Time course of serum collagen types I and III metabolism products after reperfused acute myocardial infarction in patients with and without systemic hypertension.

We examined 55 consecutive patients successfully treated with primary percutaneous coronary intervention (PCI) for a first acute myocardial infarction with left ventricular (LV) systolic dysfunction. In all patients we performed echocardiographic examination, dosage of plasma brain natriuretic peptide, serum carboxy-terminal propeptide and telopeptide of procollagen type I and amino-terminal propeptide of procollagen type III at days 1 and 3, and at 1 and 6 months after index infarction. The hypertensive patients (group 1; n=30) differed for higher baseline blood pressure (133+/-4 mm Hg vs 118+/-4 mm Hg; P=0.03), greater LV mass index (108+/-5 vs 94+/-4 g m(-2), P=0.03) and lower mitral E/A wave peak (0.8+/-0.06 vs 1.1+/-0.12, P=0.02) with respect to non-hypertensive patients (group 2; n=25). From day 1 to month 6 carboxy-terminal propeptide of procollagen type I and amino-terminal propeptide of procollagen type III increased (P<0.005 and P<0.05, respectively) in both groups, whereas carboxy-terminal telopeptide of procollagen type I increased from day 1 to day 3 (P<0.01 in both groups, respectively) and then decreased from day 3 to month 6 (P<0.01 and P<0.05 in both groups, respectively). From day 1, brain natriuretic peptide decreased in both groups (P<0.005). There was no significant difference between the two groups in values of procollagens and natriuretic peptide. Finally, LV diastolic volume and function at 6 months were similar in the two groups. Thus, in patients with reperfused acute myocardial infarction and LV dysfunction, antecedent hypertension was not associated with a different pattern of serum procollagen release and ventricular remodelling at 6 months of follow-up.

Prognostic implications of restrictive left ventricular filling in reperfused anterior acute myocardial infarction.

OBJECTIVES: We sought to assess the relative prognostic role of a restrictive left ventricular (LV) filling pattern after a first anterior acute myocardial infarction (AMI) in patients treated with primary percutaneous transluminal coronary angioplasty (PTCA). BACKGROUND: In thrombolized patients, a short Doppler-derived mitral deceleration time (DT) of early filling is a powerful independent predictor of heart failure and death. However, it is still unknown whether the outcome of patients with AMI with a short DT may be improved by a more aggressive treatment. METHODS: In 104 patients, two-dimensional and Doppler echocardiograms were obtained three days after the index AMI. Coronary angiography was performed in all patients one and six months after PTCA. The patients were classified into two groups according to the DT duration: group 1 (n = 34) with DT < or = 130 ms and group 2 (n = 70) with DT >130 ms. All patients were followed-up for a mean (+/- SD) period of 32 +/- 10 months. RESULTS: During the follow-up period, 14 patients (13%) were admitted to the hospital for congestive heart failure, and 9 patients (9%) died. All cardiac deaths (n = 7) occurred in group 1. The survival rate at mean follow-up was 79% in group 1 and 97.2% in group 2 (p = 0.003). Multivariate Cox analysis showed that only age and restrictive filling were independent predictors of event-free survival. Furthermore, when survival with no cardiovascular events was analyzed, a short DT still emerged as the most powerful independent predictor. CONCLUSIONS: Patients with a restrictive LV filling pattern early after anterior AMI have a poor clinical outcome, even if treated with primary PTCA.

Direct infarct artery stenting without predilation and no-reflow in patients with acute myocardial infarction.

BACKGROUND: In patients with acute myocardial infarction (AMI), the rate of microvascular embolization and no-reflow promoted by coronary stenting with the use of conventional techniques (CS) appears to be greater than the one that occurs with balloon angioplasty. The minor invasiveness of direct stenting (DS) of the infarct artery without predilation could be expected to reduce embolization in the coronary microvasculature and no-reflow in patients with AMI. METHODS: In a cohort of 423 consecutive patients with AMI who underwent infarct-artery stenting, we compared CS and DS in terms of angiographic no-reflow rate and 1-month clinical outcome. RESULTS: At baseline patients who underwent DS (n = 110) had a better risk profile compared with the use of CS (n = 313). The incidence of angiographic no-reflow was 12% in the CS group and 5.5% in the DS group (P =.040). The 1-month mortality rate was 8% in the CS group and 1% in the DS group (P =.008). The mortality rate was 11% in patients with no-reflow and 5.6% in patients with a normal flow. Multivariate analysis showed that age, preprocedure patent infarct artery, and lesion length were related to the risk of no-reflow. In the subset of patients with a target lesion length

A randomized study of intravenous magnesium in acute myocardial infarction treated with direct coronary angioplasty.

