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Zusammenfassung. Das Wissen um kardiovaskuläre Veränderungen im Alter und deren therapeutische Optionen ist wichtig. Es kann zur Hypertrophie des linken Ventrikels, zur diastolischen Dysfunktion, Herzklappenveränderungen und pulmonaler Hypertonie kommen. Im Alter entwickeln Patienten häufig eine arterielle Hypertonie. Bei über 100-Jährigen sind valvuläre Veränderungen häufig (Aortenstenose und Mitralinsuffizienz). Das Risiko einer koronaren Herzkrankheit beträgt 35 % für Männer und 24 % für Frauen. Im Alter sind Sinusknotendysfunktion und Vorhofflimmern gehäuft. 25 % aller Schlaganfälle sind kardiale Embolien bei Vorhofflimmern. Kardiale Interventionen bei Betagten werden zunehmend häufiger durchgeführt und beinhalten koronare kathetertechnische Revaskularisationen oder Klappeneingriffe (perkutaner Aortenklappenersatz oder MitraClip). Die optimale Therapie im Alter beinhaltet neben kardiovaskulären Interventionen auch Medikamente und eine Lebensstilmodifikation und dient vor allem der Verbesserung der Lebensqualität.

BACKGROUND Little is known about differences in therapies and outcomes of patients with first myocardial infarction (MI) or recurrent MI (reMI). This study aimed to evaluate the impact of prior MI on therapies and outcomes in patients who presented with ST-elevation MI (STEMI). METHODS All STEMI patients enrolled from 2002 to 2014 in the AMIS Plus registry were included. Outcome was analyzed using logistic multivariate regression. RESULTS From 19,665 STEMI patients, 2845 (14%) had reMI. These patients were older (69.5y vs. 64.2y; p

Background The randomized BASKET-PROVE study showed no significant differences between sirolimus-eluting stents (SES), everolimus-eluting stents (EES), and bare-metal stents (BMS) with respect to the primary end point, rates of death from cardiac causes, or myocardial infarction (MI) at 2 years of follow-up, in patients requiring stenting of a large coronary artery. Clinical risk factors may affect clinical outcomes after percutaneous coronary interventions. We present a retrospective analysis of the BASKET-PROVE data addressing the question as to whether the optimal type of stent can be predicted based on a cumulative clinical risk score. Methods A total of 2,314 patients (mean age 66 years) who underwent coronary angioplasty and implantation of ≥1 stents that were ≥3.0 mm in diameter were randomly assigned to receive SES, EES, or BMS. A cumulative clinical risk score was derived using a Cox model that included age, gender, cardiovascular risk factors (hypercholesterolemia, hypertension, family history of cardiovascular disease, diabetes, smoking), presence of ≥2 comorbidities (stroke, peripheral artery disease, chronic kidney disease, chronic rheumatic disease), a history of MI or coronary revascularization, and clinical presentation (stable angina, unstable angina, ST-segment elevation MI). Results An aggregate drug-eluting stent (DES) group (n = 1,549) comprising 775 patients receiving SES and 774 patients receiving EES was compared to 765 patients receiving BMS. Rates of death from cardiac causes or nonfatal MI at 2 years of follow-up were significantly increased in patients who were in the high tertile of risk stratification for the clinical risk score compared to those who were in the aggregate low-mid tertiles. In patients with a high clinical risk score, rates of death from cardiac causes or nonfatal MI were lower in patients receiving DES (2.4 per 100 person-years, 95% CI 1.6-3.6) compared with BMS (5.5 per 100 person-years, 95% CI 3.7-8.2, hazard ratio 0.45, 95% CI 0.26-0.80, P = .007). However, they were not significantly different between receivers of DES and BMS in patients in the low-mid risk tertiles. Conclusions This exploratory analysis suggests that, in patients who require stenting of a large coronary artery, use of a clinical risk score may identify those patients for whom DES use may confer a clinical advantage over BMS, beyond lower restenosis rates.

The Old-Age Heart Abstract. Knowledge of cardiovascular changes in old age and their therapeutic options is important. Old age can lead to hypertrophy of the left ventricle, diastolic dysfunction, heart valve changes and pulmonary hypertension. Patients often develop arterial hypertension. Valvular changes are common in people over 100 years of age (aortic stenosis and mitral insufficiency). The risk of coronary heart disease is 35 % for men and 24 % for women. In old age, sinus node dysfunction and atrial fibrillation are common. 25 % of all strokes are cardiac embolisms in atrial fibrillation. Cardiac interventions in the elderly are increasingly frequent and include coronary catheter revascularization or valve interventions (percutaneous aortic valve replacement or MitraClip). Optimal therapy in old age includes not only cardiovascular interventions also include drugs and a lifestyle modification and mainly serves to improve the quality of life.Zusammenfassung. Das Wissen um kardiovaskuläre Veränderungen im Alter und deren therapeutische Optionen ist wichtig. Es kann zur Hypertrophie des linken Ventrikels, zur diastolischen Dysfunktion, Herzklappenveränderungen und pulmonaler Hypertonie kommen. Im Alter entwickeln Patienten häufig eine arterielle Hypertonie. Bei über 100-Jährigen sind valvuläre Veränderungen häufig (Aortenstenose und Mitralinsuffizienz). Das Risiko einer koronaren Herzkrankheit beträgt 35 % für Männer und 24 % für Frauen. Im Alter sind Sinusknotendysfunktion und Vorhofflimmern gehäuft. 25 % aller Schlaganfälle sind kardiale Embolien bei Vorhofflimmern. Kardiale Interventionen bei Betagten werden zunehmend häufiger durchgeführt und beinhalten koronare kathetertechnische Revaskularisationen oder Klappeneingriffe (perkutaner Aortenklappenersatz oder MitraClip). Die optimale Therapie im Alter beinhaltet neben kardiovaskulären Interventionen auch Medikamente und eine Lebensstilmodifikation und dient vor allem der Verbesserung der Lebensqualität.

There are few studies on patients suffering acute myocardial infarction (AMI) when already in hospital for other reasons; therefore, this study aimed to compare patients with in-hospital-onset AMI admitted for either medical or surgical reasons versus patients with outpatient-onset AMI.Patients enrolled in the AMIS Plus registry from 2002 to 2014 were analyzed. The main endpoint was in-hospital mortality.Among 35,394 AMI patients, 356 (1%) had inpatient-onset AMI following hospital admission due to other pathologies (surgical 175, non-surgical 181). These patients were older (74 vs. 66 years; P0.001), more often female (35% vs. 27%; P0.001), had less frequently ST-elevation myocardial infarction (35.5% vs. 55.5%; P0.001), but higher risk profiles: hypertension (83% vs. 62%; P0.001), diabetes (28% vs. 20%; P=0.001), known coronary artery disease (54% vs. 35%; P0.001), and more comorbidities (Charlson Comorbidity Index above 1 in 51% vs. 22%; P0.001) than those with outpatient-onset AMI. Percutaneous coronary intervention was less frequently applied (OR 0.45; 95% CI 0.36-0.57), and they were less likely to be treated with aspirin (OR 0.43; 95% CI 0.37-0.59), P2Y12 blockers (OR 0.42; 0.34-0.52) or statins (OR 0.51; 95% CI 0.41-0.63). Crude mortality was higher (14.3% vs. 5.5%; P0.001) and inpatient-onset AMI was an independent predictor of in-hospital mortality (OR 2.35; 95% CI 1.63-3.39; P0.001).Patients with in-hospital-onset AMI were at greater risk of death than those with outpatient-onset AMI. More work is needed to improve the identification of hospitalized patients at risk of AMI in order to provide the appropriate management.

