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Byline: Rephael Mohr, Yaron Moshkovitch, Itzhak Shapira, Gabriel Amir, Hanoch Hod, Jacob Gurevitch Abstract: Objective: Between January 1992 and December 1994, 57 patients having an acute myocardial infarction with coronary anatomy suitable for coronary artery bypass grafting without cardiopulmonary bypass underwent this procedure within 1 week of the infarction. We describe the surgical results of these high-risk patients. Methods: The study population included 43 male patients (75%) and 14 female patients (25%) whose mean age was 58.5 [+ or -] 10.4 years. Thirty-two patients (56%) underwent emergency bypass grafting within 48 hours of an acute myocardial infarction, 4 of them (12.5%) as a bailout procedure after complicated percutaneous transluminal coronary angioplasty. Of these 32 patients, 7 patients (22%) were in cardiogenic shock, and 10 patients (31%) required preoperative intra-aortic balloon pump. Twenty-five patients (44%) underwent coronary bypass grafting 2 to 7 days after an acute myocardial infarction. The mean number of grafts per patient was 1.8 (range, 1-4), and the internal thoracic artery was used in 47 patients (82%). Only 7 patients (12%) received grafts to a circumflex marginal branch. Results: Operative mortality was 1.7% (1 patient), and the mean postoperative hospital stay was 6.8 [+ or -] 3 days. One- and 5-year actuarial survivals were 94.7% and 82.3%, respectively. Angina returned in 7 patients (12%), 1 of whom underwent reoperation. Multivariate analysis revealed renal failure and preoperative cardiogenic shock to be independent predictors of overall mortality. Old myocardial infarction and operation within the first 48 hours were independent predictors of overall unfavorable outcome events. Conclusions: These results suggest that coronary artery bypass grafting without cardiopulmonary bypass is a relatively low-risk procedure for patients having an infarction with coronary anatomy suitable for this technique. (J Thorac Cardiovasc Surg 1999;118:50-6) Author Affiliation: From The Department of Thoracic and Cardiovascular Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv,.sup.a and The Heart Institute, The Chaim Sheba Medical Center, Tel Hashomer,.sup.b affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel Article History: Received 17 September 1998; Revised 4 November 1998; Revised 3 March 1999; Accepted 3 March 1999 Article Note: (footnote) [star] Address for reprints: Rephael Mohr, MD, The Department of Thoracic and Cardiovascular Surgery, Tel Aviv Sourasky Medical Center, 6 Weizman St, Tel Aviv 64239, Israel., [star][star] 12/1/98437

Background: Patients with a history of stroke presenting with acute myocardial infarction (MI) are often excluded from thrombolytic therapy owing to fear of intracranial hemorrhage. Few data, however, are available on the risks vs the benefits of thrombolysis in patients with an acute MI and a prior cerebrovascular event (PCE). Methods: Data were derived from 2 nationwide surveys of 2012 consecutive patients with acute MI admitted to all 25 coronary care units in Israel during 1992 and 1994. Thrombolytic therapy was given to patients with a PCE at the discretion of the treating physicians. Outcomes were compared between patients with an acute MI with and without a PCE and between patients with a PCE treated with or excluded from thrombolysis. Results: Patients with a PCE (n=115 [6%]) were older, with higher rates of atherosclerotic risk factors and in-hospital complications than their counterparts without a prior event (n=1897). They were treated less often with thrombolysis or mechanical reperfusion. The 1-year mortality rates were higher among patients with a PCE (28% vs 19%, P[is less than].01), but not after multivariate adjustments for clinical characteristics (adjusted hazard ratio, 1.08; 95% confidence interval, 0.75-1.55). Patients with an acute MI and a PCE who were treated with thrombolysis (n=29 [25%]) were compared with 46 patients found ineligible for thrombolysis primarily because of their PCE. The timing of the PCE was comparable in both groups (one fifth in the preceding year), while prior transient ischemic attacks were more prevalent among patients who had undergone thrombolysis. The patients who were treated with thrombolysis (n=29) were older, had a higher rate of anterior infarction, and, while in the hospital, received aspirin, anticoagulants, and [Beta]-blockers more often than their counterparts (n=46). In-hospital intracranial hemorrhage did not occur in either group. The 1-year mortality rates were 2-fold higher among patients who had not undergone thrombolysis compared with those who had (33% vs 18%; adjusted hazard ratio, 2.44; 95% confidence interval, 0.78-7.64). Conclusions: These findings, derived from 2 nationwide surveys of consecutive patients with acute MI, suggest that patients with PCEs have an adverse outcome attributed to their older age and less favorable risk profile. Thrombolytic therapy, however, based on our preliminary data, may be beneficial in selected patients with an acute MI with a nonrecent PCE. Arch Intern Med. 1998;158:601-606

