Q-wave Myocardial Infarction Research Articles

Stress-induced ST-segment elevation in patients without prior Q-wave myocardial infarction

Background Stress-induced ST-segment elevation is an uncommon finding that usually occurs in patients with prior myocardial infarction (MI). Our purpose was to assess the angiographic and clinical significance of this finding in patients without prior MI. Methods Of the 29 002 consecutive ambulatory patients who underwent stress myocardial perfusion imaging over a 5-year period, 205 (0.7%) developed stress-induced ST-segment elevation, of whom 39 (19%) had no Q-wave MI in leads showing ST-segment elevation during either exercise (n = 31) or dipyridamole (n = 8) stress myocardial perfusion imaging. All 39 patients were hospitalized and underwent coronary angiography. Results Significant coronary artery disease was found in all 39 patients: 87% had critical (≥90%) stenosis, and 59% had multiple vessel disease. During hospitalization, 37 patients (95%) underwent revascularization. Conclusions In patients without prior Q-wave MI, stress-induced ST-segment elevation is associated with critical coronary artery disease. Therefore, these patients should be considered for early coronary investigation.

Staged bilateral carotid stenting, an effective strategy in high-risk patients – insights from a prospective multicenter trial

To prospectively evaluate outcomes of high-risk patients undergoing bilateral carotid artery stenting (CAS). A total of 747 patients at increased risk for carotid endarterectomy (CEA) were enrolled in a prospective registry at 47 US sites of the Boston Scientific EPI: A Carotid Stenting Trial for Risk Surgical Patients (BEACH) trial. Among them, 78 (10.4%) patients underwent contralateral CAS > 30 days after the primary CAS procedure. Patients were followed at 1, 6, and 12 months, and annually thereafter for 3 years. The primary endpoint was the cumulative incidence of non Q-wave myocardial infarction within 24 hours, periprocedural (<or=30 days) death, stroke or Q-wave MI, and late ipsilateral stroke or death due to neurological events from 31 days up to 12 months. The bilateral patients are independent from the pivotal cohort. Mean follow-up was 885 + 320 days in the bilateral and 861 + 343 in the pivotal group. The primary endpoint occurred in 6.8% (5/73) of the bilateral patients and 8.9% (40/447) of the pivotal group (P = .66). There were no statistically significant differences between the bilateral and the pivotal groups with regard to any of the components of the primary or secondary endpoints. The univariate 1-year major adverse event (MAE) free survival was 93.6% and 91.6% in the bilateral and pivotal groups, respectively (P = .55). Multivariate logistic regression analysis with adjustment for various clinical baseline factors revealed no differences in the primary endpoint when comparing the bilateral with the pivotal groups at 30 days (odds ratio [OR]: 0.8673, 95% confidence interval [CI] 0.4590-1.6389, P = .66) or 1 year (OR: 0.9102, 95% CI 0.5503-1.5053, P = .73). Bilateral carotid stenting is an effective treatment strategy in patients determined to be at high-risk for CEA with no increase in morbidity or mortality results extended out to one year in a prospective multicenter trial.

Use of secondary prevention drug therapy in patients with acute coronary syndrome after hospital discharge.

