Primary Percutaneous Transluminal Coronary Angioplasty Research Articles

Acute Myocardial Infarction After Sildenafil Citrate Ingestion

To report a case of acute myocardial infarction (MI) associated with the use of oral sildenafil in a nitrate-free patient. A 45-year-old man was admitted to the hospital with acute left-sided chest pain, nausea, and vomiting that started approximately 30 minutes after taking sildenafil 100 mg before a sexual contact. The patient was diagnosed with an acute anterior MI, and therapy with aspirin, metoprolol, and unfractionated heparin was initiated. Early coronary reperfusion treatment with primary percutaneous transluminal coronary angioplasty was performed after initial evaluation. Balloon angioplasty followed by coronary stenting was performed successfully in the 80%-occluded left anterior descending artery. The patient was discharged one week after the coronary intervention without complication. Sildenafil-associated MI is rarely seen in patients without documented coronary artery disease. By inhibiting phosphodiesterase type 5, sildenafil can cause an increase in cyclic guanosine monophosphate levels, which mediates the relaxation of vascular smooth muscle in the corpus cavernosum. Although sildenafil can cause a major decline in systemic arterial pressure in the existence of organic nitrates, physicians should be aware of its adverse cardiovascular effects even in nitrate-free patients. The Naranjo probability scale indicates that sildenafil was the possible cause of the MI. Sildenafil may rarely be associated with MI in patients with no known cardiac history. Physicians should be aware of this rare and serious adverse reaction to sildenafil and counsel patients not to take sildenafil before undergoing a complete physical evaluation and further testing if warranted.

Transient silent ischemia after percutaneous transluminal coronary angioplasty manifested with a bizarre electrocardiogram

Silent myocardial ischemia is recognized as a common manifestation after percutaneous coronary interventions possibly due to induction of coronary artery spasm. A 54-year-old man was performed primary percutaneous transluminal coronary angioplasty with the diagnosis of acute myocardial infarction. His 18-hour control electrocardiogram showed big-notched inverted T waves in precordial, III, and aVF leads without any chest pain. These bizarre electrocardiographic findings were restored after a brief period indicating silent ischemia that is caused by coronary artery spasm.

Identification of Stunned Myocardium With Parametric Imaging-Based, Quantitative Myocardial Contrast Echocardiography After Acute Myocardial Infarction

Microvascular integrity demonstrated by myocardial contrast echocardiography (MCE) predicts functional recovery after an acute myocardial infarction (AMI). Recently, parametric imaging-based quantitative MCE has been developed. Our aim was to assess the usefulness of parametric imaging-based quantitative MCE parameters to predict the functional recovery of akinetic segments after primary percutaneous transluminal coronary angioplasty (PTCA). Fifty-three consecutive patients with a first AMI were enrolled. They underwent primary PTCA. Standard echocardiography and real-time MCE were performed. Qualitative analysis and parametric imaging-based quantitative parameters were measured offline by different blinded investigators. Dobutamine stress echocardiography was performed 1 month later. A new standard echocardiogram to assess the functional status of the akinetic segments and coronary angiography to evaluate the presence of restenosis at the level of the culprit lesion were performed 6 months later. The mean patient age was 62.9 +/- 14 years, and 42 were men (79%); 170 segments were akinetic. Of these, 105 (62%) recovered their function. The best parameter to predict functional recovery was the myocardial blood flow velocity (beta). These results were better than those obtained using dobutamine stress echocardiography and qualitative MCE to predict functional recovery. In conclusion, parametric imaging-based quantitative MCE is an accurate diagnostic tool to detect stunned myocardium after AMI. Its diagnostic accuracy in predicting the functional recovery of akinetic segments after primary PTCA is better than the accuracy of dobutamine stress echocardiography and qualitative MCE.

Symptomatic Acute Myocardial Infarction in a Cardiac Transplant Recipient Successfully Treated With Primary Coronary Angioplasty: Evidence of Prognostic Importance of Chest Pain After Cardiac Transplantation

Accelerated coronary artery disease remains the limiting factor in the long-term survival of heart transplant (HT) recipients and occurs in approximately 50% of patients by 5 years after transplantation. Sequelae of graft arteriosclerosis include congestive heart failure (due to acute or chronic ischemia), graft loss, and death. Unfortunately, as a consequence of cardiac denervation, symptoms are often atypical or completely absent, and thus presentation with an acute coronary syndrome is extremely uncommon. We describe the case of an HT recipient with a typical clinical picture of an acute myocardial infarction (MI), who presented to our hospital 2 hours after the onset of symptoms and was successfully treated with primary percutaneous transluminal coronary angioplasty (PTCA).

