Nonfatal Infarction Research Articles

Coronary endarterectomy for severe diffuse coronary artery disease.

To determine the outcome of Coronary Endarterectomy (CE) in patients undergoing Coronary Artery Bypass Graft (CABG) surgery for diffuse Coronary Artery Disease (CAD), in terms of postoperative mortality and morbidity, relief from angina and survival at one year. A case series. Department of Cardiac Surgery, Armed Forces Institute of Cardiology and National Institute of Heart Diseases, Rawalpindi, from January 2003 to November 2005. Included in the study were all patients with such diffuse CAD that conventional bypass grafting was not possible. Those with the diseased coronary artery supplying an akinetic myocardium and a fixed perfusion defect on perfusion scan, or with poor left ventricular function (ejection fraction<30%) in association with severe chronic hepatic disease and deranged liver function tests, permanent severe immune deficiency state, or poor results at lung function tests were excluded. Cardiopulmonary Bypass (CPB) was used in all patients. All patients were followed up for a mean time of one year, for assessment of postoperative mortality and morbidity, relief from angina and survival. Fifty five patients (3.2%) underwent CE of at least one major coronary artery for severe diffuse atheromatous disease. The mean age was 53.9+/-9.5 years. Twenty six (47.3%) had previous Myocardial Infarction (MI), 16 (29.1%) had unstable angina, 12 (21.8%) had poor Left Ventricular (LV) function, 5 (9.1%) underwent emergency CABG surgery for impending infarction, 39 (70.9%) had angina Canadian Cardiovascular Society (CCS) class II/III, 11 (20%) had critical left main stem disease and 12 (21.8%) required Intra-Aortic Balloon Pump (IABP) for hemodynamic support. There were 2 (3.6%) early deaths and 2 (3.6%) cases of non-fatal infarctions. Three (5.4%) patients had low Cardiac Output (CO) after operation. At one year follow-up, there were no late deaths and 43 patients (91.5% of those reporting for follow-up) did not have angina. CE acted as an adjunct to CABG surgery with acceptable operative risks and satisfactory results at one year in terms of mortality and angina relief.

A Welcomed New Myocardial Perfusion Imaging Agent for Positron Emission Tomography

It has been quite some time since a new myocardial perfusion agent for radionuclide imaging was introduced into clinical practice. For more than 30 years, rest and stress myocardial perfusion imaging (MPI), employing first planar and then single photon emission computed tomography (SPECT) technology, have been performed with thallium-201, Tc-99m sestamibi and Tc-99m tetrofosmin. MPI with these agents has provided useful diagnostic and prognostic information superior to that attained with exercise electrocardiography alone in patients with suspected or known coronary artery disease (CAD).1 With the exception of diabetic patients1 and patients with advanced chronic kidney disease,2 subjects with normal exercise perfusion scans have a <1.0% death or nonfatal infarction rate per year, whereas patients with abnormal scans have an ≈6% yearly hard event rate.1 Patients with normal pharmacological stress scans have a slightly higher annual event rate3 because patients who are unable to exercise are at higher clinical risk for CAD. For positron emission tomography (PET) imaging, the dominant perfusion tracers used in the clinical setting are N-13 ammonia and Rb-82, the latter eluted from a generator.4 The short-lived cyclotron-produced radionuclide Oxygen-15 water is another PET perfusion agent that has predominantly been used in the research setting. Sensitivity and specificity of PET myocardial perfusion imaging appear to be higher compared with that reported for SPECT,5 and the prognostic value of PET MPI is similar to that observed with SPECT.6,7 One potential advantage of PET over SPECT MPI is the ability to quantitate myocardial blood flow in mL · min−1 · g−1 and measure coronary flow reserve using dynamic imaging and tracer kinetic models.8,9 Article see p 2333 All the existing myocardial perfusion agents for SPECT and PET have some limitations that affect accuracy in detecting CAD or detecting its …

