Incidence Of Previous Myocardial Infarction Research Articles

Paclitaxel-eluting stents versus paclitaxel-coated balloons in coronary artery disease: a meta-analysis of randomized controlled trials.

The efficacy of drug-coated balloons (DCB) versus drug-eluting stents (DES) for coronary artery disease (CAD) remains inconclusive. Despite paclitaxel's common use in both DES and DCB, there is a lack of meta-analyses comparing paclitaxel-eluting stents (PES) and paclitaxel-coated balloons (PCB). This meta-analysis aimed to evaluate and compare the outcomes of DES and DCB with paclitaxel. A systematic literature search of the Medline and Cochrane databases yielded six randomized controlled trials with 951 patients (1:1 ratio). Primary endpoints were mortality, target lesion vascularization (TLV), myocardial infarction (MI), target vessel revascularization (TVR), and major adverse cardiovascular events (MACEs). Secondary endpoints included in-device binary stenosis, in-segment binary stenosis, late luminal loss (LLL), post-minimal lumen diameter (MLD), and post-diameter stenosis. Within the study populations, the incidence of previous MI was significantly lower in the PES group than in the PCB group (26.70% vs. 39.22%, OR:0.56, 95% CI [0.41-0.76], p=0.0002). The meta-analysis results showed that mortality (OR:1.57, 95% CI [0.67-3.66], p=0.29), TLV (OR:0.74, 95% CI [0.37-1.48], p=0.39), MI (OR:1.76, 95% CI [0.79-3.88], p=0.16), TVR (OR:0.76, 95% CI [0.51-1.12], p=0.16), and MACEs (OR, 1.11; 95% CI [0.48-2.58]; p=0.81) did not exhibit significant differences between the PES and PCB groups in CAD. Furthermore, in stent or in balloon binary stenosis (OR:0.80, 95% CI [0.34-1.87], p=0.60), in segment binary stenosis (OR:1.16, 95% CI [0.48-2.80], p=0.74), LLL (MD:0.03, 95% CI [-0.11 to 0.17], p=0.65), post MLD (MD:0.04, 95% CI [-0.23 to 0.30], p=0.77), and post diameter stenosis (MD:-5.48, 95% CI [-13.88 to 2.92], p=0.20) were similar in both groups. Our comprehensive analysis concludes that both PES and PCB manifest comparable effectiveness and safety in CAD management.

Clinical performance of the atrial fibrillation in the Russian population depending on the antithrombotic therapy: findings from the GLORIA-AF registry phase 2

Aim. To analyze clinical characteristics of patients with nonvalvular atrial fibrillation (AF) in the Russian population, enrolled in the GLORIA-AF registry phase 2, depending on the antithrombotic therapy received, and to assess the potential for patient retention with dabigatran during a 2-year follow-up.Material and methods. In the Russian Federation, 408 patients were included in the second phase of GLORIA-AF which is a global prospective observational registry of newly diagnosed patients with AF. The patient characteristics are presented depending on received antithrombotic therapy (dabigatran, factor Xa inhibitors, vitamin K antagonist, antiplatelet agents, or no antithrombotic therapy), with a dabigatran dosing regimen of either 110 mg or 150 mg twice daily. Duration of patient retention on dabigatran therapy was also analyzed during a 2-year follow-up.Results. Of the 405 patients with recently diagnosed nonvalvular AF, 358 (88%) received oral anticoagulants (OAC), and 47 (12%) patients received antiplatelet drugs or received no antithrombotic therapy. Most patients were treated with dabigatran (n=275, 68%), and 75 (19%) patients received vitamin K antagonist. Clinical and demographic characteristics of patients receiving dabigatran were comparable with those in the general group of the Russian patients. The mean age was 63,5 years. The most common comorbidities in Russian patients receiving dabigatran were hypertension (93%), congestive heart failure (57%), coronary artery disease (35%). It is noteworthy that 12% and 10% of patients had a previous myocardial infarction and stroke, respectively. The mean CHA2DS2-VASc score for stroke risk for these patients was 3,2; 88% of patients had a high stroke risk (score of >2). Of the 275 patients with AF who received dabigatran therapy, 164 (60%) patients received dabigatran at the dose of 150 mg twice daily, and 111 (40%) patients received 110 mg twice daily. Dabigatran doses of 110 mg twice daily were more frequently prescribed for female patients aged 65 years or older and patients with a previous coronary events and impaired renal function, who had a higher CHA2DS2-VASc score for stroke risk. There was a higher proportion of AF patients with marked symptoms in the dabigatran 150 mg twice daily group. A median duration of treatment with dabigatran with the initial dosing regimen was 24 months. The estimated dabigatran therapy retention rate was 0,87, 0,81 and 0,73 after 6, 12 and 24 months of follow-up, respectively.Conclusion. In the Russian Federation, patients with newly diagnosed AF who have an increased risk of stroke are more likely to receive OAC therapy, such as direct thrombin inhibitor (dabigatran), compared to the global cohort of the GLORIA AF Registry Program. Patients in the Russian cohort receiving dabigatran differ from the global cohort of patients by greater comorbidity. At the same time, patients receiving reduced doses of dabigatran, both in the Russian Federation and in the global Registry, are characterized by a greater proportion of patients aged >75 years, a higher incidence of previous myocardial infarction, coronary artery disease, heart failure, impaired renal function, higher CHA2DS2-VASc score for stroke risk. The potential dabigatran therapy retention rate after 24 months in the Russian Federation and in the global cohort was high and amounted to about 70%.

