In-Hospital Outcomes after Rescue Percutaneous Coronary Intervention in Patients with ST Segment Elevation Myocardial Infarction.

Objective: To investigate the outcomes of patients who underwent rescue percutaneous coronary intervention (PCI) for ST segment elevation myocardial infarction (STEMI) after failed thrombolytic therapy. Material and Method: This observational cohort study was conducted between June 1, 2008 and May 31, 2013. Consecutive STEMI patients who underwent either emergency rescue PCI or primary PCI were included. Rescue PCI patients were compared with primary PCI patients. Clinical data including baseline characteristics, angiographic results, periprocedural details, and in-hospital adverse events were reviewed. Results: Three hundred sixteen patients were enrolled, of which 72.5% were male. Mean age of participants was 59.5 years. Rescue PCI and primary PCI was performed in 24 and 292 patients, respectively. Median time from symptom onset to emergency room (ER) arrival was 175 minutes and not statistically different between groups. Thirteen percent of patients were critically ill and in cardiogenic shock upon arrival. Radial artery access was significantly more frequently used in the rescue PCI group. The rescue PCI group had a significantly higher proportion of initial TIMI grade 3 flow than the primary PCI group (rescue PCI 33.3% vs. primary PCI 13.4%, p = 0.042). No significant differences were observed in final TIMI grade 3 between the two groups (rescue PCI 87.5% vs. primary PCI 89.7%, p = 0.77). Rate of platelet glycoprotein IIb/IIIa receptor blocker use was significantly higher in the primary PCI group (41.4% vs. 4.2%, p<0.001). Left ventricular ejection fraction was significantly higher in the rescue PCI group (rescue PCI 57.7% vs. primary PCI 50%, p = 0.013). There were no significant differences between groups for angiographic success rate (rescue PCI 83.3% vs. primary PCI 88.7%, p = 0.229) or procedural success rate (rescue PCI 79.2% vs. primary PCI 85.6%, p = 0.164). Forty-one patients (14%) in primary PCI group and two patients (8.3%) in rescue PCI group died during hospitalization (p = 0.75). Stroke and reinfarction were rare events in this study. Hemorrhagic stroke occurred in one patient in each group. There were no significant differences in major bleeding or major vascular complications between groups. Conclusion: The angiographic outcome and procedural success rates in patients who underwent rescue PCI were not significantly different from rates in patients who underwent primary PCI. Rescue PCI in STEMI can be performed with favorable success rates and in-hospital outcomes and should be considered in patients that experience failure after thrombolytic therapy.

Differentiation of Takotsubo Cardiomyopathy from ST Elevation Myocardial Infarction in Patients Activated for Fast-Track Coronary Angiography.

Objective: To compare clinical and electrocardiographic (ECG) features between Takotsubo cardiomyopathy (TC) and ST-elevation myocardial infarction (STEMI). Material and Method: We retrospectively reviewed clinical, electrocardiographic, and laboratory features of 20 consecutive TC patients and 155 consecutive STEMI patients who were activated for fast-track coronary angiography and were ultimately diagnosed with either TC or STEMI and compared these data between the two groups. Results: Patients with TC were older (p = 0.001), more often female (p = 0.001), had more often been triggered by intense emotional or physical stress (p = 0.001) or illness (p = 0.001), and had a lower rate of smoking (p = 0.005) than STEMI patients. Compared with patients who presented with anterior wall STEMI, those with TC less commonly had Q waves (30.0% vs. 62.9%, p = 0.007) and reciprocal change (0.0% vs. 37.1%, p = 0.001), and had a lower rate of ST-segment elevation in lead V1 (5.0% vs. 59.8%, p = 0.001). ST-segment depression was also more common in TC in lead aVR (20.0% vs. 2.1%, p = 0.008). Previously proposed ECG criteria had low sensitivity, but high specificity in our patients. Our proposed point scoring model includes the use of both clinical and ECG findings. According to our proposed model, a score ≥4 had 90% sensitivity and 98% specificity in differentiating TC from acute anterior STEMI (AUC = 0.976, p<0.001). Conclusion: In patients activated for fast-track coronary angiography because of acute coronary ST-segment elevation syndrome, a number of clinical and ECG features differ between TC patients and patients with true STEMI. Our proposed point scoring model that uses clinical and ECG findings demonstrated improved diagnostic accuracy in differentiating TC from acute anterior STEMI.

Coronary-artery bypass surgery in patients with left ventricular dysfunction.

