NT-proBNP level before primary PCI and risk of poor myocardial reperfusion: Insight from the On-TIME II trial

BACKGROUND

N-terminal fragment of the brain natriuretic peptide prohormone (NT-proBNP), a marker for neurohumoral activation, has been associated with adverse outcome in patients with myocardial infarction. NT-proBNP levels may reflect extensive ischemia and microvascular damage, therefore we investigated the potential association between baseline NT-proBNP level and ST-resolution (STR), a marker of myocardial reperfusion, after primary percutaneous coronary intervention (pPCI).

METHODS

we performed a post-hoc analysis of the On-TIME II trial (which randomized ST-elevation myocardial infarction (STEMI) patients to pre-hospital tirofiban administration vs placebo). Patients with measured NT-proBNP before angiography were included. Multivariate logistic-regression analyses was performed to investigate the association between baseline NTproBNP level and STR one hour after pPCI.

RESULTS

Out of 984 STEMI patients, 918 (93.3%) had NT-proBNP values at baseline. Patients with STR <70% had higher NT-proBNP values compared to patients with complete STR (>70%) [Mean ±SD 375.2 ±1021.7 vs 1007.4 ±2842.3, Median (IQR) 111.7 (58.4-280.0) vs 168.0 (62.3-601.3), P <.001]. At multivariate logistic regression analysis, independent predictors associated with higher risk of poor myocardial reperfusion (STR <70%) were: NT-proBNP (OR 1.17, 95%CI 1.04-1.31, P = .009), diabetes mellitus (OR 1.87, 95%CI 1.14-3.07, P = .013), anterior infarct location (OR 2.74, 95% CI 2.00-3.77, P <.001), time to intervention (OR 1.06, 95%CI 1.01-1.11, P = .021), randomisation to placebo (OR 1.45, 95%CI 1.05-1.99, P = .022).

CONCLUSIONS

In STEMI patients, higher baseline NT-proBNP level was independently associate with higher risk of poor myocardial reperfusion, supporting the potential use of NT-proBNP as an early marker for risk stratification of myocardial reperfusion after pPCI in STEMI patients.

P954Value of a single bolus erythopoetin in STEMI patients treated with the Genous endothelial progenitor cell capture stent

Background

The Endothelial Progenitor Cell (EPC) stent was designed to capture circulating EPCs and promote early stent re-endothelization. Erythropoietin (EPO) stimulates mobilization of EPC from the bone marrow. Combination of EPO and the EPC stent in the setting of ST-segment elevation myocardial infarction (STEMI) has never been investigated.

Methods

STEMI patients enrolled in the HEBE-III trial were randomized to a single bolus of EPO or No-EPO after implantation of the EPC capture stent. Late lumen loss (LLL) was determined at 9-month angiographic follow-up. Clinical data was collected at 30 days and 12 months.

Results

196 patients were randomized to EPO (n=100) or No-EPO (n=96). No significant difference in baseline characteristics was observed between the two groups. A significant reduction in angiographic LLL was observed with EPO (0.43±0.57mm) as compared to No-EPO (0.74±0.63mm) (p=0.011). At 12 months follow up, no difference with regard to death or re- infarction was observed in both groups, whereas significant reduction in the need for target vessel revacularization for the EPO versus No-EPO was observed with rates of 7.1% and 19.1% respectively (p=0.013).

Angiographic and clinical results EPO (n=39) No-EPO (n=45) P-value Angiography   Lume late loss 0.43±0.57 0.74±0.63 0.011 12 months clinical   Death 0 0 ns   Re infarction 0 1 (2.2%) ns   Additional PCI 4 (10.3%) 17 (37.8%) 0.004   CABG 2 (5.1%) 2 (4.4%) ns   CVA 0 0 ns   Bleeding 3 (7.7%) 4 (8.9%) ns ns = not significant; CVA = cerebrovascular accident; CABG = coronary bypass graft; PCI = percutaneous coronary intervention.