Acute coronary syndrome includes life-threatening clinical conditions ranging from unstable angina to non-Q-wave myocardial infarction and Q-wave myocardial infarction that are a major cause of emergency medical care and hospitalization in the United States. The American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the management of patients with unstable angina and non-ST-segment elevation myocardial infarction (2002-2004) recommend (1) angiotensinconverting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) for ACE inhibitor intolerance, (2) beta-blockers, and (3) statins for long-term treatment of patients after an acute coronary event. To examine rates of use of 3 key evidence-based drug therapies (ACE inhibitors/ARBs, beta-blockers, and statins) after hospital discharge for patients with acute coronary syndromes (ACS). The study cohort was identified using medical claims from commercial health plans within a managed care organization located in the Mid-Atlantic states, with approximately 3.4 million members with medical benefits of whom 1.2 million members (35.3%) had pharmacy benefits. Members were included if they were (1) aged >or= 18 years, (2) continuously enrolled with the same commercial plan from January 1, 2003, through December 31, 2005, (3) had any medical claims for hospitalization for ACS defined by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 410.xx (acute myocardial infarction) or 411.1 (intermediate coronary syndrome) during the sample identification period from July 1, 2003 through June 30, 2004, and (4) had no medical claims for ACS hospitalizations from January 1, 2003, through June 30, 2003, in any of 10 diagnosis fields on an inpatient hospital claim. Pharmacy claims for ACE inhibitors, ARBs, beta-blockers, and statins were obtained for 18 months following each index date, defined as the earliest ACS diagnosis date during the identification period. Utilization was defined as the member having at least 1 pharmacy claim within each class from index date to 3 months post-index date. Five time periods were examined to assess therapy: - 180 to 0 days (6 months prior), 0 to 90 days (3 months), 0 to 180 days (6 months), 0 to 365 days (12 months), and 0 to 548 days (18 months) following the index date. ACE inhibitors and ARBs were considered together (i.e., a patient had to have at least 1 pharmacy claim for an ACE inhibitor or an ARB). Logistic regression analyses were used to predict use of the 3 drug classes for patients with different clinical (diagnosis and prior use) and demographic (sex and age) characteristics. The study cohort included 1,135 patients (0.27% of 424,526 continuously enrolled members) with ACS as defined by ICD-9-CM codes in medical claims from July 1, 2003, to June 30, 2004. Nearly 65% of the sample patients were men (n = 734 men and n = 401 women), with a mean (standard deviation [SD]) age of 63.8 (SD 13.1) years. Of the 1,135 members with ACS, 588 (51.8%) had at least 1 pharmacy claim for an ACE inhibitor or ARB, 725 (63.9%) for a beta-blocker, and 710 (62.6%) for a statin during the 3-month follow-up period; receipt of at least 1 prescription in all 3 classes was found in 339 (29.9%) of patients. Patients who were aged < 45 years, 65-79 years, and e 80 years were significantly less likely than patients aged 45-64 years to receive statins (P < 0.05). In addition, patients who were aged e 80 years were significantly less likely to receive ACE inhibitors/ARBs (P = 0.003), beta-blockers (P < 0.001), or all 3 classes (P = 0.002). Women were less likely than men to receive statins (P = 0.004) and all 3 drug classes (P = 0.012). Patients with intermediate coronary syndrome were significantly less likely than those with acute myocardial infarction to receive any of the study drugs (P < 0.001). Those patients who had used ACE inhibitors/ARBs, beta-blockers, statins, and all 3 drug classes during the 6 months prior to the index diagnosis of ACS were more likely than those without prior use (odds ratios of 12.2, 9.4, 8.3, and 4.9, respectively, P < 0.001) to have these medications continued after ACS diagnosis. At 3 months following the index ACS hospitalization, the majority of the patients were not receiving the 3 guideline medication therapies. ACS patients with intermediate coronary syndrome and those aged 80 years or older were less likely to be receiving any of the 3 therapies, and women were less likely than men to receive statin therapy.

Stents versus Coronary-Artery Bypass Grafting for Left Main Coronary Artery Disease

Several studies have compared the treatment effects of coronary stenting and coronary-artery bypass grafting (CABG). However, there are limited data regarding the long-term outcomes of these two interventions for patients with unprotected left main coronary artery disease. We evaluated 1102 patients with unprotected left main coronary artery disease who underwent stent implantation and 1138 patients who underwent CABG in Korea between January 2000 and June 2006. We compared adverse outcomes (death; a composite outcome of death, Q-wave myocardial infarction, or stroke; and target-vessel revascularization) with the use of propensity-score matching in the overall cohort and in separate subgroups according to type of stent. In the overall matched cohort, there was no significant difference between the stenting and CABG groups in the risk of death (hazard ratio for the stenting group, 1.18; 95% confidence interval [CI], 0.77 to 1.80) or the risk of the composite outcome (hazard ratio for the stenting group, 1.10; 95% CI, 0.75 to 1.62). The rates of target-vessel revascularization were significantly higher in the group that received stents than in the group that underwent CABG (hazard ratio, 4.76; 95% CI, 2.80 to 8.11). Comparisons of the group that received bare-metal stents with the group that underwent CABG and of the group that received drug-eluting stents with the group that underwent CABG produced similar results, although there was a trend toward higher rates of death and the composite end point in the group that received drug-eluting stents. In a cohort of patients with unprotected left main coronary artery disease, we found no significant difference in rates of death or of the composite end point of death, Q-wave myocardial infarction, or stroke between patients receiving stents and those undergoing CABG. However, stenting, even with drug-eluting stents, was associated with higher rates of target-vessel revascularization than was CABG.

