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Background/Aims: Both high-dose atorvastatin and rosuvastatin have been shown to reduce contrast-induced acute kidney injury (AKI) occurrence and improve clinical outcomes in high-risk coronary patients undergoing angiographic procedures. However, there is a lack of head-to-head comparative studies on the effects of atorvastatin or rosuvastatin administered upon hospital admission in statin-naive patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS). Methods: In this open-label, noninferiority study, we compared changes in renal function in 709 NSTE-ACS patients randomized to atorvastatin (80 mg upon admission followed by 40 mg/day) or rosuvastatin (40 mg upon admission followed by 20 mg/day). The primary end point was AKI (increase in serum creatinine ≥0.5 mg/dL or ≥25% above baseline within 72 h). Worsening renal function (WRF) (decrease of ≥25% in the glomerular filtration rate from baseline to 30 days), 30-day major adverse cardiovascular events, and 12-month myocardial infarction (MI) or death were also evaluated. Results: The AKI incidence was similar in the 2 groups (i.e., 8.2% with rosuvastatin and 7.6% with atorvastatin; absolute risk difference = 0.54; 90% CI –3.9 to 2.8), satisfying the noninferiority criteria. WRF occurred in 53 (7.5%) patients, 19 (34%) of whom had developed AKI. The rates of WRF and adverse events at 30 days and at 12 months did not differ significantly between the 2 groups. Both AKI and WRF were found to be closely associated with the 12-month cardiovascular outcome irrespectively of statin choice. Conclusions: High-dose rosuvastatin or atorvastatin started upon hospital admission led to similar rates of AKI, 30-day renal function changes, and 12-month death or MI in NSTE-ACS patients who underwent an early invasive strategy (clinical trial registration: https://www.clinicaltrials.gov; unique identifier: NCT01870804).

Different pharmacologic agents have been tested in the effort to prevent contrast-induced acute kidney injury (AKI) in the last two decades. To date, however, no individual drug has received unanimous approval for this aim. Since 2014 statins have been included as preventive treatment in the European guidelines for revascularization procedures in cardiac patients. The present update presents the latest findings in this field focusing on the changing paradigms in the definition and consequently the approach to nephroprotection that considers clinical prognosis as the major issue. We note the current shift from attention to contrast-induced AKI to contrast-associated AKI.

Background: Elderly patients are at elevated risk of both ischemic and bleeding complications after an acute coronary syndrome and display higher on-clopidogrel platelet reactivity compared with younger patients. Prasugrel 5 mg provides more predictable platelet inhibition compared with clopidogrel in the elderly, suggesting the possibility of reducing ischemic events without increasing bleeding. Methods: In a multicenter, randomized, open-label, blinded end point trial, we compared a once-daily maintenance dose of prasugrel 5 mg with the standard clopidogrel 75 mg in patients >74 years of age with acute coronary syndrome undergoing percutaneous coronary intervention. The primary end point was the composite of mortality, myocardial infarction, disabling stroke, and rehospitalization for cardiovascular causes or bleeding within 1 year. The study was designed to demonstrate superiority of prasugrel 5 mg over clopidogrel 75 mg. Results: Enrollment was interrupted, according to prespecified criteria, after a planned interim analysis, when 1443 patients (40% women; mean age, 80 years) had been enrolled with a median follow-up of 12 months, because of futility for efficacy. The primary end point occurred in 121 patients (17%) with prasugrel and 121 (16.6%) with clopidogrel (hazard ratio, 1.007; 95% confidence interval, 0.78–1.30; P =0.955). Definite/probable stent thrombosis rates were 0.7% with prasugrel versus 1.9% with clopidogrel (odds ratio, 0.36; 95% confidence interval, 0.13–1.00; P =0.06). Bleeding Academic Research Consortium types 2 and greater rates were 4.1% with prasugrel versus 2.7% with clopidogrel (odds ratio, 1.52; 95% confidence interval, 0.85–3.16; P =0.18). Conclusions: The present study in elderly patients with acute coronary syndromes showed no difference in the primary end point between reduced-dose prasugrel and standard-dose clopidogrel. However, the study should be interpreted in light of the premature termination of the trial. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01777503.

Background Intravascular volume expansion plays a major role in the prevention of contrast-induced acute kidney injury (CI-AKI). Recommended standard amounts of fluid infusion before procedures do not produce homogeneous responses in subjects with different initial hydration status. Objectives The goal of this study was to compare the effect of standard and double intravenous (IV) infusion volumes in patients with low body fluid level, assessed by using bioimpedance vector analysis (BIVA), on the incidence of CI-AKI after elective coronary angiographic procedures. Methods A total of 303 patients with low BIVA level on admission were randomized to receive standard volume saline (1 ml/kg/h for 12 h before and after the procedure) or double volume saline (2 ml/kg/h). Patients (n = 715) with an optimal BIVA level received standard volume saline and were included in a prospective registry. The saline infusion was halved in all patients with an ejection fraction Results The incidence of CI-AKI was significantly lower (11.5% vs. 22.3%; p = 0.015) in patients receiving double volume saline than in those receiving standard volume saline, respectively. Before the angiographic procedure, 50% of the double volume patients achieved the optimal BIVA level compared with only 27.7% in the standard group (p = 0.0001). The findings were consistent in all the pre-specified subgroups excluding patients with a left ventricular ejection fraction Conclusions Evaluation of BIVA levels on admission in patients with stable coronary artery disease allows adjustment of intravascular volume expansion, resulting in lower CI-AKI occurrence after angiographic procedures. (Personalized Versus Standard Hydration for Prevention of CI-AKI: A Randomized Trial With Bioimpedance Analysis; NCT02225431)

In the effort to prevent contrast-induced acute kidney injury (CI-AKI), several pharmacologic agents have been tested for their single or combined nephroprotective properties. To date, however, no drug has been officially approved for this aim. This article focuses on the three agents that have been most extensively studied: statins, N-acetylcysteine, and ascorbic acid. Particular attention is paid to the impact of these drugs on the CI-AKI prevention and improved prognosis.

Objectives This study sought to investigate whether the beneficial impact of high-dose rosuvastatin against contrast-induced acute kidney injury (CI-AKI) in acute coronary syndrome (ACS) patients varied in relation to baseline high-sensitivity C-reactive protein (hs-CRP) levels. Background High-dose rosuvastatin administered on admission has been shown to prevent CI-AKI and improve short- and mid-term clinical outcome in ACS patients. Methods All 504 statin-naive ACS patients enrolled in the PRATO-ACS (Protective Effect of Rosuvastatin and Antiplatelet Therapy on Contrast-Induced Acute Kidney Injury and Myocardial Damage in ACS Patients) study were stratified into baseline hs-CRP tertiles: Results Patients with higher baseline hs-CRP values presented a significantly higher incidence of CI-AKI (5.4%, 8.7%, and 18.3% in the first, second, and third tertiles, respectively; p = 0.0001). The beneficial effect of rosuvastatin was markedly significant in the third hs-CRP tertile (odds ratio: 0.20; 95% confidence interval: 0.07 to 0.54; p = 0.002). Statin-treated patients in the third tertile presented a significantly lower rate of adverse events at 30 days (7.2% vs. 17.4%, p = 0.043) with a trend toward better outcome at 6 months (6.02% vs. 13.04%, p = 0.12). Conclusions High-dose rosuvastatin administered on admission appears to exert more effective kidney protection in ACS subjects with higher baseline hs-CRP levels resulting in better short- and mid-term clinical outcome. (Protective Effect of Rosuvastatin and Antiplatelet Therapy on Contrast-Induced Nephropathy and Myocardial Damage in Patients With Acute Coronary Syndrome Undergoing Coronary Intervention [PRATO-ACS]; NCT01185938 )