Background: The aim of the study was to prove the concept that correction of established parameters of dyssynchrony is a requirement for favorable long-term outcome in patients with cardiac resynchronization therapy (CRT), whereas patients with persisting dyssynchrony should have a less favorable response. Methods: After CRT implantation and optimization of dyssynchrony parameters, we evaluated whether correction or persistence of dyssynchrony predicted long-term outcome. Primary endpoint was a combination of cardiac mortality/heart transplantation and hospitalization due to worsening heart failure, and secondary endpoint was NYHA class. Results: One hundred twenty-eight consecutive patients (mean age 68 ± 10 years) undergoing CRT with a mean left ventricular ejection fraction of 27±9% were followed for 27 ± 19 months. All cause mortality was 17.2%, cardiac mortality was 7.8% and 3.1% had to undergo heart transplantation. Rehospitalization due to worsening heart failure was observed in 14.8%. NYHA class before CRT implantation was 2.8 ± 0.8 and improved during follow-up to 2.0 ± 0.8 (P < 0.001). A clinical response was observed in 76% (n = 97) and an echocardiographic response was documented in 66% (n = 85). After individually optimized AV and VV intervals with echocardiography, atrioventricular dyssynchrony was still present in 7.2%, interventricular dyssynchrony in 13.3% and intraventricular dyssynchrony in 16.4%. Despite persistent atrioventricular, interventricular and intraventricular dyssynchrony at long-term follow-up, the combined primary and secondary endpoints did not differ compared to the group without mechanical dyssynchrony (P = ns). QRS duration with biventricular stimulation did not differ between responders vs. nonresponders. Conclusion: After successful CRT implantation, clinical long-term response is independent of correction of dyssynchrony measured by echocardiographic parameters and QRS width. Cardiol Res. 2014;5(6):163-170 doi: http://dx.doi.org/10.14740/cr368w

We investigated the prognostic value of normal predischarge exercise test in 109 patients after myocardial infarction treated with i.v. thrombolysis within 4 h. In 29 of these 109 patients, elective PTCA or bypass surgery was performed for prognostic reasons after coronary angiography; 80 patients were treated conservatively with drug therapy. Recurrent postinfarct angina early after hospital discharge was the reason in 4 of 80 for PTCA or bypass surgery. Twenty-three of the remaining 76 conservatively treated patients developed recurrent ischaemia during long-term follow-up of 12.0 +/- 6.2 months, including one patient with reinfarction. Late recurrent ischaemia during long-term follow-up was observed in one third of the conservatively treated patients with a normal predischarge exercise test, although a high percentage (30%) of patients in this subgroup had been treated with PTCA or bypass surgery mainly for prognostic reasons. Predischarge exercise test is therefore of limited value for detection of still viable myocardium at risk of further ischaemic events after acute myocardial infarction and thrombolysis.

Ventricular late potentials have been identified as a prognostic factor in the prediction of ventricular arrhythmias in patients after myocardial infarction. In this prospective study the possible impact of late potentials on the prediction of ventricular arrhythmias in the short- and long-term follow-up after coronary artery bypass grafting was evaluated. In 188 patients (165 men, 23 women, age 57 ±8 years) with chronic coronary heart disease 48 (26%) had late potentials before bypass grafting; after the procedure this was reduced to 39 (21%) (ns). In 16 (33%) of the 48 patients with late potentials before bypass grafting, late potentials were no longer present in the short-term follow-up (9 ±6 days). Conversely, seven (5%) of the 140 patients without late potentials before bypass grafting had late potentials in the short-term follow-up after grafting. Nine (19%) of the 48 patients with late potentials before bypass grafting had ventricular arrhythmias in the peri-operative phase, which had to be treated with antiarrhythmic agents. In contrast, only three (2%>) of the 140 patients without late potentials before bypass grafting had to be treated for ventricular arrhythmias (P

Aims: We examined what type of STEMI patients are more likely to undergo multivessel PCI (MPCI) in a "real-world" setting and whether MPCI leads to worse or better outcomes compared with single-vessel PCI (SPCI) after stratifying patients by risk. Methods and results: Among STEMI patients enrolled in the Swiss AMIS Plus registry between 2005 and 2012 (n=12,000), 4,941 were identified with multivessel disease. We then stratified patients based on MPCI use and their risk. High-risk patients were identified a priori as those with: 1) left main (LM) involvement (lesions, n=263); 2) out-of-hospital cardiac arrest; or 3) Killip class III/IV. Logistic regression models examined for predictors of MPCI use and the association between MPCI and in-hospital mortality. Three thousand eight hundred and thirty-three (77.6%) patients underwent SPCI and 1,108 (22.4%) underwent MPCI. Rates of MPCI were greater among high-risk patients for each of the three categories: 8.6% vs. 5.9% for out-of-hospital cardiac arrest (p

Elevated heart rate (HR) is associated with mortality in a number of heart diseases. We examined the long-term prognostic significance of HR at discharge in a contemporary population of patients with stable angina (SAP), non-ST-segment elevation acute coronary syndromes (NSTE-ACS), and ST-segment elevation myocardial infarction (STEMI) revascularized with percutaneous coronary intervention (PCI).Patients from the BASKET-PROVE trial, an 11-center randomized all-comers trial comparing bare-metal and drug-eluting stenting in large coronary vessels, were included. Discharge HR was determined from a resting ECG. Long-term outcomes (7 days to 2 years) were evaluated for all-cause mortality and cardiovascular death and non-fatal myocardial infarction.A total of 2029 patients with sinus rhythm were included, 722 (35.6%) SAP, 647 (31.9%) NSTE-ACS, and 660 (32.5%) STEMI. Elevated discharge HR was associated significantly with all-cause mortality: when compared to a reference of60 beats per minute (bpm), the adjusted hazard ratios were (95% CI) 4.5 (1.5-13.5, p=0.006) for 60-69 bpm, 3.8 (1.2-11.9, p=0.022) for 70-79 bpm, 4.3 (1.2-15.6, p=0.025) for 80-89 bpm, and 16.9 (5.2-55.0, p0.001) for90 bpm. For cardiovascular death/myocardial infarction, a discharge HR90 bpm was associated with a hazard ratio of 6.2 (2.5-15.5, p0.001) compared to a HR60 bpm. No interaction was found for disease presentation, diabetes or betablocker use.In patients revascularized with PCI for stable angina or acute coronary syndromes an elevated discharge HR was independently associated with poor prognosis. Conversely, a HR60 bpm at discharge was associated with a good long-term prognosis irrespective of indication for PCI.

Background To date, no published data are available regarding long-term follow-up of new generation DES implanted in coronary artery bypass graft (CABG) lesions. Objectives To assess the long-term clinical outcome of patients receiving the new generation Biolimus A9-coated drug-eluting stent (DES) with biodegradable polymer in saphenous vein grafts (SVG). Methods Three thousand sixty-seven patients were included in the NOBORI 2 registry: 71 patients with a total of 117 lesions received at least 1 biolimus A9 DES in SVG lesions and 2,959 patients received percutaneous coronary intervention in other lesions. Clinical follow-up was performed at 1, 6, and 12 months, and annually up to 3 years. Results Compared to the non-CABG group, patients with CABG lesions were older (P

Objectives: To assess independent predictors of stent thrombosis (ST) in an all-comer trial. Methods: This is an observational case-control study based on a retrospective analysis of the Basel Stent Kosten Effektivitäts Trial (BASKET) (n = 826). Patients with ST were compared to controls with regard to baseline parameters. Multivariate models were performed to identify independent predictors of ST. Results: At 36 months, there were 53 (6.4%) patients with ST, 17 (32%) of whom had early ST and 36 (68%) of whom had late/very late ST. Patients with ST were at a higher cardiovascular risk but received lower doses of statins than the controls (n = 212). Stents in ST patients were longer, had more overlap and were not as well expanded, with significantly more remaining stenoses than the stents in the controls. Multivariable analysis revealed interventions in saphenous vein grafts, malapposed stents, an overlap >3 mm, complex coronary anatomy and treatment with low-dose/no statins as risk factors for ST, while interventions in saphenous vein grafts, underexpanded or malapposed stents, a history of myocardial infarction and treatment with low-dose/no statins were risk factors for late ST. Conclusions: The use of statins might have a protective effect against ST. This observation is new, hypothesis-generating and should be evaluated in an adequately powered randomized trial.

