Platelet inhibition with cangrelor in patients undergoing PCI.

BACKGROUND: Cangrelor, a nonthienopyridine adenosine triphosphate analogue, is an intravenous blocker of the adenosine diphosphate receptor P2Y(12). This agent might have a role in the treatment of patients who require rapid, predictable, and profound but reversible platelet inhibition. METHODS: We performed a large-scale international trial comparing cangrelor with 600 mg of oral clopidogrel administered before percutaneous coronary intervention (PCI) in patients with acute coronary syndromes. The primary efficacy end point was a composite of death from any cause, myocardial infarction, or ischemia-driven revascularization at 48 hours. RESULTS: We enrolled 8877 patients, and 8716 underwent PCI. At 48 hours, cangrelor was not superior to clopidogrel with respect to the primary composite end point, which occurred in 7.5% of patients in the cangrelor group and 7.1% of patients in the clopidogrel group (odds ratio, 1.05; 95% confidence interval [CI], 0.88 to 1.24; P=0.59). Likewise, cangrelor was not superior at 30 days. The rate of major bleeding (according to Acute Catheterization and Urgent Intervention Triage Strategy criteria) was higher with cangrelor, a difference that approached statistical significance (3.6% vs. 2.9%; odds ratio, 1.26; 95% CI, 0.99 to 1.60; P=0.06), but this was not the case with major bleeding (according to the Thrombolysis in Myocardial Infarction criteria) or severe or life-threatening bleeding (according to Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries criteria). A secondary exploratory end point of death from any cause, Q-wave myocardial infarction, or ischemia-driven revascularization showed a trend toward a reduction with cangrelor, but it was not significant (0.6% vs. 0.9%; odds ratio, 0.67; 95% CI, 0.39 to 1.14; P=0.14). CONCLUSIONS: Cangrelor, when administered intravenously 30 minutes before PCI and continued for 2 hours after PCI, was not superior to an oral loading dose of 600 mg of clopidogrel, administered 30 minutes before PCI, in reducing the composite end point of death from any cause, myocardial infarction, or ischemia-driven revascularization at 48 hours. (ClinicalTrials.gov number, NCT00305162.)

64-Detector CT angiography in renal artery stent evaluation: prospective comparison with selective catheter angiography.

PURPOSE: To prospectively assess the diagnostic accuracy of 64-detector computed tomographic (CT) renal artery (RA) angiography for the evaluation of RA in-stent restenosis (ISR) by using selective catheter RA angiography as the reference standard. MATERIALS AND METHODS: Institutional review board approval and written informed consent were obtained. Eighty-six patients (46 men, 40 women; mean age +/- standard deviation, 71 years +/- 9) with 95 RA stents were examined with 64-detector CT RA angiography by experienced radiologists 1 day before selective catheter RA angiography was performed by experienced cardiologists. Each group was blinded to the results of the other imaging method. For image reconstruction, a standard (B25f) and an edge-enhancing (B46f) kernel were chosen. An ISR of more than 50% was considered as hemodynamically significant. Sensitivity, specificity, and positive and negative predictive values for the detection of ISR by using CT RA angiography were calculated. RESULTS: At CT RA angiography, 93 (98%) of 95 stents were assessable for diagnosis. Two stents could not be evaluated owing to hardening artifacts affected by vessel calcifications. All nine cases of significant ISR seen at selective catheter RA angiography were correctly diagnosed by using CT RA angiography, giving a sensitivity of 100% and a negative predictive value of 100%. One case of nonsignificant ISR seen at selective catheter RA angiography was interpreted as significant by using CT RA angiography, giving a specificity of 99% and a positive predictive value of 90%. In four of 78 patients without ISR seen at selective catheter RA angiography, CT RA angiography showed nonsignificant ISR, giving a specificity of 95% and a positive predictive value of 56%. CONCLUSION: Sixty-four-detector CT RA angiography can provide an excellent noninvasive technique to help detect and evaluate ISR within the RA stents used in our study.

