Search

Calcium channel blockers (CCBs) do not reduce the risk of initial or recurrent myocardial infarction (MI) in patients diagnosed with stable coronary artery disease (CAD). The aim of this current study was to evaluate the association between CCBs and aspirin resistance in patients with CAD. Patients with stable CAD who were regularly taking aspirin (75–100 mg qd) for at least 1 month prior to enrollment in the study were included. The VerifyNow system was used for platelet function testing with high on-aspirin platelet reactivity (HAPR) defined as aspirin reaction units (ARU) >550. We compared patients treated with CCBs versus control group. Five hundred three patients with CAD were included in this study, and 88 were treated with CCBs. Mean age (67.9±9.7 in the CCB group vs. 66.5±11.4 in the control group), gender (77.3 male vs. 82.9%), rates of diabetes mellitus (34.7 vs. 36.9%), rates of CKD (23.5 vs. 23.5%), dyslipidemia (85.1 vs. 85.3%), and statin therapy (89.5 vs. 90.7%) were similar. The mean ARU was 465.4±70.0 for patients treated with CCBs versus 445.2±60.0 in controls (p=0.006). Similarly, 15.9% of CCB patients demonstrated HAPR compared to 7.0% (p=0.006). The administration of CCBs was independently associated with HAPR in a multivariate analysis (OR 1.72, 95% CI: 1.04–8.91, p=0.047) as well as in propensity score matched analysis (OR 1.56; CI: 1.22–1.93; p

Multi-vessel coronary artery disease (MV-CAD) is correlated with worse clinical outcomes compared with single-vessel CAD (SV-CAD). The aim of this study was to evaluate the association between MV-CAD and high on-aspirin platelet reactivity (HAPR) in patients with stable CAD treated with aspirin.The current study is an analysis of prospectively enrolled randomly selected patients with known stable CAD, who were taking aspirin (75-100 mg qd) regularly for at least one month, and had undergone coronary angiography at least 3 months prior to the enrollment to the study.acute coronary syndrome at the time of platelet function testing, active malignancy, acute infection, active inflammatory/rheumatic disease, major surgery in the past 6 months, chronic liver failure, treatment with oral anticoagulation, non-adherence with Aspirin and thrombocytopenia (100 K/micl). Blood was drawn from the participants and sent for platelet function testing (VerifyNow, Instrumentation Laboratory Company, Bedford, Massachusetts, United States). MV-CAD was defined as50% stenosis in ≥2 separate major coronary territories per coronary angiography. HAPR was defined as aspirin reaction units (ARU)550.Overall, 507 patients were analyzed; age 66.7 ± 11.2, 17.9% women, 223 (44%) had MV-CAD. The rate of HAPR was significantly higher among patients with MV-CAD vs. SV-CAD (14.8% vs. 3.5%, p 0.001, respectively). Furthermore, a "dose response"-like association was found between the number of stenotic coronary arteries and the rate of HAPR (3.5%, 13.5 and 17.3% for SV-CAD, 2-vessel and 3-vessel disease, respectively). In a multivariate analysis adjusted for potential confounders, MV-CAD was found to be a strong independent predictor of HAPR [OR = 1.8 (95%CI: 1.05-4.7), p = 0.014].A significant association between MV-CAD and HAPR was found. Additional studies designed to investigate the mechanisms of HAPR and different therapeutic options for this subset of patients are warranted.

Purpose: Calcium channel blockers (CCBs) do not reduce the risk of initial or recurrent myocardial infarction (MI) in patients diagnosed with stable coronary artery disease (CAD). The aim of this current study was to evaluate the association between CCBs and aspirin resistance in patients with CAD. Methods: Patients with stable CAD who were regularly taking aspirin (75-100 mg qd) for at least one month prior to enrollment in the study were included. The VerifyNow system was used for platelet function testing with high on-aspirin platelet reactivity (HAPR) defined as aspirin reaction units (ARU) >550. We compared patients treated with CCBs versus control group. Results: 503 patients with CAD were included in this study, 88 were treated with CCBs; Mean age (67.9±9.7 in the CCB group vs 66.5±11.4 in the control group, p=0.288), gender (77.3 male vs. 82.9%, p=0.214) and rates of diabetes mellitus (34.7 vs. 36.9%, p=.121) were similar. Rates of hypertension were higher in the CCB group (83.9 vs. 63.5%, pConclusions: Usage of CCBs is positively correlated with aspirin resistance. These findings may suggest an adverse pharmacologic effect of CCBs among patients with stable CAD treated with aspirin.

Serum albumin (SA) level is a powerful cardiovascular prognostic marker, suggested to be involved in regulation of platelet function. High on-aspirin platelet reactivity (HAPR) is associated with increased risk for deleterious cardiovascular events. The aim of the present study was to evaluate the association between HAPR and albumin levels in patients with stable coronary artery disease (CAD) treated with aspirin. Patients with known stable CAD, who were taking aspirin (75 to 100 mg qd) regularly for at least 1 month, were screened for the present study. Exclusion criteria: cancer, sepsis or acute infection, active inflammatory/rheumatic disease, recent major surgery, chronic liver failure, the administration of other antiplatelet drugs, nonadherence with aspirin and thrombocytopenia. Blood was drawn from the participants and sent for SA level and platelet function test (VerifyNow). HAPR was defined as aspirin reaction units (ARU)550. Overall 116 patients were analyzed; age 69 ± 10, 28% women. Twenty (17%) were hypoalbuminemic (≤3.5 g/dl). Hypoalbuminemic patients had similar characteristics to the normal albumin group except mildly higher creatinine in the former. SA levels were significantly lower in the hypoalbuminemic group (3.2 ± 0.2 g/dl vs 4.2 ± 0.4 g/dl, respectively, p0.001) whereas mean ARU was significantly higher compared with the normal albumin group (548 ± 45 vs 444 ± 66 ARU, respectively, p0.001). A significant inverse association was observed between SA and ARU with (R

Background Multi-vessel coronary artery disease (MV-CAD) is correlated with worse outcomes compared with single-vessel CAD (SV-CAD), potentially attributed to more advanced atherosclerotic disease in other vascular beds, greater endothelial dysfunction, thrombin activation and possibly greater platelet reactivity. Objectives The aim of the current study was to evaluate the association between MV-CAD and high on-aspirin platelet reactivity (HAPR) in patients with stable CAD treated with aspirin. Methods Patients with known stable CAD, who were taking aspirin (75–100 mg qd) regularly for at least one month, and had undergone coronary angiography at least 3 months prior to the test, were enrolled. Blood was drawn from the participants and sent for platelet function testing. MV-CAD was defined as >50% stenosis in ≥2 separate major coronary territories per coronary angiography. HAPR was defined as aspirin reaction units (ARU) >550. Results Overall 507 patients were analyzed; age 66.7±11.2, 17.9% women, 223 (44%) had MV-CAD. Mean ARU was significantly higher among patients with MV-CAD vs. SV-CAD (460±68 vs. 440±55, p Conclusions MV-CAD is significantly associated with HAPR. This could potentially explain, in part, the increased risk and/or worse outcomes in patients with MV-CAD and implies considering intensive anti-thrombotic therapy among these patients. Funding Acknowledgement Type of funding source: None