Incidence and In-Hospital Outcomes of Patients Presenting With Stent Thrombosis (from the Japanese Nationwide Percutaneous Coronary Intervention Registry)

Clinical presentation of stent thrombosis (ST) and its sequela under contemporary practice have not been fully elucidated largely due to rare incidence of ST. We sought to assess the characteristics in patients with clinical presentation of ST and their in-hospital outcomes, utilizing nationwide registration system for percutaneous coronary interventions (J-PCI). The present study included acute coronary syndrome (ACS) patients undergoing PCI with clinical findings of definite ST from January 2014 to December 2016. Patients' characteristics, in-hospital mortality and its composite with periprocedural complications were evaluated. Full match comparison was performed. During the study period, 256,610 ACS patients (37.9% of total PCI cases) underwent PCI and 1,367 ST patients (1.9%) were identified from 73,241 ACS patients' records who had a history of previous PCI. Overall, patients with ST were younger but had higher incidence of previous myocardial infarction, compared with those without. In addition, ST patients had increased rate of crude in-hospital death (4.8% vs 1.1%, p <0.001). After full match comparison, the incidence of recurrent ST (post-PCI) was significantly higher in ST patients when compared with ACS patients presenting without ST (4.3% vs 0.9%, p <0.001). Despite younger age, patients with ST had significantly higher incidence of in-hospital mortality and cardiovascular complications, including recurrent ST, compared with those without.

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.

In-hospital and long-term outcomes of coronary artery bypass graft surgery in patients ≤ 45 years of age and older (from the KROK registry).

There is a paucity of data concerning the clinical characteristics, management, and outcomes of coronary artery bypass graft surgery (CABG) in patients ≤ 45 years old. We aimed to compare the clinical characteristics, and in-hospital and long-term outcomes of patients ≤ 45 years and > 45 years old, who underwent isolated CABG. We identified consecutive patients who had isolated CABG in the Department of Cardiac Surgery and Transplantology in the Silesian Centre for Heart Diseases in Zabrze between January 2006 and December 2011 and were enrolled in the Polish National Registry of Cardiac Surgery Procedures (KROK registry). A total of 8196 patients were identified and split into two groups, age ≤ 45 years old (young group; n = 130) and > 45 years old (old group; n = 8066). Patients ≤ 45 years old were less often females (18.5% vs. 27.6%, p < 0.027), more often smokers (84.6% vs. 66.9%, p < 0.0001), and had a higher incidence of previous myocardial infarction (MI) (40.8% vs. 29.6%, p = 0.008). Patients ≤ 45 years old more often received only one graft (27.7% vs. 15.0%, p < 0.0001), were operated on with minimally invasive direct coronary artery bypass (MIDCAB) technique (12.3% vs. 3.9%, p < 0.0001), and had complete arterial revascularisation (55.4% vs. 18.1%, p < 0.0001). There were no significant differences between the groups regarding in-hospital mortality (0.8% vs. 1.4%, p = 0.808). Long-term outcomes revealed that young patients, compared with the older patients, showed no significant differences in the number of MI (4.6% vs. 5.6%), unstable angina (8.5% vs. 9.9%), coronary angioplasty (12.3% vs. 15.1%), reCABG (0.8% vs. 0.1%), and strokes (2.3% vs. 4.3%) during the follow-up period; long-term mortality occurred less often in the young patients (4.6% vs. 15.0%, p = 0.002). We conclude that patients ≤ 45 years old requiring CABG differ from their older counterparts in clinical and surgical characteristics. We noted no significant differences in the in-hospital mortality; however, patients ≤ 45 years old had a lower mortality rate in the long-term follow-up.

