infarct artery, we analyzed angiograms of 902 patients undergoing emergent coronary angioplasty for acute MI. METHODS: Patients underwent a structured standardized interview. Smokers (n= 348; 39%) were asked the time of last cigarette smoked prior to symptom onset. Quantitative indices of reference vessel diameter, segmental and cross-sectional intracoronary thrombus area, and ordinal TIMI thrombus grades were analyzed by 2 angiographers using a validated, computer-assisted program. RESULTS: Compared to nonsmokers, smokers were younger (54 ± 12 vs 65 ± 13 years; p &lt; 0.001), more likely to be male (75% vs 65%; p = 0.003), normotensive (68% vs 44%;p &lt; 0.001), physically active (36% vs 29%; p = 0.03), tended to present early (277 ± 91 vs 293 ± 98 minute; p = 0.02), have more single-vessel disease (37 vs 25%;p &lt; 0.001), but with larger thrombus area (16.9 ± 17 vs 13.7 ± 17 mm 2 ; p = 0.009). Intracoronary thrombus burden was larger when symptom onset was closer to the time of last cigarette, however, smokers had a greater chance of achieving complete reperfusion (TIMI grade 3 flow: 96% vs 90%; p=0.01). CONCLUSIONS: Despite less coexistent risk factors among smokers, smoking appears to increase thrombogenicity and is temporally related to the magnitude of intracoronary thrombus in the infarct-related artery. Thus, in addition to chronic effects, smoking may acutely trigger acute MI by enhancing thrombogenecity. Table 1.

Hemartrosis como complicación hemorrágica tras tratamiento trombolítico

Hemorrhage of variable severity is the main complication of thrombolytic treatment. We present the case of a rare hemorrhagic location after the use of this treatment for acute myocardial infarction, as ankle hemarthrosis. In the first twelve hours the patient had a joint hemorrhagic effusion with refractory pain and arthrocentesis was required. Recurrence occurred while receiving heparin and after discontinuation of heparin perfusion stopped the patient developed occlusion of the coronary artery related to the infarct requiring emergency angioplasty. We discuss the severity and possible treatment of this situation.