Combination use of a TandemHeart with an extracorporeal oxygenator in the treatment of five patients with refractory cardiogenic shock after acute myocardial infarction.

Cardiogenic shock remains the leading cause of in-hospital death for patients admitted with acute myocardial infarction. For patients with refractory cardiogenic shock, early revascularization and intra-aortic balloon pump support are often inadequate to reverse the persistent circulatory collapse. We report 5 cases in which an extracorporeal oxygenator in series with the TandemHeart system was instituted emergently in patients with refractory cardiogenic shock from acute myocardial infarction. From our experience, we showed that the device can be safely and easily inserted and that it is able to reverse circulatory collapse and provide hemodynamic stability in patients who otherwise have a high mortality rate.

Effects of optimal medical treatment with or without coronary revascularization on angina and subsequent revascularizations in patients with type 2 diabetes mellitus and stable ischemic heart disease.

BACKGROUND: In the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial, an initial strategy of coronary revascularization and optimal medical treatment (REV) compared with an initial optimal medical treatment with the option of subsequent revascularization (MED) did not reduce all-cause mortality or the composite of cardiovascular death, myocardial infarction, and stroke in patients with type 2 diabetes mellitus and stable ischemic heart disease. In the same population, we tested whether the REV strategy was superior to the MED strategy in preventing worsening and new angina and subsequent coronary revascularizations. METHODS AND RESULTS: Among the 2364 men and women (mean age, 62.4 years) with type 2 diabetes mellitus, documented coronary artery disease, and myocardial ischemia, 1191 were randomized to the MED and 1173 to the REV strategy preselected in the percutaneous coronary intervention (796) and coronary artery bypass graft (377) strata. Compared with the MED strategy, the REV strategy at the 3-year follow-up had a lower rate of worsening angina (8% versus 13%; P<0.001), new angina (37% versus 51%; P=0.001), and subsequent coronary revascularizations (18% versus 33%; P<0.001) and a higher rate of angina-free status (66% versus 58%; P=0.003). The coronary artery bypass graft stratum patients were at higher risk than those in the percutaneous coronary intervention stratum, and had the greatest benefits from REV. CONCLUSIONS: In these patients, the REV strategy reduced the occurrence of worsening angina, new angina, and subsequent coronary revascularizations more than the MED strategy. The symptomatic benefits were observed particularly for high-risk patients. CLINICAL TRIAL REGISTRATION: URL: http://www.ClinicalTrials.gov. Unique identifier: NCT00006305.

Major adverse cardiac events in patients with hepatitis C infection treated with bare-metal versus drug-eluting stents.

BACKGROUND: There are no data comparing the long-term outcome of bare-metal stents (BMS) vs drug-eluting stents (DES) in patients with hepatitis C virus (HCV) infection. HYPOTHESIS: In patients with HCV infection, the rate of major adverse cardiac events (MACE) would be less, and the mortality rates similar, in patients treated with DES than in patients treated with BMS. METHODS: The incidence of major adverse cardiac events (MACE) during long-term follow-up, including death, myocardial infarction, and target-vessel revascularization, was investigated in HCV-infected patients who also underwent percutaneous coronary intervention with bare-metal or drug-eluting stents. RESULTS: Of 78 patients studied, BMS were placed in 41 patients and DES stents in 37 patients. Stepwise Cox regression analyses were performed to identify significant independent risk factors for MACE. At 42 +/- 11-month follow-up, MACE occurred in 9 of 41 patients (22%) in the BMS group (mean age 63 +/- 11 years, 66% men) vs in 7 of 37 patients (19%) in the DES group (mean age 61 +/- 9 years, 65% men). There was no significant difference in MACE in the BMS group vs the DES group. This persisted even after controlling for length of the stent, complexity of lesion, and other comorbidities. All-cause mortality was not significantly different in the BMS group vs the DES group (7% vs 5%). CONCLUSIONS: At long-term follow-up of HCV-infected patients with stable liver function, the rates of MACE and of all-cause mortality were similar in the BMS and DES groups.

Usefulness of clopidogrel to protect against diabetes-induced vascular damage.

