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This study addresses the impact of availability of on-site catheterization laboratories on the 1-year survival of patients with post-acute myocardial infarction ischemia (P-AMI-I), a high-risk subgroup of AMI patients.A prospective 5 month national survey was conducted in 1996 in all operating intensive care units (ICCUs) in Israel (N=26) and included 2377 patients. Four hundred and three (17%) had P-AMI-I, 317 of them were admitted to 18 ICCUs with on-site catheterization laboratories (CATH+) and 86 patients to 8 ICCUs without such facilities (CATH-). A retrospective analysis was performed comparing the in-hospital course and 7 day, 1 month and 1 year mortality data of CATH+ vs. CATH- patients.Patient characteristics in both groups were similar with regard to age, gender AMI location, risk factors, hemodynamic parameters on admission and rate of thrombolytic therapy. Of patients in CATH+, 79% were catheterized before hospital discharge vs. 42% in CATH- (P0.0001), 45 vs. 15% had PTCA (P0.0001) and 19 vs. 9% had CABG (P0.05). At 30 days, patients in CATH+ still had significantly more revascularization procedures (71 vs. 48%, P0.001). Patients hospitalized in ICCUs with CATH+ and CATH- facilities had similar cardiac mortality rates at 7 days (2.0 vs. 2.3%), 30 days (5.7 vs. 4.7%) and at 1 year (7.6 vs. 7.0%).Despite a more invasive strategy used during the index hospitalization of patients with P-AMI-I hospitalized in CATH+ ICCUs, their survival was similar to CATH- patients at 7 days, 30 days and at 1 year follow-up.

OBJECTIVEThis study was performed to evaluate the recent changes in the outcome of coronary interventions in patients with unstable angina (UA).BACKGROUNDAn early invasive strategy has not been shown to be superior to conservative treatment in patients with UA. Earlier studies had utilized older technology. Interventional approaches have changed in the recent past, but to our knowledge, no large studies have addressed the impact of these changes on the outcome of coronary interventions.METHODSWe analyzed the in-hospital and intermediate-term outcome in 7,632 patients with UA who underwent coronary interventions in the last two decades. The study population was divided into three groups: group 1, n = 2,209 who had coronary intervention from 1979 to 1989; group 2, n = 2,212 with interventions from 1990 to 1993; and group 3, n = 3,211 treated from 1994 to 1998.RESULTSGroup 2 and 3 patients were older and sicker compared with group 1 patients. The clinical success improved significantly in group 3 (94.1%) compared with group 2 (87%) and group 1 (76.5%) (p < 0.001). There was a significant reduction in in-hospital mortality, Q-wave myocardial infarction and need for emergency bypass surgery in group 3 compared with the earlier groups. One-year event-free survival was also significantly higher in the recent group compared with the earlier groups: 77% in group 3, 70% in group 2 and 74% in group 1 (p < 0.001). With the use of multivariate models to adjust for clinical and angiographic variables, treatment during the most recent era was found to be independently associated with improved in-hospital and intermediate-term outcomes.CONCLUSIONSThere has been significant improvement in the in-hospital and intermediate-term outcome of coronary interventions in patients with UA in recent years; newer trials comparing conservative and invasive strategies are therefore needed.

Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study

Acute coronary syndrome is a spectrum ranging from ST elevation myocardial infarction to troponin-negative unstable angina. Plaque rupture or erosion leads to thrombus formation resulting in ischemic myocardial damage. Guidelines recommend primary angioplasty for patients with STEMI and early invasive strategy [

A mathematical model for the clonal growth of the alga Bostrychia radicans was constructed based on architectural growth rules and Lindenmayer systems. The sequence of theoretical growth and invasive strategy of space is shown in several graphical schemes which represent different steps of the model. We postulate that Bostrychia radicans has a `phalanx' strategy of colonization (Lovett Doust, L. 1981. J. Ecol. 69, 743–755.) based on the biological interpretation of the model and field observations.

