Left Anterior Descending Artery Involvement Research Articles

Clinical and coronary angiographic profiling in young patient with acute ST-elevation myocardial infarction admitted in cardiac critical care unit of tertiary care centre at south Tamil Nadu

Background: Premature coronary artery disease (PCAD) is associated with a high rate of ischemic recurrence and mortality, causing a significant impact on public health. The present study focuses on the assessment of the risk factors, clinical presentation, angiographic profiling considering severity, and management of extremely young adults (aged ≤45 years) affected with first ST elevation acute myocardial infarction (STEMI). Methods: The current study (cross-section) was carried out among 94 consecutive patients with STEMI. The study on patients was carried out between January 2022 and June 2022 at Tirunelveli Medical College Hospital, department of cardiology. Results: This study involved 94 patients with a mean age of 37.80 years, 8.5% <25, and 84.9% male patients. Risk factors included smoking, being overweight, diabetes, hypertension, chest pain, syncope, and obstructive coronary artery disease (CAD). The most common symptom was chest pain (98.9%). Left anterior descending (LAD) was the most common culprit artery (26.1%), and ostial LAD was (3.2%). Percutaneous coronary intervention (PCI) was done in 53.2% of patients, elective PCI was 26.6%, pharma co-invasive PCI was 24.5%, and primary PCI was 2.1%. The patient was referred to coronary artery bypass grafting was 10.6%. 23.4% of patients had recanalized and normal coronaries, and 36% received medical management. No mortality occurred in this study. Conclusions: Most commonly, AMI is found in very young male adults, and smoking is the commonly associated risk factor. LAD artery involvement was the leading cause of AWMI and the most common presentation observed.

Clinical and Angiographic Predictors of suboptimal Coronary Flow After Primary Percutaneous Coronary Intervention in Patients with ST-Elevation Myocardial Infarction.

This study aimed to investigate the clinical and angiographic characteristics of patients with ST-elevation myocardial infarction who experienced primary percutaneous coronary intervention failure. This retrospective observational study was derived from the Primary Angioplasty Registry of Sina Hospital (PARS). A total of 548 consecutive patients with ST-elevation myocardial infarction who underwent primary percutaneous coronary intervention between November 2016 and January 2019 were evaluated. Percutaneous coronary intervention failure was defined as Thrombolysis in Myocardial Infarction (TIMI) flow ≤ 2 or corrected TIMI frame count (cTFC) ≥ 28. The study population consisted of 458 (83.6%) males and 90 (16.4%) females with a mean age of 59.2 ± 12.49 years. TIMI flow 3 was achieved in 499 (91.1%) patients after the procedure, while 49 (8.9%) patients developed TIMI ≤ 2. The findings showed that cTFC ≥ 28 was present in 50 (9.1%) patients, while 489 (89.2%) patients had cTFC < 28. Multiple regression analysis shows that age 1.04 (1.01, 1.07), duration of pain onset to first medical contact time 1.04 (1.00, 1.18), and left anterior descending artery involvement 3.15 (1.21, 8.11) were independent predictors of TIMI ≤ 2. Even though TIMI ≤ 2 was uncommon among the study population, it was associated with adverse in-hospital outcomes. The results indicate that earlier emergency medical service arrival and shorter transfer time to the referral center can dramatically reduce the primary percutaneous coronary intervention failure rate.

Autopsy Study of Sudden Death Cases With Special Reference to Histopathological Changes in Heart

Background: Sudden cardiac death and arrhythmia accounts for 15 – 20% of all deaths. Though Coronaryartery disease is the major cause of sudden deaths, diagnosis of other underlying causes is necessary. Hence weintended to analyze the various cardiac causes related to sudden deaths and the associated histopathologicalfindings of heart.Methods: Present study was an autopsy based cross sectional observational study conducted at MaduraiMedical College mortuary for a period of one year. 100 cases of sudden deaths were subjected to autopsy andhistopathological changes of heart were studied.Results: In the present study, majority of cases belonged to the age group of 40 - 60 years with male preponderance.In histopathological examination, atherosclerosis was the most common finding with involvement of left anteriordescending artery. Other findings include myocardial infarction, myocarditis, pericarditis and dysarrythmogenicventricular hypoplasia. Multiple cardiac lesions were noted in few cases.Conclusion: An accurate diagnosis of the underlying morbidity at risk of sudden death either at postmortemor in living patients and life threatening arrhythmias is the pre – requisite to adopt therapeutic and preventivestrategies.