PURPOSE: The aim of this study was to determine the proportion of patients with acute myocardial infarction (AMI) excluded from thrombolytic therapy on a national basis and to evaluate the prognosis of these patients by reasons of ineligibility and according to the alternative therapies that they received during hospitalization. PATIENTS AND METHODS: During a national survey, 1,014 consecutive patients with AMI were hospitalized in all the 25 coronary care units operating in Israel. RESULTS: Three hundred and eighty-three patients (38%) were treated with a thrombolytic agent and included in the GUSTO study. Ineligible patients for GUSTO were treated: (1) without any reperfusion therapy (n = 449), (2) by mechanical revascularization (n = 97), or (3) given 1.5 million units of streptokinase (n = 85) outside of the GUSTO protocol. The in-hospital and 1-year post-discharge mortality rates were 6% and 2% in patients included in the GUSTO study; 6% and 5% in those mechanically reperfused; 15% and 10% in those treated with thromoblysis despite ineligibility for the GUSTO trial, and 15% and 13% among patients not treated with any reperfusion therapy. CONCLUSIONS: Ineligibility for thrombolysis among patients with AMI remains high. Patients ineligible for thrombolysis according to the GUSTO criteria, but nevertheless treated with a thrombolytic agent were exposed to an increased risk.

Background: Since the introduction of thrombolytic therapy for patients with acute myocardial infarction, the use of coronary angiography has substantially increased. We sought to determine whether the presence of on-site coronary angiographic facilities influenced the utilization of coronary procedures in patients with acute myocardial infarction hospitalized in Israel's coronary care units. Methods: A prospective survey was conducted in January and February 1992 in the 25 coronary care units operating in Israel, 15 of which had on-site catheterization facilities. Data on demographics, clinical features, thrombolytic therapy, and the type of coronary diagnostic or therapeutic procedures performed during the current in-hospital stay were recorded. Mortality, both in-hospital and 1 year after discharge, was assessed for all patients in the survey. Results: One thousand fourteen consecutive patients with acute myocardial infarction were hospitalized during the survey, 307 (30%) of whom were admitted to 10 coronary care units without and 707 of whom were treated in hospitals with on-site coronary angiography facilities. Demographic and baseline characteristics were similar in both groups. Thrombolytic therapy was provided equally (46%) to patients admitted to hospital with and without catheterization laboratories. Patients admitted to hospitals with these laboratories underwent coronary angiography (26%) and percutaneous transluminal angioplasty and/or coronary artery bypass grafting (12%) in greater numbers than counterparts admitted to hospitals without such laboratories (10% and 5%, respectively). Hospital and cumulative 1-year mortality rates were 11% and 18%, respectively, in patients admitted to hospitals with on-site catheterization facilities vs 10% and 17%, respectively, in the patient group admitted to the other hospitals. Patients receiving thrombolytic therapy had similar hospital mortality rates unrelated to the availability of coronary catheterization laboratories. Conclusion: This national survey showed that the availability of invasive coronary facilities led to increased use of diagnostic and therapeutic coronary procedures among patients with acute myocardial infarction. There was no difference in hospital or 1-year mortality rates in patients admitted to hospitals with or without on-site coronary angiographic facilities.