Management of Cardiogenic Shock Due to Acute Coronary Syndromes

Despite advances in the treatment of patients with acute coronary syndromes, there has been no significant decrease in the incidence of cardiogenic shock, while its mortality remains frustratingly high. Shock is a progressive state of hypotension (systolic blood pressure < 90 mm Hg) lasting at least 30 minutes, which leads to systemic hypoperfusion. It is more common in patients with ST-segment elevation myocardial infarction than in patients with other acute coronary syndromes. Revascularization is associated with better outcomes than intensive medical therapy, especially in patients < 75 years of age with cardiogenic shock. Adjunctive therapies include inotropes, vasopressor therapy, intra-aortic balloon pump counterpulsation, and IIb/IIIa blockade to prevent no-reflow phenomenon during primary percutaneous transluminal coronary angioplasty. Other adjunctive therapies which are investigated are improved mechanical support devices, and as medical therapy for myocyte protection nicorandil, glucose/insulin/potassium infusions and direct inhibition of Na+/H+ exchanger.

Right Bundle Branch Block in Acute Myocardial Infarction Treated by Primary Coronary Angioplasty and Stenting

Patients with right bundle branch block (RBBB) in acute myocardial infarction (AMI) have a significantly higher mortality rate even with the advent of thrombolytic therapy. This study was undertaken to assess the impact of primary percutaneous transluminal coronary angioplasty (PTCA) and stenting on the outcome of patients with RBBB in AMI. A total of 600 patients with AMI who underwent primary PTCA and stenting (rate: 61%) < 12 hours of onset were studied. A 12-lead ECG was obtained at least every 6 hours. Serial creatine kinase was measured, and left ventricular ejection fraction was obtained during the hospital stay. Among 600 patients with AMI, 94 patients (15.7%) had RBBB; it was persistent in 31 (33%) and transient in 63 (67%). In-hospital mortality rate was 7.3% in patients without RBBB, 7.9% in transient RBBB, and 25.8% in persistent RBBB (p < 0.02). The incidence of heart failure was 26.5% in those without RBBB, 34.9% in transient RBBB, and 58.1% in persistent RBBB (p < 0.001). There was no significant difference among these 3 groups in ventricular arrhythmias and complete atrioventricular block. Peak creatine kinase was 3,214+/-2,293 U/L in those without RBBB, 4,558+/-3,316 U/L in transient RBBB (p < 0.001), and 5,635+/-3,920 U/L in persistent RBBB (p < 0.001). Left ventricular ejection fraction was 50+/-11% in those without RBBB, 47+/-11% in transient RBBB (p < 0.05), and 42+/-13% in persistent RBBB (p < 0.001). Patients with AMI treated by primary PTCA and stenting had an increased incidence of transient RBBB, especially following reperfusion therapy, although the clinical outcome was similar to that of those without RBBB. In contrast, there was no satisfactory improvement in clinical outcomes in those with persistent RBBB.

Primary angioplasty in acute myocardial infarction: Hypothetical estimate of superiority over aspirin or untreated controls

Primary percutaneous transluminal coronary angioplasty (PTCA) in the setting of ST-segment-elevation myocardial infarction has been compared with intravenous thrombolysis, but its effects versus no treatment are not known. Knowledge of the effects of PTCA in this setting is useful as a substantial minority of patients do not receive thrombolysis because of contraindications. A hypothetical primary PTCA versus placebo/control odds ratio was computed using a recently described statistical technique that employed the logarithm of the odds ratios of the pooled results of meta-analyses of PTCA versus thrombolysis and thrombolysis versus placebo or controlled trials. Using data from 30 trials, the synthesized odds ratio for mortality for primary PTCA versus placebo/untreated controls is 0.56 (95% confidence interval [CI]: 0.46 to 0.68; P <0.00001), consistent with a 44% reduction. Primary PTCA and aspirin reduces mortality by 69% versus no aspirin (OR = 0.31; 95% CI: 0.21 to 0.45; P <0.00001). In a high-risk group of otherwise eligible patients with thrombolysis contraindications, the absolute benefit is estimated as 93 per 1000 treated (95% CI: 53 to 132 per 1000 treated). The risk of stroke is reduced with primary PTCA (OR = 0.46; 95% CI: 0.30 to 0.71; P = 0.0004). In this setting, primary PTCA would hypothetically reduce the short-term risk of death by 44%. Despite the use of aggressive antithrombotic regimens, the risk of stroke would also be reduced substantially with primary PTCA.