Electrocardiographic and cardiovascular diagnostic characteristics of patients receiving long-term opioid therapy for pain

To examine cardiovascular and electrocardiogram (ECG) abnormalities seen in patients with chronic pain receiving long-term opioid therapy and to compare them with findings in normal subjects. Clinical pharmaceutical drug trial in a phase I pharmacology unit (normal subjects) and multiple phase 2b study sites (pain patients). Four hundred sixty-one pain patients with constipation due to long-term opioid therapy who were screened for a clinical trial of an investigational treatment for opioid-induced constipation. None; all data used in this study were obtained prior to drug treatment. This is a retrospective analysis of ECG abnormalities and clinical cardiovascular abnormalities in study participants compared with those in a normal reference group of 36,999 subjects. Numerical ECG values were modestly but not clinically significantly different in the pain patients requiring opioids (mean heart rate +1.5 BPM, PR +5.2 milliseconds, QRS -4.7 milliseconds, and QT corrected for heart rate using the Fridericia formula +7.2 milliseconds). The largest difference in ECG diagnoses between the two groups was a fivefold greater incidence of previous myocardial infarction in the pain patient group (4.1 percent vs 0.8 percent). In addition, 50 percent of the pain patient group had a clinical cardiovascular diagnosis. Patients with significant chronic pain requiring opioids have underlying clinical disorders that may be associated with abnormal cardiovascular physiology and ECGs. Clinicians who manage patients with chronic pain should be aware of the higher incidence of cardiovascular disease in this group.

Robotically Assisted Hybrid Coronary Revascularization: Does Sequence of Intervention Matter?

Hybrid coronary revascularization (HCR) is a treatment strategy for the revascularization of multivessel coronary disease that combines the advantages of both minimally invasive surgical techniques and percutaneous coronary intervention (PCI). The optimal sequence by which revascularization should be accomplished has not been determined. We investigated clinical outcomes in a series of patients planned for HCR via robotically assisted totally endoscopic coronary artery bypass (TECAB) and standard PCI based on revascularization sequence. A total of 238 patients planned for HCR between 2001 and 2011 were divided into three groups based on treatment sequence: (a) TECAB before PCI, (b) PCI before TECAB, and (c) same-session procedure. Multiple procedural and clinical end points before discharge and up to 2 years after the procedure were compared between the three groups in an intention-to-treat analysis. Demographic features were reviewed to determine baseline differences between each group. Of the 238 patients, 175 (73.5%) underwent TECAB before PCI, 38 patients (16.0%) underwent PCI before TECAB, and 25 (10.5%) underwent a simultaneous revascularization procedure. At baseline, the patients undergoing TECAB before PCI were significantly older. There was a significantly higher incidence of previous myocardial infarction in the PCI-first group (P < 0.001). There was a significant difference in intensive care unit (ICU) length of stay (LOS), with shorter ICU stays in the simultaneous revascularization group (P = 0.031) and shorter hospital LOS in the PCI before TECAB group (P = 0.021). In conclusion, revascularization sequence did not dramatically impact clinical outcomes in our observational study. The patients undergoing PCI-first and same-session interventions had shorter hospital and ICU LOS compared with the patients undergoing surgery first. Our findings suggest that no revascularization approach is arbitrarily superior and that revascularization sequence should be individualized on the basis of patient presentation and anatomical considerations.

ACE2 gene polymorphisms and invasively measured central pulse pressure in cardiac patients indicated for coronarography

The objective of this research was to determine whether invasively measured central pulse pressure (PP) in patients indicated for coronarography is associated with two common polymorphisms in the ACE2 region (rs4646156 and rs4646174). A total of 307 patients were enrolled in the study. The genotyping of both SNPs from peripheral blood samples was carried out using 5'exonuclease (Taqman®) chemistry on the ABI Prism® 7000 system (Applied Biosystems, Foster City, CA, USA). In both polymorphisms, the associations with central PP were found to be highly significant when all five possible genotypes in the population had been compared (p = 0.0001). In men, there was a higher incidence of previous myocardial infarction in G0 genotype carriers of rs54646174 (OR ratio = 7; p = 0.005). The AA genotype of rs4646156 had a 7.81× higher risk of severe angina pectoris in women (OR = 7.81, p = 0.05). A significant difference in allelic frequency of ACE2rs4646174 was found between women with and without significant stenoses of the circumflex branch of the left coronary artery. More research into the role of ACE2 genetic variability in PP regulations is necessary for more detailed physiological and pathophysiological comprehension of PP regulation.

