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Background: Efficacy and safety of primary percutaneous coronary angioplasty (PCI) in elderly patients with acute ST-elevation myocardial infarction (STEMI) have not yet been definitely established because these patients were usually excluded from large randomised trials., Aim: To evaluate in-hospital and one-year outcome after primary PCI in elderly patients, and to assess clinical characteristics of this group., Methods: The study population included 1061 consecutive STEMI patients, mean age 60.6+/-17 years, treated with primary PCI. Clinical characteristics and results of 127 patients aged > or = 75 years were compared to the younger group., Results: Elderly patients were more frequently female (48.4 vs. 23.6%, p <0.005) and diabetics (22.2 vs. 12.1%, p <0.02) and more frequently had renal and/or left ventricular failure (22.3 vs. 9.1%, and 9.1 vs. 4.5%, p <0.005, respectively). In older patients less frequently stents were implanted and TIMI flow 3 was restored (65.1 vs. 78.8%, p <0.05 and 74.6 vs. 84.7%, p <0.03). In-hospital mortality in older versus younger patients was 11.8 vs. 3.0%, p <0.005. The incidence of in-hospital complications (stroke, major bleeding and reinfarction) was similar in both groups. The one-year mortality and MACE rates were higher in older patients (21.3 vs. 6.0% and 24.9 vs. 11.0%, p <0.0005). In multivariate analysis Killip class II-IV (OR 6.73; 95% CI 1.75-25.97, p=0.006) and heart rate (OR 1.04; 95% CI 1.01-1.07, p=0.03) were independent predictors of one-year mortality in patients aged > or = 75 years., Conclusions: Primary PCI in older STEMI patients is associated with a favourable in-hospital and one-year outcome, although inferior to that seen in younger patients. The in-hospital complication rate is similar in the elderly and in younger patients.

We describe a case of a 59-year-old male with permanent VT in the course of an acute coronary syndrome. Coronary angiography revealed acute occlusion of the right coronary artery. Although the underlying condition was treated by implantation of 4 stents with excellent haemodynamic effect (TIMI 3), the tachycardia continued, being refractory to drugs (amiodarone). The attempts to restore sinus rhythm by DC electrical cardioversion or transvenous pacing were unsuccessful. The patient was referred to the EP lab. A critical isthmus localised at the paraseptal region of the LV and parallel to the mitral annulus was identified. The isthmus was closed by linear RF application, resulting in VT termination. Due to impaired LV ejection fraction (<30%) the patient was scheduled for ICD implantation. During 6-week follow-up the patient remained free of arrhythmia.

Background: TIMI scale is commonly used for angiographic assessment of reperfusion effectiveness and early risk stratification in patients treated with primary angioplasty for ST-elevation myocardial infarction (STEMI). Since ST-resolution analysis allows a noninvasive insight into the reperfusion status at the myocardial tissue level, it may be a better predictor of outcome after primary angioplasty., Aim: To compare the prognostic value of the reperfusion effectiveness evaluation based on either the epicardial blood flow assessment according to the TIMI scale, or ST-segment resolution analysis in patients treated with primary coronary angioplasty for STEMI., Methods: 324 consecutive patients treated within 12 hours from the pain onset were studied. Based on the analysis of maximal ST-segment elevation/depression identified in a single ECG lead recorded after the procedure (maxSTE), patients were classified into groups of high versus medium/low risk. Independently, distinguished were groups with restored normal (TIMI 3) and abnormal (TIMI 0-2) final blood flow in infarct related artery., Results: The 30-day and one-year mortality rates were higher in the high-risk maxSTE group (25% of all patients) than in the other patients (14.8% vs. 2.5%, p<0.001 and 18.5% vs. 5.4%, p<0.001 respectively). In subjects (82%) with restored TIMI grade 3 blood flow, mortality at one-month and one-year was lower than in the group with abnormal final blood flow (3.1% vs. 15.6%, p=0.001 and 6.2% vs. 18.8%, p=0.005). Comparison in multivariate analysis revealed that maxSTE stratification but not final TIMI grade assessment remained an independent predictor of both, 30-day and one-year mortality (high vs. medium/low-risk category; OR 5.3, 95% CI 1.6-16.7, p=0.005, and OR 3.3, 95% CI 1.4-7.8, p=0.007, respectively). Furthermore, maxSTE proved to stratify the risk of death even in subgroup of patients with restored normal blood flow (OR 6.2, 95% CI 1.4-27.8, p=0.016, and OR 3.0, 95% CI 1.1-8.7, p=0.039, respectively)., Conclusions: Analysis of extent of maximal ST-segment elevation or depression identified in a single ECG lead after primary coronary angioplasty allows better prognosis of subsequent 30-day and one-year mortality than the assessment of final epicardial blood flow, stratifying risk of death even in a subgroup of patients with restored normal blood flow.