Response to The J-Point Revisited

We thank Dr Rosendorff1 for his interest in our editorial2 accompanying the article by Thune et al.3 The data presented by Thune et al3 indicated, in their words, an association (but no definite specification of cause and effect) between low blood pressure and adverse cardiovascular outcomes. As you suggest for their data, low pressure may not be an independent variable in the prediction of future adverse cardiovascular outcomes. Instead, low pressure may be the result of previous anterior myocardial infarction, Q-wave myocardial infarction, and/or degree of elevation of creatine kinase, genuine independent variables. We agree and would add …

Percutaneous coronary intervention utilizing a new endothelial progenitor cells antibody‐coated stent: A prospective single‐center registry in high‐risk patients

To prospectively evaluate the outcome with circulating endothelial progenitor cell (EPC) capture stent implantation in a cohort of consecutive patients with high-risk angiographic and/or clinical features. Genous R-stent is a stainless steel coronary stent covered with antibodies specific to EPC's surface antigens, designed to promote the formation of a confluent functional endothelial layer over the device; conceivably, this may prevent both stent thrombosis and restenosis. From November 2005 to March 2007, 80 patients received 93 EPC capture stents at Campus Bio-Medico, University of Rome. Patients had two or more of the following high-risk features: diabetes mellitus (33%), unstable coronary syndromes (73%), left ventricular dysfunction (8%), multivessel intervention (9%), B2/C lesions (56%). Acute success was achieved in 79/80 patients (98%), without Q-wave myocardial infarction (MI), in-hospital death or emergency bypass surgery; no patient had acute or subacute stent thrombosis. Follow-up was available in 78 patients (mean 14 +/- 4 months): noncardiac death occurred in one patient, acute MI in one patient; no patient required bypass surgery; 10 patients (13%) underwent percutaneous target lesion revascularization (TLR); three patients (4%) had reintervention on a nontarget vessel. Kaplan-Meyer life-table analysis showed event-free survival of 86% and TLR-free survival of 90% at one and a half year follow-up. The cell capture stent is safe and effective, with satisfactory immediate results and mid-term outcome, without evidence of stent thrombosis. Whether those devices represent a viable alternative to currently available drug-eluting or bare metal stents will need to be evaluated in larger randomized studies.

The J-Point Revisited

To the Editor: Oh, the diabolical J-curve! Will we ever resolve this issue? Recently, you published a posthoc analysis1 of data from the Valsartan in Acute Myocardial Infarction Trial that showed, inter alia, that, after a myocardial infarction (MI), a sustained low blood pressure (BP; systolic BP <100 mm Hg on 2 of the post-MI visits at 1, 3, and 6 months) was a marker for bad cardiovascular outcomes. We were also told, incidentally, that this subset of patients had a significantly higher incidence of anterior MI and Q-wave MI and significantly higher maximum creatine kinase values during the MI than those who had normal BPs at 1, 3, and 6 months. In my view, these …

Prevalence of metabolic syndrome components in patients with acute coronary syndromes

Many studies report that the components of the metabolic syndrome--arterial hypertension, abdominal obesity, diabetes mellitus, and atherogenic dyslipidemia--are associated with an increased risk of cardiovascular disease. We investigated the prevalence of different components of the metabolic syndrome and frequency of their combinations and acute hyperglycemia among patients with acute coronary syndromes. The study population consisted of 2756 patients (1670 men and 1086 women with a mean age of 63.3+/-11.3 years) with acute coronary syndromes: Q-wave myocardial infarction was present in 41.8% of patients; non-Q-wave MI, in 30.7%; and unstable angina pectoris, in 27.5%. The metabolic syndrome was found in 59.6% of the patients according to modified NCEP III guidelines. One component of the metabolic syndrome was found in 13.5% of patients; two, in 23.0%; and none, in 3.9%. Less than one-third (29.2%) of the patients had three components of the metabolic syndrome, and 30.4% of the patients had four or five components. Arterial hypertension and abdominal obesity were the most common components of the metabolic syndrome (82.2% and 65.8%, respectively). Nearly half of the patients had hypertriglyceridemia and decreased level of high-density lipoprotein cholesterol (55.0% and 51.1%, respectively), and 23.9% of patients had diabetes mellitus. Acute hyperglycemia (> or =6.1 mmol/L) without known diabetes mellitus was found in 38.1% of cases. The combination of arterial hypertension and abdominal obesity was reported in 57.8% of patients in the case of combinations of two-five metabolic syndrome components. More than half of patients with acute coronary syndromes had three or more components of the metabolic syndrome, and arterial hypertension and abdominal obesity were the most prevalent components of the metabolic syndrome.

