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Gender-related differences after ST-segment elevation myocardial infarction (STEMI) have been reported, but studies have generally focused on high-risk groups and results are inconsistent. This study aims to determine gender-related differences in the treatment of STEMI and in-hospital mortality in a contemporary cohort of young patients. We included patients aged <55 years admitted to the Acute Cardiac Care Unit with STEMI during an 11-year period. We retrospectively reviewed the clinical charts to register information on demographics, clinical and laboratory data, angiography, treatment received, complications, and in-hospital mortality. A total of 812 patients were included (712 men and 100 women). There were no gender-related differences in age or prevalence of cardiovascular risk factors. Women, as compared with men, had higher incidence of nonobstructive angiography (14.0% vs 2.4%) and coronary tortuosity (4.0% vs 0.8%), and lower incidence of multivessel disease (35.0% vs 49.6%) (p <0.05). Less frequently than men, women received percutaneous transluminal coronary angioplasty (94.0% vs 98.2%), and stent placement (82.0% vs 93.8%), inotropic agents (2.0% vs 8.3%), hypothermia after cardiac arrest (25.0% vs 84.0%), and mechanical ventilation (4.0% vs 11.0%) (p <0.05). These differences were not explained by the different angiographic findings. In-hospital mortality was 2.0% and 3.4%, in women and men, respectively (adjusted odds ratio 0.712, 95% confidence interval 0.164 to 3.093, p = 0.650). In conclusion, women aged <55 years with STEMI were held to different treatment standards than men., Competing Interests: Disclosures The authors have no conflicts of interest to declare., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Ventricular septal rupture (VSR) following acute myocardial infarction (AMI) is a dangerous condition. Surgical VSR closure is the definitive therapy, but there is controversy regarding the surgical timing and the bridging therapy between diagnosis and intervention. The objective of this study is to analyze the ideal time of surgical repair and to establish the contribution of mechanical circulatory support (MCS) devices on the prognosis., Methods: We designed an observational, retrospective, multicenter study, selecting all consecutive patients with post-AMI VSR between January 1, 2008 and December 31, 2018, with non-exclusion criteria. The main objective of this study was to analyze the optimal timing for surgical repair of post-AMI VSR. Secondary endpoints were to determine which factors could influence mortality in the patients of the surgical group., Results: A total of 141 patients were included. We identified lower mortality rates with an odds ratio of 0.3 (0.1-0.9) in patients operated on from day 4 compared with the surgical mortality in the first 24 hours after VSR diagnosis. The use of MCS was more frequent in patients treated with surgery, particularly for intra-aortic balloon pump (IABP; 79.6% vs. 37.8%, p < 0.001), but also for veno-arterial extracorporeal membrane oxygenation (VA-ECMO; 18.2% vs. 6.4%, p = 0.134). Total mortality was 91.5% for conservative management and 52.3% with surgical repair (p < 0.001)., Conclusions: In our study, we observed that the lowest mortality rates in patients with surgical repair of post-AMI VSR were observed in patients operated on from day 4 after diagnosis of VSR, compared to earlier interventions.