Percutaneous transluminal coronary angioplasty in the right ventricle myocardial infarction treatment

To present the results of percutaneous transluminal coronary angioplasty (PTCA) in the treatment of the patients with acute right ventricle myocardial infarction (ARVMI), with adjuvant analyses of the obtained results in the period of five years (2000-2004). Thrombolytic therapy and the primary percutaneous transluminal coronary angioplasty (PPTCA) was applied within the first 6 hours from the onset of anginous disorders, and rescue PTCA in the period from 6-24 hours from the onset of ARVMI. Results. A total number of 1175 patients, both sexes, 763 (64.8%) males and 412 females (35.2%), mean age 58.4 +/- 7.8 years, were treated for acute myocardial infarction (AIM) of different localization in the period of five years (2000-2004). Anterior infarction was found in 645 (54.8%) of the patients, and inferoposterior infarction (IPI) was localized in 530 patients (45.2%) patients of which in 134 (25.2%) AIMDK was proven. Out of 134 patients with proven acute myocardial of the right ventricle AIMDK, 53 (39.5%) got thrombolytic therapy, 64 patients (47.7%) were treated with the conservative heparin therapy, whereas in 17 patients (12.8%), primary percutaneous coronary angioplasty (PPTCA) was done. Delayed or rescue PTCA was done in 22 (18.8%) patients, in 8 (36.3%) from the group which got thrombolytic therapy, and in 14 (63.7%) treated with the heparin therapy. Out of the total number of 22 patients who got heparin or thrombolytic therapy combined with rescue PTCA, in 7 patients (31.8%) the complete clinical and angiographic effect of thrombolysis with AIM was achieved only by using a balloon. Baloon dilatation with the implantantion of intracoronary stent was performed in another 11 patients (50%), while 2 (9.1%) were sent to revascularization of the myocard due to diffusion changes in each of the 3 blood vessels, and 2 patients (9.1%) died. Of the patients, 17 (12.6%) had PPTCA with the implantation of intracoronary stent with the additional direct inhibitor of the platelet membrane glycoproteins IIb/IIIa (abciximab). All the patients treated in this way survived. They had no side effects nor serious complications. Their clinical recovery was satisfactory. In the first three weeks of the intrahospital period in the group of 45 patients (33.5%) with AIMDK, who got only thrombolytic therapy, 7 patients (15.5%) died, whereas in the group of 50 patients (37.3%) treated only with heparin, 13 (26%) died. In the group of 22 patients (18.8%) treated with the combined therapy with rescue PTCA and heparin or thrombolytic therapy, 2 patients (9.1%) died. In the group of 84 patients (62.6%) with AIMDK, who were treated with thrombolytic therapy with primary or rescue PTCA, 9 (10.7%) died. In the AIMDK group of 134 patients, 22 patients (16.4%) died in the period of 1 month of the hospital treatment, whereas in the second group of 396 patients with IPI, but without IDK, 36 (9.1%) died (chi2 = 4.789; p < 0.001). Out of the total number of 1175 patients with AIM in the five-year period of the intrahospital treatment, 145 patients (12.3%) died. In the group of patients with IPI, 58 patients out of 530 (10.9%) died, whereas 87 patients out of 645 (13.4%) with anterior infarction died, (chi2 = 0.567; p < 0.452). The combination of thrombolytic therapy and PTCA shown in the obtained results completely justified this kind of treatment, and offered the patients with AIMDK a greater chance to surve than they had before.