The clinical impact of an early invasive strategy (EIS) on elderly patients with acute coronary syndromes (ACSs) has yet to be completely defined because of the poor enrolment of elderly patients in randomized trials in this setting. The reluctance to treat elderly ACS patients is mainly due to the higher risk profile of these patients when percutaneous or surgical revascularization is planned. However, recent clinical data from different centres strongly support the use of an EIS in the elderly, showing a significantly larger absolute reduction in 30-day major adverse clinical events in elderly patients than that in younger patients, and prompt the need for dedicated randomized trials.

In the USA the density of coronary catheter laboratories is lower than in Germany. To reach the next available coronary catheter laboratory in takes more than 100 km of distance. In this situation it is usual practise to apply i.v. fibrinolysis on the way to the next available coronary catheter laboratory. Fibrinolysis and consecutive PCI gained very good results [1–5]. In Germany the situation is different. According to the heart report published every year by Ernst Bruckenberger themortality in the treatment of acute ST-segment elevation myocardial infarction is 7%. To reducemortality it is no longer valuable to instal new coronary catheter laboratories, but pharmaco-invasive strategies have to be discussed. The mortality which should be reached might be no more than 4.7–5% [6]. In Germany two scenarios are often met: in small non-university hospitals with coronary catheter laboratory 2–3 clinicians perform the 24 hour coronary care service. In these hospitals the rate of coronary catheter investigations are few and the clinicians are not so experienced in case of emergency. In large centres there are much more clinicians who perform interventions. The personal experience is again low in case of emergency. In Germany there are more than 900 coronary catheter laboratories and the number is still increasing. In Germany it takes less than 50 km of distance to reach the next available coronary catheter laboratory. Some small hospitals with coronary catheter laboratory cannot compensate the costs of a coronary catheter laboratory with few investigations and low income. Fibrinolysis in acute ST-segment elevation myocardial infarction revealed very good results. These data have gained no attention in Germany and in other European countries like the Netherlands and in Switzerland. Two thirds of patients profited the most from fibrinolysis and only one third of patientsmust have intervention [5]. After successful fibrinolysis plenty of patients have an indication for cardiac surgery

We report the case of a patient diagnosed with a pathological fracture of the odontoid dens related to a renal carcinoma metastasis and treated by an original technique. In order to achieve correct stabilization of the fracture and to preserve rotational neck mobility, an anterior approach combining an odontoid screw fixation and a balloon kyphoplasty was performed. This minimal invasive strategy provided satisfactory clinical and radiological results for this unstable lesion. To our knowledge, this technique has not been previously reported and could be a valuable alternative approach in the management of craniocervical metastatic lesions for these fragile patients.

A survey was conducted among 1644 cardiac surgeons on the surgical strategy regarding the invasiveness of the procedure they would prefer as a patient in a number of simple clinical scenarios. A total of 380 (23%) replies were received. Only in the case of aortic valve surgery, a notable preference of minimally invasive strategy was registered, as transcatheter aortic valve implantation was indicated by 49% of the respondents. Regarding the size of the incision for mitral valve surgery, there was a substantial equality between preferences of standard surgery and minimally invasive option (port access: 42%; standard surgery with full sternotomy: 40%). With regard to the use of extracorporeal circulation for coronary surgery, the traditional option received more preferences than the less-invasive one (on-pump CABG: 42%; off-pump CABG: 31%). When respondents’ age was taken into account, surgeons aged

Introduction: An early invasive strategy with follow-on percutaneous coronary intervention (PCI) is recommended in the management of high risk acute coronary syndromes (ACS). This article aimed to assess the impact of a new PCI service in a remote population. Method: The study compared patient treatment pre- and post-introduction of the PCI service in a remote regional centre. Patients were identified using ICD discharge code during two 12 week periods (‘pre’ and ‘post’ introduction of the new PCI service). Further data was obtained from a catheter laboratory database, electronic patient management systems and clinical notes. Non-parametric statistical tests were used. Results: There were 182 patients in the pre-PCI group and 204 in the post-PCI group. There were no demographic differences between the groups. Patients admitted post service introduction who required active treatment were more likely to have PCI rather than an angiogram only (p=0.046). Furthermore, patients admitted after the introduction of the PCI service had a shorter period of time from admission to PCI (p=0.002), were less likely to be transferred to another hospital (p