Objectives The aim of this study was to evaluate the relationship between pre-procedural fluid status assessed by bioimpedance vector analysis (BIVA) and development of contrast-induced acute kidney injury (CI-AKI). Background Accurate fluid management in patients undergoing angiographic procedures is of critical importance in limiting the risk of CI-AKI. Therefore, establishing peri-procedural fluid volume related to increased risk of CI-AKI development is essential. Methods We evaluated the fluid status by BIVA of 900 consecutive patients with stable coronary artery disease (CAD) immediately before coronary angiography, measuring the resistance/height (R/H) ratio and impedance/height (Z/H) vector. CI-AKI was defined as an increase in serum creatinine ≥0.5 mg/dl above baseline within 3 days after contrast administration (iodixanol). Results CI-AKI occurred in 54 patients (6.0%). Pre-procedural R/H ratios were significantly higher in patients with CI-AKI than without CI-AKI (395 ± 71 Ohm/m vs. 352 ± 58 Ohm/m, p = 0.001 for women; 303 ± 59 Ohm/m vs. 279 ± 45 Ohm/m, p = 0.009 for men), indicating lower fluid volume in the patients with CI-AKI. When patients were stratified according to R/H ratio, there was an almost 3-fold higher risk in patients with higher values (odds ratio [OR]: 2.9; 95% confidence interval [CI]: 1.5 to 5.5; p = 0.002). The optimal receiver-operating characteristic curve analysis threshold values of R/H ratio for predicting CI-AKI were 380 Ohm/m for women and 315 Ohm/m for men. R/H ratio above these thresholds was found to be a significant and independent predictor of CI-AKI (OR: 3.1; 95% CI: 1.8 to 5.5; p = 0.001). Conclusions Lower fluid status evaluated by BIVA immediately before contrast medium administration resulted in a significant and independent predictor of CI-AKI in patients with stable CAD. This simple noninvasive analysis should be tested in guiding tailored volume repletion.

Objectives This study sought to determine if in addition to standard preventive measures on-admission, high-dose rosuvastatin exerts a protective effect against contrast-induced acute kidney injury (CI-AKI). Background Patients with acute coronary syndrome (ACS) are at high risk for CI-AKI, and the role of statin pre-treatment in preventing renal damage remains uncertain. Methods Consecutive statin-naive non-ST elevation ACS patients scheduled to undergo early invasive strategy were randomly assigned to receive rosuvastatin (40 mg on admission, followed by 20 mg/day; statin group n = 252) or no statin treatment (control group n = 252). CI-AKI was defined as an increase in creatinine concentration of ≥0.5 mg/dl or ≥25% above baseline within 72 h after contrast administration. Results The incidence of CI-AKI was significantly lower in the statin group than in controls (6.7% vs. 15.1%; adjusted odds ratio: 0.38; 95% confidence interval [CI]: 0.20 to 0.71; p = 0.003). The benefits against CI-AKI were consistent, even applying different CI-AKI definition criteria and in all the pre-specified risk categories. The 30-day incidence of adverse cardiovascular and renal events (death, dialysis, myocardial infarction, stroke, or persistent renal damage) was significantly lower in the statin group (3.6% vs. 7.9%, respectively; p = 0.036). Moreover, statin treatment given on admission was associated with a lower rate of death or nonfatal myocardial infarction at 6 month follow-up (3.6% vs. 7.2%, respectively; p = 0.07). Conclusions High-dose rosuvastatin given on admission to statin-naive patients with ACS who are scheduled for an early invasive procedure can prevent CI-AKI and improve short-term clinical outcome. (Statin Contrast Induced Nephropathy Prevention [PRATO-ACS]; NCT01185938 )

Diabetes mellitus (DM) is associated with impaired platelet response to clopidogrel. In patients with high on-treatment platelet reactivity (HTPR) while on standard-dose clopidogrel, high-dose atorvastatin enhances the pharmacodynamic (PD) effects of double-dose clopidogrel. It is unknown if similar effects are achieved in patients with DM. This study compare the PD effects of high-dose atorvastatin associated with double dose clopidogrel in HTPR patients with and without DM undergoing elective percutaneous coronary intervention (PCI). This is a post hoc analysis of a prospective randomized PD study that compared double-dose (150 mg) clopidogrel associated with high-dose (80 mg) atorvastatin to double-dose clopidogrel alone in statin naive patients with HTPR undergoing elective PCI. In this analysis, patients were divided in two groups according to DM (n = 27) and non-DM (n = 49) status. Platelet reactivity was evaluated immediately before PCI and at 30 days using the VerifyNow P2Y12 assay. HTPR was defined as P2Y12 reaction units (PRU) ≥235. Administering high-dose atorvastatin in addition to high-dose clipodogrel, the 30 days absolute PRU changes (106 ± 75 vs 100 ± 42, p = 0.7) and optimal response rates (83 vs 84 %; p = 0.9) were similar in DM and non-DM patients. The baseline variables significantly associated with 30-day optimal response to high-dose clopidogrel were: atorvastatin treatment (OR = 7.5 [95 % CI 1.19–47]; p = 0.032) in DM patients; PRU values (OR = 0.9 [95 % CI 0.95–0.99]; p = 0.031) and creatinine clearance (OR = 1.07 [95 % CI 1.008–1.13]; p = 0.025) in non-DM patients. High-dose atorvastatin significantly improved the PD effects of double-dose clopidogrel in DM patients with HTPR undergoing elective PCI.

Objectives: The goal of this study was to investigate the impact of high-dose atorvastatin on the pharmacodynamic (PD) effects of double-dose clopidogrel in statin-naive patients with stable corona...

Statin use is associated with enhanced pharmacodynamic response to clopidogrel in patients with stable coronary artery disease undergoing percutaneous coronary intervention (PCI). However, the impact of statin therapy on clopidogrel response profiles in patients with acute coronary syndrome (ACS) undergoing PCI has not been established and represents the objective of this investigation. On-treatment -P2Y(12) platelet reactivity was measured using the vasodilator stimulated phosphoprotein (VASP) phosphorylation assay before PCI, at hospital discharge, and at 1 month after PCI in ACS patients enrolled in the multicenter, prospective GEne polymorphisms, Platelet Reactivity, and Syntax Score (GEPRESS) study (n = 962). High platelet reactivity (HPR) was defined as platelet reactivity index >= 50%. Statins were prescribed at hospital discharge in 87% (n = 835) of patients. All patients were followed for 1 year. The 1-month HPR rate was lower in statin than in non-statin treated patients (39.6 vs 52%, respectively, p=0.009). This finding was confirmed also among statin-treated patients with high Syntax score (>= 15). After adjustment for differences in baseline characteristics, statin use at discharge was independently associated with 1-month HPR rate (odds ratio, 0.58, 95% confidence interval, 0.38-0.89; p=0.015). In ACS patients undergoing PCI treated with clopidogrel the use of statins at discharge was associated with significantly lower 1-month HPR rates compared with patients not treated with statins.

