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OBJECTIVES We sought to compare survival after coronary artery bypass graft (CABG) and percutaneous transluminal coronary angioplasty (PTCA) in high-risk anatomic subsets. BACKGROUND Compared with medical therapy, CABG decreases mortality in patients with three-vessel disease and two-vessel disease involving the proximal left anterior descending artery (LAD), particularly if left ventricular (LV) dysfunction is present. How survival after PTCA and CABG compares in these high-risk anatomic subsets is unknown. METHODS In the Bypass Angioplasty Revascularization Investigation (BARI), 1,829 patients with multivessel disease were randomized to an initial strategy of PTCA or CABG between 1988 and 1991. Stents and IIb/IIIa inhibitors were not utilized. Since patients in BARI with diabetes mellitus had greater survival with CABG, separate analyses of patients without diabetes were performed. RESULTS Seven-year survival among patients with three-vessel disease undergoing PTCA and CABG (n = 754) was 79% versus 84% (p = 0.06), respectively, and 85% versus 87% (p = 0.36) when only non-diabetics (n = 592) were analyzed. In patients with three-vessel disease and reduced LV function (ejection fraction

Among 214 patients treated with abciximab within 24 hours of full-dose thrombolytic therapy, major bleeding occurred in 50 patients (23%; 95% confidence interval [CI] 18% to 30%) and intracranial hemorrhage occurred in 3 patients (1.4%; 95% CI 0.3% to 4%). The independent multivariate predictors of major bleeding were age (odds ratio [OR] 1.53/10 years, 95% CI 1.05 to 2.21, p = 0.03), time from thrombolytic to abciximab (OR 0.91/hour, 95% CI 0.83 to 0.99, p = 0.03), and intra-aortic balloon pump insertion (OR 4.42, 95% CI 2.00 to 9.72, p = 0.0002).

Percutaneous coronary intervention (PCI) in patients with diabetes mellitus (DM) is associated with higher rates of adverse cardiac events. Recent data suggest that adverse events are reduced in DM after PCI using stents with abciximab. We performed a retrospective analysis of a prospective PCI registry for all patients with DM who underwent stent placement at the Mayo Clinic from 1995 to 1997 (n = 570), and divided them into 2 groups based on whether abciximab was administered. Characterization and comparison of the clinical and angiographic variables, procedural outcomes, and short- and long-term event rates between groups was performed. The baseline clinical characteristics of the groups were similar, but patients treated with abciximab were more likely to be men with a lower left ventricular ejection fraction. Patients treated with abciximab had more multivessel intervention, saphenous vein graft intervention, and thrombus before intervention. The 30-day mortality rate (0.6% vs 3.0%, p = 0.03) and repeat PCI (0% vs 1.1%, p = 0.03) was lower in patients treated with abciximab. The 30-day rates of bypass surgery, myocardial infarction (MI), and a composite of death, MI, and revascularization were similar. The 1-year event rates did not differ significantly between patients taking and not taking abciximab for the end points of death (8.9% vs 8.8%, p = 0.97), MI (13.3% vs 11.4%, p = 0.57), bypass surgery (10.3% vs 6.2%, p = 0.20), repeat PCI (14.7% vs 15.9%, p = 0.76), and a composite of death, MI, and revascularization (30.4% vs 26.7%, p = 0.43). After adjusting for baseline variables, abciximab did not influence the occurrence of late adverse events.

To characterize and determine the overall impact of changes in primary percutaneous coronary intervention (PCI) on the clinical outcome of patients presenting within 24 hours of acute myocardial infarction (AMI).We retrospectively analyzed a prospective PCI registry for 1073 consecutive patients undergoing primary PCI for AMI at the Mayo Clinic in Rochester, Minn, from 1991 through 1997. The primary outcome measure was mortality from any cause within 30 days and 1 year.The number of patients treated for AMI by primary PCI per year increased from 119 in 1991 to 193 in 1997. Intracoronary stent use increased from 1.7% in 1991 to 64.8% in 1997 (P.001). This coincided with an increase in ticlopidine use from 3.6% in 1994 to 62.1% in 1997 (P.001) and in abciximab use from 2.7% in 1995 to 63.2% in 1997 (P.001). An increase in beta-blocker (58.3% to 75.3%; P.001), angiotensin-converting enzyme inhibitor (0.9% to 40.0%; P.001), and 3-hydroxy-3-methylglutaryl coenzyme A reductase use (1.9% to 40.5%; P.001) as well as a decrease in calcium channel antagonist (34.3% to 8.4%; P.001) use occurred on discharge. From 1991 through 1997, there was a significant decrease in the 30-day mortality rate (10.1% to 5.2%; P = .05). The 1-year mortality rate also decreased (13.4% in 1991 to 10.4% in 1997) (P = .09). After adjustment for other confounding variables, treatment in more recent years was associated with a significant decrease in death at 30 days (odds ratio, 0.89; 95% confidence interval, 0.79-1.00; P = .05) and during long-term follow-up (odds ratio, 0.93; 95% confidence interval, 0.87-1.00; P = .04).Percutaneous coronary intervention methods of reperfusion for AMI, along with adjuvant pharmacotherapy, have changed over recent years and have been associated with improved short- and long-term survival.