Clopidogrel enhances the levels of endothelial nitric oxide and prostacyclin in tissue culture. We have previously described a marked increase in circulating endothelial cells (CECs), an ex vivo indicator of vascular injury, in patients with type 2 diabetes mellitus. We hypothesized that clopidogrel treatment would result in a decrease in CEC number and increased activity of endothelial progenitor cell recruitment signaling pathways in diabetic patients. CECs were isolated from the peripheral blood of 9 patients with type 2 diabetes using anti-CD146-coated Dynabeads. The cells were stained with acridine orange and counted by fluorescence microscopy. Endothelial progenitor cells were isolated in a similar fashion using anti-CD34 and anti-CD133 and assayed for expression of phosphorylated Akt and phosphorylated adenosine monophosphate kinase. The patients were then treated with clopidogrel 75 mg/day for 30 days, after which repeat blood specimens were analyzed. As previously observed, diabetic patients had an elevated number of CECs (mean 79 +/- 15 cells/ml peripheral blood), which was reduced by clopidogrel treatment (mean 10 +/- 4 cells/ml; p <0.001). This was associated with a significant increase in the expression of both phosphorylated Akt and phosphorylated adenosine monophosphate kinase (p

Major adverse cardiac events in patients with moderate to severe renal insufficiency treated with first-generation drug-eluting stents.

No data are available comparing the long-term outcome of sirolimus-eluting stents (SESs) versus paclitaxel-eluting stents (PESs) in patients with moderate to severe renal insufficiency. The incidence of major adverse cardiac events (MACE), including death, myocardial infarction, and target vessel revascularization, during long-term follow-up were studied in patients with a glomerular filtration rate of <60 ml/min/1.73 m(2), as measured by the Modification of Diet in Renal Disease (MDRD) study equation, who also underwent percutaneous coronary intervention with drug-eluting stents. Of 428 patients studied, PESs were placed in 287 patients and SESs in 141 patients. Stepwise Cox regression analyses were performed to identify significant independent risk factors for MACE. At 47 + or - 19 months of follow-up, MACE had occurred in 49 (17%) of 287 patients in the PES group (mean age 71 + or - 11 years, 55% men) and in 31 (22%) of 141 patients in the SES group (mean age 71 + or - 12 years, 53% men). No significant difference was found in the MACE rate between the PES and SES groups. This persisted even after controlling for stent length, lesion complexity, and other co-morbidities. Also, all-cause mortality was not significantly different between the PES and SES groups (7.1% vs 8.5%, respectively). In conclusion, during long-term follow-up of patients with moderate to severe renal insufficiency, the rates of MACE and all-cause mortality were similar in the PES and SES groups.

Prevalence of in-hospital complications in 500 patients undergoing percutaneous coronary intervention treated with heparin 5000 IU administered systemically versus 500 age-matched and sex-matched patients treated with heparin 70 IU/kg administered systemically.

We investigated the prevalence of in-hospital complications in 500 patients undergoing percutaneous coronary intervention (PCI) treated with heparin 5000 IU administered systemically (group 1) at the time of PCI versus in 500 age-matched and sex-matched patients undergoing PCI treated with heparin 70 IU/kg administered systemically (group 2) at the time of PCI. There was no significant difference in baseline characteristics, indications for PCI, cardiovascular drug therapy at the time of PCI, prevalence of 1-vessel, 2-vessel, and 3-vessel obstructive coronary artery disease, and in-hospital complications between the 2 groups. In-hospital death occurred in 0.2% of group 1 patients versus 0.8% of group 2 patients. Non-ST-segment elevation myocardial infarction occurred in 0.2% of group 1 patients versus 0.4% of group 2 patients. Stroke occurred in 0.2% of group 1 patients versus 0.2% of group 2 patients. Stent thrombosis occurred in 0.2% of group 1 patients versus 0.8% of group 2 patients. Occlusion of a side branch occurred in 0.2% of group 1 patients versus 0.4% of group 2 patients. A hematoma needing intervention occurred in 0.2% of group 1 patients versus 0.2% of group 2 patients. Regression analysis showed that none of the differences between the 2 groups were significant. The sample size was adequate to conclude that a fixed low dose of heparin 5000 IU administered systemically at the time of PCI is noninferior to standard therapy with heparin.