A national study was performed in early 1992 in the 25 operating coronary care units in Israel, which enabled the assessment of whether the therapeutic management of patients with acute myocardial infarction was affected by patient gender. During a 2-month period, 1,014 consecutive patients with acute myocardial infarction were hospitalized. Thrombolytic therapy wa given to 47% of men (362 of 769), and 43% of women 106 of 245) (p = NS). After adjustment for age, no gender differences in the administration of thrombolytic therapy were noted (odds ration 0.95; 95% confidence interval 0.73-1.23). Coronary angiography was more frequently performed n men (22%) than in women (16%) (p

Heart attacks (myocardial infarction) occur when ischemia (decrease in oxygen supply due to reduced or no blood flow) is so severe that a portion of the heart muscle can not function and may die. Heart attacks may be precipitated by the lodging or formation of a clot in a coronary artery. A relatively novel therapeutic approach has been to give thrombolytic (clot-breaking) agents that disrupt the clot and restore blood flow. However, thrombolytic therapy is not successful in a number of heart attack patients, who may need emergency treatment if they are to survive. To improve survival of patients with myocardial infarction, it is important to determine which patients are most likely to be responsive to thrombolytic therapy. Electrocardiogram provides an indication of heart function during each heartbeat, and elevation of the ST segment of the electrocardiogram has generally been regarded as an indicator of heart ischemia. However, some studies have suggested that ST elevation is not sensitive enough to detect restoration of coronary artery flow following a heart attack. The usefulness of ST elevation and other indicators of heart function were evaluated in 286 heart attack patients treated with alteplase, a thrombolytic agent. Alteplase was given within four hours of symptom onset, the period when thrombolytic therapy is most likely to be effective. ST elevation diminished quickly in 189 patients, but persisted in 97 patients. Rapid resolution of ST elevation was significantly associated with a good medical outcome; the group in which this occurred had a better initial medical status. However, early reperfusion was independent of this factor and correlated significantly with better heart function and a lower rate of illness and death. Although angiography was used to determine if reperfusion of coronary arteries occurred, correction of ST segment elevation was a better predictor of medical outcome. Rapid resolution of pain was not associated with persistent elevation or normalization of ST segment. Resolution of ST elevation may also reflect the contribution of other factors important to survival of heart tissue, as well as reperfusion. The results also indicate that high-risk patients, such as those with congestive heart failure, may require additional therapy, in spite of resolution of ST elevation. (Consumer Summary produced by Reliance Medical Information, Inc.)

Although both the European Cooperative Study Group and the Thrombolysis in Myocardial Infarcdon IIB trial indicated that aregiography and angioplasty as routine measures after thrombolytic treatment do not improve clincal outcome in patients with acute myocardial infraction, the potential benefit of angioplasty may have been negated by the fact that the precedure was too soon ( (Am J Cardiol 1990;66:538-545), A major heart attack, or an acute myocardial infarction (MI), results from the deterioration of heart tissue due to the cessation of blood supply to the heart. Patients with MI are treated with thrombolytic agents that break up blood clots blocking the blood supply to the heart. Invasive procedures, such as angiography (the X-ray of the blood vessels supplying the heart) and angioplasty (the repair of the narrowed or obstructed blood vessels) may also be performed. Studies have shown that such invasive procedures do not improve the outcome of patients with MI after thrombolytic therapy. However, it is possible that angioplasty is not beneficial when it is performed too early (less than 32 hours after admission). The effectiveness of delayed angioplasty was compared with that of conservative treatment in 201 patients with acute MI. All patients received recombinant-type plasminogen activator, which prevents blood clot formation. The invasive group consisted of 97 patients who underwent angiography and angioplasty five days after drug treatment. The conservative group consisted of 104 patients who only underwent angiography after recurrent chest pain associated with MI or exercise. In the invasive group, 92 patients underwent angiography, 49 had angioplasty, and 11 required coronary artery bypass grafting (CABG), a surgical procedure to restore the blood flow to the heart. Among patients of the conservative group, 40 developed ischemia, an insufficient blood supply to the heart; 39 underwent angiography; 20 had angioplasty; and four required CABG. The recurrence of MI and maintenance of left ventricle function were similar for both invasive and conservative groups eight weeks after discharge from the hospital. If only the deaths which occurred after the scheduled invasive procedures are considered, 5 of 97 patients in the invasive group and none of 100 patients of the conservative group died within the 10-month follow-up period. Re-hospitalization was more frequent among patients of the conservative group and was associated with a history of chest pain. These findings suggest that conservative treatment is preferable to invasive treatment of patients with acute MI. (Consumer Summary produced by Reliance Medical Information, Inc.)

