Gender gap in medical care in ST segment elevation myocardial infarction networks: Findings from the Catalan network Codi Infart. / Brecha de género en los cuidados médicos en las redes de atención al infarto agudo de miocardio con elevación del segmento ST: hallazgos de la red catalana Codi Infart.

OBJECTIVE: To assess the impact of gender upon the prognosis and medical care in a regional acute ST-elevation myocardial infarction management network. DESIGN: An observational study was made of consecutive patients entered in a prospective database. SCOPE: The Catalan acute ST-elevation myocardial infarction management network. PATIENTS: Patients treated between January 2010 and December 2011. INTERVENTIONS: Primary angioplasty, thrombolysis or conservative management. VARIABLES OF INTEREST: Time intervals, proportion and type of reperfusion, overall mortality, and in-hospital complication and overall mortality at 30 days and one year were compared in relation to gender. RESULTS: Of the 5,831 patients attended by the myocardial infarction network, 4,380 had a diagnosis of acute ST-elevation myocardial infarction, and 961 (21.9%) were women. Women were older (69.8±13.4 vs. 60.6±12.8 years; P<.001), had a higher prevalence of diabetes (27.1 vs. 18.1%, P<.001), Killip class>I (24.9 vs. 17.3%; P<.001) and no reperfusion (8.8 vs. 5.2%; P<.001) versus men. In addition, women had greater delays in medical care (first medical contact-to-balloon: 132 vs. 122min; P<.001, and symptoms onset-to-balloon: 236 vs. 210min; P<.001). Women presented higher percentages of overall in-hospital complications (20.6 vs. 17.4%; P=.031), in-hospital mortality (4.8 vs. 2.6%; P=.001), 30-day mortality (9.1 vs. 4.5%; P<.001) and one-year mortality (14.0 vs. 8.3%; P<.001) versus men. Nevertheless, after multivariate adjustment, no gender differences in 30-day and one-year mortality were observed. CONCLUSIONS: Despite a higher risk profile and poorer medical management, women present similar 30-day and one-year outcomes as their male counterparts in the context of the myocardial infarction management network.

Short-term effects of transdermal estrogen replacement therapy on coronary vascular reactivity in postmenopausal women with angina pectoris and normal results on coronary angiograms.

OBJECTIVES: This study sought to analyze the effect of short-term transdermal estradiol treatment on in vivo coronary endothelial function in postmenopausal women with angina and normal results on coronary arteriograms. BACKGROUND: The incidence of coronary heart disease increases in women after menopause. Estrogen replacement therapy has been associated with a global reduction in cardiovascular disease incidence and mortality. In addition, coronary endothelial dysfunction has been demonstrated in a group of postmenopausal women. It has been shown that intravenous or intracoronary estrogens improve endothelial function in postmenopausal women with coronary atherosclerosis. However, the efficacy of this treatment is unknown in patients with angina and normal coronary arteries. METHODS: Endothelium-dependent coronary reactivity was analyzed in 15 postmenopausal women with angina and normal coronary arteries at baseline and after 24 h of estradiol transdermal administration (100 microg). RESULTS: Estradiol concentration increased from 22 +/- 8 pg/ml (mean +/- SEM) at baseline to 76 +/- 13 pg/ml (p < 0.01) at 24 h. At baseline, acetylcholine induced vasoconstriction, with a mean diameter reduction of -23 +/- 6% (p = 0.002). After estrogen treatment, there was no vasoconstriction with acetylcholine, with a mean diameter change of 0 +/- 4%, significantly different from the pretreatment diameter reduction observed (p = 0.003). Similarly, estimated coronary blood flow significantly increased in response to acetylcholine after estrogen treatment, with a mean change of 50 +/- 30% compared with 5 +/- 24% before estradiol administration (p = 0.04). CONCLUSIONS: Early after transdermal estrogen administration, endothelium-dependent coronary vasomotion is improved in postmenopausal women with angina and normal coronary arteries.

Randomized comparison of coronary stent implantation and balloon angioplasty in the treatment of de novo coronary artery lesions (START): a four-year follow-up.