Introduction and Objectives: Postinfarction ventricular septal rupture is a rare but severe complication of myocardial infarction with high mortality rates. Our goal was to analyze which factors could have an impact on mortality due to this entity over the past decade, including those related to mechanical circulatory support., Methods: The CIVIAM registry is an observational, retrospective, multicenter study carried out in Spain. We designed a comparative analysis, focused on description of in-hospital management and in-hospital and 1-year total mortality as the primary endpoints, dividing the total observation time into 2 equal temporal periods (January 2008 to June2013 and July 2013 to December 2018)., Results: We included 120 consecutive patients. Total mortality during this period was 61.7% at 1-year follow-up. Patients in the second period were younger. One-year mortality was significantly reduced in the second period (75.6% vs 52.7%, P=.01), and this result was confirmed after adjustment by confounding factors (OR, 0.40; 95%CI, 0.17-0.98). Surgical repair was attempted in 58.7% vs 70.3%, (P=.194), and percutaneous closure in 8.7% and 6.8%, respectively (P=.476). Heart transplant was performed in 1 vs 5 patients (2.2% vs 6.8%, P=.405). The main difference in the clinical management between the 2 periods was the greater use of venoarterial extracorporeal membrane oxygenatiom in the second half of the study period (4.4% vs 27%; P=.001)., Conclusions: Postinfarction ventricular septal rupture still carries a very high mortality risk. There has been a progressive trend to increased support with venoarterial extracorporeal membrane oxygenatiom and greater access to available corrective treatments, with higher survival rates., (Copyright © 2020 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Physical activity has benefits on health. However, there is a small risk of effort-related adverse events. The aim of this study is to describe exercise-related severe cardiovascular events and to relate them with the type of sport performed. We performed a ten-year retrospective study in eight Spanish cardiac intensive care units. Adverse cardiac events were defined as acute myocardial infarction, cardiac arrest or syncope related to physical activity. From 117 patients included, 109 were male (93.2%), and mean age was 51.6 ± 12.3 years; 56 presented acute myocardial infarction without cardiac arrest (47.9%), 55 sudden cardiac death (47.0%) and six syncope (5.1%). The sports with higher number of events were cycling (33%-28.2%), marathon or similar running competitions (19%-16.2%), gymnastics (18%-15.3%) and soccer (17%-14.5%). Myocardial infarction was observed more frequently in cyclists compared to other sports (69.7% vs 39.3%, P = .001). The most common cause of sudden cardiac death was myocardial infarction in those >35 years (23%-63.9%) and idiopathic ventricular fibrillation in younger patients (5%-62.5%). Significant coronary artery disease was present in 85 (79.4%). Only one patient with cardiac arrest presented with a non-shockable rhythm (asystole). Eleven patients (9.4%) died during hospitalization; in all cases, they had presented cardiac arrest. All discharged patients were alive at the end of follow-up. Exercise-related severe cardiac events are mainly seen in men. Coronary heart disease is very frequent; about half present acute myocardial infarction and the other half cardiac arrest. In our cohort, prognosis was good in patients without cardiac arrest., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

The atypical characteristics of acute coronary syndrome in women lead to differences in management and treatment. We investigated these differences in the urgent management of non-ST-segment acute myocardial infarction (NSTEMI). Data on 39 variables were collected from 539 patients with NSTEMI treated at 97 Spanish emergency departments. After adjustment for 10 baseline differences, the only significant differences were that time-to-arrival at the emergency department was longer for women (odds ratio [OR]=0.52; 95% confidence interval [CI], 0.28-0.95) and that they received more clopidogrel (OR=1.65; 95% CI, 1.06-2.56). The trend to fewer admissions to coronary or intensive care units (42.9% vs 55.6%) and fewer catheterization procedures (29.7% vs 40.7%) disappeared after adjustment. We conclude that there are virtually no differences in treatment in women with N-STEMI in prehospital and emergency care., (Copyright © 2011 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.)

Introduction and Objectives: Although of proven effectiveness, there are no data available on the patterns of aldosterone antagonists use in the setting of acute myocardial infarction., Methods: The REICIAM registry is a prospective study designed to provide data regarding the incidence and management of heart failure after acute myocardial infarction. The aim of the present analysis was to determine the patterns of aldosterone antagonists use in this situation., Results: From a total of 2703 patients with acute myocardial infarction, 416 (15.4%) were considered optimal candidates to receive aldosterone antagonists, but only 228 (54.8%) received the treatment. The independent factors associated with their administration were male sex (odds ratio=2.06; 95% confidence interval, 1.23-3.49; P=.006), absence of prior kidney failure (odds ratio=3.31; 95% confidence interval, 1.26-9.06; P=.02), presentation with ST elevation (odds ratio=2.01; 95% confidence interval, 1.21-3.35; P=.007) and the development of malignant arrhythmias (odds ratio=2.75; 95% confidence interval, 1.3-6.05; P=.009). The lower the ejection fraction, the higher the likelihood of receiving aldosterone antagonists. The major independent predictor for receiving aldosterone antagonists was the prescription of diuretics during hospitalization (odds ratio=7.11; 95% confidence interval, 3.72-14.23; P <.00001), but also treatment with clopidogrel, beta-blockers, and statins. Although patients treated with aldosterone antagonists had a higher risk profile, they had a better 30-day survival rate than untreated patients (88.3% and 77.7% respectively; P <.0001)., Conclusions: The use of aldosterone antagonists in post-acute myocardial infarction is only 54.8% of the optimal candidates. Their use is associated with male sex, a higher risk profile, and the use of diuretics and other drugs of proven efficacy in secondary prevention., (Copyright © 2011 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.)