Frequency of Left Anterior Descending Artery Involvement as a Culprit Vessel in Young Patient with ST Elevation Myocardial Infarction

Objective: To determine the frequency of left anterior descending artery involvement as a culprit vessel in young patient with ST elevation myocardial infarction (STEMI) at tertiary care hospital. Study Design: A cross-sectional study. Place and Duration: The Department of Cardiology, “National Institute of Cardiovascular Diseases, Karachi” Pakistan from October 2019 to April 2020. Methodology: Patients of both genders aged 25-45 years who were presented with onset of chest pain for more than 30 minutes with STEMI were included. All patients were clinically evaluated after detailed history. Routine biochemistry investigations were asked and ECG and echocardiography were performed. Frequency of left anterior descending artery involvement in patients with STEMI was noted. Results: In a total of 191 patients, mean age was 33.6±6.7 years while mean duration of chest pain was 42.5±8.3 minutes. There were 135 (70.7%) male and 56 (29.3%) female cases. In distribution of vessel disease, 76 (39.8%) had single vessel disease (SVD), 37 (19.37%) had double vessel disease (DVD) while 78 (40.84%) had triple vessel disease (TVD). Left anterior descending artery found to be positive in 88 (46.1%) patients. Practical Implications: To reduce the complications of STEMI, it is very important to increase the awareness and proper knowledge in the general public. Conclusion: Involvement of left anterior descending artery as a culprit vessel was fairly common in young patient with ST elevation myocardial infarction. Keywords: Left anterior descending artery, culprit vessel, ST elevation myocardial infarction, coronary artery disease

Outcomes following PCI in CABG candidates during the COVID-19 pandemic: The prospective multicentre UK-ReVasc registry.

ObjectivesTo describe outcomes following percutaneous coronary intervention (PCI) in patients who would usually have undergone coronary artery bypass grafting (CABG).BackgroundIn the United Kingdom, cardiac surgery for coronary artery disease (CAD) was dramatically reduced during the first wave of the COVID‐19 pandemic. Many patients with “surgical disease” instead underwent PCI.MethodsBetween 1 March 2020 and 31 July 2020, 215 patients with recognized “surgical” CAD who underwent PCI were enrolled in the prospective UK‐ReVasc Registry (ReVR). 30‐day major cardiovascular event outcomes were collected. Findings in ReVR patients were directly compared to reference PCI and isolated CABG pre‐COVID‐19 data from British Cardiovascular Intervention Society (BCIS) and National Cardiac Audit Programme (NCAP) databases.ResultsReVR patients had higher incidence of diabetes (34.4% vs 26.4%, P = .008), multi‐vessel disease with left main stem disease (51.4% vs 3.0%, P < .001) and left anterior descending artery involvement (94.8% vs 67.2%, P < .001) compared to BCIS data. SYNTAX Score in ReVR was high (mean 28.0). Increased use of transradial access (93.3% vs 88.6%, P = .03), intracoronary imaging (43.6% vs 14.4%, P < .001) and calcium modification (23.6% vs 3.5%, P < .001) was observed. No difference in in‐hospital mortality was demonstrated compared to PCI and CABG data (ReVR 1.4% vs BCIS 0.7%, P = .19; vs NCAP 1.0%, P = .48). Inpatient stay was half compared to CABG (3.0 vs 6.0 days). Low‐event rates in ReVR were maintained to 30‐day follow‐up.ConclusionsPCI undertaken using contemporary techniques produces excellent short‐term results in patients who would be otherwise CABG candidates. Longer‐term follow‐up is essential to determine whether these outcomes are maintained over time.