Age-associated time delays in the treatment of acute myocardial infarction with primary percutaneous transluminal coronary angioplasty

Multiple studies have shown that age is a significant factor associated with suboptimal treatment for acute myocardial infarction (AMI). We performed a retrospective pilot study using a chart review of patients who presented with AMI who were subsequently treated with percutaneous transluminal coronary angioplasty (PTCA) from November 1995 to January 1997 at our institution. Ninety-four patients met inclusion criteria, with 5 excluded for insufficient data. Mean time for “door-to-balloon” in all patients was 118 ± 48 minutes. The mean patient age was 60 years. Mean times (minutes) for patients grouped by decades of life are as follows: 143 ± 59 (30-39 years), 114 ± 51 (40-49 years), 99 ± 41 (50-59 years), 116 ± 44 (60-69 years), 135 ± 47 (70-79 years), and 133 ± 133 (80 years and older). Statistical analysis was performed using analysis of variance ( P = 0.04). In this study, age was associated with treatment delays. There was a parabolic relationship of age with time, with a greater time delay occurring in “younger” and “older” patients.

The results of the treatment of right ventricle myocardial infarction

To present the results and experience in diagnosing and treating of patients with acute right ventricle infarction, during the period of hospitalization of one month, with adjuvant analyses of the obtained results in the period of fifteen years. Acute right ventricle infarction porved clinicaly, enzymologicaly, by ECG, echochardiographically or scintigraphically we treated with thrombolitic therapy within first six hours after admittion, with salvaged PTA in case of the cardiogenic shock or AV block II degrees-III degrees despite of thrommbolitic therapy, or with postponed PTA within first month of intrahospital treatment. In the period from 1990 to 2004, 3 225 patients of both sexes were treated for acute myocardial infarction at the different localization in patients' at the mean age of 53.7 +/- 5.8. One-hundred-thirty-nine (43.9%) patients were treated with thrombolitic therapy according to the speed up protocole. Heparin was administered to 160 (50.7%) patients with water load, and 17 (5.4%) patients had the primary percutaneous transluminal coronary angioplasty (PPTCA), so that the mechanical blood flow could be established, by the implantation of a stent when necessary. In 316 patients with right ventricle infarction, 58 (18.3%) had postponed and salvaged percutaneous transluminal coronary angioplasty (PTCA). Twenty-two (15.8%) patients had thrombolitic therapy, whereas 36 (22.5%) patients were treated with heparin. We had a successful balloon dilatation in 21 (36.2%), whereas 32 (55.2%) patients had 1-3 intracoronary stents inplanted, depending upon the necessity, and 5 (8.6%) patients from this group were sent to surgical intervention. In the group of 214 (67.7%) patients treated with heparin or thrombolitic therapy combined therapy, with PTCA, 12 (5.7%) patients died, whereas in the group of 124 (39.3%) patients treated only with heparin 26 (16.2%) patients died, statistically significant difference (p < 0.001, chi2 = 18.423). Was noticed n the group of 1 204 patients with inferoposterior infarction, 122 (10.1%) patients died. In the group of 316 patients with right ventricle infarction, 38 (12%) died. In the group of 888 control patients with inferoposterior infarction, but without right ventricle infarction, 84 (9.4%) patients died. In the group of 2 021 patients (62.2%) with anterior infarction, 248 (12.3%) died. CONCLUSION. The obtained results showed that the patients with right ventricle infarction, due to the great expansion of necrosis and the involvement of the inferoposterior wall of the left ventricle, as well as the ischemia of sinus and AV nodes, were the patients of a high risk. That was why it was essential to do urgent widening of the artery to reestablish blood flow either by using drugs or by means of mechanical methods.

Bone Marrow-Derived Cell Mobilization with G-CSF and GM-CSF in Patients with Acute Myocardial Infarction: A Pilot Study on Feasibility, Safety and Efficacy.

