Effects of a myocardial ischaemia-guided therapeutic program on survival and incidence of coronary events in asymptomatic patients with diabetes: the ARCADIA study.

AIM: To assess the prognostic impact of a therapeutic program based on bioclinical risk-stratification and myocardial-perfusion-imaging (MPI) data on survival and the occurrence of coronary events (CE=death+myocardial infarction) in asymptomatic patients with diabetes. METHOD: Five hundred twenty one consecutive asymptomatic diabetic outpatients were prospectively enrolled and clinically classified as being at either low or high cardiac risk. All high-risk patients (n=245, age 61+/-9 years) underwent MPI and an intensive multifactorial medical therapeutic program, including anti-ischaemic agents in cases of moderate ischemia; a coronary angiography was performed in all high-risk patients with severe ischaemia (n=38), followed by immediate revascularization if necessary (n=21). Low-risk patients (n=276, age 57+/-9 years) underwent medical management of their risk factors. RESULTS: At the 19-month (median) follow-up (range, 12-36 months), both high- and low-risk patients showed similarly low CE rates (2.3% and 1.5% per year, respectively; age- and gender-adjusted log-rank P=NS). None of the patients who underwent myocardial revascularization experienced any CEs, and none of the low-risk patients died during follow-up. The negative predictive value of first-line bioclinical stratification was 0.98 for the occurrence of CEs, and 0.95 when low-risk patients were combined with high-risk patients who had normal MPI findings. CONCLUSIONS: Bioclinical first-line stratification allows identification of diabetic patients who have a good medium-term cardiac prognosis. The CE rate is similar in selected high-risk asymptomatic patients with diabetes using an intensive MPI-guided program that combines medical therapy, coronary angiography in the 16% of cases with severe ischemia and, if appropriate, revascularization.

[Study of a detection strategy for silent ischemia in diabetic patients: 18 month follow-up of the ARCADIA register]. / Etude d'une stratégie de détection de l'ischémie silencieuse chez les patients diabétiques: suivi à 18 mois du registre ARCADIA.

BACKGROUND: The prognostic impact of a myocardial ischemia-based therapeutic program in asymptomatic diabetic patients remains controversial. We prospectively assessed the benefit of a stratification algorithm based upon clinical and myocardial perfusion imaging (MPI) data on cardiovascular events in such patients in a non-randomized register. METHOD: 701 consecutive asymptomatic diabetic patients were classified to be at low or intermediate-to-high cardiac risk according to 13 simple boil-clinical parameters. Intermediate-to-high risk patients were scheduled for MPI and underwent either a conventional (Group 1, n=180) or an intensive multifactorial (Group 2, n=245) therapeutic program. Low risk patients (Group 3, n=276) underwent no specific management. RESULTS: At the end of the survey and as a consequence of intensive management, lipid lowering therapy, antiplatelet drugs, and beta-blockers were more often prescribed in Group 2 than in Group 1 (55, 31 and 17% versus 36, 23, and 8% respectively, p<0.01). Planned coronary angiography in case of severe ischemia on MPI and revascularization were more frequent in Group 2 (16.2 and 8.9%) than in Group 1 (8.0 and 2.8% - p<0.01). At 19-month follow-up (96.7% completed), major event rate in Group 2 was significantly lower than in Group 1 (3.9 versus 9.8%, p<0.01) and similar to that of Group 3 (2.2%, NS). CONCLUSION: Easy-to-perform risk stratification is able to select diabetic patients with good medium-term prognosis. In clinically selected higher risk patients, an intensive medical therapy combined with coronary angiography +/- revascularization in case of large ischemia on MPI is effective to improve prognosis.

[Comparison of mortality according to the revascularisation strategies and the symptom-to-management delay in ST-segment elevation myocardial infarction]. / Comparaison de la mortalité en fonction de la stratégie de revascularisation et du délai douleur-prise en charge des syndromes coronaires aigus avec sus-décalage du segment ST.