Mid-Term Outcome of Mitral Valve Repair and Coronary Artery Bypass Grafting for Ischemic or Degenerative Mitral Regurgitation

Aim of the study: To verify the impact of the etiology of mitral valve regurgitation on a 5-year outcome after repair and concomitant coronary artery bypass grafting (CABG). Methods: One hundred and eleven consecutive patients (mean age of 69±8 years) who underwent mitral valve repair, 65 for ischemic and 46 for degenerative mitral regurgitation, and concomitant CABG, were retrospectively analyzed. The mean follow-up was 40±28 (9-104) months. Five-year survival (including operative mortality), and survival free from events (postoperative low output syndrome, progression of mitral regurgitation, onset or worsening of congestive heart failure, recurrence of myocardial infarction, and the need for mitral valve replacement) were analyzed. Results: Compared with degenerative, ischemic mitral regurgitation was associated with a higher incidence of previous myocardial infarction (P<0.0001), left ventricular ejection fraction (LVEF) <0.45 (P<0.0001), and more diseased coronary vessels per patient (P<0.0001). Five-year all-cause mortality was 18% (20/111). Independent predictors of mortality were older age at operation (P=0.0008), LVEF<0.45 (P=0.04), and the ischemic etiology of mitral regurgitation (P=0.03). At five years, survival was 69%±7.6% for ischemic versus 87%±6.5% for degenerative etiology (P=0.03); event-free survival was 58%±8.4% versus 75%±8% (P=0.02), and freedom from late cardiac death was 85%±6.6% versus 100% (P=0.02). Freedom from mitral valve reoperation was 97±2.4%. Conclusions: Ischemic mitral regurgitation “per se” predicted limited survival and event-free survival. Left ventricular dysfunction is frequently associated with the ischemic etiology. An early surgi cal indication to prevent left ventricular dysfunction could be important to improve the mid-term outcome.

High-frequency QRS electrocardiogram analysis during exercise stress testing for detecting ischemia

Introduction ECG stress testing is an inexpensive and non-invasive detector of myocardial ischemia; addition of high-frequency QRS analysis (HFQRS) may improve accuracy. This study compared HFQRS during exercise in patients with and without ischemia as defined by multiple criteria. Material and methods High-resolution ECGs were recorded for 139 patients undergoing T99-sestamibi/T201-thallium stress testing. Twenty-three were positive by at least two and 37 were negative for ischemia by all three of the following criteria: nuclear scan, ST-segment analysis and typical angina. Sixty-four not meeting criteria for positive or negative, six with adenosine test and nine patients with ECG recording artifacts were excluded. Mean age of the study group was 62 ± 10 years, 83% were male. Ischemic patients had a higher incidence of previous myocardial infarction and coronary intervention than non-ischemic patients (74% vs. 46%; P = 0.03 and 70% vs. 43%; P = 0.05, respectively), but had a lower body mass index (28.7 ± 5 vs. 33.0 ± 8; P = 0.015). HFQRS analysis consisting of signal averaging (150–250 Hz) and calculation of root mean squared values for each lead at different time points was performed and was similar between the groups. The relative change in HFQRS (RCQ) was calculated for each lead: {(maxHFQRS − minHFQRS) / maxHFQRS}. For each patient an RCQ index was calculated by averaging the two leads with the greatest RCQ value. The RCQ index was greater in ischemic vs. non-ischemic patients (45% vs. 34%; P = 0.0069). Conclusion Maximum decrease in HFQRS, as quantified by RCQ index, was greater in ischemic vs. non-ischemic patients. Use of the RCQ index may improve the diagnosis of ischemia during exercise stress testing.

Is a New Classification of Postoperative Myocardial Infarction Justified?