Introduction. Intracoronary or intramyocardiac injection of bone marrow stem cells or growth factor-mobilized peripheral blood stem cells (PBSC) may contribute to myocardial regeneration and neovascularization of the ischemic myocardium either in animal models or in human. This effect is probably due to a selective colonization of the ischemic area by PBSC. Very few studies were done in the acute setting of ischemic heart disease, with controversial results. Aims of this pilot study were: i) to verify feasibility and safety of PBSC mobilization in patients with acute myocardial infarction (AMI); ii) to monitor clinical effects of PBSC mobilization in terms of global and segmental myocardial perfusion and function.Patients and methods. Eight male patients (mean age: 51,7±5,6 years) were enrolled. All were treated with a primary percutaneous transluminal coronary angioplasty (PTCA) for an anterior (5 patients) or an inferior (3 patients) AMI. The mobilization regimen consisted of G-CSF 5 μg/kg/12h from day 1 to day 3 and GM-CSF 2.5 μg/kg/24h from day 1 to day 5 (starting within 24 hours from PTCA). Since transient severe hypotension was noticed in the first three patients, the protocol was amended by reducing and tapering GM-CSF administration (2.5 μg/kg/24h at days 3, 5, 7). All patients underwent coronary angiography, intracoronary doppler flow study, echocardiography, and nuclear Thallium scan before treatment and at 6 months apart.Results. WBC and PBSC peaked during the 3th day of mobilization. Mean WBC and PBSC peaks were 34960± 10794 leukocytes/μL and 29.71± 30.8 CD34+/μL. Five in hospital adverse events were recorded: severe hypotension in 3 patients (as previously mentioned), atrial fybrillation in 1 patient, recurrent ischemia in 1 patients. No death was observed. At present 7 patients completed a 6-months follow-up evaluation: target lesion revascularization rate was 14,3% (1 patient) and target vessel revascularization rate was 42,8% (3 patients). Angiographic mean ejection fraction increased from 49,8±11,9 to57,1±8,9 (p=NS), and mean coronary flow reserve raised from 1,63±0,42 to 2,45±0,36 (p=0,005). Perfusion improvement was observed by nuclear study in 66% of patients.Conclusions. We conclude that: a) cytokine-induced stem cell mobilization is feasible in AMI patients with adequate GM-CSF administration; b) myocardial perfusion appears to improve within the first six months of follow-up; c) the 3 cases of progressive coronary disease give a concern about a potential negative effect of hematopoietic cytokines (particularly GM-CSF) on silent coronary lesions. However, PBSC mobilization using G-CSF only is worthwhile of further investigation.

Prognostic implication of ST-segment resolution following primary percutaneous transluminal coronary angioplasty for ST-elevation acute myocardial infarction.

ST-segment changes have been shown to correlate with myocardial tissue perfusion. Complete ST-segment resolution after thrombolysis in acute myocardial infarction is associated with lower mortality and better left ventricular function. Primary percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction restores better epicardial coronary flow to the infarct-related artery than thrombolysis. However, ST changes may persist and flow can remain poor despite a patent vessel. To examine the prognostic implication of ST-segment resolution immediately following primary and rescue PTCA for ST-elevation acute myocardial infarction (STEMI). Records of 201 consecutive primary and rescue PTCA performed at Westmead Hospital for STEMI from January 2000 to December 2001 were reviewed. ST-segment elevation (taken 20 ms after the end of the QRS complex) was measured immediately before and after the procedure. ST-segment resolution of greater than 70% after the procedure was considered as -'complete' ST-segment resolution, whereas ST-segment resolution of less than 70% was considered as 'incomplete' ST-segment resolution. Of the 201 patients, 117 (58%) had complete ST-elevation resolution and 84 (42%) did not. There was a significant difference in survival free of major adverse cardiovascular events; 60% of those with complete ST-segment resolution were event-free at 2 years compared with 35% of those patients without complete ST-segment resolution. ST-segment resolution after primary and rescue PTCA for STEMI is associated with significantly higher event-free survival. The goal of primary angio-plasty should be the restoration of normal epicardial flow with normalization of ST-segments.

Circulating procoagulant microparticles and soluble GPV in myocardial infarction treated by primary percutaneous transluminal coronary angioplasty. A possible role for GPIIb‐IIIa antagonists