The aim of this study was to compare the mortality associated to primary angioplasty and thrombolysis in patients managed for an elevated ST-segment acute coronary syndrome in less than or more than 3 hours after the onset of symptoms. We analyzed the in-hospital mortality of 846 patients (including 276 [33%] treated by primary angioplasty, 511 [60%] by thrombolysis, and 59 [7%] without revascularisation) included from October 2002 to December 2003 in a registry of patients with an elevated ST-segment acute coronary syndrome managed in less than 12 hours in Northern Alps districts. The overall in-hospital mortality was at 6.0% (51/846). For the 631 managed in <3 hours, the mortality rates were respectively at 5.0%, 4.6% and 11.1% respectively in case of primary angioplasty, thrombolysis and without revascularisation (p=0.21). For the 215 patients with pain lasting more than 3 hours, the mortality rates were at 2.7%, 10.3% and 21.7% in case of primary angioplasty, thrombolysis and no revascularisation, respectively (p=0.01). In the multivariable analysis, the OR of death in case of thrombolysis compared to primary angioplasty was at 1.65 (95% IC: 0.73 - 3.75) for patients with pain " 3 hours, and 4.98 (95% IC: 1.32-18.37) for those with pain > 3 hours. These results are in line with randomized trials conclusions and confirm the international guidelines suggesting primary angioplasty for patients with a chest pain >3 hours and either angioplasty or thrombolysis in case of chest pain < 3 hours.

[Coronary risk related to sport]. / Risque coronaire lié au sport.

Regular physical activity is beneficial because it is associated with a 40% reduction in the risk of death or myocardial infarction. However, sport momentarily increases the risk of adverse cardiovascular events during the sporting activity. This increased risk is higher in the less accomplished sportsmen and in those with cardiovascular risk factors. Regular weekly exercise, even of mild to moderate intensity, has a protective effect. An adverse coronary event on exercise is observed in 1200 to 1500 patients per year in France. It results from underlying coronary artery disease which is often occult. In the under 35 year age group, although atherosclerotic plaque is already present, the possibility of a congenital anomalous coronary arterial anatomy should be considered. This can sometimes be detected by transoesophageal echocardiography. After 35 years of age, coronary arteriosclerosis is almost the only pathology observed. The probability of a coronary event is higher in under trained "veteran" with known classical cardiovascular risk factors, often occurring by "error" in the practice of an activity too intense for the level of physical fitness. It should be remembered that 50% of these complications occur in people who have experienced symptoms on exercise in the days or weeks before the event. This article also discusses which risk factors aggravate the risk in known coronary patients and what advice should be given to coronary patients who want to benefit from the effects of regular physical exercise.

Long-term additive prognostic value of thallium-201 myocardial perfusion imaging over clinical and exercise stress test in low to intermediate risk patients : study in 1137 patients with 6-year follow-up.

BACKGROUND: The exercise treadmill test (ETT) and Tl201 single proton emission computed tomography (SPECT) are of short- to medium-term prognostic value in coronary heart disease. We assessed the long-term prognostic value of these tests in a large population of patients with low- to intermediate risk of cardiac events. METHODS AND RESULTS: One thousand one hundred thirty-seven patients (857 men, age 55+/-9 years) referred for typical (62.1%) or atypical (22.4%) chest pain, or suspected silent ischemia (15.5%), were followed up for 72+/-18 months. Overall mortality was higher after strongly positive (ST depression >2 mm, or >1 mm for a workload /=3 abnormal segments on SPECT, respectively (P<0.002). An abnormal SPECT was predictive of MI (P<0.001), whereas ETT was not. In multivariate analysis, SPECT was of incremental prognostic value over clinical and ETT data for predicting overall mortality and major cardiac events. CONCLUSIONS: The incremental predictive value of SPECT is maintained over 6 years and is particularly relevant after positive, strongly positive, and nondiagnostic ETT.

Prognostic value of thallium-201 single-photon emission computed tomographic myocardial perfusion imaging according to extent of myocardial defect. Study in 1,926 patients with follow-up at 33 months.