Incidence of myocardial infarction or stroke or death at 47-month follow-up in patients with diabetes and a predicted exercise capacity 85% during an exercise treadmill sestamibi stress test.

A treadmill exercise sestamibi stress test (TESST) was performed in 609 consecutive diabetic persons with a mean age of 70 years and no history of coronary artery disease (CAD) who were referred for a TESST because of chest pain or dyspnea. Of 609 patients, 301 (49%) had a predicted exercise capacity 85% (group B). Group A patients had a higher prevalence of myocardial ischemia (43% vs 30%, P=.0005), 2- or 3-vessel obstructive CAD (38% vs 18%, P=.001), myocardial infarction (17% vs 9%, P=.004), death (10% vs 4%, P=.008), and myocardial infarction or stroke or death at 47-month follow-up (21% vs 12%, P=.001). Stepwise Cox regression analysis showed that the only significant independent predictor for the time to development of myocardial infarction or stroke or death was a predicted exercise capacity >85% (hazard ratio, 0.52; 95% confidence interval, 0.34-0.78; P=.002). Diabetic persons with a predicted exercise capacity >85% had a 48% lower chance of myocardial infarction, stroke, or death than those with a predicted exercise capacity

A planar QRS-T angle >90 degrees is associated with multivessel coronary artery disease in patients undergoing coronary angiography.

BACKGROUND: The aim of the study was to investigate the severity of coronary artery disease (CAD) in patients who had a planar QRS-T angle >90 degrees versus 50% obstruction of >or=1 major coronary artery. All QRS-T angle measurements were made from a 12-lead electrocardiogram by 2 authors who agreed on the measurement and who were blinded to the coronary angiographic findings. A QRS-T angle >90 degrees was considered abnormal. RESULTS: Obstructive CAD of 2 or 3 vessels was present in 309 of 495 patients (62%) with a planar QRS-T angle >90 degrees and in 250 of 734 patients (34%) with a planar QRS-T angle or=30 kg/m2 (odds ratio =1.5). CONCLUSIONS: The prevalence of 2- or 3-vessel obstructive CAD was significantly higher in patients with a planar QRS-T angle >90 degrees than in patients with a planar QRS-T angle

Major adverse cardiac events at long-term follow-up in patients treated with single versus multiple stents during single-vessel percutaneous coronary intervention.

BACKGROUND: Although insertion of multiple stents into a single coronary vessel during single-vessel percutaneous coronary intervention (PCI) is common, there are no data on long-term occurrence of major adverse cardiac events (MACE) in patients treated with multiple stents versus a single stent. METHODS: The incidence of MACE (death, myocardial infarction, or target vessel revascularization) during long-term follow-up was investigated in 634 patients who underwent single-vessel PCI. Of the 634 patients, 319 (50%) had a single stent, and 315 (50%) had multiple stents inserted. Stepwise Cox regression analyses were performed to identify significant independent prognostic factors for MACE. RESULTS: At 47-month follow-up, MACE occurred in 61 of 319 patients (19%) who had a single stent versus in 57 of 315 patients (18%) who had multiple stents (P not significant). Significant independent predictors of MACE were use of vein grafts (hazard ratio = 1.94; 95% CI, 1.24-3.03; P = 0.0038) and use of drug-eluting stents (hazard ratio = 0.49; 95% CI, 0.34-0.72; P = 0.0002). CONCLUSIONS: At long-term follow-up of single-vessel PCI, the incidence of MACE was similar in patients with multiple or single stents inserted even after controlling for the length of stents.

Major adverse cardiac events at follow-up after bare-metal stenting versus drug-eluting stenting in ST-elevated myocardial infarction.

