The American journal of cardiology
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Randomized Controlled Trial Comparative Study
Prevalence and prognostic implications of ST-segment deviations from ambulatory Holter monitoring after ST-segment elevation myocardial infarction treated with either fibrinolysis or primary percutaneous coronary intervention (a Danish Trial in Acute Myocardial Infarction-2 Substudy).
Ambulatory Holter monitoring has been shown to be useful in stratifying cardiovascular risk after acute myocardial infarction. However, it remains unclear whether ST-segment deviations might predict clinical outcomes in a population treated with primary percutaneous coronary intervention (PCI) compared with thrombolysis. Holter monitoring was initiated at discharge from ST-segment elevation myocardial infarction in 958 patients followed for 2,773 patient-years, randomized to immediate revascularization with either fibrinolysis (n=474) or PCI (n=484). ⋯ In PCI-treated patients, there was no association between either STe or STd and outcome. In conclusion, immediate revascularization with PCI during STe myocardial infarction does not affect the subsequent prevalence of ST-segment deviation compared with fibrinolysis. However, although STe is an independent predictor of mortality and nonfatal major cardiovascular events in patients treated with fibrinolysis, it does not predict outcome after PCI, perhaps because of more complete revascularization.
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Currently, left ventricular (LV) ejection fraction (EF) and/or LV volumes are the established predictors of mortality in patients with coronary artery disease (CAD) and severe LV dysfunction. With contrast-enhanced magnetic resonance imaging (MRI), precise delineation of infarct size is now possible. The relative merits of LVEF/LV volumes and infarct size to predict long-term outcome are unknown. ⋯ Nineteen patients (8.2%) died during a median follow-up of 1.7 years (interquartile range 1.1 to 2.9). Cox proportional hazards analysis revealed that infarct size defined as spatial extent (hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.1 to 1.6, chi-square 6.7, p=0.010), transmurality (HR 1.5, 95% CI 1.1 to 1.9, chi-square 8.9, p=0.003), or total scar score (HR 6.2, 95% CI 1.7 to 23, chi-square 7.4, p=0.006) were stronger predictors of all-cause mortality than LVEF and LV volumes. In conclusion, infarct size on contrast-enhanced MRI may be superior to LVEF and LV volumes for predicting long-term mortality in patients with healed myocardial infarction.
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Coronary plaque composition cannot be assessed accurately using gray-scale intravascular ultrasound (IVUS). Using virtual histology IVUS (VH-IVUS), a comparison of coronary plaque composition between acute coronary syndromes (ACS) and stable angina pectoris (SAP) was performed. Preintervention IVUS of de novo culprit and target lesions was performed in 318 patients (123 with ACS and 195 with SAP). ⋯ The percentages of fibrotic and fibrofatty plaque areas and volumes were smaller, and the percentages of necrotic core areas and volumes were larger in VH-TCFAs compared with non-TCFAs. Ruptured plaques in VH-IVUS analyses showed intermediate findings between VH-TCFAs and non-VH-TCFAs. In conclusion, culprit lesions in patients with ACS were more unstable and had greater amounts of necrotic core and smaller amounts of fibrofatty plaque compared with target lesions in patients with SAP.
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Randomized Controlled Trial Comparative Study
Effect of glucagon-like peptide-1 (GLP-1) on glycemic control and left ventricular function in patients undergoing coronary artery bypass grafting.
Increasing evidence suggests that tight glycemic control improves clinical outcomes after coronary artery bypass grafting (CABG). However, the risk for hypoglycemia with insulin often results in less aggressive glycemic control. Glucagon-like peptide-1 (GLP-1) is a naturally occurring peptide whose insulinotropic effects are predicated on the glucose concentration, minimizing the risk for hypoglycemia. ⋯ There were also more frequent arrhythmias requiring antiarrhythmic agents in the control group. GLP-1 resulted in better glycemic control in the pre- and perioperative periods (GLP-1 95 +/- 3 mg/dl, control 140 +/- 10 mg/dl, p
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We investigated the impact of ambulance-based prehospital triage on treatment delay and all-cause mortality (in hospital and long term) in patients with ST-elevation myocardial infarction (STEMI) complicated by cardiogenic shock referred for primary percutaneous coronary intervention in a prospectively collected registry. During the study period (January 2003 to December 2005), a total of 121 patients was referred for primary percutaneous coronary intervention at our intervention laboratory through 2 main triage groups: (1) after prehospital, ambulance-telemedicine-based triage (42 patients) and (2) by more conventional routes (79 patients) represented by the institutional S. Orsola-Malpighi hospital emergency department triage (44 patients) and spoke hospital triage (35 patients). ⋯ In the entire study population, patients revascularized within an optimal time (2 hours from symptom onset or 90 minutes from STEMI diagnosis) showed remarkably low in-hospital mortality (20% and 29%, respectively). At the 1-year follow-up, patients with prehospital triage had a higher survival rate (74% vs 52%, p = 0.019). In conclusion, this study indicates that prehospital triage with direct transportation to the intervention laboratory is associated with shorter treatment delay and better clinical outcome in patients with STEMI complicated by cardiogenic shock.