Royal Brompton Hospital, London, United Kingdom. dylanbould@yahoo.co.ukI read with interest the prospective audit of routinely measuring cardiac troponin I (cTnI) levels postoperatively in infrarenal aortic surgery by Le Manach et al. 1The authors have proposed a classification of two separate groups of postoperative myocardial infarction (PMI) based on their findings. However, I think that aspects of both the methodology of the study and the presentation of results are open to criticism and that the validity of their distinction between early and delayed PMI is questionable.It is not clear why the value for cTnI that the authors consider to be abnormal changed in the study and in their participating institution from 0.5 ng/ml from September 1995 to November 1999 to 0.2 ng/ml from November 1999 onward. It seems that the same machine was used for testing cTnI throughout the study period. This parameter is the basis of the definitions of both myocardial damage and delayed PMI and also the proposed difference between the early and delayed PMI groups and is clearly a key issue. Regardless of whether the institution changed its normal values for cTnI, it would seem that the most appropriate methodology would be to analyze the whole population by the same rules. It would be of interest whether the endpoints would differ from that reported if all patients were reanalyzed together at 0.2 ng/ml and at 0.5 ng/ml.The abstract states that the cTnI profiles between the delayed PMI group before the cTnI threshold for PMI was reached and the myocardial damage group were identical. In the main part of the Results, it is only written that the profiles are comparable. Even so, the only evidence presented for this is a graph of two “representative” patients. To describe the two profiles mentioned as identical would require descriptive statistics of cTnI values to be presented against time for each of the different groups, with a mathematical analysis of their difference. I also note that there was not even a “representative” example described of the other two groups.The timing of the 24-h cutoff for the difference between early and delayed PMI was predetermined and arbitrary. The authors state that in the early PMI group, PMI was not preceded by subinfarction myocardial damage, but did any of the early PMI group patients have abnormal cTnI for 18 rather than 24 h? If so, how do we know that this was not significant myocardial damage? It would seem to be a more robust choice of timing if at first the pattern within the population was examined and then the most appropriate cutoff was chosen.The authors note that only the early PMI group had an increased incidence of previous myocardial infarction and hint that this supports their hypothesis of different etiology in the two PMI groups. I note that 57 comparisons are made in table 2. Because the P values are only described as less than 0.05 and not specified, it is hard to know how significant their four P values of less than 0.05 in table 2 really are when you would expect almost three to occur just by statistical probability. Defining two groups on their differing temporal characteristics, proving statistical difference in a clearly related temporal parameter in the absence of any other differences in nonrelated parameters, and then inferring that the two groups are fundamentally different is a weak argument.The opinion that the time when the cTnI is abnormal but not diagnostic of PMI should be considered a “golden period,” and the hypothesis that intensive interventions may influence outcome is attractive. The description of the natural history of cTnI changes would be more useful if we knew whether the ischemia was silent or associated with evidence that would have resulted in appropriate therapy anyway. I would like to know whether the myocardial damage group or the patients with abnormal cTnI before PMI had chest pain, dyspnea, heart failure, arrhythmias, or other electrocardiographic changes suggestive of ischemia.In conclusion, the authors have not shown a bimodal distribution that would justify the classification of PMI as early and delayed, nor have they conclusively shown a fundamental difference between rapid-onset and delayed-onset PMI groups on the evidence as presented. Moreover, I think the suggestion that early PMI is “hitherto unrecognized in the postoperative setting” is unfounded.Royal Brompton Hospital, London, United Kingdom. dylanbould@yahoo.co.uk

Aortic Valve Replacement and Concomitant Mitral Valve Regurgitation in the Elderly

The impact of mitral regurgitation (MR) on elderly patients (> or = 70 years) undergoing isolated aortic valve replacement (AVR) is not clearly defined. This study investigates the long-term effects of preoperative, moderate MR on survival and functional outcome in elderly AVR patients. A retrospective review identified 408 consecutive elderly patients who underwent isolated AVR from January 1983 to February 2004. The pathologic etiology of MR was determined on preoperative echocardiogram, and patients were stratified into no/mild MR (Group I; n = 338) versus moderate MR (Group II; n = 70). Follow-up was 95.1% complete. Functional outcome was evaluated using the Short Form-12 questionnaire. On univariate analysis, Groups I and II differed in incidence of previous myocardial infarction (13.9% versus 28.6%; P = 0.004), hyperlipidemia (18.7% versus 33.3%; P = 0.009), and congestive heart failure (50.0% versus 70.0%; P = 0.002). On multivariate analysis, moderate MR was an independent risk factor impacting long-term survival (P = 0.04). Actuarial survival at 1, 5, and 10 years for Group I was 93.8%, 73.3%, and 40.1% versus 92.3%, 58.2%, and 14.6% for Group II (P = 0.04). Available postoperative echocardiograms for Group II (n = 37) demonstrated improvement in MR in 81.8% of functional MR patients. However, MR persisted or worsened in 65.4% of patients with intrinsic mitral valve disease (myxomatous, calcific, or ischemic MR). Functional outcomes showed 77% of Group I versus 78.6% of Group II rated their health as good to excellent post-AVR. Moderate MR is an independent risk factor impacting long-term survival in elderly patients undergoing AVR. Therefore, patients with intrinsic mitral valve disease should be considered for concomitant MV surgery.

