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A temperature-controlled sample stage with an operational range of ~60 °C above or below ambient laboratory temperature (~ −35 to 85 °C) was constructed for in situ X-ray diffraction of minerals and materials using a Bruker D8 Discover diffractometer with θ-θ geometry. The stage was primarily designed for characterizing mirabilite-bearing samples from a Mars analog High Arctic perennial cold spring at an in situ temperature. Operation of the stage was demonstrated through the analysis of a synthetic sample of the hydrated sodium sulfate, mirabilite (Na 2 SO 4 ·10H 2 O). Mirabilite was held at −25 °C for approximately two hours without significant dehydration and then incrementally warmed to ambient laboratory temperature at 5 °C intervals, during the acquisition of in situ diffraction data. At ambient laboratory temperature, the mirabilite dehydrated and only polycrystalline thenardite (Na 2 SO 4 ) remained. Preliminary analysis of the cold spring precipitates demonstrates that when mirabilite is present in the sample the dehydration reaction is occurring between collection and analysis at ambient laboratory temperature. This temperature-controlled stage was designed for versatility and ease of X-ray access, with applications that can extend to many geological and planetary settings, including Mars analog environments.

Objectives The aim of this study was to determine whether response to prasugrel is associated with the proportion of circulating reticulated platelets (RPs) in patients with ST-segment elevation myocardial infarction (STEMI). Background Despite better pharmacodynamic properties and clinical efficacy of prasugrel compared with clopidogrel, antiplatelet responses to prasugrel are not uniform. The mechanism of this variability in response is not clear. RPs, young hyperactive forms, are increased during situations of enhanced platelet turnover. Methods Patients with STEMI treated with primary percutaneous intervention (PCI) and prasugrel were tested for platelet reactivity using purinergic receptor P2Y, G-protein coupled, 12 (P2Y12) assay and multiple electrode aggregometry (MEA). RP levels were determined using flow cytometry with thiazole orange staining. Tests were performed at 2 to 4 days and 30 days post-PCI. Platelet function was compared by varying levels of RPs, analyzed as continuous (regression analysis) and categorical (tertiles) variables. Results Sixty-two patients were included (mean age: 57.5 � 8 years; 21.2% women; 27.7% diabetes). At the early time point, RP levels were strongly correlated with platelet reactivity when evaluated by the P2Y12 assay (Spearman’s correlation coefficient: 0.55 for P2Y12 reaction units, –0.49 for percent inhibition) and MEA (Spearman’s: 0.50). The upper tertile of RPs displayed higher platelet reactivity compared with the middle and lower tertiles, according to P2Y12 assay and MEA. Similar results with strong correlations between RP and platelet reactivity were noted at 30 days post-PCI. Conclusions The proportion of circulating RPs strongly correlates with response to prasugrel in patients with STEMI treated with PCI. High levels of RPs are associated with increased platelet reactivity despite prasugrel treatment. (J Am Coll Cardiol 2014;63:513–7) a 2014 by the American College of Cardiology Foundation

Aims: To gain insight in the prognosis and treatment of atrial fibrillation (AF) patients during 1-year follow-up in the Euro Heart Survey (EHS) on AF. Methods and results: The EHS enrolled 5333 AF patients in 2003-2004. One-year follow-up data were available for 80%. Of first detected AF patients, 46% did not have a recurrence during 1 year, paroxysmal AF largely remained paroxysmal AF (80%), and 30% of persistent AF progressed to permanent AF. Many treatment changes occurred since baseline. Oral anticoagulation was started in 19% and discontinued in 16% of all patients. Of patients initially on rhythm control 27% did not receive rhythm control during follow-up, whereas 15% of patients initially on rate control received rhythm control. Mortality was highest in permanent AF (8.2%), but also substantial in first detected AF (5.7%). In multivariable analysis, sinus rhythm at baseline was associated with lower mortality, but no significant effect was observed regarding the application of either rhythm or rate control. Conclusion: The EHS on AF provides unique prospective observational data on AF progression, long-term treatment, prognosis, and determinants of adverse outcome of the total clinical spectrum of AF in a European cardiology-based patient cohort. © The Author 2008.

Aims To describe guideline adherence and application of different stroke risk stratification schemes regarding antithrombotic therapy in real-life atrial fibrillation (AF) patients and to assess which factors influence antithrombotic management decisions. Methods and results The Euro Heart Survey enrolled 5333 AF patients in 35 countries, in 2003 and 2004. Prescription of antithrombotic drugs, especially oral anticoagulation (OAC), was hardly tailored to the patient's stroke risk profile as indicated by the joint guidelines of the American College of Cardiology, American Heart Association, and the European Society of Cardiology, ACCP guidelines, or CHADS2 and Framingham risk scores. In multivariable analysis, only a limited number of the well-known stroke risk factors triggered OAC prescription. In contrast, less relevant factors, of which clinical type of AF and availability of an OAC monitoring outpatient clinic were the most marked, played a significant role in OAC prescription. Electrical cardioversions and catheter ablations clearly triggered OAC prescription, whereas pharmacological cardioversions even in the presence of stroke risk factors did not. Conclusion Antithrombotic therapy in AF is hardly tailored to the patient's stroke risk profile. Factors other than well-known stroke risk factors were significantly involved in antithrombotic management decisions. To facilitate this tailored treatment, guideline writers and physician educators should focus on providing one uniform and easy to use stroke risk stratification scheme.

Detailed data on patients admitted for acute myocardial infarction (AMI) on a European-wide basis are lacking. The Euro Heart Survey 2009 Snapshot was designed to assess characteristics, management, and hospital outcomes of AMI patients throughout European Society of Cardiology (ESC) member countries in a contemporary 'real-world' setting, using a methodology designed to improve the representativeness of the survey.Member countries of the ESC were invited to participate in a 1-week survey of all patients admitted for documented AMI in December 2009. Data on baseline characteristics, type of AMI, management, and complications were recorded using a dedicated electronic form. In addition, we used data collected during the same time period in national registries in Sweden, England, and Wales. Data were centralized at the European Heart House.Overall, 4236 patients (mean age 66±13 years; 31% women) were included in the study in 47 countries. Sixty per cent of patients had ST-segment elevation myocardial infarction, with 50% having primary percutaneous coronary intervention and 21% fibrinolysis. Aspirin and thienopyridines were used in90%. Unfractionated and low-molecular-weight heparins were the most commonly used anticoagulants. Statins, beta-blockers, and angiotensin-converting enzyme inhibitors were used in80% of the patients. In-hospital mortality was 6.2%. Regional differences were observed, both in terms of population characteristics, management, and outcomes.In-hospital mortality of patients admitted for AMI in Europe is low. Although regional variations exist in their presentation and management, differences are limited and have only moderate impact on early outcomes.

Transcatheter aortic valve implantation (TAVI) is an established technique for the treatment of severe symptomatic aortic stenosis. Data on long-term TAVI outcomes, both hemodynamic and clinical, in real-world practice settings are limited. We aim to explore the long-term clinical results in patients with severe symptomatic aortic stenosis using multiple catheter-based options: 360 TAVI-treated patients were followed up for ≤5 years. The Medtronic CoreValve was used in 71% and the Edwards SAPIEN in 26%. The primary end point was all-cause mortality during follow-up. Outcomes were assessed based on the Valve Academic Research Consortium 2 criteria. The mean ± SD patient age was 82.1 ± 6.9 years (56.4% women). The Society of Thoracic Surgeons score was 7.5 ± 4.7. The clinical efficacy end point and time-related valve safety at 3 years was 50% and 81.7%, respectively. The calculated 3- and 5-year survival rates were 71.6% and 56.4%, respectively. Five-year follow-up data were obtained for 54 patients alive; 96.2% of alive patients were in the New York Heart Association class I and II, 4 years after TAVI. No gender differences in all-cause mortality rates were observed (p = 0.58). In multivariate analysis, hospitalization 6 months previous to TAVI (hazard ratio [HR] 1.92, 95% confidence interval [CI] 1.17 to 3.15, p = 0.01), frailty (HR 1.89, 95% CI 1.11 to 3.2, p = 0.02), acute kidney injury (HR 1.93, 95% CI 1.03 to 3.61, p = 0.04), and moderate or more paravalvular aortic regurgitation after TAVI (HR 4.26, 95% CI 2.54 to 7.15, p

Endothelial progenitor cells (EPCs) have an important role in repair following vascular injury. However, in patients with diabetes, EPC number and function are markedly reduced. It is unclear whether intensive glycaemic control can modify EPC properties in diabetic patients. We aimed to examine whether glycaemic control can improve EPC number and function in patients with long-standing uncontrolled type 2 diabetes.Thirty-five patients with treated type 2 diabetes and HgA1c ≥ 8.5% were included. Patients were tested at baseline and after 3-4 months of an intensive glycaemic control programme, with the aim of achieving HgA1c of 7%. The diabetes group was compared to 20 patients without diabetes (control). Circulating EPC levels were assessed by flow cytometry for expression of VEGFR2, CD133, and CD34. The capacity of the cells to form colony-forming units (CFUs), and their migration and viability were quantified after 1 week of culture. Patients with diabetes (mean age 61.1 ± 7 years, 28.6% women, disease duration of 19.2 ± 8 years) had a baseline HgA1c of 9.4 ± 0.8%. After the glycaemic control period, HgA1c decreased to 8 ± 0.8%. Circulating EPC levels increased significantly after the intensive control period and reached a level similar to the control group. The number of EPC CFUs also increased significantly after glycaemic control but remained lower than the control group. All EPC functional assays improved following the glycaemic control.In patients with uncontrolled long-standing type 2 diabetes, intensive glycaemic control was associated with an increase in the levels of circulating EPCs, and improvement in their functional properties.