Introduction and Objectives: To investigate how thienopyridine treatment, with or without associated fibrinolysis, affects the rates of major bleeding and inhospital death in patients with ST-elevation myocardial infarction (STEMI)., Methods: The rates of major bleeding and in-hospital death were studied in 14,259 consecutive patients with STEMI. During hospitalization, 5340 (38%) received thienopyridines, 3007 (21%) received fibrinolytic drugs, and 2044 (14%) received both., Results: Major bleeding occurred more frequently in patients who received thienopyridines with or without fibrinolytics, in 4.6% and 4.1%, respectively, compared with 2.3% in those who received fibrinolytics alone and 2.8% in those who received neither (P< .001). Multivariate analysis, which included adjustments for risk factors for bleeding, percutaneous coronary intervention and cardiac catheterization, showed that thienopyridine treatment was an independent risk factor for bleeding (odds ratio=1.68; 95% confidence interval, 1.23-2.31). In-hospital mortality was lower in patients who received a thienopyridine, and such treatment was an independent predictor of lower mortality (odds ratio=0.50; 95% confidence interval, 0.39-0.60)., Conclusions: Thienopyridine treatment was associated with an increased risk of major bleeding but also with a better in-hospital prognosis. These findings in unselected patients with STEMI, who are representative of those seen in daily clinical practice, complement, but do not replace, the data obtained in randomized clinical trails of selected patients.

Background and Objective: There are limited data regarding the need for intensive care or the appropriate length of hospital stay for patients with ST elevation acute myocardial infarction (STEMI). In order to optimize resources, we tried to determine the need of coronary care unit (CCU) admission for patients with STEMI who remained in Killip class I after a successful primary percutaneous coronary intervention (PPCI)., Methods: From August of 2006 till June of 2008, we analyzed data from all patients admitted in our CCU who met these criteria, a total of 278. We prospectively recorded all in-hospital adverse events and event-free survival at 30 and 90 days (all cause death, stroke, new acute coronary syndrome or re-hospitalization due to heart failure). Medical treatment was optimized according to the current guidelines., Results: A coronary stent was implanted in 96% of the patients. None of the patients had any adverse event that could not be resolved in a step-down unit. Survival at 30 and at 90 days was 99.6% and 98.3% respectively. Event-free survival was 97.3% at 30 days and 94.3% at 90 days. The median length of stay was three days in the CCU and five days in the hospital., Conclusion: Patients with STEMI treated with PPCI who remained in Killip class I after the procedure and receive optimal pharmacological treatment have an excellent prognosis. All of them can probably be admitted safely to a step-down unit. Wide application of this management strategy may result in substantial cost savings.

The type of acute coronary syndrome may account for different prognoses between men and women after myocardial infarction. This study assessed gender differences in 28-day mortality rates for first or recurrent Q-wave and non-Q-wave myocardial infarctions and unstable angina by using data from 5 registries that included 20,836 patients (24.8% women). Mortality rates were higher in women with first Q-wave myocardial infarction but not in the other patients after adjusting for confounding variables.