OBJECTIVE: The purpose of this study was to test the hypothesis that stent implantation in de novo coronary artery lesions would result in lower restenosis rates and better long-term clinical outcomes than balloon angioplasty. BACKGROUND: Placement of an intracoronary stent, as compared with balloon angioplasty, has proven to reduce the rate of restenosis. However, the long-term clinical benefit of stenting over angioplasty has not been assessed in large randomized trials. METHODS: We randomly assigned 452 patients with either stable (129 patients) or unstable (323 patients) angina pectoris to elective stent implantation (229 patients) or standard balloon angioplasty (223 patients). Coronary angiography was performed at baseline, immediately after the procedure and six months later. End points were the rate of restenosis at six months and a composite of death, myocardial infarction (MI) and target vessel revascularization over four years of follow-up. RESULTS: Procedural success rate was achieved in 84% and 95% (balloon angioplasty vs. stent, respectively). The increase in the minimal luminal diameter was greater in the stent group both after the intervention (2.02 +/- 0.6 mm vs. 1.43 +/- 0.6 mm in the angioplasty group; p < 0.0001), and at six-month follow-up (1.98 +/- 0.7 mm vs. 1.63 +/- 0.7 mm; p < 0.001). The corresponding restenosis rates were 22% and 37%, respectively (p < 0.002). After four years, no differences in mortality (2.7% vs. 2.4%) and nonfatal MI (2.2% vs. 2.8%) were found between the stent and the angioplasty groups, respectively. However, the requirement for further revascularization procedures of the target lesions was significantly reduced in the stent group (12% vs. 25% in the angioplasty group; relative risk 0.49, 95% confidence interval 0.32 to 0.75, p = 0.0006); most of the repeat procedures (84%) were carried out within six months of entry into the study. CONCLUSIONS: Patients who received an intracoronary stent showed a lower rate of restenosis than those treated with conventional balloon angioplasty. The benefit of stenting was maintained four years after implantation, as manifested by a significant reduction in the need for repeat revascularization.

The TITAN-AMI multicenter registry evaluating the usage of Titan2 stent in patients with ST segment elevation myocardial infarction. Final result at 12-month follow-up.

AIM: Primary percutaneous coronary intervention with stent implantation is the recommended treatment for patients with ST elevation myocardial infarction (STEMI). Data from randomised trials showed good performance by a titanium-nitric-oxide coated stent in this context. The aim of this study was to confirm these data. METHODS: A multicentre registry was compiled in 23 hospitals in Spain in an all-comers population. We selected patients with STEMI from a global Titan AMI registry that included patients with acute coronary syndrome. Primary endpoint was the composite of cardiac death, non-fatal myocardial infarction, stent thrombosis and target lesion revascularisation, at 12-month follow-up. RESULTS: The study included 893 patients with STEMI. We included all possibilities for PCI: 86.6% primary, 5% facilitated after successful fibrinolysis and 8.4% rescue PCI after failed fibrinolysis. The primary endpoint was reached in 8.4% of the patients: cardiac death 2.7%, reinfarction 3.4%, target lesion revascularisation 3.5% and definite or probable stent thrombosis 2.8%. The majority of stent thromboses presented in the first 30 days after PCI. CONCLUSION: A bioactive stent (titanium-nitric-oxide coated stent) is a possible alternative for the treatment of patients with STEMI. One-year follow-up showed better results than those presented by a regular bare-metal stent or first-generation drug-eluting stent in terms of stent thrombosis.

Development of myocardial beta-adrenergic receptor density and adenylate cyclase activity after human heart transplantation.

