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The prognosis of patients with coronary artery disease (CAD) is mainly influenced by organic factors such as cardiac muscle loss and extent of CAD. The aim of this study was to investigate whether a functional factor--reversible myocar, dial ischemia at rest--plays an independent prognostic role. Thus, 2 groups of patients were studied and followed up for 46 [+ or -] 32 months: 1 group (483 patients) had ischemic electrocardiographic changes only on effort and another group (224 patients) both on effort and at rest. The 2 groups did not differ significantly as to age, gender, coronary risk factors, baseline electrocardiographic abnormalities, incidence of previous myocardial infarction, angiographic left ventricular dysfunction, and extent of coronary stenoses (>50% diameter reduction). There were 65 deaths (40 of which were from cardiac causes) during the 5-year follow-up. Despite the similar incidence of known predictors of prognosis, Kaplan-Meier survival analysis revealed a significantly lower 5-year survival rate in patients with mixed (84.4%) rather than exertional (92.1%) ischemia (p

PURPOSE: To determine the prognostic capability of the dipyridamole echocardiography test (DET) early after an acute myocardial infarction. PATIENTS AND METHODS: On the basis of 11 different echocardiographic laboratories, all with established experience in stress echocardiography and fulfilling quality-control requirements for stress echocardiographic readings, 925 patients were evaluated after a mean of 10 days from an acute myocardial infarction and followed up for a mean of 14 months. RESULTS: During the follow-up, there were 34 deaths and 37 nonfatal myocardial infarctions; 104 patients developed class III or IV angina and 149 had coronary revascularization procedures (bypass or angioplasty). Considering all spontaneous events (angina, reinfarction, and death), the most important univariate predictor was the presence of an inducible wall motion abnormality after dipyridamole administration ([[chi].sub.2] = 45.8). With a Cox analysis, echocardiographic positivity, age, and male gender were found to have an independent and additive value. Considering survival (and, therefore, death as the only event), age was the most meaningful parameter, followed by the wall motion score index during dipyridamole administration ([[chi].sub.2] = 12.1). Among other parameters, the resting wall motion score index was a significant predictor of death. In a multivariate analysis, the prognostic contributions of age (relative risk estimate = 1.08) and wall motion score index during dipyridamole administration (relative risk estimate = 4.1) were independent and additive. In particular, considering death only, the event rate was 2% in patients with negative DET results, 4% in patients with positive high-dose DET results, and 7% in patients with positive low-dose DET results. CONCLUSIONS: DET is feasible and safe early after uncomplicated myocardial infarction and allows effective risk stratification on the basis of the presence, severity, extent, and timing of the induced dyssynergy.

This study evaluated the effect of pirenzepine, an [M.sub.1] antimuscarinic agent, on exercise duration and ischemic threshold in patients with angiographically documented coronary artery disease and clear-cut ST depression (>0.2 mV, 0.08 second after the J point) during ergometric stress testing. Twenty-five patients, mean age 56 [+ or -] 8 years, underwent 3 randomized multistage bicycle exercise stress tests after intravenous administration of saline solution (2 ml), isosorbide dinitrate (1 mg) and pirenzepine (2 mg). Isosorbide dinitrate, an endothelium-independent coronary dilating agent, was used as a reference drug. Compared with saline, both pirenzepine and isosorbide dinitrate significantly improved time to ischemia (0.15 mV ST-segment depression) from 6.5 [+ or -] 2 to 7.8 [+ or -] and 8.6 [+ or -] minutes and rate-pressure product at ischemia from 21,498 [+ or -] 4,903 to 24,083 [+ or -] 6,692 and 24,547 [+ or -] 5,390 mm Hg beats/min, respectively. Compared with saline, pirenzepine did not induce significant changes in blood pressure either at rest or during exercise, whereas it decreased resting heart rate from 71 [+ or -] 9 to 60 [+ or -] 11 beats/min (p These results suggest that pirenzepine can improve exercise tolerance in patients with effort ischemia; if the results of this study were to be confirmed, the [M.sub.1] antimuscarinic agents could be considered as a new alternative treatment of effort myocardial ischemia. (Am J Cardiol 1992;69:1407-1411)

A medical approach to treatment was adopted in 652 patients with documented myocardial ischemia at rest during both the acute and follow-up phases. No patient underwent coronary revascularization during hospitalization and only 86 patients (13%) underwent coronary bypass surgery within 8 months from discharge. During hospitalization 13 patients died. in the remaining group (639 patients), the likelihood of death in the 10-year period after discharge was 28% for all patients and 20% for cardiac causes only. A series of factors studied during the acute stage were assessed in an effort to predict long-term outcome. The following noninvasive characteristics, listed in decreasing order of statistical significance, were found to be significant univariate predictors of survival: abnormal basal electrocardiogram, duration of coronary artery disease, previous myocardial infarction, pattern of ST-T changes during episodes of ischemia at rest, age and systemic hypertension. The average annual mortality rate for patients with T-wave changes, ST-segment elevation and ST-segment depression was 0.9, 1.8 and 3%, respectively. The Cox survival analysis identified abnormal basal electrocardiogram, duration of coronary artery disease and pattern of ST-T changes as significant, independent predictors al death. When invasive characteristics were entered in the model, number of [greater than or equal to] 50% narrowed coronary arteries, left ventricular election fraction, abnormal basal electrocardiogram and smoking habit were found to be independent and additive prognostic variables. Thus, long-term prognosis of patients with ischemia at rest is related to the severity of anatomic impairment, independent of the pattern of ST-T changes observed during the acute phase. However, noninvasive features can also be used to assess prognosis in ischemia at rest and to select high-risk populations. (Am J Cardiol 1989;64:889-895), Myocardial ischemia is the insufficient supply of blood to the heart, and may be associated with chest pain (angina). Certain factors including left ventricle function, coronary artery disease, and the electrical activity of the heart can be evaluated to predict the outcome of angina, which may progress to heart attack or death. The factors influencing the prognosis of myocardial ischemia were assessed in 652 patients over a 10-year period. The restoration of blood flow in the coronary arteries by surgery was not required during hospitalization, although 86 patients later required coronary bypass surgery by eight months following discharge. Thirteen patients died during hospitalization. Among the remaining 639 patients, the overall probability of death in the 10-year period after discharge was estimated at 28 percent, and at 20 percent for heart-related causes. Noninvasive factors that influenced survival included abnormal electrical activity of the heart; duration of coronary artery disease; previous heart attack; abnormalities in specific features detected by electrocardiogram (a record of the electrical activity of the heart); age; and systemic hypertension. Death rates were estimated for specific changes in the electrocardiogram. Invasive factors influencing survival included stenosis (narrowing) of the coronary arteries; left ventricular ejection fraction (volume of blood pumped by the left ventricle); abnormal electrical activity of the heart; and smoking. Thus, several factors, including physical impairment and abnormal electrical activity, can be used to assess prognosis in patients with ischemia and to identify those at high risk for heart attack and death. (Consumer Summary produced by Reliance Medical Information, Inc.)