Acute results of pulmonary vein isolation in patients with paroxysmal atrial fibrillation using a single mesh catheter.

INTRODUCTION: Catheter-based pulmonary vein isolation (PVI) is an established therapy to treat patients with paroxysmal atrial fibrillation. We evaluated the efficacy of a simplified interventional procedure for PVI by using a single mesh catheter for mapping as well as ablation and with guidance of fluoroscopic imaging only. METHODS AND RESULTS: Forty-eight patients with paroxysmal atrial fibrillation were screened by cardiac computed tomography for their anatomical suitability to undergo PVI with the high-density mesh ablator catheter as the only left atrial device. The procedure was performed in 26 patients (12 males, mean age 61 years) who met the criteria of four clearly separated pulmonary veins (PVs) with an ostial diameter of 15-25 mm. No three-dimensional mapping systems or additional ablation devices were used. In all 26 patients, all four PVs could be accessed and mapped with the high-density mesh ablator catheter. Electrical isolation was achieved in 99 of 102 (97%) of the pulmonary veins that revealed PV potentials. Mean total procedure time and fluoroscopy time were 187 +/- 36 minutes and 34.6 +/- 10.0 minutes, respectively. CONCLUSION: The single-catheter approach using the high-density mesh ablator catheter for mapping as well as ablation reveals a high acute success rate of PVI while, at the same time, reducing the complexity of the procedure, and the procedure time. Long-term data on clinical success are needed to justify this simplified approach.

Predictors of death and stroke after carotid angioplasty and stenting: a subgroup analysis of the Pro-CAS data.

BACKGROUND AND PURPOSE: Little is known about the significance of patient characteristics, clinical indications, and technical details on the risk of carotid angioplasty and stenting (CAS). The purpose of this study was to test these parameters as to their predictive value for the peri-interventional risk of CAS. METHODS: Pro-CAS is a prospective, multicenter registry of CAS. Logistic regression analysis of possible predictive factors was performed on 5341 interventions that had been entered by 25 clinical centers between July 1999 and June 2005. RESULTS: The combined in-hospital mortality and stroke rate was 3.6%. The following were found to be significant predictors of peri-interventional stroke and death: center experience (< or = 50 versus 51 to 150 versus > or = 151 interventions), age, prior symptoms, primary intervention as compared with intervention for restenosis, angioplasty without stent, predilatation, and heparin dosage > 5000 IU. No statistically significant result was found for year of intervention, patient volume, gender, interval between symptoms and CAS, ocular versus neurological symptoms, side of CAS, degree of stenosis of the target lesion, presence of contralateral high-degree stenosis or occlusion, method of gaining access to the carotids, stent type, and use of a protection system. CONCLUSIONS: Our findings underline the need for dedicated training and strict credentialing rules for CAS. In addition, they might help to identify subgroups of patients at differential risk for CAS and carotid endarterectomy and yield a basis for correcting risks due to differences in case mix in reports about CAS.

Long-term outcomes in patients with atrioventricular block undergoing septal ventricular lead implantation compared with standard apical pacing.

AIMS: Left ventricular function may be altered by right ventricular apical pacing. The aims of the study were to compare the long-term course of different parameters of left ventricular dysfunction in patients undergoing implantation of a dual-chamber pacemaker with the ventricular lead in a septal position vs. in a standard apical position. METHODS: We randomized 98 patients with atrioventricular block (AV-block) undergoing pacemaker implantation to positioning the ventricular lead in the high or mid septum (n = 53) or in the apex (n = 45) of the right ventricle. N-terminal pro-brain natriuetic peptide (BNP) levels, left ventricular ejection fraction (LVEF), and exercise capacity were analysed 3 days, 3 months, and 18 months after the implantation. The primary endpoints were the changes of these parameters from baseline to 18 months. RESULTS: Changes of BNP levels, LVEF, and exercise capacity from baseline to 18 months were statistically not different between septal and apical stimulation. The clinical occurrence or deterioration of overt heart failure was similar in both treatment arms. CONCLUSION: With regard to different parameters of congestive heart failure, a septal stimulation site is not superior to conventional apical pacing in unselected patients undergoing pacemaker implantation for AV-block.