After thrombolytic therapy with tenecteplase for ST-segment elevation acute myocardial infarction, 376 patients were transferred from their hospital to Westchester Medical Center for percutaneous coronary intervention with stenting. Of 376 patients, 102 (27%) received bare-metal stents and 274 (73%) received drug-eluting stents with sirolimus-eluting or paclitaxel-eluting stents. At 43 months of follow-up, major adverse cardiac events occurred in 25 (25%) of 102 patients treated with bare-metal stents versus 40 (15%) of 274 patients treated with drug-eluting stents (p = 0.024). Cox regression analysis showed that significant independent prognostic factors for major adverse cardiac events were previous coronary artery bypass surgery (hazard ratio 2.2, p = 0.019), width of stent (hazard ratio 0.44, p = 0.006), and bare-metal stent (hazard ratio 1.8, p = 0.019). In conclusion, patients with bare-metal stents had a 1.8 times greater risk of developing major adverse cardiac events than did those using drug-eluting stents after controlling the confounding effects of previous coronary artery bypass surgery and stent width.

Obstructive coronary artery disease in high-risk diabetic patients with and without atrial fibrillation.

OBJECTIVE: To investigate the severity of coronary artery disease by coronary angiography in age-matched and sex-matched patients with diabetes mellitus with atrial fibrillation versus sinus rhythm. METHODS: The patients included 245 men and women, mean age of 70 years, with diabetes and atrial fibrillation and 245 age-matched and sex-matched patients with diabetes and sinus rhythm who underwent coronary angiography. Baseline characteristics and indications for coronary angiography were similar in both groups. RESULTS: Greater than 50% narrowing of one, two, or three major coronary arteries were present in 229 of 245 patients (94%) with diabetes and atrial fibrillation and in 211 of 245 patients (86%) with diabetes and with sinus rhythm (P<0.01). Greater than 50% narrowing of three major coronary arteries were present in 150 of 245 patients (61%) with diabetes and atrial fibrillation and in 75 of 245 patients (31%) with diabetes and sinus rhythm (P<0.001). CONCLUSION: Patients with diabetes and atrial fibrillation have a significantly higher prevalence of greater than 50% narrowing of one or more major coronary arteries and of three major coronary arteries than patients with diabetes and sinus rhythm.

Incidence of new stroke or new myocardial infarction or death at 39-month follow up in patients with diabetes mellitus, hypertension, or both treated with and without angiotensin-converting enzyme inhibitors or angiotensin receptor blockers.

We investigated in 306 patients, mean age 57 ± 10 years, with diabetes mellitus (202 patients) or hypertension (179 patients), whether treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ARBs) reduced the incidence of new stroke or new myocardial infarction (MI) or death. At 39-month follow up, new stroke or new MI or death developed in 49 of 228 patients (21%) treated with ACE inhibitors or ARBs and in 33 of 78 patients (42%) treated without angiotensin-converting enzyme inhibitors or ARBs (P = 0.0001). Stepwise Cox regression analysis showed that significant independent predictors of the time to development of new stroke or new MI or death were 1) use of angiotensin-converting enzyme inhibitors or ARBs (risk ratio, 0.21), 2) diabetes (risk ratio, 4.01), 3) left ventricular hypertrophy (risk ratio, 6.71), 4) prior stroke (risk ratio, 4.00), and 5) prior MI (risk ratio, 3.69).

Relation of bone mineral density to frequency of coronary heart disease.

Coronary angiography was performed because of chest pain in 198 patients (146 women, 52 men; mean age 66 years) who had dual-energy x-ray absorptiometry scans of the spine and left hip because of suspected osteoporosis or osteopenia. Of the 198 patients, 53 (27%) had osteoporosis, 79 (40%) had osteopenia, and 66 (33%) had normal bone mineral density (BMD). Obstructive coronary artery disease with >50% narrowing of > or =1 major coronary artery was present in 40 of 53 patients (76%) with osteoporosis, in 54 of 79 patients (68%) with osteopenia, and in 31 of 66 patients (47%) with normal BMD (p <0.005 comparing osteoporosis with normal BMD, p <0.01 comparing osteopenia with normal BMD). In conclusion, in patients who undergo coronary angiography because of chest pain, patients with osteoporosis or osteopenia have a higher prevalence of obstructive coronary artery disease than those with normal BMD.