To investigate changes in sympathetic activity, perfusion, and left ventricular (LV) functionality in takotsubo cardiomyopathy (TTC) patients from onset (T-0) to post-onset conditions at 1 month (T-1), 1-2 years (T-2, T-3). Twenty-two patients (70 +/- 11 years) underwent serial gated single photon emission tomography (G-SPECT) studies with I-123-mIBG and Tc-99m-Sestamibi. Statistics were performed using ANOVA/Sheff, post-hoc, correlation test, and receiver operating characteristic (ROC) curve analysis (p < 0.05). Patients presented at T-0 with LV ballooning and reduced early-late mIBG uptake (95%, 100%), left ventricular ejection fraction (LVEF)(G-SPECT) (86%) and perfusion (77 %). Adrenergic dysfunction was greater in apex, it overlaps with contractile impairment, and both were more severe than perfusion defect. During follow-up, LVEFG-SPECT, contractility, and perfusion were normal, while 82% and 90% of patients at T-1 and 50% at T-2 and T-3 continued to show a reduced apical early-late mIBG distribution. These patients presented at T-0-T-1 with greater impairment of adrenergic function, contractility, and perfusion. A relationship was present within innervation and both perfusion and contractile parameters at T-0 and T-1, and between the extent of adrenergic defect at T-3 and both the defect extent and age at T-0 (cut-off point 42.5%, 72 years). Outcome for TTC is not limited to a reversible contractile and perfusion abnormalities, but it includes residual adrenergic dysfunction, depending on the level of adrenergic impairment and age of patients at onset. The number of patients, as well as degree of perfusion abnormalities were found to be higher than those previously reported possibly depending on the time-interval between hospital admission and perfusion scan.

Background— The temporal evolution of renal function in patients with acute kidney injury after contrast medium (CI-AKI) is not well known. The aim of this observational study was to evaluate the incidence, risk factors, and prognostic implications of persistent renal damage (RD) in patients with preexistent moderate-to-severe renal dysfunction. Methods and Results— From June 2003 to March 2008, 3986 patients underwent coronary angiography at our institution; 1490 of 3986 had an estimated creatinine clearance of P =0.015) and those without CI-AKI ( P =0.0001). A similar trend was observed for the combined end point of death, dialysis and cardiovascular events. Conclusions— These results suggest that CI-AKI is not always a transient, benign creatininopathy, but rather a direct cause of worsening renal function. The occurrence of CI-AKI can identify patients at increased risk of cardiovascular events.

OBJECTIVES: Short-term high-dose atorvastatin administered before percutaneous coronary intervention (PCI) reduces the rate of periprocedural myocardial infarction (pMI) in high-risk patients, such as those with acute coronary syndromes and those with elevated high-sensitivity C-reactive protein. It is unknown whether short-term high-dose administration reduces the rate of pMI in patients with chronic kidney disease. Recently, we observed that in 304 patients with estimated creatinine clearance less than 60 ml/min randomized to receive 80 mg/day of atorvastatin or placebo for 48 h before elective coronary angiography and/or angioplasty, statin administration did not reduce contrast-induced nephropathy (CIN). In this post-hoc analysis, we evaluate the pMI in the subgroup of 161 patients who underwent PCI. METHODS: In all patients, creatine kinase myocardial isoenzyme (CK-MB) [upper reference limit (URL) 5 ng/ml] was assessed before and at 12 and 24 h after PCI. The pMI, defined as CK-MB elevation more than three times the URL, occurred in 27 (17%) patients. RESULTS: The incidence of pMI was 10.4% (of 77 patients) in the atorvastatin and 23% (of 84 patients) in the placebo group (P < 0.05). Multivariate analysis identified the pretreatment with high-dose atorvastatin as an independent predictor of reduced risk of pMI [odds ratio 0.39, 95% confidence interval 0.16-0.96, P < 0.05]. CONCLUSION: This post-hoc analysis shows that short-term high-dose atorvastatin administration reduced pMI in patients with renal dysfunction submitted to elective PCI, but without benefit regarding CIN prevention.

Because of persistent stunning, post-treatment functional abnormalities could identify the initial risk area. The study aims to detect myocardial salvage using post-revascularization gated SPECT in acute myocardial infarction (AMI) treated by reperfusion therapy.In 36 AMI patients, we performed a first gated SPECT injecting (99m)Tc-sestamibi before primary percutaneous coronary intervention (PCI), and a second 5 days later. The salvage index defined by the two perfusion images was compared with the value obtained by subtracting in the second gated SPECT the extent of perfusion defect from the extent of wall thickening abnormalities.The wall thickening salvage index correlated with the reference perfusion salvage index (Spearman's ρ = .92, P .0001), with a 95% limit of agreement = ±.25. The agreement between the classifications in salvage index tertiles of the reference and of the wall thickening salvage index was good (kappa = .75). All patients with optimal PCI result and 18/24 of those with intermediate or poor outcome were correctly classified.Comparing function and perfusion in a single post-PCI (99m)Tc-sestamibi gated SPECT it is possible to estimate myocardial salvage. This could have useful implications in studies comparing different treatment strategies for AMI.

To develop a simplified scoring system based on preprocedure clinical characteristics to predict contrast-induced nephropathy (CIN) before elective coronary angiography and percutaneous coronary intervention (PCI).CIN is associated with increased mortality and morbidity following coronary angiography and PCI and accounts for increased hospital costs.Several baseline clinical characteristics of 1218 patients were considered as candidate univariate predictors of CIN (increaseor =0.5 mg/dl in serum creatinine within 5 days after contrast exposure). On the basis of the odds ratio at multivariate logistic regression, seven markers (with weighted scores) were identified as independent correlates of CIN: age at least 73 years (1), diabetes mellitus (2), left ventricular ejection fraction 45% or less (2), baseline serum creatinine value at least 1.5 mg/dl (2), baseline creatinine clearance 44 ml/min or less (2), posthydration creatinineor = prehydration creatinine value (2) and one procedure effected within the past 72 h (3).CIN occurred in 114 (9.4%) patients [range 1.1-52.1% for a low (or =3) and very high (or =9) risk score, respectively]; the odds of CIN increased significantly with each class (Cochran-Armitage chi-square, P0.0001) and the risk score allowed us to determine patients with low and high risk for postprocedure CIN (c-statistic = 0.86). These results were reproduced in a validation set.Preprocedural clinical risk factors have different influences on the likelihood of CIN. Risk classification based on the most significant parameters can be used to predict CIN before contrast exposure. The simple scoring system proposed here provides a good estimate of the risk of CIN, allowing the interventional team to make adequate adjustment to the procedures.

We investigated the efficacy of short-term high-dose atorvastatin in decreasing the risk of contrast-induced nephropathy (CIN) in patients with chronic kidney disease (CKD) subjected to coronary angiography and/or angioplasty. CIN occurs in up to 15% of patients with pre-existing CKD and affects clinical outcome. The protective effect of statin therapy against CIN is still controversial. A prospective, single-center study of 304 patients with baseline estimated creatinine clearance60 ml/min were randomized to receive atorvastatin 80 mg/day or placebo for 48 hours before and 48 hours after contrast medium administration. All patients received intravenous saline hydration and oral N-acetylcysteine 1,200 mg 2 times/day. Iso-osmolar contrast medium was used. CIN was defined as an absolute increase of serum creatinineor = 0.5 mg/dl within 5 days after the procedure. CIN occurred in 31 patients (10%), 16 (11%) in the placebo group and 15 (10%) in the atorvastatin group (p = 0.86). Mean increase in creatinine was not significantly different in the 2 groups (0.59 + or - 0.17 in placebo group vs 0.72 + or - 0.26 mg/dl in atorvastatin group, p = 0.31). Persistent kidney injury, defined as 1-month increase from baseline creatinine valueor = 25%, was observed in 30% in the placebo group and in 31% in the atorvastatin group (p = 0.58). In conclusion, a short-term administration of high doses of atorvastatin before and after contrast exposure, in addition to standard intravenous hydration and oral N-acetylcysteine, does not decrease CIN occurrence in patients with pre-existing CKD.