Objectives: To assess the influence of the department of initial admission on the hospital management and 3-month prognosis of patients with non-ST elevation acute coronary syndromes., Patients and Method: The data for the 4115 patients admitted to 18 hospitals in the PEPA study were compared according to the department of initial admission., Results: Twenty-six percent of the patients were admitted to the coronary care unit, 53% to the cardiology department, 9% to the internal medicine department, and 12% were discharged from the emergency ward. The baseline risk profile was high in patients admitted to the coronary care unit and decreased progressively in patients admitted to the cardiology, internal medicine and emergency departments (P<.00001). The intensity of medical management was progressively lower in these departments, but not in parallel to their different baseline lower risk profile. Beta blockers were administered to 50%, 45%, 27% and 21% of the patients, respectively; an exercise test was performed in 34%, 44%, 35% and 12%; coronary angiography in 46%, 34%, 19% and 0%; and coronary revascularization in 22%, 12%, 9% and 0% (P<.00001). The 3-month incidence of mortality or myocardial infarction was 12.2%, 6.4%, 8.7% and 3.8%, respectively (P<.00001), differences that became nonsignificant after adjustment for risk profile on admission., Conclusions: Patients with non-ST elevation acute coronary syndrome admitted to the coronary care unit or cardiology department have a profile of higher risk on admission than patients admitted to the internal medicine department. Also, these patients more frequently receive pharmacological treatments and diagnostic and therapeutic procedures of proven efficacy but not in a manner that parallels their different risk profile on admission. However, these differences in the intensity of in-hospital management do not seem to lead to differences in the 3-month prognosis.

Introduction and Objectives: The usefulness and safety of transesophageal echocardiography have been assessed in other studies but there is no report in which these factors have been evaluated in the acute phase of myocardial infarction. Patients and method. Transesophageal echocardiography was performed 56 times in 55 patients in the first week after a myocardial infarction., Results: The study was completed in 54 of 56 patients. The indications were a transthoracic acoustic window that did not provide an accurate diagnosis in 13 (23.2%), diagnosis of mechanical complications and severity assessment of mitral regurgitation in 35 (62.5%), exclusion of aortic dissection in 4 (7.1%), assessment of the severity of aortic stenosis in 1 (1.8%), exclusion of the presence of atrial thrombus in 1 (1.8%), evaluation of the left ventricular outflow tract gradient in 1 (1.8%), and evaluation of the presence of a left ventricular thrombus in 1 patient (1.8%). Two patients (3.6%) died while the study was being made, the first one 10 minutes after finishing the echocardiogram due to progression of a partial rupture of the papillary muscle and the second due to left ventricle free wall rupture. In both patients, the indication for transesophageal echography was the need for proper evaluation of a post-Acute Myocardial Infarction mechanical complication., Conclusions: Transesophageal echocardiography is a very useful technique for evaluating patients during the acute phase of myocardial infarction but further studies are needed to establish its safety in these patients.

Patients with suspected non-ST-segment elevation acute coronary syndromes (NSTEACS) constitute a heterogeneous population with variable outcomes. Risk stratification in this population of patients is difficult due to the complexity in patient risk profile. We conducted this study to characterize the value of clinical and electrocardiographic variables for risk stratification in an unselected population of consecutive patients with NSTEACS on admission. Thirty-five clinical and electrocardiographic variables at presentation in the emergency room of 18 hospitals were prospectively analyzed in 4,115 patients with NSTEACS and related with the outcomes at 90 days. We also developed a risk score using the variables found to be independent predictors of ischemic events to facilitate risk stratification. Cardiovascular mortality was 4.3% and the rate for the outcome of either cardiovascular death or nonfatal myocardial infarction was 6.9%. The only independent predictors of mortality were age, diabetes, peripheral vascular disease, postinfarction angina, Killip class > or = 2, ST-segment depression, and elevation of cardiac markers. A risk profile using the variables found to be independent predictors of events was calculated for cardiovascular mortality and for the combination of either death or nonfatal myocardial infarction. Event rates increased significantly in all subgroups of patients based on the number of independent risk factors as the risk score increased. Using these factors, 90-day mortality ranged from as low as 0.4% in patients with no risk factors to 21.1% for those with more than 4 risk factors. In conclusion, simple clinical and electrocardiographic data obtained at hospital admission allow an accurate risk stratification of patients with NSTEACS. In the PEPA registry, simple variables easy to obtain at admission appear to be a valuable tool in discerning between patients at very low and very high risk according to the cluster of factors for each patient. The risk score developed was obtained from an unselected population, representative of the whole spectrum of patients with NSTEACS, allowing identification of patients at different risks for adverse outcomes, and, therefore, permitting optimization of therapy.