BACKGROUND: The role of coronary-artery bypass grafting (CABG) in the treatment of patients with coronary artery disease and heart failure has not been clearly established. METHODS: Between July 2002 and May 2007, a total of 1212 patients with an ejection fraction of 35% or less and coronary artery disease amenable to CABG were randomly assigned to medical therapy alone (602 patients) or medical therapy plus CABG (610 patients). The primary outcome was the rate of death from any cause. Major secondary outcomes included the rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes. RESULTS: The primary outcome occurred in 244 patients (41%) in the medical-therapy group and 218 (36%) in the CABG group (hazard ratio with CABG, 0.86; 95% confidence interval [CI], 0.72 to 1.04; P=0.12). A total of 201 patients (33%) in the medical-therapy group and 168 (28%) in the CABG group died from an adjudicated cardiovascular cause (hazard ratio with CABG, 0.81; 95% CI, 0.66 to 1.00; P=0.05). Death from any cause or hospitalization for cardiovascular causes occurred in 411 patients (68%) in the medical-therapy group and 351 (58%) in the CABG group (hazard ratio with CABG, 0.74; 95% CI, 0.64 to 0.85; P<0.001). By the end of the follow-up period (median, 56 months), 100 patients in the medical-therapy group (17%) underwent CABG, and 555 patients in the CABG group (91%) underwent CABG. CONCLUSIONS: In this randomized trial, there was no significant difference between medical therapy alone and medical therapy plus CABG with respect to the primary end point of death from any cause. Patients assigned to CABG, as compared with those assigned to medical therapy alone, had lower rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes. (Funded by the National Heart, Lung, and Blood Institute and Abbott Laboratories; STICH ClinicalTrials.gov number, NCT00023595.).

Predictors of in-hospital adverse events after PCI for NSTEMI in the National Percutaneous Coronary Intervention (PCI) Registry.

OBJECTIVE: Evaluate the in-hospital major adverse cardiovascular events (MACE) and clinical predictors of non-ST-T Mt that undergoing percutaneous coronary interventions (PCI) in Thailand. MATERIAL AND METHOD: Thailand National PCI Registry enrolled 4156 patients that underwent PCI in Thailand between May 1 and October 31, 2006. Four hundred eighty three patients underwent PCI with indication of non-ST-T MI. Baseline demographic and angiographic characteristic were recorded. MACE included CV death, M, and stroke. RESULTS: In-hospital MACE occurred in 27 patients (5.6%), included CV death in 15 patients (3.1%), MI in 14 patients (2.9%), and stroke in 2 patients (0.4%). In-hospital MACE were higher in patients with previous history of CABG (19.2% versus 4.8%, p = 0.01), cardiogenic shock at presentation (29.3% versus 3.4%, p<0.001), significant left main disease (19.4% versus 4.6%, p = 0.005), baseline ejection fraction <30% (25% versus 4.4%, p = 0.003), and used of intra-aortic balloon counter pulsation (IABP) during PCI (26.3% versus 3.8%, p<0.001). After multiple logistic regression analysis, prior history of CABG (OR = 6.1, 95% CI: 1.1-32.4, p = 0.03), baseline ejection fraction <30% (OR = 6.5, 95% CI: 1.7-24.4, p = 0.005), and used of lABP during PCI (OR = 4.7, 95% CI: 1.3-16.8, p = 0.01) are the strongest predictors of in-hospital MACE. CONCLUSION: In the National Thai PCI Registry, patients with non-ST-T MI undergoing PCI had in-hospital major adverse events rate at 5.6%. Prior CABG, low EF <30%, unstable hemodynamic required used of lABP during PCI and procedure scheduled as an urgent or emergent were predictors of in-hospital MACE.

First medical contact to device time in the Thailand percutaneous coronary intervention (PCI) registry.

