Independent predictors of bleeding complications in patients undergoing PCI with concomitant treatment with bivalirudin in clinical practice results from the ImproveR registry.

BACKGROUND: Bleeding complications are associated with an adverse outcome after a percutaneous coronary intervention (PCI) is performed. Traditional risk factors for bleeding complications are age, gender, underweight, hypertension, and renal impairment. The aim of our study was to identify the independent predictors of bleeding complications in patients undergoing a PCI with concomitant treatment with bivalirudin. METHODS: Between January 2005 and June 2006, a total of 3799 patients, undergoing a planned or urgent PCI with concomitant bivalirudin treatment, were prospectively enrolled in the ImproveR registry. One hundred two centers out of 12 European countries participated in the ImproveR registry. In this analysis, we report the incidence of bleeding complications in subgroups to be at a high risk for developing bleeding complications. A multivariate logistic regression model was performed to identify the independent predictors of bleeding complications. RESULTS: Major bleeding complications occurred in 1.7% of the patients. The highest incidence of major bleeding complications was observed in the subgroup with a sheath size ≥7F (4.3%), heparin use after the PCI (3.5%), and additional use of GP IIb/IIIa inhibitors (3.3%). The multivariate regression analysis revealed female gender [odds ratio (OR), 2.3; 95% confidence interval (CI), 1.4-3.8], heparin after the PCI (OR, 3.1; 95% CI, 1.9-5.1), and sheath size ≥7F (OR, 3.1; 95% CI, 1.8-5.4) as the independent predictors of bleeding. CONCLUSIONS: The rate of occurrence of bleeding complications in patients undergoing a PCI with concomitant use of bivalirudin is low in clinical practice. Female gender and procedural factors, such as sheath size and heparin after PCI, were associated with an increase in bleeding complications, whereas other traditional risk factors associated with bleeding, such as age, diabetes mellitus, and renal impairment, had no impact.

Impact of the COVID-19 pandemic on cardiovascular mortality and catherization activity during the lockdown in central Germany: an observational study.

AIMS: During the COVID-19 pandemic, hospital admissions for cardiac care have declined. However, effects on mortality are unclear. Thus, we sought to evaluate the impact of the lockdown period in central Germany on overall and cardiovascular deaths. Simultaneously we looked at catheterization activities in the same region. METHODS AND RESULTS: Data from 22 of 24 public health-authorities in central Germany were aggregated during the pandemic related lockdown period and compared to the same time period in 2019. Information on the total number of deaths and causes of death, including cardiovascular mortality, were collected. Additionally, we compared rates of hospitalization (n = 5178) for chronic coronary syndrome (CCS), acute coronary syndrome (ACS), and out of hospital cardiac arrest (OHCA) in 26 hospitals in this area. Data on 5,984 deaths occurring between March 23, 2020 and April 26, 2020 were evaluated. In comparison to the reference non-pandemic period in 2019 (deaths: n = 5832), there was a non-significant increase in all-cause mortality of 2.6% [incidence rate ratio (IRR) 1.03, 95% confidence interval (CI) 0.99-1.06; p = 0.16]. Cardiovascular and cardiac mortality increased significantly by 7.6% (IRR 1.08, 95%-CI 1.01-1.14; p = 0.02) and by 11.8% (IRR 1.12, 95%-CI 1.05-1.19; p < 0.001), respectively. During the same period, our data revealed a drop in cardiac catherization procedures. CONCLUSION: During the COVID-19-related lockdown a significant increase in cardiovascular mortality was observed in central Germany, whereas catherization activities were reduced. The mechanisms underlying both of these observations should be investigated further in order to better understand the effects of a pandemic-related lockdown and social-distancing restrictions on cardiovascular care and mortality.

Guideline-recommended secondary prevention drug therapy after acute myocardial infarction: predictors and outcomes of nonadherence.