BACKGROUND: Notwithstanding the negative result of the International Study of Infarct Survival-4 (ISIS-4), the controversy about the role of magnesium in acute myocardial infarction is still open because, according to experimental data, magnesium could decrease myocardial damage and mortality only if infusion is started before reperfusion. This randomized placebo-controlled trial was designed to evaluate the effect of intravenous magnesium, delivered before, during, and after direct coronary angioplasty, in patients with acute myocardial infarction. METHODS: One-hundred fifty patients were randomized to intravenous magnesium sulfate or placebo. The primary end point was an infarct zone wall motion score index at 30 days, as a measure of infarct size. The secondary end points included creatine kinase peak, ventricular fibrillation/tachycardia within the first 24 hours, death and congestive heart failure within the 30-day follow-up, and 30-day left ventricular ejection fraction. Analysis was by intention to treat. RESULTS: There were no significant differences between the magnesium and placebo groups in the 30-day infarct zone wall motion score index (1.93 +/- 0.61 vs 1.85 +/- 0.51, P =.39), ventricular arrhythmias (24% vs 15%, P =.15), death (0 vs 1%, P =.32), heart failure (8% vs 7%, P =.75), and 30-day left ventricular ejection fraction (49% +/- 11% vs 50% +/- 9%, P = 0.55). There was a trend toward a higher creatine kinase peak in the magnesium group (3059 +/- 2359 vs 2404 +/- 1673,P =.052). CONCLUSIONS: Intravenous magnesium delivered before, during, and after reperfusion did not decrease myocardial damage and did not improve the short-term clinical outcome in patients with acute myocardial infarction treated with direct angioplasty.

Early dobutamine echocardiography predicts improvement in regional and global left ventricular function after reperfused acute myocardial infarction without residual stenosis of the infarct-related artery.

BACKGROUND: The accuracy of dobutamine echocardiography (DE) early after reperfused acute myocardial infarction (AMI) without residual stenosis of the infarct-related artery is unknown. The objective of this study was to assess whether in reperfused AMI DE can predict early as well as late regional and global spontaneous functional recovery. METHODS: DE was performed in 157 patients (61 +/- 11 years; 33 women) 3 days after AMI treated with successful direct percutaneous transluminal coronary angioplasty (Thrombolysis in Myocardial Infarction flow grade 3, residual stenosis <30%). All patients underwent 2-dimensional echocardiography and coronary angiography at 1 month and 145 (92%) at 6 months. RESULTS: Patency and restenosis rate were similar between those who did and did not respond to DE. DE showed a high accuracy in predicting both early and late regional functional recovery (86% and 81%, respectively). DE accuracy in predicting early and late reversible dysfunction was also high on a patient-by-patient analysis (89% and 87%). In DE responders left ventricular ejection fraction increased from 44% +/- 9% at baseline to 57% +/- 9% at 6 months (P <.00005), whereas only a slight, although significant improvement was found in nonresponders (from 40% +/- 10% to 44% +/- 12%; P =.03). A significant correlation was found between the number of dobutamine-responder segments and the magnitude of their functional improvement at peak dobutamine and changes in ejection fraction (r =.72; P <.000001; r =.68, P <.000001, respectively). CONCLUSIONS: These data indicate that in patients with AMI in whom anterograde flow is fully restored without residual stenosis, DE can predict the recovery of regional function and whether a relevant change in ejection fraction will occur at early and late follow-up.

Reperfusion therapy in cardiogenic shock complicating acute myocardial infarction.