OBJECTIVE: The aim of this study is to evaluate the first medical contact (FMC) to device time in the Thai national PCI registry 2006, and its effect on the clinical outcome. MATERIAL AND METHOD: Thailand national PCI registry enrolled 4,156 patients who underwent PCI from the all catheterization laboratories in Thailand between May 1st and October 31st, 2006. RESULTS: 581 patients with acute myocardial infarction (AMI), 352 patients underwent primary angioplasty, 229 patients underwent rescue angioplasty/facilitated PCI or after successful thrombolytic. Median FMC.to device time in primary angioplasty group was 115 minutes (range 24-1335 minutes); only 29.8% of patients who able to achieve FMC to device time ≤ 90 minutes. Cardiogenic shock was significant lower if FMC to device time ≤ 90 minutes (2.1% (1/48) versus 12.4% (14/113) if FMC to device time > 90, p = 0.040). In-hospital mortality occurred for 4.8% (2/48) ifFMC to device time ≤ 90 minutes and was 8.8% (10/113) if FMC to device time > 90 minutes, p = 0.510). Death occurred in 4.2% (2/48) if FMC to device time ≤ 90 minutes, 6.3% (5/79) if FMC to device time between 91-180 minutes, 6.7% (1/15) if FMC to device time between 181-270 minutes, 42.9% (3/7) if FMC to device time between 271-360 minutes and 8.3% (1/12) if FMC to device time > 360 minutes, (p = 0.040). CONCLUSION: FMC to device time is strongly associated with the risk ofcardiogenic shock and mortality. In Thailand national PCI registry in 2006, the majority of the patients did not receive primary PCI in timely fashion.

One-year clinical outcomes of ST segment elevation myocardial infarction patients treated with emergent percutaneous coronary intervention: the impact of thrombus burden.

OBJECTIVE: To investigate the impact of thrombus burden on 1-year clinical outcomes in patients who underwent emergent percutaneous coronary intervention (PCI) for ST segment elevation myocardial infarction (STEMI). MATERIAL AND METHOD: Angiographic evidence of intracoronary thrombus adversely affects the outcome of PCI in STEMI. Large thrombus burden (> or = 2 times vessel diameter) has been shown to be a significant predictor of major adverse cardiac events (MACE). The impact of thrombus burden in Asian patients who undergo PCI in STEMI has not been described. This is an observational cohort of patients with STEMI from June 1, 2008 through May 31, 2011, who underwent emergent PCI (primary or rescue). The patients were categorized into two groups according to the angiographic thrombus burden, large thrombus burden (> or = 2X vessel diameter size, LTB) and small thrombus burden (< 2X vessel diameter size, STB). MACE was defined as the composite of death, repeat myocardial infarction, target vessel revascularization and stent thrombosis. RESULTS: 202 patients were enrolled, 72% were male and the mean age was 60 years old. 134 patients (66%) presented with an occluded infarct related artery. Primary PCI was performed in 90.6% of the patients and the remainder underwent rescue PCI. One hundred eleven (55%) patients were categorized into the STB group and 91 patients (45%) into the LTB group. The use of aspiration thrombectomy was significant higher in the LTB group (LTB 80.2% vs. STB 60.44%, p = 0.002). A higher proportion of patients in the STB group underwent direct stenting strategy (STB 32.4% vs. LTB 18.7%, p = 0.027). There were no significant differences in final TIMI grade 3 flows and procedural success between the groups. Overall, in hospital, mortality was 13.4% and there were no significant differences among the groups. At 1-year follow-up, there was no significant difference in cumulative MACE-free survival in the LTB vs. STB group (82.4% vs. 79.3%, 95% confidence interval for the difference: -8.0% to 13.8%, p = 0.59). CONCLUSION: In the current study, large thrombus burden is not an independent predictor of 1-year cumulative MACE in STEMI patients who were treated with emergent PCI.

High on-clopidogrel treatment platelet reactivity in Thai patients with chronic stable angina scheduled for percutaneous coronary intervention.

OBJECTIVE: To determine the prevalence, clinical profile, and risk factors of high on-clopidogrel treatment platelet reactivity in Thai patients with chronic stable angina scheduled for percutaneous coronary intervention. MATERIAL AND METHOD: The patients were prospectively recruited from the consecutive patients undergoing coronary angiography and planned for elective percutaneous coronary intervention (PCI). Ten ml of blood samples were cautiously drawn from the antecubital vein of the patients to determine the hemoglobin and platelet count. Platelet aggregation test was performed by light transmittance aggregometry using platelet-rich plasma. Platelets were stimulated with 5 microM adenosine diphosphate (ADP). Platelet aggregation was expressed as the maximal percent change in light transmittance from baseline. High on-clopidogrel treatment platelet reactivity was defined as post treatment maximal platelet aggregation > 46% with 5 micromol/l ADP used as agonist. RESULTS: The present study consecutively enrolled two hundred four patients diagnosed with chronic stable angina planned for PCI. Seventy-nine patients demonstrated the high on-clopidogrel treatment platelet reactivity (38.7%). Among these patients, 48% were men with a mean age of 66 years. Diabetes mellitus and chronic kidney disease were detected in 34.2%. Original clopidogrel (Plavix) was prescribed in 72% of the patients and 28% received generic clopidogrel (Apolets). The prevalence of high on-clopidogrel treatment platelet reactivity increased in the older patients, patients with CKD and patients receiving angiotensin receptor blockers (ARB). However from multivariate analysis, none of the risk factors, including age, BMl, diabetes mellitus, smoking, CKD, ARB use, and type of clopidogrel (Plavix versus Apolets) had a statistically significant association with the high on-clopidogrel treatment platelet reactivity. CONCLUSION: The prevalence of high on-clopidogrel treatment platelet reactivity in the present study was 38.7%. No significant association was demonstrated between age, BMI, diabetes mellitus, smoking, CKD, ARB use, type of clopidogrel, and high on-clopidogrel treatment platelet reactivity.