Traffic-Generated Air Pollution and Myocardial Infarction

Although long-term air pollution exposure has been linked to cardiovascular mortality, data on incidence and nonfatal coronary disease are limited and inconclusive. The aim of this study was to investigate the association between long-term residential exposure to air pollution from traffic and the risk of nonfatal and fatal myocardial infarction. The records of all individuals aged 15 to 79 with a first event of myocardial infarction in Stockholm County during 1985 to 1996 were retrieved from a registry. Population controls were randomly selected from the study base stratified by age, sex, and calendar year. Individual socioeconomic data and home addresses were obtained from population censuses 1970 to 1995. Annual air pollution exposure was assessed by dispersion modeling at the home addresses of 24,347 cases and 276,926 controls. Five-year average traffic-generated air pollution exposure corresponding to a difference in nitrogen dioxide from the fifth to the 95th percentile (31 microg/m) was associated with an odds ratio for fatal myocardial infarction adjusted for age, sex, calendar year, and socioeconomic status of 1.23 (95% confidence interval [CI] = 1.15-1.32). The corresponding odds ratio was 2.54 (1.96-3.29) among those with least expected misclassification of true individual exposure (those who did not move between censuses). Different time-windows and analyses of other pollutants including carbon monoxide and particles less than 10 mum in diameter (PM10) produced weaker associations. There was no increased risk for nonfatal myocardial infarction (ORs 0.94-0.98). Long-term exposure to traffic-generated air pollution is associated with fatal myocardial infarction but not with nonfatal infarction.

Prognostic Value of Multislice Computed Tomography and Gated Single-Photon Emission Computed Tomography in Patients With Suspected Coronary Artery Disease

This study was designed to determine whether multislice computed tomography (MSCT) coronary angiography has incremental prognostic value over single-photon emission computed tomography myocardial perfusion imaging (MPI) in patients with suspected coronary artery disease (CAD). Although MSCT is used for the detection of CAD in addition to MPI, its incremental prognostic value is unclear. In 541 patients (59% male, age 59 +/- 11 years) referred for further cardiac evaluation, both MSCT and MPI were performed. The following events were recorded: all-cause death, nonfatal infarction, and unstable angina requiring revascularization. In the 517 (96%) patients with an interpretable MSCT, significant CAD (MSCT > or =50% stenosis) was detected in 158 (31%) patients, and abnormal perfusion (summed stress score [SSS]: > or =4) was observed in 168 (33%) patients. During follow-up (median 672 days; 25th, 75th percentile: 420, 896), an event occurred in 23 (5.2%) patients. After correction for baseline characteristics in a multivariate model, MSCT emerged as an independent predictor of events with an incremental prognostic value to MPI. The annualized hard event rate (all-cause mortality and nonfatal infarction) in patients with none or mild CAD (MSCT <50% stenosis) was 1.8% versus 4.8% in patients with significant CAD (MSCT > or =50% stenosis). A normal MPI (SSS <4) and abnormal MPI (SSS > or =4) were associated with an annualized hard event rate of 1.1% and 3.8%, respectively. Both MSCT and MPI were synergistic, and combined use resulted in significantly improved prediction (log-rank test p value <0.005). MSCT is an independent predictor of events and provides incremental prognostic value to MPI. Combined anatomical and functional assessment may allow improved risk stratification.

Effect of gender on cardiovascular risk stratification with ECG gated SPECT left ventricular volume indices and ejection fraction

BackgroundOptimal gender-specific risk prediction using ECG-gated SPECT left ventricular (LV) volumes and ejection fraction (EF) remains undefined despite reported gender differences in baseline LV function. MethodsECG-gated SPECT studies of 891 consecutively referred patients (43% women) were evaluated for LV end-systolic and diastolic volume indices (ESVI, EDVI) and EF. Effects of gender on prediction of hard cardiac events (HCE) and the combined endpoint of all-cause mortality or non-fatal infarction (ACMMI) were evaluated. ResultsWomen had smaller ESVI (37 vs 55 mL/m2), EDVI (78 vs 99 mL/m2), and higher LVEF (56 vs 47%, P < 0.0001 for each) with equivalent rates of HCE (6.1%) and ACMMI (11.8%). HCE risk started at smaller ESVI and EDVI in women compared to men (P ≤ 0.05 for each). In women, ESVI 37 mL/m2 provided maximum HCE prediction compared to 53 mL/m2 in men. A 1 mL/m2 increase in ESVI was associated with a 2.9% increased HCE risk in women (P < 0.0001) and a 0.9% increased ACMMI risk in men (P = 0.03). Women with ESVI > 35 mL/m2 had HCE HR 12.0 compared to women with ESVI < 23 mL/m2. ConclusionLV volume indices and LVEF predict subsequent morbid clinical events in men and women. In women, risk of subsequent events started at smaller LV volume indices compared to men despite similar risk profiles.

