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The study was designed to examine the safety and efficacy of acute interventional use of captopril on left ventricular volumes, ventricular arrhythmias and neurohormones during thrombolysis in patients with a first anterior myocardial infarction, within 6 h of onset of symptoms. Left ventricular dysfunction and prognosis after myocardial infarction can be improved by angiotensin converting enzyme inhibition started after the ischaemic phase. Experimental evidence suggests that intervention during thrombolysis may lead to even further benefit. In a randomized, double-blind placebo-controlled trial, 298 patients with a first anterior myocardial infarction, eligible for thrombolytic therapy were treated with captopril 6.25 mg or placebo, started immediately upon streptokinase infusion and titrated to 2.5 mg t.i.d.. The efficacy of captopril by an intention-to-treat-analysis to reduce left ventricular volumes, ventricular arrhythmias, neurohumoral activation and enzymatic infarct size was measured. During dose titration, mean blood pressure and heart rate were similar in both groups. However, hypotension after the first dose was reported in 18 patients on placebo and 31 patients on captopril (P<0.05). At discharge, 80% of patients were on study medication. Left ventricular volumes were significantly increased in both groups at 3 months, but they tended to be lower in the captopril group; however, the differences were not statistically significant. The incidence of accelerated idioventricular rhythm and non-sustained ventricular tachycardia in captopril patients was lower than in placebo patients (P<0.05), parallelled by transiently lower norepinephrine levels (P<0.05) upon thrombolysis. In addition, enzymatic infarct size was smaller in captopril patients, especially in larger infarcts (P<0.05), and a 34% (95% confidence interval; 0–56%) lower incidence of heart failure during 3 months follow-up was reported in the captopril group. Captopril is well tolerated, although hypotension after the first dose was more common than in patients on placebo. In agreement with experimental studies, captopril reduces repetitive ventricular arrhythmias and catecholamine levels in the acute thrombolytic phase of myocardial infarction. Although left ventricular volumes were not significantly smaller in captopril patients, in the chronic phase, these patients showed a reduced incidence of heart failure. This study was carried out under auspices of the Interuniversity Institute of the Netherlands (ICIN) and the Working Group of Cardiovascular Research the Netherlands (WCN). Financial support was received from Bristol-Myers Squibb, Pharmaceutical Research Institute, Princeton, N.J., U.S.A. [ABSTRACT FROM PUBLISHER]

Patients with three-vessel coronary artery disease have been found to have better outcomes with coronary-artery bypass grafting (CABG) than with percutaneous coronary intervention (PCI), but studies in which PCI is guided by measurement of fractional flow reserve (FFR) have been lacking. METHODS In this multicenter, international, noninferiority trial, patients with three-vessel coronary artery disease were randomly assigned to undergo CABG or FFR-guided PCI with current-generation zotarolimus-eluting stents. The primary end point was the occurrence within 1 year of a major adverse cardiac or cerebrovascular event, defined as death from any cause, myocardial infarction, stroke, or repeat revascularization. Noninferiority of FFR-guided PCI to CABG was prespecified as an upper boundary of less than 1.65 for the 95% confidence interval of the hazard ratio. Secondary end points included a composite of death, myocardial infarction, or stroke; safety was also assessed. RESULTS A total of 1500 patients underwent randomization at 48 centers. Patients assigned to undergo PCI received a mean (±SD) of 3.7±1.9 stents, and those assigned to undergo CABG received 3.411.0 distal anastomoses. The 1-year incidence of the composite primary end point was 10.6% among patients randomly assigned to undergo FFR-guided PCI and 6.9% among those assigned to undergo CABG (hazard ratio, 1.5; 95% confidence interval [CI], 1.1 to 2.2), findings that were not consistent with noninferiority of FFR-guided PCI (P=0.35 for noninferiority). The incidence of death, myocardial infarction, or stroke was 7.3% in the FFR-guided PCI group and 5.2% in the CABG group (hazard ratio, 1.4; 95% CI, 0.9 to 2.1). The incidences of major bleeding, arrhythmia, and acute kidney injury were higher in the CABG group than in the FFR-guided PCI group. CONCLUSIONS In patients with three-vessel coronary artery disease, FFR-guided PCI was not found to be noninferior to CABG with respect to the incidence of a composite of death, myocardial infarction, stroke, or repeat revascularization at 1 year. (Funded by Medtronic and AbbottVascular; FAME 3 ClinicalTrials.gov number, NCT02100722.) [ABSTRACT FROM AUTHOR]

