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Saphenous vein grafts (SVGs) have high rates of in-stent restenosis (ISR). We compared the baseline clinical and angiographic characteristics of patients and lesions that did develop ISR with those who did not develop ISR during a median follow-up of 2.7 years in the DIVA study (NCT01121224). We also examined the ISR types using the Mehran classification. ISR developed in 119 out of the 575 DIVA patients (21%), with similar incidence among patients with drug-eluting stents and bare-metal stents (BMS) (21% vs 21%, p = 0.957). Patients in the ISR group were younger (67 ± 7 vs 69 ± 8 years, p = 0.04) and less likely to have heart failure (27% vs 38%, p = 0.03) and SVG lesions with Thrombolysis In Myocardial Infarction 3 flow before the intervention (77% vs 83%, p0.01), but had a higher number of target SVG lesions (1.33 ± 0.64 vs 1.16 ± 0.42, p0.01), more stents implanted in the target SVG lesions (1.52 ± 0.80 vs 1.31 ± 0.66, p0.01), and longer total stent length (31.37 ± 22.11 vs 25.64 ± 17.42 mm, p = 0.01). The incidence of diffuse ISR was similar in patients who received drug-eluting-stents and BMS (57% vs 54%, p = 0.94), but BMS patients were more likely to develop occlusive restenosis (17% vs 33%, p = 0.05).

Background It is unclear whether achieving multiple risk factor (RF) goals through protocol-guided intensive medical therapy is feasible or improves outcomes in type 2 diabetes mellitus. Objectives This study sought to quantify the relationship between achieved RF goals in the BARI 2D (Bypass Angioplasty Investigation Revascularization 2 Diabetes) trial and cardiovascular events/survival. Methods We performed a nonrandomized analysis of survival/cardiovascular events and control of 6 RFs (no smoking, non–high-density lipoprotein cholesterol Results In 2,265 patients (mean age 62 years, 29% women) followed up for 5 years, the mean ± SD number of RFs in control improved from 3.5 ± 1.4 at baseline to 4.2 ± 1.3 at 5 years (p Conclusions Simultaneous control of multiple RFs through protocol-guided intensive medical therapy is feasible and relates to cardiovascular morbidity and mortality in patients with coronary disease and type 2 diabetes mellitus. (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes [BARI 2D]; NCT00006305 )

High-output heart failure from arteriovenous fistula (AVF) is an often overlooked cause of pulmonary hypertension. A 63 year-old male with hepatitis C, cirrhosis, and chronic atrial fibrillation presents with worsening exertional dyspnea since a nail gun injury 7 years ago. Vitals are normal. He

There is conflicting evidence about the impact of gender on outcomes after coronary artery bypass grafting (CABG).We performed a multivariate logistic regression and propensity score matched analyses in 13,115 patients (75% men) who underwent CABG between January 1, 1995 and December 31, 2009. The primary outcome was in-hospital mortality. Secondary outcomes included post-operative respiratory failure, stroke, myocardial infarction, sternal and leg wound infections, atrial fibrillation (AF), renal failure, need for postoperative intra-aortic balloon pump (IABP) support, and length of hospital stay.A higher proportion of women (184; 5.6%) suffered in-hospital death compared to men (264; 2.7%), p0.0001. After propensity score matching (n=3600 total, 1800 in each group), female gender was an independent predictor of mortality after isolated CABG (odds ratio [OR]=1.84; 95% confidence interval [CI] 1.22-2.78). Women also experienced a higher incidence of postoperative complications including stroke (3.8% vs. 2.3%, OR 1.37; 95% CI 1.08-1.73) and leg wound infection (3.4% vs. 1.7%, OR 1.75; 95% CI 1.36-2.54) on multivariate regression analyses. However, these differences were not significant after propensity score matching. We also observed a lower risk of post-operative AF (21.2% vs. 22.1%, OR 0.78; 95% CI 0.70-0.86) in women that remained significant after propensity matching (O.R. 0.76; 95% C.I. 0.65-0.90). Length of hospital stay was longer in women compared with men (11.9 ± 9.0 vs. 10.4 ± 9.2 days, p0.0001).Female gender is an independent predictor of increased mortality and a lower incidence of post-operative AF after isolated CABG.

Several recent randomized controlled trials (RCTs) demonstrated better outcomes with multivessel complete revascularization (CR) than with infarct-related artery-only revascularization (IRA-OR) in patients with ST-segment elevation myocardial infarction. It is unclear whether CR should be performed during the index procedure (IP) at the time of primary percutaneous coronary intervention (PCI) or as a staged procedure (SP). Therefore, we performed a pairwise meta-analysis using a random-effects model and network meta-analysis using mixed-treatment comparison models to compare the efficacies of 3 revascularization strategies (IRA-OR, CR-IP, and CR-SP). Scientific databases and websites were searched to find RCTs. Data from 9 RCTs involving 2,176 patients were included. In mixed-comparison models, CR-IP decreased the risk of major adverse cardiac events (MACEs; odds ratio [OR] 0.36, 95% CI 0.25 to 0.54), recurrent myocardial infarction (MI; OR 0.50, 95% CI 0.24 to 0.91), revascularization (OR 0.24, 95% CI 0.15 to 0.38), and cardiovascular (CV) mortality (OR 0.44, 95% CI 0.20 to 0.87). However, only the rates of MACEs, MI, and CV mortality were lower with CR-SP than with IRA-OR. Similarly, in direct-comparison meta-analysis, the risk of MI was 66% lower with CR-IP than with IRA-OR, but this advantage was not seen with CR-SP. There were no differences in all-cause mortality between the 3 revascularization strategies. In conclusion, this meta-analysis shows that in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease, CR either during primary PCI or as an SP results in lower occurrences of MACE, revascularization, and CV mortality than IRA-OR. CR performed during primary PCI also results in lower rates of recurrent MI and seems the most efficacious revascularization strategy of the 3.