The most frequent cause of cardiogenic shock complicating acute myocardial infarction is extensive myocardial damage involving a relevant amount of myocardium. Treatment is aimed at support for the circulation with the use of drugs and mechanical devices and at restoration of perfusion to the ischemic myocardium as soon as possible. Therefore, emergency coronary angiography is indicated in all patients. Coronary angioplasty is the first option in patients with suitable anatomy because it is the fastest available technique able to recanalize the infarct-related vessel. Stenting of the infarct artery must be considered because stent implantation has been shown to improve results in comparison with the balloon alone. Complete revascularization is likely to offer a better outcome in patients with multivessel disease. Coronary surgery is indicated as first-line intervention in patients who have a coronary anatomy not suitable for angioplasty; it may also serve to complete revascularization in patients with multivessel disease initially treated with emergency coronary angioplasty. In a hospital without facilities for emergency coronary interventions, mechanical circulatory support with an intra-aortic balloon pump should be instituted and thrombolysis started; then patients should be transferred immediately to a tertiary center to undergo coronary angiography and revascularization procedures, if needed. In patients not benefiting from this aggressive revascularization strategy who develop irreversible extensive myocardial damage, heart transplantation must be considered.

Detecting myocardial salvage after primary PTCA: early myocardial contrast echocardiography versus delayed sestamibi perfusion imaging.

UNLABELLED: The extent of myocardial salvage after primary percutaneous transluminal coronary angioplasty (PTCA) in acute myocardial infarction (AMI) is variable and cannot be predicted on the basis of either vessel patency or early regional wall motion assessment. The aim of this study was to evaluate the reliability of microvascular integrity, as shown by myocardial contrast echocardiography (MCE), as an indicator of tissue salvage and a predictor of late functional recovery, and to compare MCE with the quantification of tracer activity in sestamibi perfusion imaging. METHODS: Twenty-six patients with AMI who received successful treatment with primary PTCA were examined with MCE during cardiac catheterization immediately before and after vessel recanalization. Myocardial contrast effect was scored as 0 (absent), 0.5 (partial) or 1 (normal). Wall motion was assessed by two-dimensional echocardiography on admission and 1 mo later with a 16-segment model and 4-point score. Resting sestamibi SPECT was collected within 1 wk after AMI. The risk area was defined by MCE as the sum of the segments with no perfusion (score 0) before PTCA. Myocardial viability was defined by MCE as an increase in contrast score in the same segments after PTCA and by sestamibi SPECT as a preserved tracer activity (>60% of peak activity). The functional recovery after 1 mo detected by two-dimensional echocardiography was the reference standard for viability. RESULTS: A total of 50 segments showed perfusion defects before PTCA (risk area). Immediately after PTCA, the MCE score increased in 44 of 50 segments, whereas sestamibi SPECT showed preserved activity in 22 of 50 segments. After 1 mo, the wall motion score decreased in 22 of 50 segments (viable segments) and was unchanged in the remaining 28 segments. Thus, MCE showed a sensitivity of 91% and a specificity of 14% in detecting viable myocardium, whereas sestamibi SPECT showed a lower sensitivity (68%) but a significantly higher specificity (75%; P < 0.00001). The positive predictive values were 45% and 68% for MCE and SPECT (P < 0.005), respectively, and the negative predictive values were 67% and 71%, respectively. On a patient basis, SPECT was more specific (79% versus 21%; P < 0.01) and showed a higher overall predictive accuracy (88% versus 50%; P < 0.01) than MCE. CONCLUSION: The demonstration of microvascular integrity by MCE performed immediately after primary PTCA has a limited diagnostic value in predicting salvaged myocardium. Conversely, tracer activity quantification in resting sestamibi SPECT performed in a later stage is confirmed to be a reliable approach for recognizing myocardial stunning and predicting functional recovery.

Doppler-derived mitral deceleration time: an early strong predictor of left ventricular remodeling after reperfused anterior acute myocardial infarction.

BACKGROUND: The relation between remodeling and left ventricular (LV) diastolic function has not yet been fully investigated. The aim of this study was to determine whether early assessment of Doppler-derived mitral deceleration time (DT), a measure of LV compliance and filling, may predict progressive LV dilation after acute myocardial infarction (AMI). METHODS AND RESULTS: Fifty-one patients (aged 61+/-11 years; 6 women) with anterior AMI successfully treated with direct coronary angioplasty underwent 2-dimensional and Doppler echocardiographic examinations within 24 hours of admission, at days 3, 7, and 30 and 6 months after the index infarction. Mitral flow velocities were obtained from the apical 4-chamber view with pulsed Doppler. End-diastolic volume index (EDVI) and end-systolic volume index (ESVI) were calculated with the Simpson's rule algorithm. Patients were divided according to the DT duration assessed at day 3 in 2 groups: group 1 (n=33) with DT >130 ms and group 2 (n=18) with DT

[Systematic treatment of acute myocardial infarction with primary angioplasty. Early clinical and angiographic results and after 6 months]. / Trattamento sistematico dell'infarto miocardico acuto con angioplastica primaria. Risultati clinici ed angiografici precoci e a sei mesi.