Background: Only few data are available on the predictive value of ST deviation (both ST elevation and depression). Therefore, we have examined the predictive value of ST elevation and ST deviation in STEMI patients on 30-day and long term mortality., Methods: All STEMI patients with an interpretable diagnostic electrocardiogram, who were referred to the Isala hospital and were planned to undergo a primary coronary intervention (pPCI) in the period 2001 until 2009, were prospectively registered in a cohort study. These patients were divided in tertiles based on the cumulative (cum) ST deviation (D1, D2 and D3) and cum ST elevation (E1, E2 and E3), as assessed by an independent core-lab., Results: In total, 4513 patients were registered. 30-day mortality increased with cum ST deviation (0-9 mm: 1.9%, > 9-16 mm: 2.4%, > 16 mm: 3.9%, P = 0.001), but not significant with cum ST elevation. Long term mortality increased with cum ST-deviation (0-9 mm: 18.6%, > 9-16 mm: 22.1%, > 16 mm: 25.7%, P < 0.001) and with cum ST-elevation (0-6mm: 19.7%, > 6-11 mm: 22.7%, > 11 mm: 24.2%, P = 0.070). After multivariable adjustment using Cox proportional Hazard models, cum ST deviation (D1: reference, D2: HR: 1.09 95% CI (0.67-1.77), D3: HR: 1.76 95% CI (1.14-2.73)) was independently associated with 30-day mortality. Both cum ST deviation (D1: reference, D2: HR: 1.14 95% CI (0.98-1.34), D3: HR: 1.32 95% CI (1.13-1.53)) and ST elevation (E1: reference, E2: HR: 1.17 95% CI (1.00-1.38), E3: HR: 1.21 95% CI (1.04-1.42)) were independently associated with long term mortality., Conclusions: Besides ST elevation, taking the extent of ST depression into account improves the predictive value of the diagnostic 12 lead electrocardiogram especially for 30-day mortality in STEMI patients who are planned to undergo pPCI., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Pre-hospital infarct diagnosis gives the opportunity to start anti-platelet and anti-thrombotic agents before arrival at the PCI centre. However, more evidence is necessary to demonstrate whether high dose (HD) clopidogrel (600 mg) administered in the ambulance is associated with improved initial patency of the infarct related vessel (IRV) and/or clinical outcome compared to in-hospital initiation of HD clopidogrel. From 2001 until 2009 all consecutive ST-Segment Elevation Myocardial Infarction (STEMI) patients who underwent pre-hospital diagnosis and therapy in the ambulance were prospectively included in our single-centre cohort study. We compared initial patency of the IRV and clinical outcome in patients treated from 2001 until June 2006 (in-hospital HD clopidogrel) with patients treated from July 2006 until 2009 (ambulance HD clopidogrel). A total of 2,475 patients with STEMI were registered; of these 1,110 (44.8%) received in-hospital HD clopidogrel and 1,365 (55.2%) received ambulance HD clopidogrel. Ambulance HD clopidogrel was not independently associated with initial patency (TIMI-2/3-flow pre-PCI (odds ratio: 1.18, 95% confidence interval [CI] 0.96-1.44); however, it was associated with fewer recurrent myocardial infarctions at 30 days (hazard ratio [HR]: 0.45, 95% CI 0.22-0.93) and at one year (HR: 0.45, 95% CI 0.25-0.80). No difference in TIMI 2/3 flow post-PCI, major bleeding, mortality, MACE - and the combination of mortality and recurrent myocardial infarction at 30-days and at one year was present between the two groups. In conclusion, early in-ambulance as compared to in-hospital initiation of HD clopidogrel in STEMI patients did not improve initial patency of the IRV or clinical outcome, except for a reduction of recurrent myocardial infarction. Therefore, early administration of HD clopidogrel seems to have net clinical benefit for these patients.