In-stent restenosis in bare metal stents versus sirolimus-eluting stents after primary coronary intervention for acute myocardial infarction and subsequent transcoronary transplantation of autologous stem cells.

BACKGROUND: Following stenting for acute myocardial infarction, transcoronary transplantation of granulocyte-colony stimulating factor (G-CSF) mobilized autologous stem cells (ASC) has been shown to result in an increased in-stent restenosis rate of bare metal stents (BMS). HYPOTHESIS: This study sought to compare the extent of neointimal growth in BMS and sirolimus-eluting stents (SES) after primary implantation, and subsequent transcoronary transplantation of G-CSF mobilized stem cells. METHODS: Patients with stenting of the left anterior descending coronary artery for acute anterior myocardial infarction were randomly assigned to receive a BMS or SES. Intracoronary stem cell injection was performed after G-CSF application for at least 4 d and cell apheresis. The angiograms obtained after cell transplantation and after 6 mo were analyzed by quantitative coronary angiography. RESULTS: We performed primary stenting and stem cell transplantion in 16 patients who received a BMS (n = 8) or an SES (n = 8). In 2 patients with a BMS, late stent thrombosis occurred after 58 d and 177 d, respectively. In the remaining patients, control angiography after 6 mo revealed in-stent restenosis of >50% in no patients with SES but in 4 patients with BMS (67%). Late lumen loss and in-stent plaque volume were significantly higher in patients with BMS compared with patients with SES. CONCLUSIONS: Compared with BMS, SES impair in-stent intima hyperplasia after stenting for acute myocardial infarction and transcoronary transplantation of G-CSF mobilized ASC.

Routine upstream initiation vs deferred selective use of glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: the ACUITY Timing trial.

CONTEXT: In patients with moderate- and high-risk acute coronary syndromes (ACS) who undergo an early, invasive treatment strategy, current guidelines recommend administration of platelet glycoprotein IIb/IIIa (Gp IIb/IIIa) inhibitors, either upstream to all patients prior to angiography or deferred for selective use in the catheterization laboratory just prior to angioplasty. The preferred approach is undetermined. OBJECTIVE: To determine the optimal strategy for the use of Gp IIb/IIIa inhibitors in patients with moderate- and high-risk ACS undergoing an early, invasive treatment strategy. DESIGN: Prospective, randomized, open-label trial with 30-day clinical follow-up. SETTING: Four hundred fifty academic and community-based institutions in 17 countries. PATIENTS: A total of 9207 patients with moderate- and high-risk ACS undergoing an invasive treatment strategy. INTERVENTIONS: Patients were randomly assigned to receive either routine upstream (n=4605) or deferred selective (n=4602) Gp IIb/IIIa inhibitor administration, respectively. MAIN OUTCOME MEASURES: The primary outcome was assessment of noninferiority of deferred Gp IIb/IIIa inhibitor use compared with upstream administration for the prevention of composite ischemic events (death, myocardial infarction, or unplanned revascularization for ischemia) at 30 days, using a 1-sided alpha level of .025. Major secondary end points included noninferiority or superiority of major bleeding and net clinical outcomes (composite ischemia or major bleeding). RESULTS: Glycoprotein IIb/IIIa inhibitors were used more frequently (98.3% vs 55.7%, respectively) and for a significantly longer duration (median, 18.3 vs 13.1 hours; P<.001) in patients in the upstream group compared with the deferred group. Composite ischemia at 30 days occurred in 7.9% of patients assigned to deferred use compared with 7.1% of patients assigned to upstream administration (relative risk, 1.12; 95% confidence interval, 0.97-1.29; P = .044 for noninferiority; P = .13 for superiority); as such, the criterion for noninferiority was not met. Deferred use compared with upstream use resulted in reduced 30-day rates of major bleeding (4.9% vs 6.1%, respectively; P<.001 for noninferiority; P = .009 for superiority) and similar rates of net clinical outcomes (11.7% vs 11.7%; P<.001 for noninferiority; P = .93 for superiority). CONCLUSIONS: Among patients with moderate- and high-risk ACS undergoing an invasive treatment strategy, deferring the routine upstream use of Gp IIb/IIIa inhibitors for selective administration in the cardiac catheterization laboratory only to patients undergoing percutaneous coronary intervention resulted in a numerical increase in composite ischemia that, while not statistically significant, did not meet the criterion for noninferiority. This finding was offset by a significant reduction in major bleeding. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00093158.