Levels of reticulated platelets (RP) increase during high platelet turnover conditions, and have been shown to correlate with diabetes mellitus (DM) status. Little is known regarding the prognostic significance of levels of RP among patients with stable coronary artery disease (SCAD). The study consisted of patients with SCAD and DM, who visited our cardiology outpatient clinic between June 2016 and February 2017. RP levels were measured at baseline as immature platelet fraction (IPF)%, using flow cytometry. Outcomes at 2 years consisted of bleeding events and major adverse cardiovascular events (MACE), which included death, myocardial infarction, cerebrovascular accident and urgent revascularization. The study included 104 patients (mean age - 71.2 ± 9.5 years, 76.9% were male, and 83.7% had hypertension). IPF was significantly higher at baseline among patients who had suffered from a MACE (4.57% vs. 2.53%

Left ventricular (LV) dyssynchrony by phase analysis has been studied by myocardial perfusion imaging (MPI)-gated SPECT in patients with LV dysfunction in various clinical settings. We aimed to investigate the routine use of phase analysis with gated SPECT for predicting cardiac outcome. Patients referred to a tertiary medical center in 2010-2011 prospectively underwent a gated SPECT and phase analysis, and follow-up for cardiac events. The values of clinical variables, MPI, LV function, and LV dyssynchrony in predicting cardiac events were tested by univariate and multivariate analyses. The study group included 787 patients (66.5 ± 11 years, 81% men) followed for a mean duration of 18.3 ± 6.2 months. There were 45 (6%) cardiac events defined as composite endpoint; cardiac death occurred in 26 patients, and the rest had new-onset or worsening heart failure and life-threatening arrhythmias. In multivariate analysis, it was shown that NYHA class, diabetes mellitus, and LVEF

Recent studies have suggested that clopidogrel response may vary significantly with age. Limited data are available exploring the age dependency of ex vivo aspirin response in young and old patients with stable coronary artery disease. Patients with stable coronary artery disease (n = 583) who had been treated with aspirin 75 to 325 mg/day for ≥1 week were recruited from a general cardiology practice. The study cohort was divided into 2 groups: patients aged75 years (n = 438) and patients aged ≥75 years (n = 145). Aspirin response was determined using the VerifyNow Aspirin Test, and resistance was defined as ≥500 or 550 aspirin reaction units (ARU). The independent predictive value of age on VerifyNow score (as a continuous function) was determined using multivariate linear regression, adjusted for gender, body mass index, and diabetes mellitus. Younger and older patients had similar baseline clinical profiles, including relative doses of aspirin therapy. The mean VerifyNow Aspirin Test score was significantly higher in patients aged ≥75 years: 450 ± 54 versus 434 ± 53 ARU (p = 0.0007). After accounting for the primary covariates, age remained a predictor of VerifyNow score (p = 0.007). Aspirin resistance on the basis of the 500-ARU cutoff was higher in older patients (19% vs 11%, p = 0.009), but there was no difference when the 550-ARU cutoff was used (7% vs 5%, p = 0.40). In conclusion, aspirin response differs significantly by age in patients with stable CAD.

We previously described the feasibility of performing myocardial perfusion imaging (MPI) with half the technetium (Tc-99m) activity using ordered-subset expectation maximization with resolution recovery (OSEM-RR) processing. This study sought to assess the accuracy of this technique by correlating the findings with coronary angiography. Of 290 patients who underwent MPI-gated SPECT using a half dose of Tc-99m sestamibi and OSEM-RR software in 2010-2012 at a tertiary medical center, 62 were referred for invasive coronary angiography within 90 days and formed the study group. Ischemia was defined as a summed difference score (SDS) of >3 on the MPI scan. Luminal stenosis of ≥70% on invasive coronary angiography served as the reference. Mean Tc-99m activity per study was 23.9 ± 11.5 mCi and mean effective radiation dose was 7.2 ± 3.4 mSv. MPI revealed no abnormalities in 10 patients (16.2%), myocardial infarction only in 8 patients (12.9%), and ischemia in 44 patients (71.1%). Overall sensitivity, specificity, and positive and negative predictive values for MPI compared to invasive angiography were 89.1%, 75.0%, 91.1%, and 70.5%, respectively. MPI SPECT performed with a half dose of Tc-99m and OSEM-RR image processing correlates well with invasive angiography. (J Nucl Cardiol 2013)

This study sought to assess the feasibility of performing myocardial perfusion imaging (MPI) with half the technetium activity using ordered-subset expectation maximization with resolution recovery (OSEM-RR), an iterative reconstruction software developed to improve count statistics and acquisition time.Two hundred eighteen patients referred for MPI were randomly allocated to undergo stress-rest or rest-stress protocols with standard full-dose (FD) injections of technetium (Tc)-99m sestamibi or half-dose (HD) injections and OSEM-RR processing. Dose activities were adjusted individually by weight. The groups were compared for image quality and clinical results.The groups were similar for mean patient age, weight, and body mass index, sex distribution, pre-test probability of CAD and CAD prevalence. Mean Tc-99m activities for the low-dose and high-dose stages were as follows: FD group: 429 ± 85 MBq and 1132 ± 200 MBq; HD group: 263 ± 129 MBq and 629 ± 85 MBq (P.0001 for both). Mean effective dose per study was 13.6 ± 1.4 mSv in the FD group and 7.7 ± 1.0 mSv in the HD group (P.001). Over all image quality was good-to-excellent in 98% and 95% of the groups, respectively. However, when we analyzed the low-dose stage separately, image quality was slightly worse in the HD than the FD, though still within the good-to excellent range.MPI with nearly half the radiation dose is feasible with good image quality.

To examine the yield of an ultra-low-dose computed tomography (CT) transmission module for attenuation-correction (AC) on a dedicated cardiac camera in evaluation of SPECT-myocardial perfusion imaging (MPI) in the diagnosis of CAD and for additional chest abnormalities. The study group included 150 patients with known or suspected CAD referred for technetium sestamibi SPECT MPI. CT transmission scanning (effective radiation 0.17 mSv) was performed after each gated SPECT scan. AC and non-corrected (NC) SPECT scans were evaluated on a 5-point scale using a 17-segment model, and the sum stress score (SSS) and sum rest score (SRS) were calculated for each condition. Overall image quality, sensitivity and normalcy rate (51 patients) and processing of 28 CT slices were screened for chest findings. CT-based AC significantly improved image quality (P = .01). Mean SSS was 3.8 ± 5.8 with AC and 6.1 ± 7.1 with NC (P

BACKGROUND Myocardial perfusion imaging with single-photon emission tomography (SPECT) is associated with reduced specificity due to tissue attenuation. This can be corrected by prone imaging while necessitating additional imaging time. Image processing with iterative reconstruction allows for a half-time (HT) acquisition. OBJECTIVE To assess the feasibility of myocardial perfusion with SPECT using prone imaging with HT acquisition. METHODS Ninety-one patients referred for SPECT myocardial perfusion imaging and weighing up to 90 kg were enrolled for HT supine and prone SPECT protocol. Patients with known myocardial infarction were excluded. HT prone imaging was performed when supine imaging was visually equivocal or abnormal. Image quality was compared for each patient between supine and prone imaging. RESULTS Acquisition time was 17.9 ± 2.9 min in the HT group compared with 31.8 ± 5.8 min in patients imaged with full-time acquisition. Image quality was good or excellent in 85.7% of studies in a supine position and in 81.3% of studies in the prone position (P = 0.25). No study was considered as nondiagnostic. Prone imaging reduced the rate of equivocal scans from 40.7 to 15.4% and of ischemic studies from 34.1 to 7.7%. In the study population, 80% of inferior and septal defects were corrected by the prone position. CONCLUSION In a selected population, HT prone and supine imaging is feasible and is associated with a good image quality in most studies whereas acquisition time is reduced almost by half.

