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Aim: MULTIPRAC was designed to provide insights into the use and outcomes associated with prehospital initiation of antiplatelet therapy with either prasugrel or clopidogrel in the context of primary percutaneous coronary intervention. After a previous report on efficacy and safety outcomes during hospitalization, we report here the 1-year follow-up data, including cardiovascular (CV) mortality., Methods and Results: MULTIPRAC is a multinational, prospective registry of patients with ST-elevation myocardial infarction (STEMI) from 25 hospitals in nine countries, all of which had an established practice of prehospital start of dual antiplatelet therapy in place. The key outcome was CV death at 1 year. Among 2,036 patients followed-up through 1 year, 49 died (2.4%), 10 during the initial hospitalization and 39 within 1 year after hospital discharge. The primary analysis was based on the P2Y12-inhibitor, used from prehospital loading dose through hospital discharge. Prasugrel (n=824) was more commonly used than clopidogrel (n=425). The observed 1-year rates for CV death were 0.5% with prasugrel and 2.6% with clopidogrel. After adjustment for differences in baseline characteristics, treatment with prasugrel was associated with a significantly lower risk of CV death than treatment with clopidogrel (odds ratio 0.248; 95% confidence interval 0.06-0.89)., Conclusion: In STEMI patients from routine practice undergoing primary angioplasty, who were able to start oral antiplatelet therapy prehospital, treatment with prasugrel as compared to clopidogrel was associated with a lower risk of CV death at 1-year follow-up.

All guidelines recommend primary percutaneous coronary intervention as the default strategy for achieving reperfusion in ST-segment elevation myocardial infarction patients. These recommendations are based upon randomized trials which compared primary percutaneous coronary intervention with stand-alone intravenous fibrinolysis. Since the time these trials were performed, however, it has been shown in further trials that use of rescue percutaneous coronary intervention in patients without signs of reperfusion after lysis, and routine coronary angiography within 24 h of the administration of lysis for all other patients, substantially improved the results of intravenous fibrinolytic treatment. This has led to proposing the pharmaco-invasive strategy as an alternative to primary percutaneous coronary intervention. Actually, it is not uncommon that circumstances prevent performing primary percutaneous coronary intervention within the recommended time limits set by the guidelines. In such cases, using a pharmaco-invasive strategy may constitute a valid alternative. Both the STREAM randomized trial and real-world experience, in particular the long-term results from the FAST-MI registry, suggest that the pharmaco-invasive strategy, when used in an appropriate population, compares favorably with primary percutaneous coronary intervention. Therefore, implementing a pharmaco-invasive strategy protocol may be an important complement to compensate for potential weaknesses in ST-segment elevation myocardial infarction networks., (Copyright © 2014 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.)

The national observational study of diagnostic and interventional cardiac catheterization (ONACI) is a prospective multicenter registry of the French Society of Cardiology including all interventional cardiology procedures performed from 2004. We aimed to evaluate "real-world" management of patients with coronary artery disease in France from this registry. The present study was focused on data collected from 2004 to 2008. Patient demographics and co-morbidities, invasive parameters, treatment options, and procedural techniques were prospectively collected. Patients were recruited from 99 hospitals (55% of patients were hospitalized in private clinics and 45% in public institutions). During a 5-year period, a total of 298,105 patients underwent coronary angiography and 176,166 patients underwent percutaneous coronary intervention. Diagnosis was acute coronary syndrome in 22%, stable angina or silent ischemia in 23%, and atypical chest pain in 9% of cases. Normal coronary arteries or nonsignificant coronary narrowing were found in 26% of patients. Radial access was increasingly used over the years regardless of the indication. The average number of percutaneous coronary interventions per procedure was 1.5 ± 0.7 (range, 1.3 ± 0.7 to 1.5 ± 0.7) and that of stents per procedure was 1.5 ± 0.8 (range, 1.5 ± 0.8 to 1.6 ± 0.8). Drug-eluting stents were used in 45% (range, 34% to 62%), increasing from 2004 to 2006, and then decreasing after the 2006 controversy. In conclusion, ONACI is one of the largest catheterization registries during this period, providing a detailed and comprehensive global description of the spectrum and management of patients with suspected coronary artery disease undergoing cardiac catheterization., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Aim: To assess gender differences in characteristics, management, and hospital outcomes in patients participating in the French FAST-MI 2010 registry., Population: Three thousand and seventy-nine patients hospitalised for ST-elevation (STEMI) or non-ST-elevation (NSTEMI) myocardial infarction in 213 French centres during a 1-month period at the end of 2010., Results: Women account for 27% of the population and more frequently present with NSTEMI. They are 9 years older than men on average, although 25% of women with STEMI are less than 60 years of age. Management of STEMI is similar, after adjustment for baseline characteristics. However, fewer women are treated with primary percutaneous coronary angioplasty. In NSTEMI, although use of coronary angiography is similar, fewer women get treated with angioplasty. Most medications are used in a similar way in men and women, except thienopyridines, with fewer women receive prasugrel. After adjustment, in-hospital mortality is similar for men and women., Conclusion: Myocardial infarction is not specific to men: one out of four patients admitted for myocardial infarction is a woman. Initial management is rather similar for men and women, after taking into account differences in baseline characteristics. Percutaneous coronary angioplasty, however, remains less frequently used in women. In-hospital complications have become rarer and do not differ according to sex., (Copyright © 2013. Published by Elsevier SAS.)

Objectives: This study sought to assess whether patient age modifies the comparative effectiveness of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI)., Background: Increasingly, CABG and PCI are performed in older patients to treat multivessel disease, but their comparative effectiveness is uncertain., Methods: Individual data from 7,812 patients randomized in 1 of 10 clinical trials of CABG or PCI were pooled. Age was analyzed as a continuous variable in the primary analysis and was divided into tertiles for descriptive purposes (≤56.2 years, 56.3 to 65.1 years, ≥65.2 years). The outcomes assessed were death, myocardial infarction and repeat revascularization over complete follow-up, and angina at 1 year., Results: Older patients were more likely to have hypertension, diabetes, and 3-vessel disease compared with younger patients (p < 0.001 for trend). Over a median follow-up of 5.9 years, the effect of CABG versus PCI on mortality varied according to age (interaction p < 0.01), with adjusted CABG-to-PCI hazard ratios and 95% confidence intervals (CI) of 1.23 (95% CI: 0.95 to 1.59) in the youngest tertile; 0.89 (95% CI: 0.73 to 1.10) in the middle tertile; and 0.79 (95% CI: 0.67 to 0.94) in the oldest tertile. The CABG-to-PCI hazard ratio of less than 1 for patients 59 years of age and older. A similar interaction of age with treatment was present for the composite outcome of death or myocardial infarction. In contrast, patient age did not alter the comparative effectiveness of CABG and PCI on the outcomes of repeat revascularization or angina., Conclusions: Patient age modifies the comparative effectiveness of CABG and PCI on hard cardiac events, with CABG favored at older ages and PCI favored at younger ages., (Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