Conclusion

In STEMI patients treated with EPC capture stent, additional EPO can further improve angiographic LLL

Use, timing and outcome of coronary angiography in patients with high-risk non-ST-segment elevation acute coronary syndrome in daily clinical practice: insights from a 'real world' prospective registry

Background

An early invasive strategy (EIS) is recommended in high-risk patients with non-ST-elevation acute coronary syndrome (NSTE-ACS), defined as coronary angiography (CAG), within 24 h of admission. The aim of the present study is to investigate guideline adherence, patient characteristics associated with timing of the intervention and clinical outcome.

Methods

In a prospective registry, the use and timing of CAG and the characteristics and clinical outcome associated with timing were evaluated in high-risk ACS patients. The outcome of early versus delayed invasive strategy (DIS) was compared.

Results

Between 2006 and 2014, 2,299 high-risk NSTE-ACS patients were included. The use of CAG increased from 77% in 2006 to 90% in 2014 (p trend <0.001) together with a decrease of median time to CAG from 23.3 to 14.5 h (p trend <0.001) and an increase of patients undergoing EIS from 50 to 60% (p trend = 0.002). Patient factors independently related to DIS were higher GRACE risk score, higher age and the presence of comorbidities. No difference was found in incidence of mortality, reinfarction or bleeding at 30-day follow-up. All-cause mortality at 1‑year follow-up was 4.1% vs 7.0% in EIS and DIS respectively (hazard ratio 1.67, 95% confidence interval 1.12–2.49) but was comparable after adjustment for confounding factors.

Conclusion

The percentage of high-risk NSTE-ACS patients undergoing CAG and EIS has increased in the last decade. In contrast to the guidelines, patients with a higher risk profile are less likely to undergo EIS. However, no difference in outcome after 30 days and 1 year was found after multivariate adjustment for this higher risk.

Effects of radial versus femoral artery access in patients with acute myocardial infarction: A large centre prospective registry

Aim

This study sought to assess whether radial artery access improves clinical outcomes in patients presenting with acute myocardial infarction compared with femoral artery access.

Methods

This is a single-centre, prospective observational registry of all STEMI and NSTEMI patients who underwent coronary angiography and/or primary PCI in the period January 2010 to December 2013. Primary endpoint was 30-day all-cause mortality. Choice of access was left to the discretion of the cardiologist. Differences in the risk of death at 30 days between patients undergoing transradial intervention versus transfemoral intervention was assessed on an intention-to-treat comparison.

Results

Retrospective analysis of prospectively collected data was performed in 3580 patients with an acute coronary syndrome who underwent coronary angiography, of which 1310 had radial artery access. PCI was performed in 77 % of the patients. Before propensity score matching, patients who underwent transradial intervention and those intended to undergo transfemoral approach differed significantly in intra-aortic balloon pump use (1.7 % vs. 6.7 %, p < 0.001), and Killip class (Killip 1: 10.8 % vs. 17.3 %, p < 0.001). 30-day mortality rates were 1.7 % in the transradial group and 4.6 % in the transfemoral group (p < 0.001). After matching on the propensity score, the hazard ratio for 30-day mortality in the transradial group was 0.56 (95 % CI: 0.29–1.07, p = 0.08).

Conclusion

This registry-based study showed that radial access is associated with improved outcome in patients with an acute coronary syndrome. However, this difference was no longer significant after multivariate and propensity score adjustment for differences in baseline characteristics.

Is the difference in outcome between men and women treated by primary percutaneous coronary intervention age dependent? Gender difference in STEMI stratified on age

AIM

Poorer outcomes in women with ST-elevation myocardial infarction (STEMI) are often attributed to gender differences in baseline characteristics. However, these may be age dependent. We examined the importance of gender in separate age groups of patients with STEMI undergoing primary percutaneous coronary intervention (PPCI).