BACKGROUND: Guideline-recommended pharmacotherapy after myocardial infarction (MI) has been shown to reduce cardiovascular morbidity and mortality. Our objectives were to determine factors of, and to measure outcomes associated with nonadherence after MI. DESIGN: Multicentre, prospective, observational study (Acute Coronary Syndromes Registry). METHODS: We analyzed data of 11,823 consecutive hospital survivors of acute MI and evaluated their discharge medication with the five following drugs: acetyl salicylic acid, clopidogrel, ß-blocker, angiotensin-converting enzyme inhibitor/sartan and statin. Patients receiving less than four drugs (group 1, n=3439, 29.1%) were compared with those receiving 4-5 drugs (group 2, n=8384, 70.9%). The impact of clinical, demographic and treatment factors on not prescribing each of these five drugs at discharge was investigated by using multiple logistic regression models. RESULTS: Patients of group 1 were older, had more comorbidities, more frequently suffered a nonST elevation MI and less often received reperfusion therapy. In the multivariate analysis, group 1 was associated with an increased risk for death at 1-year follow-up [odds ratio (OR): 1.6, 95% confidence interval (CI): 1.4-1.9]. After adjustment for confounding variables chronic oral anticoagulation was the strongest predictor for not receiving acetyl salicylic acid (OR: 19.6, 95% CI: 15.9-24.0) at discharge, no percutaneous coronary intervention within 48 h for not receiving statin (OR: 2.1, 95% CI: 1.9-2.4) and clopidogrel (OR: 10.4, 95% CI: 9.4-11.5), chronic obstructive lung disease for not receiving ß-blocker (OR: 4.2, 95% CI: 3.6-4.9) and chronic renal insufficiency for not receiving angiotensin-converting enzyme inhibitor/sartan (OR: 2.8, 95% CI: 2.2-3.5). CONCLUSION: In clinical practice guideline-adherent secondary prevention drug therapy is linked with an improved 1-year survival. Comorbidities and no interventional treatment were strong negative predictors for guideline-adherent discharge medication.

Effect of chronic statin pretreatment on hospital outcome in patients with acute non-ST-elevation myocardial infarction.

PURPOSE: We sought to investigate the impact of prior statin therapy on in-hospital outcome in patients presenting with acute non-ST-elevation myocardial infarction. METHODS AND RESULTS: We analyzed the data of consecutive patients with non-ST-elevation myocardial infarction who were prospectively enrolled in the German Acute Coronary Syndrome Registry between July 2000 and November 2002. Overall, 6358 patients were included, and we compared the patients who received statins before hospital admission (n = 1247, 19.6%) with those who did not (n = 5111, 80.4%). There was no age difference between the two groups; however, pretreated patients had a higher incidence of prior atherothrombotic events diabetes mellitus and renal insufficiency. The percentage of patients undergoing percutaneous coronary intervention and coronary artery bypass grafting was similar. Infarct size measured by peak creatine kinase level was lower in statin users (238 vs. 283 U/L, P < 0.0001). After adjustment for confounding variables, a significant reduction of in-hospital death could be observed in patients on statins (odds ratio 0.65, 95% confidence interval 0.46-0.90). CONCLUSIONS: In clinical practice, pretreatment with statins was associated with smaller myocardial infarction size (peak creatine kinase level) and a significant reduction of hospital mortality. However, the data were obtained from an observational study, and the results need further prospective confirmation.

Efficacy and safety of enoxaparin in unselected patients with ST-segment elevation myocardial infarction.