Background: Clinical outcomes of percutaneous coronary intervention (PCI) in patients with saphenous vein grafts (SVGs) remain poor despite the use of drug-eluting stents (DES). There is a disparity in clinical outcomes in SVG PCI based on various registries, and randomized clinical data remain scant. We conducted a meta-analysis of all existing randomized controlled trials (RCTS) comparing bare-metal stents (BMS) and DES in SVGPCIs. Hypothesis: PCI in patients with SVG disease using DES may reduce need for repeat revascularization without an excess mortality when compared to BMS. Methods: An aggregate data meta-analysis of clinical outcomes in RCTs comparing PCI with DES vs BMS for SVGs reporting at least 12 months of follow-up was performed. A literature search between Janurary 1, 2003 and September 30, 2011 identified 4 RCTs (812 patients; DES = 416, BMS = 396). Summary odds ratio (OR) and 95% confidence interval (CI) were calculated using the random-effects model. The primary endpoint was all-cause mortality. Secondary outcomes included nonfatal myocardial infarction (MI), repeat revascularization, and major adverse cardiac events (MACE). These outcomes were assessed in a cumulative fashion at 30 days, 18 months, and 36 months. Results: There were no intergroup differences in baseline clinical and sociodemographic characteristics. At a median follow-up of 25 months, patients in the DES and BMS group had similar rates of death (OR: 1.63, 95% CI: 0.45–5.92), MI (OR; 0.83, 95% CI: 0.27-2.60), and MACE (OR: 0.58, 95% CI: 0.25–1.32). Patients treated with DES had lower rates of repeat revascularization (OR: 0.40, 95% CI: 0.22–0.75). Conclusions: In this comprehensive meta-analysis of all RCTs comparing clinical outcomes of PCI using DES vs BMS in patients with SVG disease, use of DES was associated with a reduction in rate of repeat revascularization and no difference in rates of all-cause death and MI. Clin. Cardiol. 2012 DOI: 10.1002/clc.21984 Dr. Virani is supported by a Department of Veterans Affairs Health Services Research and Development Service (HSR&D) Career Development Award (CDA-09-028), and has research support from Merck and National Football League Charities (all grants to the institution and not individual). The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. The authors have no other funding, financial relationships, or conflicts of interest to disclose.

Objectives The purpose of this study was to determine the extent to which effectiveness of cardiac and diabetes treatment strategies varies by patient age. Background The impact of age on the effectiveness of revascularization and hyperglycemia treatments has not been thoroughly investigated. Methods In the BARI 2D (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes) trial, 2,368 patients with documented stable heart disease and type 2 diabetes were randomized to receive prompt revascularization versus initial medical therapy with deferred revascularization and insulin sensitization versus insulin provision for hyperglycemia treatment. Patients were followed for an average of 5.3 years. Cox regression and mixed models were used to investigate the effect of age and randomized treatment assignment on clinical and health status outcomes. Results The effect of prompt revascularization versus medical therapy did not differ by age for death (interaction p = 0.99), major cardiovascular events (interaction p = 0.081), angina (interaction p = 0.98), or health status outcomes. After intervention, participants of all ages had significant angina and health status improvement. Younger participants experienced a smaller decline in health status during follow-up than older participants (age by time interaction p Conclusions Among patients with stable heart disease and type 2 diabetes, the relative beneficial effects of a strategy of prompt revascularization versus initial medical therapy and insulin-sensitizing versus insulin-providing therapy on clinical endpoints, symptom relief, and perceived health status outcomes do not vary by age. Health status improved significantly after treatment for all ages, and this improvement was sustained longer among younger patients. (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes [BARI 2D]; NCT00006305 )

The progressive nature of heart failure is linked to multiple factors, including an ongoing loss of cardiomyocytes and necrosis. Necrotic cardiomyocytes leave behind several footprints: the spillage of their contents leading to elevations in serum troponins; and morphologic evidence of tissue repair with scarring. The pathophysiologic origins of cardiomyocyte necrosis relates to neurohormonal activation, including the adrenergic nervous system. Catecholamine-initiated excessive intracellular Ca accumulation and mitochondria Ca overloading in particular initiate a mitochondriocentric signal-transducer-effector pathway to necrosis and which includes the induction of oxidative stress and opening of their inner membrane permeability transition pore. Hypokalemia, ionized hypocalcemia and hypomagnesemia, where consequent elevations in parathyroid hormone further account for excessive intracellular Ca accumulation, hypozincemia and hyposelenemia each compromise metalloenzyme-based antioxidant defenses. The necrotic loss of cardiomyocytes and adverse structural remodeling of myocardium is related to the central role played by a mitochondriocentric pathway initiated by neurohormonal activation.

Purpose A case of paralytic ileus in a patient receiving oral diltiazem therapy for atrial fibrillation is reported. Summary A 64-year-old man with a history of multiple serious comorbidities, poly-pharmacy, and a recent hospital stay for acute cardiac problems was readmitted to the hospital for gastrointestinal (GI) bleeding. On day 2 of the readmission, he suffered a myocardial infarction complicated by atrial fibrillation with a rapid ventricular response. After initial treatment with oral metoprolol for ventricular rate control was discontinued (due to ineffective rate control and patient complaints of respiratory symptoms), oral diltiazem hydrochloride therapy (30 mg every six hours) was initiated on day 7; the dose was adjusted to a maximum of 120 mg every six hours on day 10. On day 12, the patient complained of nausea, abdominal pain and tenderness, and infrequent bowel movements; imaging studies on day 13 indicated paralytic ileus. Pursuant to a surgical consultation, a nasogastric tube was inserted and nothing was given by mouth except medications. After initial improvement of the GI symptoms, the feeding tube was removed; however, the symptoms worsened over the next two to three days, requiring reinsertion of the tube on day 16. On day 18, after other potential causes of ileus were ruled out, diltiazem therapy was withdrawn. The man experienced rapid symptomatic improvement, with no further GI symptoms, and was discharged four days later. Conclusion A 64-year-old man receiving high-dose diltiazem to treat atrial fibrillation developed paralytic ileus, which quickly resolved after the medication was discontinued.