Risk or Beneficial Factors Associated with Unplanned Revascularization Risk Following Percutaneous Coronary Intervention: A Large Single-Center Data

ObjectiveTo analyze factors associated with unplanned revascularization (UR) risk in patients with coronary artery disease (CAD) who underwent percutaneous coronary intervention (PCI). MethodsA total of 10,640 cases with CAD who underwent PCI were analyzed. Multivariate COX regressions and competing risk regressions were applied. ResultsThe patients who underwent UR following PCI in 30 days, 1, and 2 years accounted for 0.3%, 6.5%, and 8.7%, respectively. After multivariate adjustment, the number of target lesions [hazard ratio (HR) = 2.320; 95% confidence interval (CI): 1.643–3.277; P < 0.001], time of procedure (HR = 1.006; 95% CI: 1.001–1.010; P = 0.014), body mass index (HR = 1.104; 95% CI: 1.006–1.210; P = 0.036), incomplete revascularization (ICR) (HR = 2.476; 95% CI: 1.030–5.952; P = 0.043), and age (HR = 1.037; 95% CI: 1.000–1.075; P = 0.048) were determined as independent risk factors of 30-day UR. Factors, including low-molecular-weight heparin or fondaparinux (HR = 0.618; 95% CI: 0.531–0.719; P < 0.001), second-generation durable polymer drug-eluting stent (HR = 0.713; 95% CI: 0.624–0.814; P < 0.001), left anterior descending artery involvement (HR = 0.654; 95% CI: 0.530–0.807; P < 0.001), and age (HR = 0.992; 95% CI: 0.985–0.998; P = 0.014), were independently associated with decreased two-year UR risk. While, Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery score (HR = 1.024; 95% CI: 1.014–1.033; P < 0.001) and ICR (HR = 1.549; 95% CI: 1.290–1.860; P < 0.001) were negatively associated with two-year UR risk. ConclusionSpecific factors were positively or negatively associated with short- and medium-long-term UR following PCI.

A risk score based on simple angiographic characteristics to aid in choosing the optimal revascularization strategy for patients with multivessel disease presenting with ST-elevation myocardial infarction.

The optimal revascularization strategy is not clearly defined for patients with ST-elevation myocardial infarction with multivessel disease (MV-STEMI). We aimed to develop a simple angiographic risk score for identifying patients with MV-STEMI that might benefit from a multivessel percutaneous coronary intervention (MV-PCI), compared to a PCI for only the infarct-related artery (IRA-PCI). This retrospective study acquired data from a single-center STEMI registry on 841 consecutive patients with MV-STEMI (645 IRA-PCI and 196 MV-PCI). Patients were stratified according to high- and low-risk scores. We devised a score based on three characteristics of non-culprit lesions previously reported to predict overall mortality (proximal left anterior descending artery involvement, maximal % stenosis, and number of involved vessels). The primary endpoint was major adverse cardiac events (MACEs: a composite of death/MI/urgent repeat revascularization). After a median follow-up of 1909 days, MACE occurred in 205/841 (24.4%) patients. MACE risk was higher in the high-risk than in the low-risk group (HR 1.43, P < 0.001). In comparing the IRA-PCI and MV-PCI approaches within each risk group, we found that these revascularization strategies had differential effects on outcome. Compared to the MV-PCI, IRA-PCI was associated with less MACE in the low-risk group (HR 0.597, P = 0.033), and more MACE in the high-risk group (HR 3.14, P < 0.001). For patients with MV-STEMI that undergo primary PCI, a simple risk score based on three angiographic characteristics could identify patients at high risk of future adverse events. This score might facilitate choosing the optimal revascularization strategy.

Association of left anterior descending artery involvement on clinical outcomes among patients with STEMI presenting with and without out-of-hospital cardiac arrest

BackgroundST-segment elevation myocardial infarction (STEMI) outcomes are influenced by the location of the culprit vessel with worse outcomes portended with a left anterior descending (LAD) culprit lesion. However, relatively little...

Heart Team decision making and long-term outcomes for 1000 consecutive cases of coronary artery disease.