Objectives: This study aimed to evaluate the effect of primary angioplasty (PA) over the risk of free wall rupture (FWR) in reperfused acute myocardial infarction (AMI)., Background: It has been suggested that PA reduces the risk of FWR compared with thrombolysis. However, few studies have evaluated this issue, and there are no data demonstrating this hypothesis., Methods: A total of 1,375 patients with AMI treated with PA (n = 762, 55.4%) or thrombolysis (n = 613, 44.6%) within 12 h after symptoms onset were included. The diagnosis of FWR was made either in the presence of sudden death due to electromechanical dissociation with large pericardial effusion on an echocardiogram or when demonstrated post mortem or at surgery. A multivariable analysis was performed including type of reperfusion strategy., Results: The overall incidence of FWR was 2.5% (n = 34): 1.8% and 3.3% in patients treated with PA and with thrombolysis, respectively (p = 0.686). The following characteristics were associated with a higher rate of FWR in the univariable analysis: age >70 (5.2% vs. 1.2%, p < 0.001), female gender (5.1% vs. 1.8%, p = 0.006), anterior location (3.3% vs. 1.4%, p = 0.020) and treatment >2 h after symptoms onset (3.6% vs. 1.7%, p = 0.043). In the multivariable analysis, age >70 (odds ratio [OR]: 4.12, 95% confidence interval [CI]: 2.04 to 8.62, p < 0.001) and anterior location (OR: 2.91, 95% CI: 1.36 to 6.63, p = 0.008) were independent risk factors of FWR, whereas treatment with PA was an independent protective factor (OR: 0.46, 95% CI: 0.22 to 0.96, p = 0.0371)., Conclusions: In patients with AMI, PA reduces the risk of FWR in comparison with thrombolysis.

Aims: The objective of this study was to report the experience in the treatment of acute myocardial infarction (AMI) with early coronary angioplasty (PTCA) in a single European center during one decade, attempting to identify the characteristics associated with a poor prognosis in these patients., Methods and Results: Eight hundred patients with AMI were treated with PTCA < 12 hours after symptom onset. Mean age was 64 +/- 13 years, 12% were in cardiogenic shock, AMI location was anterior in 61% and PTCA was performed after failed thrombolysis in 5%. Coronary stents and abciximab were used in 51% and 10%, respectively. An angiographic successful result was obtained in 93%, and final TIMI flow grade 3 was achieved in 83%. The overall in-hospital mortality rate was 12.5% (2.7%, 16.1%, 25.7% and 63.8% in patients in Killip class I, II, III and IV, respectively). Over the years, an improvement in the angiographic results and a reduction in the rates of reinfarction and target vessel revascularization were observed. The independent predictors of death were age > 70 years, absence of hyper-cholesterolemia, anterior location, cardiogenic shock, multi-vessel disease and unsuccessful PTCA. The leading causes of mortality were cardiogenic shock (63%) and ventricular free wall rupture (14%). The rates of non-fatal reinfarction, documented reocclusion and in-hospital repeated revascularization were 2%, 3% and 4%, respectively., Conclusion: In most cases, PTCA performed in a non-selected patient population with AMI results in angiographic success. Mortality especially occurs in patients who are in cardiogenic shock at the beginning of the procedure. We have observed an improvement in the results throughout the course of the decade.