METHODS AND RESULTS

Data of 6746 consecutive patients with STEMI admitted for PPCI between 1998 and 2008 in our hospital were evaluated. Age was stratified into two groups, <65 years (young group) and ≥65 years (elderly). Endpoints were enzymic infarct size as well as 30-day and 1 year mortality. We studied a total of 4991 (74.0%) men and 1755 (26.0%) women; 40% of women were <65 years and 60% of men were <65 years of age. In the elderly group (≥65 years), women had more frequently diabetes and hypertension while they smoked less frequently than men. Younger women smoked more often than similarly aged men and had more hypertension. At angiography, single-vessel disease and TIMI 3 flow before PPCI was more present in younger women than men, whereas these differences were not found in the older age group. Patient delay before admission was shorter in men at all ages, while women had lower creatine kinase levels. Younger women had a higher mortality after 30 days (HR 2.1, 95% CI 1.3-3.4) and at 1 year (HR 1.7, 95% CI 1.2-2.6), whereas in the older age group women mortality rates were higher at 30 days (HR 1.5, 95% CI 1.1-2.0) but not at 1 year (HR 1.2, 95% CI 0.9-1.5). After multivariate analysis, 1-year mortality remained significantly higher in women at younger age (HR 1.7, 95% CI 1.1-2.5). Patient delay before admission was shorter in men in both age groups. Creatine kinase levels were in both age groups higher in men.

CONCLUSIONS

Differences in mortality between men and women with STEMI treated with PPCI are age dependent. Although young women have less obstructive coronary artery disease and more often TIMI 3 flow before PCI (suggesting a lower risk), survival was worse compared to similarly aged men. Women had a longer patient delay compared to men, but this was not related to gender-specific mortality.

Atrial fibrillation after but not before primary angioplasty for ST-segment elevation myocardial infarction of prognostic importance

AIM

In patients with ST-segment elevation myocardial infarction (STEMI), it is uncertain whether atrial fibrillation has prognostic implications. There may be a difference between atrial fibrillation before and after reperfusion therapy.

METHODS AND RESULTS

In patients with STEMI treated with primary percutaneous coronary intervention (PCI), ECGs were analysed before and after primary PCI. Of the 1623 patients with electrocardiographic data before primary PCI, 53 patients (3.3%) had atrial fibrillation. Patients with atrial fibrillation were older, were more often female, and less often had anterior MI location. Of the 1728 patients with electrocardiographic data after primary PCI, 52 patients (3.0%) had atrial fibrillation. Atrial fibrillation was more common in older patients and in those with Killip class >1. Also patients with occlusion of the right coronary artery or TIMI flow 0 before primary PCI more commonly had AF after the procedure. Not successful reperfusion was also associated with a higher incidence of AF after primary PCI. Although both atrial fibrillation before and after primary PCI were associated with increased mortality, multivariable analyses, adjusting for differences in age, gender and Killip class on admission, revealed that atrial fibrillation after PCI (OR 3.69, 95% CI 1.87-7.29) but not before PCI (OR 1.86, 95% CI 0.89-3.90) was independent and statistically significantly associated with long-term mortality.

CONCLUSION

In patients with STEMI, atrial fibrillation after but not before primary PCI has independent prognostic implications. Possibly, atrial fibrillation after the PCI is a symptom of failed reperfusion and a sign of heart failure.

Electrical storms in Brugada syndrome successfully treated with isoproterenol infusion and quinidine orally

Brugada syndrome is an inherited cardiac disease and is associated with a peculiar pattern on the electrocardiogram and an increased risk of sudden death. Electrical storm is a malignant but rare phenomenon in symptomatic patients with Brugada syndrome. We describe a patient who presented with repetitive ICD discharges during two episodes of recurrent VF. After the initiation of isoproterenol infusion and oral quinidine, the ventricular tachyarrhythmias were successfully suppressed. (Neth Heart J 2007;15:151-4.).