UNLABELLED: Starting in 1995, at our institution all patients with acute myocardial infarction (AMI) who gave informed consent were treated by primary percutaneous transluminal coronary angioplasty (PTCA) without limitations in entry criteria. This report presents early and six-month clinical and angiographic results of the 720 patients (77% male, median age 64 years) treated by direct PTCA between January 1, 1995 and July 31, 1998. On admission, 33% of patients were in Killip class > 1, and 101 patients (14%) were in early cardiogenic shock. Optimal acute angiographic success (TIMI grade 3 flow with residual stenosis < 30%) was achieved in 683 patients (95%). Primary or unplanned stenting of infarct related artery (IRA) for a suboptimal or poor angiographic result after primary PTCA was performed in 454 patients (63%). The mean time from hospital arrival to recanalization was 62 +/- 28 min. At 30 days, the mortality rate was 4.9% (1.8% in Killip class < 4 patients and 24% in patients with cardiogenic shock). The reinfarction rate was 1.2%. At 30 days, coronary angiography showed restenosis or reocclusion of the IRA in 55 patients (8.9%). During the six-month follow-up (30-180 days), there were 11 deaths (1.5%) and 2 non-fatal reinfarctions (0.3%). At six months, the IRA patency rate was 95%, while the mean ejection fraction improvement in 422 patients with paired ventriculograms was 7%. Recurrent ischemia occurred in 144 patients (20%) and resulted in 7 deaths, 11 non-fatal reinfarctions and 126 repeat targeted vessel revascularization. CONCLUSIONS: The major finding of our experience is that direct coronary angioplasty may result in excellent early and late outcome in a population without limitations in entry criteria. The low mortality and the few recurrent myocardial ischemic events are connected with the high patency rate at 6 months. The extensive use of stents improves the angiographic results and the clinical outcome.

Relation between ST-segment changes and myocardial perfusion evaluated by myocardial contrast echocardiography in patients with acute myocardial infarction treated with direct angioplasty.

The aim of this study was to evaluate the relation between myocardial perfusion and ST-segment changes in patients with acute myocardial infarction treated with successful direct angioplasty. Thirty-seven patients, successfully treated with direct angioplasty, underwent myocardial contrast echocardiography before and after angioplasty. The sum of ST-segment elevation divided by the number of the leads involved (ST-segment elevation index) was calculated at 1, 5, 10, 20, and 30 minutes after restoration of a Thrombolysis In Myocardial Infarction trial grade 3 flow. After recanalization, myocardial reperfusion within the risk area was observed in 26 patients, whereas a no-reflow phenomenon occurred in 11. In patients with myocardial reperfusion, the ST-segment elevation index progressively declined, whereas in patients with no reflow, no significant change was observed. Reduction of > or = 50% in the ST-segment elevation index occurred in 20 of the 26 patients with reflow and in 1 of the 11 with no reflow (p = 0.0002). An additional increase of > or = 30% in the ST-segment elevation index occurred in 3 patients with reflow and in 7 with no reflow (p = 0.003). Sensitivity, specificity, positive and negative predictive values, and accuracy of the reduction in the ST-segment elevation index for predicting microvascular reflow were 77%, 91%, 95%, 62%, and 81%, respectively. The corresponding values of the increase in ST-segment elevation index for predicting no reflow were 64%, 88%, 70%, 85%, and 81%, respectively. In conclusion, after successful angioplasty, different patterns of myocardial perfusion are associated with different ST-segment changes. Analysis of ST-segment changes predicts the degree of myocardial reperfusion.

[Rapid resolution of ST-segment elevation predicts functional recovery in acute myocardial infarction treated with primary percutaneous transluminal coronary angioplasty]. / La rapida riduzione del sovraslivellamento del tratto ST è predittiva del recupero della funzione nell'infarto miocardico acuto trattato con angioplastica coronarcia primaria.

