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Background: The optimal length of bed rest after femoral coronary angiography is still unknown. Short immobilisation could cause puncture site complications due to the modern antiplatelet therapy used, while long immobilisation time increases the risk of back pain for the patient., Purpose: To assess the safety, as well as perceived comfort, of early mobilisation after coronary angiography with femoral approach., Methods: A randomised, single centre pilot trial with 104 coronary angiography patients (including 58 patients with non ST-elevation acute coronary syndrome) assigned to a post-procedural bed rest time for either 1.5 or 5 h. The primary endpoint was any incidence of vascular complication. Patients' discomfort was measured as self-perceived grade of pain in the back., Results: The presence of haematomas ≥ 5 cm was 5.8% in the short immobilisation group vs. 3.8% in the control group (ns). There was a significantly lower rate of perceived back pain in the short immobilisation group, compared to the controls, at the time of mobilisation, which remained significant also after 2 h of mobilisation., Conclusion: Early ambulation after coronary angiography is safe, without affecting the incidence of vascular complications, and decreases the patients' pain, both during and after the bed rest., (Copyright © 2010 European Society of Cardiology. Published by Elsevier B.V. All rights reserved.)

Aims: Patient access to reperfusion therapy and the use of primary percutaneous coronary intervention (p-PCI) or thrombolysis (TL) varies considerably between European countries. The aim of this study was to obtain a realistic contemporary picture of how patients with ST elevation myocardial infarction (STEMI) are treated in different European countries., Methods and Results: The chairpersons of the national working groups/societies of interventional cardiology in European countries and selected experts known to be involved in the national registries joined the writing group upon invitation. Data were collected about the country and any existing national STEMI or PCI registries, about STEMI epidemiology, and treatment in each given country and about PCI and p-PCI centres and procedures in each country. Results from the national and/or regional registries in 30 countries were included in this analysis. The annual incidence of hospital admission for any acute myocardial infarction (AMI) varied between 90-312/100 thousand/year, the incidence of STEMI alone ranging from 44 to 142. Primary PCI was the dominant reperfusion strategy in 16 countries and TL in 8 countries. The use of a p-PCI strategy varied between 5 and 92% (of all STEMI patients) and the use of TL between 0 and 55%. Any reperfusion treatment (p-PCI or TL) was used in 37-93% of STEMI patients. Significantly less reperfusion therapy was used in those countries where TL was the dominant strategy. The number of p-PCI procedures per million per year varied among countries between 20 and 970. The mean population served by a single p-PCI centre varied between 0.3 and 7.4 million inhabitants. In those countries offering p-PCI services to the majority of their STEMI patients, this population varied between 0.3 and 1.1 million per centre. In-hospital mortality of all consecutive STEMI patients varied between 4.2 and 13.5%, for patients treated by TL between 3.5 and 14% and for patients treated by p-PCI between 2.7 and 8%. The time reported from symptom onset to the first medical contact (FMC) varied between 60 and 210 min, FMC-needle time for TL between 30 and 110 min, and FMC-balloon time for p-PCI between 60 and 177 min., Conclusion: Most North, West, and Central European countries used p-PCI for the majority of their STEMI patients. The lack of organized p-PCI networks was associated with fewer patients overall receiving some form of reperfusion therapy.

Aims: Patients with diabetes mellitus have more extensive coronary artery disease, more disease progression, and restenosis. The use of drug-eluting stents (DES) in these patients is widespread, despite uncertain long-term safety and efficacy., Methods and Results: All consecutive patients with diabetes mellitus in Sweden who underwent percutaneous coronary intervention were entered into the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) during 2003-06 with complete follow-up for 1-4 years (median 2.5). Patients who received at least one DES (n = 4754) were compared with those who received only bare metal stents (BMS) (n = 4956) at the index procedure. Combined outcome of death or myocardial infarction (MI) showed no difference for DES vs. BMS, relative risk (RR), 0.91 [95% confidence interval (CI), 0.77-1.06]. Myocardial infarction was significantly less common with DES in patients who received only one stent RR, 0.80 (95% CI, 0.66-0.96). The restenosis rate was 50% lower in DES-treated patients RR, 0.50 (95% CI, 0.35-0.70) and was associated with a higher adjusted RR of MI, RR, 5.03 (95% CI, 4.25-5.97). DES was associated with reduced restenosis rates in all subgroups of diabetic patients with the greatest benefit in stent diameters <3 mm or stent length >20 mm. The number of lesions treated with DES to prevent one restenosis ranged from 11 to 47 in various subgroups., Conclusion: This real-life registry study shows that restenosis was halved by DES in diabetic patients with stable or unstable coronary disease, with similar risk of death or MI up to 4 years compared with BMS.

Background: The purpose of this study was to assess the independent contribution of left bundle branch block (LBBB) on long-term mortality in a large cohort with symptomatic heart failure (HF) requiring hospitalization., Methods and Results: We studied a prospective cohort of 21 685 cases of symptomatic HF requiring hospitalization in the Register of Information and Knowledge about Swedish Heart Intensive care Admissions in 1995-2003. Long-term mortality was evaluated by Logistic regression analysis, adjusted for multiple covariates that could influence long-term prognosis. LBBB was present in 20% (4395 of 21 685) of HF admissions. Patients with LBBB had a higher prevalence of cardiac comorbid conditions than patients with no LBBB. 1-, 5-, and 10-year mortality was 31.5 vs. 28.4%, 69.3 vs. 61.3%, and 90.1 vs. 84.7% for HF patients with and without respectively LBBB. When adjusting for comorbidity, LBBB was associated with increased 5-year mortality (OR, 1.21; 95% CI, 1.10-1.35; P < 0.001). When left ventricular ejection fraction was included in the analysis LBBB had no longer any independent influence on 5-mortality (OR, 0.99; 95% CI, 0.62-1.56; P = 0.953)., Conclusion: LBBB occurs in 1/5 in HF patients requiring hospitalization and is associated with a very high mortality. However, the high long-term mortality appears to be caused by cardiac comorbidities and myocardial dysfunction rather than the LBBB per se.

