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OBJECTIVE Rates of coronary angiography (CA) after myocardial infarction (MI) vary widely between institutions. Furthermore, the indications for CA are often in conflict with recognized guidelines. The present study sought to determine the characteristics and the one-year mortality in patients with MI, regardless of age and hospital facilities, according to the use of CA after MI. METHODS AND RESULTS Data were prospectively collected in all patients with MI admitted to all hospitals in three departments in the Rhone-Alpes region. Among 2493 patients, 1117 (45%) underwent CA. In multivariate analysis, CA rate was lower with increasing age, female sex, in patients with comorbidity or heart failure. CA was performed in 49% of patients admitted to hospitals with on-site CA vs. 32% in hospitals without on-site CA (OR: 3.54, after adjustment for patients' characteristics). One-year mortality rate was 6.5% for the CA group and 36.9% for the no-CA group. In multivariate analysis, age, history of angina pectoris, presence of Q waves, Killip class at admission II, III, or IV and CPK ratio > or = 9 were significant predictors of a higher one-year mortality, but performance of CA did not significantly influence it: RR: 0.79 (95% CI 0.58 to 1.07). CONCLUSIONS Among patients with MI in a large unselected cohort in a French region, the one-year mortality was significantly lower in those referred for angiography. However, after correction for the confounding effects of simple baseline clinical indicators of risk, this apparent benefit reflected the fact that angiography was performed in those at lowest risk.

Objective -There is an excess mortality after myocardial infarction in diabetics, but also documented significant differences in the characteristics of Ml and in management between diabetics and non-diabetics. The aim of this prospective study in a large unselected patient cohort in a single French region was to determine if baseline characteristics, management, or in-hospital and one-year mortality differed in diabetic and non-diabetic patients with myocardial infarction. Methods and results - Data were prospectively collected in consecutive patients with myocardial infarction admitted to all hospitals in three departments in the Rhone-Alpes region between September 1, 1993 and January 31,1995. Among the 2,297 patients, 410 patients (17.8%) were diabetic. Although diabetics were older than non-diabetics (70.3 vs. 67.8 years; p < 0.0004), and less likely to receive thrombolysis (31% vs. 36%; p = 0.043), in-hospital mortality was not significantly higher (17.3% vs. 14.7%) than in non-diabetics. In multivariate analysis, diabetes was a significant predictor of one-year mortality (relative risk: 1.41; 95% Cl = 1.10 - 1.79; p = 0.0063) but not of in-hospital mortality (relative risk: 1.2; 95% Cl = 0.9 - 1.7; p = 0.25). Multivariate predictors of in-hospital and one-year mortality in diabetics were age and Killip class at admission. Conclusions - In this large unselected French cohort, diabetes mellitus was a significant predictor of one-year but not of in-hospital mortality after myocardial infarction in a French region.This negative effect of diabetes on mortality was not related to differences in baseline characteristics, or in initial or post-discharge management between diabetics and non-diabetics.

Resume Objectifs – L'etude prospective PRIMA (Prise en charge de l'Infarctus du Myocarde Aigu) avait pour buts de determiner l'incidence de l'aggravation de l'insuffisance cardiaque, ses facteurs de risque et son importance pronostique chez des patients avec infarctus myocardique, sans distinction de structures d'accueil ni de limite d'âge, dans une region francaise, en utilisant une analyse multivariee. Methodes – Les donnees ont ete colligees de maniere prospective chez tous les patients admis pour infarctus du myocarde dans trois departements de la region Rhone-Alpes entre le 1er septembre 1993 et le 31 janvier 1995. Resultats – Parmi les 2507 patients inclus, 33 % etaient en stade de Killip II–IV a l'admission. Quatre cent seize patients (17 %) ont eu une aggravation de leur stade de Killip durant les cinq premiers jours. La mortalite hospitaliere (totale : 14 %) a augmente de maniere considerable avec le stade de Killip a l'admission (9 % en stade I ; 62 % en stade IV) et avec l'aggravation du stade de Killip durant les cinq premiers jours (36 % vs 8 % en l'absence d'aggravation). En analyse multivariee, l'âge eleve, le diabete et la localisation anterieure avec onde Q sont apparus comme facteurs predictifs significatifs du stade de Killip a l'admission et de son aggravation. Les facteurs predictifs d'une mortalite hospitaliere accrue etaient l'âge eleve, un stade de Killip III a l'admission et l'aggravation du stade de Killip durant les cinq premiers jours. Conclusions – Cette importante cohorte non selectionnee a montre que, chez les patients avec infarctus du myocarde, l'insuffisance cardiaque et son aggravation sont frequentes, surtout chez les patients âges, et augmentent de maniere considerable la mortalite hospitaliere.

