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Objectives: To investigate the long-term impact of multivessel coronary artery disease (MVD) on cause-specific mortality in patients with ST elevation myocardial infarction (STEMI) treated with reperfusion therapy. Methods and results: Patients with STEMI (n = 395) treated with primary angioplasty or thrombolysis in the setting of a randomised clinical trial were enrolled in the study. Follow up was 8 (2) years. For patients who died all available records were reviewed to assess the specific cause of death. MVD was present in 57% of patients. Patients with MVD were older and more of them had diabetes and previous myocardial infarction. Compared with the non-MVD group, residual left ventricular ejection fraction was lower (45.9% v 49.6%, p = 0.001) and total mortality was higher in patients with MVD (32% v 19%, p = 0.002). After adjustment for potential confounders this association was not significant (hazard ratio 1.4, 95% confidence interval (CI) 0.9 to 2.2). When the specific cause of death was considered, sudden death was comparable between patients with and without MVD (10% v 8%, p = 0.49) but death caused by heart failure was significantly higher in patients with MVD (hazard ratio 7.4, 95% CI 1.7 to 32.2). Conclusion: Patients with STEMI and MVD have a higher long-term mortality than do patients with non-MVD. MVD is not an independent predictor of long-term total mortality or sudden death. However, MVD is a very strong and independent predictor of long-term death caused by heart failure.

Objectives: To study the clinical significance of infarct location during long term follow up in a trial comparing thrombolysis with primary angioplasty. Design: Retrospective longitudinal cohort analysis of prospectively entered data. Setting: Patients with acute ST elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). Patients: In the Zwolle trial 395 patients with acute STEMI were randomly assigned to intravenous streptokinase or PCI. Main outcome measures: Survival according to infarct location and treatment after 8 (2) years of follow up. Results: 105 patients died: 63 patients in the streptokinase group and 42 patients in the primary PCI group (relative risk (RR) 1.6, 95% confidence interval (CI) 1.0 to 2.6; p = 0.03). In patients with non-anterior STEMI there was no difference in mortality between streptokinase and PCI treated patients (RR 1.1, 95% CI 0.6 to 2.1; p = 0.68) but the streptokinase group had significantly more major adverse cardiac events (MACE) than the PCI group (RR 2.1, 95% CI 1.2 to 3.6). The number needed to treat to prevent one MACE was four. In patients with anterior STEMI, mortality was higher in the streptokinase group than in the PCI group (RR 2.7, 95% CI 1.4 to 5.5; p = 0.004). The number needed to treat to prevent one death was five. Kaplan-Meier analysis confirmed the benefits of primary angioplasty in the first year and showed additional benefit of PCI compared with streptokinase between 1–8 years after the acute event. Conclusions: Patients with anterior STEMI have better long term survival when treated with PCI than with streptokinase. In patients alive one year after the acute event, PCI confers a significant additional survival benefit, probably due to better preserved residual left ventricular function.

OBJECTIVE—To investigate the long term clinical outcome and cost-effectiveness of stenting compared with balloon angioplasty in patients with acute myocardial infarction. METHODS—Patients with acute myocardial infarction were randomly allocated to primary stenting (112) or balloon angioplasty (115). The primary end point was the cumulative first event rate of death, non-fatal reinfarction, or target vessel revascularisation. Secondary end points were restenosis at six months and the cost-effectiveness at follow up. RESULTS—After 24 months, the combined clinical end point of death/reinfarction was 4% after stenting and 11% after balloon angioplasty (p = 0.04). Subsequent target vessel revascularisation was necessary in 15 patients (13%) after stenting and in 39 (34%) after balloon angioplasty (p

Objective—To investigate the feasibility of primary coronary angioplasty as a treatment option in patients with acute myocardial infarction after initial diagnosis in a local community hospital. Setting—Referral centre for interventional treatment of coronary artery disease. Methods—During a five year period, 520 candidates for primary coronary angioplasty were treated in our institution, 104 after transfer from a community hospital. The transferred patients and the non-transferred patients (n = 416) were compared with regard to baseline clinical characteristics, time interval from symptom onset to treatment, and clinical outcome at six months. Results—In this setting, the influence of transportation on total ischaemic time was limited, and there was no difference in clinical outcome between the transferred and the non-transferred patients. Clinical outcome was mainly dependent on the indication for transfer. Conclusions—Safe and expedient transportation may facilitate the more widespread use of primary angioplasty in patients with acute myocardial infarction. A large randomised multicentre trial is needed to compare the relative merits of intravenous thrombolytic treatment in a local hospital with primary angioplasty after transfer in selected high risk patients with acute myocardial infarction. Keywords: myocardial infarction; coronary angioplasty; reperfusion

Lyme disease is a recognised cause of atrioventricular block. In most cases the conduction disturbances are reversed by treatment with antibiotics. A 44 year old man with third degree atrioventricular block in Lyme carditis had a temporary decrease in heart rate during resolution of the heart block two days after treatment with antibiotics was started.