In randomized clinical trials the low-molecular-weight heparin enoxaparin has been shown to reduce ischemic complications in patients with acute ST elevation myocardial infarction (STEMI) treated with fibrinolysis. Little is known about the use and efficacy of enoxaparin in unselected patients with STEMI in clinical practice. In a retrospective analysis of the prospective ACOS registry we compared the outcomes of patients with STEMI treated with enoxaparin or unfractionated heparin. A total of 6,299 patients with STEMI < 12 hours were included in this analysis, 609 (10%) were treated with enoxaparin and 5,690 (90%) with unfractionated heparin. In the multivariable propensity score analysis enoxaparin was associated with a reduction in the combined endpoint of death and non-fatal reinfarction in the entire group (odds ratio 0.59; 95% CI 0.43-0.80) and the subgroups of patients treated without early reperfusion (odds ratio 0.65, 95% CI 0.43-0.97), fibrinolysis (odds ratio 0.64; 95% CI 0.33-1.26) and primary percutaneous coronary intervention (odds ratio 0.33; 95% CI 0.15-0.72). There was no significant increase in severe bleeding complications with enoxaparin (6.5% versus 5.5%, p = 0.4). In clinical practice in unselected patients with STEMI treated with or without early reperfusion therapy early treatment with enoxaparin compared to unfractionated heparin is associated with a significant reduction of the combined endpoint of inhospital death and reinfarction without a significant increase in severe bleeding complications.

Clopidogrel in addition to aspirin reduces in-hospital major cardiac and cerebrovascular events in unselected patients with acute ST segment elevation myocardial.

We sought to assess the effect of clopidogrel on in-hospital events in unselected patients with acute ST elevation myocardial infarction (STEMI). In a retrospective analysis of consecutive patients enrolled in the Acute Coronary Syndromes (ACOS) registry with acute STEMI we compared outcomes of either adjunctive therapy with aspirin alone or aspirin plus clopidogrel within 24 hours after admission.A total of 7,559 patients were included in this analysis, of whom 3,541 were treated with aspirin alone, and 4,018 with dual antiplatelet therapy. The multivariable analysis with adjustment for baseline characteristics and treatments showed that the rate of in-hospital MACCE (death, non-fatal reinfarction, non-fatal stroke) was significantly lower in the aspirin plus clopidogrel group,compared to the aspirin alone group in the entire cohort and all three reperfusion strategy groups (entire group odds ratio 0.60, 95% CI 0.49-0.72 , no reperfusion OR 0.69,95% CI 0.51-0.94,fibrinolysis OR 0.62,95% CI 0.44-0.88, primary PCI OR 0.54, 95% CI 0.39-0.74). There was a significant increase in major bleeding complications with clopidogrel (7.1% vs. 3.4%, p<0.001). In clinical practice early adjunctive therapy with clopidogrel in addition to aspirin in patients with STEMI is associated with a significant reduction of in-hospital MACCE regardless of the initial reperfusion strategy. This advantage was associated with an increase in major bleeding complications.

Clinical benefit of enoxaparin in patients with high-risk acute coronary syndromes without ST elevations in clinical practice.

In randomized clinical trials, low-molecular-weight heparin enoxaparin has been shown to decrease ischemic complications in patients with acute coronary syndromes (ACSs) without ST elevations who are treated conservatively. Enoxaparin has been shown to be equally effective as unfractionated heparin in high-risk patients with an early invasive approach. Little is known about the use and efficacy of enoxaparin in unselected patients with non-ST-elevation ACSs in clinical practice. In a retrospective analysis of the prospective ACOS registry, we compared the outcome of patients who were >60 years of age with non-ST-elevation myocardial infarction or unstable angina with ST-segment changes who were treated with enoxaparin or unfractionated heparin. In total, 4,806 patients (55%) with non-ST-elevation ACS fulfilled our inclusion criteria for this analysis; 1,178 (25%) were treated with enoxaparin and 3,628 (75%) with unfractionated heparin. There were no differences between groups in baseline characteristics. We observed a significant decrease in the combined end point of death or nonfatal reinfarction with enoxaparin in the entire study group (odds ratio 0.51, 95% confidence interval 0.37 to 0.70) and in subgroups treated with early percutaneous coronary intervention (n = 1,333, odds ratio 0.36, 95% confidence interval 0.17 to 0.80), coronary artery bypass grafting during the index hospitalization (n = 270, odds ratio 0.31, 95% confidence interval 0.04 to 2.42), or conservatively (n = 3,203, odds ratio 0.57, 95% confidence interval 0.40 to 0.81). There was no significant increase in severe bleeding complications with enoxaparin (5.2% vs 4.5%). In conclusion, in clinical practice, in unselected high-risk patients with non-ST-elevation ACSs who are treated conservatively or with early percutaneous coronary intervention, early treatment with enoxaparin is associated with a significant decrease in the combined end point of in-hospital death and reinfarction, without a significant increase in severe bleeding complications.