Out of hospital cardiac arrest (OHCA) is associated with an extremely poor survival rate, with mortality in most cases being related to neurological injury. Among patients who experience return of spontaneous circulation (ROSC), therapeutic hypothermia (TH) is the only proven intervention shown to reduce mortality and improve neurological outcome. First described in 1958, the field of TH has rapidly evolved in recent years. While recent technological advances in TH will likely improve outcomes in OHCA survivors, several fundamental questions remain to be answered including the optimal speed of cooling, which patients benefit from an early invasive strategy, and whether technological advances will facilitate application of TH in the field. An increased awareness and understanding of TH strategies, devices, monitoring, techniques, and complications will allow for a more widespread adoption of this important treatment modality.

Thermoablation of cancerous cells using probe-based strategies has received a lot of attention because it provides a localised minimally invasive strategy that minimizes injuries to collateral tissues. Although radiofrequency ablation is the most widely used probe-based method, skin injuries at the site of the grounding pad are a major complication that limits its efficacy. This paper presents a novel plasmonic photo-thermal probe that has the potential to achieve reasonable lesion sizes without skin burns. First, the concept and its embodiment are presented. Then, its performance is investigated using a 3-D finite-element method (FEM) model. The FEM model was tested for its validity using an analytical model. Lesions are shown to have an ellipsoidal shape and their sizes controlled by the length of the active tip of the probe. The comparison with the analytical model showed reasonably good agreement to within 2%. Our predictions demonstrate the feasibility of our novel probe to achieve reasonable lesion sizes as well as show that generated heat is localised.

Antiplatelet therapy constitutes a cornerstone in the strategies aimed at the effective management of acute coronary syndrome. Abciximab is the oldest and most commonly used intravenous antiplatelet agent in this context, in particular when an invasive strategy is adopted. It is very commonly used in more unstable and high-risk patients. Trials have proven the event-free survival benefits of using abciximab in the right context. This agent also has some adverse outcomes associated with its use that the clinicians need to be well aware of and take precautions against. The comparative cost efficacy with its use too is of significance. There is a growing evidence base on the different ways abciximab is used and the benefits and risks thereof. Since the development and introduction of novel anticoagulants and more potent oral anti-platelet agents, the place of abciximab in the treatment of acute coronary syndrome today needs to be reviewed and clearly defined. This review attempts to study the cross-section of the evidence base to date on the clinical use, efficacy and risks related to the use of abciximab and spotlight the most recent guidelines published by the different global peak bodies to provide a practical overview to the clinician.

We thank Drs. Bertrand and Tanguay for their in-depth analysis and constructive comments on our study [(1)][1], which demonstrated improved clinical outcomes in patients with non–ST-segment elevation myocardial infarction (MI) treated with an immediate versus a delayed invasive strategy, and we

Contemporary guidelines recommend an invasive strategy in patients with non-S-elevation myocardial infarction or unstable angina. Any uncertainty about the relevance of this recommendation to patients aged 80 years or older—who are under-represented in previous trials— should now be dispelled by the fi ndings of the After Eighty study (March 12, p 1057), which showed a signifi cant reduction in the primary outcome in the group randomised to early coronary angiography. However, 35% of the 4187 patients assessed for eligibility for the trial were excluded because of short life expectancy or dementia. These exclusions seem entirely appropriate and remind us that in at least one in three patients aged 80 years or older presenting with acute coronary syndromes, clinicians should carefully consider whether or not to expose them to invasive procedures that might prolong the process of dying without infl uencing quality of life. The decision to intervene is often much easier than the decision not to intervene, but in frail patients aged 80 or older who have multiple comorbidities, intervention might be the wrong decision.

Source Citation Tegn N, Abdelnoor M, Aaberge L, et al; After Eighty study investigators. Invasive versus conservative strategy in patients aged 80 years or older with non-ST-elevation myocardial in...

