Pharmacological Revascularization Research Articles

Successful Primary Percutaneous Coronary Intervention in a young patient in peripheral hospital and its out come.

Among all coronary artery disease (CAD) ST-T elevated MI is the most emergency condition to treat within time. but in our country all peripheral hospital has no enough scope for the recommended treatment, that is primary percutaneous coronary intervention (PCI) due to lake of infrastructure and trained cardiologist. Most of our patients does not reach to hospital within the golden time. In most of these patients are treated with pharmacological revascularization by Streptokinase or Tenecteplase. Few patients are saved who are with no other risk factors and can reach in hospital within the time frame of myocardial infarction cascade. For this consequence most of our patients suffers from the sequalae of myocardial infarction, that may be arrhythmias, cardiomyopathy to death. We performed primary PCI in peripheral hospital in a young patient successfully and the outcome is satisfactory. We want to continue this service in our hospital for preventing mortality and morbidity of our cardiac patients. J Inv Clin Cardiol 2023; 5(1): 24-28

Trends in all-cause and cardiovascular mortality in patients with acute myocardial infarction: a nationwide analysis over 10 years

Abstract Background The decline in mortality reported during last decades in patients with acute myocardial infarction (AMI) has been attributed mainly to improved use of reperfusion therapy. We sought to determine the trends in all-cause and cardiovascular mortality for patients with AMI seen at a nationwide level in recent years. Methods Based on the administrative hospital-discharge database, we collected information for all patients treated with AMI between 2010 and 2019 in France. Adverse outcomes including all-cause death and cardiovascular (CV) death were investigated during follow-up. Results We used the French administrative hospital-discharge database, including all patients admitted for AMI between 2010 and 2019 (n=797,212, mean age 69 years, 66% male). Among them, 520,258 patients (65%) had ST-segment elevation myocardial infarction (STEMI) and 276,954 (35%) had non-STEMI (NSTEMI). Reperfusion therapy with primary percutaneous coronary intervention increased from 40% in 2010 to 58% in 2019 for patients with STEMI. Revascularization between day 0 and day 8 increased from 38% in 2010 to 49% in 2019 for patients with NSTEMI. At day 30, all-cause death was recorded in 78,826 patients (9.9%), among whom 56,582 (72%) had CV death. The rate of all-cause death and CV death in patients with STEMI and NSTEMI are in the table. Our data showed higher reduction rates in NSTEMI vs STEMI patients regarding both all cause death (−18,4% vs −14,1%) and CV death (−24.21% vs −9.2%). Conclusion In a large and systematic nationwide analysis of patients with AMI, the rate of all-cause death and CV death at day 30 decreased from 2010 to 2019, both for those with STEMI and those with NSTEMI. Both death rate reductions were more important in NSTEMI patients despite a lower increase of reperfusion therapy compared to STEMI patients. Earlier diagnosis and management as well as improvement of pharmacological intervention and revascularization strategy may explain this difference. Funding Acknowledgement Type of funding sources: None.

In Hospital Frequency of Heart Failure in STEMI after Thrombolysis in Patient with Diabetes

Objective: To determine the frequency of heart failure after thrombolysis in STEMI patients with diabetes mellitus.
 Methodology: Through a prospective study we have enrolled all the diabetic patients who presented with acute ST-Segment Elevation Myocardial Infarction (STEMI) having age more than 35 years and less than 70 years who underwent pharmacological revascularization both males and females were included in this study. Patients with previous history of revascularization, end stage kidney, liver or heart disease, known advanced valvular heart disease, pregnant women, and those who develop serious complication related to streptokinase were excluded from our study. Echocardiography was done immediately after thrombolysis then after 3 days and then before discharge of the patients to determine the frequency of heart failure. Baseline and clinical data were entered and analysed using SPSS and a chi square test and p-value ≤0.05 was considered as significant.
 Results: A total of 175 patients were finally analysed and most of them were males as compared to females, 63.42% (N = 111) vs. 36.57% (N = 64), respectively. Mean age and SD of the patients was 55.90±10.49 years and mean duration of DM was 12.95±8.40 years. The overall frequency of heart failure in patients with post-STEMI was 56% (N = 98) and their mean ejection fraction was 38.46±8.20%. Frequency of heart failure in diabetic post-STEMI thrombolysed patients was significantly observed higher with increased age, increased duration of diabetes mellitus, hypertension, and smoking (p≤0.05).
 Conclusion: High prevalence of heart failure was observed in diabetic patients admitted with acute STEMI and underwent thrombolysis. The burden is even higher in males having age more than 55 years.