A very important aspect in the successful treatment of patients following an acute myocardial infarction (MI) is prompt initiation of thrombolytic treatment. Thrombolysis relies upon drugs that are capable of dissolving clots in the area of the infarction, the tissue death resulting from reduced blood supply. A thrombolytic agent has been demonstrated to be most effective if administered within two hours after the onset of pain. This prompt drug therapy can preserve heart function, specifically, left ventricular function, and can reduce short- and long-term mortality. The goal of this study was to correlate clinical outcome with the time from onset of symptoms to initiation of thrombolytic treatment with a recently approved new drug, recombinant tissue plasminogen activator (rt-PA). One hundred ninety patients with AMI were administered rt-PA an average of two hours after the onset of their symptoms. Prehospitalization thrombolysis was possible in a substantial number of these patients by use of mobile intensive care units. Short- and long-term effects of early versus late administration of rt-PA were evaluated by examining left ventricular function, and cardiac morbidity and mortality. The overall two-year mortality was low; there were 10 deaths out of the 190 patients treated. Eight of those deaths (4 percent) were cardiac in nature. The patients that were treated within two hours from the onset of symptoms had a lower 60-day and 24-month mortality than patients treated two to four hours after symptoms began. It is also important to understand that the 96 patients who received early treatment were generally more seriously ill, which can be interpreted to mean that sicker patients seek treatment sooner. It is essential that patients seek early treatment in order to salvage heart muscle tissue. Unfortunately, many patients delay seeking treatment by one to two hours and the initiation of valuable thrombolytic treatment is delayed. Mobile intensive care units are valuable in providing treatment early in the homes of patients and this method was found to be both safe and effective. The authors recommend this prehospital therapy to shorten the interval between symptom onset and treatment initiation to potentially reduce mortality. (Consumer Summary produced by Reliance Medical Information, Inc.)

Patients with cardiac arrhythmias, sudden cardiac death, and acute myocardial infarction (MI, heart attack) have been shown recently to have low levels of magnesium in their blood. Low levels of magnesium have also been identified in heart muscle tissue of patients with AMI. A disturbance of magnesium is believed to occur in the acute phase of the MI and there is a high incidence of life-threatening arrhythmias and high mortality during this initial period. Blood levels of magnesium in patients that survive an MI are generally low or normal. Patients diagnosed with acute MI were given either magnesium sulfate injection or placebo shortly after admission, and the incidence of cardiac arrhythmias and congestive heart failure and hospital mortality were examined. A variety of arrhythmias were seen in 45 percent of patients who received placebo and 32 percent of patients who received magnesium. There was a higher mortality in the placebo group, with a total of nine deaths, with only one death in the magnesium group. Rapid administration of magnesium by intravenous injection has a possible protective role; however, it is unknown whether this is due to correction of a condition of low magnesium (hypomagnesemia) or to an increase of magnesium to above normal levels. This study was conducted before the routine use of thrombolytic agents was initiated in the coronary care unit, but magnesium should be considered a safe, simple, and inexpensive method of reducing immediate mortality in patients with MI. (Consumer Summary produced by Reliance Medical Information, Inc.)