Selective reduction of Von Economo neuron number in agenesis of the corpus callosum

Von Economo neurons (VENs) are large spindle-shaped neurons localized to anterior cingulate cortex (ACC) and fronto-insular cortex (FI). VENs appear late in development in humans, are a recent phylogenetic specialization, and are selectively destroyed in frontotemporal dementia, a disease which profoundly disrupts social functioning and self-awareness. Agenesis of the corpus callosum (AgCC) is a congenital disorder that can have significant effects on social and emotional behaviors, including alexithymia, difficulty intuiting the emotional states of others, and deficits in self- and social-awareness that can impair humor, comprehension of non-literal or affective language, and social judgment. To test the hypothesis that VEN number is selectively reduced in AgCC, we used stereology to obtain unbiased estimates of total neuron number and VEN number in postmortem brain specimens of four normal adult controls, two adults with isolated callosal dysgenesis, and one adult whose corpus callosum and ACC were severely atrophied due to a non-fatal cerebral arterial infarction. The partial agenesis case had approximately half as many VENs as did the four normal controls, both in ACC and FI. In the complete agenesis case the VENs were almost entirely absent. The percentage of neurons in FI that are VENs was reduced in callosal agenesis, but was actually slightly above normal in the stroke patient. These results indicate that the VEN population is selectively reduced in AgCC, but that the VENs do not depend on having an intact corpus callosum. We conclude that in agenesis of the corpus callosum the reduction in the number of VENs is not the direct result of the failure of this structure to develop, but may instead be another consequence of the genetic disruption that caused the agenesis. The reduction of the VEN population could help to explain some of the social and emotional deficits that are seen in this disorder.

Exercise and cardiovascular risk reduction: time to update the rationale for exercise?

although it is generally accepted that the promotion of exercise accords with clinical best practice, the anecdotal experience of many primary care physicians, cardiologists, and exercise physiologists is that, even when exercise prescriptions are adhered to, risk factors often fail to demonstrate

Primary Percutaneous Coronary Intervention Compared With Fibrinolysis for Myocardial Infarction in Diabetes Mellitus

There is growing evidence for a clinical benefit of primary percutaneous coronary intervention (PCI) compared with fibrinolysis; however, whether the treatment effect is consistent among patients with diabetes mellitus is unclear. We compared PCI with fibrinolysis for treatment of ST-segment elevation myocardial infarction in patients with diabetes mellitus. A pooled analysis of individual patient data from 19 trials comparing primary PCI with fibrinolysis for treatment of ST-segment elevation myocardial infarction was performed. Trials that enrolled at least 50 patients with ST-segment elevation myocardial infarction and randomized patients to receive either primary PCI or fibrinolysis were considered for inclusion in our study. Clinical end points were total deaths, recurrent infarction, death or nonfatal recurrent infarction, and stroke, measured 30 days after randomization. Of 6315 patients, 877 (14%) had diabetes. Thirty-day mortality (9.4% vs 5.9%; P < .001) was higher in patients with diabetes. Mortality was lower after primary PCI compared with fibrinolysis in both patients with diabetes (unadjusted odds ratio, 0.49; 95% confidence interval, 0.31-0.79; P = .004) and without diabetes (unadjusted odds ratio, 0.69; 95% confidence interval, 0.54-0.86, P = .001), with no evidence of heterogeneity of treatment effect (P = .24 for interaction). Recurrent infarction and stroke were also reduced after primary PCI in both patient groups. After multivariable analysis, primary PCI was associated with decreased 30-day mortality in patients with and without diabetes, with a point estimate of greater benefit in diabetic patients. Diabetic patients with ST-segment elevation myocardial infarction treated with reperfusion therapy have increased mortality compared with patients without diabetes. The beneficial effects of primary PCI compared with fibrinolysis in diabetic patients are consistent with effects in nondiabetic patients.