Fate of patients with prehospital resuscitation for ST-elevation myocardial infarction and a high rate of early reperfusion therapy (results from the PREMIR [Prehospital Myocardial Infarction Registry]).

Patients with acute ST-segment elevation myocardial infarction (STEMI) needing prehospital cardiopulmonary resuscitation (CPR) have a very high adverse-event rate. However, little is known about the fate of these patients and predictors of mortality in the era of early reperfusion therapy. From March 2003 through December 2004, 2,317 patients with prehospital diagnosed STEMI were enrolled in the Prehospital Myocardial Infarction Registry. One hundred ninety patients (8.2%) underwent prehospital CPR and were included in our analysis. Overall 90% of patients were treated with early reperfusion therapy, 56.3% received prehospital thrombolysis and 1/2 of these patients received early percutaneous coronary intervention after thrombolysis, 28.4% of patients were treated with primary percutaneous coronary intervention, and 5.3% received in-hospital thrombolysis. Total mortality was 40.0%. The highest mortality was seen in patients with asystole (63%) or pulseless electric activity (64%). Independent predictors of mortality were need for endotracheal intubation and older age, whereas ventricular fibrillation as initial heart rhythm was associated with survival. In conclusion, in this large registry with prehospital diagnosed STEMI, incidence of prehospital CPR was about 8%. Even with a very high rate of early reperfusion therapy, in-hospital mortality was high. Especially in elderly patients with asystole as initial heart rhythm and with need for endotracheal intubation, prognosis is poor despite aggressive reperfusion therapy.

Effect of an invasive strategy on in-hospital outcome and one-year mortality in women with non-ST-elevation myocardial infarction.

BACKGROUND: Subgroup analyses from randomized studies show inconsistent results regarding an early invasive approach in women with non-ST-elevation myocardial infarction (NSTEMI). We sought to investigate the impact of an invasive strategy in clinical practice, analyzing data from the German Acute Coronary Syndromes registry (ACOS). METHODS: Overall 1986 consecutive women were enrolled in the registry between June 2000 and November 2002 and were divided into two groups: 1215 (61.2%) underwent coronary angiography, 771 (38.8%) received conservative treatment. In the invasive group percutaneous coronary intervention was performed in 40.7% within 48 h and in 16.4% after 48 h, whereas 8.3% underwent coronary artery bypass grafting within hospital stay. RESULTS: In-hospital death (3.2% vs 10.5%, p<0.0001), in-hospital death/myocardial infarction (MI) (7.1% vs 14.9%, p<0.0001) and one-year death (8.1% vs 24%) occurred significantly less often in patients with invasive strategy. After adjustment of the confounding factors in the propensity score analysis the invasive strategy showed no significant benefit for in-hospital death (OR 0.86, 95% CI 0.51-1.44) or death/MI (OR 0.70, 95% CI 0.47-1.04) but remained superior for mortality (OR 0.47, 95% CI 0.3-0.7) and death/MI one year after discharge (OR 0.47, 95% CI 0.33-0.68). CONCLUSIONS: In clinical practice women presenting with NSTEMI have a long-term benefit from an invasive therapeutic strategy with a significant reduction in mortality as well as the composite endpoint of death/MI.

Inferior ST-Elevation Myocardial Infarction Associated with Takotsubo Cardiomyopathy.