Introduction: In patients with acute myocardial infarction treated with primary angioplasty, the inability to achieve successful coronary reperfusion is associated with higher mortality. The objective of the study was to identify which characteristics may predict a lower angiographic success rate in patients with acute myocardial infarction treated with coronary angioplasty., Patients and Methods: The study population is constituted by the 790 patients with acute myocardial infarction that were treated with angioplasty within the 12 hours after the onset of symptoms from 1991 to 1999 at our institution. A successful angiographic result was considered in presence of a residual stenosis < 50% and a TIMI flow 2 or 3 after the procedure., Results: A successful angiographic result and a final TIMI 3 flow were achieved in 736 (93.2%) and 652 (82.5%) patients, respectively. In-hospital mortality was higher in patients with angiographic failure than in those with angiographic successful result (48 vs. 10%; p < 0.01). Age under 65 (91 vs. 95%; p = 0.02), non smoking (90 vs. 96%; p < 0,01), previous infarction (87 vs. 94%; p < 0.01), angioplasty after failed thrombolysis (83 vs. 94%; p = 0. 02), cardiogenic shock (80 vs. 95%; p < 0.01), undetermined location (67 vs. 93%; p < 0.01), non-inferior location (92 vs. 96%; p = 0.04), left bundle branch block (64 vs. 94%; p < 0.01), multivessel disease (91 vs. 95%; p = 0.02), left ventricular ejection fraction < 0.40 (89 vs. 97%; p < 0.01), no utilization of coronary stenting (90 vs. 96%; p < 0.01), and use of intraaortic balloon counterpulsation pump (82 vs. 95%; p < 0.01) were associated with a lower angiographic success rate. In the multivariable analysis, the following were independent predictors for angiographic failure: left bundle branch block (odds ratio [OR], 12.95; CI 95%, 3.00-53.90), cardiogenic shock (OR, 4.20; CI 95%, 1.95-8.75), no utilization of coronary stent (OR, 3.44; CI 95%, 1.71-7.37), and previous infarction (OR, 2.82; CI 95%, 1.29-5.90)., Conclusions: Coronary angioplasty allows a successful coronary recanalization in most patients with acute myocardial infarction. Some basic characteristics, however, may identify some subsets in which a successful angiographic result may be more difficult to obtain.

A total of 590 patients with myocardial infarction treated with primary angioplasty were studied, to assess the incidence and related factors of free-wall rupture in patients with acute myocardial infarction when treated with primary angioplasty. The incidence of free-wall rupture was 2.2% (13 patients); this incidence was higher in patients >65 years old, women, nonsmokers, as well as in those with anterior location and an initial TIMI grade 0 flow, but it was similar in patients with a successful or unsuccessful angiographic result.

In the recent years, new possibilities have emerged in the diagnosis and management of acute myocardial infarction with ST segment elevation and its complications. Moreover, a deep transformation has taken place in the health care system organization, particularly in aspects related to care of patients presenting non-traumatic chest pain, both in pre-hospital and hospital areas. All these issues warrant a consensus document in Spain dealing with the role that these important changes should play in the whole management of myocardial infarction patients. This document revises and updates all the main clinical issues of acute myocardial infarction patients from the moment they contact with the health care system outside the hospital until they return home, after staying at the coronary care unit and the general hospitalization ward. All those aspects are considered not only in the uncomplicated myocardial infarction but also in the complicated one. This review also includes a set of recommendations on structural and organisational aspects, mainly referred to the prehospital and emergency levels.