ObjectivesThe purpose of this study was to compare the efficacy of sodium bicarbonate versus isotonic saline in addition to N-acetylcysteine (NAC) to prevent contrast-induced nephropathy (CIN) in a larger population of patients with renal dysfunction undergoing coronary angiography or intervention.BackgroundContrast-induced nephropathy accounts for more than 10% of hospital-acquired renal failure. Recent studies suggest that hydration with sodium bicarbonate is more protective than isotonic saline in the prevention of CIN.MethodsThe prospective, single center study included 502 patients with estimated creatinine clearance

Objectives This prospective randomized trial evaluates the impact of early abciximab administration on angiographic and left ventricular function parameters. Background Glycoprotein IIb/IIIa inhibitors improve myocardial reperfusion in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI), but optimal timing of administration remains unclear. Methods Two-hundred ten consecutive patients with first AMI undergoing primary PCI were randomized to abciximab administration either in the emergency room (early group: 105 patients) or in the catheterization laboratory, after coronary angiography (late group: 105 patients). Primary end points were initial Thrombolysis In Myocardial Infarction (TIMI) flow grade, corrected TIMI frame count (cTFC), and myocardial blush grade (MBG), as well as left ventricular function recovery as assessed by serial echocardiographic evaluations. Results Angiographic pre-PCI analysis showed a significantly better initial TIMI flow grade 3 (24% vs. 10%; p = 0.01), cTFC (78 ± 30 frames vs. 92 ± 21 frames; p = 0.001), and MBG 2 or 3 (15% vs. 6%; p = 0.02) favoring the early group. Consistently, post-PCI tissue perfusion parameters were significantly improved in the early group, as assessed by 60-min ST-segment reduction ≥70% (50% vs. 35%; p = 0.03) and MBG 2 or 3 (79% vs. 58%; p = 0.001). Left ventricular function recovery at 1 month was significantly greater in the early group (mean gain ejection fraction 8 ± 7% vs. 6 ± 7%, p = 0.02; mean gain wall motion score index 0.4 ± 0.3 vs. 0.3 ± 0.3, p = 0.03). Conclusions In patients with AMI treated with primary PCI, early abciximab administration improves pre-PCI angiographic findings, post-PCI tissue perfusion, and 1-month left ventricular function recovery, possibly by starting early recanalization of the infarct-related artery.

Background: Age is a major predictor of contrast-induced acute kidney injury (CI-AKI). Few studies have focused on CI-AKI in elderly patients with acute coronary syndrome (ACS). Methods: We compare the incidence of CI-AKI in patients Results: Rate of CI-AKI was significantly higher in patients ≥75 years (15.9% vs 8.7%, odds ratio: 2.001; 95% confidence interval: 1.14-3.53, P = .015). No significant interaction was observed between age and statin treatment ( P = .17). Pretreatment with rosuvastatin was associated with 65% relative reduction in CI-AKI rate (22/170 [12.9%] vs 8/177 [4.5%], P = .007) in younger patients and 38% (16/82 [19.5%] vs 9/75 [12%], P = .20) in the elderly individuals. The greatest protective effect of statin treatment was achieved in patients with the highest hs-CRP values in both age-groups. Conclusion: Patients ≥75 years with ACS had a higher risk of developing CI-AKI. Early high-dose rosuvastatin is efficacious in reducing kidney injury in all patients, especially those with the highest baseline hs-CRP values.

Background In patients with non-ST elevation acute coronary syndrome (NST-ACS) that is treated invasively, glycoprotein (GP) IIb/IIIa inhibitors can be used either as upstream treatment in a coronary care unit or as downstream provisional treatment in selected patients who are undergoing percutaneous coronary intervention (PCI). The relative advantage of either strategy is unknown. The purpose of this study was to assess 30-day outcome of patients enrolled in a prospective NST-ACS registry and treated invasively with either of these two therapeutic strategies. Methods Patients treated invasively (coronary arteriography within 4 days of admission), in the prospective registry ROSAI-2, were divided into two groups according to the upstream use of GPIIb/IIIa inhibitors (n = 241), or not (n = 548). In the latter group, 76 (14%) patients received GPIIb/IIIa in association with a PCI procedure. Clinical and angiographic characteristics as well as in-hospital and 30-day outcome of these two groups of patients were compared. Results The two groups were similar with respect to age, sex, presence of hypertension, diabetes, number of PCI procedures. However, patients treated with upstream GPllb/llla blockers had more frequently ST-segment depression (P = 0.002), a high TIMI risk score (P = 0.01) and were more frequently admitted to centres with Cath Lab facilities (P = 0.001). At 30-day follow-up, the composite of death, acute myocardial infarction and stroke, as well as major bleeding, was not significantly different between the two groups, although it occurred more frequently in patients who received upstream GPIIb/IIIa blockers (9.5% versus 5.7% and 1.7% versus 0.2%, respectively). By multivariate analysis, diabetes [odds ratio (OR) = 2.22, 95% confidence interval (CI) = 1.2-4.09] and a diagnosis on admission of non-Q-wave myocardial infarction (OR = 2.0, 95% Cl = 1.10-3.6) were independently related to outcome. No additional risk or benefit was related to upstream GPIIb/IIIa inhibitor treatment (OR = 1.5, 95% Cl = 0.84-2.68). Conclusions Among invasively-treated patients with NST-ACS, upstream treatment with GPIIb/IIIa inhibitors was used in those with a higher clinical risk profile, whereas downstream treatment was reserved for a limited number of patients undergoing PCI. Thirty-day outcome was similar in the two groups, irrespective of the treatment strategy used.

Background Glycoprotein IIb/IIIa inhibitors improve myocardial reperfusion and clinical outcomes of patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI), but optimal timing of administration remains unclear. In this prospective randomized trial, we evaluated the impact of early abciximab administration on angiographic findings, myocardial salvage and left ventricular function. Methods and results Fifty-five consecutive patients with first AMI, undergoing primary PCI, were randomized to abciximab administration either in the emergency room (early group: 27 patients) or in the catheterization laboratory after coronary angiography (late group: 28 patients). The primary outcome measures were initial Thrombolysis In Myocardial Infraction (TIMI) grade flow, corrected TIMI frame count and myocardial blush grade as well as salvage index and left ventricular function recovery as assessed by serial scintigraphic scans performed at admission, and 7 days and 1 month after PCI. Angiographic analysis showed a significant difference in initial TIMI grade 3 flow, corrected TIMI frame count and myocardial blush grade favouring early group. Moreover, salvage index and left ventricular function recovery were significantly greater in the early group ( P =0.007; and P =0.043, respectively). Conclusions In patients with AMI, treated with primary PCI, early abciximab administration improves myocardial salvage and left ventricular function recovery probably by starting early recanalization of the infarct-related artery.

Background:Myocardial blush grade (MBG), corrected TIMI frame count (cTFC), and ST-segment reduction are indices of myocardial reperfusion. Hypothesis:We evaluated their predictive value for left ventricular (LV) function recovery by gated single-photon emission computed tomography (SPECT) after acute myocardial infarction (AMI) treated with primary percutaneous coronary intervention (PCI). Methods:In 40 patients with AMI, gated SPECT was performed at admission and repeated 7 and 30 days after PCI. Left ventricular function recovery was defined as an increase ≥ 10 points in SPECT LV ejection fraction from baseline to 1 month. The MBG, cTFC, and ST-segment elevation index 1 h after PCI were determined to evaluate reperfusion. Results:Twenty-four patients (Group 1) had LV function recovery and 16 (Group 2) did not. A significant correlation was found between LV function recovery and MBG (r = 0.66; p=0.0001), and ST-segment elevation index at 1 h(r=−0.55; p = 0.0001), but not with cTFC. Univariate predictors of LV function recovery were MBG (p = 0.0003) and ST-segment elevation index 1 h after intervention (p = 0.0026), but not cTFC. In a multivariate analysis, MBG was the only predictor of LV function recovery. Myocardial blush grade ≥ 2 and ST-segment elevation index reduction had the same accuracy (88%) for predicting LV function recovery. Lower accuracy (75%) was shown by fast cTFC (< 23 frames). Myocardial blush grade ≥ 2 showed the better negative likelihood ratio, and ST-segment elevation index reduction had the higher positive likelihood ratio in predicting LV function recovery. Conclusions:Myocardial blush grade was the best parameter for prediction of LV function recovery: MBG ≥ 2 and ST-segment elevation index reduction showed good accuracy in predicting LV function recovery. The cTFC failed to be a significant predictor.