Immediate invasive approach for acute myocardial infarction (MI) may permit treatment of the underlying plaque rupture as early as possible with subsequent reduction of death and recurrent MI. We sought to assess clinical impact of immediate invasive strategy for acute non-ST-segment elevation MI (

The benefit of an invasive strategy in non-ST-segment elevation myocardial infarction (NSTEMI) was established from randomized trials that included few anemic patients. The aim of this study was to describe the characteristics, therapies, and mortality of patients with NSTEMIs who undergo an invasive strategy in relation to their admission hemoglobin levels. Data from 73,067 patients with NSTEMIs who underwent cardiac catheterization and who were captured by the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines (ACTION-GWTG) were examined. Patients were divided into 3 hemoglobin groups on the basis of initial hemoglobin level: (1)10 g/dl, (2) 10 to 12 g/dl, or (3)12 g/dl. Patients with hemoglobin10 g/dl had more co-morbidities and more 3-vessel coronary artery disease at catheterization compared with those with hemoglobin12 g/dl (46.2% vs 33.9%, all p values0.0001). They received fewer acute antithrombotic therapies, less often underwent revascularization (57.4% vs 74.1%), and had higher rates of red blood cell transfusion before catheterization (32.1% vs 0.3%, all p values0.0001). After adjustment, in-hospital mortality was inversely associated with initial hemoglobin, with a 7% increase for each 1 g/dl decrease in hemoglobin lower than 15 g/dl (odds ratio 1.07, 95% confidence interval 1.02 to 1.11). In conclusion, in patients presenting with NSTEMIs and managed with an invasive strategy, a lower hemoglobin level is associated with more extensive coronary artery disease, less use of revascularization and evidence-based therapies, and increased mortality.

Little is known about the impact of early invasive treatment in patients following out-of-hospital cardiac arrest (OHCA). The present study investigated the clinical characteristics and long-term prognosis of 1254 patients with suspected acute coronary syndrome, including 65 with OHCA who underwent successful cardiopulmonary resuscitation (CPR) and 1189 patients who did not require CRP. All patients underwent immediate coronary angiography even if clear signs of myocardial infarction (MI) were absent. The incidence of ST-elevation and non-ST-elevation MI did not differ between the two groups. Cardiac biomarkers were significantly higher in CPR patients despite a shorter period from symptom onset to admission. The 6-month mortality rate was 29% in the CPR group and 4% in the non-CPR group, with > 90% of fatalities occurring ≤ 3 weeks after admission. In summary, early invasive treatment leads to a considerably reduced mortality and improved prognosis in patients after OHCA.

Image-guided tumor ablation is a minimally invasive strategy to treat focal tumors in the liver, lung, kidney, bone, and adrenal glands by inducing irreversible cellular injury through the application of thermal, and more recently, nonthermal energy, or chemical injection. Given the multiplicity of treatment types and potential complexity of paradigms in oncology, and the wider application of thermal ablation techniques, a thorough understanding of the basic principles and recent advances in thermal ablation is a necessary prerequisite for their effective clinical use. This chapter will review several of these key concepts related to tumor ablation including those that relate to performing a clinical ablation, such as understanding the goals of therapy and mechanisms of tissue heating or tumor destruction, and understanding the proper role of tumor ablation and the strategies that are being pursued to improve overall ablation outcome.

Under the heading of acute coronary syndrome (ACS), we include myocardial infarction with ST segment elevation (STEMI), myocardial infarction without ST segment elevation (NSTEMI) and unstable angina (UA). Given the similar pathophysiological mechanisms, clinical manifestations, diagnostic and therapeutic algorithm UA and NSTEMI are sorted into a common group of ACS without ST segment elevation (NSTE-ACS). ACS is a serious clinical disease, which is associated with higher mortality than stable angina pectoris. High proportion of patients die of sudden death in the early hours of ACS (especially STEMI), before admission to the hospital, therefore it is difficult to assess the real incidence of ACS. The incidence of ACS also depends on the sensitivity of the humoral markers of myocyte necrosis. The annual hospital admissions rate for NSTE-ACS is estimated from the results of registers and surveys about 3 per 1000 inhabitants. The proportion of STEMI represents approximately 20% of NSTE ACS.