The Heart Team has been recommended as standard care for patients with coronary artery disease (CAD). However, little is known about the real benefits, potential treatment delays and late outcomes of this approach. Our goal was to determine the safety and feasibility of multidisciplinary Heart Team decision making for patients with CAD. We retrospectively assessed 1000 consecutive cases discussed by the Heart Team between November 2010 and January 2012. We assessed (i) time intervals between different care steps involving the Heart Team; (ii) the distribution of patients according to the complexity of their CAD; and (iii) the 5-year survival as estimated from Kaplan-Meier curves. Of 1000 case discussions, 40 were repeat cases, resulting in 960 unique cases. The mean age was 65 years, 73% were men, and 29% had diabetes. Native vessel disease was present in 86.4%, of which 69% had simple 1-vessel disease (1VD) or 2-vessel disease (2VD), and 31% had complex left main (LM) or 3-vessel disease (3VD). The time interval between referral by a community hospital and final treatment was less than 6 weeks for 90% of cases. Treatment decisions were delayed in 35% of cases due to a need for additional diagnostic information. For simple 1- or 2VD with or without proximal left anterior descending artery involvement, treatment was medical therapy in 6% and 12%, respectively; percutaneous coronary intervention (PCI) in 88% and 85%, respectively; and coronary artery bypass grafting (CABG) in 6% and 3%, respectively. For 3VD disease, treatment was equally split between CABG and PCI (46% for both). PCI was preferred for isolated LM or LM with 1VD (81% vs CABG 16%), whereas CABG was preferred in LM with 2- or 3VD (71% vs PCI 19%). The 5-year mortality rate was 16% for 1- or 2VD, 17% for 3VD, 3% for isolated LM or with 1VD and 27% for LM with 2- or 3VD. In this single-centre analysis, the Heart Team approach was feasible, with decision making and treatment by the Heart Team following within a short time after referral. However, the timing of treatment could be further optimized if adequate information and imaging were available at the time of the Heart Team meeting. The final treatment recommendation by the Heart Team was largely in accordance with clinical guidelines.

Medical Treatment and Revascularization Options in Patients With Type 2 Diabetes and Coronary Disease

BackgroundThere are scant outcomes data in patients with type 2 diabetes and stable coronary artery disease (CAD) stratified by detailed angiographic burden of CAD or left ventricular ejection fraction (LVEF). ObjectivesThis study determined the effect of optimal medical therapy (OMT), with or without percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), on long-term outcomes with respect to LVEF and number of diseased vessels, including proximal left anterior descending artery involvement. MethodsA patient-level pooled analysis was undertaken in 3 federally-funded trials. The primary endpoint was the composite of death, myocardial infarction (MI), or stroke, adjusted for trial and randomization strategy. ResultsAmong 5,034 subjects, 15% had LVEF <50%, 77% had multivessel CAD, and 28% had proximal left anterior descending artery involvement. During a median 4.5-year follow-up, CABG + OMT was superior to PCI + OMT for the primary endpoint (hazard ratio [HR]: 0.71; 95% confidence interval [CI]: 0.59 to 0.85; p = 0.0002), death (HR: 0.76; 95% CI: 0.60 to 0.96; p = 0.024), and MI (HR: 0.50; 95% CI: 0.38 to 0.67; p = 0.0001), but not stroke (HR: 1.54; 95% CI: 0.96 to 2.48; p = 0.074). CABG + OMT was also superior to OMT alone for prevention of the primary endpoint (HR: 0.79; 95% CI: 0.64 to 0.97; p = 0.022) and MI (HR: 0.55; 95% CI: 0.41 to 0.74; p = 0.0001), and was superior to PCI + OMT for the primary endpoint in patients with 3-vessel CAD (HR: 0.72; 95% CI: 0.58 to 0.89; p = 0.002) and normal LVEF (HR: 0.71; 95% CI: 0.58 to 0.87; p = 0.0012). There were no significant differences in OMT versus PCI + OMT. ConclusionsCABG + OMT reduced the primary endpoint during long-term follow-up in patients with type 2 diabetes and stable CAD, supporting this as the preferred management strategy.

Comparison of Coronary Computed Tomographic Angiographic Findings in Asymptomatic Subjects With Versus Without Diabetes Mellitus

There are limited data on the impact of diabetes mellitus (DM) on the risk of subclinical atherosclerosis. Therefore, we sought to investigate the impact of DM on the risk of subclinical atherosclerosis in asymptomatic subjects. We analyzed 2,034 propensity score-matched asymptomatic subjects who underwent coronary computed tomographic angiography (mean age 55.9 ± 8.2years; men 1,725 [84.8%]). Coronary artery calcium score, degree and extent of coronary artery disease (CAD), and clinical outcomes were assessed. High-risk CAD was defined as at least 2-vessel coronary disease with proximal left anterior descending artery involvement, 3-vessel disease, or left main disease. Compared with subjects without DM, those matched with DM had higher coronary artery calcium score (89.9 ± 240.4 vs 62.8 ± 179.5, p= 0.004) and more significant CAD (≥50% diameter stenosis, 15.2% vs 10.2%, p= 0.001), largely in the form of 1-vessel disease (10.8% vs 7.3%, p= 0.007). However, there were no significant differences between matched pairs in significant CAD in the left main or proximal left anterior descending artery (5.3% vs 3.8%, p= 0.138), multivessel disease (4.4% vs 2.9%, p= 0.101), and high-risk CAD (4.3% vs 2.7%, p= 0.058). During the follow-up period (median 21.8, interquartile range 15.2 to 33.4 months), there was no significant difference in the composite of all-cause death, myocardial infarction, acute coronary syndrome, and coronary revascularization between 2 groups (hazard ratio 1.438, 95% confidence interval 0.844 to 2.449, p= 0.181). In asymptomatic subjects, those matched with DM have more subclinical atherosclerosis, mainly confined to non-high-risk CAD, than those matched without DM, and there are no differences in high-risk CAD and clinical outcomes.