Background: Retroperitoneal bleeding (RPB) is an unusual but potentially fatal vascular complication occurring after cardiac catheterization (CC). Contemporary data of RPB in the era of dual antiplatelet therapy and vascular closure devices are lacking. Methods: We retrospectively examined all RPB cases that occurred after CC in the Rabin Medical Center between the years 2005 and 2011. Results: Of 26,487 patients who underwent CC, a total of 48 patients (mean age 60.9 ± 13.8 years, 52.1% female) with RPB were identified (0.18%). The indication for CC was acute coronary syndrome (43.7%), myocardial infarction (35.4%), stable angina pectoris (8.3%), hemodynamic studies for valvular heart disease (10.4%) and others (2.1%). Coronary intervention was performed in 34 patients (70.9%) and a vascular closure device (VCD) was used in 16 patients (33.3%). Seventy-seven percent of patients were treated with clopidogrel, 20.8% with glycoprotein IIb-IIIa inhibitors and 85.4% with anticoagulation during CC. Median time to diagnosis of bleeding was 9.0 h, while the median time to bleeding differed between patients with and without a VCD (12 vs. 5 h, respectively). The clinical presentation of RPB was hemorrhagic shock in 39.6% of patients and 50.0% required at least one blood transfusion. Patients were managed either with conservative treatment (79.2%), angiography stenting (14.6%) or vascular surgery (6.2%). A total of 3 patients died during hospitalization, of which RPB was the etiology in 2 (4.2%). Conclusions: RPB which is a rare complication of CC is associated with younger age and female gender, as compared to patients without RPB. Onset of bleeding can be delayed in patients with VCDs. With careful and early diagnosis, most patients with RPB after CC can be managed conservatively.

Background The study sought to assess the clinical profile, outcome, and predictors for mortality of “real-world” high-risk severe aortic stenosis patients according to the mode of treatment assigned. Methods Patients were referred to a dedicated clinic for meticulous screening and multidisciplinary team assessment and 343 were finally assigned treatment (age 81.3 ± 7.2 years, 42.3% men): transcatheter aortic valve replacement (TAVR) with the Edwards SAPIEN or CoreValve device, 100 (29.2%); surgical aortic valve replacement (SAVR), 61 (17.8%); balloon valvuloplasty (as definitive therapy), 27 (7.9%); medication only, 155 (45.2%). No patient was lost to follow-up. Results The balloon valvuloplasty group had a significantly higher 1-month mortality rate (18.5%) than the TAVR group (3%, P = 0.006) and medical therapy group (3.9%; P = 0.004), without significant difference from the SAVR group (11.5%, P = 0.5). One-year cumulative survival was significantly higher in the TAVR group (92%) than in the other groups (SAVR 71%, balloon valvuloplasty 61.5%, medication 65%; all P < 0.001). Among survivors, 1-year rates of high functional class (NYHA I/II) were as follows: TAVR, 84.6%; SAVR, 63.3%; balloon valvuloplasty, 18.2%; medication, 21.4% (TAVR vs. SAVR, P = 0.04; SAVR vs. balloon valvuloplasty or medical therapy, P = 0.01). On multivariate regression analysis, renal failure (hazard ratio [HR] = 5.3, P < 0.001), not performing TAVR (HR = 4.9, P < 0.001), and pulmonary pressure (10 mm Hg, HR = 1.2, P = 0.02) were independent predictors of 1-year mortality. Conclusions TAVR, performed in carefully selected high-risk patients, is associated with an excellent survival rate and high functional class. Patients treated with another of the available modalities, including SAVR, had a worse outcome, regardless of which alternative treatment they receive. © 2012 Wiley Periodicals, Inc.

High on-treatment platelet reactivity (HTPR) despite clopidogrel therapy is associated with adverse cardiac events after acute myocardial infarction (AMI). Most studies to date have assessed clopidogrel response at a single time point before or after percutaneous coronary intervention (PCI). It is unclear, however, whether the HTPR phenotype is stable over time. Therefore, we aimed to examine response to clopidogrel in patients with AMI treated with PCI over a 6-month period. Patients (n = 57) with AMI treated with PCI were assessed for response to clopidogrel at 3 time points: in hospital, 30 days, and 6 months after index hospitalization. Response to clopidogrel was determined by the VerifyNow P2Y12 assay (reported as P2Y12 response units) and multiple electrode aggregometry (MEA; reported as aggregation units). HTPR was defined as ≥235 P2Y12 response units or ≥47 aggregation units. Patients' mean age was 54.5 ± 10.9 years, 91% were men, 19% had diabetes, and 74% were admitted with ST-segment elevation MI. HTPR based on MEA was observed in 22.8% of patients in hospital, 26.3% at 30 days, and 17.5% at 6 months (p = NS). HTPR based on the VerifyNow assay was observed in 38.6% of patients in hospital, 28.1% at 30 days, and 33.3% at 6 months (p = NS). Individual HTPR phenotypic assignment at baseline was stable in 73.7% (based on MEA) and 70.2% (based on VerifyNow) of patients at 6-month follow-up. In conclusion, this is the first study evaluating the stability of clopidogrel response over time after AMI. Rates of HTPR to clopidogrel therapy appear to be relatively stable up to 6 months after AMI.

AIMS To conduct a risk-adjusted gender-based analysis of clinical outcomes following drug-eluting stent (DES) versus bare metal stent (BMS) implantation in patients with coronary artery disease. METHODS AND RESULTS We compared risk-adjusted total mortality rate, myocardial infarction, and event-free survival (defined as freedom from death, myocardial infarction and/or repeat revascularisation) in a consecutive cohort of 7,662 patients undergoing percutaneous coronary intervention at our institution, including 1,835 (25.4%) women. Follow-up was six months to 6.2 years (mean: 3.5 years; median: 3.6 years). The women were older than men and more likely to suffer from diabetes, hypertension or congestive heart failure. Smokers were more often men, and men were more likely to have had prior coronary bypass surgery compared to women. A DES was used in 39.9% of males and 39.5% of females. Both genders derived a significant long-term clinical benefit from DES compared to BMS; advantages were observed for mortality (men: HR=0.78, 95% CI: 0.64-0.96, p=0.016; women: HR=0.62, 95% CI: 0.45-0.85, p=0.003) and major adverse cardiac events (men: HR=0.73, 95% CI: 0.63-0.84, p

Objectives: Patients with antiphospholipid antibody syndrome (APS) have an increased risk of atherothrombotic complications. There are limited data regarding the outcome of patients with APS who undergo percutaneous coronary intervention (PCI). Accordingly, we aimed to assess the long-term outcomes of these patients. Methods: Nineteen APS patients who underwent PCI between the years 2003 and 2008 were compared to 380 patients who had undergone PCI during the same period (PCI group) and were matched by age (±5 years), gender, diabetes and hypertension. In addition, APS patients were compared to 1,458 patients with ST segment elevation myocardial infarction (MI) who were treated with PCI during the same period. Six-month to 4-year clinical outcomes were evaluated. Results: The indication for PCI in the APS group was acute coronary syndrome in 52.6% of patients. After 1 year of follow-up, patients with APS had higher rates of target vessel revascularization than the other two groups, which translated to higher rates of major adverse cardiac events. There were no differences in MI or mortality rates between the groups. Conclusions: Patients with APS who undergo PCI have worse long-term clinical outcomes, driven by higher rates of revascularization, than other patients undergoing PCI. Further study is warranted to examine the mechanisms underlying these findings.