Circulating procoagulant microparticles (MP) were measured as markers of vascular damage and prothrombotic risk in patients undergoing ST-segment myocardial infarction (STEMI) treated by primary percutaneous transluminal coronary angioplasty (PTCA) and additional GPIIb-IIIa antagonists. Cells possibly more responsive to GPIIb-IIIa (alpha(IIb)beta(3)) antagonists were evidenced through MP phenotypes by comparison with healthy volunteers (HV) and STEMI patients treated by PTCA without GPIIb-IIIa antagonist (CP). In 50 STEMI patients, blood samples were collected at day 1 and day 6. Circulating procoagulant MP were captured on annexin V and quantified by prothrombinase assay as nanomolar phosphatidylserine equivalents (nm PhtdSer). Platelet activation by thrombin was confirmed through independent measurement of soluble GPV (sGPV). With respect to HV, procoagulant MP levels were high in patients with STEMI or unstable angina, platelet-derived MP and elevated sGPV testifying to significant platelet activation. A substantial release of endothelial-derived MP was evidenced simultaneously. In abciximab-treated patients, procoagulant MP, mainly of platelet origin, decreased precociously at day 1 (4.2 +/- 0.6 vs. CP 15.5 +/- 2.1 nm PhtdSer; P = 0.001) together with sGPV (36 +/- 3 vs. CP 58 +/- 8 ng mL(-1); P = 0.02). Leukocyte-derived MP decreased at day 6 (0.12 +/- 0.04 vs. CP 0.56 +/- 0.12 nm PhtdSer; P = 0.01) suggesting a possible effect on underlying inflammatory status. In patients presenting cardiovascular events at 6-month follow-up, procoagulant MP levels at day 1 could be indicative of a worsened outcome. MP could constitute a relevant parameter for the follow-up of STEMI patients treated by GPIIb-IIIa antagonists.

Landmark study: the Carvedilol Post-Infarct Survival Control in Left Ventricular Dysfunction Study (CAPRICORN)

The benefit of β-blockers for secondary prevention of death and reinfarction after myocardial infarction (MI) has been conclusively demonstrated in randomized clinical trials. Before the Carvedilol Post-Infarct Survival Control in Left Ventricular Dysfunction Study (CAPRICORN)—a multicenter, multinational, double-blind, randomized, placebo-controlled trial that enrolled 1,959 patients who had an acute MI and a left ventricular ejection fraction of ≤0.40—it was not known whether β-blockers confer additional benefit when used in the context of modern post-MI management (eg, fibrinolytic therapy and primary percutaneous transluminal coronary angioplasty, aspirin, and angiotensin-converting enzyme inhibitors). Patients in CAPRICORN were treated with a maximum dose of 25 mg bid and observed until 633 validated primary end points had occurred. Because the overall mortality was lower than had been predicted, a co-primary end point was adopted that included the original primary end point (all-cause mortality) plus the first of the prespecified secondary end points (all-cause mortality or cardiovascular hospitalizations). A significant 23% reduction in the original primary end point of all-cause mortality was observed. A total of 340 (35%) patients died or had a cardiovascular hospitalization in the carvedilol group versus 367 (37%) in the placebo group. Therefore, the revised primary end point of all-cause mortality or cardiovascular hospitalization was reduced by 8%, which was not statistically significant. Significant reductions in cardiovascular mortality, nonfatal MI, and the combination of all-cause mortality or nonfatal MI were observed. Although statistical significance for the revised primary end point was not reached, CAPRICORN has an important role in guiding future use of β-blockers in the early post-MI period.

Management of acute coronary syndromes, a questionnaire survey of the clinical practice of cardiologists and other medical physicians belonging to west midland hospitals

Objective: To assess the management of acute coronary syndromes by cardiologists and other medical physicians in a clinical setting. Design: Questionnaire survey consisting of 10 hypothetical clinical scenarios and four possible therapeutic options for each scenario. Setting: Consultants and specialist registrars in Cardiology (with or without access to interventional facilities) and consultant physicians belonging to various hospitals in the west midland region of United Kingdom. Main outcome measures: Respondents' ability to recognise high risk patients and their management of the hypothetical clinical cases. To establish any differences in management strategy between cardiologists and general physicians, and whether these differences, if any, relate to access to interventional cardiac facilities. Results: Overall no significant differences were found in the responses between cardiologists and general physicians with or without access to cardiac interventional facilities. However, cardiologists were more inclined to use percutaneous transluminal coronary angioplasty (PTCA) compared to other physicians (scenario 8, 18.4% vs. 6.7%, p=0.05 and scenario 9, 44.9% vs. 26.7%, p=0.01). In two other situations, physicians from institutions with access to interventional facilities were more inclined to use ‘other’ treatment strategies (intravenous nitrates, antiplatelet treatment, inotropes, Intra-aortic balloon pump) compared to their colleagues from non-tertiary hospitals with no interventional facility on site (scenario 3, 21.7% vs. 2.4%, p=0.04) and more use of PTCA ( scenario 6, 52.2% vs. 26.8%, p=0.04). Conclusions: The management of acute coronary syndromes in this questionnaire survey was satisfactory and evidence based. No real differences were found between the management strategies adopted by cardiologists or non-cardiologists. Physicians working in centres with interventional facilities were no more inclined towards using primary PTCA or rescue angioplasty than those working in centres without such facilities.