Baseline High-density Lipoprotein Cholesterol as a Predictor of Major Adverse Cardiac Events After Elective Percutaneous Coronary Stenting Among Filipinos

BACKGROUND: Low high density lipoprotein (HDL), a common problem among Filipinos, is associated with cardiovascular disease. The association between HDL and outcomes of coronary stenting particularly among Filipinos has not been evaluated. OBJECTIVE: To determine the association of baseline HDL levels to major adverse cardiac events (MACE) at 1 month and 1 year after percutaneous coronary stenting among Filipinos. METHODOLOGY: Adult patients who underwent elective coronary stenting were included in the study. Baseline demographic, clinical and angiographic variables were determined. Baseline lipid profile was taken. Association between baseline HDL stratified into low (&lt;40mg/dL in men, &lt;45 mg/dL in women) and high levels (≥ 40 mg/dL in men and ≥ 45 mg/dL in women) with MACE at 1month and 1 year was prospectively determined. RESULT: A total of 126 patients, 55 with high HDL and 71 with low HDL, were included in the study. The mean levels of HDL of the two groups were 50 mg/dL and 34 mg/dL, respectively. The high HDL group was generally older, had lower triglyceride levels, had fewer smokers, and had more left anterior descending artery involvement. Both groups had similar event-rates during the first 30 days post-stenting. However, the composite of MACE during the 31st day to 1 year was significantly higher in the low HDL group (5 (9.1%) vs 13 (18.3%); p= 0.007) even after adjusting for baseline characteristics. This result was largely driven by acute myocardial infarction and stroke (9.8% vs 1.8 and 8.5 vs 5.5% for low and high HDL group, respectively). CONCLUSION: Low baseline HDL (&lt;40mg/dL in men, &lt;45 mg/dL in women) is an independent predictor of MACE at one year among Filipinos who underwent coronary stenting.

All-cause mortality benefit of coronary revascularization vs. medical therapy in patients without known coronary artery disease undergoing coronary computed tomographic angiography: results from CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter Registry)

To date, the therapeutic benefit of revascularization vs. medical therapy for stable individuals undergoing invasive coronary angiography (ICA) based upon coronary computed tomographic angiography (CCTA) findings has not been examined. We examined 15 223 patients without known coronary artery disease (CAD) undergoing CCTA from eight sites and six countries who were followed for median 2.1 years (interquartile range 1.4-3.3 years) for an endpoint of all-cause mortality. Obstructive CAD by CCTA was defined as a ≥50% luminal diameter stenosis in a major coronary artery. Patients were categorized as having high-risk CAD vs. non-high-risk CAD, with the former including patients with at least obstructive two-vessel CAD with proximal left anterior descending artery involvement, three-vessel CAD, and left main CAD. Death occurred in 185 (1.2%) patients. Patients were categorized into two treatment groups: revascularization (n = 1103; 2.2% mortality) and medical therapy (n = 14 120, 1.1% mortality). To account for non-randomized referral to revascularization, we created a propensity score developed by logistic regression to identify variables that influenced the decision to refer to revascularization. Within this model (C index 0.92, χ2 = 1248, P < 0.0001), obstructive CAD was the most influential factor for referral, followed by an interaction of obstructive CAD with pre-test likelihood of CAD (P = 0.0344). Within CCTA CAD groups, rates of revascularization increased from 3.8% for non-high-risk CAD to 51.2% high-risk CAD. In multivariable models, when compared with medical therapy, revascularization was associated with a survival advantage for patients with high-risk CAD [hazards ratio (HR) 0.38, 95% confidence interval 0.18-0.83], with no difference in survival for patients with non-high-risk CAD (HR 3.24, 95% CI 0.76-13.89) (P-value for interaction = 0.03). In an intermediate-term follow-up, coronary revascularization is associated with a survival benefit in patients with high-risk CAD by CCTA, with no apparent benefit of revascularization in patients with lesser forms of CAD.