Abciximab is effective for the prevention of complications when administered prior to percutaneous coronary intervention (PCI). The efficacy and safety of abciximab as an unplanned or rescue agent for complications of PCI is unknown. Rescue versus planned use was compared in 186 consecutive patients. Primary or rescue PCI for acute myocardial infarction (MI) and shock were excluded. Rescue abciximab use was undertaken in 101 patients (54.3%) and planned abciximab was used in 85 (45.7%). The rescue abciximab patients had a lower incidence of previous MI, preprocedural thrombus, multivessel, and vein graft intervention. In-hospital endpoints in the rescue versus planned abciximab patients were death (1.0% vs. 1.2%, P = 1.0), Q-wave MI (2.0% vs. 2.4%, P = 1.0), any MI (14.9% vs. 9.4%, P = 0.3), target vessel revascularization (TVR; 0% vs. 1.2%, P = 1.0), and composite (15.8% vs. 10.6%, P = 0.3). At 6 months, events were death (4.0% vs. 2.3%, P = 0.69), MI (14.9% vs. 9.4%, P = 0.26), TVR (20.8% vs. 4.7%, P = 0.001), and composite (30.7% vs. 15.3%, P = 0.01). In-hospital complications between the rescue and planned abciximab patients of major bleed (1.0% vs. 1.8%, P = NS), stroke (0% vs. 1.8%, P = NS), and thrombocytopenia (3.0% vs. 1.8%, P = NS) were similar. There was a significantly higher procedural time (99.6 min vs. 86.1 min, P = 0.02), contrast volume (278.8 ml vs. 223.5 ml, P = 0.04), and heparin use (8984 u vs. 6003 u, P = 0.0006) in the rescue group. In this nonrandomized comparison, rescue abciximab allowed for the safe discharge from hospital in the majority of patients. However, during a 6-month follow-up, more patients treated with rescue abciximab required TVR with either repeat PCI or CABG. Further studies are warranted to evaluate the overall strategy of rescue abciximab use in PCI. Cathet. Cardiovasc. Intervent. 51:138–144, 2000. © 2000 Wiley-Liss, Inc.

In patients receiving coronary stents treated with aspirin and coumadin, the peak incidence of stent thrombosis occurs on the fifth and sixth days following the implantation procedure. Little is known about the timing of stent thrombosis in patients treated with aspirin and ticlopidine. We compared the timing of coronary stent thrombosis in patients treated with ticlopidine and aspirin with the timing in those receiving coumadin and aspirin. A retrospective databank analysis was performed and 39 patients were identified who experienced stent thrombosis after successful coronary stent implantation. Of these, 21 had been treated with ticlopidine and aspirin and 18 with coumadin and aspirin therapy. The median time from stent implantation to stent thrombosis in the ticlopidine and aspirin group was 12 hours (interquartile range 6 to 72 hours) compared with 4 days in the coumadin and aspirin group (interquartile range 21 to 68 hours) (p

s S21 dose-adjusted and full-dose TNK compared to primary PCI were evaluated in an elderly STEMI cohort. METHODS: Within the Vital Heart Response (VHR) registry, data on consecutive elderly STEMI was evaluated from Jan 2013 to Mar 2014. In this STEMI network of care (VHR), the reperfusion modality (pharmacoinvasive or primary PCI) is based on individual patient characteristics and site of presentation. VHR covers a catchment area of 440, 000km2, serving 1.8 million inhabitants, with two PCI-capable facilities located in Edmonton, Canada. Within the pharmacoinvasive strategy, the pre-hospital treated group received half-dose TNK while patients presenting to a non-cath lab facility emergency room received full-dose TNK. All patients within the three treatment groups received evidence based protocolized parenteral anticoagulation and evidence based dual antiplatelet therapy. RESULTS: The baseline characteristics of STEMI patients 75 years in the three treatment groups {(half-dose TNK, n1⁄426), (full-dose TNK, n1⁄427), (primary PCI, n1⁄4125)} are depicted in table 1. Variances in patient age and gender were present with the full dose TNK group being younger and more likely male. The cardiac risk factor profiles, demonstrate comparable demographics at presentation, ischemic and treatment times. In the pharmacoinvasive strategy, 46.1% (n1⁄412/26) and 63% (n1⁄417/27) within the half-dose and fulldose TNK group, respectively required rescue PCI. In hospital clinical events in the half-dose TNK, full dose-TNK and primary PCI were: in-hospital all cause mortality {(11.5%, n1⁄43/26), (7.4%, n1⁄42/27) and (8.0%, n1⁄410/125)}, cardiogenic shock {(15.4%, n1⁄44/26), (7.4%, n1⁄42/27) and (10.4%, n1⁄413/125)}, and major bleed (excluding intracranial bleed) {(3.8%, n1⁄41/26), (7.4%, n1⁄42/27) and (7.2%, n1⁄49/125)} respectively. Intracranial hemorrhage occurred in two patients one in the half dose TNK group (1/26) and one receiving primary PCI group (1/125). CONCLUSION: This preliminary ‘real-world’ all-comer STEMI dataset supports the emerging evidence on both safety and efficacy of a half-dose TNK strategy compared to full-dose TNK and primary PCI in the elderly; limited by the small numbers, these observations currently remain hypothesis generating and require validation in adequately power trials. 042 OUTCOMES FOLLOWING TRANSCATHETER AORTIC VALVE IMPLANTATION (TAVI) IN ONTARIO (2007-2013) EA Cohen, DT Ko, GH Oakes, M Koh, H Guo, MK Natarajan, HC Wijeysundera, JL Velianou, KJ Kingsbury