Objectives The aim of this study was to evaluate whether addition of omega-3 fatty acids or increase in aspirin dose improves response to low-dose aspirin among patients who are aspirin resistant. Background Low response to aspirin has been associated with adverse cardiovascular events. However, there is no established therapeutic approach to overcome aspirin resistance. Omega-3 fatty acids decrease the availability of platelet arachidonic acid (AA) and indirectly thromboxane A2 formation. Methods Patients (n = 485) with stable coronary artery disease taking low-dose aspirin (75 to 162 mg) for at least 1 week were screened for aspirin response with the VerifyNow Aspirin assay (Accumetrics, San Diego, California). Further testing was performed by platelet aggregation. Aspirin resistance was defined by ≥2 of 3 criteria: VerifyNow score ≥550, 0.5-mg/ml AA-induced aggregation ≥20%, and 10-μmol/l adenosine diphosphate (ADP)-induced aggregation ≥70%. Thirty patients (6.2%) were found to be aspirin resistant and randomized to receive either low-dose aspirin + omega-3 fatty acids (4 capsules daily) or aspirin 325 mg daily. After 30 days of treatment patients were re-tested. Results Both groups (n = 15 each) had similar clinical characteristics. After treatment significant reductions in AA- and ADP-induced aggregation and the VerifyNow score were observed in both groups. Plasma levels of thromboxane B2 were also reduced in both groups (56.8% reduction in the omega-3 fatty acids group, and 39.6% decrease in the aspirin group). Twelve patients (80%) who received omega-3 fatty acids and 11 patients (73%) who received aspirin 325 mg were no longer aspirin resistant after treatment. Conclusions Treatment of aspirin-resistant patients by adding omega-3 fatty acids or increasing the aspirin dose seems to improve response to aspirin and effectively reduces platelet reactivity.

Concomitant carotid artery disease (CaAD) in patients with coronary artery disease (CAD) is associated with worse cardiac and neurologic outcomes. The reported prevalence and risk factors for concomitant CaAD in CAD patients varied among previous studies.To examine these factors in ambulatory patients with CAD and well-documented cholesterol levels treated with cholesterol-lowering medications.We retrospectively analyzed prospectively collected data from 325 unselected patients with CAD (89 women, mean age 68.8 ± 9.9 years) undergoing routine evaluation at the coronary clinic of our hospital.The low density lipoprotein-cholesterol (LDL-C) was100 mg/dl in 292 patients (90%). Age at onset of CAD symptoms was 59.4 ± 10.8 years. Carotid stenosis ≥ 50% was seen in 83 patients (25.5%) and between 30% and 49% in 55 patients (17%) (duplex method). Carotid stenosis was significantly associated with hypertension (P = 0.032), peripheral arterial disease (P = 0.002) and number of coronary arteries with ≥ 50% stenosis (P = 0.002), and showed a borderline association with age at CAD onset (P = 0.062) and diabetes mellitus (P = 0.053). On linear regression analysis, independent predictors of CaAD were peripheral vascular disease (OR 3.186, 95% CI 1.403-7.236, P = 0.006), number of coronary arteries with ≥ 50% stenosis (OR 1.543, 95% CI 1.136-2.095, P = 0.005), and age at CAD onset (OR 1.028, 95% CI 1.002-1.054, P = 0.003). None of the variables studied predicted freedom from CaAD.Carotid atherosclerosis is very common in stable ambulatory patients with CAD regularly taking statins. The risk is higher in patients with peripheral arterial disease, a greater number of involved coronary arteries, and older age at onset of CAD.

Background Right ventricular (RV) involvement during acute inferior myocardial infarction (MI) is associated with increased early morbidity and mortality. With recent improvement in percutaneous coronary intervention (PCI) techniques, it is unclear which factors may improve the outcomes of these patients. We sought to assess the prognostic significance of the presence of right ventricular myocardial infarction (RV-MI) in patients undergoing primary PCI and to explore factors associated with improved outcomes by using a large database representing the "real life" of patients with acute MI (AMI) treated by primary PCI. Methods We analyzed our database of patients with AMI undergoing primary PCI within 12 hours of chest pain between January 2001 and June 2005, excluding patients with cardiogenic shock. Results Of the 666 consecutive patients with MI fulfilling our inclusion criteria, 329 had anterior wall MI, 264 had inferior (230 inferior + 34 lateral) wall MI, and 73 had RV-MI. Mortality at hospital discharge, 30 days, and 6 months was highest in patients with RV-MI involvement (5.5%, 9.6%, and 12.3%, respectively), intermediate in patients with anterior MI (2.4%, 4.6%, and 7.3%, respectively), and lowest in patients without RV myocardial involvement (0.8%, 1.1%, and 3%, respectively) ( P P = .1 for 6 months). After adjustment for the CADILLAC score, odds ratio for 30-day morbidity was 5.2 (95% CI 1.6-17, P = .005) for patients with RV-MI versus those without RV-MI. Within the group of patients with RV-MI, complete revascularization of the right coronary artery including the major RV branch was associated with higher rate of RV function recovery by echocardiography and improved 30-day mortality (odds ratio 0.4, 95% CI 0.1-1.05, P = .06). Conclusions Right ventricular infarction is an independent risk factor for increased mortality even in these days of primary PCI. Intensive medical therapy including restoring blood flow into the right coronary artery including the major RV branch may improve clinical outcomes.

Renal insufficiency (RF) was shown to be associated with a worsened prognosis following acute myocardial infarction (AMI).The authors analyzed the outcomes of AMI patients with impaired renal function tests treated using primary percutaneous coronary intervention (PCI), to determine factors associated with increased mortality risk.This study included 558 consecutive AMI patients treated using primary PCI between January 2001 and June 2005. The authors compared outcome results according to glomerular filtration rate (GFR). An abbreviated equation was used to calculate GFR. Patients were grouped as follow: normal (or =90 mL/min/1.73 m(2)), mildly impaired (60-89 mL/min/1.73 m(2)), moderately impaired (30-59 mL/min/1.73 m(2)), and severely impaired GFR (30 mL/min/1.73 m(2)).There was a stepwise increase in 30-day mortality among patients with normal, mildly, moderately, and severely impaired RF: 2.1%, 3.7%, 8.2%, and 22.2%, respectively (P = 0.004). Seventeen out of the 324 with any degree of RF died within 1 month [5.3%] of these nine patients [53%] died because of cardiac cause. Univariate correlation analysis, factors associated with an increased risk of 1 month mortality included: age75 years, left ventricular ejection fraction35%, lower GFR, killip class1, multivessel coronary artery disease, failure to achieve TIMI flow grade = 3, the occurrence of no-reflow, IABP use, lack of administration of anti GP 2b/3a. The amount of contrast media used during the procedure [mL/Kg] as well as renal function deterioration were also associated with increased mortality.Clinical and angiographic parameters collected before and during PCI can be used to predict 30-day mortality among AMI patients with RF. Findings indicate that in the setting of contemporary catheter-based reperfusion strategy for AMI, the extent of coronary artery disease, measures of PCI complexity, and degree of renal impairment prior/following the procedure are altogether related to mortality.