Background: Elderly patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) may receive benefit from an early invasive strategy. However, aged patients often suffer from comorbidities that may contraindicate an invasive approach and affect prognosis adversely. The impact of comorbidities on an invasive approach to NSTE-ACS in the elderly has not been fully investigated. Hypothesis: This study sought to examine the outcome of an unselected population of patients with NSTE-ACS stratified according to age and treatment approach. Methods: The feasibility and efficacy of an invasive strategy for NSTE-ACS and the 6-month outcome were assessed in 253 unselected consecutive patients ≥ 70 years (elderly) and compared with those of 235 unselected consecutive patients < 70 years. Results: Angiography was not performed in 69 patients (86% ≥ 70 years) because of contraindications. In the whole population, the 6-month event rate was significantly higher in elderly compared with younger patients (22 vs. 14%; odds ratio 1.8, 95% confidence interval 1.1-2.9; p

We examined the incidence and predictors of acute kidney injury (AKI) in elderly patients (≥75 years) enrolled in the prospective Italian Elderly acute coronary syndrome (ACS) study and explored the impact of AKI on clinical outcome. Acute kidney injury, defined according to the Acute Kidney Injury Network criteria, occurred in 128 (21%) of 615 patients. Patients submitted to coronary angiographic procedures did not present higher rate of AKI. The only baseline variables independently associated with AKI development were creatinine clearance (odds ratio [OR]: 0.98; 95% confidence interval [CI]: 0.97-0.99) and left ventricular ejection fraction (OR: 0.98; 95% CI: 0.96-0.99). Adverse clinical events were significantly higher in patients who developed AKI. After multivariable adjustment, AKI (hazard ratio: 2.73; 95% CI: 1.87-4.0) was an independent predictor of all-cause mortality within 1 year.

The simultaneous assessment of perfusion and function with the use of technetium 99m sestamibi gated single photon emission computed tomography (SPECT) is helpful for the detection of myocardial viability, but its value in comparison with more established methods is not yet defined. This study compared low-dose dobutamine (LDD) nitrate-enhanced gated SPECT with LDD echocardiography for predicting recovery of regional ventricular function after revascularization in 25 patients with ischemic cardiomyopathy. In both studies, regional function (wall motion and thickening) at rest, during inotropic stimulation, and after revascularization was scored by a 4-point scale. In LDD echocardiography, the prediction of reversible dysfunction was based on the recognition of contractile reserve in asynergic (hypokinetic or a-dyskinetic) segments. In LDD gated sestamibi SPECT, reversible dysfunction was predicted on the basis of perfusion quantification (sestamibi uptake > 50%) in a-dyskinetic segments and on the basis of contractile reserve in hypokinetic segments. LDD echocardiography predicted reversible dysfunction with sensitivity, specificity, and global accuracy of 57%, 85%, and 75%, respectively. The sensitivity and specificity of LDD gated SPECT for identifying dysfunctional segments capable of functional recovery were 77% and 88%, respectively, with a diagnostic accuracy of 84% (P < .02 vs LDD echocardiography). The combined use of 2 different markers of viability, such as cellular integrity in a-dyskinetic segments and contractile reserve in hypokinetic segments, as permitted by LDD gated sestamibi SPECT, showed higher predictive accuracy for reversible dysfunction than the assessment of contractile reserve in all asynergic segments with LDD echocardiography. (J Nucl Cardiol 2002;9:402-6.)

Gated single-photon emission computed tomography (SPECT) imaging allows analysis of myocardial perfusion and assessment of baseline global and regional left ventricular (LV) function and their changes during low-dose dobutamine infusion. The study examined whether the changes in LV ejection fraction induced by dobutamine and evaluated using technetium-99m sestamibi- gated SPECT predict the evolution of ejection fraction after revascularization in patients with ischemic cardiomyopathy. Thirty-seven patients underwent resting and dobutamine nitrate-enhanced sestamibi-gated SPECT before revascularization and baseline-resting sestamibi gated SPECT after intervention to assess global functional changes. A postrevascularization improvement in ejection fractionor =5 U was defined as significant. At follow-up, ejection fraction increased significantly in 19 patients. According to receiver-operating characteristic curve analysis, an increase in ejection fractionor =5 U during dobutamine was the optimal cutoff value for predicting a significant postrevascularization improvement, with 79% sensitivity, 78% specificity, and 78% accuracy. A significant correlation was found between dobutamine and postrevascularization ejection fraction (r = 0.85; p0.0001). The increase in ejection fraction during dobutamine is a good predictor of an improvement in ejection fraction after revascularization. This represents another important diagnostic contribution obtained using gated SPECT imaging for the assessment of myocardial viability in patients with ischemic cardiomyopathy.

Background There is a strong correlation between adverse clinical events and peak values of myocardial necrosis markers in non–ST-elevation acute coronary syndrome patients. In this clinical setting, high-dose statin treatment exerts acute beneficial effects against renal and myocardial damage. The aim of this report was to evaluate if, on admission, high-dose rosuvastatin can exert cardioprotective effects when administered in addition to high-dose clopidogrel. Methods In the PRATO-ACS trial, 504 consecutive statin-naive non–ST-elevation acute coronary syndrome patients scheduled for early invasive strategy and pretreated with high-dose clopidogrel were randomly assigned to rosuvastatin (40 mg on admission followed by 20 mg/d; statin group, n = 252) or no statin treatment (control group, n = 252). Serial myocardial biomarker samples were collected before and after angiography and/or percutaneous coronary intervention. The primary end point was the peak level of cardiac troponin I (cTnI) during the index event. Results Statin-treated patients presented median cTnI peak values similar to controls (3.9 [0.6-12.8] vs 3.5 [1.2-11.9] ng/mL, respectively; P = .60]; no differences were found between the 2 groups in cTnI and creatine kinase–MB values at any time point, in either preangiography and postangiography peak values or their cumulative release. In patients submitted to percutaneous coronary intervention, periprocedural myocardial infarction occurred in 8 (4.7%) of 171 statin-treated and 7 (4.3%) of 162 control patients (P = .87). Conclusion In the PRATO-ACS trial, early high-dose rosuvastatin did not show cardioprotective effects when administered in addition to high-dose clopidogrel.