Effects of pyridoxal-5′-phosphate (MC-1) in patients undergoing high-risk coronary artery bypass surgery: Results of the MEND-CABG randomized study

Coronary artery bypass graft surgery remains associated with significant postoperative cardiovascular morbidity and mortality in high-risk patients. MC-1 (pyridoxal-5'-phosphate monohydrate) inhibits purinergic receptors and intracellular influx of Ca2+, thereby reducing cellular injury during experimental ischemia and reperfusion. The MEND-CABG trial tested the hypothesis that MC-1 reduces cardiovascular morbidity and mortality after coronary artery bypass graft. In a phase 2, double-blinded, placebo-controlled study, 901 patients scheduled for coronary artery bypass graft surgery with cardiopulmonary bypass and at high risk for subsequent cardiac or neurologic complications were randomly assigned to receive oral MC-1 (250 mg or 750 mg/d once daily) or placebo beginning 3 to 10 hours prior to surgery and continued to postoperative day 30. At 30 days, MC-1 250 mg (compared with placebo) reduced the composite of death, nonfatal cerebral infarction, and nonfatal myocardial infarction by 14.0% (P = .3124) with peak creatinine kinase-myocardial band > or =50 ng/mL (prespecified primary end point); 32.3% (P = .0349) with peak creatinine kinase-myocardial band > or =70 ng/mL; and 37.2% (P = .0283) with peak creatinine kinase-myocardial band > or =100 ng/mL. Myocardial infarctions with peak creatinine kinase-myocardial band> or =100 ng/mL were reduced by 47.2% in the MC-1 250-mg group versus placebo (P = .0083). Greater efficacy was demonstrated with 250 mg than with the 750-mg dose of MC-1. In high-risk patients undergoing coronary artery bypass graft, treatment with MC-1 did not significantly affect the prespecified primary end point but was associated with a significant reduction in perioperative myocardial infarction with creatinine kinase-myocardial band > or =100 ng/mL. A larger, well-powered trial is needed to evaluate the cardioprotective effects of MC-1.

Gamma-glutamyltransferase as a cardiovascular risk factor

The association of a novel factor with clinical vascular disease must meet the same high standard met by ‘traditional’ risk factors. Serum gamma-glutamyltransferase (GGT) activity is a low-cost, highly sensitive laboratory test: though it is currently considered as an index of hepato-biliary dysfunction and alcohol abuse,1 pathology studies from our group since 1998 have indicated its possible role in the pathogenesis of atherosclerosis.2,3 Furthermore, epidemiology studies on a total of 218 561 subjects from unselected populations4–6 or cohorts with ascertained disease7 have proven the role of GGT not only in predicting mortality from all causes, but also the clinical evolution of cardiac and cerebrovascular diseases towards life-threatening events, such as myocardial infarction, stroke, and cardiac death, independently from the occurrence of hepatic disease, alcohol consumption, and established traditional risk factors in multivariable analyses. As for what specifically concerns the occurrence of coronary events, first observations by Wannamethee et al .4 in British middle-aged men were confirmed in 2001 in this Journal by us for patients with angiographically established coronary artery disease (CAD).7 Serum GGT was associated with an increasing risk of cardiac death and non-fatal infarction for activity values within reference limits with a graded response relationship … *Corresponding author. Tel: +39 050 3152189; fax: +39 050 3152109. E-mail address : emdin{at}ifc.cnr.it

Two-Year Clinical Follow-Up in 200 Patients Receiving Sirolimus-Eluting Stents in Lesions at a High Risk of Restenosis

Sirolimus-eluting stents (SESs) have been shown to reduce the rate of restenosis significantly in all types of coronary lesion. However, reports of late cases of thrombosis and restenosis have raised questions about long-term outcome in patients treated with these stents. Our aim was to evaluate long-term outcome in patients undergoing SES placement in lesions at a high risk of restenosis. Since SESs became available, we have used them to treat lesions at risk of restenosis. We studied clinical outcomes in consecutive patients treated with SESs who were followed up for more than 2 years. The study included 200 patients (age 60[11] years, 22% diabetics) who were treated between June 2002 and April 2003 for 309 lesions: 16% were total occlusions, 16.8% in-stent restenoses, 28% diffuse lesions, and 30% small-vessel lesions. The total stent length per patient was 29 (16) mm and the mean diameter was 2.78 (0.27) mm. In a mean clinical follow-up period of 29 (3.2) months (range 24-34 months), there were four deaths, two (1%) of which were cardiac, four (2%) non-fatal infarctions, four (2%) in-stent thromboses (all occurred late, at 3, 7, 26 and 31 months), four (2%) cases requiring target lesion revascularization (at 3, 5, 14 and 15 months), and six (3%) requiring revascularization of a new lesion. Long-term follow-up of patients undergoing SES placement in lesions at a high risk of restenosis revealed a very low restenosis rate. However, the incidence of late thrombosis appeared to be elevated and warrants further evaluation in larger studies.