Regarding “A prospective study of subclinical myocardial damage in endovascular versus open repair of infrarenal abdominal aortic aneurysms”

Background Endovascular repair of abdominal aortic aneurysms (AAAs) is considered to be less invasive and better tolerated by the cardiovascular system than open repair. Our aim was to assess the true incidence of perioperative myocardial damage associated with endovascular vs open infrarenal AAA repair. Methods Between July 1999 and June 2001, preoperative and postoperative serum troponin T (TnT) levels were measured in all patients presenting for elective AAA repair at Royal Prince Alfred Hospital. The incidence of myocardial damage was recorded on the basis of standard clinical, biochemical, and electrocardiographic changes or a subclinical increase of 50% or more in serum TnT. Patients were excluded if the TnT increase was associated with a significant increase of serum creatinine (≥50%) with no other evidence of myocardial ischemia. The differences between the two groups were analyzed with the χ 2 test and odds ratios. Results A total of 35 open and 112 endovascular AAA repairs were included in the study. There was no significant difference in age, sex, preoperative serum creatinine, or preoperative serum TnT between the two treatment groups. Seventeen patients had biochemical evidence of myocardial damage, which was clinically obvious in only one patient. Even though the incidence of previous myocardial infarction was significantly higher in patients undergoing endovascular repair (41%) than open repair (22%; P P Conclusions There is a previously underestimated incidence of subclinical myocardial damage associated with surgery for infrarenal AAA which is lower after endovascular than open repair.

A prospective study of subclinical myocardial damage in endovascular versus open repair of infrarenal abdominal aortic aneurysms

Endovascular repair of abdominal aortic aneurysms (AAAs) is considered to be less invasive and better tolerated by the cardiovascular system than open repair. Our aim was to assess the true incidence of perioperative myocardial damage associated with endovascular vs open infrarenal AAA repair. Between July 1999 and June 2001, preoperative and postoperative serum troponin T (TnT) levels were measured in all patients presenting for elective AAA repair at Royal Prince Alfred Hospital. The incidence of myocardial damage was recorded on the basis of standard clinical, biochemical, and electrocardiographic changes or a subclinical increase of 50% or more in serum TnT. Patients were excluded if the TnT increase was associated with a significant increase of serum creatinine (> or =50%) with no other evidence of myocardial ischemia. The differences between the two groups were analyzed with the chi 2 test and odds ratios. A total of 35 open and 112 endovascular AAA repairs were included in the study. There was no significant difference in age, sex, preoperative serum creatinine, or preoperative serum TnT between the two treatment groups. Seventeen patients had biochemical evidence of myocardial damage, which was clinically obvious in only one patient. Even though the incidence of previous myocardial infarction was significantly higher in patients undergoing endovascular repair (41%) than open repair (22%; P < .05), the overall incidence of myocardial damage (clinical or subclinical) was significantly higher in the open group compared with the endovascular group (8 [25%] of 32 vs 9 [8%] of 109, respectively; odds ratio, 3.7; 95% confidence interval, 1.28-10.49; P < .02). There is a previously underestimated incidence of subclinical myocardial damage associated with surgery for infrarenal AAA which is lower after endovascular than open repair.

Enalapril decreases the incidence of atrial fibrillation in patients with left ventricular dysfunction: insight from the Studies Of Left Ventricular Dysfunction (SOLVD) trials.

Atrial fibrillation (AF) is frequently encountered in patients with heart failure (HF) and is also a predictor of morbidity and mortality in this population. Recent experimental studies have shown electrical and structural atrial remodeling with increased fibrosis in animals with HF and have suggested a preventive effect of ACE inhibitors (ACEi) on the development of AF. To verify the hypothesis that ACEi prevent the development of AF in patients with HF, we conducted a retrospective analysis of the patients from the Montreal Heart Institute (MHI) included in the Studies Of Left Ventricular Dysfunction (SOLVD). Clinical charts were reviewed and serial ECGs interpreted by a single cardiologist blinded to drug allocation. Patients with AF or flutter on the baseline ECG were excluded. Baseline characteristics were obtained from the SOLVD databases. The mean follow-up was 2.9+/-1.0 years. Of the 391 patients randomly assigned at MHI, 374 were in sinus rhythm at the time of random assignment, with 186 taking enalapril and 188 taking placebo. Baseline characteristics were similar in the two groups except for a higher incidence of previous myocardial infarction in the enalapril group. Fifty-five patients had AF during the follow-up: 10 (5.4%) in the enalapril group and 45 (24%) in the placebo group (P<0.0001). By Cox multivariate analysis, enalapril was the most powerful predictor for risk reduction of AF (hazard ratio, 0.22; 95% CI, 0.11 to 0.44; P<0.0001). Treatment with the ACEi enalapril markedly reduces the risk of development of atrial fibrillation in patients with left ventricular dysfunction.