Takotsubo cardiomyopathy (TCM) is usually characterized by transient left ventricular apical ballooning. Due to the clinical symptoms which include chest pain, electrocardiographic changes, and elevated myocardial markers, Takotsubo cardiomyopathy is frequently mimicking ST-elevation myocardial infarction in the absence of a significant coronary artery disease. Otherwise an acute occlusion of the left anterior descending coronary artery can produce a typical Takotsubo contraction pattern. ST-elevation myocardial infarction (STEMI) is frequently associated with emotional stress, but to date no cases of STEMI triggering TCM have been reported. We describe a case of a female patient with inferior ST-elevation myocardial infarction complicated by TCM.

Primary percutaneous coronary intervention and thrombolysis improve survival in patients with ST-elevation myocardial infarction and pre-hospital resuscitation.

BACKGROUND: Patients with ST-elevation myocardial infarction (STEMI) surviving pre-hospital resuscitation represent a selected subgroup of patients with a very high adverse event rate. Only few data on the outcome of primary percutaneous coronary intervention (primary PCI) and thrombolysis in such patients are available. METHODS: We analysed the Maximal Individual Therapy of Acute Myocardial Infarction (MITRA) Plus registry. 1529 survivors of pre-hospital resuscitation with STEMI were included. 593 (38.8%) of those patients did not receive early reperfusion therapy, 793 (51.9%) patients received thrombolysis and 143 (9.4%) patients received primary PCI. Hospital mortality in patients receiving primary PCI or thrombolysis was adjusted for confounding factors with a propensity score analysis. RESULTS: Primary PCI as well as thrombolysis in survivors of pre-hospital resuscitation with STEMI were associated with a significant reduction of hospital mortality (OR: 0.29, 95% CI 0.17-0.50; and 0.74, 95% CI 0.54-0.99, respectively), while primary PCI was superior compared to thrombolysis (OR 0.50, 95% CI 0.30-0.84). CONCLUSION: Reperfusion therapy improves mortality of patients with STEMI surviving pre-hospital resuscitation, while primary PCI seems to be more effective than thrombolysis.

Tako-tsubo cardiomyopathy after administration of ergometrine following elective caesarean delivery: a case report.

INTRODUCTION: Tako-tsubo cardiomyopathy (stress-induced cardiomyopathy or transient left ventricular ballooning) is characterized by clinical suspicion of an acute myocardial infarction with transient apical or midventricular dyskinesia of the left ventricle without significant coronary stenosis on angiography. The etiology of this disease remains obscure. One of the possible causes is myocardial ischemia induced by coronary vasospasm due to sympathetic activation. It has been hypothesized that the application of ergometrine could induce tako-tsubo cardiomyopathy. CASE PRESENTATION: We report the case of a 28-year-old Turkish woman who developed tako-tsubo cardiomyopathy after administration of ergometrine for release of placenta and prevention of bleeding during the post-partum phase in the course of an elective caesarean delivery. Tako-tsubo cardiomyopathy was diagnosed by echocardiography and urgent cardiac magnetic resonance imaging. A coronary angiography was not performed because of the absence of myocardial necrosis or ischemia and signs of myocarditis on cardiac magnetic resonance imaging. CONCLUSION: This life-threatening disease should be excluded in the differential diagnosis by comparing the symptoms with those of typical heart failure, particularly after use of ergometrine.

Efficacy and safety of enoxaparin in combination with and without GP IIb/IIIa inhibitors in unselected patients with ST segment elevation myocardial infarction treated with primary percutaneous coronary intervention.