To examine the yield of an ultra-low-dose computed tomography (CT) transmission module for attenuation-correction (AC) on a dedicated cardiac camera in evaluation of SPECT-myocardial perfusion imaging (MPI) in the diagnosis of CAD and for additional chest abnormalities. The study group included 150 patients with known or suspected CAD referred for technetium sestamibi SPECT MPI. CT transmission scanning (effective radiation 0.17 mSv) was performed after each gated SPECT scan. AC and non-corrected (NC) SPECT scans were evaluated on a 5-point scale using a 17-segment model, and the sum stress score (SSS) and sum rest score (SRS) were calculated for each condition. Overall image quality, sensitivity and normalcy rate (51 patients) and processing of 28 CT slices were screened for chest findings. CT-based AC significantly improved image quality (P = .01). Mean SSS was 3.8 ± 5.8 with AC and 6.1 ± 7.1 with NC (P

Objectives: We aim to explore the clinical outcome of drug-eluting stents (DES) versus bare-metal stents (BMS) implantation in diabetics versus nondiabetic patients. Background: Diabetic patients sustain worse long-term clinical outcomes after percutaneous coronary interventions (PCI) when compared with nondiabetics. The use of DES decreases the rate of repeat revascularization in this population but data concerning long-term clinical benefits, such as myocardial infarction (MI) or mortality is scant. Methods: We analyzed data from a comprehensive registry of 6,583 consecutive patients undergoing PCI at our center. A propensity score was used for analysis of outcomes and for matching (DES vs. BMS). Outcome parameters were total mortality, MI, repeat target vessel revascularization (TVR) rates, and risk-adjusted event-free survival. Within this cohort, we identified 2,571 nondiabetic patients and these were compared with 1,826 diabetic coronary patients. Results: Mean and median follow up time was 3 and 3.25 years, respectively. Overall, diabetics had higher rates of major-adverse cardiovascular events (MACE) at 4 years compared with nondiabetics (23.03 vs. 31.96 P > 0.001). DES use was associated with lower rates of TVR in both groups [diabetics hazard ratio (HR) = 0.56, 95% confidence interval (CI): 0.42–0.76, P < 0.001, nondiabetics HR = 0.73, 95% CI: 0.55–0.97, P = 0.03] while sustained decreased rates of both mortality and MI were evident solely among diabetics (HR = 0.71, 95% CI: 0.56–0.89, P = 0.004 in diabetic vs. HR = 0.88, 95% CI: 0.69–1.13, P = 0.3). Conclusions: In a “real-world,” unselected population and extended clinical use, DES in diabetics was associated with sustained decreased rates of MI, death, TVR, and MACE while this benefit was attenuated in the nondiabetic population. © 2011 Wiley-Liss, Inc.

Background: Current guidelines regarding the use of intravenous morphine (IM) in the management of patients with acute decompensated heart failure (ADHF) are discordant; whereas the American guidelines reserve IM for terminal patients, the European guidelines recommend its use in the early stage of treatment. Our aim was to determine the impact of IM on outcomes of ADHF patients. Methods: Stepwise logistic regression and propensity score analysis of ADHF patients with and without use of IM was performed in a national heart failure survey. Results: Of the 4102 enrolled patients, we identified 2336 ADHF patients, of whom 218 (9.3%) received IM. IM patients were more likely to have acute coronary syndromes, acute rather than exacerbation of chronic heart failure, and diabetes mellitus and dyslipidemia. They had higher heart rate, were less likely to receive diuretics and more likely to receive aspirin and statins. Unadjusted in-hospital mortality rates were 11.5% versus 5.0% for patients who did or did not r...

BACKGROUND Myocardial perfusion imaging with single-photon emission tomography (SPECT) is associated with reduced specificity due to tissue attenuation. This can be corrected by prone imaging while necessitating additional imaging time. Image processing with iterative reconstruction allows for a half-time (HT) acquisition. OBJECTIVE To assess the feasibility of myocardial perfusion with SPECT using prone imaging with HT acquisition. METHODS Ninety-one patients referred for SPECT myocardial perfusion imaging and weighing up to 90 kg were enrolled for HT supine and prone SPECT protocol. Patients with known myocardial infarction were excluded. HT prone imaging was performed when supine imaging was visually equivocal or abnormal. Image quality was compared for each patient between supine and prone imaging. RESULTS Acquisition time was 17.9 ± 2.9 min in the HT group compared with 31.8 ± 5.8 min in patients imaged with full-time acquisition. Image quality was good or excellent in 85.7% of studies in a supine position and in 81.3% of studies in the prone position (P = 0.25). No study was considered as nondiagnostic. Prone imaging reduced the rate of equivocal scans from 40.7 to 15.4% and of ischemic studies from 34.1 to 7.7%. In the study population, 80% of inferior and septal defects were corrected by the prone position. CONCLUSION In a selected population, HT prone and supine imaging is feasible and is associated with a good image quality in most studies whereas acquisition time is reduced almost by half.

Background: By and large, prior registries and randomized trials have not distinguished between acute heart failure (AHF) associated with acute coronary syndrome (ACS) versus other causes.Aims: To examine whether the treatments and outcomes of ACS-associated AHF are different from non-ACS-associated AHF.Methods: We examined in a prospective, nationwide hospital-based survey the adjusted outcomes of AHF patients with and without ACS as its principal cause.Results: Of the 4102 patients in our national heart failure survey, 2336 (56.9%) had AHF, of whom 923 (39.5%) had ACS-associated AHF. These patients were more likely to receive intravenous inotropes and vasodilators and to undergo coronary angiography and revascularization, but less likely to receive intravenous diuretics. The unadjusted in-hospital, 30-day, one-year, and four-year mortality rates for AHF patients with or without ACS were 6.5% versus 5.0% (P = 0.13), 10.3% versus 7.5% (P = 0.02), 26.6% versus 31.0% (P = 0.02), and 55.3% versus 63.3% (P = ...

ObjectivesIt is a common clinical observation that collateral vessel development is impaired in diabetic patients with ischaemic vascular diseases. Consequently, alternative revascularisation strategies in diabetic patients are needed. This study presents the effect and mechanism of new peptide therapeutic angiogenesis in an ischaemic and diabetic mouse model.DesignStreptozocin-injected mice that had undergone hind-limb ischaemia were treated with angiogenic peptides. Blood flow restoration was calculated by laser Doppler imager and corroborated by histological section. For the mechanism study, endothelial cells were exposed to hypoxia and high glucose concentrations to study the effect of the peptides on proliferation and anti-apoptosis.ResultsThe peptides significantly restored blood perfusion 21 days after surgery in the diabetic mice (p

Effective management of stable angina usually includes drug therapy. There are several agents that are considered vasculoprotective such as aspirin, angiotensin converting enzyme inhibitors and statins. Conventional anti ischemic therapy includes nitrates, beta-blockers and calcium-channel blockers. In recent years, several other drugs with novel anti ischemic mechanisms have become available including ranolazine, ivabradine, nicorandil and many others. This article reviews drugs that alleviate the symptoms of chronic angina with emphasis on several novel pharmacological agents.

ObjectiveOur objective was to assess the effect of the timing of cardiac angiography, contrast media dose, and preoperative renal function on the prevalence of acute renal failure after cardiac surgery.MethodsData on 395 consecutive patients who underwent coronary artery bypass grafting were prospectively collected. Creatinine clearance was estimated by the Cockcroft–Gault equation. Patients were divided into 3 groups according to the time between cardiac angiography and surgery (group A, ≤ 1 day; group B, > 1 day and ≤ 5 days; group C, > 5 days). Patients who underwent a salvage operation or were receiving dialysis before surgery were excluded. Acute renal failure was defined as 25% decrease from baseline of estimated creatinine clearance and estimated creatinine clearance of 60 mL/min or less on postoperative day 3. Owing to differences in preoperative characteristics between groups, propensity score analysis was used to adjust those differences.ResultsAcute renal failure developed in 13.6% of patients. Hospital mortality was 3.3% and was higher in patients in whom acute renal failure developed (22%) versus those in whom it did not (0.3%; P < .001). Multivariable analysis identified preoperative estimated creatinine clearance of 60 mL/min or less (odds ratio [OR], 7.1), operation within 24 hours of catheterization (OR = 3.7), use of more than 1.4 mL/kg of contrast media (OR = 3.4), lower hemoglobin level (OR = 1.3), older age (OR = 1.1), and lower weight (OR = 0.95) as independent predictors of postoperative acute renal failure. Analysis of interaction between contrast dose and time of surgery revealed that high contrast dose (>1.4 mL/kg) predicted acute renal failure if surgery was performed up to 5 days after angiography.ConclusionsWhenever possible, coronary bypass grafting should be delayed for at least 5 days in patients who received a high contrast dose, especially if they also have preoperative reduced renal function.