Evaluation of the role of abciximab (Reopro) as a rescue agent during percutaneous coronary interventions: In‐hospital and six‐month outcomes

Abciximab is effective for the prevention of complications when administered prior to percutaneous coronary intervention (PCI). The efficacy and safety of abciximab as an unplanned or rescue agent for complications of PCI is unknown. Rescue versus planned use was compared in 186 consecutive patients. Primary or rescue PCI for acute myocardial infarction (MI) and shock were excluded. Rescue abciximab use was undertaken in 101 patients (54.3%) and planned abciximab was used in 85 (45.7%). The rescue abciximab patients had a lower incidence of previous MI, preprocedural thrombus, multivessel, and vein graft intervention. In-hospital endpoints in the rescue versus planned abciximab patients were death (1.0% vs. 1.2%, P = 1.0), Q-wave MI (2.0% vs. 2.4%, P = 1.0), any MI (14.9% vs. 9.4%, P = 0.3), target vessel revascularization (TVR; 0% vs. 1.2%, P = 1.0), and composite (15.8% vs. 10.6%, P = 0.3). At 6 months, events were death (4.0% vs. 2.3%, P = 0.69), MI (14.9% vs. 9.4%, P = 0.26), TVR (20.8% vs. 4.7%, P = 0.001), and composite (30.7% vs. 15.3%, P = 0.01). In-hospital complications between the rescue and planned abciximab patients of major bleed (1.0% vs. 1.8%, P = NS), stroke (0% vs. 1.8%, P = NS), and thrombocytopenia (3.0% vs. 1.8%, P = NS) were similar. There was a significantly higher procedural time (99.6 min vs. 86.1 min, P = 0.02), contrast volume (278.8 ml vs. 223.5 ml, P = 0.04), and heparin use (8984 u vs. 6003 u, P = 0.0006) in the rescue group. In this nonrandomized comparison, rescue abciximab allowed for the safe discharge from hospital in the majority of patients. However, during a 6-month follow-up, more patients treated with rescue abciximab required TVR with either repeat PCI or CABG. Further studies are warranted to evaluate the overall strategy of rescue abciximab use in PCI. Cathet. Cardiovasc. Intervent. 51:138–144, 2000. © 2000 Wiley-Liss, Inc.

Are there gender differences in patients presenting with unstable angina?

Background: There are limited studies on gender differences in patients with unstable angina. We investigated the influence of gender in these patients in a tertiary referral centre. Methods and results: Three hundred and thirteen consecutive patients (210 men and 103 women) with unstable angina were studied over a 42-month period. Patient characteristics, cardiovascular risk factors and subsequent management including coronary artery bypass graft (CABG) operation and percutaneous transluminal coronary angioplasty (PTCA) were investigated. There was no difference in age [61.6 (11.0) (S.D.) years for men vs. 63.5 (10.5) years for women]. Diabetes mellitus and hypertension were more common in women (diabetes, 11% vs. 23%, P=0.007; hypertension, 32% vs. 52%; P=0.001). The number of smokers was greater in men (73% vs. 46%, P=0.00001). There was no difference in the prevalence of hypercholesterolaemia or in the incidence of previous myocardial infarction, previous history of angina and family history of ischaemic heart disease. The duration of unstable angina before presentation to the referring hospital was similar in both sexes. The use of aspirin, intravenous heparin and antianginal drugs was also comparable in the two genders. The number of coronary arteries involved in men and women appeared similar (one vessel, 22% vs. 27%; two vessels, 26% vs. 21%; three vessels, 52% vs. 52% in men and women, respectively). The proportion of men and women who underwent subsequent revascularisation was also similar (CABG, 31% vs. 33%; PTCA, 42% vs. 40%). The overall in-hospital mortality was higher in women (6.8% vs. 2.8%), but was not statistically significant ( P=0.18). Conclusions: Gender differences in unstable angina manifest in the preponderance of selected risk factors including diabetes mellitus and hypertension in women and smoking in men. There is no difference in age, the degree of coronary artery involvement and the subsequent management in a tertiary referral centre.