AIM OF FAST-MI 2010: To gather data on characteristics, management and outcomes of patients hospitalised for acute myocardial infarction (AMI) at the end of 2010 in France., Interventions: To provide cardiologists and health authorities national and regional data on AMI management every 5 years., Setting: Metropolitan France. 213 academic (n=38), community (n=110), army hospitals (n=2), private clinics (n=63), representing 76% of centres treating AMI patients. Inclusion from 1 October 2010., Population: Consecutive patients included during 1 month, with a possible extension of recruitment up to one additional month (132 centres); 4169 patients included over the entire recruitment period, 3079 during the first 31 days; 249 additional patients declining participation (5.6%)., Startpoints: Consecutive adults with ST-elevation and non-ST-elevation AMI with symptom onset ≤48 h. Patients with AMI following cardiovascular procedures excluded., Data Capture: Web-based collection of 385 items (demographic, medical, biologic, management data) recorded online from source files by external research technicians; case-record forms with automatic quality checks. Centralised biology in voluntary centres to collect DNA samples and serum. Long-term follow-up organised centrally with interrogation of municipal registry offices, patients' physicians, and direct contact with the patients., Data Quality: Data management in Toulouse University., Statistical Analyses: Université Paris Descartes, Université de Toulouse, Université Pierre et Marie Curie-Paris 06, Paris., Endpoints and Linkages to Other Data: In-hospital events; cardiovascular events, hospital admissions and mortality during follow-up. Linkage with Institute for National Statistics., Access to Data: Available for research to any participating clinician upon request to executive committee (fastmi2010@yahoo.fr).

Content: Clopidogrel, one of the most commonly prescribed medications, is a prodrug requiring CYP450 biotransformation. Data suggest its pharmacologic effect varies based on CYP2C19 genotype, but there is uncertainty regarding the clinical risk imparted by specific genotypes., Objective: To define the risk of major adverse cardiovascular outcomes among carriers of 1 (≈ 26% prevalence in whites) and carriers of 2 (≈ 2% prevalence in whites) reduced-function CYP2C19 genetic variants in patients treated with clopidogrel., Data Sources and Study Selection: A literature search was conducted (January 2000-August 2010) in MEDLINE, Cochrane Database of Systematic Reviews, and EMBASE. Genetic studies were included in which clopidogrel was initiated in predominantly invasively managed patients in a manner consistent with the current guideline recommendations and in which clinical outcomes were ascertained., Data Extraction: Investigators from 9 studies evaluating CYP2C19 genotype and clinical outcomes in patients treated with clopidogrel contributed the relevant hazard ratios (HRs) and 95% confidence intervals (CIs) for specific cardiovascular outcomes by genotype., Results: Among 9685 patients (91.3% who underwent percutaneous coronary intervention and 54.5% who had an acute coronary syndrome), 863 experienced the composite end point of cardiovascular death, myocardial infarction, or stroke; and 84 patients had stent thrombosis among the 5894 evaluated for such. Overall, 71.5% were noncarriers, 26.3% had 1 reduced-function CYP2C19 allele, and 2.2% had 2 reduced-function CYP2C19 alleles. A significantly increased risk of the composite end point was evident in both carriers of 1 (HR, 1.55; 95% CI, 1.11-2.17; P = .01) and 2 (HR, 1.76; 95% CI, 1.24-2.50; P = .002) reduced-function CYP2C19 alleles, as compared with noncarriers. Similarly, there was a significantly increased risk of stent thrombosis in both carriers of 1 (HR, 2.67; 95% CI, 1.69-4.22; P < .0001) and 2 (HR, 3.97; 95% CI, 1.75-9.02; P = .001) CYP2C19 reduced-function alleles, as compared with noncarriers., Conclusion: Among patients treated with clopidogrel for percutaneous coronary intervention, carriage of even 1 reduced-function CYP2C19 allele appears to be associated with a significantly increased risk of major adverse cardiovascular events, particularly stent thrombosis.

Drug-eluting stents (DES) are known to dramatically reduce restenosis. However, they are more expansive than bare-metal stents (BMS) and they require prolonged dual antiplatelet therapy. In France, the French Society of Cardiology and the "Haute Autorité de santé" have defined recommendations for the use of DES (restricted to patients in high-risk group). The aim of this work was to evaluate our practice (whether these recommendations were well respected or not in our center). Between November 2007 and January 2008 then November 2008 and January 2009 we evaluated all Percutaneous Coronary Interventions (PCI). Two hundred and sixteen (216) patients (mean age 65 ± 13 years, 164 (76 %) were males and, 41 (19 %) were diabetics) had a PCI for stable angina or silent ischemia (47 %), unstable angina or acute coronary syndrome (ACS) ST- (26 %), ACS ST+<48 hours (24 %) or ACS ST+>48 hours-1 month (3 %). Two hundred and seventy six (276) stents were used, including 35 % of DES. The recommendations were well respected in 82 % of cases. However, 27 % of BMS were implanted in patients in whom DES were indicated. The French recommendations for DES are a reference to help practitioners, but they require to be adapted to each patient, depending on clinical state and their ability to be treated with prolonged dual antiplatelet therapy., (Copyright 2010 Elsevier Masson SAS. All rights reserved.)

Bivalirudin, with provisional GP IIb/IIIa inhibitor use allows the same protection against ischemic complications while reducing the hemorrhagic complications compared with the systematic association of a GP IIb/IIIa inhibitor plus heparin (The Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events-2 [Replace-2]). In clinical practice, the use of heparin is not systematically associated with a GP IIb/IIIa inhibitor. That's why we studied the clinical and economic interest of bivalirudin only versus heparin (UFH) only. Opened pragmatic monocentric study carried out in 2007. We made a chronological matching: for each patient treated with bivalirudin, we included the next patient with the same clinical presentation treated with unfractionated heparin. Ninety-two patients were included (46 in each group). The need for a GP IIb/IIIa inhibitor during the PCI was not significantly different between the two groups (p=0.11). No major hemorrhagic complications were observed in the two groups. Prevalence of ecchymosis was not significantly different: 22 % in the UFH group versus 13 % in the bivalirudin group (p=0.27). The average troponin level the next day was significantly higher in the bivalirudin group (p=0,049), although the change in troponin levels before and after the procedure was similar in the two groups. The average cost by patient of anticoagulation by bivalirudin and HNF is very different, respectively 473+/-150 and 51+/-146 euro (p=0.0001). Bivalirudin can be an interesting alternative for patients with a high risk of having complications. But considering its cost this therapy must be used only for selected patients.