Background: Despite the proven benefit of glycoprotein IIb/IIIa blockers in patients with acute ST-segment elevation myocardial infarction (STEMI), there is still debate on the timing of administration of these drugs and whether all or only a selection of patients should be treated. We evaluated the effect of routine upfront versus provisional use of high-dose tirofiban (HDT) in a large real-world population of non-selected STEMI patients., Methods: Consecutive STEMI patients were registered in a single-centre dedicated database. Patients with upfront HDT therapy before first balloon inflation were compared with patients who received the drug on a provisional basis, after first balloon inflation. Initial TIMI flow of the infarct-related vessel and enzymatic infarct size and 30-day clinical outcome were assessed., Results: Out of 2679 primary PCI patients HDT was given upfront in 885 (33.0%) and provisionally in 812 (45.3%). Upfront as compared with provisional HDT showed higher initial patency (22.3 vs. 17.9%, p=0.006), smaller infarct size (1401 IU/l (IQR 609 to 2948) vs. 1620 (753 to 3132), p=0.03) and a lower incidence of death or recurrent MI at 30 days (3.3 vs. 5.1%, p=0.04) without an increase in TIMI bleeding (p=0.24). Upfront HDT independently predicted initial patency (odds ratio (OR) 1.47, 95% confidence interval (CI) 1.15 to 1.88, p=0.02), enzymatic infarct size (OR 0.70, 95% CI 0.56 to 0.86, p=0.001) and 30-day death or recurrent MI (OR 0.59, 95% CI 0.37 to 0.95, p=0.03)., Conclusion: Our findings support the use of upfront potent antiplatelet and antithrombotic therapy in STEMI patients and encourage further clinical investigations in this field. (Neth Heart J 2010;18:592-7.).

Background. In patients with unstable angina or non-ST-elevation acute coronary syndrome (NSTE-ACS) who are eligible for PCI, routine stenting is the recommended treatment strategy, based on the opinion of experts. Provisional stenting may provide a viable alternative by retaining the early benefits of stenting without its potential late hazards.Method. Patients with NSTE-ACS were randomised to provisional or routine stenting after coronary angiography. Patients were followed for up to ten years. The occurrence of major adverse cardiac events (MACE) was recorded.Results. 237 consecutive patients with NSTE-ACS were randomly assigned to routine stenting (n=116) or provisional stenting (n=121). No difference in the incidence of MACE at 30 days was observed. At six months, angiographic restenosis was lower in the routine stenting group (41 vs. 20%, p=0.02), paralleled by more MACE in the provisional stenting group at one year (40.5 vs. 27.6%, p=0.036). At complete follow-up the difference in MACE was not significant (61.2 vs. 50%, p=0.084) because of relatively more target lesion revascularisations in the routine stent group. There was no difference in the incidence of very late stent thrombosis (1.7 vs. 3.4%, p=0.439). The only independent predictor of MACE was beta-blocker use (RR 0.62 [0.431; 0.892] p=0.010).Conclusion. In selective patients with NSTE-ACS, routine stenting was more beneficial than provisional stenting for a period of up to five years, driven by a reduction in repeat revascularisation procedures. After this period, the benefit was no longer significant. Beta-blocker use was the only independent predictor of MACE throughout the complete follow-up period. (Neth Heart J 2010;18:307-13.).