Long-term comparison of balloon angioplasty with provisional stenting versus routine stenting in patients with non-ST-elevation acute coronary syndrome

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.).

Therapeutic mild hypothermia improves outcome after out-of-hospital cardiac arrest

Purpose. Therapeutic mild hypothermia (TMH) is indicated for comatose survivors of an out-ofhospital cardiac arrest (OHCA) to improve general outcome. Although widely used, there are not many reports on its use on a critical care unit (CCU) or on the comparison of cooling methods.Methods. In a retrospective analysis covering January 2005 to December 2006, 75 consecutive comatose subjects post-OHCA due to ventricular fibrillation and nonventricular fibrillation rhythms (asystole/pulseless electrical activity) were studied in a single tertiary PCI centre. Subjects treated with conventional post-resuscitation care without TMH served as controls (n=26; Jan 2005-Sep 2005). Outcome from controls at hospital discharge was compared with subjects treated with TMH (n=49; Oct 2005-Dec 2006). During the study period, TMH was induced by either external (n=25; Oct 2005-Feb 2006) or endovascular (n=24; Mar 2006-Dec 2006) approach.Results. Besides more females in the control group, there were no major differences in baseline characteristics present between all groups. TMH improved survival (OR 0.36 [0.13-0.95], p<0.05) and neurological outcome (OR 0.23 [0.07-0.70], p<0.01). After subanalysis, TMH-improved outcome did not differ between the two cooling methods used. However, the times to reach TMH and normothermia were shorter with the endovascular approach.Conclusion. TMH induced on a CCU improves survival and neurological outcome after post-OHCA coma. TMH by endovascular approach was more feasible compared with external cooling, but the two cooling methods did not result in a different outcome. (Neth Heart J 2009;17:378-84.).

Routine upstream versus selective down stream use of tirofiban in non-ST elevation myocardial infarction patients scheduled for early invasive therapy; a randomized comparison

BACKGROUND

Despite their proven beneficial effects and inclusion in the guidelines, glycoprotein (GP) IIb/IIIA blockers are underused in daily practice in patients with non ST-segment elevation acute coronary syndrome (NSTE ACS). This study combines the data from two randomized controlled trials, comparing routine upstream versus selective down stream use of tirofiban in patients with NSTE ACS.

METHODS

Inclusion criteria for both studies (ELISA-1 and 2) were angina pectoris, with ST depression >1 mm and or a positive cardiac biomarkers. All patients were scheduled for coronary angiography. The primary and secondary end points for both studies were enzymatic infarct size (LDHQ48) and initial TIMI flow of the culprit lesion respectively.

RESULTS

From August 2000 to January 2005, 273 patients were randomized to routine upstream tirofiban and 275 patients to selective down stream use of tirofiban. Selective down stream tirofiban was used in 55 patients (20%). Patients in the upstream group more often had a patent culprit lesion (65% vs. 50%, P=0.003) and a significantly smaller enzymatic infarct size, LDHQ48 median (25-75%): 125 (55-309) vs. 189 (68-504) IU/l, P=0.006 as compared to the selective down stream group. Subgroup analysis showed that routine upstream tirofiban was particularly effective in males, patients with a positive troponin on admission and in those not pretreated with clopidogrel.

CONCLUSION

Routine upstream GP IIb/IIIa is mainly effective in patients with elevated troponin on admission and those not pretreated with clopidogrel. Large scale randomized trials are needed to evaluate the effect of GP IIb/IIIa blockers on top of clopidogrel pretreatment on major adverse cardiac events.

Glucose dysregulation in nondiabetic patients with ST-elevation myocardial infarction: acute and chronic glucose dysregulation in STEMI

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.