ST-segment elevation myocardial infarction (STEMI) is one of the greatest medical emergencies, for which organization of care has a determinant impact on patient outcomes. The purpose of this paper is to review systems of care for STEMI patients. Although primary percutaneous coronary intervention (PCI) is the preferred option for patients with STEMI, offering easy and emergent access to this procedure often remains difficult because of geographic and diverse structural difficulties. intravenous fibrinolysis, especially when administered early after symptom onset and as part of a pharmacoinvasive strategy (i.e., followed by rapid coronary angiography with PCI when necessary), offers a reasonable therapeutic option in selected cases and has yielded satisfactory clinical results. Network organization is central for optimizing patient care at the acute stage of myocardial infarction. This review describes different clinical experiences with network implementation both in Europe and in North America. In all instances, early recognition of STEMI and, particularly in the pre-hospital setting, shortening time delays is central for the achievement of optimal clinical results. Overall, the encouraging results described in the models presented here, as diverse as they might be, should be an encouragement to promote and implement regional protocols according to the specific local constraints and to monitor their effectiveness by recording simple quality indicators in ongoing registries.

Background: Coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) are alternative treatments for multivessel coronary disease. Although the procedures have been compared in several randomised trials, their long-term effects on mortality in key clinical subgroups are uncertain. We undertook a collaborative analysis of data from randomised trials to assess whether the effects of the procedures on mortality are modified by patient characteristics., Methods: We pooled individual patient data from ten randomised trials to compare the effectiveness of CABG with PCI according to patients' baseline clinical characteristics. We used stratified, random effects Cox proportional hazards models to test the effect on all-cause mortality of randomised treatment assignment and its interaction with clinical characteristics. All analyses were by intention to treat., Findings: Ten participating trials provided data on 7812 patients. PCI was done with balloon angioplasty in six trials and with bare-metal stents in four trials. Over a median follow-up of 5.9 years (IQR 5.0-10.0), 575 (15%) of 3889 patients assigned to CABG died compared with 628 (16%) of 3923 patients assigned to PCI (hazard ratio [HR] 0.91, 95% CI 0.82-1.02; p=0.12). In patients with diabetes (CABG, n=615; PCI, n=618), mortality was substantially lower in the CABG group than in the PCI group (HR 0.70, 0.56-0.87); however, mortality was similar between groups in patients without diabetes (HR 0.98, 0.86-1.12; p=0.014 for interaction). Patient age modified the effect of treatment on mortality, with hazard ratios of 1.25 (0.94-1.66) in patients younger than 55 years, 0.90 (0.75-1.09) in patients aged 55-64 years, and 0.82 (0.70-0.97) in patients 65 years and older (p=0.002 for interaction). Treatment effect was not modified by the number of diseased vessels or other baseline characteristics., Interpretation: Long-term mortality is similar after CABG and PCI in most patient subgroups with multivessel coronary artery disease, so choice of treatment should depend on patient preferences for other outcomes. CABG might be a better option for patients with diabetes and patients aged 65 years or older because we found mortality to be lower in these subgroups.

Background: Intravenous thrombolysis remains a widely used treatment for ST-elevation myocardial infarction; however, it carries a higher risk of reinfarction than primary PCI (PPCI). There are few data comparing PPCI with thrombolysis followed by routine angiography and PCI. The purpose of the present study was to assess contemporary outcomes in ST-elevation myocardial infarction patients, with specific emphasis on comparing a pharmacoinvasive strategy (thrombolysis followed by routine angiography) with PPCI., Methods and Results: This nationwide registry in France included 223 centers and 1714 patients over a 1-month period at the end of 2005, with 1-year follow-up. Sixty percent of the patients underwent reperfusion therapy, 33% with PPCI and 29% with intravenous thrombolysis (18% prehospital). At baseline, the Global Registry of Acute Coronary Events score was similar in thrombolysis and PPCI patients. Time to initiation of reperfusion therapy was significantly shorter in thrombolysis than in PPCI (median 130 versus 300 minutes). After thrombolysis, 96% of patients had coronary angiography, and 84% had subsequent PCI (58% within 24 hours). In-hospital mortality was 4.3% for thrombolysis and 5.0% for PPCI. In patients with thrombolysis, 30-day mortality was 9.2% when PCI was not used and 3.9% when PCI was subsequently performed (4.0% if PCI was performed in the same hospital and 3.3% if performed after transfer to another facility). One-year survival was 94% for thrombolysis and 92% for PPCI (P=0.31). After propensity score matching, 1-year survival was 94% and 93%, respectively., Conclusions: When used early after the onset of symptoms, a pharmacoinvasive strategy that combines thrombolysis with a liberal use of PCI yields early and 1-year survival rates that are comparable to those of PPCI.

Objectives: We sought to assess the frequency and causes of stent thrombosis in diabetic and nondiabetic patients after implantation of sirolimus-eluting stents., Background: Safety concerns about late stent thrombosis have been raised, particularly when drug-eluting stents are used in less highly selected patients than in randomized trials., Methods: The EVASTENT study is a matched multicenter cohort registry of 1,731 patients undergoing revascularization exclusively with sirolimus stents; for each diabetic patient included (stratified as single- or multiple-vessel disease), a nondiabetic patient was subsequently included. Patients were treated with aspirin + clopidogrel for at least 3 months and were followed for 465 (range 0 to 1,062) days (1-year follow-up in 98.5%). The primary end point was a composite of stent thrombosis (according to Academic Research Consortium definitions), cardiovascular death, and nonfatal myocardial infarction (major adverse cardiac events [MACE])., Results: During follow-up, MACE occurred in 78 patients (4.5%), cardiac death in 35 (2.1%), and stent thrombosis in 45 (2.6%): 30 definite, 23 subacute, and 22 late, including 9 at >6 months. In univariate analysis, the 1-year stent thrombosis rate was 1.8 times higher in diabetic than in nondiabetic patients (3.2% vs. 1.7%; log rank p = 0.03), with diabetic patients with multiple-vessel disease experiencing the highest rate and nondiabetic single-vessel disease patients the lowest (4.3% vs. 0.8%; p < 0.001). In multivariate analysis, in addition to the interruption of antithrombotic treatment, independent stent thrombosis predictors were previous stroke, renal failure, lower ejection fraction, calcified lesion, length stented, and insulin-requiring diabetes., Conclusions: The risk of sirolimus stent thrombosis is higher for multiple-vessel disease diabetic patients.