AIMS: We sought to determine the efficacy of enoxaparin in unselected patients with STEMI treated with primary percutaneous coronary intervention in clinical practice. METHODS AND RESULTS: In a retrospective analysis of the prospective MITRA-plus registry we compared the outcomes of patients with primary PCI and either enoxaparin or unfractionated heparin. A total of 2,655 patients with STEMI < 12 hours were included in this analysis, 374 (14%) were treated with enoxaparin and 2,281 (86%) with unfractionated heparin. In the univariate analysis enoxaparin reduced mortality (1.6% versus 6.0%, < 0.001), fewer non-fatal reinfarctions (1.9% versus 3.8%, p = 0.05) and no significant difference in major bleeding (5.6% versus 7.2%, p = 0.2) was observed. In the multivariable propensity score analysis enoxaparin was associated with a reduction in the combined endpoint of death and non-fatal reinfarction (odds ratio 0.42; 95% CI 0.2-0.8). This advantage was observed both in subgroups without (odds ratio 0.33 95% CI 0.1-0.8) and with GP IIb/IIIa inhibitors (odds ratio 0.44, 95% CI 0.2-1.0). CONCLUSIONS: Our data suggest that in unselected patients with STEMI treated with primary PCI enoxaparin compared to unfractionated heparin reduces the combined endpoint of in-hospital death and reinfarction and does not increase severe bleeding complications.

Gender differences in patients with acute ST-elevation myocardial infarction complicated by cardiogenic shock.

INTRODUCTION: The aim of our analysis is to assess gender differences in baseline characteristics, acute therapies, and clinical outcome in patients with acute ST-elevation myocardial infarction (STEMI) complicated by cardiogenic shock. METHODS: The Maximal Individual Therapy of Acute Myocardial Infarction PLUS registry (MITRA PLUS) is a German prospective, multicenter, observational data pool of current treatment of STEMI. RESULTS: STEMI was more often (P < 0.0001) complicated by cardiogenic shock in female patients (12.9%) when compared to male patients (9.3%). This was still true after adjusting for confounding variables (OR 1.19, 95% CI 1.09-1.30). Women with STEMI admitted in a cardiogenic shock were older (P < 0.0001) and had more often concomitant diseases (P < 0.0001). There was no differences in rates of reperfusion therapy (OR 0.92, 95% CI 0.77-1.09). Hospital mortality was 67.7% in female patients, when compared to 57.2% in male patients (P < 0.0001). After adjusting for confounding variables in the multivariate analysis hospital mortality did not differ between men and women (OR 1.16, 95% CI 0.98-1.38). Early reperfusion therapy was associated with a significant reduction of hospital mortality in female patients with STEMI complicated by cardiogenic shock (OR 0.68, 95% CI 0.52-0.90) with primary PCI being more effective than thrombolytic therapy (OR 0.46, 95% CI 0.31-0.68). CONCLUSION: In women, STEMI was more often complicated by cardiogenic shock when compared to men. However, the use of early reperfusion therapy did not differ between the sexes. Primary PCI was associated with the best outcome in female patients with STEMI complicated by cardiogenic shock and is therefore the therapy of choice.

Clinical benefit of early reperfusion therapy in patients with ST-elevation myocardial infarction usually excluded from randomized clinical trials (results from the Maximal Individual Therapy in Acute Myocardial Infarction Plus [MITRA Plus] registry).

Randomized clinical trials (RCTs) usually enroll selected patient populations that may not be representative for patients seen in everyday practice. Therefore, concerns have been raised regarding their external validity. For the present study we evaluated the MITRA Plus registry and included 20,175 patients with ST-elevation myocardial infarction. We defined RCT-ineligible patients as patients fulfilling >or=1 of the following criteria: age >or=75 years, prehospital delay >12 hours, prehospital cardiopulmonary resuscitation, cardiogenic shock, impaired renal function, and previous stroke. Those patients (n = 9,369, 46.4%) were compared to patients eligible for enrollment in RCTs (n = 11,806, 53.6%). Ineligible patients were older (p <0.0001), more often were women (p <0.0001), and more often had concomitant diseases (p <0.0001). Ineligible patients less often received early reperfusion therapy (p <0.0001), aspirin (p <0.0001), clopidogrel (p <0.0001), and statins (p <0.0001). Ineligible patients had a higher hospital mortality (20.1% vs 4.9%; p <0.0001) and a higher rate of nonfatal strokes (1.5% vs 0.4%, p <0.0001) compared to eligible patients. Early reperfusion therapy (thrombolysis and/or percutaneous coronary intervention [PCI]) in ineligible patients was associated with a significant decrease of hospital mortality (odds ratio 0.62, 95% confidence interval 0.49 to 0.79), with primary PCI being more effective than thrombolytic therapy (odds ratio 0.52, 95% confidence interval 0.41 to 0.65). In conclusion, about 50% of patients with ST-elevation myocardial infarction seen in clinical practice are usually excluded from RCTs. Hospital mortality in those patients is very high. Primary PCI improves the prognosis and is therefore the preferred reperfusion strategy in these patients.