Few data are available concerning the impact of gender on temporal trends in patients with acute ST-segment elevation myocardial infarction (STEMI).All STEMI patients consecutively enrolled in the AMIS (Acute Myocardial Infarction in Switzerland) Plus project from 1997-2011 were included. Temporal trends in presentation, treatment and outcomes were analyzed using multiple logistic regressions with generalized estimations.Of 21,620 STEMI patients, 5786 were women and 15,834 men from 78 Swiss hospitals. Women were 8.6 years older, presented 48 minutes later with less pain, but more dyspnea, and more frequently had atrial fibrillation (5.5 vs. 3.9%, p0.001), heart failure (Killip class2) (9.7 vs. 7.3%, p0.001), and moderate or severe comorbidities (24.8 vs. 18.2%, p0.001). Women were less likely to undergo primary reperfusion treatment after adjustment for baseline characteristics and admission year (OR 0.80, 95% CI 0.71-0.90, p0.001) or receive early and discharge drugs, such as thienopyridines, angiotensin-converting-enzyme inhibitors, angiotensin II receptor antagonists, and statins. In 1997, thrombolysis was performed in 51% of male and 39% of female patients; its use rapidly decreased during the 1990s and has now become negligible. Primary percutaneous coronary intervention increased from under 10% in both genders in 1997 to over 70% in females and over 80% in males since 2006. Patients admitted in cardiogenic shock increased by 8% per year in both genders. The incidence of both reinfarction and cardiogenic shock developing during hospitalization decreased significantly over 15 years while in-hospital mortality decreased from 10 to 5% in men and from 18 to 7% in women. This corresponds to a relative reduction of 5% per year for males (OR 0.95, 95% CI 0.92-0.99, p=0.006) and 6% per year for female STEMI patients (OR 0.94, 95% CI 0.91-0.97, p0.001). Despite higher crude in-hospital mortality, female gender per se was not an independent predictor of in-hospital mortality (OR 1.07, 95% CI 0.84-1.35, p=0.59).Substantial changes have occurred in presentation, treatment, and outcome of men and women with STEMI in Switzerland over the past 15 years. Although parallel trends were seen in both groups, ongoing disparities in certain treatments remain. However, these did not translate into worse risk-adjusted in-hospital mortality, suggesting that the gender gap in STEMI care may be closing.

To improve the outcome in patients with acute coronary syndrome (ACS), public campaigns have been launched aimed at shortening presentation delays and allowing more efficient treatment. Their impact is uncertain.Pre-hospital delays and outcome in patients with ACS included in the Swiss National AMIS Plus registry were assessed prospectively before and after a nationwide multimedia campaign ('HELP') by the Swiss Heart Foundation in 2007. The campaign aimed at better awareness of symptoms, increasing knowledge in laymen of resuscitation and more rapid access to medical services. The primary study endpoint was the time between onset of symptoms and hospital admission. Secondary endpoints were successful out-of-hospital resuscitation, symptoms upon admission, and outcome.Between January 2005 and December 2008, 8906 ACS patients (61% ST-segment elevation myocardial infarction (STEMI), 39% non-ST-segment elevation myocardial infarction/unstable angina pectoris (NSTEMI/UAP), mean age 65 ± 13 years, 75% males) admitted within 24 hours after onset of symptoms were enrolled. The median pre-hospital delay was reduced from 197 minutes during the pre-intervention period to 180 minutes during the post-intervention period (reduction 10% (95% confidence interval (CI) 6-14%); P 0.001), in STEMI (reduction 10% (95% CI 5-14%); P 0.001) and NSTEMI patients (reduction 11% (95% CI 4-17%); P = 0.001), due to pronounced effects in males (reduction 12% (95% CI 7-16%); P 0.001) and in patients ≤75 years (reduction 12% (95% CI 8-16%); P 0.001). Out-of-hospital resuscitation increased (odds ratio (OR) 1.26 (95% CI 1.06-1.54); P = 0.02). Overall outcome remained unchanged, however, the rate of re-infarction showed a decrease (OR 0.58 (95% CI 0.36-0.91); P = 0.021).After a nationwide educational campaign, shorter pre-hospital delays were observed, and more patients were able to be treated promptly. These results may be useful in planning future health strategies to improve management and outcome of patients with ACS, especially in female and elderly patients.

To improve long-term survival, prompt revascularization of the infarct-related artery should be done in patients with acute myocardial infarction (AMI); therefore, a large proportion of these patients would be hospitalized during out of hours. The clinical effects of out-of-hours AMI management were already questioned, with conflicting results. The purpose of this investigation was to compare the in-hospital outcome of patients admitted for AMI during out of hours and working hours. All patients with AMI included in the AMIS Plus Registry from January 1, 1997, to March 30, 2006, were analyzed. The working-hours group included patients admitted from 7 a.m. to 7 p.m. on weekdays, and the out-of-hours group included patients admitted from 7 p.m. to 7 a.m. on weekdays or weekends. Major cardiac events were defined as cardiovascular death, reinfarction, and stroke. The study primary end points were in-hospital death and major adverse cardiac event (MACE) rates. A total of 12,480 patients met the inclusion criteria, with 52% admitted during normal working hours, and 48%, during out of hours. Patients admitted during weekdays included more women (28.1% vs 26%; p = 0.009), older patients (65.5 +/- 13 vs 64.1 +/- 13 years; p = 0.0011), less current smokers (40.1% vs 43.5%; p0.001), and less patients with a history of ischemic heart disease (31.5% vs 34.5%; p = 0.001). A significantly higher proportion of patients admitted during out of hours had Killip's class III and IV. No differences in terms of in-hospital survival rates between the 2 groups (91.5% vs 91.2%; p = 0.633) or MACE-free survival rates (both 88.5%; p = 1.000) were noted. In conclusion, the outcome of patients with AMI admitted out of hours was the same compared with those with a weekday admission. Of predictors for in-hospital outcome, timing of admission had no significant influence on mortality and/or MACE incidence.

Aims Large randomized trials comparing DDD with VVI pacing have shown no differences in mortality, but conflicting evidence exists in regard to heart failure endpoints. Here we evaluated the effect of pacing mode on serum levels of brain natriuretic peptide (BNP) and amino-terminal-proBNP (NT-proBNP). Methods Forty-one patients (age 73 ± 10 years) with dual-chamber pacemakers were included in a prospective, single-blind, randomized crossover study evaluating the impact of DDD(R)/VDD versus VVI(R) mode on objective and functional parameters. Data were collected after a 2-week run-in phase and after 2 weeks each of VVI(R) and DDD(R)/VDD pacing or vice versa. Results BNP and NT-proBNP levels during DDD(R)/VDD stimulation (151 ± 131 and 547 ± 598 pg/mL) showed no change compared with baseline (154 ± 130 and 565 ± 555 pg/mL), but a significant 2.4-fold increase was observed during VVI(R) mode [360 ± 221 and 1298 ± 1032 pg/mL; P < 0.001 compared with DDD(R)/VDD]. The assessment of functional class, the presence of pacemaker syndrome [49% in VVI(R) mode] and the patients' preferred pacing mode showed significant differences in favour of DDD(R)/VDD pacing. Conclusion Patients can differentiate between DDD(R)/VDD and VVI(R) pacing, and prefer the former. Compared with DDD(R)/VDD pacing, VVI(R) stimulation induces a two- to three-fold increase in serum BNP and NT-proBNP levels.