Comparison of prevalence of >70% diameter narrowing of one or more major coronary arteries in patients with versus without mitral annular calcium and clinically suspected coronary artery disease.

The prevalence of >70% narrowing of 1, 2, or 3 major coronary arteries and of 3 major coronary arteries was investigated in 2,465 patients (1,437 men, 1,028 women; mean age 69 +/- 13 years) with severe, moderate, mild, or no mitral annular calcium (MAC) diagnosed by 2-dimensional echocardiography who underwent coronary angiography for suspected coronary artery disease. Greater than 70% narrowing of 1, 2, or 3 major coronary arteries was present in 259 of 315 patients (82%) with severe MAC (group 1), in 835 of 1,052 patients (79%) with moderate or mild MAC (group 2), and in 756 of 1,098 patients (69%) with no MAC (group 3) (p <0.001 comparing group 1 with group 3 and group 2 with group 3). Greater than 70% narrowing of 3 major coronary arteries was present in 149 of 315 patients (47%) in group 1, in 366 of 1,052 patients (35%) in group 2, and in 325 of 1,098 patients (30%) in group 3 (p <0.001 comparing group 1 with group 3 and group 1 with group 2; p <0.01 comparing group 2 with group 3). In conclusion, MAC is associated with obstructive >or=1-vessel coronary artery disease and with obstructive 3-vessel coronary artery disease.

Pseudoaneurysm with thrombus and left ventricular inflow obstruction after left circumflex stenting.

A 61-year-old woman had stenting of the left circumflex coronary artery. She had a repeat coronary angiogram the day after stenting because of hypotension and orthopnea. The left circumflex stent was patent. A transesophageal echocardiogram showed a 2.5 cm x 3.0-cm mass in the atrioventricular groove compressing the left atrium. A pseudoaneurysm with thrombus and left ventricular inflow obstruction was diagnosed. The patient was observed for 48 hours to allow the pseudoaneurysm to seal and coagulate. She then had surgical evacuation of the thrombus, which had caused her hypotension and orthopnea by compression of the left atrium.

Comparison of sensitivity, specificity, positive predictive value, and negative predictive value of stress testing versus 64-multislice coronary computed tomography angiography in predicting obstructive coronary artery disease diagnosed by coronary angiography.

Sixty-four-multislice coronary computed tomographic angiography (CTA) and coronary angiography were performed in 145 patients (mean age 67 +/- 10 years), and stress testing was performed in 47 of these patients to determine the sensitivity, specificity, positive predictive value, and negative predictive value of coronary CTA and of stress testing in diagnosing obstructive coronary artery disease (CAD) in patients with suspected CAD. In 145 patients, coronary CTA had 98% sensitivity, 74% specificity, 90% positive predictive value, and 94% negative predictive value in diagnosing obstructive CAD. In 47 patients, stress testing had 69% sensitivity, 36% specificity, 78% positive predictive value, and 27% negative predictive value for diagnosing obstructive CAD, whereas coronary CTA had 100% sensitivity, 73% specificity, 92% positive predictive value, and 100% negative predictive value for diagnosing obstructive CAD. In conclusion, coronary CTA has better sensitivity, specificity, positive predictive value, and negative predictive value than stress testing in diagnosing obstructive CAD.

Prevalence of an increased ascending thoracic aorta diameter diagnosed by two-dimensional echocardiography versus 64-multislice cardiac computed tomography.

The prevalence of an enlarged ascending thoracic aortic diameter (AAD) diagnosed by 2-dimensional echocardiography compared with 64-slice cardiac computed tomography (MSCT) was investigated in 97 women and 117 men (mean age 65 +/- 12 years). Enlarged AADs were diagnosed in 42 of 214 patients (20%) by echocardiography and in 45 of 214 patients (21%) by MSCT (p = NS). The sensitivity, specificity, positive predictive value, and negative predictive value of echocardiography in diagnosing an enlarged AAD using MSCT were 69%, 93%, 74%, and 92%, respectively. A Bland-Altman plot showed that the agreement for AAD measured by echocardiography and MSCT was 95% inside the 2-SD limits. In conclusion, the sensitivity, specificity, positive predictive value, and negative predictive value of 2-dimensional echocardiography in diagnosing enlarged AAD using MSCT were 69%, 93%, 74%, and 92%, respectively.