We thank Drs Correia and Barreto-Filho for their interest in our work.1,2 In response, patients with acute coronary syndromes enrolled in the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial underwent guideline-recommended early invasive angiography followed by revascularization when appropriate. Our study (in contrast to Invasive Versus Conservative Treatment in Unstable Coronary Syndromes [ICTUS]) was neither meant to confirm nor refute the correctness of this practice (currently class I level of recommendation in the North American and European Guidelines3,4), but rather the value of specific angiographic findings in further assigning patient risk once angiography is performed. However, because the issue has been raised, it is worth noting that ICTUS was only one such randomized trial examining the utility of an early invasive strategy in acute coronary syndrome, and modestly sized at that, resulting in end points with wide confidence intervals. All such studies (including …

A recently developed immunoassay for high-sensitivity measurement of cardiac troponin T (hsTnT) allows measurement at the 99th percentile for a normal population with an assay imprecision

Aims To assess gender differences in outcome with an early invasive or non-invasive strategy in patients with non-ST-elevation acute coronary syndromes (NSTE ACS). less thanbrgreater than less thanbrgreater thanMethods and results We included 46 455 patients [14 819 women (32%) and 31 636 men (68%)] from the SWEDEHEART register, with NSTE ACS, between 2000 and 2006, and followed them for 1 year. In the non-invasive strategy arm, the relative risk (RR) of death was (women vs. men) 1.02 [95% confidence interval (CI), 0.94-1.11] and in the invasive strategy arm 1.12 (95% CI, 0.96-1.29). After adjustment for baseline differences between the genders, with propensity score and discharge medication, there was a similar trend towards better outcome among women in both the early non-invasive cohort [RR 0.90 (95% CI, 0.82-0.99)] and the early invasive cohort [RR 0.90 (95% CI, 0.76-1.06)], although it did not reach statistical significance in the early invasive cohort. Results were similar with the combined endpoint death/myocardial infarction. An early invasive treatment was associated with a marked, and similar, mortality reduction in women [RR 0.46 (95% CI, 0.38-0.55)] and men [RR 0.45 (95% CI, 0.40-0.52)], without interaction with gender. less thanbrgreater than less thanbrgreater thanConclusion In this large cohort of patients with NSTE ACS, reflecting real-life management, women and men had similar and better outcome associated with an invasive strategy. Funding Agencies|County Council of Ostergotland||National Board of Health and Welfare||Swedish Society of Cardiology||Swedish Association of Local Authorities and Regions

benefit as compared to mild therapeutic hypothermia by inhibiting multiple deleterious pathways. OBJECTIVE: We sought to determine the feasibility of cooling and maintaining comatose post-cardiac arrest patients with ROSC at a target temperature of 31 degrees Celsius over a 24 hour interval. The ability to achieve and maintain moderate therapeutic hypothermia (31 degrees Celsius) in a clinical setting has never been studied in post-cardiac arrest patients. METHODS: The University of Ottawa Heart Institute (UOHI) is currently conducting a randomized controlled therapeutic hypothermia trial, CAPITAL CHILL. Patients presenting with out-of-hospital cardiac arrest, whose treatment includes therapeutic hypothermia, are randomly allocated to mild (34 degrees Celsius) or moderate (31 degrees Celsius) hypothermia through the use of an endovascular cooling device. We identified the first 20 patients who were randomized to 31 degrees Celsius. We examined the ability to achieve and maintain a target temperature of 31 degrees Celsius during a 24 hour interval. RESULTS: Between August 2013 and April 2014, we identified the first 20 consecutive patients randomized to 31 degrees Celsius: the mean age was 60 16 yr. A complete temperature dataset was available on 18 patients, however, out of these patients, 2 expired 12 and 16 hrs following randomization. The figure depicts the mean temperatures with standard deviations evaluated during a 24 hour period at the following time points; 0, 2, 4, 8, 12, 16, 20 and 24 hours. The zero time point was defined as the temperature at randomization.