Surgical Versus Percutaneous Revascularization for Multivessel Disease in Patients With Acute Coronary Syndromes: Analysis From the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) Trial

The aim of this study was to evaluate outcomes of patients with moderate- and high-risk acute coronary syndromes (ACS) and multivessel coronary artery disease managed with percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). There is uncertainty about the preferred revascularization strategy for high-risk patients with multivessel disease. Among 13,819 moderate- and high-risk ACS patients enrolled in the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial, 5,627 had multivessel disease (including left anterior descending artery involvement) and were managed by PCI (n = 4,412) or CABG (n = 1,215). Propensity score matching was applied to adjust for differences in baseline clinical and angiographic characteristics, yielding a total of 1,056 patients (528 managed by PCI, and 528 managed by CABG). Propensity-matched patients undergoing CABG had higher 1-month rates of stroke (1.1% vs. 0.0%, p = 0.03) and myocardial infarction (13.3% vs. 8.8%, p = 0.03), received more blood transfusions (40.3% vs. 6.3%, p < 0.0001) and more frequently developed acute renal injury (31.7% vs. 14.2%, p < 0.0001), whereas PCI was associated with higher rates of unplanned revascularization at both 1 month and at 1 year (0.8% vs. 5.2%, p < 0.0001; and 3.8% vs. 16.5%, p < 0.0001, respectively). There were no significant differences between the CABG and PCI groups in 1-month or 1-year mortality (2.5% vs. 2.1%, p = 0.69; and 4.4% vs. 5.7%, p = 0.58, respectively). In this propensity-matched comparison from the ACUITY trial, moderate- and high-risk patients with ACS and multivessel disease treated with PCI rather than CABG had lower rates of peri-procedural stroke, myocardial infarction, major bleeding, and renal injury, with comparable 1-month and 1-year rates of mortality, but more frequently developed recurrent ischemia requiring repeat revascularization procedures during follow-up. (Comparison of Angiomax Versus Heparin in Acute Coronary Syndromes [ACS]; NCT00093158).

Outcomes of revascularization strategies for two-vessel coronary artery disease involving the proximal left anterior descending artery in an era of improved pharmacotherapy and stenting

The best therapeutic strategy for patients with double-vessel coronary artery disease and proximal left anterior descending artery involvement (2VD + pLAD) is not clear. To compare the survival experience of a cohort of cardiac catheterization patients with 2VD + pLAD based on chosen therapeutic strategy (medical management versus percutaneous coronary intervention [PCI] versus coronary artery bypass graft surgery [CABG]). The authors identified and studied a total of 603 patients with 2VD + pLAD from all patients who underwent diagnostic coronary angiography in Alberta between January 1997 and May 1999. The primary end point was five-year survival from index catheterization for each of the treatment groups and from time of revascularization when the two revascularization strategies were compared. Risk-adjusted hazard ratios (HR) comparing cumulative five-year survival rates of patients treated medically, or with PCI or CABG indicated a survival benefit for patients treated with CABG (HR 0.24, 95% CI 0.11 to 0.54; P<0.001) and PCI (HR 0.43, 95% CI 0.24 to 0.77; P=0.003) compared with medical management. Meanwhile, a risk-adjusted comparison of revascularization strategies suggested a possible trend toward higher mortality for PCI-treated patients versus CABG-treated patients (HR 1.56, 95% CI 0.65 to 3.72; P=0.125). The results of this registry-based observational study suggest a survival benefit from revascularization compared with medical management in patients with 2VD + pLAD. Furthermore, the authors found a trend toward better survival in CABG-treated patients compared with PCI-treated patients.