Risk score for peri-interventional complications of carotid artery stenting.

BACKGROUND AND PURPOSE: Routinely available independent risk factors for the peri-interventional outcome of patients undergoing elective carotid artery stenting (CAS) are lacking. The rationale of the study was to create a risk score identifying high-risk patients. METHODS: We prospectively enrolled 606 consecutive patients assigned to CAS at a secondary care hospital. Various biochemical, clinical, and lesion-related risk factors were prospectively defined. The primary end point reflecting periprocedural complications encompassed minor and major stroke, nonfatal myocardial infarction and all-cause mortality within 30 days. RESULTS: Three percent of patients (n=18) experienced a nonfatal minor (n=13) or major (n=5) stroke. 1.3% of patients (n=8) died from fatal stroke (n=4) or other causes (n=4). No myocardial infarction was observed within 30 days after stenting. Multivariable analysis revealed diabetes mellitus with inadequate glycemic control (HbA1c > 7%), age > or = 80 years, ulceration of the carotid artery stenosis, and a contralateral stenosis > or = 50% as independent risk factors. A risk score formed with these variables showed a superior predictive value (C-statistic = 0.73) compared with single risk factors. The presence of 2 or more of these risk factors identified patients with a risk of 11% for a periprocedural complication compared with 2% in patients with a score of 0 or 1. CONCLUSIONS: In patients undergoing elective CAS, a risk score based on routinely accessible variables was able to identify patients at high-risk for atherothrombotic events and all-cause death within 30 days after the intervention.

Effects of peripheral blood stem cell mobilization with granulocyte-colony stimulating factor and their transcoronary transplantation after primary stent implantation for acute myocardial infarction.

BACKGROUND: There is increasing evidence that transplantation of autologous stem cells improves cardiac function after acute myocardial infarction (AMI). For propagation of peripheral blood stem cells (PBSCs), application of granulocyte-colony stimulating factor (G-CSF) has been shown to be feasible, effective, and safe. We sought to evaluate a clinical and angiographic long-term safety profile of G-CSF application combined with transcoronary PBSC transplantation after recent stent implantation for AMI. METHODS: In patients with AMI and successful primary stenting of the infarct-related coronary artery, pharmacological bone marrow stimulation with G-CSF was initiated on the second postinterventional day. At least after 4 days of G-CSF therapy, apheresis as well as transcoronary transplantation of PBSCs was performed. The PBSCs were infused via a balloon catheter which was inflated inside the stent. Ventriculography and quantitative coronary angiography were performed at baseline and after 6 months. RESULTS: In the 20 patients who received PBSCs, mean left ventricular ejection fraction improved from 46.4% +/- 8.1% at baseline to 54.3% +/- 11% after 6 months (P < .001) because of an increase in systolic function in the infarct region. Control coronary angiography revealed a significant in-stent restenosis of the infarct-related coronary artery, defined as >50% stenosis, in 8 patients (40%), which was complicated by reinfarction in 2 patients (10%). CONCLUSIONS: Transcoronary transplantation of G-CSF-mobilized PBSCs favorably influences cardiac function and can be performed without adverse periprocedural events. However, significant in-stent restenosis and reinfarction seem to occur frequently during the following 6 months.