Aims: To determine whether revascularization within 14 days reduces 1-year mortality in patients with a previous CABG admitted for non-ST-elevation ACS. Current guidelines for patients with acute coronary syndrome (ACS) include early revascularization. The evidence is derived from studies, in which patients with previous coronary artery by-pass graft (CABG) surgery often were excluded and thus insufficient to support a similar strategy in these high-risk patients in whom coronary interventions are associated with lower success and higher complication rates., Methods and Results: A cohort of 10 469 patients < 80 years old from a national registry, admitted to coronary care units in Sweden, was studied. We obtained 1-year mortality data from the Swedish National Cause of Death Registry. Relative risk (RR) in patients undergoing revascularization within 14 days (n = 4269) of admission compared to those who did not (n = 6200) was calculated by using multivariable logistic regression analyses and propensity scores for the likelihood of early revascularization. At 1-year, unadjusted mortality was 5.4% in the revascularized group and 13.1% in the conservatively treated group. In multiple regression analyses, revascularization was associated with a reduction of 1-year mortality (RR 0.67; 95% CI, 0.56-0.81; P < 0.001)., Conclusion: In patients with a previous CABG admitted for ACS, revascularization within 14 days of hospital admission was associated with a marked reduction in 1-year mortality, supporting an early invasive approach also in this subset of patients.

Aims: There are sparse data on the impact of pre-hospital thrombolysis (PHT) in real-life patients. We therefore evaluated treatment delays and outcome in a large cohort of ambulance-transported real-life patients with ST-elevation myocardial infarction (STEMI) according to PHT delivered by paramedics or in-hospital thrombolysis., Methods and Results: Prospective cohort study used data from the Swedish Register of Cardiac intensive care on patients admitted to the coronary care units of 75 Swedish hospitals in 2001-2004. Ambulance-transported thrombolytic-treated patients younger than age 80 with a diagnosis of acute myocardial infarction were included. Patients with PHT (n=1690) were younger, had a lower prevalence of co-morbid conditions, fewer complications, and a higher ejection fraction (EF) than in-hospital-treated patients (n=3685). Median time from symptom onset to treatment was 113 min for PHT and 165 min for in-hospital thrombolysis. One-year mortality was 7.2 vs. 11.8% for PHT and in-hospital thrombolysis, respectively. In a multivariable analysis, after adjusting for baseline characteristics and rescue angioplasty, PHT was associated with lower 1-year mortality (odds ratio 0.71, 0.55-0.92, P=0.008)., Conclusion: When compared with regular in-hospital thrombolysis, pre-hospital diagnosis and thrombolysis with trained paramedics in the ambulances are associated with reduced time to thrombolysis by almost 1 h and reduced adjusted 1-year mortality by 30% in real-life STEMI patients.

Aims: The prognosis after an acute myocardial infarction is worse for patients with diabetes mellitus than for those without. We investigated whether differences in the use of evidence-based treatment may contribute to the differences in 1-year survival in a large cohort of consecutive acute myocardial infarction patients with and without diabetes mellitus., Methods: We included patients below the age of 80 years from the Register of Information and Knowledge about Swedish Heart Intensive care Admissions (RIKS-HIA), which included all patients admitted to coronary care units at 58 hospitals during 1995-1998. In all 5193 patients had the combination of acute myocardial infarction and diabetes mellitus while 20440 had myocardial infarction but no diabetes diagnosed. Multivariate logistical regression analyses were performed to evaluate the influence of diabetes mellitus on the use of evidence-based treatment and its association with survival during the first year after the index hospitalisation., Results: The prevalence of diabetes mellitus was 20.3% (males 18.5%; females 24.4%). The 1-year mortality was substantially higher among diabetic patients compared with those without diabetes mellitus (13.0 vs. 22.3% for males and 14.4 vs. 26.1% for female patients, respectively) with an odds ratio (OR) (95% confidence interval (CI)) in three different age groups: <65 years 2.65 (2.23-3.16); 65-74 years 1.81 (1.61-2.04) and >75 years 1.71 (1.50-1.93). During hospital stay patients with diabetes mellitus received significantly less treatment with heparins (37 vs. 43%; p<0.001), intravenous beta blockade (29 vs. 33%; p<0.001), thrombolysis (31 vs. 41%; p<0.001) and acute revascularisation (4 vs. 5%; p<0.003). A similar pattern was apparent at hospital discharge. After multiple adjustments for dissimilarities in baseline characteristics between the two groups, patients with diabetes were significantly less likely to be treated with reperfusion therapy (OR 0.83), heparins (OR 0.88), statins (OR 0.88) or to be revascularised within 14 days from hospital discharge procedures (OR 0.86) while the use of ACE-inhibitors was more prevalent among diabetic patients compared to non-diabetic patients (OR 1.45). The mortality reducing effects of evidence-based treatment like reperfusion, heparins, aspirin, beta-blockers, lipid-lowering treatment and revascularisation were, in multivariate analyses, of equal benefit in diabetic and non-diabetic patients., Interpretation: Diabetes mellitus continues to be a major independent predictor of 1-year mortality following an acute myocardial infarction, especially in younger age groups. This may partly be explained by less use of evidence-based treatment although treatment benefits are similar in both patients with and without diabetes mellitus. Thus a more extensive use of established treatment has a potential to improve the poor prognosis among patients with acute myocardial infarction and diabetes mellitus.