To cardiologists, the term ''late potentials'' refers to electrical signals seen on an electrocardiogram (ECG) at the end of what is called the QRS complex or during the ST segment of the heartbeat. It is thought that these signals come from areas in the heart muscle where the electrical impulses have been slowed because of the damage done in those areas. If that is true, then late potentials may be indicators that arrhythmias may occur. When late potentials occur one to four weeks after an acute myocardial infarction (heart attack or AMI; death of heart tissue due to a loss of blood supply), they are carry a higher risk of sudden cardiac death and ventricular tachycardia (ineffective rapid beating of the ventricles) in the next 6 to 24 months. Thrombolytic therapy involves injection into the heart of enzymes to dissolve an existing blood clot in a heart vessel. Performed within a few hours of AMI, thrombolytic therapy has been shown to improve not only patient survival, but to preserve heart muscle (myocardial) function as well. This study of 158 patients during the first 10 days after AMI compared the occurrence of late potentials in patients who did and those who did not receive thrombolytic therapy. Late potentials occurred at about the same rate in both groups in the first two days after infarction. But the incidence of late potentials increased significantly in the untreated group after 7 to 10 days. Thrombolytic therapy does seem to reduce the development of late potentials. Since late potentials and fatal arrhythmias are associated, thrombolytic therapy within four hours of AMI may explain the reduced mortality rate associated with it. (Consumer Summary produced by Reliance Medical Information, Inc.)

Acute myocardial infarction (AMI), heart attack, occurs when an acute partial or total obstruction of one or more coronary arteries results in a reduction of blood flow to the heart (myocardial ischemia). This can cause permanent damage to the cardiac muscle, which in severe cases causes death. A common therapeutic approach to AMI is the administration of thrombolytic (clot-dissolving) drugs such as streptokinase or tissue plasminogen activator. It has been reported that impairment of liver function may be a side effect of thrombolytic therapy. To study the effects of thrombolysis on liver function in more detail, 108 consecutive AMI patients were randomly assigned to receive either recombinant tissue-type plasminogen activator (r-TPA) or streptokinase intravenously. Liver function was determined by measuring bilirubin, and levels of the liver enzymes alkaline phosphatase, alanine aminotransferase, and gamma glutamyl transferase. These measurements were performed at admission, at five-day intervals, and at three-month follow-up. Thirty-two patients who did not consent to thrombolytic therapy or who were excluded from treatment for a variety of reasons were used as an untreated control group. Levels of all three liver enzymes were significantly increased during hospitalization in the patients receiving streptokinase; in the r-TPA group, only alanine aminotransferase showed any tendency to increase. All changes had normalized in both groups by the time of the three-month follow-up. Since r-TPA induced less elevation of liver enzymes than streptokinase, it should probably be the drug of choice for patients with impaired liver function who require thrombolysis. (Consumer Summary produced by Reliance Medical Information, Inc.)

Assessment of global myocardial performance by a single index (ie, the myocardial performance index [MPI]) has been suggested as an appealing alternative to the individual assessment of systolic and diastolic left ventricular (LV) function We sought to test the prognostic value of MPI in comparison to clinical characteristics and echocardiographic parameters of LV filling and ejection in acute myocardial infarction (AMI).

Prior studies have yielded conflicting data on the advantage of primary angioplasty compared with thrombolysis in elderly patients with acute myocardial infarction (AMI). These studies, however, were performed before the contemporary widespread use of intracoronary stents and glycoprotien IIb/IIIa antagonists.

OBJECTIVES

OBJECTIVES

OBJECTIVES

The significance of inferior ST segment changes during acute anterior myocardial infarction was studied in 60 patients with acute anterior infarction who had angiographic visualization of the entire distribution of the left anterior descending artery after thrombolytic therapy with streptokinase. In 34 patients (Group 1) this artery supplied the anterior wall of the left ventricle up to or including the apex but did not reach the inferior wall; in 16 patients (Group 2) it continued beyond the apex onto the inferior wall of the left ventricle; and in 10 patients with prior inferior infarction (Group 3) it partially supplied the inferior wall of the left ventricle through collateral channels to an occluded right or dominant circumflex coronary artery.

