The efficacy of statin therapy in patients with acute coronary syndromes and concomitant carotid disease.

BACKGROUND: Statins prevent recurrent ischemic coronary events after acute coronary syndrome (ACS) and improve cardiovascular outcome of patients with peripheral artery disease. AIM: We sought to evaluate the interrelationship between statin use, phenotype of carotid plaques as assessed by ultrasound, and outcome of patients with ACS and concomitant carotid disease. METHODS: A total of 337 consecutive patients with ACS were assessed by coronary angiography and Doppler ultrasound of the carotid arteries and followed up for a median period of 19 months. RESULTS: Carotid plaques were detected in 144 (42%) patients. Of these patients, 99 (69%) had echogenic carotid plaques and 45 (31%) had echolucent plaques. The groups did not differ significantly with regard to the lipid profiles, the prevalence of risk factors, and 1-vessel, 2-vessel, or 3-vessel coronary artery disease. During follow-up, 227 (67%) patients were receiving statins. We observed 14 cardiac deaths and 17 myocardial infarctions. After adjustment for treatment strategy (medical therapy or myocardial revascularization), patients with echolucent carotid plaques receiving statin therapy (n = 32, 71%) showed a better event-free survival than did patients with echolucent plaques not treated with statins (log-rank P = .038). In patients with echogenic carotid plaques, the benefit of statin therapy on event-free survival was less evident (log-rank P = .56). CONCLUSION: In patients with ACS and echolucent carotid plaques, statin therapy is associated with better event-free survival, while in patients with ACS and echogenic carotid plaques no clear benefit of statins is observed.

Quality of life and behavioral compliance in cardiac rehabilitation patients: a longitudinal survey.

BACKGROUND: Few data regarding inter-relations between health-related quality of life (HRQoL) and compliance are available. The aim of present study was to assess which aspects of HRQoL might predict patients' behavioral compliance to medical suggestions and whether questionnaires might be useful for patients undergoing cardiac rehabilitation. METHODS: HRQoL and compliance were measured in 52 consecutive patients undergoing cardiovascular rehabilitation. The measurements were performed at the beginning, at the end of rehabilitation, and after 6 months follow-up. Baseline, demographic and HRQoL characteristics were linked to compliance by multiple regression modelling. RESULTS: Over time no significant differences between HRQoL and compliance scores were observed. Age (odds ratio (OR) 1.37, 95% confidence interval (CI) 1.08-2.45), number of taken drugs (OR=1.45; 95% CI: 1.02-2.11), anxiety score (OR=0.32; 95% CI: 0.15-1.02), depression score (OR=0.48; 95% CI: 0.06-0.78), and social health score (OR=1.09; 95% CI: 1.01-1.24), appeared to be independent predictors of compliance. CONCLUSION: Older age, higher number of drugs, high social health score, and low anxiety and depression scores predict better behavioral compliance in cardiac rehabilitation patients.

Predictive value of associations between carotid and coronary artery disease in patients with acute coronary syndromes.

The present study evaluated the association among sonographic characteristics of carotid plaques, angiographic morphology of coronary lesions, and outcomes of patients who had acute coronary syndromes. In treatment-stratified Cox's proportional hazards regression analysis, hard carotid plaques and coronary lesions of complex morphology were found to be independent predictors of future cardiac events.

Impact of carotid arterial narrowing on outcomes of patients with acute coronary syndromes.

The present prospective observational study was conducted in 323 consecutive patients with acute coronary syndrome, 101 (31%) of whom were diagnosed with carotid arterial narrowing by ultrasonography. At follow-up, patients with carotid disease had a greater incidence of cardiovascular events than did those with normal carotid arteries. Outcomes of patients with concomitant carotid disease who underwent cardiac revascularization were similar to those who received conservative treatment.

Cost of strategies after myocardial infarction (COSTAMI): a multicentre, international, randomized trial for cost-effective discharge after uncomplicated myocardial infarction.