OBJECTIVE The role of hypertension and its impact on outcome in patients with acute coronary syndrome (ACS) is still debated. This study aimed to compare the outcomes of hypertensive and nonhypertensive ACS patients. METHODS Using data of ACS patients enrolled in the Acute Myocardial Infarction in Switzerland Plus Registry from 1997 to 2013, characteristics at presentation and outcomes in hospital and after 1 year were analyzed. Hypertension was defined as previously diagnosed and treated by a physician. The primary endpoint was mortality. Data were analyzed using multiple logistic regressions. RESULTS Among 41 771 ACS patients, 16 855 (40.4%) were without and 24 916 (59.6%) with preexisting hypertension. Patients with preexisting hypertension had a more favorable in-hospital outcome [odds ratio (OR) in-hospital mortality 0.82, 95% confidence interval (CI) 0.73-0.93; P = 0.022]. The independent predictors of in-hospital mortality for patients with preexisting hypertension were age, Killip class greater than 2, Charlson Comorbidity Index greater than 1, no pretreatment with statins and lower admission systemic blood pressure. Preexisting hypertension was not an independent predictor of 1-year mortality in the subgroup of patients (n = 7801) followed: OR 1.07, 95% CI 0.78-1.47; P = 0.68. Independent predictors of mortality 1 year after discharge for the 4796 patients with preexisting hypertension were age, male sex and comorbidities. Angiotensin-converting enzyme inhibitors or angiotensin II receptor antagonists and statins prescribed at discharge improved the outcomes. CONCLUSION Outcome of ACS patients with preexisting hypertension was associated with an improved in-hospital prognosis after adjustment for their higher baseline risk. However, this effect was not long-lasting and does not necessarily mean a causal relationship exists. Short-term and long-term management of patients with hypertension admitted with ACS could be further improved.

OBJECTIVE: Compliance with guidelines is increasingly used to benchmark the quality of hospital care, however, very little is known on patients admitted with acute coronary syndromes (ACS) and treated palliatively. This study aimed to evaluate the baseline characteristics and outcomes of these patients. DESIGN: Prospective cohort study. SETTING: Eighty-two Swiss hospitals enrolled patients from 1997 to 2014. PARTICIPANTS: All patients with ACS enrolled in the AMIS Plus registry (n=45,091) were analysed according to three treatment groups: palliative treatment, defined as use of aspirin and analgesics only and no reperfusion; conservative treatment, defined as any treatment including antithrombotics or anticoagulants, heparins, P2Y12 inhibitors, GPIIb/IIIa but no pharmacological or mechanical reperfusion; and reperfusion treatment (thrombolysis and/or percutaneous coronary intervention during initial hospitalisation). The primary outcome measure was in-hospital mortality and the secondary measure was 1-year mortality. RESULTS: Of the patients, 1485 (3.3%) were palliatively treated, 11,119 (24.7%) were conservatively treated and 32,487 (72.0%) underwent reperfusion therapy. In 1997, 6% of all patients were treated palliatively and this continuously decreased to 2% in 2013. Baseline characteristics of palliative patients differed in comparison with conservatively treated and reperfusion patients in age, gender and comorbidities (all p

Electrical cardioversion of atrial fibrillation seems to be enhanced by pretreatment with ibutilide, but only few is known about the effects of ibutilide in atrial fibrillation which failed to convert with class III antiarrhythmic agents and electrical cardioversion. The objectives of this study were to evaluate the efficacy and safety of ibutilide administration in patients with persistent atrial fibrillation refractory to long-term therapy with class III antiarrhythmic drugs and transthoracic cardioversion.Prospective study in 22 patients (16 men and 6 women, mean age 63+/-9 years) with structural heart disease and persistent atrial fibrillation for a mean duration of 39+/-50 (range 1-145) months. All patients had failed to convert to sinus rhythm after transthoracic cardioversion while on treatment with class III antiarrhythmic drugs (amiodarone in 82%, sotalol in 18%). One milligram of ibutilide was administered in all patients and electrical cardioversion was performed again, if necessary.The total conversion rate to sinus rhythm was 95% (21 of 22 patients). Two patients (9%) were successfully converted after ibutilide alone and 19 patients (86%) when transthoracic cardioversion was repeated after ibutilide. The QTc intervals increased from 451+/-28 to 491+/-49 ms (p0.001) after ibutilide. No adverse effects occurred. The rate of freedom from atrial fibrillation after 1 month of follow-up was 64%.The efficacy of concomitant use of ibutilide infusion and, if necessary, repeated transthoracic cardioversion for restoration of sinus rhythm in long-term persistent atrial fibrillation and previously failed antiarrhythmic and electrical cardioversion was 95%. There were no adverse effects associated with ibutilde administration. Our results suggest that this combined strategy may be safe and successful in patients with atrial fibrillation resistant to conventional cardioversion methods and may be an alternative to internal cardioversion.

Background: Single-photon emission computed tomography (SPECT) sestamibi (MIBI) is an excellent tool for detection of coronary artery disease (CAD), preoperative risk assessment, and follow-up management after coronary revas-cularization. While the sensitivity of MIBI SPECT for detecting CAD has been reported to exceed 90%, the specificity ranges between 53–100%. Hypothesis: The study was undertaken to assess characteristics of patients with abnormal stress technetium Tc 99m sestamibi SPECT (MIBI) studies without significant coronary artery diameter stenoses (< 50%). Methods: Between January 1999 and November 2000, 270 consecutive patients were referred for coronary angiography due to reversible MIBI uptake defects during exercise. In 41 patients (15%; 39% women, mean age 59 ± 9 years), reversible MIBI uptake defects were assessed although coronary angiography showed no significant CAD. These patients were compared with age- and gender-matched patients with perfusion abnormalities (39% women, mean age 60 ± 9 years), due to significant CAD (coronary artery stenosis > 50%). Results: There were no significant differences between the two groups regarding body mass index, left bundle-branch block (LBBB), or method of stress test (dipyridamole in patients with LBBB or physical inactivity [n= 11] and exercise in all the others [n= 30]). Left ventricular hypertrophy (44 vs. 23%, p = 0.05) and left anterior fascicularblock (LAFB) (17 vs. 0%, p = 0.005) were more common in patients with perfusion abnormalities with no significant CAD, whereas ST-segment depression during exercise (17 vs. 37% p = 0.05) and angina during exercise (15 vs. 29%, p = 0.02) were significantly less common than in patients with abnormal MIBI perfusion studies and angiographically significant CAD. Sestamibi uptake defects during exercise were significantly smaller in patients without significant CAD than in matched controls with significant CAD (p < 0.0004). Conclusion: Of 270 consecutive patients, 41 (15%) referred to coronary angiography due to reversible MIBI uptake defects showed coronary artery stenoses

In this study we present appropriateness and necessity assessments of coronary angiographies and revascularizations to determine adherence to Swiss guidelines by using the computerized second-opinion system (SOS) as a reference. We prospectively compared SOS ratings with ratings of treating cardiologists and surgeons for 203 coronary angiographies and 100 percutaneous transluminal coronary angioplasties. We also retrospectively assessed indications of 103 coronary artery bypass grafts. SOS ratings of appropriate, uncertain, and inappropriate indications for coronary angiography were 85.5%, 10%, and 4.5%, respectively, and 99.5%, 0.5%, and 0%, respectively, for revascularization. Corresponding clinicians' ratings were 95%, 4%, and 1% and 100%, 0%, and 0%, respectively. SOS ratings of necessary, uncertain, and unnecessary indications for angiography were 82.4%, 17.6%, and 0%, respectively, and 97%, 3%, and 0%, respectively, for revascularization. Corresponding clinicians' values were 88.2%, 10.6%, and 1.2% and 98%, 2%, and 0%, respectively. Significant statistical differences for coronary angiography were found for patients with acute myocardial infarction and for patients within 12 weeks of myocardial infarction. A high accordance between estimated SOS and clinically estimated appropriateness of procedures was found, which might suggest that the guidelines are valid. Regular validation and updating of the guidelines is highlighted. Possible overuse of angiography in patients within 12 weeks of myocardial infarction may need further investigation.