OBJECTIVES: This study was designed to assess the prognostic value of thallium-201 single-photon emission computed tomographic (thallium SPECT) perfusion imaging in patients evaluated for stable angina pectoris and to examine the relation, if any, between the presence and extent of myocardial defect and future fatal or nonfatal cardiovascular events (revascularization, secondary myocardial infarction). BACKGROUND: Compared with planar scintigraphy, thallium SPECT enables better evaluation of the extent of myocardial perfusion defect. However, its prognostic value has not yet been studied in a large population of patients. METHODS: Between 1987 and 1989 we studied 3,193 patients. After exclusion of patients with unstable angina, myocardial infarction during the previous month or earlier revascularization, 1,926 patients were followed up for 33 +/- 10 (mean +/- SD) months after stress thallium SPECT imaging (performed after exercise in 1,121 patients or during dipyridamole infusion in 805 patients). Thallium SPECT imaging of the left ventricle was divided into six segments. RESULTS: After normal thallium SPECT imaging (715 patients), the annual total and cardiovascular mortality rates were, respectively, 0.42%/year and 0.10%/year and were significantly higher after abnormal thallium SPECT imaging (respectively, 2.1%, relative risk 5, p = 0.012; 1.5%, relative risk 15, p < 0.0001 [log-rank test]). There was a significant relation between the number of abnormal segments and cardiovascular mortality during follow-up (p < 0.02) or the occurrence of nonfatal events (p < 0.001). The extent of defect on the initial scan provided the best SPECT variable for long-term prognosis. Thallium SPECT imaging provided additive prognostic information compared with other clinical variables (gender, previous myocardial infarction) and exercise electrocardiogram. CONCLUSIONS: In patients with stable angina, normal thallium SPECT imaging indicates a low risk patient, and the extent of myocardial defect is an important prognostic predictive factor.

Multicenter trial of intravenous anisoylated plasminogen streptokinase activator complex (APSAC) in acute myocardial infarction: effects on infarct size and left ventricular function.

Two hundred thirty-one patients with a first acute myocardial infarction were randomly allocated within 5 h after the onset of symptoms either to treatment with anisoylated plasminogen streptokinase activator complex (APSAC), 30 U over 5 min, or to conventional heparin therapy, 5,000 IU in a bolus injection. Heparin was reintroduced in both groups 4 h after initial therapy at a dosage of 500 IU/kg per day. One hundred twelve patients received APSAC and 119 received heparin within a mean period of 188 +/- 62 min after the onset of symptoms. Both groups were similar in age, location of the acute myocardial infarction, Killip functional class and time of randomization. Elective coronary arteriography was performed on an average of 4 +/- 1.2 days after initial therapy. Follow-up radionuclide angiography and thallium-201 single photon emission computed tomography were performed before hospital discharge. Infarct size was estimated from single photon emission computed tomography and expressed as a percent of total myocardial volume. The patency rate of the infarct-related artery was 77% in the APSAC group and 36% in the heparin group (p less than 0.001). Left ventricular ejection fraction determined from contrast angiography was significantly higher in the APSAC group than in the heparin group. This was true for the entire study group (0.53 +/- 0.13 versus 0.47 +/- 0.12; p = 0.002) as well as for the subgroups of patients with anterior and inferior wall infarction (0.47 +/- 0.13 versus 0.40 +/- 0.11; p = 0.04 and 0.56 +/- 0.10 versus 0.51 +/- 0.11; p = 0.02, respectively). At 3 weeks, the difference remained significant for the anterior myocardial infarction subgroup. A significant 31% reduction in infarct size was found in the APSAC group (33% for the anterior infarction subgroup [p less than 0.05] and 16% for the inferior infarction subgroup [p = NS]). A close inverse relation was found between the values of left ventricular ejection fraction and infarct size (r = -0.73, p less than 0.01). By the end of a 3 week follow-up period, seven APSAC-treated patients and six heparin-treated patients had died. In conclusion, the early infusion of APSAC in acute myocardial infarction produced a high early patency rate, significant limitation of infarct size and significant preservation of left ventricular systolic function, mainly in anterior wall infarction.

Early angiography cannot predict postthrombolytic coronary reocclusion: observations from the GUSTO angiographic study. Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries.