This study was performed to evaluate, using a randomized double-blind, placebo-controlled protocol, the long-term efficacy and safety of propafenone and sotalol in maintaining sinus rhythm after conversion of recurrent symptomatic atrial fibrillation (AF). The maintenance of sinus rhythm in patients with recurrent AF has several potential benefits, the most important being a reduced risk of thromboembolic events. Three hundred patients with recurrent AF (> or = 4 episodes in the last year) and AF at enrollment lasting < 48 hours were randomized to receive either propafenone (mean daily dose 13 +/- 1.5 mg/kg; 102 patients), sotalol (mean daily dose 3 +/- 0.4 mg/kg; 106 patients), or placebo (92 patients). After 1-year follow-up, Kaplan-Meier estimates of the proportion of patients remaining in sinus rhythm were comparable between propafenone (63%) and sotalol (73%) and superior to placebo (35%; p = 0.001 vs both drugs). Symptomatic recurrences occurred later with propafenone and sotalol than with placebo. Nine patients (9%) in the propafenone group, 11 (10%) in the sotalol group, and 3 (3%) in the placebo group discontinued therapy due to adverse effects. Malignant nonfatal arrhythmias due to proarrhythmic effects were documented with sotalol only, and occurred < 72 hours from the beginning of therapy in 4 patients (4%). During recurrences, the ventricular rate was significantly reduced in patients taking propafenone and sotalol (p = 0.001 for both drugs vs placebo). The likelihood of remaining in sinus rhythm during follow-up was higher in younger patients with smaller left atrial size and without concomitant heart disease. In patients with recurrent symptomatic AF, propafenone and sotalol are not significantly different from each other and are superior to placebo in maintaining sinus rhythm at 1 year. Recurrences occur later and tend to be less symptomatic with propafenone and sotalol compared with placebo.

The value of gated single photon emission computed tomography (SPECT) in the assessment of wall motion (WM) in patients with severe perfusion defects and in the evaluation of low-dose dobutamine (LDD)-induced changes is not yet established. In patients with chronic coronary artery disease who have left ventricular (LV) dysfunction, the results of nitrate-enhanced technetium 99m sestamibi (sestamibi) gated SPECT for the evaluation of resting and LDD WM were compared with those of baseline and LDD echocardiography (LDDE).Thirty-seven patients underwent echocardiography and nitrate-enhanced sestamibi gated SPECT within 1 week at rest and during LDD infusion. WM was scored from 1 (normal) to 4 (dyskinetic) by using a 16-segment model. Segments with sestamibi uptake less than 30% were considered unsuitable for WM analysis (36 of 592 segments). Echocardiography was technically unreliable in 10 of 592 segments. The precise agreement between echocardiography and gated SPECT for baseline regional WM was 68.4% (kappa = 0.54), without significant differences for the involved coronary artery territory. The agreement for +/- 1 WM scoring was 96.5% (kappa = 0.94). Contractile reserve during LDD was detected by means of echocardiography in 36% and by means of sestamibi gated SPECT in 33% of baseline asynergic segments. Agreement for detection of WM improvement in response to LDD was 74% (kappa = 0.41). The overall and +/-1 WM score agreement for LDD WM was 67.5% (kappa = 0.50) and 94.7% (kappa = 0.91), respectively. A significant correlation between echocardiography and gated SPECT was observed for both baseline (p = 0.78) and LDD (p = 0.74) WM score index.In patients with coronary artery disease who have LV dysfunction, nitrate-enhanced sestamibi gated SPECT allows a reliable WM evaluation, both at rest and during LDD infusion, in almost all segments and provides results in agreement with LDDE.

Background Serum cystatin C (Cys-C), a good marker of renal function, predicts prognosis in non-ST-elevation acute coronary syndromes (NSTE-ACS). However, no data are available on the time course of Cys-C values after discharge. In this study, Cys-C was measured during admission (ACS sample) and 6 weeks after discharge, and was correlated with troponin (c-TNT), high-sensitivity C-reactive protein (hsCRP), interleukin 6 (IL-6) and the N-terminal portion of the pro-brain natriuretic peptide (proBNP) peptide (NT-proBNP) in a highly selected homogeneous group of NSTE-ACS patients. Methods In this prospective, multicentre study, patients with a first NSTE-ACS, single-vessel disease and successful percutaneous coronary interventions (PCIs) had their sera collected, aliquoted and stored at the enrolling site and then shipped for analysis to the clinical chemistry core laboratory. Results Cys-C values slightly, but significantly, increased from the ACS samples to the 6-week samples. In contrast, hsCRP, NT-proBNP and IL-6 values significantly decreased from the ACS to the 6-week sample. Patients with elevated c-TNT levels had higher hsCRP, NT-proBNP and IL-6 values than patients with normal c-TNT levels in the ACS sample, whereas Cys-C levels were similar in patients with and without elevated c-TNT. Cys-C was highly correlated with estimated glomerular filtration rate in both the ACS and 6-week samples. Conclusions In contrast to inflammatory and biochemical stress markers, Cys-C is not affected by the occurrence of myocardial necrosis or by acute left-ventricular impairment, being a reliable marker of renal function during NSTE-ACS.

The purpose of this study was to evaluate feasibility, safety, and efficacy of bailout Palmaz-Schatz stenting in a series of 39 patients with coronary dissection associated with acute or unequivocal threatened closure complicating conventional angioplasty. No anatomical characteristics other than reference vessel diameter3 mm were considered as contraindications for bailout coronary stenting. Stringent criteria were adopted in defining optimal results (10% residual stenosis, no angiographic evidence of residual dissection), suboptimal results (10% residual stenosis or angiographic evidence of residual dissection), deployment failure (failure to deploy the stent because of poor trackability or persistent occlusion despite stent deployment). A total of 49 stents and 7 half-stents were implanted in 36 patients (range 1-5; mean 1.45 +/- 0.84). Successful stenting without in-hospital death, urgent or semielective coronary surgery, stent thrombosis, or Q-wave myocardial infarction was achieved in 33/39 patients (85%). A suboptimal result was associated with an increased risk of in-hospital recurrence of ischemia and other related major adverse events (2/5 patients with suboptimal results vs. 1/31 patients with complete deployment success; P0.05). Multiple stents implantation did not carry a significant risk of major cardiac adverse events. The results of this study suggest that bailout Palmaz-Schatz stenting may be considered a stand-alone treatment of coronary dissection if an optimal acute angiographic result is achieved.

Background— Intravascular volume expansion represents a beneficial measure against contrast-induced acute kidney injury (CI-AKI) in patients undergoing elective angiographic procedures. However, the efficacy of this preventive strategy has not yet been established for patients with ST-elevation–myocardial infarction (STEMI), who are at higher risk of this complication after primary percutaneous coronary intervention (PCI). In this randomized study we investigated the possible beneficial role of periprocedural intravenous volume expansion and we compared the efficacy of 2 different hydration strategies in patients with STEMI undergoing primary PCI. Methods and Results— We randomly assigned 450 STEMI patients to receive (1) preprocedure and postprocedure hydration of sodium bicarbonate (early hydration group), (2) postprocedure hydration of isotonic saline (late hydration group), or (3) no hydration (control group). The primary end point was the development of CI-AKI, defined as an increase in serum creatinine of ≥25% or 0.5 mg/dL over the baseline value within 3 days after administration of the contrast medium. Moreover, we evaluated a possible relationship between the occurrence of CI-AKI and total hydration volume administered. There were no significant differences in baseline clinical, biochemical, and procedural characteristics in the 3 groups. Overall, CI-AKI occurred in 93 patients (20.6%): the incidence was significantly lower in the early hydration group (12%) with respect to both the late hydration group (22.7%) and the control group (27.3%) ( P for trend=0.001). In hydrated patients (early and late hydration groups), lower infused volumes were associated with a significant increase in CI-AKI incidence, and the optimal cutoff point of hydration volume that best discriminates patients at higher risk was ≤960 mL. Conclusions— Adequate intravenous volume expansion may prevent CI-AKI in patients undergoing primary PCI. A regimen of preprocedure and postprocedure hydration therapy with sodium bicarbonate appears to be more efficacious than postprocedure hydration only with isotonic saline. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00770614.