OBJECTIVES: This study was designed to prospectively assess the ability of the 12-lead electrocardiogram (ECG) and optimal ECG criteria to predict late functional recovery in patients with acute myocardial infarction (AMI) treated with primary coronary angioplasty (PTCA) BACKGROUND: A simple clinical method to predict clinical outcome in patients with reperfused AMI is highly desirable from a clinical point of view. METHODS: Seventy-five patients with AMI treated with successful PTCA (TIMI flow grade 3 and residual stenosis < 30%) underwent serial 12-lead ECG before PTCA and every hour for the first 6 hours and then at 9, 12, and 18 hours after PTCA. All patients underwent two-dimensional echocardiography before PTCA and 1 and 6 months later for the evaluation of regional wall motion. The ST segment level in the lead exhibiting the maximal ST elevation (ST increase max) and the sum of the ST segment elevation (sigma ST increases) were calculated on initial ECG and a cut-off values of > or = 50% reduction of ST increases max sigma ST increases elevation and sampling intervals were correlated with late functional recovery. A wall motion score index (WMSI: 1 = normal to 4 = dyskinesia) and 16-segment model were used. Reversible dysfunction was defined as a decrease of > or = 0.22 in WMSI. RESULTS: At univariate analysis a > or = 50% reduction of both ST increases max and sigma ST increases was related to late functional recovery. Multiple logistic regression analysis revealed that reduction of sigma ST increases was the most powerful predictor of late functional recovery (p = 0.008). A > or = 50% reduction of sigma ST increase within 4 hours of PTCA provided the optimal criterion for predicting late functional recovery. CONCLUSIONS: Rapid reduction of sigma ST increases elevation is an accurate predictor of left ventricular functional recovery in patients with AMI treated with primary PTCA. Optimal criteria include a reduction in sigma ST increases elevation > or = 50% within 4 hours of PTCA.

Head-to-head comparison of exercise stress testing, pharmacologic stress echocardiography, and perfusion tomography as first-line examination for chest pain in patients without history of coronary artery disease.

BACKGROUND: To overcome the relatively low accuracy of exercise stress testing (EST) in detecting coronary artery disease (CAD), both echocardiography and perfusion scintigraphy have been evaluated in conjunction with pharmacologic stress, but there is still uncertainty of the relative value of these tests as possible first-line examinations for suspected CAD. This study evaluated the accuracy of EST, dipyridamole and dobutamine stress echocardiography (DIP-ECHO, DOB-ECHO), and dipyridamole and dobutamine technetium 99m sestamibi tomography (DIP-MIBI, DOB-MIBI) for the detection of CAD in patients evaluated for the first time because of chest pain. METHODS AND RESULTS: Sixty patients underwent EST, DIP-ECHO, DOB-ECHO, DIP-MIBI, and DOB-MIBI. Echocardiographic images were acquired simultaneously with sestamibi injections, and the scintigraphic images were collected 1 hour later. Coronary angiography was performed within 15 days. Out of 33 patients with significant (>70%) coronary stenoses, 19 (58%) were correctly identified by EST, 18 (55%) by DIP-ECHO, 20 (61%) by DOB-ECHO, 32 (97%) by DIP-MIBI, and 30 (91%) by DOB-MIBI (p < 0.005 for MIBI vs EST and ECHO). The specificity of EST was 67% (p < 0.05 vs ECHO and MIBI), 96%, 96%, 89%, and 81%, respectively. Of the 62 stenotic coronary arteries, 20 (32%) were correctly identified by DIP-ECHO, 24 (39%) by DOB-ECHO, 48 (77%) by DIP-MIBI, and 45 (73%) by DOB-MIBI. The sensitivity of the imaging techniques in predicting the presence of multivessel disease was 14% and 29% for DIP and DOB-ECHO compared with 48% and 57% for DIP and DOB-MIBI. CONCLUSIONS: Our results confirm the limited reliability of EST in detecting CAD and the good diagnostic value of DIP and DOB-MIBI. Conversely, the lower sensitivity and the poorer capability to recognize multivessel CAD do not support the role of either DIP or DOB-ECHO as first-line examination for suspected CAD.

Influence of infarct-zone viability on left ventricular remodeling after acute myocardial infarction.