Background. Myocardial blush grade (MBG) and myocardial contrast echocardiography (MCE) are both indices for myocardial perfusion in patients with ST-elevation acute myocardial infarction (STEMI). We aimed to compare MBG with MCE in the infarct-related artery segment for assessing infarct size in patients with STEMI treated with primary percutaneous coronary intervention (PCI).Methods. 43 patients underwent successful (postprocedural TIMI flow 3) primary PCI for STEMI. MBG was assessed at the end of the PCI procedure and MCE was assessed 1.7+/-1.8 days after PCI. Enzymatic infarct size was estimated by measurementof enzyme activities by using lactate dehydrogenase (LDH) as the referenceenzyme. Cumulative enzyme release (LDHQ(48)) from at least five serial measurements up to 48 hours after symptom onset was calculated. Also peak creatine kinase, CK-MB and peak LDH were measured.Results. MBG 0/1, 2 and 3 were observed in 14, 12 and 17 patients, respectively, and was compared with tertiles of MCE. We found a parallel correlation between both MBG and MCE and LDHQ(48). However, there was no correlation between MCE and MBG. Patients with both normal MCE and a normal MBG had least myocardial damage and those with both impaired MCE and an impaired MBG had most myocardial damage.Conclusion. Both MBG and MCE are good predictors of infarct size in STEMI patients treated with PCI. However, these markers are not mutually related, possibly due to time-related changes in myocardial perfusion. Combining these two markers may yield a more accurate prediction of final myocardial damage. (Neth Heart J 2010;18:25-30.).

BACKGROUND.: Although techniques for percutaneous coronary intervention (PCI) have improved, patients with PCI of more vessels may still have an increased risk. We performed a prospective observational study evaluating the differences between multivessel and single-vessel procedures according to postprocedural troponin T (TnT) elevation and events during follow-up. METHODS.: The study included 713 patients without elevated TnT (<0.05 ng/ml) before PCI. Primary endpoint was the combined endpoint of death, myocardial infarction, stroke, repeat coronary angiography and readmission for anginal symptoms during the mean follow-up of 10.9 months. RESULTS.: TnT after PCI was elevated in 150 patients (21%) and was significantly associated with an increased incidence of the primary endpoint (RR 1.55, 95% CI 1.01 to 2.38). PCI of more than one vessel was performed in 146 patients (20%). These patients more often had increased TnT levels after the procedure (31.5 vs. 18.3%, p=0.001) and an increased incidence of the primary endpoint during follow-up (28 vs. 19%, p=0.01). After multivariable analysis, multivessel PCI was a statistically significant predictor of postprocedural TnT increase (OR 1.90, 95% CI 1.17 to 3.06). Multivessel PCI was also associated with an increased risk of the primary endpoint (OR 1.73, 95% CI 1.18 to 2.52), but after adjusting for multivessel disease this association was not statistically significant (OR 1.42, 95% CI 0.92 to 2.19). CONCLUSION.: Elective PCI of more vessels in one session is, in comparison with single-vessel PCI, more often associated with postprocedural troponin T rise and a (nonsignificantly) higher incidence of cardiac events during follow-up. Whether staged PCI is associated with less morbidity has to be assessed. (Neth Heart J 2007;15:178-83.).

Background: Admission hyperglycaemia is associated with an increased risk of mortality after myocardial infarction. Whether long-term glucose dysregulation (assessed by HbA1c) is more important than acute hyperglycaemia is unknown. We evaluated the prognostic value of admission glucose and HbA1c levels in nondiabetic patients with ST-segment elevation acute myocardial infarction (STEMI)., Methods: In 504 unselected, consecutive patients with STEMI, glucose and HbA1c levels were measured on admission. Glucose was categorised as <11.1 mmol/l (n=422) and >or= 11.1 mmol/l (n=82). HbA1c levels were categorised as <6.0% (n=416) and >or=6.0% (n=88). Mean follow-up was 1.6+/-0.6 years., Results: Patients with hyperglycaemia on admission were comparable with those with normoglycaemia. However,patients with HbA1c >or=6.0%, as compared with those with HbA1c <6%, were older, were more often on beta-blockers and more frequently had multivessel disease. Thirty-day mortality in the subsequent glucose categories (<11.1 mmol/l and >or=11.1 mmol/l) was 4% and 19% (p<0.001) and in the subsequent HbA1c categories (<6% and >or=6%) was 5% and 12% (p=0.03). After multivariable analyses, admission glucose (OR 4.91,95% CI 2.03 to 11.9, p< 0.001) but not HbA1c (OR 1.33, 95%CI 0.48 to 3.71, p=0.58) was significantly associated with 30-day mortality. Among 30-day survivors, neither admission glucose nor HbA1c were predictors of long-term mortality., Conclusion: Elevated admission glucose is an important predictor of 30-day outcome after STEMI, while prior long-term glucose dysregulation is a covariate of other high-risk clinical characteristics. Among 30-day survivors, neither admission blood glucose nor HbA1c were predictors of long-term outcome.