In patients with acute myocardial infarction (AMI), the off-hour presentation is one of the major determinants of door-to-balloon delay. Moreover, the nighttime presentation is associated with increased mortality after primary coronary intervention (PCI). The prompt starting of a therapy able to start recanalization of the infarct-related artery before intervention might improve the results of off-hour primary PCI. We compared the outcome of 212 consecutive patients with AMI undergoing either direct or facilitated PCI according to the hour of presentation. Patients arriving off-hours were pretreated with alteplase (20 mg) and abciximab and underwent facilitated PCI. Patients presenting on-hours underwent direct PCI. A basal Thrombolysis in Myocardial Infarction (TIMI) flow grade 3 was observed in 1.0% of patients undergoing direct PCI and in 44% of patients undergoing facilitated PCI (P = 0.001). More patients starting PCI with a TIMI 3 flow achieved a postinterventional fast TIMI frame count (72.0% vs. 38.8% direct PCI group vs. 34.9% facilitated PCI group with basal TIMI 0-2; P = 0.001) and a TIMI perfusion grade 3 (66.0% vs. 38.8% direct PCI group vs. 39.7% facilitated PCI group with basal TIMI 0-2; P = 0.004). Preinterventional TIMI flow grade 3 was associated with a higher gain in left ventricular ejection fraction at 1 month (10.9% +/- 6.4% vs. 7.0% +/- 9.6% direct PCI group vs. 6.1% +/- 6.0% facilitated PCI group with basal TIMI 0-2; P = 0.005). No significant difference was observed in major bleedings, although there was a trend toward a higher risk in the facilitated PCI group. Patients in the facilitated PCI group achieving a basal TIMI 3 flow showed improved myocardial reperfusion and better left ventricular function recovery. Bleeding complications associated with combination therapy remained an important concern.

Preserved thrombolysis in myocardial infarction (TIMI) flow before percutaneous coronary intervention (PCI) in acute myocardial infarction is related to improved outcome. Gated single-photon emission computed tomography (SPECT) allows the simultaneous assessment of left ventricular perfusion and function. We evaluated the initial risk area and subsequent evolution of perfusion and function according to TIMI flow before successful primary PCI.In 36 patients, treated with abciximab, primary PCI and stenting, 99mTc-sestamibi was injected before PCI and gated SPECT acquired thereafter. Gated SPECT was repeated 7 and 30 days later. Perfusion defect, wall motion score index, left ventricular ejection fraction and volumes were examined.Before PCI, 14 patients (group A) showed TIMI flow 2-3 and 22 (group B) TIMI flow 0-1, but no differences in clinical variables, initial risk area, wall motion score, ejection fraction or volumes. Perfusion defect was smaller in group A at 7 (9%+/-11% vs 19%+/-14%, p0.02) and 30 days (7%+/-7% vs 16%+/-12%, p0.02) and the salvage index was higher at 30 days (77%+/-22% vs 55%+/-28%, p0.02). Wall motion score was lower in group A at 30 days (p0.05). Ejection fraction significantly improved in both groups at 7 and 30 days. End-diastolic volume showed a trend towards a reduction in group A, whilst it was significantly increased in group B. Conversely, end-systolic volume was significantly decreased in group A but remained unchanged in group B.In the setting of optimal myocardial reperfusion for myocardial infarction, preserved TIMI flow before PCI does not limit the initial risk area but it does improve myocardial salvage and functional recovery.

A main goal of revascularization in patients with chronic ischemic cardiomyopathy is to improve global left ventricular (LV) function. This study aimed to verify whether it is possible to predict an increase in LV ejection fraction (EF) after revascularization on the basis of the extent of LV asynergy, myocardial viability, and revascularization completeness. We studied 77 patients with chronic LV ischemic dysfunction using baseline resting and nitrate-enhanced technetium-99m sestamibi single-photon emission computed tomography. Regional wall motion and global LVEF were assessed with echocardiography before and after revascularization, which was complete in 51 patients and incomplete in 26. The number of viable asynergic segments included in revascularized coronary artery territories was the strongest predictor of significant (or = 5 EF U) functional improvement in univariate discriminant analysis. According to multivariate stepwise discriminant analysis, this parameter, together with the number of baseline asynergic segments, allowed the detection of patients with significant LVEF improvement with 75% accuracy. With use of a multivariate regression model, including the 2 mentioned variables, the measure of postrevascularization LVEF increase could be accurately quantified (R(2) 0.43, p0.000001). In conclusion, this study suggests that the severity of baseline asynergy, the extent of myocardial viability, and the completeness of revascularization are the main determinants of postrevascularization functional recovery in patients with LV ischemic dysfunction, and that on the basis of these variables it is possible to predict the measure of LVEF increase.

The role of gated single photon emission computed tomography (SPECT) in improving viability detection with the use of perfusion imaging is uncertain. This study aimed to verify whether the classification of baseline regional dysfunction with gated SPECT helps to predict functional recovery with the use of quantitative perfusion imaging. Resting nitrate-enhanced sestamibi gated SPECT was performed in 31 patients with left ventricular dysfunction, who later underwent coronary revascularization. With the use of a 16-segment model, tracer activity was quantified, and wall motion and thickening were estimated with a 4-point scoring scheme. Reversible dysfunction was assessed with follow-up gated SPECT. According to receiver operating characteristic curve analysis, the best overall cutoff for predicting reversible dysfunction in asynergic segments was 50% of peak activity or greater, with 83% sensitivity, 54% specificity, and 64% accuracy. When the segments were divided according to wall motion in resting gated SPECT, the optimal activity cutoff was greater than 68% for hypokinetic and 50% or greater for adyskinetic segments. With the use of 2 thresholds, the overall sensitivity remained good (76%), whereas specificity increased to 73% (P < .0005) and accuracy to 74% (P < .02). Regional dysfunction assessment directly on perfusion images permits use of different activity thresholds with an improvement over a single cutoff for all asynergic segments. Therefore combining perfusion and functional data with nitrate-enhanced gated SPECT at rest appears to be a promising approach for viability detection.

Acceptance of technetium-99m sestamibi as a tracer of myocardial viability is growing, particularly when nitrate-enhanced imaging is used. However, few data are available on the ability of 99mTc-sestamibi to predict the evolution of global left ventricular ejection fraction (EF). The aim of this study was to examine the ability of resting and nitrate 99mTc-sestamibi single-photon emission tomography (SPET) to predict EF changes after revascularisation in patients who have chronic coronary artery disease with left ventricular dysfunction. Using baseline resting and nitrate 99mTc-sestamibi SPET, we studied 61 patients scheduled for revascularisation because of left ventricular dysfunction. EF was estimated using two-dimensional echocardiography before and after the intervention. A post-revascularisation improvement ofor =5 EF units was defined as significant. Using a 13-segment model, 99mTc-sestamibi activity was quantified and the nitrate-induced activity changes calculated. Three different criteria for detecting viability (defined as post-revascularisation reversible dysfunction) in asynergic segments were compared: (1) resting 99mTc-sestamibi activityor =60%; (2) nitrate 99mTc-sestamibi activityor =65%; and (3) nitrate-induced increase+10% or nitrate-induced increaseor =+10% and nitrate activityor =65%. EF increased significantly in 32 patients. The number of viable asynergic segments was significantly higher in these patients than in the remaining 29 subjects, and the difference was greater (P0.0002) using definition (3) than using either baseline (P0.002) or nitrate activity (P0.0005). There was a significant relationship between EF changes and number of viable asynergic segments: Spearman R=0.38, P0.005 using baseline; Spearman R=0.39, P0.002 using nitrate activity; and Spearman R=0.55, P0.000005 using definition (3). According to receiver operating characteristic (ROC) curve analysis, this last criterion achieved the best results (81% sensitivity, 69% specificity and 75% accuracy), with an area under the ROC curve of 0.838; this area was significantly larger than when using either baseline (0.744, P0.02) or nitrate activity (0.747, P0.005). 99mTc-sestamibi SPET appears able to predict the evolution of global left ventricular EF after revascularisation, thereby confirming the value of 99mTc-sestamibi as a tracer of myocardial viability. The combination of baseline resting and nitrate imaging seems to significantly improve the diagnostic accuracy of 99mTc-sestamibi SPET for this particular purpose.