BACKGROUND: The relation between residual myocardial viability after acute myocardial infarction (AMI) and ventricular remodeling has yet to be fully elucidated. We hypothesized that the presence of residual viability would favorably influence left ventricular remodeling after AMI and that serial changes in left ventricular dimensions might be related to the extent of myocardial viability in the infarct zone. METHODS AND RESULTS: Ninety-three patients with a first AMI successfully treated with primary coronary angioplasty underwent two-dimensional echocardiography within 24 hours of admission and low-dose dobutamine echocardiography at a mean of 3 days after AMI. Two-dimensional echocardiography and coronary angiography were obtained in all patients 1 and 6 months after coronary angioplasty. On the basis of dobutamine echocardiography responses, patients were divided in two subsets: those with (n=48; group I) and those without (n=45; group II) infarct-zone viability. There was no difference in minimal lesion diameter and infarct-related artery patency at 1 and 6 months between the two groups. Group II patients had significantly greater end-diastolic (76+/-18 versus 53+/-14 mL/m2; P<.0003) and end-systolic (42+/-17 versus 22+/-11 mL/m2; P<.0003) volumes at 6 months than did patients in group 1. The extent of infarct-zone viability was significantly inversely correlated with percent changes in end-diastolic volumes at 6 months (r=-.66; P<.000001) and was the most powerful independent predictor of late left ventricular dilation. CONCLUSIONS: After reperfused AMI, the degree of left ventricular dilation, when it occurs, is inversely related to the extent of residual myocardial viability in the infarct zone. Thus, the absence of residual infarct-zone viability discriminates patients who develop progressive left ventricular dilation after reperfused AMI from those who maintain normal left ventricular geometry.

Rapid reduction of ST-segment elevation after successful direct angioplasty in acute myocardial infarction.

The aim of this study was to evaluate whether assessment of ST-segment changes in the 12-lead electrocardiogram from admission to 30 minutes after successful direct coronary angioplasty can predict myocardial damage and functional outcome in patients with acute myocardial infarction (AMI). Of 158 consecutive patients, 117 (92 men, aged 61 +/- 11 years) were prospectively classified into 2 groups: group 1, <50% reduction in ST-segment elevation in a single selected lead (42 patients); group 2, > or =50% reduction in ST-segment elevation (75 patients). Baseline characteristics were similar except for anterior wall AMI and Killip class >2, which were more prevalent in group 1. Peak creatine kinase was significantly higher in group 1 (3,690 +/- 2,809 vs 2,592 +/- 1,960 U/L; p = 0.018). One-month echocardiograms were obtained in 102 patients (87%). Infarct zone wall motion score index decreased in both groups, but this reduction was higher in group 2 (p <0.001). Functional recovery (>0.22 decrease in infarct zone wall motion score index) was observed in 34% of group 1 and in 78% of group 2 patients (p <0.001). One-month left ventricular ejection fraction was higher in group 2 (p <0.001). At multivariate analysis, reduction of ST-segment elevation was the only independent predictor of functional recovery (p <0.001). In conclusion, ST-segment analysis provides rapid and inexpensive information allowing identification of patients who are likely to benefit the most from myocardial reperfusion as early as 30 minutes after the last balloon inflation.

Left ventricular cavity-to-myocardium count ratio in technetium-99m-sestamibi SPECT in the detection of resting left ventricular dysfunction.

UNLABELLED: The aim of this study was to assess the value of the cavity-to-myocardium count ratio (C/M ratio) calculated in resting 99mTc-sestamibi SPECT images to identify patients with depressed left ventricular ejection fraction (LVEF). METHODS: In the 95 patients studied, the C/M ratio was calculated from the midventricular short-axis slice using regions of interest drawn in the center of the cavity and in the most active area of the ventricular wall; its value was compared with LVEF measured using two-dimensional echocardiography. RESULTS: The C/M ratio correlated with LVEF (r = 0.6, p < 0.000001) and was significantly lower in patients with abnormal LVEF than those with normal LVEF: 0.026 +/- 0.028 versus 0.125 +/- 0.093, p < 0.000001. In the entire patient population, a C/M ratio < 0.07 identified the patients with depressed LVEF with a 94% sensitivity, 71% specificity and 82% accuracy. CONCLUSION: The resting 99mTc-sestamibi C/M ratio is a useful parameter in identifying patients with depressed LVEF directly from the SPECT perfusion images.