Mechanical left ventricular dyssynchrony (MLVD) might contribute in the therapeutic decision-making in patients with heart failure (HF) prior to cardiac resynchronization therapy (CRT). Our aim was to assess MLVD in patients with HF prior to implantable cardioverter-defibrillator (ICD) compared to patients with CRT-D. In a prospective study, patients with LVEF ≤ 35% who were scheduled for ICD or CRT-D, underwent gated SPECT myocardial perfusion imaging with technetium 99m sestamibi within 3 months prior procedure. MLVD was measured by phase analysis. The study cohort consisted of 143 patients, 71 with ICD and 72 with CRT-D. Age 68.3 ± 11 and LVEF 24 ± 6%. Phase standard deviation (SD) was 62.5 ± 18 and 59.7 ± 20 (P = NS), respectively. During follow-up of 23.7 ± 12.1 months, there were 10 vs 14 cardiac death in ICD and CRT-D, respectively (P = NS), hospitalization for HF, in 34 vs 53 (P

Most patients with Primary Pulmonary Hypertension (PPH) have severe exertional limitation which ultimately leads to right heart failure and death. The purpose of the study was to assess the correlation between right ventricular (RV) systolic and diastolic noninvasive variables and exercise tolerance, as well as the predictors of adverse outcome in treated patients.We prospectively studied 29 patients, 17 with PPH and 12 with PPH due to collagen disease. RV parameters were assessed by echocardiography and Radionuclide ventriculography. Pulmonary function and clinical profile were assessed by 6 min walk test and NYHA class. The patients were followed-up during 2 years for cardiac death and cardiac deterioration.Mean age was 51 +/- 15 years, 22 (78%) women. NYHA class1 in 2 pts, class 2 in 17, class 3 in 8 and class 4 in 2 pts. Pulmonary function (DLCO) was low in 25 (86%) pts, mean 22 +/- 48%. Six minutes walk distance was 358 +/- 132 m, RVEF was 34 +/- 11% (range 16-51%). Among RV variables, RVEF, RA area and TR were independently correlated to 6 min walk. Within follow up of 2 years, there were 10 patients with adverse outcome (4 deaths and 6 deteriorated to NYHA class 3 and 4). Among all clinical and noninvasive variables, RVEF only was correlated to adverse outcome.The noninvasive tests of RVEF, RA size and TR were closely correlated to exercise tolerance. However, among the various clinical, functional and RV variables, RVEF was the only variable correlated with adverse outcome in pts with PPH.

The aim of this study was to evaluate the value of myocardial perfusion imaging (MPI) in predicting major adverse cardiovascular events (MACE) in symptomatic and asymptomatic patients after percutaneous coronary intervention (PCI). We revised retrospectively patients after PCI that underwent MPI and were followed for a year for the presence of MACE. We found no differences in the incidence of MACE between symptomatic and asymptomatic patients. On multivariate analysis, the presence of ischemia by MPI was the most important independent predictor of MACE (OR 5.09, CI 95% 2.15–12.05, p < 0.001). The presence of myocardial ischemia by MPI performed after PCI, and no symptom status, predicts a worse outcome during 1 year of follow-up.

Aim: To determine the frequency and outcomes of coronary artery bypass graft (CABG) surgery in patients with a wide spectrum of acute coronary syndromes (ACS). Methods and Results: We prospectively enrolled 10,484 ACS patients from 103 hospitals in 25 countries across Europe and the Mediterranean basin. Of the 10,204 patients with complete data, 460 (4.5%) underwent CABG while in hospital; 3.4% had ST elevation ACS, 5.4% had non-ST elevation ACS, and 4.4% had undetermined ECG ACS (p = 0.001 for non-ST elevation ACS vs. others). In general, patients who underwent CABG were more likely to be males, to have diabetes mellitus, hyperlipidemia, a positive family history of premature coronary disease, and prior angina pectoris, but had less often prior heart failure. While in hospital, all CABG patients underwent coronary angiography and 15.2% also underwent percutaneous revascularization, as compared with 51.3 and 33.1% in the remaining patients, respectively. The in-hospital mortality was 3.7% for ACS patients who underwent CABG and 4.8% for non-CABG ACS patients (p = nonsignificant) with an adjusted odds ratio of in-hospital death for CABG patients of 1.00 (95% CI 0.59–1.61). Conclusions: Approximately 4.5% of ACS patients underwent CABG during their initial hospitalization, with a greater likelihood among non-ST elevation ACS patients. Of the CABG patients, 15.2% also underwent percutaneous revascularization. The outcome of CABG patients was as good as non-CABG patients, indicating that CABG remains an effective and safe means to achieve revascularization among ACS patients in current clinical practice.

Coronary stenting in acute coronary syndromes might be associated with increased procedural complications and stent thrombosis risk. Heparin-coated stent (HCS) may improve procedural outcomes when treating these high-risk lesions. The purpose of this study was to determine the safety and efficacy of HCS in patients with acute coronary syndromes and thrombus containing lesions.Between January 2001 and January 2002, 49 patients (42 male) with thrombus containing lesions (32 sustained acute myocardial infarction) received HC BX stents (HepaCoat) at our hospital. Procedural, hospital and six-month outcomes and quantitative angiographic analysis data were obtained from all patients.The mean age of patients was 58 +/- 14 years, 45% had multi-vessel disease and 24% were diabetics. Fifteen patients (31%) received a second HCS for sub-optimal results or threatened closure. Procedural success was achieved in 94% of patients. The mean stent diameter and length was 3.2 +/- 0.2 mm and 18.2 +/- 7.4 mm. The mean TIMI flow increased from 1.3 +/- 1.3 to 2.9 +/- 0.3 and the mean diameter stenosis before and after intervention was 84 +/- 21% and 12 +/- 14%. In-hospital and 30-day follow-up were eventually without occurrence of death, myocardial infarction, stent thrombosis, coronary bypass. At six-months follow-up, cardiac event-free survival was 89.8%, target vessel revascularization was 6.1 and 90% of patients were free of angina.In this series of patients with acute ischemic syndromes associated with visible thrombus, the use of HCS resulted in (1) favorable procedural and six-month outcomes, (2) no incidence of stent thrombosis, and (3) overall good cardiac prognosis at six-month follow-up.

Left internal mammary artery (LIMA) grafting to the left anterior descending artery (LAD) is known to have long-term patency. However, myocardial ischemia in the territories supplied by LIMA to LAD is still demonstrated. The aim of this study is to examine the relationships between the extent, location, and clinical outcome of myocardial ischemia in LAD territories (ILAD) by use of myocardial perfusion imaging (MPI) and angiographic characteristics of such a bypass conduit.We studied 38 consecutive patients with prior coronary artery bypass grafting who showed stress-induced ischemia in LIMA to LAD territories by MPI single photon emission computed tomography between the years 1996-2000. All patients underwent quantitative coronary angiography within 6 months of the nuclear study. Single photon emission computed tomography parameters of ILAD were assessed by location (septum, apex, anterior, and anterolateral) and included extension score (1-4 per patient), severity score (0-3 per territory), and total sum score. LIMA to LAD quantitative coronary angiography parameters included minimal lumen diameter, lesion length, reference diameter, and diameter stenosis (percentage). LAD and LIMA diameters and ratio (in normal segments) were determined within 10 mm proximal and distal to the anastomotic site. The study group was compared with 18 control subjects without ischemia or stenosis treated with LIMA to LAD. The patients were followed up for cardiac death at an interval of 3.2 +/- 1.5 years from the time of MPI testing. The patients' mean age was 66 +/- 12 years (31 men and 7 women); the mean period after surgery was 6.2 +/- 1.5 years. The ILAD distribution was as follows: septum, 12 (32%); apex, 20 (52%); anterior, 24 (63%); and anterolateral, 18 (47%). The mean extension score was 1.9 +/- 1.0, and the mean total sum score was 3.4 +/- 2.3. Of 38 patients with ILAD, only 17 (45%) had greater than 50% luminal stenosis (2 LIMA and 15 anastomosis or distal). Among clinical variables during stress testing, the prevalence of angina was significantly higher in the luminal stenotic patients versus patients without stenosis (P =.04). A significant correlation was found between anterior wall ischemia and reference diameter (r = -0.7, P =.002) and between total sum score and minimal lumen diameter (r = -0.48, P =.05). Of note, the LAD-to-LIMA ratio was significantly lower in patients with ILAD and without luminal stenosis compared with the control group (0.73 +/- 0.16 vs 0.87 +/- 0.15, P =.004). Cardiac death occurred in 8 patients (21%), 5 patients with luminal stenosis versus 3 patients without stenosis (P = not significant).In patients with LIMA to LAD anastomosis, myocardial ischemia could occur even without angiographic luminal stenosis and apparently reflects a mismatch between LAD and LIMA diameters at distal anastomotic sites. Regarding the similar prevalence of cardiacdeath, invasive evaluation and aggressive treatment are recommended in all patients with ischemia in LIMA/LAD territories.