OBJECTIVES: The purpose of this study was to determine whether early qualitative or quantitative angiographic features can predict reocclusion after initially successful coronary thrombolysis. BACKGROUND: Although both the benefits of early reperfusion and the consequences of subsequent reocclusion after thrombolysis for acute myocardial infarction have been well described, efforts to describe angiographic markers of lesions at high risk for reocclusion have produced conflicting results. The Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO) angiographic trial provides the opportunity to examine these relations in the largest single, prospective patient cohort studied to date. METHODS: We studied 559 patients undergoing follow-up angiography at 90 min and 5 to 7 days after thrombolysis in the GUSTO trial. Patients received one of four thrombolytic regimens: 1) streptokinase with intravenous heparin; 2) streptokinase with subcutaneous heparin; 3) accelerated-dose recombinant tissue-type plasminogen activator (rt-PA) with intravenous heparin; or 4) a combination of streptokinase and conventionally dosed rt-PA with intravenous heparin. Qualitative variables examined at 90-min angiography included Thrombolysis in Myocardial Infarction (TIMI) flow grade, visible thrombus and lesion morphology. Quantitative variables included percent diameter stenosis, percent area stenosis, minimal lumen diameter and lesion length. The study contained a power > 0.85 to detect clinically important differences in percent diameter stenosis, percent area stenosis and minimal lumen diameter between the groups with subsequent reocclusion and sustained patency at the p = 0.05 level. RESULTS: At follow-up, 33 patients (5.9%) had reocclusion. The reocclusion rate for patients with early TIMI grade 2 flow was 6.3% versus 5.6% for TIMI grade 3 flow (p = NS). When the group with reocclusion was compared with the group with continued patency, there were no differences in presence of early visible thrombus, complex lesion morphology, percent diameter stenosis, percent area stenosis, minimal lumen diameter or lesion length. CONCLUSIONS: Our findings demonstrate that neither qualitative nor quantitative angiographic variables at 90 min after initiation of thrombolytic therapy can be used to predict subsequent coronary reocclusion.

Effect of pravastatin on angiographic restenosis after coronary balloon angioplasty. The PREDICT Trial Investigators. Prevention of Restenosis by Elisor after Transluminal Coronary Angioplasty.

OBJECTIVES: This study sought to determine whether pravastatin affects clinical or angiographic restenosis after coronary balloon angioplasty. BACKGROUND: Experimental data and preliminary clinical studies suggest that lipid-lowering drugs might have a beneficial effect on restenosis after coronary angioplasty. METHODS: In a multicenter, randomized, double-blind trial, 695 patients were randomized to receive pravastatin (40 mg/day) or placebo for 6 months after successful balloon angioplasty. All patients received aspirin (100 mg/day). The primary angiographic end point was minimal lumen diameter (MLD) at follow-up, assessed by quantitative coronary angiography. A sample size of 313 patients per group was required to demonstrate a difference of 0.13 mm in MLD between groups (allowing for a two-tailed alpha error of 0.05 and a beta error of 0.20). To allow for incomplete angiographic follow-up (estimated lost to follow-up rate of 10%), 690 randomized patients were required. Secondary end points were angiographic restenosis rate (restenosis assessed as a categoric variable, > 50% stenosis) and clinical events (death, myocardial infarction, target vessel revascularization). RESULTS: At baseline, clinical, demographic, angiographic and lipid variables did not differ significantly between groups. In patients treated with pravastatin, there was a significant reduction in total and low density lipoprotein cholesterol and triglyceride levels and a significant increase in high density lipoprotein cholesterol levels. At follow-up the MLD (mean +/- SD) was 1.47 +/- 0.62 mm in the placebo group and 1.54 +/- 0.66 mm in the pravastatin group (p = 0.21). Similarly, late loss and net gain did not differ significantly between groups. The restenosis rate (recurrence > 50% stenosis) was 43.8% in the placebo group and 39.2% in the pravastatin group (p = 0.26). Clinical restenosis did not differ significantly between groups. CONCLUSIONS: Although pravastatin has documented efficacy in reducing clinical events and angiographic disease progression in patients with coronary atherosclerosis, this study shows that it has no effect on angiographic outcome at the target site 6 months after coronary angioplasty.

[Pacemaker and intra cardiac defibrillator lead extraction techniques]. / Les techniques de remplacement de matériel de stimulation cardiaque et défibrillation implantable.