Myocardial contrast echocardiography versus dobutamine echocardiography for predicting functional recovery after acute myocardial infarction treated with primary coronary angioplasty.

OBJECTIVES: We sought to compare myocardial contrast echocardiography with low dose dobutamine echocardiography for predicting 1-month recovery of ventricular function in acute myocardial infarction treated with primary coronary angioplasty. BACKGROUND: The relation between myocardial perfusion and contractile reserve in patients with acute myocardial infarction, in whom anterograde flow is fully restored without significant residual stenosis, is still unclear. METHODS: Thirty patients with acute myocardial infarction treated successfully with primary coronary angioplasty underwent intracoronary contrast echocardiography before and after angioplasty and dobutamine echocardiography 3 days after the index infarction. One month later, two-dimensional echocardiography and coronary angiography were repeated in all patients and contrast echocardiography in 18 patients. RESULTS: After coronary recanalization, 26 patients showed myocardial reperfusion within the risk area, although 4 did not. At 1-month follow-up, all patients had a patient infarct-related artery without significant restenosis. Both left ventricular ejection fraction and wall motion score index within the risk area significantly improved in the patients with reperfusion ([mean +/- SD] 38 +/- 8% vs. 48 +/- 12%, p < 0.005; and 2.35 +/- 0.5 vs. 2 +/- 0.6, p < 0.001, respectively), but not in those with no reflow. Of the 72 nonperfused segments before angioplasty, 27 showed functional improvement at follow-up. Myocardial contrast echocardiography had a sensitivity and a negative predictive value similar to dobutamine echocardiography in predicting late functional recovery (96% vs. 89% and 89% vs. 93%, respectively), but a lower specificity (18% vs. 91%, p < 0.001), positive predictive value (41% vs. 86%, p < 0.001) and overall accuracy (47% vs. 90%, p < 0.001). CONCLUSIONS: Microvascular integrity is a prerequisite for myocardial viability after acute myocardial infarction. However, contrast enhancement shortly after recanalization does not necessarily imply a late functional improvement. Thus, contractile reserve elicited by low dose dobutamine is a more accurate predictor of regional functional recovery after reperfused acute myocardial infarction than microvascular integrity.

[Comparison of outcome of primary PTCA for acute myocardial infarction in patients younger and older than 70 years of age]. / Confronto dei risultati della PTCA primaria nell'infarto miocardico acuto nei soggetti di età inferiore e superiore a 70 anni.

BACKGROUND: The Primary Angioplasty in Myocardial infarction Study Group reported that the benefit of primary PTCA was observed mainly among patients who were classified as "not low risk" including those over age 70, with anterior infarction and heart rate > 100 bpm. The present study compares procedural success rate and in-hospital and one-month clinical outcome of primary PTCA in acute myocardial infarction patients < 70 and > or = 70 years of age. METHODS AND RESULTS: During 1995 121 patients with acute myocardial infarction underwent primary PTCA within 6 hours of symptoms onset or within 24 hours in case of evidence of ongoing ischemia. Eighty-two patients (Group I) were < 70 (mean age 56 +/- 9) and 39 patients (Group II) were > or = 70 (mean age 75 +/- 3). In group II there was a trend, although not significant, toward a higher prevalence of prior angina and infarction. Multivessel disease was more frequent in group II than in group I (69% vs 48%; p = 0.041). Ejection fraction was markedly depressed in both groups (38 +/- 10% in group I vs 34 +/- 11% in group II). Ejection fraction < or = 30% and shock on admission were more frequent in group II (39% vs 15% and 36% vs 21%, respectively). Optimal angiographic success (< or = 30% stenosis associated with TIMI grade 3 flow) was achieved in 77% of group II and in 98% of group I (p = 0.00059). The in-hospital mortality rate was 26% in group II and 1.2% in group I (p = 0.000042). Shock on admission and PTCA failure predicted high mortality rates. There was no difference between the two groups as regards to non-fatal reinfarction, recurrent ischemia, life-threatening arrhythmias, severe heart failure, revascularization procedures. There were no strokes. At one-month follow-up, recurrence of ischemia or positive response to stress test were more frequent in group II (24% vs 8%; p = 0.039). CONCLUSIONS: In patients with acute myocardial infarction < 70 years of age primary coronary angioplasty is associated with low rates of mortality and cardiac events. Mortality rate remains high in patients over age 70, especially when shock is present on admission or PTCA falls.