Stress Recovery Index for Risk Stratification of Asymptomatic Patients Following Coronary Bypass Surgery

To prospectively assess the prognostic value of the stress recovery index (SRI) following coronary bypass surgery. Two hundred seventy-eight patients who had undergone coronary bypass surgery and participated in a secondary prevention program were exercise tested and prospectively followed up for a median of 36 months. Cardiac death, nonfatal infarction, and need for further revascularization were target end points. SRI, defined as the difference in absolute values between the area of heart rate-adjusted ST-segment depression during exercise and recovery, was derived in all. Clinical data, resting ejection fraction, and exercise testing data of patients were entered into a sequential Cox model; SRI was entered last. Model validation was performed by bootstrap adjusted by the degree of optimism in estimates. Survival curves were set up using Kaplan-Meier method and compared by the log-rank test. SRI was the only significant and independent prognostic indicator (hazard ratio, 0.68; 95% confidence interval, 0.53 to 0.89) and increased the prognostic power of the model on top of clinical and exercise testing variables, as demonstrated by the significant (p = 0.01) increase of the area under the receiver operating characteristic curve of the risk function. Survival analysis showed ascending SRI quartiles to identify a significant (p = 0.001) increase in event-free survival. SRI is of value in predicting outcome after coronary bypass surgery and provides additional prognostic information over clinical and exercise testing data.

Revascularização miocárdica em multiarteriais

led us to believe that such objectives were better achieved with surgery, especially when indicated to patients with a lesion in the left main coronary artery, three-vessel disease or ventricular dysfunction. Great advances in clinical (statins, potent antiplatelet agents) and surgical (greater use of arterial grafts, better myocardial protection, procedures without extracorporeal circulation) therapy have occurred, resulting in an undeniable improvement in the prognosis of those patients. In recent years, percutaneous transluminal coronary angioplasty has become the most common form of myocardial revascularization used for the treatment of coronary artery disease. The improvement in the techniques and instruments allowed such less invasive form of revascularization to be offered to patients with multivessel disease with safety and efficacy similar to those of surgical revascularization reported in several studies. Silva et al 4 have reported the results of a randomized study carried out in a single center in our country, assessing the long-term advantages of both strategies of revascularization regarding the clinical evolution of patients with multivessel coronary disease. The first case series, published in the 1990s, compared coronary artery bypass surgery with balloon-catheter coronary angioplasty 5-12 . Those studies showed in a uniform way that the mortality and infarction rates did not statistically differ between the 2 forms of treatment (fig.1); patients undergoing the percutaneous coronary intervention, however, more often required a new revascularization in the long run, due to the occurrence of restenosis. Although those studies had limitations regarding the selection of patients (inclusion of patients with one-vessel disease, clinical and angiographic differences between the populations), they confirmed the safety of coronary angioplasty and its indication to patients with one- or two-vessel disease and less complex lesions. Initially used for managing complications of angioplasty (acute occlusions, vessel dissections), the implantation of coronary stents has become frequent and has been recommended due to their mechanical properties of preventing elastic recoil and negative remodeling of the vascular wall, which are determinant factors in the process of coronary restenosis after balloon angioplasty. By reducing the occurrence of restenosis and acute complications, stent implantation produced results even closer to those obtained with surgery. A meta-analysis 13 comparing coronary artery bypass graft with percutaneous transluminal coronary angioplasty involving 2,643 patients and comprising the ARTS 14 , ERACI II 15 , and SOS 16 studies showed no difference in the mortality and non-fatal infarction rates between the 2 groups at the end of one year. The need for a new revascularization in the group undergoing percutaneous transluminal coronary angioplasty with stents was 15%, half of the incidence reported for balloon angioplasty in patients with multivessel disease. The indices of new revascularization, however, continued significantly greater than those of coronary artery bypass graft, mainly due to intra-stent restenosis. The article by Silva et al 4 corroborated those results: the combined-event-free survival in 5 years reported in the study in question (82% for the surgical group, and 55% for the PTCA group, P < 0.001) was similar to that reported in the ARTS I study for the same follow-up period (tab. I) 17 . We face a new era in the percutaneous treatment of coronary artery disease. The use of stents coated with antiproliferative drugs, carried and released in a controlled way in the vascular wall from biocompatible polymers proved effective in reducing neointimal hyperplasia, which is the major determinant of the occurrence of intra-stent restenosis. Since the first clinical use of sirolimus-eluting stents here in Brazil 18