Troponin ratio and risk stratification in subjects with acute coronary syndrome undergoing percutaneous coronary intervention

Background Cardiac enzyme release after percutaneous coronary intervention (PCI) seems to play a role in risk stratification. After PCI, CK-MB plasmatic concentrations three times above the upper level of normal (ULN) are currently the most used risk stratification parameters. We sought to assess whether peak cardiac troponin I (cTn-I) concentration/base concentration ratio (PBTR) may act as a predictor of major adverse cardiac events (MACEs) after PCI, regardless of cTn-I ULN. Methods We evaluated 326 consecutive patients with acute coronary syndrome (ACS) who underwent PCI. Baseline and post-PCI cTn-I values were evaluated over serial blood samples every 6h for at least 72h. Patients were further divided into four groups according to their PBTR values (< 1, 1–4, 4–10, > 10). MACEs were recorded over a 6-month follow-up period. Patients with primary PCI or unsuccessful PCI were excluded from the study. Results Higher values of PBTR significantly correlated with a worse prognosis at 6 months (< 1, 16.30% of MACEs; 1–4, 19.42%; 4–10, 24.39%; > 10, 35.63%; p < 0.05), both in Q-wave myocardial infarction (MI) and unstable angina (UA) subgroups. The correlation remained statistically significant, even considering subjects with peak cTn-I less than three times the ULN ( p < 0.05) and after correction for age, gender, risk factors, diagnosis (MI versus UA), and peak cTn-I levels in a multiple Cox' regression analysis (HR 1.62, p < 0.05). Conclusions PBTR is an independent predictor of MACEs after PCI in a 6-month follow-up period. This risk stratification tool may be useful to predict adverse events in PCI patients, even in the case of apparently non-elevated peak cTn-I concentrations.

Unrecognized Myocardial Infarction in Relation to Risk of Dementia and Cerebral Small Vessel Disease

Men, but not women, with unrecognized myocardial infarction (MI) have an increased risk of cardiac events and stroke compared with those without MI or with recognized MI. We investigated whether unrecognized MI is also a risk factor for dementia and cerebral small vessel disease (white matter lesions and brain infarction) in 2 population-based cohort studies. In the Rotterdam Study, 6347 participants were classified at baseline (1990 to 1993) into those with recognized MI (subdivided into Q-wave and non-Q-wave MI), with unrecognized MI, and without MI based on electrocardiography and interview and were followed for incident dementia (n=613) until January 1, 2005. In the Rotterdam Scan Study, 436 nondemented persons were similarly classified based on electrocardiography and interview and underwent brain MRI for the assessment of white matter lesions and brain infarction. In men, unrecognized MI was associated with an increased risk of dementia (compared with men without MI hazard ratio, 2.14; 95% CI, 1.37 to 3.35) and with more white matter lesions and more often brain infarction on MRI. In women, no associations were found with unrecognized MI. Recognized MI was not associated with the risk of dementia in either sex. Men, but not women, with recognized MI had more often any brain infarction or asymptomatic brain infarction, especially if they had Q-wave MI. No consistent associations were found between recognized Q-wave or non-Q-wave MI and severity of white matter lesions. Additional adjustment for cardiovascular risk factors did not change the results. Men with unrecognized MI have an increased risk of dementia and more cerebral small vessel disease.

Meta-analysis of Four Randomized Controlled Trials on Long-Term Outcomes of Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention With Stenting for Multivessel Coronary Artery Disease

To provide a quantitative analysis of long-term clinical outcomes, a meta-analysis of 4 randomized controlled trials of percutaneous coronary intervention (PCI) with stenting versus coronary artery bypass grafting (CABG) for multivessel coronary artery disease was conducted. The search identified 4 randomized controlled trials of PCI with stenting versus CABG that enrolled patients with multivessel coronary artery disease. In conclusion, pooled analysis demonstrated no statistically significant differences in death, cardiac death, Q-wave myocardial infarction, cerebrovascular accidents, and angina pectoris between PCI with stenting and CABG. However, PCI with stenting was associated with a statistically significant increase in subsequent PCI, subsequent CABG, subsequent revascularization (PCI or CABG), and major adverse cardiovascular events relative to CABG.