Background: Despite evidence on the efficacy and safety of percutaneous coronary intervention (PCI) for patients with acute myocardial infarction, it is unclear whether patients admitted to hospitals with on-site PCI facilities (herein after, PCI hospitals) have improved outcomes in routine practice., Methods: We compared processes of care, hospital outcomes, and 1-year mortality rate for 1176 consecutive patients admitted to 126 PCI hospitals and 738 patients admitted to 190 non-PCI hospitals in France from November 1 to November 30, 2000., Results: Patients admitted to PCI hospitals were more likely to receive evidence-based acute (within 48 hours of admission) and discharge medications and to undergo PCI within 48 hours of admission than those admitted to non-PCI hospitals (54% vs 6.2%; P<.001). Despite comparable rates of in-hospital stroke (0.9% vs 1.1%; P=.75) and reinfarction (1.7% vs 2.5%; P=.25), patients admitted to PCI vs non-PCI hospitals had lower in-hospital (7.5% vs 12%; P=.001) and 1-year (13% vs 20%; P<.001) mortality rates. Admission to PCI hospitals was associated with decreased hazard ratios of mortality after adjusting for baseline characteristics (0.75; 95% confidence interval, 0.57-0.98) or propensity score (0.76; 95% confidence interval, 0.59-0.97). Most of the survival benefit of admission to a PCI hospital was explained by the use of PCI and evidence-based discharge medications., Conclusions: In this prospective observational study, admission of patients with acute myocardial infarction to PCI hospitals was associated with greater use of PCI and evidence-based medications and with improved 1-year survival. Although we cannot exclude the possibility that some unmeasured confounding factors might explain the survival benefit of admission to PCI hospitals, our findings support routine use of PCI and evidence-based medications for these patients.

Background: The interaction between the use of percutaneous coronary intervention (PCI) for non-ST-elevation acute coronary syndromes and the use of secondary prevention medications was analysed in the French S-Témoin Registry., Methods: The population consisted of 2433 patients seen by their cardiologists at an outpatient clinic 2-12 months after non ST-elevation ACS; the survey was carried out from September 2004 to April 2005., Results: Overall, patients undergoing PCI (75% of the population) had higher levels of prescription of recommended secondary prevention medications. Multivariate logistic regression analysis showed that the use and type of coronary intervention (drug eluting versus bare metal stents) was an independent correlate of the use of dual antiplatelet therapy. In addition, time from the acute episode was also a strong correlate of dual antiplatelet therapy. Statins were also more often used in patients with PCI., Conclusion: Patients not treated with PCI are less likely to receive appropriate secondary prevention medications after non ST-elevation acute coronary syndromes. Specific efforts should be directed towards these patients, in particular as regards the prescription of dual antiplatelet therapy.

Objective: To compare processes of care for acute myocardial infarction among patients admitted to alpine vs other French hospitals., Methods: Prospective observational study of patients with ST-elevation and non ST-elevation myocardial infarction of less than 48 hours hospitalized in 369 intensive care units in November 2000., Results: Fifty-five patients were enrolled in nine alpine hospitals and 2265 patients in 360 other French hospitals. Patients baseline characteristics did not differ between the two groups with the exception of ST-elevation myocardial infarction which was less frequent in patients admitted to alpine hospitals (71 vs. 83%, P = 0.02). Patients living in the alpine area were less likely to be admitted to hospitals with on-site cardiac catheterization facilities (42 vs. 60%, P < 0.01) although the use of primary (20%) and rescue (24%) percutaneous coronary intervention did not differ significantly between the two groups. There were no differences in the use of medical treatments between the two groups with the exception of low-molecular-weight heparin. The risk of in-hospital death and complications did not differ significantly between the two groups while the risk of death at one year was lower in patients admitted to alpine hospitals (5 vs. 16%, P = 0.04)., Conclusion: In 2000, a lower proportion of patients living in the alpine area had access to hospitals with cardiac catheterization facilities compared to other French patients. This finding supports the creation of an additional cardiac catheterization laboratory with experienced operators performing percutaneous coronary interventions 24 hours/7 days and the implementation of an emergency medical care network for acute coronary syndromes in the alpine area.

This paper presents the protocol of the PACIFIQUE survey, carried out in the most important French interventional cardiology centres (>600 procedures/year) during a 2-week period in January 2004, in order to determine actual practices in terms of medical management at hospital discharge and 6-month follow-up in patients treated with coronary angioplasty.

Ticlopidine or clopidogrel combined with aspirin decrease major cardiac events (Mace) after PTCA with stent implantation. It has not be proven yet that pretreatment by T or C was superior to conventional post-treatment, especially in unstable patients. The aim of the present study was to determine the influence of thienopyridine pretreatment on the risk of Mace (death, Q wave myocardial infarction, need for repeat PTCA or surgery, angina recurrence, stent thrombosis) during the hospitalization period in a population prospectively included in 2 multicentre registries of patients undergoing placement of a S670 or S7 stent (Medtronic) implanted in native coronary arteries (> or = 3.0 mm). Among the 2929 patients included into the registries, 1205 had unstable angina (41%). 50.2% of the patients were pretreated by T or C (T = 15.7%, C = 34.5%); 85.5% received aspirin before the procedure; definition of pretreatment was the administration of drug at least 6 hours before stent implantation. GPIIb-IIIa antagonists were administered in only 13.9% of patients. Mace were observed in 2% of the patients. Factors correlated with Mace by univariate and multivariate analyses were: age > 73 years (RR: 2.37; 95% CI: 1.05-5.36, P < 0.037), previous myocardial infarction (RR: 2.56; 95% CI: 1.08-6.11, P < 0.034), pretreatment by T or C (RR: 0.389; 95% CI: 0.16-0.95, P < 0.038). In patients who did not receive GPIIb-IIIa antagonists, age > 73, and pretreatment by T or C were the only independent predictors of Mace.

Intracoronary brachytherapy aims at a reduction of in-stent restenosis by lessening neo-intimal proliferation. To assess its clinical potential, a systematic review of the literature indexed in the standard biomedical bibliographic databases selected eight prospective randomized clinical trials; seven of them, comparing coronary brachytherapy and non-treatment or placebo, have been included in the present meta-analysis. This analysis confirms the angiographic benefit of this procedure, as reported in the individual studies; it also shows, however an excess of clinical adverse effects not exhibited by any individual trial. Therefore, intracoronary brachytherapy cannot be recommended as routine practice, while one cannot rule out its interest in special situations.

