The American journal of cardiology
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Randomized Controlled Trial Multicenter Study Comparative Study
Impact of an initial strategy of medical therapy without percutaneous coronary intervention in high-risk patients from the Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation (COURAGE) trial.
We explored the safety and quality-of-life consequences of treating patients with stable coronary disease and high-risk features initially with optimal medical therapy (OMT) alone compared to OMT plus percutaneous coronary intervention. This was a post hoc analysis of Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation (COURAGE) trial patients. We defined high risk as the onset of Canadian Cardiovascular Society class III angina within 2 months or stabilized acute coronary syndrome within 2 weeks of enrollment. ⋯ No significant difference was found in the prevalence of angina between the 2 groups at 1 year. During the first year of follow-up, 30% of the OMT patients crossed over to the revascularization group. In conclusion, an initial strategy of OMT alone for high-risk patients in the COURAGE trial did not result in increased death or myocardial infarction at 4.6 years or worse angina at 1 year, but it was associated with a high rate of crossover to revascularization.
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Case Reports
Propofol infusion syndrome with arrhythmia, myocardial fat accumulation and cardiac failure.
Propofol is a potent and widely used central-acting sedative drug. It has been implicated in the development of a usually fatal syndrome characterized by metabolic acidosis, rhabdomyolysis, ventricular arrhythmia, and Brugada-like cardiac rhythm disturbances, all leading to cardiac and renal failure. ⋯ Postmortem investigation showed not only the well-known myocytolysis in skeletal and cardiac muscle but also not previously demonstrated widespread fat accumulation in the myocardium. In conclusion, this cardiac fat accumulation illustrates the proposed underlying pathophysiology of impaired (muscular) free fatty acid utilization.
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Multicenter Study Comparative Study
Trends in the age adjusted mortality from acute ST segment elevation myocardial infarction in the United States (1988-2004) based on race, gender, infarct location and comorbidities.
Treatment of acute ST-segment elevation myocardial infarction (STEMI) has dramatically changed over the past 2 decades. The goal of this study was to determine trends in the mortality of patients with acute STEMIs in the United States over a 16-year period (1988 to 2004) on the basis of gender, race, infarct location, and co-morbidities. The Nationwide Inpatient Sample database was used to analyze the age-adjusted mortality rates for STEMI from 1988 to 2004 for inpatients age >40. ⋯ This decrease was similar between the genders, among most ethnicities, and in patients with diabetes and those with congestive heart failure. However, women and African Americans had higher rates of acute STEMI-related mortality compared to men and Caucasians over the years studied. In conclusion, age-adjusted mortality from acute STEMIs has significantly decreased over the past 16 years, with persistent higher mortality rates in women and African Americans the study period.
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A low response to clopidogrel has been associated with an increased risk of stent thrombosis. However, the definition of a nonresponse to clopidogrel remains controversial, and different tests have been used to assess the clopidogrel response. The present study was designed to assess the predictive value of adenosine diphosphate (ADP)-induced platelet aggregation (ADP-Ag) and the Platelet Reactivity Index of vasodilator-stimulated phosphoprotein for the occurrence of stent thrombosis in patients admitted for non-ST-elevation acute coronary syndrome undergoing percutaneous coronary intervention. ⋯ The construction of receiver operating characteristic curves to examine the most predictive value of ADP-Ag for stent thrombosis gave a threshold of ADP-Ag of >67% to identify low responders. These patients were at a greater risk of stent thrombosis than the clopidogrel responders (4.3% vs 0.8%, odds ratio 5.8, 95% confidence interval 1.9 to 24.6, p = 0.003). In conclusion, in patients with non-ST-elevation acute coronary syndrome undergoing percutaneous coronary intervention, ADP-Ag is a good parameter to identify clopidogrel nonresponders who are at increased risk of stent thrombosis, with a cutoff value of ADP-Ag of >67%.
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Multicenter Study Comparative Study
Clinical benefit of early reperfusion therapy in patients with ST-elevation myocardial infarction usually excluded from randomized clinical trials (results from the Maximal Individual Therapy in Acute Myocardial Infarction Plus [MITRA Plus] registry).
Randomized clinical trials (RCTs) usually enroll selected patient populations that may not be representative for patients seen in everyday practice. Therefore, concerns have been raised regarding their external validity. For the present study we evaluated the MITRA Plus registry and included 20,175 patients with ST-elevation myocardial infarction. ⋯ In conclusion, about 50% of patients with ST-elevation myocardial infarction seen in clinical practice are usually excluded from RCTs. Hospital mortality in those patients is very high. Primary PCI improves the prognosis and is therefore the preferred reperfusion strategy in these patients.