Objectives. This study sought to compare the relation between smoking and the 30-day and 6-month outcome after acute myocardial infarction in an Israeli nationwide survey.

Objectives. The aim of this study was to investigate whether a new variable of mitral inflow, A wave deceleration time, identifies patients with elevated left ventricular filling pressures.

The growing recognition of the importance of early thrombolysis in evolving myocardial infarction was the basis for the present study, which evaluated the effectiveness, feasibility and safety of prehospital thrombolytic therapy. In a relatively small study, 118 patients were allocated to receive either prehospital treatment with recombinant tissue-type plasminogen activator (rt-PA) in the mobile intensive care unit (group A, 74 patients) or hospital treatment (group B, 44 patients). A total of 120 mg of rt-PA was infused over a period of 6 h. All patients were fully heparinized and underwent radionuclide left ventriculography and coronary angiography during hospitalization.

Exercise-induced double tachycardia, i.e., the simultaneous occurrence of atrial and ventricular tachycardia, is described in three patients: one patient had coronary artery disease; the other two were young and had no apparent heart disease. One of the latter patients later died suddenly. Double tachycardia could not be initiated by programmed atrial or ventricular stimulation. In two patients atrial tachycardia always preceded ventricular tachycardia and, in one patient, ventricular tachycardia was terminated by the administration of adenosine triphosphate. Reentry does not seem to be the underlying mechanism for these arrhythmias; abnormal automaticity or triggered activity may be the mechanism.

Objectives. We sought to examine the hypothesis that rapid resolution of ST-segment elevation in acute myocardial infarction (AMI) patients with early peak creatine kinase (CK) after thrombolytic therapy differentiates among patients with early recanalization between those with and those without adequate tissue (myocardial) reperfusion.

Objectives. This study was designed to examine whether ST segment elevation in posterior chest leads (V7to V9) during acute inferior myocardial infarction (MI) identifies patients with a concomitant posterior infarction and whether these patients might benefit more from thrombolysis.

We studied the clinical outcome of Q wave and non-Q wave infarction after thrombolytic therapy.

Objectives. This study was designed to investigate the association between wall motion abnormalities and the occurrence of ischemic mitral regurgitation in patients with a first inferior or posterior myocardial infarction and to reassess the role of thrombolytic treatment in these patients.

Objectives. This study was designed to test the hypothesis that reperfusion therapy with thrombolysis will prevent the development of significant mitral regurgitation in patients with inferior myocardial infarction.

When conventional treatment of patients with early clinical reinfarction after thrombolytic therapy fails, mechanical revascularization may be attempted. An alternative strategy, repeat thrombolytic infusions, is reported. Fifty-two patients with acute myocardial infarction were treated with one or two additional thrombolytic infusions of recombinant tissue-type plasminogen activator (rt-PA) because of nonsustained ischemia after initial treatment with rt-PA or streptokinase. Thirty-five patients received the second infusion within 1 h of the first; 13 patients received the second infusion 1 to 72 h after the first and 4 patients received it later during their hospitalization.

Objectives. This study was undertaken to test the hypothesis that early inversion of T waves after thrombolytic therapy for acute myocardial Infarction predicts patency of the infarct-related artery with high Thrombolysis in Myocardial Infarction (TIMI) perfusion flow and better in-hospital outcome.

Objectives. The aim of this study was to investigate the significance of further ST elevation that occurs during the 1st h of thrombolytic therapy before the expected resolution.

Objectives. This study sought to compare the incidence of early cerebrovascular events and subsequent mortality in two cohorts of consecutive patients with acute myocardial infarction (AMI), admitted to coronary care units (CCUs) in Israel, in the prethrombolytic and thrombolytic eras.