s S147 186 EFFICACY AND SAFETY OF A ROUTINE EARLY INVASIVE STRATEGY IN RELATION TO TIME FROM SYMPTOM ONSET TO FIBRINOLYSIS: A SUBGROUP ANALYSIS FROM TRANSFER-AMI JJ Russo, SG Goodman, WJ Cantor, M Tan, B Borgundvaag, D Fitchett, V Dzavik, RT Yan, JJ Graham, SR Mehta, AT Yan

Introdução: A idade é um importante factor prognóstico em contexto de síndromes coronárias agudas (SCA). A estratégia invasiva tem demonstrado benefício em muitas populações com SCA sem supradesnivelamento de ST; contudo, continua a ser um tema controverso em doentes mais susceptíveis a complicações relacionadas com o procedimento, como os idosos, uma população sub-representada nos estudos sobre a matéria. Objectivo: Comparar o prognóstico intra- -hospitalar e a longo prazo de doentes idosos com SCA sem supradesnivelamento do segmento ST submetidos a estratégia invasiva versus estratégia conservadora. Pretendemos ainda caracterizar os doentes seleccionados para uma abordagem inicialmente invasiva. Métodos: Estudo observacional, longitudinal, prospectivo e contínuo, incluindo 307 doentes com idade superior a 75 anos consecutivamente hospitalizados por SCA sem supradesnivelamento de ST. Foram formados dois grupos de acordo com a abordagem adoptada: Grupo A (n=91) – doentes submetidos a uma estratégia invasiva precoce; Grupo B (n=216) – doentes submetidos a uma estratégia conservadora. Procedeu-se a um seguimento clínico mediano de 18 meses. Resultados: Os doentes abordados de forma invasiva eram mais novos (79,8 ± 3,2 versus 81,4 ± 3,9 anos, p

The relationship between levels of amino-terminal pro-B-type natriuretic peptide (NT-proBNP) and left ventricular function determined by magnetic resonance imaging (MRI) in ST-segment-elevation myocardial infarction (STEMI) is largely unknown.This was a substudy of the Norwegian Study on District Treatment of STEMI, in which patients received thrombolysis followed by early or late invasive strategy. NT-proBNP was measured at 3 days and 3 months after the myocardial infarction, and magnetic resonance imaging was performed after 3 months (n = 160). Log NT-proBNP levels at both time points were significantly associated with ejection fraction (EF) (r(2) values 0.25 and 0.42, respectively) as well as infarct size (r(2) values 0.38 and 0.47, respectively; P.0001 for all, adjusted for confounders). Furthermore, receiver operating characteristic (ROC) curves used to analyze the ability of NT-proBNP to discriminate long-term low EF (≤40%) and large infarct size (≥15.7%), were significant at both time points (P.001 for all). Pairwise comparison of the ROC curves showed a significantly better performance of NT-proBNP at 3 months compared with 3 days for discrimination of low EF (P = .023).Repeated measurements of NT-proBNP in STEMI patients showed that NT-proBNP levels at 3 months were more strongly associated with long-term EF and infarct size than NT-pro BNP levels after 3 days. Our data suggest that measurement of NT-proBNP 3 months after myocardial infarction is a better indicator of left ventricular function compared with NT-proBNP in the acute phase.

Thoracoscopic lobectomy has become an accepted, safe, and oncologically sound procedure compared with open lobectomy. Several studies have reported that it reduces the length of stay, postoperative pain, and postoperative complications, including air leaks. Although there are specific technical considerations that must be taken into account, it is increasingly becoming the preferred method of anatomic lobectomy. Surgeons should be encouraged to embrace the minimally invasive strategy, which may be learned in courses using novel simulation techniques. Future directions suggest that this technique will be expanded to address even the most challenging thoracic procedures.