Transcatheter aortic valve implantation (TAVI) has become an option for patients with symptomatic severe aortic stenosis whose co-morbidities place them at high surgical risk. However, little is known regarding treatment allocation. From May 2008 to May 2011, all high-risk patients with symptomatic severe aortic stenosis referred to an experienced single-center TAVI clinic were reviewed. A total of 170 consecutive patients were evaluated. Of these, 58 (34%) were accepted for TAVI (mean age 81 ± 8 years). Thirty-three patients (19%) were accepted for conventional aortic valve replacement (AVR; mean age 83 ± 6 years). Sixty-two patients (37%) were treated conservatively (mean age 83 ± 6 years). Seventeen patients (10%) died awaiting complete assessment. At 30 days, all-cause mortality was 10% in the TAVI group, 3% in the conventional AVR group, and 32% in the conservatively treated group. Multivariate-adjustment identified the absence of chronic obstructive pulmonary disease (hazard ratio 0.30, 95% confidence interval 0.09 to 0.98, p0.05) and the absence of frailty (hazard ratio 0.19, 95% confidence interval 0.07 to 0.55, p0.01) as independent predictors of conventional AVR. In conclusion, of the high-risk patients with severe aortic stenosis referred for TAVI at a large single center, approximately 1/2 were accepted for intervention (conventional AVR or TAVI), and roughly 1/3 were treated conservatively.

Patients with prosthetic valves are at high risk for complications in pregnancy. 29-year-old female at 12 weeks gestation presented with dyspnea and exertional chest pain. Her medical history included congenital bicuspid aortic valve stenosis, at the age of 24 she underwent aortic valve replacement

Background ‘Typical’ angina is often used to describe symptoms common among men, while ‘atypical’ angina is used to describe symptoms common among women, despite a higher prevalence of angina among women. This discrepancy is a source of controversy in cardiac care among women. Objectives To redefine angina by (1) qualitatively comparing angina symptoms and experiences in women and men and (2) to propose a more meaningful construct of angina that integrates a more gender-centred approach. Methods Patients were recruited between July and December 2010 from a tertiary cardiac care centre and interviewed immediately prior to their first angiogram. Symptoms were explored through in-depth semi-structured interviews, transcribed verbatim and analysed concurrently using a modified grounded theory approach. Angiographically significant disease was assessed at ≥70% stenosis of a major epicardial vessel. Results Among 31 total patients, 13 men and 14 women had angiograpically significant CAD. Patients describe angina symptoms according to 6 symptomatic subthemes that array along a ‘gender continuum’. Gender-specific symptoms are anchored at each end of the continuum. At the centre of the continuum, are a remarkably large number of symptoms commonly expressed by both men and women. Conclusions The ‘gender continuum’ offers new insights into angina experiences of angiography candidates. Notably, there is more overlap of shared experiences between men and women than conventionally thought. The gender continuum can help researchers and clinicians contextualise patient symptom reports, avoiding the conventional ‘typical’ versus ‘atypical’ distinction that can misrepresent gendered angina experiences.