Long-term follow-up in patients with lost coronary stents during interventional procedures.

The aim of this retrospective study was to determine the incidence of stent loss during interventional procedures and to identify the associated immediate and long-term consequences of such loss. We evaluated 36 cases in which the stents were prematurely displaced from the stent delivery device. Five stents were completely removed from the vascular system successfully. Five stents could not be retrieved from the coronary circulation and led to significant adverse events in 3 patients, in whom the lost stents were not excluded by the placement of another stent. In 26 patients, peripheral embolism below the renal arteries occurred after successful stent retrieval from the coronary arteries. Of these 26 patients, 1 patient died during hospital stay, unrelated to the peripheral stent loss. Additional follow-up examinations were performed for 20 of the remaining 25 patients. Clinical patient status and the ankle-brachial index were evaluated 59 +/- 30 months after stent loss. All patients were free of any stent-related peripheral ischemic symptoms. We also attempted to determine the exact physical locations of the lost stents using computed tomography during follow-up. In 15 patients, we were able to detect the stent in the peripheral arteries using computed tomography. In conclusion, if stents cannot be retrieved from the coronary system, severe problems may occur. Stent loss with peripheral embolization is asymptomatic in long-term follow-up.

Effects of a high dose intravenous bolus amiodarone in patients with atrial fibrillation and a rapid ventricular rate.

BACKGROUND: Amiodarone, given as intravenous bolus has not yet been studied in patients with atrial fibrillation and a high ventricular rate. METHODS: One hundred consecutive patients with atrial fibrillation and a ventricular rate above 135 bpm were randomized to receive either 450 mg amiodarone or 0.6 mg digoxin given as a single bolus through a peripheral venous access. If the ventricular rate exceeded 100 bpm after 30 min, another 300 mg amiodarone or 0.4 mg digoxin were added. Primary endpoints of the study were the ventricular rate and the occurrence of sinus rhythm after 30 and 60 min. Secondary endpoints were blood pressure during the first hour after drug administration, and safety regarding drug induced hypotension, and phlebitis at the infusion site. RESULTS: Baseline heart rate was 144+/-19 in the amiodarone group and 145+/-15 in the digoxin group (p=0.72). Following amiodarone, heart rate was 104+/-25 after 30 min compared to 116+/-23 in the digoxin group (p=0.02) and 94+/-22 versus 105+/-22 after 60 min (p=0.03). After 30 min, sinus rhythm was documented in 14 (28%) patients following amiodarone compared to 3 (6%) patients in the digoxin group (p=0.003), and after 60 min in 21 (42%) versus 9 (18%) patients (p=0.012). Asymptomatic hypotension was observed in 4 amiodarone treated patients, and superficial phlebitis in 1 patient. CONCLUSIONS: Amiodarone, given as an intravenous bolus is relatively safe and more effective than digoxin for heart rate control and conversion to sinus rhythm in patients with atrial fibrillation and a rapid ventricular rate.

Electrocardiogram changes and wall motion abnormalities in the acute phase of Tako-Tsubo syndrome.