Mechanical and Pharmacological Revascularization Strategies for Prevention of Microvascular Dysfunction in ST-Segment Elevation Myocardial Infarction: Analysis from Index of Microcirculatory Resistance Registry Data.

Objectives We aimed to identify mechanical and pharmacological revascularization strategies correlated with the index of microcirculatory resistance (IMR) in ST-elevation myocardial infarction (STEMI) patients. Background Microvascular dysfunction (MVD) after STEMI is correlated with infarct size and poor long-term prognosis, and the IMR is a useful analytical method for the quantitative assessment of MVD. However, therapeutic strategies that can reliably reduce MVD remain uncertain. Methods Patients with STEMI who underwent primary percutaneous coronary intervention (PCI) were enrolled. The IMR was measured with a pressure sensor/thermistor-tipped guidewire immediately after primary PCI. High IMR was defined as values ≥66th percentile of IMR in enrolled patients (IMR > 30.9 IU). Results A total of 160 STEMI patients were analyzed (high IMR = 54 patients). Clinical factors for Killip class (P=0.006), delayed hospitalization from symptom onset (P=0.004), peak troponin-I level (P=0.042), and multivessel disease (P=0.003) were associated with high IMR. Achieving final thrombolysis in myocardial infarction myocardial perfusion grade 3 tended to be associated with low IMR (P=0.119), whereas the presence of distal embolization was significantly associated with high IMR (P=0.034). In terms of therapeutic strategies that involved adjusting clinical and angiographic factors associated with IMR, preloading of third-generation P2Y12 inhibitors correlated with reducing IMR value (β = −10.30, P < 0.001). Mechanical therapeutic strategies including stent diameter/length, preballoon dilatation, direct stenting, and thrombectomy were not associated with low IMR value (all P > 0.05), and postballoon dilatation was associated with high IMR (β = 8.30, P=0.020). Conclusions In our study, mechanical strategies were suboptimal in achieving myocardial salvage. Preloading of third-generation P2Y12 inhibitors revealed decreased IMR value, indicative of MVD prevention.

НЕСТАБИЛЬНАЯ СТЕНОКАРДИЯ ИЛИ НЕСТАБИЛЬНЫЕ КОРОНАРНЫЕ СИНДРОМЫ?