Background: Admission hyperglycaemia is associated with poorer prognosis in patients with an acute coronary syndrome (ACS). Whether hyperglycaemia is more important than prior long-term glucose metabolism, is unknown., Aim: To investigate the prognostic value of admission glucose and HbA(1c) levels in patients with ACS., Methods: We measured glucose and HbA(1c) at admission in 521 consecutive patients with suspected ACS. Glucose was categorized as <7.8 (n = 305), 7.8-11.0 (n = 138) or > or =11.1 mmol/l (n = 78); HbA(1c) as <6.2% (n = 420) or > or =6.2% (n = 101). Mean follow-up was 1.6 +/- 0.5 years., Results: The diagnosis of ACS was confirmed in 332 patients (64%), leaving 189 (36%) with atypical chest pain. In ACS patients, mortality by glucose category (<7.8, 7.8-11.0 or > or =11.1 mmol) was 9%, 8% and 25%, respectively (p = 0.001); mortality by HbA(1c) category (<6.2% vs. > or =6.2%) was 10% vs. 17%, respectively (p = 0.14). On multivariate analysis, glucose category was significantly associated with mortality (HR 3.0, 95% CI 1.1-8.3), but HbA(1c) category was not (HR 1.5, 95%CI 0.6-4.2)., Discussion: Elevated admission glucose appears more important than prior long-term abnormal glucose metabolism in predicting mortality in patients with suspected ACS.

A 78-year-old man presented with dyspnoea and a 57-year-old with chest pain. Both had a history of coronary atherosclerosis and were now found to have a cardiac murmur. They proved to have a ventricular septal rupture (VSR) that had not been recognized as such. In the older man, the myocardial infarction that caused the VSR had initially not been recognized and in both men the clinical course was erroneously attributed to heart failure caused by myocardial infarction alone. Both underwent surgical correction of the VSR; the older man died due to postoperative intestinal necrosis, the younger man recovered. Patients with a high cardiac-risk profile, atypical chest pain, symptoms ofdyspnoea and a new specific murmur should be suspected of having a VSR. Early recognition and treatment of VSR may reduce mortality significantly.

BACKGROUND: Apart from diabetes itself, even minor glycometabolic dysregulation may be associated with an increased risk of cardiovascular disease. We analyzed the prevalence and predictive value of glycometabolic disturbances in patients with a suspected acute coronary syndrome (ACS). METHODS: In a prospective follow-up study, admission glucose and Hba1C levels in all consecutive patients with suspected ACS were measured. Dysglycemia was defined as a Hba1C of 5.6-6.1% with a non-fasting glucose above 7.8 mmol/L. Both predictors of glycometabolic disturbances and the predictive value of glycometabolic disturbances were studied. RESULTS: Of the 521 patients with a suspected ACS who were included in the study, 332 (64%) had an ACS and 189 (36%) had atypical chest pain. A total of 115 patients (22%) had diabetes and 65 (13%) had dysglycemia. Patients with diabetes or dysglycemia had an increased risk of a confirmed diagnosis of ACS (RR 2.3, 95% CI 1.5-3.4). Multivariate analyses did not change these findings. CONCLUSIONS: One in three patients with suspected ACS had a glucose metabolism disturbance. Glycometabolic disturbance was strongly associated with a confirmed diagnosis of ACS. Whether intensive treatment of patients with disturbed glucose metabolism may improve long-term prognosis needs to be assessed.