Thrombolytic therapy reduces in-hospital mortality. However, 70% to 80% of patients do not receive thrombolysis and their in-hospital mortality is high. During the last decade some clinical trials demonstrated that magnesium sulfate reduced in-hospital mortality. The aim of this study was to evaluate the effects of magnesium sulfate in patients with acute myocardial infarction (AMI) who were considered unsuitable for thrombolytic therapy. Intravenous magnesium sulfate was evaluated in 194 patients with AMI ineligible for thrombolytic therapy in a randomized, double-blind, placebo-controlled study. Group I consisted of 96 patients who received 48-hour intravenous magnesium. Group II consisted of 98 patients who received isotonic glucose as a placebo. Magnesium reduced the incidence of arrhythmias, congestive heart failure, and conduction disturbances compared with placebo (27% vs 40%, p = 0.04; 18% vs 23%, p = 0.27; 10% vs 15%, p = 0.21, respectively). Left ventricular ejection fraction 72 hours and 1 to 2 months after admission was higher in patients who received magnesium sulfate than in those taking placebo (49% vs 43% and 52% vs 45%; p = 0.01, respectively). In-hospital mortality was significantly reduced in patients receiving magnesium sulfate than in those receiving placebo (4% vs 17%; p < 0.01), and also in the subgroup of elderly patients (70 years) (9% vs 23%; p = 0.09). In conclusion, magnesium sulfate should be considered as an alternative therapy to thrombolysis in patients with AMI.

Aims Multi-detector computed tomography (MDCT) has emerged as an efficient tool for detection of obstructive coronary artery disease (CAD) and assessment of patients with acute chest pain. MDCT may detect premature, non-obstructive atherosclerotic lesions which otherwise would have not been detected upon functional cardiac imaging tests. Currently, there is scarce data regarding the clinical significance of these lesions. The purpose of this study was to prospectively analyse the intermediate term outcome of patients admitted to chest pain unit (CPU) with findings of non-obstructive CAD upon MDCT. Method and results The study comprised 444 patients admitted to the CPU at Sheba Medical Center and underwent evaluation by MDCT for complaints of acute chest pain. Studies were classified as: normal; non-obstructive CAD (defined as any narrowing <50% diameter stenosis); obstructive CAD (narrowing of ≥50% diameter stenosis); or non-diagnostic. Patients were followed up for a minimum of 1 year and outcomes were compared between the non-obstructive (n= 115) and the normal (n= 266) MDCT groups in regard to MACE [coronary revascularization, acute coronary syndrome (ACS), and death]. Comparing the groups, those with non-obstructive CAD were older, more likely to be males, and dyslipidaemic. During an intermediate term follow-up (2.5 ± 0.4 years) MACE was equally low between the two groups (1% for both groups; P= 0.9). Conclusion Among patients evaluated by MDCT for acute chest pain, during an intermediate term follow-up, those with non-obstructive CAD had a benign clinical outcome compared with those with normal coronary arteries.

Background: In patients with stable coronary artery disease, and patients undergoing elective percutaneous coronary intervention (PCI), laboratory resistance to aspirin is associated with a higher incidence of adverse events. Nevertheless, the responsiveness to aspirin in acute myocardial infarction (AMI) and its implications have not yet been investigated. Methods: The study comprised 76 aspirin naïve patients who underwent primary PCI (PPCI) for ST-elevation MI (STEMI). Platelet reactivity was assessed 30–60 mins after a loading dose of 300mg chewable aspirin, by conventional aggregometry and Impact R, where platelet reactivity to arachidonic acid (AA) was expressed by platelet deposition under flow conditions. Results: Patients were stratified using the median value of AA-induced platelet aggregation (PA) (49%) to good responders to aspirin (n=38), who had a median AA-induced PA of 33% (25–41), and poor responders to aspirin (n=38), who had a median AA-induced PA of 77% (70–84). Similarly, good compared with poor responders had higher surface coverage by Impact R (3.9±2.6 vs. 2.2±1.3, p=0.003). Good versus poor responders were similar regarding baseline demographic, clinical and angiographic characteristics. However, good responders were more likely to demonstrate early ST-segment resolution ≥ 70% after PPCI (84% vs 54%, p <0.01), suggestive of better myocardial reperfusion. Good compared to poor responders had a lower incidence of adverse cardiovascular events (re-infarction, need for re-intervention, congestive heart failure and/or death) throughout a 6-month follow-up (11% vs 24%, respectively; p<0.05). Conclusions: Ex vivo poor platelet responsiveness to aspirin loading in STEMI patients is associated with a worse prognosis in patients