Summary Background:The two most useful methods for myocardial viability assessment are perfusion imaging and dobutamine echocardiography. Hypothesis:The present study investigated the additive value of a new method, dobutamine technetium 99m ( 99m Tc)-sestamibi-gated single-photon emission computed tomography (SPECT), which combines these two modalities, to the prediction of wall motion improvement after revascularization. Methods: Fifty-five consecutive patients with ischemic cardiomyopathy, who were referred for viability evaluation, underwent resting and dobutamine (dose, 5‐10 µkg/kg/min) gated SPECT with 99m Tc-sestamibi. Of these patients, 36 underwent coronary artery bypass graft (CABG) within 1 month of the study and 32 had repeat resting gated SPECT within 1 year. Global and regional wall motion, wall thickness, and perfusion were simultaneously analyzed at rest and after dobutamine using the 20-segment model; the sestamibi uptake and wall motion response to dobutamine of each segment were rated quantitatively. Based on these findings, the segments were categorized as normal, viable, or nonviable. The predictive values for wall motion improvement were assessed by perfusion, using cutoffs of 50 and 60% of sestamibi uptake, and thereafter by the addition of dobutamine response in the segments that were rated nonviable. Results: Of the 1,080 myocardial segments studied, 906 (84%) had abnormal wall motion and were analyzed for viability. Concordance between perfusion and wall motion response to dobutamine was 60% with the 50% cutoff of sestamibi uptake, and increased to 65% with the 60% sestamibi cutoff (p < 0.04). The respective predictive values of wall motion improvement using the 50 and 60% cutoff points were as follows: sensitivity 93 and 70%, respectively, (p < 0.01); specificity 59 and 86% (p < 0.001), respectively; accuracy 77% for both. The addition of the wall motion response to dobutamine to the assessment of the nonviable segments by perfusion (60% cutoff) increased the sensitivity from 70 to 85% (p = 0.001) and the negative predictive value from 70 to 81% (p = 0.009); the positive predictive value remained high (86 vs. 82%). No additive value of wall motion response to dobutamine was demonstrated for nonviable segments by perfusion with a 50% cutoff. Conclusion:Dobutamine sestamibi-gated SPECT is a feasible method for the analysis of myocardial perfusion, function, and contractile reserve of individual myocardial segments in patients with ischemic cardiomyopathy. Viability assessment based on a threshold of 60% uptake of sestamibi, with the addition of the wall motion response to dobutamine in the nonviable segments, seems to yield better predictive values for wall motion improvement after CABG.

Some prospective randomized trials have established the superiority of primary percutaneous coronary intervention (PCI) over fibrinolytic treatment in patients with acute myocardial infarction (MI). These excellent PCI results are not duplicated in smaller hospitals where there may be delays in getting the cardiac catheterization team to the laboratory. This study aimed to compare the outcome of patients with anterior wall MI, without cardiogenic shock on admission, treated with primary PCI or thrombolytic therapy, in everyday practice. The data of all patients with MI hospitalized in all coronary care units operating in Israel during three consecutive national surveys was analyzed. A total of 1,038 patients with anterior wall MI were treated by reperfusion (886 received thrombolytic therapy, 152 primary PCI). Overall, the outcome of patients treated using primary PCI was better compared to patients treated with thrombolysis, with 68% relative risk reduction of 30-day mortality (mortality at 30 days: 2% vs. 6.3%; P = 0.04). A subanalysis of patients according to age showed that the beneficial effect of primary PCI on mortality was mainly clustered among the younger. In our study, patients (especially younger than 75 years) with anterior wall MI allocated to primary PCI have a better clinical outcome. Catheter Cardiovasc Interv 2004;61:79–83. © 2004 Wiley-Liss, Inc.

Clinical data from observational as well as prospective randomized trials has shown an increased risk for ischemic events in the 90 days following cessation of dual antiplatelet therapy (DAPT). A possible explanation for this finding is a “rebound” effect of DAPT cessation on platelet reactivity

The relationship between Helicobacter pylori infection and coronary artery disease (CAD) has as yet not been fully examined. The myocardial perfusion imaging (MPI) stress test has proven its efficacy as an integral part of diagnosing CAD.To investigate the association between CAD and H. pylori infection using MPI.This prospective study evaluated CAD positivity among consecutive patients referred to a tertiary medical center for a stress/rest MPI. All patients were tested for serum anti-H. pylori and CagA protein immunoglobulin G antibodies. The CAD positivity group included patients with ischemia and/or myocardial infarction (MA) on a stress MPI, coronary artery bypass graft surgery (CABG), or percutaneous coronary interventions (PCI). CAD-negative subjects were defined as participants with a normal MPI, no pathological Q waves in resting ECG tracing, and no history of CAD. Both groups were compared for H. pylori and CagA seropositivity. Patients' demographic data, risk factors for CAD, and childhood socioeconomic status were recorded.The study group consisted of 300 consecutive patients, 170 men and 130 women; 64% (110/173) CAD-positive patients and 47% (60/127) CAD-negative participants were found seropositive for H. pylori infection (P = 0.005). In the adjusted analysis, H. pylori infection was found to be associated with CAD positivity (odds ratio 1.83, 95% confidence interval 1.06-3.17, P = 0.031), and MI (fixed perfusion defects on MPI) (OR 3.36, 95% CI 1.44-7.84, P = 0.005). No association was noted with CagA positivity.In patients undergoing a stress MPI, serum anti-H. pylori antibodies positivity was found to be associated with CAD, independent of traditional cardiovascular risk factors.

Estrogen has been reported to have both short- and long-term effects on the cardiovascular system. However, it remains to be examined how short-term transdermal estrogen therapy (TET) affects insulin sensitivity (SI) in patients with cardiac syndrome X (CSX), who are characterized by elevated insulin resistance. SI was assessed in a randomized, double-blind, placebo-controlled crossover study by minimal model analysis in seven postmenopausal women with CSX treated by TET. SI decreased by 32 ± 8.3%, from 5.94 ± 1.14 at baseline to 3.61 ± 0.40 [(10–4 × min–1)/(µU/ml)] during TET (p = 0.03). Time to the onset of symptoms increased from 414.2 ± 51.0 s at baseline to 450.0 ± 53.2 s (p = 0.04). We conclude that TET increases SI in postmenopausal women with CSX. This effect is unrelated to the beneficial anti-ischemic effects on exercise duration.