It is unclear whether achieving multiple risk factor (RF) goals through protocol-guided intensive medical therapy is feasible or improves outcomes in type 2 diabetes mellitus.This study sought to quantify the relationship between achieved RF goals in the BARI 2D (Bypass Angioplasty Investigation Revascularization 2 Diabetes) trial and cardiovascular events/survival.We performed a nonrandomized analysis of survival/cardiovascular events and control of 6 RFs (no smoking, non-high-density lipoprotein cholesterol 130 mg/dl, triglycerides 150 mg/dl, blood pressure [systolic 130 mm Hg; diastolic 80 mm Hg], glycosylated hemoglobin 7%) in BARI 2D. Cox models with time-varying number of RFs in control were adjusted for baseline number of RFs in control, clinical characteristics, and trial randomization assignments.In 2,265 patients (mean age 62 years, 29% women) followed up for 5 years, the mean ± SD number of RFs in control improved from 3.5 ± 1.4 at baseline to 4.2 ± 1.3 at 5 years (p 0.0001). The number of RFs in control during the trial was strongly related to death (global p = 0.0010) and the composite of death, myocardial infarction, and stroke (global p = 0.0035) in fully adjusted models. Participants with 0 to 2 RFs in control during follow-up had a 2-fold higher risk of death (hazard ratio: 2.0; 95% confidence interval: 1.3 to 3.3; p = 0.0031) and a 1.7-fold higher risk of the composite endpoint (hazard ratio: 1.7; 95% confidence interval: 1.2 to 2.5; p = 0.0043), compared with those with 6 RFs in control.Simultaneous control of multiple RFs through protocol-guided intensive medical therapy is feasible and relates to cardiovascular morbidity and mortality in patients with coronary disease and type 2 diabetes mellitus. (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes [BARI 2D]; NCT00006305).

An 81-year-old man presented with a 1-week history of dry cough. He also complained of mild dyspnea, wheezing, and low-grade fever. He denied hemoptysis, fever, rashes, or chest pain. The patient's medical history included coronary artery bypass surgery, hypertension, gastroesophageal reflux disease, and COPD. The patient was a retired welder and an ex-smoker.

Cardiac fibrosis interferes with the structural homogeneity of the myocardium in hypertensive heart disease (HHD). Its morphologic presentations include: widely scattered microscopic scars which have replaced myocytes lost to necrosis; and a perivascular fibrosis of intramural coronary arteries. An animal model of aldosterone/salt treatment has been used to examine the pathogenic origins of myocyte necrosis and coronary vasculopathy. A common cellular/subcellular pathway involving parathyroid hormone-mediated, intracellular Ca2+ overload-induced, mitochondrial-derived oxidative stress was identified. Myofibroblasts and their secretome which includes de novo generation of angiotensin peptides, are responsible for fibrogenesis at these sites. Cardioprotection includes upstream prevention of myocyte loss and vascular remodeling or downstream ablation of myofibroblasts and ongoing fibrogenesis at these sites.

Background.Research has shown less aggressive treatment and poorer control of cardiovascular disease (CVD) risk factors in women than men.Methods.We analyzed sex differences in pharmacotherapy strategies and attainment of goals for hemoglobin A1c (HbA1c), blood pressure (BP), and low density lipoprotein cholesterol (LDL-C) in patients with type 2 diabetes and established coronary artery disease enrolled into the BARI 2D trial.Results.Similar numbers of drugs were prescribed in both women and men. Women were less frequent on metformin or sulfonylurea and more likely to take insulin and to be on higher doses of hydroxymethylglutaryl-CoA reductase inhibitors (statins) than men. After adjusting for baseline differences and treatment prescribed, women were less likely to achieve goals for HbA1c (OR = 0.71, 95% CI 0.57, 0.88) and LDL-C (OR = 0.64, 95% CI 0.53, 0.78). More antihypertensives were prescribed to women, and yet BP ≤ 130/80 mmHg did not differ by sex.Conclusions.Women entering the BARI 2D trial were as aggressively treated with drugs as men. Despite equivalent treatment, women less frequently met targets for HbA1c and LDL-C. Our findings suggest that there may be sex differences in response to drug therapies used to treat diabetes, hypertension, and hyperlipidemia.

We hypothesized that functional mitral and tricuspid valvular incompetence (MR and TR, respectively) are reversible causes of reduced cardiac output in decompensated heart failure (DF) that accompanies systolic dysfunction in ischemic or nonischemic cardiomyopathy.DF, defined as signs and symptoms of heart failure at rest, is rooted in a salt-avid state transduced by neurohormonal activation secondary to impaired renal perfusion. Functional MR and TR are reversible causes of reduced systemic blood flow. Their impact on cardiac output, thoracic fluid content, cardiac chamber dimensions, and valvular apparatus function can be monitored noninvasively, before and after optimized medical management.Fourteen male subjects (66 +/- 8 years old) with reduced ejection fraction (24 +/- 5%) secondary to ischemic (71%) or nonischemic (29%) cardiomyopathy, who developed DF with clinical evidence of mitral (MR) and tricuspid (TR) valvular incompetence, were each assessed by bioimpedance and echocardiography before and 1 week after optimized medical management restored compensated failure.Pharmacologic elimination of DF was accompanied by a reduction in body weight (P0.01). Hemodynamic improvements included a rise in cardiac index (2.1 to 2.6 L/min/m2; P0.01) and a reduction in predicted pulmonary artery systolic pressure (58 to 35 mm Hg; P0.001), thoracic fluid content (39 to 32 kOhm; P0.001), and systemic vascular resistance (1633 to 1209 dynes/sec/cm5; P0.001). Improvements in functional MR and TR included reductions in left and right atrial areas (27 to 24 cm and 26 to 23 cm2, respectively; P0.001), color-flow grading of MR and TR severity (P0.01), mitral regurgitant volume (105 to 65 mL; P0.001), and effective MR orifice size (0.8 to 0.6 cm2; P0.01).In DF, functional MR and TR contribute to reduced cardiac output, increased thoracic fluid content, and systemic vascular resistance, together with enlarged atria and valvular orifice size, which can be improved by medical management. Bioimpedance and echocardiography provide for serial noninvasive assessments of hemodynamic status and valvular function in such cases.