This retrospective study evaluates the influence of an invasive strategy of urgent coronary revascularization on the in-hospital mortality of patients with acute myocardial infarction (AMI) complicated early by cardiogenic shock. Among 1,981 patients with AMI admitted to our institution from 1994 to 1997, 162 patients (8.2%) developed cardiogenic shock unrelated to mechanical complications. The strategy of management was considered invasive if an urgent coronary angiography was indicated within 24 hours of symptom onset. Every other strategy was considered conservative. Fifty-seven patients who developed the shock late or after a revascularization procedure, or who died on admission, were excluded. The strategy was invasive in 73 patients (70%). Five of them died before angiography could be performed and 65 underwent angioplasty (success rate 72%). By univariate analysis the invasive strategy was associated with a lower mortality than conservative strategy (71% vs 91%, p = 0.03), but this association disappeared after adjustment for baseline characteristics. Older age, nonsmoking, and previous ischemic heart disease were independent predictors of mortality. In conclusion, we have failed to demonstrate that a strategy of urgent coronary revascularization within 24 hours of symptom onset for patients with AMI complicated by cardiogenic shock is independently associated with a lower in-hospital mortality. This strategy was limited by the high mortality within 1 hour of admission in patients with cardiogenic shock, the modest success rate of angioplasty in this setting, and the powerful influence of some adverse baseline characteristics on prognosis.

Objectives: This study compares the efficacy of primary angioplasty and systemic thrombolysis with t-PA in reducing the in-hospital mortality of patients with anterior AMI., Background: Controversy still exists about the relative benefit of primary angioplasty over thrombolysis as treatment for AMI., Methods: Two-hundred and twenty patients with anterior AMI were randomly assigned in our institution to primary angioplasty (109 patients) or systemic thrombolysis with accelerated t-PA (111 patients) within the first five hours from the onset of symptoms., Results: Baseline characteristics were similar in both groups. Primary angioplasty was independently associated with a lower in-hospital mortality (2.8% vs. 10.8%, p = 0.02, adjusted odds ratio 0.23, 95% confidence interval 0.06 to 0.85). During hospitalization, patients treated by angioplasty had a lower frequency of postinfarction angina or positive stress test (11.9% vs. 25.2%, p = 0.01) and less frequently underwent percutaneous or surgical revascularization after the initial treatment (22.0% vs. 47.7%, p < 0.001) than did patients treated by t-PA. At six month follow-up, patients treated by angioplasty had a lower cumulative rate of death (4.6% vs. 11.7%, p = 0.05) and revascularization (31.2% vs. 55.9%, p < 0.001) than those treated by t-PA., Conclusions: In centers with an experienced and readily available interventional team, primary angioplasty is superior to t-PA for the treatment of anterior AMI.

Beneath the expression of unstable angina are joined an heterogeneous group of patients with different prognosis. In the initial presentation it is difficult to differentiate from non-Q wave myocardial infarction. The present review attempts to establish the relative importance of the clinical presentation, the electrocardiogram, the Holter monitoring and the biochemical markers of myocardial damage for risk stratification of these patients. The clinical factors related with prognosis are the general risk factors related to the prognosis in other presentations of the ischemic heart disease as the presence of previous myocardial infarction, age, presence of heart failure or left ventricular dysfunction, diabetes and peripheral vascular disease. The electrocardiogram is the most helpful method for risk stratification of unstable angina patients, especially depression. The continuous monitoring of the ST-segment through Holter monitoring constitutes an important investigation area, but presumably it can not be recommended as routine utilisation yet in the managing of this sort of patients. The rising of cardiac troponins T or I constitute other important risk marker. Possibly three different risk groups could be established: a) patients at low risk, those with normal electrocardiogram or only negative T-waves and normal cardiac troponins; b) intermediate risk, those patients with rising of cardiac troponins and normal electrocardiogram or electrocardiogram with ST-segment depression and normal cardiac troponins, and c) high risk, corresponding to the patients with rising of cardiac troponins and electrocardiogram with ST-segment depression.

We report the case of a 62-year-old patient with a mitral prosthesis hospitalized with an anterior acute myocardial infarction who was treated with r-tPA. Some days later, the patient had mitral thrombosis with heart failure. Because of the high risk of surgical intervention, he was successfully treated with a new dose of r-tPA.