Background: Statin therapy can reduce long-term mortality in several subgroups of patients with coronary artery disease, but the benefits after primary angioplasty for ST-segment elevation myocardial infarction (STEMI) have yet to be established. Thus the aim of the current study was to determine whether statin therapy is associated with a reduction in mortality in patients with STEMI treated with primary angioplasty., Methods: Our population is represented by a total of 1513 consecutive in-hospital survivors treated with primary angioplasty for STEMI between April 1997 and October 2001. Patients were divided into two groups according to statin therapy (statin group, n=893; control group, n=620) at discharge. Clinical follow-up was performed at one year. Multivariate analysis was performed including a propensity score for statin use., Results: At one-year follow-up statin therapy was associated with a significantly lower mortality (1.2 vs. 71.%, RR [95% CI] 0.16 [0.09-0.32], p<0.0001). Also at multivariate analysis, including the propensity score, statin therapy was associated with a significant mortality reduction (adjusted RR [95% CI] 0.24 [0.12-0.47], p<0.0001)., Conclusion: Statin therapy at discharge was associated with a significant reduction in one-year mortality after primary angioplasty for STEMI. Therefore, the use of statins after STEMI is highly recommended.

Aims: The role of collateral flow in the first hours of infarction remains unclear. Our aim was to determine whether the presence of coronary collateral flow, as evidenced by angiography, has a beneficial effect on infarct size and left ventricular function in acute myocardial infarction (MI) treated by means of early percutaneous coronary intervention (PCI)., Methods: Between 1994 and 2001, 1059 patients with acute MI treated with primary PCI, TIMI (Thrombolysis in Myocardial Infarction) 0 or 1 flow at first contrast injection and technically adequate angiograms for collateral flow detection were analysed., Results: Comparison of collateral flow grades 0, 1, and 2/3 showed that increased collateral flow was associated with a lower incidence of Killip class >/= 2 at presentation (12% vs. 10% vs. 3%, p for trend 0.02), less need for intra-aortic balloon pumping after PCI (17% vs. 13% vs. 5%, p for trend 0.005), better myocardial blush grade (MBG) in infarcts related with the left anterior descending coronary artery (LAD) (MBG3: 14% vs. 18% vs. 34%, p for trend 0.01), and smaller enzymatic infarct size (cumulative lactate dehydrogenase release 36 h after symptom onset [LDHQ(36)]) (1932+/-1531 U/l vs. 1870+/-1458 U/l vs. 1217+/-762 U/l, p for trend 0.041). These beneficial effects were particularly evident in LAD-related infarcts., Conclusion: The presence of angiographically detectable collaterals has a protective effect on enzymatic infarct size and pre- and postintervention haemodynamic conditions in patients with acute MI treated by primary PCI, in particular when Rentrop grade 2/3 is present and the LAD is involved in the infarct.

Background: Time between symptom onset and effective reperfusion is of paramount importance in patients with acute myocardial infarction (MI) treated with reperfusion therapy. In the PHIAT (Pre-Hospital Infarction Angioplasty Triage) project, safety and feasibility of in-ambulance electrocardiography facilities for prehospital triage for direct transfer to an interventional centre to undergo immediate coronary angiography and angiography-guided therapy were evaluated., Methods and Results: The ambulances were equipped with a defibrillator and electrocardiography unit with computerised electrocardiographic analysis. Patients with acute MI symptoms and fulfilling certain criteria compatible with a large MI were included and pretreated with heparin and aspirin during transportation. During the study period, 284 patients were included. Eleven percent did not have an acute MI. PCI, performed in 94% (n=239) of the patients, was successful in 94%. Prehospital triage reduced time to treatment. In 32% of the patients triage resulted in direct transportation to the interventional centre instead of to the nearest community hospital. All-cause mortality was 9% after a mean follow-up of nine months. No serious bleeding complications were seen., Conclusion: Prehospital triage in the ambulance is safe and feasible. A striking percentage (11%) of the identified patients does not have an acute MI and this is more than has been reported from prehospital thrombolysis trials.