Unstable angina pectoris (UA) is a variant of acute coronary syndrome without ST segment elevation (NSTEACS), which is characterized by the absence of biochemical criteria for myocardial damage, a change in the clinical picture of angina pectoris (an increase in the functional class of angina pectoris, the appearance of resting angina and a high probability of transformation of the process into myocardial infarction (MI). UA and the developed MI without ST segment elevation (NSTEMI) are not accompanied by the appearance of a pathological Q wave and are characterized by a general complex pathogenesis associated with progressive atherosclerosis, a non-occlusive thrombus in the area of erosion or rupture of an atherosclerotic plaque, vasospasm, coronary microcirculatory dysfunction or other causes of imbalance between oxygen intake and oxygen consumption resulting in myocardial ischemia, and are distinguished by increased levels of myocardial necrosis in the blood in case of NSTEMI. It is difficult to differentiate UA and NSTEMI in the first hours of the development of the process when a decision is made on reperfusion technologies and drug therapy without laboratory, and in some cases, additional examination with visualization of the probable new loss of viable myocardium, therefore, the diagnosis and management of these two clinical conditions are usually considered in the same clinical recommendations. A fairly common point of view that the risk of death in UA is significantly lower and the patient is less in need of an intensive strategy than with verified NSTEMI, is controversial given the likely cases of sudden cardiac death of ischemic genesis at the prehospital stage and the difficulties of differential diagnosis of these clinical states. The factors contributing to diagnostic errors include severity of the patient's condition, a variety of clinical atypical manifestations and pathophysiological mechanisms of myocardial ischemia, the presence of comorbid pathology. The article discusses various mechanisms of the development of myocardial ischemia, diagnostic and therapeutic invasive and non-invasive technologies that improve the prognosis of patients with UA. The optimal management tactics of NSTEACS includes early diagnosis and risk stratification, emergency hospitalization, monitoring, the use of non-invasive and invasive strategies, including coronary angiography and revascularization, as well as emergency and long-term treatment aimed at preventing acute cardiovascular events taking into account the age, gender differences and comorbid pathology. A differentiated approach to the administration of emergency therapy is the key to improving the prognosis of this high-risk category of patients. Due to the lack of the possibility of using revascularizing technologies in patients with obstructive coronary disease, non-pharmacological technologies that positively affect microcirculation processes are likely to be used: exposure of the patient’s blood to an alternating magnetic field (extracorporeal autohemomagnetotherapy) or to ultraviolet optical radiation (ultraviolet blood modification). In view of the difficulty in identifying the mechanism of myocardial ischemia in each individual patient with UA and a high likelihood of combination of various pathophysiological factors, myocardium rescue should be in the focus of therapeutic intervention, which dictates the validity and utility of all the recommended and available methods of pharmacological and non-pharmacological therapy and revascularization to reduce the effects of myocardial ischemia.

The Prevalence, Clinical Spectrum and the Long Term Outcome of ST-segment Elevation Myocardial Infarction in Young - A Prospective Observational Study

Incidence of coronary artery disease at the younger age is rising. We studied the prevalence, clinical spectrum and long term outcome of ST-segment elevation myocardial infarction in young. This is a prospective observational study, performed at a tertiary care center from January 2015 to June 2016. Of the total 977 consecutive patients with ST segment elevation myocardial infarction (STEMI), 130 patients aged ≤45 years were included. All patients were followed-up for at least 1-year from the index admission. The overall prevalence of STEMI among younger patients was 12.8%. There was male dominance (96.8%). Smoking (37.6%) was observed to be the most common risk factor for young STEMI, followed by diabetes mellitus (16.8%) and hypertension (16%). Younger patients with acute MI had preponderance to anterior wall (68.8%), single-vessel disease (50%) and left anterior descending artery being the culprit lesion (67.3%). Near normal/normal coronary arteries were observed in 12.9% of cases. The most commonly used management strategy was mechanical revascularisation (43.2%), followed by thrombolysis (28.8%) and medical management (28%). The overall mortality and combined MACCE rates at 1 year were 3.2% and 18.4% respectively. Outcome was better in patients who received mechanical revascularization/thrombolysis than those who received medical management only, with a lower MACCE rates (hazard ratio: 0.36; 95% CI: 0.16-0.8, p = 0.01. The young MI patients are unique in having male dominance, better outcome, more of single-vessel disease with significant number of normal coronaries, better response to mechanical as well as pharmacological revascularization.

TCTAP A-125 Mechanical and Pharmacological Revascularization Strategies for Prevention of Microvascular Dysfunction in ST Segment Elevation Myocardial Infarction: Analysis from Index of Microcirculatory Resistance Registry Data

Microvasculardys function (MVD) after STEMI is correlated with infarct size and long-termprognosis. We aimed to identify mechanical and pharmacological revascularization strategies correlated with index of microcirculatory resistance (IMR) in STEMI. STEMI patients who underwent primary PCI were

Traditional and Alternative Therapies for Refractory Angina.