An increase in basal heart rate caused by a lack of vagal control and chronotropic supersensitivity to epinephrine has been shown in transplanted human hearts. Prejunctional and/or postjunctional origins for this supersensitivity have been suggested, the latter involving changes in the number of myocardial beta-adrenergic receptors or in the receptor adenylate cyclase system. To directly determine the time course of change, serial determinations were performed during the first 3 months after heart transplantation. The beta-adrenergic receptor density measured by iodine 125-labelled iodocyanopindolol binding in 61 endomyocardial biopsy specimens (a mean of 6.1 +/- 0.58 biopsies from each of 10 patients) showed great intraindividual and interindividual variability (56.6 +/- 6.8 fmol/mg protein) with no mean trend toward gradually changing receptor densities. Isoproterenol-stimulated adenylate cyclase activity measured in 33 biopsy specimens (a mean of 5.5 +/- 0.67 biopsy specimens from each of six patients) varied considerably (112.5 +/- 13.8 pmol cyclic adenosine monophosphate/mg protein/min), again with no definite tendency with regard to the development over time. The beta-adrenergic receptor densities showed no statistical correlation with the degree of rejection as assessed by histologic criteria and antimyosin ration. These results suggest that in the first 3 months after heart transplantation beta-adrenergic receptor density and adenylate cyclase responses to 10 mumol/L isoproterenol do not change and that beta-adrenergic receptor density in the transplanted myocardium does not seem to be affected by the degree of rejection.

Comparison of serum total sialic acid, C-reactive protein, alpha 1-acid glycoprotein and beta 2-microglobulin in patients with non-malignant bowel diseases.

Total sialic acid (TSA), C-reactive protein (CRP); alpha 1 acid glycoprotein (alpha 1-AG), and beta 2-microglobulin were determined in 84 patients affected by non-malignant intestinal diseases, Crohn's disease (CD) and ulcerative colitis (UC), active and in remission; non-ulcerative proctosigmoiditis; diverticulosis; diverticulitis (ie, inflammatory complication of diverticulosis). Only in patients with acute phase CD, TSA was statistically higher than those in remission, as well as in controls. In patients with acute CD and in those with diverticulitis, CRP was significantly higher than in the controls. alpha 1-AG was found significantly increased in acute UC and CD patients versus the respective groups in remission, as well as versus controls. Moreover, alpha 1-AG was higher in patients with diverticulitis. beta 2-microglobulin did not differ in any group of patients. In five patients with CD in acute phase, investigated before and during the pharmacological treatment (5-aminosalycilic acid and steroids), CRP values fell into the normal range after the second week of therapy, whereas TSA values reached the higher limit of the normal range after the third week, except for two CD patients with a larger location (ileocolonic) of the disease. The results are briefly discussed.

Effects of the recombinant human erythropoietin (rHuEPO) administration on hematologic parameters, red cell creatine and 2,3-diphosphoglycerate contents, in patients affected by end-stage renal disease.

Twenty patients with renal failure and severe anemia (hemoglobin range 6.6-8.7 g/dl) on thrice-weekly maintenance hemodialysis were treated with recombinant human erythropoietin (rHuEPO). After three months of intravenous (iv) therapy the hemoglobin increase averaged 2 g/dl, and was steadily maintained even after two months of subcutaneous (sc) therapy. The significant increase of macrocyte counts, determined by an automated red blood cell counter after both steps of therapy, suggested the release of young red cells (large cells) into blood circulation. This assumption may be supported by the significant increase of the red cell creatine contents. 2,3-diphosphoglycerate (2,3-DPG) levels of the erythrocytes did not significantly change after rHuEPO administration.

Relation between the osmolality trend and ornithynedecarboxylase activity in red blood cells of uremic patients during hemodialytic treatment.

In uremic patients during chronic hemodialysis an increase in the volume of red blood cells is observed. Contemporaneously there is an increase in intraerythrocytic ornithynedecarboxylase activity beyond the normal content (P < 0.01), a high level of seric and plasmatic polyamines (P < 0.01) and a decrease in seric osmolality (P < 0.01) with pH improvement. The trends of osmolality, ornithynedecarboxylase, mean cell volume and pH are significantly related. Our data support the hypothesis that, during hemodialysis, red blood cell volume changes and increased ornithynedecarboxylase activity are dependent on the general improvement of plasma tonicity. Moreover, the absence of inhibition of ornithynedecarboxylase activity by high levels of putrescine is noted.

CCK-containing paraneurons in human adenomatous prostate.