To evaluate the feasibility of stenting without predilatation, we registered all interventional procedures over a 6-month period. Six hundred patients were registered, and 684 lesions were treated. Interventions were divided into four groups: stenting without predilatation (SWOP), 221 lesions (32.4%); primary stenting with predilatation (PDS), 161 lesions (23.5%); provisional stenting (PRS), 131 lesions (19.2%); and plain-old balloon angioplasty (POBA), 171 lesions (25%). Interventional strategy was at the discretion of the operator based on few simple angiographic criteria and his clinical judgment. Procedural success was similar in all stent groups. We conclude that when primary stenting is planned, about 60% of lesions can be treated by SWOP effectively with excellent procedural results and considerable cost saving.

We correlated ST elevation in various leads on admission and regional dysfunction in 132 patient with first anterior acute myocardial infarction using echocardiography. ST elevation in leads I and a VL and II, III and aVF was not associated with a specific pattern of regional dysfunction. Basal anterior and septal regional dysfunction were seen more often in patients with ST elevation in V1 (49 vs. 25%, p = 0.006; 35 vs. 17%, p = 0.048, respectively). Patients with ST elevation in V2 had more regional dysfunction of the apical inferior region (84 vs. 53%; p = 0.01). ST elevation in V5 and V6 was not associated with more apical or lateral wall motion abnormalities. ST elevation in lead V1 in anterior myocardial infarction is associated with a high incidence of regional dysfunction of the basal anterior, anteroseptal and septal regions.

Background —Organic nitrates are widely used in the treatment of chronic heart failure (CHF). No information, however, is available regarding their effect in patients already treated with ACE inhibitors. Methods and Results —In a randomized, double-blind, crossover design, we studied the effects of high-dose (50 to 100 mg) transdermal nitroglycerin (NTG) and placebo given daily for 12 hours in 29 patients with CHF (NYHA functional classes II to III). Exercise time (4 hours after patch application) showed a progressive improvement during NTG administration, with an increase of 38±35 seconds (9±7%) at the end of the first month ( P =NS), 76±28 seconds (16±6%) at the end of the second month ( P =0.01), and 117±34 seconds (27±6%) at the end of the third month ( P =0.003). No significant change was seen during placebo administration (12±20, 5±26, and 19±28 seconds, all P =NS). Exercise time 8 hours after NTG application measured at 3 months was also significantly longer, with a difference of 87±28 seconds ( P =0.006), but not with placebo (23±36 seconds, P =0.53). Assessment of quality of life and need for additional diuretics or hospitalizations for CHF failed to demonstrate a significant difference between the 2 treatment periods. In contrast, NTG decreased left ventricular end-diastolic (−2.1±0.1%, P P P Conclusion —High-dose nitrate therapy significantly improves exercise tolerance and left ventricular size and systolic function in patients with chronic, mild to moderate CHF already treated with ACE inhibitors. These findings support the role of organic nitrates as an adjunctive therapy to ACE inhibitors in patients with chronic CHF.

Saphenous vein graft stenting without predilation may potentially decrease procedural complications such as distal embolization and no-reflow phenomenon. In this report the authors describe the deployment of stents (three Wallstents, one Palmaz-Schatz, one Multilink, and one NIR) without predilation in five patients with unstable angina pectoris due to high-grade stenosis in old saphenous vein grafts. Stent deployment was successful in all patients without procedure-related complications. Stenting without predilation appears to be feasible in old bypass grafts with significant stenosis. The potential of this new stenting technique to reduce the risk of stenting complications should be tested by a randomized trial.

Aims The aim of this study was to assess the value of the electrocardiogram in predicting the patency of the left anterior descending artery and left ventricular ejection fraction in patients with a first acute anterior wall myocardial infarction at discharge from the coronary care unit. Methods We included 116 consecutive patients with an acute anterior myocardial infarction who had undergone coronary angiography and left ventriculography before discharge from the coronary care unit (7th to 10th day). The ST segment, either elevated or isoelectric (< 1 mm), and the T wave (positive or negative) in precordial leads V2−V4 were analysed and compared to the TIMI flow from each patient. Results Out of 69 patients with negative T waves, 38 (55%) had TIMI flow 3 compared with 20 (29%) and 11 (16%) with TIMI flow 2 and 0–1, respectively; and out of 47 patients with positive T waves seven (15%) had TIMI flow 3, 17 (36%) TIMI flow 2 and 23 (49%) TIMI flow 0–1 ( p

Hypothesis: The presence of late potentials on the signalaveraged electrocardiogram (SAECG) identifies patients at high risk for development of ventricular tachyarrhythmias after myocardial infarction (MI). Methods: The electrocardiogram and left ventricular function in 65 patients recovering from a first acute anterior wall MI were analyzed. We compared the pattern of the ST segment (isoelectric or elevated) and of the T wave (positive or negative) with the SAECG using an orthogonal bipolar lead configuration (X, Y, Z) with bidirectional Butterworth filtering (Simson's method). Results: Abnormal SAECG was found in 17 (26%) patients; 11 of 18 patients with ST elevation had abnormal SAECG, and only 6 of 47 patients with isoelectric ST segment developed abnormal SAECG (p

We examined whether the pattern of ST segment depression in lateral leads (I, aVL, V5, V6) in the initial electrocardiogram of patients (n = 88) with inferior wall acute myocardial infarction (ST segment elevation of > or = mm in > or = 2 inferior leads) correlates with the site of obstruction, as determined angiographically during acute hospitalization. Of the 62 patients in which the culprit artery could be determined unequivocally, in 46 the culprit artery was the right coronary artery (20 proximal to the first right ventricular branch and 26 distal), and in 16 the left circumflex coronary artery (seven proximal to the first marginal branch or involving a high first marginal branch, and nine with distal obstruction). Significant ST segment depression (ST < or = 1 mm) in leads I and aVL was more common in right coronary artery obstruction (P < 0.05 and P < 0.0001, respectively). The absence of significant ST segment depression in lead aVL was most common in proximal circumflex obstruction (P < 0.0001), with a similar trend for lead I (P < 0.11). ST segment depression patterns in leads V5 and V6 were not indicative of the infarct-related artery or the site of obstruction. Thus, significant ST segment depression in leads I and aVL indicates right coronary artery-associated inferior wall acute myocardial infarction with a sensitivity of 70% and 100%, and a specificity of 63% and 38%, respectively, whereas the lack of ST segment depression in these leads indicates proximal circumflex obstruction with a sensitivity of 71% and 86%, and a specificity of 65% and 100%, respectively.