Background— Guidelines recommend that noncardiac surgery be delayed until 30 to 45 days after bare-metal stent implantation and 1 year after drug-eluting stent implantation. Methods and Results— We used linked registry data and population-based administrative health care databases to conduct a cohort study of 8116 patients (≥40 years of age) who underwent major elective noncardiac surgery in Ontario, Canada between 2003 and 2009, and received coronary stents within 10 years before surgery. Approximately 34% (n=2725) underwent stent insertion within 2 years before surgery, of whom 905 (33%) received drug-eluting stents. For comparison, we assembled a separate cohort of 341 350 surgical patients who had not undergone coronary revascularization. The primary outcome was 30-day major adverse cardiac events (mortality, readmission for acute coronary syndrome, or repeat coronary revascularization). The overall rate of 30-day events in patients with coronary stents was 2.1% (n=170). When the interval between stent insertion and surgery was Conclusions— The earliest optimal time for elective surgery is 46 to 180 days after bare-metal stent implantation or >180 days after drug-eluting stent implantation.

See related research article by Siha and colleagues on page [1135][1] and at [www.cmaj.ca/lookup/doi/10.1503/cmaj.111683][2] Acute myocardial infarction (MI) is a leading cause of morbidity and mortality. A common type of MI is ST-segment elevation myocardial infarction (STEMI).[1][3] During STEMI

Kreatsoulas C, Natarajan MK, Khatun R, Velianou JL, Anand SS (McMaster University; CARING Network, McMaster University; Population Health Research Institute, McMaster University and Hamilton Health Sciences; Interventional Cardiology, Hamilton Health Sciences; Eli Lilly Canada–May Cohen Chair in Women's Health, McMaster University; Michael G. DeGroote-Heart and Stroke Foundation of Ontario Chair in Population Health Research, McMaster University; Population Genomics Program, McMaster University; McMaster University, Hamilton, ON, Canada). Identifying women with severe angiographic coronary disease. J Intern Med 2010; 268:66–74. Objectives. To determine sex/gender differences in the distribution of risk factors according to age and identify factors associated with the presence of severe coronary artery disease (CAD). Design. We analysed 23 771 consecutive patients referred for coronary angiography from 2000 to 2006. Subjects. Patients did not have previously diagnosed CAD and were referred for first diagnostic angiography. Outcome measures. Patients were classified according to angiographic disease severity. Severe CAD was defined as left main stenosis ≥50%, three-vessel disease with ≥70% stenosis or two-vessel disease including proximal left anterior descending stenosis of ≥70%. Univariate and multivariate logistic regression was used to assess the association between risk factors and angina symptoms with severe CAD. Results. Women were less likely to have severe CAD (22.3% vs. 36.5%) compared with men. Women were also significantly older (69.8 ± 10.6 vs. 66.3 ± 10.7 years), had higher rates of diabetes (35.0% vs. 26.6%), hypertension (74.8% vs. 63.3%) and Canadian Cardiovascular Society (CCS) class IV angina symptoms (56.7% vs. 47.8%). Men were more likely to be smokers (56.9% vs. 37.9%). Factors independently associated with severe CAD included age (OR = 1.05; 95% CI 1.05–1.05, P

In randomized trials, paclitaxel-eluting stents (PES) are superior to bare metal stents (BMS) in reducing target lesion revascularization (TLR). However, recent reports suggest there may be an increase in late stent thrombosis with long-term follow-up in PES-treated patients.Prospectively collected data from a regional cardiac referral centre were analyzed to compare PES versus BMS in all consecutive patients undergoing percutaneous coronary intervention from April 2003 to March 2004. Outcomes included combined death, myocardial infarction and clinically driven TLR, as well as stent thrombosis at four years follow-up.A total of 512 patients were treated with PES and 722 patients with BMS. At four years, there was 92% follow-up in both groups. The composite outcome of death, myocardial infarction and TLR was 13.9% in the PES group compared with 20% in the BMS group (P=0.01). This difference was primarily driven by the reduction in TLR in the PES cohort (3.9% versus 8%, P0.01). The rate of definite stent thrombosis was 1.6% in the PES group compared with 0.4% in the BMS group (P=0.03).While PES offers an absolute 4.1% reduction in clinically driven TLR at four years, there is an associated increased risk of stent thrombosis. Further long-term studies addressing clinical outcomes including stent thrombosis with PES versus BMS are required to clarify this risk/ benefit balance.

In randomized trials, paclitaxel-eluting stents (PES) have been shown to be superior to bare metal stents (BMS) in reducing restenosis. However, the effectiveness of PES in patients treated during routine practice has not been fully established.A retrospective comparison of PES with BMS in consecutive patients undergoing percutaneous coronary intervention (PCI) from April 2003 to March 2004 was conducted. Outcomes included the composite of death, myocardial infarction and target lesion revascularization (TLR) at one year, as well as stent thrombosis.A total of 512 patients were treated with PES, and 722 patients were treated with BMS. Patients in the PES group were more likely to receive stents that were 20 mm in length or longer (52.2% versus 33.3%, P0.0001), 2.5 mm in diameter or smaller (29.1% versus 12.5%, P0.0001) and implanted in bifurcation positions (15.4% versus 11.6%, P=0.02). At one year, the composite outcome of death, myocardial infarction and TLR was 6.1% in the PES group compared with 10.8% in the BMS group (P=0.004). The one-year rate of stent thrombosis was 0.59% in the PES group compared with 0.28% in the BMS group (P=0.4).Despite being used in higher-risk lesions, there was a lower rate of major cardiac events at one year in patients treated with PES, primarily driven by the reduction in TLR. Thus, the experience with PES in contemporary practice applied to a broader population appears to be consistent with the results reported in randomized trials.