In survivors of myocardial infarction normal signal-averaged electrocardiogram (SAECG) identifies patients at low risk of death. The aim of this study was to see whether this routine, noninvasive test can also help identify low risk individuals among patients with idiopathic dilated cardiomyopathy (DCM) with markedly depressed left ventricular function. We performed time-domain SAECG using Butterworth 40-250 Hz filter in 67 DCM patients with no coronary stenoses and no bundle branch block on standard electrocardiogram (age 30 +/- 10 years, ejection fraction 35 +/- 12%) and followed them prospectively for the mean of 27 months. Ten cardiac events occurred defined as cardiac death (n = 6) or heart transplantation (n = 4). Mean fQRS, LAS, and RMS values and incidence of abnormal SAECG did not differ significantly between patients with events and event-free survivors (124 +/- 20 vs 123 +/- 17 ms; 32 +/- 10 vs 39 +/- 16 ms; 31 +/- 23 vs 27 +/- 21 mV and 3/10 (30%) vs 26/57 (46%) respectively; p = NS for all comparisons). We did not find significant difference between event-free survival curves of patients with normal and abnormal SAECG, and also of patients with fQRS > 114 ms and L 114 ms; LAS > 38 ms and L 38 ms, and of patients with RMS < 20 microV and > or = 20 microV (log-rank p = 0.4-0.6). We conclude that in patients with DCM with markedly depressed left ventricular function normal time-domain SAECG is probably not useful in identifying low risk individuals.

Background: Mortality in acute myocardial infarction (MI) complicated by cardiogenic shock approaches 90%, regardless of the type of pharmacological treatment., Aim: To assess in-hospital and mid-term results of invasive treatment of patients with acute MI with ST segment elevation (STEMI) complicated by cardiogenic shock., Methods: From a prospective registry of all patients admitted to our institution for urgent coronary angiography due to acute coronary syndrome between February 2001 and June 2002, patients with STEMI, symptom duration up to 12 hours and cardiogenic shock diagnosed on admission were identified. The in-hospital and mid-term outcome of 37 patients (mean age 65 years, range 54-77, 68% of males) treated with primary percutaneous coronary intervention (PCI) was analysed., Results: Of the 41 patients with STEMI and cardiogenic shock, total occlusion or critical stenosis of a coronary artery were found in 38 patients. One patient with the occlusion of three main coronary arteries underwent urgent surgical revascularisation and remains alive after an 18-month follow-up. In the remaining 37 patients primary PCI of an infarct-related artery was performed (stent implantation in 70%, abciximab administration in 54%) which restored normal blood flow (TIMI grade 3 flow) in 54% of subjects. In patients with TIMI grade 3 flow the in-hospital mortality was 25%. Of the whole PCI-treated group, 18 (48.6%) patients died during stay in our institution, an additional two - after transfer to another hospital, and one - during a 19-month follow-up period. The remaining 16 patients remain alive (median follow-up of 8 months)., Conclusions: Invasive treatment of patients with STEMI complicated by cardiogenic shock significantly reduces mortality in this high-risk population. The mid-term results in patients discharged from hospital are good. Invasive treatment of acute MI should be accessible for all patients with extensive acute MI.