Percutaneous Pace-maker and ICD lead extraction techniques has been developped: by superior approach using locking stylet and more and more efficient outher sheats (laser assisted); and also by femoral approach using double lasso catheters (Needle's eye snare). Indication range has increased and is not only reserved for lead infection. Because of scar tissue holding the lead and also the impact of the distal tip, those techniques are not simples. Extraction recommandations do advise those procedures to be performed by expert physicians, in cardiac surgery centers, where complications can be managed and reduced. The use of laser assisted outher sheats will make lead extraction easier and will reduce complication rate. Alternative procedure in case of failure with superior approach remain femoral approach. All those techniques give a success rate of about 98 % for percutaneous lead extraction in an expert center.

Prediction of cardiovascular events in clinically selected high-risk NIDDM patients. Prognostic value of exercise stress test and thallium-201 single-photon emission computed tomography.

OBJECTIVE: We evaluated the prognostic value of an exercise stress test and thallium-201 scintigraphy for the prediction of cardiac events in selected high-risk NIDDM patients. RESEARCH DESIGN AND METHODS: NIDDM patients (n = 158, 105 men, aged 63 +/- 9 years) with two or more of the following criteria were prospectively included: age > or = 65 years, active smoking, hypertension > 160/95 mmHg, hypercholesterolemia (cholesterol > 5.70 mmol/l or LDL > 3.10 mmol/l), peripheral artery disease, abnormal rest electrocardiogram, or microalbuminuria (20-200 micrograms/min). An exercise-stress scintigraphy was performed in 77 patients able to exercise, while a dipyridamole scintigraphy was performed in 80 patients unable to exercise. Follow-up was 23 +/- 17 months. Major end points were cardiac deaths or nonfatal myocardial infarction. RESULTS: The annual event rate was 7.31% (deaths: 8, myocardial infarction: 14). Independent predictors of events were as follows: an age > 60 (P = 0.02), an abnormal rest electrocardiogram (P = 0.02), microalbuminuria (P = 0.001), the inability to exercise (P = 0.009), and the presence of more than two defects on scintigraphy (P = 0.001). A cardiac death occurred in 1.3% of patients able to exercise versus 8.8% of patients unable to exercise (odds ratio = 6.8, P = 0.001). Among patients unable to exercise, large perfusion defects corresponded to an annual mortality rate of 22.3%. Conversely, the negative predictive value of a normal scintigraphy for the occurrence of death was 97%. CONCLUSIONS: Inability to exercise and large perfusion defects on thallium-201 scan are major predictors of future death and myocardial infarction in high-risk NIDDM patients.

Assessment of radical activity during the acute phase of myocardial infarction following fibrinolysis: utility of assaying plasma malondialdehyde.

Numerous experimental and clinical studies have reported a role of radical forms of oxygen in the etiology of the manifestations of reperfusion of the ischemic myocardium. However, clinical results remain controversial. The aim of this study was to ascertain the existence of reperfusion-related radical stress after thrombolysis with a marker that is easy to use and reliable. Thirty patients hospitalized for acute myocardial infarction were involved in the study. Of these, 18 had been subjected to intravenous thrombolysis (Group I) and 12 had not (Group II). They were compared to two control groups who had no history of myocardial infarction. Of these, 16 were patients with coronary heart disease hospitalized for stable angina (Group III) and 17 were patients free of any known cardiovascular disease (Group IV). Radical activity was assessed in plasma samples taken from a peripheral vein over a 10-day period of hospitalization by measuring (1) malondialdehydes (MDA) concentrations using fluorometry techniques or HPLC, (2) the antioxidant activity of glutathione peroxidase (GPx) and (3) the concentration of various antiradical compounds (beta-carotene, vitamins A and E, uric acid). All patients in Group I had a patent artery on coronary angiography and showed a significant increase in plasma MDA when compared to those who had not been subjected to thrombolysis (3.15 +/- 0.62 and 2.70 +/- 0.40 mole/l of plasma, respectively). Furthermore, GPx plasma activity was also significantly increased following thrombolysis. By contrast, there was no significant alteration in the antiradical compounds measured. These data suggest that MDA measurements (an early measurement 1-2 days and a late measurement 5-7 days after reperfusion) by fluorometry is a good marker of radical stress during reperfusion in man. The assessment of this marker in patients might represent a simple and reliable test of reperfusion efficacy following thrombolysis, and it might enable one to test the effect of various antioxidant therapies associated with thrombolytic treatment.