Aspirin resistance in Thai patients with chronic stable angina.

OBJECTIVE: To determine the prevalence, clinical profile and risk factors of aspirin resistance in Thai patients with chronic stable angina. MATERIAL AND METHOD: The patients were prospectively recruited from the consecutive patients diagnosed chronic stable angina at Siriraj Hospital during March 2011 to February 2012. Ten milliliter of blood samples were cautiously drawn from the antecubital vein of the patients to determine the hemoglobin, platelet count and platelet aggregation test performed by light transmittance aggregometry using platelet-rich plasma. Platelets were stimulated with 0.5 mg/ml of arachidonic acid and 10 mM adenosine diphosphate. Platelet aggregation was expressed as the maximal percent change in light transmittance from baseline. Aspirin resistance was defined as the mean platelet aggregation of > or = 70% with 10 mM ADP and the mean platelet aggregation of > or = 20% with 0.5 mg/ml of arachidonic acid. RESULTS: One-hundred and fifty seven patients diagnosed chronic stable angina were enrolled in the present study. There were 34 patients (21.6%) demonstrating aspirin resistance. The clinical characteristic of these patients included male 58.8% with mean age of 66 years, body mass index 27.5 kg/m2, diabetes mellitus 52.9%, smoking 8.8%, hypercholesterolemia 70.6% and proton pump inhibitor use 23.5%. Multivariate analysis demonstrated none of the risk factors including age, female, body mass index, diabetes mellitus, hypercholesterolemia, smoking and proton pump inhibitor (PPI) use had a statistically significant association with aspirin resistance. CONCLUSION: Our study demonstrated that the prevalence of aspirin resistance in Thai patients with chronic stable angina was 21.6%. No significant association was demonstrated between age, female, body mass index, diabetes mellitus, hypercholesterolemia, smoking, proton pump inhibitor (PPI) use and aspirin resistance.

Utilizing a registry for ST segment elevation myocardial infarction from a tertiary care hospital in Thailand: opportunities to improve the quality of care.

BACKGROUND: Treatment of acute coronary syndrome requires a reliable measurement of quality for ensuring evidence-based care. Clinical registries have been used to support quality improvement activities in some countries, but there are few data concerning their implementation in developing countries. In 2008, a multidisciplinary Siriraj ST segment elevation myocardial infarction (STEMI) registry team was formed with the intention to improve the process of care. This report summarizes observational data collected within the first year to characterize the clinical profile, management and in-hospital outcomes of STEMI patients at the author's institute. MATERIAL AND METHOD: The present study is a prospective, observational study. From June 2008 through June 2009, data from all consecutive patients presenting within 24 hours of STEMI at Siriraj Hospital were collected. The patient's data on demographics, procedures, medications and in-hospital outcomes were collected. RESULTS: During the 1-year period, 112 patients with STEMI were enrolled. The mean age was 59.3 years old and 81.3% were males. There was a high prevalence of diabetes, hypertension, dyslipidemia and current smoking. Median time from symptom onset to presentation was 120 minutes. 98 patients (84.8% of the patients) received reperfusion therapy in the form of thrombolytic therapy (21.4%) or primary percutaneous coronary intervention (PCI, 63.40%). For thrombolytic therapy, the median door to needle time was 68 minutes. Rescue PCI was performed in 20.8% of the thrombolytic treated patients. For primary PCI, the median door to balloon time was 118 minutes. In-hospital coronary artery bypass graft surgery was performed in 6% of the patients. In-hospital mortality rate was 9.8%. Re-infarction and stroke were rare events. CONCLUSION: Despite a high utilization rate of reperfusion therapy the time to reperfusion therapy exceeds the length of time recommended by current guidelines. The authors' findings provide important data for future benchmarking and represent a significant opportunity for quality improvement in STEMI-related care and outcomes.