The presence of CCK-containing neuroendocrine cells in human adenomatous prostates, and the colocalization of CCK together with serotonin in the same cell, have been demonstrated by means of an immunohistochemical technique and by a double labeling immunofluorescent staining. CCK-containing neuroendocrine cells had a focal distribution in the prostates and sometimes showed dendrite-like cytoplasmic processes. The major part of CCK (96.55%) colocalized with serotonin. CCK probably stimulates muscle contraction and endocrine/exocrine secretions in the urogenital tract.

Early and late hyperferremia during cisplatin chemotherapy.

Changes in plasma iron levels were evaluated in 48 neoplastic patients receiving a total of 56 courses of polychemotherapy in which high doses of cisplatin were administered on day 1. Serum iron showed a three-fold mean increase 24 hours after cisplatin infusion, rising from a basal mean value of 78.25 +/- 45.74 micrograms/dl to 242.12 +/- 72.67 micrograms/dl (P less than 0.001). Hyperferremia began to lower after the 3rd day and pretreatment levels were again observed the 10th day. Ferritin increased progressively from a basal mean value of 565.81 +/- 435.18 micrograms/l to 928.73 +/- 665.41 micrograms/l the 7th day (P less than 0.001). Hemolysis and tissutal necrosis were excluded, since red cells, hemoglobin, muscular and hepatic enzymes and indirect bilirubin remained unmodified. Reticulocytes began to lower on the 3rd day and reached the nadir the 7th day: therefore the cisplatin-induced blockage of erythropoiesis, with consequent reduced iron use was maximum the 3rd day--as observed in animals by other Authors--and could not explain the early hyperferremia developing within 24 hours. Consequently hyperferremia seems to consist of two overlapping stages: an early stage by unknown interference of cisplatin on iron-loaded reticulo-endothelial cells, with consequent acute iron emissions into the blood stream; and a later stage by toxic effect of the drug on erythroid precursors with reduced iron uptake by bone marrow.

Two-year follow-up after laser thermal balloon angioplasty (LTBA) in lower extremities: initial experience.

We describe the results obtained with the use of laser thermal balloon angioplasty (LTBA) in the treatment of atherosclerosis obliterans of the lower limbs in 37 patients (34 males, 3 females, mean age 58 +/- 9 years) with occlusive arterial disease (Fontaine stages II-IV) presenting 39 significant lesions. Immediate results and two years of clinical follow-up are analyzed. Initial ankle/brachial Doppler index was 0.51 +/- 0.17. Eighteen lesions were located in the iliac area (13 stenoses 2.3 +/- 1 cm and 5 occlusions 4.2 +/- 3 cm) and 21 lesions in the femoropopliteal area (5 stenoses 2.6 +/- 2 cm and 16 occlusions 5.7 +/- 3 cm). A percutaneous procedure was used in 38 cases. In only one case was femoral dissection needed. The laser source was argon in 26 cases and Nd-YAG in 13. Initial success was 85% (89% in iliac lesions and 81% in femoropopliteal lesions; 100% in stenoses and 70% in occlusions). The presence of occlusion (p less than 0.01) and/or calcium (p less than 0.05) negatively influenced the immediate results. No major complications were observed; seven (17%) minor complications occurred. Ankle/brachial Doppler index after treatment was 0.82 +/- 0.21. Cumulative clinical patency for successfully treated patients after two-year follow-up was 91%. LTBA thus represents an effective and less aggressive way of treating peripheral atherosclerosis obliterans. In spite of some limitations, it is useful in selected patients. The results of this study are very much like those in the literature for similar series and early experience.

Ornithine decarboxylase activity and polyamines level from red cells lysate of uraemic patients and normal healthy subjects.

We studied the ornithine decarboxylase (ODC) activity and polyamines (PAs) content in the red cells lysate before and after haemodialysis of 15 uremic patients and 15 healthy subjects. ODC activity is significantly increased after haemodialysis but the PAs concentrations (particularly spermine and spermidine) do not increase. This could be because of a minimal loss of PAs surplus production. On the contrary the increase of ODC activity could be explained in several ways, e.g. by stimuli during haemodialysis (hypoxia of the first hour of treatment, decrease of plasmatic osmolarity and biological stimulation of the blood during its passage through the filter).

Antiplatelet agents and their effect on complications during or soon after percutaneous transluminal coronary angioplasty.