Acute myocardial infarction (AMI) is usually associated with increased mortality and morbidity following standard CABG. Between Jan 1992 and Jul 1994, 47 pts with coronary anatomy suitable for CABG without cardiopulmonary bypass (CPB) underwent this procedure within one week of AMI. There were 36 (77%) males and 11 (23%)females. Mean agewas 59.6±11.4 years (range 37–80). Thirty-three pts (70%) underwent anterior and 14 (30%) inferior AMI. Twenty-seven underwent emergency CABG within 48 hours of AMI, 9 (33%) as a bailout procedure following complicated PTCA. Of this group, 9 (33%) were in cardiogenic shock, and 12 (44%) pts required preop IABP. Twenty pts underwent urgent CABG 2 to 7 days following AMI, one (5%) with cardiogenic shock, and 3 (15%) with preop IABP. Mean number of grafts/pt was 1.8 (range 1–4), and IMA was used in 37 (79%). Only 6 pts (13%) received a graft to a circumflex marginal branch. There was no operative mortality, and mean hospital stay was 6.3±2.9 days. At mean follow-up of 18±8 months, there was one cardiac-related (in a pt with preoperative EF 13%). and 2 non-cardiae-related deaths. Two-year actuarial survival was 92%. However, in 9 pts (19%) angina returned. Eight had CHF, 5 of whom were in preoperative cardiogenic shock. These results suggest that CABG without CPB is a relatively low-risk procedure for AMI pts with coronary anatomy suitable for this technique. However, the cost might be increased risk of early retu rn of angina.

AbstractThe effect of nitrates during evolving myocardial infarction is controversial. While previous studies showed that nitrates improve left ventricular function and have a beneficial effect on survival, two recent randomized megatrials showed that nitrates did not alter mortality after acute myocardial infarction (AMI). The present study analyzes the use of nitrates in clinical practice and their impact on mortality in a cohort of unselected consecutive AMI patients admitted to all 25 coronary care units operating in Israel during 2 months in 1994. Among 966 patients in Killip class I–III on admission, 81% (n = 783) received nitrate therapy by intravenous infusion or orally. Baseline characteristics of patients treated with or without nitrates were quite similar. Seven-day mortality was markedly reduced in the nitrate-treated group (5 and 11%, p < 0.001) in comparison with those who did not receive nitrates. After adjustment for pertinent variables the 7-day relative risk (RR) of mortality was 0.51 [95% confidence interval (CI) 0.25–1.07; p = 0.08], whereas, the 7-day to 1-year mortality after AMI was not altered by nitrate use (RR = 0.97; 95% CI 0.56–1.68; p = 0.92). Nitrate therapy remains a widespread and a valid symptom-oriented therapeutic approach, especially early after AMI, in the community.

The beneficial effect of aspirin (ASA) in unstable angina is well established, yet data on effect of ASA during the hyperacute phase of myocardial infarction (AMI) is limited. We evaluated the effect of early chewed ASA administration on reperfusion rate and hospital outcome in 90 consecutive AMI patients treated at home or in the Emergency Room. All patients had ischemic chest pain of ≥30minutes, associated with ≥2mm ST↑. Early reperfusion within 30 minutes occurred in 42 patients (46.7%); only 3 patients needed thrombolysis. In 27 controls reperfusion occurred in 7 patients (25.9%); p=0.05. No difference in hospital outcome was observed between patients with ASA-induced reperfusion and patients treated by thrombolytics.