Intravascular Imaging Guidance Reduce 1-Year MACE in Patients Undergoing Rotablator Atherectomy-Assisted Drug-Eluting Stent Implantation.

Objectives: This study aimed to investigate the incidence of 1-year major adverse cardiac events (MACE) compared between intravascular imaging guidance and angiographic guidance in patients undergoing rotablator atherectomy (RA)-assisted percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation. Methods: This retrospective analysis included 265 consecutive patients with heavy calcified lesion who underwent RA-assisted PCI with DES implantation at our institution during the January 2016-December 2018 study period. This study was approved by the Siriraj Institutional Review Board. Patients were divided into either the angiographic guidance PCI group or the imaging guidance PCI group, which was defined as intravascular ultrasound or optical coherence tomography. The primary endpoint was 1-year MACE. Results: Two hundred and sixty-five patients were enrolled, including 188 patients in the intravascular imaging guidance group, and 77 patients in the angiographic guidance group. One-year MACE was significantly lower in the imaging guidance group compared to the angiographic guidance group (4.3 vs. 28.9%, respectively; odds ratio (OR): 9.06, 95% CI: 3.82-21.52; p < 0.001). The 1-year rates of all-cause death (OR: 8.19, 95% CI: 2.15-31.18; p = 0.002), myocardial infarction (MI) (OR: 6.13, 95% CI: 2.05-18.3; p = 0.001), and target vessel revascularization (TVR) (OR: 3.67, 95% CI: 1.13-11.96; p = 0.031) were also significantly lower in the imaging guidance group compared with the angiographic guidance group. The rate of stroke was non-significantly different between groups. Conclusion: In patients with heavy calcified lesion undergoing RA-assisted DES implantation, the intravascular imaging guidance significantly reduced the incidence of 1-year MACE, all-cause death, MI, and TVR compared to the angiographic guidance.

The effectiveness of "Siriraj Leg Lock" brace on back pain after percutaneous coronary intervention: PCI.

BACKGROUND: The most common problem experienced by patients after Percutaneous Coronary Intervention (PCI) is back pain. After the procedure, patients are restricted to complete bed rest with no hip flexion for up to 10 hours, causing much discomfort, especially back pain. In some patients, anxiety arises due to limited movement, with the belief that movement might cause re-bleeding from the wound. To alleviate these problems, the "Siriraj Leg Lock" brace or SLL was initiated to confine the hip while allowing patients to freely move other parts of their body without complicating the wound. Hence, anxiety is relieved and mobility can lower the chance of getting back pain with more comfort. OBJECTIVE: The aims of this experimental study were to investigate the effect and satisfaction of SLL on back pain in post-PCI patients, and to compare bleeding and/or hematoma occurrences at the site of incision between experimental and control groups. MATERIAL AND METHOD: The randomized controlled trial (RCT) was conducted in 100 patients who underwent coronary angioplasty and/or stent placement interventions and received post procedural care at the intermediate cardiac care ward, Her Majesty Cardiac Center from December 2006 to February 2007. The control group (49 patients) was to get standard care after the intervention, whereas the experimental group (51 patients) was fitted with the SLL device to allow free mobility right after the procedure. RESULTS: Lower maximum back pain scores and mean back pain scores in the experimental group than in the control group, with statistical significance (p < 0.001). Back pain score reduced from the day of admission in the experimental group after applying SLL, but increased in the control group. The occurrence of hematoma in both groups was not significantly different (p = 0.114). The experimental group with the SLL could freely change positions from upright to decubitus without any effects to the wound, feeling more comfortable and experiencing less back pain. Patients' satisfaction towards the SLL from 1 to 5 scale was 4.3. The satisfaction was evident especially in patients who had previous PCI experience, and desired to ask for SLL application if a future procedure to be needed. CONCLUSION: Using SLL after sheath removal post PCI allows the patient to freely change position without any effects to the wound and reduces back pain with more patients' satisfaction.

Evaluation of the firebird sirololimus eluting stent in all comers with coronary artery stenosis.