Background: Early VF accounts for the majority of deaths during the acute phase of acute MI. In patients treated with fibrinolytics, in-hospital VF occurs most frequently with inferior MI. Contrariwise, out-of-hospital VF seems to be associated with anterior wall MI and preinfarction angina (preconditioning) may protect against VF., Aim: To study clinical characteristics of patients with or without VF before or during reperfusion therapy., Study Design and Methods: From January 1995 until December 2001, we treated 2826 patients for acute MI and reviewed the clinical records of all patients. Patients who developed early VF were classified according to the first episode of VF: either before or during the angioplasty procedure., Results: VF developed in 219 (8%) patients. Early VF before reperfusion therapy (n=145, 5%) was independently related to anterior MI (RR 2.3 (95% CI 1.53-3.50), p<0.001), absence of preinfarction angina (RR 2.1 (95% CI 1.38-3.24), p=0.001) and Killip class >1 (RR 3.8 (95% CI 2.34-6.10), p<0.001). The majority of patients with VF during angioplasty (n=74, 3%) had inferior MI (61%)., Conclusion: Early VF before reperfusion therapy is independently associated with anterior MI, absence of preinfarction angina and Killip class >1, whereas the majority of patients with VF during angioplasty have inferior MI.

Objective: To study the impact of patency of the infarct-related artery on the coronary angiogram, both before and after primary angioplasty for acute myocardial infarction, on 30-day mortality., Method: Data of 1702 consecutive patients treated with primary angioplasty for acute myocardial infarction were collected prospectively from 1994 to 2000., Results: Patients with a (partially) patent infarct artery before primary angioplasty had less damage to the myocardium and a lower 30-day mortality (1.6% versus 3.4%, p=0.04) compared with patients with an occluded artery. Patients with pre-hospital treatment with aspirin and heparin more often presented with a patent artery before angioplasty (31% versus 20%, p<0.001). After primary angioplasty, 95% of patients had a patent artery with a 30-day mortality of 2.2%. The 5% of patients with failed angioplasty had extensive myocardial damage and a 30-day mortality rate of 17%., Conclusion: Patency of the infarct-related artery on the coronary angiogram, both before and after primary angioplasty, has a major impact on 30-day mortality.

Background: We investigated the impact of distal embolisation and other angiographic determinants in patients after successful primary angioplasty for acute myocardial infarction., Methods: Angiographic data were assessed on the coronary angiogram carried out immediately after successful (TIMI 2 or 3) coronary angioplasty in 631 consecutive patients with acute myocardial infarction. Embolisation was defined as a distal filling defect with an abrupt 'cutoff' in ≥1 of the peripheral coronary artery branches of the infarct-related artery, distal to the site of angioplasty. Endpoints were left ventricular ejection fraction (LVEF) and enzymatic infarct size., Results: Left anterior descending artery related myocardial infarction, impaired myocardial blush and distal embolisation were independent determinants of infarct size. Distal embolisation was present in 102 patients (16%) and was associated with a larger enzymatic infarct size (LDH Q 48 2250 vs. 1532, p=0.001) and a lower LVEF (41% vs. 44%, p=0.04). There was no difference in the frequency of distal embolisation between patients treated with or without stents., Conclusions: In successful primary angioplasty, infarct-related artery, impaired myocardial blush and distal embolisation are independent determinants of infarct size. Distal embolisation can be visualised in 16% of the patients and is associated with a larger enzymatic infarct size and lower LVEF. Intracoronary stenting is not associated with an increased risk of distal embolisation during primary angioplasty.