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In the prethrombolytic era, in-hospital mortality of patients with non–Q wave myocardial infarction (MI) was only one-half that of patients with Q wave MI (see discussion in reference [1][1]). Despite this more favorable early outcome, patients with non–Q wave MI have a higher incidence of

Objectives. The purpose of this study was to determine whether there are gender differences in the outcome of percutaneous transluminal coronary angioplasty performed for postmyocardial infarction ischemia.Background. Although women have a higher mortality rate after myocardial infarction than that of men, they are less frequently referred for coronary angioplasty (and coronary artery bypass graft surgery) than are men, possibly because of expectations of a worse procedural outcome.Methods. We analyzed the morbidity and mortality at coronary angioplasty and during a mean follow-up period of 34.4 months for women and 34.2 months for men in 505 consecutive patients (164 women and 341 men) with postmyocardial infarction ischemia between 1981 and 1989.Results. Compared with men, women had similar procedural success rates (89.6% and 91.2%, respectively), need for coronary artery bypass surgery (3.7% and 2.6%) and mortality rates at coronary angioplasty (0.6% and 0.9%). During the follow-up period there were no significant gender differences in the requirement for coronary artery bypass surgery (3.6% and 4%), repeat angioplasty (18.7% and 17.3%), reinfarction (5.8% and 6%) and death (3.6% and 3.7%) or the combined end points of all four events (26.6% and 26.6%). Women had significantly more recurrent angina than did men (54% vs. 42.5%, p < 0.01), even though the extent of coronary artery disease and frequency of incomplete revascularization were similar in men and women.Conclusions. The procedural outcome of coronary angioplasty for postmyocardial infarction ischemia is similar in women and men. Long-term follow-up is also similar except that women experience an increased incidence of recurrent angina, an outcome also reported after bypass surgery. Therefore, concerns over the safety of coronary angioplasty in women should not adversely influence decisions concering referral of women for coronary angioplasty after myocardial infarction complicated by ischemia.

The recent findings that lipid lowering therapy reduces clinical events to a greater degree than it reduces stenosis severity suggest beneficial effects other than plaque regression. To determine if a favorable lipid profile is associated with decreased thrombotic tendency, we determined the relationship between two hemostatic risk factors, fibrinogen and plasminogen activator inhibitor (PAI-l), and LDL cholesterol (LDL-C) in 1,878 subjects free of cardiovascular disease in the Framingham Offspring Study. The subjects studied ranged from those with hypobetalipoproteinemia, a condition characterized by LDL-C ≤ 70 mg/dl, and a low incidence of thrombosis and coronary heart disease, to other LDL-C levels grouped by NCEP guidelines. LDL-C (mg/dl) l 70 70–99 100 129 g 130 * p-value Number subjects 41 389 653 795 Fibrinogen (mg/dl) 264 ± 54 287 ± 59 297 ± 57 303 ± 55 l 0.0001 PAI-l antigen (ng/ml) 14 ± 9 27 ± 18 22 ± 17 23 ± 46 l 0.0001 * p-value for linear effect of LDL-C These findings were similar in men and women. Multivariate adjustment for age, gender, body mass index, diabetes, smoking, alcohol intake, and use of antihypertensive medication did not alter the results. Conclusion Decreasing LDL-C levels are associated with decreasing levels of hemostatic risk factors. These findings support the hypothesis that lipid lowering therapy may reduce clinical events by reducing thrombotic tendency.