Brain Natriuretic Peptide and Other Risk Markers for Outcome Assessment in Patients With Non–ST-Elevation Coronary Syndromes and Preserved Systolic Function

Several emerging cardiac markers constitute strong predictors among patients with coronary artery disease. In particular, brain natriuretic peptide (BNP), troponin T (TnT), and C-reactive protein (CRP) are related to increased risk of recurrent ischemic events and death. However, little is known about the utility of these biomarkers in combination. This study examined risk assessment in patients with coronary artery disease and preserved systolic function. We studied 208 consecutive patients (138 men, 70 women) with stable angina, unstable angina, and non-Q-wave myocardial infarction whose plasma BNP, TnT, and CRP levels were measured at hospital admission. All recruited patients underwent echocardiographic examination, and selective coronary angiography was performed. After adjusting for clinical presentation, age, gender, and common risk factors, BNP was demonstrated as a strong predictor of heart failure (6 months, odds ratio [OR] 2.03, 95% confidence interval [CI] 1.24 to 2.9, p <0.01; 12 months, OR 2.65, 95% CI 1.69 to 3.5, p <0.001) and mortality at 3, 6, and 12 months (p <0.001). BNP was also significantly related to extent of coronary artery disease and left anterior descending artery involvement (p <0.01). Patients with a BNP level >80 pg/ml in all 3 groups had a significantly poorer prognosis with increased incidence of heart failure and death. CRP was related to recurrent ischemic events (infarct or recurrent angina, OR 1.4, 95% CI 1.14 to 2.08, p <0.01) and was associated with major cardiac revascularization at 12 months (OR 1.51, 95% CI 1.29 to 1.73, p <0.001). TnT demonstrated a mild correlation with recurrent infarct or angina at 12 months (OR 1.1, 95% CI 0.96 to 1.22, p <0.05) but appeared related to multivessel coronary artery disease (OR 1.47, 95% CI 1.05 to 1.99, p <0.01). In conclusion, BNP appears to be associated with a long-term increased risk of mortality and heart failure in patients with apparently mild risk. BNP is also associated with a larger extent and greater severity of myocardial ischemia. Early BNP measurement could provide incremental information to TnT and CRP, and it may be the strongest independent predictor of cardiac outcome in subjects without left ventricular dysfunction or enlargement.

Predictors of Mortality Following Rescue Percutaneous Intervention

Rescue percutaneous transluminal coronary angioplasty (PTCA) is a mechanical reperfusion strategy aimed at achieving patency of the infarct-related artery after failed thrombolysis. However, in randomized studies the indication for rescue PTCA was per protocol rather than based on clinical criteria. The aim of this study was to determine predictors of mortality at 30 days following rescue percutaneous intervention. Seventy-one consecutive patients who underwent rescue PTCA were included. Mean age was 61 (11) years, 80% were men and 9.8% had diabetes. The infarct-related artery was the left anterior descending artery in the 46.5%, and the mean percentage of stenoses was 91.0 (11.6)%. A stent was implanted in 97.2% and TIMI II-III flow was obtained in the 97.2% of the patients. Overall mortality was 9.8% at 30 days follow-up and 11.3% at 1 year follow-up. In the multivariate analysis, the independent predictors of mortality at 30 days were age (OR=1.2, 95% CI: 1.03-1.5, P=.001), Killip class III-IV (OR=20.1; 95% CI: 1.7-500; P=.003), PTCA failure (OR=indeterminate; P=.04) and left anterior descending artery involvement (OR=12.6; 95% CI: 0.7-214.9; P=.04). Rescue PTCA is effective in restoring blood flow in the infarct-related artery in the majority of patients in whom thrombolysis failed. The independent predictors of mortality were similar to those previously reported in acute myocardial infarction.

Is anteroseptal myocardial infarction an appropriate term?

