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Background: Data regarding the management of non-ST-segment elevation acute coronary syndromes (NSTE ACS) in Hispanic patients, the largest and fastest-growing minority in the United States, are scarce., Methods: We sought to describe the clinical characteristics, process of care, and outcomes of Hispanics presenting with NSTE ACS at US hospitals. We compared baseline characteristics, resource use, and inhospital mortality among 3936 Hispanics and 90280 non-Hispanic whites with NSTE ACS from the CRUSADE Quality Improvement Initiative., Results: The regional distribution of Hispanics in CRUSADE paralleled that in the US Census. Hispanics were younger (65 vs 70 years, P < .0001) and had less hyperlipidemia (45.4% vs 49.0%, P < .0001) but were more likely to be hypertensive (72.2% vs 67.9%, P < .0001) and diabetic (46.5% vs 30.9%, P < .0001). Hispanics were also more likely to be uninsured (12.5% vs 5.1%, P < .001). During hospitalization, Hispanics were more often managed conservatively, undergoing stress tests more frequently (13.0% vs 10.1%, P < .0001), with less use of cardiac catheterization within 48 hours (48.7% vs 55.5%, P < .0001) or percutaneous coronary intervention (39.6% vs 46.4%, P < .0001) at any time. Hispanics received similar discharge treatments but were less frequently referred for cardiac rehabilitation (38.5% vs 49.2%, P < .0001). Adjusted inhospital mortality was similar in both groups (odds ratio 0.87, 95% CI 0.72-1.05)., Conclusions: Although hispanics have a different risk factor profile and are treated less aggressively during hospitalization when they present with NSTE ACS, these treatment differences do not appear to affect inhospital outcomes. Further research is warranted to explore the long-term consequences of these findings.

In the ever evolving field of cardiovascular medicine and coronary intervention, the intra-aortic balloon pump (IABP) is a mature technology, which still plays an important role. The balloon pump invasively supports patient hemodynamics by augmenting diastolic perfusion and increasing diastolic blood pressure, thereby increasing coronary perfusion and reducing afterload. Its efficacy has been demonstrated in a multitude of clinical situations, including acute coronary syndromes, high-risk coronary interventions, cardiogenic shock, and cardiovascular surgery. The potential complications of aortic counterpulsation are serious, although much lower than once feared. With proper patient selection, insertion technique, and management, the IABP is a powerful tool to assist in the treatment of patients with cardiovascular disease. This article will review the hemodynamics, indications, and complications associated with its use.

Background: Renal artery stenosis (RAS) is a potentially reversible cause of hypertension and renal insufficiency and is associated with poor prognosis., Methods: We aimed to identify simple predictors of significant RAS among patients undergoing coronary angiography. Prospective data were collected on 843 consecutive patients who underwent cardiac catheterization and abdominal aortography. Stenoses > or = 75% were considered significant. Multivariable logistic regression was used to assess the relationship between baseline characteristics and coronary anatomy with significant RAS. A simple risk score was derived from the model., Results: The prevalence of RAS > or = 75% was 11.7%. Independent predictors of significant RAS were older age, higher creatinine levels, peripheral vascular disease, number of cardiovascular drugs, hypertension, female sex, and 3-vessel coronary artery disease or previous coronary artery bypass graft. The concordance index of the model was 0.802. These variables were used to develop a simple predictive score of significant RAS for patients undergoing cardiac catheterization. The prevalence of RAS increased stepwise with increasing score values: 0.6% for a score < or = 5, 1.5% for 6 to 7, 6.1% for 8 to 9, 12.2% for 10 to 11, 18.7% for 12 to 14, 35.7% for 15 to 17, and 62.1% for > or = 18 (P < .001). Approximately one third of the patients had a score > or = 11, which yielded a sensitivity of 76% and a specificity of 71%., Conclusions: Renal artery stenosis is a relatively common finding among patients referred for coronary angiography. A simple score can predict the presence of significant RAS among patients referred for cardiac catheterization.

Intracoronary thrombus is associated with increased risk of in-laboratory vessel closure, recurrent myocardial infarction (MI), urgent vessel revascularization, and death. There is a lack of consensus on what represents the ideal treatment for patients with thrombotic complications during percutaneous coronary intervention (PCI), but the development of newer thrombolytic agents with increased fibrin specificity and longer half-life provides a potentially useful treatment option. In this study, the safety and efficacy of intracoronary tenecteplase (TNK) was evaluated in 34 patients (22 with acute ST elevation MI, 4 with rescue PCI, 6 with non-ST elevation MI, and 2 during elective PCI) who developed no-reflow, distal embolization, or visible intracoronary thrombus during PCI. The mean age was 57 years, 76% were Caucasian, and there were 14 women and 20 men. Cardiogenic shock was present in seven (21%) patients at baseline. All patients were being treated with aspirin and either unfractionated heparin (33 patients) or bivalrudin. Glycoprotein IIb/IIIa inhibitors were used in 76% of patients. Intracoronary TNK was used at a mean dose of 10.2 +/- 5.2 mg (median, 10 mg; range, 5-25 mg). There was one TIMI major bleeding event and three TIMI minor bleeding events. The mean hematocrit measured the morning following PCI was 35.5% +/- 4.9% in patients receiving TNK and 36.5% +/- 4.4% in a randomly selected sample of 150 consecutive patients undergoing PCI (P = 0.25). In conjunction with mechanical intervention, TNK was successful at dissolving angiographic thrombus and/or improving flow in 91% of patients. In conclusion, intracoronary TNK is safe and well tolerated in patients who develop thrombotic complications during complex PCI., (Copyright 2005 Wiley-Liss, Inc.)