Refractory angina (RFA) is an unfavourable condition that is characterized with persistent angina due to reversible myocardial ischemia in patients with coronary artery disease that remains uncontrollable despite an optimal combination of pharmacological agents and revascularization. Despite significant advances in revascularization techniques and agents used in pharmacological therapy, there is still a significant population suffering from RFA and the global prevalence is even increasing. Anti- anginal treatment and secondary risk-factor modification are the traditional approaches for this group of patients. Furthermore, now there is still a large number of alternative treatment options. In order to review traditional and alternative treatment strategies in patients with RFA, we searched Pubmed for articles in English using the search terms "pharmacological therapy, refractory angina", "alternative therapy, refractory angina" between inception to June 2016. We also went through separately for each alternative treatment modality on Pubmed. To identify further articles, we handsearched related citations in review articles and commentaries. We also included data from the European Society of Cardiology (2013), and the Canadian Society of Cardiology/ Canadian Pain Society (2012) guidelines. Data show that besides traditional pharmacological agents, such as nitrates, beta- blockers or calcium channel blockers, novel antiischemic drugs and if symptoms persist, several non- invasive and/ or invasive alternative strategies may be considered. Impact of some pharmacological agents, such as rho- kinase inhibitors, and novel alternative treatment modalities, such as coronary sinus reducers, stem cell therapy, gene and protein therapy, on outcomes are still under investigation.

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

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

Thrombectomy in Patients With Large Cerebral Artery Occlusion

The Trevo device, a new stent retriever, may be utilized in patients with large cerebral artery occlusion. Fifty patients with large cerebral artery occlusion and treated with the Trevo device were analyzed. Patients may have received intravenous thrombolysis as a bridging concept in addition to thrombectomy. Outcome and recanalization parameters were documented using the National Institutes of Health Scale, the modified Ranking Scale (mRS) and Thrombolysis in Cerebral Infarction (TICI) score. In all, 82% (95% confidence interval [CI]: 69%-91%) were documented with TICI 2b and 3. Good clinical outcome after 90 days (mRS ≤ 2) was assessed in 61% (95% CI: 46%-75%). Symptomatic intracerebral hemorrhage occurred in 6 patients (12%, 95% CI: 1%-17%). The overall mortality rate was 14% (95% CI: 6%-27%). Thrombectomy with the new stent retriever device is feasible and effective and has an acceptable risk of intra-cerebral hemorrhage even in combination with pharmacological revascularization techniques.

Intermittent Claudication: New Targets for Drug Development

Peripheral artery disease (PAD) is the result of extensive atherosclerosis in the arterial supply to the lower extremities. PAD is associated with increased systemic cardiovascular morbidity and mortality as well as substantial disability due to walking impairment. Claudication is the classic symptom of leg pain with walking that is relieved by rest, but patients with PAD without typical claudication also have a walking limitation. Treatment of the patient with PAD is directed towards reducing cardiovascular risk and improving exercise capacity. The pathophysiology of the physical impairment is complex as changes in the muscle distal to the arterial stenoses contribute to the limitations. Current treatment options to improve exercise performance have limitations emphasizing the need for new pharmacotherapies for this highly prevalent condition. The multifactorial contributors to the exercise impairment in PAD suggest potential targets for novel drug therapies. Advances in understanding angiogenesis make pharmacologic revascularization possible. However, ensuring that new blood vessels develop in a distribution relevant to the clinical impairment remains a challenge. Skeletal muscle metabolism and its regulation are altered in patients with PAD and strategies to improve the efficient oxidation of fuel substrates may improve muscle function. PAD is associated with increased oxidative stress which may result in injury to the muscle microvasculature and myocyte. Minimizing this oxidative stress by enhancing cellular defense mechanisms, administration of anti-inflammatory agents or by providing antioxidants, could prevent oxidative injury. Given the central role of atherosclerosis in the flow limitation, therapies to induce regression of atherosclerotic lesions could result in improved blood flow and oxygen delivery. Drugs targeting the distribution of blood flow in the microcirculatory environment of the muscle have the potential to better match oxygen delivery with working myocytes. The physical disability and flow limitations contribute to a loss of leg muscle mass in patients with PAD. Drugs to increase muscle mass and strength could enhance walking ability in these patients. Pharmacotherapies that recapitulate the muscle adaptations induced by preconditioning may result in improved physical performance in patients with PAD. Adjunctive therapies combined with exercise training or revascularization may be important given the complexity of integrative muscle function and the multiple pathologic changes induced by PAD. New research into the pathophysiology of the physical impairment associated with PAD has identified potential new targets for drug therapy, and will likely continue to do so in the years to come. Translation of these opportunities into effective therapeutics will be important as the already high prevalence of PAD is expected to increase as the population ages.