Incidence and predictors of subacute thrombosis in patients undergoing primary angioplasty for an acute myocardial infarction

Subacute thrombosis (SAT) is a major concern in patients undergoing percutaneous coronary intervention (PCI). So far, only little data has been available on characteristics and outcome of patients with SAT after primary PCI for ST elevation myocardial infarction (STEMI). From 1997-2001, 1,548 unselected consecutive patients underwent primary PCI for STEMI as part of a randomized controlled trial stenting vs. balloon angioplasty. All patients received acetylsalicylic acid (500 mg i.v.) and heparin (5,000 IU) before the procedure. After stenting, all patients received ticlopidine 250 mg daily (before July 1999) or clopidogrel 75 mg daily (after July 1999) for one month. Five percent of patients received glycoprotein IIb/IIIa blockers. We prospectively recorded incidence and characteristics of patients with SAT during one year follow-up. SAT occurred in 4.1% (63/1548) and reinfarction in 6.0% of patients. The incidence of SAT did not change over time (1997: 8/175[4.6%],1998: 8/325 [2.5%],1999: 13/358 [3.6%], 2000: 22/426 [5.2%], 2001: 12/264 [4.5%]). SAT occurred in 39/63(62%) patients during hospital stay. The incidence did not differ between patients after ticlopidine 23/681 (3.4%) or clopidogrel 40/867 (4.6%, p = 0.222). Univariate predictors of SAT were: patients with an LAD stenosis (5.4% vs. 2.9%, p = 0.016), with Killip class >1 at presentation (8.6% vs. 3.7%, p = 0.007) and in patients who received a stent (5.1% vs. 2.7%, p = 0.022). After multivariate analysis, Killip class >1 on admission was the only independent predictor of SAT(OR 2.26, 95% CI 1.14-4.47, p = 0.019). SAT was associated with a higher mortality at long-term follow-up (15% vs. 7%, p = 0.026). In a prospectively recorded, unselected consecutive series of patients undergoing PCI for STEMI, SAT occurred in 4.1% of patients at one-year follow-up. Signs of heart failure on admission, anterior myocardial infarction and stenting were predictors of SAT.

Successful reperfusion for acute ST elevation myocardial infarction is associated with a decrease in WBC count

BACKGROUND

Elevated white blood cell (WBC) count on admission in patients with ST segment elevation myocardial infarction (STEMI) has been associated with an adverse prognosis. Whether successful reperfusion by primary percutaneous coronary intervention (PCI) is associated with a decrease in WBC count is unknown.

METHODS

In this subanalysis of the On-TIME trial, WBC count was measured on admission and 6 h and 24 h after primary PCI for STEMI (n = 364). Angiographic measurements of reperfusion, including TIMI-flow and myocardial blush grade, were compared with changes in WBC count.

RESULTS

Restoration of TIMI 3 flow by primary PCI was associated with a significant decrease in median WBC count (11.5 (9.7-14.2), 10.7 (9.0-12.5), 9.9 (8.5-11.5) at baseline, 6 h and 24 h), whereas after unsuccessful PCI (TIMI < 3 flow) WBC count remained elevated (12.5 (9.5-14.6), 12.1 (9.9-14.4), and 11.4 (9.2-15.2)). Improved myocardial blush was also related to a decrease in WBC count. After multivariate analysis, improved myocardial perfusion (TIMI 3 flow and myocardial blush grade 3) was an independent predictor of a decrease of WBC count after PCI.

CONCLUSION

Impaired myocardial reperfusion after primary PCI for STEMI is associated with persistent WBC elevation.

Prognostic value of admission glucose and glycosylated haemoglobin levels in acute coronary syndromes

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 patient with heart failure and a new murmur: not always a valvular problem]

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.

Dysglycemia in suspected acute coronary syndromes

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.

Role of collateral circulation in the acute phase of ST-segment-elevation myocardial infarction treated with primary coronary intervention

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.

Prehospital triage for angiography-guided therapy for acute myocardial infarction

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.

The importance of patency of the infarct-related artery in treatment of patients with acute myocardial infarction

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.