The chest radiographic, echocardiographic (transthoracic and transesophageal), MRI, CT and cardiac catheterization findings in a 72-year-old patient with extensive pericardial lipomatosis are presented. Diastolic pressures in the left heart were elevated. The massive lipomatous mass was partially resected surgically with good symptomatic relief. Histologically the neoplasm consisted of mature non-malignant adipose tissue. Cushing's Syndrome was absent. (ECHOCARDIOGRAPHY, Volume 20, February 2003)

Background: A substantial proportion of patients with coronary artery disease do not achieve complete revascularization and continue to experience refractory angina in spite of optimal medical therapy (OMT). Recently, stem cell therapy has emerged as a potential therapeutic option for these patients

Aspirin in combination with platelet P2Y12 receptor blocker has become the mainstay antiplatelet treatment strategy for the prevention of stent thrombosis. Ticlopidine was the first widely used P2Y12 receptor blockers, but clopidogrel has mostly replaced the use of ticlopidine due to its more favorable adverse event profile on bone marrow. However, when clopidogrel induced bone marrow toxicity occurs, little is known about the efficacy and safety of alternative treatments, and thus, in these cases, medical decisions may be very difficult. We report a case of clopidogrel-induced severe neutropenia in a patient treated with coronary stent and safety of alternative treatment with ticagrelor.

BACKGROUNDPercutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG) are being applied to high-risk populations, but previous randomized trials comparing revascularization methods have excluded a number of important high-risk groups.OBJECTIVESThis five-year, multicenter, randomized clinical trial was designed to compare long-term survival among patients with medically refractory myocardial ischemia and a high risk of adverse outcomes assigned to either a CABG or a PCI strategy, which could include stents.METHODSPatients from 16 Veterans Affairs Medical Centers were screened to identify myocardial ischemia refractory to medical management and the presence of one or more risk factors for adverse outcome with CABG, including prior open-heart surgery, age >70 years, left ventricular ejection fraction

The recently concluded Angina With Extremely Serious Operative Mortality Evaluation (AWESOME) was a randomized clinical trial of percutaneous coronary intervention versus coronary bypass graft surgery among patients with medically refractory ischemia who were at high risk for coronary bypass graft surgery because ofor =1 risk factors that included severely reduced left ventricular (LV) function, defined as LV ejection fraction35%. This study reports the outcome of patients with LV ejection fraction35% in the randomized clinical trial and the physician-directed and patient choice registries of the AWESOME study.

The symptoms and signs constituting the congestive heart failure (CHF) syndrome have their pathophysiologic origins rooted in a salt-avid renal state mediated by effector hormones of the renin-angiotensin-aldosterone and adrenergic nervous systems. Controlled clinical trials, conducted over the past decade in patients having minimally to markedly severe symptomatic heart failure, have demonstrated the efficacy of a pharmacologic regimen that interferes with these hormones, including aldosterone receptor binding with either spironolactone or eplerenone. Potential pathophysiologic mechanisms, which have not hitherto been considered involved for the salutary responses and cardioprotection provided by these mineralocorticoid receptor antagonists, are reviewed herein. In particular, we focus on the less well-recognized impact of catecholamines and aldosterone on monovalent and divalent cation dyshomeostasis, which leads to hypokalemia, hypomagnesemia, ionized hypocalcemia with secondary hyperparathyroidism and hypozincemia. Attendant adverse cardiac consequences include a delay in myocardial repolarization with increased propensity for supraventricular and ventricular arrhythmias, and compromised antioxidant defenses with increased susceptibility to nonischemic cardiomyocyte necrosis.

This study examines the relative importance of patency of the left anterior descending (LAD) coronary artery on long-term survival when the LAD is the only significantly narrowed coronary artery. From a cardiac disease registry of 21,786 patients, 826 medically treated patients with isolated LAD disease were identified. These patients were followed for5 years. Patients were divided into those with open versus those with closed arteries. With the use of univariate and multivariate analysis, the relative importance of the patency of the LAD was determined. All patients with previous anterior wall infarction were analyzed as a separate group, and those with and without a patent LAD were compared. Overall, survival was significantly better in patients with an open LAD. However, multivariate analysis of either the entire study group or the group with myocardial infarction showed that coronary artery patency was not an independent predictor of long-term survival. Analysis of patients with prior anterior myocardial infarction showed significantly improved 5-year survival in younger patients (70 years) who had an open (but stenosed) versus a closed LAD without angiographic collateral formation (94% vs 81%, p = 0.025). Furthermore, this survival difference was most striking in patients with left ventricular dysfunction. Survival in younger patients with an open LAD was similar to that of patients with a closed LAD with collateral formation (94% vs 92%, p = 0.55). No differences in survival were observed in the groups without infarction. This study implies that an open LAD improves long-term survival for younger patients with a previous anterior myocardial infarction and no collateral support to the ischemic or infarcted myocardium.