A thromboembolic model for the efficacy and safety evaluation of combined mechanical and pharmacologic revascularization strategies

Background and purposeRecanalization strategies mediated by intra-arterial fibrinolytic therapy in combination with mechanical clot disruption may be a more effective treatment approach than either therapy used alone. There are few...

Pharmacological Revascularization of Acute Ischaemic Stroke

The only currently approved treatment for acute ischaemic stroke (AIS) is alteplase, a thrombolytic agent given intravenously (IV) within 4.5 hours of symptom onset, in an attempt to reopen occluded intracerebral arteries. However, no more than 5% of all AIS patients receive IV alteplase, mainly because of too long symptom-onset-to-hospital intervals. Moreover, this strategy is effective for less than half of the patients treated within the therapeutic window. Early recanalization is the most powerful prognostic factor, and novel drugs or therapeutic strategies are primarily aimed at improving alteplase efficacy to rapidly and safely reopen the occluded arteries. Because IV alteplase-resistant thrombi are those with the largest clot burden, responsible for the most devastating brain-tissue infarctions, development of novel approved AIS therapies is an urgent priority. At present, in the absence of controlled trials, no valid recommendations can be made. However, the most promising emerging strategy is a combination of standard or low-dose IV alteplase with an intra-arterial (IA) procedure, including additional endovascular thrombolytic and/or mechanical clot retrieval. Notably, results of open trials using the IA route had relatively disappointing clinical outcomes, despite remarkable arterial recanalization rates. Controlled trials are urgently needed to evaluate strategies including an IA route. In addition, logistic and cost constraints will likely limit their routine use, even in industrialized countries. Combining of another IV drug and IV alteplase is a far less studied option, although much easier to implement. Add-on IV drugs could be an antiplatelet glycoprotein (GP) IIb/IIIa receptor antagonist, a direct thrombin inhibitor or a second thrombolytic agent, e.g. tenecteplase. However, neuroimaging to measure the clot burden and infarction size will probably be necessary to predict IV alteplase failure and the subsequent use of these eventual additional therapies.

TESPI (Thrombolysis in Elderly Stroke Patients in Italy): A Randomized Controlled Trial of Alteplase (Rt-PA) versus Standard Treatment in Acute Ischaemic Stroke in Patients Aged more than 80 Years Where Thrombolysis is Initiated within Three Hours after Stroke Onset