There are few data concerning prognostic markers of acute myocarditis. The purpose of this study was to assess the prognostic value of initial measurements of creatine kinase (CK), cardiac troponin I (cTnI) and myoglobin as regards late recovery of the left ventricular ejection fraction on follow-up.A total of 22 patients (53+/-15 years old, 11 female) with acute myocarditis were followed up in a prospective observational study. Of these, 11 (50%) showed a history of acute infection prior to hospitalisation and seven (32%) had pericardial effusion. The median ejection fraction during the acute phase was 47+/-17%; after a mean follow-up of 119+/-163 days it improved to 60+/-9% (P0.001). Considering maximal CK-rise values of 641+/-961 U/l (P=0.38), cTnI-rise values of 3.7+/-8.6 microg/l (P=0.16) and myoglobin values of 7.4+/-12 nmol/l (P=0.69), there was no correlation between initial cardiac enzyme levels and the initial and late left ventricular ejection fraction.After acute myocarditis, there is late recovery of left ventricular ejection fraction, which is independent of the initial myocardial damage measured by cardiac enzyme release.

Background: Early drug therapy in patients with ST-elevation infarction is essential for improved short- and long-term outcomes. Most of the drugs used currently have been extensively studied in the era prior to reperfusion therapies, and thus it is important to assess the value of these drugs in today’s clinical practice and compare the results with those of randomized trials. Objectives: The study assessed the effects of age, gender, risk factors, reperfusion therapy and early drug therapy in patients with acute myocardial infarction with ST elevation or new left bundle-branch block on in-hospital mortality. Methods: The analysis of drug administration and in-hospital mortality is based on the AMIS Plus project, a registry of acute coronary syndromes in Switzerland since 1997. Data from 7,279 patients admitted to participating hospitals between 1997 and 2002 were analyzed, and the effect of factors and drug therapies on in-hospital mortality was assessed by logistic regression analysis. Results: Age and diabetes were identified as factors associated with a higher likelihood of in-hospital mortality, while a significant and important reduction of in-hospital mortality was due to the use of thrombolytic therapy or primary percutaneous coronary intervention (PCI) [relative risk reduction (RRR) of 31%, odds ratio (OR) and 95% confidence interval: 0.69; 0.54–0.87; p = 0.002 for thrombolysis, RRR of 34%; OR 0.66; 0.44–0.99; p = 0.044 for PCI]. Early administration of aspirin or ADP antagonists is associated with a risk reduction of in-hospital mortality by 36% (OR 0.63; 0.45–0.89; p = 0.009) and 50% (OR 0.49; 0.35–0.70; p < 0.001), respectively. The use of unfractionated heparin did not reduce in-hospital mortality. Administration of ACE inhibitors, nitrates or beta-blockers reduced the relative risk of in-hospital death by 40% (OR 0.60; 0.49–0.75; p = 0.009), 42% (OR 0.58; 0.46–0.72; p < 0.001) and 54% (OR 0.46; 0.37–0.57; p < 0.001), respectively. Less frequent use of reperfusion therapies and beta-blockers was documented for older patients. Gender was not a determining factor for in-hospital survival. Conclusion: Early administration of aspirin or ADP inhibition with ticlopidine or clopidogrel as well as the early use of beta-blockers, nitrates and ACE inhibitors had a beneficial effect on in-hospital mortality in the reperfusion era with either thrombolytics or PCI. The association of a beneficial effect of ADP inhibition was more pronounced than that found in randomized trials for non-ST-elevation infarction. However, it cannot be excluded that patients with a lower risk for in-hospital death who were selected for early invasive assessment received more frequently ADP inhibitors and that this influenced this beneficial effect. Diabetes and age had negative effects on in-hospital mortality, and both reperfusion therapy and beta-blockers were much less frequently used in elderly patients.

Sildenafil inhibits cGMP breakdown by phosphodiesterase 5. In vitro, increased cGMP levels inhibit cAMP breakdown by phosphodiesterase 3. It is uncertain, however, whether sildenafil increases biological effects of interventions increasing cAMP levels in vivo. The objective of the present study in 40 healthy male volunteers was to determine the existence and extent of interactions with sildenafil and vasodilators acting via cGMP or cAMP or independently from these mediators on the arterial tone of the human forearm. Forearm blood flow (FBF) responses (plethysmography) to brachial artery infusions of 3 doses each of nitroglycerin, which increases cGMP levels; of isoprenaline and milrinone, which increase cAMP levels; and of verapamil as a control were assessed at baseline and 80 minutes after 50 mg oral sildenafil in 10 volunteers each. Sildenafil increased FBF (2.5±0.1 to 3.5±0.2 mL/min per 100 mL, P P P

The aim of this study was to determine the long-term outcome in unselected, consecutive patients after acute percutaneous transluminal angioplasty (PTCA) for acute myocardial infarction (AMI) complicated by cardiogenic shock. This involved a follow-up study from a prospectively conducted patient registry in a tertiary referral center. A total of 59 patients (10 female/49 male; median age 62 years (32-91)) with percutaneous transluminal cardiac interventions in primary cardiogenic shock were identified between January 1995 and January 2000. Twenty-two patients (37%) had been resuscitated successfully before intervention. The in-hospital mortality of shock patients was 36% (n=21, median age 68 (47-84)). The median follow-up of survivors was 18.1 (7-57.3) months, during which three further patients died (8%; two because of sudden cardiac deaths, one because of acute reinfarction). Achievement of thrombolysis in myocardial infarction (TIMI) flow III after acute PTCA (84% in survivors vs. 38% in non-survivors; P

A role of the potent and long-acting vasoconstrictor peptide endothelin (ET)-1 in the pathophysiology of chronic human heart failure has been postulated, based upon indirect evidence such as elevated plasma ET- 1 levels and their relationship to the degree of haemodynamic impairment. Acute heart failure shares many features of chronic heart failure, albeit in an exaggerated fashion. As both the mixed ET A /ET B -receptor antagonist bosentan and the selective ET A receptor antagonist BQ 123 acutely improved the haemodynamics of chronic heart failure patients, there seems to be good reason to believe that ET-1 receptor antagonism may also be of benefit in the setting of acute heart failure. However, appropriate trials will have to be performed to document the clinical benefit of such an approach. Finally, the question remains open as to whether mixed ET-1 receptor antagonists like bosentan will prove better, worse or equal to antagonists that block the ET A receptor only.

Background Anginal chest pain without creatine kinase (CK) elevation is frequently observed in the first hours after coronary stenting. Possible causes of ischemic episodes are microembolism, side branch occlusion, coronary vasospasm, and disturbances of microvascular circulation. In a prospective, double-blind, randomized trial, we tested the effect of intravenous nitroglycerin on the incidence of angina and minor myocardial necrosis (MMN), as detected by cardiac troponin I increase, after elective coronary stenting. Methods and Results One hundred patients were randomly assigned to intravenous nitroglycerin (group A: n=50, goal dose 100 μg/min) or placebo (group B: n=50, NaCl 0.9%) during 12 hours after stenting. Patients with acute myocardial infarction, known intolerance to nitrates, and hemodynamic instability during angioplasty were excluded. The 2 groups were comparable in respect to baseline and interventional variables, except for age (group A: 60 ± 9 years, group B: 56 ± 10 years; P = .04). The incidence of chest pain was not influenced by nitroglycerin (group A: 18%, group B: 22%; P = not significant). However, the occurrence of MMN was significantly reduced by nitroglycerin (group A: 5%, group B: 19%, P = .036). A rise in CK with significant CK-MB fraction was observed in only 2 patients in group B (both less than twice upper limit). Only 4 of the 10 patients with MMN also had chest pain. Conclusions Routine use of intravenous nitroglycerin after coronary stenting significantly reduced the occurrence of minor myocardial necrosis. However, the incidence of postprocedural chest pain remained unchanged. (Am Heart J 2000;139:35-43.)