This study was designed to determine the impact of noncritical (less than 70% narrowing of the luminal diameter) coronary stenoses on the long-term survival rate of patients with coronary artery disease. The survival rate of 3,342 patients with normal coronary arteries (Group 1A) was compared with that of 2,184 patients with only noncritical stenoses (Group IB). Similarly, the survival rate of 1,128 patients with one or more critical lesions (Group 2A) was compared with that of 5,944 cases with noncritical plus critical lesions (Group 2B). Patients with noncritical lesions had significantly lower 10-year survival rates (85.8%) than did those with normal coronary arteries (90.1%). However, the difference in survival rate was attributable to older age, male sex, and higher prevalence of cigarette smoking, diabetes mellitus, and hypertension in Group IB than in Group 1A; presence of noncritical stenoses was not a statistically significant independent determinant of survival. Long-term survival rates of the patients with one or more critical lesions (Group 2A) were equivalent to that of patients with critical stenoses plus one or more noncritical lesions (Group 2B). Therefore, 1) patients with only noncritical stenoses have more risk factors for coronary artery disease than do those with normal coronary arteries; 2) these patients have a reduced long-term survival rate that reflects these risk factors rather than the presence of noncritical lesions; and 3) in patients with critical lesions, the presence of additional non-critical stenoses does not affect the long-term survival rate.

Several randomized controlled trials (RCTs) demonstrated that trans-radial access (TRA), particularly if performed by radial expert, decreased major adverse cardiac events (MACEs) and mortality in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). As a

Item does not contain fulltext BACKGROUND: The effect of intensified platelet inhibition for patients with unstable angina or myocardial infarction without ST-segment elevation who do not undergo revascularization has not been delineated. METHODS: In this double-blind, randomized trial, in a primary analysis involving 7243 patients under the age of 75 years receiving aspirin, we evaluated up to 30 months of treatment with prasugrel (10 mg daily) versus clopidogrel (75 mg daily). In a secondary analysis involving 2083 patients 75 years of age or older, we evaluated 5 mg of prasugrel versus 75 mg of clopidogrel. RESULTS: At a median follow-up of 17 months, the primary end point of death from cardiovascular causes, myocardial infarction, or stroke among patients under the age of 75 years occurred in 13.9% of the prasugrel group and 16.0% of the clopidogrel group (hazard ratio in the prasugrel group, 0.91; 95% confidence interval [CI], 0.79 to 1.05; P=0.21). Similar results were observed in the overall population. The prespecified analysis of multiple recurrent ischemic events (all components of the primary end point) suggested a lower risk for prasugrel among patients under the age of 75 years (hazard ratio, 0.85; 95% CI, 0.72 to 1.00; P=0.04). Rates of severe and intracranial bleeding were similar in the two groups in all age groups. There was no significant between-group difference in the frequency of nonhemorrhagic serious adverse events, except for a higher frequency of heart failure in the clopidogrel group. CONCLUSIONS: Among patients with unstable angina or myocardial infarction without ST-segment elevation, prasugrel did not significantly reduce the frequency of the primary end point, as compared with clopidogrel, and similar risks of bleeding were observed. (Funded by Eli Lilly and Daiichi Sankyo; TRILOGY ACS ClinicalTrials.gov number, NCT00699998.).

Takotsubo cardiomyopathy (TCM) is an unusual form of acute cardiomyopathy showing left ventricular apical ballooning. TCM can masquerade as ST elevation myocardial infarction (STEMI). TCM usually occurs following a variety of emotional stressors, but physical stressors can also trigger the condition, as highlighted by the present case. TCM can occur after an acute medical illness; therefore, physicians should be aware of this condition as a potential cause of inotrope-resistant hypotension. In patients with hypotension and moderate-to-severe left ventricular outflow tract (LVOT) obstruction, inotropic agents should be avoided, because they can worsen the degree of obstruction. Instead, beta-blockers are preferred, because they are capable of resolving the obstruction and consequently improve the haemodynamics.

Use of cocaine may complicate the diagnosis of myocardial infarction (MI) and may influence treatment strategy. Patients with symptoms suggestive of acute coronary syndrome (ACS) should be questioned about the use of cocaine. Initial management of cocaine users presenting with chest pain and ST segment elevation should include administration of glyceryl trinitrate (GTN). Assessment for resolution of chest discomfort and ECG changes should be undertaken before fibrinolytic therapy or angiography is considered. We present a case of patient with chest pain (CP) and ST elevation after cocaine use, whose symptoms and ST changes promptly resolved after medical therapy. Our case highlights the importance of medical therapy in patient with CP and ST elevation after cocaine abuse, before activating cardiac catheterization laboratory for emergent angiography.

To compare the effects of fenoldopam (n = 15), a selective dopamine-1 agonist, and nitroprusside (n = 14) on left ventricular (LV) function in severely hypertensive subjects (diastolic blood pressure (BP) greater than 120 mm Hg), both agents were infused to reduce diastolic BP by 40 mm Hg (or less than 110 mm Hg). Indexes of LV systolic and diastolic functions were obtained using gated radionuclide angiography before the initiation of treatment and after targeted BP was achieved. Both fenoldopam and nitroprusside effectively reduced systolic and diastolic BP to target levels. Changes in heart rate, peak filling rate and relative end-diastolic volume were similar with both agents. Baseline ejection fraction increased after infusion of both drugs. The magnitude of the increase in ejection fraction was far greater with fenoldopam than with nitroprusside (+22% vs +8%; p = 0.04), despite a lesser reduction in systolic BP (-12 vs -22%, p = 0.002). Furthermore, the reduction in relative end-systolic volume (-35 vs -20%; p = 0.04), and increase in the ratio of peak systolic pressure to relative end-systolic volume (+43 vs +6%; p = 0.007) were greater after fenoldopam than after nitroprusside. The greater increment in parameters of LV systolic function produced by fenoldopam than by nitroprusside suggests an effect on LV performance that is independent of afterload reduction.