Background It is unclear if computed tomographic coronary angiography (CTA), an evolving technique for the evaluation of coronary artery disease (CAD), can identify patients with high-risk coronary anatomy. Methods Among patients referred for invasive angiography at Hamilton Health Sciences (Hamilton, Ontario, Canada), those with an intermediate pretest probability (25%-60% likelihood of a significant stenosis) were prospectively identified using a multivariate risk score and were studied on a 64-detector Toshiba Aquilion scanner (Toshiba Medical Systems, Tokyo, Japan) before invasive angiography. Patients with high-risk anatomy (left main, 3-vessel CAD, or 2-vessel CAD involving the proximal left anterior descending artery) or at least 1 significant stenosis were identified on CTA and invasive angiography, and the results of these modalities were compared on a per patient basis. Results Eighty patients were enrolled in the study (mean age 56 ± 9 years, male-female ratio 43:37). Nondiagnostic scan results were obtained in 5 patients (6%). By CTA, 13 patients had high-risk anatomy and 31 patients had at least 1 significant stenosis. For the per patient detection of high-risk anatomy, CTA had 100% sensitivity (95% CI 69%-100%), 95% specificity (95% CI 86%-95%), a positive likelihood ratio of 18.0 (95% CI 6.4-50.3), and a negative likelihood ratio of 0.05 (95% CI 0-0.072). Revascularization was performed in 100% of patients with high-risk anatomy on CTA, 83% with at least 1 significant stenosis on CTA, and 0% without a significant stenosis on CTA. Conclusion In appropriately selected patients, CTA is a highly sensitive and specific technique for the detection of high-risk anatomy and maybe a valuable method for noninvasive risk stratification.

To evaluate the effect of body mass index (BMI) on in-hospital outcomes in patients undergoing percutaneous coronary intervention (PCI) at a tertiary care hospital center in Ontario, Canada.Obesity is present in a large population of patients undergoing revascularization with PCI.Retrospective analysis of 4,631 patients aged 62.0 +/- 12 years, stratified by BMI into five groups: nonobese (25 kg/m2); overweight (25-29.9 kg/m2); class I obese (30-34.9 kg/m2); class II obese (35-39.9 kg/m2); and class III obese (or =40 kg/m2).A BMI25 kg/m2 was present in 79% of patients, and 35% were obese (BMIor =30 kg/m2). Obese patients, particularly the class III obese, were significantly younger and had higher prevalence of diabetes, hypertension, and dyslipidemia (P0.0001). After adjustment for several covariates, lower BMI was independently associated with higher risk of major bleeding requiring transfusion (adjusted odds ratio [OR]= 1.40, 95% confidence interval [CI] 1.04-1.88, P = 0.025), and femoral hematoma (adjusted OR = 1.14, 95% CI 1.05-1.25, P = 0.003) in lean (20 kg/m2) and normal BMI (20-24.9 kg/m2) patients. Obesity was not associated with death, myocardial infarction, repeat PCI, coronary artery bypass grafting, or major adverse cardiac event.Obesity is not associated with increased risk of adverse postprocedural in-hospital outcomes. These findings, however, do not discount the need for sustained efforts in secondary prevention of obesity and its consequences.

Previous studies have shown that a significant proportion of patients undergoing percutaneous coronary intervention (PCI) are not receiving guideline-recommended statin therapy upon hospital discharge. We evaluated the impact of the implementation of routine cholesterol profile measurements and standardized orders post-PCI on the number of patients receiving statin therapy.We conducted a prospective, observational study on all patients undergoing PCI in an urban teaching hospital from February 2002 to March 2003. Patient baseline characteristics, statin therapy pre- and post-PCI, and fasting lipid profiles were recorded as part of an ongoing PCI database. A similar cohort of patients undergoing PCI in the one-year time period immediately before the intervention was used as a comparison group.A total of 1,748 patients underwent PCI during the study period. Statin therapy was prescribed in 78% of patients pre-PCI and increased to 92% at hospital discharge. In the year before implementation of the standardized post-PCI orders, there was only a 5% absolute increase in statin use after PCI compared to a 14% absolute increase in the study time period (p =0.0001). Low-density lipoprotein (LDL) levels were available in 1,268 patients. The median LDL level was 2.08 mmol/L for patients on statin therapy versus 2.40 mmol/L for those not on statins.Routine assessment of LDL levels and lipid-lowering therapy at the time of PCI resulted in a further increase in statin use. However, approximately one-third of patients still had an LDL level above recommended guidelines for secondary prevention.