Incidence of new stroke or new myocardial infarction or death at 39-month follow-up in patients with diabetes mellitus, hypertension or both with and without microalbuminuria.

We investigated in 306 patients, mean age 57 +/- 10 years, with diabetes mellitus (202 patients) or hypertension (179 patients) whether microalbuminuria was a significant independent risk factor for the development of new stroke or new myocardial infarction (MI) or death. At 39-month follow-up, new stroke or new MI or death developed in 44 of 111 patients (40%) with microalbuminuria and in 38 of 195 patients (19%) without microalbuminuria (p = 0.0001). Stepwise Cox regression analysis showed that significant independent predictors of the time to development of new stroke or new MI or death were (1) diabetes (risk ratio = 1.76), (2) left ventricular (LV) mass index (risk ratio = 1.020 for each 1 g/m(2) increase), (3) prior stroke (risk ratio = 5.39), and (4) prior MI (risk ratio = 3.29). Microalbuminuria was not a significant independent predictor of new stroke or new MI or death, but LV mass index, diabetes mellitus, prior stroke, and prior MI were significant independent predictors.

Prevalence of an increased ascending and descending thoracic aorta diameter diagnosed by multislice cardiac computed tomography in men versus women and in persons aged 23 to 50 years, 51 to 65 years, 66 to 80 years, and 81 to 88 years.

The prevalence of increased ascending thoracic aortic diameter (AAD) and increased descending thoracic aortic diameter (DAD) diagnosed using multislice cardiac computed tomography was investigated in 624 consecutive patients at an academic cardiology practice in 2006. Increased AAD (>3.7 cm) was present in 71 of 361 men (20%) and in 23 of 263 women (9%) (p <0.001). Increased DAD (>3.0 cm) was present in 26 of 339 men (8%) and in 8 of 258 women (3%) (p <0.02). Increased AAD was present in (1) 7 of 96 patients (7%) aged 23 to 50 years, (2) 22 of 234 patients (9%) aged 51 to 65 years, (3) 53 of 263 patients (20%) aged 66 to 80 years, and (4) 12 of 31 patients (39%) aged 81 to 88 years (p <0.005 comparing groups 3 and 1; p <0.001 comparing groups 4 and 1, groups 4 and 2, and groups 3 and 2; p <0.02 comparing groups 4 and 3). Increased DAD was present in (1) 0 of 96 patients (0%) aged 23 to 50 years, (2) 5 of 227 patients (2%) aged 51 to 65 years, (3) 21 of 244 patients (9%) aged 66 to 80 years, and (4) 8 of 30 patients (27%) aged 81 to 88 years (p <0.005 comparing groups 3 and 1, groups 3 and 2, and groups 4 and 3; p <0.001 comparing groups 4 and 1 and groups 4 and 2). In conclusion, men have a higher prevalence of increased AAD and DAD than women, and increasing age increases the prevalence of increased AAD and DAD.

Comparison of age, body mass index, and frequency of systemic hypertension and diabetes mellitus in patients having coronary angioplasty in 1996 versus in 2006.

The data submitted to the New York State Department of Health Coronary Angioplasty Reporting System Database on coronary angioplasties performed at Westchester Medical Center/New York Medical College from 1996 to 2005 were analyzed. Compared with 1996, during 2005, more coronary angioplasties were performed (1,624 vs 1,122), and the patients were older (mean age 64.5 vs 61.0 years, p <0.001), weighed more (84.2 vs 82.0 kg, p <0.001), had a higher mean body mass index (28.8 vs 28.3 kg/m(2), p <0.001), and had a higher prevalence of diabetes mellitus (27% vs 17%, p <0.001). The prevalence of systemic hypertension was significantly higher in 2005 (76%) than in 1996 (54%) (p <0.001). In conclusion, in 2005 compared with 1996, patients who underwent coronary angioplasty at Westchester Medical Center/New York Medical College were older, had higher body mass indexes, and had higher prevalences of diabetes mellitus and systemic hypertension.