Role of endogenous interleukin-10 production and lipid peroxidation in patients with acute myocardial infarction treated with primary percutaneous transluminal coronary angioplasty interleukin-10 and primary angioplasty

Background: Currently available evidence suggests a potentially protective role for interleukin (IL)-10 in atherosclerosis. Reactive oxygen species, such as superoxide anion, hydrogen peroxide, peroxynitrite, and hydroxyl radical, seem to play a pivotal role in the pathogenesis of ischemia-reperfusion injury. The aim of this study was to assess whether a rise in lipid peroxidation (LPx), as malondialdehyde (MDA) and 4 hydroxyalkenal (4-HNE), during acute myocardial infarction (AMI) is associated with serum concentrations of IL-10. Methods: A total of 50 patients diagnosed with AMI and 50 control subjects were studied. Primary angioplasty was performed in the 50 patients with an indication for reperfusion. Serum IL-10 and LPx (MDA+4-HNE) concentrations were measured using commercially available enzyme-immunoassays. The venous blood samples were taken 90±35 min after having obtained a TIMI III flow in patients with AMI. In control subjects, blood samples were taken at the time of admission to hospital. Results: IL-10 concentrations were higher in patients with AMI compared with control subjects (32.45±2.17 vs. 22.10±2.40 pg/ml; P=0.03). Serum LPx concentrations were higher in the AMI group (22.20±3.63 vs. 11.90±1.26 μM; P=0.01). IL-10 levels in patients with AMI were significantly correlated with the concentrations of LPx (Pearson's r=0.49, P=0.02). Conclusions: Our results provide evidence that (1) IL-10 is increased in a human model of myocardial ischemia-reperfusion and (2) reperfusion injury and elevated IL-10 levels are related in patients with AMI treated with primary percutaneous transluminal coronary angioplasty.

Managed Care, Information, and Diffusion: The Case of Treatment for Heart-Attack Patients.

Growth in the size and power of managedcare organizations seems to have had widespread effects on the health-care system. Not only may health maintenance organizations (HMOs) and other forms of managed care influence the care provided to the patients that they cover, but the activities of these organizations may also bring about broader changes in the delivery of health care. Such “spillover effects” of managed care could ultimately affect even health care for patients who have not joined managed-care organizations. While previous literature on the relationship between area HMO market share and spending is consistent with the presence of spillover effects (e.g., Baker, 1999), few studies have examined treatment patterns directly (e.g., Heidenreich et al., 2002). Nevertheless, the potential for changes in patient care are of central importance for gaining a full understanding of the overall effects of managed care on the health-care system. This paper examines the relationship between area HMO activity and the use of two relatively common therapies for heart-attack patients: percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft surgery (CABG). We study patients covered by fee-for-service Medicare who suffered a new acute myocardial infarction (AMI, or heart attack) between 1985 and 1999. If HMO activity does have an impact on the use of PTCA or CABG for these fee-for-service patients, it will signal the ability of HMOs to influence treatment patterns outside of their own patients. We also investigate the extent to which information dissemination plays a role in managedcare spillover effects. The HMOs may have networks and other information-dissemination mechanisms, as well as financial and other points of leverage over treatment decisions, which allow them to alter physicians’ treatment decisions more effectively than less-managed health plans. Assuming that HMOs find it in their interest to encourage changes in treatment in response to new medical information, their efforts could lead to changes in physician practice patterns that are generally applied. We explore the role of information dissemination by studying the use of primary PTCA, defined here as PTCA performed within one day of an AMI patient being brought to the hospital. Prior to 1993, the typical immediate treatment for an AMI patient with a recently blocked artery was the administration of thrombolytic drugs to dissolve blood clots. Available evidence at that time suggested that the immediate use of PTCA was harmful (e.g., E. J. Topol et al., 1987). However, in 1993 three landmark studies were published simultaneously in the New England Journal of Medicine (Raymond J. Gibbons et al., 1993; Cindy L. Grines et al., 1993; Felix Zijlstra et al., 1993), demonstrating that immediate angioplasty was superior to thrombolytic therapy in improving blood flow and preventing the affected artery (or arteries) from becoming blocked again. A series of additional studies followed, demonstrating the superiority of primary PTCA for additional clinical endpoints (e.g., W. D. Weaver et al., 1997). If areas with high HMO market shares are differently able to alter physician practice patterns in response to new medical knowledge, we hypothesize that a differential trend may be observable in the use of primary PTCA in areas with higher and lower HMO market share * Baker: Department of Health Research and Policy, HRP Redwood Building, Room 110, Stanford University, Stanford, CA 94305-5405, and NBER; Afendulis: Center for Primary Care and Outcomes Research, 117 Encina Commons, Stanford, CA 94305-6019, and NBER; Heidenreich: VA Palo Alto Healthcare System, 111C, 3801 Miranda Avenue, Palo Alto, CA 94304, and Stanford University. The data used in this study are proprietary. This research was supported by AHRQ grant 5 R01 HS10925-03, and a career development award from the VA Health Services Research and Development Service for Heidenreich. We are grateful to Mark McClellan for assistance with the data and comments on a much earlier draft of this paper.