BACKGROUND: The Tako-Tsubo syndrome is still rarely diagnosed in patients presenting with symptoms of acute myocardial ischaemia. It is accompanied by wall motion abnormalities of the left ventricle but significant narrowings or occlusions of epicardial coronary arteries are absent. We investigated a potential relationship between electrocardiogram (ECG) changes, wall motion abnormalities and gender influence of Tako-Tsubo syndrome in an Austrian cohort of Tako-Tsubo syndrome patients. METHODS AND RESULTS: We were recently able to describe four different anatomical types of Tako-Tsubo syndrome in 153 patients of the Austrian Tako-Tsubo syndrome registry. In the present retrospective analysis we investigated ischaemia-related changes in the first diagnostic ECG for the different types of Tako-Tsubo syndrome: the apical and the combined apical-midventricular type showed most frequently a ST elevation (41.1% and 35.3%), whereas the midventricular type of Tako-Tsubo syndrome was more often accompanied by T wave inversion (60%). ECG changes in relation to the Tako-Tsubo syndrome type were similar in women and men. There was no difference in the prevalence of clinical complications among patients presenting with ST elevation or left bundle branch block (14.5%) compared with patients without ST elevation (10.4%) (p=0.476). CONCLUSION: Patients with Tako-Tsubo syndrome show characteristic ECG changes in the first diagnostic ECG which are associated to some extent with the anatomical type of Tako-Tsubo syndrome, but these ECG changes were not related to clinical outcome.

Recurrent symptomatic bradycardia due to secret ingestion of beta-blockers--a rare manifestation of cardiac Münchhausen syndrome.

The term Münchhausen syndrome was established in 1951 by Asher to describe a severe psychiatric illness in which patients simulate false symptoms and signs. We report on a female general practitioner who repeatedly ingested high doses of beta-blockers in order to simulate symptomatic sick-sinus syndrome. She had been admitted to intermediate care units in several hospitals before the correct diagnosis was made by finding the tablets in her toilet bag. Following psychiatric exploration and psychotherapy, she has been working in her community again for about a year. This is the first report on the clinical presentation and course of disease in a patient with cardiac Münchhausen syndrome who secretly ingested beta-blockers to provoke a menacing bradycardia. The follow-up indicates that frequent and intense symptomatic episodes of this remarkable psychiatric disease can be interrupted by long normal intervals.

Abciximab bolus injection does not reduce cerebral ischemic complications of elective carotid artery stenting: a randomized study.

BACKGROUND AND PURPOSE: Abciximab has been shown to significantly reduce thromboembolic complications of coronary artery stenting. A prospective, randomized study was performed to test whether abciximab has comparable beneficial effects in carotid artery stenting. METHODS: Seventy-four consecutive patients undergoing elective stenting of the carotid artery were included in the study. Standard antithrombotic medication consisted of aspirin, clopidogrel, and heparin. In addition, half of the patients received an abciximab bolus of 0.25 mg/kg body weight given prophylactically before the intervention. RESULTS: The procedure was successful in all but 1 patient. In patients receiving abciximab, ischemic complications consisted of 4 transient ischemic attacks, 1 minor stroke, 1 nonfatal major stroke, and 1 fatal stroke caused by cerebral hemorrhage. In the control group, 2 transient ischemic attacks and 1 major nonfatal stroke occurred. In summary, the total number of periprocedural ischemic events was 7 (19%) in the abciximab group and 3 (8%) in the control group. Nonischemic complications consisted of 1 inguinal hematoma requiring blood transfusions in each group. CONCLUSIONS: Abciximab bolus given prophylactically before elective carotid artery stenting does not reduce ischemic complications.

Pro-CAS: a prospective registry of carotid angioplasty and stenting.

BACKGROUND AND PURPOSE: The German Societies of Angiology and Radiology have instituted a prospective registry of carotid angioplasty and stenting (CAS) to limit uncontrolled use of CAS and to collect data about technique and results of CAS outside clinical trials. METHODS: A total of 38 centers register their patients prospectively before CAS is performed. At discharge, technical details, periprocedural medication, and the clinical course are reported on a standardized form. RESULTS: During the first 48 months, 3853 planned interventions were recorded, and CAS was actually attempted on 3267 patients of whom 1827 (56%) were symptomatic and 1433 (44%) were asymptomatic. In 3127 (98%) cases, stents were used, of which 2784 (89%) were of the self-expanding type. Other technical aspects such as the use of guiding catheters and protection devices varied widely among the centers. Periprocedural medication rather uniformly included aspirin and clopidogrel before and after CAS and high-dose heparin and atropin during CAS. CAS was successful in 3207 (98%) cases. There was a 0.6% (n=18) mortality rate, a 1.2% (n=38) major stroke rate, and a 1.3% (n=41) minor stroke rate. The combined stroke and death rate was 2.8% (n=90). CONCLUSIONS: These prospective multicenter data are likely to give a realistic picture of the possibilities and limitations of CAS in the general community. They suggest that CAS may be performed with similar results in the general community as they have been reported by highly specialized centers and in clinical studies.