OBJECTIVE: Percutaneous coronary intervention (PCI) has been widely used to treat obstructive coronary artery disease. With the advent of drug-eluting stent (DES) in real world registry was proved as promising therapy. The limitation of the use of DES is the limited health care expenditure. We propose the use of Chinese made DES among Thai patients and that this will solve the cost issue. The clinical result of this DES has not been well known. METHODS: Prospective study from November 2005 to March 2007 using the structured registry form to evaluate the safety and efficacy of new Chinese made Firebird sirolimus eluting stent (Firebird SES) on clinical parameters from in-hospital, 30 days and 12 months or longer term follow-up. End point is major adverse cardiac event (MACE) including death, MI, TLR and CABG at 30 day and cumulative MACE at 12 month follow-up. RESULTS: Ninety consecutive patients who were treated with Firebird stent implantation (107 target lesions) were analyzed. Angiographic success (defined as < 30% diameter stenosis) was 85%. Procedure success was 77.8%. MACE at 30 day was 16.6%, cumulative MACE at 12 months was 18.8%. There were total 9 deaths during the study period, two deaths occurred at before 30 days, 3 deaths occurred before 12 months and other 4 deaths occurred after 12 months to 1305 days. Eighty patients (88.9%) had either office visit or telephone call follow-up after 12 months, 38 patients (42.2%) underwent clinical driven coronary arteriography, binary restenosis was 26.3%. Shock and smoking history was the analyzed predictor of MACE at follow-up. CONCLUSION: The implantation of Firebird DES in unselected patients (all comers) is safe, effective and could be an alternative choice of stent for Thai patients.

Early and intermediate outcomes of left main coronary intervention.

OBJECTIVE: We examined the immediate and long-term outcomes after stenting of all comers for left main coronary artery (LMCA) stenoses. BACKGROUND: Left main coronary artery disease is regarded as an absolute contraindication for coronary angioplasty. Recently, several reports on protected or unprotected LMCA stenting, or both, suggested the possibility of percutaneous intervention for this prohibited area. MATERIAL AND METHOD: Eighty-one consecutive patients with LMCA stenoses were treated with stents. The post-stent antithrombotic regimens were aspirin and clopidogrel. The major adverse cardiac events (MACE) including death, Q-wave myocardial infarction, or repeat target lesion revascularization were followed. Patients were followed very closely and all attended office visit at 12 months. RESULTS: The procedural success rate was 86.4%, with no episodes of acute thrombosis. Follow-up angiography was performed in 30 of 65 eligible patients (46.2%). Angiographic restenosis occurred in eight patients (9.9%). Cumulative death occurred in 16 patients (19.7%). MACE at 30 day and 12-month was 12.3% and 33.3% respectively. From multivariate analysis, dialysis (HR =3.22, p = 0.048), urgent PCI (HR =2.39, p = 0.036), post-procedure TIMI flow < 3 (HR =25.99, p = 0.001) and final kissing balloon inflation (HR = 0.30, p = 0.04) were independent predictors of MACE at 12-month. There was one definite late stent thrombosis (1.2%). CONCLUSION: Stenting of LMCA stenosis may be a safe and effective alternative to CABG in carefully selected patients. Further studies in larger patient populations are needed to assess late outcome.

Primary percutaneous transluminal coronary intervention compared with intravenous thrombolysis in patients with ST segment elevation myocardial infarction.

BACKGROUND: Primary percutaneous transluminal coronary intervention (PCI) and thrombolytic therapy (TT) are alternative means of achieving reperfusion in patients with acute ST segment elevation myocardial infarction (STEMI). OBJECTIVE: To compare the outcomes between both reperfusion strategies. The authors sought to compare in-hospital outcomes after PCI or TT for patients with acute STEMI. MATERIAL AND METHOD: From August 2002 through June 2004, data from all patients who received reperfusion therapy for acute STEMI were collected prospectively. The decision regarding type of reperfusion strategy was at the attending cardiologist's discretion. The patient's data on demographics, procedures, medications, and in-hospital outcomes were analyzed. RESULTS: From August 2002 through June 2004, 234 patients were admitted to the authors' institute with the diagnosis of acute STEMI. Of the 146 patients who received reperfusion therapy, 91 were treated with primary PCI and 55 received intravenous TT as the reperfusion modality. In the TT group, 51 (93%) patients received streptokinase and 11 (21.6%) underwent rescue angioplasty. The two groups had similar baseline characteristics. Both patient groups had frequent presence of diabetes (PCI 44.2% vs. TT 39.6%, p = 0. 6). Cardiogenic shock on admission was present in 11% of the PCI patients and 7.3% of the TT patients (p = ns). In-hospital mortality was not significantly different in the two groups (PCI 14.3% vs. TT 10. 9%, p = 0.56). In the TT group, there was a trend toward a higher rate of major bleeding (PCI 6.6% vs. TT 16.4%, p = 0.06) and stroke (PCI 2.2% vs. TT 7.3%, p = 0.13) complications without statistical significance. CONCLUSION: The present findings suggest that both PCI and TT are comparable alternative methods of reperfusion among STEMI patients in terms of in-hospital mortality. In certain subgroups that are at increased risk of bleeding or stroke, primary PCI may be the preferred treatment strategy.