We conducted a retrospective comparison of paclitaxel-eluting stents (PESs, n = 60) versus bare metal stents (BMSs, n = 137) in consecutive patients who underwent primary or rescue percutaneous coronary intervention over 1 year. The PES cohort had no in-stent thromboses and had a 65% (p = 0.02) decrease in the combined end point of death, recurrent myocardial infarction, and target vessel revascularization at 1 year compared with the BMS group. PES implantation appears to be safe and possibly superior to BMS implantation in terms of 1-year major cardiovascular outcomes in the setting of ST-elevation myocardial infarction.

Direct comparison of low-molecular-weight heparin, dalteparin, with unfractionated heparin (UFH) during percutaneous coronary intervention (PCI) is limited. This study examined the relative effects of dalteparin and UFH on coagulation and angiographic and clinical indices during PCI.This was a double-blind randomized study, stratified by planned glycoprotein IIb/IIIa inhibitor use. Both UFH and dalteparin were administered as an intra-arterial bolus immediately before PCI.All randomized patients received the assigned study drug and underwent PCI. Mean activated clotting time levels were 344 seconds for UFH and 234 seconds for dalteparin (P.0001). Anti-factor Xa levels were higher for dalteparin at 30 minutes (UFH 1.3 IU/mL vs dalteparin 1.7 IU/mL, P = .005)) and at 4 hours (UFH 0.27 IU/mL vs dalteparin 0.69 IU/mL, P.0001). Angiographic success was90% in both groups, and angiographic complications were similar (UFH 2.5% vs dalteparin 3.8%). The composite of death, myocardial infarction, target vessel revascularization, or bailout glycoprotein IIb/IIIa at hospital discharge was 13.7% in the UFH group and 13.1% in the dalteparin group (P = not significant). There were 2 major bleedings requiring transfusion, both occurring in the UFH group.This study suggests that a single intra-arterial bolus of low-molecular-weight heparin without monitoring is feasible and warrants further investigation as an alternative to UFH during PCI.

Background Transradial percutaneous coronary intervention (PCI) results in fewer vascular complications, earlier ambulation, and improved patient comfort. Limited data exist for radial access in acute myocardial infarction, where reperfusion must occur quickly. Methods In a multicenter pilot trial, 50 patients with myocardial infarction requiring either primary or rescue PCI were randomized to radial or femoral access. All operators had previously performed at least 100 transradial cases. Procedure times were prospectively recorded. Results Thrombolysis was used in 66% of the cases and glycoprotein IIb/IIIa inhibitors in 94%. Crossover from radial to femoral access was required in one case. Percutaneous coronary intervention was performed in 47 patients, with stenting in 45. One procedural failure occurred with radial access because of inability to cross the occlusion. The time from local anesthesia to first balloon inflation was 32 (25th percentile 26, 75th percentile 38) minutes for radial access and 26 (22, 33) minutes for femoral access ( P = .04). There were no significant differences in contrast use or fluoroscopy time. No patient experienced major bleeding or required transfusion. Doppler studies demonstrated 2 asymptomatic radial occlusions and 2 pseudoaneurysms (1 from each group). One patient in the femoral group died 2 days after PCI. At 30 days, there were no strokes or reinfarctions and no patient required bypass surgery or repeat PCI. Conclusions Primary and rescue PCI can be performed with high success rates using either radial or femoral access. Although radial access was associated with a longer time to first balloon inflation, the difference was small and likely not clinically significant. In patients without shock, major bleeding and vascular complications are infrequent with either access site despite the high use of thrombolysis and glycoprotein IIb/IIIa inhibitors.

Acute ST elevation myocardial infarction (STEMI) is a cause of significant morbidity and mortality in patients with coronary artery disease. Reperfusion therapy, either with thrombolytic agents or primary percutaneous coronary intervention (PCI), is the mainstay of therapy. Worldwide, systemic thrombolysis is the more commonly utilized reperfusion strategy, although an increasing number undergo primary PCI. PCI techniques and adjuvant therapies are evolving. Stents appear to be more useful than thrombolytic therapy or PTCA in acute AMI, especially in decreasing the need for subsequent target lesion revascularization. In patients with STEMI, administration of abciximab with stent placement decreased the primary endpoint [composite of major adverse cardiac events (death, reinfarction, urgent TVR)] by over 50% at 30 days in the Abciximab before Direct angioplasty and stenting in acute Myocardial Infarction Regarding Acute and Long-term follow-up (ADMIRAL) trial, and the benefit appeared to be maintained at 6 months. Despite these promising results, administration of abciximab with a stent did not afford greater benefit over stent alone in the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial. The apparent lack of benefit with abciximab in the CADILLAC trial may be explained by the fact that this trial was not powered to detect differences in mortality and enrolled patients were selected after angiography, and were thus at lower risk. The adjuvant therapies of intracoronary stents and abciximab are becoming the standard of care, based on multiple studies. Stent placement during STEMI decreases the risk of restenosis and TVR. Treatment with abciximab may reduce the risk of acute adverse events in the short term.