Intravenous (i.v.) thrombolysis with recombinant tissue-Plasminogen Activator (rt-PA) (alteplase) within three hours from symptom onset is the only approved treatment of pharmacological revascularization in acute ischaemic stroke. However, the current license limits the use of rt-PA to patients aged ≤80 years due to the lack of evidence of safety and efficacy of this treatment in the elderly from randomized clinical trials. This article describes the design of the Thrombolysis in Elderly Stroke Patients in Italy (TESPI) trial planned to fill the lack of controlled data on i.v. thrombolysis in this age category of stroke patients. To collect efficacy and safety data on i.v. alteplase (rt-PA) in patients aged more than 80 years, to demonstrate that the treatment of these patients within three hours of symptoms onset of an acute ischaemic stroke with i.v. rt-PA, compared to patients receiving standard treatment (according to the national guidelines), will result in an improved clinical outcome with a favourable benefit/risk ratio. TESPI is a prospective, multicenter, national, open-label, controlled (non-treated group as control), randomized, parallel group trial with blinded evaluation of outcome in patients older than 80 years treated with i.v. rt-PA within three hours after ischaemic stroke onset. The randomization procedure assigns patients to the treatment group with IV alteplase (0·9 mg/kg of body weight) or to standard treatment group with a 1 : 1 basis. A three-month follow-up, when applicable, is performed by a blind assessor. Six hundred patients will be enrolled (300 patients per arm) The study period has been planned to be of three years. The primary efficacy end-point is the disability at day 90, dichotomized as a favourable outcome (modified Rankin Scale 0-2) or unfavourable outcome (modified Rankin Scale 3-6). The main primary safety end-point is symptomatic intracerebral haemorrhage defined as any hemorrhage at the 22-36 h post-treatment scan combined with neurological deterioration leading to an increase of one or more points at the National Institutes of Health Stroke Scale. The TESPI trial, with the protocol number FARM65KNKY, is registered in the European Union Drug Regulating Authorities Clinical Trials database with the number 2007-006177-88 and in the Stroke Trials Registry of the Washington University Internet Stroke Center.

Abstract 17275: Induction of Arteriogenesis in Mouse Hindlimb by Human Peripheral Blood B Cells as Determined by Micro-CT Imaging

For patients with critical limb ischemia, restoration of blood flow through mechanical or pharmacological revascularization is an important therapeutic goal. Clinical studies have been unsuccessful in enhancement of neovascularization by treatment with angiogenic growth factors. We have shown that bone marrow derived B cells delivered into rat ischemic myocardium preserves cardiac function (Goodchild et al, 2009) and we sought to determine if B cells could be therapeutically beneficial in a mouse model of critical limb ischemia. Since commonly used histological determination of angiogenesis only provides semi-quantitative measure of vessels in limited tissue area without confirming perfusion functionality, this study measured the angiogenic and arteriogenic activities of B cell therapy using high resolution computed tomography. Mice (n=16, Balb/c) had iliac and femoral arteries and veins ligated. Mouse bone marrow B cells (CD19+) isolated by antibody-magnetic bead selection or saline control was injected directly into ischemic muscles. A post-ligation laser Doppler scan was performed to ensure ligation consistency then scanned weekly. On Day 28, mice were euthanized, vasculature flushed, fixed and perfused with contrast agent. Limbs were imaged by micro-CT with reconstruction at 25um. Data represented as vascular segment number and area counted in 500 slices in 3D micro-CT images. At Days 7, 14, 21 and 28, blood flow increased in B cell treated ischemic hindlimbs compared to controls. At Day 28, B cell treatment increased number of vessels in treated-ligated legs compared to unligated legs (8033±439 vs. 5297±710 vessels, respectively; P=0.010) and vessel area (175.9±45.4 vs. 99.0±28.6 mm2, respectively; P=0.012). Vessels ranging from 25-175 and 225-350um were increased in B cell treated-ligated legs compared to unligated legs (P&lt;0.05). Vessel number ratio in treated-ligated legs to unligated legs was higher in B cell treated compared to control treated mice (1.66 vs. 1.05; P=0.025). These data show that unlike angiogenic response to treatment with growth factors, B cells enhanced development of vessels with a wide range of diameters suggesting that B cells may offer therapeutic potential for treatment of ischemic peripheral artery disease.