Role of apoptosis in reperfusion injury.

Many changes occur during reperfusion of the myocardium after ischemic damage. Necrosis and apoptosis appear to be ongoing during ischemia, while apoptosis is boosted by the reperfusion event. In the past 10 years, distinct intracellular pathways important for hypertrophy, apoptosis, cardiac failure, ischemic preconditioning and reperfusion damage have been recognized. The eventual response of the cardiomyocyte will depend on energy and time available as well as changes in pH and ion handling and the delicate balance of activation of signaling molecules and transcription factors. There is agreement on the central role of mitochondria and nitric oxide (NO) in programmed cell death. However, although many groups analyzed the contribution of NO to cell death, still the circumstances and levels required for cardioprotection or death are unclear. Growth factors, cytokines, and downstream signaling molecules have been shown to influence programmed cell death through mechanisms reminiscent of preconditioning. Here, the role of apoptosis in ischemia reperfusion-related cell death is reviewed. Important data have been obtained in isolated cells, intact hearts and intact animals. Both pharmacological as well as genetic interventions are discussed. Proof for apoptosis in man post-myocardial infarction (MI) treated through primary Percutaneous Trans-luminal Coronary Angioplasty or other reperfusion therapy is reviewed. Finally, the currently available quantification methods for apoptosis post-MI are mentioned.

Door-to-Balloon Delays with PCI in Acute Myocardial Infarction.

In the treatment of acute myocardial infarction (AMI), the length of time from symptom onset to revascularization is a crucial determinant of clinical outcomes such as mortality and reinfarction. Direct, or primary, percutaneous transluminal coronary angioplasty (PTCA) produces higher rates of infarct-related artery patency and improved clinical outcomes compared to thrombolytic therapy. However, primary PTCA is associated with an increased time interval from hospital arrival to revascularization, the so-called door-to-balloon time. Numerous data support the theory that increased door-to-balloon time reduces the benefits of primary PTCA in the treatment of AMI. Therefore, institutions that offer PTCA must strive to decrease door-to-balloon delays through the use of established treatment protocols and frequent assessment of performance.

Thrombolytic therapy is indicated for patients over 75 years of age with st-elevation acute myocardial infarction: antagonist viewpoint.

From the available data, one cannot conclude whether thrombolytic therapy is beneficial or detrimental in patients older than age 75 years with acute myocardial infarction. Data favor the use of primary percutaneous transluminal coronary angioplasty rather than thrombolysis in eligible patients older than age 75 years with acute myocardial infarction to reduce mortality, recurrent myocardial infarction, stroke, and intracranial hemorrhage. High-risk elderly patients with acute myocardial infarction, such as those with a large anterior myocardial infarction complicated by heart failure and hypotension, those with persistent ischemic pain or marked ST-segment changes, those with hemodynamic instability, and those at high risk for stroke or bleeding complications, should, especially, be treated with percutaneous transluminal coronary angioplasty.