The role of early reperfusion therapy at the acute stage of myocardial infarctus in elderly patients is debated. The aim of this study was to analyze the prognostic role of reperfusion with i.v. thrombolysis or primary PTCA in the nationwide USIK database, which prospectively included all pts admitted to a CCU for an AMI < 48 hours in France in November 1998. For the purpose of the present study, only patients admitted within 24 hours of AMI and with one-year follow-up available were included. Of the 1838 patients included, 785 were > 70 years-old, of whom 225 (29%) had early reperfusion therapy with thrombolysis (N = 173) or primary PTCA (N = 52). Patients treated with early reperfusion had a baseline profile that differed substantially from that of patients treated conventionally: women (31% vs 50%, p < 0.001), admission within six hours of symptom onset (84% vs 55%, p < 0.001), history of systemic hypertension (48% vs 60%, p < 0.002), stroke (5% vs 11%, p < 0.01), peripheral arterial disease (8% vs 18%, p < 0.001); congestive heart failure (5% vs 20%, p < 0.001) or previous MI (12% vs 25%, p < 0.001), more anterior location of current MI (40% vs 28%, p < 0.002). Overall one-year Kaplan-Meier survival was 78% for patients with versus 64% for those without reperfusion therapy (p < 0.01). In patients with Q wave myocardial infarction, Cox multivariate analysis showed that reperfusion therapy was an independent predictor of survival (RR 0.66; 95% Confidence Interval: 0.45-0.96), along with age, anterior location and history of congestive heart failure. Therefore, data from this large "real life" registry indicate that reperfusion therapy with either thrombolysis or primary PTCA is associated with improved one-year survival in patients over 70 years of age.

Unlabelled: RESTENOSIS AFTER CORONARY ANGIOPLASTY: Restenosis after coronary angioplasty remains a common clinical problem. Even after the advent of stenting, the rate of restenosis is still to the order of 20% or even higher in certain patient subgroups. Treatment is difficult, particularly in case of diffuse restenosis within stent lumens. POTENTIAL CONTRIBUTION OF BRACHYTHERAPY: After stent implantation, restenosis is generally due to excessive intimal proliferation producing a "benign tumor" formation that progressively obstructs the arterial lumen. Endocoronary curietherapy has been proposed for its "antiproliferative" effect. SYSTEMS USED: Two radiation sources are used: gamma emitters with powerful tissue penetration properties, and beta emitters which exhibit less tissue penetration. Radioprotection is a greater problem with gamma emitters but dosimetry is more difficult to control with beta emitters. In clinical practice, the sources are placed close to the target site via conventional percutaneous catheterization and are employed as a complement to standard angioplasty used to destroy the stenosis. Endocoronary brachytherapy requires close collaboration between the interventional cardiologist and the radiotherapist., Clinical Trials: After the preliminary feasibility studies, several randomized trials have assessed the contribution of brachytherapy in the prevention of restenosis. Using gamma emitters (192Ir), the SCRIPPS, WRIST and GAMMA-1 studies demonstrated good immediate safety and a real effect on restenosis with 50% reduction. Inversely, groups of treated patients have a higher rate of severe complications (death and infarction) related to late acute coronary thrombosis after interruption of antiplatelet therapy combining ticlopidin and aspirin. These complications result from the frequent introduction of stents during angioplasty procedures and by delayed endothelialization of the stents leaving a starting point for thrombosis formation longer than usual. The same type of complications have been observed with beta brachytherapy in the PREVENT trial, while in the START trial that used the 90Sr/y source in 476 patients, severe events were not more frequent in the irradiated group. In the latest trial, the frequency of new stent implantations was lower (21%) and antiplatelet treatment was maintained longer. Finally, the rate of restenosis was significantly lower (29% versus 45%)., Practical Applications: Current data confirm the efficacy of endocoronary brachytherapy to limit intimal proliferation after angioplasty and reduce the rate of restenosis. The question of safety remains open, with the potential risk of late coronary thrombosis; no long-term data (more than 5 years) are available. It is undoubtedly too early to propose routine use of brachytherapy, excepting perhaps cases where interventional cardiology raises particularly difficult problems, for example in case of diffuse restenosis within an endoprosthesis.

Background: We hypothesized that intramural delivery of nadroparin, a low molecular weight heparin, would prevent in-stent restenosis by inhibiting neointimal hyperplasia in an angioplasty model free of arterial remodelling., Methods and Results: In a prospective randomized multicentre trial, 250 patients submitted to balloon angioplasty followed by stent implantation were randomized into control group (no local drug delivery) or intramural delivery of nadroparin (2 ml of 2500 anti-Xa-units/ml with a microporous catheter). An ancillary intravascular ultrasound substudy was performed to supplement angiographic data with specific measurements of in-stent neointimal hyperplasia. The primary end-point was the late loss in minimal luminal diameter on the 6 month follow-up angiogram. Secondary end-points included feasibility and safety of local nadroparin delivery, and major adverse cardiac events at 8 weeks and 6 months follow-up. Local delivery of nadroparin was successful in 124 patients (99.2% success rate) and was not associated with an increase in stent thrombosis, coronary artery dissection, side branch occlusion, distal embolization or abrupt arterial closure. At angiographic follow-up, the late loss in lumen diameter was 0.84 +/- 0.62 mm in the control group compared to 0.88 +/- 0.63 mm in the nadroparin group (P=0.56). Angiographic restenosis rate (defined as a >50% diameter stenosis) did not differ in the control group (20%) compared to the nadroparin group (24%). The average area of neointimal tissue within the stent was 2.86 +/- 0.64 mm(2) vs 2.90 +/- 0.53 mm(2) (P=0.57), control vs nadroparin groups. There was no difference in major adverse cardiac events at any time (88.8% vs 89.6% event free survival at 6 months, control vs nadroparin)., Conclusion: Intramural delivery of nadroparin with a microporous catheter after stent deployment was feasible and safe but had no effect in reducing restenosis or the occurrence of major adverse clinical events over 6 months.

In the last few years, coronary angioplasty has been the object of real progress in the treatment of total chronic coronary occlusion; The primary success rate of the procedure regularly exceeds 70% with the use of improved equipment; however, these procedures are not without risk with a reported complication rate close to that of angioplasty of non-occlusive stenosis. The use of stents has significantly reduced the restenosis rate, mainly by decreasing the risk of reocclusion. The indications of angioplasty for chronic occlusion remain controversial: the procedure is justified in patients with angina; in asymptomatic patients, angioplasty may improve global and regional left ventricular function in those with documented myocardial viability and limit ventricular remodelling but the results of a randomised trial of systematic angioplasty versus medical treatment in this type of indication are not yet available.