Current guidelines have recommended intravenous narcotics (IVNs) for patients with ST-segment elevation acute coronary syndromes (STEACS) and patients with non-STEACS (NSTEACS), although the safety of IVNs has been challenged. We performed a retrospective analysis of the 30-day outcomes stratified by IVN use among patients enrolled in a national survey, using logistic regression and propensity score analysis. Of the 765 patients with STEACS and 993 patients with NSTEACS, 261 (34.1%) and 97 (9.8%) had received IVNs, respectively. The patients with STEACS who received IVNs were more likely to undergo reperfusion (79.7% vs 55.2%, p0.0001), received it more rapidly (median 59 minutes vs 70 minutes, p = 0.02), and were more likely to undergo coronary angiography and revascularization. No difference was found in hemodynamic status. The patients with NSTEACS who received IVNs were more likely to present with Killip class II-IV (39.2% vs 10.0%, p0.001) and to have left ventricular systolic dysfunction (39.0% vs 17.0%, p0.001). No difference was found in the use of invasive procedures. Using propensity score analysis, of 249 matched STEACS pairs, the rate of 30-day death was lower in the group that had received IVNs (2.4% vs 6.2%, p = 0.04), and this trend persisted after logistic regression analysis (odds ratio 0.40, 95% confidence interval 0.14 to 1.14, p = 0.09). Using propensity score analysis, of 95 matched NSTEACS pairs, no difference was found in the 30-day death rate (2.2% for patients receiving IVNs vs 6.3%, p = 0.16), even after logistic regression analysis (odds ratio 0.56, 95% confidence interval 0.14 to 2.33, p = 0.43). In conclusion, IVNs were commonly used in different scenarios-patients with STEACS were more likely to receive IVNs in the context of prompt reperfusion, and patients with NSTEACS were more likely to receive IVNs in the context of heart failure. In both scenarios, IVN use did not adversely affect the outcomes.

Objectives The aim of this study was to evaluate whether addition of omega-3 fatty acids or increase in aspirin dose improves response to low-dose aspirin among patients who are aspirin resistant. Background Low response to aspirin has been associated with adverse cardiovascular events. However, there is no established therapeutic approach to overcome aspirin resistance. Omega-3 fatty acids decrease the availability of platelet arachidonic acid (AA) and indirectly thromboxane A2 formation. Methods Patients (n = 485) with stable coronary artery disease taking low-dose aspirin (75 to 162 mg) for at least 1 week were screened for aspirin response with the VerifyNow Aspirin assay (Accumetrics, San Diego, California). Further testing was performed by platelet aggregation. Aspirin resistance was defined by ≥2 of 3 criteria: VerifyNow score ≥550, 0.5-mg/ml AA-induced aggregation ≥20%, and 10-μmol/l adenosine diphosphate (ADP)-induced aggregation ≥70%. Thirty patients (6.2%) were found to be aspirin resistant and randomized to receive either low-dose aspirin + omega-3 fatty acids (4 capsules daily) or aspirin 325 mg daily. After 30 days of treatment patients were re-tested. Results Both groups (n = 15 each) had similar clinical characteristics. After treatment significant reductions in AA- and ADP-induced aggregation and the VerifyNow score were observed in both groups. Plasma levels of thromboxane B2 were also reduced in both groups (56.8% reduction in the omega-3 fatty acids group, and 39.6% decrease in the aspirin group). Twelve patients (80%) who received omega-3 fatty acids and 11 patients (73%) who received aspirin 325 mg were no longer aspirin resistant after treatment. Conclusions Treatment of aspirin-resistant patients by adding omega-3 fatty acids or increasing the aspirin dose seems to improve response to aspirin and effectively reduces platelet reactivity.

Aims: Given the anecdotal reports and case series suggesting that drug-eluting coronary stents [DES] may be still vulnerable to coronary thrombosis after six months, we sought to assess this risk in patients undergoing non-cardiac surgery six months after stenting. Methods and Results: Linking the Rabin Medical Centre interventional cardiology database with its non-cardiac surgical database, we identified 78 patients who underwent DES placement and subsequently [after six months] had noncardiac surgery [15-vascular, 37- abdominal and genitourinary and 26-others, excluding ophthalmic surgery]. Outcome measures included 30-day rate of postoperative myocardial infarction (MI), DES-related thrombosis, and cardiac mortality. Major adverse cardiac events [death and non-fatal MI] occurred in 6 (7.7%) patients including 2 cardiac deaths (2.6%), 4 (5.1%) non-fatal myocardial infarctions (MIs). Two patients (2.6%) sustained stent thrombosis [one patient had ‘definite’ and one ‘probable’ stent thrombosis]. All MIs [including stent thrombosis] occurred in the vascular and abdominal surgery group. Two of the MIs events occurred while the patients were on dual antiplatelet agents. In conclusions: Perioperative cardiac events during non cardiac surgery after six months of DES deployment still occur. These cardiac complications [not entirely prevented by continued dual antiplatelet agents] remain a matter of diagnostic and therapeutic challenge and concern. © 2009 Wiley-Liss, Inc.

Elevated homocysteine levels are associated with increased risk for mortality in patients with coronary artery disease (CAD). However, the benefit of homocysteine-lowering therapy remains controversial. The aim of this study was to examine the impact of homocysteine-lowering therapy on the long-term outcomes of patients with CAD and its interaction with the methylenetetrahydrofolate reductase genotype. The study sample included 492 patients with early-onset CAD who were genotyped for the C677T mutation in the methylenetetrahydrofolate reductase gene or screened for elevated homocysteine from January 1997 to December 2002. Folic acidor =400 microg/day with or without additional B vitamins was administered at the attending physicians' discretion. There was no difference between treated (n = 140) and untreated patients in age, gender, or prevalence of coronary risk factors. Forty-six patients (9%) died during a median follow-up period of 115 months. Treatment was associated with significantly lower all-cause mortality in patients with homocysteine levels15 micromol/L (4% vs 32%, p0.001) but not in patients with lower levels (5% vs 7%, p0.05). On Cox regression analysis, the following factors were independently associated with all-cause mortality: vitamin therapy (hazard ratio 0.33, 95% confidence interval 0.11 to 0.98, p = 0.046), elevated homocysteine level (hazard ratio 3.5, 95% confidence interval 1.31 to 9.43, p = 0.013), and older age (hazard ratio 1.1, 95% confidence interval 1.04 to 1.14, p0.0001 for an increment of 5 years). The methylenetetrahydrofolate reductase genotype was not associated with outcomes. In conclusion, long-term folate-based vitamin therapy was independently associated with lower all-cause mortality in patients with CAD and elevated homocysteine levels. This association was not observed in patients with lower homocysteine levels.

Background The poor prognosis of primary percutaneous coronary intervention (PCI) in patients resuscitated from cardiac arrest complicating acute ST-segment elevation myocardial infarction (STEMI) may at least partly be explained by the common presence of cardiogenic shock. This study examined the impact of emergency primary PCI on outcome in patients with STEMI not complicated by cardiogenic shock who were resuscitated from cardiac arrest. Methods and results The study group included 948 consecutive patients without cardiogenic shock who underwent emergency primary PCI from 2001 to 2006 for STEMI. Twenty-one of them were resuscitated from cardiac arrest before the intervention. Data on background, clinical characteristics, and outcome were prospectively collected. There were no differences between the resuscitated and nonresuscitated patients in age, sex, infarct location, or left ventricular function. The total one-month mortality rate was higher in the resuscitated patients (14.3 vs. 3.4%, P=0.033), but noncardiac mortality accounted for the entire difference (14.3 vs. 1.2%, P=0.001), whereas cardiac mortality was similarly low in the two groups (0 vs. 2.0%, P=NS). Predictors of poor outcome in the resuscitated patients were older age (r=0.47, P=0.032), unwitnessed sudden death (r=0.44, P=0.04), longer interval between onset of cardiac arrest and arrival of a mobile unit (r=0.67, P=0.001) or to spontaneous circulation (r=0.65, P=0.001), low glomerular filtration rate (r=−0.50, P=0.02), and the initial thrombolysis in myocardial infarction grade of flow (r=−0.51, P=0.017). Conclusion Emergency PCI for STEMI not associated with cardiogenic shock exerts a similar effect on cardiac mortality in patients who were resuscitated from cardiac arrest and in those without this complication. The higher all-cause mortality rate among resuscitated patients is explained by noncardiac complications.