AIMS: Risk stratification after uncomplicated acute myocardial infarction is mostly applied by either symptom-limited post discharge exercise electrocardiography or pre-discharge submaximal exercise test. Aim of the present study was to determine if early pharmacological stress echocardiography and discharge within 24 hours of the test in cases without induced myocardial ischemia leads to lower costs and similar clinical outcome during 1 year follow up when compared to clinical evaluation and exercise electrocardiography after discharge. METHODS AND RESULTS: Four-hundred fifty-eight patients from 10 participating centers with a recent uncomplicated myocardial infarction were randomized to pharmacological stress echocardiography on day 3-5 followed by early discharge in the case of negative test result (early discharge strategy) (n=233) or clinical evaluation with hospital discharge on day 7-9 and symptom-limited post-discharge exercise electrocardiography at 2-4 weeks after myocardial infarction (usual care strategy) (n=225). At 1 year follow up there were 63 events (4 deaths, 9 non fatal reinfarctions, 50 chest pains requiring hospitalization) in patients randomized to early discharge, and 69 events (6 deaths, 13 reinfarctions, 50 chest pains requiring hospitalization) in usual care (p=ns). Total median individual costs calculated on the basis of hospitalizations, investigations and interventions during 1 year follow up were 3561 for early discharge strategy vs 3850 for usual care strategy (p<0.05). CONCLUSIONS: Early pharmacological stress echocardiography followed by early discharge in case of negative test result gives similar clinical outcome and lower costs after uncomplicated myocardial infarction than clinical evaluation and delayed post-discharge symptom-limited exercise electrocardiography.

Predischarge exercise electrocardiogram and stress echocardiography can predict long-term clinically driven revascularization following acute myocardial infarction.

BACKGROUND: Predischarge stress testing provides suboptimal prediction of spontaneous hard events following uncomplicated acute myocardial infarction (AMI). HYPOTHESIS: This study was aimed at assessing whether soft cardiac ischemic events requiring late revascularization could be predicted more accurately. METHODS: In all, 428 patients undergoing exercise electrocardiography (ECG) and stress echocardiography (SE, 345 dobutamine and 83 dypiridamole) within 15 days of uncomplicated AMI were followed up for 425 (range 20-2220) days. Soft ischemic events (effort angina>class II [Canadian Cardiovascular Society Classification] and unstable angina) driving late (>6 months) revascularization were regarded as endpoints. RESULTS: A total of 58 events (29 effort and 29 unstable angina with subsequent 47 coronary artery bypass grafts and 11 percutaneous transluminal coronary angioplasties) occurred: 26 in patients with positive exercise ECG and 34 in patients with positive SE. Univariate predictors of revascularizations were positive exercise ECG (p = 0.0001), peak wall motion score index (WMSI) (p = 0.0009), low workload (p = 0.0018), rest WMSI (p = 0.02) and positive SE (p = 0.02). Cox multivariate analysis selected peak WMSI, positive exercise ECG, and low workload positive exercise ECG as independent predictors of late revascularizations. CONCLUSIONS: Predischarge stress testing identifies the long-term occurrence of soft ischemic events driving late revascularization after uncomplicated AMI.

Evidence of reverse mismatch with positron emission tomography imaging in a patient with reversible myocardial dysfunction.

We describe the case of a patient who came to our attention because of a reversible depression of myocardial contractility, probably due to myocarditis. A positron emission tomography study showed, in correspondence to the malfunctioning segments, a decreased F18-2-fluoro-2-deoxyglucose (F18-FDG) uptake in the presence of a normal perfusion as assessed by means of N13-labeled ammonia uptake. This phenomenon, called "reverse mismatch", shows that viability is not always dependent on FDG uptake and that it could be associated with the recovery of myocardial contractility. Some interpretations of the association between a reversible dysfunction and a reduced myocardial glucose metabolism are presented. The central role of nitric oxide and of cyclic guanosine monophosphate is hypothesized to explain both the mechanical and metabolic abnormalities.