Clinical significance of a single measurement of troponin-I and C-reactive protein at admission in 1773 consecutive patients with acute coronary syndromes

Background The clinical significance of biochemical markers of myocardial damage or inflammation has not been prospectively established in populations representing the whole spectrum of acute coronary syndromes. We investigated whether the elevation of these biomarkers at admission has a prognostic value that is independent and incremental to baseline clinical variables and quantitative electrocardiographic ischemia. Methods We measured blood levels of cardiac troponin I (cTnI) and C-reactive protein (CRP) in 1773 consecutive patients admitted to 31 Italian coronary care units within 12 hours from an episode of acute coronary syndrome. Primary and secondary outcomes were (1) 30-day incidence of death or nonfatal (re)infarction and (2) death alone. Results In a multivariate model, cTnI was independently associated with the risk of death or (re)infarction (OR, 1.8; 95% CI, 1.2 to 2.6; P = .002) and death (OR, 2.2; 95% CI, 1.4 to 3.4; P < .001), whereas CRP was of borderline significance for the primary outcome but was associated with death (OR, 1.4; 95% CI, 1.0 to 2.1; P = .06, and OR, 1.7; 95% CI, 1.1 to 2.6; P = .01, respectively). However, the inclusion of the biomarkers did not increase the prognostic capacity of the clinical risk model (C-index of both models with and without biomarkers was 0.73 for the primary outcome measures and 0.80 for the secondary outcome measures). CRP further stratified cTnI-negative patients. The prognostic significance of the biomarkers was similar in patients with and in those without persistent ST-segment elevation. Conclusions In acute coronary syndromes, the elevation of cTnI and CRP at admission has an independent prognostic value that is not incremental to baseline clinical variables and quantitative electrocardiographic ischemia.

Major Ongoing Stroke Trials

Major Ongoing Stroke Trials

Prognostic value of normal stress echocardiogram in patients with suspected coronary artery disease—A British general hospital experience

Aims: To determine the prognostic value of a normal stress echocardiogram in the setting of a large district general nonuniversity hospital in the United Kingdom. Methods: Between January 1996 and December 1999, all patients who had undergone stress echocardiography were identified and those with normal results were studied. Normal stress echocardiograms were found in 252 patients, 19 of whom were lost to follow-up. Deaths and nonfatal myocardial infarctions were considered hard cardiac events and data was collected in the remaining 233 patients. Results: Among the 233 patients, the pre-test probability of coronary artery disease was low in 68 (27.9%) and intermediate or high in 168 (72.1%). During a follow-up period of mean (SD) 2.7 (1.1) years, death occurred in 4 patients of which 3 were consequent to acute myocardial infarctions and 1 was unexplained. One patient sustained a nonfatal infarction. Thus, the annualized mortality and hard event rates were 0.6% per patient/year and 0.8% per patient/year, respectively. Conclusions: A normal stress echocardiogram portends an excellent prognosis, even in a cohort with a high proportion of patients having intermediate or high pre-test probability of coronary artery disease.