Estrogen usage in postmenopausal women is associated with a decrease in cardiovascular events, however the mechanism is not well characterized. Although observational studies suggest that estrogen may act in part through an improvement in fibrinolytic potential, this has not been established in placebo-controlled trials before and after estrogen therapy. We performed a randomized, double-blind, placebo-controlled crossover trial of oral estradiol (Estrace®, 1 mg, 2 mg) in 20 postmenopausal women. Samples for fibrinolytic activity (fibrin plate assay) and tissue type plasminogen activator (t-PA) antigen were collected at baseline and after 3, 6 and 9 weeks of therapy. Elevated t-PA antigen levels are associated with increased measures analysis of variance was performed. There were significant treatment effects on fibrinolytic activity and t-PA antigen. Results are presented for basal and 9 week timepoints. Fibrinolytic activity (mm2) tPA antigen (ng/ml) basal 9 weeks basal 9 weeks Placebo 46 ± 8 56 ± 8 10.3 ± 1.8 10.3 ± 1.8 Estrace® 1 mg 50 ± 8 62 ± 8 9.9 ± 1.8 8.8 ± 1.8 Estrace® 2 mg 48 ± 8 * 85 ± 8 9.8 ± 1.8 * 7.8 ± 1.8 * p l 0.05, basal vs 9 weeks Fibrinolytic potential is increased by estrace therapy, as indicated by an increase in fibrinolytic activity and a reduction in tPA antigen. The effect was more marked with the 2 mg preparation. Since increased fibrinolytic activity has been associated with reduced cardiovascular risk. these data suggest that one mechanism of the risk reduction associated with estrogen therapy in postmenopausal women may be via a reduction in thrombotic tendency.

Hormone replacement therapy (HRT) is associated with a decreased risk of coronary heart disease (CHD) in postmenopausal women, but the mechanism of its protective effect is not fully characterized. To evaluate the relation ship between postmenopausal HRT and fibrinogen, an established hemostatic risk factor for CHD, we measured fibrinogen using the Clauss method in 858 women free of CHD in cycle 4 of the Framingham Offspring Study. The table shows mean ± SD fibrinogen levels for pre and postmeonopausal women according to use of HRT N Fibrinogen (mg/dl) %Δ p-value Premenopause 303 289 ± 53 Postmenopause (No HRT) 383 313 ± 58 ↑7.7% * l 0.001 * Postmenopause (HRT) 86 284 ± 44 ↓9.3% ** l 0.001 ** * Premenopause vs. Postmenopause (No HRT); ** Postmenopause (No HRT) vs. Postmenopause (HRT) (Age adjusted) These differences persisted upon multivariate adjustment for smoking, use of antihypertensive medication, diabetes mellitus, body mass index, alcohol intake, total cholesterol and HDL cholesterol. Postmenopausal HRT is associated with fibrinogen levels that are comparable to those found in premenopausal women. These data suggest that the protective effect of postmenopausal HRT may be mediated in part by favorable alterations in the hemostatic system.

Prognosis after myocardial infarction (MI) is influenced by the occurrence of post-myocardial infarction ischemia and by the presence of an open infarct related artery. Revascularization is performed in patients with postmyocardial infarction ischemia to alleviate symptoms. Due to small numbers of patients in studies observing outcome after PTCA for post-infarction ischemia, it has not been possible to determine outcome for patients with open versus severely narrowed or closed vessels following PTCA. In this study, we compared long-term outcome for reinfarction and death in patients with open versus closed or severely narrowed coronary arteries following PTCA for post-infarction ischemia. 505 consecutive patients undervvent PTCA for post-infarction ischemia at Deaconess Hospital between 1981 and 1989. Follow-up (mean 34 months) after hospital discharge for reinfarction, death, repeat PTCA and coronary bypass grafting was then compared based on the status of the artery at the end of angioplasty (open versus closed or severely narrowed). The 5-year Kaplan-Meier actuarial mortality rate was 4.7% for patients with open vessels and 11.4% for those with severely narrowed or closed vessels. Patients with open vessels had a significantly lower mortality (p = 0.009) and mortality or reinfarction (p = 0.007) as judged by the log-rank statistic. Multivariate Cox proportional hazards analyses controlling for age, gender, type and location of MI and year of PTCA revealed a hazard ratio for death for closed or severely narrowed compared with open arteries of 4.7 (95% CI, 1.49-14.75) and for the combined endpoint of MI or death of 3.2 (95% CI, 1.38-7.39). Conclusion Patients who undergo successful revascularization with PTCA for post-infarction ischemia have significantly lower death rates than those with severely narrowed or closed arteries following attempted PTCA.