Aim To test whether emergency revascularization improves survival in patients with acute myocardial infarction and shock. Methods and Results Patients with acute myocardial infarction and early shock were randomized either to undergo emergency angiography, followed immediately by revascularization when indicated, or to receive initial medical management. In five of the nine participating centres, patients with shock but not randomized were entered in a registry. Only 55 patients could be randomized. Of the 32 patients in the invasive group, 30 (94%) underwent early angiography, 27 (84%) PTCA, and one (4%) CABG. Twenty-two (69%) died within 30 days in the invasive group vs 18/23 (78%) in the medically managed group (ns, RR=0·88, 95% confidence interval 0·6–1·2). Among the registry patients, 24/51 were excluded from randomization solely because of patient or physician preference for the invasive approach: 23 (96%) of them underwent emergency angiography, 21 (88%) PTCA, and 12 (50%) died within 30 days. Among the remaining registry patients (n=27) only nine (33%) underwent early angiography, nine (33%) PTCA and 20 (74%) died. Conclusion We failed to demonstrate that emergency PTCA significantly improves survival in patients with acute myocardial infarction and early cardiogenic shock. Because the study was stopped prematurely, due to an insufficient patient inclusion rate, a clinically meaningful benefit of early reperfusion may have been missed.

Of 123 randomized patients, 59 underwent CABG and 62 received a stent (2 patients were excluded). Follow-up after 10 years was obtained for 98% of the randomized patients. Twenty-six patients (42%) in the percutaneous coronary intervention group and 10 patients (17%) in the CABG group reached an end point (p 0.001). This difference was due to a higher need for additional revascularization. The incidences of death and myocardial infarction were identical at 10%. Progression of the disease requiring additional revascularization was rare (5%) and was similar for the 2 groups. Stent thrombosis occurred in 2 patients (3%). Angina functional class showed no significant differences between the 2 groups. Conclusions Both stent implantation and CABG are safe and highly effective in relieving symptoms in patients with isolated, proximal left anterior descending coronary artery stenosis. Stenting with bare-metal stents is associated with a higher need for repeat interventions. The long-term prognosis for these patients is excellent with either mode of revascularization. (J Am Coll Cardiol 2008;52:815‐7) © 2008 by the American College of Cardiology Foundation

Objective This study aimed to assess the impact of individual comorbid conditions as well as the weight assignment, predictive properties and discriminating power of the Charlson Comorbidity Index (CCI) on outcome in patients with acute coronary syndrome (ACS). Methods A prospective multicentre observational study (AMIS Plus Registry) from 69 Swiss hospitals with 29 620 ACS patients enrolled from 2002 to 2012. The main outcome measures were in-hospital and 1-year follow-up mortality. Results Of the patients, 27% were female (age 72.1±12.6 years) and 73% were male (64.2±12.9 years). 46.8% had comorbidities and they were less likely to receive guideline-recommended drug therapy and reperfusion. Heart failure (adjusted OR 1.88; 95% CI 1.57 to 2.25), metastatic tumours (OR 2.25; 95% CI 1.60 to 3.19), renal diseases (OR 1.84; 95% CI 1.60 to 2.11) and diabetes (OR 1.35; 95% CI 1.19 to 1.54) were strong predictors of in-hospital mortality. In this population, CCI weighted the history of prior myocardial infarction higher (1 instead of −0.4, 95% CI −1.2 to 0.3 points) but heart failure (1 instead of 3.7, 95% CI 2.6 to 4.7) and renal disease (2 instead of 3.5, 95% CI 2.7 to 4.4) lower than the benchmark, where all comorbidities, age and gender were used as predictors. However, the model with CCI and age has an identical discrimination to this benchmark (areas under the receiver operating characteristic curves were both 0.76). Conclusions Comorbidities greatly influenced clinical presentation, therapies received and the outcome of patients admitted with ACS. Heart failure, diabetes, renal disease or metastatic tumours had a major impact on mortality. CCI seems to be an appropriate prognostic indicator for in-hospital and 1-year outcomes in ACS patients. ClinicalTrials.gov Identifier NCT01305785

To date, no published data are available regarding long-term follow-up of new generation DES implanted in coronary artery bypass graft (CABG) lesions.To assess the long-term clinical outcome of patients receiving the new generation Biolimus A9-coated drug-eluting stent (DES) with biodegradable polymer in saphenous vein grafts (SVG).Three thousand sixty-seven patients were included in the NOBORI 2 registry: 71 patients with a total of 117 lesions received at least 1 biolimus A9 DES in SVG lesions and 2,959 patients received percutaneous coronary intervention in other lesions. Clinical follow-up was performed at 1, 6, and 12 months, and annually up to 3 years.Compared to the non-CABG group, patients with CABG lesions were older (P 0.001), had a higher Charlson Comorbidity Index (P = 0.004), and presented more often with acute coronary syndrome (P = 0.02). At 3-year follow-up, cardiac death occurred in 9.7% versus 2.1% (P 0.001), myocardial infarction (MI) in 8.3% versus 3.0% (P = 0.02), target lesion failure in 13.9% versus 6.4% (P = 0.03), and major adverse cardiac event in 18.1% versus 8.6% (P = 0.01). No differences were observed in TV-MI and TLR, nor stent thrombosis (ST) which was generally low in both groups (1.4% vs 0.8%, P = NS).Albeit 3-year outcomes were less favorable in the CABG group, the higher cardiac mortality was apparently not driven by ST, target vessel MI, or TLR, but is likely due to advanced disease and age as well as comorbidity. The low TLR rate as well as the absence of late and very late ST suggest that BES are safe and effective for the treatment of CABG lesions.

Dual chamber pacemakers are increasingly implanted to achieve optimal hemodynamics by AV synchrony, but the effect of AV delay programming on the patient's quality-of-life has been less well studied. The influence of an individually programmed AV delay between 100 and 250 ms on quality-of-life was investigated in a randomized, double-blind crossover study of 13 patients (69 +/- 10 years of age) with dual chamber pacemakers implanted because of high degree AV block. During radionuclide ventriculography at rest, the "optimal AV delay" with the maximal left ventricular ejection fraction and the "most unfavorable AV delay" with the least ejection fraction were determined. The ejection fraction at rest with the "optimal AV delay" was 51% +/- 10%, and with the "most unfavorable AV delay," 44% +/- 11% (P < 0.0001). The optimal AV delay determined by radionuclide ventriculography correlated well with the optimal AV delay determined by Doppler echocardiography using flow velocity integrals (r = 0.78, P < 0.0016). Each patient was assigned in random order to either AV delay during a 2-week period and then the pacing mode was switched for another 2-week period. At the end of each period, patients were assessed by a functional status questionnaire to assess physical capability and two further questionnaires to quantify cardiovascular symptoms or self-perceived health. There were no differences in the two AV delays regarding the patient's perceived physical capability and specific symptoms. The patient's total judgment was identical to the optimal AV delay (score 36% +/- 19%) and the most unfavorable AV delay (33% +/- 21%). Thus, in patients with a dual chamber pacemaker, an individually programmed AV delay affects left ventricular function at rest, but has no influence on quality-of-life. The determination of the flow velocity integral by Doppler echocardiography is a simple and reliable method to optimize the AV delay if necessary.