Pretreatment with clopidogrel before elective primary percutaneous coronary intervention (PCI) has been shown to reduce ischemic complications. There are limited data about the value of clopidogrel pretreatment in the setting of PCI for ST-elevation myocardial infarction (STEMI). We aimed to examine the effect of clopidogrel preloading on angiographic and clinical outcomes in patients with STEMI who were treated with PCI. We conducted a prospective registry of all patients treated with primary PCI for STEMI from March 2003 to June 2006. Excluded were patients with cardiogenic shock. For the current analysis, patients (n = 292) were allocated into 2 groups. One group received clopidogrel loading dose before PCI (in the emergency department or coronary care unit, n = 165); the other,immediately after PCI (n = 127). TIMI myocardial perfusion (TMP) grade at the end of PCI and 30-day and 6-month clinical outcomes were assessed. Clinical characteristics were similar among the groups. However, patients pretreated with clopidogrel were more likely to receive aspirin and beta blockers before the current admission. TMP grade 3 occurred in a higher proportion of patients in the clopidogrel pretreatment group than in the no-pretreatment group (85% vs 71%, p = 0.01). Multivariate logistic regression analysis showed that clopidogrel pretreatment was associated with an odds ratio of 2.2 for TMP grade 3 (1.2 to 3.9, p = 0.01). Furthermore, the incidence of reinfarction at 30 days was lower in the pretreatment group (0% vs 3.2%, respectively, p = 0.04). In conclusion, these findings support the early use of clopidogrel in patients with STEMI who are treated with primary PCI.

Therapeutic angiogenesis emerged as a non-invasive mean of promoting neovascularization in ischemic tissues. We have searched for new molecules that induce angiogenesis by screening a phage display combinatory peptide library on endothelial cells. One of the selected peptides identified by binding to endothelial cells under hypoxic conditions was further studied. The aim of this study was to assess the therapeutic value of this peptide, RoY, in a mouse hind limb ischemia model and to identify it's receptor on endothelial cells. RoY, a 12 amino-acid synthetic peptide, induced in vitro angiogeneic activity under hypoxic conditions by increasing endothelial cell proliferation, migration and tube formation. In order to assess its therapeutic properties in ischemic tissues, a hind limb ischemia model was induced in C57BL mice by a femoral artery excision. A single local intramuscular injection of RoY peptide to the operated limb, significantly restored blood perfusion and alleviated hind limb ischemia as determined by a laser Doppler imager. Increased capillary density in histological sections corroborated these findings. Protein precipitation and mass spectroscopy studies identified GRP78, a heat shock protein, as the peptide-binding membrane receptor that was increased on endothelial cell membranes under hypoxic conditions. This study demonstrates the efficacy of RoY peptide in alleviation of hind limb ischemia. In addition, it provides evidence that GRP78 is an angiogenic receptor on hypoxic endothelial cells.

To evaluate the potential protective affects of Epo on left ventricular (LV) function and remodeling after acute myocardial infarction (MI).Epo was injected into the peritoneum of male Wistar rats (250 g) during 6 weeks post induction of MI. Rats were divided into five groups: MI treated with single high dose (MT1, 5,000 U/kg, n=10), single high dose (5,000 U/kg) and repeated high doses (MTHi, 1,000 U/kg twice a week; n=8), or single high dose (5,000 U/kg) and repeated low doses (MTLo, 750 U/kg once a week, n=10), MI non-treated (MNT, n=10), sham (S, n=5). Echocardiography was performed 3.6+/-1.5 days and 43.7+/-2.3 days post MI. Collagen deposition and infarct size were measured on histological sections using computerized image analysis. Apoptosis was assessed by ApopTag staining.Baseline fractional shortening (FS) was similar between groups. Six weeks after MI the FS of MTLo (26.9%) was significantly higher compared to MNT (17.8%), MT1 (19.5%) and MTH (22.3%) (p=0.01). However, remodeling indices (end diastolic and end systolic areas, LV circumference) did not improve in the Epo groups, and even worsened in the MTHi group. There was significantly less collagen staining in non-infarct areas in MT1 and MTHi groups compared to MNT and MTLo (0.38+/-0.3%, 0.49+/-0.34%, vs 0.89+/-0.41%, 0.95+/-0.33%, respectively, p0.001). The number of ApopTag positive nucleus was significantly higher in the MNT group compared to the MT1, MTHi, MTLo groups (14.4+/-8, 7.6+/-4, 5.8+/-7, 4.8+/-5, respectively, p=0.01 for trend).Repeated low doses of Epo after MI improved LV function, but the role of Epo on remodeling is not clear. It did not reduce left ventricular indices, but reduces fibrosis and apoptosis. High Epo doses reduced LV function and aggravated remodeling.

Coronary artery disease is still highly prevalent worldwide, and stable angina pectoris is one of its more common presentations. Stable angina is a clinical expression of myocardial ischaemia associated with fixed atherosclerotic coronary stenosis, which prevents the adaptation of coronary perfusion to an increased oxygen requirement. The goals of treatment include relief of symptoms, inhibition or slowing of disease progression, prevention of future cardiac events such as myocardial infarction (MI), and improved survival. This article reviews the treatment modalities currently available to alleviate the symptoms of chronic angina and to reduce the risk of future MI and cardiac death, including several novel pharmacological treatments, coronary revascularisation, as well as novel technologies that may benefit selected groups of patients who are refractory to both drugs and revascularisation (fig 1⇓). Figure 1 Different modalities of treatment of stable angina. ACE, angiotensin-converting enzyme; CABG, coronary artery bypass grafting; EECP, enhanced external counter pulsation; PCAB, percutaneous in situ coronary artery bypass; PCVA, percutaneous in situ coronary venous arterialisation; PCI, percutaneous coronary intervention; TMR, transmyocardial laser revascularisation. Three major classes of anti-ischaemia drugs are currently used in the medical management of angina pectoris: β-blockers, nitrates (short- and long-acting), and calcium channel antagonists (table 1⇓). All three have been shown to prolong the duration of exercise before the onset of angina and ST segment depression as well as to decrease the frequency of angina. However, none prevents MI or death caused by coronary disease in patients being treated specifically for chronic stable angina. View this table: Table 1 Treatments for stable angina Although the clinical guidelines of the American College of Cardiology/American Heart Association (2002) and the European Society of Cardiology (2006) suggest that β-blockers be used as the first-line agents in patients with stable angina,1–,3 head-to-head comparative trials failed to demonstrate a greater antianginal efficacy for …

No-reflow is a frequent event during percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI), and it may affect cardiac prognosis. We evaluated the occurrence of no-reflow as a predictor of outcomes in patients who underwent PCI for AMI. We prospectively collected data from 599 consecutive patients who underwent stent-based PCI for ST-elevation AMI by identifying those with no-reflow (Thrombosis In Myocardial Infarction [TIMI] grade3 flow at completion of the procedure) and analyzing their baseline characteristics and clinical outcomes. Patients with no-reflow (n = 40, 6.7%) were older (67 +/- 13 vs 60 +/- 13 years, p = 0.002) and had longer ischemic times (5.5 +/- 3.7 vs 4.4 +/- 3.0 hours, p = 0.04) with more TIMI grade 0/1 flow at presentation (90% vs 64%, p = 0.001). No-reflow occurred mostly (73%) after stenting and often required intra-aortic balloon pump counterpulsation (30% vs 4.3%, p0.001). Peak creatine kinase level was higher in patients with no-reflow (2,700 +/- 1,900 vs 2,000 +/- 1,800, p = 0.03) and more often associated with moderate or severe left ventricular dysfunction (68% vs 45%, p = 0.006) and increased 6-month mortality (12.5% vs 4.3%, p = 0.04). By multivariate analysis, no-reflow was an independent predictor of long-term mortality (odds ratio 3.4, p = 0.02). In addition, renal failure (odds ratio 4.39, p = 0.0025) and preprocedure TIMI grade 0/1 flow (odds ratio 2.1, p = 0.003) were independent predictors of no-reflow. In conclusion, the association of no-reflow with longer ischemic time and worse initial TIMI flow may indicate the presence of highly organized thrombus burden with higher propensity for distal embolization. Regardless of its mechanism, no-reflow was an independent predictor of increased mortality.