Direct angioplasty and stenting of the infarct-related artery in acute myocardial infarction.

This study provides the incidence of in-hospital and 1-month recurrent ischemia in 118 patients with acute myocardial infarction when an aggressive direct angioplasty strategy was performed, including stenting of the infarct artery. Coronary stenting in acute myocardial infarction is feasible, and acute and 1-month angiographic results after stenting seem superior to those after standard angioplasty alone.

Early coronary angioplasty as compared with delayed coronary angioplasty in patients with high-risk unstable angina pectoris.

BACKGROUND: Percutaneous transluminal coronary angioplasty (PTCA) results in a higher complication rate in patients with unstable angina pectoris than in patients with stable angina. The current management approach is directed towards achieving stabilization by medical treatment in order to reduce the rate of major complications, but the value of a conservative strategy has not been proved by clinical trials, nor has the duration of therapy been established. On the other hand, the definition of unstable angina encompasses a heterogeneous spectrum of patients with different prognoses. It is more appropriate to stratify patients according to different risk in order to evaluate the results of different therapeutic strategies. The purpose of this study was the evaluation of the results of early and delayed coronary angioplasty in patients with high-risk unstable angina. METHODS: We compared immediate and follow-up results of early and delayed coronary angioplasty in a series of 263 patients with high-risk unstable angina because of prolonged (more than 15 min) angina or early post-infarction angina at rest. Early PTCA (within 4 h of the last ischaemic episode) was performed in 110 patients with unstable angina refractory to maximized medical treatment, whereas 153 patients with stabilized angina underwent delayed PTCA (at more than 72 h and less than 1 week from the last ischaemic episode). RESULTS: No significant differences between the two groups were found in primary lesion success rates (92.7% compared with 94.1%), major in-hospital adverse events such as reocclusion (5.4% compared with 2.6%), emergency coronary artery surgery (1.8% compared with 3.2%), myocardial infarction (3.6% compared with 2.6%) and death (1.8% compared with 0.7%). The rates of major adverse events during 6 months follow-up were similar in the two groups: recurrent ischaemia (13.4% compared with 19.7%), repeat coronary angioplasty (11.5% compared with 14.9%), coronary artery surgery (1.9% compared with 4.7%), myocardial infarction (0), and death (0). CONCLUSIONS: The results of this study suggest that an aggressive coronary angioplasty strategy in patients with high-risk unstable angina may result in a favourable outcome both immediately and at 6 months' follow-up, The achievement of a stabilization period seems neither to improve the clinical success rates nor to reduce major cardiac event rates.

Bailout Palmaz-Schatz coronary stenting in 39 patients with occlusive dissection complicating conventional angioplasty.

The purpose of this study was to evaluate feasibility, safety, and efficacy of bailout Palmaz-Schatz stenting in a series of 39 patients with coronary dissection associated with acute or unequivocal threatened closure complicating conventional angioplasty. No anatomical characteristics other than reference vessel diameter < 3 mm were considered as contraindications for bailout coronary stenting. Stringent criteria were adopted in defining optimal results (< 10% residual stenosis, no angiographic evidence of residual dissection), suboptimal results (> 10% residual stenosis or angiographic evidence of residual dissection), deployment failure (failure to deploy the stent because of poor trackability or persistent occlusion despite stent deployment). A total of 49 stents and 7 half-stents were implanted in 36 patients (range 1-5; mean 1.45 +/- 0.84). Successful stenting without in-hospital death, urgent or semielective coronary surgery, stent thrombosis, or Q-wave myocardial infarction was achieved in 33/39 patients (85%). A suboptimal result was associated with an increased risk of in-hospital recurrence of ischemia and other related major adverse events (2/5 patients with suboptimal results vs. 1/31 patients with complete deployment success; P < 0.05). Multiple stents implantation did not carry a significant risk of major cardiac adverse events. The results of this study suggest that bailout Palmaz-Schatz stenting may be considered a stand-alone treatment of coronary dissection if an optimal acute angiographic result is achieved.