BACKGROUND: Coronary artery disease (CAD) a leading cause of mortality among women and despite this, there is a perception that “CAD is a man’s disease”. Little is known about the perceptions that influence patients and how it affects the process to seek medical care. The study objectives include 1) to understand from a gender-centered patient perspective the underlying process that urge women and men to seek medical attention when experiencing chest-pain and 2) to determine the association of factors which influence a patient’s decision to seek medical care. METHODS: Using a mixed Methods approach, the study was conducted in two parts: first, angina symptoms and perceptions influencing the decision to seek medical care were qualitatively explored using in-depth semi-structured interviews and analyzed using modified grounded theory approach. A new cohort of patients was enrolled into the second phase of study, which sought to quantify the reasons why patients decided to seek care according to gender. The entry criteria for both studies were the same: patients with suspected CAD and at least one prior abnormal test, referred for theirfirst coronary angiogram.Logistic regression was used to estimate the association of gender with factors that influence seeking medical care, adjusted for age. RESULTS: The qualitative analysis of 31 men and women revealed that symptoms alone did not prompt medical care. We developed the term, “symptomatic tipping point” to capture the transitional period between experiencing the symptom and seeking medical attention. We identified 6 stages before patients seek medical attention and the stages were similar between men and women varying only in duration between and within the stages, as women wouldwait for amore severe confirmatory event to occurbefore they would qualify their symptoms as “possibly cardiac”. In our quantitative study of 237 patients we found that men would seek medical attention when they perceived that their symptoms were “severe” (OR1⁄42.1 95%CI 1.2-3.7) and if the symptoms occurred “more frequently” (OR1⁄41.9, 95%CI 1.1-3.3) compared to women. CONCLUSION: We captured the process in which patients seek medical attention, as the symptomatic tipping point. Women and men went through a similar series of stages, however women would often delay seeking care for more severe or frequent symptoms to occur. The reasons for this are unclear. This has important public health implications to improve timely cardiac care among women.

Background The outcome of patients with previous coronary artery bypass grafting (CABG) undergoing primary percutaneous coronary intervention (PCI) for the treatment of acute myocardial infarction (AMI) is unclear. We sought to assess the outcome of patients with prior CABG undergoing primary PCI for the treatment of AMI. Methods and Results Between 1991 and 1997, 1072 patients with AMI underwent primary PCI without antecedent thrombolytic therapy at the Mayo Clinic. There were 128 patients with previous CABG and 944 without previous CABG. Patients with previous CABG were further subdivided according to the treated vessel: native vessels (n = 65) and bypass graft (n = 63). Clinical and angiographic characteristics and 30-day and 1-year outcomes were evaluated. Patients with previous CABG were significantly older and had a higher incidence of diabetes, hypertension, and hypercholesterolemia. They had a lower left ventricular ejection fraction and were also more likely to have congestive heart failure. After 1 year of follow-up, adverse cardiac events (death, MI, CABG, or repeat PCI) were significantly greater in patients with prior CABG (49.2% vs 35.9%, P =.04). With use of multivariate logistic regression analysis to adjust for differences in baseline characteristics, the treatment of vein graft was independently associated with adverse cardiac events (relative risk 1.48 [95% confidence interval 1.07-2.03], P =.02), but a history of prior CABG itself was not (relative risk 1.22 [95% confidence interval 0.96-1.56], P =.11). Conclusions Primary PCI for AMI in patients with previous CABG is associated with higher adverse events largely attributable to adverse baseline clinical characteristics and the treatment of a vein graft. (Am Heart J 2001;142:452-9.)

Coronary artery disease (CAD) is a significant cause of morbidity and mortality today. The treatment of CAD is improving, but its prevalence is increasing: both primary and secondary prevention measures are of vital importance. Atherosclerosis starts at an early age; it is initiated at the vascular endothelium level, a single layer entity that modulates vascular function. Modulation of vascular function is carried out through the L-arginine/nitric oxide (NO) pathway. Normal endothelial function requires an intact L-arginine/NO pathway and endothelium. Endothelial dysfunction may be a precursor to overt CAD. CAD risk factors have been shown to influence endothelial function, and the treatment of these risk factors can restore endothelial function. L-Arginine is a safe, novel, semiessential amino acid that increases NO production, thereby improving endothelial function. L-Arginine/NO has numerous beneficial neurohormonal modulating properties. Numerous animal model and human studies have been carried out to assess L-arginine in CAD and other related disorders such as congestive heart failure (CHF), peripheral vascular disease (PVD) and acute myocardial infarction (AMI). Prospective clinical trials are required to assess the promising role of L-arginine in CAD and related disorders