Impaired glucose regulation, elevated glycated haemoglobin and cardiac ischaemic events in vascular surgery patients

Cardiac morbidity and mortality is high in patients undergoing high-risk surgery. This study investigated whether impaired glucose regulation and elevated glycated haemoglobin (HbA(1c)) levels are associated with increased cardiac ischaemic events in vascular surgery patients. Baseline glucose and HbA(1c) were measured in 401 vascular surgery patients. Glucose < 5.6 mmol/l was defined as normal. Fasting glucose 5.6-7.0 mmol/l or random glucose 5.6-11.1 mmol/l was defined as impaired glucose regulation. Fasting glucose > or = 7.0 or random glucose > or = 11.1 mmol/l was defined as diabetes. Perioperative ischaemia was identified by 72-h Holter monitoring. Troponin T was measured on days 1, 3 and 7 and before discharge. Cardiac death or Q-wave myocardial infarction was noted at 30-day and longer-term follow-up (mean 2.5 years). Mean (+/- sd) level for glucose was 6.3 +/- 2.3 mmol/l and for HbA(1c) 6.2 +/- 1.3%. Ischaemia, troponin release, 30-day and long-term cardiac events occurred in 27, 22, 6 and 17%, respectively. Using subjects with normal glucose levels as the reference category, multivariate analysis revealed that patients with impaired glucose regulation and diabetes were at 2.2- and 2.6-fold increased risk of ischaemia, 3.8- and 3.9-fold for troponin release, 4.3- and 4.8-fold for 30-day cardiac events and 1.9- and 3.1-fold for long-term cardiac events. Patients with HbA(1c) > 7.0% (n = 63, 16%) were at 2.8-fold, 2.1-fold, 5.3-fold and 5.6-fold increased risk for ischaemia, troponin release, 30-day and long-term cardiac events, respectively. Impaired glucose regulation and elevated HbA(1c) are risk factors for cardiac ischaemic events in vascular surgery patients.

Changing trends in the evaluation of ejection fraction in patients hospitalized with acute myocardial infarction: The Worcester Heart Attack Study

Extent of left ventricular dysfunction in patients with acute myocardial infarction (AMI) is an important predictor of subsequent morbidity and mortality. It is unclear, however, how often ejection fraction (EF) findings are evaluated in the setting of AMI, and the characteristics of patients who do not have their EF evaluated, particularly from the more generalizable perspective of a population-based investigation. The purpose of this study was to examine nearly 3 decade long trends (1975-2003) in the evaluation of EF in patients admitted with confirmed AMI (n = 12,760) to all greater Worcester (Massachusetts) hospitals during 14 annual periods. The percentage of patients undergoing evaluation of EF before hospital discharge increased substantially between 1975 (4%) and 2003 (73%). Despite these encouraging trends, approximately one quarter of patients in our most recent study year did not receive an EF evaluation. In the mid-1970s through mid-1980s, radionuclide ventriculography was typically used to assess EF, whereas echocardiography was most often used to evaluate EF during more recent periods. Predictors of not undergoing an evaluation of cardiac function included older age, shorter length of hospital stay, code status limitations, dying during hospitalization, Medicare insurance, several comorbidities, and a recent non-Q-wave myocardial infarction. The results of this community-wide study suggest that a considerable proportion of patients with AMI fail to have their EF evaluated. Efforts remain needed to optimize the use of cardiac imaging studies and link the results of these studies to improved patient outcomes.

The effect of drug-eluting stents on intermediate angiographic and clinical outcomes in diabetic patients: Insights from randomized clinical trials

Implantation of drug-eluting stents has emerged as the predominant percutaneous revascularization strategy in diabetic patients, despite limited outcomes data. Accordingly, our aim was to conduct a meta-analysis to assess the benefit and safety profile of drug-eluting stents in diabetic patients. We included randomized trials comparing either the paclitaxel- or sirolimus-eluting stent with a bare-metal stent or with each other in diabetic patients during a follow-up of at least 6 months. A total of 16 studies were identified, which included 2951 diabetic patients who were followed up for 6 to 12 months. Target lesion revascularization was less frequently performed in patients who received drug-eluting stents compared with bare-metal stents (risk ratio [RR] 0.35, 95% CI 0.27-0.46, P < .0001). Similar reductions were noted in the incidence of major adverse cardiovascular events (RR 0.42, 95% CI 0.31-0.56, P < .0001), in-segment restenosis (RR 0.31, 95% CI 0.25-0.40, P < .0001), and non-Q-wave myocardial infarction (RR 0.57, 95% CI 0.32-0.99, P = .046). Event rates were similar for Q-wave myocardial infarction (RR 0.72, 95% CI 0.25-2.07, P = .54), death (RR 0.64, 95% CI 0.32-1.28, P = .20), and stent thrombosis (RR 0.41, 95% CI 0.13-1.27, P = .12). In conclusion, diabetic patients who receive drug-eluting stents have a significantly lower incidence of target lesion revascularization, in-segment restenosis and myocardial infarction at 6 to 12 months, compared with bare-metal stents. The rates of mortality and stent thrombosis are similar.