Intramyocardial delivery of genes and cells derived from bone marrow has been evaluated in several small studies of 'no-option' symptomatic patients with chronic ischemic coronary artery disease. Clinical experience with intramyocardial gene delivery is limited to genes encoding isoforms of vascular endothelial cell growth factor. In the largest study (Euroinject One), 80 patients were randomized to receive a plasmid encoding vascular endothelial cell growth factor 165 or placebo. The results of this study suggested no beneficial therapeutic effect of this strategy. The experience with stem cells is limited to use of autologous, nonexpanded, nonmanipulated bone-marrow-derived cells; thus, the number of injected stem cells reflects their natural proportion within the bone marrow. The results of these preliminary studies suggest this approach is feasible and has a high safety profile. Although no conclusion can yet be made regarding efficacy, the improved myocardial perfusion in all four studies described in this Review is encouraging. Data from assessments of individual patients, however, suggests a wide variability in response, underscoring the need for further bench and clinical investigations.

Background Right ventricular (RV) involvement during acute inferior myocardial infarction (MI) is associated with increased early morbidity and mortality. With recent improvement in percutaneous coronary intervention (PCI) techniques, it is unclear which factors may improve the outcomes of these patients. We sought to assess the prognostic significance of the presence of right ventricular myocardial infarction (RV-MI) in patients undergoing primary PCI and to explore factors associated with improved outcomes by using a large database representing the "real life" of patients with acute MI (AMI) treated by primary PCI. Methods We analyzed our database of patients with AMI undergoing primary PCI within 12 hours of chest pain between January 2001 and June 2005, excluding patients with cardiogenic shock. Results Of the 666 consecutive patients with MI fulfilling our inclusion criteria, 329 had anterior wall MI, 264 had inferior (230 inferior + 34 lateral) wall MI, and 73 had RV-MI. Mortality at hospital discharge, 30 days, and 6 months was highest in patients with RV-MI involvement (5.5%, 9.6%, and 12.3%, respectively), intermediate in patients with anterior MI (2.4%, 4.6%, and 7.3%, respectively), and lowest in patients without RV myocardial involvement (0.8%, 1.1%, and 3%, respectively) ( P P = .1 for 6 months). After adjustment for the CADILLAC score, odds ratio for 30-day morbidity was 5.2 (95% CI 1.6-17, P = .005) for patients with RV-MI versus those without RV-MI. Within the group of patients with RV-MI, complete revascularization of the right coronary artery including the major RV branch was associated with higher rate of RV function recovery by echocardiography and improved 30-day mortality (odds ratio 0.4, 95% CI 0.1-1.05, P = .06). Conclusions Right ventricular infarction is an independent risk factor for increased mortality even in these days of primary PCI. Intensive medical therapy including restoring blood flow into the right coronary artery including the major RV branch may improve clinical outcomes.

Advances in the identification of vulnerable plaque can be an important step in preventing myocardial infarction and sudden cardiac death. The recognition that non-flow-limiting plaques often produce cardiac events has led to the development of invasive and non-invasive methods to identify such plaques prospectively. This review will present the use of noninvasive imaging modalities for identifying vulnerable plaque such as computed tomography and magnetic resonance imaging. We will also review the different invasive modalities such as intravascular magnetic resonance imaging, intravascular ultrasound, coronary angioscopy, coronary thermography, optical coherence tomography, near-infrared spectroscopy, and palpography.

Heart failure (HF) is associated with poor outcome after acute myocardial infarction (AMI). Women have higher mortality rate than men after AMI, however, it is unknown whether women with HF after AMI have different prognosis than men.To compare the prognosis of men and women with AMI and mild-moderate HF.We analyzed data of 3456 consecutive patients with AMI hospitalized in all cardiac care units in Israel during two nationwide surveys.Among patients with AMI and HF on admission: women were older, had more risk factors, and were less likely to undergo percutaneous coronary angiography/intervention. Women with HF had higher (7-days, 30-days, and 1-year) crude mortality rates than men. However, adjusted mortality rates were not significantly different between genders.Women with AMI complicated by HF had higher crude mortality rate than men that was eliminated after multivariate analysis, suggesting that the higher mortality rate may be attributed to increased prevalence of risk factors and lower rate of revascularization and medical therapies among women. Women with AMI and HF should be considered as a high-risk subgroup with adverse outcome. It remains to be determined whether more intensive management will improve their prognosis.

Increased left ventricular mass index (LVMI) is associated with a greater incidence of acute myocardial infarction (AMI), but there are no data regarding its impact on infarct size.The objective of this study was to determine whether LVMI impacts on infarct size.We analyzed consecutive patients with a first ST-elevation AMI and successful reperfusion of the culprit artery who underwent an echocardiographic assessment of LVMI and regional wall motion score index (RWMSI)72 hours post AMI.Of the 165 patients (76.4% men) with a mean age of 61.0 +/- 13.9 years, 53.9% had anterior wall involvement and 59.3% had increased LVMI. There were no significant differences in baseline characteristics between patients with and without increased LVMI, except for a greater prevalence of hypertension among patients with increased LVMI (44.0% vs 22.4%, P.001). The distributions of anterior wall AMI location and culprit artery involvement were similar between the groups. Patients with increased LVMI were more likely to present with single-vessel coronary artery disease (P = .04) and heart failure upon presentation (P = .03). There was no significant difference between patients with and without increased LVMI in peak creatine kinase (2106.8 +/- 1642.7 vs 2551.2 +/- 2357.4 U/L, P = .16) or RWMSI (1.62 +/- 0.44 vs 1.61 +/- 0.38, P = .91). In addition, no correlation was observed between LVMI as a continuous variable and RWMSI (r = 0.11, P = .18) or peak creatine kinase values (r = 0.02, P = .81).Among patients with a first ST-elevation AMI and successful reperfusion, antecedent increased LVMI was fairly common and did not impact on infarct size.

The aim of this study was to evaluate the value of myocardial perfusion imaging (MPI) in predicting major adverse cardiovascular events (MACE) in symptomatic and asymptomatic patients after percutaneous coronary intervention (PCI). We revised retrospectively patients after PCI that underwent MPI and were followed for a year for the presence of MACE. We found no differences in the incidence of MACE between symptomatic and asymptomatic patients. On multivariate analysis, the presence of ischemia by MPI was the most important independent predictor of MACE (OR 5.09, CI 95% 2.15–12.05, p < 0.001). The presence of myocardial ischemia by MPI performed after PCI, and no symptom status, predicts a worse outcome during 1 year of follow-up.

Background: It remains unknown whether patients with severe decompensated class IV heart failure (HF) receiving intravenous inotropic treatment benefit from cardiac resynchronization therapy (CRT). Methods: We identified patients who underwent urgent CRT implantation due to decompensated class IV HF necessitating intravenous inotropic therapy. Results: Of 10 patients with chronic ischemic cardiomyopathy (median QRS duration of 170 ms), CRT implantation was associated with symptomatic improvement in 8 patients. The mortality rate was 50% during a median follow-up of 9.5 months, with a median CRT-to-death duration of 6 months. Conclusions: CRT was feasible among class IV patients receiving inotropic treatment and was associated with clinical improvement.

Background/Aims:A large proportion of patients with a ST-elevation acute coronary syndrome do not receive reperfusion therapy. In order to contribute to a better understanding of the clinical decision making process, we analyzed which factors are associated with the application of reperfusion therapy. Methods: From the Euro Heart Survey of Acute Coronary Syndromes I, 4,260 patients with ST-elevation acute coronary syndrome were selected for the current analysis, of which 1,539 (36%) patients received fibrinolysis and 904 (21%) primary percutaneous coronary intervention (PCI). The analysis contained 32 variables on demographics, medical history, admission parameters and reperfusion therapy. Results: A short pre-hospital delay, arrival in a hospital with PCI facilities, severe ST-elevation, and participation in a clinical trial were the strongest predictors for receiving reperfusion therapy. Primary PCI was more likely to be performed than fibrinolysis in patients with a long pre-hospital delay, arriving in a hospital with PCI facilities, not participating in a clinical trial, and with at least one previous PCI. Conclusion:Hospital facilities and culture, pre-hospital delay and infarction size play a major role in management decisions regarding reperfusion therapy in ST-elevation acute coronary syndrome. This analysis indicates which factors require special attention when implementing and reviewing the reperfusion guidelines.