Abstract 5021: The Paradox of Gender in Long-Term Survival Following AMI: A Comparison of the 1995 and 2001 Minnesota Heart Survey Cohorts

Improved mortality following acute myocardial infarction (AMI) has been observed in recent decades. We sought to identify how improved adherence to standard pharmacologic therapies and widespread use of percutaneous coronary intervention (PCI) impact mortality in men (M) and women (W). The Minnesota Heart Survey (MHS) abstracted a random sample of all medical records from patients age 30 –74 hospitalized with an AMI in the Minneapolis metro area in 1995 and 2001. Hospital mortality was ascertained from the medical record and verified using death certificates. General linear models were used to compare the outcomes of M and W between the 1995 and 2001 surveys. Survival curves were estimated using Cox proportional hazard models incorporating demographic factors and baseline characteristics. We identified 1313 AMI patients (764 M, 549 W) in 1995 and 1518 AMI patients (630 M, 888 W) in 2001. W were younger in 2001 compared to 1995; there was no significant age difference in M. The prevalence of hypertension and diabetes in AMI patients increased between 1995 and 2001. The use of aspirin, beta-blockers and ACE inhibitors during hospitalization as well as coronary angiography and PCI significantly increased between 1995 and 2001. There was a significant decline in hospital length of stay for M (2.0 days) and W (1.5 days). There was a significant decline in 3-year adjusted mortality for M but a nonsignificant increase in mortality in W [Figure ]. Improved utilization of recommended AMI pharmacologic therapies and coronary revascularization between 1995 and 2001 in M and W have only translated into improved survival among M in a population-based study.

Intravenous Thrombolysis with rt-PA in Acute Ischemic Stroke Patients Aged Older than 80 Years in Italy

Background: Intravenous (i.v.) thrombolysis with rt-PA within 3 h from symptom onset is the only approved treatment of pharmacological revascularization in acute ischemic stroke. However, little information exists on its use in elderly patients, in particular those aged >80 years, who at present are excluded from treatment. Methods: In a multicenter Italian study on i.v. thrombolysis, patients aged >80 years (n = 41) were compared with those aged ≤80 years (n = 207) regarding the percentage of symptomatic (nonfatal and fatal) intracerebral hemorrhage (SICH), favorable 3-month functional outcome (modified Rankin Scale score 0–2) and poor outcome (death or dependence, i.e. modified Rankin Scale score 3–5). Results: The percentage of SICH (nonfatal and fatal) was comparable between older (2.4%, 2.4%) and younger (2.4%, 2.4%) patient groups (p = 1.0). At 3 months, favorable outcome occurred in 44% and dependence in 22% of the older, and respectively in 58.5 and in 30.9% of the younger patients (p = 0.897). Patients aged >80 years had a higher mortality (34.1%) as compared to those aged ≤80 years (10.6%) (p < 0.001). Baseline National Institute of Health Stroke Scale score was the only statistically significant predictor of both mortality (OR = 1.26; 95% CI = 1.07–1.50) and poor outcome (OR = 1.39; 95% CI = 1.14–1.68) in the >80-year-old group. Conclusions: Acute ischemic stroke patients aged >80 years treated with i.v. rt-PA have a higher mortality than younger patients, but there are no differences for SICH nor for favorable outcome. Our data suggest that thrombolytic therapy should not be a priori denied for appropriately selected >80-year-old patients but randomized controlled clinical trials are necessary before definite recommendations can be given.

Coronary Calcium Scanning in Geriatric Cardiology

Coronary artery disease (CAD) is prevalent in the elderly, often leads to disability, and is the number one cause of death in this population. Older adults represent an increasingly important and challenging subset of the population with CAD. They are more likely to have comorbid conditions, atypical presentations, and unfavorable outcomes than their younger counterparts. The available data suggest that standard pharmacologic, thrombolytic, and definitive revascularization techniques have important roles in the treatment of geriatric patients but have been underutilized. Consequently, strategies for optimizing the prevention and treatment of CAD in the elderly are important from both the individual and societal perspectives. Coronary artery calcium has been shown to be highly specific for atherosclerosis, occurring only in the intima of the coronary arteries. There is evidence to show that elevated coronary calcium scores are predictive of future cardiovascular events, both independently of and incrementally to conventional cardiovascular risk factors. This article will review such a screening method, namely coronary calcium scanning, in the field of geriatric cardiology.