This study aimed to assess whether contractile reserve evaluation using dobutamine gated single-photon emission computed tomography (SPECT) improves the capability of quantitative perfusion analysis to predict functional recovery of viable hibernating myocardium. Resting and dobutamine nitrate-enhanced technetium-99m sestamibi (sestamibi) gated SPECT studies were performed in patients with coronary artery disease who had left ventricular dysfunction. Tracer activity was quantified, and wall motion and thickening visually scored. Reversible dysfunction was identified with gated SPECT repeated after coronary revascularization. Using the best activity threshold, perfusion quantification achieved 85% sensitivity and 55% specificity. Contractile reserve detection was significantly less sensitive (64%, p

Injection of sestamibi during low-dose dobutamine (LDD) infusion might improve tracer ability to detect viable myocardium. This study investigated the potential value of LDD technetium-99m sestamibi (sestamibi) single-photon emission computed tomography (SPECT) in predicting functional recovery after revascularization by comparing its results with those of sestamibi SPECT at rest and of LDD echocardiography. Before revascularization, 23 patients with chronic coronary artery disease and regional left ventricular dysfunction underwent sestamibi SPECT at rest and, on a separate day, LDD echocardiography and sestamibi SPECT with tracer injection during LDD infusion. Echocardiography at rest was repeated after revascularization. Semiquantitative sestamibi uptake results (grading from 0 = normal to 4 = absent) and wall motion (grading from 1 = normal to 4 = dyskinesia) were evaluated with a 16-segment model. The ventricular wall was divided into 3 vascular territories. At follow-up, 20 of 32 asynergic vascular territories showed functional recovery, whereas 12 showed no changes. For prediction of functional recovery, LDD SPECT achieved better accuracy than SPECT at rest (87% vs 65%, p

This study provides the incidence of in-hospital and 1-month recurrent ischemia in 118 patients with acute myocardial infarction when an aggressive direct angioplasty strategy was performed, including stenting of the infarct artery. Coronary stenting in acute myocardial infarction is feasible, and acute and 1-month angiographic results after stenting seem superior to those after standard angioplasty alone.

Pre- and post-treatment myocardial scintigraphy with technetium-99m hexakis 2-methoxy-isobutyl-isonitrile (Tc-99m sestamibi) was performed in patients who underwent thrombolytic therapy for acute myocardial infarction comparing planar imaging and single-photon emission computed tomography (SPECT). Twenty-one patients were injected with Tc-99m sestamibi before thrombolytic treatment. SPECT and planar imaging were acquired after completion of the treatment. The scintigraphy was repeated 5 days later in 20 subjects. Planar and SPECT studies were evaluated using an uptake score. Patients were divided according to the status of the infarct-related vessel (patent in 13 patients, group 1, and occluded in seven, group 2) and to the presence of functional recovery in serial echocardiographic controls (present in 10 patients, group A, and absent in 10, group B). The scintigraphic defect extent in the 5-day images correlated with the enzymatic infarct size: SPECT: r = 0.75, p less than 0.0002; planar: r = 0.68, p less than 0.002. The decrease of the uptake defects correlated with the reduction of the left ventricular wall asynergy (admission versus 1 month echocardiogram): SPECT: r = 0.92, p less than 0.000001; planar: r = 0.82, p less than 0.00001. The percent decrease of the uptake defects was significantly higher in patients in group 1 and group A compared with group 2 and, respectively, group B--SPECT: group 1: 51.4 +/- 27.7 versus group 2: 13.1 +/- 8.6, p less than 0.02; group A: 64.2 +/- 15.3 versus group B: 11.9 +/- 8.1, p less than 0.0002; planar group 1: 41 +/- 30.4 versus group 2: 7.7 +/- 6.2, p less than 0.05; group A: 52.5 +/- 24.3 versus group B: 6.1 +/- 6, p less than 0.0002. This study confirms the reliability of pre- and post-treatment myocardial scintigraphy with Tc-99m sestamibi for evaluating the outcome of thrombolytic treatment in myocardial infarction. The results seems slightly more accurate using SPECT, but a simple three-view planar study also gives useful data.

Single photon emission computed tomography (SPECT) with technetium-99m hexakis 2-methoxyisobutyl isonitrile was investigated as a method to evaluate the results of intravenous thrombolytic treatment in 14 patients (11 men and 3 women) with acute myocardial infarction admitted to the coronary care unit within 4 h of the onset of symptoms. All patients received an injection of 740 MBq of the tracer before starting the thrombolytic therapy, and isonitrile tomography was performed 3 to 4 h later. The tomographic study was repeated 5 days after the acute event. The results of thrombolytic treatment were independently evaluated taking into account the clinical, electrocardiographic (ECG) and enzymatic data and the findings of left ventricular and coronary angiography. Furthermore, all patients were studied with two-dimensional echocardiography on admission, 5 days later and 1 month later. The site and extent of the perfusion defects on admission scintigraphy were consonant with the ECG and echocardiographic findings. A good correlation could be established between the 5 day scintigraphic estimate of infarct dimension and the enzymatic infarct size (r = 0.907, p less than 0.00002). The comparison between pre- and postthrombolytic treatment images enabled the identification of successful and unsuccessful reperfusion even in patients whose other noninvasive findings were inconclusive. Finally, the reduction in defect size predicted late functional improvement that was demonstrated by echocardiography performed 1 month later (r = 0.89, p less than 0.00005). The results of the study suggest the feasibility and the possible usefulness of isonitrile tomography in demonstrating the presence and size of myocardial damage and in assessing the extent of myocardial salvage after thrombolytic therapy in acute myocardial infarction.

Background In non–ST-elevation acute coronary syndromes (NSTE-ACS), a strong correlation between adverse clinical events and peak values of myocardial necrosis markers has been found. In this study, we evaluated whether the adjunctive treatment with upstream tirofiban reduces the peak levels of cardiac troponin I and creatine kinase–MB (CK-MB) fraction in patients with NSTE-ACS undergoing early invasive strategy and pretreated with aspirin, heparin, and clopidogrel. Methods A total of 300 patients were randomized to receive tirofiban (group 1) or not (group 2). Serial marker samples were collected before and after coronary angiography in all cases and after percutaneous coronary intervention (PCI) when performed. Results Between the 2 groups, no differences were observed in clinical and angiographic findings. Percutaneous coronary intervention was globally performed in 198 patients (66%) . Of 99 group 2 patients, 26 (26%) received abciximab just before PCI. No significant differences between the 2 groups were observed with regard to cardiac troponin I and CK-MB values at admission and at 6, 12, and 24 hours thereafter; peak values before coronary angiography; and peak values of index event. In addition, the cumulative biomarkers release of the index event was similar between the 2 groups. Major bleeding rate was 2% in group 1 and 1% in group 2 ( P = not significant). Composite incidence of death, myocardial infarction, or rehospitalization for ACS at 30 days was 9% in group 1 and 10% in group 2. Conclusions In patients with NSTE-ACS undergoing early invasive strategy, the adjunctive administration of upstream tirofiban did not reduce the peak values and the cumulative release of myocardial necrosis markers, compared with aspirin, heparin, and clopidogrel given on admission and associated with selective use of abciximab just before PCI.