Objectives: To assess bleeding complications among patients undergoing percutaneous coronary intervention (PCI) and receiving triple therapy of warfarin, aspirin, and a thienopyridine. Background: Triple therapy of warfarin, aspirin, and a thienopyridine is strongly discouraged, given the potential risk of bleeding complications. Methods and Results: Post-PCI patients receiving triple therapy thereafter underwent assessment for bleeding complications. Continuous variables are presented as median (25th–75th percentiles). The study group included 180 patients (80% males; age 65 (52, 75.5)). PCI was on an urgent/emergent basis in 86.6%. The main indications for warfarin use were left ventricular mural thrombus and atrial fibrillation (46.9 and 36.9% respectively). Glycoprotein IIb/IIIa receptor antagonists were used in 47.7%. Post-PCI triple therapy duration was 30 days (30, 30). During the post-triple therapy, 104 patients (57.8%) continued treatment with warfarin and aspirin for 376 days (150, 775). During the triple therapy period, 20 patients developed bleeding complications, (mean INR 2.1 ± 0.7 at 7 (6, 8.5) days post-PCI): 2 major groin hematoma (initial phase of warfarin treatment during overlap with heparin) and 18 minor. During post-triple therapy, primarily under warfarin and aspirin, 19 patients developed bleeding complications: 1 major and 18 minor. Conclusion: Short-term triple therapy after PCI was not associated with prohibitively high bleeding complication rates, and thus should be favorably considered in patients with a clear indication for warfarin use. © 2006 Wiley-Liss, Inc.

Aims To examine the value of the anteroposterior pericardial sac diameter (APD) for prediction of the volume of pericardial effusion. Methods and results We measured the APD by echocardiography before 52 pericardiocentesis procedures and correlated it with the aspirate volume, etiology, symptoms, and clinical outcome. The volume of the aspirate ranged from 60 to 2300ml (median 650ml). The APD (range 8.0cm–15.9cm, median 12cm) correlated well with the cubic root of the volume of the effusion [volume=(0.8APD−0.6)3, r 2=0.533, p

Environmental Physical Activity. Background: Studies by our group have shown an inverse relationship between sudden death and cardiac rhythm disturbances and environmental levels of geomagnetic activity (GMA). The aim of this study was to use the precise data provided by automatic implantable cardioverter defibrillators (ICDs) regarding the onset of ventricular fibrillation and ventricular tachycardia to link these events to GMA level. Patients and Methods: The study group included 25 patients (22 men; 22 with ischemic cardiomyopathy) aged 28-81 years in whom an ICD had been implanted between 1995 and 2004. Patients were referred to the cardiac intensive care unit after each event that induced one or more discharges. The number of events and the day on which they occurred were recorded. Data on GMA and other cosmophysical parameters were obtained from the U.S. National Geophysical and Space Service Centers and the Russian Academy of Sciences. GMA levels, graded from I (quiet) to IV (stormy) in the middle latitutes, were recorded for 1974-2003 (10,954 days) and for each day on which an ICD discharge occurred. Results: A total of 402 discharges were recorded on 137 days during the study period. Forty-six percent of the discharges took place on days of GMA I, compared with 38% - II, 13% - III, and 3% - IV. The daily distribution of GMA was as follows: level I - 35.2%, II - 37.3%, III - 21.86%, IV - 5.61%. Comparison of ICD discharge days and actual multiyear levels of GMA (in percent) yielded a ratio of 1.326 for GMA I, 1.076 - II, 0.459 - III, 0.390 - IV. There was a significant inverse correlation between GMA level and number of discharges (r = -0.97, P = 0.03) and days of treatment (r = -0.96, P = 0.039), and a significant difference between ICD discharges on days of GMA I and GMA II-IV (Χ 2 = 5.05, P = 0.02). Conclusion: The higher number of ICD discharges on days of lowest GMA maybe explained by a possible antiarrhythmic effect of GMA. Environmental arrhythmogenic factors that act inversely to GMA may be activated at times of low GMA.

We measured body temperature in 40 consecutive patients treated for a first ST elevation acute myocardial infarction (AMI) with primary percutaneous coronary interventions. Left ventricular function was assessed by echocardiography, and blood samples were drawn for highly sensitive C-reactive protein (hs-CRP), white blood cell (WBC) count, fibrinogen, creatine kinase (CK), and cardiac troponin I levels (cTnI). The median (25th, 75th quartiles) peak 24-hour temperature was 37.4 degrees C (36.9 degrees C, 37.6 degrees C). Variables significantly associated with peak 24-hour temperature were CK (p = 0.01, r = 0.42), wall motion index (p = 0.01, r = 0.41), hs-CRP (p = 0.01, r = 0.41), and cTnI (p = 0.03, r = 0.35). There was no significant correlation between peak 24-hour temperature and WBC count (p = 0.39, r = 0.14) and fibrinogen (p = 0.12, r = 0.21). Thus, peak 24-hour body temperature after ST elevation AMI probably reflects infarct size rather than a nonspecific inflammatory response.

Aim: To determine the frequency and outcomes of coronary artery bypass graft (CABG) surgery in patients with a wide spectrum of acute coronary syndromes (ACS). Methods and Results: We prospectively enrolled 10,484 ACS patients from 103 hospitals in 25 countries across Europe and the Mediterranean basin. Of the 10,204 patients with complete data, 460 (4.5%) underwent CABG while in hospital; 3.4% had ST elevation ACS, 5.4% had non-ST elevation ACS, and 4.4% had undetermined ECG ACS (p = 0.001 for non-ST elevation ACS vs. others). In general, patients who underwent CABG were more likely to be males, to have diabetes mellitus, hyperlipidemia, a positive family history of premature coronary disease, and prior angina pectoris, but had less often prior heart failure. While in hospital, all CABG patients underwent coronary angiography and 15.2% also underwent percutaneous revascularization, as compared with 51.3 and 33.1% in the remaining patients, respectively. The in-hospital mortality was 3.7% for ACS patients who underwent CABG and 4.8% for non-CABG ACS patients (p = nonsignificant) with an adjusted odds ratio of in-hospital death for CABG patients of 1.00 (95% CI 0.59–1.61). Conclusions: Approximately 4.5% of ACS patients underwent CABG during their initial hospitalization, with a greater likelihood among non-ST elevation ACS patients. Of the CABG patients, 15.2% also underwent percutaneous revascularization. The outcome of CABG patients was as good as non-CABG patients, indicating that CABG remains an effective and safe means to achieve revascularization among ACS patients in current clinical practice.

BACKGROUND Patients with acute coronary syndromes (ACS) complicated by heart failure (HF) are at increased risk of death. Treatment with angiotensin-converting enzyme inhibitors (ACEI), beta-blockers, and early invasive risk stratification are recommended for these patients. AIM The purpose of the current study was to assess adherence to treatment guidelines of patients with ACS complicated by HF in Europe and the Mediterranean region. METHODS AND RESULTS Of the 10,484 patients who participated in Euro-Heart ACS survey, 9587 had known HF status and were without cardiogenic shock; 7058 (74%) did not have symptomatic HF and 2529 (26%) presented with or developed symptomatic HF during hospitalization. HF patients were older and had more cardiovascular risk factors. ACEI were more commonly used in HF patients (75% vs 56%, P < .01), whereas beta-blockers were less frequently used (75% vs 82%, P < .01). Coronary angiography and in hospital revascularization rates were lower among HF patients (42% vs 57% for coronary angiography, P < .01, and 32% vs 42% for revascularization, P < .01). Similar trends were noticed among patients with left ventricular dysfunction (symptomatic and asymptomatic).Adjusted in-hospital mortality risk was higher among patients with ACS complicated by symptomatic HF regardless of electrocardiographic type of ACS: (ST-elevation ACS, OR 2.5, 95% CI 1.6-3.9; non-ST-elevation ACS, OR 8.9,95% CI 4.5-17.7; undetermined-ECG ACS, OR 9.3, 95% CI 2.5-34). CONCLUSIONS Patients with ACS complicated by HF were at increased risk of dying. A relatively high percentage of HF patients were treated with ACEI and beta-blockers in accordance with current recommendations. Rates of coronary angiography and revascularization were significantly lower in ACS patients with HF versus those without HF, which potentially contributed to their worse mortality [corrected]

Patients with rheumatic mitral valve disease (n = 48) underwent treadmill stress echocardiography and were classified as those with mitral stenosis (n = 24) or those with mitral regurgitation with mild mitral stenosis (n = 24). Despite marked differences in mitral valve area (1.1 +/- 0.3 vs 2.1 +/- 0.6 cm(2), respectively; p

OBJECTIVES The goal of this study was to compare the antithrombotic effects of enoxaparin versus unfractionated heparin (UFH) when combined with eptifibatide in acute coronary syndrome (ACS) patients. BACKGROUND An increasing number of high-risk ACS patients are treated with low-molecular-weight heparin and a glycoprotein (GP) IIb/IIIa inhibitor. There is a paucity of data regarding the antithrombotic properties of such a combination as compared with UFH and GP IIb/IIIa inhibitors. METHODS Twenty-six ACS patients scheduled to undergo coronary angiography were treated with subcutaneous enoxaparin (n = 13) or intravenous UFH (n = 13). All patients received eptifibatide just before coronary angiography. Antithrombotic effects were assessed as changes in platelet-thrombus formation using the Badimon ex vivo perfusion chamber. Perfusions were carried out at a high shear rate (HSR) and a low shear rate (LSR). Patients underwent two perfusion studies: at baseline (under enoxaparin or UFH) and 10 min after the eptifibatide bolus. Platelet function was evaluated by ADP-induced platelet aggregation and the rapid platelet function analyzer. RESULTS Both therapeutic combinations achieved a marked reduction in platelet aggregation after eptifibatide (83% to 89.7% reduction in the enoxaparin-eptifibatide group and 77.8% to 85.5% reduction in the UFH-eptifibatide group, inter-group differences not significant). Both groups also demonstrated marked reductions in thrombus formation, but the reductions achieved in the enoxaparin-eptifibatide group were significantly higher than those achieved in the UFH-eptifibatide group (HSR: 75.6% reduction vs. 63.9%, respectively, p = 0.01; LSR: 79.7% reduction vs. 66.1%, respectively, p = 0.0001). CONCLUSIONS The combination of eptifibatide with enoxaparin appears to have a more potent antithrombotic effect than that of eptifibatide and UFH in the doses tested.