In a retrospective study, during which 179 patients had undergone percutaneous transluminal coronary angioplasty (PTCA), the overall initial success rate fell suddenly and unexpectedly from more than 90% to 70.4%: 54.9% in patients not receiving antiplatelet therapy and 86.4% in patients treated orally with 300 mg triflusal three times daily or 300 mg acetylsalicylic acid plus 75 mg dipyridamole three times daily. The initial success rate was similar in patients with unstable (66.0%) and stable (77.6%) angina. The overall incidence of severe complications (mainly occlusion) was 16.2% and was significantly (P less than 0.01) greater in the patients not receiving antiplatelet therapy (23.1% versus 9.1%). There was no significant difference between incidence according to antiplatelet therapy used. It is concluded that antiplatelet therapy during the peri-angioplasty period (from 2 days before to 2 days after) may prevent periprocedural events in patients undergoing PTCA.

[Stents and de novo coronary lesions. Meta-analysis]. / Stent en lesiones coronarias de novo. Metaanálisis.

OBJECTIVES: The purpose of this investigation was to provide an overview of the effect of coronary artery stent and balloon angioplasty on major clinical outcomes and restenosis from 3 trials (BENESTENT, STRESS and START) comparing the two treatments in the novo lesions. METHODS: The trials included a total of 1,374 patients, 693 of whom were randomized to stent and 682 to conventional angioplasty. Relative risk, 95% confidence interval and p values were calculated for death, infarction and need for revascularization at 6 month follow-up. Restenosis was assessed by using the binary definition. RESULTS: The incidence of combined clinical outcomes was similar to the two treatment strategies (relative risk 0.96; 95% CI 0.64-1.45). However, the odds for needing a new revascularization procedure were reduced by 35% in patients treated with stents (relative risk 0.65; 95% CI 0.51-0.82; p < 0.001). Restenosis rates were 25% and 36.6% (stent vs angioplasty, respectively), which represents a reduction of 31% (relative risk 0.69; 95% CI 0.58-0.81; p > 0.0001). CONCLUSIONS: Compared with balloon angioplasty, coronary stents of de novo lesions in native coronary arteries decreases restenosis at 6 months. This translates into clinical benefit, as shown by a reduction in the number of new revascularization procedures.

Clinical presentation of acute coronary syndrome in HIV infected adults: a retrospective analysis of a prospectively collected cohort.

OBJECTIVES: To compare clinical presentation and short-term prognosis of acute coronary syndrome (ACS) in HIV-infected and uninfected adults. DESIGN: Retrospective analysis of a prospectively collected cohort. METHODS: HIV-infected patients with myocardial infarction or unstable angina were identified by clinical history and specific characteristics of HIV infection were consecutively registered. Surviving patients were followed for at least one month after discharge. Risk factors for cardiovascular disease, clinical symptoms at admission, type of ACS, delivery of care, and factors associated with prognosis were compared between HIV-infected and uninfected adults. RESULTS: Among 627 patients included, 44 (7%) were HIV-infected patients. HIV-infected patients were younger, more frequently men, and had higher prevalence of cardiovascular risk factors than uninfected patients. HIV-infected patients persisted frequently with less pain at Emergency Department (ED) (34% vs 82%, P<0.001) and complained of dyspnea (2% vs 15%, P<0.05) persisted in respect to HIV-uninfected patients. ST-elevation myocardial infarction was the most frequent ACS in HIV-infected patients (59% vs 24%) whereas non-ST-elevation myocardial infarction (23% vs 38%) and unstable angina (18% vs 38%) were the predominant ones in uninfected patients (P<0.001). Catheterism was performed more commonly in HIV-infected patients (75% vs 62%, P<0.01) and similarly admitted in the coronary care unit (38% vs 41%, P=0.81). The evolution was similar in both groups. When HIV-infected patients were matched by age and sex with a subgroup of 88 HIV-uninfected patients, most of the differences disappeared. CONCLUSIONS: HIV-infected adults presenting with ACS are younger and have fewer symptoms than uninfected. Despite having a more established disease, short-term prognosis is similar.