Effect of gender on postoperative outcomes and hospital stays after coronary artery bypass grafting

Background. Compared to men, women undergoing coronary artery bypass grafting appear to have a higher morbidity and mortality, particularly in the perioperative period. This study was designed to answer the questions of whether such differences in clinical outcomes between men and women still exist with improvements in surgical techniques and determine whether it is gender or associated comorbid conditions in women that lead to higher morbidity.Methods. An analysis of a single center’s contemporary experience (1994 to 1997) of 1,743 consecutive patients undergoing primary coronary artery bypass grafting was performed. Only reoperations were excluded. Data were collected prospectively and presented as mean ± standard deviation (p < 0.05).Results. Women represented 30.0% of patients. Compared with men, women were older (68.4 versus 63.8 years; p < 0.05), and had more urgent surgical interventions (70.0% versus 56.7%; p < 0.05), a higher incidence of diabetes (42.1% versus 26.7%; p < 0.05), hypertension (82.0% versus 73.9%; p < 0.05), lower body surface area (1.73 ± 0.18 m2 versus 2.03 ± 0.19 m2; p < 0.05), and hematocrit (31.7% ± 3.9% versus 36.2% ± 3.9%; p < 0.05). Ejection fraction, incidence of previous myocardial infarction, chronic obstructive pulmonary disease, left main (LM) disease, renal insufficiency, extent of coronary disease, and preoperative intraaortic balloon pump were similar. Women received fewer arterial grafts (91.0% versus 95.5%; p < 0.05) and distal anastomoses (3.31 ± 0.88 versus 3.49 ± 0.94 p < 0.05). Despite these differences, there were no statistical differences in the incidence of postoperative death (1.5% versus 1.0%), myocardial infarction (0.6% versus 0.6%), or cerebrovascular accident/transient ischemic attack (1.1% versus 0.4%) between men and women. Women had a higher inotropic support (10.2% versus 4.4%; p < 0.05) and longer hospital stays (7.3 ± 5.7 days versus 6.3 ± 4.2 days; p < 0.05). Using multivariate analysis, female gender was not an independent predictor of death or postoperative complications but was a predictor of length of hospital stay, use of arterial grafts, and extent of coronary revascularization.Conclusions. After accounting for differences in their risk variables, the incidences of death, perioperative myocardial infarction and cerebrovascular accident/transient ischemic attack after coronary artery bypass grafting in women and men were not statistically significant. Perioperative complications are related to comorbid risk factors but not to female gender itself. Further studies are warranted.

The natural history of aneurysmal coronary artery disease.

OBJECTIVE: To assess the contribution of coronary artery ectasia, either isolated or in association with obstructive coronary artery disease, to morbidity and mortality from ischaemic heart disease. DESIGN: A retrospective...

Prospective Comparison of Patient Characteristics and Outcome of Non-prior Aspirin Users versus Aspirin Users with Unstable Angina or Non-Q-Wave Myocardial Infarction Treated with Combination Antithrombotic Therapy.

The objective of this study was to determine if aspirin users presenting with acute coronary syndromes are at higher risk for subsequent clinical events. In a trial evaluating combination antithrombotic therapy in resting angina or non-Q-wave myocardial infarction (MI), patients were prospectively dichotomized on admission into nonprior versus recent aspirin users. Then 105 nonprior users and 144 users were randomized to treatment with aspirin plus heparin/warfarin for 12 weeks. Recurrent myocardial ischemia occurring during the 12-week follow-up period was defined as recurrent angina (with electrocardiographic changes or prompting coronary revascularization), MI, or death. Prior aspirin users had a significantly higher incidence of previous MI, prior bypass grafting, beta-blocker use, or hypertension (p </= 0.003) and were more likely to present with unstable angina as opposed to non-Q-wave MI. (p </= 0.008). The cumulative probability of recurrent ischemic endpoints for nonprior versus recent users was 10% versus 21% at 14 days (log rank p = 0.03), and 19% versus 29%, at 12 weeks (p = 0.06). Using the Cox model, adjusting for variables significantly associated with outcome, aspirin use remained a significant predictor of 14-day outcome (p = 0.04) but not of 12-week outcome (p = 0.06). In conclusion, even after adjusting for significant differences in baseline variables, aspirin users presenting with rest angina or non-Q-infarction have a worse short-term prognosis in spite of maximal medical therapy.