Coronary stenting in acute coronary syndromes might be associated with increased procedural complications and stent thrombosis risk. Heparin-coated stent (HCS) may improve procedural outcomes when treating these high-risk lesions. The purpose of this study was to determine the safety and efficacy of HCS in patients with acute coronary syndromes and thrombus containing lesions.Between January 2001 and January 2002, 49 patients (42 male) with thrombus containing lesions (32 sustained acute myocardial infarction) received HC BX stents (HepaCoat) at our hospital. Procedural, hospital and six-month outcomes and quantitative angiographic analysis data were obtained from all patients.The mean age of patients was 58 +/- 14 years, 45% had multi-vessel disease and 24% were diabetics. Fifteen patients (31%) received a second HCS for sub-optimal results or threatened closure. Procedural success was achieved in 94% of patients. The mean stent diameter and length was 3.2 +/- 0.2 mm and 18.2 +/- 7.4 mm. The mean TIMI flow increased from 1.3 +/- 1.3 to 2.9 +/- 0.3 and the mean diameter stenosis before and after intervention was 84 +/- 21% and 12 +/- 14%. In-hospital and 30-day follow-up were eventually without occurrence of death, myocardial infarction, stent thrombosis, coronary bypass. At six-months follow-up, cardiac event-free survival was 89.8%, target vessel revascularization was 6.1 and 90% of patients were free of angina.In this series of patients with acute ischemic syndromes associated with visible thrombus, the use of HCS resulted in (1) favorable procedural and six-month outcomes, (2) no incidence of stent thrombosis, and (3) overall good cardiac prognosis at six-month follow-up.

Left internal mammary artery (LIMA) grafting to the left anterior descending artery (LAD) is known to have long-term patency. However, myocardial ischemia in the territories supplied by LIMA to LAD is still demonstrated. The aim of this study is to examine the relationships between the extent, location, and clinical outcome of myocardial ischemia in LAD territories (ILAD) by use of myocardial perfusion imaging (MPI) and angiographic characteristics of such a bypass conduit.We studied 38 consecutive patients with prior coronary artery bypass grafting who showed stress-induced ischemia in LIMA to LAD territories by MPI single photon emission computed tomography between the years 1996-2000. All patients underwent quantitative coronary angiography within 6 months of the nuclear study. Single photon emission computed tomography parameters of ILAD were assessed by location (septum, apex, anterior, and anterolateral) and included extension score (1-4 per patient), severity score (0-3 per territory), and total sum score. LIMA to LAD quantitative coronary angiography parameters included minimal lumen diameter, lesion length, reference diameter, and diameter stenosis (percentage). LAD and LIMA diameters and ratio (in normal segments) were determined within 10 mm proximal and distal to the anastomotic site. The study group was compared with 18 control subjects without ischemia or stenosis treated with LIMA to LAD. The patients were followed up for cardiac death at an interval of 3.2 +/- 1.5 years from the time of MPI testing. The patients' mean age was 66 +/- 12 years (31 men and 7 women); the mean period after surgery was 6.2 +/- 1.5 years. The ILAD distribution was as follows: septum, 12 (32%); apex, 20 (52%); anterior, 24 (63%); and anterolateral, 18 (47%). The mean extension score was 1.9 +/- 1.0, and the mean total sum score was 3.4 +/- 2.3. Of 38 patients with ILAD, only 17 (45%) had greater than 50% luminal stenosis (2 LIMA and 15 anastomosis or distal). Among clinical variables during stress testing, the prevalence of angina was significantly higher in the luminal stenotic patients versus patients without stenosis (P =.04). A significant correlation was found between anterior wall ischemia and reference diameter (r = -0.7, P =.002) and between total sum score and minimal lumen diameter (r = -0.48, P =.05). Of note, the LAD-to-LIMA ratio was significantly lower in patients with ILAD and without luminal stenosis compared with the control group (0.73 +/- 0.16 vs 0.87 +/- 0.15, P =.004). Cardiac death occurred in 8 patients (21%), 5 patients with luminal stenosis versus 3 patients without stenosis (P = not significant).In patients with LIMA to LAD anastomosis, myocardial ischemia could occur even without angiographic luminal stenosis and apparently reflects a mismatch between LAD and LIMA diameters at distal anastomotic sites. Regarding the similar prevalence of cardiacdeath, invasive evaluation and aggressive treatment are recommended in all patients with ischemia in LIMA/LAD territories.

Aims To examine the application of the redefinition of acute myocardial infarction (AMI) published on 4 September 2000. Methods and results The Euro Heart Survey of Acute Coronary Syndromes (ACS) prospectively surveyed 10484 patients in 103 hospitals across 25 European and Mediterranean basin countries during 4 September 2000 to 15 May 2001. We evaluated the use of cardiac troponin assays and whether the diagnosis of unstable angina (UA) or AMI was in accordance with the results of biomarker assays (cardiac troponins, CK-MB mass, CK-MB%, or CK). Troponin assays were used in 6036 (63.3%) of the 9538 patients with available biomarker levels; of whom elevated troponin levels were recorded in 648 of 2307 (28.1%) patients with UA and in 2957 of 3729 (79.3%) patients with AMI. Of the 8871 patients with available creatine kinase values, levels above the upper limit of normal were recorded in 848 of 3625 (23.4%) patients with UA and in 3948 of 5246 (75.3%) patients with AMI. Conclusions Cardiac troponin assays are still not universally available for the evaluation of ACS patients. A substantial proportion of ACS patients receive a diagnosis of UA or AMI, irrespective of the result of biomarker assays, indicating that the redefinition of AMI has not yet been universally adopted, and that additional efforts are warranted to ensure its appropriate implementation.

Aim To determine the frequency of pre-existing valvular disease (VD) among patients with acute coronary syndromes (ACS) and to compare the clinical characteristics, clinical course, treatment, and outcomes of ACS patients with and without pre-existing VD. Methods and results The Euro Heart Survey ACS prospectively enrolled 10,484 ACS patients in 103 hospitals in 25 countries across Europe and the Mediterranean basin. Of the 10,207 patients with data on VD status, 489 (4.8%) had a diagnosis of pre-existing VD: 3.7% of 4339 ST-segment-elevation-ACS patients, 5.2% of 5210 non-ST-segment-elevation-ACS patients, and 10.8% of 658 undetermined-electrocardiogram-ACSpatients. Moderate/severe mitral regurgitation had been diagnosed in 54.0% (48.7% without and 5.3% with concomitant mitral stenosis), and moderate/severe aortic stenosis occurred in 31.7% (26.4% without and 5.3% with concomitant aortic regurgitation). Patients with pre-existing VD had worse baseline clinical and demographic characteristics, were more likely to present with heart failure and less likely to have typical angina, and had a more complicated in-hospital course (heart failure, atrial arrhythmias, and renal failure). They were more likely to receive inotropic agents, diuretics, amiodarone, and warfarin, and less likely to receive antiplatelet agentsand beta-adrenergic blockers. As compared to patients without VD, the adjustedrisk (95% confidence interval) of in-hospital death for VD patients was 1.55 (0.85, 2.80), 1.92 (1.03, 3.59), and 1.77 (0.75, 4.17) for ST-segment-elevation-ACS, non-ST-segment-elevation-ACS, and undetermined-electrocardiogram-ACS, respectively. Conclusions Patients with ACS and pre-existing VD constitute about 5% of all ACS patients; they have high-risk features and poor prognosis. There is a need to better define their optimal treatment, in order to improve their prognosis.