Previous studies have documented a reduced survival time in patients with an electrocardiographic (ECG) ST-T wave abnormality. This study was designed to determine the clinical, hemodynamic and angiographic correlates of this observation. Data from 9,731 patients undergoing cardiac catheterization from 1976 through 1986 were analyzed; 5,531 had severe (greater than 70%) obstruction of at least one major coronary artery, 1,706 had mild (10 to 69%) obstruction and 2,494 had no obstruction. Of the patients with severe obstruction, 2,536 were treated medically and 2,995 were treated by surgical revascularization. Patients with an ST-T abnormality had more clinical risk factors (including older age and greater prevalence of diabetes mellitus, hypertension and prior myocardial infarction) and greater left ventricular dysfunction (including higher end-diastolic pressure and ventricular volume, reduced ejection fraction and greater prevalence of contraction abnormality) than did those without this ECG pattern. Survival time was significantly (p less than 0.01) reduced in subsets of patients with an ST-T abnormality and with severe or mild coronary artery disease; in those without coronary disease, ST-T changes did not correlate with reduced survival. Stepwise regression analysis was applied to each group to determine the independent predictors of 5-year survival. In patients with severe disease or no disease, an ST-T abnormality was not chosen as an independent predictor of 5-year survival; in the group with mild disease, ST-T changes were an independent predictor of reduced survival. Thus, the independent impact of an ST-T abnormality on survival is dependent on the severity of underlying coronary artery disease.

With the advent of effective antiatherosclerotic therapies, especially lipid lowering agents, cardiovascular morbidity and mortality rates associated with coronary atherosclerosis can be reduced. A growing body of evidence suggests such therapies can retard the progression of coronary atherosclerosis and with aggressive treatment regimens can cause regression. Antiatherosclerotic, and especially lipid lowering therapies, have the potential to become an alternative to invasive interventions. This report examines clinical studies that have addressed the regression of human coronary atherosclerosis by medical therapy.

Summary: Transthoracic echocardiography (7TE) has substantial limitations for the study of abnormalities of the coronary tree. Transesophageal echocardiography (TEE) allows a more complete examination of the coronary arteries, particularly the proximal segments. This report describes the use of TEE after cardiac catheterization in the clinical management of a patient with unstable angina. While angiography fist showed the giant aneurysm of the left circumflex coronary artery, TEE, by revealing an active thrombus of the lumen, prompted an immediate surgical resolution.

The relationship among postmenopausal estrogen use, coronary stenosis, and survival was examined retrospectively in 2268 women undergoing coronary angiography. The patients were selected for study if their age was 55 years or older at the time of angiography or if they had previously undergone bilateral oophorectomy. Postmenopausal estrogen use in 1178 patients with coronary artery disease (greater than 70% stenosis) and 644 patients with mild to moderate coronary artery disease (5% to 69% stenosis) was compared with 446 control subjects (0% stenosis) using life-table analysis. Over 10 years of follow-up, there was no significant difference in survival among patients initially free of coronary lesions on arteriography who had either never used (377) or ever used (69) estrogens. Among patients with mild to moderate coronary stenosis, 10-year survival of those who had never used estrogens was 85.0% and it was 95.6% among 99 "ever users." Survival was 60.0% among those with more than 70% coronary stenosis who had never used estrogen and it was 97.0% among 70 ever users. The "never users" group were older (65 vs 59 years), had a lower proportion of cigarette smokers (40% vs 57.1%), a higher proportion of subjects with diabetes (21.7% vs 12.9%) and hyperlipidemia (58% vs 44%), and approximately equal numbers of hypertensives (56.0% vs 54.3%). Cox's proportional hazards model was used to estimate survival as a function of multiple covariables. Estrogen use was found to have a significant, independent effect on survival in women. We conclude that estrogen replacement after menopause prolongs survival when coronary artery disease is present, but it has less effect in the absence of coronary artery disease.

We examined the relation between postmenopausal estrogen placement therapy (ERT) and survival in 1,098 women who underwent coronary artery bypass grafting (CABG). Patients were selected for the study if their age wasor = 55 years at the time of preoperative coronary angiography or if they had previously undergone bilateral oophorectomy. Life-table analysis was used to compare survival after surgery in 92 women who received ERT and 1,006 women who did not. Five-year survival was 98.8% in the estrogen users and 82.3% in the non-users. Ten-year survival was 81.4% in the users and 65.1% in the nonusers (p = 0.0001 by Lee Desu test). The women who did not take estrogen were significantly older (p0.001), had more vessels with significant stenosis (p = 0.033), lower ejection fractions (p = 0.051), and more prior myocardial infarctions (p = 0.054). However, a Cox proportional-hazards model selected the number of coronary arteries narrowed (RR 1.43, p0.0001), estrogen use (RR 0.38, p = 0.001), left main coronary stenosis (RR 1.83, p = 0.001), and diabetes mellitus (RR 1.57, p = 0.003) as the significant independent predictors of survival. These data suggest that ERT improves survival significantly after CABG in postmenopausal women with coronary artery disease.