Objective - The prospective PRIMA study (Prise en charge de l'Infarctus du Myocarde Aigu; management of acute Ml) sought to determine characteristics, management, and in-hospital mortality of myocardial infarction (MI), regardless of age and hospital facilities, in the real world in a region in France. Methods and results - Data were prospectively collected in all patients with Ml admitted in all hospitals in three departments in the Rhone-Alpes region between September I, 1993 and January 31, 1995. 2,519 patients (68% men; mean ± SD: 68 ± 14 years) were included. Time from onset of symptoms to admission was I in 33%. The overall rate of thrombolysis was 36%. It was significantly higher in men than in women, in younger patients than in older patients, in lower Killip classes, in Q wave MI, and when the delay before initial medical intervention was < 6 hours. After age-adjustment, there was no difference between men and women for thrombolysis rate (odds ratio women/men: 0.92; p = 0.10). During the first 5 days, Killip class worsened in 17%. In-hospital mortality rate was 14%. Multivariate analysis identified age, anterior location, presence of Q waves, and higher Killip classes as significant predictors of in-hospital mortality. Conclusions - This large unselected cohort revealed that among patients with Ml in a French region, there was a high proportion of elderly patients, a low rate of thrombolysis, and a high in-hospital mortality.

Drug-eluting stents, since their approval in the United States, have become the treatment of choice for de novo coronary artery narrowing due to their ability to reduce restenosis and the need for repeat revascularization. We present two patients who underwent percutaneous coronary intervention for the treatment of multivessel coronary artery disease; both patients were treated with sirolimus-eluting stents (SES) and bare metal stents (BMS).

Although the safety profiles of coronary stents eluting sirolimus or paclitaxel do not seem to differ from those of bare metal stents in the short-to-medium term, concern has arisen about the potential for late stent thromboses related to delayed endothelialisation of the stent struts. We report four cases of angiographically-confirmed stent thrombosis that occurred late after elective implantation of polymer-based paxlitaxel-eluting (343 and 442 days) or sirolimus-eluting (335 and 375 days) stents, and resulted in myocardial infarction. All cases arose soon after antiplatelet therapy was interrupted. If confirmed in systematic long-term follow-up studies, our findings have potentially serious clinical implications.

Sirolimus-eluting stents (SESs) are currently being used in patients undergoing percutaneous coronary intervention (PCI). SESs have not been evaluated in the treatment of acute myocardial infarction by primary angioplasty. We report our initial experience with SESs implanted during primary angioplasty. One hundred and three patients were treated within 12 hr after onset of acute myocardial infarction (AMI) with primary angioplasty and SES implantation. Those patients were compared to 504 patients treated with bare metal stents (BMSs). Angiographic success (TIMI flow grade 3 and residual stenosis < 50%) was completed in 98% of patients with SESs and no subacute stent thrombosis was reported. In-hospital outcomes were similar in the SES and BMS groups. At 6 months, major cardiac events were less frequent in the SES group than in the BMS group (9% vs. 24%, respectively; P < 0.001), driven by a lesser need for repeat revascularization with SESs (1% vs. 10.3% with BMSs; P = 0.014). Mortality at 6 months was 7% with SESs and 11% with BMSs (P = 0.14). SESs are safe and effective for the treatment of AMI by primary angioplasty. As compared to BMSs, SESs improve long-term outcome after AMI, mainly by reducing the need for repeat revascularization.

Background— The pattern of saphenous vein graft (SVG) calcification before percutaneous intervention has not been studied. Methods and Results— We used diagnostic and preintervention intravascular ultrasound (IVUS) to determine the incidence and magnitude of SVG calcification in 334 SVG lesions in 274 consecutive patients. Calcium was found in 133 SVGs (40%). Calcium was uniformly distributed among 48 lesion sites (14%), 43 proximal references (13%), and 42 distal references (13%). Calcium was superficial in 20 (40%) and deep in 28 (60%). Over the entire length of the SVGs, the maximum arc and length of calcium (in calcium-containing SVGs) averaged 174±107° and 6.8±4.8 mm, respectively. In calcium-containing SVGs, lesion site arc and length of calcium measured 151±107° and 4.1±3.7 mm, similar to the proximal and distal references (175±121° and 4.0±2.3 mm and 177±121° and 4.1±2.5 mm, respectively). Graft age (7.5±4.7 versus 10.5±4.7 years, P P =0.02), and tobacco use (44% versus 55%, P =0.06) were clinical independent predictors of SVG calcification. Conclusions— Sixty-five percent of calcium-containing SVGs had reference calcium in the absence of lesion calcium. Calcium was located primarily in SVG wall and not at the plaque. These data suggest that SVG calcium is not just part of lesion formation and maturation. SVG calcium occurred more commonly in older grafts, in insulin-treated diabetic patients, and in smokers.