Sicilian DES Registry: prospective in-hospital and 9-month clinical and angiographic follow-up in selected high restenosis risk patients

This is a multicentre, open label, prospective non-randomized registry, with 9-month angiographic follow-up, conducted to evaluate the safety and effectiveness of drug-eluting stents (DES) when used in high restenosis risk patients from the real world. From June 2004 to February 2005, a total of 1622 consecutive patients were enrolled to the Sicilian DES Registry, according to specific inclusion criteria. Both paclitaxel-eluting and sirolimus-eluting stents were used. The analysis was performed on 1472 patients because 150 patients were excluded from the study. The primary endpoint was to evaluate the rate of major adverse cardiac events (MACE) within 9 months after DES implantation. Major adverse cardiac events were defined as cardiac death, non-Q-wave or Q-wave myocardial infarction (MI) and target vessel revascularization (TVR). The secondary endpoints were procedural success, angiographic binary restenosis and stent thrombosis within 9 months post-procedure. Patients were more frequently male; 472 (32.1%) were diabetics, of whom 130 (27.5%) were treated with insulin. Mean ejection fraction of the left ventricle was 51.5 +/- 8.7%. Multivessel disease was found and treated in 627 patients (42.6%). A total of 2439 lesions were treated with DES. Final angiographic success was achieved in 2422 (99.3%) lesions. Procedural success was achieved in 1422 (96.6%) patients. The 9-month cumulative incidence of MACE was 7.3% with 0.8% of cardiac deaths, 0.8% non-fatal MI, 7.9% TVR. Binary restenosis was observed in 101 patients (8.3%). Stent thrombosis was documented in 11 patients (0.8%). Drug-eluting stents appear to be safe and associated with a low incidence of MACE at 9-month follow-up, even in patients selected for their complexity.

Understanding sex differences in health-related quality of life following myocardial infarction

Background The role of sex differences in health-related quality of life (HRQoL) after myocardial infarction (MI) remains controversial. Methods In total 408 Norwegian patients completed the Short Form 36 (SF-36) questionnaire 2.5 years after MI. We compared HRQoL between sexes and with national norms. Multiple linear regression analysis was used to explore the association of scores on the Physical (PCS) and Mental (MCS) component summary scales with clinical and sociodemographic variables. Results Women scored lower than norms on the Physical functioning, Role functioning-physical, General health, and Role functioning-emotional scales. Men scored higher on Bodily pain, and lower on the other 7 scales compared to norms. Women < 70 years scored lower than men on 3 out of 8 scales and on PCS. Women ≥ 70 scored lower than men on 5 out of 8 scales and on PCS. Relative to sex- and age-specific norms, there were no sex-differences in SF-36 scores. Age, time since the index MI, chronic obstructive pulmonary disease (COPD), previous MI, and stroke predicted PCS scores in women. Education, COPD, infarct localization, number of indications for cardiovascular medication at discharge, medication for heart failure, and subsequent MI predicted PCS scores in men. Smoking status, education, and Q-wave MI were determinants for MCS scores in men. Conclusion Patients had impaired HRQoL compared to sex- and age-specific norms 2.5 years after MI. Women had lower HRQoL scores than men, but relative to norms HRQoL was equally affected in both sexes. Men and women had different determinants of HRQoL.