Objectives.This study sought to evaluate the hemodynamic effects of intravenous sematilide hydrochloride, a selective class III antiarrhythmic agent, in patients with heart failure and left ventricular systolic dysfunction.Background.Class I antiarrhythmic agents, which primarily slow conduction, can depress ventricular function, particularly in patients with heart failure. In contrast, pure class III agents, which selectively prolong repolarization, do not adversely affect hemodynamic variables in animal models, but there are no data evaluating their hemodynamic effects in humans.Methods.In 39 patients with congestive heart failure and a left ventricular ejection fraction 25% and in patients with cardiac index

Category: 12. Pericardial/Myocardial DiseasePresentation Number: 925-6Authors: Mahboob Alam, Salman Bandeali, Waleed Kayani, henry huang, Salim Virani, Kodangudi Ramanathan, Hani Jneid, Memphis Veterans Affairs Medical Center / University of Tennessee Health Sciences Center, Memphis, TN, USA, Baylor College of Medicine, Houston, TX, USA Background: Impact of colchicine on recurrence of acute pericarditis & primary prevention of post-cardiotomy syndrome (PPS) is not well defined. We conducted a meta-analysis of all randomized clinical trials (RCTs) to assess the impact of colchicine therapy on rate of PPS and recurrent pericarditis.Methods: A comprehensive literature search [PubMed] identified 5 RCTs (3 RCTs evaluating acute or recurrent pericarditis & 2 RCTs evaluating PPS). Primary clinical endpoint included rate of recurrent pericarditis or incidence of PPS. Review Manager 5.1 (Cochrane Collaboration) was used to conduct meta-analysis. Odds ratios (OR) & 95% confidence interval (CI) were calculated using Random Effects Model.Results: Of the 795 patients analyzed, 389 received colchicine & 406 received conventional therapy. Majority of patients in the colchicine (61%) and conventional therapy (56%) arms were males (P= 0.94), & had comparable age(59.8 & 60.7 yrs, respectively, P= 0.99). At a total follow-up of 1,216 patient-years, colchicine use was associated with significant reduction in primary clinical end-point (incidence of PPS or recurrent pericarditis): 15.7 vs. 36.0%; OR = 0.25, 95% CI 0.13 - 0.47; NNT = 4.9 (Figure-1). The rates of adverse events related to therapy were similar in the colchicine (7.4%) and conventional therapy (5.9%) arms (P = 0.71).Conclusion: Colchicine use was associated with a 75% relative risk reduction (NNT = 4.9) in recurrent pericarditis or the incidence of PPS compared with conventional therapy.

Clinical, hemodynamic and coronary angiographic data from 9,801 patients were evaluated to determine the correlates of ST-segment depression, with or without T-wave inversion, on the resting routine electrocardiogram. The relative risk (RR) of having a measured clinical or angiographic variable was computed whether or not ST-T-wave abnormalities were observed. ST-segment depression was seen significantly more often in subjects greater than 55 years of age (RR = 1.4) who were women (RR = 1.3) or nonwhite (RR = 1.5), were hypertensive (RR = 1.8), had diabetes mellitus (RR = 1.6) or who smoked cigarettes (RR = 1.5). Angiographic findings related to presence of ST-T-wave abnormalities included severe coronary obstruction (less than 70%), higher number of diseased vessels, and the presence of obstruction in the left anterior descending coronary artery. In a multivariate model, the most significant correlates of ST-T-wave abnormalities were presence of left ventricular contraction abnormality, followed by age, gender, presence of left anterior descending coronary artery disease, elevated end-systolic volume index, and a diagnosis of hypertension. Thus, electrocardiographic ST-T abnormalities has specific and significant clinical and pathophysiologic correlates.

The effect of age at the time of coronary artery bypass graft surgery on postoperative survival was studied in 2,507 patients with significant coronary artery disease. Patients were subdivided into five groups based on age at the time of surgery: 20 to 39, 40 to 49, 50 to 59, 60 to 69 and greater than or equal to 70 years. The observed death rate was compared with that expected for subjects from the general U.S. population matched for age, gender, race and calendar year. For patients less than or equal to 59 years of age, the ratio of observed to expected death rates was significantly greater than unity (observed/expected = 4.9 for ages 20 to 39, 1.9 for ages 40 to 49 and 1.3 for ages 50 to 59 years, p less than 0.01). The prevalence of risk factors, including diabetes mellitus, hypertension, hypercholesterolemia and cigarette smoking, was evaluated in the different age subgroups. When patients were subdivided on the basis of history of cigarette smoking, the decreased relative survival rate of younger (less than 60 years old) patients existed only in those who smoked (observed/expected = 6.0 for ages 20 to 39, 2.2 for ages 40 to 49 and 1.4 for ages 50 to 59 years). In nonsmokers, observed/expected ratios for every age group were not significantly different from unity. Thus, the reduced relative survival rate of younger patients after coronary artery bypass graft surgery may be attributed to the interactive harmful effects of cigarette smoking.

Background: Left ventricular ejection fraction (EF) is a valuable prognostic index in patients with congestive heart failure (CHF). Although EF can be readily measured, many clinicians use roentgenographic heart size as a clue to differentiate systolic from diastolic dysfunction, even in the absence of solid supportive data. Objective: To test the hypothesis that the cardiothoracic ratio (CTR) measured from the chest roentgenogram can be used to estimate left ventricular EF in individuals with CHF. Methods: To answer this question, the database of the Digitalis Investigation Group trial was used. The CTR, determined using the Danzer method, and quantitative EF, measured locally using angiographic, radionuclide, or 2-dimensional echocardiographic techniques, were compared in 7476 patients with clinical CHF (New York Heart Association functional classes I-IV) due to acquired left-sided cardiac disease of ischemic, hypertensive, idiopathic, and alcohol-related causes. Results: Mean (±SD) CTR for the cohort was 0.53±.07. Mean (±SD) EF was 31.7%±12.2%. A weak, negative correlation between CTR and EF was observed (r=˛0.176). Similar findings were obtained when the results were stratified by cause of CHF, presence of clinically defined right ventricular dysfunction, and method of EF measurement. Categorical analysis failed to yield a CTR cutoff point that facilitated useful segregation of individuals with an EF greater than 35% or 35% and below; greater than 40% or 40% and below; and greater than 45% or 45% and below in any patient group. Conclusions: Although a weak, negative correlation exists between CTR and EF, this relationship does not allow for accurate determination of systolic function in individual patients with CHF. Considering the morbidity and mortality associated with CHF, and the clinical implications of systolic function in this syndrome, direct measurement of EF is recommended. Arch Intern Med. 1998;158:501-506

