Current analysis of the results of the COURAGE trial: has an optimal treatment been reached in clinical practice?

The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial was designed to evaluate the benefits of percutaneous coronary intervention in reducing the risk of cardiovascular events in patients with chronic stable coronary artery disease. The results reinforce the prior evidence regarding the importance of medical treatment which should be a universal goal. The study population enrolled was quite average for a routine cardiology clinic. However, the results of cardiac intervention are center-dependent and therefore need to be analyzed as such. Patients should initially receive the optimal medical treatment. Patients with symptom persistence, intolerance to medical treatment, and moderate to severe ischemia should be considered candidates for combined treatment. Treatment needs to be individualized and discussed with the patient. New studies, without the limitations of the COURAGE trial, enrolling high-risk patients treated with new interventional technologies, are needed to assess the impact of ischemia in long-term prognosis.

[Evaluation of mitral regurgitation severity using a simplified method based on proximal flow convergence]. / Estimación de la severidad de la insuficiencia mitral según un método simplificado basado en el flujo de convergencia proximal.

INTRODUCTION AND OBJECTIVES: Calculation of the effective regurgitant orifice (ERO) is regarded as the most accurate way of assessing the severity of mitral regurgitation (MR), but the technique's complexity limits its use. Our objective was to modify and validate a previously published semiquantitative method of assessment based on measurement of the proximal isovelocity surface area (PISA) in order to adapt it to recent recommendations from American and European cardiology societies. METHODS: In the PISA method, maximum regurgitant flow (MRF) is a function of the radius and aliasing velocity (AV). Using this relationship, it is possible to construct a nomogram formed by lines of different MRF value, which can be easily derived by looking for radius values on the graph and observing where they cross with AV values. The MR severity limits on the nomogram were set to reflect the different severity grades and limits recommended for use with ERO measurements by American and European cardiology societies. RESULTS: We studied 76 patients with MR using Doppler echocardiography. There was an excellent correlation between MRF and ERO (r=0.98, P< .001). Estimates of MR severity made using the new nomogram were in good agreement with those derived from the ERO: for a scale with three severity grades, kappa was 0.951 and the standard error was 0.11; for four grades, kappa was 0.969 and the standard error, 0.11. CONCLUSIONS: Estimates of MR severity derived semiquantitatively from MRF using the nomogram proposed here were in excellent agreement with quantitative estimates obtained using the ERO, and the method was faster and easier to use.

Role of noninvasive antimyosin imaging in infants and children with clinically suspected myocarditis.

UNLABELLED: Endomyocardial biopsy is an invasive procedure, often performed on children for the diagnosis of myocarditis, and is not without risk. Therefore, a noninvasive test of adequate diagnostic accuracy is highly desirable. We evaluated the role of antimyosin scintigraphy in infants and children with clinically suspected myocarditis. METHODS: Forty patients (age range, 2 mo to 14 y) with suspected myocarditis underwent (111)In-antimyosin scintigraphy. All patients were clinically followed for 29 +/- 17 mo; 21 patients underwent serial antimyosin scans (3.8 +/- 1.7 per patient). The antimyosin uptake was assessed by heart-to-lung ratio (HLR). The scan results were compared with endomyocardial biopsy results in 22 patients. RESULTS: Thirty-five of the 40 patients showed abnormal antimyosin findings; 17 patients showed intense myocardial antimyosin uptake (HLR > 2). The HLR was higher in patients presenting within the first 2 mo of illness (2.09 +/- 0.43 vs. 1.74 +/- 0.34, P = 0.01). Of 22 patients with endomyocardial biopsy, 17 demonstrated myocarditis. All 9 patients who had an HLR > 2 and underwent endomyocardial biopsy had histologic evidence of myocarditis. Of the remaining 13 patients with HLR < 2, 8 had biopsy-verified myocarditis (62%). The intensity of antimyosin uptake was the major determinant of survival in children, with a relative risk of 18 (confidence interval, 1.34-242; P = 0.027). High antimyosin uptake (HLR > 2) seen within 2 mo of the onset of symptoms was associated with a higher mortality rate. The survivors with an HLR > 2 and those with an HLR < 2 showed a high likelihood of complete functional recovery. Furthermore, the patients with serial antimyosin scans having persistently positive findings showed a poor clinical outcome. CONCLUSION: Intense myocardial uptake of antimyosin antibody is a reliable indicator of myocarditis in infants and children. Severe myocardial damage detected in the early phase of disease is associated with a higher mortality rate. The persistence of antimyosin uptake is associated with poor clinical outcomes.