Aims: Percutaneous transluminal coronary angioplasty (PTCA) has become the most widely used major intervention in western medicine. However, there is disparate use of this technique among different European countries and the U.S.A. In an attempt at quality assurance, the working group Coronary Circulation of the European Society of Cardiology has carried out a study on appropriateness, necessity, and performance of PTCA in Europe. The present paper reports on the procedural results of this survey., Methods: In a multicentre case-control study in Europe, 750 patients (544 men, 206 women) with documented vascular disease of the From the countries participating in the European Registry of Coronary Intervention, the three countries with the highest absolute PTCA volume (Germany, France, and the United Kingdom) and two randomly selected countries (Belgium and Italy) were chosen for investigation. In these countries, five centres were selected at random according to the following criteria: one centre with >1000, three centres with 300-1000, and one centre with <300 procedures per year. In each of these, 10 cases from the first half of 1997 were randomly identified and all pertinent documentation was collected., Results: In 250 cases, 325 stenoses were addressed as target lesions. Single vessel disease was present in 41%. History included stable angina in 49%, unstable angina in 32%, atypical chest pain in 6%, no anginal pain in 12%, and acute/subacute myocardial infarction in 13%. The percentage of patients with either positive stress test and/or unstable angina, acute/subacute infarction, previous infarction (within 6 months) or coronary revascularization amounted to 98%. Single vessel intervention accounted for 90%. In 41% balloon-only angioplasty was performed and in 54% at least one stent was implanted with considerable variation among countries. The use of other new devices amounted to only 3%. In 92%, the operators documented a successful procedure. Major complications (myocardial infarction, emergency bypass surgery, or death) were found in 4.8%., Conclusions: Based on scrutinized hospital and operator data, the present study revealed a satisfactorily high percentage of justifiable indications, an adequate procedural success rate, and an acceptably low complication rate. Further analysis by an expert panel will address appropriateness, necessity, and procedural performance of the individual cases., (Copyright 1999 The European Society of Cardiology.)

Aim: To test whether emergency revascularization improves survival in patients with acute myocardial infarction and shock., Methods and Results: Patients with acute myocardial infarction and early shock were randomized either to undergo emergency angiography, followed immediately by revascularization when indicated, or to receive initial medical management. In five of the nine participating centres, patients with shock but not randomized were entered in a registry. Only 55 patients could be randomized. Of the 32 patients in the invasive group, 30 (94%) underwent early angiography, 27 (84%) PTCA, and one (4%) CABG. Twenty-two (69%) died within 30 days in the invasive group vs 18/23 (78%) in the medically managed group (ns, RR=0.88, 95% confidence interval 0.6-1.2). Among the registry patients, 24/51 were excluded from randomization solely because of patient or physician preference for the invasive approach: 23 (96%) of them underwent emergency angiography, 21 (88%) PTCA, and 12 (50%) died within 30 days. Among the remaining registry patients (n=27) only nine (33%) underwent early angiography, nine (33%) PTCA and 20 (74%) died., Conclusion: We failed to demonstrate that emergency PTCA significantly improves survival in patients with acute myocardial infarction and early cardiogenic shock. Because the study was stopped prematurely, due to an insufficient patient inclusion rate, a clinically meaningful benefit of early reperfusion may have been missed., (Copyright 1999 The European Society of Cardiology.)

Background: Recent randomized trials comparing primary coronary angioplasty and intravenous thrombolysis at the acute stage of myocardial infarction have shown a limited but definite advantage for primary angioplasty. The aim of this study was to document 1-year outcome in patients receiving either thrombolysis or primary angioplasty for acute myocardial infarction in the "real world.", Methods and Results: We used a nationwide prospective registry of all patients admitted for acute myocardial infarction in French intensive care units in November 1995. Of the 721 patients who received reperfusion therapy, 152 were treated with primary angioplasty and 569 received intravenous thrombolysis. The two groups were remarkably similar with respect to all baseline descriptors, except that a higher proportion of patients in the angioplasty group had a history of cerebrovascular accident (10% versus 2%, P<0.01). In-hospital outcome was not different in the 2 groups. One-year survival was 85.5% in the angioplasty group and 89. 5% in the thrombolysis group (P=0.18). Multivariate analysis showed that older age, anterior location of infarction, female sex, and history of heart failure were related to 1-year mortality. In patients alive on day 5, the use of primary angioplasty and higher Killip class were additional adverse prognostic indicators., Conclusions: The results of this large registry of real-world practice indicate no survival benefit for patients treated with primary angioplasty compared with those who received thrombolytic therapy.

We studied the in-hospital outcome of 138 consecutive patients who received abciximab as a "rescue" intervention for complicated coronary angioplasty in a high-risk clinical setting. "Rescue" treatment with abciximab was associated with clinical and angiographic success rates of 83% and 84%, respectively, whereas the risk of bleeding was higher in patients of low body weight.

Background: Fluoroscopic and cineradiographic procedures expose patients undergoing coronarography to high doses of ionizing irradiation., Case Report: We report four cases of radiodermitis following cardiac catheterization. A 69-year-old man developed a radio-induced ulceration on the left scapular region in 1991 which required excision with skin graft. He had undergone 3 coronarographies and 2 angioplasties from 1989 to 1991. In 1992, a 59-year-old women developed a hard dorsal lesion with central ulceration and scar formation requiring excision and graft. From 1990 to 1992, she had undergone two coronary dilatations with angioplasty during one procedure. An atrophic necrotic wound situated under the right nipple developed in a 63 year old man. Excision with flap reconstruction was performed in 1993, two years after an unsuccessful angioplasty then two-vessel bypass. In a fourth case, a 52 year-old woman developed a telangiectasic ulceration on the right breast in 1990. The diagnosis of radio-induced dermitis was confirmed in 1996 and the patient was treated by excision. She had had three angioplasties in 1989., Discussion: Four other cases of radio-induced dermatitis following cardiac catheterism have been reported in the literature since 1996. Six other cases were also recently reported in France. All of these patients had undergone coronarography with transluminal coronary angioplasty. Besides coronarography, irradiation exposure is greatest for guide and balloon insertion required for dilatation procedures. Angioplasty is particularly dangerous because the irradiation beam is focused on the stenosis while the entire coronary network is concerned for coronarography. In most cases of radio-induced dermatitis following cardiac catheterism, the diagnosis is usually evident from the clinical context and the localization of the coronary lesion. In many cases however, the long delay to onset may make diagnosis a difficult task. In addition, the radiation dose delivered to the skin during cardiac procedures is not measured.