Aims: We sought to determine whether the extent of myocardial ischaemia on the admission electrocardiogram (ECG) has independent predictive value for short-term risk stratification of patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS). Although the presence of ischaemic ECG changes on admission has been shown to predict outcome, the relationship between the extent of ECG changes and the risk of cardiac events is still ill defined., Methods and Results: We analysed the admission ECGs of 5192 ACS patients enrolled in the GUSTO-IIb trial, without an ECG indication for thrombolysis. ECG tracings showing one or more of the following were eligible: ST-segment depression >0.5 mm, T-wave inversion >1 mm, and ST-segment elevation >0.5 mm but <1 mm. ECG variables associated with unfavourable 30 day outcomes in a univariable analysis were further assessed in a multivariable logistic regression model including independent clinical predictors. In the multivariable clinical, enzymatic, and ECG model, the sum of ST-segment depression (in millimetres) in all leads was a powerful independent predictor of 30 day death (P<0.0001), with a continuous increase in risk with the extent of ST-segment depression. The sum of ST-segment depression (P<0.0001) and the presence of minimal inferior ST-segment elevation (P<0.0001) or anterior ST-segment elevation (P=0.0182) were also independent predictors of the composite of death and myocardial infarction or reinfarction. The extent of ST-segment depression showed a highly significant correlation with the prevalence of three-vessel (P<0.0001) or left main coronary disease (P<0.0001), and also with the peak levels of creatine kinase (P<0.0001) during the index episode of ACS., Conclusion: In patients with NSTE ACS, the sum of ST-segment depression in all ECG leads is a powerful predictor of all-cause mortality at 30 days, independent of clinical variables and correlates with the extent and severity of coronary artery disease. The presence of even minimal (<1 mm) ST-segment elevation in anterior or inferior leads is independently associated with adverse outcomes.

Facilitated percutaneous coronary intervention (PCI) refers to a strategy of immediate PCI following the administration of pharmacological therapies in acute myocardial infarction. It has evolved primarily from the time delays (due to geography or logistics) in getting acute myocardial infarction patients to the catheterization laboratory and the associated irreversible loss of myocardial muscle that occurs as door-to-balloon time increases. Facilitated PCI provides an opportunity to start treating many of these patients before they reach the catheterization laboratory and provides an ability to open the infarct-related artery before PCI, which is associated with better outcomes for AMI patients. Pharmacological strategies before PCI include: thrombolytic therapy, glycoprotein IIb/IIIa inhibitor alone, or a combination of thrombolytic therapy plus glycoprotein IIb/IIIa inhibitor. Initial results of angiographic studies show better patency with the latter strategy but at the expense of higher bleeding event rates. Ongoing trials are evaluating different combinations of thrombolytic and glycoprotein IIb/IIIa inhibitor therapy.

Background: Primary percutaneous coronary intervention (PCI) has become an alternative to thrombolytic therapy as a reperfusion strategy for ST-elevation acute myocardial infarction (AMI)., Methods: The main goal of this study was to determine whether PCI and thrombolytic therapy achieve comparable reperfusion rates, as evidenced by ST-segment resolution. Secondary end points included infarct vessel patency rates before hospital discharge and short- and long-term outcomes. Patients with ischemic chest pain with duration < or =12 hours and no contraindication for thrombolytic therapy were included., Results: Between October 1993 and August 1995, 58 patients were randomly assigned to streptokinase (SK) and 54 patients to primary PCI. Baseline clinical characteristics and infarct location were well balanced in both groups. Median age (interquartile range) was 68 (58, 75) years, 29% were women, and 78% of the patients met at least one criterion for "not low risk" AMI (anterior location, age >70 years old, previous MI, systolic blood pressure <100 mm Hg, and/or heart rate >100 bpm). The median time from symptom onset to random assignment was 217 (139, 335) minutes in the PCI group and 210 (145, 334) minutes in the SK group. Median random assignment to balloon time was 82 (55, 100) minutes, and median random assignment to needle time was 15 (10, 26) minutes (P <.0001). TIMI grade 3 flow after primary PCI was obtained in 85% of patients. The proportion of patients with ST-segment resolution > or =50% at 120 minutes was 80% in the PCI group and 50% in the SK group (P =.001). The predischarge angiogram showed the presence of TIMI 3 flow in 96% of patients who received PCI and 65% of patients who received SK (P <.001). A composite of in-hospital death, reinfarction, severe heart failure, stroke, and major bleeding occurred in 15% of patients who received PCI and 21% of patients who received SK (P =.4). At 3 years, freedom from the composite end point of AMI, postdischarge revascularization, and death was 61% in the PCI group and 40% in the SK group (P =.025)., Conclusions: Our study shows that primary PCI, as compared with SK, is associated with more effective ST-segment resolution, higher patency rates in the infarct vessel at 7 days, and more favorable clinical outcomes at 3 years of follow-up.