Impact of chronic antithrombotic therapy on hospital course of patients with acute myocardial infarction.

BACKGROUND: Little is known about the influence of chronic antithrombotic therapy on treatment and clinical outcome in patients with acute ST-elevation myocardial infarction (STEMI). HYPOTHESIS: The purpose of this study was to investigate the hospital course of STEMI patients on antithrombotics. METHODS: We analyzed data of consecutive patients with STEMI, who were prospectively enrolled in the German Acute Coronary Syndromes registry between July 2000 and November 2002. Overall, 8224 patients were stratified into 3 groups: group 1 had no prior chronic antithrombotic medication (n = 6004), group 2 was on chronic acetylsalicylic acid (ASA) therapy (n = 2022), and group 3 was on chronic oral anticoagulation therapy (n = 198). RESULTS: Patients on antithrombotic medication were older and had a higher baseline risk profile. The rate of patients receiving early reperfusion (group 1: 74.6%, group 2: 61.2%, group 3: 52.0%) and guideline-adherent adjustment therapy was lower among patients on antithrombotics. Age and left bundle branch block were strong negative predictors for early reperfusion therapy in patients with prior antithrombotic treatment. Infarct size measured by peak creatine kinase level was lower in patients on antithrombotics. Hospital mortality (group 1: 8.0%, group 2: 12.8%, group 3: 16.2%) and major bleeding complications (group 1: 1.6%, group 2 2.0%, group 3 4.1%) were highest in patients on oral anticoagulants. However, after adjustment for confounding factors, prior ASA (odds ratio [OR]: 0.98, 95% confidence interval [CI]: 0.80-1.21) and oral anticoagulant treatment (OR: 1.06, 95% CI: 0.66-1.71) were not independent predictors for in-hospital death. CONCLUSIONS: Despite a higher risk profile, patients with STEMI on a chronic antithrombotic therapy were less likely to receive early reperfusion therapy. However, after adjustment, prior ASA or oral anticoagulant therapy was not associated with higher in-hospital mortality.

Angioplasty within 24 h after thrombolysis in patients with acute ST-elevation myocardial infarction: current use, predictors and outcome. Results of the MITRA plus registry.

BACKGROUND: Percutaneous coronary intervention (PCI) early after thrombolysis (early PCI) in patients with ST-elevation myocardial infarction (STEMI) is currently advised by clinical guidelines, but little is known about its use in clinical practice. METHODS: We analysed the MITRA (Maximal Individual Therapy of Acute Myocardial Infarction) plus registry. RESULTS: Out of a total of 34276 patients with STEMI, 10600 (30.9%) were treated with intravenous thrombolysis. Out of these patients, 487 (4.6%) patients received an angioplasty between 61 min and 24 hours after thrombolysis. They were compared to 10113 (95.4%) patients who received PCI either later than 24 hours after thrombolysis or not at all. A continuous increase in the frequency of early PCI between the years 1994 (2%)-2002 (16.7%) was observed. After adjusting for confounding variables independent predictors to use early PCI were the increasing year of inclusion, the facility of the hospital to perform PCI, younger age and male gender. Hospital mortality was 7.2% in patients receiving early PCI, compared to 11.2% in the other group (<0.01). Independent predictors for a higher hospital mortality were shock, age >65 years, female gender, an anterior STEMI and a prehospital delay of >3 hours. However, early PCI was not longer associated with a lower mortality (OR 0.95, 95% CI 0.64-1.14). CONCLUSION: Early PCI after thrombolysis is used infrequently in current clinical practice in Germany. Especially 'low risk' patients were treated with an early PCI, which may contribute to the missing effect on mortality compared to no or late PCI after thrombolysis.