Effectiveness of Drug-Eluting Stent Implantation for Patients With Unprotected Left Main Coronary Artery Stenosis

This study was aimed to evaluate outcomes of patients with unprotected left main coronary artery (LMCA) stenosis who were treated with drug-eluting stents. Sixty-three consecutive patients with unprotected LMCA stenosis were treated with sirolimus-eluting stents in 52 (83%) patients and paclitaxel-eluting stents in 11 (17%) patients, in whom percutaneous intervention was considered the sole alternative because of high surgical risk and/or patient preference. Urgent percutaneous coronary intervention within 24 hours after angiography was performed in 6 (10%) patients. The patients were predominantly at high surgical risk with 35 (56%) having EuroSCORE >6 and 39 (62%) having Parsonnet score >15. Involvement of the distal LMCA was observed in 46 (73%) patients. Procedural success was achieved in all patients. Intravascular ultrasound was used in 51 (81%) patients. Single-stenting strategy was adopted in 36 (78%) patients with bifurcation stenosis. There were no death, Q-wave myocardial infarction, stent thrombosis, or urgent repeat revascularization events during hospitalization. Over a mean follow-up of 11.7 +/- 7.7 months, 18 (29%) patients experienced major adverse cardiac events, including 3 (5%) deaths, 7 (11%) myocardial infarctions, and 10 (16%) target lesion revascularizations. Stent thrombosis developed in 1 (0.6%) patient at 35 days after the procedure. Bifurcation involvement was an independent predictor of major adverse cardiac events by multivariate analysis (hazard ratio 12.90, 95% confidence interval 1.36 to 122.45, p = 0.0259). In conclusion, drug-eluting stent placement for unprotected LMCA stenosis may be a feasible therapeutic alternative in patients at high surgical risk. However, bifurcation stenosis remains a significant predictor of unfavorable clinical outcome.

Adjunct Thrombus Aspiration Reduces Mortality in Patients Undergoing Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction With High-Risk Angiographic Characteristics

Routine aspiration thrombectomy (AT) in percutaneous coronary intervention for patients with ST-segment elevation myocardial infarction (STEMI) has not proved effective in randomized trials. However, in patients undergoing primary percutaneous coronary intervention with severely reduced flow or visible thrombus, AT remains an intuitively attractive option. The use of adjunctive AT in a high-risk cohort of 158 consecutive patients with STEMI and Thrombolysis In Myocardial Infarction (TIMI) 0 to 1 flow or visible thrombus on baseline angiography was examined. Of these, 80 patients underwent AT as an adjunct to primary percutaneous coronary intervention, and 78 underwent percutaneous coronary intervention without AT (non-AT). TIMI 3 flow rates, residual thrombus after percutaneous coronary intervention, and major adverse cardiac events (mortality and nonfatal Q-wave myocardial infarction) at 30 days, 6 months, and 1 year were compared. Baseline characteristics were similar between groups. The AT group more frequently achieved TIMI 3 flow after the intervention (91.3% AT vs 67.9% non-AT; p <0.001) and had less residual thrombus (7.5% AT vs 19.2% non-AT; p = 0.03). AT was associated with reduced major adverse cardiac events at 6 months (6.8% AT vs 24.0% non-AT; p = 0.004) and 1 year (16.6% AT vs 29.2% non-AT; p = 0.009), and decreased mortality rates in the AT group at 6 months (5.4% AT vs 21.3% non-AT; p = 0.004) and 1 year (7.7% AT vs 26.2% non-AT; p = 0.005). In conclusion, for patients with STEMI and TIMI 0 or 1 flow or visible thrombus on baseline angiography, AT was associated with increased TIMI 3 flow rates, decreased residual thrombus, and decreased clinical events, including mortality.

Carotid Artery Revascularization in High-Surgical-Risk Patients Using the Carotid WALLSTENT and FilterWire EX/EZ: 1-Year Outcomes in the BEACH Pivotal Group