We previously described the feasibility of myocardial perfusion imaging (MPI) with nearly half the radiation dose using ordered-subset expectation maximization with resolution recovery (OSEM-RR) processing. This study sought to determine if the findings can be expanded to obese patients. Fifty obese patients (>100 kg) referred for MPI underwent stress-rest or rest-stress studies with a half dose of Tc-99m sestamibi in a 1-day protocol using OSEM-RR processing. Image quality and clinical results were compared with matched patients (by age, sex, weight, presence/probability of coronary artery disease) evaluated with standard “full-dose” Tc-99m sestamibi, mostly in a 2-day protocol. Dose activities were adjusted individually by weight. Mean Tc-99m activity was 33.4 ± 13.9 mCi in the half-dose group and 60 ± 10 mCi in the full-dose group (P

We describe eight patients with a distinct electrocardiographic pattern of anterior wall myocardial infarction characterized by three main features: (1) a pattern of ‘transmural ischemia' (ST-elevation with positive T-wave) in nonconsecutive leads: aVL and V 2 , and two different types of ST-depression; (2) a pattern of ‘true reciprocal changes' (ST-depression and negative T-wave) in III and aVF; (3) a pattern of ‘sub-endocardial ischemia' (ST-depression with positive T-wave) in V 4–5 , while ST in V 3 was either isoelectric or depressed. We characterize the electrocardiographic features and correlate them with the echocardiographic, radionuclide, and angiographic data. All patients admitted to the coronary care unit from January 1990 to April 1992 with evolving acute myocardial infarction were evaluated prospectively. Patients whose admission electrocardiogram met the description above were included. The electrocardiographic evolution, echocardiographic, Technetium MIBI tomography, and coronary angiography are described. Of 471 patients with acute anterior wall myocardial infarction, admitted to the coronary care unit during the study period, eight patients met the inclusion criteria (1.7% of acute anterior wall myocardial infarction). Echocardiographyic studies revealed mid-anterior hypokinesis in two patients, anterior and apical hypokinesis in one, and no wall motion abnormality in four patients. Technetium MIBI tomography, done in five patients, was consistent with mid-anterior or mid-anterolateral infarction without involvement of the septum or apex. Coronary angiography, performed in seven patients, demonstrated significant obstruction of the first diagonal branch in all of the patients. In four patients, the diagonal occlusion was the only significant coronary lesion in the left coronary artery. Conclusion : Most of the anterior myocardial infarctions also involve the septal and apical regions. Anterior wall myocardial infarctions limited to the mid-anterior or mid-anterolateral wall, without apical or septal wall involvement are relatively rare. This study describes a special electrocardiographic form of anterior wall acute myocardial infarction. This distinct electrocardiographic pattern represents true mid-anterior wall myocardial infarction, caused by occlusion of a first diagonal branch of the left anterior descending coronary artery. The septal and apical regions are not involved because the blood supply via the left anterior descending artery is not interrupted.

This study assesses the significance of inferior ST-segment depression during anterior acute myocardial infarction (AMI) by investigating the relationship between inferior ST-segment depression and (1) the site of the left anterior descending (LAD) coronary artery lesion and (2) ST-segment deviation in the various anterior and lateral leads. We studied 126 patients with anterior AMI who underwent coronary angiography within 21 days of hospitalization. The admission 12-lead electrocardiograms were evaluated for ST-segment amplitude in each lead at 0.08 second after the J-point. Coronary angiography was evaluated for the site and severity of luminal narrowing of the coronary arteries. The site of the culprit lesion in the LAD artery, relative to the origin of the first septal and diagonal branches, was determined. In four patients no lesion was identified in the LAD artery. Of the remaining 122 patients, 40 and 53 patients had a LAD artery lesion proximal to the first septal and first diagonal branches, respectively. Additional luminal narrowing (≥70% of diameter) was found in the circumflex and the right coronary arteries in 27 and 37 patients, respectively. ST-segment depression of >1 mm in leads II, III, and aVF was noted in 24, 29, and 24 patients, respectively. The prevalence of a LAD artery preseptal and prediagonal lesion was higher in patients with inferior ST-segment depression. The positive predictive values of ST-segment depression >1 mm in leads II, III, and aVF for a lesion proximal to the first septal branch were 58.3%, 65.5%, and 75%, respectively, and those for a prediagonal lesion were 70.8%, 79.3%, and 87.5%. The corresponding specificities were 88%, 88%, and 93% for a preseptal lesion, and 90%, 91%, and 96% for a prediagonal lesion. No differences were observed between the groups with interior ST-segment depression in the distribution of single-vessel or three-vessel disease or significant right or circumflex coronary artery narrowing. Univariate linear regression models revealed that the magnitude of the ST amplitude in leads III and aVF is mainly affected by the ST amplitude in leads I and aVL (coefficient of the regression −0.75 and −0.80, R 2 = 43% and 68%, for lead III, respectively; coefficient of the regression −0.57, and −0.66, R 2 = 32% and 58%, for lead aVF, respectively). The magnitude of the ST deviation in the precordial leads has only a minor impact on the inferior ST-segment deviation. Multivariate regression models confirmed that the ST deviation in leads III and aVF is mainly influenced by the ST levels in aVL. It is concluded that ST-segment depression in the inferior leads during anterior AMI represents reciprocal changes to the high anterolateral region, shown by ST-segment elevation in leads I and aVL. ST depression in the inferior leads predicts a culprit lesion proximal to the origin of the first diagonal branch. No relationship was found between the magnitude of ST-segment depression in leads II, III, and aVF and the occurrence of right coronary or left circumflex artery narrowing or three-vessel disease.

Early clustering of adverse cardiovascular events after abrupt cessation of clopidogrel has been reported in patients with acute coronary syndromes. A platelet rebound phenomenon may contribute to this increased thrombotic risk and a gradual drug tapering may attenuate this proposed platelet effect. Accordingly, we aimed to assess the effect of clopidogrel tapering on platelet reactivity. Twenty patients who underwent elective percutaneous coronary interventions with bare metal stents receiving 3 months of clopidogrel therapy (75 mg daily) were randomized to either of two discontinuation strategies: (1) Off group–abrupt drug cessation or (2) Tapering group–receiving clopidogrel 75 mg every other day for 4 weeks duration. Light transmission aggregometry, induced by ADP (5 and 10 μM) and collagen, was measured at four time-points (at baseline and 2, 4 and 6 weeks after randomization). In the off group, there was an early rise in platelet reactivity at 2 weeks after abrupt drug cessation compared to baseline, as measured by ADP 5 μmol/l (39.6 ± 2.8 vs. 67.9 ± 6.0, P < 0.001). The tapering regimen suppressed this rebound platelet aggregation by ADP 5 μmol/l at 2 weeks (P = 0.001) and 4 weeks (P = 0.001). Similar results were found with ADP 10 μmol/l and collagen agonists. Abrupt cessation of clopidogrel results in an early rise in platelet aggregability in patients with BMS that is attenuated by a tapering regimen. Clopidogrel administration every other day may achieve similar levels of platelet inhibition as full dose therapy. Further investigations evaluating clopidogrel tapering strategies and their potential clinical impact are warranted.

Aims The pathogenesis of late coronary stent thrombosis may be related to impaired arterial healing. Endothelial progenitor cells (EPCs) have been shown to play an important role in repair and re-endothelialization following vascular injury. We hypothesized that patients who develop late stent thrombosis may have reduced or dysfunctional EPCs, and aimed to compare EPC level and function in patients who experienced stent thrombosis vs. matched controls. Methods and results Patients who developed late (>30 days) stent thrombosis within the past 3 years were compared with matched patients who underwent stenting and did not develop stent thrombosis. All patients had blood samples taken ≥3 months from the stent thrombosis or index procedure. The proportion of peripheral mononuclear cells (PMNCs) expressing vascular endothelial growth factor receptor 2 (VEGFR-2), CD133, and CD34 was evaluated by flow cytometry. Endothelial progenitor cell colony forming units (CFUs) were grown from PMNCs, characterized and counted following 7 days of culture. The two groups ( n = 30 each) were well-matched (93.3% men, mean age 60–62 years, 33.3% diabetes, 73–80% DESs). The proportion of cells co-expressing VEGFR-2, CD133, and CD34 was lower in the stent thrombosis group compared with the control [VEGFR-2+CD133+: 0.18% (0.03–0.41%) vs. 0.47% (0.16–0.66%), P = 0.01; VEGFR-2+CD34+: 0.32% (0.22–0.70%) vs. 0.66% (0.24–1.1%), P = 0.03]. The number of EPC CFUs was also lower in the stent thrombosis group [3.9% (3.2–5.5%) vs. 8.3% (6.5–13.4%) colonies/well, respectively, P < 0.0001]. Conclusion Patients who suffered late coronary stent thrombosis appear to have reduced levels of circulating EPCs and impaired functional properties of the cells. These findings require validation by further studies, but may contribute to understanding the pathogenesis of late stent thrombosis.