Pressure gradients calculated from echo-cardiography after aortic valve replacement are commonly much higher than would be expected from in vitro measurements.The mean, peak-to-peak, and maximal gradients across bileaflet aortic prostheses (St. Jude Medical) were measured invasively in 52 patients at high and low heart rate, cardiac index, and stroke volume. One week after operation the gradients were calculated from a standard transthoracic echocardiogram (delta p = 4v2(2)). In a second study 3 to 12 months later, gradients were calculated using the standard, simplified Bernoulli equation, and with the equation considering subvalvular flow velocities (delta p = 4(v2(2-)v1(2)). Invasive and echocardiographic measurements were matched and compared.Invasively measured mean gradients for 21 to 29-mm valves ranged from 7.4 +/- 4.9 to 4.3 +/- 1.6 mm Hg at systolic flow rates from 11.3 +/- 0.7 to 16.2 +/- 1.8 L.min-1.m-2. Mean echocardiographic gradients were 15.1 +/- 4.5 to 7.5 +/- 2.2 mm Hg (p0.001) with the standard method, and 10.5 +/- 1.9 to 5.6 +/- 1.5 mm Hg when considering the subvalvular flow velocity (p0.001).Mean gradients across bileaflet prostheses are generally low, even in small valves and with high systolic flow. The correlation of the invasive in vivo with in vitro gradients is good. Standard echocardiography overestimates gradients across bileaflet heart valves and high gradients are not due to valve dysfunction. Gradients obtained by echocardiography considering the subvalvular flow velocity correlate better to invasively measured and in vitro gradients.

To the Editor: Both patients and health care professionals should be aware of potential pacemaker interactions in the environment, since cardiac pacemakers and defibrillators are sensitive to many kinds of electromagnetic interference. A 52-year-old man with a dual-chamber pacemaker, implanted because of intermittent, symptomatic, high-degree atrioventricular block, presented with short episodes of dizziness and near-fainting. A detailed history revealed that the symptoms occurred exclusively during self-prescribed therapy with a Zapper device. The Zapper, which is available worldwide, is a simple, battery-powered, direct-current–offset pulse generator with square-wave output at a constant frequency of 33.3 kHz ±10 percent. These electronic pulse frequencies . . .

Internal mammary artery (IMA) malperfusion syndrome is caused by an acute imbalance between myocardial demand and nutritional support through the mammary artery. In a consecutive series of 2326 isolated myocardial revascularizations-with at least one IMA to the left anterior descending branch (LAD) in 91.3% (2125/2326)-we identified 45 patients (1.9%) with a perioperative course suggesting IMA malperfusion syndrome. Additional saphenous vein graft to the distal segment of the LAD was performed during normothermic ventricular fibrillation in all patients. Hospital mortality was 4.4% (2/45), intra-aortic balloon pumping was required in 15.5% (7/45) and anterior myocardial infarction occurred in 28.8% (13/45). Coronary angiography was performed in all survivors between 3 and 24 months postoperatively. Wide patent IMA graft and patent saphenous vein graft were observed in 56% (24/43), narrowed but patent IMA graft and patent vein graft in 35% (15/43), while patent vein graft and not visualized IMA in 7% (3/43); in one patient with severely diseased peripheral LAD, no flow could be demonstrated in the IMA graft or in the additional vein graft (1/43, 2.4%). No major differences were found between early and late coronary angiography in these patients. Additional vein graft to distal LAD is the treatment of choice in acute IMA malperfusion syndrome. Despite patent vein graft with superior blood flow, early and late postoperative IMA flow to LAD is maintained in the majority of patients.

Chronic kidney disease (CKD) is associated with worse outcomes in patients with coronary artery disease (CAD). How CKD influences the benefit-risk balance of drug-eluting stents (DES) versus bare-metal stents (BMS) is less known.In the multicentre BASKET-PROVE trial, 2314 patients in need of large coronary stenting (≥ 3.0mm) were randomised 2:1 to DES or BMS. In an a priori planned secondary analysis, outcomes were evaluated according to renal function defined by estimated glomerular filtration rates (eGFR; normal: eGFR ≥ 60 ml/min/1.73 m(2); CKD: eGFR60 ml/min/1.73 m(2)). The primary endpoint was the first major adverse cardiac event (MACE: cardiac death, myocardial infarction, target vessel revascularisation) up to 2 years. A Cox proportional-hazard model was used to evaluate adjusted relative risks (hazard rates, HRs) for BMS versus DES. The interaction of stent type and renal function was tested. CKD patients (189 (11.2%)/1681 with such data) had a 2-year MACE rate of 8.5% versus 7.4% in those without CKD [HR 0.98 (0.56-1.72), p=0.95] with cardiac mortalities of 5.3% and 1.5%, respectively (p=0.002, non-significant after baseline adjustments). The MACE rate was lower in CKD patients with DES than with BMS [4.9% versus 15.2%, p=0.017, HR 0.29(0.10-0.80)] as was the MACE rate in patients without CKD [5.6% with DES versus 11.1% with BMS, p0.0001, HR 0.51(0.35-0.75)]. No significant interaction between stent type and renal function was found.This analysis of patients needing large coronary artery stenting confirms the increased mortality of CKD patients and documents a long-term benefit of DES compared to BMS irrespective of kidney function.

Introduction: Few data describe temporal trends in presentation, treatment and outcome in men and women with acute ST-segment elevation myocardial infarction (STEMI). Methods: Swiss STEMI patients enrolled in the AMIS Plus registry from1997-2010 were analyzed using multivariate logistic regression. Results: From 20,363 STEMI patients, 5458 were women and 14,905 men. Women were 8.6 years older, had more co-morbidities (Charlson Index ≥2 16.9% vs 12.8%; P Conclusion: Therapy of STEMI patients has changed greatly during the past 14 years in Switzerland, largely in accordance with guideline recommendations.

Aims: To evaluate the efficacy and safety of intravenous enoxaparin as an alternative to unfractionated heparin (UFH) as antithrombotic therapy in unselected patients undergoing percutaneous coronary intervention (PCI). Methods and results: Eight hundred and seventy-six (876) consecutive eligible patients undergoing PCI were prospectively randomised to either intravenous enoxaparin 0.75 mg/kg or dose-adjusted UFH in this open-label study that was prematurely stopped due to slow recruitment. Randomisation was stratified on elective PCI or PCI for acute coronary syndrome (ACS). The primary endpoint was a combination of death, myocardial infarction, unplanned target vessel revascularisation and major bleeding at 30 days. Secondary endpoint was a composite of major and minor bleeding and thrombocytopenia < 50x109. The primary endpoint of intravenous enoxaparin did not differ from those of UFH (5.5% vs. 7.0%, p=ns) whereas safety endpoints were reduced with enoxaparin compared to UFH (9.9% vs. 20.0%, p

Percutaneous coronary intervention (PCI) is the most effective reperfusion modality in patients with acute myocardial infarction (MI). Data concerning long-term survival and functional outcome are sparse.One thousand consecutive patients treated by emergency PCI were systematically ana-lysed in a single-centre registry. Multivariate predictors of in-hospital mortality, post-discharge mortality and late functional capacity were identified.Follow-up was completed for 978 patients. The median clinical follow-up length was 3.2 years. In-hospital and post-discharge mortality were 7.6% and 7.3%, respectively. Annualised post-discharge mortality remained stable over time at 2% per year. Independent predictors of in-hospital death were cardiogenic shock, TIMI flow3 after PCI, left ventricular ejection fraction40%, age and time to patent artery6 h. Independent predictors of post-discharge mortality were TIMI flow after PCI3, prior MI, elevated glucose levels at admission, and increasing age. In contrast, cardiogenic shock, time to patent artery and left ventricular ejection fraction40% were not independently associated with post-hospital death. At late follow-up, 47% of patients had normal functional capacity and 49.1% were in New York Heart Association functional class II. Predictors of impaired functional capacity at follow-up were age, gender, smoking habits and multivessel coronary disease.Post-discharge mortality after PCI for acute MI was 2% per year. Significant differences exist between predictors of in-hospital and post-discharge mortality. The functional capacity of surviving patients was remarkably good, even when presented in cardiogenic shock.

