Eptifibatide infusion versus placebo in high risk patients with non-st segment elevation acute coronary syndromes managed with urgent coronary artery bypass graft surgery. a prospective multicenter randomized placebo-controlled clinical trial.

AIM: This randomized prospective clinical trial aimed to evaluate safety and efficacy of preoperative use of eptifibatide in high risk patients with non--ST--segment elevation acute coronary syndrome (NSTE--ACS), requiring urgent coronary artery bypass graft surgery (CABG). METHODS: A total of 140 patients with NSTE--ACS eligible for urgent surgical revascularization received either eptifibatide (bolus plus infusion) 12--48 hours prior to surgery (n=72 patients) or placebo (normal saline; n=68 patients) followed by routinely administered enoxaparin and aspirin. Patients were regarded as unsuitable for percutaneous coronary intervention by the heart team. CABG was performed 4 hours after discontinuation of eptifibatide or placebo infusion. The primary end point was major adverse cardiac and cerebrovascular events (MACCE) defined as death, nonfatal myocardial infarction (MI), stroke and the need for re--hospitalization due to recurrent ischaemia at 12 months follow--up. Secondary endpoints included MACCE rate at 1 month, bleeding complications, platelet inhibition efficacy and correlation of platelet activity with MACCE rate. RESULTS: Cumulative one year MACCE rate was 35% vs 14% in the control and treated group respectively (p=0.012). Mortality rate at 30 days follow--up was 10% vs 3% (p=0.021) and was not changed at 12 months follow--up. There was a significant difference between both groups regarding perioperative MI (22% vs. 8%, p=0.03). The rates of stroke, blood loss and blood transfusion were similar in both groups. CONCLUSION: Preoperative use of eptifibatide vs. placebo is linked to significantly reduced 12--month MACCE rate in patients with NSTE--ACS requiring urgent CABG, while it simultaneously seems not to confer a greater risk of postoperative bleeding.

Microvolt T-wave alternans predicts cardiac events after acute myocardial infarction in patients treated with primary percutaneous coronary intervention.

BACKGROUND: Current risk stratification after acute myocardial infarction (MI) depends on left ventricular ejection fraction. Microvolt T-wave alternans (MTWA) is one of promising markers to predict cardiac events in patients after acute MI treated according to current guidelines. METHODS: In this single center study, 112 consecutive patients with the first anterior ST-elevation MI undergoing PCI <12 hours from symptom onset, were enrolled prospectively. Demographics, established risk factors, myocardial contrast echocardiography (MCE) perfusion, index event data and MTWA were assessed. Composite cardiac events (CCE) defined as: death, recurrent MI, sustained ventricular tachycardia (sVT) or readmission for acute heart failure (HF) were recorded during follow-up. RESULTS: MTWA test was negative in 76, positive in 18 and undetermined in 7 patients. MTWA negative patients had significantly higher LVEF at 30 days. At 4 years, 26 patients experienced CCE (10 died, 2 reinfarcted and 14 HF events). In multivariate Cox proportional hazard model maximum CKMB, non-negative MTWA and reduced LVEF made the best model to predict CCE. Four year CCE free survival was 77% and was significantly lower for non-negative MTWA (94% vs 50%, p<0.003). CONCLUSIONS: Non-negative MTWA with infarct size index and reduced LVEF could predict cardiac events in patients with anterior STEMI treated with primary PCI. MTWA non-negative patients have significantly worse outcome.

[Taking history in diagnosing coronary artery disease in the 21st century--wasting time or a valuable diagnostic tool?]. / Badanie podmiotowe w rozpoznawaniu choroby wiencowej w XXI wieku--strata czasu czy tez moze wartosciowa metoda diagnostyczna?

UNLABELLED: The relation of chest pain characteristics and other features of the history of disease to coronary angiograms was assessed in 551 patients with chest pain regarded as definite or probable stable angina pectoris. A standardised questionnaire was used to record demographic details and chest pain characteristics of interviewed patients. The differentiation between typical, atypical or nonanginal pain was based on classification proposed by Diamond. The indications for catheterization in each patient were determined at the discretion of the attending physician. All patients underwent diagnostic coronary angiography (clinically important coronary artery disease was defined as > 50 per cent narrowing of the diameter of at least one major vessel or > or = 50 per cent of the left main coronary artery). CONCLUSION: Chest pain characteristics remains an effective tool for estimating probability of coronary artery disease.

[Left ventricular systolic function after PTCA--recent and late assessment by exercise echocardiography]. / Funkcja skurczowa lewej komory po plastyce tetnicy wiencowej--wczesna i odlegla ocena metoda echokardiografii wysilkowej.