The use of low molecular weight heparins in patients with acute ST-elevated myocardial infarction

INTRODUCTION According to the published guidelines for the management of acute coronary syndromes (ACS), treatment of acute ST-elevated myocardial infarction is based on rapid revascularization, either mechanical or pharmacological. Pharmacological revascularization consists of fibrinolytic therapy with antiplatelet and anticoagulant therapy. In regard to the anticoagulant therapy, low molecular weight heparins (LMWHs) are of special importance. LMWHs cause less complications (bleeding, thrombocytopenia, better bioviability) in comparison with unfractionated heparin (UFH). Some studies on use of LMWHs in ACS, show that LMWHs are equally efficient and safe as UFH, causing less complications (different types of hemorrhagic complications) (ESSENCE, TIMI 11B (enoxaparin), FRAXIS-fraxiparin), whereas some studies show better efficacy and safety of enoxaparin in therapy of acute ST-elevated myocardial infarction (ASSENT 3, ASSENT 3 PLUS, HART II, AMI-SK). acute anterior myocardial infarction with ST-elevation, first myocardial infarction, no other structural heart defects, no signs of cardiogenic shock. Our study included 30 patients receiving fibrinolytic therapy with streptokinase, antiplatelet therapy and LMWH during 6 days, and 30 patients receiving UFH instead of LMWH. The follow-up period lasted for 6 months. Significantly more patients receiving unfractionated heparin presented with major adverse cardiac events (73.3%) in regard to patients in the study group (44.2% nadroparin, 39.8% enoxaparin) (p = 0.025). In the group receiving UFH, 6.7% patients had hemorrhagic complications, while none of patients receiving LMWHs. An equal number of patients died. Patients who were treated with LMWHs experienced less major adverse cardiac events and lower mortality. None suffered from hemorrhagic complications.

A Comparison of the AVID and DAVID Trials of Implantable Defibrillators

We compared 2 studies of implantable cardiac defibrillators (ICDs) to determine the effects of device mode on outcomes. The Antiarrhythmics Versus Implantable Defibrillators (AVID) trial (1993 to 1997) demonstrated improved survival with the ICD compared with antiarrhythmic drug therapy. The Dual-chamber And VVI Implantable Defibrillator (DAVID) trial (2000 to 2002) showed that VVI pacing at 40 beats/min in patients with ICDs reduced the combined end point of death and hospitalization for congestive heart failure compared with DDDR pacing at 70 beats/min. Patients in the AVID trial (631 of 1,016) and the DAVID trial (221 of 506) meeting common inclusion and all exclusion criteria were studied. The major end points were the time to death, and the composite end point of time to death or hospitalization for congestive heart failure. Patients in the AVID and DAVID trials were similar, but more AVID patients had coronary artery disease (p = 0.04), history of myocardial infarction (p = 0.005), and previous ventricular arrhythmias (p = 0.03). DAVID patients underwent more previous revascularization procedures (coronary artery bypass surgery, p = 0.03; percutaneous coronary intervention, p = 0.001), and were more often taking beta-blocking drugs at hospital discharge (p <0.001). The backup VVI ICD groups in both studies had similar outcomes (p = 0.4), even when corrected for the previous demographic differences. The time-to- composite end point was similar in AVID patients treated with antiarrhythmic drugs and DAVID patients treated with DDDR ICDs (p = 0.6). Despite improved pharmacologic therapy and revascularization, outcomes have not improved with backup VVI pacing ICDs. If DDDR ICDs had been used in the AVID trial, benefit from ICDs for patients with serious ventricular arrhythmias could have been missed.