Carotid Artery Revascularization in High-Surgical-Risk Patients Using the Carotid WALLSTENT and FilterWire EX/EZ: 1-Year Outcomes in the BEACH Pivotal Group Sriram S. Iyer, Christopher J. White, L. Nelson Hopkins, Barry T. Katzen, Robert Safian, Mark H. Wholey, William A. Gray, Rocco Ciocca, William B. Bachinsky, Gary Ansel, James D. Joye, Mary E. Russell, for the BEACH Investigators The multicenter, single-arm BEACH (Boston Scientific EPI: A Carotid Stenting Trial for High-Risk Surgical Patients) trial (n = 480) evaluated outcomes in high-surgical-risk patients with carotid artery stenosis treated with the WALLSTENT plus FilterWire EX/EZ. Follow-up included duplex imaging and independent neurologic examination. The 1-year composite primary end point (30-day stroke, death, Q-wave myocardial infarction [MI]; 24-h non–Q-wave MI; 1-year ipsilateral stroke or neurologic death) occurred in 8.9% of patients (11.5% upper 95% confidence limit), well within the 16.6% calculated noninferiority margin (12.6% objective performance criterion for high-risk carotid endarterectomy [CEA] plus 4% margin). In high-surgical-risk patients, stenting with the WALLSTENT plus FilterWire EX/EZ is noninferior (equivalent or better, p < 0.0001) to CEA at 1 year. The multicenter, single-arm BEACH (Boston Scientific EPI: A Carotid Stenting Trial for High-Risk Surgical Patients) evaluated outcomes in high-surgical-risk patients with carotid artery stenosis treated with the Carotid WALLSTENT plus FilterWire EX/EZ Emboli Protection System (Boston Scientific, Natick, Massachusetts). Carotid artery stent (CAS) placement offers a less invasive alternative for high-risk surgical carotid endarterectomy (CEA) patients. The trial enrolled 480 pivotal patients who were candidates for carotid revascularization but considered high surgical risk due to pre-specified anatomic criteria and/or medical comorbidities. The primary end point (all stroke, death, or Q-wave myocardial infarction [MI] through 30 days; non–Q-wave MI through 24 h; and ipsilateral stroke or neurologic death through 1 year) was compared with a proportionally weighted objective performance criterion (OPC) of 12.6% for published surgical endarterectomy results in similar patients, plus a pre-specified noninferiority margin of 4%. Among pivotal patients, 41.2% were at high surgical risk due to comorbid risk factors, and 58.8% due to anatomic risk factors; 76.7% were asymptomatic with flow-limiting carotid stenosis >80%. At 1 year, the composite primary end point occurred in 8.9% (40 of 447), with a repeat revascularization rate of 4.7%. With an upper 95% confidence limit of 11.5% for the primary composite end point, the BEACH trial results met the pre-specified criteria for noninferiority relative to the calculated OPC plus noninferiority margin (16.6%) for historical surgical CEA outcomes in similar patients (p < 0.0001 for noninferiority). The BEACH trial results demonstrate that CAS with the WALLSTENT plus FilterWire embolic protection is non-inferior (equivalent or better than) to CEA at 1-year in high-surgical-risk patients (Boston Scientific Embolic Protection, Inc. [EPI]: A Carotid Stenting Trial for High-Risk Surgical Patients [BEACH]; http://clinicaltrials.gov/ct2/show/NCT00316108?term=NCT00316108&rank=1 ; NCT00316108 ).

Influence of Renal Function on the Usefulness of N-Terminal Pro-B-Type Natriuretic Peptide as a Prognostic Cardiac Risk Marker in Patients Undergoing Noncardiac Vascular Surgery

N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) is related to stress-induced myocardial ischemia and/or volume overload, both common in patients with renal dysfunction. This might compromise the prognostic usefulness of NT-pro-BNP in patients with renal impairment before vascular surgery. We assessed the prognostic value of NT-pro-BNP in the entire strata of renal function. In 356 patients (median age 69 years, 77% men), cardiac history, glomerular filtration rate (GFR, ml/min/1.73 m(2)), and NT-pro-BNP level (pg/ml) were assessed preoperatively. Troponin T and electrocardiography were assessed postoperatively on days 1, 3, 7, and 30. The end point was the composite of cardiovascular death, Q-wave myocardial infarction, and troponin T release. Multivariate analysis was used to evaluate the interaction between GFR, NT-pro-BNP and their association with postoperative outcome. Median GFR was 78 ml/min/1.73 m(2) and the median concentration of NT-pro-BNP was 197 pg/ml. The end point was reached in 64 patients (18%); cardiac death occurred in 7 (2.0%), Q-wave myocardial infarction in 34 (9.6%), and non-Q-wave myocardial infarction in 23 (6.5%). After adjustment for confounders, NT-pro-BNP levels and GFR remained significantly associated with the end point (p = 0.005). The prognostic value of NT-pro-BNP was most pronounced in patients with GFR > or =90 (odds ratio [OR] 1.18, 95% confidence interval [CI] 0.80 to 1.76) compared with patients with GFR 60 to 89 (OR 1.04, 95% CI 1.002 to 1.07), and with GFR 30 to 59 (OR 1.12, 95% CI 1.03 to 1.21). In patients with GFR <30 ml/min/1.73 m(2), NT-pro-BNP levels have no prognostic value (OR 1.00, 95% CI 0.99 to 1.01). In conclusion, the discriminative value of NT-pro-BNP is most pronounced in patients with GFR > or =90 ml/min/1.73 m(2) and has no prognostic value in patients with GFR <30 ml/min/1.73 m(2).