Proinflammatory parameters as CRP and IL-6 do not discriminate between post-PCI cardiac patients with and without exercise-induced ischemia as indicated by Tl-201 myocardial scintigraphy.

INTRODUCTION: Atherosclerosis is looked upon as an inflammatory disease. The production of proinflammatory markers may indicate activity in this inflammatory state. METHODS: We prospectively evaluated a range of proinflammatory serum parameters in 136 cardiac patients who had previously undergone percutaneous coronary intervention (PCI). RESULTS: By means of myocardial scintigraphy, an ischemia group (A; n=49) and a group with stable cardiovascular disease without exercise induced ischemia (B; n=87) were distinguished. Risk factors and lipoprotein profile of both groups were comparable. Serum levels of serum C-reactive protein (CRP), IL-6, sTNF-RI, IGF-I, neopterin, serotonin and prolactin did not present any significant difference between the two groups. CONCLUSIONS: We conclude that measurement of these (inflammatory) parameters does not help to delineate post-PCI cardiac patients with and without exercise-induced ischemia.

Thrombus aspiration prior to primary angioplasty in acute myocardial infarction: estimation of rescued myocardial tissue by return of ST-segment elevation.

BACKGROUND: The goal of the study was to validate the clinical benefit of adjunctive thrombus aspiration prior to balloon or stent angioplasty in patients with acute myocardial infarction. HYPOTHESIS: Adjunctive thrombus aspiration reduces no-reflow by eliminating peripheral thromboembolism. METHODS: In all, 143 consecutive patients underwent primary angioplasty for acute myocardial infarction in our institution. We excluded patients with subacute stent thrombosis or bundle-branch pattern of the electrocardiogram (ECG) and divided the remaining 131 into two groups: 62 patients who underwent intervention without a thrombus aspiration device (Group 1) and 69 patients who were treated as soon as a specifically designed thrombus aspiration catheter became available at our institution (Group 2). The intention was to use thrombus aspiration in every suitable case with proximal occlusion of a major vessel. The reduction of the sum of ST-segment elevation following angioplasty as a marker of rescued myocardial tissue was compared between the two groups. RESULTS: Thrombus aspiration was technically feasible in 23 of 25 attempted cases. The reduction of the sum of ST-segment elevation following intervention was 0.41 +/- 0.39 mV in Group 1 and 0.37 +/- 0.42 mV in Group 2 (p > 0.05). CONCLUSIONS: Thrombus aspiration may be helpful during primary angioplasty in selected cases but does not improve the general outcome. Other reasons for "no-reflow," apart from peripheral thromboembolism, seem to be responsible for the lack of clinical benefit.

Intravenous amiodarone bolus for treatment of atrial fibrillation in patients with advanced congestive heart failure or cardiogenic shock.

