Revascularization algorithm in acute STEMI should take into account age.

BACKGROUND: In the elderly patients, the optimal reperfusion strategy of acute ST-segment elevation myocardial infarction (STEMI) remains a topic of debate. Moreover, there is a lack of data regarding the effect of time to treatment (TT) on prognosis of STEMI in elderly patients. PURPOSE: The goal of our work was to analyze, in real life, the link between TT and 1-year mortality in patients with STEMI (> or =75 years) who were treated with thrombolysis (THL) or primary percutaneous coronary intervention (PCI). METHODS AND MATERIALS: Data were extracted from our university hospital prospective registry. Between 1995 and 2005, all patients who met the criteria (> or =75 years old, has had an acute STEMI <12 h, has been admitted directly into our cardiologic care unit, and has had a revascularization procedure) were included in the analysis. Using logistic regression, we studied the relation between TT and 1-year mortality for each strategy of reperfusion in patients with STEMI who were > or =75 years old. RESULTS: One hundred fifty-nine consecutive patients with STEMI <12 h were analyzed; 35 were treated with THL and 124 were treated with primary PCI. Mean age (+/-S.D.) was 80+/-4 years, and 56% of patients were men. In logistic regression analysis, TT was not associated to death after THL (P=.81), while it was positively correlated after PCI (P=.03). All-cause 1-year mortality was markedly higher in the THL group than in the PCI group (51.4% vs. 15.3%; P<.001). CONCLUSION: Our work suggests that the extrapolation of algorithm of revascularization used in younger patients is not appropriate for elderly patients. Specific algorithm of revascularization and recommendations are needed in elderly patients.

Four-dimensional speckle tracking for assessing improvement in left ventricular contractility after coronary angioplasty.

The objective of the study was to identify and quantify the potential improvement of left ventricular contractility after percutaneous transluminal coronary angioplasty (PTCA) using 4-dimensional (4D) speckle tracking echocardiography (4D STE). We investigated 41 patients with coronary disease by 4D STE pre- and 24 hours postcoronarography with (n = 18) or without (n = 23) PTCA. The 4D STE visualizes in real time the myocardium strain on 2- and 4-chamber apical views and on 3 transverse views of the left ventricle. Average and total strain of the left ventricle were measured. Of the 18 PTCA patients, 15 showed significant increase in left ventricle mean (+15 ± 6) and total strain (240 ± 100), which corresponded to an increase of 93% ± 55% from precoronarography, whereas the remainder showed no change. The total strain corresponded to 33% ± 10% (before PTCA) and 59% ± 11% (post PTCA) of the estimated normal strain for each patient. Strain improved in 70% of the segment downstream from the stent, and there was a negative correlation between the amplitude of the mean and total strain improvements after 24 hours and the mean and total strain values before PTCA. In the non-PTCA group, 21 of the 23 patients showed no changes in strain, whereas 2 showed improvement. The 4D STE showed significant improvements in left ventricular contractility in more than 70% of the areas downstream from the PTCA segment. This corresponded to an increase in the initial contractility by approximately 93% ± 55%; however, the myocardium contractility remained approximately 59% of normal level. No changes were seen in patients without PTCA.