Objectives: This study sought to determine whether pravastatin affects clinical or angiographic restenosis after coronary balloon angioplasty., Background: Experimental data and preliminary clinical studies suggest that lipid-lowering drugs might have a beneficial effect on restenosis after coronary angioplasty., Methods: In a multicenter, randomized, double-blind trial, 695 patients were randomized to receive pravastatin (40 mg/day) or placebo for 6 months after successful balloon angioplasty. All patients received aspirin (100 mg/day). The primary angiographic end point was minimal lumen diameter (MLD) at follow-up, assessed by quantitative coronary angiography. A sample size of 313 patients per group was required to demonstrate a difference of 0.13 mm in MLD between groups (allowing for a two-tailed alpha error of 0.05 and a beta error of 0.20). To allow for incomplete angiographic follow-up (estimated lost to follow-up rate of 10%), 690 randomized patients were required. Secondary end points were angiographic restenosis rate (restenosis assessed as a categoric variable, > 50% stenosis) and clinical events (death, myocardial infarction, target vessel revascularization)., Results: At baseline, clinical, demographic, angiographic and lipid variables did not differ significantly between groups. In patients treated with pravastatin, there was a significant reduction in total and low density lipoprotein cholesterol and triglyceride levels and a significant increase in high density lipoprotein cholesterol levels. At follow-up the MLD (mean +/- SD) was 1.47 +/- 0.62 mm in the placebo group and 1.54 +/- 0.66 mm in the pravastatin group (p = 0.21). Similarly, late loss and net gain did not differ significantly between groups. The restenosis rate (recurrence > 50% stenosis) was 43.8% in the placebo group and 39.2% in the pravastatin group (p = 0.26). Clinical restenosis did not differ significantly between groups., Conclusions: Although pravastatin has documented efficacy in reducing clinical events and angiographic disease progression in patients with coronary atherosclerosis, this study shows that it has no effect on angiographic outcome at the target site 6 months after coronary angioplasty.

The effects of late angioplasty of the culprit artery after myocardial infarction on the decisive prognostic factors of left ventricular function and remodeling are not well known. When the culprit artery is narrowed but patent, angioplasty leads to improvement in segmental contractility and global left ventricular function: it does not seem to influence left ventricular end-diastolic volume. When the artery remains occluded, global and regional left ventricular function is also improved when the recanalised artery remains patent. Moreover, restoration of satisfactory artery patency prevents ventricular remodeling whereas in failed angioplasty or reocclusion, there is a progressive increase in left ventricular volume. However, these results observed in unselected patients could be improved: it would seem that the different beneficial effects only occur when there is residual myocardial viability; in the absence of signs of myocardial viability, the ventricular effects of limitations of angioplasty (incidence of restenosis or reocclusion in this specific context, lower primary success rate in complete arterial occlusion) explain the negativity of rare randomised studies comparing the outcome of left ventricular function depending on whether a conventional attitude or systematic revascularisation of the culprit artery is adopted.

Coronary angioplasty has undergone major technical changes since the period of inclusion in the randomized trials, comparing it with surgery, particularly with the increased use of coronary stents. This study shows improved in-hospital outcome in terms of primary success and complication rates in patients treated with coronary angioplasty for multivessel disease from 1994 to 1995, compared with the 1990 to 1991 period.

The clinical benefit of late recanalization of complete coronary occlusion is debated. Left ventricular (LV) function and volumes are major prognostic determinants in patients with coronary artery disease. We sought to assess comprehensively the evolution of global and regional LV function and LV volumes after percutaneous recanalization of chronic complete coronary artery occlusions. A consecutive series of 55 patients who underwent successful percutaneous recanalization of a chronic (> or = 10 days), total (Thrombolysis in Myocardial Infarction trial flow grade 0) occlusion of the left anterior descending or dominant right coronary arteries, and in whom a complete angiographic evaluation was available before angioplasty and at follow-up was studied. At follow-up, 38 patients had a patent artery (group 1) and 17 had a reocclusion (group 2). Baseline parameters were similar in the 2 groups. In group 1, LV ejection fraction increased from 55 +/- 14% to 62 +/- 13% (p <0.001), with an increase in fractional shortening in the occluded artery territory (0.43 +/- 0.30 to 0.71 +/- 0.34, p <0.001), while LV end-diastolic volume remained unchanged. In group 2, ejection fraction and regional wall motion were unchanged, while LV end-diastolic volume index increased (86 +/- 22 ml/m2 to 99 +/- 34 ml/m2, p <0.02). The evolution in LV global and regional function was similar in patients with or without previous myocardial infarction; however, prevention of LV remodeling was observed only in patients with previous infarction. Maintained potency after successful recanalization of totally occluded coronary arteries improves global and regional LV function and, in patients with previous myocardial infarction, avoids LV remodeling.

Intravascular metallic stents are increasingly used in the non-surgical management of coronary atherosclerosis. Despite intensive anticoagulation, subacute stent thrombosis, which usually has serious clinical consequences, and major haemorrhagic complications remain major problems after stent implantation. In addition, conventional management with anticoagulant therapy requires prolonged hospitalization. In a prospective multicentre study, we investigated the efficacy of a combination of two antiplatelet agents, ticlopidine 500 mg daily and aspirin 200 mg daily, without oral anticoagulation after stent implantation. Since November 1993, 529 consecutive patients, in whom 545 vessels were successfully stented with conventional (non-heparin coated) stents have been enrolled. Stenting was performed as a bailout procedure for failed angioplasty in 112 patients, for a suboptimal result after angioplasty in 314 patients, and electively in the remaining 103 patients. Coronary events related, or possibly related, to stent thrombosis occurred in 5.4% of patients stented as a bailout procedure and in 1.8% of patients stented for a suboptimal result. Serious bleeding complications occurred in 5.4% of patients stented as a bailout procedure and 1.5% of patients stented for a suboptimal result. Neither stent thrombosis nor serious bleeding complications were seen in patients stented electively. Ticlopidine therapy was discontinued in 1.9% of patients due to neutropenia (0.6%) or rash (1.3%). Mean hospital stay decreased from 6.16 +/- 2.14 days to 4.2 +/- 2.15 days during the study period. A combination of two antiplatelet agents can be employed in the vast majority of patients after coronary stent implantation. Subacute stent thrombosis rates and bleeding complications compare favourably with those reported using conventional therapy and the duration of hospitalization is reduced.