Background More and more young people are being referred for evaluation or screening for coronary artery disease (CAD). However, the value of myocardial perfusion imaging (MPI) in this population is unclear, especially in the absence of symptoms. Methods The study sample included 1765 consecutive patients less than 51 years old who were referred to a major medical center for stress/rest MPI study. Clinical and MPI variables were compared between patients with and without known CAD, by gender. Results There were 1346 (76%) men and 419 (24%) women of mean age 44 ± 6 years; 461 (26%) had known CAD. Stress-induced ischemia was detected in 321 patients (18.2%) and significant ischemia in 131 (7.4%); there was no difference in the rate or severity of ischemia by presence of symptoms. Among those without known CAD, the rate of stress-induced ischemia by MPI was significantly lower in women than men. On logistic regression analysis, the independent predictors of ischemia in men were high cholesterol, diabetes, angina during stress testing, ST depression, and smoking (P

Background: Atrial natriuretic peptide (ANP) is released from cardiac atrium secondary to increased atrial pressure. The plasma levels of ANP have been found to be related to short-and long-term prognosis after acute myocardial infarction (MI). The purpose of the present study was to investigate the plasma levels of ANP in three groups of patients with inferior wall acute MI classified according to ST-segment depression in the precordial leads. Methods: The study population consisted of 18 patients with inferior wall acute MI classified into three types: Type 1 = no precordial ST-segment depression (7 patients), Type 2 = sum of ST-segment depression in leads V1 to V3 equal to or more than the sum of ST-segment depression in leads V4 to V6 (4 patients), and Type 3 = maximal precordial ST-segment depression in leads V4 to V6 (7 patients). Results: Radioimmunoassay showed that plasma ANP levels were significantly higher in patients with Type 3 acute inferior wall myocardial infarction compared with those with Types 1 and 2 (313.1 ± 233, 73.0 ± 27.5), and 84 ± 32.7 pg/ml, respectively, p = 0.018). Conclusions: Plasma ANP levels are higher in patients with Type 3 acute inferior wall MI compared with patients with Types 1 and 2. These findings, together with earlier ones, may contribute to our understanding of the pathophysiology of the presence of ST-segment depression in the precordial leads in inferior wall acute MI.

Background: Octogenarian patients referred for stress myocardial perfusion imaging (MPI) differ from younger (non-octogenarian) patients in that they have lower prevalence of risk factors for CAD, but more frequent ischemic events and higher cardiac mortality. Hypothesis: The purpose of this study was to investigate the efficacy of MPI in octogenarian men and women compared with that in the younger population, and to compare the prognostic value of stress MPI in both populations. Methods: We studied 162 consecutive patients aged ≥ 80 years who were referred for stress MPI, and compared them with 253 consecutive patients aged < 80 years. Patients completed a questionnaire encompassing information about the existence of coronary risk factors, cardiac symptoms, coronary artery disease (CAD), myocardial infarction, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, and results of stress MPI. The patients were followed up for cardiac mortality for a mean of 45 ± 12 months. Results: There were 61 women and 101 men (17% of all referrals) with a mean age of 83 ± 3 (range 80-90). Parameters of octogenarian patients demonstrated a significantly lower prevalence of non-insulin-dependent diabetes mellitus (p < 0.02), hypercholestrolemia (p < 0.001), and smoking (p = 0.001) compared with non-octogenarian patients. The prevalence of known CAD was similar, but the prevalence of abnormal resting electrocardiogram, left ventricular (LV) dilatation, and stress-induced ischemia was significantly higher in octogenarians (p < 0.002). Cardiac mortality rate peryear was 4.3%in octogenarians versus 1.3%in the younger population (p < 0.0001). The independent predictors according to MPI of cardiac death were LV dilatation and presence of ischemia in octogenarians, and severity of ischemia in non-octogenarians. Conclusions: The octogenarian population referred for stress single-photon emission computed tomography differed from the non-octogenarian group in that it had a lower prevalence of risk factors for CAD, but more frequent ischemic events and higher cardiac mortality; however, MPI variables predict adverse outcome in both populations.

The objective of this study was to compare two techniques to treat bifurcation lesions: a single drug-eluting stent (DES) implanted in the main branch combined with balloon dilatation for the side branch vs. stenting of both branches (double stent).Percutaneous coronary intervention in coronary bifurcation lesions remains challenging. Although DES reduce restenosis in lesions, the double stent procedure has not shown clear advantages over a single stent with balloon dilation.Fifty-three symptomatic patients with true bifurcation lesions were treated using either the double stent technique (n = 25) or one stent in the parent vessel plus balloon angioplasty of the side branch (n = 28). Procedural results and major adverse cardiac event rates (MACE: cardiac death, myocardial infarction, target vessel revascularization (TVR)) were compared.Angiographic procedural success (residual stenosis30% in both branches) was 75% in the single stent group and 100% in the double stent group (P = 0.01). All differences were due to residual stenosis of the side branch. Clinical follow-up (6-18 months) was available for all patients; 90.5% of patients had a coronary angiography or nuclear stress test. Three patients (11%) in the single stent group and two (8%) in the double stent group had ischemia-driven TVR (P = NS). Asymptomatic angiographic restenosis (50% diameter stenosis) in the ostium of the side branch was seen in two patients in the double-stent group. At 6 months, MACE-free was comparable between groups (89.3% vs. 88%, P = 0.7).When treating bifurcation lesions with sirolimus-eluting stents, restenosis following a single stent procedure is comparable to stenting both parent and side branch vessels. Thus, stenting the main-branch lesion, coupled with balloon angioplasty in the side branch, produces a high success rate and good clinical outcomes at 6 months.

The degree of left ventricular dysfunction determines the prognostic outcome of patients with acute myocardial infarction.To define the clinical, angiographic and procedural variables related to LV dysfunction in patients with anterior wall AMI referred for primary percutaneous coronary intervention.The sample included 168 patients treated by primary PCI for first anterior wall AMI. Clinical, demographic and medical data were collected prospectively into a computerized registry, and clinical outcome (death, reinfarction, major cardiovascular event) were evaluated during hospitalization and 30 days after discharge. Patients were divided into three groups by degree of LV dysfunction (mild, moderate, severe) and compared for clinical, angiographic and procedural variables.LV dysfunction was associated with pre-PCl renal failure (serum creatinine1.4 mg/dl), peripheral vascular disease, high peak creatine kinase level, longer door to balloon time, low TIMI flow grade before and after PCl, and use of an intraaortic balloon pump. On multivariate analysis adjusted for baseline differences, peak creatine kinase level (r = 0.3, P = 0.0001) and door to needle time (r = 0.2, P = 0.008) were the most significant independent predictors of moderate or severe LV dysfunction after anterior AMI.Abnormal LV function after first anterior AMI can be predicted by door to balloon time and the size of the infarction as assessed by creatine kinase levels. Major efforts should be made to decrease the time to myocardial reperfusion.