Manifestations of cardiac amyloidosis may include congestive heart failure and sudden cardiac death. Although vascular involvement in patients with amyloidosis is common, systemic amyloidosis presenting with angina is rare.To report on patients with systemic amyloidosis presenting with angina pectoris.Case series.Academic medical center.Five patients who presented with angina pectoris and normal coronary angiogram as the initial manifestation of systemic amyloidosis.Endothelial-dependent and endothelial-independent coronary flow reserve.All patients had coronary flow reserve abnormalities and subsequently developed congestive heart failure and systemic manifestations of amyloidosis. Histologic evaluation revealed amyloid deposition in the intramyocardial coronary vessels.Cardiac amyloidosis can present as angina pectoris associated with coronary flow reserve abnormalities despite normal coronary angiograms. This finding may have major therapeutic and prognostic implications in this patient population.

To the Editor: The recently published report describing a case of cardiogenic shock following nasal septoplasty1 helps to raise our awareness of the issue and suggests that beta blockade can be ineffective and, at times, harmful in that situation. Unfortunately, the authors fail to discuss other therapeutic options which may have been appropriate and should have been considered. Since, as a rule, the effects of single injections of epinephrine are transient, should the ensuing hypertension and tachycardia simply be ignored, or should definitive alpha blockade, either alone or in combination with a beta adrenergic blocking drug, be considered? This case report also raises the question as to what are the most appropriate resuscitative measures to assume when faced with a cardiac arrest in this scenario. The problem is already postulated to be excess alpha stimulation in the presence of beta blockade; therefore, administering additional epinephrine in this case may not have been ideal. Should the use of beta stimulants (e.g., isoproterenol) to achieve a positive chronotropic effect be considered? The answers to these questions may not be straightforward; however, the authors might have considered discussing the additional treatment options.

ObjectivesThe aim of this study was: 1) to evaluate the acute and late outcomes of a transcatheter aortic valve implantation (TAVI) program including both the transfemoral (TF) and transapical (TA) approaches; and 2) to determine the results of TAVI in patients deemed inoperable because of either porcelain aorta or frailty.BackgroundVery few data exist on the results of a comprehensive TAVI program including both TA and TF approaches for the treatment of severe aortic stenosis in patients at very high or prohibitive surgical risk.MethodsConsecutive patients who underwent TAVI with the Edwards valve (Edwards Lifesciences, Inc., Irvine, California) between January 2005 and June 2009 in 6 Canadian centers were included.ResultsA total of 345 procedures (TF: 168, TA: 177) were performed in 339 patients. The predicted surgical mortality (Society of Thoracic Surgeons risk score) was 9.8 ± 6.4%. The procedural success rate was 93.3%, and 30-day mortality was 10.4% (TF: 9.5%, TA: 11.3%). After a median follow-up of 8 months (25th to 75th interquartile range: 3 to 14 months) the mortality rate was 22.1%. The predictors of cumulative late mortality were peri-procedural sepsis (hazard ratio [HR]: 3.49, 95% confidence interval [CI]: 1.48 to 8.28) or need for hemodynamic support (HR: 2.58, 95% CI: 1.11 to 6), pulmonary hypertension (PH) (HR: 1.88, 95% CI: 1.17 to 3), chronic kidney disease (CKD) (HR: 2.30, 95% CI: 1.38 to 3.84), and chronic obstructive pulmonary disease (COPD) (HR: 1.75, 95% CI: 1.09 to 2.83). Patients with either porcelain aorta (18%) or frailty (25%) exhibited acute outcomes similar to the rest of the study population, and porcelain aorta patients tended to have a better survival rate at 1-year follow-up.ConclusionsA TAVI program including both TF and TA approaches was associated with comparable mortality as predicted by surgical risk calculators for the treatment of patients at very high or prohibitive surgical risk, including porcelain aorta and frail patients. Baseline (PH, COPD, CKD) and peri-procedural (hemodynamic support, sepsis) factors but not the approach determined worse outcomes.

Early reperfusion of the myocardium is crucial in treating patients with acute ST segment elevation myocardial infarction (STEMI). Emergency medical services (EMS) plays an important role in minimizing delays to reperfusion. This study demonstrates that a large proportion of patients presenting with STEMI do not use EMS. Thus, such patients cannot benefit from many mechanisms designed to minimize time delays. Healthcare providers are challenged with both implementing strategies for improving care (minimizing delays to reperfusion) for patients not using EMS, and encouraging patients to access care via EMS in the event of acute chest pain.