Acute coronary syndrome in 1366 patients at Siriraj Hospital: clinical characteristics, management and in-hospital outcomes.

OBJECTIVE: To characterize the baseline characteristics, management and in-hospital outcomes of all patients admitted with acute coronary syndrome (ACS). MATERIAL AND METHOD: The present study is a prospective, observational study of all consecutive patients admitted with ACS. From August 1, 2002 through October 31, 2005, data from 1366 ACS patients were collected. RESULTS: The patients were classified according to the final discharge diagnosis as ST-segment elevation myocardial infarction (STEMI, 33.5%), non-ST-segment elevation myocardial infarction (NSTEMI, 47%) and unstable angina (UA, 19.5%). Approximately half of the patients were older than 65 years old. The STEMI patients were significantly younger and had a higher percentage of men than the NSTE-ACS patients. There was a very high prevalence of diabetes, hypertension and dyslipidemia in the patients. Only 60% of the STEMI patients received reperfusion therapy. Of these, primary percutaneous coronary intervention (PCI) was performed more frequently (35%) than thrombolytic therapy (24%). There were substantial delays in time to treatment. Median door to needle and door to balloon time were 135 and 130 minutes respectively. Half of the NSTEMI and UA patients underwent coronary angiography and about one-third had PCI or coronary artery bypass grafting in the same hospital admission. In-hospital mortality rate was high: STEMI 19%, NSTEMI 16% and UA 4%. CONCLUSION: The present study provides invaluable information regarding the spectrum of ACS in our country. Overall in-hospital mortality was higher than that reported from international registries. The present findings represent a significant opportunity for quality improvement in the care of patients with ACS and the implementation of preventive strategies for patients with and at risk for coronary artery disease.

One-year outcome of cardioversion of atrial fibrillation in patients with mitral stenosis after percutaneous balloon mitral valvuloplasty.

Our objectives were to study the success rate of electrical cardioversion after percutaneous balloon mitral valvuloplasty (PBMV) in patients with symptomatic moderate-to-severe mitral stenosis and atrial fibrillation (AF) and the maintenance rate of sinus rhythm for < or =1 year. We studied patients with mitral stenosis and AF who were scheduled for PBMV. Electrical cardioversion was performed 1 month after PBMV. Amiodarone 200 mg/day was started the day after PBMV. The primary outcomes studied were the rate of successful cardioversion and the maintenance rate of sinus rhythm at 12 months. Of 272 patients scheduled for PBMV, 70 were enrolled. The average age was 45 +/- 10 years. The average mitral valve area was 0.82 +/- 0.22 cm(2). Cardioversion was successful in 50 patients (71%). Logistic regression analysis revealed that left atrial size and associated aortic valvular disease were predictors of successful cardioversion. Of the 50 patients with successful cardioversion, AF recurred in 24 (48%). An increased left atrial diameter was the only factor associated with AF recurrence at 12 months. In conclusion, good candidates for cardioversion after PBMV were those with a left atrial diameter of <60 mm and no associated aortic valvular disease -- approximately 43% of patients with AF scheduled for PBMV. In this group, about 2/3 were in sinus rhythm at 12 months after cardioversion.

Balloon expandable stents for coarctation of the aorta: current status and technical considerations: case report.

BACKGROUND: Balloon expandable stents have been used to manage coarctation of the aorta (Co) in selected patients with very encouraging results. MATERIAL AND METHOD: The authors report here the first group of patients with Co who underwent a successful implantation of the new Palmaz Genesis stent with intermediate term follow up. RESULTS: There were 5 patients with an age range from 14 to 23 years old. All of them had significant Co and were receiving multiple anti-hypertensive medications. Primary stenting was performed in all patients. All of them had an immediate relief of the gradient. All antihypertensive medications were discontinued immediately in 4 patients. All patients had one year follow up which revealed a minimum gradient. One patient continues to receive oral antihypertensive medication. CONCLUSION: In patients with coarctation of the aorta (native or recoarctation of aorta), stent implantation may be a feasible and improved option to relieve the stenosis. Short and mid term followup of these patients have shown encouraging results.

An electrocardiographic survey of elderly Thai people in the rural community.