The purpose of this study was to determine whether global and segmental left ventricle (LV) systolic function, assessed by exercise echocardiography (EE), improves after PTCA in patients without previous myocardial infarction (MI) and after infarction and angioplasty of infarct related coronary artery. 32 patients without MI and 35 patients with previous (4 +/- 3 months) MI were examined before PTCA (percutaneous transluminal coronary angioplasty), 3-5 days after successful elective PTCA and 6 months later with EE (modified Bruce protocol). LV ejection fraction (EF) and wall motion score index (WMSI) at the baseline and immediately after exercise were assessed. Following angioplasty (after 3-5 days and 6 months later), exercise duration was significantly (p < 0.001) increased in both groups of patients. Resting EF and WMSI did not change after angioplasty of infarct-related artery, but in patients without prior MI resting EF increased (p < 0.001) after PTCA in comparison with pre-PTCA values. Significant improvement of exercise EF and WMSI were observed in both groups of patients. In 25 of 35 patients with old MI wall motion improvement in the infarcted region after PTCA was observed. Twenty of these 25 patients developed exercise-induced akinesia in this area during pre-PTCA EE. Among 10 patients without improvement of the regional contractility were 9 after type Q-wave infarction and only 2 developed angina during EE. These data demonstrate improvement in global and regional systolic LV function and better exercise tolerance following successful PTCA both in patients without prior MI and with old MI after angioplasty of a stenosis in an infarct-related coronary artery.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effect of physical exercise on the function of prosthetic heart valves--evaluation by doppler echocardiography]. / Wplyw wysilku fizycznego na funkcje sztucznych zastawek serca--ocena metoda echokardiografii Dopplerowskiej.

Although considerable data exist regarding the function of prosthetic heart valves (PHV) at rest, few data exist regarding the response to exercise. Thus, we studied by Doppler echocardiography 81 asymptomatic patients with PHV (46 mitral, 45 aortic) of varying type and 20 normal persons before and after symptom limited upright bicycle exercise. Rest and exercise hemodynamics (blood velocity, gradients, heart rate, stroke volume and cardiac output) was examined. In patients with mitral PHV maximal (Gmax) and mean (Gmean) gradients increased from 9.9 to 17.8 mmHg and from 4.4 to 7.8 mmHg (both p < 0.001), respectively. In patients with aortic PHV Gmax and Gmean increased from 27 to 42 mmHg and from 16 to 24 mmHg (both p < 0.001), respectively. Linear regression analysis demonstrated a relationship between the % change in gradient with exercise nd % change in stroke volume and cardiac output. Importantly, the largest gradient produced by exercise is related and predicted by the rest gradient. In comparison with normal valves, maximal and mean blood velocity were significantly (p < 0.001) greater across PHV, but % change in velocity with exercise did no differ significantly between prosthetic and normal valves. In conclusion, exercise Doppler echocardiography provides a good method to assess PHV function.

[PTCA and left ventricular systolic function (evaluation by exercise two-dimensional echocardiography)]. / Przezskórna plastyka tetnic wiencowych a funkcja skurczowa lewej komory (ocena metoda echokardiografii wyslkowej).

Successful transluminal coronary angioplasty (PTCA) should improve left ventricular systolic function. To assess the effect of this procedure 25 patients with coronary heart disease were examined before and 3-to 5 days after successful PTCA with electrocardiographic treadmill exercise test, and exercise two-dimensional echocardiography (modified Bruce protocol). Echocardiographic examination was obtained prior to and immediately following exercise. Left ventricular ejection fraction and segmental wall motion at the baseline and immediately after exercise were assessed. Electrocardiographic evidence of ischemia was found in 16 of 25 patients prior to PTCA and in 9 patients after PTCA. Following angioplasty, exercise duration was increased and the exercise-induced angina rate was significantly decreased. Ejection fraction did not change significantly in patients prior and after PTCA (52 +/- 10% versus 55 +/- 16%, p = NS). Following angioplasty, ejection fraction increased from 55 +/- 10% (rest) to 64 +/- 11% (exercise) (p less than 0.001). New exercise-induced echocardiographic segmental wall motion abnormalities were found in 16 of 25 patients prior to PTCA and in only one patient following PTCA. Significant improvement of ejection fraction and segmental wall motion were also observed in 11 patients with old myocardial infarction subjected to successful angioplasty of infarct-related coronary artery. Opposite to post-exercise results, the resting mean values of these echocardiographic parameters did not differ significantly between pre and post-PTCA examinations. These data demonstrate an improvement in systolic left ventricular function and better exercise tolerance following successful PTCA. This occurs also in patients with old myocardial infarction after angioplasty of infarct-related coronary artery. Two-dimensional exercise echocardiography may be helpful in assessing the early results of successful angioplasty.