Major Ongoing Stroke Trials

Major Ongoing Stroke Trials

Benefits of direct angioplasty for women and men with acute myocardial infarction: results of the global use of strategies to open occluded arteries in acute coronary syndromes (GUSTO II-B) Angioplasty Substudy

BackgroundDirect angioplasty (PTCA) and thrombolytic therapy are the chief therapies for treating an ST-segment elevation myocardial infarction (MI). ObjectiveThis study was designed to evaluate sex differences in the relative benefit of direct PTCA versus thrombolytic therapy among patients enrolled in the Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes Angioplasty (GUSTO II-B PTCA) Substudy. MethodsWomen and men presenting with an acute ST-segment elevation MI were randomized to receive either direct PTCA or accelerated tissue plasminogen activator (t-PA). Patients were then randomized to treatment with either heparin or bivalirudin. A gender analysis of outcome was performed. ResultsWomen were older than men (68.6 ± 11.5 vs 59.5 ± 12.0 years, P < .001) and were more likely to have diabetes (22.5% vs 13.5%, P <.0001) and hypertension (53.3% vs 34.8%, P = .001). After adjusting for differences in baseline variables, the odds ratio (OR) for reaching a 30-day clinical end point (death, nonfatal infarction, or nonfatal disabling stroke) was similar for women and men (1.35, 95% CI 0.88–2.08). The OR for reaching a clinical end point at 30 days for the PTCA-treated women compared with the t-PA–treated women was 0.685 (95% CI 0.36–1.32) and similar to the OR in men, 0.565 (95% CI 0.35–0.91), P for interaction = .535. Because women had a higher event rate than men, the absolute number of major events prevented when treating women with direct PTCA was higher than men (56 events/1000 women treated with PTCA vs 42 events per 1000 men treated with PTCA). ConclusionsAlthough the relative benefit of direct PTCA to t-PA for the treatment of an acute MI appears to be similar in women and men, women may derive a larger absolute benefit from direct PTCA.

Depression as a risk factor for mortality after acute myocardial infarction

The ENRICHD clinical trial, which compared an intervention for depression and social isolation to usual care, failed to decrease the rate of mortality and recurrent acute myocardial infarction (AMI) in post-AMI patients. One explanation for this is that depression was not associated with increased mortality in these patients. The purpose of this study was to determine if depression was associated with an increased risk of mortality in a subsample of the ENRICHD trial's depressed patients compared with a group of nondepressed patients recruited for an ancillary study. Three hundred fifty-eight depressed patients with an acute AMI from the ENRICHD clinical trial and 408 nondepressed patients who met the ENRICHD medical inclusion criteria were followed for up to 30 months. There were 47 deaths (6.1%) and 57 nonfatal AMIs (7.4%). After adjusting for other risk factors, depressed patients were at higher risk for all-cause mortality (hazard ratio 2.4, 95% confidence interval 1.2 to 4.7) but not for nonfatal recurrent infarction (hazard ratio 1.2, 95% confidence interval 0.7 to 2.0) compared with nondepressed patients. In conclusion, depression was an independent risk factor for death after AMI, but it did not have a significant effect on mortality until nearly 12 months after the acute event, nor did it predict nonfatal recurrent infarction.

Paradoxical diminution in finger blood flow with exercise predicts adverse outcomes among patients with coronary artery disease

Background: Whereas normal subjects increase finger blood flow during exercise (EX), patients (pts) wth coronary disease (CAD) have been shown to manifest a paradoxical decrease in fmger blood flow with EX. The clinical significance of this obsewatlon is unknown. Methods: 327 CAD pts (mean age 56 * 10,64% male) underwent EX myocardial perfusion SPECT while measuring finger blood flow using peripheral arterial tonometry. Pulse wave amplitude (PWA) ratio was assessed for each EX minute and PWA slope values were determined; slope values ~0 = vasoconstriction. SPECT scans were read blindly using a conventional 20.segment, B-point scale. A follow up of 1.86 + 1 .O years was obtaine for cardiac death, non-fatal myocardlal infarction and revascularization z-60 days after EX testing. Results: There were a total of 34 events (annualized event rate of 5,7%/year). A negative (versus positwe) slope for PWA during EX was associated with a greater frequency of cardiac events (hazards ratio 3.3 (1.2 9.5), pcO.OOl)](figure). Negative PWA slope was the most potent predictor of events by multivariate analysis, and remained so even after significant clinkxl variables including EX and SPECT results, were forced first into the analysis (adjusted risk ratlo = 2.62 [1.07,6.42]). Conclusions: Paradoxical decrease in finger blood flow during EX is associated with an increased frequency of cardiac events. Moreover, this measure adds incremental value to existing clinical and exercise SPECT data for cardiac risk assessment