BACKGROUND: The clinical course of patients with advanced organic heart disease is often complicated by the occurrence of atrial fibrillation. Slowing the ventricular rate and, if possible, restoration of normal sinus rhythm is crucial but difficult in the state of decreased ventricular function. METHODS: We included 78 consecutive patients with atrial fibrillation and heart rate above 135 beats min(-1) in an observational, uncontrolled study in the coronary care unit of a tertiary care center. Thirty-nine patients suffered from advanced congestive heart failure, 26 patients had pulmonary edema, and 13 patients were in cardiogenic shock. All patients were treated with 450 mg amiodarone given as a single intravenous bolus through a peripheral venous access without further infusion. Ventricular heart rate and cardiac rhythm were measured within 30 minutes after drug administration. Cardiac rhythm was monitored for 24 hours. The site of venous access was examined 30 minutes after drug administration and every 6 hours until the needle was removed after a maximum of 48 hours. RESULTS: Twenty-five patients (32%) converted to normal sinus rhythm within 30 minutes. Another 15 (19%) reverted into sinus rhythm during the following 24 hours. Within 30 minutes after amiodarone administration, ventricular heart rate decreased significantly from 152 +/- 12 to 88 +/- 17 (p < 0.0001) beats min(-1) in patients who converted to sinus rhythm and from 157 +/- 14 to 98 +/- 16 beats min(-1) in patients who did not. The degree of reduction in heart rate was similar among patients presenting with exacerbated congestive heart failure, pulmonary edema, or cardiogenic shock. Systolic blood pressure decreased in two patients, from 115 to 80 mmHg and from 130 to 100 mmHg, but was reversible after 10 and 90 minutes respectively without specific intervention. No proarrhythmia or clinical relevant bradycardia was observed, and no inflammation detected at the site of venous access. CONCLUSIONS: Amiodarone, given as a single intravenous bolus through a peripheral vein rapidly reduced ventricular rate and was well tolerated in patients with atrial fibrillation, even in the presence of congestive heart failure and cardiogenic shock.

Stress-induced cardiomyopathy (Tako-Tsubo syndrome) in Austria.

BACKGROUND: Tako-Tsubo syndrome (TS) is a still rarely diagnosed clinical syndrome, which is characterized by acute onset of chest pain, transient cardiac dysfunction with (frequently) reversible wall motion abnormalities (WMAs), but with no relevant obstructive coronary artery disease. METHODS AND RESULTS: Among 179 consecutive patients with proven diagnosis of TS that were retrospectively analysed in this multicentre registry, women represented the majority of patients (94%) while only 11 men (6%) developed TS. Mean age was 69.1±11.5 years (range 35-88 years). Cardinal symptoms of TS, which led to admission, were acute chest pain (82%) and dyspnoea (32%), respectively. All patients demonstrated typical WMAs, whereby four different types of WMAs could be defined: (1) a more common apical type of TS (n=89; 50%); (2) a combined apical and midventricular form of TS (n=23; 13%); (3) the midventricular TS (n=6; 3%); and (4) an unusual type of basal WMAs of the left ventricle (n=3). Only in 101 patients (57%), a clear causative trigger for onset of symptoms could be identified. In-hospital cardiovascular complications occurred in 25 patients (14%) and consisted of cardiac arrhythmias in 10 patients (40%), cardiogenic shock in six patients (24%), cardiac decompensation in eight patients (32%) and cardiovascular death in one patient, respectively. Echocardiographic control of left ventricular function after the initial measurement was available in almost 70% of the patients: complete recovery of WMAs was found in 73 patients (58.87%); 49 patients (39.52%) showed persistent WMAs. Recurrences of TS were only seen in four patients. During the follow-up period, 13 patients died: three of cardiovascular causes and 10 of non-cardiac causes. In-hospital mortality was 0.6%, 30-day mortality was 1.3% and 2-year mortality was 6.7%. CONCLUSIONS: This study represents to date the largest series of patients suffering from TS in Austria and worldwide. Similar to others, in our series the prevalence of TS was significantly higher in women than in men, while in contrast to other studies, the apical type of TS was detected most frequently. The similar clinical presentation of TS patients to the clinical picture of acute myocardial infarction demonstrates the importance of immediate coronary angiography for adequate differential diagnosis of TS. TS is not necessarily a benign disease due to cardiovascular complications as well as persistent WMAs with delayed recovery.