UNLABELLED: Electrocardiographic findings in the elderly reflect both common cardiac diseases and physiologic ageing change. This cross-sectional population-based study explored the prevalence of various abnormalities in the electrocardiograms of active older people and those who are free from any cardiac pathology and determined their relationship to age and gender in a rural area of Thailand. Nine hundred and sixty three people aged 60 years or more were recruited. The electrocardiographic prevalence of ischemic heart disease, atrial fibrillation, left axis deviation and conduction defect were 5.5 per cent, 2.2 per cent, 2.5 per cent and 3.1 per cent respectively. After excluding diseases potentially affecting the heart, the prevalence of atrial fibrillation, left axis deviation and conduction defect decreased to 1.3 per cent, 2.0 per cent and 2.2 per cent. The prevalence of atrial fibrillation and ischemic heart disease were significantly less (p = 0.015 and 0.003) in the 80+ year old group. Regarding gender difference, only left axis deviation was found significantly more frequently in older men with an odds ratio of 5.23 (95% confidence interval, 1.28-30.29) in those who were free from diseases potentially affecting the heart. IN CONCLUSION: Atrial fibrillation should not be regarded as degenerative change, but the result of cardiac pathology instead. The most common electrocardiographic abnormality in normal older men was left axis deviation and was found consistently more often than in older women. Therefore, it is appropriate to investigate for any reversible causes of atrial fibrillation while it is not so for left axis deviation in older men.

Stent placement compared with balloon angioplasty for obstructed coronary artery disease in Thai elderly patients: initial result and 6 months follow-up.

UNLABELLED: Percutaneous Old Balloon Angioplasty (POBA) is accepted worldwide for the treatment of obstructive coronary artery disease because this technique is safe, and quick and the patient may return to work earlier than with bypass surgery (particularly elderly patients). But the major problem with POBA is restenosis which occurs between 20-40 per cent. Stent placement has been reported to reduce the restenosis rate to 10-20 per cent. OBJECTIVE: The purpose of this study was to compare the effects of stent placement with those of balloon angioplasty on clinical and angiographic outcomes in elderly Thai patients with obstructive coronary artery disease. METHOD: The study was a randomized controlled trial. The sample size was 45 lesions in 42 patients who were assigned into 2 groups; 23 in the balloon angioplasty group and 22 in the stent placement group (Crown Stent). Clinical information and coronary angiography were recorded and performed at the time of the index procedure and six months later. RESULTS: There was 100 per cent procedural success in 22 lesions treated in the stent group and 82.6 per cent in the 23 lesions treated in the balloon angioplasty group. Patients in the stent group had a lesser degree of stenosis immediately after the procedure (8.78 +/- 8.63 vs 30.92 +/- 9.01%, p < 0.001) and a greater minimal luminal diameter (MLD) (3.04 +/- 0.44 vs 2.15 +/- 0.33 mm, p < 0.001). There were no major complications in either group during the procedure or during their hospital stay. These were not maintained at the six months follow-up. (26.88 +/- 16.23 vs 33.82 +/- 14.63 mm, p = 0.19, 2.28 +/- 0.67 vs 2.01 +/- 0.51 mm, p = 0.17) for the degree of stenosis and the MLD respectively. The restenosis rate, which was the primary endpoint of the study, was 4.5 per cent in the stent group and 21 per cent in the balloon angioplasty group (p = 0.10). CONCLUSIONS: Stenting in Thai elderly ischemic patients has a higher procedural success rate when compared with balloon angioplasty. The restenosis rate of stenting is also lower than that of balloon angioplasty but did not reach statistical significance. However, both techniques had no major complications either during the procedure or in-hospital.

Efficacy and safety of percutaneous metallic mitral valvuloplasty in rheumatic mitral stenosis at Siriraj Hospital.

Mitral stenosis is an important problem that leads to heart failure and stroke in Thailand. The options of treatment at present are either surgical or balloon mitral commissurotomy. However, the cost of balloon is very expensive. To reduce the expense of the procedure, the authors prospectively did a study using a new device called the metallic valvulotome in symptomatic severe mitral stenosis to assess the safety, feasibility and immediate outcomes. Fifty-seven patients were included in the study. The successful outcome achieved by the metallic valvulotome was 96.2 per cent in patients in whom the procedure was actually performed. The mean transmitral gradient, left atrial pressure and pulmonary artery pressure were significantly decreased and the mitral valve area was also significantly increased. Three cases failed the procedure due to inappropriate position of the septal puncture. No death occurred in the study and complications of the procedure included only two cases of hemopericardium. In the future, it is believed that this new innovative device will provide improvement and reduce the cost of the procedure in patients with severe mitral stenosis.