Purpose Anteroseptal myocardial infarction is defined by the presence of electrocardiographic Q-waves limited to precordial leads V 1 to V 2, V 3, or V 4. We sought to determine whether this term is appropriate by correlating electrocardiographic, echocardiographic, and angiographic findings. Subjects and methods We studied 50 consecutive patients admitted for a first acute myocardial infarction with Q-waves in precordial leads V 1 to V 2–V 4, and who had undergone echocardiography and coronary angiography during hospitalization. Echocardiograms in the apical long-axis, two-chamber, and four-chamber views were studied using a wall motion scoring index. Results Q-waves were present in precordial leads V 1–V 2 in 4 patients, V 1–V 3 in 28 patients, and V 1–V 4 in the remaining 18 patients. The presumptive culprit lesion was in the proximal segment of the left anterior descending artery in 15 patients, in the middle segment in 33 patients, and indeterminate in 2 patients. This lesion was before the first septal branch in 19 patients and after the first septal branch in 29. Mean (± SD) left ventricular ejection fraction was 51% ± 10%. Echocardiographic analysis showed that the septal wall was never the only wall that was affected. However, the apex was affected in all patients and was the only wall that was affected in 26 (52%) patients (apical wall index, 2.1 ± 0.5). In the remaining 24 patients, the septum was also affected (septal index, 1.5 ± 0.3), but less severely than was the apex (apical index, 2.3 ± 0.4; P <0.0001 vs. septum). In these 24 patients, the anterior and lateral walls were also affected (anterior index, 1.4 ± 0.4; lateral index, 1.1 ± 0.2), but again, less severely than was the apex ( P <0.0001 for both vs. apex). Conclusion Neither angiographic nor echocardiographic data support the notion of an isolated anteroseptal myocardial infarction. Left anterior descending artery involvement appears more often to be midsegment and postseptal. The apex is always and principally affected. These findings suggest that anteroseptal myocardial infarction is a misnomer and that the V 1 to V 2–V 4 Q-wave pattern should be considered to indicate a predominantly apical, and generally limited, myocardial infarction.

Reevaluation of an Old Electrocardiographic Criterion for Coronary Disease: TV1 &gt; TV6

Background:Two different studies were conducted to evaluate the value of T wave in V1 taller than T wave in V6 (TV1 &gt; TV6) pattern as an indicator of coronary artery disease. Method: In the first study 5,300 resting ECGs were examined and the criterion was found in 283 patients. All of these patients were examined with echocardiography. In the second study, ECG tracings and coronary angiograms of another 500 patients were evaluated. Results:In the first study, in 59 of 283 patients left ventricular hypertrophy was detected and these patients were excluded from the study. There were ST segment‐T wave changes and/or Q wave on ECG suggesting coronary ischemia or myocardial infarction in 160 of the 224 patients. TV1, &gt; TV6 criterion was the sole finding in 64 of the 224 patients. All of the 224 patients underwent coronary angiography and coronary artery disease was detected in 185 patients; 134 of the 160 patients (83.3%) and 51 of 64 patients (80%) had one‐vessel or multivessel disease. There was no significant difference among the groups regarding coronary artery disease. Left anterior descending artery was involved in all of the 185 patients. In the second study, 408 patients were found to have coronary disease involvement and 92 patients showed normal or insignificant coronary disease. Sixty‐six of the 408 patients with coronary disease and four of 92 patients were found to have the TV1 &gt; TV6 pattern. Sensitivity of the criterion was 16.1%, specificity was 95.6%, and accuracy was 94.2%. Conclusions: According to these results, it is concluded that TV1 &gt; TV6 with or without other ECG findings is a good criterion suggesting coronary artery disease, especially left anterior descending artery involvement in patients without left ventricular hypertrophy. A.N.E. 1999;4(4):397–400

Chronotropic response to exercise predicts angiographic severity in patients with suspected or stable coronary artery disease

Inappropriate chronotropic response to exercise has been observed to correlate with poor prognosis in patients with coronary disease, but the mechanism for this association is not well defined. We attempted to examine the association between chronotropic response to exercise and angiographic severity of coronary disease in patients with suspected or stable coronary artery disease. The chronotropic response, expressed as peak heart rate, chronotropic index (ratio of heart rate reserve and metabolic reserve utilized), or percent maximal heart rate achieved, was correlated with angiographic findings obtained within 180 days of the test. Significant coronary disease was defined as ≥1 stenosis of ≥50% in a major epicardial artery or its main branches; severe coronary disease was defined as ≥50% stenosis in all 3 epicardial arteries, or in the left main coronary trunk, or 2-vessel disease with ≥70% proximal left anterior descending artery stenosis. We observed that peak heart rate and percent maximal heart rate achieved were independent negative predictors of both significant and severe coronary disease by logistic regression. The chronotropic index predicted severe coronary disease only. All 3 parameters of chronotropic response exhibited a significant gradient of abnormality across the spectrum of coronary disease (p < 0.01 for all), expressed by the number of vessels involved and correlated with left anterior descending artery involvement (p < 0.05 for all). We conclude that chronotropic response to exercise predicts the presence and angiographic severity of coronary disease. This association is likely related to the proportion of left ventricular myocardium rendered ischemic during stress.