Biodistribution, dosimetry, and safety of myocardial perfusion imaging agent 99mTcN-NOET in healthy volunteers.

UNLABELLED: 99mTcN-NOET (bis[N-ethoxy,N-ethyl]dithiocarbamato nitrido technetium (V)) has been proposed for myocardial perfusion imaging. Biodistribution, safety, and dosimetry were studied in 10 healthy volunteers (5 at rest and 5 during exercise). METHODS: Biodistribution was studied by acquiring dynamic images up to 60 min after injection and whole-body images up to 24 h after injection. The MIRDOSE3 analysis program was used for radiation dosimetry calculations. RESULTS: Safety parameters measured to 48 h after injection revealed no clinically significant changes. Cardiac uptake of 99mTcN-NOET was high (2.9%-3%), with biologic half-life of 210-257 min on average. Lung uptake of 99mTcN-NOET was higher (10%-20%) but, on average, biologic half-life was shorter (1-77 min). Clearance from the blood was rapid (5% by 5 min). Radiation dosimetry calculations indicated an effective absorbed dose of 5.11 x 10(-3) mSv/MBq at rest and 5.38 x 10(-3) mSv/MBq after exercise. CONCLUSION: 99mTcN-NOET exhibits high cardiac uptake and an estimated effective absorbed dose comparable with that of the other 99mTc-labeled compounds used in myocardial perfusion imaging.

Balloon angioplasty versus rotational angioplasty in chronic coronary occlusions (the BAROCCO study).

Chronic total coronary occlusion remains one of the limitations of percutaneous transluminal coronary angioplasty, and few therapeutic devices are specifically designed to address this problem. Among such devices, low-speed rotational angioplasty could improve the primary success rate of the procedure but has never been studied in a controlled trial. One hundred consecutive patients with total coronary occlusion (duration 10 days to 1 year) and an indication for myocardial revascularization were randomized to either rotational or conventional angioplasty if the occlusion morphology was judged suitable for either technique. All baseline variables were evenly distributed among the 2 groups. The primary success rate in the rotational angioplasty groupø was 66% (33 of 50) compared with 52% (26 of 50) in the conventional angioplasty group before crossover to the rotational technique (p=NS). According to lesion morphology, the respective primary success rates were 77% (10 of 13) versus 92% (11 of 12) for tapered occlusions (p=NS), and 61% (22 of 36) versus 38% (14 of 37) for "stump-like" occlusions (p < 0.05). After taking into account the crossovers after failed conventional angioplasty, there was no benefit in performing rotational angioplasty first versus conventional angioplasty first (primary success rates 66% vs 60%, p=NS). Thus, in chronic coronary occlusions of tapered morphology, rotational angioplasty is not superior to conventional angioplasty. In stump-like occlusions, the primary success rate is higher with the rotational angioplasty technique; however ther is a disadvantage in using rotational angioplasty as a second-line device if the conventional technique is unsuccessful.

Use of left ventricular function as an end point of thrombolytic therapy.

In recent acute myocardial infarction, early reperfusion of the infarct-related artery by intracoronary or intravenous thrombolytic therapy induces a significant limitation of infarct size, provided reperfusion occurs within a time frame that myocardial salvage can still be expected. Limitation of infarct size reduces scar tissue formation, aneurysm formation, infarct zone expansion, left ventricular volume enlargement, and eventually results in higher left ventricular ejection fraction. Infarct size limitation and left ventricular function preservation occur with all thrombolytic agents currently in clinical use: streptokinase, alteplase and, more recently, anistreplase. When anistreplase is compared with conventional heparin therapy, a 31% reduction in infarct size is found (estimated from single photon emission computed tomography, or SPECT). This translates into a significant preservation of left ventricular ejection fraction as observed in anistreplase-treated patients compared with heparin-treated patients (0.53 +/- 0.13 vs 0.47 +/- 0.12, p less than 0.002). In comparative trials of 2 thrombolytic agents, anistreplase was demonstrated to be as efficient as alteplase on left ventricular ejection fraction preservation and infarct size limitation.