The relation between electrocardiographic changes and the infarct-related coronary artery was studied in 76 patients with acute myocardial infarction 77 +/- 49 months after coronary artery bypass surgery in a retrospective series. When the infarct-related coronary artery was a graft, the electrocardiogram showed ST elevation and new Q waves less often; although the infarction was smaller, these patients presented a worse in-hospital prognosis.

In patients with acute myocardial infarction (AMI) thrombolysis reduces the infarct area, preserves ventricular function and improves survival. This effect is more significant in men with age between 65 and 75 years, anterior ST segment elevation or branch block, during the first 6 hours of evolution. In this review the comparative studies with placebo and between different fibrinolytic agents, in different doses or in combination are reviewed, and the drug selection, the actual impact or fibrinolysis and future directions of thrombolysis in patients with AMI are discussed. Reperfusion is highest with the use of double bolus tPA of front-loaded rapid tPA infusion. Reocclusion is more frequent after tPA and minimal after urokinase or the combination of tPA and urokinase. In the GISSI-2 and ISIS-3 studies, the mortality of patients treated with streptokinase, tPA or APSAC was similar. However, in the GUSTO study, with front loaded, rapid infusion of tPA, mortality was lower than with streptokinase, although this effect was only statistically significant in patients with anterior infarction or age < 75 years. Bleeding is more common with tPA, and allergic reactions are more frequent after streptokinase and APSAC than after tPA or urokinase. Symptomatic hypotension and bradycardia are also more frequent after streptokinase or APSAC, specially in patients with right ventricular infarction. Streptokinase and APSAC generate antibodies that may neutralize the effect of a second administration even years after the first dose. On the basis of the current clinical evidence it is not possible to recommend the use of a single fibrinolytic and, due to its lowest cost, streptokinase could be considered the first choice. However, in patients with previous thrombolysis, as well as in those with right ventricular infarction, the drug of choice should be tPA or urokinase; in young patients with anterior infarction tPA is more effective and in patients with difficult controls (mobile CCU, emergency wards, etc.) APSAC or urokinase may be considered the agent of choice because their easier administration. In spite of clear evidence of the efficacy of the thrombolytic therapy, it is only used in 20%-30% of the patients with AMI, and probably there is a selection of low risk patients. For these reasons, the impact of thrombolysis in the whole population of AMI is probably lower than it could be. Future directions for the use of thrombolytic agents include a better selection of the candidates and the drug to be used as well as the early administration of thrombolytics, even before the admission to the CCU.

Inversion of the normal interatrial septum convexity has been described in patients with right atrial pressure or volume overload, but there is no reference to this abnormality in acute myocardial infarction. A group of 576 consecutive patients with acute infarction and serial echocardiographic studies were prospectively evaluated during a mean follow-up period of 406 days. Inverted interatrial septum convexity was found in 30 patients (5.2%); 29 of the 30 presented with inferior infarction with right ventricular involvement (29 [24.4%] of 119) and the remaining presented with cardiac tamponade secondary to heart rupture. The incidence of inverted interatrial septum convexity rapidly decreased, and after 3 months it was present in only five patients. All patients with inverted interatrial septum convexity had a right atrial pressure greater than or equal to pulmonary capillary pressure, a relation found in only 2 of 43 patients with right ventricular involvement and normal septal convexity. In patients with right ventricular infarction, right atrial pressure was higher in the presence of inverted septal convexity (15.9 +/- 4.1 versus 10.5 +/- 4.1 mm Hg, p less than 0.0001) and the incidence of hypotension (10 [34.4%] of 29 versus 15 [17.4%] of 90, p = 0.04) and third degree atrioventricular block (10 [34.4%] of 29 versus 11 [12.2%] of 90, p = 0.006) as well as the mortality rate after 3 months (9 [31%] of 29 versus 11 [12.2%] of 90, p = 0.04) were higher in the presence of inverted convexity than in patients with normal septal convexity.(ABSTRACT TRUNCATED AT 250 WORDS)