Cryoablation is a viable minimally invasive strategy for the treatment of small renal masses. One of the most common postoperative complaints is pain or paresthesia at the cryoprobe insertion site. The use of a 14-gauge angiocatheter to insulate the flank during renal cryotherapy was investigated.Six Yorkshire swine underwent laparoscopy-guided percutaneous cryoablation of the upper and lower poles of both kidneys with a 1.47 mm (17 gauge) cryoneedle. Treatment consisted of a double 10-minute freeze separated by a 5-minute active thaw. Trials were randomized to placement of the cryoneedle directly through the flank or through a 14-gauge angiocatheter as an insulating sheath. Temperatures were recorded adjacent to the cryoneedle at two depths in the flank with a Multi-Point Thermal Sensor.Twelve trials were completed each with a bare and sheathed cryoneedle. The coldest temperature observed was -26 degrees C for the bare cryoneedle and -21 degrees C for the sheathed cryoneedle. At the outer sensor, there was a 4.1 degrees C increase in mean temperature for freeze 1, and 6.2 degrees C increase in mean temperature for freeze 2 with sheath use. At the inner sensor, there was a 3.0 degrees C increase in mean temperature for freeze 1, and 9.4 degrees C increase in mean temperature for freeze 2 with sheath use. There was a trend toward statistical significance of sheath insulation at the outer (p = 0.07) and inner (p = 0.08) temperature sensors.A 14-gauge angiocatheter may provide some insulation and thereby might help protect against "ice burn" during renal cryotherapy.

Twenty-three patients were randomized to a minimally invasive strategy or to standard percutaneous transluminal coronary angioplasty followed by intracoronary ultrasound. There was no difference in intracoronary ultrasound-determined dissection after the procedure in the 2 groups, and the mechanism of lumen enlargement by percutaneous transluminal coronary angioplasty in both groups predominantly was due to vessel stretch.

The value of invasive therapy in elderly patients with acute myocardial infarction is controversial. The authors performed a retrospective chart review of 140 consecutive patients 80 years and older who were hospitalized with acute myocardial infarction. Hospital outcomes and long-term survival were compared in 79 patients referred for cardiac catheterization during hospitalization with outcomes in 61 patients managed conservatively. Vital status as of December 2003 was determined from the Social Security Death Index. Propensity analysis was used to limit confounding from 13 variables. After a mean follow-up of 333 days, unadjusted mortality was lower in the invasive group (16.5% vs 50.8%; P

Transcatheter aortic valve implantation (TAVI) is mainly done via a conventional strategy (CS); i.e., under general anesthesia (GA) in hybrid operating rooms with transesophageal Echo (TEE) guidance. Some centers, mostly in Europe, have demonstrated the feasibility of a minimally invasive strategy (

Introduction Non ST elevation Acute Coronary Syndrome (NSTEACS) is more common in older patients and invasive treatment is an established management strategy in the United Kingdom. Frailty is an independent marker of adverse cardiovascular (CV) outcomes in older patients. Older patients with atherosclerotic disease are at risk of developing cognitive impairment. Frailty and cognitive impairment in older patients with NSTEACS can be a predictor of poor CV outcomes. The prevalence of undiagnosed early cognitive impairment in frail older patients with NSTEACS managed by invasive strategy is not known. Methods Cognitive status was assessed using Montreal Cognitive Assessment (MoCA) tool (maximum score 30, normal ≥26) in consecutive patients (≥ 75 years) admitted to a tertiary cardiac centre for invasive management of NSTEACS as a sub-study of an ongoing prospective study. Patients with known severe dementia were excluded from the study. Frailty status was assessed by Fried (Cardiovascular Health Study) frailty assessment tool (score 0–5) and patients categorised into frail (score ≥3) and non-frail (score 0–2) groups. Results MoCA score was available in 175 (89.3%) patients. About a third (30.8%) of these patients were frail and half of the patients (50.3%) had MoCA score Conclusion Undiagnosed early cognitive impairment is very common in 75+ year old patients presenting with NSTEACS managed by invasive strategy. Cognitive impairment is more common in frail patients compared to non-frail patients. Combination of frailty and cognitive impairment may have an adverse impact on the cardiovascular outcomes of older patients with NSTEACS managed by invasive strategy. Frailty and cognitive assessment may need to be part of risk assessment in older patients planned for invasive management.