The relationship among postmenopausal estrogen use, coronary stenosis, and survival was examined retrospectively in 2268 women undergoing coronary angiography. The patients were selected for study if their age was 55 years or older at the time of angiography or if they had previously undergone bilateral oophorectomy. Postmenopausal estrogen use in 1178 patients with coronary artery disease (greater than 70% stenosis) and 644 patients with mild to moderate coronary artery disease (5% to 69% stenosis) was compared with 446 control subjects (0% stenosis) using life-table analysis. Over 10 years of follow-up, there was no significant difference in survival among patients initially free of coronary lesions on arteriography who had either never used (377) or ever used (69) estrogens. Among patients with mild to moderate coronary stenosis, 10-year survival of those who had never used estrogens was 85.0% and it was 95.6% among 99 "ever users." Survival was 60.0% among those with more than 70% coronary stenosis who had never used estrogen and it was 97.0% among 70 ever users. The "never users" group were older (65 vs 59 years), had a lower proportion of cigarette smokers (40% vs 57.1%), a higher proportion of subjects with diabetes (21.7% vs 12.9%) and hyperlipidemia (58% vs 44%), and approximately equal numbers of hypertensives (56.0% vs 54.3%). Cox's proportional hazards model was used to estimate survival as a function of multiple covariables. Estrogen use was found to have a significant, independent effect on survival in women. We conclude that estrogen replacement after menopause prolongs survival when coronary artery disease is present, but it has less effect in the absence of coronary artery disease.

Electrocardiographic R and S wave changes occur after transmural myocardial infarction. It was the purpose of this study to define the spatial characteristics of these changes and their pathologic determinants after nontransmural as well as transmural necrosis. Twenty-six dogs were studied after occlusion of the left circumflex coronary artery for 60 to 240 minutes, followed by re-perfusion. Electrocardiographic potentials were recorded before and 1 week after infarction using an 84 electrode array to compute maximal and root-mean-square R and S wave voltages. Infarct size was quantitated by computer-aided evaluation of heart slices stained by tri-phenyltetrazolium chloride. R and S wave amplitudes after infarction varied widely from one torso site to another in a pattern generally consistent with the inferoposterior location of the in-farcted zones. Although changes in peak R and S wave potentials did not significantly correlate with infarct size, differences in pre- and postocclusion root-mean-square R and S wave amplitudes did, with correlation coefficients of −0.79 and −0.63, respectively. Root-mean-square values increased for small lesions and decreased for larger ones. These data indicate that nontransmural as well as transmural infarction can produce R and S wave changes that are dependent on overall lesion size and the specific lead studied. Such changes may represent useful methods to quantitate lesion size.

Clinical and experimental data have documented the ability of nontransmural myocardial infarction to produce abnormal Q waves on both the epicardial and body surfaces. We undertook this study to define the anatomic determinants of such Q wave development. Thirty dogs were studied before and after occlusion-reperfusion (26 dogs) or latex embolization (four dogs) of the left circumflex coronary artery. Occlusion was maintained for 60 to 240 min before reperfusion to produce nontransmural lesions of various sizes. Electrocardiographic data were registered from 84 torso electrodes by body surface mapping techniques before and 1 week after infarction. Infarct size was quantitated by computer analysis of heart slices stained with triphenyl tetrazolium chloride. Six dogs did not develop infarction. Of the remaining 24, 10 did and 14 did not develop significant changes in body surface Q wave duration and width. The incidence of Q wave changes was not different in dogs with nontransmural and those with transmural lesions. Infarct size (expressed as a percentage of the left ventricle infarcted), the percentage of endocardium subjacent to infarction, the average depth of necrosis, the percent of the four outer fifths of the ventricular wall infarcted, and the duration of occlusion were significantly (p less than .05) greater in dogs with than in those without Q wave changes. Logistic regression modeling demonstrated that only two anatomic parameters--percentage of left ventricle infarcted and average lesion depth--significantly and independently predicted Q wave development. A model including only these two variables accurately classified all 24 cases.(ABSTRACT TRUNCATED AT 250 WORDS)

It has been demonstrated that temporary occlusion of major epicardial arteries of the dogs produces a nontransmural myocardial infarction (MI) whose size is reduced by early reperfusion. This study was undertaken to determine the location and extent of MI following acute occlusion and reperfusion of the septal artery (SA). The SA was occluded for four hours in group I (7 dogs). Occlusion time for group II (6 dogs) was 2 hours and for group III (6 dogs) was 1 hour, followed by 2 and 3 hours of reperfusion, respectively. The hearts were then removed and cut into transverse slices from base to apex. The triphenyl tetrazolium chloride technique identified the areas of infarction, which were quantitated with a microcomputer-based graphics system. To determine the extent of necrosis across the interventricular septum (IVS), the IVS was divided into 5 transverse segments of equal depth and the amount of MI was determined for each. In group I, MI involved 3.42 +/- 0.9% (mean +/- SEM) of the left ventricle (LV) and 13.49 +/- 3.4% of the IVS. In group II, 6.11 +/- 1.3% of the LV and 25.00 +/- 5.5% of the IVS were infarcted. In group III, 5.63 +/- 1.3% of the LV and 31.9 +/- 14.3% of the septum were infarcted. MI was larger on the left side of the IVS than on the right in all groups, and the extent of MI did not differ significantly between the three groups. This study showed that early reperfusion of the SA did not reduce MI as reported for other coronary beds.