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Aims: patients with diabetes mellitus (DM) have high platelet reactivity and are at increased risk of ischaemic events and bleeding post-acute coronary syndromes (ACS). In the PLATelet inhibition and patient Outcomes (PLATO) trial, ticagrelor reduced the primary composite endpoint of cardiovascular death, myocardial infarction, or stroke, but with similar rates of major bleeding compared with clopidogrel. We aimed to investigate the outcome with ticagrelor vs. clopidogrel in patients with DM or poor glycaemic control., Methods and Results: we analysed patients with pre-existing DM (n = 4662), including 1036 patients on insulin, those without DM (n = 13 951), and subgroups based on admission levels of haemoglobin A1c (HbA1c; n = 15 150). In patients with DM, the reduction in the primary composite endpoint (HR: 0.88, 95% CI: 0.76-1.03), all-cause mortality (HR: 0.82, 95% CI: 0.66-1.01), and stent thrombosis (HR: 0.65, 95% CI: 0.36-1.17) with no increase in major bleeding (HR: 0.95, 95% CI: 0.81-1.12) with ticagrelor was consistent with the overall cohort and without significant diabetes status-by-treatment interactions. There was no heterogeneity between patients with or without ongoing insulin treatment. ticagrelor reduced the primary endpoint, all-cause mortality, and stent thrombosis in patients with HbA1c above the median (HR: 0.80, 95% CI: 0.70-0.91; HR: 0.78, 95% CI: 0.65-0.93; and HR: 0.62, 95% CI: 0.39-1.00, respectively) with similar bleeding rates (HR: 0.98, 95% CI: 0.86-1.12)., Conclusion: ticagrelor, when compared with clopidogrel, reduced ischaemic events in ACS patients irrespective of diabetic status and glycaemic control, without an increase in major bleeding events.

Background: Primary percutaneous coronary intervention (PCI) performed in large community hospitals without cardiac surgery back-up facilities (off-site) reduces door-to-balloon time compared with emergency transferal to tertiary interventional centers (on-site). The present study was performed to explore whether off-site PCI for acute myocardial infarction results in reduced infarct size., Methods and Results: One hundred twenty-eight patients with acute ST-segment elevation myocardial infarction were randomly assigned to undergo primary PCI at the off-site center (n = 68) or to transferal to an on-site center (n = 60). Three days after PCI, (99m)Tc-sestamibi SPECT was performed to estimate infarct size. Off-site PCI significantly reduced door-to-balloon time compared with on-site PCI (94 +/- 54 versus 125 +/- 59 min, respectively, p < 0.01), although symptoms-to-treatment time was only insignificantly reduced (257 +/- 211 versus 286 +/- 146 min, respectively, p = 0.39). Infarct size was comparable between treatment centers (16 +/- 15 versus 14 +/- 12%, respectively p = 0.35). Multivariate analysis revealed that TIMI 0/1 flow grade at initial coronary angiography (OR 3.125, 95% CI 1.17-8.33, p = 0.023), anterior wall localization of the myocardial infarction (OR 3.44, 95% CI 1.38-8.55, p < 0.01), and development of pathological Q-waves (OR 5.07, 95% CI 2.10-12.25, p < 0.01) were independent predictors of an infarct size > 12%., Conclusions: Off-site PCI reduces door-to-balloon time compared with transferal to a remote on-site interventional center but does not reduce infarct size. Instead, pre-PCI TIMI 0/1 flow, anterior wall infarct localization, and development of Q-waves are more important predictors of infarct size.

Background: Recent studies demonstrated that rate control is an acceptable alternative for rhythm control in patients with persistent atrial fibrillation (AF). However, optimal heart rate during AF is still unknown., Objective: To show that in patients with permanent AF, lenient rate control is not inferior to strict rate control in terms of cardiovascular mortality, morbidity, neurohormonal activation, New York Heart Association class for heart failure, left ventricular function, left atrial size, quality of life, and costs., Methods: The RACE II study is a prospective multicenter trial in The Netherlands that will randomize 500 patients with permanent AF (< or = 12 months) to strict or lenient rate control. Strict rate control is defined as a mean resting heart rate < 80 beats per minute (bpm) and heart rate during minor exercise < 110 bpm. After reaching the target, a 24-hour Holter monitoring will be performed. If necessary, drug dose reduction and/or pacemaker implantation will be performed. Lenient rate control is defined as a resting heart rate < 110 bpm. Patients will be seen after 1, 2, and 3 months (for titration of rate control drugs) and yearly thereafter. We anticipate a 25% 2.5-year cardiovascular morbidity and mortality in both groups., Results: Enrollment started in January 2005 in 29 centers in The Netherlands and is expected to be concluded in June 2006. Follow-up will be at least 2 years with a maximum of 3 years., Conclusion: This study should provide data how to treat patients with permanent AF.

Unlabelled: 201Tl imaging and dobutamine echocardiography (DE) can both identify viable myocardium. Prediction of functional outcome after revascularization remains suboptimal with either technique because of the relatively low specificity of (201)Tl and low sensitivity of DE. This study was undertaken to develop an optimal testing strategy for prediction of post-revascularization functional outcome., Methods: Seventy-three patients (mean [+/-SD] left ventricular ejection fraction [LVEF], 32% +/- 8%) underwent DE and resting (201)Tl SPECT (4-h delayed imaging) before surgical revascularization. Dysfunctional segments with (201)Tl activity > or = 50% or with contractile reserve were considered viable. LVEF was assessed before and 3-6 mo after revascularization., Results: Analysis of receiver operator characteristic curves showed that the optimum criteria to predict improvement (> or = 5%) in LVEF after revascularization were > or = 6 viable dysfunctional segments (using a 16-segment model) on (201)Tl and > or = 4 segments on DE. Sensitivity and specificity were 84% and 63% for (201)Tl (P < 0.05 vs. DE) and 63% and 85% for DE (P < 0.05 vs. (201)Tl). Changing the (201)Tl criteria to improve specificity to 78% (> or = 8 segments) yielded a low sensitivity of 44%, and changing the DE criteria to improve sensitivity to 84% (> or = 2 segments) lowered specificity to 56%. Two sequential testing strategies were explored to achieve optimal sensitivity and specificity. In strategy 1, 33 (45%) of 73 patients with an intermediate likelihood of viability by (201)Tl (5-8 viable segments) underwent DE. In strategy 2, 31 (42%) of 73 patients with an intermediate likelihood of viability by DE (2-4 viable segments) underwent (201)Tl. For strategy 1, sensitivity did not change significantly (69%), whereas specificity was improved significantly (93%, P < 0.01 vs. (201)Tl). For strategy 2, sensitivity improved significantly (78%, P < 0.05 vs. DE) and specificity remained unchanged (80%)., Conclusion: Sequential testing by (201)Tl SPECT and DE in a subgroup of patients with an intermediate likelihood of viability by either test significantly enhanced prediction of post-revascularization improvement of LVEF.