To evaluate the in-hospital outcome of STEMI (ST elevation myocardial infarction) patients admitted to Swiss hospitals between 2000 and December 2007, and to identify the predictors of in-hospital mortality and major cardiac events. Data from the Swiss national registry AMIS Plus (Acute Myocardial Infarction and Unstable Angina in Switzerland) were used. All patients admitted between January 2000 and December 2007 with STEMI or a new LBBB (left bundle branch block) were included in the registry. We studied 12 026 STEMI patients admitted to 68 hospitals. The mean age was 64 +/- 13 years and 73% of the patients were male. Incidence of in-hospital death was 7.6% in 2000 and 6% in 2007. Reinfarction fell from 3.7% in 2000 to 0.9% in 2007. Thrombolysis decreased from 40.2% in 2000 to 2% in 2007. Clinical predictors of mortality were: age >65 years, Killips class III or IV, diabetes, Q wave myocardial infarction (at presentation). Patients undergoing percutaneous coronary intervention (PCI) had lower mortality and reinfarction rates (3.9% versus 11.2% and 1.1% versus 3.1% respectively, p

Background: Early risk stratification is important in the management of patients with acute coronary syndromes (ACS). Objective: To develop a rapidly available risk stratification tool for use in all ACS. Design and methods: Application of modern data mining and machine learning algorithms to a derivation cohort of 7520 ACS patients included in the AMIS (Acute Myocardial Infarction in Switzerland)-Plus registry between 2001 and 2005; prospective model testing in two validation cohorts. Results: The most accurate prediction of in-hospital mortality was achieved with the “Averaged One-Dependence Estimators” (AODE) algorithm, with input of seven variables available at first patient contact: age, Killip class, systolic blood pressure, heart rate, pre-hospital cardiopulmonary resuscitation, history of heart failure, history of cerebrovascular disease. The c-statistic for the derivation cohort (0.875) was essentially maintained in important subgroups, and calibration over five risk categories, ranging from 30% predicted mortality, was accurate. Results were validated prospectively against an independent AMIS-Plus cohort (n = 2854, c-statistic 0.868) and the Krakow-Region ACS Registry (n = 2635, c-statistic 0.842). The AMIS model significantly outperformed established “point-of-care” risk-prediction tools in both validation cohorts. In comparison to a logistic regression-based model, the AODE-based model proved to be more robust when tested on the Krakow validation cohort (c-statistic 0.842 vs 0.746). Accuracy of the AMIS model prediction was maintained at 12-month follow-up in an independent cohort (n = 1972, c-statistic 0.877). Conclusions: The AMIS model is a reproducibly accurate point-of-care risk stratification tool for the complete range of ACS, based on variables available at first patient contact.

ObjectivesThis study was designed to compare the long-term clinical outcome of coronary artery bypass grafting (CABG) with intracoronary stenting of patients with isolated proximal left anterior descending coronary artery.BackgroundAlthough numerous trials have compared coronary angioplasty with bypass surgery, none assessed the clinical evaluation in the long term.MethodsWe evaluated the 10-year clinical outcome in the SIMA (Stent versus Internal Mammary Artery grafting) trial. Patients were randomly assigned to stent implantation versus CABG.ResultsOf 123 randomized patients, 59 underwent CABG and 62 received a stent (2 patients were excluded). Follow-up after 10 years was obtained for 98% of the randomized patients. Twenty-six patients (42%) in the percutaneous coronary intervention group and 10 patients (17%) in the CABG group reached an end point (p < 0.001). This difference was due to a higher need for additional revascularization. The incidences of death and myocardial infarction were identical at 10%. Progression of the disease requiring additional revascularization was rare (5%) and was similar for the 2 groups. Stent thrombosis occurred in 2 patients (3%). Angina functional class showed no significant differences between the 2 groups.ConclusionsBoth stent implantation and CABG are safe and highly effective in relieving symptoms in patients with isolated, proximal left anterior descending coronary artery stenosis. Stenting with bare-metal stents is associated with a higher need for repeat interventions. The long-term prognosis for these patients is excellent with either mode of revascularization.

Background To assess the impact of the new definitions of myocardial infarction, we retrospectively analyzed 9190 patients from 63 hospitals with reported peak troponin values included between 2001 and 2007 in the Swiss AMIS (Acute Myocardial Infarction in Switzerland) Plus registry. Methods Patients were classified as belonging to the "classic" myocardial infarction group (peak total CK or CK-MB above the upper limit of normal, or troponin T [TnT] >0.1 μg/L or troponin I [TnI] >0.1-0.8 μg/L [depending on the assay]) or "new" myocardial infarction group (TnT >0.01 μg/L or TnI >0.01-0.07 μg/L). Results There were 489 patients in the "new" group who were similar to the 8701 "classic" patients in terms of age, sex, and prevalence of both diabetes and renal failure, but more frequently had a history of prior coronary artery disease, hypertension, and hyperlipidemia. At admission, they less frequently had ST elevation on their electrocardiogram, were more frequently in Killip class I, and received less primary percutaneous coronary intervention. Hospital mortality was 3.5% in the "new" and 6.7% in the "classic" myocardial infarction group ( P =.004). In a subset of patients with a longer follow-up, mortality at 3 and 12 months was 1% and 5.6%, respectively, for "new" and 1.6% and 4%, respectively, for "classic" myocardial infarction (NS). Conclusions Patients with minimal elevation of serum troponin have smaller infarctions, less aggressive treatment, fewer early complications, and a better early prognosis than patients with higher serum biomarker levels. After discharge, however, their prognosis currently appears no different from that of patients with a "classic" myocardial infarction event.

Background Based on a subgroup analysis of 18-month BAsel Stent Kosten Effektivitats Trial (BASKET) outcome data, we hypothesized that very late (>12 months) stent thrombosis occurs predominantly after drug-eluting stent implantation in large native coronary vessel stenting. Methods To prove or refute this hypothesis, we set up an 11-center 4-country prospective trial of 2260 consecutive patients treated with ≥3.0-mm stents only, randomized to receive Cypher (Johnson & Johnson, Miami Lakes, FL), Vision (Abbott Vascular, Abbott Laboratories, IL), or Xience stents (Abbott Vascular). Only patients with left main or bypass graft disease, in-stent restenosis or stent thrombosis, in need of nonheart surgery, at increased bleeding risk, without compliance/consent are excluded. All patients are treated with dual antiplatelet therapy for 12 months. The primary end point will be cardiac death/nonfatal myocardial infarction after 24 months with further follow-up up to 5 years. Results By June 12, 229 patients (10% of the planned total) were included with a baseline risk similar to that of the same subgroup of BASKET (n = 588). Conclusions This study will answer several important questions of contemporary stent use in patients with large native vessel stenting. The 2-year death/myocardial infarction—as well as target vessel revascularization—and bleeding rates in these patients with a first- versus second-generation drug-eluting stent should demonstrate the benefit or harm of these stents compared to cobalt-chromium bare-metal stents in this relevant, low-risk group of everyday patients. In addition, a comparison with similar BASKET patients will allow to estimate the impact of 12- versus 6-month dual antiplatelet therapy on these outcomes.

Background: Gender differences in management and outcomes have been reported in acute coronary syndrome (ACS). Objectives: To assess such gender differences in a Swiss national registry. Methods: 20 290 patients with ACS enrolled in the AMIS Plus Registry from January 1997 to March 2006 by 68 hospitals were included in a prospective observational study. Data on patients’ characteristics, diagnoses, procedures, complications and outcomes were recorded. Odds ratios (ORs) of in-hospital mortality were calculated using logistic regression models. Results: 5633 (28%) patients were female and 14 657 (72%) male. Female patients were older than men (mean (SD) age 70.9 (12.1) vs 63.4 (12.9) years; p Conclusions: The analysis showed gender differences in baseline characteristics and in the rate of PCI in patients admitted for ACS in Swiss hospitals between 1997 and 2006. Reasons for the significant underuse of PCI in women, and a slightly higher in-hospital mortality in the 51–60 year age group, need to be investigated further.