Limitation of myocardial infarct size and preservation of left ventricular function by early administration of APSAC in myocardial infarction.

In cases of acute myocardial infarction (MI), it has been shown that preserving left ventricular function and limiting infarct size with early reperfusion of the occluded artery by means of a thrombolytic agent could eventually result in a reduced mortality rate. The aim of the APSIM study (anisoylated plasminogen streptokinase activator complex [APSAC] dans l'infarctus du Myocarde) was to demonstrate that early administration of APSAC in patients with recent acute MI could limit the infarct size and preserve left ventricular systolic function. In all, 231 patients with a first acute MI were randomly allocated to either APSAC (30 U over 5 minutes) or to conventional heparin therapy (5,000 IU in bolus injection) within 5 hours of the onset of symptoms. Of these patients, 112 received APSAC and 119 received heparin within a mean period of 188 +/- 62 minutes after the onset of symptoms. The patency rate of the infarct-related artery was 77% in the APSAC group and 36% in the heparin group (p less than 0.001). Left ventricular ejection fraction determined from contrast angiography was significantly higher in the APSAC than in the heparin group. This was true for the entire population (0.53 +/- 0.13 vs 0.47 +/- 0.13, p = 0.002) as well as for the subgroups of anterior and inferior wall infarctions (0.47 +/- 0.13 vs 0.4 +/- 0.16, p = 0.004 and 0.56 +/- 0.11 vs 0.51 +/- 0.09, p = 0.02). At 3 weeks, the difference remained significant for patients with anterior MI.(ABSTRACT TRUNCATED AT 250 WORDS)

Additive value of thallium single-photon emission computed tomography myocardial imaging for prediction of perioperative events in clinically selected high cardiac risk patients having abdominal aortic surgery.

The present study was designed to prospectively evaluate whether reinjection thallium-201 single-photon emission computed tomography (SPECT) has a significant additive predictive value for occurrence of perioperative cardiac events in clinically selected patients at high cardiac risk undergoing abdominal aortic surgery. Of a group of 517 consecutive patients referred, 134 had > or = 2 of the following clinical or electrocardiographic cardiac risk variables: age > 70 years; history of myocardial infarction, angina, or congestive heart failure; diabetes mellitus; hypertension with severe left ventricular hypertrophy; and Q waves or ischemic ST-segment abnormalities on electrocardiogram at rest. Operation was performed after thallium SPECT study. Twelve patients (9%) had major perioperative events (cardiac death or nonfatal myocardial infarction) and 18 patients had other cardiac events (unstable angina, congestive heart failure, or severe ventricular tachyarrhythmia). Variables correlated with the occurrence of major events were history of myocardial infarction (p < 0.05) and the presence (p < 0.001) and number of segments with thallium reversible defects (p < 0.001). In multivariate analysis, history of myocardial infarction (p < 0.05) and the number of segments with reversible thallium defects (p < 0.001) were independent predictors. When all the cardiac events were taken into consideration, all the previous variables, as well as Q waves and ischemic ST abnormalities on the electrocardiogram, showed significant predictive value in both univariate and multivariate analyses. Furthermore, thallium SPECT imaging has an additive predictive value for major cardiac events over clinical and electrocardiographic risk factors. When performed on clinically selected patients at high cardiac risk undergoing abdominal aortic surgery, thallium SPECT demonstrates significant prognostic value for cardiac events over that provided by clinical variables alone.

"Rescue" abciximab for complicated percutaneous transluminal coronary angioplasty.

We studied the in-hospital outcome of 138 consecutive patients who received abciximab as a "rescue" intervention for complicated coronary angioplasty in a high-risk clinical setting. "Rescue" treatment with abciximab was associated with clinical and angiographic success rates of 83% and 84%, respectively, whereas the risk of bleeding was higher in patients of low body weight.

Myocardial infarction and Turner's syndrome.

This paper reports the case of a patient with Turner's syndrome, who developed a myocardial infarction at the age of 36. Turner's syndrome, associated with gonadal insufficiency, increases atherosclerotic cardiovascular risks that must be assessed during the patient's follow-up.