Efficacy of a 24-h primary percutaneous coronary intervention service on outcome in patients with ST elevation myocardial infarction in clinical practice.

BACKGROUND: Primary percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) improves outcome in comparison to fibrinolysis. However, it is unclear whether patients treated in interventional facilities with 24-h primary PCI service have lower rates of adverse events. METHODS: We analyzed data of consecutive patients with STEMI prospectively enrolled in the German Acute Coronary Syndromes registry between July 2000 and November 2002 who were admitted to hospitals with catheterisation laboratory. RESULTS: Overall 6,350 patients were divided into two groups: 2,779 (43.8%) were treated in hospitals with and 3,571 (56.2%) without 24-h on-call cardiac catheter laboratories. 83.0% of the patients at facilities with and only 69.9% of the patients at facilities without 24-h PCI service received early reperfusion therapy (P < 0.001). Hospital death (7.4% vs. 9.9%, P < 0.001), non-fatal myocardial reinfarction (2.5% vs. 6.4%, P < 0.0001) and stroke (0.3 vs. 1.0%, P < 0.01) occurred significantly less often in patients treated in hospitals with 24-h primary PCI service. After adjustment for the confounding factors in the propensity score analysis the 24-h on-call strategy remained superior for the combined endpoint of death, reinfarction and stroke (OR 0.63, 95% CI 0.54-0.75). CONCLUSIONS: In clinical practice the rate of patients receiving reperfusion therapy was significantly higher in hospitals with 24-h primary PCI service which was associated with an improved in-hospital outcome. Though the data was collected at a time that does not completely represent current clinical practice, these results could have an impact on planning efficient infarct networks in the future.

Midventricular form of takotsubo cardiomyopathy as a recurrence 1 year after typical apical ballooning: a case report.

Takotsubo cardiomyopathy was first described in Japan and is characterized by transient left ventricular apical ballooning in the absence of a significant coronary artery disease.Caused by the clinical presentation including chest pain, electrocardiographic changes and elevated myocardial markers this syndrome is frequently misdiagnosed as an acute coronary syndrome. Recurrences of Takotsubo Cardiomyopathy, especially in variant regions of the left ventricle are rareWe describe a midventricular form of Takotsubo Cardiomyopathy as a recurrence 1 year after typical apical ballooning.

Clinical, angiographic and cardiovascular magnetic resonance findings in consecutive patients with Takotsubo cardiomyopathy.

BACKGROUND: The aim was to assess clinical, angiographic and cardiovascular magnetic resonance (CMR) findings in patients with Takotsubo cardiomyopathy. METHODS: Between 2003 and 2007, 20 consecutive patients admitted to our hospital with suspected acute myocardial infarction and presenting with apical ballooning in the left ventricular (LV) angiogram in the absence of a significant coronary artery disease, were included in the study. Echocardiography and CMR was performed in all patients. RESULTS: The mean age of patients with Takotsubo cardiomyopathy was 62 +/- 8 years (range 43-78 years). Eighteen (90%) were female. Clinical presentations included chest pain (95%) and cardiogenic shock (5%). The mean angiographic LV ejection fraction on admission was 45% +/- 9% (range 26%-60%) and resolved rapidly in all cases. Mean time delay between presentation CMR was 2 +/- 1 days (range 1-6 days). Mean ejection fraction was 51% +/- 15% (range 25%-81%). While 19 (95%) patients showed no evidence of late enhancement or signs of myocarditis in the CMR, 1 (5%) patient who was resuscitated showed hyperenhancement confined to the apex. CONCLUSION: In patients showing the clinical picture of an acute myocardial syndrome and angiographic picture of a TakoTsubo cardiomyopathy, CMR might be helpful in confirming the diagnosis through the exclusion of other causes for the acute LV dysfunction.