Objectives: This study sought to determine the 1-year clinical follow-up of patients included in the Benestent trial., Background: The Benestent trial is a randomized study comparing elective Palmaz-Schatz stent implantation with balloon angioplasty in patients with stable angina and a de novo coronary artery lesion. Seven-month follow-up data have shown a decreased rate of restenosis and fewer clinical events in the stent group. It is not established whether this favorable clinical outcome is maintained for longer periods or whether coronary stenting defers restenosis and its subsequent clinical manifestations., Methods: To clarify this uncertainty, we updated clinical information on all but 1 of 516 patients enrolled in the Benestent trial (257 in balloon group, 259 in stent group) at least 12 months after the intervention. Major clinical events (primary clinical end point) were tabulated according to the intention to treat principle and included death, the occurrence of a cerebrovascular accident, myocardial infarction, the need for bypass surgery or a further percutaneous intervention in the previously treated lesion., Results: After 1 year, no significant differences in mortality (1.2% vs. 0.8%), stroke (0.0% vs. 0.8%), myocardial infarction (5.0% vs. 4.2%) or coronary bypass graft surgery (6.9% vs. 5.1%) were found between the stent and balloon angioplasty groups, respectively. However, the requirement for a repeat angioplasty procedure was significantly lower in the stent group (10%) than the balloon angioplasty group (21%, relative risk [RR] 0.49, 95% confidence interval [CI] 0.31 to 0.75, p = 0.001), and overall primary end points were less frequently reached by stent group patients (23.2%) than those in the balloon group (31.5%, RR 0.74, 95% CI 0.55 to 0.98, p = 0.04). No differences were found between groups with respect to functional class angina and prescribed medication at the time of follow-up., Conclusions: These clinical follow-up data show that the benefit of elective native coronary artery stenting in patients with stable angina is maintained to at least 1 year after the procedure and results in a significantly reduced requirement for repeat intervention.

This study compares the incidence and management of acute closure complicating coronary angioplasty in three historic populations of patients having undergone the procedure at the same center: group 1 (n = 146 of 881) ("early years" of angioplasty, 1980 to 1986), group 2 (n = 113 of 1781) (bailout stenting learning curve, 1990 to 1992), and group 3 (n = 34 of 525) (1993). The incidence of acute closure decreased from group 1 (146 [17%] of 881) to groups 2 and 3 (147 [6%] of 2306); (p < 0.001). Management of the occlusion changed over the years, with less emergency coronary bypass surgery ([36%] 52 of 146, 15 [13%] 113, and 3 [9%] of 34), respectively, p < 0.01) and more repeat angioplasty (70 [48%] of 146; 87 [78%], of 113, and 30 [88%] of 34, p < 0.001). The use of prolonged inflations (> 10 minutes) and stenting increased from group 2 (15 [13%] of 113 and 16 [14%] of 113, respectively) to group 3 (12 [35%] of 34, and 10 [30%] of 34, respectively). In-hospital death occurred in 18 (12%) of 146, 7 (6%) of 113), and (2 (6%) of 34) patients in the three groups. Acute myocardial infarction decreased from 64% to 46% and 27%, respectively (p < 0.01). Overall, the number of patients free of events at hospital discharge increased from 38 (26%) of 146 to 53 (47%) of 113 (p < 0.001) and to 23 (68%) of 34 (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous transluminal coronary angioplasty of chronic total coronary occlusions has a low primary success rate and is associated with a high percentage of restenosis. The aim of this retrospective study was to assess the long-term benefits of these procedures. In a series of 201 patients with 203 chronic total occlusions, the technical success rate was 51%, the clinical success rate was 46% with 3% of major complications. The only factor associated with a favourable outcome was the presumed duration of the occlusion. The clinical follow-up period was established at 6 years. The result of the initial procedure was used to establish two groups of patients: group I, clinical success, and group II, clinical failure. Patients in group I had a probability of survival greater than that of those in group II (97 vs 92%; p < 0.05); survival without coronary bypass surgery was also significantly better (89 vs 74%; p < 0.003). On the other hand, the probability without angioplasty was less in group I (70 vs 77%; p < 0.01), the result of a high restenosis rate (48%). A Cox analysis identified clinical success of angioplasty as a good prognostic factor for survival. Moreover, the clinical status at long-term was significantly better in patients in group I. These results indicate that in patients with chronic total coronary occlusions, the success of angioplasty has a favourable effect on long-term outcome both in terms of survival and in quality of life. They must be interpreted in the light of the limitations inherent in a retrospective study and should be confirmed by prospective trials.

Between 1985 and 1990, right coronary artery recanalisation was attempted in 60 consecutive patients. In order to evaluate the long-term benefits, 2 groups were compared: group A (27 patients: 26 men, 1 woman) with an initial success; 1 patient was lost to follow-up (3.7%); group B (33 patients, 31 men, 2 women) with an initial failure; no patients were lost to follow-up and 1 patient died after secondary coronary artery surgery. After a follow-up of at least 1 year, the patients assessed their health and compared it with their pre-angioplasty state with the aid of a questionnaire. Age, initial left ventricular ejection fraction, the percentage of multiple vessel disease and the number of patients at work before angioplasty were the same in the two groups. After a mean follow-up period of two and a half years, 7.6% of patients had undergone coronary bypass surgery in group A compared with 18.2% in group B (NS); 69% of patients in group A claimed to be improved compared with only 24% in group B (p = 0.07); a bi or triple anti-anginal therapy was used in 58% of patients in group B and 42% of patients in group A (NS); however, 59% of patients returned to work in group B compared with 44% in group A (NS). Initial successful recanalisation of chronic right coronary occlusion improves the quality of life at long-term but does not increase the chances of returning to work.(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic total coronary occlusion remains one of the limitations of percutaneous transluminal coronary angioplasty, and few therapeutic devices are specifically designed to address this problem. Among such devices, low-speed rotational angioplasty could improve the primary success rate of the procedure but has never been studied in a controlled trial. One hundred consecutive patients with total coronary occlusion (duration 10 days to 1 year) and an indication for myocardial revascularization were randomized to either rotational or conventional angioplasty if the occlusion morphology was judged suitable for either technique. All baseline variables were evenly distributed among the 2 groups. The primary success rate in the rotational angioplasty groupø was 66% (33 of 50) compared with 52% (26 of 50) in the conventional angioplasty group before crossover to the rotational technique (p=NS). According to lesion morphology, the respective primary success rates were 77% (10 of 13) versus 92% (11 of 12) for tapered occlusions (p=NS), and 61% (22 of 36) versus 38% (14 of 37) for "stump-like" occlusions (p < 0.05). After taking into account the crossovers after failed conventional angioplasty, there was no benefit in performing rotational angioplasty first versus conventional angioplasty first (primary success rates 66% vs 60%, p=NS). Thus, in chronic coronary occlusions of tapered morphology, rotational angioplasty is not superior to conventional angioplasty. In stump-like occlusions, the primary success rate is higher with the rotational angioplasty technique; however ther is a disadvantage in using rotational angioplasty as a second-line device if the conventional technique is unsuccessful.